Advanced carcinoma of the nasopharynx. Treatment results.

From 1947 through 1977, 93 patients with carcinoma of the nasopharynx were treated. Most (83%) of the patients, had stage IV disease including 9 per cent who had a systemic tumor dissemination. Cervical lymph node metastases were present in 73 (78%) patients. The 5-year actuarial survival for all 93 patients was 13 per cent, 40 for stage II, 18 for stage III and 10 for stage IV patients. The factors with significant influence on survival were Initial Performance Status and T4 disease. The presence of N3 disease was a good indicator of a subsequent systemic tumor spread.

Management of carcinoma arising in the lateral nasal wall.

Carcinoma of the lateral nasal wall is an uncommon lesion in the general population. However, among certain groups exposed to occupational dusts, there is a significant incidence of such malignancy. This article presents a summary of the suspected causal agents and describes in detail the surgical technique of widely removing the nasoantral-ethmoid complex en bloc. A review of 32 such malignant neoplasms of the lateral nasal wall, representing cases seen in the past 20 years, is included. This type of respiratory tract cancer is ideally suited for preventive measures, such as reducing airborne carcinogens and the use of masks, local hygienic routines, and biological monitoring.

Cranial complications of frontal sinusitis.

Complications of frontal sinusitis are potentially serious. The best prevention is adequate antibiotic treatment of acute sinusitis or of the acute exacerbation of chronic sinusitis. Intracranial complications include extradural, subdural and brain abscesses, meningitis and cavernous sinus thrombophlebitis. Bony complications include localized or spreading osteomyelitis. Surgical intervention is often required to prevent unacceptable mortality.

Variations of nickel in plasma and urine during the work period.

One of the basic problems in monitoring exposure of nickel refining workers has been the unclear correlation between plasma nickel, urine nickel, and airborne nickel during the eight-hour work period or throughout the 24-hour day. In previous studies the authors have demonstrated the value of biological sampling in an occupational health program in the nickel processing industry. Whether a single plasma or single urine sample is an adequate gauge of exposure or whether 24-hour urine specimens or a three-day average plasma level are more accurate indices remained to be determined. The purpose of this paper is to report the results of studies of diurnal variations which affect the significance of single biological samples. In addition, data gathered on the correlation of plasma and urine nickel levels with soluble and insoluble nickel compounds in the atmosphere are presented.

Afterloading interstitial implant in head and neck cancer.

Seventy-nine patients with head and neck malignancies were treated using afterloading interstitial iridium 192 techniques at Los Angeles County-University of Southern California Medical Center and Southern California Cancer Center from Feb 1, 1974 to Nov 30, 1975. Twelve of the 13 T1 and T2 lesions and 17 of 25 T3 and T4 lesions remain locally controlled to a minimum follow-up period of 24 months. Surgical salvage in case of treatment failure is possible with low morbidity because of relatively low external irradiation to the total volume. Twenty of 41 patients who were reirradiated for persistent or recurrent cancers still have local control to a minimum follow-up period of 24 months. We discuss sites of involvement, implantation techniques, reactions, and complications.

Nickel-related cancers of the respiratory tract.

Nickel-related cancers of the respiratory tract have been recognized for nearly 50 years and represent a unique opportunity for prevention among refinery workers. Studies of exposed employees have been conducted in which evaluations were made of the histopathologic changes in the respiratory mucosa and the body burden of nickel was measured by regular plasma nickel determinations. The sites of tumor predilection are related to airflow patterns of the nose and tracheobronchial tree. The metaplastic changes in these areas are accompanied by increased tissue concentrations of nickel. Close monitoring of nickel workers has led to a lower incidence of respiratory cancers and earlier diagnosis.

The use of synthetic implant material in osteoplastic frontal sinusotomy.

The use of homologous fat in obliterating frontal sinus operations has proved to be a satisfactory technique. It does entail, however, a separate procedure to obtain the graft. Furthermore, the implanted fat has a tendency to shrink or absorb in varying degrees. Proplast has been used in a series of osteoplastic frontal sinus operations. The implant block is a highly porous preparation of Teflon fluorocarbon polymer and vitrous carbon fibers. It can be easily carved into desired shapes or it may be implanted in peices. The porosity of the substance permits in-growth of connective tissue. Eight obliterating frontal sinus procedures using the osteoplastic flap technique and implanting the synthetic material are reported. There have been no failures to date after 1 to 5 years follow-up.

Treatment of spastic dysphonia by recurrent laryngeal nerve section.

The problem of management of patients with spastic dysphonia has been complicated by a general resistance to speech therapy, psychotherapy, hypnotherapy, and drug therapy. Dedo introduced the concept of recurrent laryngeal nerve section in an attempt to eliminate the hyperfunction and excessive adduction of the vocal folds. Eleven patients were treated by RLN section with satisfactory results in 8 and some improvement in the other 3. The operation was found to be generally uncomplicated and required on average 4 days of hospitalization. Dedo's theory that spastic dysphonia is caused by a neurotropic viral-induced proprioceptive nerve deficit represents a new search for organic cause. His most recent report of finding unmyelinated fibres in one-third of the resected recurrent laryngeal nerves is of questionable significance. The evidence of deep emotional conflict and/or compulsive life-style is found in the majority of the patients, but the syndrome is not typical of an hysterical or conversion neurosis. Regardless of etiologic theory, RLN section is an effective treatment in selected, long-standing, and resistant instances of spastic dysphonia.

Mediastinal goiter and superior vena cava syndrome.

Mediastinal goiter as a cause of superior vena cava syndrome and tracheal compression is rare. A case is presented, the literature is reviewed and the otolaryngologic implications are emphasized.

Unusual vascular lesions of the neck.

Vascular lesions of the neck may initially appear atypically, without the expected findings of a bluish discoloration, pulsations, or a bruit. The initial characteristics may mimic that of a metastatic carcinoma. The true nature of the lesion may remain obscure, despite a thorough preoperative evaluation, including angiography. The head and neck surgeon must be aware of the occasional unusual appearance and must be prepared to treat whatever vascular lesion he might encounter.

Nickel carcinogenesis of the respiratory tract.

The role of some nickel compounds and other chemical carcinogens in the causation of cancer of the nose and paranasal sinuses must be recognized. Preventive health measures taken by the nickel industry to eliminate the hazard of nickel carcinogenesis have included improved worker hygiene, reduction of refinery dusts and aerosols, and a strict monitoring of employees by regular examination and plasma nickel testing. The treatment of carcinoma limited to the naso-antral wall or ethmoid labyrinth by an en bloc resection is described, as well as the management of cribriform plate CSF leaks sometimes associated with the ethmoid resection. A subcutaneous cheek flap from the lateral rhinotomy is reflected inward against the cribriform plate to control cerebrospinal fluid rhinorrhea.

Treatment of squamous cell carcinoma of the floor of the mouth.

Treatment of 88 selected patients with Stages I and II squamous cell carcinoma of the floor of the mouth by monobloc resection has produced a high five year cure rate. The death of one patient in the series postoperatively was considered a surgical one. Disability after such a procedure is minimal, and dental complications are not a factor. Elective irradiation of the neck is recommended in those instances of positive sublingual or submandibular nodes found in the monobloc specimen and in all patients with Stages III and IV lesions. Radiation therapy is recommended for highly anaplastic neoplasms, for instances when speech impairment is important, for lesions in the posterior limits of the floor of the mouth, for edentulous patients without bone invasion, for the treatment of recurrent lesions after operation and for synchronous multiple primary carcinomas of the head and neck if one of which is a carcinoma of the floor of the mouth.

Preventive health program for nickel workers.

The possible hazards of exposure to certain nickel compounds during nickel refining have been recognized for over 40 years. Much progress has been made in worker protection by cleaning up the process and by other protective means, and improved personal hygiene. The problem in the past has been determining those employees who are most exposed. This has been accomplished in this project by regular plasma and urine nickel determinations, demonstrating that nickel process workers absorb nickel which can be measured in plasma and urine. It was found that the highest plasma and urine nickel levels were seen in workers in those departments in which the greatest incidence of respiratory cancer occurs. Whether persistently elevated plasma nickel can be correlated with the eventual development of respiratory tract cancer is the subject for continued years of follow-up. It is not possible to conclude at this time that there is any association between the raised plasma and urine nickel and the incidence of cancer.

Technique for closure of the floor of the mouth in monobloc resection.

Closure of the floor of the mouth after resection with or without partial mandibulectomy is often unsatisfactory. The wound may fail to heal per primum and transient orocutaneous fistulas are not uncommon. A technique of closure of the floor of the mouth, based on a series of 68 patients treated by monobloc or "three-dimensional" resection, uses the hyoglossal muscle as a new muscular sling to close the surgical defect. The overlying hypoglossal nerve is mobilized in a neuromuscular transplant that preserves tongue function and speech. Such a procedure facilitates the successful surgical management of stages I and II carcinomas of the floor of the mouth.

Mucosal melanomas of the head and neck.

Malignant melanomas arising from the mucosal areas of the head and neck are rare. When such neoplasms are encountered, the problem of their management is often poorly resolved. Cases of primary malignant melanoma of the maxillary sinus, the nasopharynx, oral cavity and laryngo-pharynx are presented and the results of treatment analyzed. Much of the difficulty in therapy is due to an incomplete understanding of the mechanisms which determine survival. A brief discussion of melanoma immunology is presented. Surgery (including cryosurgery) remains the primary therapy when possible. The role of chemotherapy, immunotherapy and radiation therapy in such lesions cannot be clearly delineated at this time.