Complicated frontal sinusitis: evaluation and management.

The diagnosis and management of complicated cases of frontal sinusitis are challenging problems. Unacceptable mortality and morbidity from delay in diagnosis and treatment must be weighed against the early performance of deforming surgical procedures. Many of these patients require prolonged hospitalization for intravenous antibiotic therapy. The assessment of the optimal time course for such therapy has been difficult. Six illustrative cases of frontal sinusitis, complicated by intracranial suppuration, osteomyelitis, and/or bone erosion, are presented. The use of CT, bone, and gallium scans in the diagnosis of complications--and in the timing of antibiotic therapy and surgical intervention--are discussed. Guidelines are formulated for the evaluation and treatment of complicated frontal sinusitis.

The extended pectoralis major flap in head and neck reconstruction.

Historically, major extirpative surgery for control of head and neck cancer developed well in advance of reconstructive procedures that could provide acceptable functional and cosmetic rehabilitation. Introduction of cutaneous axial and random flaps--followed more recently by the description of musculocutaneous flaps--represented major advances in reconstructive techniques.

Management of giant cystic hygromas in infants.

Giant cystic lymphangioma is a rare lesion that presents major therapeutic challenges. Four infants presented in the first weeks of life with diffuse cysts in the neck. The tongue was involved in three, the mediastinum in one, and the pharynx and supraglottic larynx in two. These lesions are characterized by hundreds of cysts that infiltrate in and around muscles, nerves, and vessels. Complete excision is not possible without damaging the normal structures. All four infants initially had partial removal with unroofing and drainage of the remaining cysts and temporary tracheostomy to protect the airway. One infant died from a thrombosed sagittal sinus. She had severe venous congestion of the head and neck postoperatively which may have been caused by an overzealous attempt to remove all of the cysts. The other three have required nine additional operations for removal of recurrent neck cysts (one operation), removal of mediastinal cysts (one operation), partial glossectomy (three operations), and laser excision of lymphangiomas of the pharynx and supraglottic larynx (four operations). Two patients have required partial glossectomy which should be performed early to protect the airway, to allow normal speech development, and to prevent malocclusion and prognathism from constant pressure of the tongue against the teeth. Removal of wedges of tissue from each side and from the center of the dorsum of the tongue reduces bulk with minimal risk to the lingual arteries and nerves. Recurrent tongue enlargement is common and can be treated by repeated partial glossectomy. Lymphangiomatosis of the pharynx and supraglottic larynx is difficult to treat. The carbon dioxide laser allows very precise excision of individual cysts with minimal drainage to adjacent mucosa, but in our limited experience it has not prevented recurrence. Despite the extensive nature of these lesions, the impossibility of complete excision, and the need for multiple operations, the long-term results in the three surviving patients have been satisfactory. Asymmetry of the neck and face due to lymphedema tends to improve with time. All three children have an acceptable appearance and normal speech for their ages.

Primary tumors of the facial nerve: diagnosis and management.

Benign primary tumors of the facial nerve are frequently misdiagnosed because of variable and subtle clinical manifestations. Three such cases of facial nerve neuroma seen in the past 3 years will be presented. Difficulties in patient assessment including the lack of specificity for topographic testing, as well as the capricious behavior of the facial nerve in these patients will be discussed. The efficacy of diagnostic techniques presently available and in use including computerized tomography and electrodiagnostic studies will be discussed. Diagnosis of these tumors might generally be thought to be straightforward and easier with the advent of new diagnostic techniques, but this has, in fact, not been the case. Techniques for removal and repair will be presented. The combined approach utilizing the mastoid and middle fossa will be presented.

Myocutaneous flaps for challenging problems in head and neck reconstruction.

We treated three cases of recurrent head and neck carcinoma viewed as challenging reconstructive problems because of the extent of the extirpative surgery necessary and the substantial risk of complications that would be associated with previous treatment techniques. In each case, the versatility of myocutaneous flaps is illustrated. In case 1, a double-paddle pectoralis major flap was employed. In case 2, with an exposed infected carotid artery and a failed pectoralis major flap, reconstruction was accomplished by using an ipsilateral trapezius myocutaneous flap. In case 3, for reconstruction of the pharynx with a low esophagostoma, a double-paddle pectoralis major and split-thickness skin graft were used.

Foreign-body aspiration. Potential misdiagnosis.

Clandestine aspiration of foreign bodies lodged high in tracheal airway can mimic subglottic croup. Although this relationship is emphasized in textbooks of otolaryngology, documentation in the recent literature is lacking. This report underscores our awareness of a potentially lethal diagnosis masquerading as a more benign viral infection of the laryngotracheal airway.