Trichoepithelioma: report of an unusual case and review of the literature.

Trichoepitheliomas are benign and uncommon skin tumors presenting in the head and neck region. Although they can be solitary, they occur more frequently as multiple lesions with an autosomal dominant inheritance. To the surgeon, they often present the problem of clinical differentiation from basal-cell carcinoma. An unusual case is described, and experience in the treatment of 19 patients is reviewed.

Partial laryngectomy for glottic cancer after high-dose radiotherapy.

A vertical partial laryngectomy (VPL) for salvage was performed on 25 patients with locally persistent or recurrent squamous cell carcinoma of the vocal cord(s) after high-dose radiotherapy at the UCLA Medical Center between 1969 and 1988. Patients were followed for a minimum of 2 years and a median of 4.4 years after VPL. Ninety-six percent of patients remained free of disease. Tumor was controlled in patients with impaired vocal cord mobility and involvement of the contralateral cord or false cord. The actuarial survival rate was 80% at 5 years. There were no serious wound healing problems. A permanent tracheostomy was required in one patient due to recurrent aspiration pneumonia. Swallowing and voice function were satisfactory in all other patients. These results indicate that the selection criteria for initial VPL can be applied to the salvage situation with similar success.

Epiglottic reconstruction after supraglottic laryngectomy.

It has been well established that supraglottic laryngectomy is an effective treatment of laryngeal cancer arising above the vocal cords with cure rates equaling total laryngectomy. Although there is preservation of a near normal voice after supraglottic laryngectomy, chronic aspiration occurs in some patients particularly after extended supraglottic laryngectomy or when there is associated compromised pulmonary function. During normal deglutition, the epiglottis serves to divert food to the pyriform fossae and partially covers the inlet to the airway. These important functions can be accomplished after supraglottic laryngectomy by reconstructing a neoepiglottis from an epiglottic remnant whenever one third or more of the epiglottis can be preserved which is microscopically free of tumor. Our results in 14 patients have shown no clinically significant aspiration after epiglottic reconstruction.

Sternohyoid myofascial flap reconstruction of the larynx for vertical partial laryngectomy.

Reconstruction of the larynx for vertical partial laryngectomy is of paramount importance in eventual voice and deglutition rehabilitation. Many different methods of laryngeal reconstruction have been tried attesting to the challenge of minimizing hoarseness and aspiration after this type of surgery. During the past decade the scope of partial laryngeal surgery has broadened, mandating more extensive reconstructive procedures in order to acceptably rehabilitate upper aerodigestive function. During the past 6 years the author has employed a superiorly-based sternohyoid myofascial flap to reconstruct the larynx after vertical partial laryngectomy in 31 patients. Swallowing was resumed in all patients without significant aspiration. Although decannulation was delayed in 8 patients, all patients were eventually extubated. Voice quality was considered far superior to other reconstructive methods formerly used by the author.

Tongue flap repair of postlaryngectomy hypopharyngeal stenosis.

Hypopharyngeal stenosis after total laryngectomy has been reported as high as 40%. The most consistent and important causal factor is the extent of the pharyngeal resection since cancers of the pyriform sinus and postcricoid region have the highest incidence of stenosis. Dilation is frequently unsuccessful in the management of postlaryngectomy hypopharyngeal stenosis probably because of its excessive length. The laterally-based tongue flap is effective for repair of these stenoses because of its proximity, epithelial compatibility, and ample length. The technique, details, and successful use in three patients are presented.

Bilateral omohyoid muscle flap reconstruction for anterior commissure cancer.

Partial laryngectomy for anterior commissure cancer often results in a shortened glottis which produces a high pitched strained voice and an inadequate airway lumen which requires permanent tracheostomy. Vocal fold vibration is impaired both by the shortened length and anterior scarring which profoundly affects the myoelastic properties of the larynx. Many different methods of reconstructing the anterior commissure have been attempted with limited success and many require multiple procedures. A method of anterior commissure reconstruction employing bilateral omohyoid muscle flaps has been performed successfully in four patients. The omohyoid muscles and investing fascia are readily available during partial laryngectomy and can be tailored to reconstitute the anterior commissure. The myofascial flaps epithelialize rapidly and there is little tendency for anterior glottic stenosis. The sphincteric function of the larynx remains intact and the vocal quality surpasses other methods of reconstruction employed by the author.

Parotid hypertrophy with bulimia: a report of surgical management.

Benign hypertrophy of the salivary glands can occur in patients with anorexia nervosa. This enlargement has been related to nutritional deficiencies and bulimia, which is a form of episodic binge eating followed by vomiting. The surgical management of a patient with bulimia and benign bilateral parotid enlargement secondary to bulimia will be discussed. Superficial parotidectomy may be a useful adjunct in managing the cosmetic and psychological aspects of patients with anorexia nervosa and bulimia complicated by massive parotid hypertrophy intractable to medical management.

Supraglottic laryngectomy: series report and analysis of results.

Forty-one consecutive patients who underwent supraglottic laryngectomy at UCLA were reviewed. All of the operations were performed by or under the direct supervision of the same surgeon (T.C.). The majority (68%) had advanced squamous cell carcinoma (Stage III-IV). Approximately one half received radiation therapy as part of planned combined therapy. The overall tumor-free survival, with a two-year minimum follow-up period, was 90%. The most common site of tumor recurrence was neck metastasis. There were four laryngeal recurrences, three of which were salvaged with completion laryngectomy. There was only one completion laryngectomy for severe aspiration. The favorable results in this series are attributed to frozen section control of surgical margins, surgical or radiation therapy treatment of cervical lymph nodes at risk for metastatic disease, and the employment of surgical techniques designed to minimize aspiration.

Pseudomonas meningitis complicating head and neck surgery.

Three patients, each of whom had Pseudomonas meningitis as a sequela of an extensive head and neck operation, have been treated successfully. All three patients had cerebrospinal fluid leaks, and operative management of this complication is discussed. Antibiotic management included the parenteral administration of the recently developed drugs gentamicin, carbenicillin, and intrathecal gentamicin. Since extensive head and neck operations are being performed, with increasing frequency and since infectious complications are inevitable, it is mandatory that the otolaryngologist be familiar with current methods of managing these potentially lethal conditions.

Current adjuncts for surgery of the sphenoid sinus and pituitary gland.

Surgical intervention in the region of the sphenoid sinus pituitary gland requires extreme precision because of enveloping vital structures. The rhinologic approach to the pituitary gland, once abandoned due to limited visibility and the risk of meningitis, has experienced a renaissance as a result of recent medical and technical advances. Antibiotics have almost eliminated the risk of meningitis, and the operating microscope and televised radiofluoroscope now provide sufficient illumination, magnification, and orientation that injury to nearby structures can be avoided. A mid-line rhinologic approach provides ample exposure and further minimizes operative hazards.

Prosthetic rehabilitation of large midfacial defects.

Advanced tumors of the midfacial region often require removal of the nose, upper lip, portions of the maxilla, and other adjacent structures. When the resultant defects do not lend themselves to surgical reconstruction, prosthetic appliances may be used successfully to restore the functions of speech and swallowing to near-normal levels. The degree of success depends upon the nature of the previous treatment, the existing surgical defect, and the adaptability of the patient. The most important anatomical consideration is the form and amount of the remaining maxilla. Recent advances in the development of the polyurethanes have resulted in lighter, more flexible, and, therefore, better tolerated prostheses. Close cooperation between the surgeon and the prosthodontist is necessary if successful rehabilitation of these patients is to be achieved.

The coexistence of parathyroid adenoma and thyroid carcinoma.

Not well-known and inadequately understood is the high incidence of conexistent parathyroid adenoma and nonmedullary thyroid carcinoma. In a series of 144 patients with parathyroid adenoma, 11 (8%) were found to have concurrent thyroid carcinoma. Although similar to other multiple endocrine tumor syndromes, these two tumors have no common embryologic cell origin. The most likely explanation for this apparent relationship is the specific oncogenic effect of hypercalcemia on the thyroid gland.

Aerodigestive dysfunction secondary to thyroid tumors.

Although most thyroid tumors first manifest clinically by a neck mass, several patients with thyroid tumor have been treated whose initial complaint was a disturbance of the respiratory and digestive tracts. Because this association is not well recognized, the diagnosis of a thyroid tumor can be delayed, or even missed until the tumor grows much larger causing other symptoms. A series of 269 patients with thyroid tumors seen at UCLA from 1979-1980 was reviewed. Approximately 16% of these patients sought treatment because of aerodigestive dysfunction such as dyspnea, dysphagia, hoarseness, throat discomfort and hemoptysis. Such symptoms often indicate malignancy of substernal extension of tumor. The management of these tumors is discussed.

Antral-ethmoidal decompression of the orbit in Graves' disease: ten-year experience.

The orbital manifestations of Graves' disease usually comprise the most distressing component of this inadequately understood disease entity. Patients with optic neuropathy, exposure keratopathy, or disfiguring proptosis can be helped considerably by decompression of the swollen orbital tissues into the maxillary and sinus cavities. Experience with 104 patients personally operated by the senior author and analyzed by chart review and patient questionnaire indicates that antral-ethmoidal decompression is a successful form of therapy, generally free of serious complications. It is now employed earlier in the course of Graves' ophtholmopathy than in the past.

Transpharyngeal approach to base of tongue tumors: a comparative study.

Tumors of the tongue base have been traditionally removed by resecting the mandible or using a translabial transmandibular approach. These procedures involve significant morbidity including lip and chin scars, malocclusion, compromised deglutition, chronic aspiration, and altered speech articulation. Therefore alternative techniques have been described to minimize the morbidity associated with transmandibular tongue resection. A retrospective analysis of patients with base of tongue tumors treated at the University of California, Los Angeles, Medical Center between 1981 and 1994 was undertaken. Thirteen patients were treated using a transpharyngeal approach compared with 18 patients who underwent a transmandibular resection. There was no difference in terms of survival or tumor-free margins. However, there was a significant difference in function (P < .05). Patients who underwent transpharyngeal resection had significantly better speech and swallowing and less aspiration compared with those who underwent transmandibular resection of tumors.

The enigma of post-radiation edema and recurrent or residual carcinoma of the larynx.

Persistence of significant edema of the larynx beyond six months after completion of radiotherapy presents the laryngologist with a diagnostic dilemma. Review of the results of 43 cases demonstrated a high incidence of residual or recurrent carcinoma. Based upon this experience earlier and frequent laryngeal biopsies are recommended for these cases.

Combined radiotherapy with planned neck dissection for small head and neck cancers with advanced cervical metastases.

BACKGROUND: We have previously described our treatment algorithm for patients with small head and neck cancers with advanced cervical metastases (stage N2 or greater). Primary radiotherapy is given to the primary site and neck, followed 6 weeks later with endoscopy and biopsy of the primary site. If biopsy of the primary site is negative by frozen section, an immediate neck dissection is performed even when no clinical residual neck disease is present. Our initial review found that 36% of patients with a complete clinical response to radiotherapy had positive nodes on histological examination. STUDY DESIGN: Retrospective. METHODS: The medical records of 71 patients treated at UCLA Medical Center from 1986 to 1999 by this algorithm were reviewed. RESULTS: After radiotherapy, 69 of 71 patients had a complete response at their primary site. Forty-two patients had a complete clinical response in the neck. Seventy-one neck dissections were performed. Overall, 31 of 71 neck dissections (44%) had positive nodes. Among the 42 patients with a complete response to radiotherapy, 13 (31%) had positive histological nodes. Among the 29 patients with a partial response to radiotherapy, 17 (59%) had positive nodes. Follow-up and incidence of neck recurrence are discussed. CONCLUSION: Planned neck dissection for advanced cervical metastases remains controversial for patients with a complete clinical response to radiotherapy. However, our results suggest that clinical assessment after radiotherapy cannot assure the absence of neck disease. Until there are reliable methods to distinguish which patients are truly free of neck disease, we believe the benefits of a planned neck dissection outweigh the low morbidity of this procedure.

Efficacy and morbidity of partial laryngectomy and postoperative radiation therapy.

In recent years, we have seen increasing use of partial laryngectomies for larger lesions that were previously treated by total laryngectomy. The resultant closer margins have made postoperative radiation therapy an important adjuvant treatment to conservation laryngeal surgery. We review the University of California, Los Angeles, experience with combination partial laryngectomy and postoperative radiation therapy between 1973 and 1987 for treatment of carcinoma of the larynx. Twenty-four such patients who underwent partial laryngectomies and postoperative radiation therapy are examined. Techniques of treatment, complications, and the functional ability of the remaining larynx are discussed. The locoregional control rate at 5 years was 80%. Risk factors associated with an increased risk of recurrence were positive margins, vascular invasion, and extranodal spread. There were no major problems with postoperative wound healing or airway management during the radiation treatment. Vocal and swallowing function were well preserved in most cases. We conclude that combination partial laryngectomy and radiation therapy permits preservation of laryngeal function without serious complications, and therefore is an effective treatment for selected patients with carcinoma of the larynx.

Regulation of transforming growth factor-beta 1-mediated apoptosis in head and neck squamous cell carcinoma.

The apoptotic cell death in Cal-27 cells induced by exposure to transforming growth factor-beta 1 was inhibited by the endonuclease inhibitor aurintricarboxylic acid (ATA) in a concentration-dependent fashion. In vitro studies of cytotoxicity, DNA fragmentation, and protein synthesis by Cal-27 cell lines were performed. Inhibition of cytotoxicity as well as endonucleolytic DNA cleavage was detected. ATA did not inhibit cytotoxicity either via transforming growth factor cell-surface-receptor alteration or by inhibition of macromolecular synthesis. ATA-sensitive events occurred late during treatment. These data suggest that endonucleolytic DNA cleavage is a mandatory event leading to cell death in this system.

Ischemic paralysis of the facial nerve: a possible etiologic factor in Bell's palsy.

Numerous causes of peripheral facial nerve paralyses have been described; however, none has satisfactorily explained the genesis of the most common type of paralysis, Bell's palsy. Two patients undergoing an experimental embolization of vascular intracranial tumors suffered a total peripheral facial nerve paralysis when occlusion of the middle meningeal artery had been accomplished. It is speculated that this paralysis resulted from ischemia of the horizontal portion of the facial nerve, an observation that has not previously been described and that might be applicable as well to the etiology of Bell's palsy.