Computed tomography of the normal larynx.

A computed tomographic analysis of normal laryngeal anatomy was undertaken using cadaver larynxes. This was part of a larger project in which patients with laryngeal carcinoma were routinely evaluated in the computed tomographic (CT) body scanner. The appearance of normal laryngeal anatomy had to be delineated before disease processes of the larynx were evaluated, and this was accomplished using a computed tomographic technique with 5-mm slice thicknesses and a 3-mm overlap. The scan slices were then compared with anatomic sections taken at the same levels. The comparisons demonstrate an ideal level of accuracy that can be approached in the in-vivo larynx only with use of the latest-generation scanners. However, CT scanning is of immediate usefulness in the diagnosis of laryngeal pathology.

Surgery for chronic hyperplastic rhinosinusitis.

Davison pointed out in 1953 that his purpose in treating sinusitis was to utilize the smallest amount of surgery that would produce permanent relief of symptoms. By 1963 he had become convinced that extensive disease required extensive surgery. Hyperplastic rhinosinusitis is treated by a variety of surgical techniques including polypectomy, turbinate cautery, submucous resection of the turbinates or nasal septum, anterior ethmoidectomy, and spheno-ethmoidectomy. Sixty-eight patients are presented who have undergone bilateral sphenoethmoidectomy between January, 1969, and January, 1974. These patients were predominantly allergic, with a high percentage of previous polypectomies and desensitization which failed to control their recurring nasal polyps. Ten patients were lost to follow-up. Forty-seven of 68 patients have had no recurrence of polyps in from 12 to 60 months. All patients continued to have mucosal manifestations of allergy or infection, but the recurrence of late polyps was limited to 11 patients. The spheno-ethmoidectomy technique is utilized, stressing complete removal of the middle turbinate. Kidder has shown an improved rate of polyp control in patients following ethmoidectomy with middle turbinate removal rather than with partial or total preservation of the middle turbinate. Complete resection of the middle turbinate with opening of the sphenoid air sinus permits a thorough exenteration of the ethmoid labyrinth and better control of chronic disease. A complication rate of 5.9 percent is presented and is deemed acceptable, since there no disabling complications or complications related to poor visualization.

Evaluation of nasal tip surgery.

Nasal tip surgery has been evaluated with respect to correction of the lower lateral cartilages. Indications, techniques, results, and complications related to three generic approaches to the lower lateral cartilages are described. In 673 consecutive rhinoplasties the commonest type of nasal tip surgery was excisional, utilizing either a marginal or cartilage splitting technique. These techniques were utilized: 1. to accomplish debulking, and 2. to accomplish the installation of facets. The excisional technique found its greatest utility in primary rhinoplasties. The version technique, utilizing a change of direction of the thrust of the lower lateral cartilages was utilized in a variety of situations, particularly for the correction of moderately congenitally hypoplastic tip cartilages. It also found great utility in surgery of the Negro or cleft palate nose, increasing tip projection, correcting unacceptable bifidity, and in revision rhinoplasty. Augmentation rhinoplasty, utilizing conchal cartilage as an elastic strut was particularly useful for severe hypoplastic cartilage deficits, the Negro nose, columellar retraction, and alar rim deficits. The overall complication rate of lower lateral rhinoplasty was 17.4 percent. The rate of unacceptable complications related to lower lateral rhinoplasty was 2.7 percent.

Intranasal and transantral ethmoidectomy: a 20-year experience.

Ethmoidectomy is an operation that has engendered controversy concerning the best route of surgical access. The purpose of this study was to present the results of the authors' experience in more than 1300 intranasal sphenoethmoidectomies and transantral sphenoethmoidectomies performed over a 20-year period. The authors contend that the most effective ethmoidectomy is the most complete ethmoidectomy and have previously presented a case for ethmoid marsupialization. Polyp recurrence rates of less than 20% and a major complication rate of less than 1% were reported in this study.

Current management of cerebrospinal fluid rhinorrhea.

Forty-two patients with cerebrospinal fluid (CSF) rhinorrhea presenting over a 5 year period were analyzed as to age, sex, etiology, anatomical and clinical findings, and methods of investigation and treatment. Eighty-eight were traumatic in origin, with the most common anatomical sites being ethmoid, frontal and sphenoid sinuses, and the cribriform plate region. Meningitis and pneumocephalus were the most frequently associated clinical findings each present in 31% of the cases. Chemical analysis of the CSF for protein was positive in 88% of cases vs. 13% when the protein content was quantitatively analyzed. The demonstration and localization of CSF leaks were most effective using metrizamide and CAT scanning when they were active and by indium cisternography when they were small, intermittent, or questionable. The clinical management was divided into medical and surgical approaches with the advantages and disadvantages discussed.

The role of computed tomography in revision sinus surgery.

In this retrospective study, 34 patients with recurrent hyperplastic rhinosinusitis who subsequently underwent further surgical intervention were evaluated with computed tomography scans in order to assess the role of computed tomography in revision sinus surgery. Fourteen of these patients had originally undergone sphenoethmoidectomies, 8 had endoscopic sinus surgeries, 6 had Caldwell-Luc operations, and 6 had intranasal antrostomies. Computed tomography scan was instrumental in correctly identifying the site and reasons for failure and assisted in localizing further surgical intervention to the appropriate sites in 30 patients. The indications for computed tomography and revision surgery are discussed and defined.

Computed tomography staging of the paranasal sinuses in chronic hyperplastic rhinosinusitis.

In this study, the computed tomography scans of 100 patients with chronic hyperplastic rhinosinusitis were reviewed to establish a clinical staging system. Fourteen percent of the patients were classified as Stage I (single-focus disease); 36% as Stage II (multifocal disease responsive to conservative therapy); 32% as Stage III (diffuse disease partially responsive to medication); and 16% as Stage IV (diffuse disease associated with bony changes and poorly responsive to conservative treatment). The incidence of recurrent or persistent disease ranged from 13% for Stage II to 30% for Stage IV. Stage I and III patients had 13% and 18% recurrence rates, respectively. Computed tomography staging is shown to be useful in outlining operative strategies and is a reliable prognosticator of the disease process.

Oncogenes: preliminary studies in head and neck cancer.

DNA has been extracted from squamous cell carcinomas of the larynx, base of tongue, and nasopharynx. These tumors were excised from patients at the St. Louis University Medical Center and processed at the Institute for Molecular Virology of the St. Louis University Medical Center. NIH/3T3 cells were transfected with the DNAs from these cancers. Malignant, transformed foci of NIH/3T3 cells have been observed. These foci have been cloned and grown in quantity. The cloned foci have been injected into nude mice with the production of highly malignant sarcomas. DNA extracted from these sarcomas has shown homology with human DNA on hybridization analyses of both nasopharynx and tongue cancer. Further hybridization studies are being conducted on the larynx cancer-induced sarcomas and on the DNAs taken from the original transformed foci of NIH/3T3 cells transfected with squamous cell cancers of the larynx, nasopharynx, and tongue base. Our preliminary results indicating the presence of human sequences in the mouse sarcomas support the hypothesis that human cellular transforming gene(s) may be present in the DNA isolated from the head and neck cancers. Additional studies will include repetitive retransfection of NIH/3T3 cells, molecular cloning of putative oncogenes, and DNA sequence analysis of the cloned oncogenes. It is hoped that identification of putative oncogene sequences will result in the identification of the proteins coded for by the specific nucleotide sequences responsible for malignant cellular transformation by DNA extracted from head and neck tumors.

Oncogenes: their presence and significance in squamous cell cancer of the head and neck.

DNA extracted from squamous cell carcinomas of the larynx and tongue has been shown to contain cellular transforming genes characterized by their ability to transform mouse fibroblasts into malignant foci of cells which, when subsequently cloned and grown to volume, have been found to contain human DNA sequences. This DNA has been serially passaged through subsequent populations of NIH/3T3 mouse fibroblasts. Higher malignant transformation efficiencies have been observed and reported with serial passage. Of greater significance is the repeated identification of oncogenes of identical characteristics on electrophoretic radioisotope analysis.

Nasopharyngeal complications following uvulopalatopharyngoplasty.

This report presents our experience with nasopharyngeal complications of UPPP in 85 patients undergoing the procedure from May, 1982 to January, 1985. Three patients developed nasopharyngeal stenosis and one patient developed permanent velopharyngeal insufficiency. Surgical management in two patients with nasopharyngeal stenosis resulted in adequate nasopharyngeal airway, while one patient still has a moderate stenosis following two surgical procedures. The patient with velopharyngeal insufficiency underwent Teflon paste injection in the posterior pharyngeal wall. This resulted in complete alleviation of his nasal regurgitation.

Sphenoethmoidectomy: the case for ethmoid marsupialization.

The authors report 510 sphenoethmoidectomies performed on 255 patients between 1969 and 1985. An overall polyp recurrence rate of 19.2% and less than a 1% complication rate are reported during that time. In patients followed jointly by the otolaryngologists and allergist, including 374 consecutive sphenoethmoidectomies on 187 patients who had this operation performed by the senior author, there was an overall polyp recurrence rate of 15% and a complication rate which was again less than 1%. Recent improvements in recurrence rates and diminished complication rates are attributed to better visualization and adherence to the concept of complete exenteration or marsupialization of the ethmoid labyrinth including middle turbinate resection in every case. Cooperation between the otolaryngologist and allergist is stressed, along with the realization that pulmonary and sinus diseases are frequently interrelated and may both be benefited by the performance of sphenoethmoidectomy in the patient with hyperplastic rhinosinusitis.

Isolated sphenoid sinus disease.

Forty-three cases of isolated sphenoid sinus disease were reviewed. In 33 cases, headache was a presenting symptom. Seven of 29 cases of inflammatory disease and nine of 13 patients with tumors of the sinus presented with cranial nerve findings. When nonspecific visual disturbances were eliminated, two of 29 cases of inflammation and eight of 13 cases of tumors of the sphenoid sinus had cranial nerve deficits. Ten of 12 CT scans performed on patients with tumors of the sinus demonstrated bony erosion or perisinus extensions. This was not found in any of the 27 scans of patients with inflammatory disease. A thorough cranial nerve examination and a CT scan should be performed early in patients who present with vague and unusual headaches.

The surgical treatment of snoring: a patient's perspective.

An increasing number of loud snorers seek medical attention because of the social impact of snoring as well as its association with sleep apnea. Uvulopalatopharyngoplasty is reported to reduce or eliminate snoring in the majority of patients; however, little data are available to document the procedure's success. From February 1987 through August 1988, 125 patients underwent uvulopalatopharyngoplasty for habitual snoring; many of these patients had also documented sleep apnea. Of the 74 patients who responded to a postoperative questionnaire, 64 (86.48%) indicated that their snoring was either completely eliminated or markedly reduced. Only two patients reported significant side effects.

Stylohamular dissection: a new method for en bloc reaction of malignancies of the infratemporal fossa.

This study is a description of the "stylohamular" dissection, a technique for the en bloc resection of the infratemporal fossa. The medial plane of this dissection extends from the styloid process to the hamulus of the pterygoid just lateral to the foramen lacerum, allowing the surgeon to spare the internal carotid artery. The foramen ovale and foramen spinosum are routinely exposed during this procedure. Medially, the pterygoid musculature serves as the margin of the cancer block. Posteriorly, the mastoid tip may be included in this resection. Anteriorly, the lateral pterygoid plate is resected making it the anterior vertical plane of the dissection. Laterally, skin and mandible are the block margins. In the last three years, this approach has been utilized in eight patients with advance malignancies involving the infratemporal fossa. The results are encouraging. Five patients have remained well and free of disease for a maximum of three years postoperatively. Two patients have had recurrence of their tumor from six months to one year postoperatively. Palliation in all patients was excellent. The literature on various infratemporal dissections and their results is reviewed.

The effects of lower lateral cartilage excision on nasal tip projection.

Nasal tip projection is an important defining feature of the nasal profile. Loss of projection is often the bane of the rhinoplastic surgeon. While augmentation techniques for maintaining or increasing tip projection are useful in selected patients, the majority of rhinoplasties rely on excision of cartilage, particularly cartilage of the cephalic border of the lower lateral crura, to produce the desired cosmetic result. The purpose of this study was to measure the effects of lower lateral cartilage excision on nasal tip projection resulting from three common forms of nasal tip surgery. These techniques included cephalic border resection without vertical dome division, cephalic border resection with vertical dome division, and cephalic border resection with dome division and suture reapproximation of the mesial crura, the so-called "Goldman tip." Despite the fact that overall excellent results were obtained and loss of projection was rarely a noticeable feature, a measurable loss of projection can be seen in all but one case in this series. Although loss of tip projection is usually acceptable due to the masking effect, the concurrent reduction in dorsal nasal height, loss of projection must be anticipated in excisional techniques of the lower lateral cartilage.

Unilateral sensorineural deafness in children.

Heredity, viral infection, and head or acoustic trauma are considered the common etiologies for a unilateral sensorineural deafness in children. The incidence of perilymphatic fistula in a unilateral hearing loss is still unknown. Inner ear-related symptoms in children are scarce, and little diagnostic laboratory testing is available. A definite diagnosis of a perilymphatic fistula can therefore be made only by an exploratory tympanotomy. Four children, ages 5 to 15 years, with a history of a recent and rapidly progressive unilateral sensorineural hearing loss, were explored. Preoperative laboratory data, which included a fistula test, ENG, CT scan of the temporal bones, and an ABR, were all within normal limits. An overt fistula was found in only one of the patients. Only an exploratory tympanotomy can arrest and possibly reverse a unilateral hearing loss or discontinue a middle ear-cranial cavity communication. It is therefore our feeling that, in patients with an appropriate history, the potential benefit outweighs the risk and morbidity of an exploratory tympanotomy.

Transantral revision of recurrent maxillary and ethmoidal disease following functional intranasal surgery.

Recurring disease in the maxillary sinus, despite inferior meatal antrostomies, has led to the widespread use of middle meatal antrostomy or simple decompression of the natural ostium of the middle meatus in attempts to restore function to the maxillary sinus. We have reported recurrent disease in the maxillary sinus in patients with stage III or stage IV hyperplastic rhinosinusitis in whom attempts at functional surgery of the middle meatus were unsuccessful in reversal of retrograde changes. One hundred patients who had previously undergone intranasal sphenoethmoidectomy with removal of the middle turbinate, decompression of the maxillary ostium, and removal of overt hyperplastic disease of the middle meatus underwent revision transantral ethmoidectomy. All recurrent or residual diseased mucosa was removed, including polyps, occasional mucoceles, and hyperplastic changes that occurred despite patency of a middle meatal maxillary ostium. In many of these patients the maxillary sinus was widely marsupialized secondarily into the posterior nasal vault. While the initial overall polyp recurrence rate after intranasal sphenoethmoidectomy in these patients was as high as 19.2%, the rate of polyp recurrence after transantral revision was less than 5% in from 18 to 48 months postoperatively. The experience in this series suggests that mucosal changes have played a primary role in unsuccessful treatment, independent of whether or not adequate functional egress for maxillary secretion, drainage, or ventilation has been created or restored.(ABSTRACT TRUNCATED AT 250 WORDS)

Palatal extension of middle meatal antrostomy.

The palatine bone is an important posterior landmark in the performance of ethmoidectomy. This usually unrecognized structure forms the posterior one third of the lateral nasal wall. Resection of a portion of the palatine bone completes the marsupialization of the sphenoethmoidal recess and medial maxilla. It is a major landmark for localization of the sphenopalatine artery at its entrance into the nose. Middle meatal antrostomy is enhanced by removal of the part of the palatine bone that forms the posterior medial wall of the maxillary sinus. In 1110 consecutive sphenoethmoidectomies, marsupialization of the maxillary sinuses has included partial removal of the perpendicular plate of the palatine bone. Patency has been maintained in all of these antrostomies. Pertinent anatomy and surgical technique are reviewed.

Intranasal sphenoethmoidectomy: an evolution of technique.

Intranasal sphenoethmoidectomy was originally used primarily for the provision of adequate drainage of acute and subacute bacterial sinusitis. However, the spectrum of inflammatory sinus disease has changed dramatically since the popularization of broad-spectrum antibiotics, and chronic hyperplastic rhinosinusitis has replaced acute sinusitis as the primary indication for ethmoidectomy. In such cases total or almost total disease removal is crucial to providing long-term drainage and ventilation. We describe several modifications of the Yankauer sphenoethmoidectomy technique that enable the sinus surgeon to provide clearance of disease and excellent drainage for all sinuses by complete marsupialization of the sphenoid, ethmoid, and maxillary sinuses. These modifications include (1) complete rather than partial removal of the middle turbinate, (2) extended middle meatal antrostomy with palatine bone resection to the pterygoid process with delineation of the inferior and medial orbital wall, and (3) introduction of operative endoscopes as adjunctive tools in areas inaccessible to conventional visualization. The current technique and results in nearly 2000 procedures are described.

The surgical management of advanced malignancies of the parotid gland.

Advanced malignancies of the parotid gland frequently invade the parapharyngeal space and the infratemporal fossa. The majority of these lesions have not been cured by surgery and/or radiotherapy, and palliation or cure can only be achieved by en bloc resection of this region. Stylohamular dissection is a systematic method for en bloc resection of the infratemporal fossa and lateral skull base. From January 1980 until December 1987, 18 patients with advanced parotid malignancies underwent stylohamular dissection. Pathologic examination revealed the following diagnosis: adenocarcinoma (7), squamous cell carcinoma (5), high-grade mucoepidermoid carcinoma (2), metastatic adenocarcinoma (1), fibrosarcoma (1), malignant hemangiopericytoma (1), and melanoma (1). Nine patients in this series are alive after a mean follow-up period of 3.5 years (range 1 to 9 years). Three patients are dead of uncontrolled local disease and three of distant metastasis. Three patients died of unrelated causes. All patients except the three who had uncontrolled disease experienced marked palliation from their pain, trismus, and unmanageable ulcerative lesions after surgery. The operative morbidity was relatively low.