Pulmonary lymphangitic carcinomatosis from hypopharyngeal adenosquamous carcinoma.

Although pulmonary lymphangitic carcinomatosis (PLC) is not uncommon for breast, bronchial, and stomach cancers, it is rarely associated with head and neck malignancy. A case of PLC is reported with the primary lesion being an adenosquamous carcinoma of the hypopharynx. A literature review is discussed, highlighting the varied radiographic picture of PLC, the possible diagnostic modalities, the proposed pathogenesis, and the treatment options. The prognosis even if antemortum diagnosis and treatment are given remains fatal, although with temporary improved quality of life and lengthened survival. There is hope that with greater awareness of the disease process an increased incidence of diagnosis may allow progress to be made in therapeutic interventions.

Squamous cell carcinoma with positive margins. Surgery and postoperative irradiation.

The charts of patients treated surgically for squamous cell carcinoma of the head and neck were reviewed retrospectively to correlate the pathologic report of the adequacy of margins with subsequent treatment and eventual outcome. Three hundred forty-nine patients were studied. Thirty-one patients (8.8%) had positive margins. Positive margins were most commonly encountered in patients with tonsillar and hypopharyngeal lesions. Twenty-nine (94%) of the patients had stage III or IV disease. Two patients (6.4%) remain free of disease 36 months or longer following surgery. Radiation therapy was administered postoperatively to 25 patients. Sixty percent of these patients failed to achieve local-regional control, and 84% are dead of disease. When free margins of resection cannot be obtained due to anatomic limitation, postoperative radiation therapy has been unsatisfactory in our hands. Alternative treatment, such as radiation implants or chemotherapy, would appear to offer the only hope of improving the chances for long-term survival.

Dematiaceous fungal sinusitis.

Six cases of dematiaceous fungal sinusitis are reported, together with a review of 33 other cases collated from a review of the English literature. The sinusitis was more often unilateral vs. bilateral. A characteristic serpiginous hyperdense intrasinus opacification, as well as sinus expansion with bone erosion, was often seen on CT scan. MRI scan showed lucent sinus cavities on T1 and T2 weighting. A comparison of surgical treatment vs. surgery with systemic antifungal therapy revealed decreased recurrence and complication statistics in the combined therapy group. There was a trend toward increased recurrence/persistence and complications associated with invasive histologic findings and only surgical treatment, but not statistically significant. At the present time, we recommend comprehensive surgical treatment followed by systemic antifungal therapy, though clinical judgment and individualization should occur. Future studies are planned to further define the disease entity and its therapy.

Analysis of the cocaine metabolite in the urine of patients and physicians during clinical use.

Cocaine is considered a superb anesthetic for many otolaryngologic procedures and has been shown to be positive in the urine of patients for up to 72 hours after surgery with a standard radioimmunoassay test. The standard cutoff for drug screening of benzoylecgonine, the main urine metabolite of cocaine, has been 300 ng/ml. However, the new threshold value in many laboratories is now 150 ng/ml. In review of the literature, no study has been performed that quantitates the actual level of the urine cocaine metabolite after a routine otolaryngologic procedure in both physicians and their patients with the gold standard for urine testing, gas chromatography. This study documents the quantitative level of the urine cocaine metabolite in patients and reveals that there are metabolite levels present in physicians during a single exposure, although they are below the current cutoff level that will be picked up on current screening assays. Evidence has also been presented demonstrating a cumulative effect on the benzoylecgonine levels in physicians who clinically use cocaine anesthesia more frequently; these levels can be above the cutoff level on current screening assays.

Composite resection reconstruction: split-thickness skin graft--a preferred option.

In dealing with reconstruction of the oral cavity postcomposite resection, many options are available. Maximization of function with minimization of complications, physiologic sequelae, and cost must be considered. Fifty consecutive patients who underwent composite resections and were reconstructed by split-thickness skin grafts were analyzed. Factors examined included: number of blood units transfused, disease status vs. stage, length of hospital stay, complications, use of prosthetic devices for aiding in swallowing and speech production, and patient diet at discharge. This evaluation and literature review revealed that the amount of tissue resection was considered to be the most significant functional determinant, followed by maintenance of residual tissue mobility. The use of a split-thickness skin graft was believed to give excellent results for the previously mentioned parameters and is our preferred method for reconstruction of composite resection defects that do not require tissue bulk as in anterior mandible defects, anticipated mandible reconstruction, total or near-total glossectomy, or very massive defects.

KTP laser excision of a soft palate squamous cell carcinoma: a case report.

Squamous cell carcinoma of the soft palate is an infrequently seen tumor of the oral cavity. The use of the KTP laser in the treatment of a 52-year-old man with a T2N0M0 soft palate carcinoma is reported. The natural history and treatment of this entity is reviewed. The application of tumor thickness as related to therapy of the neck and prognosis is commented on. Use of the KTP laser for resection of oral cavity lesions is felt to be a technological improvement beneficial to both patients and practitioners.