Base of tongue salivary gland tumors.

Salivary tumors of the base of the tongue are encountered infrequently. A retrospective review of medical records from 1955 to 1985 was undertaken to determine the incidence of occurrence and to assess the outcome of the therapy provided. One hundred seventy-eight minor salivary gland tumors of the oral cavity and oropharynx were identified, of which 22 (13%) were located in the tongue base. All were malignant. The most common histologic type was mucoepidermoid carcinoma (10 patients), followed by adenocarcinoma (6 patients), and adenoid cystic carcinoma (6 patients). Thirteen patients were available for a mean follow-up of 5 years. Treatment was most often a combination of wide resection combined with postoperative radiation therapy. Ten patients (77%) are alive, one with persistent disease 8 years after diagnosis. Three patients died within 2 years of diagnosis, one with intercurrent disease. Improved control of disease in this series, when compared to previously reported series, is attributed to adequate surgical therapy and adjuvant radiotherapy. The deaths in our series occurred in patients who were unable to proceed with the recommended therapy. These unusual lesions require aggressive multimodality treatment for improved survival.

Abscess of the sphenoid sinus after transsphenoidal surgery.

A case of a bacterial abscess developing in the sphenoid sinus 2 weeks after transsphenoidal surgery is presented. Although abscesses within the sella turcica have been reported as rare complications of transsphenoidal surgery, this is the first reported case of the postoperative formation of an abscess of the sphenoid sinus. The patient sought treatment for severe headaches, nausea and vomiting, and marked temperature elevation. A computed tomographic scan demonstrated soft tissue and air within the sphenoid sinus. A regimen of stress doses of hydrocortisone and antibiotics was prescribed, and the patient underwent transsphenoidal drainage of the sphenoid sinus. The sella turcica was not involved. Anaerobic cultures were positive for Fusobacterium necrophorum.

A new method to predict safe resection of the internal carotid artery.

A patent internal carotid artery (ICA) is essential in most patients. Management of skull base lesions often requires translocation, balloon embolization, or resection of this vessel. Preoperative tests to assess the availability of collateral flow have not been uniformly accurate. A new test that significantly increases the safety of surgical removal of the ICA is described. One hundred thirty-six patients were studied with temporary balloon occlusion (TBO) of the ICA and determination of stable xenon-enhanced computed tomography cerebral blood flow (Xe/CT CBF) measurements. Eleven patients failed TBO and were determined to be at very high risk of stroke with loss of the ICA. Ninety-six of the patients were predicted to be at minimal risk with permanent loss of the ICA by Xe/CT CBF studies. Twenty-one patients in this group had either permanent balloon occlusion (PBO) or surgical resection of the ICA with no permanent neurologic sequelae. Our studies show that the combination of preoperative TBO and Xe/CT CBF studies significantly increases the safety of ICA resection.

Elective resection of the internal carotid artery without reconstruction.

Curability of skull base tumors is related to the ability to achieve a complete resection. Resection of the internal carotid artery with the tumor puts the patient at risk for catastrophic cerebral injury. Autogenous vein grafting is not always technically or physiologically possible. We present eight patients with tumors eroding the cranial base who underwent safe resection or occlusion of the internal carotid artery as predicted by three tests: 1. carotid arteriography, 2. temporary balloon occlusion of the internal carotid artery, and 3. xenon computerized tomography cerebral blood flow mapping. No patient suffered permanent central nervous system injury.

Hypopharyngeal reconstruction: a comparison of two alternatives.

Gastric pull-up or free jejunal interposition was used for reconstruction after total laryngopharyngectomy in 31 patients. Complications and functional outcomes of the two methods are compared. Primary swallowing was achieved in 86% of patients after gastric pull-up and in 82% of patients after jejunal interposition. Patients who underwent jejunal interposition were able to swallow sooner and had a shorter hospital stay than patients who underwent gastric pull-up. Esophageal tumor recurrence after jejunal interposition was not observed. Hepatic failure occurred in two gastric pull-up patients, leading to perioperative death in one. Flap necrosis occurred in two jejunal interposition patients and one gastric pull-up patient. Two additional fistulas occurred in jejunal interposition patients as a result of microvascular complications. Stricture developed in four jejunal interposition patients, requiring revision surgery in two. Minor complications were more common in the gastric pull-up group. Long-term speech and swallowing function are compared. Our current choice of jejunal interposition or gastric pull-up for reconstruction after total laryngopharyngectomy primarily depends on the location of the tumor.

Neutropenic enterocolitis. A new complication of head and neck cancer chemotherapy.

Neutropenic enterocolitis is a recognized complication of immunosuppression or chemotherapy for leukemia. It presents as severe abdominal pain and tenderness, fever, and diarrhea associated with granulocytopenia. Gastrointestinal symptoms associated with chemotherapy for head and neck neoplasms include nausea and emesis, but not acute abdominal distress. We present, to our knowledge, the first case of neutropenic enterocolitis in a patient receiving cisplatin and fluorouracil chemotherapy for metastatic head and neck cancer.

Auricular injury as a presentation of child abuse.

Child abuse causes serious physical and emotional injury. Those abused, however, are usually unable or unwilling to gain access to agencies that might help them. The otolaryngologist, while usually not the patient's primary physician, may be in the position to detect child abuse. We describe a 3-year-old boy who sustained auricular trauma as the result of child abuse. The importance of physician recognition of an abuse case and the institution of appropriate measures are discussed.

Reconstruction of the cervical esophagus: free jejunal transfer versus gastric pull-up.

Use of enteric grafts is a popular method for reconstruction of the cervical esophagus and hypopharynx. Free jejunal transfer (FJT) and gastric pull-up (GP) are the most popular methods used. This discussion is a retrospective review of our experience with 50 cases of free jejunal transfer and 15 cases of gastric pull-up. The graft survival rate was 94 percent (47 of 50) for free jejunal transfer and 87 percent (13 of 15) for gastric pull-up. Successful swallowing was achieved in 88 percent (44 of 50) of free jejunal transfers and 87 percent (13 of 15) of gastric pull-ups. Patients with free jejunal transfers were able to swallow and leave the hospital sooner: 10.6 versus 16.0 days and 22.3 versus 29.0 days, respectively. Fistulas occurred in 16 percent (8 of 50) of free jejunal transfers, most of which (6 of 8) healed spontaneously. Fistulas occurred in 20 percent (3 of 15) of gastric pull-ups, only one of which healed spontaneously. Stricture was the most common late complication for free jejunal transfers, 22 percent (11 of 50), whereas reflux was most common in gastric pull-ups, 20 percent (3 of 15). In patients with advanced cancer, extensive esophageal resection into the chest is often required, and gastric pull-up seems to be an easier and more direct form of reconstruction. In limited resection of the hypopharynx and esophagus, especially with proximal lesions, free jejunal transfer is simpler and avoids mediastinal dissection. This concept as well as other advantages and disadvantages of both techniques will be discussed.

Jejunal interposition for repair of stricture or fistula after laryngectomy.

Complications following total laryngectomy may include pharyngocutaneous fistula or pharyngeal stricture. Traditional techniques of repair of fistula and stricture with local or regional flaps lead to a high rate of failure. In this study, we report 18 patients treated by secondary jejunal interposition (JI) to rehabilitate swallowing following recalcitrant postlaryngectomy stricture or fistula. All patients had undergone total laryngectomy with or without partial pharyngectomy for treatment of squamous cell carcinoma of the larynx (8) or hypopharynx (10). Four were stage II; 5, stage III; and 9, stage IV. Thirteen patients (72%) regained swallowing function. Complications of secondary JI included perioperative death (2), flap loss (1), and persistent fistulas (3). Jejunal interposition may be the best modality in the rehabilitation of swallowing in patients with persistent fistula or stricture that fails to respond to traditional management.

Nasopharyngeal teratoma involving the temporal bone.

Teratoma is the most common nasopharyngeal tumor in neonates. The tumor is usually limited to the oropharynx and is manifest by stridor and respiratory distress. Complete excision affects a cure. An unusual case of nasopharyngeal teratoma extending into the temporal bone, causing facial paralysis and conductive hearing loss, in addition to stridor, is presented. Stridor was relieved by transoral partial excision shortly after birth. Complete removal of the tumor by way of a subtemporal and infratemporal fossa approach was performed at 14 months of age. The defect was filled with a rectus abdominis muscle graft with microvascular anastomoses. The facial nerve was reconstructed secondarily with a sural nerve graft. The patient has no recurrence tumor and has good facial function at 30 months. This case demonstrates the first known case of facial paralysis due to nasopharyngeal teratoma. The surgical approach for tumor removal: lateral infratemporal fossa dissection, and the method of reconstruction: free rectus abdominis muscle flap with microvascular anastomoses, had so far not been described in a patient this young.

Analysis of fat-soluble vitamins. XXIX. Liquid chromatographic determination of vitamin D in AD concentrates: collaborative study.

A simplified liquid chromatographic (LC) method for determining vitamin D in vitamin AD concentrates (greater than or equal to 5000 IU vitamin D/g) was collaboratively studied. In the simplified method, the 2 columns specified in AOAC LC method 43.101-43.109 are replaced by a single column, which separates the vitamin D isomers and the vitamin A esters. The procedure for oils includes dissolution and quantitation by normal phase LC. Dry multivitamin concentrates and aqueous dispersions are treated with an enzyme system and the vitamins are extracted with n-pentane. Six coded samples were distributed to 16 laboratories; 15 collaborators returned their results. Estimates of repeatability and reproducibility for the oil samples were 1.1 and 3.1%, respectively; for the high-level concentrated dry preparation 1.4 and 3.9% and for the low-level concentrated dry preparation 1.3 and 11.4%, respectively. These values are a considerable improvement over the results obtained in the 1979 multivitamin collaborative study. The method has been adopted official first action for determination of vitamin D in vitamin AD concentrates containing greater than or equal to 5000 IU vitamin D/g.

Analysis of fat-soluble vitamins. XXVII. High performance liquid chromatographic and gas-liquid chromatographic determination of vitamin D in fortified milk and milk powder: collaborative study.

A collaborative study of the high performance liquid chromatographic (HPLC) method for vitamin D in fortified milkpowder (skimmed and whole milk) and a milkpowder preparation was carried out on 182 samples distributed to 26 laboratories. Thirteen laboratories submitted results. The level of vitamin D was 2-7 IU vitamin D3/g milkpowder. All samples also contained vitamin A. Three laboratories were excluded from the statistical evaluation because of incomplete results or deviation from the analytical procedure. Other laboratories reported acceptable results. At the same time, 63 samples were distributed to 9 laboratories which used a gas-liquid chromatographic method for determining vitamin D in milkpowder. Only one laboratory reported results. The HPLC method has been adopted official first action.

Analysis of fat-soluble vitamins. XXII. High performance liquid chromatographic determination of vitamin D in concentrates. Collaborative study.

A collaborative study was carried out which compared the official chemical method (43.B14-43.B24), the HPLC method according to Hofsass et al. including maleic anhydride treatment, and the HLPC procedure according to De Vries et al. for vitamin D concentrates. A total of 396 samples were distributed to 33 collaborators for analysis. Five laboratories performed both the chemical and the HPLC methods. Five laboratories performed the Hofsass method and 16 laboratories performed the De Vries method. The results for the chemical method agreed with the theoretical values for the samples, and the standard deviation was comparable to that obtained in previous AOAC collaborative studies. Collaborative results for the Hofsass method were low. In addition, incorrect use of a fixed conversion factor (1/0.586) and necessity of a double chromatogrpahic system on a non-treated and a treated vitamin D sample reduce the effectiveness of the method. There were no adverse reactions to the DE Vries HPLC method. It is recommended that the method be adopted official first action as an alternative procedure for determining vitamin D in concentrates, excluding powders containing irradiated 7-dehydrocholesterol.

Analysis of fat-soluble vitamins. XXIV. High performance liquid chromatographic determination of vitamin D in vitamin D resin containing powders: collaborative study.

Further study of vitamin D methodology solved the discrepancy between the AOAC chemical method, 43.068-43.078, and the HPLC assay for vitamin D3 in resin containing dry powders. The discrepancy is caused by the difference in solubility of the vitamin D3 resin in benzene and in pentane. The method has been modified accordingly, and has been adopted official first action for vitamin D3 resins and vitamin D3 resin containing powders and aqueous dispersions.

Analysis of fat-soluble vitamins. XXV. High performance liquid chromatographic determination of vitamin D in multivitamin preparations: collaborative study.

The HPLC method for determining vitamin D in multivitamin preparations was studied collaboratively. Samples were distributed to 43 laboratories in 10 countries. Twenty-four laboratories gave their results. The method specifies a reverse phase system for the cleanup and a straight phase system for the determination. Difficulties arise when laboratories are equipped with HPLC apparatus with a single column. Laboratories experienced in vitamin D analysis reported good results, even if they were equipped with a single column HPLC apparatus. Eleven of the 24 laboratories reported satisfactory results. For this rather complicated method, the coefficient of variation for a single assay is acceptable. The method has been adopted official first action as an alternative procedure to the chemical method for determining vitamin D in multivitamins.

Growth and transmission of gut bacteria in the Western flower thrips, Frankliniella occidentalis.

The Western flower thrips (Frankliniella occidentalis), a polyphagous insect with global distribution, has a permanent association with a near Erwinia species TAC bacterium in its hindgut. Since this bacterium is able to grow outside the thrips, it is a facultative symbiont that is not completely dependent on the host. In this study we address the question of how the association is maintained and how bacteria are transmitted to newly hatched thrips larvae. Bacteria are passed on to new thrips via the food source. No evidence was found for vertical transmission from mother to offspring via the egg. Gut bacteria show unlimited growth during the larval (feeding) stages, and in the second instar stage 100% of the larvae become infected with high numbers of bacteria. In the prepupal and pupal stage, the number of bacteria declines, but increases again during the adult phase. A method to rear aposymbiotic (bacteria-free) thrips is described which enables studies on the impact of bacteria on the fitness of thrips.

Analysis of fat-soluble vitamins. XXVIII. High performance liquid chromatographic determination of vitamin D in pet foods and feeds: collaborative study.

A high performance liquid chromatographic (HPLC) method for vitamin D in pet foods and feeds at low concentrations (2-8 IU/g = 50-200 ppb) was studied collaboratively. The procedure consists of the following purification steps: saponification, extraction of the unsaponifiable fraction, chromatography on alumina, cleanup on reverse phase HPLC, and quantitation with straight phase HPLC. The original method, developed by Knapstein, was simplified by deleting the quantitative TLC step. Six coded samples were distributed to 31 laboratories, along with a known sample containing 15 IU/g to allow practice of the rather complicated procedure. Eighteen collaborators returned their results. Results for the spiked samples show good recovery. The estimates of repeatability and reproducibility are 0.96 and 2.2 IU/g for spiked samples and 1.5 and 3.1 IU/g for commercial samples, respectively, which are considered acceptable for these low concentrations. The method has been adopted official first action.