A new external approach to the pterygomaxillary fossa and parapharyngeal space.

A new direct approach to the area of the pterygomaxillary fossa and the parapharyngeal space is described. This procedure was developed because previously described methods either offered limited access to the area or resulted in significant functional defects. The approach described here results in a wide-field exposure of both the pterygomaxillary and parapharyngeal spaces with no sacrifice of either mandibular function or the sensory supply of the face or oral cavity. The parapharyngeal space is entered through a transcervical incision. This, combined with double osteotomies of the mandible, allows the ascending ramus with its intact neurovascular bundle to be reflected laterally and superiorly, along with the attached masseter muscle and the overlying skin. The result is an excellent exposure of the pterygomaxillary fossa and the base of skull. Following removal of the tumor, the ramus of the mandible is replaced and fixed with interosseous wiring and the application of arch bars, thus restoring normal dental occlusion. The technique described here was worked out on cadaveric dissection before being applied to a clinical case.

Laryngectomee study: clinical and radiologic correlates of esophageal voice.

This study reports the results of an analysis of the relationship between clinical and radiologic factors, on the one hand, and the acquisition of esophageal speech, on the other. It involved 25 laryngectomees who underwent videofluoroscopy of their pseudoglottis at least 6 months following laryngectomy. Significant correlations were found between esophageal speech performance and each of the following variables: tumor size, pseudoglottis length, pseudoglottis shape, and presence of a geometric prominence on the posterior hypopharyngeal wall. The most important is the logarithmic correlation between speech skill and pseudoglottis length. Other factors that yielded controversial results in previous studies were not found significant in this investigation.

Halitosis.

Bad breath, halitosis, is an unpleasant problem most people try to avoid. Physicians seem particularly adept at avoiding halitosis by referring patients with this problem to a dentist. However, halitosis may be a symptom of a serious disease. Even if a serious disorder is not present, the cause of bad breath can usually be determined and appropriate therapy given. In this article the causes of halitosis and suggestions for treatment are outlined.

A conceptual approach to learning and organizing the surgical anatomy of the skull base.

The surgical anatomy of the skull base is often considered to be complicated. In order to devise a system for organizing the various anatomical relationships into a learnable package, 20 skull base dissections were performed on preserved specimens. The findings from the dissections indicate that it is possible to organize the relationships into a three-dimensional set of coordinates that interrelates nearly all the important structures of the parapharyngeal area of the skull base. This system consists of three vertical and three horizontal planes. It uses the temporomandibular joint (TMJ) as a landmark and as an access pathway to the system. Additionally the findings from the dissections indicate that the classical concept of the parapharyngeal space is not accurate when applied to the skull base.

Pneumocephalus in frontal sinus osteoma: a case report.

Osteomas are the most commonly encountered neoplasms of the frontal sinus. Extension of these lesions through the posterior table can result in life-threatening complications. We present the case of a 70-year-old man with yellow nail syndrome who complained of persistent rhinorrhea and the sensation of "sloshing" when moving his head. Radiographic investigation revealed a frontal mucocele that had extended to a dramatic intracerebral pneumatocele. This occurred secondary to a frontal sinus osteoma that had been incidentally noted seven years earlier. Surgical exploration via an osteoplastic flap approach allowed us to excise both the osteoma and the associated pneumatomucocele. The resulting dural defect was resurfaced using a flap of pericranium to facilitate anterior cranialization. The features of this interesting case are discussed as an illustration of the potential complications of frontal sinus osteomas. The literature is reviewed regarding management of these lesions and their complications.

Malignant fibrous histiocytomas of the head and neck.

Fibrous histiocytomas are soft tissue neoplasms of histiocytic origin showing partial fibroblastic and histiocytic differentiation. The histopathology of these tumors and their nomenclature are discussed. A case of primary intraosseous malignant fibrous histiocytoma of the mandible is presented and added to the previously reported nine cases. One hundred and ten cases of fibrous histiocytoma are reviewed, a rapidly increasing number of reported cases in the deep tissues of the head and neck region. No definite reliable histologic criteria have been found to predict the true malignant lesions. Malignant fibrous histiocytomas show the most aggressive behavior in the head and neck region with a metastatic rate of 30-42%. Aggressive surgery remains the treatment of choice with a five year survival rate of approximately 60%, chemotherapy and radiotherapy being used as adjunctive treatment.

Hemangiopericytoma of the temporal bone.

Hemangiopericytomas are uncommon soft tissue tumors. While their occurrence in sinuses and soft tissues around the ear is well documented, there are no reports of primary involvement of the temporal bone. This article discusses the case of a 21 year old patient who had a right temporal angioblastic meningioma resected and presented two years later with a hemangiopericytoma that extensively involved the right temporal bone and external auditory canal. In review, the "meningioma" had the same histological features as the auditory tumor and it was evident that both lesions resulted from the growth of a hemangiopericytoma arising from the intracranial aspect of the temporal bone. Electron microscopic examination of the tumor proved useful in making the diagnosis and in evaluating the cytological features that influence prognosis and treatment. Temporal bone involvement was a major problem and the opportunity is taken to document this rare occurrence and to discuss the biological behavior, pathological characteristics, and differential diagnosis of these neoplasms.

Intranasal presentation of a pituitary adenoma.

Unilateral intranasal polypoidal lesions should always arouse suspicion of unusual pathology. A case of an intranasal extension of a pituitary adenoma is presented. Fourteen other cases that have been reported in the literature are summarized and modalities of treatment of this entity are briefly discussed.

Extrinsic civilian trauma to the larynx and cervical trachea--important predictors of long-term morbidity.

Injuries to the larynx and cervical trachea are uncommon, making the development of treatment protocols and subsequent data analysis in any one hospital difficult. This prompted a review of our experience with emphasis on variables related to long-term morbidity. The records of 20 patients with laryngotracheal injuries seen at the Montreal General Hospital from January 1974 to December 1984 were reviewed. The majority were young males (18 to 20 years old), and there was blunt trauma in 14 and penetrating trauma in six. The level of injury was laryngeal in 16 and tracheal in four. There were no airway-related deaths. One patient died with uncontrollable retroperitoneal hemorrhage before definitive repair of the tracheal transection. All but two of the remaining 19 patients had significant morbidity in the form of aphonia, dysphonia, or airway stenosis. The major factors contributing to the high morbidity were delay in diagnosis, anatomic level of injury, and associated multisystem trauma. A high index of suspicion, liberal use of fiberoptic bronchoscopy for diagnosis, and early airway control will lead to earlier diagnosis. Computerized tomography of the upper airway facilitates definitive surgical repair. Long-term followup is essential. Laryngeal trauma remains a major challenge.

Caring for head and neck oncology patients. Does social support lead to better quality of life?

OBJECTIVE: To determine whether social support contributes to better quality of life and psychological state of head and neck oncology patients. DESIGN: A structured questionnaire, administered orally to patients face-to-face, with specific questions about demographic and medical information and social support and two standardized scales; a cancer-specific quality of life scale and a depression scale. SETTING: Head and Neck Oncology Clinic, an institutional referral centre providing ambulatory care at the Camp Hill Medical Centre in Halifax, NS. PARTICIPANTS: Forty-five head and neck oncology patients (33 men, 12 women) who came for follow-up appointments at the clinic. One person did not complete the interview. Fifty patients were approached, but five were not included: one died before the interview, and four agreed to participate but were prevented by transportation or timing problems. MAIN OUTCOME MEASURES: Scores on the Functional Living Index-Cancer Scale and the Center for Epidemiologic Studies Depression scale. RESULTS: Four main factors predicted quality of life: satisfaction with family physician support, severity of cancer, sex of patient, and type of cancer. Three important predictors of psychological state were loss of appetite, family physician support, and sex of patient. CONCLUSION: Social support, particularly from family physicians, contributes greatly to better quality of life and psychological state for head and neck oncology patients.

An anatomic and CT scan study of the lateral wall of the sphenoid sinus as related to the transnasal transethmoid endoscopic approach.

Interest in endoscopic sinus surgery has expanded to include the sphenoid sinus. While the transnasal transethmoid approach is an established route to the sphenoid sinus, instrumentation is brought close to the lateral wall. This study organizes the lateral wall of the sphenoid sinus into three distinct areas. Fifteen fixed cadaver specimens, 15 fresh specimens and 25 axial as well as coronal CT scans are used to examine each area of the lateral wall. The orbital apex, spongy vascular tissue of the cavernous sinus and the internal carotid artery are found in tandem sequence adjacent to the lateral wall of the sphenoid sinus. A highly pneumatized sphenoid sinus may attenuate the bone over the lateral wall placing the optic nerve and carotid artery at greater risk. Anatomic variations, as examined in this study, and limitations imposed by endoscopic vision via the transnasal transethmoid approach dictates a need to understand the anatomy as well as familiarity with endoscopic surgery. Axial CT scans of the sphenoid sinus can image anatomic variations which may compromise safety of the lateral sphenoid sinus wall.

Undifferentiated carcinoma with lymphoid stroma of the parotid gland.

Six cases of undifferentiated carcinoma of the parotid gland with heavy lymphocytic infiltration have been treated at Montreal General Hospital over the past 23 years. A thorough review of the literature revealed another 31 similar cases which are discussed. For unknown reasons, these malignant tumors seem to be more common in North American Inuit. Their relatively better prognosis may be attributed to the protective function of the heavy lymphocytic infiltration. Surgery has been the treatment of choice with postoperative radiotherapy in indicated cases. Longer follow-up is necessary to assess the role of lymphocytic infiltration in improving survival.