Surgical management of pulmonary carcinoma secondary to recurrent respiratory papillomatosis.

Recurrent respiratory papillomatosis is a rare, but acknowledged, risk factor for pulmonary squamous cell carcinoma. Although previous reports suggest a poor prognosis for lung cancer associated with papillomatosis, we have successfully treated 1 such patient, who presented with three synchronous pulmonary malignancies, using parenchyma-sparing resection techniques.

Analysis of disability resulting from treatment including radical neck dissection or modified neck dissection.

A multiinstitutional study to define the impact of total treatment programs involving radical neck dissection (RND) and modified neck dissection (MND) on patients' permanent disability was undertaken. A total of 243 patient responses were included in the study. Comparative analyses between the treatment groups show no advantage of one surgical operation over the other in returning patients to their pretreatment employment status. Radiation therapy was identified as adding significantly to the patient's permanent disability.

The efferent supply of the trapezius muscle: a neuroanatomic basis for the preservation of shoulder function during neck dissection.

The hypothesis that there is an alternative motor input to the trapezius muscle through cervical spinal nerves is evaluated through a review of the literature and through experimental studies performed by the author. Electrophysiologic testing of the spinal accessory nerve and of the ventral rami of the cervical spinal nerves was performed in cats and humans. These studies indicated that motor potentials recorded in the trapezius muscle after stimulation of the ventral rami of cervical spinal nerves in general represented the spread of current to the contiguous portions of the spinal accessory nerve or directly to the trapezius muscle. Rarely did there seem to be evidence of motor innervation to the upper and lower trapezius by fibers conveyed by the ventral rami of cervical spinal nerves. The predominant motor input to the trapezius muscle is through the spinal accessory nerve. Subjective evaluation, objective strength testing, and electromyographic evaluation were performed on patients who had undergone neck dissections. Three types of neck dissection were employed. These were modified neck dissection with preservation of the spinal accessory nerve, radical neck dissection with sacrifice of the spinal accessory nerve, and reconstruction using a cable graft and classical radical neck dissection. Regarding all of the methods of evaluation and comparison, the patients who retained function of the spinal accessory nerve in the postoperative period fared better than those who had a classical radical neck dissection with sacrifice of the spinal accessory nerve. This again supports the concept that the most important and predominant motor supply to the trapezius muscle is through the spinal accessory nerve. All of this information was used to construct a model of the spinal portion of the accessory nerve and of the innervation of the trapezius muscle. The clinical implications of this model are stated.

Modified supraglottic laryngectomy and resection of lesions of the base of tongue.

Extensive malignant tumors involving the base of tongue and adjacent pharyngeal walls usually require surgical resection combined with radiation therapy and sometimes chemotherapy. Often it is elected to perform a concomitant laryngectomy to prevent chronic aspiration, but not because of tumor extension to the larynx. A new technique allowing preservation of glottic function is described. This involved preservation of the false vocal folds and their surgical closure. The interarytenoid mucosa is preserved. This provides a fistula with a sphincteric function in the interarytenoid area. A permanent tracheostoma is created. This procedure has been used in the treatment of eight patients from April of 1979 to April of 1982. One patient died of sepsis in the early postoperative period. Of the seven evaluable patients, only one experienced significant aspiration postoperatively. All patients achieved adequate phonation. Four patients developed good speech. The remaining three patients have some speech, but are limited in their articulation because of resection of a significant portion of the oral tongue. Three patients are alive and have developed a recurrence. Two patients are alive with recurrent disease and two patients died of their disease. This procedure appears to allow adequate surgical resection of extensive oropharyngeal neoplasms with preservation of the laryngeal functions of phonation and protection of the lower tracheal-bronchial tree.

Cranial neuropathies in sinus disease.

To study the problem of cranial neuropathies in sinus disease the inpatient experience at the University of California, San Francisco, and San Francisco General Hospitals was reviewed. The incidence of cranial nerve involvement in acute and chronic sinus inflammations was low (8 percent and 4 percent respectively). The incidence in neoplastic disease of the sinuses was considerably higher (32 percent). Cranial neuropathies occurred in inflammatory disease more frequently when associated with mucopyocele, mucormycosis, and orbital cellulitis. In both inflammatory and neoplastic disease, when cranial nerve deficits occurred, there was a high predelication for sphenoid sinus involvement. Several instructive case histories are included. The important anatomy of the cavernous sinus region and of the orbital apex as it pertains to this problem is discussed.

Apneic anesthesia with intermittent ventilation for microsurgery of the upper airway.

Apneic anesthesia with intermittent ventilation (AAIV) has been used in 250 procedures on the larynx and trachea at Indiana University Medical Center since October 1989. Initially employed for laryngeal papilloma removal in children, this anesthetic technique is now used for other procedures and in adult patients. The advantages of AAIV include improved visualization of the airway, absence of combustible material, and lack of vocal cord motion during surgery. No significant complications have occurred with AAIV. The high degree of safety for this anesthetic technique relates largely to the constant monitoring of oxygen saturation using pulse oximetry and the periodic measurement of end-tidal carbon dioxide (CO2) levels. Contraindications to AAIV are age less than 2 years, significant cardiopulmonary disease, and any hypermetabolic state. Relevant pulmonary physiology includes the unique aspects of oxygen and CO2 metabolism in children.

Resorbable fixation plates in head and neck surgery.

A skeletal fixation system employing plates made of polylactic and polyglycolic acid has been employed at Indiana University Medical Center since July 1993 in 105 craniofacial reconstructions, 45 cases of maxillofacial trauma, 10 craniotomy flap repairs, and five cases involving reconstruction of the laryngotrachea. Because these plates eventually resorb, they offer significant theoretical advantages. No inhibition of structural growth should occur when using this system in children. Tissue tolerance of these plates has been excellent. The technical details of using heat to allow reshaping of the plates as well as the methods of fixation of the plates are discussed.

Unusual presentations of lymphoma of the head and neck in childhood.

Lymphoma of the head and neck in children can pose a significant diagnostic problem, especially when histologic analysis indicates non-Hodgkin's lymphoma and the initial site of involvement is extranodal. This report describes 15 pediatric cases of lymphoma seen from 1981 to 1987 with an initial presentation in the head and neck. Cervical lymph nodes represented the initial site of involvement in 10 of the cases. The other five cases presented with disease in the tonsillar fossa; maxillary sinus and mandible; parotid; pharyngeal wall; trachea and thyroid gland; and ethmoid sinus, sphenoid sinus, and anterior fossa. The histologic type was non-Hodgkin's lymphoma in 12 cases and Hodgkin's lymphoma in 3 cases. Our experience has shown that lymphoma of the head and neck in children presents a confusing clinical picture and was initially confused with inflammatory disease, polymorphic reticulosis, and other neoplasms such as rhabdomyosarcoma. In one patient, Epstein-Barr virus infection and an inherited immunodeficiency state probably played a role in the pathogenesis of the lymphoma.

Apneic anesthesia for improved endoscopic removal of laryngeal papillomata.

During a 2-year period at Indiana University Medical Center, nine patients underwent 51 endoscopic procedures employing the technique of apneic anesthesia for removal of papillomata involving the larynx. The apneic anesthesia technique affords improved visualization of the larynx and subglottis because the view is unencumbered by an endotracheal tube. This unencumbered view allows a more thorough removal of diseased tissue, especially in the posterior commissure and subglottis. In addition, the absence of an endotracheal tube reduces the risk of a fire occurring in the upper airway and eliminates the chance of physically disseminating papilloma particles into the lower tracheal-bronchial tree or toward the physician--a problem that is inherent in the intermittent jet ventilation technique. No significant complications related to the use of this technique have been encountered; however, the safety of apneic anesthesia is greatly enhanced by using a pulse oximeter and transcutaneous oxygen monitor to continuously monitor arterial oxygen saturation. Details of the apneic anesthesia technique are described, as are the relevant aspects of pulmonary physiology, which must be clearly understood to safely employ this method.

Cable grafting of the spinal accessory nerve for rehabilitation of shoulder function after radical neck dissection.

From January 1981 through December 1985, 9 patients underwent radical neck dissection with sacrifice of the spinal accessory nerve for removal of metastatic cancer to cervical nodes followed by reconstruction of the spinal accessory nerve utilizing a cable graft from the greater auricular nerve. Shoulder function on the operated side was assessed postoperatively using a subjective questionnaire, objective strength testing, and EMG recordings. The group that had cable grafts of the spinal accessory nerve were compared to a group who had modified radical neck dissection with preservation of the spinal accessory nerve, and to a third group that had classical radical neck dissection with sacrifice of the spinal accessory nerve and no cable graft reconstruction. The group with cable grafts scored in a position intermediate between the modified neck dissection group and the classical radical neck dissection group on subjective and objective testing. Most of the patients with cable grafts demonstrated voluntary motor potentials in the trapezius muscle on postoperative EMG testing. Cable grafting of the spinal accessory nerve sacrificed during radical neck dissection results in improved shoulder function in the postoperative period. Indications and contraindications for the use of this rehabilitative procedure are presented.

Modified neck dissection for metastatic nonseminomatous testicular carcinoma.

OBJECTIVE: To examine the role of neck dissection in the treatment of metastatic stage 3 nonseminomatous germ-cell tumors (NSGCTs) of testicular origin. METHOD: A retrospective review was made of 45 patients with metastatic NSGCT who underwent 48 unilateral and 3 bilateral neck dissections. Only level III-VI nodes were dissected, often with concomitant or staged mediastinal dissection, thoracotomy, and/or retroperitoneal node dissection. Occasionally, resection of the clavicle, jugular vein, or subclavian artery, or a combination of these, was required to eradicate the disease. RESULTS: There were only four instances of recurrence in dissected necks. There was one case of dedifferentiation of mature teratoma to adenocarcinoma Patients who were followed for a mean period of 32 months had a disease-free survival of 72%. Prognosis for patients with stage 3 disease but negative preoperative tumor markers (alpha-fetoprotein and human chorionic gonadotropin) was excellent, with 97% of these patients having no evidence of disease at follow-up. Factors having a negative impact on survival included positive tumor markers, elements of germ-cell cancer in excised nodes, and a neck mass that represents late relapse of disease. CONCLUSION: Modified neck dissection has a demonstrated role in the treatment of metastatic NSGCT. It prevents reversion of mature teratoma to malignant germ cell tumor with minimal morbidity. Aggressive resection of disease is indicated, often in conjunction with thoracic surgery, to eradicate disease extending into the chest. There is an excellent prognosis in patients with negative preoperative serologic tumor markers.

Endoscopic stapled diverticulotomy: treatment of choice for Zenker's diverticulum.

OBJECTIVE: To evaluate the efficacy and safety of endoscopic stapled diverticulotomy in the treatment of patients with Zenker's diverticulum. STUDY DESIGN: Cohort study. METHODS: Fourteen elderly patients (11 men and 3 women) with Zenker's diverticulum were evaluated in a community hospital setting from July 1996 to November 1999. Before surgery patients had significant dysphagia, regurgitation, cough, or aspiration pneumonia. The common septum between the diverticulum and cervical esophagus was visualized with a Weerda diverticuloscope. While using videoendoscopic monitoring, the septum was divided and the edges simultaneously sealed with a linear endoscopic stapler. Average operative time was 31 minutes. RESULTS: The operation was successfully performed in 11 of 14 patients. In the three unsuccessful cases, one patient's pouch was too small to staple and the other two patients had a septum that was difficult to visualize with the diverticuloscope. There was no significant postoperative morbidity or mortality. Patients started a liquid diet on the first postoperative day and resumed a soft diet a week later. They were usually discharged on the first postoperative day. Most patients reported significant improvement with resolution of dysphagia and regurgitation. CONCLUSIONS: Compared with the traditional open technique, the endoscopic stapled diverticulotomy technique is safe, quick, and effective and requires a shorter length of stay in the hospital. Therefore it has become our treatment of choice for elderly, high-risk patients with a large (>2 cm) hypopharyngeal (Zenker's) diverticulum.

Wound complications associated with brachytherapy for primary or salvage treatment of head and neck cancer.

Brachytherapy can be employed in the primary or salvage treatment of head and neck cancer. The advantage of brachytherapy is the stereotactic limitation of radiation exposure to noninvolved tissues. Wound complications associated with brachytherapy have been discussed only sporadically in the literature. This retrospective study examines 28 patients, 20 for initial treatment and eight for salvage, with varying site and stage head and neck cancer treated with brachytherapy in addition to external beam radiation therapy and/or surgery. The overall complication rate was 50% (14/28), with infection and minor flap breakdown being the most common problems. Tumor site in the primary treatment group was the only significant factor in wound complications. In the salvage group complications were minor and primarily related to flap coverage of brachytherapy catheters.

Radiologic percutaneous gastrostomy: results in 56 patients with head and neck cancer.

OBJECTIVE: The establishment of a direct enteral feeding route is critical in the overall treatment of many patients with head and neck cancer. Use of radiologic percutaneous gastrostomy (RPG), the newest technique for gaining enteral access, has not been studied in such patients extensively. This study evaluated the indications, technique, success rate, and complications associated with RPG in patients with head and neck cancer. STUDY DESIGN: Retrospective. METHODS: A comprehensive chart review was undertaken of 56 patients with head and neck cancer treated at a tertiary care institution who had undergone successful or attempted RPG at some point during their treatment course. RESULTS: Most study patients had advanced oropharyngeal squamous cell carcinoma. The most frequent indications for RPG were dysphagia/aspiration following tumor resection (n = 26) and dysphagia following completion of single- or combined-modality therapy (n = 22). The success rate of attempted RPGs was 98.2%. The overall complication rate for RPG was 12.7% (10.9% minor and 1.8% major). CONCLUSIONS: RPG is a valuable tool for establishing enteral nutrition in patients with head and neck cancer. Advantages of RPG include high success rate despite obstructing lesions, low complication rate, time efficiency and scheduling ease compared with intraoperative percutaneous gastrostomy (PEG) by a second team, no reported tumor seeding of the tube site, and the fact that postoperative RPG allows for more accurate selection of patients who require a gastrostomy tube.

Zenker's diverticulum: analysis of surgical complications from diverticulectomy and cricopharyngeal myotomy.

OBJECTIVE: To identify risk factors for postoperative complications in patients undergoing diverticulectomy and cricopharyngeal (CP) myotomy for Zenker's diverticulum. STUDY DESIGN: Retrospective. MATERIALS AND METHODS: A chart review was conducted of all patients with a Zenker's diverticulum who were treated with diverticulectomy and cricopharyngeal myotomy at three tertiary care centers in central Indiana between 1988 and 1998. RESULTS: Of the 24 patients identified, 9 developed postoperative complications (2 medical and 7 surgical). Statistical analysis of multiple potential risk factors revealed that only diverticulum size greater than 10 cm2 at surgery placed the patient at increased risk for postoperative surgical complications. To our knowledge, this is the first report that has specifically addressed diverticulum size as an independent risk factor for postoperative surgical complications following diverticulectomy and CP myotomy. CONCLUSIONS: Given our findings, we recommend considering diverticulopexy rather than diverticulectomy in a patient with a Zenker's diverticulum greater than 10 cm2 in size if a cervical approach is the selected treatment.

Cable grafting of the spinal accessory nerve after radical neck dissection.

BACKGROUND: From January 1981 through March 1996, 20 patients with head and neck cancer underwent radical neck dissection with sacrifice of the spinal accessory nerve and immediate reconstruction of the nerve using a microsurgical technique and a cable graft of the great auricular nerve. METHODS: Postoperative shoulder function was assessed via a subjective questionnaire, objective strength testing, and/or postoperative electromyography. The latter was used to evaluate for the presence and amplitude of voluntary motor potentials, the presence of fibrillation potentials, and nerve conduction latency. The group of patients who underwent cable grafting of the spinal accessory nerve was compared with a group of patients who underwent modified radical neck dissection with preservation of the spinal accessory nerve and with another group of patients who underwent a classic neck dissection with sacrifice of the spinal accessory nerve and no reconstruction. RESULTS: In terms of shoulder function, the group of patients in whom the spinal accessory nerve was reconstructed occupied an intermediate position; ie, their postoperative shoulder function was better than that of the patients who underwent radical neck dissection without reconstruction but not as good as that of the patients who underwent modified neck dissection with preservation of the spinal accessory nerve. CONCLUSION: Cable grafting of the spinal accessory nerve that has been sacrificed during radical neck dissection results in improved shoulder function in the postoperative period.

Intraoperative microwave processing of bone margins during resection of head and neck cancer.

OBJECTIVE: To develop an accurate method for performing histopathologic analysis for a full cross-section of cortical bone within 2 to 3 hours. METHODS: Microwave technology was used to augment and to more rapidly perform fixation and decalcification of cortical bone. RESULTS: Using the methods described, slides suitable for histopathologic analyses regarding the presence or absence of malignant tumor were prepared in 2 to 3 hours and, in 10 patients studied, had a 100% correlation with slides prepared in 7 days using the standard decalcification technique. CONCLUSION: Microwave technology allows accurate assessment of a full cross-section of cortical bone regarding the presence or absence of malignant tumor within the time limits required for resection of a malignant head and neck tumor and reconstruction of the surgical defect.

Cancer of the scalp.

Carcinomas on the scalp have a tendency to recur following traditional treatment. Their management is often difficult because of the extent of the tumor and the unique anatomy of the area. In order to maximize cure rates for complicated carcinomas, Mohs micrographic surgeons and other surgical specialists have formed interdisciplinary treatment teams. Resection of bone, parotid/facial nerve dissection, and neck dissection are often necessary. Interdisciplinary cooperation in the treatment of skin cancer leads to maximal utilization of expertise and is a major advance in cancer treatment.

Endoscopic treatment of aspiration using a laryngeal stent.

The use of a laryngeal stent to obturate the glottis and prevent chronic aspiration has been described. Comparison with previously described surgical techniques used in treating chronic aspiration has been made. We believe laryngeal stenting is a good alternative for the initial and temporary treatment of chronic aspiration for as long as one year. The main advantage of the procedure is that it can be performed and reversed endoscopically. Patients with uncorrectable underlying conditions, causing them to chronically aspirate will require a more permanent surgical solution to their problem.

Otolaryngologists' role in diagnosis and treatment of orbital pseudotumor.

Patients with pseudotumor of the orbit often present with proptosis, inflammatory changes of the orbital structures, loss of vision, and abnormalities of extraocular motility. Because these signs and symptoms mimic more common disorders of the paranasal sinuses, the otolaryngologist often plays an important role in the diagnosis of this clinical entity. Also, since orbital pseudotumor can be secondary to an inflammatory disease of the paranasal sinuses, appropriate medical and surgical treatment must be rendered by the otolaryngologist. The experience of orbital pseudotumor at Indiana University Medical Center in the Department of Otolaryngology-Head and Neck Surgery is presented. Appropriate diagnostic workup is discussed, including the importance of the CT scan. The differential diagnosis of space-occupying orbital processes is examined. It is important that the otolaryngologist become more familiar with this clinical entity and its appropriate treatment.