Current trends in the detection and management of carotid body tumors.

PURPOSE: Because the natural history of carotid body tumors is believed to be unpredictable, immediate surgical removal has been recommended. The present study reviews our experience in the diagnosis and treatment of these uncommon lesions. METHODS: The medical records of patients who appeared for treatment with carotid body tumors between 1981 and 1997 were reviewed. Patients demographics, mode of presentation, imaging and treatment modalities, Shamblin classification, and neurologic complications (stroke, cranial nerve injuries) were analyzed. RESULTS: Over the past 16 years, 31 patients with 32 carotid body tumors have been evaluated, with an average follow-up of 3.2 years. The patients were arbitrarily classified into two groups on the basis of the mode of detection. Seventy percent (23 of 32) of the tumors discovered on clinical or self-examination were classified as Group 1; 28% (9 of 32) of the tumors detected during duplex scanning for carotid artery disease (8) or MRI (1) were classified as Group 2. The mean size of chemodectomas found on palpation (4.3 +/- 1.7 cm) was larger than that of those detected by duplex ultrasound (2.7 +/- 1.0 cm; p < 0.05, by paired t test). Preoperative embolization was successfully performed in 5 of 6 instances of large tumors; the remaining patient suffered a procedure-related stroke. Thirty-one carotid body tumors were resected. In one case, the tumor was felt by the primary surgeon to be too small (0.9 x 0.7 cm on duplex scan) to warrant immediate excision; this patient is being followed by periodic duplex scanning. Five neurologic complications were noted in Group 1, one after preoperative embolization and four after surgery. One cranial nerve injury occurred in Group 2. One patient had a large recurrent chemodectoma with clinical evidence of metastatic disease. CONCLUSION: The increasing use of sophisticated imaging modalities may allow earlier discovery of carotid body tumors before they can be clinically detected. Resection of carotid body tumors of all sizes in appropriate surgical candidates remains the standard of care. Unfortunately, resection of even small tumors is associated with a low but constant incidence of neurologic complications.

Low-dose radiation therapy for benign salivary disorders.

Two patients, one with a persistent salivary fistula after surgery for a skin tumor overlying the parotid region, and the other with a ranula recurrent after surgery, were treated with low-dose irradiation. Both problems resolved after a total dose of less than 30 Gy, and neither patient experienced xerostomia. In selected patients, low-dose radiation therapy offers a solution to persistent salivary flow refractory to surgical management.

Intubation granuloma of the larynx: successful eradication with low-dose radiotherapy.

Postintubation granuloma of the larynx is a well recognized entity, which has accompanied the increased use of endotracheal intubation for general anesthesia. Voice rest, corticosteroids, antibiotics, antacids, and surgical removal are generally accepted conventional therapies, although select cases are fraught with a high rate of recurrence. We recently evaluated a patient who had undergone 6 surgical excisions of a postintubation laryngeal granuloma during a 5-month interval. The larynx was treated with 1,200 cGy photon irradiation during a 4-day period, and there has been no granuloma recurrence in 36 months of follow-up. The rationale and selection criteria for patients who might benefit from low-dose radiotherapy for recurrent laryngeal granulomas are discussed.

Laryngeal involvement in disseminated coccidioidomycosis.

Coccidioidomycosis is a pulmonary fungal infection endemic to the desert southwest of the United States and northern Mexico. Rarely (0.5% of cases), the fungus disseminates widely, causing life-threatening complications. Seven percent of these cases will involve the head and neck. We report a case of disseminated coccidioidomycosis that involved the larynx and cervical lymph nodes in a 40-year-old white woman who presented with hoarseness and unsuspected airway compromise. Review of the 12 reported cases of laryngeal coccidioidomycosis showed a predominance of male and dark-skinned patients; seven were children, and nine presented with airway compromise. Other reported sites of head and neck involvement include the skin, mucosa, bones of the skull, and meninges, and there have been reports of abscesses of the soft tissues and fascial spaces of the neck.

Radiation therapy for paragangliomas of the temporal bone.

Treatment of paragangliomas of the temporal bone (glomus jugulare and glomus tympanicum tumors) is controversial, with both surgery and radiation therapy having their advocates. This paper discusses the experience at the University of Arizona Health Sciences Center in treating 10 cases of this uncommon tumor between 1971 and 1988. Seven of 10 cases were initially treated using irradiation and achieved complete tumor control for a mean of 67 months (range = 23-107 months). Two patients, one treated surgically and the other by embolization, had recurrences and were salvaged by radiation, and neither has recurred. The final patient is disease-free 9 months after embolization and surgery. There have been no serious sequelae of treatment. We conclude that moderate-dose irradiation can safely control most temporal bone paragangliomas.

Radiation therapy for squamous cell carcinoma of the supraglottic larynx.

Sixty-five patients with invasive squamous cell carcinoma of the supraglottic larynx received irradiation with curative intent between 1975 and 1984, with a 5-year actuarial survival of 48% and a local control rate of 70%. Five-year survivals for clinical Stages I, II, and III + IV were 60, 53, and 52%, respectively; local control rates were 88, 76, and 63%, respectively. These patients included one treated with preoperative irradiation, 35 treated with surgery followed by postoperative irradiation, and 29 treated with radiation therapy alone. In the surgery plus irradiation group, 5-year local control was 93% for clinical Stages I + II (14 patients), and 61% for clinical Stages III + IV (21 patients). Three patients had pathologic Stage II disease, with the remainder demonstrating a higher pathologic than clinical stage. Multiple positive nodes predisposed to local/regional recurrence, while no relationship could be established between recurrence and extracapsular nodal spread, positive margins, emergency tracheostomy, total versus less-than-total laryngectomy, radiation field size, radiation dose, or delay until radiation therapy, probably because of patient numbers. Six patients, five with positive nodes, developed distant metastases, and three developed second primary tumors outside the head and neck region. In the radiation therapy alone group, 5-year local control rates were 86, 59, and 53% for clinical Stages I (7 patients), II (11 patients), and III + IV (11 patients), respectively. However, three of four Stage II local/regional failures were surgically salvaged for periods greater than 30 months, for an ultimate Stage II local control of 89%. No relationship could be established between local control and radiation dose or field size, again probably because of small patient numbers. Three patients developed distant metastases, and eight developed second malignancies, one within the irradiated volume. Fifteen patients developed acute toxicity during irradiation, and there were eight chronic complications, five requiring surgery; toxicity was more common in the group treated with radiation alone. Radiation therapy alone with surgical salvage is an effective, function-preserving treatment for clinical Stages I and II carcinoma of the supraglottic larynx, and appears to yield local control and survival comparable with that of combined irradiation and surgery in more advanced disease.

Eagle's syndrome: an atypical cause of dysphonia.

We report an unusual case of dysphonia secondary to Eagle's syndrome. Despite documentation of the stylohyoid syndrome in the literature, the appropriate diagnosis in this case eluded several clinicians. Once the diagnosis was made, surgical therapy rendered the patient completely free of her symptoms. Although the patient's pain was somewhat atypical for the stylohyoid syndrome, we believe that this case underscores the importance of the head and neck surgeon's need for familiarity with the various causes of head and neck pain.

Mucosal melanoma of the head and neck.

Nine cases of primary malignant melanoma of the upper respiratory tract treated at the University Hospital over the past 10 years are presented. Of the 9 cases, 6 had primary lesions located in the nasal cavity with the remaining 3 presenting in the nasopharynx, hard palate, and larynx, respectively. The authors review presenting symptoms, diagnostic evaluation, current therapeutic modalities, and clinical course in these cases. Specific cases are discussed to emphasize items of clinical or therapeutic importance.

Regression of aggressive laryngeal papillomatosis with 13-cis-retinoic acid (accutane).

Laryngeal papillomatosis often involves a relentless growth of papillomas on the vocal cords, requiring repeated excisions to maintain an adequate airway. Because of its antiproliferative effects on epithelial tissues, 13-cis-retinoic acid (0.5-2.0 mg/kd/day p.o.) was used in five patients whose disease was poorly controlled by laser beam surgery. Control of disease for 24+, 5+, and 12 months has been achieved in three of the patients, with two complete and one partial responses. Side effects of treatment were mild and rapidly reversible, following a 25-50% reduction in drug dose.

Sialadenitis in children.

Sialadenitis in children has been discussed. A literature review highlighting salient points in sialadenitis is presented. Classification of sialadenitis is discussed using the categories of several authors. An unusual case involving acute suppurative parotitis in a child is presented. The development of contralateral disease while treatment was in progress was unusual. In this case, association with mumps parotitis was strongly suspected despite previous immunization. Progression of disease with abscess formation is also unusual. Mumps virus parotitis has been rarely reported in association with acute suppurative parotitis. Immunization affords protection, but a definite failure rate exists. Based upon histologic examination, mumps parotitis would seem to be a predisposing factor for bacterial infection.

Retropharyngeal abscess--a ten-year experience.

The authors present an extensive review of current literature as well as their ten-year experience in management of patients with retropharyngeal abscesses. Emphasis is placed upon age, sex, type and duration of symptoms, bacteriology, methods of diagnosis, therapy, and complications. The authors' series reveals that retropharyngeal abscesses are found in adults, there is a wide spectrum of bacteriological organisms represented, and with appropriate antibiotic and surgical management the majority of patients survive without major residual sequelae.

Digital subtraction angiography: applications in otolaryngology--head and neck surgery.

Digital electronic technology has made its most notable contribution to radiology in the form of the CT scanners which have so greatly benefited medical practice. Experience with intravenous angiography using a digital fluoroscopy unit developed at the University of Arizona gives promise of a further major benefit in the area of angiography. The majority of examinations are conducted on an outpatient basis with a risk level comparable to that of an intravenous pyelogram. The authors review their experience with this unit, including it's diagnostic and therapeutic applications to congenital and acquired vascular diseases, neoplasms, and vascular trauma of the head and neck.

Infectious facial and nasal cutaneous necrosis: evaluation and diagnosis.

A review of the literature reveals that pyogenic gangrenosum (ecthyma gangrenosum) is fatal to most patients, especially infants. In this article, the authors review the differential diagnosis of facial necrosis, present two cases of infants who succumbed to the systemic manifestations of the disorder, and a third case of survival in an adult with concomitant systemic lupus erythematosus and pyogenic gangrenosum. Finally, a brief discussion of Pseudomonas gastroenteritis, Pseudomonas septicemia, and pseudomembranous enterocolitis is presented.

Complications of carotid artery replacement in head and neck neoplasms.

Carotid artery involvement by neoplastic disease has grave prognostic implications. However, with the advent of postoperative radiation therapy and chemotherapy, carotid artery sacrifice and replacement is more widely performed. In this report the authors discuss their experience with preoperative and intraoperative evaluation of cerebral blood flow and complications of carotid artery replacement.