Extraordinary growth of giant cell reparative granuloma during pregnancy.

A 25-year-old woman had a giant cell reparative granuloma (GCRG) in the nasal fossa during the fifth month of pregnancy. This was treated with a partial excision, but the lesion recurred three months later. By this time, there was extension into the anterior fossa. Because of rapidly decreasing visual acuity, headache, and facial pain, a combined craniofacial approach was undertaken. The lesion encroached on the optic chiasm and a piecemeal, but incomplete, removal of the lesion was performed. The patient spontaneously gave birth to a normal child while in the recovery room. She received no additional therapy and her symptoms disappeared. She remains well 11 years later. The course of disease in this patient is compared with eight other patients from the literature who had GCRG during pregnancy.

Stage II glottic carcinoma: prognostic factors and management.

Three hundred thirty-six patients with squamous cell carcinoma of the glottic larynx treated at the University of Virginia Medical Center from 1960 through 1977 were reviewed. Seventy patients with T2N0M0 disease, grouped according to the criteria of the American Joint Committee on Cancer, 1978, form the basis of this report. The 5-year actuarial survivals, recurrences, salvages, and prognostic factors were examined. Treatment was radiation, surgery, or a combination of radiation and surgery. Impaired vocal cord mobility in Stage II glottic squamous cell carcinoma is the crucial significant prognostic factor in predicting response to therapy, survival, and response to salvage therapy for recurrences. The 90% 5-year recurrence-free rate with freely mobile cords is comparable to that achieved with Stage I lesions. Impaired mobility resulted in a 5-year recurrence-free rate of 73%, which is comparable to that of T3N0 lesions. We support the concept of reclassifying Stage II disease into Stage IIa (mobile cords) and Stage IIb (impaired mobility). Based on this review and those reported in the literature, we recommend radiation therapy for Stage IIa disease. Surgery results in fewer recurrences and in longer survival than irradiation when the vocal cords are not freely mobile (Stage IIb).

Cancer of the posterior hypopharyngeal wall.

Thirty-five patients with cancer of the posterior pharyngeal wall treated at the University of Virginia Hospital since 1956 have been reviewed. A minimum follow-up of five years was available in all patients. These have been analyzed by stage and treatment modality, and the crude and determinate three and five year survival figures presented. In contradistinction to results reported for other hypopharyngeal sites, radiotherapy alone has proved the most effective treatment in the posterior wall, particularly for T1 and T2, NO lesions, where the crude and determinate survival after 5 years were 45 and 50% respectively. For advanced lesions no treatment approach has approved efficacious, although 2 or 10 (20%) patients treated initally by radiotherapy alone survived disease free for 3 years with subsequent surgical removal of residual nodal disease.

Invasive tracheal papillomatosis.

A 27-year-old man had a tracheal resection and laryngectomy for a large papillary mass in the upper trachea which extended between the cartilages into the adjacent soft tissues. Small intracystic papillary structures were formed focally in the invasive component. The epithelium in the invasive elements and the mucosal mass was identical and consisted of cytologically benign squamous, intermediate (transitional), and ciliated cells. Metastasis has not occurred and the patient is well 4 years later. We suggest the term "invasive tracheal papillomatosis" for this infiltrative lesion comprised of multiple types of cytologically benign epithelium.

Mycotic carotid artery aneurysm.

A painful, pulsatile neck mass with associated fever should suggest the presence of a mycotic carotid artery aneurysm. Diagnosis can be confirmed from angiograms. Broad spectrum antibiotics are indicated, and an operation should be performed promptly. The lack of tissue planes uninvolved by infection will almost always prevent vascular reconstruction. Carotid artery ligation with excision of the aneurysms is recommended.

Platysma myocutaneous flap for intraoral reconstruction.

Fourteen patients were treated for intraoral epidermoid carcinoma with a single stage reconstructive technic employing a myocutaneous flap based upon the platysma muscle. This flap carries on its distal tip a portion of isolated cervical skin to be used for intraoral replacement of the resected tissue. The flap has proved to be highly reliable and has significant benefits over many other technics commonly employed for head and neck reconstruction.

Esthesioneuroblastoma: diagnosis and treatment.

Esthesioneuroblastoma is a nasal tumor which arises from cells of neural crest origin. It is a difficult tumor to diagnose clinically and histopathologically. First described in 1924, approximately 160 cases have been reported with over 125 of these in the last 15 years. This reflects an increased awareness of the tumor by physicians rather than an icreased incidence. In the past 17 years, 12 cases of esthesioneuroblastoma have been treated at the Department of Otolaryngology and Maxillofacial Surgery of the University of Virginia Medical Center. Reviewing these cases and the literature leads us to make the following recommendations for diagnosis and treatment: The diagnosis of esthesioneuroblastoma can be made by 1) the clinician who suspects it in any patient with a nasal mass causing unilateral obstruction; 2) the finding of plexiform intercellular fibrils by light microscopy (rosettes and pseudorosettes are not as common as reported); 3) the finding of secretory granules and neurites by electron microscopy of the highly undifferentiated tumors; and 4) formaldehyde-fume-induced fluorescence. Combined therapy with preoperative irradiation followed by craniofacial resection of the tumor to include the cribriform plate is recommended. This treatment should result in a five-year survival in excess of 50% of patients.

Malignant neoplasms of the nasal cavities and paranasal sinuses: (a retrospective study).

This study presents a retrospective look at 115 patients evaluated here from 1957 to 1974. In this series, 57 percent were males and 43 percent females, 84 percent were Caucasian and 16 percent Negro. Lesions confined to or originating in the antrum made up 67 percent while nonantral lesions were 33 percent. Mean age at diagnosis was 59.1 years. Smoking and drinking history did not appear to be contributory. Antral lesions were retrospectively staged according to Sisson's TNM classification. Sixteen tumor types were involved, with the most common being epidermoid. Diagnosis was most often made by intranasal or Caldwell-Luc biopsy. Most frequent symptoms, as well as earliest symptoms, were nasal obstruction, localized pain, and epistaxis. Average duration of symptoms was 6.4 months. Therapy was generally in the form of radiotherapy alone, preoperative radiotherapy and surgery, surgery and postoperative radiotherapy, or surgery alone. Local recurrences occurred in 44 percent of antral lesions and 50 percent of non-antral lesions. Regional (cervical) nodal metastases developed in 25 percent of antral lesions and 11 percent of non-antral lesions. Distant metastases developed in 30 percent of antral cases and 35 percent of non-antral cases. Five-year survival was 32 percent (35 percent determinate) for the total group. The more advanced the staging of the antral lesions, the worse the prognosis. Best survival figures were in the areas of preoperative radiotherapy and surgery at 38 percent (43 percent) and surgery alone at 56 percent (59 percent).

Intracranial carotid catastrophies encountered by the otolaryngologist.

Arteriographic studies are utilized to illustrate the presence and document the results of arterial ligation on three intracranial carotid aneurysms. All three aneurysms resulted from trauma, surgical and otherwise, and all presented as otolaryngologic dilemmas. All were successfully controlled by a combined Otolaryngological and Neurosurgical Team employing varying combinations of intra and extra cranial arterial ligations. None developed significant neurological impairments. The two major indications for common or internal carotid ligation are the resection of neoplasm and the control or prevention of hemorrhage. Sixty percent of patients undergoing elective carotid ligation survive these procedures without evidence of neurological sequelae. This uncompromised survival is based upon the presence or rapid development of collateral circulation to the cerebrovascular bed. Further arteriographic studies are employed to illustrate the development of intra and extra cranial collateralization to the internal carotid artery after surgical interruption of the ipsilateral common carotid. The major collateral circuits demonstrated via a case report are as follows: a. from the vertebral artery to the external carotid and hence to the internal carotid; b. from the posterior communicating artery to the internal carotid; and c. from the ophthalmic artery to the internal carotid.

Malignant fibrous xanthoma with metastasis to cerebellopontine angle.

Malignant fibrous xanthoma is an uncommon tumor of histiocytic origin. It is a difficult tumor to diagnose, and may have an unpredictable and confusing clinical course. The malignant fibrous xanthoma described herein probably represents the first reported case of metastasis to the cerebellopontine angle. When properly diagnosed, the preferred treatment is wide excision. Metastases are usually to the lungs and regional lymph nodes, and portend a poor prognosis. Radiotherapy appears to be of little value.

Bilateral synchronous mixed tumors of the parotid gland.

A 62-year-old man had bilateral parotid masses. This case represents a rare occurrence of bilateral synchronous mixed tumors of the parotid gland. We discuss this case, including preoperative evaluation, reason for rarity, treatment, and a review of the literature.

Radiotherapeutic management of cancer of the glottis, University of Virginia, 1956-1971.

All patients with cancer of the glottis treated by radiotherapy with curative intent at the University of Virginia from 1956 through 1971 have been reviewed. Follow-up is complete through December, 1973. Results are presented by both stage and treatment policy and indicate that with our present methods of management a high degree of local control is achieved. The complications of treatment are examined, particularly those arising as a result of combined radiotherapy and surgery. A small number of cases have been salvaged following local recurrence and these are described in detail. Particularly striking has been the effectiveness of radiotherapy in the treatment of advanced (Stage III and IV) lesions. In this group 58 percent of the patients survive with their larynges intact. Considering the poor general condition and advanced nature of the lesions in these cases this result is important and may indicate the nature of future trends in treatment, namely radiotherapy, with surgery held in abeyance until there is overt recurrence.

The value of Gallium67 scanning in the evaluation of head and neck malignancy.

Gallium (67Ga) citrate is a scanning agent that has been shown to have a differential uptake in a variety of malignancies. Investigation of the usefulness of 67Ga scanning patients with proven squamous cell carcinoma of the head and neck region is now in progress. These patients have a 67Ga total body scan as part of the pre-treatment evaluation. The accuracy of the procedure is then judged by correlation with clinical and surgical findings. The results in 25 patients show that a clearly positive uptake occurs in 60 percent in the region of the primary. Uptake in metastatic disease in lymph nodes is much less, occurring in 6 of 18 sides of the neck. In one case, where clinical examination was considered to be negative, the gallium scan was positive and subsequently proven to be correct by histological examination of the surgical specimen. The various difficulties encountered in interpreting gallium scans in the head and neck region are described. It is felt that by improved patient selection and special techniques the yield of positive cases can be improved and unsuspected extension of malignancy demonstrated.

Use of thermography to evaluate the optimum time for surgery after preoperative radiation.

At the University of Virginia Hospital, patients undergoing preoperative irradiation for carcinoma in the head and neck region are usually scheduled for surgery four to six weeks after completion of therapy. Since preoperative irradiation produces no significant difference in the operative difficulty or postoperative morbidity, it is assumed that the vascularity of the area has returned to the pre-treatemtn level. Thermography is being used to quantitatively gauge the amount of vascularity and thus, help predict the optimum time for surgery. Thermography is obtained at two-week intervals after a pre-treatment baseline and is carried out for eight weeks after completion of therapy. During therapy the vascularity as determined by thermography is noted to increase to a maximum at approximately three to four weeks or 3 to 4,000 rads. Following completion of treatment, the vascularity subsides gradually and returns to the pre-treatment level at four to six weeks after completion of therapy.

Intermediate dose pre-operative radiotherapy for cancer of the larynx. - End results.

A retrospective study has been made of the role of intermediate (4500-5000 rads in five weeks) pre-operative radiotherapy in the treatment of advanced carcinoma of the larynx. The results of treatment in 72 cases treated at the University of Virginia have been analyzed with particular attention to local recurrences and complications. The local recurrence rate is comparable to that achieved with higher doses of pre-operative irradiation and the complication rate and the pre-operative level of radiation dose employed. Deaths from causes other than local recurrence indicate that a considerable number of patients die from a second primary or distant metastases even though the local disease has been controlled.

The value of tantalum powder as a contrast medium in laryngography.

Dionosil and powdered tantalum laryngograms are compared in 18 patients with known laryngeal cancer. Dionosil more reliably defined the epiglottis, valleculae, and pyriform fossae. The glottic and subglottic regions were more clearly visualized with the use of tantalum. Both agents were equally effective in the evaluation of the supraglottis.