Laryngeal evoked brainstem responses in humans: a preliminary study.

Laryngeal evoked brainstem responses (LBRs) were recorded in normal human subjects in an attempt to develop a central laryngeal function test and enhance our understanding of neurolaryngologic disorders. The results showed that the human LBR consists of five positive peaks and five negative peaks reproducible within 10 ms after a vibratory stimulation to the superior laryngeal nerve (SLN). The waveform reproducibility was verified by blocking the SLN and topically anesthetizing the hypopharyngeal cavity. The morphology and latency of peak 5 were similar to results obtained in animal LBR experiments. It was concluded that a vibratory stimulation to the SLN was a noninvasive method to elicit far-field potentials from the central laryngeal pathway. These findings encourage further effort to establish normative data and explore clinical correlations.

Posterior glottic stenosis mechanism and surgical management.

Posterior glottic stenosis with arytenoid fixation is an uncommon complication of laryngeal injury. Though etiologies vary; the most common is prolonged intubation. Patients with this problem are tracheotomy dependent and have compromised voice production. There has been no acceptable approach to reconstruction of the larynx, the majority of patients being treated with some type of vocal fold lateralization. The success rate with this approach varies, and this procedure does not take advantage of the intact neuromuscular status of the larynx. Over the past 3 years we have utilized an alternative approach, to repair the stenosis and mobilize the arytenoids in 10 patients. Our surgical technique involves laryngeal exposure via a laryngofissure, the removal of posterior glottic cicatricial tissues, and the application of an autologous graft. Subsequently, all but one of the patients were able to be decannulated. Subjective postoperative voice analysis showed improved voice production. The pathophysiology for this disorder and a review of different treatment modalities are discussed.

Neurophysiological evaluation of acute facial paralysis in children.

Objective evaluation of facial nerve paralysis represents a unique challenge to the clinician. Electroneurography (ENoG) and the acoustic reflex (AR) have been widely used as neurophysiological tests in an assessment of facial nerve function. However, ENoG or AR alone does not suffice diagnostic and prognostic purposes of facial function evaluation in children. To further investigate the diagnostic aspects of facial nerve paralysis, the prognostic value of AR and ENoG, and the time course of the disease in pediatric population, a series of 30 children with acute facial paralysis were investigated by correlation of findings from video-taped House-Brackmann facial grading system. AR and ENoG. The results showed that AR was absent or abnormal for thresholds in 68.2% of patients with Bell's palsy and normal middle ear function. Shorter duration and higher percentage of recovery were found in the children with a normal AR than those with an abnormal AR. Three children showed an abnormal tympanogram and hearing loss associated with acute facial paralysis. These findings should alert the clinician to the presence of a specific, treatable disease in the evaluation of Bell's palsy. The percentage of electroneurographic response varied with different days after onset. ENoG showed minimal responses at weeks 1 3 after onset of Bell's palsy in most patients. The study of the time-course in the children with Bell's palsy demonstrated a functional gap in the early (< 1 week) and late clinical stage (after 6 weeks) of the disease, suggesting that ENoG predicted well only during weeks 1-4 after onset. In general, ENoG showed a good recovery in children, however, recurrent Bell's palsy becomes a concern. The need for neurophysiological follow-up for possible incomplete recovery of the facial nerve is emphasized. It is recommended that AR and ENoG should be included in the diagnostic workup when evaluating pediatric facial function.

Supraglottic laryngeal or base of tongue cancer involving vallecula.

To determine the outcome of patients with supraglottic laryngeal or base of tongue cancer affecting the vallecula relative to the applied method of definitive treatment, a retrospective analysis was performed of 30 consecutive patients treated during a 12-year period (1981-93). Management consisted of surgical resection with adjuvant radiation in 19 patients and radiotherapy in 11 patients with adjuvant chemotherapy (n = 4). The overall actuarial survival rate was 20% at 2 years. Among the 29 evaluable patients, the locoregional failure rate was 52% and the distant failure rate was 31%. Surgery with radiotherapy was associated with better survival (p > 0.20) and less locoregional failure (p > 0.05) but more systemic failure (p > 0.20) than the nonoperative method(s) of treatment. Cure rate by conventional therapy in supraglottic laryngeal or base of tongue cancer involving the vallecula is dismal. In light of these observations, the multimodality treatment approach may have to be considered in the overall management of the disease.

The use of tissue expanders in the correction of ectropion in an animal model.

The use of tissue expanders in eyelid reconstruction has seen limited application. To determine the efficacy of tissue expanders in the correction of cicatricial ectropion, an animal model was developed. Lower-eyelid blepharoplasty with overcorrection was performed on 18 New Zealand white rabbits. After 1 month, if significant ectropion was present, tissue expanders (1.8-cm3 Cylindrical/Microdome [CUI Corporation, Carpinteria, Calif.]) were inserted on one side, the other eye being the control. These were inflated in the following weeks to a total volume of 2 cm3. The tissue expanders were then removed, and the animals were followed for 1 month. Although the early results were encouraging, the ectropion progressed toward its preoperative severity. It appears that lower-eyelid ectropion remains a therapeutic problem that is only partially corrected with tissue expansion alone.

Screening bone scintigraphy in the staging of locally advanced head and neck cancer.

A retrospective determination of the yield from screening bone scintigraphy in detecting bone metastasis when used for disease staging of 93 asymptomatic patients with locally extensive head and neck cancer was undertaken. The bone scintigraphy findings were correlated with observations from other radioimaging studies done within 1 month of head and neck cancer diagnosis. Bone scintigraphy did not reveal a single case of bone metastasis outside the head and neck region. On the other hand, 3 cases (8%) of resectable and 2 cases (5%) of non-resectable bone metastasis located within the head and neck area were observed among the 40 patients with abnormal bone scintigraphy. Old rib fracture or degenerative disease was responsible for the increased radionuclide uptake in bony areas below the clavicle in less than half of the remaining 35 cases. We conclude that the routine use of bone scintigraphy for disease staging in asymptomatic patients with locally advanced head and neck cancer is not warranted because the positive yield is low.

Rhinophyma: review of pathophysiology and treatment.

Rhinophyma is an uncommon condition that often results in both functional as well as cosmetic impairment. Different treatment modalities have been devised, with varying degrees of success. A review of the pathophysiology of this condition, together with the authors' experience in managing 76 cases utilizing six different treatment methods, is presented. A simple and atraumatic surgical method has evolved using a Weck blade and argon beam coagulator. The operating time is decreased significantly when compared to other techniques with equal to superior cosmetic results.

Head and neck squamous cell carcinoma metastatic to the orbital apex.

Primary squamous cell carcinoma of the head and neck most commonly metastasizes to the lymph nodes, lung, bone, and liver. Many other rare sites of metastatic disease have been reported. To date, metastatic squamous cell carcinoma of the head and neck to the orbital apex has not been described. Presented are two cases, one tonsil and one parotid primary with metastatic disease to the orbital apex. Many tumors have been found to metastasize to the eye and orbit, but head and neck neoplasms are rarely reported. A review of the literature is presented in addition to the detailed case reports with their radiologic findings and clinical course. Surgical resection followed by postoperative radiotherapy appears the treatment of choice at this time.

Nasal reconstruction with conchal cartilage. Correcting valve and lateral nasal collapse.

OBJECTIVE: To analyze the causes and the subsequent management of a collapsed valve and lateral nasal wall. The causes, including both predisposing anatomy and the surgical contributions, are presented. DESIGN: Analysis of consecutive patients with lateral nasal wall collapse corrected surgically with autogenous conchal cartilage grafts. PATIENTS: Fifty-six patients (37 women and 19 men; age range, 19 to 71 years) with nasal wall collapse were operated on. Forty-one of these patients had undergone at least one previous nasal procedure. The collapse of the nasal wall as a result of senescence was repaired in 13 patients. Two instances of nasal collapse were thought to be due to trauma. Forty-five patients had bilateral involvement. RESULTS: All 56 patients showed subjective improvement in nasal airway breathing. Rhinomanometry was performed in 24 patients and documented the improvement in all 24. Fifty-three patients noted an improvement in the appearance of their noses. Minimal morbidity was noted and no major complications were seen. Follow-up ranged from 18 months to 13 years. CONCLUSION: Surgery is very beneficial in cases of severe nasal collapse. This major functional complication warrants this major surgical reconstructive procedure and, as the results of this study demonstrate, predictable positive results with little morbidity and no major complications are possible.

Spinal epidural compression in head and neck cancer. Report of five cases.

Patients with newly diagnosed head and neck cancer (HNC) during a 13-year period were retrospectively studied for the development of spinal epidural compression (SEC). Of the 759 patients studied, 5 developed epidural compression (1%), 4 of whom were relatively young. SEC occurred simultaneously with HNC in 2 patients and long after the diagnosis of HNC in 3 individuals. There was no observed tendency to involve a particular segment of the spine. Local control of HNC following definitive treatment along with regained ability to walk after palliative radiotherapy in a patient was associated with long-term survival. Recommendations are made for aggressive treatment of SEC to achieve a satisfactory outcome.

Rhinophyma: a new approach to hemostasis.

Rhinophyma is a benign tumor of the nose. It possesses both functional and cosmetic implications. The pathophysiology of the disease is reviewed to illustrate the basis for the treatment options. Many different therapeutic modalities have been reported in the literature, each with reasonable success. A new treatment approach to this condition is developed using a combination of the Weck blade and the argon beam coagulator. This modality is found to be relatively simple and less traumatic than all the other techniques used by the senior author.

A comparative acoustic analysis of voice production by near-total laryngectomy and normal laryngeal speakers.

Limited objective data are available on voice characteristics of patients following near-total laryngectomy. Acoustic characteristics of near-total voice were quantified and compared to laryngeal voice production. High quality audio recordings were obtained from 11 subjects who had undergone near-total laryngectomy and 11 age-matched laryngeal speakers. Subjects performed vocal tasks which provided frequency, intensity and duration measures. These data were computer analyzed and indicated that substantial inter and intrasubject variability existed in the acoustic measures for near-total laryngectomy patients. These patients demonstrated a general restriction in fundamental frequency, reduced intensity and a limitation in duration of phonation when compared to laryngeal speakers.