Mandibular and temporomandibular joint arthropathy in the differential diagnosis of the parotid mass.

OBJECTIVE: To increase awareness of temporomandibular joint and mandibular disease in the overall evaluation and diagnosis of the parotid mass. STUDY DESIGN: We describe clinical presentations of pigmented villonodular synovitis and synovial chondrocalcinosis of the temporomandibular joint, as well as osteoma of the mandible, as they may initially suggest primary neoplasms of the parotid gland. CONCLUSIONS: Preauricular swelling is a common presenting symptom for patients visiting an otolaryngologist. Often this symptom is suggestive of a parotid mass. However, lesions of the temporomandibular joint and mandible may also present in this fashion.

Horizontal maxillotomy for exposure of the central skull base: the Yale experience.

Le Fort I osteotomy allows the surgeon to safely down-fracture the maxilla for wide exposure of the central skull base. This surgical approach is easily extended inferiorly to include the arch of C1, providing 8 cm of horizontal anterior exposure and 5 cm of posterior. Wide operative exposure and a low rate of complications afford superior functional and cosmetic preservation in removing tumors of the central cranial base.

Recurrent carotid blowout syndrome: diagnostic and therapeutic challenges in a newly recognized subgroup of patients.

BACKGROUND AND PURPOSE: To our knowledge, recurrent carotid blowout syndrome (rCBS) has not been well described. Our purpose was to review our institution's recent experience with patients who presented with multiple episodes of carotid blowout syndrome (CBS), and who were referred for emergent diagnostic angiography and endovascular therapy. METHODS: We retrospectively reviewed the last 46 consecutive patients who had a clinical diagnosis of CBS. All patients were examined and treated prospectively according to a standardized protocol. Most patients (43 of 46) had undergone extensive primary and salvage radical surgery with intraoperative brachytherapy or external beam radiation or both. The remaining three patients had either traumatic or iatrogenic CBS. RESULTS: Twelve patients (26%) in our series had more than one episode of CBS in which a total of 32 (20 recurrent) events were observed (average 2.7, range 2-4). Intervals of rCBS ranged from 1 day to 6 years. Thirteen (65%) of 20 recurrent events were attributed to progressive disease (PD), and seven (35%) of 20 to treatment failures (TFs). In the PD group, seven (54%) of 13 had recurrent ipsilateral disease, and six (46%) of 13 had recurrent contralateral disease. Etiologies of rCBS were as follows: seven exposed carotids; seven carotid pseudoaneurysms; eight small-branch pseudoaneurysms; five tumor hemorrhages; three hyperemic/ulcerated wounds; and one aortic arch rupture. Twenty-seven of 32 events were treated with endovascular therapy, which included the following: nine carotid occlusions; 11 small-branch embolizations; three transarterial tumor embolizations; one carotid stent; and two direct-puncture embolizations. Four of six TFs were retreated successfully with endovascular therapy; the remaining two TFs were managed successfully by surgery. In the PD group, hemorrhagic complications of rCBS were managed successfully in all but one patient, who died. No permanent neurologic or ophthalmologic complications occurred. CONCLUSION: Recurrent CBS is a frequently encountered problem in which most cases are caused by PD resulting from both multifocal iatrogenic arteriopathy and occasional wound complications that are characteristic of aggressively managed head and neck surgical patients. Initial TFs are encountered often as well. Despite the diagnostic and therapeutic challenges of rCBS, most cases can be retreated effectively.

Effect of anesthesia of the chorda tympani nerve on taste perception in humans.

Individuals who have sustained considerable damage to parts of the taste system often fail to experience changes in everyday taste experience. The two halves of the tongue are independently innervated: the chorda tympani (branch of the facial or VIIth cranial nerve) innervating the anterior two-thirds and the glossopharyngeal (IXth cranial nerve) innervating the posterior one-third. Anesthesia of the chorda tympani nerve on one side produced increased taste intensities for some stimuli on the area innervated by the glossopharyngeal nerve on the other side. Because this effect occurs across the midline and taste projects ipsilaterally, the effect must occur in the central nervous system (CNS). This supports Halpern and Nelson's release-of-inhibition hypothesis that the area to which the chorda tympani projects in the CNS must normally inhibit that of the glossopharyngeal nerve. Anesthesia of the chorda tympani abolishes that inhibition and leads to perception of increased taste intensities from areas innervated by the glossopharyngeal nerve.

Le Fort I osteotomy approach to the skull base.

Horizontal osteotomy allows the surgeon to safely down-fracture the maxilla for wide exposure of the central skull base. This surgical approach is easily extended posteriorly in the midline to include the clivus and the arch of C1, providing 8 cm of horizontal anterior exposure and 5 cm of posterior. Wide operative exposure and a low rate of complications afford superior functional and cosmetic preservation in removing tumors of the central cranial base.

Allogeneic (homograft) reconstruction of the mandible.

Reconstruction of the tumor-ablated patient remains one of the most challenging problems for the head-and-neck surgeon. Various methods have been described, including alloplastic reconstruction, free vascularized flaps, osteomyocutaneous flaps, and allogeneic reconstruction with particulate marrow grafts. Sixteen patients who have undergone homograft mandibular replacement at the Yale New Haven Hospital are described. Eighty-one percent of these grafts were successful in restoring form and function to a high degree of patient satisfaction. Eleven of the sixteen patients had radiation therapy after initial tumor surgery; 91% of these grafts were successful.

Temporal origin of viral phospholipids of the enveloped bacteriophage phi 6.

The enveloped bacteriophage phi 6 contains a higher relative level of the negatively charged phospholipid phosphatidylglycerol than is found in the membranes of the host bacterium. During infection of Pseudomonas phaseolicola with phi 6, the level of phosphatidylglycerol synthesis increases significantly. The lipid used to form the viral envelope consists almost entirely of cellular phospholipids synthesized before infection and phosphatidylglycerol synthesized after infection. Based on these and previously published results, a speculative model for this viral envelope formation process is presented.

Assembly of the enveloped bacteriophage phi 6 in environments which perturb the host cell membranes.

The effects of known membrane-perturbing agents (pH, Na+, Ca2+, and a small lipid-soluble molecule) on the enveloped bacteriophage phi 6 host cell system were investigated at the levels of cellular growth, virus assembly and stability, and the physical and chemical properties of host cell membranes. Spin-label probes of cellular membranes indicate that growth in high levels of Na+ or the small spherical hydrophobic molecule adamantanone results in membranes having increased "fluidity," while growth in high levels of Ca2+ results in slightly greater rigidity of the membranes. In addition, the phospholipid composition of the cellular membranes is dependent on the NaCl concentration in the growth medium. None of these membrane alterations, however, prevent the production of infectious phi 6 virus particles.