Cisplatin and 5-fluorouracil chemotherapy in advanced or recurrent squamous cell carcinoma of the head and neck.

Fifty-three patients with advanced or recurrent squamous cell carcinoma of the head and neck (SCCHN) were treated with bolus cisplatin (CDDP) and 96-hour infusion of 5-fluorouracil (5-FU). Twenty-six patients with advanced disease (21 T4 and/or N3) and no prior therapy (NPT) received 2 to 3 cycles of chemotherapy prior to surgery and/or radiation. There were four complete responses (CR) and 12 partial responses (PR) to chemotherapy for an overall response rate of 61%. In 20 patients with locally recurrent or disseminated disease there was one CR and six PR for an overall response rate of 35%. All but one responding patient in both groups showed clear evidence of tumor response after the initial cycle of chemotherapy. Two of the five complete responders required at least three courses to achieve CR. Disease-free survival was poor: only five of 26 patients in the NPT group remain alive and free of disease 8 to 28 months from initial therapy. CDDP and 5-FU is an active combination for SCCHN, but survival benefit remains to be proven.

Immunoperoxidase characterization of extramedullary plasmacytoma of the head and neck.

A retrospective analysis of 18 cases of extramedullary plasmacytoma (EMP) was done to characterize the type of immunoglobulin being synthesized by the neoplastic cells. The immunoperoxidase stain can be performed on previously fixed tissue and offers a means of predicting the likelihood of progression to multiple myeloma (MM). Tumors producing IgG make up the majority of cases of EMP in the literature and only 9% have progressed to MM. Smaller numbers of tumors producing other immunoglobulin classes have been studied, but it is clear that their prognosis is much more grave.

Contractile properties of laryngeal muscles in young and old baboons.

Aging is associated with changes in voice and/or laryngeal protective reflexes in humans. To assess the role of the laryngeal muscles in this change, we have examined in vitro thyroarytenoid (vocalis) muscles excised from the larynxes of young and old baboons. Contractile properties, fatigue characteristics, and resting oxygen consumption of these muscles were measured. The results indicate that the thyroarytenoid muscle of the baboon is a fast muscle that is resistant to fatigue. The thyroarytenoid muscles of older baboons contracted more slowly and recovered less rapidly from fatigue induced by prolonged contractions but developed more maximum active tension than thyroarytenoid muscles of young adult baboons. These small differences in the characteristics of thyroarytenoid muscle of older baboons are probably not sufficient to explain observed changes in laryngeal function in the elderly. The results suggest that changes in neural pathways and/or morphology of the larynx may play a larger role in the altered laryngeal function with age.

Neuromuscular disorders.

Laryngeal innervation and the functional disorders associated with lower motor neuron paralyses are reviewed. Causes of diffuse denervation, such as drug toxicities and demyelinating disease, are also discussed. Symptoms and treatment of myasthenia gravis, amyotrophic lateral sclerosis, and botulism are discussed as examples of neuromuscular blockade at various levels.

Aneurysmal bone cyst of the larynx.

Aneurysmal bone cyst is a rare lesion of the head and neck, and the mandible and maxilla are the most common sites of occurrence. To the authors' knowledge, two cases of aneurysmal bone cyst of the larynx described here are the first to be reported. Although the exact pathogenesis of this lesion is unknown, several theories of its origin are discussed. Complete surgical excision is the treatment of choice. Radiation therapy for this benign lesion is not indicated because of a possible association with the development of sarcoma. Histologic misdiagnosis of carcinoma or sarcoma of the larynx leading to unnecessary radical surgery is a risk and should be avoided by obtaining expert pathologic consultation.

External ethmoidectomy.

Complete exploration and exenteration of the ethmoid labyrinth are best done via a transorbital approach. Since the anatomy is consistent and directly visualized, the complication rate is lower with this approach although it is used primarily for more extensive or recurrent disease.

Muscle transposition in the rehabilitation of the paralyzed larynx.

Muscle transposition of the innervated omohyoid muscle into the tendon of the paralyzed posterior cricoarytenoid muscle was studied in a small series of subhuman primates. A similar procedure was described previously by King for treatment of bilateral recurrent nerve injuries. Our studies confirm that this procedure adequately enlarges the airway to allow normal activity without a tracheostomy. Histologic studies appear to show nerve ingrowth occurring at 6 months as in other neuromuscular pedicle procedures. The procedure is easily performed and causes no other muscle denervation.

Invasive Pseudomonas osteitis of the temporal bone.

Advances in the diagnosis and treatment of invasive Pseudomonas osteitis have improved the prognosis of this condition. The addition of hyperbaric oxygen therapy to the newer antibiotic regimens appears to enhance their efficacy. Radionuclide scanning can result in earlier diagnoses and also determine an end point for therapy. Surgical intervention should be reserved for those patients who do not respond to medical therapy and should be governed by knowledge of the temporal bone histopathology from available specimens.

Horseradish peroxidase studies in animals with neuromuscular transpositions.

Horseradish peroxidase (HRP) is used to trace axonal connections from the motor end-plate to the driving neuron. This technique has confirmed that the neurons activating the sternothyroid muscle are located in the cervical spinal cord, while those controlling the posterior cricoarytenoid (PCA) are found in the nucleus ambiguus ipsilaterally. Eight rabbits underwent a sternothyroid ansa pedicle implantation to the PCA at the time of sectioning the recurrent laryngeal nerve ipsilaterally. After two months, four of these animals received HRP injections into the previously implanted PCA. Brainstem staining HRP did not reveal any retrograde transport to the motor neurons that were known to control the sternothyroid. Possible for the failure of retrograde transport are discussed.

Delayed reinnervation of unilateral vocal cord paralysis in dogs.

The neuromuscular implantation technique for rehabilitation of unilateral vocal cord paralysis was performed in four dogs at the time of denervation and in six dogs after varying intervals of chronic denervation. As would be expected, the chronically denervated animals did not achieve the vocal cord excursion of the acute denervations, but some return of motion was noted even after six months. Histologic examination of the posterior cricoarytenoid muscle was correlated with the return of movement.

Phenytoin pharmacokinetics in burned rats and plasma protein binding of phenytoin in burned patients.

Unexpectedly low serum phenytoin levels occurred in burned epileptic patients, suggesting the possibility of altered phenytoin disposition. Subsequently, phenytoin log-linear elimination kinetics after a 10 mg/kg i.v. single dose was examined in a burned rat model. Clearance increased from 1.08 +/- 0.28 liters/hr/kg in control rats to 1.50 +/- 0.38 liters/hr/kg in burned rats (P less than .05). The volume of distribution increased from 0.82 +/- 0.058 liters/kg in control rats to 1.01 +/- 0.11 liters/kg in burned rats (P less than .0005). The first order elimination rate constant (KE) did not change significantly (1.31 +/- 0.37) hr-1 in control rats vs. 1.52 +/- 0.48 hr-1 in burned rats; P greater than .05). The increase in clearance and in volume of distribution could be explained on the basis of a decrease in plasma protein binding. The free fraction in plasma increased from 27.1% +/- 1.2 in controls to 33.4% +/- 1.6 in burned rats (P less than .0005). The change in binding was consistent with a decrease in serum albumin from 2.64 +/- 0.33 g/dl in controls to 1.98 +/- 0.16 g/dl in burned rats (P less than .0005). Plasma samples of four burned human subjects revealed low serum albumin and markedly decreased plasma protein binding of phenytoin (2- to 3-fold increase in free fraction in plasma).

The use of the argon laser-assisted quartz scalpel for burn wound excision to fascia.

We have developed a new method for coupling the hemostatic capabilities of argon laser light with the mechanical advantages of a sharpened quartz blade using fiberoptics. Using the new laser-assisted scalpel, a series of symmetrical skin excisions was done in 20- to 30-kg pigs on one side and with electrosurgery on the other. The laser scalpel was superior in its hemostatic properties (p less than 0.01) with no statistically significant difference in surgical speed. Take of split-thickness skin grafts was 90% in beds excised with either the laser or the electrosurgical device. Histologic sections showed less tissue damage with the laser-assisted scalpel than with electrocautery.