Tympanic membrane perforation in survivors of a SCUD missile explosion.

On February 25, 1990, an Iraqi SCUD missile exploded inside a building housing United States military personnel in Dhahran, Kingdom of Saudi Arabia. One hundred seventy-two individuals who were near the impact site at the time of the blast were interviewed and examined to determine blast injury to the ear. Tympanic membrane (TM) perforation was used as the clinical marker for aural blast injury. Thirty-four personnel had unilateral TM perforation and 28 had bilateral TM perforation. Eighty-six sustained sufficient injury to be hospitalized. Fifty-nine of hospitalized personnel (70%) had TM perforation. Of a total of 90 TM perforations, 39% were estimated to be 25% or less of the tympanic membrane surface area, 36% were 26% to 50%, 16% were 51% to 75%, and 10% were greater than 75%. Morphology of the perforations and estimated proximity to the blast were documented. Personnel distant from the blast, in open doorways or wearing headphones, had relative protection from TM perforation. Historic nuclear blast data were used to estimate the SCUD blast waveform based on measurements of the SCUD impact crater. A mathematical model based on the estimated waveform was validated against the actual field data by comparing the proximity and incidence of TM perforations in the SCUD missile explosion.

Granular cell tumors of the trachea.

In contrast to the relative frequency of granular cell tumors (GCT) in the larynx and bronchi, the occurrence of these tumors in the trachea is rare. A 50-year review of the English-language literature disclosed only 24 described cases of tracheal GCT. This report reviews the clinicopathologic data from those 24 cases, along with the data from 2 cases obtained via a personal communication and the data from 4 previously unpublished cases obtained from a 30-year review of the Armed Forces Institute of Pathology archives. Tracheal resection was the predominant mode of therapy and often was performed as a salvage procedure for failed endoscopic excisions. Recommendations for a more uniform approach to surgical management are provided.

The pectoralis major flap.

The pectoralis major myocutaneous flap (PMC) is a major flap for reconstruction of large head and neck defects. Its principle advantages are its dependability and ability to cover large defects. It is, however, a bulky flap, preventing its use for delicate reconstruction. The PMC flap is justifiably a popular flap that will continue to command an important place in the head and neck surgeon's reconstructive armamentarium.

The trapezius myocutaneous flap.

The three trapezius myocutaneous flaps remain valuable adjuncts in head and neck reconstructive surgery. Overall, the lower vertical trapezius flap has the most versatility and reliability, and the least morbidity. There are several advantages of this flap compared to the pectoralis myocutaneous (PMC) flap. It has a thin vascular pedicle, and thus does not add excessive bulk to the neck, as the PMC can. Also, the skin island has less subcutaneous tissue and therefore more pliability than the PMC, which is a definite advantage for oral cavity and oropharyngeal defects. The trapezius flap generally has less hair than the PMC flap, and the donor scar is better hidden.

Metastatic melanoma to the facial nerve.

Isolated metastatic malignant melanoma to the facial nerve has never been reported. This presentation illustrates a primary melanoma of the helix of the ear that was treated by excisional biopsy and then wedge resection in 1983. The primary melanoma was Clark's level IV and 1.3 mm in thickness. In 1985, a facial paresis slowly developed. There was no gross evidence of recurrent melanoma in the ear or neck, but CT scan showed a mass in the region of the stylo mastoid foramen. A reoperation of the primary site revealed metastatic melanoma in the facial nerve, expanding it to approximately 10 times its normal size. A composite resection was done for the melanoma, and the paralyzed face was immediately rehabilitated by a masseter muscle transfer. The patient received 6000 rads to this area postoperatively and has remained free of disease to date, having returned to his profession as a dentist. A detailed study of all the specimens indicated that this represented a primary metastasis to the facial nerve.

Vocal cord paralysis and reoperative parathyroidectomy. A prospective study.

One hundred sixty-three patients undergoing reoperative parathyroidectomy were evaluated before and after operation to determine the incidence of, risk factors for, and morbidity of vocal cord paralysis. These patients were compared to 77 patients undergoing initial parathyroid operation, only one of whom had vocal cord paralysis on postoperative indirect laryngoscopy (1.3%). Preoperative examination of the reoperative patients revealed vocal cord paralysis from initial exploration in 11 patients who were excluded from this study. After re-exploration, 10 patients (6.6%) had vocal cord paralysis, eight unilateral and two bilateral. Right vocal cords were paralyzed twice as often as left. In 90%, vocal cord paralysis was associated with removal or biopsy of an ipsilateral gland. Vocal cord paralysis occurred despite intraoperative visualization of the recurrent laryngeal nerves. Preoperative localization, parathyroid gland pathology, and concomitant thyroidectomy were not associated with increased risk of vocal cord paralysis. Hoarseness was the major symptom. Tracheostomy was required for two patients, one was permanent. One patient was treated for aspiration with a temporary gastrostomy. Nine of 10 patients had return of normal voice quality in an average of 4 months time. On examination 4 years or more after surgery, two of five patients had normal vocal cord motion. The oblique anatomic course of the right recurrent laryngeal nerve may account for the greater frequency of right vocal cord paralysis.

Nasogastric tube perforation of the nasopharynx.

We have presented two unusual cases of nasogastric tube perforation of the posterior nasopharynx. Complications included subcutaneous emphysema, pneumomediastinum, and pleural effusion. Both patients recovered. Recommendations to improve nasogastric tube safety include gentle placement using lubricant and an appropriately sized tube, confirmation of tube placement before any infusion, and awareness of patients at increased risk of mucosal injury.

Pharyngeal obstruction by Kaposi's sarcoma in a homosexual male with acquired immune deficiency syndrome.

A homosexual man with AIDS developed multifocal KS with involvement of the palate, larynx, trachea, and esophagus. Symptoms included dysphagia and gagging with resultant inanition. Short-course local radiation therapy effectively resolved the mucosal KS lesions in the treated areas. Other otolaryngologic manifestations included herpes stomatitis and oral candidiasis.

Analysis of human nasal mucous glycoproteins.

Human nasal turbinates were cultured in the presence of 3H-glucosamine, which is incorporated into nasal mucous glycoproteins. Nasal mucous glycoprotein was then characterized biochemically, and the effects of various neurohormones and immunologic stimulation on mucous glycoprotein release were analyzed. Fractionation of nasal mucous glycoprotein by gel filtration chromatography revealed a molecular size range of 2 to 200 X 10(5) (as judged by protein markers) but displayed a single, acidic charge, as reflected both in a narrow elution pattern from DEAE-cellulose and a sharp isoelectric focusing point of 2.6. Highly enriched nasal mucous glycoprotein preparations consisted of 80 per cent carbohydrate and 20 per cent protein (by weight) and included enzymatically cleavable carbohydrate side chains with molecular weights of 1,600 to 1,800. Thus, nasal mucous glycoproteins are a family of molecules that express uniform acidic charge characteristics and a wide range of molecular sizes. Cholinergic stimulation of atropine-inhibitable muscarinic receptors increased nasal mucous glycoprotein release in a dose-related manner, as did alpha-adrenergic stimulation. However, beta-adrenergic stimulation did not affect mucous glycoprotein release. Immunologic stimulation of nasal mast cells by either reversed anaphylaxis or antigen challenge after passive sensitization caused both histamine release and increased mucous glycoprotein release. Thus, nasal turbinates provide an accessible source of tissue for the analysis of nasal mucus secretion and mast cell degranulation and may provide a model for the study of pharmacologic approaches to the universally experienced discomfort of rhinorrhea.

Production of mucous glycoproteins by nasal turbinates in vitro.

An in vitro system of human nasal turbinate tissue culture has been developed. Nasal turbinate tissue resected during surgery for nasal obstruction is dissected free of bone, placed on absorbable gelatin sponges, and cultured with CMRL-1066 medium containing antibiotics. Viability of explants may be demonstrated both physiologically and histologically through a period of 4 weeks. 3H-glucosamine added to the medium is biosynthetically incorporated into mucous glycoprotein (MGP). Gel filtration column chromatography on Sephacryl S-1000 in 6M urea in 0.005M phosphate buffer demonstrates human turbinate MGP to fractionate with 85% of the radiolabel filtered and 15% excluded by the column. The excluded MGP fractionates with globular proteins of greater than 20 X 10(6) daltons, while the fractions that enter the column filter with molecular sizes of 0.4 X 10(6) to 20 X 10(6) daltons. MGP synthesized by human lung airways has comparable sizing characteristics, suggesting a similarity in upper and lower airway mucus chemistry.

Kaposi's sarcoma of the head and neck in the acquired immune deficiency syndrome.

Since 1981 a new syndrome of acquired immune deficiency (AIDS) has been recognized. Male homosexuals, male and female intravenous drug abusers, and recipients of blood products (i.e., hemophiliacs) appear to be the populations at risk. The syndrome has been manifested by community-acquired opportunistic infections and/or Kaposi's sarcoma (KS). Otolaryngologic manifestations of AIDS are not infrequent. Thirteen AIDS patients at the National Institutes of Health with KS of the head and neck region are presented. All 13 patients were homosexual or bisexual males. Nine initially presented with KS, five with KS of the head or neck. As a group the patients demonstrated lesions involving the oropharyngeal, tracheobronchial, and gastrointestinal regions. Their clinical course and complications are presented in detail. The mortality rate in this subgroup of AIDS patients is extraordinarily high (62%), with an average longevity of 11 months following initial diagnosis.