Matrix-driven translocation of cells and nonliving particles.

Cells of metazoan organisms produce and react to complex macromolecular microenvironments known as extracellular matrices. Assembly in vitro of native, compositionally nonuniform collagen-fibronectin matrices caused translocation of certain types of cells or polystyrene-latex beads from regions lacking fibronectin into regions containing it. The translocation process was not due to diffusion, convection, or electrostatic distribution effects, but may depend on nonequilibrium phenomena at the interface of contiguous collagen matrices formed in the presence and absence of fibronectin or particles. Extracellular matrix formation alone was sufficient to drive translocation by a biophysical process that may play a role in cellular migration during embryogenesis, as well as in other types of tissue reorganization such as inflammation, wound healing, and tumor invasion.

Degloving approach for total excision of inverted papilloma.

Inverted papilloma, because of its insidious and aggressive clinical course, must be completely excised. Previously, the customary procedure advocated for this goal was a lateral rhinotomy. The degloving approach, which consists of lifting the soft tissues from the mid portion of the face, thereby furnishing unlimited exposure to the pyriform fossae and the lateral nasal walls, offers an excellent alternative to the lateral rhinotomy technique. The degloving procedure involves no external scarring and improves the visibility of the total operative field. En bloc dissection of the lateral nasal wall is then accomplished and extended to include a sphenoethmoidectomy or partial excision of the medial orbital wall, as dictated by the extent of disease. The procedure has been performed by the authors in 46 cases, and has proved to be an extremely valuable technique, displaying excellent cosmetic and functional results with minimal complications.

Local excision and radiotherapy for cancer of the oral tongue. A preliminary report.

A group of 18 patients with squamous cell carcinoma of the mid one-third of the tongue was treated by local resection and planned postoperative radiotherapy between 1976 and 1980. Tumors 0.5 cm or greater in thickness were included; no patients had cervical adenopathy. Six were categorized as T1, 10 as T2 and two as T3. In eight patients, histologic review showed tumor extension at or near the resection margin, despite a tumor-free margin at frozen section, while in 10 patients the margins were clear. Local tumor control was achieved in 16 patients (89%). Two failures were evident within 3 months after completion of treatment. The relatively short follow-up of such a small series limits the conclusions from this preliminary study, but the excellent results thus far merit further study.

Myofacial pain dysfunction syndrome: a clinical study of asymptomatic subjects.

The diagnosis of myofacial pain dysfunction (MPD), commonly called temporomandibular joint syndrome, has traditionally been made on the presence of a group of clinical symptoms that produce pain and limitation of movement. The cause of this common illness has been the subject of controversy for over half a century. There has been a lack of agreement on diagnosis, a cause, and treatment. Advanced bioelectronic technology now makes an accurate diagnosis possible, based not merely on clinical symptoms, but on reproducible scientific data. A cause of MPD is discernable and reliable treatment possible, as well as long lasting resolution objectively monitorable with the Mandibular Kinesiograph (MKG 5-R) and Bioelectric Processor (EMIR). A study of mandibular movement and masticular muscle function of 26 "normal" subjects (i.e., clinically asymptomatic) revealed that the overwhelming majority did indeed have dysfunction of the muscles which move and posture the mandible. The significance of this study is twofold. First it demonstrates a valid testing procedure for measuring mandibular movement and muscle function. Second it establishes the fact that most individuals have a physical predisposition to MPD. Changes in the adaptive capacity of the neuromusculature by physical or emotional trauma could then precipitate MPD.

Intralaryngeal release for tracheal anastomosis.

An operation for obtaining additional length in order to achieve end-to-end anastomosis of the trachea without significant suture-line tension is described. The intralaryngeal procedure lengthens the larynx approximately 1 to 2 cm without restricting its function. It is an expedient, effective technique when used primarily, or adjunctively, with a suprahyoid or mediastinal release.

Treatment results of combined high-dose preoperative radiotherapy and surgery for oropharyngeal cancer.

Fifty eight patients receiving planned high-dose preoperative radiotherapy followed by en bloc oro-mandibular-cervical resection for oropharyngeal cancer were reviewed. These patients received continued close observation and care from both the Otolaryngology and Radiotherapy services. In light of the ongoing controversy of preoperative vs. postoperative radiotherapy, we present our data demonstrating the value of preoperative radiation. An overall tumor control rate of 66% was achieved, with an adjusted survival rate of 62%. This was not only for early lesions, but also in patients having advanced (T3, T4) tumor and/or nodal disease (N1-4). These figures are somewhat higher than expected from the literature. A review and discussion of the surgical complications are also presented.

Radiotherapy for carcinoma of the nasal cavity.

Twenty-five patients with primary epithelial carcinoma of the nasal cavity without nodal or distant metastases were treated by irradiation between 1967 and 1978. Small field, beam-directed techniques delivered 6,000 to 7,000 rads with conventional fractionation. Control of the primary tumor was achieved in 21 (84%) patients after irradiation. All five treatment failures (one infield only, three infield recurrence with lymph node metastases, and one regional cervical node metastasis) were evident within six months; all five patients died of cancer. The adjusted actuarial survival rate at three years was 76%. Failure in the untreated neck was only 5% when the primary carcinoma was controlled and 16% overall. The literature has been reviewed with attention to tumor control rates and survival.

Prophylactic neck irradiation.

Treatment of subclinical cervical metastases from advanced squamous carcinomas of the nasopharynx, oropharynx, oral cavity, hypopharynx, and larynx remains contentious. Watchful waiting, elective neck surgery, and, more recently neck irradiation all have their advocates. The possibility of "sterilization" of the neck showing no clinical signs of metastasis has been especially appealing in concept. Wth this in mind, and by use of an external high-dose megavoltage technique, radiation therapy was used in 152 patients with clinically negative necks at the Upstate Medical Center from 1968 to 1977. Lymph node failures were extremely low (4%) when wide-field radiation ports were used and the primary lesion controlled.

Bronchiectasis in pediatric patients resulting from aspirated grass inflorescences.

A grass inflorescence (flowering head) aspirated by a child is difficult to diagnose, and frequently cannot be retrieved by bronchoscopy. Of four pediatric patients with aspirated grass inflorescences, two had severe hemoptysis and the other two were septic at the time of diagnosis. Their chronic debilitation and bronchiectasis necessitated an eventual pulmonary resection, with full recovery in all four patients.

Fibrous dysplasia of the ethmoid sinus.

Fibrous dysplasia of bones comprising the paranasal sinuses is well recognized. Depending on the anatomic areas of the skull involved by this neoplasm, a combined approach for surgical removal may be necessitated. A case of a patient with fibrous dysplasia of the ethmoid sinus, possibly the first reported case of such change in the ethmoid bone itself, is presented. A two-stage, combined otolaryngologicneurosurgical craniofacial resection was the method of treatment.

Unusual parapharyngeal lesions.

Six cases of unusual parapharyngeal lesions are presented in detail along with discussions of the anatomy, pathology, clinical aspects, and treatment methods of lesions in the parapharyngeal space. Newer techniques of CT scanning and selective embolization are discussed as they apply to management of such lesions. A plasmalymphocytic tumor with amyloidosis is described. The authors believe that such a lesion has not been reported previously in the parapharyngeal space.

Composite resection without mandibular reconstruction.

While composite resection remains the fundamental surgical approach to carcinoma of the posterior oral cavity, removal or reconstruction of the adjacent segment of mandible remains contentious. Various grafts have been used with less than satisfactory and unpredictable results. Bone has been brought in, borrowed, reshaped, and implanted into the area of mandibular deficit; mandibular osteotomy has been attempted with primary closure as well. A review of 78 composite resections at Upstate Medical Center reveals that of this number, 61 have undergone primary lateral mandibulectomy without reconstruction while four others have undergone more extended resection without reconstruction at the time of initial surgery. In the others, mandibular reconstruction has been unsatisfactory; mandibular osteotomy in the presence of irradiated tissue has been unsuccessful in all cases. In our experience, satisfactory results, functionally and cosmetically, have been attained with partial mandibulectomy and primary closure of the wound obviating more involved reconstructive procedures. A review of therapy with attention to surgical detail, complications, and results is presented.

Composite resection in the elderly: a well-tolerated procedure.

The advisability of surgery in the elderly must be weighed against continued nonoperative care. The gloomy prospects of the patient with uncontrolled carcinoma of the head and neck led to the development and wide application of the composite resection for control of carcinoma of the oral cavity. The risks involved in this major undertaking in the elderly have not been previously reported. To this end a retrospective study of charts of patients over the age of 64 were reviewed and complications categorized. A representative group of younger patients were similarly reviewed for comparison. Wound complication rates were similar in the two groups, however the elderly were more likely to suffer associated medical problems which tended to be of a more serious nature. An overally complication rate of 29% was encountered with a mortality of 4%.

Use of computerized axial tomography of the head and neck region.

The use of the computerized axial tomography has been well received in the field of otolaryngology. Five cases are presented illustrating the capability of the total body scanner (Delta scanner) to contribute to radiologic diagnosis below the level of the base of the skull. The advantages of non-invasibility and three dimensionality are compared to the disadvantages of added cost, added radiation exposure, comparatively long exposure time and relatively poor detail. Because of the overall usefulness of this diagnostic tool, evolution of rapid scanning devices with greater detail is awaited with interest.

Apnea and airway obstruction during feeding and sleep.

Recent awareness of the magnitude of sudden unexplained deaths in apparently healthy infants has lead to an increased interest in those circumstances that are associated with or can elicit prolonged and serious apneic episodes. In the present studies, attention was directed toward the study of physiologic activity during sleep and feeding. Apneic episodes of varying durations occur during sleep which, in some instances, can be of sufficient length to warrant resuscitative intervention. A number of infants also reveal transient upper airway obstruction following brief periods of sleep apnea. This functional airway obstruction produces sudden and severe bradycardia. Similarly, infant feeding can induce dangerously prolonged periods of apnea and, in some infants, transient airway obstruction. Few detailed studies have been performed to identify the anatomical level or characteristics of the obstruction. Available evidence suggests that this can take the form either of muscle hypotonicity or hypertonicity. Two infants observed by means of direct laryngoscopy revealed transient failure of vocal cord abduction. These results have provided for the development of two theoretical models that can result in the sudden infant death syndrome; furthermore, continuous recordings of respiratory and cardiac activity during feeding and sleep can be extremely valuable in elucidating the mechanisms responsible for the sudden development of apneic and cyanotic episodes in infants.