Partial parotidectomies: morbidity and benign tumor recurrence rates in a series of 94 cases.

OBJECTIVES: Review the methods available for parotidectomy. Describe the technique of partial parotidectomy assisted by evoked electromyographic nerve location and the expected morbidity and benign and low-grade cancer tumor recurrence rates from this modified procedure. STUDY DESIGN: From 1983 to 1999 the author performed or assisted in 94 parotidectomies (79 partial), all done by a single specialty group and all using evoked electromyographic nerve location. The cases were surveyed by reviewing all the hospital and office records on these cases and tabulating the type and extent of surgery, pathology, postoperative problems recorded, and long-term follow-up. METHODS: Partial parotidectomy was elected in those cases of benign and low-grade malignant disease in which adequate tumor removal required a less than complete lobectomy or total parotidectomy. Heavy reliance was placed on proactive nerve location by an evoked electromyographic device with dissecting/stimulating hemostat. A retrospective review focusing on these cases was performed based on the patient charts and their continued documentation by the practice. RESULTS: In 79 partial parotidectomies there were no documented facial nerve injuries and one incidence of recurrence of a benign mixed tumor and an acinic cell carcinoma, respectively. CONCLUSION: Partial parotidectomy has the advantages of reduced risk to the facial nerve, reduced operating time, possible outpatient surgery, and no apparent risk of increased recurrence of benign tumors.

Occupational and environmental medicine in preventionist residency training programs.

In the United States today, there remains a need to train physicians with expertise in occupational medicine and its corollary, environmental medicine. To determine whether preventive medicine residency training programs provide trainees with skills and knowledge in occupational and environmental medicine, we conducted a survey among directors of general preventive medicine and combined general preventive medicine/public health programs in the United States that listed such emphases in the Directory of Preventive Medicine Residency Programs in the United States and Canada. Of the programs surveyed, over 50% included occupational and environmental medicine training opportunities. Individuals who have trained in these settings have obtained employment in positions related to this training, and some have obtained certification. Our findings suggest that preventive medicine training programs may provide an avenue for training and certification in occupational and environmental medicine.

A survey of residency management training: general preventive medicine graduates.

General preventive medicine residents at the University of Arizona are introduced to management skills and issues during graduate medical training to prepare them for future administrative positions. Our objectives were to learn whether administration training was effective and if acquired skills are useful in present job duties of graduates. We mailed a questionnaire to former general preventive medicine residents who had graduated between 1983 and 1992. Twenty-one (81.8%) of the 26 graduates returned a completed questionnaire rating the extent to which certain training activities improved administration skills and assessing the extent to which residency training overall prepare them for administrative work. Ratings reflected adequate preparation and usefulness of skills on the job. The survey indicates that administrative training should begin during residency years and that a variety of short-term and long-term activities, organized throughout both academic and practicum years can produce reasonable success in graduates. Medical Subject Headings (MeSH): preventive medicine, training.

Outcome analysis for lip carcinoma.

Carcinoma of the lip is a relatively common malignancy of the head and neck region, accounting for approximately one quarter of oral cavity cancers. Although this form of cancer is generally readily curable compared with malignancies at other head and neck sites, regional metastases, local recurrence, and even death from this disease may occasionally occur. A review of 1252 patients who were diagnosed with lip cancer from 1940 to 1987 was undertaken to identify and rank prognostic variables, clarify differential incidences of site predilection between male and female patients, and examine the correlation between tumor site and histopathologic diagnoses. Large tumor size, high tumor grade, the presence of adenopathy, a subsite other than the lower lip, and inadequate surgical margins were found to have a negative impact on determinate survival of patients with lip carcinoma. Twenty-one percent of lip cancers in female patients arose on the upper lip, whereas only 3% of lip cancers in male patients developed on the upper lip. Basal cell carcinomas comprised 13% of upper lip cancers and only less than 1% of lower lip cancers. Recurrence developed in 15.1% of the patients reviewed and was strongly associated with large tumor size and poor differentiation. Local recurrence was associated with a determinate survival of 78%, whereas patients having regional recurrences had a survival rate of 52%. These data support aggressive treatment of lip cancers greater than 3 cm in diameter, high-grade tumors, tumors associated with cervical lymphadenopathy, and upper lip and commissure tumors. Lip cancer in women seems to be slightly more aggressive than in men.

Postcricoid surface laryngeal electrode.

Progress in identification of the recurrent laryngeal nerve in thyroid and parathyroid surgery has lagged behind the identification of other head and neck nerves. Attempts to use electronic pulsed nerve stimulators with evoked response electromyography have failed due to the absence of a convenient and effective method of monitoring the larynx. A Postcricoid Laryngeal Surface Electrode as herein described shows excellent initial results as an electrode for electromyographic monitoring of the larynx for recurrent laryngeal nerve identification.

Use of a hemostat/stimulator probe and dedicated nerve locator/monitor for parotid surgery.

Traditionally, parotidectomy is performed by the surgical routine of locating the main trunk of the extratemporal facial nerve followed by lateral lobectomy or total parotidectomy. The use of a dissecting/stimulating hemostat and of a continuous electromyography (EMG) locator/monitor was studied in terms of its effectiveness on the technique and outcome of parotid surgery.

Factors associated with age of onset of necrotizing enterocolitis.

To investigate factors associated with risk and age of onset for necrotizing enterocolitis (NEC), a retrospective case-control review was performed of patients with NEC and control infants matched for birthweight and date of admission. NEC cases were defined by Bell staging criteria and were included if pneumatosis intestinalis, histologic confirmation, or a recognized complication of NEC was identified in association with clinical signs and symptoms. NEC was significantly related to birthweight and premature post-conceptional age. In contrast to control infants, patients with NEC had higher 5 minute Apgar scores, less significant respiratory disease, and more rapid feeding practices. Two distinct subgroups of patients with NEC based on postnatal age of onset were apparent. Patients with early onset NEC (21 days or less postnatal age) had less significant respiratory disease and were fed more rapidly than late onset patients. Late onset NEC (more than 21 days postnatal age) occurred frequently in convalescing, relatively well premature infants who were still, however, of preterm postconceptional age. Relatively well premature infants with minimal respiratory disease are still at risk for NEC. Advances in neonatal care and survival of very low birthweight infants may account for a shift in prevalence to older infants who are yet of preterm postconceptional age.

Recurrent laryngeal nerve localization using a microlaryngeal electrode.

Damage to the recurrent laryngeal nerve is a frequently seen complication in head and neck surgery. A system for intraoperative monitoring of the recurrent laryngeal nerve is presented. The key to this system lies in the use of a microlaryngeal electrode and inserter. Application of this system to various situations is described.

Recurrent nerve locating system.

One recurring problem for otolaryngologists is the patient with vocal cord paralysis after thyroid surgery. We review the literature to assess the magnitude of this problem and to assess presently available techniques for sparing the recurrent laryngeal nerve. We present a new system for intraoperative recurrent laryngeal nerve location during thyroid surgery.

Design and testing of a new electrode for laryngeal electromyography.

Electromyography of the intrinsic laryngeal muscles has not been widely used, partly because of the difficulty of accurate insertion and stabilization of existing electrodes. The sampling portion of our original electrode has been redesigned. Two needle electrodes, 4 mm in length, protrude from a truncated coneshaped, nonconducting body that has been fashioned to sit in the laryngeal ventricle. The depth of insertion is controlled, and the device resists accidental extrusion.

Design and testing of a transistorized nerve stimulator.

Presently available equipment for nerve stimulation includes the relatively expensive multifunction pulse generators and the disposable dc stimulators. We have designed a semidisposable, two-transistor pulse generator that is portable, inexpensive, and capable of dynamic nerve stimulation.

Reinnervation of an Abbe-Estlander and a Gillies fan flap of the lower lip: electromyographic comparison.

Electromyographic examination of a left Gillies fan flap 29 months after operation and of a right Abbe-estlander flap 17 months after operation showed complete motor innervation of both.