Dual-Acquisition Extracranial Computed Tomographic Angiography-Enhanced Neck Computed Tomography before Transoral Laser Microsurgery in Head and Neck Cancer Patients. Preliminary results.

Transoral laser microsurgery (TLM) is an alternative surgical technique for piecemeal endoscopic resection of mucosal-based aerodigestive tract tumors. Though uncommon, potentially catastrophic postoperative bleeding may occur with this technique secondary to vascular injury along invasive tumor inner margins. We describe our preliminary results using a preoperative dual-acquisition extracranial computed tomographic angiography (CTA)-enhanced neck computed tomographic (CT) imaging and postprocessing protocol developed to improve visualization of mucosal-based head and neck tumors and adjacent arterial branches with the objective of facilitating TLM surgery and reducing secondary bleeding complications. Twenty patients with known head and neck cancers anticipated for TLM resection were selected for a dual-acquisition CTA-CT scanning and postprocessing protocol. The mucosal-based pharyngeal tumors and peritumoral vessel enhancement were compared on matched CTA and enhanced neck CT axial images. Operative reports and clinical notes were retrospectively reviewed to identify patients in whom the TLM surgical approach was altered or changed to conventional open surgery as a result of presurgical CTA-CT findings. Enhancement of peritumoral vasculature was almost uniformly superior (19 of 20 patients) on extracranial CTA compared with enhanced neck CT images. In six candidates for TLM surgery (30%), CTA findings resulted in a change in surgical approach to improve intraoperative peritumoral vascular control. In this small pilot series, primary tumor-peritumoral vessel relationships delineated by the addition of extracranial CTA to preoperative enhanced neck CT frequently impacted the surgical approach and facilitated TLM planning.

Prophylactic placement of gastrostomy feeding tubes before radiotherapy in patients with head and neck cancer: is it worthwhile?

BACKGROUND: After radiation treatment of head and neck cancer, placement of gastrostomy feeding tubes can be technically difficult. The practice of placing tubes before treatment is probably justified if the tube is used for more than 4 weeks and if complications are infrequent. The aim of this study was to determine the outcome of prophylactically placed gastrostomy tubes in patients with head and neck cancer at our institution from 1995 to 1999. STUDY: Data collected retrospectively from the patients' medical records included demographics, duration of tube use, and complications associated with placement. RESULTS: A total of 54 patients (40 men, 14 women) with a mean age of 68.5 years (range, 49-88 years) were studied. Thirty-one patients were treated with both surgery and radiotherapy; 17, with only radiotherapy; and 6, with chemotherapy, radiation, and surgery. The gastrostomy tube was placed before initiation of radiation treatment in 41 patients and after treatment in 13. The method of placement included pull technique (n = 41), introducer technique (n = 10), and surgical (n = 3). Four patients who had a tube placed after treatment required hospitalization for dehydration, whereas no hospitalizations were needed in the prophylactic group. The median duration of tube use was 165 days (range, 0-1,105 days). Only three patients had a complication directly related to placement. CONCLUSION: Gastrostomy tube placement before treatment is appropriate, given the median number of days required for use and limited complications associated with placement.

A functional outcome swallowing scale for staging oropharyngeal dysphagia.

OBJECTIVE: To develop a simple and straightforward functional outcome swallowing scale (FOSS) for patients with oropharyngeal dysphagia to determine the severity of the disorder and the effectiveness of therapy or outcome. DESIGN: Five years ago, the author developed a dysphagia staging scale based on personal experience and a review of the English literature. This scale was shared with colleagues from the specialties of otolaryngology, speech pathology, neurology, and gastroenterology, both within and outside the author's institution. Minor modifications have been made. The scale has been used in clinical management and retrospective studies. SETTING: PATIENTS were seen in a multispecialty, tertiary care, academic center. PATIENTS: The patient population included the full spectrum of oropharyngeal dysphagia in adults, but was weighted heavily toward aging patients and patients with head and neck cancer, neurologic disorders, gastroesophageal conditions, and psychiatric problems. RESULTS: The stages are as follows: stage 0 = normal function and asymptomatic; stage I = normal function but with episodic or daily symptoms of dysphagia; stage II = compensated abnormal function manifested by significant dietary modifications or prolonged mealtime (without weight loss or aspiration); stage III = decompensated abnormal function with weight loss of 10% or less of body weight over 6 months due to dysphagia, or daily cough, gagging, or aspiration during meals; stage IV = severely decompensated abnormal function with weight loss of more than 10% of body weight over 6 months due to dysphagia, or severe aspiration with bronchopulmonary complications, nonoral feeding recommended for most of nutrition, and stage V = nonoral feeding for all nutrition. CONCLUSIONS: The FOSS was successful for staging various adult patients with dysphagia into clinically useful, overall performance categories. It has been applied successfully to retrospective outcome studies and to clinical management by clinicians from different specialties.

Results of near-total laryngectomy.

The clinical records of 225 patients undergoing primary or salvage near-total laryngectomy (NTL) for laryngeal and pyriform cancer were analyzed for local control and morbidity. If the primary cancer was laryngeal in origin, patients underwent a simple NTL; if it was pyriform, a minor modification called near-total laryngopharyngectomy (NTLP) was used. When NTLP was extended to include necessary portions of the tongue base or posterior pharyngeal wall, pharyngeal reconstructions were added. The principal outcomes studied were 1) 5-year local control of the primary cancer, 2) achievement of lung-powered shunt speech, and 3) incidence of aspiration. The local control of cancer was similar to that expected with total laryngectomy or laryngopharyngectomy. Conversational voice was achieved in 85% of patients surviving beyond 1 year. Some patients required additional surgery for voice -- usually endoscopic dilation. Aspiration was absent if primary healing was achieved. It was troublesome in wound breakdown if the shunt was directly affected. Secondary anti-aspiration procedures were required in 9% of our patients -- usually preserving shunt speech.

Proposed catheter standards for pharyngeal manofluorography (videomanometry)

With the recent introduction of commercially available pharyngeal manofluorography systems, catheter design should be standardized. Catheters of different designs can produce different data because of their design characteristics. A standard catheter design should make results between investigators comparable and facilitate acceptable normal values. The authors' combined laboratory experience with many catheter designs was reviewed and the literature consulted. For pharyngeal manofluorography, the proposed standard catheter should be 2 x 4 mm in diameter, ovoid, and 100 cm long. The catheter should be marked in centimeters with an anterior and posterior orientation. There should be a slightly malleable, 3- to 4-cm length without sensors beyond the most distal sensor. Solid state transducer sensors should be three or four in number and placed in the pharyngoesophageal segment, midhypopharynx, and tongue base (esophagus for fourth sensor). Sensor spacing should be 3 cm, except 2 cm between the midhypopharynx and tongue base. Unidirectional, in-line, posteriorly oriented sensors with the option of a single circumferential sensor in the cricopharyngeus are currently preferred over circumferential sensors because of their small diameter (patient comfort).

Recurrent adult myofibromatosis. A case report.

Myofibromatosis generally is regarded as a fibrous proliferative disease of neonates and children that, even when multicentric, has an excellent prognosis and a propensity for spontaneous involution. Reported is a case of solitary, locally recurrent myofibromatosis in the ear canal of an adult patient. It was initially thought to be a leiomyoma. The diagnosis of myofibromatosis was made on the basis of its histologic appearance and corroborated by immunohistochemical stains. Clinicians and pathologists should be aware that myofibromatosis may occur in adults in unusual locations, with a potential for local recurrence. Furthermore, its histologic appearance may mimic that of other mesenchymal neoplasms.

Know your anatomy. Local anesthesia for cutaneous lesions of the head and neck--practical applications of peripheral nerve blocks.

Peripheral nerve blocks can be used routinely in an outpatient setting. The innervation of the face and the technique we use to perform nerve blocks are reviewed. We present four cases of skin cancer and one of rhinophyma in which nerve blocks were used to minimize the discomfort associated with local anesthesia.

Polyethylene oxide gel: a new dressing after endoscopic sinus surgery.

The purpose of dressings after endoscopic sinus surgery is to absorb secretions, tamponade bleeding, discourage adhesions, and facilitate sinus and nasal hygiene. The ideal dressing should conform to the irregularities of the nasal-sinus cavity and resist adherence to the wounds so it can be easily removed. It should be economical, non-irritating, and antiseptic. The failure of previous dressings to fulfill all of these criteria led the author to evaluate a new alternative. Polyethylene oxide gel (Vigilon) was identified as a potential improvement and investigated in a clinical trial of 60 cases. This paper presents the author's observations and technique for application. Polyethylene oxide gel resulted in no significant complications. It appears superior to previously described dressings, primarily because of patient comfort at removal.

Polyethylene oxide gel. A new intranasal dressing after septorhinoplasty.

The purpose of intranasal dressings after septorhinoplasty is to absorb secretions, stop bleeding, act as an internal splint, discourage adhesions, and facilitate nasal hygiene. The ideal dressing should conform to the irregularities of the nasal cavity and resist adherence to the wounds of the nasal lining so it can be easily removed. It should be nonirritating, antiseptic, and economical. The failure of previously reported dressings in one or more of these requirements led us to evaluate a new alternative. Polyethylene oxide gel (Vigilon) was identified as a potential improvement and investigated in 48 patients over 17 months. There were no significant complications. Polyethylene oxide gel appears superior to previously described dressings, primarily because of comfort for the patient at removal.

Oral dantrolene sodium for tonsillectomy pain: a double-blind study.

Tonsillectomy in adults and older children is typically accompanied by 7 to 14 days of pain. On the basis of clinical observations of patients treated perioperatively with dantrolene sodium for malignant hyperthermia, we hypothesized that pharyngeal muscle spasms are a major factor in tonsillectomy pain. We entered 113 patients, 11 years of age and older, into a double-blind, placebo-controlled study to evaluate the effectiveness of dantrolene sodium in reduction of tonsillectomy pain. Patients were randomly assigned either dantrolene (1.5 mg/kg per day) or placebo orally four times a day for 5 days postoperatively. On a standardized questionnaire, the patient recorded pain, diet, activity level, analgesics, and side effects, daily for 2 weeks. Also, alkaline phosphatase (alk phos) and serum aspartate aminotransferase (SGOT) levels were determined before the operation and 2 weeks after. Patients who received dantrolene had no significant differences in subjective pain, diet, or activity level scores from those of patients who received placebo. Dantrolene patients did, however, require significantly less analgesic use than placebo patients (p = 0.034, 0.015, and 0.005 for postoperative days 2, 3, and 4, respectively). There was no significant difference in side effects or changes in liver enzyme between the dantrolene and placebo groups. We conclude that dantrolene sodium, given in the dosage noted, is effective in reduction of analgesic requirements after tonsillectomy.

Life-threatening soft-tissue infections of the neck.

Four adult patients had life-threatening soft-tissue infections of the neck. One had Hemophilus influenzae infection, one had Streptococcus pyogenes infection, and two had polymicrobial mixed aerobic and anaerobic infections. Three of the four patients died despite appropriate antimicrobial therapy and surgical intervention. These cases demonstrate the spectrum of serious soft-tissue infections of the neck in both the compromised and the uncompromised host. Soft-tissue infections of the neck may be necrotizing or nonnecrotizing. Cellulitis secondary to H. influenzae and beta-hemolytic streptococci is usually non-necrotizing, whereas necrotizing infections are caused most commonly by synergistic organisms. Potential complications include septic shock, disseminated intravascular coagulation, acute renal failure, adult respiratory distress syndrome, mediastinitis, and pericarditis. Early recognition with aggressive medical and surgical therapy is essential to reduce the mortality.

Respiratory distress after recurrent laryngeal nerve sectioning for adductor spastic dysphonia.

Adductor spastic dysphonia is a voice sign associated with various neurologic and psychologic disorders. Treatment of spastic dysphonia in selected patients is unilateral recurrent laryngeal nerve sectioning. Except for voice change or, in some patients, return of phonatory spasticity, there have been no long-term sequelae or complications of this treatment. We describe three patients with adductor spastic dysphonia who underwent recurrent laryngeal nerve sectioning and who, 3 to 38 months later, suffered respiratory distress that required tracheostomy. The respiratory distress in all three patients was due to episodic jerky vocal cord hyperadductions that caused stridor during inspiration and expiration. These repetitive laryngospasms during respiration and phonation were progressive. Two patients needed an arytenoidectomy to achieve a useful voice, and all three required a permanent tracheostomy to alleviate inspiratory laryngeal obstruction.

Malignant pyoderma.

Malignant pyoderma is a rare inflammatory pyoderma of unknown cause with characteristic destructive and necrotizing ulcers limited to the face, neck, and upper trunk. The typical lesions are small, purulent, periauricular ulcers. Enlargement and coalescence result in extensive lesions that may ultimately destroy portions of the external ear. The histopathologic findings are acute and chronic inflammation with necrosis. Treatment consists of long-term systemic corticosteroids. We present two new cases and alert otolaryngologists to the seriousness of this disease.

"Colonic type" adenocarcinoma of the nasal cavity and paranasal sinuses.

Primary "colonic type" tumors of the nasal cavity and paranasal sinuses are adenocarcinomas with histologic features similar to those of colonic cancers. Their behavior is one of local invasion and recurrence. Unlike tumors of the colon, they rarely metastasize. Surgical resection by means of lateral rhinotomy with or without radiation is the treatment of choice. Prognosis is poor. This type of tumor should be recognized by pathologists and its implications should be known to head and neck surgeons.

Gross and microscopical blood supply of the trachea.

Twenty-one human tracheal specimens were perfused and dissected, 10 with conventional techniques and 11 with clearing and microdissection techniques. The lateral pedicles of the trachea and esophagus induct vessels from the inferior thyroid, subclavian, supreme intercostal, internal thoracic, innominate, and superior and middle bronchial arteries. These vessels are interconnected along the lateral surface of the trachea by an important longitudinal vascular anstomosis. From the 2 lateral longitudinal anastomoses the lateral and anterior tracheal walls receive their blood supply through transverse segmental vessels that run in the soft tissues between the cartilages. These transverse vessels interconnect the longitudinal anastomoses across the midline and feed the submucosal capillary network that arborizes richly beneath the endotracheal mucosa. The tracheal cartilages receive nourishment from the capillary bed applied to their internal surface. The esophageal arteries and their subdivisions that supply the posterior membranous wall of the trachea contribute almost nothing to the circulation of the cartilaginous walls.