Postoperative anisocoria in a patient undergoing endoscopic sinus surgery.

OBJECTIVE: Anisocoria after sinus surgery can be related to serious complications such as intraorbital hematoma or increased intracranial pressure secondary to an expanding hematoma. CASE REPORT: A 51-year-old man underwent endoscopic surgery of sinuses, and developed anisocoria; likely a result of the local spread of cocaine used to provide local anesthesia and vasoconstriction. The localized effect of this anesthetic agent produced a typical picture of nasociliary ganglion block that subsided in a few hours. In the results, the nasociliary nerve block was noticed on recovery from anesthesia with no other neurologic deficit. Ophthalmologic examination demonstrated a short-lasting anisocoria with loss of accommodation and sensory block over the tip of the nose. CONCLUSION: The central spread of the local anesthetics should be considered as a differential diagnosis of unexplained anisocoria, especially when it is associated with loss of corneal reflex.

Positron emission tomography in the evaluation of the N0 neck.

The presence of cervical lymph node metastasis in patients with head and neck cancer is associated with an unfavorable prognosis. Reports vary as to whether various conventional radiographic studies, such as computed tomography (CT) and magnetic resonance imaging, confer an advantage over physical examination in the patient without clinical findings of cervical metastasis (N0). Positron emission tomography (PET) is a functional imaging modality that has recently been used for head and neck neoplasms. The use of PET in the evaluation of the N0-staged neck in 14 consecutive patients with squamous cell carcinoma (SCC) of the upper aerodigestive tract is reported. Seven patients (50%) undergoing 13 neck dissections had pathologic evidence of disease. PET scans were positive in five patients with pathologically confirmed cervical metastasis. PET scans were negative in seven patients (11 neck dissections) with no pathologic evidence of disease. PET scans were positive for unilateral cervical metastasis in two of three patients with involvement of a single lymph node. PET scans were positive in two of three patients with more than two lymph nodes involved. PET had an accuracy of 100% in the eight patients with SCC of the oral cavity. In patients with oropharyngeal or hypopharyngeal carcinoma PET localized cervical metastasis in two of four patients with neck metastasis. In the patient with an N0-staged neck on clinical examination, PET was found to have an overall sensitivity of 78%, specificity of 100%, positive predictive value of 100%, negative predictive value of 88%, and accuracy of 92%. CT demonstrated sensitivity of 57%, specificity of 90%, positive predictive value of 80%, negative predictive value of 75%, and accuracy of 76%. PET showed a trend in increased accuracy (P = 0.11) over CT. PET appears to be a promising diagnostic aid that may be applied when evaluating the N0-staged neck, especially for SCC of the oral cavity.

Serum-free keloid fibroblast cell culture: an in vitro model for the study of aberrant wound healing.

The purpose of this study was to develop an in vitro serum-free keloid fibroblast model. Keloid formation remains a problem for every surgeon. Prior evaluations of fibroblast characteristics in vitro, especially those of growth factor measurement, have been confounded by the presence of serum-containing tissue culture media. The serum itself contains growth factors, yet has been a "necessary evil" to sustain cell growth. The design of this study is laboratory-based and uses keloid fibroblasts obtained from five patients undergoing facial (ear lobule) keloid removal in a university-affiliated clinic. Keloid fibroblasts were established in primary cell culture and then propagated in a serum-free environment. The main outcome measures included sustained keloid fibroblast growth and viability, which was comparable to serum-based models. The keloid fibroblast cell cultures exhibited logarithmic growth, sustained a high cellular viability, maintained a monolayer, and displayed contact inhibition. Demonstrating model consistency, there was no statistically significant difference between the mean cell counts of the five keloid fibroblast cell lines at each experimental time point. The in vitro growth of keloid fibroblasts in a serum-free model has not been done previous to this study. The results of this study indicate that the proliferative characteristics described are comparable to those of serum-based models. The described model will facilitate the evaluation of potential wound healing modulators, and cellular effects and collagen modifications of laser resurfacing techniques, and may serve as a harvest source for contaminant-free fibroblast autoimplants. Perhaps its greatest utility will be in the evaluation of endogenous and exogenous growth factors.

Laser epiglottectomy: endoscopic technique and indications.

Endoscopic epiglottectomy (epiglottidectomy) may be performed with relative ease and minimal morbidity by using standard microlaryngoscopy techniques and the CO2 laser. Depending on the indications, the removal may be partial or complete. Indications for 51 epiglottectomies included treatment of supraglottic airway obstruction--30 cases; discovery of benign or malignant neoplasm (diagnosis and staging)--20 cases; treatment of malignant neoplasm--7 cases; glottic visualization--4 cases; and treatment of chronic inflammatory conditions--1 case. It is not unusual for a patient to have more than one indication for this procedure. Some epiglottic cancers invade the pre-epiglottic space. This crucial information may not be detectable by MRI or CT scanning techniques. Laser epiglottectomy provides a method to explore and perform a biopsy of the pre-epiglottic space and thereby stage these lesions accurately. There are no significant problems with postoperative alimentation, airway, or voice. Any form of primary or adjuvant therapy can be started without delay.

Clinical characteristics of nosocomial sinusitis.

Paranasal sinusitis is an important source of sepsis and morbidity in head injury victims and requires aggressive pursuit and therapy. Of 208 head-injured patients, 24 developed paranasal sinusitis. The Glasgow Coma Scale score of the sinusitis patients was 7.1 +/- 3.9. Nineteen patients were intubated nasotracheally, and five were intubated orally. Sinus air fluid levels, indicative of bleeding into the sinus, were seen on 17 initial computed tomographic scans. Maxillary sinus suppuration occurred in 23 patients; in 20 it was the initial sinus involved. Twenty-one patients developed polymicrobial sinusitis. Coexisting infections were common. In 15 patients with concurrent tracheobronchitis or pneumonia, organisms identical to those in sinus aspirations were recovered from the sputum. Seven patients had associated bacteremia. Meningitis in six patients shared a common pathogen with their sinusitis. Nonoperative management successfully resolved sinus infection in 19 cases. Five patients required open sinusotomy.

Lymphoscintigraphy of the neck.

Lymph node imaging has been helpful in managing patients with lymphoma, melanoma, and breast cancer. To evaluate 38 patients with head and neck cancers, 99mTc minicolloid was injected adjacent to the tumor and into a similar area on the uninvolved side. Lymphoscintigraphy of the neck was performed at 3- and 5-hour intervals after injection and bilateral cervical lymphatic drainage was observed. Each patient then underwent a neck dissection. The pathologic node findings were then correlated with the neck scans. Results confirmed that cervical lymphatic drainage is unpredictable in 50% of the patients once the channels are involved with metastatic disease. Lymphoscintigraphy is not a reliable method of detecting early metastatic cervical carcinoma.

Localized amyloidosis of the head and neck and upper aerodigestive and lower respiratory tracts.

Seven cases of localized amyloidosis limited to structures of the head and neck and upper aerodigestive and lower respiratory tracts evaluated and treated at Boston University Hospitals in a recent 7-year period were reviewed. Negative Congo red staining of abdominal adipose aspiration biopsy or rectal biopsy specimens established that the amyloidosis was not systemic. Localized amyloidosis occurred in discrete masses in a variety of sites in the aerodigestive tract including the orbit, nasopharynx, lips, floor of mouth, tongue, larynx, and tracheobronchial tree. Five patients required surgical excision because of significant airway obstruction or organic dysfunction. Amyloid deposits completely excised with the carbon dioxide laser have not recurred, though other amyloid masses may appear elsewhere within the same organ or region. Amyloidosis may occur primarily or secondarily to other disease states. Localized amyloidosis has not been chemically identified but is usually defined by the absence of systemic features. While rare, amyloidosis must be recognized and understood by the otolaryngologist/head and neck surgeon to allow appropriate diagnostic and therapeutic planning.

Excisional biopsy in the selective management of T1 glottic cancer: a three-year follow-up study.

Transoral excisional biopsy has been used in the evaluation and management of 103 T1 glottic cancers. A 3-year follow-up on these patients indicates that excisional biopsy unequivocally established the diagnosis and stage of the disease and that it is adequate treatment for micro and mini squamous cell cancers of the glottis in which the margins of excision are clear. Excisional biopsy with positive margins and larger T1 tumors establishes the absolute need for radiotherapy. Excisional biopsy is ideal for the diagnosis and management of verrucous carcinoma and spindle cell carcinoma. Recurrent/residual squamous cell carcinoma after radiotherapy should be explored by excisional biopsy which may be curative or will establish the need for partial or total laryngectomy. The appropriate use of excisional biopsy in the selective management of early T1 glottic cancers requires attention to detail by the surgeon and the pathologist and sound clinical judgment.

Palliation of airway obstruction from tracheobronchial malignancy: use of the CO2 laser bronchoscope.

A CO2 laser rigid bronchoscope system has been used to palliate symptoms of a malignancy obstructing the tracheobronchial airway. Fifty-nine endoscopic laser operations (34 patients) were done between 1975 and 1981. Severe dyspnea and obstructive atelectasis were the most common indications for treatment. Contraindications for treatment included extrinsic tracheobronchial compression, widespread distant metastases, rapidly progressing tumors, and highly vascular neoplasms. There were nine primary tracheal malignancies, five metastases from distant sites, and 20 primary lung cancers with tracheobronchial obstructions. Most patients were previously treated with one or more standard modalities (radiation therapy, surgery, and chemotherapy). Removal of airway obstruction was occasionally indicated prior to radiation therapy to facilitate treatment. There were seven instances of complications in this group of patients and one mortality. Most patients (23 of 34) have died from their malignancy. The best palliation was achieved in proximal (tracheal and main stem bronchial), slower growing tumors.

History of the carbon dioxide laser in otolaryngologic surgery.

The review of recent history shows that since the initial discovery of the principle of the laser, rapid dissemination and application of this modality in the field of medicine have occurred. The use of laser energy has become an established technique in microsurgery and endoscopic surgery, particularly in the field of otolaryngology and head and neck surgery. Laser instruments and surgical techniques and experience are becoming increasingly widely appreciated. All these developments are a tribute to the imagination and determination of a few individuals who were instrumental in recognizing the potential of laser energy for surgical application and in developing and using this new modality in clinical surgery. The major developments in laser surgery include early laboratory studies of laser surgical applications and their effects, the invention and development of instruments allowing application of laser energy in a variety of surgical settings, particularly the upper aerodigestive tract, and clinical studies confirming the efficacy of laser surgery. Other significant developments include the successful application of laser surgery in the eradication or control of selected cancers in the upper aerodigestive tract, including the tracheobronchial tree. Although a firm foundation for laser surgery is well established, its future offers a wide vista of new opportunities.