Laser lingual tonsillectomy.

Diseases of the lingual tonsils are generally overlooked in both clinical practice and medical literature. Infections of the lingual tonsils are usually treated medically, although in patients with symptomatic chronic inflammation or hyperplasia of the lingual tonsils, surgical intervention may be indicated. Eighty-two patients with benign inflammatory problems of the lingual tonsils, who were not improved by medical management, underwent laser lingual tonsillectomy at four different medical centers, between 1984 and 1987. The procedure was tolerated well by all of the patients, with no significant operative complications. Short- and long-term results were satisfactory. Laser surgery is an effective method for the treatment of benign hyperplastic and inflammatory diseases of the lingual tonsils.

Mediastinitis occurring as a complication of odontogenic infections.

Mediastinitis occurring from a descending odontogenic infection occurs rarely. The diagnosis is sometimes difficult to make and is often delayed until the patient is in extremis. The physical examination is often nondiagnostic, but may include brawny edema of the neck and chest. CT scanning provides the most accurate diagnostic information. The treatment is always surgical, in combination with appropriate antibiotics. Five patients with mediastinitis secondary to odontogenic infections are presented, and the technique of transcervical drainage of the anterior and posterior mediastinum is reviewed.

Chin reconstruction with pectoralis myocutaneous flap.

Chin reconstruction after radical surgery for carcinoma of the oral cavity is a complex and controversial problem. We have developed a simple, single-stage, primary procedure for chin reconstruction. It is easily mastered and is based on a simple modification of the pectoralis major myocutaneous flap. Our experience includes seven cases, including two with total chin reconstructions. The number and type of complication is low and consistent with the magnitude of the surgical procedure. This operation provides acceptable aesthetic and functional results to patients undergoing partial or total resection of the chin.

Hypoparathyroidism following total laryngopharyngectomy and gastric pull-up.

We have used the gastric pull-up technique for closure of large pharyngoesophageal defects after radical oncological surgery since 1979. The management of severe hypocalcemia and hypovitaminosis D seemed more difficult in patients undergoing pull-up reconstruction than in patients undergoing the same extirpative surgery, but reconstructed with more traditional methods. To determine if hypocalcemia and hypovitaminosis D were more common in gastric pull-up patients, and if postoperative management of these conditions is more problematic in this group, we retrospectively compared three groups of head and neck surgery patients. Group 1 consisted of 17 patients undergoing total laryngectomy with thyroid complex preservation. Group 2 consisted of 7 patients undergoing mediastinal dissection with total laryngectomy-thyroidectomy previously or concurrently. Group 3 consisted of 30 patients undergoing total laryngopharyngoesophagectomy-thyroidectomy and gastric pull-up reconstruction. The incidences of hypocalcemia requiring therapy were 12%, 50%, and 73%, respectively, with an overall incidence of 51%. The average amounts of supplemental calcium and vitamin D in the three groups were compared. A significant between the three groups was noted. Finally, the dietary calcium and vitamin D requirements for one problematic patient were prospectively recorded and summarized graphically. We conclude that any patient should be carefully monitored for the signs and symptoms of hypocalcemia after major head and neck surgery. In the special instance of the gastric pull-up patient, calcium requirements and the range of serum calcium fluctuation are greatly increased compared to patients undergoing more traditional methods of reconstruction.

Reconstructive techniques after ablative head and neck surgery.

This article describes the reconstructive alternatives available to the head and neck surgeon today. Myocutaneous flaps, osteomyocutaneous flaps, and free flaps for reconstruction in the head and neck are detailed. Complications attendant to the use of these flaps are reported and cataloged.

Management of recurrent head and neck cancer.

The management of recurrent head and neck malignancy can be one of the most frustrating experiences faced by the head and neck surgeon. A recent study indicates that twice the number of patients succumb to distant metastasis from primary tumors than did 20 years ago. This article discusses the operative management of these patients and the role of radiotherapy and chemotherapy in their treatment.

Combined functional oral rehabilitation after radical cancer surgery.

Formerly, patients requiring extensive reconstruction of the oral cavity and oropharynx after radical, ablative oncologic surgery faced the unhappy prospect of lengthy, multistaged repair to enjoy acceptable cosmesis and a functional oral cavity. The advent of the pectoralis major myocutaneous flap has made soft-tissue, single-stage closure of large oral cavity and oropharyngeal defects a reality. Unfortunately and frequently, restoration of mucocutaneous continuity of the mouth does not result in acceptable function. Advances in the materials and design of prostheses suggested the combination of myocutaneous flap reconstruction and functional, prosthetic restoration as a method of returning the patient with head and neck cancer to a state of acceptable function and appearance soon after major resection.

Immediate reconstruction after total laryngopharyngoesophagectomy and mediastinal dissection.

Advanced or recurrent carcinoma surrounding the tracheostoma in a previously laryngectomized patient is most effectively treated with transsternal radical dissection of the upper mediastinum and relocation of the trachea to the upper chest. The use of the pectoralis major myocutaneous flap, now enables the head and neck surgeon to perform immediate reconstruction and provide protection for the great vessels after mediastinal dissection for stomal recurrence. Formerly, patients with stomal recurrence also involving the cervical or upper thoracic esophagus were poor surgical candidates. Frequently, patients succumbed to their disease before the continuity of the digestive tract could be re-established. Currently, at our institution, this vexing reconstructive problem is solved with immediate, one-stage reconstruction. The esophagus is replaced by transposing the stomach through the posterior mediastinum and anastomosing to the tongue base, "gastric pull-up." The mediastinal defect is closed with the concomitant use of the pectoralis myocutaneous flap. The muscular portion of the myocutaneous flap provides excellent coverage for the great vessels of the upper mediastinum. Our experience with 39 patients who underwent this procedure between 1979 and 1983 is presented.

Voice preservation in postcricoid and cervical esophageal cancer.

Total laryngopharyngectomy has been the standard surgical treatment for postcricoid and cervical esophageal cancer. Of patients undergoing standard laryngectomy, 30% will develop esophageal speech and a substantial number of the remainder can be rehabilitated by use of the electrolarynx or tracheoesophageal puncture. However, the vast majority of patients who undergo laryngopharyngectomy with current methods of reconstruction remain voiceless. Reconstruction of the hypopharynx and cervical esophagus has been a formidable challenge to head and neck surgeons. Various types of reconstruction have been used: skin grafts, local neck flaps, deltopectoral flaps, free bowel grafts, myocutaneous flaps, etc. Gastric pull-up reconstruction of the hypopharynx and cervical esophagus is superior to other methods. A new technique uses this procedure, allowing immediate vocal rehabilitation. Five patients underwent pharyngolaryngoesophagectomy for malignant lesions of the postcricoid area and/or cervical esophagus. Reconstruction of the digestive tract using the stomach and immediate voice restoration by a tracheogastric shunt retaining the anterior half of the larynx and upper part of the trachea represent a new surgical method after pharyngolaryngoesophagectomy.

Complications after pectoralis major myocutaneous flap reconstruction of head and neck defects.

This article reviews our experience with 86 patients undergoing 95 pectoralis major myocutaneous flap reconstructions. Complications and their incidence were very similar to those reported in previous series. Three cases of hidden recurrences appear to be previously unreported complications. The problem of delayed detection of recurrence in at-risk patients is an important one and may be unique to myocutaneous flaps. With the exception of the problem of hidden recurrence, the pectoralis major myocutaneous flap compares favorably with other methods of reconstruction of head and neck defects. Its size, viability, and versatility make it a valuable tool for extending the limits of resectability and reconstruction.