Meningiomas invading the temporal bone with extension to the neck.

Meningiomas are the second largest group of brain tumors after gliomas. They account for 13 to 18 per cent of all primary intracranial neoplasms. The majority occur in the cerebral chamber; only 8 to 9 per cent are located in the cerebellar chamber. Meningiomas are hamartomatous, not truly neoplastic tumors, which arise from dural fibroblasts and particularly from arachnoid cells that tend to cluster around the tips of the arachnoid villi. Their preferential sites correspond closely with the locations where arachnoid villi are most frequently encountered, namely, along the major venous sinuses and their contributory veins, at the foramina of exit of the cranial nerves, and where arachnoid cell clusters are found within the trunk or the perineural sheaths of cranial nerves within or adjacent to the basal foramina. Of all intracranial meningiomas, 20 per cent eventually develop an extracranial extension. These extracranial extensions project, in order of decreasing frequency, to 1) the orbit, 2) the external table of the calvaria, 3) the nasal cavity and paranasal sinuses, and 4) the parapharyngeal (cervical) space. Once a meningioma has gained access to the temporal bone, its tendency to extend beyond the confinements of the skull increases to 43 per cent. The most frequent pathway is through the jugular and lacerate foramina into the parapharyngeal space, where it may manifest as a nasopharyngeal, oropharyngeal, retromaxillary, retromandibular, or cervical neck mass. A meningioma in the parapharyngeal area can represent 1) an extracranial extension of a primary intracranial tumor, 2) a neoplasm arising in the jugular foramen, 3) a neoplasm originating from an arachnoid cell cluster within the trunk of a cranial nerve or its perineural sheaths within or near a neural foramen, or 4) a metastasis to a cervical lymph node from a primary intracranial meningioma. Meningiomas extending to the neck are unique because of their tendency toward extracranial expansion, higher incidence of local recurrence, multicentric growth, and frequent combination with other neoplasms of the central nervous system. They are frequently an expression of the central form of neurofibromatosis (von Recklinghausen's disease).

Tracheostomy in neonates and small infants: problems and pitfalls.

Newborn babies and small infants who require tracheostomy often follow a complicated clinical course characterized by frequent sepsis, altered ventilatory dynamics, and eventual respiratory decompensation. Many of these problems are avoidable with use of a properly placed endotracheal tube during tracheostomy, a special surgical technique in the performance of the tracheostomy, and silicone rubber tracheostomy tubes. Seventy-four babies underwent tracheostomy at our Children's Center between 1963 and 1976. A review of this experience demonstrates the benefits of unhurried, standardized technique and management. In the 48 newborns requiring tracheostomy, no technical difficulties were encountered, and no complications occurred as a result of the tracheostomy. In the group of 26 older infants, however, there were significant complications, especially in children undergoing emergency tracheostomy without a previously placed endotracheal tube. Although there were no deaths directly related to tracheostomy, one case of pirulent tracheitis and one case of interstitial thyroid hemorrhage were noted at autopsy. Among survivors, there was one case of bilateral pneumothoraces, two cases of severe subcutaneous emphysema, and three cases of postoperative bleeding. Review of the long-term complications in this series demonstrates the benefits of the silicone rubber polymer tube. Since its routine use, problems with stomal granulation have almost disappeared. There have been no problems in extubating the very young babies. Our operative technique and intensive care management of these babies will be emphasized as the keys to the improved outcome.

Airway management in the premature infant.

Out of 262 premature newborn patients admitted with a diagnosis of respiratory distress, it was necessary to treat 70 with a ventilator. Of these 70, 25 eventually underwent tracheostomy. Indications for tracheostomy were that of an infant needing prolonged endotracheal intubation greater than one week. The procedure itself was easily performed and an overall complication rate of 7% was the result. Of the patients who underwent tracheostomy, 8% had significant complications. There was no death attributable to the treatment regime. We feel, therefore, that a combination approach starting with the endotracheal tube and progressing to tracheostomy when necessary, provided the best care for premature infants requiring intensive airway management.