Encounters with challenging bronchial foreign bodies: impromptu adaptation of technique.

We present a retrospective review of 2 cases of unusual foreign bodies and discuss methods needed for successful removal of the objects. The review stresses the need for preparation in managing difficult and unexpected situations. Specific instrumentation as well as surgical resourcefulness provided for successful removal of a carrot fragment in one instance and a plastic bead in the other. The need to individualize tracheobronchial foreign body extraction is stressed, as is the importance of keeping some of the "old-time" instruments in one's instrument cabinet.

Sinonasal hemangiopericytoma.

Sino-nasal hemangiopericytomas are rare indolent mesenchymal tumors which slowly invade local tissue. Electronmicroscopy and immunohistochemical techniques may be necessary to differentiate hemangiopericytomas from other sarcomatous tumors. Differentiation between malignant and benign tumors poses a difficult task, therefore clinical correlation as well histological confirmation is necessary to establish a diagnosis. Due to the low incidence of distant metastasis and low mortality, surgery consisting of wide local excision is usually curative.

The inverted Schneiderian papilloma: a 25-year study.

Inverted papillomas arising from the lateral nasal wall are controversial lesions which have been reported in the medical literature under a variety of titles. The designation "inverted Schneiderian papilloma" is recommended as an appropriate title to best convey the tumor's qualities of inversion, location, and distinctiveness of character. The etiology is uncertain. In the absence of a better explanation of its origin, the tumor should be considered a true epithelial neoplasm. Clinical features in 101 cases seen at the Geisinger Medical Center during the past 25 years are presented. The most frequent presenting complaint was nasal obstruction. The site of origin was the lateral nasal wall in the region of the middle meatus. The most characteristic attributes of the tumor were its tendency to recur, its destructive capacity, and its propensity to be associated with malignancy. To illustrate the pernicious nature of the lesion, a detailed description is given of the extent of bone erosion, the extraordinary sites of tumor extension, and the perioperative complications encountered. A philosophy of management has evolved based on the experiences gained from these 101 patients combined with a review of the experiences of others and study of the regional anatomy. A bold surgical approach is detailed using a lateral rhinotomy incision or a modified Weber-Ferguson incision to expose the tumor adequately and remove it completely. The recurrence rate using this approach was 2%. An associated malignancy was present in 8 patients. Four died of widespread metastases within a year of the diagnosis. The remaining 4 patients are long-term survivors free of disease.

Inverted papilloma of the nasal vault and paranasal sinuses: spectrum of CT findings.

Inverted papilloma is a benign epithelial neoplasm that arises within the nasal vault and, less commonly, in the paranasal sinuses. It is relatively uncommon, accounting for less than 4% of mucosal tumors in this region. The tumor is characterized by a high recurrence rate (emphasizing the importance of accurate tumor mapping and total tumor extirpation), associated epithelial malignant tumors (5-8%), and bone destruction. The CT appearance of inverted papilloma is variable and non-specific. Nonetheless, inverted papilloma is the most likely diagnosis when a unilateral mass in the nasal vault, producing benign bony changes, extends centrifugally into the maxillary and ethmoidal sinuses and through the nasal choana into the nasopharynx in an elderly patient with chronic nasal obstruction. The purpose of this essay is to illustrate the CT features of inverted papilloma.

Fungal infections of the larynx.

Some generalizations regarding fungal infections of the larynx can be made. The reader is cautioned to refer to discussions of the individual infections for exceptions to these generalizations. For the most part, the mycoses are organisms of low pathogenicity emerging as opportunistic organisms thriving in a compromised host. The isolated fungal infections of the larynx reported are exceptions to the rule. Involvement of the larynx and other body sites outside the lung generally indicates a widely disseminated form of the disease. Fungal infections most commonly occur in the immunocompromised patient, including those afflicted with AIDS, cancer, leukemia, and other lymphoreticular neoplasms, patients on long-term corticosteroid therapy, patients with chronic systemic diseases, including diabetes mellitus and severe pulmonary disease, and patients who have undergone successful organ transplantation, which depends on immunologic suppression. Although specific fungi are characteristically found in designated endemic areas, the diseases may surface in remote areas in persons who have recently traveled through the endemic sites. The pathologic picture can be confusing, and pseudoepitheliomatous changes at times resemble malignancy. When atypical features occur in a patient with a suspicious history, special stains and cultures as well as skin tests and serologic studies may be helpful in establishing the diagnosis. For the most part, amphotericin B has been the mainstay of therapy, although the introduction of the newer azole drugs (ketoconazole, itraconazole and fluconazole) may present a breakthrough in the future therapy of these lesions. Ketoconazole has been proven efficacious in certain fungal infections. Itraconazole has recently been released for clinical use. Because of its lower incidence of toxic side effects, it may replace ketoconazole in the therapy of these diseases. Finally, fluconazole, taken orally, effectively crosses the blood-brain barrier; appropriate clinical trials may prove it to be an acceptable agent for those fungi commonly affecting the central nervous system.

Radiotherapy. The mainstay in the treatment of early glottic carcinoma.

Early squamous cell carcinoma of the glottis may be effectively treated with surgery or radiation therapy. Controversy exists as to whether radiation therapy effects survival at the expense of vocal function by ultimately requiring more total laryngectomies for salvage of local tumor recurrence. This study reviewed the medical records of 185 patients with T1 or T2, NO invasive squamous cell carcinoma of the glottis treated with primary radiation therapy between 1969 and 1984. All patients were followed up for a minimum of 5 years after completion of therapy. One hundred sixty-one patients met the criteria for local control analysis. Radiation therapy controlled disease in 93% (105 of 113) of patients with T1 lesions and 73% (38 of 48) of those with T2 tumors. Ultimate control of disease for T1 and T2 lesions, including surgical salvage, was 111 (98%) of 113 and 44 (92%) of 48 patients, respectively. The rate of successful surgical salvage was 75% (T1) and 70% (T2). The T2 lesions with impaired vocal cord mobility or anterior commissure disease were identified as being at increased risk for recurrence after primary radiation therapy. Overall voice preservation was 90%. Our data demonstrate that radiation therapy effects disease-free survival rates that are comparable to those produced by surgery, without sacrificing voice. Although a small percentage of patients with selected early glottic lesions may be more effectively treated with primary conservation surgery, these data do not support a change in philosophy concerning primary treatment of early glottic cancer with radiation therapy.

Uvulopalatopharyngoplasty: postoperative management and evaluation of results.

Since the earliest report of success with the uvulopalatopharyngoplasty (UPPP) operation, several authors have reported less than optimal results in their experience with the procedure. Part of the difficulty in evaluating the objective results of postoperative sleep studies has been the variations in reporting data. In addition, no standard of postoperative care, including analgesia, and immediate postoperative monitoring has been described. Our experience with 42 UPPP patients (34 studied with preoperative and postoperative polysomnography) indicates a 76% response (56% successes, and an additional 20% with limited success) with use of the more stringent criteria described recently. We discuss our management of these cases, including postoperative oxygen saturation monitoring and avoidance of narcotic analgesia as necessary factors for success with this operation.

Primary small cell carcinoma of the larynx: analysis of treatment.

Primary small cell carcinoma of the larynx continues to pose problems in its treatment. Four patients with this neoplasm were seen in a seven-year period at our institution and 49 patients were reviewed from the world literature. The only variables which significantly affected survival were the presence of metastases at initial examination and treatment modality. Those patients treated with chemotherapy and radiation therapy had an increased length of survival and increased chance of survival as compared to patients subjected to other treatment modalities. Because of the small number of patients reported in the world literature and lack of controlled studies, the treatment of small cell carcinoma of the larynx remains controversial; this retrospective analysis suggests that combination chemotherapy plus radiation offers the best chance for cure.

Giant intraluminal polyps of the esophagus.

Giant intraluminal polyps of the esophagus are relatively rare. Their diagnosis often presents a confusing picture; radiographic studies are frequently misinterpreted as achalasia, and the endoscopic picture is often difficult to interpret. This report describes the case histories of three patients with giant intraluminal polyps of the esophagus. Each presents slightly different clinical features. The signs and symptoms are discussed in terms of the pathophysiology. Common pitfalls in diagnosis are reviewed. Suggestions to enable more accurate identification of these lesions are given. Finally, a systemic approach to treatment is outlined which offers the patient symptomatic relief while minimizing surgical complications and morbidity.

Hypothyroidism following treatment for head and neck cancer.

One hundred ninety-six head and neck patients were studied to determine the effects of radiation therapy and surgery on thyroid function. Serum thyroid-stimulating hormone (TSH) levels were obtained as a screening test for primary hypothyroidism. Elevated TSH levels were found in 57 of the 196 patients (29.1%). The highest incidence of abnormal TSH values (66%) occurred in the group treated with combination radiation therapy and surgery, including partial thyroidectomy. TSH levels rose early in the posttreatment period with 60% of the abnormal values occurring within the first three posttreatment years. Posttreatment thyroid dysfunction was twice as common in women (48.6%) as in men (25.4%). When serum thyroxine levels by radioimmunoassay (T4RIA) were correlated with the elevated serum TSH levels, a similar pattern was seen with 65% of the patients in Group 3 having a decreased T4RIA level indicating overt hypothyroidism. Pretreatment levels of thyroid function including thyroid antibody studies should be established for all patients. Serial TSH levels should be done every three months during the first three posttreatment years and semiannually thereafter as long as the patient will return for follow-up care. All patients treated with combination radiation therapy and surgery who develop elevated TSH levels should be treated with thyroid replacement therapy. Patients receiving radiation therapy alone should receive replacement thyroid therapy if they develop a depressed T4RIA value or a pattern of gradually increasing TSH levels.

Small cell anaplastic carcinoma of the larynx: review of the literature and report of a case.

The case study of a patient with small cell anaplastic carcinoma (oat cell) of the larynx is detailed and the literature is reviewed. Small cell anaplastic carcinoma of the larynx has been demonstrated to be histologically identical to small cell anaplastic carcinoma of bronchogenic origin. The aggressive biologic behavior of this tumor justifies managing small cell anaplastic carcinoma as a systemic disease. Because of early widespread dissemination of tumor, surgery or radiotherapy alone or in combination have not been successful in controlling the disease. The combination of radiotherapy with chemotherapy has been shown to be the most effective approach to the treatment of small cell anaplastic carcinoma of the lung. We believe that a similar regimen should be considered the treatment of choice for small cell anaplastic carcinoma of the larynx.

Multiple primary malignancies of the upper aerodigestive system.

Multiple primary carcinomas were found in 11.5% of 1,518 patients presenting with an index tumor in the oral, pharyngeal or laryngeal areas. These additional malignancies were subdivided into two groups: 1) those occurring in distant or unrelated tissues and 2) those occurring in a multicentric zone defined as including the oral area, pharyngeal area, larynx, esophagus and tracheobronchial tree. Although some trends were noted, a primary lesion may be found anywhere in the zone of multicentricity. The dynamic nature of the progressive transition of the potentially malignant tissues in the multicentric zone is reemphasized. The physician, treating patients with head and neck cancer, should be prepared not only to cope with simultaneously occurring primary cancers but also to be constantly vigilant for the later development of subsequent primary carcinomas.