Intraoperative histologic evaluation in exploration of the parathyroid glands.

In this review, 123 explorations for primary hyperparathyroidism were performed, at which at least three glands were identified and specimens were taken for biopsy. Gross operative and histologic findings were evaluated and correlated with follow-up data. A new classification for disease of the parathyroid glands is devised in which microhyperplasia occurring in grossly normal glands is subclassified into two groups. One (Class II), consisting of hypercellularity only, is thought not to produce clinical hyperparathyroidism. The second group (Class III), which includes glands with nodular hyperplasia, abnormal cytologic findings or oxyphilic nodules, is considered clinically significant. Evaluation and follow-up study revealed three instances of clinical hyperparathyroidism attributed to Class III histologic changes, while there were no instances of recurrent or persistent hyperparathyroidism attributable to Class II disease. Involvement of multiple glands, both gross and microscopic, occurred frequently (26 per cent) and was often bilateral and nonuniform. We concluded that optimal surgical management of primary hyperparathyroidism is achieved by selective removal of parathyroid glands guided by the histologic findings in each gland.

Pectoralis myocutaneous flap for replacement of cervical esophagus.

The authors report experience with 10 cases of pharyngoesophageal replacement with tubed pectoralis major myocutaneous (PM) flap. Six patients had primary reconstruction following total pharyngolaryngectomy for cancer; the other 4 had severe pharyngoesophageal stenosis requiring resection and replacement following previous laryngectomy. Seven of the patients were octogenarians, 6 had been irradiated previously, and all were severely debilitated. Two patients died postoperatively of cardiac disease. The remaining eight regained satisfactory with lasting deglutition. Four fistulae healed spontaneously, and one postoperative stenosis responded to a single dilitation. The interval to swallowing was 10-21 days in nonirradiated patients and 3-13 weeks in irradiated patients. There was one local recurrence 6 months after resection; the other patients remained free of disease. The authors conclude that the tubed PM flap is a reliable technique for pharyngoesophageal reconstruction that is particularly useful in elderly and debilitated patients.

Replacement of upper esophagus: results with myocutaneous flap and with gastric transposition.

The authors reviewed 25 cases of pharyngoesophageal replacement. A tubed pectoralis major myocutaneous flap was employed in ten cases where an adequate distal resection margin could be obtained above the thoracic inlet. Total gastric transposition was used in 15 cases where resection extended into the mediastinum. The overall rates of complications (52%), postoperative mortality (20%), and satisfactory deglutition (80%) were similar for both operations and were superior to those achieved with reconstructive procedures previously used by the authors. The choice of method is influenced by the length of the pharyngoesophagus to be replaced and the general condition of the patient. Gastric transposition is a more versatile operation and is adaptable to replacement of the entire esophagus if necessary, while the tubed pectoralis major myocutaneous flap has proven particularly effective for the rehabilitation of elderly and severely debilitated patients.

Needle aspiration biopsy of the pre-epiglottic space.

Clinical staging of supraglottic carcinoma requires evaluation of the pre-epiglottic space (PES). To explore the role of fine needle aspiration biopsy of the PES in the staging of epiglottic carcinoma, endoscopic transvallecular fine needle aspiration biopsies of the PES were performed in 16 patients with epiglottic carcinoma. The results of aspiration cytology were compared with CT scanning and postoperative histopathologic sections of the PES after total or supraglottic laryngectomy. This preliminary report shows that needle aspiration biopsy of the PES is a safe and sensitive technique, having a high correlation with histopathologic follow-up. Needle biopsy, along with CT scan, is clinically useful in staging the PES, which cannot be examined directly.

Squamous cell carcinoma of the oral cavity and oropharynx in young adults.

Studies of squamous cell carcinoma of the oral cavity and oropharynx in young adults differ as to whether younger patients resemble the general population of head and neck cancer patients. A retrospective study was performed on 23 patients (40 years old or younger) with oral and oropharyngeal carcinoma at New York University Medical Center between 1961 and 1984. Patients with oropharyngeal cancer resembled the general population of head and neck cancer patients. In contrast, oral cavity carcinoma occurred more frequently in women under the age of 35 and lacked the usual etiologic factors of tobacco and alcohol abuse. Survival correlated best with the TNM stage of disease at initial presentation. Patients with Stage I and II lesions had an excellent response to surgical treatment alone and a high 5-year survival rate. Patients with advanced Stage III and IV disease had a poor survival rate with single modality treatment. We recommend surgery and radiotherapy in patients with advanced disease.