The association of chronic inflammatory disease in lichen planus with cancer of the oral cavity.

Heavy cigarette smoking and alcohol consumption are the major contributing factors in the development of cancer of the upper aerodigestive tract. Other factors, such as chewing substances and chronic irritation, have been implicated. The purpose of this presentation is to draw attention to chronic inflammation as another likely etiologic factor in the pathogenesis of oral cavity cancer. During the past 4 years, we diagnosed squamous cell carcinoma of the oral cavity in six consecutive patients who had no history of cigarette smoking, alcohol intake, or substance abuse. Although this series is too small for significant analysis, it does suggest that chronic inflammatory processes such as lichen planus and chronic gingivitis can induce neoplastic metaplasia in the epithelium of the oral cavity.

A transfacial approach to the nasal-paranasal cavities and anterior skull base.

Large lesions of the nasal and paranasal cavities present a particularly difficult problem of surgical approach. The direct transnasal, Denker's, Weber-Fergusson, lateral rhinotomy, and facial degloving approaches have all been used with varying degrees of success. Nevertheless, these approaches fail to provide adequate exposure of the midfacial and interorbital spaces. In 1979, we developed a method called the transfacial approach in which two large midfacial flaps, one containing the entire external nose, are raised, exposing the maxillae, both medial orbital walls, and the nasal and paranasal cavities. Through this panoramic approach, one can easily expose the anterior skull base to the clivus and operate on this area under direct visual and manual control. The technique of this approach is described and our experience with 16 patients in whom it was applied is reviewed.

Acute epiglottitis in the adult.

Acute epiglottitis may be fatal when diagnosis is delayed. The literature stresses data that does not help to predict impending airway obstruction in patients who present with a sore throat, the most consistent presenting symptom among patients with acute epiglottitis. In this review of 80 cases of epiglottitis in adults, almost all patients who presented within eight hours from onset of symptoms required airway intervention, while the majority of those who presented more than eight hours after onset of symptoms never developed acute upper respiratory obstruction and were treated medically or had supportive treatment only. Artificial airway was indicated in all patients who had drooling. There were no fatalities in this series, however, we recommend keeping all patients with acute epiglottitis in an intensive care unit for at least 24 hours after admission.

Combined therapy for stage III-IV head and neck cancer: preliminary results.

As part of a combined modality treatment program using chemotherapy, surgery, and/or radiotherapy, 25 patients with previously untreated stage III or IV head and neck cancer received initial combination chemotherapy. Pathologically confirmed complete remission was noted in nine patients (36%). The overall objective major response rate (with all patients included in analysis) was 68%. The chemotherapy regimen included bleomycin, cisplatin, vinblastine, methotrexate, and 5-fluorouracil. A novel concept of drug scheduling was used, based on chemotherapy-induced improvement in RBC deformability. The underlying concept is that improved RBC deformability results in improved capillary blood flow and thereby, increased drug delivery to tumor cells. Treatment resulted in moderate hematologic and renal toxicity with no treatment-related deaths. This exceptionally high, pathologically confirmed complete response rate will hopefully provide a mechanism by which combined modality therapy can adequately be tested for its ability to prolong survival of patients with advanced head and neck cancer.

Primary small cell carcinoma of the paranasal sinuses.

An unusual case of small cell carcinoma of the ethmoid sinuses is reported in which electron microscopy confirmed the presence of dense-core granules. The relationship to Pearse's "neuroendocrine programmed" cells is cited. With increasing numbers of different extrapulmonary primary sites for this tumor now being identified, it is believed that these sites must be investigated in any case of suspected small cell carcinoma that cannot be readily attributed to the lung.

Actinomycotic osteomyelitis of the facial bones and mandible.

Actinomyces israelii is a part of the human oral flora and thus is more commensal than pathogenic. Oral trauma, accidental or purposeful, can precipitate its introduction into the soft tissues, to which infection is usually confined. The case presented is one in which, over a span of two decades (1956 to 1977), the extraction of a mandibular tooth resulted in a chronic actinomycotic osteomyelitis, destroying first the mandible, then both maxillae, and then the right zygoma, with decreased vision and proptosis despite repeated medical and surgical intervention. Adequate treatment required removal of the sequestrum and excision of all infected granulation tissue, scars, and involucra until healthy bone was exposed. Intravenous penicillin was administered for 2 weeks, followed by a 6-month course of oral penicillin. The patient was followed for 4 years and remained disease free.

Reconstruction of the mandible: use of combined homologous mandible and autologous bone.

Loss of portions of the mandible as a result of trauma or cancer surgery poses a difficult problem in reconstruction. Experience in the use of the mandibular homograft combined with autologous bone and bone marrow in 26 patients is reviewed. It is evident that this method of reconstruction has many advantages but is a failure in patients who have received radiation therapy to the recipient site.

Wegener's granulomatosis.

Wegener's granulomatosis is characterized by a necrotizing granulomatous vasculitis which can be found in both the upper and lower respiratory tracts and with either focal or proliferative glomerulonephritis. However, any organ system can be affected by the disease. Over the past 17 years, 47 patients with histologically proven Wegener's granulomatosis have been treated at the National Institute of Allergy and Infectious Disease. Since 1972, patients with head and neck manifestations have been managed in collaboration with the Department of Otolaryngology, National Naval Medical Center. Experiences with these patients have shown that all have had some degree of respiratory tract involvement, with 42/47 having disease in the nose or paranasal sinuses. An effective therapeutic regimen is possible with immunosuppressants (particularly cyclophosphamide) and locally supportive measures. As a result of such therapy, more than 80% of the patients treated have experienced long-term remissions. The clinical implications of this therapy are discussed, and a protocol for patient management presented.

Ophthalmoplethysmography in head and neck surgery.

Ophthalmoplethysmography (OPG) is a simple, noninvasive diagnostic test in which the cerebral hemispheric blood flow can be indirectly measured. Its use in head and neck surgery is invaluable because it enables the surgeon to predict preoperatively whether a patient will survive carotid artery resection. In a three-year period, nine patients have survived carotid resection on the basis of favorable OPGs, without a death or permanent neurologic complication. A comparison of the results of OPG testing with intraoperative measurement of internal carotid artery pressure showed close correlation in 14 of 20 patients who were tested. Lack of correlation in four patients can be explained by the circumstances of the intraoperative test. This study's findings demonstrate that this test has high clinical reliability.

Treatment of osteogenic sarcoma of the mandible.

Osteogenic sarcoma of the mandible is a rare tumor, comprising less than 0.5% of all head and neck tumors, and, even in large institutions, the experience in management of such tumors is limited. Current therapy for osteogenic sarcoma of the long bones is based on a more extensive experience in large centers and includes a major role for chemotherapy. We report two cases of osteogenic sarcoma of the mandible that were treated by combined chemotherapy, radiation therapy, and surgery. The expected disease-free survival of patients with this disease, treated by surgery alone, would have been less then 50% in the first year. The survival of these two consecutive patients for more than one year, free of disease, is significant and encourages further use of this type of treatment.

Solitary neurogenous sarcomas of the head and neck.

The clinical histories of three patients with neurogenous sarcomas involving the head and neck are detailed. The most satisfactory treatment suggested for such tumors involves combined therapy with chemotherapy, radiation, and radical surgical excision. By so doing, potential patient cure might be further increased and survival rates further improved.

Noninvasive chronic recording of auditory nerve potentials.

A system is described which allows repeated, noninvasive recording of auditory nerve responses in the cat to transient acoustic stimuli using a closed acoustic system. N1 responses to clicks are recorded from a stainless steel ring electrode at the end of a hollow earbar, the tapered end of which is made of insulating plastic. Acoustic stimuli are generated by a dynamic earphone coupled to the earbar. A calibrated probe microphone is also imcorporated into the earbar to measure sound pressure near the tympanic membrane. This allows better stimulus control than is available with free-field systems. To facilitate insertion of the earbar, meatoplasties were performed on all animals. Responses recorded with this system in anesthetized cats are described and compared with those recorded at the round window. Good repeatability of measurements is described for an animal population of 20 domestic cats over a period of several months. For some of these animals, response amplitude varied from one session to another, but response latency, especially for condensation clicks, was consistent. By comparing statistics of multiple measurement of both N1 amplitude and latency for rarefaction and condensation clicks, it is concluded that the N1 latency vs click-level function for condensation clicks provides the most reliable measure of the cat's auditory nerve function.

Effects of Eustachian tube ligation on auditory nerve responses to clicks.

Auditory nerve responses to condensation and rarefaction clicks were recorded from the external ear canal of cats using a closed acoustic system. Repeated control recordings from both ears formed a baseline for each of four animals used in this study. After a baseline had been established, the Eustachian tube on one side was ligated and serial recordings of N1 responses were performed for up to 140 days postligation. By comparing the shift which occurred in the N1 latency-vs-click level plots after ligation, the equivalent hearing loss was determined. In all cases where the Eustachian tube was successfully ligated, the loss was progressive for the first 20 days, then usually showed some transitory improvement. The loss stabilized after 60 days, varying from 15 to 40 dB in different animals. In addition to N1 recordings, serial tympanograms were also measured. These indicated negative middle ear pressure in the first two days postligation and the presence of middle ear fluid by one week postligation.

Elective carotid artery resection.

A retrospective study of carotid artery resection disclosed a 64% mortality when resection was performed on an emergency basis, as compared with 14% when the surgery was undertaken electively. This concurs with other studies that have demonstrated increased survival rates when elective carotid artery resection has superseded carotid artery rupture, and reemphasizes the need for a more accurate means of predicting individual tolerance for loss of the carotid artery. Use of the ocular plethysmograph (OPG) is proposed as a simple and accurate means of evaluating the adequacy of collateral hemispheric blood flow to compensate for a potentially resectable carotid artery. Eleven patients have been evaluated using this technique. Nine were predicted to successfully tolerate carotid artery resection, while intolerance was predicted for the remaining two. Four of the nine patients have undergone resection of the artery with no neurologic sequelae to date.