Vocal fold fixation due to proximal stenosis progression complicating idiopathic subglottic stenosis.

PURPOSE: This study examined the incidence and risk factors for vocal fold fixation due to proximal progression of idiopathic subglottic stenosis (ISS) over the course of serial treatments. METHODS: Records of 22 consecutive patients with ISS treated between 2004 and 2016 were retrospectively reviewed. Patient, stenosis, and treatment details were recorded. Cox regression was used to identify independent predictors of vocal fold fixation. RESULTS: All patients were female and mean age at diagnosis was 46 ± 7 years. In five patients, the stenosis was within 15 mm of the glottis at first treatment. Vocal fold fixation due to proximal stenosis progression occurred in seven (32%) patients. It led to permanent hoarseness due to unilateral vocal fold fixation in two patients and caused airway compromise due to bilateral vocal fixation in two other patients. No airway-related deaths occurred and no patient required a tracheostomy. Stenosis incision using coblation or potassium titanyl phosphate laser, and an initial glottis-to-stenosis (GtS) distance < 15 mm significantly increased the risk of proximal stenosis progression on univariable analysis. CONCLUSION: Vocal fold fixation due to proximal stenosis progression is a significant complication of idiopathic subglottic stenosis and causes permanent voice and/or airway sequelae. It should be actively looked for and documented every time a patient is assessed. If a reduction in the GtS distance is observed, definitive surgery should be promptly considered before proximal stenosis progression compromises the efficacy and safety of definitive treatment or, worse, causes vocal fold fixation.

Chest infection following head and neck surgery: a pilot study.

This paper reports the results of a pilot study which examined factors associated with chest infection following head and neck surgery. The overall rate of chest infection was 11%, but was 20% in those patients having a tracheotomy. No infection developed in patients with an intact airway. Other factors which emerged as possibly important were the duration of surgery and heavy regular alcohol intake. We recommend that prophylactic antibiotics be continued for at least 48 h in patients requiring a tracheotomy as part of their head and neck surgery. This is against the trend of shorter antibiotic regimens recommended for prevention of wound infections.

Prediction and prevention of fistulae after major head and neck surgery: a preliminary report.

A method of checking the integrity of mucosal repair after head and neck surgery using wound amylase levels is described. A low wound amylase concentration allows early resumption of oral intake; an increasing amylase concentration is a strong predictor of subsequent wound breakdown and fistula formation. A regimen has been developed which has prevented fistulae from developing in the small number of patients studied thus far.

Factors predicting response of end stage squamous cell carcinoma of the head and neck to cisplatinum.

Cisplatinum significantly prolongs survival in end stage head and neck cancer but only 30-40% of patients respond. Many receive chemotherapy with little or no benefit and it would obviously be advantageous to determine in advance those patients likely to benefit. In 2 phase III trials of chemotherapy in end stage disease, 129 patients have been treated with cisplatinum, either alone or in 2-drug combination with bleomycin, methotrexate or 5-fluorouracil. Factors analysed in the entire group were age, sex, site, previous treatment, performance status and the use of cisplatinum in combination. A high albumen and oro- or nasopharyngeal site were significantly favourable, while a hypopharyngeal, middle ear, skin or paranasal site were all significantly unfavourable. In the separate analysis of the subgroup with recurrent disease, site of recurrence and time to recurrence were analysed in addition to the factors named above. Although similar trends to those in the entire group were observed none reached significant levels. In the subgroup with advanced previously untreated disease, histological grade was analysed in addition to the above factors. Good performance status emerged as significantly favourable. The emerging trends provide some insight regarding outcome but are not sufficiently clearcut to allow a decision to be made on who should and who should not be treated.

A randomized phase III trial of cisplatinum, methotrexate, cisplatinum + methotrexate, and cisplatinum + 5-fluoro-uracil in end-stage head and neck cancer.

In a previous phase III trial of chemotherapy for patients with end-stage squamous cell carcinoma of the head and neck we have shown that Bleomycin shortened the survival period, compared with untreated controls. The survival of patients treated with Cisplatinum and Bleomycin did not differ significantly from untreated patients, but Cisplatinum significantly prolonged survival. A further similar trial is reported here, the four treatment arms were Methotrexate alone, Cisplatinum alone, Cisplatinum + Methotrexate, and Cisplatinum + 5-Fluoro-uracil. The response rates were: Methotrexate alone 19%, Cisplatinum alone 40%, Cisplatinum + Methotrexate 31%, and Cisplatinum + 5-Fluoro-uracil 33%. The median survival time for the Cisplatinum alone group, 260 days, was significantly longer than the 80 days for the Methotrexate alone group. The median survival times for Cisplatinum + Methotrexate (160 days) and for Cisplatinum + 5-Fluoro-uracil (200 days) did not differ significantly from that for Cisplatinum alone.

Electrocochleography during intravenous infusion of cisplatin.

Extratympanic electrocochleography was performed on three patients following tobramycin injection and ten patients during cisplatin (cis-dichlorodiamine platinum II infusion. The compound eighth nerve action potential and the cochlear microphonic decreased considerably in magnitude up to 45 to 60 minutes after tobramycin injection, followed by a gradual recovery to normal in all three patients. During the eight hours of continuous cisplatin infusion, there was no significant change in the eighth nerve action potential and cochlear microphonic. The immediate effect of tobramycin on the cochlear output may be due to interference with the metabolism of the inner ear by the drug. The absence of electrocochleographic change during cisplatin infusion may be due to differences in the mechanism between cisplatin and aminoglycoside ototoxicity, or it may reflect the relatively nonototoxic potential of our chemotherapy regimen.

Cisplatinum and bleomycin for advanced or recurrent squamous cell carcinoma of the head and neck: a randomised factorial phase III controlled trial.

A phase III 2 X 2 factorial trial of cisplatinum and bleomycin in 116 patients with recurrent or advanced squamous cell carcinoma of the head and neck is reported. Thirty percent of patients proved to be unfit for chemotherapy, and of those treated progression of tumour was the commonest "response". However, 25% of patients achieved a partial or complete response, with no significant difference in response rates between the treated arms. The median number of courses received was 1 (range 0-6) and the commonest causes for discontinuation of treatment were renal toxicity and death. Bleomycin reduced survival, but not significantly so, whereas cisplatinum prolonged median survival significantly by 10 weeks. Significant predictors of survival, in addition to treatment by cisplatinum, were age, performance status, N status, number of courses and response of the tumor.

The incidence of hypercalcemia in squamous cell carcinoma of the head and neck.

Hypercalcemia is a well-recognized phenomenon in squamous cell carcinoma of the head and neck, but the incidence of hypercalcemia in this group of patients is not clear. We have reviewed the records of 166 patients with squamous cell carcinoma of the head and neck presented at the Boston VA Medical Center over a 2-year period (October 1981 to September 1983). Hypercalcemia (greater than 11 mg/dl), for which a benign etiology could not be identified, occurred in the clinical course of seven patients (4.2%). Of the hypercalcemic patients, 5/7 (71.4%) had advanced stage IV disease and serum calcium levels ranging from 11.2 to 15 mg/dl at presentation. The incidence of hypercalcemia in this stage IV group was 5/78 (6.4%). On the basis of concomitant serum alkaline phosphatase, x-ray films, and radionuclide bone scans in these patients, bone metastases or a humoral factor were felt to be the etiologic agent. Six of the seven patients died within 77 days of the onset of the hypercalcemia despite vigorous antihypercalcemic and chemotherapeutic measures, and the remaining patient is under chemotherapy at present. We conclude that hypercalcemia is a late manifestation of advanced squamous cell carcinoma of the head and neck and is an ominous prognostic sign. Hypercalcemia without bone metastases is presumably due to the production of ectopic parathormone (PTH)-like substances from the tumor. To control this hypercalcemia, the underlying tumor must be treated vigorously in conjunction with symptomatic treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Hearing loss in minor head injury.

A prospective study on hearing loss in children with minor head injury was done because previous studies have indicated that a relatively high incidence of sensorineural hearing loss follows head injury. Forty patients aged 6-16 years, who had sustained loss of consciousness from head injury were interviewed and examined and compared with a control group. Most of the patients sustained frontal injuries, whereas hearing loss was most frequently noted in those who sustained parieto-occipital injuries. No correlation between the type of injury and the nature of the hearing loss was noted. Audiometrically, sensorineural hearing loss was noted. Audiometrically, sensorineural hearing loss was noted in 25 percent and in no case was it greater than 30 dB. The incidence of hearing loss after six months was 0 percent, indicating that after excluding other causes of deafness there is no great incidence of significant permanent hearing loss.