Instruments and equipment for endoscopic sinus surgery.

It is the fiberoptic endoscope and its related hardware that distinguish endoscopic sinus surgery from previous techniques. Lens angles of 0, 25, and 70 degrees, comprising a representative telescope set, accommodate virtually any endoscopic sinus procedure, diagnostic or therapeutic, with unsurpassed visualization. Each telescope may be fitted with an optional suction-irrigation adaptor, a highly controversial accessory among endoscopic surgeons. The clinical situation often dictates the optimal combination of equipment, anesthesia, and technique; surgeon's preference is equally influential. Mastery of conventional operative techniques combined with thorough endoscopic skills is essential for consistent, effective, and safe surgical performance.

Implantation of a recurrent laryngeal nerve stimulator for the treatment of spastic dysphonia.

Spastic dysphonia, a rare speech disorder, is characterized by strained phonation with excessively adducted vocal cords. Recurrent laryngeal nerve section, botulinum toxin injection into the vocalis-thyroarytenoid muscle complex, and other techniques have been used to treat this disorder. We have used percutaneous electrical stimulation of the recurrent laryngeal nerve with good results. Previous dog studies demonstrated the relative safety of an implantable recurrent laryngeal nerve stimulator. In this study, we directly stimulated the recurrent laryngeal nerve and vagus nerve in a dog without change in cardiorespiratory status. A Medtronic peripheral nerve stimulator was implanted in a patient with abductor spastic dysphonia. The cuff electrode was positioned around the recurrent laryngeal nerve and stimulation resulted in improvement in her voice. Extensive cardiopulmonary monitoring did not reveal any adverse response to stimulation and there was no discomfort to the patient. On the basis of the good results of this preliminary study, further study with long-term follow-up is under way.

[Epiglottitis in the adult. A proposition for a clinical classification and therapeutic strategy]. / Epiglottite de l'adulte. Proposition d'une classification clinique et d'une stratégie thérapeutique.

Because lack of criteria for staging and treatment of epiglottitis can lead to unnecessary morbidity and mortality, we have introduced a staging system for early classification and appropriate management of adult epiglottitis patients. We retrospectively staged 20 adults with epiglottitis to see in their final outcome would have been altered using our protocol. We found that staging and management according to our protocol were appropriate and possibly could have reduced mortality from 10% to nearly 0%.

Experience with the sternocleidomastoid myoperiosteal flap for reconstruction of subglottic and tracheal defects: modification of technique and report of long-term results.

Subglottic or tracheal reconstruction may be required in cases of subglottic stenosis, invasive thyroid carcinoma, or trauma. The sternocleidomastoid myoperiosteal flap uses clavicular periosteum on a muscle pedicle to provide vascularity. Clavicular periosteum is fibrous, durable, and will conform to the shape of the trachea, forming bone to provide stability to the airway. The procedure is relatively simple and involves single-staged reconstruction. After 4 years' experience with this flap, we present the results from a series of 11 patients who underwent subglottic or tracheal reconstruction with the sternocleidomastoid myoperiosteal flap. Ten of 11 patients were successfully decannulated. The average time from reconstruction to decannulation was 50.3 days. Follow-up ranged from 12 to 40 months. We also describe modifications of the initial technique that have been introduced to improve the flap's versatility and effectiveness.

Treatment of spastic dysphonia without nerve section.

Spastic dysphonia is a disorder characterized by strained, constricted phonation with excessively adducted vocal cords. Despite initial success with recurrent laryngeal nerve section, the search for other treatment continues. Our clinical study involved inserting a needle electrode percutaneously into the region of the recurrent laryngeal nerve in five patients with spastic dysphonia. Electrical stimulation resulted in dramatic improvement in three patients and minimal improvement in two. Our experimental study was designed to create an animal model for an implantable nerve stimulator to be used on a long-term basis. A Medtronic spinal cord stimulation system was implanted into a dog, and a cuff electrode was positioned around the recurrent laryngeal nerve. Vocal cord position could be altered by varying the stimulus frequency. Long-term stimulation of the recurrent laryngeal nerve was relatively safe and effective. Eventually, we plan to implant nerve stimulators into spastic dysphonia patients who respond well to percutaneous stimulation.

The bilobed deltopectoral advancement flap.

The bilobed deltopectoral advancement flap is a versatile reconstructive option for selected cervical defects. This modified version of Bakamjian's classic deltopectoral flap utilizes thin anterolateral neck skin to cover complex anterior neck defects. It offers the safety of a minimally rotated pedicle to reduce the chance of flap necrosis from kinking, and the convenience of a single-stage procedure. We have used this flap six times in our clinical experience. Typically, the defects were located in the anterior cervical region, and many of them were reconstructed following total laryngectomy and radical neck dissection. There was no incidence of flap necrosis in the patients, including those who had had preoperative irradiation.

Benign neoplasms of the oral cavity.

A wide variety of benign tumors present in the oral cavity. These tumors are for the most part rare and are classified by the tissue of origin. Although benign oral cavity tumors are not life-threatening, they can result in extensive loss of soft tissue and/or bone. Furthermore, many patients are subject to the threat of recurrence, multiple surgical procedures, and the possibility of malignant degeneration. Because many tumors vary little clinically, an adequate biopsy specimen must be obtained for diagnosis. Radiographs are, in general, nondiagnostic. Collaboration with an experienced pathologist is necessary to determine the tumor's probable clinical behavior. Therapy, which is dictated by tumor type, is almost always surgical.

Sternomastoid myoperiosteal flap for reconstruction of the subglottic larynx.

Reconstruction of the subglottis is usually required after resection of cricoid cartilage or tracheal tissue in cases of trauma, subglottic stenosis, or invasive thyroid carcinoma. There are multiple techniques available for reconstruction of the subglottic larynx, but most of them have a high rate of complications or graft failure. We have found the sternocleidomastoid myoperiosteal flap to be an ideal means of reconstruction. In an experimental study, we performed subglottic reconstruction using the sternomastoid myoperiosteal flap on 15 mongrel dogs to determine the presence of bone formation versus calcified fibrous scar. Radiologic studies suggested apparent metaplastic bone formation at the graft site, and histologic studies confirmed this. Functionally, 12 dogs had stable airways without stridor or subglottic narrowing. Three dogs died of complications. With successful reconstruction of large defects in the canine subglottis, attempts to repair large subglottic and tracheal defects in the human are feasible.

Malignant tumors of the major salivary glands.

A total of 512 patients with major salivary gland tumors were treated at our institution between the years 1960 to 1975. The 147 cases of malignant salivary gland tumors were reviewed according to presenting characteristics and stage, histology, and outcome. Treatment for each type is summarized. The battery of diagnostic aids and prognostic indicators available to the physician are also reviewed. The newer and more controversial procedures of CT scanning, nuclear magnetic resonance scanning, and fine-needle aspiration are discussed in detail. In the past, salivary gland tumors have been classified by histology alone. Current trends employ the TNM staging system in planning treatment and predicting end results. We have found a far better survival rate in patients with various tumor types presenting with stage I or II disease, but point out that patients with high-grade tumors often present with advanced disease. All major salivary gland tumors should be approached according to the principles of cancer surgery. The minimum procedure is thus superficial or total parotidectomy with preservation of the facial nerve. In low-grade malignancies, the diagnostic procedure will have accomplished this definitive treatment. Salivary gland tumors are rare in the pediatric population. Such malignancies often defy radical treatment. Although cure rates in many categories of high-grade tumors are low, the only hope for survival is an initial aggressive surgical approach. Although radiation was used for recurrent disease only during the years of this study, it is currently being used as adjuvant therapy in almost all malignancies except low-grade mucoepidermoid. Recurrences are almost always fatal.

Surgical treatment of hyperparathyroidism.

During the past decade, major advances have been made in many crucial areas of the surgical management of hyperparathyroidism. An up-to-date protocol is presented and stresses preoperative localization, operative technique, intraoperative diagnosis, cryopreservation, and autotransplantation designed for practical application.

Juvenile nasopharyngeal angiofibroma.

JNA is a highly vascular, benign, yet locally invasive tumor that occurs in preadolescent males. Diagnosis is based on history, physical examination, and radiographic findings. CT scanning is invaluable for evaluating tumor extent. Angiography combined with embolization aids surgeons in identifying the main feeding vessels and decreasing intraoperative blood loss. Surgery is the mainstay of therapy with radiation therapy reserved for inoperable masses. For highly aggressive, recurrent angiofibroma, chemotherapy has shown some promise.

Thyroid carcinoma.

The mode of presentation, initial findings, treatment, and survival in differentiated thyroid carcinoma were studied in 155 patients. The classic signs, symptoms, and scan findings were present in approximately 70 per cent of the patients, with the remaining 30 per cent displaying unusual manifestations or findings. The effects of neck metastases, extracapsular invasion, and recurrent laryngeal nerve involvement on long-term survival were studied in detail. Prognosis was dependent more on age at initial appearance than any other factor. Patients with prior exposure to radiation had more extensive disease and required more extensive surgery, but they ultimately had the same prognosis for 10-year cure. Treatment of distant metastatic disease by surgery, radioactive iodine, and external radiation resulted in long-term survival in certain cases.

Parietal occipital nape of neck flap. A myocutaneous flap for selected head and neck reconstruction.

Reconstruction in head and neck surgery has been greatly advanced with the use of the pectoralis major and trapezius myocutaneous flaps. Most surgical defects can be repaired with one of these flaps alone, or in conjunction with cutaneous flaps. Specific problems, however, occur that cannot be successfully reconstructed by these standard flaps. The traditional scalp flaps are cutaneous flaps. Use of these flaps is limited because of their shortened arc of rotation and accompanying forehead deformity. Three patients underwent reconstruction with a parietal occipital nape of neck myocutaneous flap. Its advantages include the following: large segments of hairless skin from the contralateral side of the neck can be used, an extensive arc of rotation and distance can be achieved with excellent vascularity in the overlying skin, and cosmetic results are superior. Angiographic studies were used to demonstrate the vascular pattern and supply to this flap. Cadaver dissections were performed to determine the pattern of distribution of the perforating vessels to the skin from underlying muscle.

Reconstruction of the subglottic larynx with a myoperiosteal flap: clinical and experimental study.

The literature describes numerous techniques for reconstruction of the subglottic larynx. The use of rigid bone grafts or flaps has been associated with problems because the rigid bone cannot conform to the defect and form an airtight seal. We have performed subglottic reconstruction using the sternocleidomastoid myoperiosteal flap with very optimistic results on long-term follow up. The sternocleidomastoid myoperiosteal flap is a relatively simple procedure that can be used for a large variety of defects. The pliable periosteal flap used for closing the defect can be molded over a stent to form an airtight seal. We have demonstrated bone formation in the periosteum which is crucial to the stability of the airway and long-term success of the procedure. The sternocleidomastoid myoperiosteal flap yields a pliable, durable tissue capable of airtight closure and a tension-free suture line. This technique will make the closure of subglottic defects a much more practical task.

Nonrecurrent laryngeal nerves and their clinical significance.

The anomalous position of a nonrecurrent laryngeal nerve predisposes the nerve to injury during thyroidectomy and to compression by a thyroid mass. We present three cases in which a seemingly benign thyroid mass traumatized a nonrecurrent laryngeal nerve resulting in either vocal cord paralysis or a vague pressure sensation over the larynx. Some of these patients feel as if they need to clear a foreign body and present with a chronic cough. Normally the nerve is protected from thyroid masses as it passes through the tracheoesophageal groove. In all three patients, surgical excision of the thyroid mass and release of the nerve resulted in recovery of the nerve and resolution of the symptoms. We have found that small, benign, or otherwise asymptomatic lesions of the thyroid gland have a greater tendency to cause vocal cord paralysis in patients with nonrecurrent laryngeal nerves. The surgeon must always be aware of the possibility of the presence of a nonrecurrent laryngeal nerve.

Metastatic neck disease. Evaluation by computed tomography.

Computed tomographic (CT) scanning has been used in the preoperative examination of patients with head and neck cancer. Although early reports on the use of CT scanning for cervical lymphadenopathy were encouraging, the accuracy of CT in detecting nodal metastases has not been well established. Fifty consecutive patients underwent radical neck dissection and preoperative CT scanning. The clinical staging of the neck, CT diagnoses, and pathologic findings were correlated; CT accuracy was then compared with clinical accuracy. Our findings show the overall accuracy of CT diagnoses to be 90%. Comparison with clinical accuracy shows the CT scan to be superior to the clinical examination, particularly in detecting occult metastases.

General techniques and clinical considerations in laryngologic laser surgery.

The carbon dioxide laser, one of the great advances in otolaryngology, has the characteristics of accuracy, reduced bleeding, reduced reaction, faster healing, and less scarring as compared with conventional surgery. Its beam is produced by creating an electric discharge within a cylinder containing carbon dioxide, nitrogen, and helium. The emitted beam is invisible, and special means are used to show exactly where the beam is going to impinge on the tissue. The effect of the power delivered to the tissue by the laser beam depends on the character of the tissues, the presence of char, the delivery device, and the condition of the lenses and mirrors. The imprint size varies with the power and the duration of exposure and is not necessarily the same as spot size. Repeated exposures increase the amount of tissue destruction and can be used to completely eradicate a lesion until the junction of normal and abnormal tissue is encountered. The following points and techniques are important in determining the results of carbon dioxide laser surgery. Increasing the power and reducing the duration of the beam result in less charring, less reaction, and faster healing. Overheating of tissues is avoided by using a skip technique. Char must be removed to prevent overheating of tissues and to aid in identifying accurately the junction of normal and pathologic tissues. Palpation may help identify pathologic tissue not readily apparent on inspection alone. The edge of the beam can be used to shave away pathologic tissue accurately while preserving normal tissues.(ABSTRACT TRUNCATED AT 250 WORDS)

Laryngeal amyloidosis and laryngocele.

Laryngeal amyloidosis and laryngoceles are uncommon. A unique case of both conditions occurring simultaneously is discussed. Preoperative computerized tomographic sections clearly demonstrated both disease processes, their extensiveness, and their intimate relation. These findings are correlated with the endoscopic and surgical findings. Gross and histopathologic specimens give full confirmation of the diagnosis. To our knowledge, this is the first case of laryngocele secondary to amyloidosis.

Nasopharyngeal lipoma.

Though lipoma is a common tumor in many anatomic sites throughout the body, its occurrence in the nasopharynx is extremely rare, with only several cases being reported in the literature. We describe a 17-year-old female with a nasopharyngeal lipoma. The mass had been present for at least 5 years and, despite its large size, was asymptomatic.