Intractible aspiration.

Chronic recurrent aspiration can be secondary to numerous pathologic processes, with potential for disastrous sequelae if not diagnosed and aggressively treated. An understanding of the physiology of the swallow can aid in the diagnosis and potential treatment of the aspirating patient. Most aspirating patients can be managed with conservative measures such as diet modification and compensatory techniques. Various innovative surgical procedures have been developed to provide an adjunctive role or definitive treatment in those with a more severe functional deficit.

External laryngeal trauma.

External laryngeal trauma, blunt or penetrating, is a rare but potentially life-threatening injury. This is frequently seen in multiple-trauma patients and can go unrecognized in the absence of astute clinical awareness. Injuries may range from small endolaryngeal hematomas or lacerations to complete laryngotracheal separation. Proper airway management is of utmost importance and is one of the most controversial aspects of treatment of laryngeal trauma. Flexible fiberoptic laryngoscopy and high resolution computed tomography scanning of the larynx has greatly enhanced the evaluation of these injuries. Treatment options range from conservative, nonsurgical observation to evaluation in the operating room. Surgical intervention may involve endoscopy, open surgical exploration, and possibly laryngeal stenting. Long-term goals are aimed at maintaining voice, airway, and swallowing ability. A systematic approach to this condition often results in predictable and acceptable outcomes.

Caustic ingestion.

Caustic and corrosive injury of the upper gastrointestinal tract can lead to significant morbidity and mortality with the development of upper gastrointestinal stricture or perforation. Household products containing alkalis, acids, and detergents are responsible for most injuries, with each having varying histological injury patterns and anatomic distribution. Early signs and symptoms after caustic ingestion are not consistent with the extent of damage, and endoscopy is the only reliable method to assess injury. Medical and surgical treatments are controversial and include steroids, antibiotics, esophageal dilation, stenting, and surgical reconstruction and are centered around prevention of esophageal strictures. Early diagnosis and prompt and aggressive treatment can improve long-term outcomes in these patients.

Tumors of the parapharyngeal space.

The parapharyngeal space may give rise to a wide variety of neoplasms. The goal of this article is to present a simple algorithm for the recognition and evaluation of parapharyngeal space lesions by primary care physicians so that timely referral can be made to an otolaryngologist for definitive therapy.

Cervical approaches to the surgery of cervicothoracic neoplasia.

Seven cases are presented to illustrate four cervical surgical approaches to the upper mediastinum and thorax. These surgical approaches are described and illustrated, and we have termed these the retrosternal, retroclavicular, posterior, and lateral approaches. Two cases of thymic cyst, one of recurrent metastatic pretracheal adenopathy, a case of tracheal stenosis, a foreign body of the left subclavian artery, a large Zenker's diverticulum, and a neoglottic reconstruction are presented to illustrate the surgical anatomy, dissection technique, and postoperative complications.