Dilemmas in the management of chronic nasal and sinus inflammatory diseases of unknown etiology.

The diagnostic criteria and therapeutic regimens for upper airway necrotizing diseases such as Wegener's granulomatosis, polymorphic reticulosis, and the recently described idiopathic midline destructive disease have been better defined and clarified in the past decades. Despite an improved understanding of the various disease processes, there continues to be difficulty in establishing an early diagnosis before proceeding with prompt treatment to minimize loss of function and cosmetic deformity. To achieve these goals, we have expanded the indications for the use of the cytotoxic drug, cyclophosphamide, in those patients whose clinical and histologic presentations are suggestive of Wegener's granulomatosis, but in whom a specific diagnosis has not been confirmed by biopsy specimen. We have seen ten patients with upper airway lesions of a chronic inflammatory nature over the past six years at the Medical College of Wisconsin affiliated hospitals. Only three of these have had a definitive histopathologic diagnosis of Wegener's granulomatosis made prior to the initiation of cytotoxic therapy. Six have undergone treatment under our expanded criteria without a prior definitive diagnosis. Five of these have had arrest of the disease process, and one has had no response to therapy. One patient was not treated. There have been no serious side-effects from cyclophosphamide therapy in these patients.

Role of esophagoscopy in the evaluation of patients with head and neck carcinoma.

A retrospective study was conducted of 696 patients with squamous cell carcinoma of the head and neck seen over a 10-year period. Special focus was placed on secondary esophageal primaries in this group in an effort to define the role of esophagoscopy in the management of these patients. Second primary esophageal lesions were infrequently encountered (17 of 696, or 2.4% of the patients). Diagnostic accuracy of the esophagogram in a series of patients with index head and neck tumors and in a separate series of patients with index esophageal lesions was found to be high (98 + %). Based upon this study, we do not feel that esophagoscopy is always indicated as part of the initial workup for all head and neck cancer patients. Rather, we consider the barium swallow esophagogram to be a relatively safe and acceptably accurate alternative in most cases, with esophagoscopy reserved for specific indications.

Sudden sensorineural hearing loss: operative complication in non-otologic surgery.

Sudden sensorineural hearing loss is a well recognized phenomenon in otologic practice with both viral and vascular etiologies being supported. However, sudden hearing loss as a complication of non-otologic surgical procedure is a seldom reported and rare phenomenon. Five cases of unilateral sudden sensorineural hearing loss which are time related and probably causally related to non-otologic surgery are presented. Two cases underwent open heart surgery and support previous reports of hearing loss secondary to cardiopulmonary bypass procedures. Three noncardiac cases are also reviewed. None of these patients had prior otologic disease which would predispose to a sudden hearing loss, and no intraoperative or postoperative complication was specifically noted as a cause of the hearing loss. The literature is reviewed and attention is drawn to the problem. We wish to encourage further reports and to recommend early identification and treatment in those cases related to cardiopulmonary bypass.

Recurrence patterns by treatment modality of carcinomas of the floor of the mouth and oral tongue.

Recurrence patterns were examined by stage of disease and treatment modality in 139 patients with 141 squamous cell carcinomas of the floor of the mouth and oral tongue, reflecting an 11-year experience at two hospitals. Treatment categories included surgery, irradiation, and combined treatment. Patients who were without evidence of disease at two years, or at the time of death, were considered cured. Cures were achieved in 87 per cent of patients with Stage I disease, 83 per cent with Stage II, 40 per cent with Stage III, and 34 per cent with Stage IV. Similar results were achieved by irradiation alone and by surgery alone in controlling early lesions. Combined treatment offered the best chance of cure for patients with advanced disease. Failure was most often associated with persistence at the primary site. No patient with advanced disease was salvaged after local treatment failure. One of 51 patients who received prophylactic treatment of the neck in the absence of clinical evidence of metastases had a regional treatment failure, while seven of 26 such patients who did not receive prophylactic treatment developed regional metastases. The ten-year adjusted survival rate, as calculated by the actuarial method, was 53 +/- 4.7 per cent. Forty-two multiple primary lesions were found in the 139 patients.

Adenoid cystic carcinoma of the submaxillary gland.

A review of submaxillary gland neoplasms over a 21 year period revealed 15 malignancies and 7 benign tumors. All of the malignancies occurred in females, and 11 of these were adenoid cystic carcinoma. Two of the 11 were found to have infiltrating ductal carcinoma of the breast (1 pre and 1 postdiagnosis of the submaxillary carcinoma) and 3 had benign breast disease. While previous reports have suggested an association of parotid gland neoplasia and breast cancer, this is the first known report of an association between adenoid cystic carcinoma of the submaxillary gland and cancer of the breast. The discussion of adenoid cystic carcinoma of the submaxillary gland emphasizes the increased frequency of this disease in females, its association with breast disease, and also experimental submaxillary gland neoplasia.

Rhinitis medicamentosa.

The diagnosis of rhinitis medicamentosa was made in 130 patients seen over a 10 year period from July 1967 to June 1977. There was an incidence of 1% in our otolaryngological practice. Patients had been taking the causal medication for an average of 21.4 months. There were 73 males and 57 females with the peak incidence in young and middle-age adults. The primary offending medications were decongestant nasal sprays in 85 patients, decongestant drops in 33, and a combination of these drugs in 12 patients. The major reasons for self-medication were 1. deviated nasal septum in 40 patients, 2. an acute upper respiratory infection in 33, 3. allergy in 18, 4. miscellaneous causes in 24 and 5. unknown in 15 patients. The initial management in addition to avoidance of the medication consisted of systemic antibiotics, decongestants, antihistamines, and sedatives depending on the severity of the rhinitis and the presence of secondary infection. Later treatment consisted of correction of the deviated septums, allergic management, and supportive care. Eight patients were considered to have complications of the disease by development of chronic ethmoiditis and nasal polyposis. The pharmacologic properties of the causal agents are thoroughly reviewed as they relate to the pathogenesis of this disease. It is felt that the ready commercial availability and limited clinical value of the topical nasal sprays and drops represents a certain risk to all patients using them.

Bone and liver scans in patients with head and neck carcinoma.

The initial evaluation of patients with malignant tumors of the head and neck must include an attempt to determine the presence or absence of distant metastases so that the patient's tumor can be accurately staged and appropriate treatment planned. To determine the value of routine bone and liver scans in detecting distant metastases, the records of 169 patients with head and neck carcinoma, on whom such scans were performed, were reviewed retrospectively. No true positive liver scans were found and the incidence of true positive bone scans was only 2%. It is felt, therefore, that routine scanning is not a worthwhile procedure and we recommend that liver and bone scans be reserved for those patients with advanced primary tumors, with regional node metastases or with clinical or laboratory evidence of liver or bone involvement.

Association of foveomacular retinitis, ankylosing spondylitis, iritis, and acquired iris atrophy.

A case of foveomacular retinitis, ankylosing spondylitis, iritis, and iris dissociation is described. Only ankylosing spondylitis was present in other family members. The differential diagnosis is discussed. The iritis of ankylosing spondylitis must be considered in cases of developmental full-thickness iris holes.

Fatal complication from an alkaline battery foreign body in the esophagus.

Foreign bodies and alkali burns in the trachea and esophagus are potentially fatal. Some camera batteries contain 45% potassium hydroxide electrolyte which can leak and cause liquification necrosis upon tissue contact. This report describes a case of an alkali battery foreign body in the esophagus with a subsequent fatal course which was masked by steroid therapy. A discussion of corrosive burns of the esophagus, their etiology, clinical course and pathology is presented.

Vocal cord fixation in laryngeal carcinoma.

The 1962 TNM classification (T, tumor and extent; N, regional lymph node metastasis, M, distant metastasis) did not emphasize vocal cord fixation in staging. In the revision of 1972, lesions with partial fixation were classified T2, stage II, and those causing fixation were T3, stage III. The therapeutic results in 39 patients with fixed cords revealed a determinante five-year survival of 41% and an absolute of 23%. These statistics support the validity of the 1972 classification. Careful evaluation of vocal cord mobility prior to selection of therapy is stressed.

Stomal recurrence following laryngectomy.

The extent of subglottic involvement and preoperative tracheostomy, appear to be the most important causative factors in peristomal carcinoma. Our case histories have demonstrated tumor foci in a tracheopstomy tract and in pretracheal lymphatics. Once established, the prognosis of the lesion is grave. Radiation and chemotherapy offer only limited palliation, and extensive resection offers the best chance of cure at the present time. Prophylactic measures such as avoiding a preliminary tracheostomy, meticulous paratracheal dissection, and microscopic control of the resected margins of the surgical specimen may reduce the incidence of peristomal carcinoma.