Microcystic adnexal carcinoma (sclerosing sweat duct carcinoma).

Microcystic adnexal carcinoma (MAC) is a recently described malignant neoplasm of the adnexal structures of skin that shows a marked propensity for early infiltrative and locally aggressive growth. Its banal clinical appearance may lead to a delay in diagnosing the tumor by biopsy, and its multifaceted histologic features may lead to an incorrect tissue diagnosis. Confusion with benign tumors and less aggressive malignancies can lead to inadequate initial treatment and extensive recurrences. We describe three cases of microcystic adnexal carcinoma and review the clinical and histologic features, treatment, and prognosis of this neoplasm.

Nonsurgical treatment of aggressive fibromatosis in the head and neck.

Aggressive fibromatosis is a poorly defined, locally aggressive, yet histologically benign fibroblastic proliferative lesion that may occur in the head and neck. The lesion is highly cellular and locally infiltrative and has a propensity to invade and erode bone, compromising vital structures within the head and neck. However, it is not a true malignancy because it does not have malignant cytologic characteristics nor does it metastasize. We present two cases of aggressive fibromatosis occurring in young adult men. The first case involved a rapidly enlarging mass of the anterior maxilla that involved the upper lip, nasal alae, nasal septum, inferior turbinates, and hard palate. The patient underwent incisional biopsy to confirm the diagnosis. Because of difficulty in determining the actual margins of this extensive lesion and the significant morbidity that would have resulted from surgical resection, we elected to treat this patient with chemotherapy and radiation therapy. The second case was an extensive lesion involving the right temporal bone, pterygomaxillary space, and infratemporal, temporal, and middle cranial fossae. Incisional biopsy confirmed the diagnosis. Because of the lack of functional and cosmetic deficits and the unavoidable morbidity of a surgical resection, this patient was treated with radiation therapy. Although wide field resection is the most satisfactory form of treatment, in situations in which this modality would result in unacceptable morbidity or if surgical margins are positive, then radiation therapy and chemotherapy should be considered. Support for these therapeutic modalities is found in larger series of cases outside the head and neck.

A multidisciplinary approach to reducing morbidity and operative blood loss during resection of carotid body tumor.

Seven carotid body tumors in six patients were successfully managed using a multimodality approach that included the vascular surgeon, head and neck surgeon and angiographer. Five tumors were managed with preoperative subselective embolization of tumor vessels. Two required vascular reconstruction. The mean operative blood loss was 332 milliliters. All of the patients survived, and the only morbidity was one instance of transient vocal cord paresis. Surgical resection remains the treatment of choice for carotid body tumors. After angiographic embolization, a combined surgical approach by both the vascular surgeon and the head and neck surgeon reduces the associated morbidity and blood loss during resection.

Human Curvularia infections. Report of five cases and review of the literature.

Curvularia lunata is a saprobic dematiaceous mould that resides primarily in soil (Ellis, 1966). Reports of human disease caused by this organism are rare but include: endocarditis, brain abscess, skin infections, onychomycosis, keratitis, pneumonia, disseminated disease, mycetoma, allergic bronchopulmonary disease, and one case of sinusitis. Since 1983, we have encountered five cases of paranasal sinusitis due to C. lunata. None of the patients suffered from known immunologic disorders or underlying debilitating diseases. These five cases are presented and the literature of human phaeohyphomycosis caused by Curvularia spp. is reviewed.

Enophthalmos and upper eyelid retraction following osteoplastic frontal sinusotomy.

A 38-year-old man presented with hyperophthalmia, enophthalmos, and upper eyelid retraction 18 months following an osteoplastic flap and frontal sinus obliteration for mucocele. Computerized tomography confirmed the presence of frontal bone absorption in the roof of the orbit with traction and elevation of the orbital contents into the obliterated frontal sinus. A fracture of the orbital roof with penetration of periorbita at the time of original surgery was the suspected precipitating cause of the complication. Surgical management included lysis of the cicatrix between the orbit and frontal sinus and interposition of a silicone sheet between the orbit and sinus, which restored the appropriate anatomic relationships and prevented recurrence.

Antibiotic prophylaxis in high-risk head and neck surgery: one-day vs. five-day therapy.

Patients who undergo major contaminated surgery of the head and neck benefit from perioperative antibiotic prophylaxis. This study was developed to determine if 5 days of antibiotic administration would be more effective than 1 day. A multi-institutional prospective randomized double-blind study was designed. Patients who were identified as requiring pedicled flap reconstruction were potential candidates for the study. Later, patients were randomly assigned to receive cefoperazone sodium for either 24 hours or 120 hours. In each case, the drug was administered intravenously, beginning 1 to 2 hours preoperatively and continued for the prescribed period. One hundred nine patients were evaluable. Fifty-three patients were assigned to 1 day of perioperative prophylaxis. Wound infection developed in ten patients (18.9%). Fifty-six patients were assigned to 5 days of perioperative antibiotic prophylaxis. Wound infection developed in 14 (25%) of these patients (P greater than .05). These data suggest that no beneficial effect from administration of antibiotics for longer than 24 hours postoperatively can be achieved in patients who undergo myocutaneous flap reconstruction.

Customized valve housing.

Numerous remarkable advancements have been made in the area of voice prosthetics. A significant, persistent problem, however, has been the development of air leaks around the tracheostome housing. This problem is particularly apparent with patients having deeply recessed, irregular stomas. This paper describes a customized tracheostome valve housing that is fabricated to minimize or alleviate difficulties associated with maintenance of an airtight seal. Our experience with 12 patients revealed that they maintain adequate seals for 72 hours and enjoy the functional benefits provided by the customized housing.

The management of eyelid laxity during lower eyelid blepharoplasty.

Lower eyelid and lateral canthal angle malposition or frank ectropion are the most common complications of lower eyelid blepharoplasty. Although these complications may result from excessive skin excision, from surgical imbrication of the orbital septum or lower eyelid retractors, or from scar formation within the eyelid, failure to correct preexisting lower eyelid laxity is the most common cause. Recently published data have established laxity at the lateral canthus as the primary cause of involutional lower eyelid laxity. We review the pathophysiology of lower eyelid laxity and present an anatomic approach for the correction of lower eyelid laxity during blepharoplasty.

Temporalis myofascial repair of traumatic defects of the anterior fossa. Technical note.

Bilateral temporalis myofascial flaps in continuity with frontal periosteum can be used in repairing extensive dural and bone defects of the anterior cranial fossa floor. The technique of preserving and using this flap is described and offers an alternative to the use of frontal pericranial tissue for repair of anterior dural defects.

Principles and hazards of electrocautery in otolaryngology.

Electrocautery is used extensively in otolaryngology--head and neck surgery. Its commonplace use and excellent safety record may lull the surgeon from heeding the device's potential dangers. User error causes the majority of patient injuries. A thorough understanding of the electrophysical principles and hazards is essential for even the occasional user. Three cases of electrosurgical injury are reported to demonstrate problem areas in electrocautery usage. The basic electrophysical properties are described, and guidelines for prevention of injury to the patient are reviewed.

Use of temporalis muscle flaps in complicated defects of the head and face.

Large defects in the upper two thirds of the face, skull, and skull base pose challenging reconstructive problems. There are a number of applicable reconstructive techniques, all with various advantages and disadvantages, available to otolaryngologists-head and neck surgeons. One method, originally described in the late 1800s, was evaluated by us. Applications of the technique included reconstruction of large defects of the forehead, dura, and anterior skull base, closure of orbital defects, and soft-tissue augmentation of the face. Advantages of this reconstructive technique are the flap's proximity to the defects and its simplicity of execution.

Extended latissimus dorsi myocutaneous flap reconstruction of major head and neck defects.

The purpose of this article is to familiarize th surgeon with the latissimus dorsi flap and some particularly useful applications of it. This flap has proved extremely versatile, with many uses, among them immediate coverage for extensive head and neck wounds. It has been equally successful in repairing defects in both normal and irradiated tissue. The range of the arc of utilization has been exceptional, easily reaching the skull vertex from the chest wall. However, to be able to extend this flap so far requires careful dissection of the neurovascular pedicle and intimate anatomic knowledge of the posterior axilla region. This flap's muscle bulk is quite acceptable and the donor site may almost always be closed primarily. There appears to be less functional disability from sacrifice of this muscle than with pectoralis or trapezius myocutaneous flaps. Accordingly, it is ideal when much tissue is needed for single-stage coverage. Additional uses are available when flaps from other sites have failed.