Prophylactic antibiotics for head and neck surgery with flap reconstruction.

The leading cause of postoperative morbidity in patients undergoing major head and neck surgical procedures is postoperative infection. This prospective randomized multi-institutional clinical trial was designed to compare the effectiveness of clindamycin phosphate and high-dose cefazolin sodium therapy in preventing postoperative wound sepsis in patients undergoing contaminated head and neck surgical procedures in which flap reconstruction was required. Either clindamycin phosphate (900 mg) or cefazolin sodium (2 g) therapy was instituted intravenously prior to surgery and continued every 8 hours, for a total of 24 hours. The patients received postoperative follow-up, and the wounds were graded according to the worst condition observed. One hundred cases were evaluated. Fifty-one patients received clindamycin and 49 patients received high doses of cefazolin; wound infection developed in 10 patients (19.6%) and 11 patients (21.6%), respectively. This difference was not statistically significant. The average duration of surgery was approximately 8 hours for both the infected and the noninfected groups of patients. High-dose cefazolin and clindamycin have similar efficacy when administered prophylactically under these circumstances. Reconstruction with free vascularized tissue may aid in reducing postoperative wound infection.

Pharyngeal ulceration in AIDS patients secondary to cytomegalovirus infection.

Cytomegalovirus (CMV) infections in patients with acquired immunodeficiency syndrome are common and may present as retinitis, encephalitis, esophagitis, gastritis, enterocolitis, adrenalitis, or pneumonitis. Three patients are presented with pharyngeal ulcerations secondary to CMV. Similar cases have not been previously described in the literature. Symptoms, physical findings, and the treatment of this clinical entity are discussed. Although pharyngeal CMV ulcers are not life-threatening, they may herald multisystemic CMV infection that may require prompt antiviral chemotherapy.

Salivary gland tumors. Diagnostic characteristics of the common types.

The salivary glands can be the site of a wide array of pathologic conditions. Information from the history is very important in diagnosis. During physical examination, the clinician can determine whether a mass is distinct or diffusely enlarged and can check for mobility and skin fixation. The depth of the mass and its relationship to other structures can be assessed and the ductal orifice evaluated for purulence, turbidity, and absence of salivary flow. Studying the patient's face also provides diagnostic clues. Surgery provides the best basis for histologic diagnosis and allows complete removal of the mass. Fortunately, most neoplasms are benign and their treatment is straightforward.

Trichinosis presenting as a neck mass.

Trichinosis is a rare cause of a neck mass, but should be considered by the physician when contemplating a differential diagnosis. This disease is still endemic in parts of the world and is directly related to the ingestion of incompletely cooked pork. A case is presented in which a 68-year-old man was diagnosed as having a squamous cell carcinoma of the mandible only to have trichinosis diagnosed on the final pathologic report. The case presentation is followed by a historical review and discussion.

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.

Preauricular approach to infratemporal fossa.

We present an approach to the skull base that allows access to both the infratemporal fossa and the middle cranial fossa with minimal morbidity. This approach is different from most of the previously described approaches in that it uses a preauricular incision, preserves the facial nerve, and avoids the mastoid bone. It involves dividing the zygomatic arch and displacing it inferiorly, dividing the malar eminence (zygoma) and displacing it anteriorly, and cutting the coronoid process and retracting it superiorly with the attached temporalis muscle. Reconstruction is accomplished by using the temporalis muscle or a pericranial flap to cover the dura, a free fat graft to fill the space left by tumor excision, and by wiring the zygomatic arch and malar eminence into their original positions. Case reports of both benign and malignant lesions are presented.

Cisplatin sensitization to radiotherapy in stage IV squamous cell carcinoma of the head and neck. A follow-up report.

Thirty-six patients with stage IV squamous cell carcinoma of the head and neck were treated with cisplatin (15 mg/m2), administered synchronously with high-dose radiation therapy. Of the original 36 patients, 26 are dead of disease. Although previous reports of an 88% response to this regimen were noted, the disease-free intervals in this 36-patient group were short. The interval of time between treatment and death ranged from two to 27 months, with an average survival time of 10.7 months. It appears that although cisplatin potentiation to radiation therapy offers an encouraging clinical response initially, persistent clinical regression of disease is unlikely. Further studies of cisplatin sensitization of radiation therapy vs radiation therapy alone and chemotherapy alone need to be performed before this regimen can be considered strong enough to stand on its own merits.

Postoperative evaluation of sleep apnea after uvulopalatopharyngoplasty.

Uvulopalatopharyngoplasty (UPPP) is an operation that is frequently performed for the treatment of obstructive sleep apnea (OSA). While UPPP usually eliminates or decreases snoring and often reduces excessive daytime sleepiness, the decrease in the number of episodes of apnea and hypopnea, and the improvement in oxygen saturation (SaO2) have been less predictable. We compared preoperative and postoperative polysomnography (PSG) in 27 patients with OSA and found that no single PSG parameter could accurately reflect the changes in respiration seen after UPPP. We suggest that a combination of indices including the apnea index, the apnea and hypopnea index, the frequency and severity of decreases in SaO2, and the lowest SaO2 be used to assess the effect of UPPP. Using this combination we determined that 30% of our patients were markedly improved, 33% were somewhat improved, and 37% were unimproved. To rely solely on the patient's subjective improvement often results in overestimating the therapeutic results of surgery, whereas to rely only on one PSG parameter may underestimate or overestimate the degree of improvement.

Extracapsular spread of carcinoma in cervical lymph nodes. Impact upon survival in patients with carcinoma of the supraglottic larynx.

The treatment results and histologic findings in the cervical lymphatics of 96 patients with squamous cell carcinoma of the supraglottic larynx were studied retrospectively. The clinical assessment of the extent of disease in the cervical lymphatics correlated poorly with histologic findings. Forty-one percent of patients judged to have no evidence of cervical metastases were found to have carcinoma in the cervical lymphatics. Twenty percent of patients judged clinically NO were found to have extracapsular spread of tumor. Patients were subdivided according to the histologic findings in the cervical lymphatics. Three-year no-evidence-of-disease (NED) follow-up was available on all patients. Patients with no tumor in cervical lymphatics had a 71% 3-year NED. By comparison, patients with cervical metastases confined to the lymph node were 79% NED. Patients with histologic evidence of extracapsular spread of tumor were 45% NED (P less than 0.05). The use of histologic findings in predicting prognosis and treatment planning is discussed.

Cisplatin potentiation of radiotherapy. Long-term follow-up.

Thirty-three patients with inoperable squamous cell carcinoma of the head and neck were treated with cisplatin, 15 mg/sq m, administered synchronously with high-dose radiation therapy. Twenty-nine patients (88%) responded to the regimen; of these, 20 had complete regression of all disease. Eight of the 20 had a relapse in less than one year of their treatment. Among those patients who did not have a relapse, the follow-up period was short. It is concluded that a clinical regression response is more likely with this treatment regimen than with radiation therapy alone, and that that response may be a better palliation. Further study of this combination of treatment modalities is warranted.

Evaluation of the adult with sleep apnea.

Twenty-seven cases of adult sleep apnea are reported. The patients were studied with all-night polysomnography. Seven (26%) had predominately obstructive sleep apnea, while another seven (26%) had predominantly central sleep apnea. Thirteen patients (48%) were found to have a mixed pattern. Obesity was not a reliable guideline for predicting differential etiology. We conclude that sleep studies with specific monitoring are essential in the evaluation of the adult with sleep apnea prior to therapeutic intervention.

Brainstem evoked potentials in adult sleep apnea.

Brainstem evoked potentials (BSEP) were recorded in 23 patients with adult sleep apnea (ASA). Three patients were studied with all-night polysomnography prior to our testing. They were categorized as having obstructive, central, or mixed sleep apnea depending on the predominant sleep findings. All patients with central sleep apnea had abnormal BSEP with prolongation of wave V. A majority of the remaining patients with obstructive sleep apnea and mixed sleep apnea had abnormal BSEP, but without specific configurations. These findings substantiate our hypothesis that brainstem dysfunction may play a role in ASA.