Metastatic hypernephroma to the head and neck.

Eight cases of metastatic hypernephroma to the head and neck are presented with CT documentation. Hypernephroma is the third most common infraclavicular tumor to metastasize to the head and neck. Such metastases occur in about 15% of patients with this neoplasm, and nearly 8% of patients with this tumor present with disease in the head and neck region. These metastases are usually vascular and may either clinically precede the diagnosis of the renal primary tumor or may occur many years after apparently successful surgery of the primary tumor. These unusual patterns of behavior are reviewed. One of the cases presented here is the first reported incidence of cervical lymph node metastasis with hemorrhage to be documented by CT, thus adding this entity to the list of imaging differential diagnoses of cystic-appearing neck masses.

Schwannomas of the larynx: review and computed tomographic scan analysis.

Neurogenic tumors consist of schwannomas, neurofibromas, and neurosarcomas that arise from the Schwann cell of a peripheral nerve. Their occurrence in the larynx is rare, with only 115 cases having been reported. Three new cases are presented, the literature is reviewed, and the first computed tomographic (CT) scan of a benign schwannoma of the larynx is demonstrated. The diagnosis and treatment of these tumors and the CT scan analysis are discussed.

Management of substernal and intrathoracic goiters.

Goiters that descend into the mediastinum can cause respiratory embarrassment, dysphagia, vascular compression, vocal cord paralysis, and sudden death. Although many such goiters remain clinically silent, their ability to produce sudden and unpredictable respiratory distress is well known. The condition was not considered uncommon in the first half of the twentieth century; some authors reported series of hundreds of thyroidectomies for intrathoracic goiter. Though seen less frequently today, the only effective treatment for mediastinal goiter is surgical removal. We report our experience with the management of 70 consecutive patients with substernal or intrathoracic goiters. The clinical presentation, preoperative evaluation, operative technique, and results and complications of therapy are discussed. Consideration is also given to the pathogenesis of intrathoracic extension. The transcervical approach for resection is emphasized--even goiters extending to the aortic arch were safely removed without requiring sternotomy. A multidisciplinary team approach, including the surgeon, anesthesiologist, and endocrinologist, is essential. Because of more conservative trends in the selection of patients for thyroidectomy, the incidence of mediastinal goiter may be increasing.

The role of supraomohyoid neck dissection at the time of supraglottic laryngectomy.

Uncontrolled cervical metastasis is the most common source of failure in the surgical treatment of supraglottic carcinoma. This study was designed to determine the value of supraomohyoid neck dissection in patients undergoing supraglottic laryngectomy. The rationale for considering the role of supraomohyoid neck dissection is that such a dissection encompasses the subdigastric and midjugular nodes which are the first echelon of lymphatic drainage of the supraglottic larynx. Thirty-eight patients with a diagnosis of epidermoid carcinoma of the supraglottis were treated by subtotal supraglottic laryngectomy (SSL). Ten patients underwent SSL with no neck dissection, 16 patients underwent SSL with supraomohyoid neck dissection (SOHD)--9 unilateral and 7 bilateral, and 12 patients underwent SSL with radical neck dissection (RND). The 3 groups had comparable T classifications. All of the SSL and SSL with SOHD patients were classified as N0. Of the 12 patients treated with SSL and RND, 4 were classified as N0, 4 as N1, 3 as N2, and 1 as N3. The patients were studied to determine the incidence and pattern of subsequent neck disease, survival, complications, and length of hospitalization. The data indicates that supraomohyoid neck dissection offers little benefit as an adjunct to supraglottic laryngectomy.

Modified tracheoesophageal diversion for chronic aspiration.

Breakdown of the normal protective function of the larynx, either through primary laryngologic or neurologic causes, leads to chronic aspiration, recurrent pneumonitis and possibly death. In this paper we discuss the existing surgical treatments for chronic aspiration. Tracheal separation and trecheoesophageal diversion are discussed, as are the difficulties of using these procedures in patients with pre-existing tracheostomies. A modification of tracheoesophageal diversion is presented whereby this procedure can now be utilized in those patients with pre-existing tracheostomies. The modified tracheoesophageal diversion is performed in five patients successfully. Since most patients have already had tracheotomies in an attempt to control aspiration, we feel that our technique of modified tracheoesophageal diversion enables this group of patients to benefit from this procedure as well.

Laryngeal nerve crush for spastic dysphonia.

Twenty-two patients with a diagnosis of spastic dysphonia were treated by laryngeal nerve crush. All patients had initial improvement. Success at 3-year follow-up was 13%. Laryngeal nerve crush is no longer advocated as treatment for spastic dysphonia.

Unusual presentations of penetrating foreign bodies of the upper aerodigestive tract.

Only a small number of ingested foreign bodies perforate the esophagus and even a smaller fraction migrate extraluminally. Four such penetrating and migrating foreign bodies of the upper aerodigestive tract are presented. Review of the literature revealed 321 cases of penetrating ingested foreign bodies, of which 252 remained intraluminal and 43 were found extraluminally, with the status of the remainder indeterminate. Analysis revealed that an intraluminal penetrating foreign body carried a higher overall mortality than one that migrated extraluminally. Although intraluminal and extraluminal penetrating foreign bodies may remain quiescent for years before presenting a complication, no correlation existed between mortality and the duration of the foreign bodies' retention. The greatest mortality was seen with vascular complications followed by diffuse and local suppurative processes. The overall mortality was significantly reduced in the post-antibiotic era.

Clinical-pathological determinants in prognosis of fibrous histiocytomas of head and neck.

Review of the literature reveals 76 cases of fibrous histiocytoma of the deep structures of the head and neck. To this we have added 11 of our own cases, and analyzed the total group to determine clinical and histological features of a high risk population. Age, sex, presence of pain, location of tumor, size of tumor, and local invasion appear to be important clinical criteria. Bizarre giant cells, numerous and atypical mitoses, necrosis, and inflammation appear to be important histologic features. The treatment of choice is wide local excision. Chemotherapy appears to produce tumor regression.

Peripheral nerve sheath tumors of the paranasal sinuses.

Only 4% of peripheral nerve sheath tumors of the head and neck occur in the paranasal sinuses. The most commonly involved sinus is the maxillary antrum and the most common histologic type is benign schwannoma. Two new cases of schwannoma occurring in the sphenoid and maxillary sinuses are reported. The clinical pathologic, and radiographic features of these lesions are reviewed.

Primary chordoma of the maxillary sinus.

A case of primary chordoma of the maxillary sinus is presented. The embryology of the notochord is reviewed and it is suggested that the frequently used adjective "ectopic" is a misnomer. The literature of primary paranasal sinus chordomas is reviewed and the clinicopathological features described. It is emphasized that these lesions can mimic other benign and malignant processes both clinically, radiographically and histologically. The treatment and prognosis is more favorable than the more common craniocervical chordoma.

Thyroid carcinoma in a patient with a coexisting functional adenoma.

Fourteen case reports have been published in which "hot" nodules have been documented as carcinoma, with or without coexisting adenomas. The diagnosis of these lesions is difficult, since hot nodules usually represent benign disease. These carcinomas are not functional, but represent coexistence of a functional area or a malignant degeneration. Hot nodule carcinomas should be suspected in high-risk patients. A euthyroid, 31-year-old woman who, as a teenager, had radiotherapy for acne is reported. She was followed up with yearly scans for a hot nodule in the right lower lobe of her thyroid. When she was 36, a node was discovered in the right side of her neck, and carcinoma was suspected. Surgical excision revealed a papillary-follicular carcinoma adjacent to an adenoma with metastases to regional lymph nodes.

Laryngeal nerve crush for spastic dysphonia.

Four patients with spastic dysphonia refractory to speech and phychiatric therapy were treated by crushing the recurrent laryngeal nerve. Vocal cord paralysis was produced in all patients. Vocal spasticity subsided in all patients. Vocal cord motion returned in four to six months. Three of four patients remained free of spasticity for a minimum of 24 months.

Olfactory groove meningioma with paranasal sinus and nasal cavity extension: a combined approach.

A 58-year-old man had an enlarging right fronto-orbital mass. A biopsy specimen of a right nasal cavity tumor was reported as meningioma. Preoperative evaluation including skull roentgenograms, tomograms of the paranasal sinuses, brain scan, computerized axial tomography, and carotid angiography substantiated a large subfrontal mass with paranasal sinus and orbital extension. A combined approach through a right frontal craniotomy and right lateral rhinotomy was used for a complete removal of this tumor. A review of the literature is contained herein.

Vertical partial laryngectomy for glottic carcinoma with posterior subglottic extension.

Posterior subglottic extension of glottic carcinoma has been a contraindication for partial laryngectomy because of the proximity of the cricoid cartilage. Resection of the upper portion of the posterior aspect of the cricoid is necessary for adequate tumor resection but is complicated by persistent aspiration. This paper presents a method of reconstruction following partial posterior cricoid resection.

Delayed tracheal reconstruction.

An extended area of stenosis of the upper mediastinal trachea, which normally would require extensive thoracic mobilization for primary anastomosis, was corrected by resection of the manubrium with the creation of a trough. This was closed in several stages utilizing embedded Marlex mesh and regional skin flaps. The development and modifications of this technique are discussed.

Hemangiomas of the salivary glands.

Five salivary gland hemangiomas in adults are reported. The feasibility of preoperative diagnosis on clinical and radiologic grounds is emphasized. Adult hemangiomas are of the cavernous type and can be differentiated from infantile capillary hemangiomas clinically as well as histologically. Cavernous hemangiomas in the adult should be treated by surgical excision.

Parotid space tumors of non-salivary origin.

A review of 700 parotidectomies showed that 98 procedures were performed for parotid space tumors of non-salivary origin. The clinical presentation in this group of patients did not differ significantly from the larger group of salivary tumors except for a higher incidence (12%) of the former in the younger age group. Of the 98 cases, 54 proved to be lymph node tumors, both neoplastic and inflammatory and 44 were tumors of various somatic origins. Among the latter group, bone and joint tumors, vascular lesions and some connective tissue tumors may be recognized preoperatively. Generally, however, the entire group of non-salivary tumors can be distinguished only intra-operatively, if at all. Correct recognition may lead to variations in operative techniques and extent of resection.