Frontal sinus fractures--their suppurative complications and surgical management.

A series of 54 patients treated for frontal sinus fractures at Charity Hospital, New Orleans, from 1967-77 is presented. There were a large number of suppurative complications related to the various medical and surgical managements. Initial treatments included: observation (15), exploration and open reduction (22), obliteration (16), and ablation (1). Four patients with open fractures were not explored and developed recurrent frontal sinusitis; one progressed to an osteomyelitis. Two with posterior table fractures were not explored and developed meningitis (one was then obliterated and developed an epidural abscess). Three patients developed frontal sinus abscesses after obliterations for anterior wall fractures. Fat gave fewer complications than the other commonly used materials. Exploration is advocated for most frontal sinus fractures. Obliteration should be avoided when possible. Fat is the material of choice when obliteration is required.

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.

Coexisting lentigo of the larynx and melanoma of the oral cavity: report of a case.

A case is presented of coexisting malignant melanoma of the oral cavity and large benign lentigo of the pyriform sinus of the larynx. The absence of a pigmented lesion of the oral cavity in this patient suggests the possibility that lentiginous lesions of the larynx and oral cavity represent simultaneous invasion of these sites by melanocytes later undergoing malignant degeneration in the oral cavity. The histologic observations of these separate lesions are presented and compared. The literature is reviewed briefly. The widespread clinical opinion that malignant melanoma is a systemic disease is illustrated by this case.

Clinical and experimental correlations in temporal bone fracture: the facial nerve.

In this review of 50 patients with fracture of the temporal bone, 11 patients had ipsilateral facial paralysis, three of immediate and eight of delayed onset. Eight patients with complete paralysis of the facial nerve had facial nerve decompression; six of these had incomplete return of function. Only one patient with a delayed complete facial paralysis had complete return of function. The poor functional results in patients with delayed complete facial paralysis due to temporal bone fracture encourage facial nerve decompression in all stable patients with the complete facial paralysis of temporal bone fracture.

Use of transverse Kirschner wires in comminuted facial fractures.

Although most facial fractures can be well managed with open reduction and direct wiring of the fracture sites, this treatment is inadequate for some comminuted fractures and further fixation is required. At Charity Hospital in New Orleans transverse Kirschner wires have been routinely used to stabilize the zygoma in these cases. Although this technic has been described previously, its indications, advantages, and limitations are not widely appreciated. Eight recent cases are presented to demonstrate the technic, and alternative methods of treatment are discussed.

Gunshot injury to the temporal bone: an analysis of thirty-five cases.

By retrospective analysis of 35 surviving gunshot injuries to the temporal bone and by presentation of 6 representative cases, the management and reconstructive procedures of these injuries in the Tulane University affiliated hospitals are presented. The most frequent single injury was facial nerve paralysis (16 cases), followed by external canal injury and conductive hearing loss. Anacusis occurred in 12 cases. In conductive hearing loss the intact posterior wall tympanoplasty with mastoidectomy (16 cases), or the modified radical mastoidectomy (5 cases), allowed middle ear reconstruction. Transmastoid facial canal decompression, combined with the above procedures or with a middle fossa craniotomy, was performed in 6 cases. Delayed facial reconstruction (5 cases) utilized microneural anastomosis between facial-facial and hypoglossal-facial nerves and fascia lata slings. Intracranial complications of thrombosis of internal carotid artery, dural venous lacerations, temporal lobe aphasia, bitemporal hemianopsia, cerebral abscesses and meningitis are also discussed.

Alveolar soft part sarcoma of the head and neck.

The twelfth case (in 25 years of literature) of alveolar soft part sarcoma of the head and neck is presented. It represents the seventh case to occur in the base of tongue and the second to be associated with pregnancy. The average age of onset is in the second decade with a 2:1 female preponderance and a marked tendency to right-sided occurrence. Treatment with surgery and/or radiotherapy is not curative. Local recurrence is common as are distant metastases, usually to lung, brain or bone. Theoretically, chemotherapy may offer better control of disease but few agents have shown dramatic response. The characteristics of the tumors are discussed and various chemotherapeutic agents are reviewed.

Malignant melanoma of conjunctiva metastatic to parotid gland. Reports of cases and discussion of surgical management.

Invasive malignant melanoma of the conjunctiva is a rare neoplasm fatal in 40% of cases. Accepted techniques of surgical management include wide local excision, conjunctivectomy, and exenteration. Recently lymphatic dissections have been proposed, but not described, for invasive conjunctival melanoma. We present five cases of invasive conjunctival melanoma, including two with intraglandular parotid metastases. The surgical management of these patients is presented, and a proposal is made for radical bloc dissection of the orbital contents and regional lymphatics. The histology of conjunctival melanoma is discussed, and a classification proposed to assist the head and neck surgical team in the management of this disease.

Impact trauma of the human temporal bone.

A cooperative study between the Department of Otorhinolaryngology and the Highway Safety Research institute of the University of Michigan was designed to study temporal bone fracture produced in cadavers subjected to realistic automotive impact situations. Utilizing sled and piston impact configurations frontal and parietal impacts were noted to produce ipsilateral and contralateral fractures of nine temporal bones in seven cadavers. The impact velocities varied between 18.1 and 25.0 mph. Using standard otologic microsurgical techniques, the temporal bones were dissected and numerous gross and microscopic injuries to middle and inner ear structures were found. The authors conclude that extensive comminuted fracture of the human temporal bone is seen with realistic crash situations of low velocity, and that lateral impact which produces a longitudinal fracture with a posterior fossa comminution is associated with disruption of the cochlea and facial nerve, as well as of middle ear structures. The classical transverse fracture of extensive skull trauma lies medial to these structures and does not involve the otologic contents of the human temporal bone. Associated brain and skull injuries are also described.

A radiologic advance in the diagnosis of disorders of the larynx.

The cervical spine greatly reduces the usefulness of anteroposterior soft tissue radiologic examination of the larynx. Fractures of the laryngeal and cricoid cartilages are difficult to diagnose by soft tissue technique, and time-consuming laminagraphy is often required. A new technique for single exposure anteroposterior soft tissue radiography of the cartilages and airway is described. An esophageal cassette containing ultraspeed dental film placed in a retrolaryngeal position is shown to yield detailed radiographs of high contrast. The feasibility of this technique is illustrated by the presentation of radiographs from patients with laryngeal disorders. The new technique is compared with existing examinations available to the clinician and its application in other disorders of laryngeal cartilages and soft tissue is discussed.

Tuberculosis of the larynx.

Tuberculosis of the larynx, once a common disease, has become quite rare with the advent of anti-tuberculous chemotherapy. In the pre-antibiotic era two modes of laryngeal infection were recognized; bronchogenic and hematogenous. The literature is briefly reviewed. Thirteen patients in the past 15 years in whom tuberculous laryngitis was diagnosed upon indirect laryngoscopy by members of the University of Michigan Department of Otorhinolaryngology are presented. Bronchogenic infection was present in 11, and in two patients the disease was consistent with hematogenous spread. Tissue biopsy from a case of bronchogenic contamination demonstrated epithelioid tubercles, while numerous subepithelial acid-fast bacilli without typical tuberculous histological change were present in a case of hematogenous laryngeal infection. A case of cicatricial laryngeal stenosis was successfully treated surgically by laryngofissure, excision of fibrosis with arytenoidectomy, and free mucous membrane grafting. Finally, the initial subtle presentation of many of our patients emphasizes the importance of a consideration of tuberculosis in the differential diagnosis of chronic laryngitis.

Static and dynamic impact trauma of the human larynx.

The response of fresh human larynges to static and dynamic compressive loading has been determined for 24 specimens. Mean static force values producing thyroid and cricoid cartilage fractures were 15.8 and 20.8 kg, respectively, and the similarity of this experimental injury to a mild clinical laryngeal fracture syndrome is discussed. Dynamic fracture loading, at velocities up to 11 mph, caused cartilage fractures at forces averaging 30% more, and comparison with the static data is made. Interaction of the thyroid and cricoid cartilages to impact force are analyzed in reference to airway protection. The 50% compressive strain level, at which structural collapse is imminent, averaged 55 kg. The significance of these previously unreported low force levels producing fracture is discussed with reference to automotive design.