Neck dissection: cause and effect.

OBJECTIVE: This study aimed to evaluate changes in neck dissection procedures over time in a tertiary university hospital to determine their influence on residency training. METHODS: Neck dissections performed in a recent decade (2003-2012) were retrospectively analysed and compared with those of an earlier decade (1981-1990). RESULTS: Nowadays, neck dissections are most frequently performed for thyroid (2003-2012 vs 1981-1990: 60.7 per cent vs 25 per cent, p = 0.002) and less often for epithelial malignancies (23.2 per cent vs 53.5 per cent, p = 0.002). Compared with dissections for thyroid spread, more dissections for epithelial malignancies are extensive (epithelial vs thyroid malignancies, 66 per cent vs 4.9 per cent) and more are performed after chemoradiation failures (25.6 per cent vs 0 per cent). CONCLUSION: This study demonstrates changes in neck dissection procedures over time. There is an increasing preference for conservative treatment for epithelial cancers. In addition, there is a large increase in both the diagnosis and surgical treatment of thyroid cancer. This shift may have a great effect on residents' learning curves and on their ability to achieve competency in performing neck dissections.

Vocal cord paralysis secondary to impacted esophageal foreign bodies in young children.

Impacted foreign bodies in the esophagus can result in respiratory symptoms including stridor and aphonia. Several mechanisms have been proposed to explain these symptoms, but the possibility of vocal cord paralysis and its cause has not been adequately emphasized. Two cases of young children with esophageal foreign body are described; both presented with respiratory symptoms, 1 with aphonia and the other with stridor. In both cases, the symptoms were secondary to vocal cord paralysis. A possible mechanism of recurrent nerve injury is proposed.

Transesophageal echocardiography: diagnostic and clinical applications in the evaluation of the stroke patient.

OBJECTIVES: Transesophageal echocardiography (TEE) is superior to transthoracic echocardiography (TTE) in diagnosing cardiac abnormalities that may result in cerebral embolism. The clinical importance of these abnormalities is unclear. METHODS: We classified 96 consecutive stroke patients into high- or low-risk groups for cardioembolism based on historical criteria. The presence of left atrial thrombus, atrial smoke, patent foramen ovale, atrial septal aneurysm, and plaque in the ascending aorta was assessed with TEE. Stroke type and other possible stroke mechanisms were evaluated. RESULTS: Left atrial thrombus occurred only in the high-risk group. Patent foramen ovale, atrial septal aneurysm, and most cases of left atrial smoke occurred in the presence of another embolic source or were associated with a stroke related to hypertensive small vessel disease. Protruding atherosclerotic plaque in the ascending aorta and aortic arch was the most significant cause of stroke diagnosed by TEE because it frequently occurred in those without other risk factors for stroke. TEE identified aortic plaque in one and left atrial smoke in two patients with lacunar infarction without risk factors for small vessel disease. CONCLUSIONS: TEE should be considered in both lacunar and nonlacunar stroke that occur in the absence of stroke risk factors, although optimal management of most TEE findings is yet to be determined.

Tongue reinnervation by hypoglossal-lingual nerve transfer.

The morbidity associated with total glossectomy for treatment of base of tongue carcinomas provides the impetus to investigate techniques to salvage the uninvolved normal anterior tongue. This report describes a method of reinnervation of the anterior tongue using a hypoglossal-lingual transfer. In Cynomolgus monkeys, unilateral transfers with and without a subsequent muscle fillet resulted in reinnervation from the base to the tip of the tongue. It is proposed that hypoglossal-lingual nerve transfers be considered to allow sparing and return of function to the anterior tongue in conjunction with a resection of the tongue base. Additional experiments confirmed that the base of the tongue, like other midline muscles, has bilateral and separate innervation. The presence of a physiological lingual-hypoglossal reflex in the normal animal was documented.

Mechanisms in lacunar infarction.

BACKGROUND AND PURPOSE: Lacunes are thought to occur in patients with hypertension or diabetes mellitus as a result of small-vessel disease. This study evaluated the importance of other stroke mechanisms in a population of patients with lacunar infarction. METHODS: We evaluated 108 consecutive patients with a lacune in the lenticulostriate distribution for other stroke risk factors such as carotid and cardiac disease. RESULTS: Hypertension was present in 68% of the patients and diabetes mellitus in 37%; both occurred in 28% and neither occurred in 23%. Noninvasive carotid studies identified atherosclerotic plaque as a possible embolic source in 23%. By previously established criteria, 18% were at high risk for cardioembolism. Of those with hypertension or diabetes mellitus, 36% were at risk for a carotid or cardiac embolus. Of those without hypertension or diabetes mellitus, 32% had a possible carotid or cardiac etiology. CONCLUSIONS: The high incidence of carotid and cardiac disease in those with and without hypertension or diabetes mellitus suggests the importance of other stroke mechanisms in this population. Patients with lacunar infarction should therefore be evaluated for other causes of stroke that may be treatable.

Repair of the wounded guinea pig tympanic membrane: organization of filamentous actin and spatial cellular reorganization.

Since the role of the epithelial cell in the repair of the wounded tympanic membrane is not well understood, the epithelial cell layers were examined using rhodamine phalloidin to localize F-actin in situ following a full-thickness traumatic perforation. The change in shape of the epithelial cells and the morphological changes in F-actin were characterized. The mucosal cells were remarkably resistant to wounding and their morphology and F-actin distribution remained unchanged. Within 24 hours following perforation, basal cells were prominently stained adjacent to the perforation, whereas the remainder of the drum showed fainter staining similar to non-wounded drums. The basal cells showed a minor shape change in the direction of movement of the surface keratin. By three days, the dense peripheral F-actin staining of basal cells was prominent throughout the entire drum. The suprabasal cells demonstrated a marked shape change by 24 hours following the injury. The normal cobblestone pattern disappeared and cells elongated and were aligned towards the perforation. This occurred first adjacent to the perforation, and by three days re-orientation was present over the entire tympanic membrane. A few fine stress fibers appeared in the suprabasal cells. Histological and electron microscopic evaluation of the areas away from the perforation did not, however, show inflammation or disruption. By one week these changes were resolving and by two weeks the drum, with the exception of the cells in the area of the healed perforation, had returned to normal. The results are discussed with respect to the role of the various cell types in the migratory aspect of tympanic membrane wound repair.

The role of surgery in the treatment of squamous cell carcinoma of the nasal vestibule.

A retrospective analysis of 61 patients who were treated for squamous cell carcinoma of the nasal vestibule is presented. The general policy was to treat these carcinomas with radiation therapy, in view of the perception that this leads to a more acceptable cosmetic result. The primary nasal carcinoma was treated by surgery in five patients and by radiation in 56 patients. Surgical salvage of recurrent carcinoma in the nasal vestibule was performed without complications in 12 patients and resulted in local control in seven. Regional node metastases present at the time of diagnosis in two patients were not controlled by combined radiation and surgery. Late-developing regional node metastases were successfully managed by node dissection in three of four patients. The policy of initial treatment of the primary tumor by radiation, reserving surgery for the management of residual or metastatic cancer, resulted in good control rates and cosmesis.

Uniform epidermal cell proliferation in the mouse tympanic membrane.

Autoradiographic studies in mice showed epidermal cell proliferation to be dispersed over the whole tympanic membrane with no specific proliferative center. This strengthens the concept that net migration of the superficial layer of the stratum corneum across the tympanic membrane is the result of random insertion of cells into a pavement-like layer of corneocytes. We also found the cell proliferation rate in tympanic epidermis to be the same as that for dorsal epidermis in both normal mouse skin and the hyperproliferative epidermis of asebia mice. There was no indication of more rapid migration in tympanic epidermis in asebia as a result of the increased proliferation rate but rather increased thickness of the tympanic epidermis. There were also unusual circular mounds of epidermal cells in all asebia tympana, apparently due to localized hyperproliferation.

Thickened patches of stratum corneum on the human tympanic membrane.

If sufficient illumination is used, discrete thickened patches of keratin can be seen on the lateral surface of the tympanic membrane. These thickened areas which consist of numerous keratinocytes are separated by valleys lined by only one to three layers of keratinocytes. Keratin patches consistently appear as linear and discontinuous white streaks arranged along geodesic lines. There is a small area we have termed the "slow zone", located anterior and inferior to the umbo, that has comparatively fewer patches and where ink dots can remain static for several weeks. This paper describes the histology and distribution of keratin patches and postulates a mechanism for their formation, based upon the movement of the superficial layer of corneocytes towards the annulus.

In situ localization of F-actin in the normal and injured guinea-pig tympanic membrane.

Although cell migration is an important function of the epithelial cells of the tympanic membrane (TM), little is known about the distribution of the F-actin cytoskeleton, a contractile protein important in cell motility. The purpose of this experiment was to study the in situ localization of F-actin in the epithelial cells of the TM. F-actin, localized using Rhodamine-phalloidin, was present as a thin cortical band at the margin of both the mucosal cells on the inner side of the drum, and the suprabasal cells of the epidermis. The basal cells showed diffuse circumferential F-actin staining sometimes appearing as short microfilaments. Following a full thickness injury, changes in the distribution of F-actin could be observed with in situ localization. While the diffuse F-actin staining of the basal cells was reduced, both long F-actin microfilament bundles extending parallel to the long axis of the cell and focal aggregates of F-actin were prominent. The suprabasal cells became elongated, and while the F-actin remained localized to the cell margin, faint central F-actin microfilaments were observed. The staining of the mucosal cells remained unchanged. This study showed that the guinea pig TM is a useful model to study the distribution of epithelial F-actin in situ under normal and repair conditions, and that the basal cell layer may be important in regulating migration in the epidermis.

Primary meningioma of the nasopharynx: case report and review of ectopic meningioma.

Meningiomas not uncommonly spread outside the central nervous system, but primary extracranial meningiomas are much less common, the sites described including the orbit, the calvarium, the neck, the temporal bone and the paranasal sinuses. Reported here is the first instance of extracranial meningioma of the nasopharynx. The histological appearance of meningiomas is diverse, and in ectopic sites can be mistaken for malignant epithelial tumors, as happened here initially. The tumor was excised via a transpalatal flap using an intracapsular debulking approach borrowed from the armamentarium of the intracranial surgeon. Prolonged follow-up with interval CT scans are recommended in patients with apparent ectopic meningioma, in case undemonstrable intracranial disease later becomes manifest.

Polyposis coli preceded by hepatocellular carcinoma: report of a case.

A case of polyposis coli preceded by hepatocellular carcinoma and epidermoid cysts is described. Only one other documented case of hepatoma in association with polyposis coli has been reported in the literature. This patient is not only the youngest to develop an extracolonic malignancy, but has also been fortunate to survive a disease often considered fatal. The possibility of a polyposis-linked resistance to extracolonic malignancies is discussed.