Otolaryngology–Head and Neck Surgery

Unilateral tonsillar enlargement may result from infection, chronic inflammatory response, or neoplasm. Neoplasms that commonly produce a unilaterally enlarged tonsil include lymphomas (lymphocytic and histiocytic types) and squamous cell carcinomas. Rarer tumors include extramedullary plasmacytomas, Hodgkin's disease, leukemia, and metastatic neoplasms.

Sixteen cases of unilateral tonsillar enlargement owing to causes other than squamous cell carcinoma are reviewed. When examining a patient with unilateral tonsillar enlargement, diagnosis of a neoplastic disease must be considered.

Serial dilutions of pyridine in water are employed for measuring the olfactory detection thresholds of patients. Experimental precautions are described that improve the precision and accuracy of the method. Existing data on the sensitivities of hyposmic patients are confirmed, but the sensitivities of normal subjects and of hyperosmic patients are believed to have been substantially overestimated in some earlier publications. Routine clinical applications of the revised pyridine odor threshold test are discussed. In the authors' experience, the average cystic fibrosis patient is slightly hyposmic, and some cases of pituitary tumor are accompanied by a 100,000-fold hyperosmia.

Superficial ulcerations of the oral mucosa often present a diagnostic challenge to the physician because of the similarity of one ulcer to another. A diagnosis is made by the analysis of multiple factors, including the lesion's location, size, grouping, onset, patient's age, involvement of other systems of the body, and course of the disease. The histopathology of the lesion may be specific, especially in certain potentially fatal diseases.

This paper presents the means for the differential diagnosis of a variety of superficial ulcers of the oral mucosa: varicella, herpangina, recurrent aphthous stomatitis, Behcet's disease, Stevens-Johnson syndrome, traumatic ulcer, verrucous carcinoma, primary herpetic gingivostomatitis, recurrent herpetic stomatitis, pemphigus vulgaris, and benign mucous membrane pemphigoid.

Synovial chondromatosis is an uncommon disease of cartilaginous transformation of synovial membrane with formation of loose bodies within the joint space. A case involving the temporomandibular joint (TMJ) is presented. In the TMJ, this disorder occurs more often in females and is usually on the right side. Symptoms include preauricular swelling, pain, and tenderness. Radiographs of the TMJ may be normal, but frequently show multiple, partially calcified loose bodies within the joint. Treatment consists of removal of the loose bodies together with all affected synovium. If the meniscus is excised, reconstruction with a Silastic prosthesis is recommended.

A case is presented in which a sphenoid sinus mucocele was indicated by rapidly progressive blindness in the left eye. Recognition and extension of the mucocele was made possible with a computerized tomographic (CT) scan and tomograms,1-5 which outlined its boundaries and the involvement of the maxillary sinus, the ethmoid, and the left orbit. Immediate decompression and marsupialization of the cyst through the left maxillary sinus, using the Caldwell-Luc approach, gave excellent results. Immediate improvement of vision was noted and almost complete return of vision occured within six weeks.

Forty hamsters received weekly installations of benzopyrene into the larynx. Twenty of these also had 10% alcohol as their total liquid intake. Carcinoma of the larynx was seen in seven alcoholic vs two nonalcoholic hamsters, supporting the evidence in humans that alcohol is a factor in epidermoid carcinogenesis of the larynx.

Skin flap necrosis is a serious problem in reconstructive head and neck surgery. Currently, the only clinically effective means of preventing flap necrosis is delay. Hypothesized mechanisms of delayed and experimental methods of increasing flap survival are discussed. Investigative data supporting the use of phentolamine to augment flap survival are presented.

Recent work has shown that pedicle osteocutaneous grafts retain their viability and participate actively in the restructuring of transferred bone. The present study investigates two aspects of this process: (1) whether or not healthy recipient bone is needed for the survival of these grafts and (2) the degree of periosteal involvement in osteogenesis. Six adult dogs were used. Pedicle osteocutaneous grafts were constructed using the anterior table of the frontal sinus. Rotation of these flaps allowed implantation of the bone transplant into the ipsilateral parietal muscle. Free bone grafts were used as controls and were implanted in the contralateral muscle. Specimens were removed at variable intervals between 8 and 40 weeks after operation. All free grafts were reabsorbed. Pedicle-assisted bone grafts retained their volume and exhibited marked periosteal osteogenesis that eventually produced enough new bone to replace the graft. These experiments provide strong evidence that bone restructuring in osteocutaneous grafts may be independent of recipient bone and that it depends almost exclusively on periosteal activity.

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.

Tattooing provides accurate localization for tumor surgery following radiation therapy. This paper describes studies done on tattooing technique and instruments available currently. Procedures tested included hypodermic needles and three types of surgical instruments. Chemicals tested included india ink, iron oxide, and colored pigments.

India ink and iron oxide used with the Spaulding-Rogers Outliner gave satisfactory tattoos.

Conservation surgery for cancer of the larynx results in deglutition problems. Rehabilitation of swallowing function can successfully be managed by a team including a surgeon, a dietitian, and a nurse. This report details surgical reconstruction to prevent or treat aspiration, postsurgical dietetic management, and the nursing approach to deglutition training in a group of patients.

The Hemovac drainage system was required postoperatively for 156 patients who had undergone major head and neck surgical treatment. This study distinguishes infectious complications from noninfectious complications by the aerobic and anaerobic cultures that were taken from the Hemovac line drainage and any subsequent complications. The 33% complication rate included only those of the head and neck and excluded general medical complications. Of the 52 patients having complications, 19 had infectious, 24 had noninfectious, and nine had both infectious and noninfectious complications.

Granular cell tumors of the larynx are uncommon lesions. Only 15 were identified at the Columbia-Presbyterian Medical Center, New York, during the past 45 years. These tumors produce hoarseness usually and are identified as small keratotic, polypoid, or sessile nodules involving the glottic region (most often posterior glottis, arytenoid, or vocal process). These lesions can usually satisfactorily be treated by endoscopic excision. On histologic examination, pseudoepitheliomatous hyperplasia is frequently seen and may be misinterpreted as squamous cell carcinoma.

Development of the flexible fiberoptic bronchoscope (FFB) has allowed visualization of the peripheral tracheobronchial tree to the level of fifth-order bronchi. Examination of this area requires an extended anatomic nomenclature to describe the pathology of findings. A system of description is presented that combines the concepts of Jackson and Huber, Boyden, Ikeda, and Weibel into a practical endoscopic shorthand lettering designation for endobronchial anatomy. Using the system, a sub-sub-subsegmental (fifth order) bronchus in the right lung could be designated RB1b1α. The principles are described and Illustrated.

Three human temporal bones with presbycusis affecting the basal turn of the cochlea were studied by light and electron microscopy. Conditions in two ears examined by light microscopy were typical of primary neural degeneration, with a descending audiometric pattern, loss of cochlear neurons in the basal turn, and preservation of the organ of Corti. Ultrastructural analysis revealed normal hair cells and marked degenerative changes of the remaining neural fibers, especially in the basal turn. These changes included a decrease in the number of synapses at the base of hair cells, accumulation of cellular debris in the spiral bundles, abnormalities of the dendritic fibers and their sheaths in the osseous spiral lamina, and degenerative changes in the spiral ganglion cells and axons. These changes were interpreted as an intermediate stage of degeneration prior to total loss of nerve fibers and ganglion cells as visualized by light microscopy.

In the third ear the changes observed were typical of primary degeneration of hair and supporting cells in the basal turn with secondary neural degeneration. Additional observations at an ultrastructural level included maintenance of the tight junctions of the scala media despite loss of both hair and supporting cells, suggesting a capacity for cellular “healing” in the inner ear. Degenerative changes were found in the remaining neural fibers in the osseous spiral lamina. In addition, there was marked thickening of the basilar membrane in the basal turn, which consisted of an increased number of fibrils and an accumulation of amorphous osmiophilic material in the basilar membrane. This finding supports the concept that mechanical alterations may occur in presbycusis of the basal turn.

Adult and juvenile albino rats were maintained on a vitamin A-free test diet for 2 to 28 weeks. Histologic study of the middle ear and eustachian tube mucosa of these animals showed extensive focal squamous metaplasia when compared with the control group. Keratinization of large areas of normally columnar, ciliated epithelium was observed without frank keratoma formation. In over half of the most vitamin A-deficient animals, acute otitis media with effusion was found. It is hypothesized that vitamin A deficiency disrupts the mucociliary clearing mechanism in the middle ear and eustachian tube, which may lead to effusion and otitis media.

Although lysosomal enzymes have been demonstrated in middle ear effusions by several investigations, the exact source of these enzymes and the role they play in the maintenance and progression of otitis media with effusion have not been thoroughly studied.

The source of lysososmal enzymes in middle ear fluids and their possible role in the inflammatory process in otitis media with effusion are explored.

The immunogenicity of the middle ear constituents is a matter of prime importance. In this work, the authors were interested in the antigenicity of the guinea pig's tympanic membrane. They reached the conclusion, after developing an antiserum (IgG), that the tympanic membrane of the guinea pig can be antigenic in the rabbit. After purification and absorption, a cross-reactivity remains between the tympanic membrane and the mucosae of the upper respiratory system.

Current knowledge of the pathophysiology of bacterial infections is elementary. The initial events leading to the invasion of host tissues are a matter of conjecture for many bacterial organisms. This is particularly true for pneumococci, the most frequent causative organisms of acute otitis media.

Bacterial enzymes may account for the initial disruption of host tissues, and this study explored their role in the infectious process. As a first step, pneumococcal cultures were analyzed, and significant levels of the enzymes lipase and hyaluronidase were demonstrated. Secondly, the presence of these enzymes in middle ear effusions was explored in an animal model of acute otitis media. The enzymes reached peak levels at seven days. The third and most important portion of the study examined the significance of these enzymes in producing inflammation and alterations in the middle ear cavity of normal experimental animals. This portion was a histologic comparison of temporal bone specimens and demonstrated that marked acute and chronic changes can be induced by placing solutions of these enzymes in the middle ear cavity. This study concludes that bacterial enzymes play an important role in the induction of acute otitis media.

This study investigated hearing aid acceptance and use as functions of the probable site of a lesion: conductive, cochlear, neural, and central as determined by an audiometric test battery. Results indicate significantly better acceptance of aids in conductive and cochlear disorders than in more central neural and central disorders.

A prospective study of 17 cleft-palate patients under the age of 37 months was performed. The otoscopic findings, as reported by the primary physician and otolaryngologist, were compared with the results of tympanometry. Preoperatively, all tympanograms were abnormal. Ears with an As pattern were not described as abnormal by any physician, and postoperatively, these ears all progressed to a more advanced stage of disease.

The effects of intra-arterial 30-, 40-, and 50-mg/kg doses of ethacrynic acid upon cochlear function in guinea pigs were studied for periods of three to five hours. Cochlear potentials recorded in the first turn included the endocochlear potential, whole nerve response, cochlear microphonics, and summating potentials in scala media, scala tympani, and scala vestibuli. Evidence of organ of Corti damage at 50 mg/kg was found in addition to electrical impedance changes in the cochlear membranes at all dose levels.

Many commonly employed otic drops contain aminoglycoside antibiotics that may be toxic to the inner ear. A variety of chemicals such as ionic solutions, certain anesthetics, and epinephrine have been shown to diffuse across the round window membrane into the perilymph. Twelve adult cats were studied in this experiment. The auditory bulla was exposed and solutions containing gentamicin or neomycin concentrations similar to that commonly used in otic drops were applied to the round window niche for 15 minutes and washed with saline solution. The gentamicin and neomycin concentrations in the round window niche wash and the perilymph were then assayed by a radioenzymatic method.

Concentrations of both antibiotics were observed in the perilymph. Thus, the round window membrane is a route through which these ototoxins may gain access to the inner ear.

The Wildervanck syndrome consists of the Klippel-Feil deformity of the spine, eyeball retraction, lateral gaze weakness, and hearing loss. Conductive hearing loss, as well as a more frequently occurring sensorineural hearing loss, is caused by dysplasia of the inner ear. Typically, polytomograms demonstrate a bulbous vestibule and dilated lateral semicircular canals with basilar impression of the skull. The Duane's eyeball retraction phenomenon completes the syndrome; this may be explained either by misdirected innervation of the extra-ocular muscles or by atrophy or fibrosis of the lateral rectus muscles.

A perilymphatic fistula of a labyrinthine window may initially present with various cochlear or vestibular symptoms. Vestibular perilymph leaks can occur spontaneously with or without hearing loss and are most readily diagnosed by a positive Hennebert's sign. Surgical correction is indicated and should initially consist of grafting of the perilymph leak. A significant incidence of recurrence warrants further investigation of grafting materials and techniques.

Dissection of the antrum requires judicious visualization of the tegmen, horizontal canal, incus, and facial nerve. Inadvertent contact with the incus by the power drill may cause significant acoustic trauma. An effective “early warning device” accurately predicting exposure of the incus may be constructed with the saline irrigation fluid. The formation of the meniscus at the antrum permits visualization of the image of the incus around the corner of the bony canal wall overhang. A thin-lens model of this phenomenon has been created for first-order analysis of the optics, and it provides useful criteria for using this image. Image minification, displacement, and distortion were analyzed. A more complex model was then created to assess the impact of changing meniscus shape. The latter helped in understanding an added “swinging-door effect” noted as the meniscus was altered. The model predicted accurately the phenomena as observed in the temporal bone preparation. Illustrative examples of the optics and photographic demonstrations of the phenomena are presented.

Hypertrophic scars and keloids continue to plague the head and neck surgeon as an unpredictable consequence of trauma or incision. The myriad suggested methods of revising such lesions indicate that no one method is foolproof. The application of conventional cryotherapy to the lesion, followed by the dilute intralesional Iriamcinalone injection, offers several advantages over other methods.

The two-stage concept is a plan for the management of rhytidectomy patients. Preoperatively, all patients are told that they may need a minor secondary temporal tuck-up procedure 6 to 12 months after surgical treatment. Although only 20% of patients require this secondary surgical procedure, the possibility of its need encourages all patients to return for follow-up and removes a source of patient discontent.

The indications for the secondary procedure are significant gravitational jowling and malar sagging developing 6 to 12 months after the primary surgical treatment. The technique is described in detail.

Roles of the otolaryngologist and the audiologist in providing hearing health care are expanding as a result of current trends in amplification technology, legislation, and patient populations. Within clinic dispensing of hearing aids has become a part of this role expansion. Requirements for setting up a dispensary, fitting procedures, fee analysis, and statistical results of 4 1/2 years' experience are discussed. On the basis of the benefits described, direct dispensing is advocated.