Otolaryngology–Head and Neck Surgery

Malignant hyperthermia (MH) is a chemically induced, genetic myopathy characterized by metabolic and respiratory acidosis, arrhythmias, hyperpyrexia, and muscular rigidity usually occurring during or within 24 hours postanesthesia. It is initiated by some anesthetic drugs, muscle relaxants, and possibly by catecholamines produced by stress. The incidence of the disease is 1:15,000 in populations who have received a general anesthetic. A recently developed platelet bioassay test allows for rapid identification of the susceptible individual, while medication with dantrolene sodium can usually prevent or reverse the syndrome.

Precise control of tissue penetration can be provided by the CO₂ laser at low power. At 1 W, superficial lesions of the tympanic membrane were successfully extirpated in ten patients. The beam produced immediate delamination and carbonization of the external layer, which usually included the lesion, with no apparent effect on the underlying tissue. This charred layer was easily removed mechanically in a bloodless field. No permanent perforations resulted. Extirpation of canal lesions was less effective.

This paper discusses descriptive and experimental embryologic material that may be of relevance in understanding the pathologic findings of, and attempting treatment of, congenital facial paralysis. The embryology of the human facial nerves and muscles is described. In experimental animals muscles undergo early stages of morphogenesis and differentiation in the absence of nerves and then undergo gradual atrophy. In the absence of muscle fibers, the bulk of embryonic motor nerves that would normally innervate the muscle die.

This paper reports on 115 pediatric patients who were treated for peritonsillar abscess at The Columbus Children's Hospital. Its purpose is to document the threefold increase of peritonsillar abscess between 1969 and 1978, relating this to the simultaneous decrease in the number of tonsillectomies by about one third. The paper further shows that 55 of 115 patients underwent successful treatment by immediate tonsillectomy with lower morbidity and shorter hospital stay when compared with 60 patients treated medically. The timing of the operation will also be discussed. We believe that immediate tonsillectomy is the treatment of choice.

Needle aspiration and antibiotics (usually penicillin) were used as the sole initial treatment of peritonsillar abscess in 29 patients over a 2 1/2-year period. Positive aspirations occurred in 23 patients, 19 (82%) of whom had complete resolution of their abscesses without further initial therapy. The implications of these findings are discussed.

Various mucoperiosteal flaps from the nose (nasal walls) are in use today in frontal sinus surgery in cases where a wide opening between the frontal sinus and the nasal cavity is created. These flaps are transferred to cover denuded bone in the area of opening and thus prevent the opening from narrowing or closing, which would result in the reappearance of frontal sinus problems. In this paper, a new mucoperiosteal flap taken from the upper extension of middle turbinate is described.

Malignant pyoderma is a rare inflammatory pyoderma of unknown cause with characteristic destructive and necrotizing ulcers limited to the face, neck, and upper trunk. The typical lesions are small, purulent, periauricular ulcers. Enlargement and coalescence result in extensive lesions that may ultimately destroy portions of the external ear. The histopathologic findings are acute and chronic inflammation with necrosis. Treatment consists of long-term systemic corticosteroids. We present two new cases and alert otolaryngologists to the seriousness of this disease.

Excessive daytime sleepiness and loud snoring are the major symptoms of obstructive sleep apnea, often leading to serious medical complications if unrecognized and untreated. Tracheostomy has been the only effective treatment in most adult cases. This paper reports on a new surgical approach to treat obstructive sleep apnea by uvulopalatopharyngoplasty designed to enlarge the potential airspace in the oropharynx. Twelve patients underwent this operation. In nine there was relief of symptoms and in eight there was objective improvement in nocturnal respiration and sleep pattern, demonstrated by polysomnography.

The fourth known case of cervical necrotizing fasciitis is presented to illustrate pertinent clinical, diagnostic, and therapeutic features of this entity. The case occurred after a dental abscess; complications included acute airway obstruction, mediastinitis, and septic shock. Extensive surgical exposure and drainage were required for control.

Serious orbital complications including blindness can develop from odontogenic sinusitis. A case history is described of a patient with odontogenic maxillary and ethmoid sinusitis in whom an orbital abscess developed followed by sudden blindness. The pathogenesis and treatment are discussed.

Blindness following facial trauma may occur with what appears to be a minor insult to the periorbital area. This report deals with our experience in treating five patients who had sudden blindness following frontal head trauma. Unselected optic nerve decompression was in general unrewarding in reversing blindness. However, the early administration of pharmacologic doses of corticosteroids does appear effective in reversing blindness in this select patient population and may indicate which patient is a good candidate for decompression. Examination of holographic experiments performed on dried skulls, in addition to clinical findings, appears to suggest that the cause of blindness associated with frontal head trauma may be related to stretching of the optic nerve and not necessarily to compression.

Sleep apnea is an entity that is becoming more commonly diagnosed as the signs and symptoms are becoming better understood. In this report, the first known case of sleep apnea secondary to a lipoma of the submandibular area of the neck is presented. A brief discussion of the types of sleep apnea, along with the most common signs and symptoms of the entity, are reported. The diagnostic workup, operative findings, and postoperative results in this patient are discussed.

A case of mixed tumor of the epiglottis, which was treated surgically, is presented. Delay in diagnosis contributed to the patient's death. This case represents the second reported case of mixed tumor of the epiglottis.

Hypopharyngeal stenosis is a frequent complication of laryngectomy and radiotherapy in patients treated for carcinoma. In a retrospective study of patients treated in the University of Washington Affiliated Hospitals, hypopharyngeal stenosis was more frequent after laryngectomy with partial pharyngectomy than after laryngectomy alone and occurred more commonly in lesions of the pyriform fossa than in glottic tumors. Neck disease and inclusion of radical neck dissection were both significant factors in the development of hypopharyngeal stenosis. Recurrent tumor was significantly more prevalent in these patients.

Papillary cystadenoma lymphomatosum, or Warthin's tumor, is a benign lesion of the salivary glands occurring most frequently in the parotid region. Since the initial report of this lesion in 1910, numerous reports have appeared in the literature concerning the occurrence of Warthin's tumor in many extraparotid locations, including the larynx. The vast majority of those tumors arising in the larynx have been disproved because of the absence of one or more of the histologic characteristics of this lesion within the surgical specimen.

This paper will review the histologic criteria of Warthin's tumor and the typical clinical occurrence. We will discuss a case of papillary cystadenoma lymphomatosum of the larynx that satisfies all the histologic criteria of this lesion. A review of the possible origins of this tumor will demonstrate that this case may lend support to the hypothesis that papillary cystadenoma lymphomatosum may be the end result of a delayed hypersensitivity reaction.

A case of tracheal obstruction by invasive papillary thyroid carcinoma is described. In this paper we will show how selection and interpretation of diagnostic studies including computed tomographic scan allowed accurate determination of tumor extent and, therefore, an accurate selection of surgical procedures.

In the past few years myocutaneous (MC) flaps have, to a large extent, replaced other flaps. Because of axial blood supply, they may be used without delay. The MC flaps, useful in head and neck reconstruction, are based on the latissimus dorsi, the pectoralis major, the sternomastoid, and the trapezius. All have discrete independent vasculature that acts as a pedicle for the muscle and skin flap. The sternomastoid MC flaps have limited range and only special areas of usefulness. The latissimus dorsi flap, because it requires special positioning of the patient, has not been as popular as the pectoralis major flap, but both have excellent blood supplies and will reach almost any area of the face and neck to fill defects and cover internal or external surfaces. In addition, the pectoralis major MC flap may be able to carry a segment of rib as a bone graft. The trapezius MC flap does not have as great a range as the others and has a long vascular pedicle that must be carefully handled, but it has the distinct advantage of being able to carry viable bone from the scapular spine to the mandible.

Thirty-nine patients (median age of 60 years) with carcinoma of the supraglottic larynx (N=16), vocal cord (N=4), and hypopharyngeal wall and pyriform sinus (N=19) were treated by combined conservation surgery and radiation therapy. Thirty-three patients had postoperative treatment, and the remaining six were given preoperative irradiation. The plan was chosen because of clinical and pathologic features known to be fraught with a high incidence of recurrence above the clavicles. Long-term complications occurred in six patients, two of whom died of aspiration pneumonia. Thirty-eight patients completed their treatment and have been followed for a median of 48 months (1 1/2 to six years). Survival rates are 56% and 63% for absolute and determinant cases, respectively.

Ninety-six patients with cancer of the tonsillar region in all stages were studied to compare full-course radiation therapy with surgical salvage to planned combined radiation and surgery. Full-course radiation therapy was effective in controlling T1 and T2 tumors without neck node involvement. Combined therapy was much more effective in treating T3 tumors with neck node disease. Patients with T4 tumors did poorly regardless of therapy.

The experimental and clinical results of the surgical treatment of patients with spastic dysphonia by selective section of the adductor branch of the recurrent laryngeal nerve are described. Experimental selective nerve section in dogs appears to retain cordal abduction during inspiration while producing a partial adductor paralysis. Selective section of the recurrent laryngeal nerve has been performed in four patients with 18- to 24-month follow-up. Speech results have been good with maintenance of partial vocal cord motion. No patient has experienced a return of spasticity. We theorize that selective nerve section may decrease the likelihood of the long-term failure that has been seen with complete nerve section by preventing medial fixation of the paralyzed vocal cord.

Two cases of fibromatosis arising in the larynx of neonates are presented, and the literature is reviewed. This tumor represents a rare cause for airway obstruction occurring clinically at birth or early in the neonatal period. Diagnosis and management of this benign but potentially life-threatening lesion are discussed.

The Fogarty catheter, developed originally for the removal of intravascular thrombi, has been used in recent years as an aid in bronchoscopic foreign body removal. Complications with the use of a Fogarty catheter are rare. We report the separation of the tip of a Fogarty catheter from the catheter body during rigid bronchoscopic management with resultant lodging of the catheter tip out of bronchoscopic range in the peripheral lower lobe of the lung. Use of a Fogarty catheter during bronchoscopic intervention is discussed as is the availability of different catheter models and their possible problems.

Eighty-five admissions for posterior epistaxis were reviewed, and treatment with posterior packs was compared with surgical ligation. The failure rates (26.2% vs 14.3%), complication rates (68.8% vs 40%), and length of hospitalization (7.8 days vs 5.6 days) all favor surgical ligation as the definitive treatment for posterior epistaxis.

A study of chemotactic activity in different middle ear effusions (MEE) was undertaken using a technique that has overcome some of the pitfalls of previous chemotactic investigations on MEE. In the present study, neutrophils were made to migrate upwards toward a chemotactic gradient. Chemotactic activity was differentiated from increased random migration by the use of a two-filter paper system. The study indicated that directed migration or chemotaxis was present in 65% of purulent effusions, in approximately 25% to 30% of serous and seromucinous effusions, but in less than 20% of mucoid effusions. Chemotactic agents in MEE have been discussed. Chemotactic activity for neutrophils may be an important part of the inflammatory response in otitis media with effusion (OME) and responsible for the elimination of bacteria and other foreign particles. On the other hand, prolonged chemotactic activity owing to immunologic or nonimmunologic mechanisms may be responsible for the release of lysosomal enzymes and the subsequent maintenance of an inflammatory response in middle ear tissue. The exact mechanism and nature of the underlying chemotactic response for leukocytes in OME remain to be determined.

The effect of kanamycin sulfate administered by three routes on the function of the stria vascularis was monitored electrophysiologically in guinea pigs. The three routes were intramuscular injection, perilymphatic perfusion, or endolymphatic perfusion. Neither systemic administration of 500 mg/kg of body weight per day for 7 to 12 days nor perilymphatic perfusion of 10-³ M kanamycin affected the endocochlear dc potential (EP). However, with perfusion of kanamycin 10-³ in the endolymphatic space, the EP declined severely. Moreover, the decline in the EP was greater with higher concentrations of kanamycin in the endolymphatic perfusate. Furosemide given by each of the three routes produced an approximately equal decrease in the EP. The effects of kanamycin on the cells of the stria vascularis and the evidence for the perilymphatic-endolymphatic and blood-cochlear barriers are discussed.

Acoustic neuromas are the most common lesions found in the cerebellopontine angle. A subarachnoid cyst rarely involves this area. A review of the literature indicates that this is only the third case report in which the subarachnoid cyst manifested itself clinically and radiographically as an intracanalicular acoustic neuroma.

A group of 95 patients with facial paralysis in the neonatal period are presented. In 74 patients it was believed to be secondary to trauma associated with pregnancy and delivery, and in 21 to be secondary to congenital lesions. The cause, extent, and clinical course of the paralyses are discussed. A classification is outlined to help in organizing a logical and systematic evaluation plan for these patients. Patients may be divided into four groups based on the time they are seen after birth, whether the nerve is stimulable, or whether the nerve loses its stimulability. On the basis of this classification, electromyogram studies, and roentgenographic findings, a presumptive diagnosis may be made and a treatment plan formulated. The treatment plan is based on the diagnosis, facial nerve excitability testing, and degree of deformity present. If there is evidence of facial nerve disruption, a facial nerve exploration is indicated. In congenital cases, reanimation procedures may be necessary.

Monosynaptic spike generation of lateral vestibular nucleus (LVN) neurons with vestibular nerve stimulation in cats was inhibited by microiontophoretic atropine and gamma-aminobutyric acid (GABA). Spontaneous firing of the LVN monosynaptic neuron was increased by iontophoretic acetylcholine and glutamate. Atropine inhibited acetylcholine-induced firing without affecting glutamate-induced firing, while GABA blocked spike generation produced by acetylcholine and glutamate. Acetylcholine probably plays a role in transmission from the vestibular nerve to the LVN monosynaptic neurons.

Adenosine diphosphate (ADP) injection into a unilateral vertebral artery in rabbits decreased per-rotational nystagmus; the nystagmus beating toward the injected side was predominantly suppressed. This influence became obvious when the animal's blood pressure was low. Field potentials were recorded in the vestibular nuclei upon electric stimulation of the vestibular labyrinth. ADP administration into the vertebral artery also suppressed the amplitude of vestibular evoked potentials (VEPs). Effects of ADP upon the vestibulo-ocular reflex and VEP were considered to be due to regional ischemia induced by the microemboli, which consisted of platelet aggregation.

The tympanometric effects of the methodologic variables of direction and rate of pressure change were studied in cats. Tympanogram morphologic findings differed between ascending and descending pressure runs, with the descending ones being simpler in configuration and less influenced by the rate of pressure change. The stability of tympanograms to repetitive testing was examined in the same cats, and five human subjects. Acoustic admittance increased sequentially during the first three pressure sweeps of a repetitive testing sequence in a majority of both groups.

The principal medications available for the prevention of motion sickness were tested for their relative efficacy in a Navy National Aeronautics and Space Administration program at Pensacola, Fla. The drugs were tested on the human centrifuge, at sea, in the air, and in zero gravity flights. The results of this research indicated that drugs with central anticholinergic actions such as scopolamine, promethazine, dimenhydrinate (Dramamine), cyclizine (Marezine), and meclizine (Bonine) were effective in increasing resistance to motion sickness. Drugs with central effects which enhanced the action of norepinephrine were also effective. These included dextroamphetamine sulfate (Dexedrine) and ephedrine. It is recommended that all antimotion sickness drugs be taken at least one hour before exposure to motion. For severe conditions of motion it is recommended that one of the following drug combinations be used: (1) scopolamine, 0.6 mg, plus dextroamphetamine sulfate, 5 mg, or (2) promethazine, 25 mg, plus ephedrine, 25 mg. Moderate conditions may be controlled by dimenhydrinate, 50 mg, and in mild conditions such as automobile travel, cyclizine, 50 mg, or meclizine, 50 mg, may be sufficient. The proper dose of an effective antimotion sickness drug given at the proper time will protect most susceptible patients from motion sickness. After motion sickness has developed, intramuscular injections of promethazine or scopolamine have a therapeutic effect.

Radical resection of the anterior portion of the oral cavity, including a portion of the tongue, floor of the mouth, mandible, and neck, has always been, and remains, a perplexing problem in immediate rehabilitation of the area of the oral cavity and mentum. In the past, these deformities were classified as “Andy Gump.” Attempts at correction of this deformity are protracted and complex. The use of the pectoralis myocutaneous flap offers an improvement in the concept of management in that it supplies a skin lining for the oral cavity and augments the chin and neck in a single-stage procedure that may be combined with the primary operation.