Annals of Otology,Rhinology & Laryngology

The symptoms of Frey's syndrome are occasionally of sufficient magnitude to warrant curative treatment. In four patients, a fascia lata graft was placed under the involved skin in an attempt to offer permanent relief from the cutaneous discomfort suffered during eating. Two of these patients have excellent long-term results. The other two patients were lost to long-term follow-up but were asymptomatic several months following grafting.

The juvenile nasopharyngeal angiofibroma is a vascular tumor. Careful and complete removal is challenging because of the brisk bleeding during surgery. The means applied to reduce this blood loss have included preoperative estrogens, ligation of feeding vessels, silicone embolization of feeding vessels, and cryosurgery. We have used preoperative Gelfoam® embolization of the internal maxillary artery in seven patients. Our clinical impression of significant reduction in loss of blood was confirmed by comparison with 16 previous patients. The average amount of blood lost in the embolized group was half that of the control group. A study of this type comprises many variables; however, the results do suggest that preoperative embolization of the internal maxillary artery is of advantage in the surgical treatment of juvenile angiofibromas.

The purpose of this paper is to familiarize the otolaryngologist with a difficult and frequently missed anomaly. It is hoped that this will increase the number of successfully managed patients with this affliction. Of the seven herein reported cases, four were posterior clefts limited to the cricoid lamina. Three were more extensive laryngotracheoesophageal clefts. Seven cases are thus added to the approximately 30 cases reported in the world literature. The limited cricoid lamina defect can only be diagnosed by endoscopic examination, and is treated medically. Feedings must be given by gastrostomy only. A tracheotomy is indicated only when oral secretions are aspirated into the tracheobronchial tree. The more extensive laryngotracheoesophageal cleft requires surgical repair through a lateral pharyngotomy approach. When the cleft is extensive and extends into the chest, surgery must include a thoracic approach. The occurrence of cleft larynx in association with tracheoesophageal fistulae, with or without atresia, may be more frequent than generally realized. A search should be made for this anomaly in patients who aspirate after atresia repair has been accomplished, before attributing this symptom to severe stricture formation, or recurrence of the fistula. The problem of aspiration in posterior cleft larynx is due to the lateral and posterior displacement of the arytenoids. This malposition is due to the absence or deficiency of the interarytenoidius muscle so that the posticus muscle is unopposed. The term “posterior cleft larynx” should be used only where the defect is limited to the cricoid lamina, while laryngotracheoesophageal cleft should be applied to the more extensive defect.

During a 20-year period, 12 patients with nontraumatic, nonneoplastic subglottic stenosis were seen at the Mayo Clinic. The etiologic factors were relapsing polychondritis, amyloidosis, sarcoidosis, and Wegener's granulomatosis. Because of the diverse initial presentation of the disease, the clinician should consider that the stenosis is a manifestation of a systemic disorder and carry out an otolaryngologic and physical examination with the appropriate roentgenograms and blood and urine tests. Treatment, if a systemic disease is proved, consists of appropriate medication. Surgery may be necessary, depending on the nature of the lesion. Small strictures may not need to be treated.

Since the early 1960's nasotracheal tubes have been used for neonates with primary respiratory diseases which necessitated positive pressure ventilation. This therapy may be required for extended periods of weeks to months meaning prolonged trauma to the neonatal larynx. The initial injury and long-term effects of the endotracheal tube in this age group have not been adequately investigated. The acute findings can be arytenoid and posterior commissure ulcerations and, in some cases, cartilage erosion. Long-term follow-up in these children to age 3.5 years showed a persistent arytenoid defect with chronic hoarseness. The consideration of a change in the structure of the endotracheal tube is suggested as a possible means of avoiding these injuries.

Thirty (5.6%) of 535 patients followed 5–25 years after treatment of cordal carcinoma (T1A,B) developed a second primary laryngeal carcinoma. When analyzed by treatment modality, 3.9% of operated cases and 9% of irradiated cases formed new laryngeal or laryngopharyngeal malignancies. An explanation by radiation-induced carcinogenesis for this statistically significant difference between the two groups is discussed. It is also suggested that supervoltage radiation directed to the laryngeal mucosa may produce the diminished latent period observed between the appearance of the second primary carcinoma.

This paper describes a series of experiments that were performed in dogs, attempting to reproduce in the laboratory a chronic granulomatous reaction of the larynx. The purpose of this work was to learn about the possible pathogenesis of these lesions and to find the reasons behind their chronicity and recurrence. The practical aspects of this research were to formulate and, hopefully, to develop reasonable diagnostic and therapeutical approaches that could be used in the treatment of patients. The positive and negative results of these experiments indicate that the granulomatous response is probably influenced not only by external factors, but also by intrinsic factors. Clinically these findings led to the concept of not circumscribing judgment to the peripheral changes only, but to the assessment of all facts surrounding each individual case.

Tracheostomies were performed on 25 mongrel dogs, employing either a vertical or inverted U flap incision in the trachea. Following cannulation for 14 days, the animals were maintained for three months and endolarygeal photographs were taken. At the time of autopsy, comparisons of the gross specimens were carried out, as well as histological sectioning through the tracheal stomal area. Both endolaryngeal examination and study of the gross specimens at autopsy revealed less distortion of the tracheal lumen following the flap versus vertical tracheostomy, especially in those animals having the flap of cartilage resewn to the trachea at the time of decannulation. Measurements of the cross sectional area at the tracheal stoma were also made. In animals having a flap tracheostomy, the stomal lumen was preserved, regardless of resuturing the flap. However, animals having a vertical tracheostomy lost an average of 18% of the tracheal area when compared with those having a flap incision. Histological examination revealed cartilaginous growth across the tracheostomy incision only in animals having the flap tracheostomy. Support for the flap tracheostomy is provided from animal experimentation.

Tumor antigens have been isolated from nine epidermoid carcinomas of the head and neck. The most strongly reactive antigens have a molecular weight of ≃ 25,000–50,000 daltons, though other antigens weighing ≃ 120,000–400,000 daltons were noted in six of the tumors. The most strongly reactive antigens from three of the tumors were further purified by isoelectric focusing. Each of these antigens had a pI between 8.36 and 8.40. The cross reactivity of these antigens will be studied next. It is hoped that the purified tumor antigen will be useful in the development of an immunodetection system for epidermoid carcinoma.

In our patient population, cancer of the hypopharynx arose 19 times as often in the pyriform sinus as in the postcricoid space (152:8). Most of the growths were far advanced when first seen (90% T3), and enlarged cervical nodes were present in 66% of the patients. Three year survival rates free of disease were as follows: primary surgical treatment (laryngectomy, radical neck dissection) (8/28) 29%; primary radiotherapy (2/55) 4%; and combined preoperative radiation (12/33) 36%. Serial section studies of 51 surgical specimens indicate that T1 and T2 lesions, especially those confined in the medial wall, are probably curable by radiotherapy. Larger lesions invade deeply into the larynx and resemble transglottic growth in their pattern of spread. Conservation surgery would have been inadequate for all but perhaps one growth in this series of 51 lesions, because of the high rate of invasion by cancer into and through the thyroid cartilage and cricoid ring (22/51). Although surface presentation of this group of pyriform sinus cancers rarely reflected the extent of invasion, each of the 22 growths that invaded portions of the thyroid or cricoid cartilages was characterized by clinical involvement of the apex and lateral wall of the pyriform sinus on laryngoscopy or barium swallow.

Overwhelming statistics have been published regarding the success of radiation therapy in the management of laryngeal carcinoma. The fate of those patients whose cancers are not controlled by radiotherapy is often left to speculation. An analysis is made of 61 patients with early and advanced laryngeal cancer treated initially with radiation therapy and subsequently operated upon because of recurrent or persistent tumor. Frequently, diagnosis of recurrence is difficult or delayed. Preservation of voice can only be accomplished when recurrence of T₁ and T₂ lesions is detected early and strict criteria are followed. Conservation surgery is not feasible for early lesions which progress after radiation failure. Advanced T₃ and T₄ lesions which become radiation failures also require laryngectomy for salvage. In cancer of the larynx, there is a definite, identifiable group of patients in whom surgery would be advisable as the initial therapy.

After classical radical neck dissection with removal of the sternocleidomastoid muscle and division of the spinal accessory nerve, there are certain disabling or disagreeable musculoskeletal defects. This paper describes the muscular deficiencies and gives a set of exercises which can be counted on to minimize the problems.

Seven children with carcinoma of the nasopharynx have been treated and followed for five years. In this group of patients there were no cranial nerve palsies or radiographic evidence of destruction of the base of the skull. Four of the seven patients are living and well. The development of lymphoepithelioma in two siblings is of great interest from an environmental and genetic point of view. The older sibling developed the clinical manifestations of the tumor at 12 years of age and four years later the younger sibling developed them at 14 years of age. The possible etiologic relationship of carcinoma of the nasopharynx to the Epstein-Barr virus is discussed. The good survival rate in these patients under 21 years of age suggests that the prognosis in carcinoma of the nasopharynx is better in the younger age group than in adults. The management of these patients illustrates that carcinoma of the nasopharynx should be managed as a regional rather than a systemic disease. Systemic drug therapy is sometimes advocated because of confusion over the name lymphoepithelioma on the assumption that these tumors are more related to lymphomas and lymphosarcomas than carcinomas. It is clear that lymphoepitheliomas should be managed as carcinomas.

In the species presented, the orifice to the subhyoid air sac is found at the tuberculum (when the epiglottis attaches at the level of the ventricle); here also is noted the presence of a cartilaginous island(s) just anterior to the duct. When seen in coronal section along the axis of the duct, the glandular elements cluster around the sac in the anterior supraglottic subhyoid wedge, in preference to the area around the ventricles.

A major complication of head and neck cancer surgery following radiation and extensive resection is pharyngocutaneous fistula. A retrospective analysis of 36 fistula patients out of 376 major head and neck procedures between January 1971 and July 1973 revealed certain guidelines for improved clinical management. Since a large discrepancy existed in the incidence of fistulas between the different surgical procedures, each operative group was examined separately. The incidence, predisposing factors, and methods of treatment for this complication following composite jaw-neck resections and various laryngeal procedures are analyzed and discussed.

An entity of episodic true vertigo of delayed onset following sudden and profound sensorineural hearing loss is described. Data on 12 patients and three case reports are presented. The latency between sudden deafness and the onset of the vertigo varied from 1 to 68 years. The vestibular symptoms are identical to the vestibular symptoms of Ménière's disease, and there is some evidence that endolymphatic hydrops in the previously deafened ear represents at least part of the labyrinthine pathology. Labyrinthectomy in the deaf ear was curative. Tentatively, this entity is best considered a variant of Ménière's disease.

The rates of movement of Na⁺, Rb⁺, Cl⁻ and HCO₃⁻ from plasma to endolymph were studied in the elasmobranch fish, Squalus acanthias, by use of the appropriate isotopes. Rb⁺ was used as a marker for K⁺. The half-times to equilibrium for Na⁺, Rb⁺ and Cl⁻ were about 100 hours; for HCO₃⁻ it was 6 hours. The equilibrium ratios, endolymph/plasma, are Na⁺ 0.87, K⁺ 26, Cl⁻ 1.37, HCO₃⁻ 1.47. Carbonic anhydrase inhibition decreased the rate of HCO₃⁻ accumulation, suggesting that the process is actually the formation of endolymphatic HCO₃⁻ from plasma or tissue CO₂. Increase in plasma pCO₂ elevates endolymph HCO₃⁻ concentration. The secretory tissue contains carbonic anhydrase and Na-K-ATPase. These and other data suggest that a dominant feature of endolymph chemistry may be HCO₃⁻ formation linked in some fashion with K⁺ transport, through rates catalyzed by these two enzymes.