Otolaryngology–Head and Neck Surgery

Eight pediatric patients with acute cervical lymphadenitis or neck mass, alone or in association with nonspecific upper respiratory complaints, were screened for the presence of a primary or reactivation Epstein-Barr virus infection. All were found to have elevated antibodies to the early antigen (EA) and 75% (6) of these were found to be reactivations. Only one had a positive heterophile. Half of the patients had elevation of the EA-specific IgA, and 75% (6) had elevation of viral capsid antigen-specific IgA. All had elevated levels of soluble immune complexes. There was not a direct relationship between the EA titer or soluble immune complex level and severity of disease.

This report is concerned with acute exudative tonsillitis as a pathologic response to the Epstein-Barr virus (EBV). The concept of a bacterial-viral etiology for tonsillitis has been suggested, and previous studies implicate EBV as a major pathogen in exudative tonsillitis. A prospective study of 16 patients with this diagnosis was conducted. EBV serologic data plus viral and bacterial throat cultures were compiled and evaluated. EBV as a causal agent alone or concurrent with other organisms was seen in 56% (9) of the patients under study. EBV activation was associated with infection by other organisms in 19% (3) of the cases. The overall total incidence of EBV in association with severe acute exudative tonsillitis was 75% (12). The data further documents EBV as a significant causal or associative agent in acute exudative tonsillitis.

Glossopharyngeal neuralgia has been reported in association with asystole, bradycardia, and convulsions secondary to a variety of causes. Two cases of glossopharyngeal neuralgia-asystole syndrome in association with ipsilateral lesions of the parapharyngeal space are described. A pathogenetic mechanism is proposed in which parapharyngeal space lesions induce neural irritation of the glossopharyngeal afferent pain fibers and reflex afferents within the nerve of Hering to produce the syndrome. The diagnostic and therapeutic dilemmas posed by these patients are discussed.

The site and severity of upper airway obstruction were accurately determined by analysis of the flow-volume curve obtained from a dyspneic patient with bullous pemphigoid. The limitation of maximum inspiratory flow to 0.5 L/s and of maximum expiratory flow to 0.7 L/s over most of the vital capacity suggested that the lumen of the extrathoracic trachea was narrowed to a diameter of 3 mm. The marked improvement in flow with the patient breathing a helium-oxygen mixture further confirmed that flow was limited in a large central airway. The predictions made from analysis of the flow-volume curve were confirmed by fiberoptic bronchoscopic examination and by computerized axial tomography, which revealed severe supraglottic obstruction. After a tracheostomy was performed, maximal inspiratory and expiratory flows were normal.

The extremely rare occurrence of invasive squamous cell carcinoma arising from normal epithelial lining of a thyroglossal duct remnant cyst is documented by demonstrating the histopathologic transition from normal squamous epithelium to squamous cell carcinoma. The requirements that must be fulfilled to accept a lesion as arising de novo from the epithelial lining are outlined, and all requirements are achieved. The lesion is differentiated from the less rare papillary or papillary-follicular adenocarcinoma of residual thyroid tissue of the thyroglossal duct tract remnants.

The combined use of skin-lined deltopectoral cutaneous and pectoralis major-serratus anterior myoepithelial flaps to construct a total extrathoracic neoesophagus provides the surgeon with an effective, low-morbidity technique, previously unreported, which may be employed as a method for, or as an adjunct to, enterocolonogastric replacement of the thoracic esophagus. The combined myoepitheliocutaneous flaps are surgically manuevered in a novel yet elementary method that culminates in the development of a total extrathoracic neoesophagus.

Large extracranial arteriovenous malformations (AVM) are considered rare. Most of these lesions appear as soft tissue masses or as bleeding. Symptoms relate to the tumor site.

The clinical diagnosis of AVM should be confirmed by selective angiography. The preferred technique for carotid angiography is selective catheterization by the retrograde femoral approach based on Seldinger's method.

A case is presented of a massive congenital, extracranial arteriovenous malformation (AVM). The origins and hemodynamic considerations that led to prior treatment failure are discussed. A sudden accelerated growth in the AVM, caused by an alteration in the hemodynamics of the feeding and draining vessels, mandated further surgical management. The treatment of choice is complete surgical excision at the time of diagnosis, if possible. Ligation of the feeding vessels alone is unsatisfactory and, like other adjunctive treatments, may lead to disastrous complications.

Natural killing (NK) may play an important role in immunosurveillance against virus-infected and malignant cells. This study has demonstrated that the NK susceptibility of Epstein-Barr virus (EBV)-related cell lines increases with increased viral expression within the cells. This finding has implications for surveillance against, and treatment of, EBV-related disease. Additionally, preliminary studies of the NK status of head and neck cancer patients reveal a distinct clustering of the patients into either groups of high or low NK reactivity. This clustering phenomenon may have a correlation with patient prognosis.

Rehabilitation of major resections of the tongue has always posed a serious problem. This paper presents the feasibility and rationale of rehabilitating partial glossectomies by the use of the pectoralis major myocutaneous flap and the fabrication of a “new tongue” by the use of this flap. The criteria for these techniques in benign and malignant tumors of the tongue are outlined. The segmental innervation of the pectoralis major muscle from a variety of three to five nerve branches permits the development of a skin-muscle flap that may be transposed with its nerve supply intact or totally denervated, depending upon the status of the hypoglossal nerves and tongue in the operative field. This presents the possibility of transposing a skin-muscle flap into a glossal wound with a completely intact nerve supply where the new flap is under constant instruction in its new physiologic environment. It also presents the possibility of neurotization of the denervated section of the muscle flap by axones from the intact segment of tongue. A third possibility is the fabrication of a “new tongue” by the transfer of the hypoglossal nerves into the denervated segment of the peripheral aspect of the myocutaneous flap. This variety and combination of rehabilitative techniques introduces a new phase into the rehabilitation of the tongue.

Calcifying epithelial odontogenic tumor, or Pindborg tumor, is the rarest of odontogenic tumors of the mandible. The tumor is distinct from ameloblastoma histologically, as well as by its less aggressive clinical behavior. Treatment must consist of complete excision—to include a rim of bone surrounding the lesion—to prevent recurrence. No instance of metastasis from this neoplasm has been reported.

The survival of irradiated homograft cartilage was investigated in cats at three- to nine-week and 14- to 16-month intervals. Compared to fresh homograft and autograft cartilage grafts, irradiated homografts showed significantly higher resorption and bony replacement. It was also clear that irradiated cartilage survived as a nonviable implant.

Medullary carcinoma of the thyroid (MCT) may masquerade for months as idiopathic vocal cord paralysis, especially in patients whose thyroid is difficult to accurately and completely palpate. A case of vocal cord paralysis secondary to invasion of the recurrent laryngeal nerve by nonfamilial MCT in a nonpalpable portion of the tracheoesophageal groove is presented. Serum calcitonin by radioimmunoassay proved to be the only definitive preoperative diagnostic test. This assay is also an effective marker to establish evidence of residual or recurrent disease.

As enthusiasm for alloplastic grafts wanes, the use of biologic materials for facial reconstructive and aesthetic surgery is regaining popularity. A plethora of methods exists for preservation of one of the most popular implants, human cartilage. The con-troversy over the efficacy of autologous v preserved homologous cartilage grafts continues. A national study was developed to determine the efficacy of autologous v the various techniques of cartilage preservation based on the criteria of graft extrusion, infection, and absorption. Autologous grafts were most commonly used. The most popular preservation methods used alcohol or merthiolate. Autologous grafts had less absorption than preserved grafts, but both groups had approximately equivalent infection and extrusion rates. Irradiated cartilage showed the least absorption of all preservation methods.

A review of 85 Mayo Clinic patients with carcinoma of the nasal septum revealed squamous cell carcinoma (58 patients) to be the predominant cell type, with adenocarcinoma (12 patients) and malignant melanoma (7 patients) being next in frequency. Twenty-five (29%) of the 85 patients had metastatic disease. Twenty percent (17) of the patients had another malignancy at some time during their lives. The study suggests that tobacco smoking may have a role in the etiology of squamous cell carcinomas of the nasal septum. In most patients, wide surgical excision was the initial choice of treatment.

Using the far-field averaging method, observations were made on the early, middle, and late components of auditory evoked responses (AER) in rat pups. These AERs, as well as a myogenic response, all appeared at nearly the same age—the 12th to 14th postnatal day. Latency decreased and amplitude increased rapidly during the two-week period following the first appearance of responses. Early in the development of these responses a new wave appeared that had a shorter latency than wave I.

The purpose of our study was to determine the sensitivity of semicircular canal afferents to linear acceleration in intact animals prepared to preserve the physical integrity of the end organ and nerve. The responses of physiologically identified lateral and vertical canal afferents to static head tilts are described, and the implications of these findings, especially with regard to positional nystagmus, are discussed.

The use of intraoperative monitoring of auditory brain stem responses is described in a small series of neurotologic procedures. This testing modality appears to give the surgeon adequate warning regarding impending damage to the auditory system. It is useful in those procedures done in and around the temporal bone in which hearing is serviceable.

We reviewed 271 intracanalicular and cerebellopontine angle lesions removed over the past ten years, 237 by the translabyrinthine or combined approach which created a mastoid defect. The patients were divided into three groups with the following results: (1) obliteration of the mastoid defect combined with older wound closure techniques in the first 188 patients produced CSF leakage in 25% and meningitis in 16% of cases; (2) not obliterating the defect intentionally in 16 patients produced CSF leakage in 50% and meningitis in 25% of cases; and (3) obliteration of the defect combined with newer packing and closure techniques in the last 33 patients produced CSF leakage and meningitis in only 6% of cases. Four problem areas were identified: The eustachian tube, middle ear, mastoid defect, and postauricular wound. Of these, obliteration of the mastoid defect was most important in minimizing postoperative CSF wound leakage, CSF rhinorrhea, and meningitis.

Osteoradionecrosis of the temporal bone is a rare but potentially lethal complication of therapeutic irradiation to the cranial vault and surrounding tissues. The possibility that radionecrosis of the endomeatal skin and secondary infection are simultaneously prerequistite and responsible for the development of this condition is reviewed. The long-term follow-up of such patients is urged as well as the continued reporting of this complication.

The relationship between electroencephalogram (EEG) and eye movements was studied in rabbits during optokinetic, vestibular, and optovestibular tests. EEG was recorded through permanently implanted electrodes. Exposure to noise and vibration increased the frequency and the velocity of optokinetic nystagmus (OKN). The increase was greater during vibration but greatest during combined noise and vibration. EEG activity was closely linked to changes in OKN and was particularly evident with the appearance of theta waves in the dorsal hippocampus. Also, rotation of the rabbit produced considerable activation in the EEG.

A laser instrument designed for use in otologic, dermatologic, and cosmetic surgery is evaluated. The argon ion laser produces a visible wavelength in the emerald green range (0.488 to 0.515μm). Its attachments include a handpiece and a micromanipulator. The handpiece is manufactured with a 1- or 2-mm spot size and may be used for treatment of cutaneous lesions such as telangiectasia, hemangiomas, and tattoo marks. The micromanipulator is made for attachment to the Zeiss Omni I microscope. The working distance coordinates with that of the operating microscope when used for otologic procedures such as ossicular reconstruction, stapedectomy, tympanoplasty, or soft tissue tumor removal. The technical specifications and medical applications are outlined.

Operations for creation of the superior palpebral fold in the oriental eye are increasingly popular in both the Orient and other areas with large Asian populations. As the desires of each patient vary, careful preoperative evaluation is mandatory to define the type of “double eyelid” that the patient requests. A reliable and predictable surgical procedure for the oriental eye that allows individualization of both the level of the superior palpebral fold and the depth of the sulcus is described.

Most State Workers' Compensation Acts base their determinations of impairment for occupational hearing loss on the formula developed by the American Academy of Ophthalmology and Otolaryngology and adopted by the American Medical Association in 1971. The professional literature tends to focus on the monetary awards for total hearing loss and thus gives the impression that extremely severe hearing loss is common among industrial workers.

A study of 8,953 industrial employees shows that 1,120, or 12.5%, are compensable. Of these, 61.5% have 5% impairment or less; 74.1% have no more than 10% impairment, and 86.7% are 20% impaired. These findings suggest that hearing professionals have the opportunity to make a major social-economic contribution to industrial management and labor by applying their expertise to the prevention of occupational hearing loss.