Otolaryngology–Head and Neck Surgery

Contraction of the cricothyroideus muscles (CTMs), innervated by the superior laryngeal nerves (SLNs), modulates the voice by tilting the thyroid cartilage anteriorly onto the top of the cricoid and tensing the vocal cords. Either unilateral or bilateral paralysis of the SLNs is disabling for individuals with above-average voice demands. Some patients never compensate for this paralysis; there is no surgical procedure recognized to correct it. This study tested the hypothesis that surgical fusion of the thyroid and cricoid cartilages anteriorly can correct the problems of SLN injury by duplicating the mechanical tilt of the thyroid onto the cricoid cartilage normally produced by the CTMs. The SLNs were cut in 12 dogs. In six the cricoid and thyroid cartilages were fused anteriorly. Vocal cord and airway function was assessed preoperatively, immediately postoperatively, and 6 to 10 weeks after surgery. Following surgery there was no airway compromise and there appeared to be a more satisfactory compensation for the SLN paralysis in the fused larynges as compared with the unfused controls as determined by cinelaryngoscopic analysis.

An inspiratory, circumferential, passive collapse of the hypopharyngeal lumen is the mechanism of airway obstruction in some patients with “idiopathic” obstructive sleep apnea syndrome. While permanent tracheotomy has resolved the obstruction and reversed the associated cardiopulmonary sequelae, it is not without complications. The expansion hyoidplasty was conceived as an alternative. The hyoid bone is trisected just medial to each lesser cornu, then held in an expanded position by a permanent brace. The greater cornua with attached middle constrictor and hyoglossus are moved laterally, while the body of the hyoid with attached geniohyoid and genioglossus shifts the base of tongue anteriorly. The procedure is potentially reversible. Twenty dogs were studied before and after hyoid expansion, 10 for superior hypopharyngeal pressure-volume measurements and 10 for the closing-pressure study. Pressure-volume studies demonstrated a consistent expansion of the superior hypopharynx. Deglutition and laryngeal competence were not grossly affected. Reexamination of four animals in the closing-pressure group 1 year postoperatively demonstrated stability of the hyoid expansion and no evidence of serious parahyoid tissue complications.

Studies undertaken at the Eye and Ear Hospital of Pittsburgh indicate that antibiotic prophylaxis can reduce the incidence of patient morbidity. In this article we will demonstrate the effect of antibiotic prophylaxis on the economics of major head and neck surgery. One hundred and one patients were assigned to one of four treatment protocols, three of which entailed 1 day of a perioperative prophylactic antibiotic and the fourth a placebo. The study was conducted in a double-blind, randomized fashion. Patients receiving a placebo experienced an infection rate of 78%. Patients receiving cefazolin experienced an infection rate of 33%. Ten percent of patients treated with cefoperazone or cefotaxime developed postoperative wound infection. Postoperative hospitalization averaged 17.9 days for patients who did not develop postoperative wound infection, in contrast to an average of 32.6 days for patients with postoperative wound infection. The added cost of postoperative infection justifies the added use of the newer, more expensive antibiotics in view of the reduced postoperative morbidity and postoperative hospitalization.

To determine whether resistance to chemotherapy in advanced head and neck squamous cell carcinoma stems from biochemical mechanisms and to assess the potential usefulness of new anticarcinogens, an in vitro test would be highly desirable. In the past 4 years our laboratory has developed methodology to establish squamous carcinoma cell lines in tissue culture from patients with squamous cancer of the head and neck. We used some of these lines to compare the in vitro effects of methotrexate on squamous carcinoma, fibrosarcoma, and melanoma cells. Three of the squamous carcinoma lines were tested for sensitivity to both methotrexate and cis-platinum; all but one squamous carcinoma cell line exposed to methotrexate showed growth inhibition at the physiologically attainable concentration of 10⁻⁷ M. In contrast, a tenfold higher concentration was required to produce similar effects in the melanoma, while no concentration inhibited fibrosarcoma growth. Cis-platinum showed consistent squamous carcinoma cytotoxicity in 10^–5 M and 10^–6 M concentrations. This approach should be useful for determining the relative sensitivity and resistance of head and neck cancers to chemotherapeutic agents in vitro.

Hematoporphyrin derivative (HpD), a mixture of compounds chemically prepared from naturally occurring crude hematoporphyrin, is preferentially concentrated in neoplastic cells and produces red fluorescence when irradiated with blue-violet light. In addition, HpD exhibits other photodynamic properties, which, in the presence of oxygen and visible light, result in cytotoxicity. Preliminary reports indicate that early, superficial carcinomas of the upper aerodigestive tract and tracheobronchial tree can be localized and treated successfully with HpD phototherapy (HpD-PT), in which a fiberoptic bundle transmits laser light to the tumors. To assess this modality's potential for treating solid tumors, the cytotoxic effect of HpD-PT was measured in a murine tumor model. We specifically assessed the effect of cooling on the pure photodynamic action of HpD-PT. Adult female mice with typical mammary tumors received interstitial phototherapy 24 hours after HpD was given intraperitoneally. Light from an argon-dye laser was delivered through an optical fiber, along with simultaneous cooling from a cryosurgical probe, for 15 minutes. After being cooled with a cryosurgical probe, tumors were excised 48 hours after treatment and the necrotic area was measured. The results indicate that cooling enhances the tumoricidal action of HpD-PT.

The extratemporal course of the facial nerve must be completely understood if surgery is required for the removal of parotid and other tumors in the infratemporal space and skull base or if the nerve itself must be exposed when it has been severed. The key to mastering this surgery is to understand the anatomy of the parotid space and its relations to surrounding structures so that the facial nerve can be found during surgery and preserved intact. Tumor masses or scar tissue may distort normal structures and relations to adjacent structures; this must be kept in mind while operating in this complicated anatomic area.

We propose an animal model from which it is possible to follow nerve-muscle unit recovery after a nerve graft easily, consistently, and relatively inexpensively. The model is also compatible with subsequent histologic or histochemical analysis. We document the recovery of a group of animals after nerve grafting to demonstrate the flexibility of the model.

The purpose of this article is to familiarize the surgeon with the latissimus dorsi flap and some particularly useful applications of it. This flap has proved extremely versatile, with many uses, among them immediate coverage for extensive head and neck wounds. It has been equally successful in repairing defects in both normal and irradiated tissue. The range of the arc of utilization has been exceptional, easily reaching the skull vertex from the chest wall. However, to be able to extend this flap so far requires careful dissection of the neurovascular pedicle and intimate anatomic knowledge of the posterior axilla region. This flap's muscle bulk is quite acceptable and the donor site may almost always be closed primarily. There appears to be less functional disability from sacrifice of this muscle than with pectoralis or trapezius myocufaneous flaps. Accordingly, it is ideal when much tissue is needed for single-stage coverage. Additional uses are available when flaps from other sites have failed.

Formerly, flap perfusion was assessed clinically by gross evaluation of the amount of fluorescein in the developed flap prior to transfer. Recently the laser Doppler velocimeter and the perfusion microfluorometer have been developed as aids in perfusion assessment. We have used each instrument in a series of reconstructive procedures employing pectoralis or trapezius myocutaneous flaps and a series of pig groin myocutaneous flaps to assess the contribution of each to the prognostication of flap viability. While the laser Doppler does provide useful information, we have found that the microfluorometer is more selective in representing the hemodynamics of the developed flap.

Hereditary hemorrhagic telangiectasia (HHT) often requires transfusion and has major ill-effects. The recent literature reports successful high-dose estrogen treatment of epistaxis caused by HHT. To investigate this, biopsy specimens taken from areas clinically involved with telangiectasia in four patients were evaluated for estrogen- and progesterone-binding receptors. Specimens from two women (ages 34 and 38) were positive for both estrogen and progesterone receptors in ranges observed in breast carcinoma specimens. Specimens from two men (ages 34 and 78) were positive only for progesterone receptors at lower but clearly detectable levels of activity. Nasal mucosa specimens from control patients −2 male and 4 female – yielded no detectable levels of estrogen or progesterone receptors. Because of the side effects of high-dose estrogen (especially in males), we have initiated systemic progesterone therapy with both megestrol acetate and medroxyprogesterone acetate. Marked diminution in epistaxis incidence and severity was observed in three patients after initial systemic progesterone treatment. All treated patients have been maintained with good epistaxis control for over 1 year.

Surgery of the inferior turbinates should be performed only after a trial period of medical therapy. Surgical reduction in turbinate size may be accomplished by outfracture crushing, cauterization, cryotherapy, laser vaporization, submucous resection, partial turbinate resection, turbinoplasty, or total turbinectomy. The procedure chosen should be the most conservative one consistent with obtaining a good airway.

Although vertigo is the expected symptom of unilateral vestibular disease, exceptions have been observed. To determine the relative frequency of this observation, a retrospective study of patients seen over a 1-year period was done. Of the 126 patients found to have unilateral labyrinthine impairment with bithermal caloric testing, only 58 (46%) characterized their symptoms as vertigo. The ramifications of these findings are discussed, and a question is raised as to the propriety of reserving vestibular testing for only those patients describing vertigo.

This study analyzes 71 stapedectomies that resulted in a sensorineural hearing loss, followed by a revision stapedectomy on the suspicion of an oval window fistula. The cases were divided between two primary stapedectomy techniques: a stainless steel Robinson prosthesis on a vein graft and a wire prosthesis with Gelfoam. The major differences between the surgical findings of the two groups were the fistula rate with the wire prosthesis was 10 times that with the Robinson prosthesis; the wire prosthesis was longer than necessary in 21% of the cases in which it was used; there was no finding of excess length with the Robinson prosthesis; and after revision stapedectomy, dizziness was lessened in 20% of the patients in the Robinson prosthesis group, in 60% of those in the wire prosthesis group, and in 75% of those with fistula. Surgical directions are given for revision stapedectomy following a sensorineural hearing loss.

This is a review of the causes of failure in 5½ years of personal experience with TORPs and PORPs. Prosthesis extrusion, the cause of failure in less than 5% of 446 TORP and PORP operations, usually was the result of a mucous membrane or eustachian tube problem. Severe sensorineural hearing impairment occurred in less than 1%, and these were operations in which the oval window was opened. Unsatisfactory hearing was the cause of failure in 18%.