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OBJECTIVES/HYPOTHESIS Applying the principles of misdirected nerve regeneration to the larynx, Roger Crumley in 1989 coined the term laryngeal synkinesis (LS) which he later (2000) classified into 4 types (type I - good voice, type II - involuntary twitches and poor voice, type III - adduction during inspiration, type IV - abduction during phonation). Neurophysiological data were not available for all LS patients at that time. The current study was undertaken to utilize and test the Crumley classification for a clinical interrater comparison and, secondly, compare predicted with actual laryngeal electromyography (LEMG) results. STUDY DESIGN Descriptive study. METHODS Laryngoscopic and LEMG data of patients with unilateral vocal fold paralysis (VFP) of 6 months duration or longer were combined for retrospective evaluation. Forty-five data sets were available for laryngoscopic classification by two local laryngologists and by Roger Crumley. Twenty-three data sets with complete thyroarytenoid (TA) and posterior cricoarytenoid (PCA) - EMG data were used to compare predicted with actual LEMG results. RESULTS Local laryngologists were able to classify 24 of 45, Crumley 30 of 45 cases into one of the 4 synkinesis types. There was substantial agreement between examiners (Cohens Kappa 0.66 [P

Objectives: Optical coherence tomography (OCT) is a high-resolution optical imaging technique that produces cross-sectional images of living tissues using light in a manner similar to ultrasound. This prospective study evaluated the ability of OCT to identify the characteristics of laryngeal cancer and measure changes in the basement membrane, tissue microstructure, and the transition zone at the edge of tumors. Materials and Methods: One hundred thirtythree patients underwent OCT examination during surgical endoscopy of the head and neck. Twenty-two patients with laryngeal cancer or a history of laryngeal cancer were imaged with a fiberoptic OCT system. Tumor and adjacent transition zones were imaged along with uninvolved subsites. OCT images were correlated with histopathology. Results: Twenty-six OCT examinations were performed in 22 patients. Basement membrane disruption was seen in 18 subjects, all of whom had histology showing classic features of cancer. A transition zone to uninvolved epithelium at the tumor periphery was also often observed. In six studies, benign or premalignant processes were histologically confirmed. In three thin, superficial lesions, an intact basement membrane was observed. The basement membrane could not be identified in three other bulky exophytic, premalignant lesions, primarily because of increased superficial signal backscattering observed in pathologic tissues. Conclusions: OCT clearly identifies basement membrane violation from laryngeal cancer and can identify transition zones at the cancer margin. In bulky exophytic lesions, OCT signal may not penetrate deeply enough to show the basement membrane, but for many suspicious lesions that require exclusion of cancer, OCT shows potential for assisting in diagnostic assessment. Key Words: Optical coherence tomography, larynx, vocal cord, laryngeal cancer, endoscopy, optical biopsy, laryngology. Laryngoscope, 116:1107–1113, 2006

First described in 1982, laryngeal synkinesis continues to play an important diagnostic and therapeutic role following recurrent laryngeal nerve (rln) injury. Vocal fold motion impairment (formerly called “vocal cord paralysis”), hyperadducted and hyperabducted vocal folds, and certain laryngeal spasmodic and tremor disorders are often best explained by synkinesis. A closer look at these mechanisms confirms that following rln injury, immobile vocal folds may be nearly normally functional (favorable), or spastic, hyperadducted, or hyperabducted (unfavorable). This has resulted in a functional classification of laryngeal synkinesis as follows: type I laryngeal synkinesis, with satisfactory voice and airway (vocal fold poorly mobile, or immobile); type II synkinesis, with spasmodic vocal folds and an unsatisfactory voice and/or airway; type III synkinesis, with hyperadducted vocal folds and airway compromise; and type IV synkinesis, with hyperabducted vocal folds, poor voice, and possible aspiration. This classification facilitates the understanding of laryngeal pathophysiology following RLN injuries and promotes a more scientific basis for management.

The purpose of this article is to review our current approach to selective modification of laryngeal neuromuscular function. Dissection of the distal branches of the recurrent laryngeal nerve allows for selective modification of laryngeal adductory and abductory function. The surgical techniques for identification of recurrent laryngeal nerve branches to the posterior cricoarytenoid muscle, the lateral cricoarytenoid muscle, and the vocalis muscle are described. Reinnervation is achieved while using motor branches of the ansa hypoglossi nerve or the superior laryngeal nerve. The techniques described are useful for the treatment of spasmodic dysphonia and laryngeal paralysis.

A retrospective review of 45 children with mucopolysaccharidoses was performed to determine the frequency of complications related to the head and neck. In this series, every patient had at least one complication involving the head and neck region, and in over half, operative intervention by the otolaryngologist was required. Upper airway obstruction occurred in 17 (38%) and necessitated a tracheostomy in 7 (16%). Cervical spine instability occurred in 8 (18%), making airway management difficult. Recurrent respiratory infections occurred in 17 (38%), and chronic recurrent middle ear effusions were noted in 33 (73%). This review demonstrates that children afflicted with the mucopolysaccharidoses frequently have otolaryngologic-related complications that are common throughout their life span and often the primary management issue in their continuing care. The otolaryngologic management of these patients is outlined based on the results of this study and review of the relevant literature.

• The treatment of keloids remains difficult. In experimental studies, lathyrogenic agents and colchicine have been shown to be effective in keloid prevention. Recently, a study was published of a new animal model utilizing human keloids implanted in athymic mice. We used the same model to compare the effects of penicillamine, acetylcysteine, colchicine, and triamcinolone acetonide. Unexpectedly, all keloids implanted showed a growth peak at 4 weeks and then regression in size. Histologic sections of the implanted keloids revealed peripheral vascularity, collagen bundles similar to the parent keloids, and no evidence of implant rejection. After 8 weeks, the mice treated with the lathyrogenic agents exhibited a higher rate of regression when compared with the control mice. While triamcinolone acetonide may have prevented keloid implant growth, drug toxic reaction may have been a factor. ( Arch Otolaryngol Head Neck Surg . 1991;117:1177-1181)

Objectives: Botulinum toxin (BTX) injection is currently the primary and most common treatment for adductor spasmodic dysphonia (ADSD). A variety of injection strategies and dosage regimens have been described. This study reports on our experience with the dosage schedule and dosing consistency of BTX for the treatment of ADSD. Methods: We retrospectively reviewed our laryngeal BTX database for the period 1991 to 2005. Our strict inclusion requirements limited our selection to 13 patients who had received a minimum of 6 injections (average, 11.5; range, 6 to 19) of BTX for ADSD. Results: The average total dose of BTX to the larynx for each treatment episode was 3.9 units (range, 1.5 to 7.5). The total dose administered tended to trend downward among patients who began treatment from 1991 to 1998, indicating that the initial dose (usually 2.5 units per side) may have been high. Those patients who began from 1999 onward had a more stable dose, indicating that the initial dose (usually 1.5 units per side) was more suitable. The subjects underwent an average of 2.2 injections (range, 1 to 5) before reaching their optimal BTX dose. The total number of treatments performed in this group of patients was 150, of which 145 were successful (96.7%). Conclusions: The BTX dose for the optimal treatment of ADSD usually remains consistent over time, as does the treatment interval. An initial dose of 1.5 units per side or less appears to improve dosing stability, indicating that the initial dosing of 2.5 units per side in our study was often greater than required. The optimal BTX dose was usually ascertained by the second or third injection. In our patient population, the long-term dosing consistency of BTX confirmed that neither tachyphylaxis nor increasing sensitivity to BTX occurred during the course of treatment for ADSD.

To describe the novel use of a delayed chondrofascial flap to increase auricular projection in microtia reconstruction.Retrospective survey analysis. Ten consecutive children with unilateral microtia without other craniofacial abnormalities were followed up for a period ranging from 6 months to 5 years after microtia reconstruction was performed with the newly described delayed flap. Individual patient reconstructed auricular projection measurements were compared with contralateral (control) auricular projection values.The auricular projection measurements taken at the superior helix and the lobule approximated those of the control side as confirmed by t test.The newly described delayed chondrofascial flap buttresses auricular projection in microtia repair to approximate the projection values of the normal side.

Objectives: Optical coherence tomography (OCT) is an emerging imaging modality that combines lowcoherence light with interferometry to produce crosssectional images of tissue with resolution about 10 m. Patients undergoing surgical head and neck endoscopy were examined using a fiberoptic OCT imaging probe to study and characterize microstructural anatomy and features of the larynx and benign laryngeal pathology in vivo. Study Design: Prospective clinical trial. Materials and Methods: OCT imaging of the larynx was performed in 82 of 115 patients who underwent surgical endoscopy for various head and neck pathologies. The OCT device employs a 1.3 m broadband light source (FWHM, 80 nm). The frame rate is 1 Hz. Imaging was performed using a handheld probe placed in near contact with the target site. The maximum axial and lateral dimensions for the region of interest imaged were 2.5 mm 6 mm, with resolutions of 10 m. Simultaneously, conventional endoscopic images were obtained to provide anatomic correlation with OCT images and histology. Optical micrometry was performed to measure the epithelium thickness. Results: Systematic OCT imaging of laryngeal structures and subsites provided information on the thickness of the epithelium, integrity of the basement membrane, and structure of the lamina propria. Microstructural features identified included glands, ducts, blood vessels, fluid collection/edema, and the transitions between pseudostratified columnar and stratified squamous epithelium. The mean epithelial thickness of laryngeal subsites was calculated: true vocal cord (129 m), false vocal cords (124 m), aryepiglottic fold (177 m), subglottis (98 m), and epiglottis (185 m). True vocal cord pathology imaged included Reinke’s edema, papillomatosis, polyps, mucous cysts, and granulation tissue. Subglottic imaging identified boundaries between epithelium, lamina propria, and cartilage. The OCT images compared favorably with conventional histopathology. Conclusion: OCT has the unique ability to image laryngeal tissue microstructure and can detail microanatomic changes in benign, premalignant, and malignant laryngeal pathologies. OCT holds the potential to guide surgical biopsies, direct therapy, and monitor disease, particularly when office-based systems are developed. This is a promising imaging modality to study the larynx. Key Words: Optical coherence tomography, larynx, vocal cord, vocal cord polyps, laryngeal cancer, Reinke’s edema, endoscopy, optical biopsy, respiratory papillomas, hyperkeratosis, laryngology. Laryngoscope, 115:1904–1911, 2005

Problem: While it is known that denervation of skeletal muscle can induce atrophy, the effect of denervation on muscle cell cycle genes is unclear. Further, while attempted reinnervation of laryngeal muscle has thus far been unsuccessful in restoring function, cell cycle gene expression might be utilized to predict reinnervation success. The objective of this study was to examine the effects of denervation and reinnervation of the posterior cricoarytenoid (PCA) muscle on key genes involved in the cell cycle. Methods: Female Sprague-Dawley rats were assigned to 1 of 3 groups: control (CON, n = 24); denervation (DEN, n = 24); or reinnervation (REIN, n = 24). DEN and REIN animals had their left recurrent laryngeal nerves transected and ligated at the fourth tracheal ring while REIN animals subsequently had their nerves repaired using 10–0 suture. Animals were then euthanized after 7, 14, and 30 days, and mRNA expression examined using RT-PCR. If significant group differences were seen using one-way ANOVA (P < 0.05), Tukey post-hoc tests were employed. Results: Expression of p21, p53, GADD45 alpha, GADD45 beta, GADD45 gamma, and cyclin D1 genes were compared. At all time points, cyclin D1 and p53 gene expressions were unchanged with DEN or REIN. However, DEN muscles were found to express significantly higher levels of p21, GADD45 alpha, and GADD45 beta than CON at all time points. Conclusion: Interestingly, while REIN p21, GADD45 alpha, and GADD45 beta expressions were found to be elevated at 7 and 14 days, GADD45 alpha and GADD45 beta levels at 30 days were not significantly different from CON, threreby suggesting a recovery of REIN muscle gene expression at later time points. Significance: Paradoxically, while the restoration of some cell cycle genes to normal levels in REIN muscles might be seen as an indication of successful reinnervation of the PCA, no significant functional recovery was associated. Support: None reported.

Objectives: We will present clinical and pathologic findings of the recurrent laryngeal nerve of a 54-year-old man with apparent idiopathic vocal fold paralysis and discuss clinical and scientific implications of these findings. Study Design: Our design is in the format of a case report with emphasis on the clinical, intraoperative, histologic, and neuropathologic findings, followed by a discussion of contemporary theories of idiopathic unilateral vocal fold immobility and the implications of our findings. Methods: A 54-year-old man presented with a 2-year history of unilateral vocal fold motion impairment (VFMI) after an upper respiratory infection. Radiographic and laboratory data revealed no organic cause. The patient clinically appeared to have a classical unilateral vocal fold paralysis and had previously undergone collagen injection and medialization thyroplasty, each with only temporary improvement of voice. We performed ansa cervicalis-recurrent laryngeal nerve anastomosis. Results: Intraoperative dissection revealed an indurated and thickened section of nerve approximately 15 mm in length, located at the beginning of the intralaryngeal segment, near the cricothyroid joint. Segments of this nerve were submitted for histologic evaluation, revealing necrosis with granulomatous inflammation. Postoperative electromyography and videostrobolaryngoscopy were consistent with successful reinnervation from the ansa procedure. Conclusions: The diagnosis of “idiopathic VFMI” likely represents a number of distinct pathologic entities. This case highlights our lack of understanding of idiopathic VFMI and raises many important questions regarding our current theories of this diagnosis. The clinical and pathologic implications are discussed, and continued investigation is recommended.

Dystonia has been described in various diseases affecting mitochondrial function but spasmodic dysphonia, a form of focal dystonia, has not. We present a patient with action myoclonus affecting the hands and arms who carried the most common mutation in mitochondrial DNA causing the myoclonic epilepsy and ragged red fibers (MERRF) syndrome (the AG substitution at nucleotide 8344 in the tRNALys gene). This patient also had spasmodic dysphonia that was responsive to treatment with intralaryngeal botulinum toxin. © 2003 Movement Disorder Society

Recurrent laryngeal nerve (RLN) injury [without injury to the superior laryngeal nerve (SLN)] is the most common traumatic neurolaryngological lesion. The acute effects are immediate flaccidity of the ipsilateral vocal fold, loss of abduction and adduction, severe dysphonia to complete paralytic aphonia, and, frequently, aspiration of food and drink into the trachea. This article reviews the function of the four intrinsic laryngeal muscles innervated by the RLN and the individual effects of RLN transection on these muscles. Following acute denervation, the subsequent progression is either chronic denervation or nerve regeneration with laryngeal muscle reinnervation. Four possible scenarios are discussed here: complete reinnervation with synkinesis, partial reinnervation with synkinesis, mixed RLN injuries, and no reinnervation (complete paralysis). Electromyography may eventually assist the laryngologist in establishing these diagnoses, but currently not enough normative data exist for confirming laryngeal synkinesis unequivocally in every case. Treatment is generally by Teflon injection, medialization thyroplasty, arytenoid adduction procedures, or reinnervation by nerve transfer. The author's preference is nerve transfer, insofar as the quality of resultant phonatory voice, in his hands, has been superior to the other techniques.

After several months, the stent was removed and the patient was successfully decannulated. One year after removal, the patient was able to phonate and was examined in the clinic with a fiberoptic flexible laryngoscope. This examination demonstrated an adequate airway with mobile vocal folds and an appreciably patent glottic aperture. Minimal non-obstructive webbing of the supraglottic region was seen as well (Figure 6). CONCLUSION: Although tuberculosis in the larynx is considered to be a relatively rare condition, recent evidence suggests that its incidence is increasing due to its novel clinical manifestations. This case demonstrates the pitfalls of utilizing a single aggressive surgical modality for laryngeal tuberculosis and the potential for multiple invasive interventions that may be required to treat this form of laryngeal stenosis. Serial evaluation and close follow up are essential in the management of this condition, due to it recurrent nature and the tenuous anatomy its affects.

A review of our recent experience in patients with bilateral laryngeal paralysis is described. While we continue to use phrenic nerve transfers in patients with mobile arytenoids, patients with fixed arytenoids generally require some sort of vocal cord lateralization, either by arytenoidectomy and arytenoidopexy or by partial vocal cord resection. The endoscopic laser medial arytenoidectomy is a convenient and effective method for opening the posterior glottic airway. One arytenoid is reduced medially with the carbon dioxide laser. After about 3 months the opposite arytenoid can be treated similarly, if necessary. The procedure does not appear to affect arytenoid mobility, as the posterior commissure mucosa and underlying interarytenoid muscle are protected and hence unaffected by the procedure. Those patients with at least one mobile arytenoid cartilage are candidates for posterior cricoarytenoid muscle reinnervation. Although ansa cervicalis and phrenic nerve techniques have been described, the author has concentrated efforts on the phrenic nerve. This report describes the endoscopic laser medial arytenoidectomy procedure, while the phrenic nerve patients will be reported in a subsequent manuscript.

• Omohyoid muscle transfer to the denervated posterior cricoarytenoid muscle (PCA) was performed in three monkeys. The transposed omohyoid muscle was reinnervated by the phrenic nerve by performing nerve anastomosis prior to muscle transfer. The muscles were sutured over the denervated ipsilateral PCA muscle to allow for neurotization of the denervated PCA muscle in such a way as to reproduce the directional vector of PCA contraction, eg, to mimic the directional pull of the PCA muscle. The muscle flaps were found to be long enough to reach the contralateral PCA muscle, confirming that the technique might be used ultimately for bilateral simultaneous PCA reinnervation. Each animal achieved reinnervation. The superiorly based omohyoid muscle flap was found to more closely emulate the size and orientation of the underlying PCA muscle. Electromyography, videolaryngoscopy, and histologic examination were used to confirm the results. The procedure has the potential for PCA muscle replacement in long-standing cases of paralysis with PCA denervation atrophy as well as for reinnervating a denervated PCA muscle. ( Arch Otolaryngol Head Neck Surg . 1991;117:1113-1117)

Twenty cases of unilateral laryngeal paralysis are reported. Satisfactory follow-up intervals and data (videostroboscopy and glottographic analysis) were available on 12 patients. The excellent to normal phonatory quality achieved in many of these patients indicates that the ansa cervicalis to recurrent laryngeal nerve anastomosis is the procedure of choice in selected patients with unilateral vocal cord paralysis. Excellent medialization of the paralyzed cord, as well as correction of arytenoid malposition and thyroarytenoid muscle atrophy appear to explain the technique's success, since the reinnervated cord neither abducts nor adducts. We feel that this technique is the procedure of choice in younger patients, or those who use their voices professionally, since the phonatory quality achieved is superior to Teflon injection or Isshiki thyroplasty, and the technique is reversible.

Optical coherence tomography (OCT) is an evolving imaging modality that combines interferometry with low-coherence light to produce high-resolution tissue imaging. Cross-sectional in vivo images were obtained using an OCT device consisting of a Michelson interferometer, 1.3-µm broadband light source, and a handheld fiberoptic imaging probe. Image pixel resolution approached 10 µm. The mucosa of the oral cavity and oropharynx were examined in 41 patients during operative endoscopy. Optical coherence tomographic imaging was combined with endoscopic photography for gross and histologic image correlation. Optical coherence tomographic images of the oral cavity and oropharynx provided microanatomical information on the epithelium, basement membrane (BM), and supporting lamina propria (LP) of the mucosa. Normal microstructures identified in these tissues included an overlying keratin layer, papillae, ducts, glands, and blood vessels. Regions of pathologic features studied included mature scar, granulation tissue, mucous cysts, leukoplakia, and invasive cancer. Optical coherence tomographic imaging showed distinct zones of normal, altered, and ablated tissue microstructures for each pathologic process studied. Abnormal findings were directly compared with regions of normal tissue or conventional histopathologic features when tissue for analysis was available. This study provides a composite series of in vivo OCT images of the oral cavity and oropharynx in a variety of normal regions and pathologic states as well as outline future applicationsofOCTtechnology. ArchOtolaryngolHeadNeckSurg.2006;132:1074-1081

Purpose Laryngeal pathology occurs in numerous forms, many of which cannot be reliably differentiated with clinical examination alone. As such, proper diagnosis often necessitates biopsy, which is not only technically challenging but also increases patient morbidity, such as by putting the patient at risk for dysphonia when involving the vocal cord. One emerging technology which may prove helpful in the diagnosis of laryngeal pathology is Optical Coherence Tomography (OCT). OCT uses the reflection of light waves to create real-time, non-invasive images of tissues at high resolution. The purpose of this study is to determine OCT9s ability to differentiate normal from benign and malignant processes in the human larynx. Methods Our laboratory assembled an OCT system which was adapted to function in the operating room. This system was used during cases that involved direct laryngoscopy to study various anatomical regions of the human upper aero-digestive tract of 40 adult patients. OCT was used to image healthy tissues and tissues displaying benign and malignant processes (as determined by biopsy). Benign laryngeal pathologies imaged included cysts, polyps, nodules, papilloma, fibrosis, follicular hyperplasia, granulation tissue, and tissue post-XRT, whereas malignant processes imaged included squamous cell carcinoma, adenocarcinoma, and neuroendocrine tumors. Results OCT images of normal larynx displayed regions of various tissue density in accordance with expected boundaries between the epithelium, lamina propria, and various tissue structures such as glands and blood vessels. Moreover, OCT detected changes in tissue architecture which were characteristic for the various benign and malignant processes imaged. Conclusions Given OCT9s remarkable, non-invasive tissue imaging capabilities, it is hoped that this technology may one day serve to aid in the diagnosis of laryngeal disease, thereby reducing the morbidity from and dependence on biopsy.

Reconstruction of the microtic auricle is a difficult process requiring considerable experience and dedication to detail. It is a multistage proposition requiring the talents of both the reconstructive surgeon and the otologic surgeon. Reconstruction of the external ear usually precedes the reconstruction of the middle ear. Often, a template is used by the reconstructive surgeon to aid in this complicated process. Traditionally, templates used by the reconstructive surgeon have been 2 dimensional (usually x-ray paper) and made from the opposite normal ear or another normal ear in cases of bilateral microtia. Use of a 2-dimensional model only provides a rough estimate of the cartilage framework needed. Considerable experience is therefore needed to get this cartilage framework "just right." We have developed a number of 3-dimensional synthetic templates to aid in the creation of an accurate cartilage framework implant. These templates serve as a more accurate guide in the complex cartilage carving and assembly process. The use of 3-dimensional templates has improved our technical reconstructive results in a small number of patients. We present these results and propose future application of these ideas.

Thirteen patients with recurrent, previously irradiated tumors of the skull base or spine were reirradiated with 125I sources implanted interstitially using microsurgical or stereotactic techniques. Patients harbored difficult, end-stage recurrences of chordoma, meningioma, malignant meningioma, fibrosarcoma, invasive pituitary adenoma, and malignant schwannoma. In two other patients with malignant meningioma, the dose of external radiation was augmented by implanting 125I sources during the initial operation for excision of the lesion or at a separate surgical procedure after conventional teletherapy. Microsurgical implantation of 125I sources into basal tumors was limited by the difficulties inherent in operating in this region; it is not possible to visualize the entire tumor that requires implantation. Three of five chordomas stabilized or regressed; these patients probably benefited from the procedure. Two patients with recurrent malignant meningiomas had long term remission after interstitial brachytherapy. Interstitial 125I brachytherapy for recurrent tumors at the base of skull or adjacent to the spine can be more successful only if more aggressive surgical exposures of these regions are attempted. Implantation of sources for a “boost” dose, either microsurgically during the initial surgical resection of the lesion before conventional teletherapy or stereotactically after conventional teletherapy, may be a valuable adjunct to external irradiation for the control of potentially devastating tumors (such as chordomas and malignant meningiomas) before they recur with the severe consequences seen in the patients reported here.

A review of the recent literature on surgery of the facial nerve is presented. Developments in the treatment of hemifacial spasm, nerve grafting, reanimation surgery, and diagnostic testing are described. Reports of facial paralysis following mandibular fractures are included. The roles of brain stem evoked response (BSER) audiometry, electroneuronography, and CT scanning in the evaluation of facial nerve disorders are noted.

Basic research and surgical cases have shown that the injured recurrent laryngeal nerve (RLN) may regenerate axons to the larynx that inappropriately innervate both vocal cord adductors and abductors. Innervation of vocal cord adductor muscles by those axons that depolarize during inspiration is particularly devastating to laryngeal function, since it produces medial vocal cord movement during inspiration. Many patients thought to have clinical bilateral vocal cord paralysis can be found to have synkinesis on at least one side. This will make the glottic airway smaller, particularly during inspiration, than would true paralysis of all the intrinsic laryngeal muscles. Patients with bilateral vocal cord paralysis should undergo laryngeal electromyography. If inspiratory innervation of the adductor muscles is present, simple reinnervation of the posterior cricoarytenoid muscle will fail. The adductor muscles also must be denervated by transection of the adductor division of the regenerated RLN.

Ten dogs underwent exploration and section of the right recurrent laryngeal nerve. A segment was removed and both stumps were ligated. Reoperation at three months and again at 15 months revealed neural regeneration through the ligated site and reconstitution of the distal nerve in seven of the eight dogs surviving the 15-month period. This strong regenerative capability of the recurrent laryngeal nerve may explain recurrences of spastic dysphonia after nerve section. It is recommended that patients be advised of the possibility for return of the spasms. Investigators should always note whether the recurrent laryngeal nerve has regained stimulability in reporting results of experimental laryngeal paralysis and reinnervation.

Several characteristics inherent in tumors of the forehead and temple provide therapeutic challenges for the physician. These include spread along anatomic structures, a propensity toward aggressive growth patterns, the risk of nerve damage, and the preservation of important cosmetic landmarks. As a result of these problems, Mohs micrographic surgery is often indicated in the treatment of skin cancer of the forehead and temple. The high cure rates afforded by micrographic surgery, even for aggressive tumors, and tissue conservation are benefits to the patient. Although most BCCs and SCCs in this region can be handled by a dermatologic surgeon, patients may present with aggressive or neglected tumors exhibiting extensive invasion. These patients may require a cooperative approach between the dermatologic and head and neck surgeon to achieve complete tumor extirpation or appropriate reconstruction. In this article, we have tried to indicate the rationale behind the use of Mohs micrographic surgery for tumors of the forehead and temple. In selected tumors, a team approach between the micrographic and other surgeons will maximize both tumor excision and functional and cosmetic repair for the patient.

The six abnormalities found in pathologic muscle biopsies are described and discussed. Those changes which are indicative of nerve denervation or muscle regeneration are tabulated. Muscle biopsy, as it related to facial paralysis, must still be considered, for the most part, an experimental tool. In certain puzzling situations, eg, neonatal facial paralysis, it can be of value as an adjunct to nerve excitability and electromyographic tests.

Postoperative chylous fistulas occur as a complication in 1-2% of all radical neck dissections. Twelve cases are reviewed herein. Chylous fistulas are more common with left neck dissections, but 25% occurred on the right side in this series. An intraoperative chylous fistula was recognized and treated in 75% of the cases which later developed a postoperative fistula. Postoperative fistulas may be divided into two groups: minor fistulas may be treated with pressure dressings and repeated aspirations; fistulas which do not respond to conservative management should be re-explored early and the fistula ligated.

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.

Roger L. Crumley, MD: The patient for discussion today was a 3-month-old girl with a complete unilateral cleft lip on the left. The child was the product of a normal gestation. There was no maternal drug usage in pregnancy, and no family history of cleft lip or palate. She was the firstborn child and, as is often the case, the cleft was a complete surprise. Labor and delivery were uncomplicated, and the Apgar score was 10 at the time of birth. On physical examination, there was a cleft of the lip and the alveolus on the left side (Fig 1). In addition, the child had the typical unilateral cleft lip nasal deformity, in that the base of the ala on the cleft side was inferiorly and posteriorly displaced. Also, the base of the columella was deviated to the noncleft side. (Of course, the reason for this is that the anterior

Patients with obstructive sleep apnea syndrome (OSAS) may have airway obstruction at various levels, including the uvula-soft palate complex, base of tongue, and/or possibly other sites. For patients with tongue base and/or laryngeal obstruction, uvulopalatopharyngoplasty (UPPP, ppp) will not alleviate the obstruction. Prior authors have proposed that the hyoid bone position as determined by cephalometric x-rays can predict which patients have obstruction at a lower site than the soft palate. In this study, patients with obstructive sleep apnea syndrome were evaluated with polysomnographic testing, fiberoptic endoscopy, and cine-CT scans (Imatron Scanner with multiple level rapid sequence scans) in an attempt to determine precisely the site of airway obstruction. Measurements of airway size taken at the time of fiberoptic pharyngoscopy were compared with those determined by the cine-CT studies. Initial results revealed that fiberoptic pharyngoscopy in the sitting and supine positions was helpful in confirming pharyngeal airway sites with smaller diameters in awake patients. However, the cine-CT exam performed in both sleeping and awake states provided more direct data regarding the airway during sleep. We feel that with more clinical experience the cine-CT technique will prove to be the most helpful study for identification of the obstructive airway site in obstructive sleep apnea syndrome.

We describe a patient with a left facial paralysis and hemotympanum following left parieto-occipital skull trauma. The initial admission diagnosis of intratemporal facial nerve injury secondary to temporal bone fracture was incorrect. Normal facial movements during involuntary activity (yawning, laughing at a joke) and focal seizure activity on the paralyzed side of the face, seen subsequently, indicated the site of lesion as supranuclear. The diagnosis of opercular syndrome was made. This syndrome can result when the contralateral frontal lobe is injured. Supranuclear weakness of muscles supplied by the hypoglossal or spinal accessory nerves is also present. Unlike other central paralyses, the facial paralysis in operculum syndrome may not demonstrate “forehead sparing,” and consequently it may be mistaken for a peripheral paralysis. The neuroanatomic basis for the syndrome is discussed. Signs and symptoms are outlined to help the otolaryngologist avoid this diagnostic pitfall.

A 26 year old man with subacute hoarseness and stridor was shown to have Wegener's granulomatosis isolated to the trachea and larynx. Although isolated laryngeal Wegener's is unusual, a review of the literature suggests that early treatment with cyclophosphamide is warranted.

When the facial nerve is injured, changes occur in muscle, proximal nerve, distal nerve, and the cell body in the nucleus. All of these changes contribute to the quality of regeneration and repair. This paper describes the usual processes of neuronal regeneration with the objective of a better understanding of why some injuries inevitably result in poor return of motion and synkinesis, while others recover completely. The possible mechanisms of synkinesis include: imperfect regeneration due to axonal misdirection, demyelination, microglial scarring in the facial nucleus, neuron depopulation, multiple axon sprouting, and misdirection of regenerating axons via vertical anastomotic filaments.

Schwannoma is an important entity in the differential diagnosis of the enlarged jugular foramen. Our recent experience with 4 consecutive large schwannomas over a 12-month period is presented. As these tumors are usually less vascular than glomus jugulare tumors, they are frequently more amenable to surgical extirpation. Radiologic clues to their identity include discrete borders and less angiographic vascularity when compared with glomus jugulare tumors. Our operative treatment of these cases has evolved to include preoperative embolization with Ivalonr sponge particles, followed by a lateral temporal bone resection in exposing the jugular foramen. A posterior fossa craniotomy is done as a second stage when necessary. This staging allows for less morbidity and greater chance for total tumor removal. The surgical technique and relevant anatomy are reviewed and illustrated.

• The reapproximation of individual fascicles has been advocated as a microsurgical method of improving neural regeneration following peripheral nerve injuries. To date, this technique has met with limited success, in part owing to an unclear understanding of the anatomic location of fibers in the proximal nerve relative to their distal distribution on the face. Fascicular repair is indicated in clean lacerations of the nerve trunk distal to the stylomastoid foramen. For long defects or injuries proximal to the mid-mastoid region (where the nerve is monofascicular), simple nerve trunk sutures should be performed until more detailed information on the fascicular anatomy of the intratemporal facial nerve becomes available. A case is reported in which a stab wound of the parotid region was complicated by hemorrhage and infection. A delayed neurorrhaphy was performed using a modified interfascicular grafting technique with sural nerve grafts. (Arch Otolaryngol106:313-316, 1980)

Teflon injection for unilateral vocal cord paralysis frequently produces an improved yet breathy voice. Ansa hypoglossi-recurrent laryngeal nerve anastomosis has been performed in five patients. In the four patients discussed in this paper, excellent phonatory quality has been achieved. Electroacoustic analysis indicates that this technique may produce normal phonatory function in paralyzed larynges. There have been no serious side effects or complications in our first five patients. Denervation of the sternothyroid muscle, which results from sectioning its nerve in preparation for suture to the RLN, appears to further improve the voice by medially positioning the vocal cord. Gelfoam paste is injected at the time of nerve transfer to rehabilitate the voice during the 2 months required for nerve regeneration. For younger patients, or those with professional use of their voices, this technique offers superior speech results when compared with Teflon injection.

This edition, volume 17 in a series of similar symposia published by the Educational Foundation of the American Society of Plastic and Reconstructive Surgeons, is a compendium of reports and discussions presented in Houston in January 1977. The contents are outlined as follows: (1) Neurophysiology and Sensation; (2) Motor Nerve Injuries: Pain and Reflex Dystrophy; (3) Upper Motor Neuron and Congenital Muscular Disorders; (4) Pressure Ulcerations; and (5) Facial Palsy. In part 1, the section on neurometabolism is applicable to otolaryngologists. However, there is little in parts 2, 3, or 4 that relates to head and neck surgery. Most of the content of these sections relates to such things as tendon transfer in hand surgery, brachial plexus injuries, decubitus ulcers, and hemiplegic disorders. The section entitled "Facial Palsy," however, is concisely and lucidly written. The cross-face graft operation, eyelid magnets used in lagophthalmos, muscle grafting, and sling procedures are discussed

This 170-page monograph will naturally find more utility among ophthalmologists than among otolaryngologists. The surgical techniques that are described for canalicular repairs and dacryocystorhinostomy can be found in other otolaryngology or reconstructive surgery texts. The first chapter, entitled "Anatomy and Embryology of the Lacrimal System," is well illustrated and serves as an excellent anatomical reference for the important medial canthal region. A concise review of total reconstruction of the lacrimal drainage system is found in chapter 10. Trauma and reconstructive problems of the eyelids are not discussed. The chapters on dacryocystography, etiology of dacryocystitis, and physiology and secretory disorders of the lacrimal system are of little perti nence to the otolaryngologist. Chapter 7, "Clinical Manifestations of Lacrimal Sac Disorders," covers the differential diagnosis of swellings of the medial canthal area. Included are helpful hints in differentiating inflammatory from neoplastic lesions. Overall, however, only those persons involved in otolaryngology training programs

Patients with squamous cell carcinoma of the pyriform sinus treated surgically from 1959 through 1979 at the University of California, San Francisco were reviewed. As several reports had previously suggested that the addition of radiation therapy, preoperatively or postoperatively, did not increase survival, our data collection and analysis was performed in such a way as to determine whether similar trends were present in our patients. Data were tabulated for patients having: 1. surgery alone (SA); 2. preoperative radiation and surgery (RS); and 3. surgery and postoperative radiation (SR). The surgery alone group demonstrated the best results, with 65% 3-year determinant survival, and 56% 5-year survival, compared to 50% 3-year and 33% 5-year survivals in the combined groups. In this patient population, the increased death rate in the combined therapy group appeared to be due primarily to a higher distant metastasis rate (50% vs. 26% for the surgery alone group). Although our numbers are too small for any of the comparisons to be significant, the findings of similar cure rates of pyriform sinus cancers by surgery alone support similar data from other authors. As staging was similar in the two groups, and none of the other variables examined appeared to explain these results, we could only conclude that further data is needed, and that the exact role of radiation therapy, in combination with surgery for pyriform sinus cancer remains to be defined.

At the recent American Laryngological Association meeting in San Francisco, Calif, Dr Roy Sessions of the Sloan-Kettering Memorial Cancer Institute, New York, NY, discussed the value of laryngeal videostroboscopy in patients with early glottic cancer. In his report, 18 patients with T1 glottic tumors and 7 patients with T2 glottic lesions underwent fiberoptic laryngoscopy with videostroboscopic examination. All were thought to have normal cord mobility. All of these patients had abnormal stroboscopic findings consisting of absent mucosal waves. In contrast, none of 29 patients with benign glottic lesions showed the abnormal cord stiffness demonstrated by the patients with tumor. Sessions felt that, after vocal cord stripping and/or radiation therapy of early cancer, the strobe examination may detect recurrent disease earlier than routine follow-up examination. The technique holds promise for following up tumor response during radiotherapy for T1 lesions. According to Sessions, videostroboscopy should be considered for all glottic cancers due

This 367-page work is divided into four parts: (1) "Mechanism of Facial Expression and Pathophysiology of Degeneration"; (2) "Etiology of Disruption of the Facial Neuromuscular Motor Unit"; (3) "Contemporary Concepts in Free Nerve and Muscle Grafting"; (4) "Re-animation of the Paralyzed Face." The contributors include otolaryngologists, plastic surgeons, a neurologist, a neurosurgeon, a neuropathologist, and a physical medicine specialist. The organization is such that the reader is taken through anatomy and pathophysiology of the various types of facial paralysis, and then an excellent section on the basic science of nerve and muscle grafting leads into the practical section that deals with reanimation procedures. This third section, itself, is well worth the purchase price of the book. The reanimation procedures are subdivided into the following categories: immediate treatment (this includes a neurologist's chapter on medical treatment for Bell's palsy and an otolaryngologist's concepts with regard to surgical treatment for this disease)