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Airway colonization with GNB and gram-positive cocci (GPC) is common in mechanically ventilated neonates. Whether it is causally related to nosocomial infections (NOS) and/or to the severity of BPD is unclear. We examine these relationships using a cohort design. Data from 260≤ 1250 g Bwgt. in-born infants (1991-95) who were intubated >2w included 917 serial tracheal cultures (TC) and 583 blood cultures. BPD severity was assessed by duration of mechanical ventilation (VENT), O2 dependency at 36 weeks of conceptional age(CA36) and by the need for home O2 supplementation (HOM). Variables equally distributed among subgroups and not related to BPD were: male (50%), black(24%), C/S (62%), Ureaplasma colonization (33%), surfactant (88%) and dexamethasone Tx (72%). After 2 w of VENT 95% of infants were colonized with GPC (S epidermidis and haemolyticus 90%).Superimposed on 30% of these infants was GNB airway colonization with Klebsiella (25%), Enterobacter (25%), E. coli (25%), Pseudomonas (10%), Serratia (10%), Acinetobacter and H. influenza (5%). Except for Serratia, all GNB were endemic. Comparisons between 174 GPC and 86 GNB infants were made. Demographics, Bwgt, GA, and perinatal risk factors were similar. GNB infants had longer LOS and VENT, also required O2 at CA36 and HOM more than GPC patients (*P

Transoral excision of supraglottic and hypopharynx cancer as a single modality is effective when lesions are selected for small size and endoscopic accessibility. Excisional biopsy with clear margins of larger supraglottic tumors in combination with postoperative radiotherapy provides an excellent treatment alternative for selected lesions in patients who are not candidates for open surgery. In this preliminary report, 45 cases using this minimally invasive approach are reviewed outlining oncologic rationale and functional advantages. A large bore tubed laryngoscope or the adjustable bivalve supraglottiscope was used along with a carbon dioxide laser in all cases. In 22 of the 45 patients (mostly TI), local en bloc excision of the primary cancer was performed as sole treatment on selected lesions of the supraglottis and hypopharynx. There were no local recurrences, however, 1 patient developed a neck recurrence and was salvaged by neck dissection. Twenty-three of the 45 patients had more extensive primaries (mostly T2, T3) and N0 necks. Transoral excisional biopsy was followed by full-course radiation therapy to the primary site and both necks. All 23 were followed a minimum of 2 years, and the median follow-up period was 58 months. Clear margins were obtained in 16 of 23, and there were no recurrences in the larynx. Two of 16 did fail in the neck and died despite neck dissection. Seven of 23 patients had positive margins and, despite full-course radiotherapy to the primary site and both necks, 5 of 7 failed locally or regionally. Two of the 7 died of their disease despite open salvage surgery. Therefore, 4 of 23 patients who underwent transoral excision of larger lesions followed by full-course radiotherapy died of recurrent cancer.

Partial endoscopic excision of obstructing laryngeal carcinoma with the CO2 laser is an alternative to emergency tracheotomy or emergency laryngectomy whenever the airway control can be initially ensured by endotracheal intubation. The practical advantages of this approach are elimination of the septic complications of tracheotomy, the opportunity for planned preoperative chemotherapy or radiation therapy, and better nutritional and psychologic preparation of the patient for surgery.

• During the past 2½ years, we have used 21 deltopectoral (DP) and 25 pectoralis major myocutaneous (PM) flaps of which 25 were applied to oral and pharyngeal defects. The concurrent use of both flaps has enabled elucidation of some specific and relative advantages and disadvantages. The following five situations have been identified in which we believe the PM flap is clearly superior: (1) lateral mandibular composite resection defects; (2) large anterior segmental defects; (3) reconstitution of tongue and base of tongue; (4) radionecrosis; and (5) through-and-through defects of skin and oral cavity. The DP flap appears to hold an advantage in the repair of the following defects: (1) limited anterior mandibular loss; (2) posterior and lateral pharyngeal loss; (3) complex resections involving the palate; and (4) cervicofacial skin. The unique advantages of each flap must be weighed against certain disadvantages. Application to each reconstructive problem should be individualized. Proficiency with both flaps enhances the surgeon's ability to deal with major ablative procedures. ( Arch Otolaryngol 1984;110:35-40)

Currently the best prognostic indicator of cancer response is that of staging by the American Joint Commission Staging System. This system is most helpful in state I and in stage IV patients as a prognosticator. Caution must be exercised in oral cavity stage I cancers which tend to be more threatening and where further staging techniques should be used. The major need for careful prognostic indicators beyond simple staging is clearly evident in the stage II and stage III group. In this group, the histologic criteria of Jakobsson, the nuclear criteria suggested by Holm, and the immunologic staging parameters discussed here will hopefully better predict survival, and more importantly, guide therapy. Finally, the role of induction chemotherapy as a prognostic indicator itself has great potential and is currently being heavily investigated.

Forty-three women underwent transsphenoidal hypophysectomy for metastatic breast cancer. Endocrine tests (luteinizing hormone, follicle-stimulating hormone, thyrotropin, prolactin and growth hormone) were done in 28 patients to evaluate the completeness of the procedure. Response of the metastatic breast cancer and duration of survival after hypophysectomy were determined and statistically compared with the posthypophysectomy hormone levels. Only one patient had an endocrinologically complete hypophysectomy, but the objective remission rate (32 percent) is comparable to the 30 to 40 percent objective remission rate reported in other studies that claim to have achieved complete hypophysectomy. No statistically significant associations were found between the levels of the hormones measured and the type of response (objective, subjective or none) to hypophysectomy. However, objective responders survived longer than nonresponders (p = 0.01). When analyzing the associations of the various hormone levels with the duration of survival after hypophysectomy, a positive correlation (p less than 0.05) of peak thyrotropin levels with duration of survival was found. Our data indicate that the clinical benefit advanced breast cancer patients received from an endocrinologically incomplete hypophysectomy is probably as great as that received from an endocrinologically complete hypophysectomy. It appears that a nonspecific disturbance of the hormonal milieu may adversely affect the growth of breast cancer. More studies are needed to elucidate the nature of the endocrine disturbance produced by hypophysectomy and its effects on hormone-sensitive tumors.

A CO2 laser rigid bronchoscope system has been used to palliate symptoms of a malignancy obstructing the tracheobronchial airway. Fifty-nine endoscopic laser operations (34 patients) were done between 1975 and 1981. Severe dyspnea and obstructive atelectasis were the most common indications for treatment. Contraindications for treatment included extrinsic tracheobronchial compression, widespread distant metastases, rapidly progressing tumors, and highly vascular neoplasms. There were nine primary tracheal malignancies, five metastases from distant sites, and 20 primary lung cancers with tracheobronchial obstructions. Most patients were previously treated with one or more standard modalities (radiation therapy, surgery, and chemotherapy). Removal of airway obstruction was occasionally indicated prior to radiation therapy to facilitate treatment. There were seven instances of complications in this group of patients and one mortality. Most patients (23 of 34) have died from their malignancy. The best palliation was achieved in proximal (tracheal and main stem bronchial), slower growing tumors.

Barry Schaitkin, MD, and associates, of the Division of Otolaryngology—Head and Neck Surgery, Milton S. Hershey Medical Center, Hershey, Pa, have conducted a retrospective review of four years' experience regarding 32 patients with epistaxis who required hospitalization. An analysis was made comparing results, complications, and financial implications for patients who received medical therapy alone vs those patients who were unable to be treated by medical therapy alone and who required surgery. Sixteen patients failed a trial of packing and required arterial ligation prior to or within a week of discharge from the hospital. There was a 47% complication rate in this group, including early recurrent epistaxis (two patients), late bleeding (two patients), myocardial infarction with cardiac arrest at extubation (one patient), T-wave inversion without infarction (one patient), intranasal synechiae (three patients), oroantral fistulas (two patients), and septal perforation (one patient). The average total bill for this group was $9750 ($7374

Paul B. Kluger, MD, and colleagues, Lahey Clinic, Burlington, Mass, reported using the neodymium-YAG laser in treating a group of 19 patients with hereditary hemorrhagic telangiectasia. Sufficient data were obtained to analyze results in 17 of 19 patients with a follow-up of two months to 3.5 years. Laser power was 20 to 30 W, with exposure settings of 0.2 to 0.5 s. A flexible unfocused quartz fiber inserted through a malleable suction tip was used with the operating microscope for treatment. With the fibertip held approximately 2 cm from the telangiectasias, laser energy was first applied circumferentially around the telangiectasia before direct photocoagulation of each lesion. Local anesthesia with intravenous sedation was used in two thirds of the treatment sessions and standard general anesthesia in the remainder. Postoperative nasal packing was not necessary in most patients, and absorbable hemostatic agents were used when packing was required. Patients with no history

The assessment of success of therapy in head and neck cancer has historically been a difficult problem. Cancers arising in the head and neck represent about 5% of cancers in men and 2% of all cancers in women occurring in the United States. The estimated number of cases of head and neck carcinoma in 1981 in the United States was approximately 37,000 while the number of deaths was approximately 10,000. These numbers represent a small proportion of the total number of cancer cases and mortality; because of this, few institutions have an opportunity to treat a large number of cases of head and neck cancer. This problem is further compounded because there are numerous sites of origin of head and neck neoplasia in the upper aerodigestive tract. When treatment of head and neck cancer is classified by specific sites of origin, even cancer centers with large numbers of patients find difficulty in accumulating very many patients. For this reason, there are very few prospective randomized studies of head and neck cancer.

Vascular malformations of the tongue (hemangiomas, lymphangiomas, AV fistulae, etc.) compromise a significant portion of head and neck angiodysplastic lesions. Complications requiring treatment include bleeding, pain, and difficulties related to increased tongue volume. Treatment modalities have included embolization, excision, cryotherapy, sclerosis, radiation, and chemotherapy. The more aggressive therapies often result in major functional disability to loss of lingual tissue. A series of nine patients has been treated for one or more of the complications of lingual vascular malformations with either argon of Nd:YAG laser photocoagulation. The therapeutic objective was provision of symptomatic relief with conservation of functioning lingual tissue. Results have varied from good to excellent with markedly decreased bleeding frequency as well as reduction in lesion size. No serious complications, such as bleeding or invasive infection, have been noted. Laser phototherapy is beneficial in the palliation of selected benign lingual vascular malformations.

The cytologic findings of 51 smears obtained by fine needle aspiration biopsy from salivary gland masses were compared with the histologic findings of permanent sections. The overall concurrence rate between cytologic and histologic findings for benign and malignant lesions was 91%. The diagnostic accuracy (exact histologic diagnosis) for the benign lesions was 87% and for the malignant tumors 60%. One case showed false-positive results and 1 case false-negative results. Fine needle aspiration biopsy has been found to be safe, free of complications, and helpful in the planning of treatment.

A technique for preserving the ipsilateral deltopectoral flap when raising the pectoralis major myocutaneous flap has been described. Excellent visualization is gained by raising the DP flap through parallel incisions, and not dividing its tip. Subsequent unrestricted use of the DP flap is possible.

Douglas A. Liening and collaborators at Madigan Army Medical Center, Tacoma, Wash, recently reported to the American Academy of Otolaryngology–Head and Neck Surgery in Washington, DC, on the incidence of hypothyroidism following full-course irradiation to the neck for treatment of squamous cell carcinoma. They found in the group of patients who received irradiation therapy alone that approximately 6% of patients had elevated thyroid-stimulating hormone (TSH) levels with normal thyroxine levels. When patients underwent radiation therapy and surgery, not including the thyroid gland, 28% had elevated TSH levels. In patients undergoing laryngectomy and partial thyroidectomy with radiation therapy, the incidence was 64%. This paper is important as it addresses the need of checking TSH levels in addition to standard triiodothyronine and thyroxine levels in treated patients with head and neck cancer. It also points to the high percentage of patients with thyroid gland abnormality following head and neck cancer therapy who

The anatomical limitations of CO2 laser cordectomy in an experimental setting with maximal exposure are presented. The major limitation is the thyroid cartilage. This is reached in the area of anterior commissure tendon by removal of only 2 to 3 mm of soft tissue. Most posteriorly in the larynx, the distance to the thyroid cartilage becomes progressively greater, being 5.3 mm at mid-cord and 9.0 mm at the anterior end of the vocal process of the arytenoid. The inferior limitation is the cricothyroid membrane. Anteriorly this is avoided by not extending laser excision more inferiorly than 5 mm's. Posterolaterally, the limitation is the para-arytenoid musculature. Excisional biopsy or staging with the laser must be within the framework of these limitations.

Bruce H. Haughey and associates at the Washington University School of Medicine, St Louis, and at the University of Texas Health Science Center, San Antonio, reported to the American Academy of Otolaryngology–Head and Neck Surgery in Washington, DC, on three cases of midline cerebral shift documented by computed tomographic scanning following flap reconstruction of lateral craniofacial-craniotemporal resections. The authors reported that three other patients undergoing anterior craniofacial resection showed no evidence of intracerebral shift. They reported that the cerebral component of the cranial contents is vulnerable to rising extrinsic pressure once the rigid protective covering of the skull is removed. Intracranial pressure falls, brain compliance rises, and contralateral cerebral shift will occur. This has been documented when craniectomy alone is performed, but certainly can be accentuated when flaps filling the surgical defect add further compression by weight or swelling. They describe several strategies to decrease the likelihood of shift.

The early postoperative hypopharyngeal anatomy of 37 consecutive patients undergoing total laryngectomy at the Boston Veteran's Administration Hospital between July 1977 and April 1980 was studied by barium swallow radiographs and correlated with the technique of closure. The "pseudoepiglottis," a structure radiographically resembling a normal epiglottis, was seen arising from the anterior hypopharynx near the base of the tongue in 21 of 28 evaluable patients. It occurred in all patients with vertical closures vs. 67% of patients with a "T" shaped closure. The average length in the "T" closure group was 9.6 mm (range 0-35) vs. 18.4 mm (6-40) in the vertical group, a statistically significant difference (p less than 0.05). Radiologic strictures occurred in 39% of all patients, dysphagia in 29%, fistulae in 18%, and sinus tracts in 14%. All complications occurred more frequently in the vertical closure group. Patients who received preoperative cis-platinum bleomycin chemotherapy and postoperative irradiation had 50% dysphagia and 67% stricture rates. The average ratio of the width of the retropharyngeal space to that of C4 was 0.48 in stricture patients vs. 0.29 in non-stricture patients (statistically significant at the p less than 0.01 level). This ratio taken in the early postoperative period may help predict which patients will develop strictures.