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The advent of newer generation high resolution computed tomography (CT) scanners has revolutionized diagnostic evaluation in head and neck cancer. Since the development of conservation surgical techniques for the larynx, a precise preoperative evaluation of the extent of laryngeal involvement by carcinoma has been of prime importance. No single diagnostic study now yields more information regarding the anatomic extent of tumor than high resolution CT scanning. This study was designed to evaluate the reliability of CT scanning in determining extent of disease at several laryngeal levels by comparing preoperative CT scans with corresponding postoperative pathology obtained by serially sectioning laryngeal specimens. We found very good correlation in the inferior larynx and good correlation in the superior larynx. Determination of cartilage invasion proved very difficult, and scanning was unreliable at all levels when severe postradiation reactions were present.

• Chondrocalcinosis, ie, calcium pyrophosphate dehydrate (CPPD) crystal deposition disease, has a spectrum of clinical manifestations ranging from an absence of symptoms to a severely destructive arthropathy. We recently treated a patient with CPPD deposition adjacent to the temporomandibular joint, which simulated a parotid tumor. The CPPD crystals are weakly positively birefringent under a polarizing microscope. Most frequently they are found roentgenographically as asymptomatic deposits in fibrocartilaginous structures, especially the knee meniscus. A less frequent manifestation is "pseudogout" acute arthritis. Rarely, joint destruction is found. ( Arch Otolaryngol 1985;111:403-405)

Adequate margins are of primary importance in a composite resection of oropharyngeal carcinomas. Secondary considerations include the functional status and cosmetic result of the patient after the operation. A series of 6 patients demonstrate that, in selected cases, a lip-splitting approach to increase exposure while ensuring adequate margins may be undertaken without undue fear of functional impairment or cosmetic deformity. The ultimate result will depend on proper placement of the incisions and careful reapproximation of tissue.

Unexpected complications may follow therapeutic embolization, even though no apparent technical errors have occurred. This report includes four cases of facial palsy following middle meningeal artery embolization, one case of aspiration pneumonia following glomus tumor embolization, and a case of pulmonary embolization following embolization of a spinal arteriovenous malformation.

Patients with unilateral exophthalmos warrant a systematic and multi-disciplinary work-up before surgical exploration or a therapeutic regimen is undertaken. The otolaryngologist is concerned primarily with the diagnosis of disease processes that arise adjacent to the orbital space in the nose, paranasal sinuses, nasopharynx, and temporal fossa. Careful head and neck examination should be supplemented by recently refined studies such as tomography, arteriography with subtraction, orbital venography, contrast orbitography, and ultrasonography.

• Malignant salivary gland tumors of the base of the tongue are unusual lesions and optimal treatment has not been established. As a group, these tumors tend to be diagnosed at an advanced stage, and consequently carry a grave prognosis. Fourteen patients were treated at UCLA between 1954 and 1984. Twenty-three percent of the patients have survived longer than ten years, although only one patient is free of disease. Eight of 14 patients developed distant metastases. Salivary tumors in this location are difficult to completely excise and surgical margins are frequently positive. Treatment using a planned combined approach is advocated. ( Arch Otolaryngol 1985;111:664-666)

Three patients, each of whom had Pseudomonas meningitis as a sequela of an extensive head and neck operation, have been treated successfully. All three patients had cerebrospinal fluid leaks, and operative management of this complication is discussed. Antibiotic management included the parenteral administration of the recently developed drugs gentamicin, car-benicillin, and intrathecal gentamicin. Since extensive head and neck operations are being performed with increasing frequency and since infectious complications are inevitable, it is mandatory that the otolaryngologist be familiar with current methods of managing these potentially lethal conditions.

The orbital manifestations of Graves' disease usually comprise the most distressing component of this inadequately understood disease entity. Patients with optic neuropathy, exposure keratopathy, or disfiguring proptosis can be helped considerably by decompression of the swollen orbital tissues into the maxillary and sinus cavities. Experience with 104 patients personally operated by the senior author and analyzed by chart review and patient questionnaire indicates that antral-ethmoidal decompression is a successful form of therapy, generally free of serious complications. It is now employed earlier in the course of Graves' ophtholmopathy than in the past.

Osteoma is the most common benign tumor of the nose and paranasal sinuses, and the frontal sinus is its most frequent location. This tumor may be discovered incidentally on radiographs or may enlarge to produce symptoms and, rarely, complications referable to its location near the orbit and anterior cranial vault. A series of 22 cases of frontal sinus osteoma treated at the UCLA Center for the Health Sciences is reviewed. The presenting symptoms of this tumor, patient examination, radiographic evaluation, diagnosis, and indications for surgical and nonsurgical management are discussed. Various surgical approaches are reviewed, with emphasis on the advantages and disadvantages of each technique. Issues at surgery include the location of the surgical incision, technique of sinus entry, tumor removal, status of the posterior sinus table, patency of the nasofrontal duct, sinus obliteration, and avoidance of cosmetic deformity. Patient outcomes are assessed and recommendations given based on our findings and experience.

Acute carotid artery rupture is frequently heralded by prodromal arterial bleeding. This warning signal provides the physician with a brief interval in which to hemodynamically stabilize a patient, electively occlude the carotid, and consequently improve the patient's chance of survival. For three years, we have employed an initial nonoperative approach to patients with impending carotid rupture. A trial of endovascular balloon occlusion followed by detachable balloon embolization of the carotid artery has been utilized. Patients unable to tolerate temporary occlusion underwent a vascular bypass procedure followed by embolization. Six patients have undergone this approach, and all had permanent cessation of bleeding. None died as a result of the procedures. One patient developed permanent neurologic deficits. Balloon embolization offers improved results over elective ligation and should be considered as an alternative treatment for patients in this dire predicament.

Hemangiomas consist of a spectrum of benign vascular tumors with variable clinical behavior and microscopic morphology, which usually occur in infancy. A rare variant of these tumors is the invasive subcutaneous hemangioma, which shows an aggressive growth pattern by invading subcutaneous structures and recurring after apparent excision. The authors describe an adult patient with a large submandibular invasive hemangioma who was treated by preoperative embolization and surgical excision.

Persistence of significant edema of the larynx beyond six months after completion of radiotherapy presents the laryngologist with a diagnostic dilemma. Review of the results of 43 cases demonstrated a high incidence of residual or recurrent carcinoma. Based upon this experience earlier and frequent laryngeal biopsies are recommended for these cases. (auth)

Numerous causes of peripheral facial nerve paralyses have been described; however, none has satisfactorily explained the genesis of the most common type of paralysis, Bell's palsy. Two patients undergoing an experimental embolization of vascular intracranial tumors suffered a total peripheral facial nerve paralysis when occlusion of the middle meningeal artery had been accomplished. It is speculated that this paralysis resulted from ischemia of the horizontal portion of the facial nerve, an observation that has not previously been described and that might be applicable as well to the etiology of Bell's palsy.

A new and more rational therapeutic approach to the diagnosis and management of juvenile angiofibromas was formulated based upon the experiences in 35 cases. Preoperative angiography is essential in delineating the mass, and demonstrating extension into surrounding areas, and for delineation of the sources of blood supply to the tumor. Arteriography has shown 20 percent of the cases to have middle fossa extension, and that the size of the tumor in the nasopharynx does not necessarily represent the size and extent of the tumor and may be only the “tip of the iceberg.” The death of a patient with intracranial extension. The cessation of bleeding, and shrinkage of the tumor was demonstrated by pre and post therapy arteriography and scanning. Because of the success of the transpalatal surgical approach and the hesitancy of administering irradiation too, surgical excision is the treatment of choice in all cases that do not have intracranial extension.

The cause of parotid gland swelling in children is often elusive when a mumps viral infection has been excluded. We treated a child with parotid gland swelling secondary to autoinsufflation of the ductal system, a condition previously unreported in the English literature to the best of our knowledge. Although a congenital abnormality of the parotid duct may have been present, psychogenic factors played a major role in the cause of the patient's pneumoparotiditis.

Partial laryngectomy with bipedicle sternohyoid muscle flap laryngoplasty is reviewed with regard to technique and indications. Results are analyzed in a group of 31 consecutive patients who were treated in this manner, and who are now more than three years postoperative. Twenty eight patients are alive and free of tumor. The five failures of treatment are analyzed from the standpoint of errors in surgical technique or in the planning of therapy.

Computed tomography (CT) offers a unique method of displaying the anatomy of laryngeal cancer. Asymmetrical contours of the thyroid cartilages have been found as a normal variant. Marked asymmetry may indicate buckling of the cartilage which could contribute to acute airway obstruction following radiation therapy. A low-density, soft-tissue plane medial to the thyroid cartilages may prove valuable in evaluating cartilaginous involvement with tumor. Computed tomography should make a significant contribution to more accurate planning of radiation therapy portals by showing the relationship of lymphatic spread to the primary tumors.

Dan J. Castro, MD, and coworkers at UCLA presented their data using rhodamine 123 as a photosensitizing agent for argon laser. This report was given at the Western Section meeting of the Triological Society in San Diego. They found complete inhibition of in vivo tumor development by human M 24 melanoma cells transplanted subcutaneously into mice after exposure to low-dose rhodamine 123 and treatment with an argon laser at nonthermal temperatures of 36°C to 40°C. This study shows remarkable tumoricidal effects of nonthermal argon when the mitochondrial dye, rhodamine 123, has been employed prior to laser therapy.—

Drs Terrence Trapp and Gerald Berke reported their work using photoglottography and electroglottography in the canine model with simulated recurrent and superior laryngeal nerve paralysis. Their presentation was before the Western Section meeting of the Triological Society, San Diego, January 1988. These two methods of photoelectric measurements of vocal cord motion are relatively noninvasive and provide detailed information about vocal cord vibration. They identified specific wave forms that can be used in differentiating normal vs flaccid states. Potential human applications were also discussed.

In Reply .—I would like to reply to the two letters that have been written in response to our article "The Value of Sialography in the Diagnosis of Parotid Tumors: A Clinicopathological Correlation" in the December 1977 issue of theArchives(103:727-729). Drs Gates and Stevens concluded that sialography has negligible value in the diagnostic evaluation of parotid masses. Our study was solely designed to determine the diagnostic accuracy of sialography, which certainly remains a controversial test. Our findings and conclusions do not suggest that sialography should be a routine part of the evaluation of all parotid masses. We were impressed with the accuracy of sialography to localize a mass within (intrinsic) or outside (extrinsic) the gland and predict the presence of a malignant tumor (four of six patients). Since this study was a clinicopathological correlation, it was necessarily confined to those patients who underwent surgical exploration. Unfortunately, those patients

Although most thyroid tumors first manifest clinically by a neck mass, several patients with thyroid tumor have been treated whose initial complaint was a disturbance of the respiratory and digestive tracts. Because this association is not well recognized, the diagnosis of a thyroid tumor can be delayed, or even missed until the tumor grows much larger causing other symptoms. A series of 269 patients with thyroid tumors seen at UCLA from 1970-1980 was reviewed. Approximately 16% of these patients sought treatment because of aerodigestive dysfunction such as dyspnea, dysphagia, hoarseness, throat discomfort and hemoptysis. Such symptoms often indicate malignancy of substernal extension of tumor. The management of these tumors is discussed.

Hypopharyngeal stenosis after total laryngectomy has been reported as high as 40%. The most consistent and important causal factor is the extent of the pharyngeal resection since cancers of the pyriform sinus and postcricoid region have the highest incidence of stenosis. Dilation is frequently unsuccessful in the management of postlaryngectomy hypopharyngeal stenosis probably because of its excessive length. The laterally-based tongue flap is effective for repair of these stenoses because of its proximity, epithelial compatibility, and ample length. The technique, details, and successful use in three patients are presented.

• The importance of sialography in the diagnostic evaluation of the condition of a patient with a parotid mass remains uncertain; some proponents advise use of sialography routinely, while others believe it to be worthless. To help resolve these conflicting opinions, a retrospective study of 40 patients was carried out that compared sialographical interpretations with respective surgical-histological findings. The results of this study show that generally reliable information, which may serve to influence therapeutic decisions concerning these patients, can be gleaned from sialography.

Partial laryngectomy for anterior commissure cancer often results in a shortened glottis which produces a high pitched strained voice and an inadequate airway lumen which requires permanent tracheostomy. Vocal fold vibration is impaired both by the shortened length and anterior scarring which profoundly affects the myoelastic properties of the larynx. Many different methods of reconstructing the anterior commissure have been attempted with limited success and many require multiple procedures. A method of anterior commissure reconstruction employing bilateral omohyoid muscle flaps has been performed successfully in four patients. The omohyoid muscles and investing fascia are readily available during partial laryngectomy and can be tailored to reconstitute the anterior commissure. The myofascial flaps epithelialize rapidly and there is little tendency for anterior glottic stenosis. The sphincteric function of the larynx remains intact and the vocal quality surpasses other methods of reconstruction employed by the author.

Forty-one consecutive patients who underwent supraglottic laryngectomy at UCLA were reviewed. All of the operations were performed by or under the direct supervision of the same surgeon (T.C.). The majority (68%) had advanced squamous cell carcinoma (Stage III-IV). Approximately one half received radiation therapy as part of planned combined therapy. The overall tumor-free survival, with a two-year minimum follow-up period, was 90%. The most common site of tumor recurrence was neck metastasis. There were four laryngeal recurrences, three of which were salvaged with completion laryngectomy. There was only one completion laryngectomy for severe aspiration. The favorable results in this series are attributed to frozen section control of surgical margins, surgical or radiation therapy treatment of cervical lymph nodes at risk for metastatic disease, and the employment of surgical techniques designed to minimize aspiration.

It has been well established that supraglottic laryngectomy is an effective treatment of laryngeal cancer arising above the vocal cords with cure rates equaling total laryngectomy. Although there is preservation of a near normal voice after supragloltic laryngectomy, chronic aspiration occurs in some patients particularly after extended supraglottic laryngectomy or when there is associated compromised pulmonary function. During normal deglutition, the epiglottis serves to divert food to the pyriform fossae and partially covers the inlet to the airway. These important functions can be accomplished after supraglottic laryngectomy by reconstructing a neoepiglottis from an epiglottic remnant whenever one third or more of the epiglottis can be preserved which is microscopically free of tumor. Our results in 14 patients have shown no clinically significant aspiration after epiglottic reconstruction.

A retrospective review of 133 patients with major salivary gland carcinomas treated between 1955 and 1981 is presented. The majority of cases (104) originated in the parotid gland. The most common histological type was mucoepidermoid carcinoma (39 cases). Tumor-free interval was longest for patients with acinic cell and mucoepidermoid carcinomas. In contrast, adenoid cystic carcinoma was poorly controlled, regardless of the form of treatment. Initial control of primary major salivary gland tumors was inversely related to the presence of disease at the surgical margins. In cases with microscopic or gross disease at the surgical margins, postoperative radiation therapy controlled the tumor locally in 18 of 26 patients (69%). Postoperative radiation therapy was generally used only in cases with high-grade histologies, advanced stages, or positive surgical margins. Of the patients treated with surgery alone, 53% achieved local control, as compared to 75% of the group which received postoperative radiation therapy. Although the difference was not statistically significant, we would have expected the combined therapy group to have a lower control rate due to more advanced disease. There was a low salvage rate (22%) and a high incidence of distant metastasis (60%) in recurrent cases. The data indicates that complete surgical resection results in the best local control, with or without adjuvant radiation. When the surgical margin is inadequate and re-excision not possible, adjuvant radiation therapy appears to have a role to optimize local control and survival.

The need for nondelayed skin flaps from the chest for postoperative reconstruction and repair has increased considerably since the advent of combined irradiation and surgical therapy for treatment of cancer of the head and neck. Survival of these pedicled flaps is of paramount concern to the surgeon, as flap necrosis can be catastrophic for the patient. Many parameters have been evaluated to predict flap viability, but recent studies strongly suggest that the arterial blood supply of the pedicle is the most important factor in the success of immediate transposition. A study was performed in 19 cadavers to delineate the cutaneous vascular anatomy of the chest in order to determine precisely where the perforating vessels of the thorax and shoulders supply the pedicle region of medially-based and laterally-based pectoral flaps. On the basis of this study, modification of the design of these flaps is recommended.

Tactile sensation to the oropharynx and hypopharynx and larynx is supplied by the internal branch of the superior laryngeal nerve and by the pharyngeal branches of the ninth and tenth cranial nerves via the pharyngeal plexus. These may be blocked precisely by a technique of percutaneous superior laryngeal nerve and transpharyngeal pharyngeal plexus infiltration, allowing rapid, comfortable production of anesthesia for peroral endoscopy. Minimal patient cooperation is required. Results have been successful in more than 500 patients, and no complications have been attributed to the technique.