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None of the consultants disagree with the initial plan to treat this T1N0 squamous cell carcinoma of the true vocal cord with radiotherapy. The consensus is that 10% to 20% of these lesions can fail conventional treatment. Dr. Rice cites incorrect radiotherapy ports, understaging, and extension into muscle or cartilage as the likely reasons for failure. He also believes that a patient who continues to smoke is at risk for persistent or recurrent disease. Drs. Wetmore and Singer add that some tumors are radioresistant for indefinable reasons. Although all the consultants agree that the differentiation between severe atypia and carcinoma in situ can be very difficult, Dr. Singer warns that the surgeon should not play a role in the histologic decision-making. He does not make a distinction between the two and suggests treating a lesion on the basis of its clinical behavior. Dr. Rice draws the line at treating T3 glottic carcinomas with radiotherapy. He states that the greater the tumor bulk the less well the lesion will do with radiotherapy. All the experts caution that involvement of cartilage at the anterior commissure and arytenoid is also a reason for failure. Dr. Wetmore adds that subglottic extension and verrucous carcinoma also contribute to radiotherapy failure. The real controversy lay with how to proceed in this case. Dr. Rice suggests excision of the lesion with the laser or microsurgical stripping. If the margins were positive he would proceed with a vertical hemilaryngectomy. Dr. Wetmore would excise the lesion with a CO2 laser and would follow the patient closely thereafter. He would only plan a hemilaryngectomy if the lesion recurred again.(ABSTRACT TRUNCATED AT 250 WORDS)

A number of different approaches can be used to expose the facial nerve. The route taken will depend on the pathology and the portion of the nerve that requires exposure. When performing a parotidectomy approach to the extratemporal portion of the facial nerve, the tragal pointer is a key landmark, but other landmarks also should be used to identify the facial nerve safely. The lateral semicircular canal, the chorda tympani nerve, the digastric ridge, and the cochleariform process are some of the useful landmarks in the mastoid and middle ear. When performing a middle fossa approach, the superior semicircular canal, the greater petrosal nerve, and a window through the tegmen tympani into the attic are useful guideposts. The surgeon should use as many of the available landmarks as feasible to perform safe facial nerve surgery.

Mohs micrographic surgery has been highly successful in treating skin cancers that grow in a contiguous manner. The technique requires removal of involved tissue in thin layers and histographic mapping to pinpoint residual tumor. This process is repeated until all of the tumor is resected. This allows 100 percent of all margins to be examined and is very tissue conservative, attributing to its unsurpassed cure rates and excellent cosmetic results. Since it is done as an outpatient procedure under local anesthetic, it also is safe and efficient.

The term lethal midline granuloma has been used to describe a number of lesions which may present in the midface. A list of possible causes is presented and three entities, midline malignant reticulosis, Wegener's granulomatosis, and malignant lymphoma, are discussed in detail. The pathological descriptions, the clinical features, and the recommended forms of therapy are outlined. It is important to vigorously pursue the patient with a midline facial lesion until a definite tissue diagnosis is obtained. Multiple biopsies may be necessary because necrosis and nonspecific inflammatory changes may be present in various of these disease entities. The correct diagnosis is essential because the treatment of these disease is different: Wegener's granulomatosis responds best to chemotherapy, whereas midline malignant reticulosis and lymphoma should be treated with radiation therapy if they are localized. Despite conceptual variations, most recent authors believe that these three diseases exist as separate entities, and furthermore, recommend that the term lethal midline granuloma be either dropped from the lexicon or relegated to a descriptive clinical term to be used only until a more definitive diagnosis can be made.

We present an approach to the skull base that allows access to both the infratemporal fossa and the middle cranial fossa with minimal morbidity. This approach is different from most of the previously described approaches in that it uses a preauricular incision, preserves the facial nerve, and avoids the mastoid bone. It involves dividing the zygomatic arch and displacing it inferiorly, dividing the malar eminence (zygoma) and displacing it anteriorly, and cutting the coronoid process and retracting it superiorly with the attached temporalis muscle. Reconstruction is accomplished by using the temporalis muscle or a pericranial flap to cover the dura, a free fat graft to fill the space left by tumor excision, and by wiring the zygomatic arch and malar eminence into their original positions. Case reports of both benign and malignant lesions are presented.

Carbon dioxide laser surgery has become the treatment of choice for laryngeal papillomatosis. The purpose of this study was to determine the type, incidence, and severity of complications that occur with laser microlaryngoscopy for a disease that often requires multiple operations. Forty patients with laryngeal papillomatosis underwent a total of 222 carbon dioxide laser laryngoscopies over the 6 1/2-year period from June 1977 through December 1983. The results showed that 13 patients sustained a total of 23 separate complications. Intraoperative complications consisted of one episode of bilateral pneumothorax and one episode of cervical subcutaneous emphysema, both associated with the use of jet ventilation anesthesia, and one episode of a loosened tooth in a child with carious teeth. The delayed complications consisted of 10 patients with anterior laryngeal webbing, 2 patients with posterior webbing, 6 patients with laryngeal edema or fibrosis, and one episode each of prolonged dysphagia and tracheal foreign body. No airway fires occurred. Only 2 of 28 patients who had 5 or fewer laser laryngoscopies developed complications, but 11 or 12 patients undergoing 6 or more laser operations had complications. In summary, although the incidence of life threatening complications was low, the occurrence of minor complications such as small anterior glottic webs and persistent edema was relatively high, especially in those patients who required multiple laser laryngoscopies.

Surgical splints are a valuable adjunct in managing certain mandible and maxillary fractures. Of the various splint materials, acrylic is the easiest, fastest, and least expensive. Acrylic splints are rigid, strong, easily adjusted and repaired, translucent, lightweight, and tolerated well by the oral mucosa. Splints are beneficial not only in the edentulous adult, but also in the child with deciduous dentition and in the patient with a partial dentition. Splints are helpful in managing fractures of the symphysis, parasymphyseal region, body, and alveolar ridges of the mandible, sagittal fractures of the hard palate, and severely comminuted mandible fractures. Construction of acrylic splints is simple and rapid if the surgeon uses the services of a dentist or a dental laboratory.

We report a 64% long-term success rate in our series of 66 patients who have undergone the tracheoesophageal puncture (TEP) procedure with follow-up ranging from one to 3 1/2 years. Poor motivation and compliance were the most common factors noted in patients who failed to obtain or maintain tracheoesophageal speech. Other problems causing failure were technical problems relating to the TEP and medical problems. The success rate in the last 24 cases of our series has improved to 83%. The "collared" prosthesis, more careful patient selection, and emphasis on a team approach seem to be important factors for the higher success rate. The Blom-Singer TEP procedure is a safe, simple, and effective means of alaryngeal communication for selected patients.

Bullous myringitis is manifested by moderately severe otalgia associated with vesicles on the tympanic membrane and medial external auditory canal wall. This disease occurs mainly in young adults, most commonly in winter, and is usually preceded or accompanied by an upper respiratory infection. A reversible sensorineural loss developed in three of 22 patients. Complement fixation antibody studies performed on ten patients failed to implicate Mycoplasma pneumoniae, influenza virus types A or B, or adenovirus as the causal agent.

Auditory brainstem response (ABR) has been used by several investigators to study the role of the brain stem in the pathophysiology of obstructive sleep apnea (OSA). These studies have produced conflicting results. We studied 27 preoperative OSA patients and 17 controls using click stimuli presented at a slow (11.7/second) rate and at a fast (57.7/second) rate. ABR was repeated postoperatively in 18 patients. There were no statistically significant differences in the ABRs of preoperative OSA patients when compared with the control group. However, the preoperative recordings showed statistically significant prolonged latencies for wave III (p less than 0.01) and interpeak latency (IPL) I-III (p less than 0.01) when compared to postoperative recordings. Rapid-rate testing was not helpful. Although normal sleep does not cause ABR abnormalities, the pathological sleepiness seen in OSA patients may cause brainstem dysfunction manifested by prolonged ABR latencies. These abnormalities may resolve with treatment of OSA.

The Singer-Blom tracheoesophageal puncture procedure for surgical-prosthetic voice restoration has proved to be a viable option for alaryngeal speech rehabilitation. Following tracheoesophageal puncture, occlusion of the tracheostoma shunts pulmonary air through the Blom-Singer prosthesis into the cervical esophagus. The pulmonary air passing through the cervical esophagus and into the hypopharynx causes a portion of the upper alimentary tract to vibrate in a manner similar to that of the pharyngoesophageal segment during the production of esophageal speech. To study the location and shape of the vibratory segment in tracheoesophageal speakers, videofluoroscopy and simultaneous voice recording were performed with 16 patients. To analyze the vibratory segment(s), photographs were made of the videotaped image while it was stopped during the patients' production of the /a/ sound. The most frequent location of the vibratory segment was in the lower third of the neck, which corresponds to cervical vertebrae C5 through C7. Five of the subjects had two separate vibratory segments and two other subjects had long vibratory segments. The vibratory segment(s) in tracheoesophageal speakers was found to be similar to the vibratory segment(s) in esophageal speakers.

A case of a large (5.5 cm), multilobulated, mucosa-covered, minor salivary gland tumor of the base of the tongue that displayed morphologic features of both a mucoepidermoid carcinoma and an acinous cell tumor is described. Generally, each of these salivary gland tumors occurs only rarely at this site. A tumor with both these elements has not previously been reported.

The Singer-Blom tracheoesophageal puncture (TEP) technique is an effective and safe surgical method for speech rehabilitation of the alaryngeal patient. The silicone prosthesis, which is fitted in the TEP tract, allows pulmonary air to be used for voice production but prevents aspiration. In a series of 63 patients, 56 (89%) were able to develop fluent speech, but only 45 patients (71%) currently use tracheoesophageal speech as their prime mode of communication. Of the 18 patients (29%) who no longer use tracheoesophageal speech, 11 experienced either inadvertent dislodgement of the prosthesis or were noncompliant, five patients failed to develop fluent speech after adequate trial, and two patients failed because of aspiration. Almost all of the successful patients have voice quality and fluency that are as good or better than accomplished esophageal speakers, despite the fact that most of these patients were unable to learn esophageal speech. Since the Singer-Blom technique has eliminated most of the problems associated with other forms of surgical speech rehabilitation, it is considered to be the best surgical technique presently available for restoring speech in the alaryngeal patient.

We treated 21 previously untreated T1 or tumor in situ squamous cell carcinomas of the true vocal cords by carbon dioxide laser excision. The mean follow-up was 42 months, with a range of 26 to 64 months. Recurrent vocal cord carcinomas, with an average interval to recurrence of 21 months developed in four patients. Three of the four recurrences involved the anterior portion of the true vocal cord, including the anterior commissure. One of the patients with recurrence was treated again with the laser, and the other three underwent radiotherapy. All four patients are alive and have retained their larynges. Laser excision of selected T1 and in situ carcinomas of the true vocal cords is a cost-effective and viable alternative to radiotherapy or more radical surgical therapy.

Spontaneous cerebrospinal fluid (CSF) otorrhea is rare. We present four new cases and an analysis of the literature. Two distinct subtypes occur. Seventy-two percent of cases are the childhood type with congenital defects of the otic capsule. Meningitis, usually pneumococcal and frequently recurrent, occurs in 92% of these cases. CSF otorrhea follows myringotomy for a presumed serous effusion. The child usually has unilateral and sometimes bilateral absence of cochlear and vestibular function and commonly exhibits a Mondini deformity. CSF usually enters the inner ear through a dural defect in the lateral aspect of the internal auditory canal and exists through the oval window. Treatment should consist of stapedectomy and packing of the vestibule with muscle or subtotal petrosectomy. Twenty-eight percent of cases of spontaneous CSF otorrhea are the adult type characterized by bony dehiscenses, most commonly of the tegmen tympani or tegmen mastoideum and less commonly of the posterior fossa plate. The meningeal defects are either meningoencephaloceles or simply holes in the dura. Therapy should consist of a mastoidectomy in conjunction with a transtemporal supralabyrinthine (middle fossa) approach if a meningoencephalocele of the tegmen is found.

The odontogenic keratocyst is a keratinizing squamous epithelium-lined cyst that occurs in the mandible and maxilla. In 5% to 10% of patients the keratocysts may be a manifestation of the basal cell nevus syndrome. The recurrence rate after surgical therapy for odontogenic keratocysts varies from 10% to 63%.

A series of 53 advanced scalp cancer patients treated with surgery is presented. A review of these patients concludes: 1) local tumor growth--not distant metastasis--is the primary problem; 2) management is based on the tendency of a tumor to spread laterally early in its development with a deep invasion occurring later on; 3) when deep invasion occurs, radical excision and reconstruction is indicated to control the disease; 4) recurrence following adequate local therapy requires a change in treatment modality.

The presence of anterior and posterior nasal packs in patients with epistaxis is known to be associated with cardiorespiratory problems and sometimes death, although the mechanism has not been well understood. To determine the incidence and severity of obstructive sleep apnea in patients with epistaxis treated with both anterior and posterior nasal packs, we obtained polysomnograms on twelve patients while the packs were in place. Ten of these patients demonstrated obstructive sleep apnea. The apnea index (apneas/hour sleep) ranged from 1 to 83, with a mean of 29; the hypopnea index (hypopneas/hour sleep) ranged from 9 to 33, with a mean of 20; and the lowest oxygen saturation (SaO2) ranged from 17% to 91%, with a mean of 77%. Ten patients returned for another polysomnogram after removal of the packs. These baseline studies showed improvement in the apnea index and in the lowest SaO2 in all patients, although four patients still demonstrated at least mild obstructive sleep apnea. This study demonstrates that nasal packs used for the treatment of epistaxis may induce obstructive sleep apnea or markedly exacerbate underlying obstructive sleep apnea and, therefore, contribute to the sudden deaths that have been reported in epistaxis patients.

Thirty-three patients with inoperable squamous cell carcinoma of the head and neck were treated with cisplatin, 15 mg/sq m, administered synchronously with high-dose radiation therapy. Twenty-nine patients (88%) responded to the regimen; of these, 20 had complete regression of all disease. Eight of the 20 had a relapse in less than one year of their treatment. Among those patients who did not have a relapse, the follow-up period was short. It is concluded that a clinical regression response is more likely with this treatment regimen than with radiation therapy alone, and that that response may be a better palliation. Further study of this combination of treatment modalities is warranted.

Thirty-six patients with stage IV squamous cell carcinoma of the head and neck were treated with cisplatin (15 mg/m2), administered synchronously with high-dose radiation therapy. Of the original 36 patients, 26 are dead of disease. Although previous reports of an 88% response to this regimen were noted, the disease-free intervals in this 36-patient group were short. The interval of time between treatment and death ranged from two to 27 months, with an average survival time of 10.7 months. It appears that although cisplatin potentiation to radiation therapy offers an encouraging clinical response initially, persistent clinical regression of disease is unlikely. Further studies of cisplatin sensitization of radiation therapy vs radiation therapy alone and chemotherapy alone need to be performed before this regimen can be considered strong enough to stand on its own merits.

Blastomycosis is an uncommon fungal disease which may mimic carcinoma of the larynx. Physical examination may show a granular appearance early in the disease with progression to laryngeal fibrosis. Histologic examination usually shows pseudoepitheliomatous hyperplasia, microabscesses, and giant cells. The broad-based budding yeast organisms may be easily overlooked unless special stains are used. Two cases of laryngeal blastomycosis which were originally treated as carcinoma are reported.

Perinephric rabbit fat was divided into small particles with scissors and razor blades and then injected subcutaneously into the donor rabbit. The injected fat was compared with surgically implanted fat. Subcutaneous augmentation with both types of fat resulted in similar findings. Grossly, 40% of injection and implantation sites were palpable after 16 to 36 weeks of observation. Histologically, fat was present at practically every site, but with a variable amount of fat cell destruction. This study demonstrates that the author's method for dividing and injecting fat produces comparable results in terms of soft tissue augmentation to those obtained by surgically implanting fat. Although injected fat does not fulfill the criteria as the ideal substance for soft tissue augmentation, fat injection may prove to be a clinically useful means for improving body contour.