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Objectives: To determine the effects of prolonged ventilation tube retention on tympanic membrane healing and the efficacy of patching procedures used concomitantly at the time of tube removal., Design: Retrospective chart review., Setting: Tertiary referral academic institution., Patients: Seventy-six patients aged 12 years and younger, with a total of 99 ears identified from January 1989 to December 1994. All patients underwent ventilation tube removal for prolonged tube retention or infection unresponsive to medical management. A minimum of 6 months of follow-up was required for inclusion., Intervention: Ventilation tube removal under general anesthesia, with or without concomitant patching., Outcome Measures: All medical charts were reviewed for age, sex, indications for tube removal, tube retention time, type of patch used (if any), type of tube, outcome after removal, other medical problems, and previous surgical history., Results: The perforation rate was significantly higher in children with tubes retained beyond 36 months (P=.02). History of previous adenoidectomy predicted poor outcome, with a rate of 47% vs 17% in patients with no such history (P=.002). Patching did not improve healing. No other patient factors significantly influenced the perforation rate., Conclusions: Ventilation tube retention longer than 36 months resulted in an increased perforation rate after surgical removal. Paper patching at the time of tube removal does not improve healing. Prospective studies are needed to confirm these findings and to determine the efficacy of other patching techniques.

Unilateral vocal cord paralysis (UVCP) is relatively common, and previously, thyroidectomy used to be the leading cause. We retrospectively reviewed 98 cases of UVCP. The left vocal cord was involved in 70% of the cases and the right vocal cord in 30%. The cause was neoplastic in 32%, surgical in 30%, idiopathic in 16%, traumatic in 11%, central in 8%, and infectious in 3% of the cases. Only 4 cases were the result of thyroid surgery. Evaluation consisted of a review of the history, a physical examination, and computerized scanning or magnetic resonance imaging, as needed. The functional recovery rate as related to the cause was as follows: surgery 31%, idiopathic 19%, traumatic 18%, and neoplastic 0%. Thirty-five percent of patients required medialization laryngoplasty or Teflon injection. Lung and skull base tumors and their surgical treatment are the most common causes of UVCP.

Objective: Hemorrhage after tonsillectomy is a potentially lethal complication. Preoperative assessment consisting of prothrombin time (PT) and activated partial thromboplastin time (PTT) has been used to identify patients at risk for hemorrhage after tonsillectomy and adenoidectomy. We sought to assess the value of PT/PTT screening as a predictor of posttonsillectomy hemorrhage., Design: A retrospective chart review was carried out with a minimum of 1 month follow-up., Setting: Tertiary academic referral center., Patients: Between January 1992 and June 1995, 382 patients undergoing tonsillectomy were examined; 339 patients with a minimum of 1 month follow-up were reviewed for this study., Main Outcome Measure: Normal and prolonged PT/PTT values were examined. Bleeding in the intraoperative, immediate postoperative, and delayed phases of healing was examined., Results: Two-hundred and twenty-two patients had normal PT/PTT, 39 had prolonged PT/PTT, and 78 had no preoperative studies performed. Bleeding occurred in 2.7%, 2.6%, and 3.3%, respectively, of patients. Eight patients had positive family histories of bleeding tendencies. One patient (12.5%) with a normal PT/PTT experienced a delayed posttonsillectomy bleed. Of 39 patients with abnormal coagulation studies, 30 were borderline elevations with no repeat studies done; one patient experienced postoperative hemorrhage. Nine abnormal results were repeated; three returned to normal, three remained prolonged but underwent tonsillectomy with no intervention, and three received hematology consultations. One patient had lupus anticoagulant, one had Hageman Factor deficiency, and one was cleared for surgery with no diagnosis. All patients underwent tonsillectomy with no episodes of postoperative bleeding., Conclusions: Preoperative PT/PTT provides no additional information than does a bleeding history for the general pediatric population undergoing tonsillectomy. This should only be done in selective cases where warranted by history.

Purpose: Head and neck masses in children are common. Suspicious or persistent masses are referred to the otolaryngologist who is faced with the dilemma of deciding which ones require surgical excision. Fine-needle aspiration (FNA) in adults helps distinguish lesions requiring excision from those that do not. Few reports exist of its use in children, Patients and Methods: Between January 1991 and December 1994, 67 FNAs were performed on children, 29 of which (43%) were for head and neck masses. Based on the FNA findings, 16 patients underwent surgery., Results: In 13 patients, the final pathology was consistent with the FNA findings: granulomatous diseases (3), branchial cysts (3), acute/chronic lymphadenitis (3), thyroglossal cyst, hemangioma, Hodgkin's lymphoma, and Castleman's disease (one each). There was one misdiagnosis, no false positives, and two nondiagnostic specimens. Based on the results of FNA, surgery was not performed in the remaining 10 patients. The cytology was: cervical lymphadenopathy (7), abscess formation (1), lymphangioma (1), and leukemia (1)., Conclusion: We conclude that FNA in an extremely useful tool in the management of head and neck masses in children. It is very well-tolerated by children, and we did not encounter any complications.

The objective of this study was to determine the incidence of internal jugular vein thrombosis in patients undergoing free flap reconstruction and simultaneous neck dissection. Patients underwent Doppler ultrasound examination of their internal jugular veins on postoperative days 1 and 7 after functional neck dissection and free flap transfer. Long-term follow up was obtained at a minimum of 3 months. The incidence of internal jugular vein thrombosis in patients undergoing free flap reconstruction with simultaneous neck dissection is similar to that of patients undergoing just neck dissection. A significant number of these veins recanalize and have excellent long term patency. There does not seem to be a correlation between venous thrombosis and free flap survival.

Objective: To determine the incidence of internal jugular vein thrombosis after functional or selective neck dissection., Design: Patients underwent serial Doppler ultrasonographic examinations of their internal jugular veins, on postoperative days 1 and 7, following functional neck dissection. Long-term follow-up was conducted at a minimum of 3 months., Setting: Department of Otolaryngology, West Virginia University, Morgantown., Patients: Sixty-five patients (51 men and 14 women) underwent 100 functional neck dissections between 1993 and 1995. Thirty-five patients had N0, 10 had N1, and 20 had N2 node involvement, respectively. Thirty-five patients underwent bilateral neck dissection, 17 underwent left neck dissection, and 13 underwent right neck dissection., Main Outcome Measures: Thrombosis of the internal jugular veins was determined using duplex Doppler scanning. Correlation with the length of the procedure, intraoperative blood loss, preoperative radiation therapy, stage of neck disease, presence of extracapsular spread, wound infection, and pedicled musculocutaneous flap closure was determined., Results: Of the 100 internal jugular veins studied, 20 (24.7%) of 81 and 19 (26.4%) of 72 were found to have evidence of thrombosis on postoperative days 1 and 7, respectively. On long-term follow-up, the incidence of internal jugular vein thrombosis was significantly lower (5.8%; P < .001). None of the variables examined correlated significantly with the presence of thrombosis. Of the 20 veins that were thrombosed initially, on follow-up 13 had normal flow and 2 had persistent thrombosis. Five patients were unavailable for follow-up. No thrombosis developed as a late finding., Conclusions: Our results indicate that even though the incidence of internal jugular vein thrombosis is relatively high immediately following neck dissection, a significant number of these veins will undergo recanalization and have excellent long-term patency.

Vasospasm is known to have an adverse effect on the survival of free tissue transfers. Prolonged vasoconstriction decreases blood flow to the flap and promotes thrombosis at the anastomotic site. Because of its wide availability and rapid effect, topically applied lidocaine is used by many surgeons to prevent and correct vasospasm. Mucosal absorption of lidocaine is known to be rapid. Absorption by the surgical bed during microvascular reconstruction has not previously been determined. We had three specific aims: (1) to determine whether systemic absorption occurs, (2) if so, to determine the degree of absorption, and (3) to determine whether the type of reconstruction affects the degree of absorption. Twelve consecutive patients were entered into the study, four in a myocutaneous reconstructive group and eight in a fasciocutaneous group. Baseline serum lidocaine levels were drawn. After the initial application of lidocaine, levels were drawn every 30 minutes. Final levels were drawn 120 minutes after the last application. The total amount of lidocaine used ranged from 720 mg to 2600 mg. Application ranged from 7.5 mg/minute to 34.7 mg/minute (2 to 9 times the estimated toxic dose of 4 mg/minute for a patient weighing 70 kg). Results ranged from undetectable (<0.5 microg/ml) to minimal therapeutic levels (1.6 microg/ml). Toxic levels (>6.0 microg/ml) were not encountered. Significant (p < 0.05) differences were found between the fasciocutaneous group, which generally had no detectable serum levels, and the myocutaneous group, which had detectable subtherapeutic to minimally therapeutic levels. Doses considered toxic by intravenous or mucous membrane application may safely be applied topically. Greater absorption was found in the myocutaneous group, which is believed to be a result of the richer absorption surface provided by the muscular tissue.

Management of patients with cerebrospinal fluid rhinorrhea (CSF) remains controversial. Most studies recommend either an endoscopic or an external extracranial approach, depending on the surgeon's preference. Eighteen patients with CSF rhinorrhea have been managed at our institution since 1990. The causes of the CSF rhinorrhea consisted of functional endoscopic sinus surgery (7), lateral rhinotomy with excision of a benign nasal tumor (3), spontaneous rhinorrhea (7), and secondary repair after intranasal ethmoidectomy (1). In 11 patients the CSF leak was recognized at the time of surgery; in 10 of these patients it was repaired during the primary surgery, whereas one patient underwent secondary repair after failure of conservative management of his CSF fistula. Seven patients underwent exploration for spontaneous CSF rhinorrhea. Four patients had computer tomography scans that showed the leak, and two patients had cisternography to localize the leak. One patient underwent magnetic resonance cisternography. Both of these leaks were identified with cisternography and were then confirmed intraoperatively. Repair methods included a pedicled septal mucosal flap (4), a free mucosal graft from the septum (7), and a middle turbinate (5). Two patients had obliteration of the sinus with muscle/fascia and fibrin glue. Eight patients were repaired endoscopically. The remainder underwent repair through external approaches. Seventeen patients (at a minimum 1 year follow-up) remain free from leakage. One patient required a second repair 8 months after surgery. Iatrogenic trauma remains the most common cause of CSF rhinorrhea. Management at the initial setting is the least morbid approach and is successful in 95% of cases. Whether an endoscopic or external approach is used depends on surgical expertise and experience.

Carcinoma of the esophagus is a disease with a poor prognosis. Surgery is considered the treatment of choice. Patients who are surgically unresectable may receive radiotherapy, plus or minus chemotherapy. While this offers reasonable palliation, a significant number of patients develop benign or malignant strictures. Frequent esophagoscopy with dilation is required if they are to swallow. Patients with strictures or malignancy of the esophagus are more prone to complications if they undergo an esophagoscopy. We examined the morbidity of esophagoscopy in a group of patients who had received radiotherapy for carcinoma of the esophagus. Over a 10-year period, 21 patients receiving irradiation for carcinoma of the esophagus were examined. All patients underwent esophagoscopy for staging and diagnosis. The tumor locations were upper (6), middle (6), and lower (9) esophagus. The T-stages were 1 (7), 2 (6), 3 (6), and 4 (2). Five patients had dilation of a malignant stricture at the time of diagnosis. Fever developed and resolved within 24 hours in 2 patients. Following completion of irradiation, a total of 83 esophagoscopies were performed (range 1 to 11 per patient). Six patients with no tumor or stricture underwent 8 esophagoscopies (3 rigid, 5 flexible). There was 1 episode of minimal bleeding and 1 fever that resolved within 24 hours. Ten patients with malignant strictures underwent 62 esophagoscopies (5 rigid, 57 flexible). There were 17 (27%) episodes of fever (all resolved within 24 hours) and 14 (22%) episodes of bleeding. Five patients with benign strictures underwent 13 esophagoscopies (2 rigid, 11 flexible). One patient had a perforation that resolved with conservative treatment, and 1 patient developed an epidural abscess 2 months following dilation. This patient is the only one that required surgical intervention and had prolonged hospitalization. Esophagoscopy of the irradiated esophagus can be performed relatively safely and excellent palliation obtained. Morbidity consisting of minimal bleeding, and fever lasting less than 24 hours, is frequent but self-limited.

Objective: To describe the role of the lateral-arm free flap in reconstruction of head and neck defects following ablative oncologic surgery and to discuss the anatomy of this flap as well as indications for its use., Design: A prospective study of all patients undergoing a lateral-arm free flap was performed. Up to 3 years of follow-up was obtained., Setting: Tertiary referral centre., Method: A total of 12 lateral-arm free flaps were utilized to reconstruct defects ranging in size from 4 x 7 to 10 x 7 cm. Maximum width of the flap was 7 cm. A mean area of 55 cm2 was harvested., Main Outcome Measures: Flap survival, morbidity, speech intelligibility, and oral function and intake were assessed., Results: The vascular pedicle was reliable with vessel diameters of 1.5 mm, and length of 6 to 7 cm. All flaps survived, and minimal donor site morbidity was encountered. Nine patients maintained good speech with adequate intelligibility while 10 patients maintained adequate oral intake., Conclusions: Functional results can be obtained with the lateral-arm free flap. A consistent pedicle of good length and size was found. It is our flap of choice in older, thinner individuals when the width of the donor site is less than 7 cm, which allows for primary closure.

Because of its unique DNA-cleaving and strand-passing activities, topoisomerase II is involved in many aspects of DNA metabolism, including replication, transcription, recombination, and repair. The cytotoxic potential of topoisomerase II-targeted drugs, such as etoposide, is related to their ability to stabilize covalently linked enzyme-DNA complexes, which are intermediates in the enzyme's catalytic cycle. Epidermal growth factor receptor is expressed on the cell surface of the majority of squamous cell carcinomas, and epidermal growth factor binding is known to stimulate a number of cellular transduction pathways, including tyrosine kinase, protein kinase C, and phospholipase C. Because topoisomerase II is a proliferation-dependent protein and has been shown to be a high-affinity substrate for many of these cellular transduction pathways, the effects of epidermal growth factor on cellular regulation and sensitivity to etoposide were studied with the human oral cavity squamous cell line, KB. Topoisomerase II catalytic activity was rapidly and transiently inhibited after the addition of epidermal growth factor to the cellular growth media. Western blot on nuclear extracts did not demonstrate alterations in topoisomerase II polypeptide levels to account for changes in catalytic activity. Epidermal growth factor treatment also led to the formation of stabilized, covalently linked enzyme-DNA complexes. Furthermore, epidermal growth factor-induced, topoisomerase II-mediated DNA strand breaks were additive to those induced by etoposide. This study indicates that epidermal growth factor specifically regulates the catalytic and DNA-cleaving activities of topoisomerase II in KB cells. This may direct clinical strategies for circumventing the intrinsic cellular resistance to chemotherapy commonly observed in squamous cell carcinomas of the head and neck.

Although malignancies of the lacrimal sac are rare, malignant melanoma of the lacrimal sac is an exceedingly rare occurrence. Patients with abnormalities of the nasolacrimal system may come to otolaryngologists for evaluation. Treatment of lacrimal sac malignancies will necessitate consultation of a head and neck surgeon. The triad of symptoms commonly found in these patients includes epiphora, bloody reflux from the lacrimal punctum, and a medial canthal mass. Early local recurrence occurs frequently. Radical surgical treatment, including wide-field en bloc resection of the entire nasolacrimal system, affords the best protection against local recurrence and provides the best opportunity for enhanced patient survival. Adjunctive therapy in this disorder remains controversial.

We describe a case of retropharyngeal hematoma after a cervical hyperextension injury in an elderly man. Progressive hoarseness, dysphagia, and dyspnea were the early signs that necessitated oral endotracheal intubation and, ultimately, tracheostomy. The hematoma was explored and drained through a lateral cervical approach, and a bleeding vessel in a small tear in the anterior spinous ligament was noted and cauterized. The patient recovered uneventfully.

Objective: To assess the postoperative complications in patients who underwent elective thyroid or parathyroid surgery without postoperative drainage., Design: During a 6-year period all patients who met study criteria were prospectively evaluated., Setting: General community and tertiary referral center., Patients: Fifty-seven patients undergoing thyroid surgery and eight patients undergoing parathyroid surgery were evaluated. Twenty-four patients were excluded because drains were placed postoperatively. Reasons for exclusion included presence of a large dead space, substernal goiter, extensive neck dissection for malignant neoplasm, and large goiters., Results: Major complications consisted of a hematoma requiring reexploration in one patient, and a recurrent nerve palsy in one patient. Minor complications consisted of temporary hypocalcemia (three), seroma (one), and superior flap edema that resolved in 3 months (20)., Conclusion: Routine prophylactic drainage in a select patient population is unnecessary after uncomplicated thyroid or parathyroid surgery.

Background: Squamous cell carcinoma of the low cervical area may be secondary to stomal recurrence following laryngectomy, low cervical esophageal disease, or peritracheal metastasis. Most often patients with disease in this area have already received both surgery and radiotherapy. Prior to Sisson's description of the trans-sternal radical neck dissection or mediastinal dissection the management and prognosis was uniformly poor. Since then, a number of authors have reported their experience with mediastinal dissection. Survival remains poor but palliation has been acceptable. Unfortunately, resectability of the disease cannot often be determined prior to the actual surgical procedure. A number of patients are explored only to have the procedure terminated. Thoracoscopy is a procedure that involves insertion of two or three trocars into the right thoracic cavity with collapse of the right lung. A form of endoscopic surgery, it permits visualization and dissection of the important structures of the mediastinum. Tracheal, esophageal, and great vessel invasion by tumor can be evaluated., Methods: Prospectively, all patients initially seen with stomal recurrence from 1991 to 1994 were evaluated. CT scans, MRIs as well as thoracoscopy were performed when indicated., Results: One patient required conversion to a minithoracotomy involving a 7-cm chest incision. The patient was found to have unresectable disease with tumor involving the great vessels of the mediastinum. A second patient was found to have unresectable disease with tumor encasing the subclavian artery. The third patient was found to have no mediastinum involvement. The patient with no mediastinum involvement underwent a stomal resection with mediastinal dissection. Reconstruction with a pectoralis major myogenous flap was performed. The patient has remained disease free to date. The remaining two patients were judged to have unresectable disease and were offered palliative treatment. Both of these patients died of the disease within 6 months., Conclusions: Thoracoscopy provides important information in judging the surgical resectability of patients with stomal recurrence. This procedure has not been previously described in the otolaryngologic literature. We provide some suggestions for its use in the evaluation of the mediastinal extent of disease.

Laryngectomy for carcinoma of the larynx has been performed since it was first described in 1880. Since that time the complication of tracheostomal stenosis has plagued both surgeons and patients. The reported incidence of tracheostomal stenosis ranges from 4% to 42%. At West Virginia University Hospitals from 1976 to 1994, 106 patients undergoing laryngectomies on the head and neck oncology service were analyzed. The charts of patients treated before 1991 were reviewed retrospectively; a prospective analysis was initiated in 1991. Only patients with a minimum of 6 months of follow-up were included in this study. The male-to-female ratio was 3:1, with an age range of 28 to 86 years (mean, 58 years). The overall rate of stenosis was 28.4%. The incidence of tracheostomal stenosis was higher in women (46.4%) than in men (21.6%) (p < 0.05). Since 1991 a plastic type of closure was used in 25 patients. The stenosis rate was 0% in these patients. Before 1991 a bevel or circle technique was used, with stenosis rates of 33% and 75%, respectively (p < 0.05). Infection at the site of the stoma, fistula, steroid use, neck dissection, pectoralis major myocutaneous flap usage, primary tracheoesophageal puncture, and radiotherapy did not correlate with an increased incidence of stenosis. The most important factor in prevention of stomal stenosis after laryngectomy is attention to detail while forming the stoma. With good technique and a plastic-type closure to break up the suture line, a minimal rate of stenosis should be encountered.

Extrapulmonary small cell carcinomas are rare tumors of the APUD system. They are most commonly seen in the esophagus with rare cases reported in the head and neck. We present the sixth reported case of primary small cell carcinoma of the tonsil. These tumors are usually widely disseminated initially. Aggressive locoregional treatment with radiation is the treatment of choice. Systemic treatment is needed for presumed metastatic disease. Surgery may be an adjunct treatment used for locoregional control.

Background: Carcinoma of the paranasal sinuses is rare. The majority of these originate in the maxillary sinus with primary ethmoid carcinomas occurring in up to 20% of cases. Adenocarcinomas comprise up to 50% of the ethmoid malignancy. The relative rarity of tumors originating in this area has led to their inclusion in series that consist mainly of maxillary antral tumors., Methods: A retrospective chart review of all patients presenting with primary ethmoid adenocarcinoma at West Virginia University Hospitals between 1988 and 1993 was undertaken. Only patients whose epicenter was believed to be in the ethmoids were included in this analysis. CT scans, MRIs, operative notes, pathology, and final outcome were all analyzed., Results: Eight patients with primary ethmoid adenocarcinoma were treated during this time span. The male to female ratio was 1:1 with a mean age of 50 years. Symptoms had been present from 3 to 18 months (mean 8 months). All patients underwent craniofacial resection with 5 patients receiving postoperative radiotherapy. Pathologically 4 patients had cribriform plate erosion, 2 had dural involvement, and 1 had extension into the sphenoid sinus. With a mean follow-up of 45 months (9-71 months) 7 patients are disease free and 1 patient has died of disease., Conclusions: Obtaining clear margins by craniofacial resection is essential to the management of adenocarcinoma of the ethmoid sinuses. Radiotherapy is reserved for positive margins, cribriform plate penetration, dural invasion, and high-grade lesions that are close to the cribriform plate. Local control was obtained in 87% of our patients.

The number of tuberculosis (TB) cases reported in the United States has been on the decline for the last three decades. This trend has been dramatically reversed in the past few years, largely owing to the human immunodeficiency virus epidemic. Laryngeal TB, while well recognized in the adult population, is a rare disease in children. Only six cases have been described in the world literature since 1960. We describe three children with laryngeal TB who presented with stridor. One child required an emergency tracheotomy for control of the airway. The pathogenesis of laryngeal TB in children is postulated to differ from that in adults. In children primary infection of the larynx occurs, while in adults, laryngeal infection is secondary to pulmonary disease. All patients had triple anti-TB chemotherapy for 1 year. Laryngeal TB, although rare, may be seen more frequently in the near future and the diagnosis should always be considered.

Extramedullary plasmacytomas are solitary tumors consisting of neoplastic plasma cell proliferations that occur in locations other than bone. On initial presentation they must be differentiated from multiple myeloma. This may prove to be difficult because a varying percentage may be associated at a later date with the development of multiple myeloma. Solitary extramedullary plasmacytomas represent up to 4% of nonepithelial lesions of the upper respiratory tract. From 1970 to 1990, at West Virginia University Hospitals, seven patients with solitary extramedullary plasmacytoma were identified. In four of these patients the tumor was located in the head and neck, with one tumor located in each of the following sites: temporoparietal scalp, maxillary sinus, nasopharynx, and cervical region. One patient had extensive destruction of the temporal bone, with extension intracranially to the middle cranial fossa. No patient had multiple myeloma, nor did any develop. Diagnosis was based on a combination of histology along with special immunoperoxidase staining for Ig lambda and kappa light chains. This will be demonstrated and discussed. Treatment consisted of radiotherapy in three cases, with doses ranging from 3175 to 6000 rad. One patient, treated with surgical excision, experienced a relapse at a distant site 6 years later. All patients have maintained local control and have been followed for a minimum of 1 1/2 years, with an average of 3 years. We describe our experience with these tumors and present a pertinent review of the literature. While these tumors may present as aggressive locally destructive lesions, their management should be as organ-sparing as possible because excellent control can be achieved in the majority of cases.(ABSTRACT TRUNCATED AT 250 WORDS)

The management of the contralateral neck in patients with head and neck cancer who have undergone a radical neck dissection (RND) is controversial. A number of these patients will require a second RND. Sacrifice of both internal jugular veins (IJV) has been felt to lead to increased intracranial pressure (ICP) with subsequent neurologic sequelae. From 1987 to 1991 four patients had staged bilateral RNDs at the West Virginia University. In these patients a subarachnoid bolt was placed to directly monitor ICP. Jugular bulb, mean arterial, pulmonary artery, and central venous pressures were monitored. Electroencephalographic (EEG) monitoring was also performed. All patients demonstrated elevations in ICP immediately on head rotation. Further marked elevations were noted immediately after IJV ligation with a maximum peak at 30 minutes. Pressure levels of greater than 40 mm Hg were observed in three of four patients. Systemic hypertension was observed in response to elevated ICP (Cushing's reflex). All patients studied recovered from surgery without significant sequelae. Within 24 hours the ICP had returned to normal in all patients. Three patients required intraoperative intervention to lower their ICP. We demonstrate that even in a staged second RND there are significant rises in ICP. These are to a level that suggests emergency medical intervention is required. We feel that when the second IJV is sacrificed an increase in ICP should be anticipated, monitored, and treated accordingly.

Epistaxis is a common condition as well as a frequent otolaryngologic emergency, with up to 60% of people experiencing one episode in their lifetime and 6% seeking medical attention. Treatment is controversial, with many options being available. We retrospectively reviewed the hospital course and management of 65 patients who experienced epistaxis from January 1, 1986, to October 31, 1991, to compare medical and surgical treatment methods. Fifty-one patients were managed medically. Of these, 36 patients required one treatment (group 1), 10 required multiple treatments (group 2), and seven required multiple admissions (group 3). The mean lengths of hospitalization were 3.27, 4.90, and 5.57 days respectively. Fourteen patients were managed surgically. The preoperative stay of nine patients who underwent unsuccessful medical management at our institution (group 4) was 3.9 days, with an average postoperative stay of 7.3 days. The difference in length of stay was statistically significant between surgical and medical groups and the postoperative stay of group 4 was different from the length of stay of group 1 patients. The remaining five patients were initially treated elsewhere (group 5). Seventeen (33.3%) medical and only 1 (7%) surgical patients underwent unsuccessful initial therapy. Complication rates were not statistically different for each group. Transfusion requirements were evaluated as a possible predictive factor. Eighteen patients (35.3%) in the medically managed group required transfusions, compared with 11 patients (78.6%) treated surgically (p < 0.01). The medical group received an average of 0.91 units, compared to the surgical group that received 2.93 units preoperatively (p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

The craniofacial approach for resection of tumors of the nose, paranasal sinuses and orbit is well established. The operation must combine good access, sound oncologic resection, and acceptable cosmesis. Many techniques have been described that encompass all of these factors. Usually some sacrifice in cosmesis is inevitable. Most techniques also suggest removal of a plate of bone with subsequent replacement. With the removal of the tumor there is a communication between the nasal chamber and the extradural space (or brain if dura has been resected). This is usually closed with an inferiorly based pericranial flap. We have utilized a technique that hinges the bone flap laterally on the temporalis muscle. This results in the bone flap remaining vascularized. By maintaining a viable vascular bone flap this may allow for better wound healing and a decreased incidence of complications. Furthermore, we describe a technique of a contralaterally-based pericranial flap that is more extensive than the anteriorly based flaps. It may also be inset without fear of vascular compromise. Use of this technique in four patients will be described.

Over a 14-year period, from 1971 to 1985, there were 15 patients referred to the Princess Margaret Hospital in Toronto for postoperative radiotherapy to the cervical lymph nodes following radical neck surgery for metastatic cancer. An intensive investigation failed to yield a primary site in any patient. All of the patients had extensive neck disease with significant indications for postoperative radiotherapy (massive neck nodes, invasion of extra nodal structures or fixation to unresectable adjacent structures). Of this highly selected group of patients with advanced neck disease: 4/15 (27%) died within one year of uncontrolled local disease, a further 2/15 (13%) died within four years of metastatic/recurrent disease, 6/15 (33%) died of intercurrent disease and 3/15 (20%) were alive with at least four years follow-up. Although all patients presented with advanced disease, survival and significant palliation was possible in this select group of patients.

Lesions of the thoracic duct may occur either in the neck or the mediastinum. The majority of lesions that present in the neck consist of chylous fistulae and are secondary to neck surgery. Cysts of the thoracic duct are very rare and are usually reported as a disease entity of the mediastinum. There are only two reported cases in the literature of thoracic duct cysts occurring in the neck. The third case of a thoracic duct cyst located primarily in the neck is reported. Thoracic duct cysts in the neck must be differentiated from other cysts of the neck, because not recognizing the inferior attachment to the thoracic duct, may result in the disastrous consequence of a chylothorax. Diagnosis can easily be made by fine-needle aspiration with biochemical analysis. Computerized axial tomography (CAT) is useful in defining the anatomic boundaries. A weakness in the wall of the thoracic duct, either on a congenital or degenerative basis, has been postulated as the etiology. The natural history of these lesions remains unknown. Smaller lesions may be followed at routine intervals. Larger lesions should be surgically removed because of the possible complications that may ensue as a result of traumatic rupture or inflammation.

Carotid body tumors are encountered rarely and can present a difficult surgical problem. We reviewed the records of 16 patients with 19 tumors, who were entered in the Head and Neck Tumour Registry of the University of Toronto. There were no functionally secreting tumors and no patients with metastases. Most tumors were identified pre-operatively by clinical examination and angiography. However, five were found at open biopsy and required a second procedure. The mortality rate was 0 following embolization. One patient suffered a severe CNS complication and one patient a TIA. The major morbidity resulted from cranial nerve palsies in seven out of 16 patients. Recently, we have utilized a new method for resection of these highly vascular tumors that results in less blood loss and an increased ease of removal.

Ectodermally derived tissue in ectopic sites is seen in the head and neck. Extracranial dermoid and epidermoid tumors are relatively rare. While most otolaryngologists are familiar with the cholesteatoma of the otic area, not very many are exposed to this lesion in other sites. Those of the cranial bones are even rarer still. These tumors may expand (1) laterally in the cranial bones, (2) externally to present as masses in the scalp or facial region, or (3) internally to involve the intracranial contents. A patient with a frontal bone epidermoid, whose tumor had expanded in all three directions to erode both inner and outer cortex of cranium and laterally to rupture into the frontal sinus, is discussed. The literature is reviewed and the management of these rare masses is discussed.

Completion thyroidectomy is the removal of any thyroid tissue that remains after less than total thyroidectomy. At our center, completion thyroidectomy is used when, on permanent sectioning, a frozen section diagnosis is revised from benign to malignant. We reviewed our experience with completion thyroidectomy to examine its indications and complications. We found that the carcinoma was misdiagnosed in 32 of 244 (13%) of cases. Twenty-five of these were initially designated follicular adenomas. The completion proved to be no more technically difficult than a routine hemithyroidectomy. There was one case of permanent hypoparathyroidism (3%). Transient vocal cord palsy occurred in one patient (3%) and transient hypocalcemia occurred in five patients (15%). Complete recovery occurred in all six of these patients. Focal areas of residual carcinoma were found in 8 of 32 (25%) of glands removed at completion. We found completion thyroidectomy to be a safe procedure with minimal morbidity. We recommend its use in those instances of well-differentiated thyroid carcinoma in which the frozen section diagnosis differs from the permanent section.

Goitres of the thyroid gland whose major component resides substernally would appear to have a different presentation and management protocol than those goitres that reside mainly in the neck. These goitres, as opposed to their supraclavicular counterparts, usually present with symptoms referrable to compression of the trachea or esophagus. Even in those patients who are asymptomatic, a precise history may elicit pertinent findings. Furthermore, these goitres do not respond to suppression and require surgical removal. The trans-cervical approach is the most desirable, but the surgeon must be willing to enter the chest on that rare occasion. We reviewed the charts of 938 patients undergoing thyroid surgery who were registered in the Head and Neck Tumour Registry of the University of Toronto. Approximately 2.4% of patients had substernal goitres. Their history, pathology and ultimate surgical management will be discussed.