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The tools described in this article are verified to be Greco-Roman medical and surgical instruments for the eye, ear, nose, and throat. They include three myrtle leaf-shaped scalpels, three ear spoons, a "Q-tip," a forceps, a needle, and two arrow-pointed scalpels. One of the arrow-pointed scalpels is nearly identical to a Juerger keratome, suggesting that in Roman times, cataracts were extracted, not just "couched" into the posterior chamber. The description presented here goes beyond traditional archeological claims, because as a head and neck surgeon, I evaluated these instruments from a surgeon's point of view. For example, nonsurgeon medical historians have claimed the myrtle leaf-shaped items were used as handles or for blunt dissection, which I feel is mistaken. Review of the literature reveals the Greco-Roman surgeons were doing tonsillectomies, tracheotomies, and cataract extractions, and recognized that swimming in dirty water could cause ear infection. However, it is clear that with poor or no anesthesia, the pain from blunt dissection would have been intolerable, and unnecessary tissue planes would have been opened increasing wound infection risks. Therefore, there would have been no need for the myrtle leaf-shaped blade if it were just a handle. Laryngoscope, 2016 127:354-358, 2017. [ABSTRACT FROM AUTHOR]

Objective Respiratory papillomas (RP) tend to recur and the difficulty in eradicating the disease makes their treatment frustrating. Meticulous CO2 laser excisions every 2 months has been the most effective treatment to date. This article analyzes the results of this plan in 244 patients with RP in the nose, nasopharynx, pharynx, hypopharynx, larynx, trachea, lung parenchyma, and skin. Methods Two hundred forty-four patients with recurrent RP were treated by the senior author with CO2 laser excisions and, in some cases, podophyllum and alpha interferon. Demographics, initial distribution of papillomas, number of operations performed on each patient, and current results were evaluated. Results Careful laser excisions of RPs every 2 months achieved 'remission' of disease (no visible RP on indirect or often direct laryngoscopy 2 mo after last removal) in 37% of patients, 'clearance' of the disease process (no RP clinically apparent for 3 y after last removal) in 6%, and 'cure' (no clinical recurrence for 5 y after last removal) in 17%. Juvenile-onset RP tends to follow a more aggressive course than adult-onset RP. Four patients (1.6%) developed malignant transformation of their papillomas. Except for ones in lung parenchyma, RP in areas other than the true vocal cords tend to be cleared faster because aggressive removal does not cause hoarseness. Lung parenchyma RPs are eventually fatal because of pulmonary failure from abscesses and cysts resulting from a lack of effective treatment. Conclusion Frequent and meticulously performed CO2 laser excisions can achieve significant voice and airway improvement, and some clinical 'cures.' However, effective antiviral medicines and/or immunologic agents are needed to achieve true cures with elimination of all human papilloma virus 6 and 11 viruses. [ABSTRACT FROM AUTHOR]

At the University of California, San Francisco, 323 patients were treated for carcinoma of the vocal cord between January 1956 and December 1975. Patients with early T1 or T2 lesions were treated with radiotherapy or conservative surgery. Patients with T3 or T4 lesions were treated with total laryngectomy, radiation alone, or combined therapy. Of the 247 patients treated with definitive radiotherapy, initial control of the primary lesion was achieved in 100% of T1S, 80% of T1, 52% of T2, and 50% of T3 and T4 lesions. Surgical salvage of radiation failures was 86%, giving ultimate control rates in this group of 100% for T1S, 97% for T1, 91% for T2 and 64% for T3 and T4. Involvement of the anterior commissure did not significantly affect local control or survival rates of the irradiated patients. Voice quality was satisfactory in 95% of controlled patients. Surgery alone was used as the primary treatment modality in 63 patients, with ultimate local control achieved in 75% of T1S, 83% of T1, 85% of T2, 81% of T3 and T4 lesions. Planned combined therapy was successful in 9/13 patients in whom it was used. The overall 3 and 5 year actuarial survival rates were 84% and 77% respectively corresponding determinate survival rates were 90% and 86%. [ABSTRACT FROM AUTHOR]

Aspiration becomes an intractable problem for some patients who have lost normal neurological function of the glottis. Over the long term, a cuffed tracheotomy tube is inadequate. Several methods have been developed to relieve this problem surgically. These include the use of muscle flaps, tracheoesophageal anastomosis, and use of an epiglottic flap. In this paper, we discuss these previous surgical attempts to alleviate aspiration and present our own technique, which involves creation of a tracheostome and closure of the larynx at the level of the first tracheal ring. This has been used with success in three patients. we feel this technique is less complex and results in less surgical trauma to the larynx, important factors when dealing with critically ill patients. This technique is theoretically reversible by re-anastomosing the trachea to the cricoid cartilage after excising the first tracheal ring. [ABSTRACT FROM AUTHOR]

Teflon injection of paralyzed and bowed vocal cords has been performed since 1962. It has been generally accepted that nothing could be done if an excess is injected or a granuloma reaction within the cord occurs causing an early or late convex cord which projects across the midline. A technique is described to correct such convex cord problems and the results are given for 12 patients for whom corrective surgery was done. [ABSTRACT FROM AUTHOR]

Every Head and Neck surgeon has special techniques which he uses to get maximum rates of five-year survival and minimum fistula formation, especially major fistula and carotid rupture. The literature reflects a wide variation in the rate of fistula formation. We reviewed the senior author's prior 78 total laryngectomies and noted a fistula rate of 10.3% (6.4% minor fistulae and 3.9% major fistulae). We also reviewed contributing factors and discuss surgical techniques designed to minimize fistula formation. [ABSTRACT FROM AUTHOR]

To study the problem of cranial neuropathies in sinus disease the in-patient experience at the University of California, San Francisco, and San Francisco General Hospitals was reviewed. The incidence of cranial nerve involvement in acute and chronic sinus inflammations was low (8 percent and 4 percent respectively). The incidence in neoplastic disease of the sinuses was considerably higher (32 percent). Cranial neuropathies occurred in inflammatory disease more frequently when associated with mucopyocele, mucormycosis, and orbital cellulitis. In both inflammatory and neoplastic disease, when cranial nerve deficits occurred, there was a high predelication for sphenoid sinus involvement. Several instructive case histories are included. The important anatomy of the cavernous sinus region and of the orbital apex as it pertains to this problem is discussed. [ABSTRACT FROM AUTHOR]

Most cases of posterior commissure stenosis today result from endotracheal intubation. The problem has been very difficult to repair. Posterior commissure stenosis has been treated by repeated dilations, which do not work, and reconstructive measures by means of laryngofissure to excise the scar followed by the placement of round stents alone or round stents in combination with mucosal or skin grafts. This treatment also fails frequently. Some, but not all, cases have been cured with laser surgery via microdirect laryngoscopy. An endoscopically placed Teflon® keel has been useful in the treatment of posterior glottic and total glottic stenosis when laser surgery is not feasible. Nine patients with posterior glottic stenosis, two of whom initially had total glottic stenosis, have undergone placement of the posterior commissure Teflon keel. Six patients had resolution of the stenosis and were decannulated. One required an arytenoidectomy for a fixed cricoarytenoid joint before successful decannulation. Two patients had marked improvement of their laryngeal airway with this approach, but have not yet been decannulated because of fixed cricoarytenoid joints. [ABSTRACT FROM AUTHOR]

Treatment of oral leukoplakia has been disappointing with the available treatment modalities, because of inaccurate removal and an approximate 30% to 35% rate of recurrence. The CO2 laser has provided a promising new approach in the management of these lesions with very low morbidity and improved control. Twenty-nine patients were treated with the CO2 laser for 38 extensive (from 1 × 1 cm to 6 × 8 cm) intraoral leukoplakic lesions, 28 for cure and one for palliation. Microscopically the lesions varied from hyperkeratosis to carcinoma in situ. Follow-up of these patients ranges from 3 to 10 years, with an average of 5 years. An initial recurrence rate of 10.8% (4/37) was observed, and a 3-year local control rate of 97% after one to two procedures. A malignant transformation rate of 2.6% was encountered. Excellent wound healing and few complications were observed with this treatment approach. Surgical technique and results are reported supporting the advantages of the CO2 laser over conventional modes of treatment in the management of oral leukoplakia. [ABSTRACT FROM AUTHOR]

Polypoid vocal cords have routinely been treated by endoscopic vocal cord stripping, often-times resulting in prolonged hoarseness postoperatively. Submucosal CO2 laser enucleation of the polypoid tissue, with preservation of a mucosal flap on the medial edge of the cord, has proved to be a valuable improvement. The surgical procedure is described and results are presented which suggest that voice quality is better earlier than is the case after vocal cord stripping. [ABSTRACT FROM AUTHOR]

Subglottic hemangiomas in infants are rare but potentially lethal. Although the majority tend to regress after 12 to 18 months, lethal compromise of the airway is always possible until then, A plethora of treatments have been advocated for subglottic hemangiomas, each with significant morbidity. Eleven consectuve patients have undergone laser resection of subglottic hemangiomas at the University of California, San Francisco. Three infants have been managed without a tracheotomy. If a tracheotomy is required, earlier removal can be achieved with laser resection. No subglottic stenosis or hemorrhage has occurred following laser resection. CO2 laser resection is now the safest and most effective treatment available. [ABSTRACT FROM AUTHOR]

Laryngeal and tracheal stenosis have been refractory to a wide variety of treatments including dilation, stents, or have required major open operation, e.g., laryngofissure with and without skin or mucosal grafts and segmental resection with larynx release. Adequate airway even when achieved was frequently at the expense of voice quality and significant morbidity or mortality. A new highly successful endoscopic technique is described for the treatment of posterior glottic stenosis (apparent bilateral vocal cord paralysis), subglottic stenosis, and tracheal stenosis up to 1 cm thick. The procedure involves the endoscopic use of the CO2 laser, and a micro-trapdoor mucosal flap. Ninety percent of the patients in the group studied obtained an adequate airway with good voice quality and no tracheotomy was required in those patients not already having one. In 19 patients there was no mortality and essentially no morbidity. [ABSTRACT FROM AUTHOR]

For over a century spastic dysphoria - a disorder of phonation - remained enigmatic and highly resistant to treatment. Recurrent laryngeal nerve surgery provides patients with elimination of their spastic dysphonia symptoms. Maintenance of long-term surgical results has been a problem in some cases. Management of this problem and of problems in the diagnosis and treatment of patients with spastic dysphonia are discussed. The observations and conclusions are based on almost 300 patients examined and/or treated for this disorder. [ABSTRACT FROM AUTHOR]

Recurrent laryngeal nerve section for spastic dysphonia was first performed in 1975 because prior forms of treatment had failed. Virtually every patient has had a detailed postoperative follow-up which includes a tape recording and a self-assessment questionnaire. The majority of patients remain free of spasticity at this medium-term follow-up. In some, spasticity recurred with less than preoperative severity. A small percentage of patients have a persistent breathy phonation. The first group is treated with vocal fold lateralization procedure using the CO2 laser; the second, with Teflon. When needed, voice therapy is also given. This paper provides a basis for diagnosis, indications for surgery, primary and secondary surgical techniques, encountered problems, and medium-term follow-up results. [ABSTRACT FROM AUTHOR]

We have now used the procedure in 19 patients with high and mid-tracheal stenosis which measured up to 3-4 cm in length. Only one recurrent nerve was paralyzed by the surgery. Two patients with severe lung disease expired after surgery from respiratory failure. Three patients restenosed and required replacement of a tracheotomy. The remaining 14 patients have had no evidence of recurrent tracheal stenoses. [ABSTRACT FROM AUTHOR]

The problem with the Lynch operation for frontal sinus disease is the high incidence of failures (30 percent) due to the closure of the nasofrontal communication. It seems to us that the use of permanent (Dacron, described as recently as 1972) or temporary (Portex) indwelling tubes to preserve this communication is unreasonable when there is available an operation that requires no gadgets. This is the mucoperiosteal flap operation. This has several advantages over the osteoplastic flap-fat obliteration procedure. It is performed through a Killian-type incision through which surgical treatment of the ethmoid and sphenoid sinuses can also be done (not possible with the osteoplastic approach). It is less formidable and not deforming, and there is no concern about the possibility of developing secondary mucoceles. The incidence of failures is extremely low. The probable reason that it is not used more is that it is not well known. It was demonstrated by Sewall and McNaught that an operative nasofrontal duct remains open if one side is epithelized. Sewall, in 1935, described a medially based mucoperiosteal flap to provide this epithelium. He described a Lynch type approach with a Killian incision. The lateral bony wall of the nose is removed carefully to the underlying mucoperiosteum. When a large enough area of the membrane is exposed, two cuts are made vertically and one horizontally, thus forming a flap, based on the septum, that eventually will be turned up into the frontal sinus after the proper surgery on the frontal sinus, the glabella, the anterior ethmoids and posterior ethmoids and sphenoid sinus, if necessary, is done. The flap is held in place with a Portex tube which is removed in seven days. McNaught, in 1936, described a laterally based mucoperiosteal flap for use in cases with large frontal sinuses with narrow nasal vaults, and particularly those with bilateral involvement. He used Lothrop's operation for removing the interfrontal septum, all the nasal portion of the floor of both frontal sinuses, and the upper part of the anterior portion of the bony nasal septum, thus making a large opening into the nose. The opening is lined unilaterally or bilaterally with mucoperiosteal flaps based from the mucosa under the nasal process of the maxilla and cut from the nasal septum and then turned into the frontal sinus over the periosteum of the orbit after the frontoethmoidal surgery has been completed. We believe that the mucoperiosteal flap operation is the best available for external surgery of the frontal sinus. The exception is in the large osteoma for which the osteoplastic flap operation is better. [ABSTRACT FROM AUTHOR]