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Stenosis of the larynx and/or trachea presents perplexing problems. No one technique has proved totally satisfactory in the management of all varieties of stenosis. Recent reports have described the successful use of the CO2 laser in the endoscopic management of stenosis of the larynx and trachea. Failures of this technique need emphasis to assure appropriate selection of therapeutic method. Retrospectively, 49 cases of laryngeal stenosis, 6 cases of tracheal stenosis and 5 cases of combined laryngeal and tracheal stenosis were studied (total 60 patients) following treatment at the Boston University Affiliated Hospitals. Follow-up ranged from 1 to 8 years. Multiple procedures were required in 35 laryngeal patients. Of the laryngeal patients 39 were successfully managed (average number of procedures in successful cases 2.18). Of 11 tracheal patients with combined laryngeal and tracheal procedures, 3 were successfully managed (average number of procedures in successful cases 6). Failures in laryngeal stenosis included four patients in whom an adequate airway was not established though voice was present while maintaining tracheostomies. Thirteen patients failing endoscopic management required open surgery with good result. Factors associated with poor result or failure include circumferential scarring with cicatricial contracture, scarring wider than 1 cm in vertical dimension, tracheomalacia and loss of cartilage, previous history of severe bacterial infection associated with tracheostomy, and posterior laryngeal inlet scarring with arytenoid fixation. In these circumstances, multiple procedures, more extensive alternative open surgical techniques, or maintenance of tracheostomy were necessary. In successful cases only three or fewer procedures on average were required. The factors associated with failure or success of endoscopic methods in the management of laryngotracheal stenosis, including use of the CO2 laser and soft Silastic stents, are analyzed.

The carbon dioxide laser has been found to be a useful surgical adjuvant in our efforts to treat carcinoma and benign tumors of the head and neck. It has been of help in establishing the proper staging, in diagnosing recurrence after radiation therapy, in re-establishing the airway blocked by tumor, and in reducing tumor mass prior to definitive therapy. It provides a simple method of excision for curative therapy. All of this is accomplished with minimal morbidity. Most patients can return home on the first postoperative day. They can eat, have a serviceable voice, and require no tracheotomy or analgesics, all of which provide a significant cost benefit.

A reliable sliding chest wall flap, allowing extensive resection of tumors invading the anterior cervical skin is described. There has been no instance of failure or significant complication in the use of this flap in this small series of cases presented. It is believed that its use has allowed more extensive resection of tumor without any increase in morbidity, and may account for the prolonged survival seen in four out of six patients.

Biopsy specimens of “normal” mucous membrane of patients susceptible to the effects of the carcinogens of tobacco revealed morphologic abnormalities on electron microscopic examination that were consistent with the concept that carcinogenesis is a multistep process of sequential neoplastic development extending over a long period of time. Such changes in the upper aerodigestive tract are probably tobacco induced and may be reversible if tobacco exposure is eliminated. Use of the electron microscope can provide the clinician with an accurate assay of the severity of mucosal alterations induced by tobacco. The ability to detect such morphologic abnormalities should provide another deterrant to smoking and a useful tool in the further study of these phenomena.

Orbital pseudotumor is believed to be a nonspecific, acute or chronic inflammatory process involving the intraorbital soft tissue. Orbital pseudotumor may masquerade as sinusitis with orbital complications or as a severe upper respiratory tract infection. Five cases are presented to illustrate the difficulties in diagnosis when initial symptoms relate to the upper respiratory system rather than to an isolated orbital mass. In these cases, orbital ultrasound and computed tomograms were helpful in making the diagnosis. Treatment consisted of systemic corticosteroids in four of the five patients. Recognition of early symptoms and findings, along with earlier involvement with the ophthalmologist, will make a more effective treatment regimen possible.

Endoscopic treatment of early carcinoma of the larynx is curative, the cure rates in our experience being equal to those achieved by radiation therapy and by laryngofissure. It is highly cost effective in terms of money and of patient out-of-work time. It can be used repeatedly and does not interfere with future treatments. It is our method of choice.

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

Keratosis, atypia, carcinoma in situ, and microinvasive cancer occurring as white or red patches on the vocal cords are part of the diathesis of cancer of the aerodigestive tract and represented a sequential continuum. Excisional biopsy is the preferred treatment for identification and potential cure of the lesion. If the margins of excision are inadequate, further treatment options are either reexcision or radiotherapy. Radiotherapy should be used only when the need for voice conservation prevails. Cessation of smoking does not remove the potential for progression of the disease, therefore, all patients must be followed indefinitely. Excisional biopsy of keratosis, carcinoma in situ, and microinvasive cancer of the larynx offers an excellent prognosis for voice preservation and survival.

The CO2 laser has been found to be a useful adjunct in our efforts to treat laryngeal carcinoma. Utilized endoscopically, it has been of help in establishing the proper staging, in diagnosing recurrence after radiation therapy, in reestablishing airways blocked with tumor, in debulking tumor mass prior to radiation and/or chemotherapy, and as a primary mode of excisional therapy, all accomplished with minimal morbidity. Most patients may return home the first postoperative day, eating, with serviceable voice, and requiring no tracheotomy or analgesics, all of which provide a significant cost benefit.

1. 1. Carcinoma of the palatine arch is part of a regional diathesis of carcinoma of the mucosa of the upper aerodigestive tract and this concept has a definite influence on the choice of treatment. 2. 2. Surgery has an important role in the management of both the primary tumors and the regional metastatic nodes. 3. 3. Radiation therapy is indispensible in the management of carcinoma of the tonsillar crypts, stage IV tumors of the palatine arch, and primary tumors of the palatine arch with certain specific extensions. 4. 4. Comprehensive management of carcinoma of the palatine arch requires careful evaluation of each patient and his disease, vigorous application of the chosen method of treatment by either the surgeon or the radiotherapist, and continuous follow-up study and supportive treatment for the rest of the patient's life.

Transoral excisional biopsy has been used in the evaluation and management of 103 T1 glottic cancers. A 3-year follow-up on these patients indicates that excisional biopsy unequivocally established the diagnosis and stage of the disease and that it is adequate treatment for micro and mini squamous cell cancers of the glottis in which the margins of excision are clear. Excisional biopsy with positive margins and larger T1 tumors establishes the absolute need for radiotherapy. Excisional biopsy is ideal for the diagnosis and management of verrucous carcinoma and spindle cell carcinoma. Recurrent/residual squamous cell carcinoma after radiotherapy should be explored by excisional biopsy which may be curative or will establish the need for partial or total laryngectomy. The appropriate use of excisional biopsy in the selective management of early T1 glottic cancers requires attention to detail by the surgeon and the pathologist and sound clinical judgment.

The sequence of histological change induced by CO2 laser irradiation was discussed in terms of two factors: the physiomechanical factor and the physiochemical factor. At sufficiently high heat energy levels, the immediate findings are characterized by crater formation resulting from rapid vaporization of the water and ejection of the solid component. In the immediate vicinity of the crater edge, the maximum tissue temperature rise is 65 degrees C above the 32 degrees C ambient tissue temperature and it decreases to the primary tissue temperature within a distance of 2 mm. The healing process of CO2 laser induced lesions proceeds with minimal delay. The lymphatic and vascular channels are occluded in the marginal area of coagulation resulting in a marked hemostatic effect. This sealing effect increases the margin of safety in preventing possible dissemination of tumor cells. By selecting the appropriate power, time, and focus cone angle, precise destruction of preselected areas of tissue can be achieved with an extraordinary hemostatic effect without damaging the underlying tissue. These advantages are especially helpful in function-preserving surgery.

The patient in whom laryngoscopy is difficult, calls for the placement of the patient's head in the optimum (Boyce) position prior to insertion of the laryngoscope. A new suspension gallows has been developed which provides for suspension of the laryngoscope with the patient in the Boyce position; this ensemble maintains stability of the laryngoscope, minimizes pressure on the maxilla and gives the best possible view of the anterior commissure.

The carbon dioxide and neodymium:yttrium aluminum garnet lasers have well documented but characteristically different biological effects, yet little is known about their cumulative, synergistic, or paradoxical effects when used sequentially on living tissue. Using a Merrimack ML 880 laser, a series of superimposed CO2 and Nd:YAG lesions in various combinations were produced on the undersurface of dog tongues. Therapeutic time and power settings were chosen and the number of applications varied, with suitable controls. Observations and measurements were made on acute, healing, and healed lesions. All lesions were excised and submitted for routine hematoxylin and eosin histology. Acute lesions were also assessed for cell viability using rhodamine 123 as a supravital marker. The results show that, even though all the lesions eventually heal, the actual cell damage produced by the Nd:YAG laser is much more than is suggested by the size of the acute lesion. This cell damage can be reduced by the surface carbonization produced by initial application of the CO2 laser. Higher surface temperatures are reached in this combination with less fibrosis and scarring than equal energy counterparts where the Nd:YAG laser was applied first. The knowledge of these synergistic effects can be used to advantage in the clinical setting. The rhodamine 123 technique also appears to be a valid measure of acute thermal tissue injury.

Eleven patients with unresectable or marginally resectable (stage III and IV) cancer of the head and neck were treated according to protocol with preoperative chemotherapy, surgical resection, and postoperative radiotherapy. Chemotherapy consisted of a combination of cis-diamminedichloroplatinum (II) (cis-DDP), 120 mg/M2, and bleomycin, 15 mg/M2, given sequentially during a three week treatment period. Seven patients initially had unresectable lesions which became amenable to surgical resection after chemotherapy. All eleven patients had approximately a 25 to 100 per cent reduction in tumor size. Histopathologic examination after chemotherapy showed a marked tendency towards cellular differentiation and keratin formation. Tumor necrosis was conspicuous by its absence. These histologic changes appear to be different from those seen after the use of other chemotherapeutic agents and radiotherapy. The histopathologic results closely resemble those found after the administration of bleomycin alone, although considerably accentuated.

The conventional management of certain problems in otolaryngology has been either inconvenient or ineffective. 110 cases have been treated with the continuous wave CO2 Laser in an attempt to identify the advantages and limiations of laser surgery. It has been found that the CO2 laser provides a practical method of tissue ablation or excision which can be carried out with excellent control. The laser beam is directed with a hand piece in the oral cavity, with the surgical microscopic laser attachment in the nose, pharynx and larynx and with the endoscope-bronchoscope assembly in the tracheo-broncial tree. Laser surgery appears to be most valuable when precise surgery is needed to preserve function.

Relapse patterns in patients with locally advanced head and neck cancer who achieved complete remission were evaluated. After combined modality therapy with induction chemotherapy followed by surgery and/or radiotherapy, 71 of 103 patients were clinically free of disease. The 5-year recurrence rate was estimated at 51%, with a 39% local and 26% distant failure rate by 5 years. The factors significantly affecting the relapse patterns were: the site of the primary tumor (those with oral cavity lesions were more likely to fail locally, whereas hypopharynx patients had a higher risk of distant metastases); the type of definitive local treatment (those patients who received surgery and radiotherapy were at lower risk of pure local failure); TN Stage (patients with T4N3 or T3N3 tumor were at higher risk of both local and distant failure); and time to response and presence of oropharyngeal lesions (patients who had a longer period from diagnosis to final complete response [CR] and patients with oropharyngeal primaries were at higher risk for simultaneous local and distant failure). Type of chemotherapy, patient age, tumor differentiation, and response to induction chemotherapy did not significantly influence the patterns of relapse. A combined modality approach with induction chemotherapy, surgery, and/or radiotherapy does not seem to reduce the incidence of distant metastases significantly.

Forty patients with advanced head and neck cancer were treated with combined Cis-platinum-Bleomycin chemotherapy. Cis-diammine dichloroplatinum (DDP) 120 mg/m2 iv was given after prehydration, with mannitol diuresis on Day 1. On Day 3, an initial loading dose of Bleomycin 15 mg/m2 was given by rapid iv push followed by continuous 24 hour intravenous infusion of Bleomycin 15 mg/m2 Day 3 through Day 10. DDP 120 mg/m2 iv was administered again on Day 22. The patients were evaluated for tumor response and resectability between Day 29 to Day 35. Of 39 patients who were evaluable, there were 8 complete responses or CR (20%) and 22 partial responses or PR (56%), for a major response rate of 76%. Nineteen patients had surgery (14 patients whose lesions were initially inoperable and 5 patients who were initially operable). Chemotherapy toxicity in 40 patients included alopecia (40), vomiting (39), mucositis (11), skin rash (10), fever (17), weight loss of more than 5 lbs. (25), WBC less than 3,000 (2), platelets less than 100,000 (1), peak serum creatinine of 2 mg% (3), severe-hearing loss (1), hypersensitivity reaction (2). Surgical complication in 19 patients were pharyngocutaneous fistulae (2), wound dehiscence (1), meningitis and brain abscess (1). There was one death secondary to nephrotoxicity. This particular combination chemotherapy when given as initial treatment, appears very effective in reduction of tumor bulk. Long-term follow-up and randomization is necessary to determine effect upon survival.

Seven cases of localized amyloidosis limited to structures of the head and neck and upper aerodigestive and lower respiratory tracts evaluated and treated at Boston University Hospitals in a recent 7-year period were reviewed. Negative Congo red staining of abdominal adipose aspiration biopsy or rectal biopsy specimens established that the amyloidosis was not systemic. Localized amyloidosis occurred in discrete masses in a variety of sites in the aerodigestive tract including the orbit, nasopharynx, lips, floor of mouth, tongue, larynx, and tracheobronchial tree. Five patients required surgical excision because of significant airway obstruction or organic dysfunction. Amyloid deposits completely excised with the carbon dioxide laser have not recurred, though other amyloid masses may appear elsewhere within the same organ or region. Amyloidosis may occur primarily or secondarily to other disease states. Localized amyloidosis has not been chemically identified but is usually defined by the absence of systemic features. While rare, amyloidosis must be recognized and understood by the otolaryngologist head and neck surgeon to allow appropriate diagnostic and therapeutic planning.

Subglottic stenosis secondary to endotracheal intubation is a distinct clinical entity. Prolonged intubation is an important causative factor, but even short-term endotracheal intubation with too large a tube can damage the cricoid sufficient to cause delayed subglottic stenosis. After studying cricoid size and other factors in 130 adult laryngectomy and autopsy specimens, the following conclusions were reached: (1) The subglottic cricoid is the smallest, fixed cross section in the upper airway. (2) Even if height is comparable, women have smaller cricoid diameters than men. (3) Height is the best predictor of cricoid size. (4) Weight and race are not accurate predictors. (5) Third finger length and cricoid size correlate well, particularly in men. (6) Thus height and third finger length can be used to choose the proper endotracheal tube for adults.

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

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

Recurrent respiratory papillomatosis is most common in childhood but it affects all age groups; it represents a diathesis of the aerodigestive tract so that lesions may develop at various sites — the nares, lips, pharynx, nasopharynx, larynx, tracheobronchial tree, and the lungs. Ablation of all visible papillomas with the surgical laser achieved remissions in approximately one-third of patients for one year or more; since relapses may occasionally occur 2 to 20 years later, cure can never be assumed. At the present time, management is directed towards total ablation of all visible papilloma consistent with preservation of the airway and voice; reduction of the tumor burden to minimal proportions is thought to allow the maximum opportunity for remission. As the host-papilloma relationship is unraveled, it may be possible in the future to provoke an immune response so that remissions can be predicted and produced consistently.

The cytologic findings in 107 aspiration smears obtained with the fine needle technique from head and neck masses were compared with the histologic findings in permanent sections. The overall concurrence rate between cytologic and histologic findings in benign and malignant tumors was 82.2 per cent. There was a 5.6 per cent incidence of false negative findings. There were no false positive results. Fine needle aspiration was found to be safe, complication free, and most helpful in planning treatment. We recommend the technique to others who deal with head and neck masses.

Endotracheal and endobronchial carbon dioxide laser surgery can be carried out using standard ventilating bronchoscopes, a recently developed laser endoscope attachment and a 50W CO2 surgical laser unit. General anesthesia, using nonflammable anesthetics, is delivered through the side arm of the ventilating bronchoscope; the tidal flow of gases keeps the trachea and bronchi free of steam and smoke. The technique has been particularly helpful in the bloodless removal of recurrent papillomas from the trachea and main stem bronchi of ten children with tracheostomies. While three of the patients have gone into remission following laser excision, the method cannot be curative of itself. There were no complications attributable to the carbon dioxide laser surgery, per se, but constant vigilance must be exercised as with all laser surgery. As instrumentation becomes refined the technique will have wider application in the management of tracheobronchial disease.

In the larynx it is frequently difficult to identify carcinoma in situ, early infiltrating carcinoma, and the exact margins of an established carcinoma. It has been found that the use of toluidine blue as a supravital stain during direct laryngoscopy is a reliable adjunct to the early and precise diagnosis of carcinoma of the larynx.

Bleeding can be minimized during general endotracheal anesthesia for mastoid-tympanoplasty surgery by a satisfactory anesthesia, normal spontaneous ventilation without expiratory or inspiratory obstruction, proper positioning of the patient, and controlled hypotension at 95 systolic blood pressure with oxygen 6 liters/min. and halothane 1.5-2 percent. Trimethaphan 0.1 percent may be added. The degree of hypotension is controlled by the depth of anesthesia with halothane, positioning, and if it is required, titration with trimethaphan. Controlled mild hypotension with halothane facilitates mastoid-tympanoplasty surgery. It has been used in more than 300 patients, with ages ranging from six to 72 years. The results have been highly successful and satisfactory. There was no morbidity or mortality related either directly or indirectly to the use of this technique.

• Ten patients with advanced or recurrent squamous cell carcinomas of the upper airway were treated with a combination of carbon dioxide laser surgery and radiation therapy to evaluate the tolerance to rapid sequencing of both modalities in a variety of clinical situations. Other considerations were to accurately stage infiltrating tumors, to provide cytoreduction for T3 and T4 tumors, and to facilitate the optimal placement of intracavitary radium applicators. Because of minimal postoperative pain or dysfunction associated with the laser, patients were able to receive irradiation considerably sooner than with conventional surgery. Local tolerance was good to excellent in seven of the ten patients treated and, based on preliminary results, the combination would appear to offer advantages in curative approaches to advanced head and neck tumors. ( Arch Otolaryngol 1983;109:240-242)

Introduction OCCULUSION OF THE external auditory canal may be due to a variety of causes ranging from foreign bodies to carcinoma. In the New England area exostoses of the canal are of common occurrence and occasionally cause complete occlusion so that surgery becomes necessary. Bony tumors, primarily found in the external canal (excluding exostoses), are rare. We are presenting a case of monostotic fibrous dysplasia involving only the temporal bone. Review of the literature reveals only two cases previously reported.14,15 Review of Fibrous Dysplasia Theterm fibrous dysplasiawas coined by Lichtenstein.9The entity has been recognized and described under other names:osteodystrophy fibrosa, osteitis fibrosa disseminata,andleontiasis ossea.1,2,8,11,5Polyostotic and monostotic lesions differ only in the fact that the former may include other extraskeletal lesions; for example, pigmentation, precocious puberty, cardiovascular anomalies, endocrine dysfunctions, besides involving more bones than one.10Harris has published an

The CO2 surgical laser and microscope assembly have been used to excise carefully selected T1 carcinomas of the membranous portions of the cord. Healing has been prompt and return of function satisfactory. General anesthesia and suspension laryngoscopy have provided excellent definitions of the lesions; the laser has provided a precise method of dissection. Initial results have been excellent and long term results will depend on the accuracy with which the margins of the tumor are defined and the presence or absence of the tendency of the larynx to produce multicentric disease.

Tracheal or endobronchial metastases from distant primary malignancies are rare. Hemoptysis, dyspnea and cough are common nonspecific presenting symptoms. Renal, breast, thyroid and colon cancers are the most common malignancies associated with tracheobronchial metastases. Since 1979, five patients with tracheobronchial metastases from distant sites have been treated by the otolaryngology service at the Boston University Medical Center. Patients with advanced tumors previously treated by conventional modalities were referred for palliation of airway obstruction. Satisfactory palliation without significant morbidity was achieved in four out of five patients utilizing a CO2 surgical laser through a rigid bronchoscope system. Four patients died from advanced cancer, 1 to 18 months after laser surgery. Although tracheobronchial metastasis from extrathoracic malignancy is associated with a poor prognosis, palliation of airway obstruction can be achieved in most patients with endobronchial or tracheal tumor.

We undertook a study of 13-cis-retinoic acid to evaluate its use as an adjuvant to laser surgery in the management of recurrent respiratory papillomatosis. In a double-blind study using placebo, four of the six subjects treated with this agent experienced recurrence while receiving therapy, with two requiring further surgical intervention. All six experienced toxicity, necessitating the withdrawal from therapy of two and dose reduction in three. When it became apparent that the therapy was ineffective, and caused toxicity, the study was closed.

• Seven patients had occult malignant neoplasms either originating in or extending to the infratemporal fossa. Common symptoms were facial pain centered over the temporomandibular joint and facial numbness. These symptoms were sometimes associated with middle ear effusion and trismus. Multiple biopsies are often necessary to establish the diagnosis. The average delay in diagnosis from first symptom was 14 months. Infratemporal fossa neoplasia belongs in the differential diagnosis of facial pain. ( Arch Otolaryngol 102:535-538, 1976)

Congenital and acquired lesions of the pediatric airway present difficulties in management. Until recently, correction of these problems frequently involved an external approach to the larynx and trachea. Development of fiberoptic instrumentation, as well as the introduction of the Zeiss operating microscope, has now given the surgeon a new means to visualize the larynx and trachea. Soon after its development, the carbon dioxide surgical laser was coupled to these instruments to permit an extremely precise form of tissue excision and ablation. Its unique properties, including an extraordinary hemostatic effect, as well as minimal postoperative adema and scarring, make it an ideal tool for management of lesions of the pediatric airway. It has been employed successfully in the treatment of 177 lesions.

1. 1. Approximately 40,000 cases of cancer of the head and neck (excluding skin) are diagnosed each year. 2. 2. Approximately 20,000 of these cases and 30,000 cases of skin cancer are treated by 366 head and neck cancer surgeons. 3. 3. Ninety per cent of the cases are treated by 63 per cent of the surgeons. 4. 4. Fifty-eight per cent of the surgeons care for between 50 and 300 cases per year. 5. 5. While 2,759 new board-certified surgeons of all specialties are recruited annually to maintain a work force of 46,000 board-certified surgeons [ 3 ], apparently 730 potential head and neck cancer surgeons are being prepared to maintain a work force of approximately 450 head and neck cancer surgeons. 6. 6. These findings indicate the need for in-depth study of the manpower needs in head and neck cancer surgery by all who are responsible for the training of surgeons in this field.

A complete response to induction cis-platinum bleomycin chemotherapy significantly increases the probability of local tumor control and overall disease-free survival. Factors that favor a good response to chemotherapy are tumor histology (well differentiated), location of the primary site (oral cavity and oropharynx), nodal status (N 0 ) and size of the primary lesion (T 3 better than T 4 ). Increased cellular maturation after chemotherapy correlates with an improved clinical response. The importance of induction and maintenance chemotherapy in the treatment of advanced head and neck cancer still needs to be determined with larger randomized series. Reliable predictors of therapy outcome are needed for realistic treatment planning, especially when the potential morbidity is considered.

• In a series of 51 cases of stage IV head and neck carcinomas, 12 selected patients were studied retrospectively, in order to determine the role of surgery in their management. Two patients who received a tumoricidal dose of radiation prior to radical neck dissection survived over five years, but no viable tumor was found in either specimen, suggesting a radiation cure. Nine patients died within three years, with either local recurrence or distant metastases; one patient died of asphyxiation, without disease, within five months. It appeared that surgery played no substantial role in improving the survival of the patients with head and neck cancer with fixed nodes. (Arch Otolaryngol101:645-648, 1975)

• We report here a case of an endotracheal tube fire occurring during carbon dioxide (CO 2 ) laser surgery in the path of gases that support combustion. The tube was thought to be ignited by flaming tissue in close proximity to the tip and not directly by the laser. Tubes 1 cm away from an object repeatedly hit by the laser can easily be ignited indirectly. Aluminum-tape wrapping does not prevent this complication. We recommend caution when using the CO 2 laser in the path of combustible gases in the presence of flammable objects. ( Arch Otolaryngol 106:639-641, 1980)

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

In an effort to design a fireproof and reliable method of ventilation during CO2 laser laryngoscopies, a new Venturi jet endotracheal tube coupler has been designed. This allows microdirect laryngoscopy. Its design features are described. Sixteen clinical cases of various laryngeal pathologies treated with direct laryngoscopy and laser excision are ventilated using this system. The clinical data and experiences are discussed. The arterial blood gases done at 20 minutes after muscular paralysis showed a median value of pH 7.45/PO2 252/PCO2 36. No complications or adverse effects were noted. The Venturi jet endotracheal tube coupler allows for jet ventilation through a metal endotracheal tube with reliable ventilation. This is an alternate, reliable, and fire-safe method during laser use.

The purpose of this paper was to investigate the immediate effects of CO2 laser radiation on soft tissue. The morphological changes were studied with gross observations, light microscopy, scanning electron microscopy and were related to the results of thermal measurements . The events which take place during the irradiation were viewed with ultra high speed photography. Air-borne tisssue particles were investigated with cytosmear test and tissue culture. Based upon the various observations, the following conclusions were drawn. The immediate effects of CO2 laser irradiation consit of two factors : physio-mechanical factor and physio-chemical factor. And the nature of the laser injury, in soft tissue, make laser surgery a practical and satisfactory method of controlled tissue removal.

One hundred patients with stage II and stage III cancer of the oropharynx and hypopharynx were treated under a protocol in which they were randomly selected for treatment by surgery alone or by combined preoperative radiotherapy and surgery. The schedule of preoperative radiation therapy chosen was 2,000 rads from a cobalt 60 machine delivered in five days. Eighty-six of the patients were evaluable at three years; there was no difference in the outcome of the treatment of the two groups. A similar study is urgently needed to determine the value of postoperative radiotherapy in the management of similar cancers.

Summary The conventional management of certain problems in the aerodigestive tract has been either inconvenient or ineffective. Seventy-five cases have been treated with the continuous wave CO 2 laser in an attempt to identify the advantages and limitations of laser surgery. It has been found that the CO 2 laser provides a practical method of tissue ablation or excision which can be carried out with excellent control. The laser beam is directed with a handpiece in the oral cavity, with the surgical microscopic laser attachment in the nose, pharynx, and larynx, and with the endoscope-bronchoscope assembly in the tracheobronchial tree. Laser surgery appears to be most valuable when precise surgery is needed to preserve function.