Anthony D. Cheesman

Juvenile angiofibroma: the lessons of 20 years of modern imaging

Seventy-two patients with juvenile angiofibroma have been investigated by computerized tomography (CT) and/or magnetic resonance imaging (MRI) over a period of 20 years. The evidence from these studies indicates that angiofibroma takes origin in the pterygo-palatine fossa at the aperture of the pterygoid (vidian) canal. An important extension of the tumour is posteriorly along the pterygoid canal with invasion of the cancellous bone of the pterygoid base, and greater wing of the sphenoid (60 per cent of patients). Distinctive features of angiofibroma are the high recurrence rate, and the rapidity with which many tumours recur. It is postulated that the principal determinant of recurrence is a high tumour growth rate at the time of surgery coupled with incomplete surgical excision. The inability to remove the tumour in toto is principally due to deep invasion of the sphenoid, as described above. In this series 93 per cent of recurrences occurred with this type of tumour extension. A contributory cause in these patients is the use of pre-operative embolization. The treatment implications of these findings are examined.

Rhinocerebral mucormycosis : use of liposomal amphotericin B

Rhinocerebral mucormycosis is a rare but often fatal condition characterized by an aggressive necrotizing infection spreading from the nose to the paranasal sinuses, orbit and hence to the central nervous system. A case is reported in which a diabetic male with advanced mucormycosis was successfully treated by a combination of surgery, supportive therapy and liposomal amphotericin B. Liposomal delivery allows the drug to be both less toxic and more effective, and this is the first reported case of its use in rhinocerebral mucormycosis.

Cricothyroid Approximation and Subluxation in 21 Male-to-Female Transsexuals

Objectives: To evaluate the medium‐term outcome of cricothyroid approximation and subluxation (CTAS) with postoperative speech therapy for pitch elevation in male‐to‐female transsexuals.

Acoustical analysis of tracheoesophageal voice

Acoustical voice analysis of laryngectomees is a complicated matter because of the often weak periodicity of the voice and the high noise component. This study consists of a feasibility study and validation of an acoustical tracheoesophageal (TE) voice analysis on a sustained vowel based upon recordings of 66 laryngectomees from four clinics in three European countries. Based on reliability analysis of the acoustical data, TE voices can be objectively divided in three categories: (I) good voices with low-frequency harmonics and noise taking over at the higher frequencies; (II) moderate voices consisting of repetitive bursts of sound energy with low repetition rate and a weak periodicity due to high levels of noise, even at the low frequencies; (III) poor voices with no detectable or very weak fundamental frequency or envelope periodicity. The voice samples from category I and II correlate well with perceptually analyzed voice quality parameters, which supports the robustness and validation of this acoustical analysis method to analyze TE voices.

Autologous fibrin glue in the repair of dural defects in craniofacial resections

Cerebrospinal fluid leakage is a serious and well recognized complication of craniofacial resection for ethmoidal tumours in which the integrity of the dura has been breached. Autologous fibrin glue is a safe, inexpensive and simple method of improving the seal of dural repair and hence minizing CSF leakage. The principles and method of autologous fibrin glue preparation are described. The technique has proven satisfactory in 20 consecutive craniofacial resections with dural defects and is recommended as an adjunct to current techniques of dural repair.

Cricothyroid Approximation and Thyroid Chondroplasty: A Patient Survey

OBJECTIVE Cricothyroid approximation is performed in male-to-female transsexuals to raise the pitch of the voice often accompanied by a thyroid chondroplasty, an aesthetic reduction of the thyroid cartilage. The survey was conducted to ascertain patient satisfaction with the procedures. STUDY DESIGN AND SETTING Fifty-four patients had the procedures performed in our department over an 8-year period; 45 patients were sent postal questionnaires to evaluate patient satisfaction with the appearance of the laryngeal prominence, pitch of the voice, and which they found more beneficial, the surgery or speech therapy. RESULTS A response rate of 93% was obtained; 86% of patients thought their laryngeal profile had improved, 79% thought their voice had improved, and 55% thought that surgery and 21% thought that speech therapy had helped more in improving the voice. Overall, 79% were satisfied with the results of the surgery. CONCLUSIONS Cricothyroid approximation and thyroid chondroplasty have a high patient satisfaction rate.

Surgical Voice Restoration with the Blom-Singer Prosthesis following Laryngopharyngoesophagectomy and Pharyngogastric Anastomosis

Surgical voice restoration using the Blom-Singer technique is a well-established procedure in patients who have undergone simple laryngectomy. Operations for hypopharyngeal carcinoma are more extensive and require reconstruction using regional skin or myocutaneous flaps, or reanastomosis with colon, jejunum, or stomach. We report the use of the Blom-Singer prosthesis in four patients who had undergone pharyngogastric repair following laryngopharyngoesophagectomy and who had failed to achieve a satisfactory voice. All patients initially developed good speech using the prosthesis. Two patients subsequently had their prostheses removed: One because of recurrent malignant disease and one because the procedure had not significantly altered the quality of the voice. The remaining two patients have continued to use the device at 2 and 5 years after insertion with good voice production.

Complications of pharyngeal myotomy for alaryngeal voice rehabilitation.

Over the eight-year period to May 1991, 256 patients were referred for post-laryngectomy voice rehabilitation. Videofluoroscopy identified 81 (32 per cent) who required pharyngeal myotomy for a spastic pharyngo-oesophageal segment. Forty-two of these (37 male, 5 female and average age 63 years) had their surgery performed at this unit with a complication rate of 17 per cent and an average post-operative stay of 10 days (range 4-41 days). The place of the operation for pharyngeal myotomy in post-laryngectomy voice rehabilitation is discussed.

Brachytherapy for recurrent nasopharyngeal and nasoethmoidal tumours

Recurrent or persistent carcinoma of the nasopharynx or naso-ethmoid region occurs even after combined surgery and radical external irradiation. The confined bony access and proximity of vital structures may compromise resection margins. Brachytherapy using implantable radioactive gold or iodine seeds is a useful adjunct to the skull base surgeon in eliminating residual microscopic disease. We report nine cases with recurrent or persistent disease of the nasopharynx or naso-ethmoid regions treated with brachytherapy with encouraging results.

Enhanced Magnetic Resonance Imaging and Subtraction Techniques in the Postoperative Evaluation of Craniofacial Resection for Sinonasal Malignancy

The use of magnetic resonance imaging (MRI) enhanced with gadolinium and diethylenetriamine pentaacetic acid (DTPA) in the preoperative evaluation of sinonasal malignancy is well established and has an accuracy of over 98%. Since 1979, 208 patients have undergone craniofacial resection at Londons Institute of Laryngology & Otology, primarily for sinonasal neoplasia affecting the anterior skull base. Thirty‐five “high‐risk” patients had MRI at follow‐up. The MRI scans were assessed before the patients were examined under anesthesia.