Bruce Leipzig

A prospective randomized study to determine the efficacy of steroids in treatment of croup.

We evaluated the use of dexamethasone in the management of acute laryngotracheobronchitis (croup). Thirty patients, ranging in age from eight to 60 months, were evaluated in a prospective, double-blind study. Patients received dexamethasone, 0.3 mg/kg at the time of admission and a similar dose 2 hours later, and were compared with a placebo group receiving saline. Sixteen patients received dexamethasone and 14 patients received the placebo. Severity of each group was scored by a standardized system. Patients receiving dexamethasone had a mean admission score of 8.46 points; patients receiving placebo, 8.14. Twenty-four hours after admission the patients in the treatment group had a mean score of 1.19 as contrasted with a score of 5.58 for the placebo group (P less than 0.01). We concluded that dexamethasone when administered in adequate dosage by an intramuscular route hastens the recovery of infants and children with acute uncomplicated croup.

Congenital Cerebrospinal Otorrhea

Four locations for congenital cerebrospinal fluid fistula in the region of a normal labyrinth are reviewed. A congenital leak may occur through the petromastoid canal, a wide cochlear aqueduct, Hyrtls fissure, or the facial canal. A fistula through the initial segment of the fallopian canal was successfully repaired in a two-year-old boy who had three episodes of meningitis following otitis media. Knowledge of these four sites of congenital defects provides a guideline for the surgeon in the identification and repair of cerebrospinal fluid leaks in the region of the labyrinth.

Neoglottic reconstruction following total laryngectomy. A reappraisal.

The purpose of this paper is to analyze the problems and complications which have resulted from neoglottic reconstruction at the University of Texas Medical Branch in Galveston. It has been performed as a primary procedure at the time of laryngectomy on 50 patients. Over 40 % of these patients have required a second operative procedure to control major complications of their neoglottis. Aspiration is a nearly constant feature of the procedure, and a significant number of patients do not tolerate it well. Radiation therapy does not appear to increase the number of problems, but the complications are more severe when they do occur, and they are more difficult to control. The indications for surgical neoglottic reconstruction cannot be extended beyond those tumors which are within the confines of the larynx without an increased incidence of major complications. Other relative contraindications to this surgery are poor patient pulmonary reserve, reflux esophageal incompetence, and a “hyperactive” gag reflex. Nine patients with prior treatment which included a total laryngectomy underwent secondary neoglottic reconstruction. In our experience, all have had significant aspiration. About one half of these patients developed speech. The procedure of neoglottic reconstruction must be reviewed critically prior to popular introduction into the surgical armamentarium. A plea for careful study by a small number of experienced surgeons is now in order.

Carcinoma of the anterior tongue.

We have reviewed 126 patients with squamous cell carcinoma of the anterior tongue. Our experience suggests that carcinoma of the anterior tongue is a highly aggressive disease. It is no less aggressive and dangerous than carcinoma of the posterior tongue. The clinically negative neck is a problem. Many clinical stage I and II cancers are, in fact, stage III when analyzed by the pathologist. This difficulty in clinical staging results in a significant management problem when stage III carcinomas are treated as stage I and stage II disease. Management, if it is to cure, must be aggressive. An adequate, wide surgical resection will control early carcinoma of the anterior tongue. Advanced cancers of the anterior tongue, clinical stages III and IV, should be widely excised; the cervical lymph nodes on the side of the primary lesion must be treated by surgery and radiation therapy. Treatment of the opposite side of the neck is indicated based on a high rate of metastases to contralateral lymph nodes in this series. Those patients treated with irradiation who had recurrence did so predominantly at the primary site of disease. Patients treated surgically tended to have recurrence in the regional cervical lymphatics.

Bronchoscopy in the staging and evaluation of head and neck carcinoma.

There is no consensus of opinion regarding the use of routine bronchoscopy, either rigid or flexible, to evaluate patients with primary squamous cell carcinomas of the upper aerodigestive tract for the possibility of second synchronous primary cancers. Whereas there is certainty of the effectiveness of this endoscopy in patients with questionable lesions or masses on chest radiographs, the value of this procedure in the face of a normal, unequivocal chest radiograph remains questionable. Six patients with primary carcinomas in the upper head and neck region and normal chest radiographs were among 98 patients evaluated within the past 6 months by triple endoscopy. In three instances, a small (less than 2 cm) lesion was discovered in the tracheobronchial tree, utilizing rigid diagnostic bronchoscopy. In three other patients with positive cytology from bronchial washings, a lung primary carcinoma has not been discovered. These presumed false-positive findings add a watchword of warning. The observation of these patients provides evidence to support the routine panendoscopic evaluation of all patients with squamous cell carcinomas of the head and neck. A valid study to identify subgroups at risk to develop these cancers should be encouraged.

Recurrent Massive Cystic Lymphangioma

THAT the first encounter with disease is the optimal time for its eradication is a maxim of surgical management. No disease exemplifies this more than cystic lymphangioma, a histologically benign tumor of infancy and childhood. These tumors are often poorly understood and unsuccessfully managed because of their infrequency. They can obtain new and rapid growth to massive size and infiltrate into and around muscles, vital nerves, and vessels even after long periods of quiescence.

Neoglottic Reconstruction following Total Laryngectomy: The Galveston Experience

A technique of primary neoglottic reconstruction for surgical restoration of voice following total laryngectomy is described in detail. This technique has been performed on 30 patients at the University of Texas Medical Branch, and our results are reported. Twenty (67%) of these patients are speaking with their neoglottises after one year. Indications for neoglottic reconstruction are discussed, based on a review of the problems and complications which we have experienced. Relative contraindications to the procedure are extension of tumor beyond the anatomic boundaries of the larynx, patients with poor pulmonary reserve, or those with significant esophageal reflux incompetence. Radiotherapy is not a contraindication to neoglottic reconstruction. It does predispose the patient to increased morbidity with spontaneous closure of the neoglottis, as well as aspiration, occurring occasionally. Other problems which are discussed include aspiration, postoperative wound infection, and patient compliance with the procedure. Results to date have been very encouraging, meriting further investigation of this one-stage vocal rehabilitation.

Massive Congenital Arteriovenous Malformation of the Pterygomaxillary Space

A case is presented of a massive congenital, extracranial arteriovenous malformation (AVM). The origins and hemodynamic considerations that led to prior treatment failure are discussed. A sudden accelerated growth in the AVM, caused by an alteration in the hemodynamics of the feeding and draining vessels, mandated further surgical management. The treatment of choice is complete surgical excision at the time of diagnosis, if possible. Ligation of the feeding vessels alone is unsatisfactory and, like other adjunctive treatments, may lead to disastrous complications.

Pindborg tumor of the mandible.

Calcifying epithelial odontogenic tumor, or Pindborg tumor, is the rarest of odontogenic tumors of the mandible. The tumor is distinct from ameloblastoma histologically, as well as by its less aggressive clinical behavior. Treatment must consist of complete excision—to include a rim of bone surrounding the lesion—to prevent recurrence. No instance of metastasis from this neoplasm has been reported.

Dermal Graft for Protection of the Pharyngeal Suture Line in Cancer Surgery of the Head and Neck

We studied the effect of free buried dermal grafts to primary pharyngeal closures among 24 nonirradiated patients undergoing radical head and neck surgery to determine if this technique would reduce the incidence of postoperative pharyngocutaneous fistula. For a control group we selected 23 patients who had undergone similar operations as the patients in the study group, but who did not have dermis used for pharyngeal protection. Our results indicate that dermal grafts do not alter the incidence of fistulization following cancer surgery of the head and neck.