Donald G. Sessions

Surgical pathology of cancer of the larynx and hypopharynx.

A study was designed to determine the influence of certain surgical pathologic findings on tumor spread and survival in patients with cancer of the larynx and hypopharynx. All patients with primary epidermoid carcinoma of the larynx and hypopharynx, treated by either surgery or preoperative irradiation and surgery, between 1955 and 1971 were included in the study. The patient population consisted of 791 patients all of whom were eligible for three‐year follow‐up.

Presurgical internal maxillary artery embolization in juvenile angiofibroma

Embolization of the internal maxillary artery with barium impregnated silastic spheres was performed in four patients with juvenile angiofibroma of the nasopharynx. Three of the cases were done prior to the initial surgical resection to reduce operative hemorrhage. The fourth case was a postoperative recurrence, and embolization was performed to evaluate the clinical response of the tumor. The technical aspects of the procedure, the rationale for embolization and pertinent literature are reviewed.

The anterior commissure in glottic carcinoma

The laryngeal anterior commissure is a specific anatomic area of the glottis which is often involved by cancer. Of 586 patients with glottic cancer, five (1 percent) had pure anterior commissure lesions and 175 (25 percent) had vocal cord tumors secondarily involving the anterior commissure. One of three of these anterior commissure tumors also had subglottic extension. Despite the presence of blood vessels and lymphatics in the anterior commissure, metastasis to regional lymph nodes in rare (8 percent). Patients with Stage 1 and 2 lesions were treated by hemilaryngectomy with satisfactory results (45/61 — 74 percent). Only three patients had local recurrence after hemilaryngectomy. Patients with bilateral cord‐anterior commissure lesions had the poorest survival and highest recurrence rate, even after total laryngectomy. Subglottic extension of these anterior commissure tumors did not correlate with survival. Survival and recurrence rates were conversely proportional to the stage of the tumor at presentation. Although the anterior commissure is a theoretical site for cancer breakthrough and lymphatic spread, its apparent significance lies in the fact that its involvement by glottic primaries represents only increasing tumor size and thus an advanced stage of disease.

Angiofibroma: A treatment approach

A systematic treatment approach for nasopharyngeal angiofibromas is presented. Surgery, as the primary treatment modality is advocated. Routine pre‐operative angiography is utilized for diagnosis and delineation of tumor extent. The surgical approach or approaches is dependent upon the tumor extent.

Total glossectomy for advanced carcinoma of the base of the tongue

The treatment of patients with advanced carcinoma of the base of the tongue is difficult. Selected patients with this lesion can be aided by an aggressive therapeutic approach to this problem. Combined therapy consisting of irradiation therapy followed by composite resection of the entire tongue and larynx and neck dissection may offer the best opportunity for cure or palliation in these patients. Reconstruction of the defect with a non‐delayed full forehead flap has provided a very satisfactory floor of the mouth. The postoperative functional abilities of these patients have clearly been compatible with useful life.

Surgical management of bilateral vocal cord paralysis.

Fifty‐five patients with bilateral abductor paralysis of the vocal cords were managed surgically from 1957 to 1973. Initially, unilateral arytenoidectomy or arytenoidopexy was employed. If this was not satisfactory, a contralateral arytenoidectomy was performed 6 to 12 months later. If the patients airway was still inadequate, then open unilateral submucous resection of the vocal cord was accomplished.

Embryonal rhabdomyosarcoma of the head and neck in children

The usual clinical course of children with embryonal rhabdomyosarcoma of the head and neck has been the rapid development of distant metastases and death within one year of clinical presentation. Since 1967, seven children with the diagnosis of embryonal rhabdomyosarcoma have been treated with a specific regimen of surgery, radiation therapy and chemotherapy. All five patients who presented with tumor localized to one region of the head and neck showed objective tumor response. In four patients, the tumor disappeared completely, and there has been no sign of recurrence for five and one half, three and one half, one and one half, and one half years, respectively.

Posterior tracheal laceration: A rare complication of tracheostomy.

Tracheostomy is an operation with a long history and many potential complications. Two case reports of acute posterior tracheal wall laceration, a rare complication, are presented. Although previously described as being secondary to inadvertent knife contact with the posterior tracheal wall, both of these cases are thought to be due to insertion of the tube with excessive force against tissue made friable by previous radiation. The diagnosis should be suspected if poor ventilation follows insertion of an endotracheal or tracheal tube. The offending tube should be removed and an oral endotracheal tube inserted. After treatment of any accompanying pneumothorax, the site should be evaluated under direct vision as the endotracheal tube is withdrawn proximal to the tracheotomy. If a tear is found, esophagoscopy is performed to insure the integrity of the esophagus. Repair of the tracheal wall is done with a single layer closure through the tracheotomy alternating suturing with ventilation. A generous tracheotomy, soft tubes and care in insertion of tubes into the trachea are suggested preventive measures.

Fibrosarcoma of the head and neck in children

A retrospective study of 11 children with fibrosarcoma of the head and neck is presented. Six of these tumors are well differentiated, and three are poorly differentiated. Nine patients were followed for over six years and are available for treatment evaluation. The results of treatment indicate that patients with superficially located, well differentiated tumors occurring at sites where wide surgical margins can be obtained have the most favorable prognosis.

Correction of saddle nose deformity.

Selection of the procedure for correction of saddle nose deformity should be determined by the severity of the deformity. Cartilage inlay grafts are satisfactory in the repair of minor supratip depressions. Moderate deformity of the cartilaginous septum is readily reconstructed by transposition of the upper lateral cartilages. Marked saddle nose deformity with destruction of large portions of the cartilaginous and bony nasal septum requires bone grafting procedures.