G. David Neal

Cisplatin and 5-fluorouracil chemotherapy in advanced or recurrent squamous cell carcinoma of the head and neck

Fifty‐three patients with advanced or recurrent squamous cell carcinoma of the head and neck (SCCHN) were treated with bolus cisplatin (CDDP) and 96‐hour infusion of 5‐fluorouracil (5‐FU). Twenty‐six patients with advanced disease (21 T4 and/or N3) and no prior therapy (NPT) received 2 to 3 cycles of chemotherapy prior to surgery and/or radiation. There were four complete responses (CR) and 12 partial responses (PR) to chemotherapy for an overall response rate of 61%. In 20 patients with locally recurrent or disseminated disease there was one CR and six PR for an overall response rate of 35%. All but one responding patient in both groups showed clear evidence of tumor response after the initial cycle of chemotherapy. Two of the five complete responders required at least three courses to achieve CR. Disease‐free survival was poor: only five of 26 patients in the NPT group remain alive and free of disease 8 to 28 months from initial therapy. CDDP and 5‐FU is an active combination for SCCHN, but survival benefit remains to be proven.

Contractile properties of laryngeal muscles in young and old baboons

Aging is associated with changes in voice and/or laryngeal protective reflexes in humans. To assess the role of the laryngeal muscles in this change, we have examined in vitro thyroarytenoid (vocalis) muscles excised from the larynxes of young and old baboons. Contractile properties, fatigue characteristics, and resting oxygen consumption of these muscles were measured. The results indicate that the thyroarytenoid muscle of the baboon is a fast muscle that is resistant to fatigue. The thyroarytenoid muscles of older baboons contracted more slowly and recovered less rapidly from fatigue induced by prolonged contractions but developed more maximum active tension than thyroarytenoid muscles of young adult baboons. These small differences in the characteristics of thyroarytenoid muscle of older baboons are probably not sufficient to explain observed changes in laryngeal function in the elderly. The results suggest that changes in neural pathways and/or morphology of the larynx may play a larger role in the altered laryngeal function with age.

Book Review: Physiology of the EarPhysiology of the Ear edited by JohnA.E. and Santos-SacchiJ.. 518 pages. Raven Press, New York, 1988.

Drawing on the very extensive material source gathered over the last twenty years from 1500 operations on the skull base at the University of Zurich, the principal author, Professor Ugo Fisch, is at pains to explain that while this type of surgery will always be formidable, the atlas he presents is intended to provide detail to assist any surgeon interested and prepared to develop the expertise needed. His co-author, Douglas Mattox, Associate Professor of Head and Neck Surgery at Johns Hopkins Hospital in Baltimore, helped edit the material during a year spent with Dr. Fisch in 1985. He kept the momentum needed to get a volume of this size, with all its technical detail, to the stage of publication. The book is systematically laid out. A chapter is devoted to analyzing each of eight surgical procedures. Starting with a discussion of rationale and indications, it goes on to surgical technique, tips, and pitfalls. The ninth chapter, contributed by Dr. Ulrich Aeppli, who was responsible for the anaesthesia of almost all of the cases, concerns his part in the surgical team and the lessons to be learned. The final chapter has been contributed by Professor Anton Valvanis, neuroradiologist at the University Hospital in Zurich. While necessarily brief because of the mass of radiographs appearing in the earlier chapters, this section provides clear descriptions of angiography, embolization techniques, and balloon occlusion of the internal carotid artery. The text hinges around the beautiful illustrations. A particularly valuable feature is the relating of the color photographs taken during surgery, cross-referenced to line drawings so that anatomic orientation is maintained. In each chapter dealing with a specific operative procedure (subtotal petrosectomy; transotic approach; infratemporal fossa type A, B, and C , transtemporal supralabyrinthine approach; translabyrinthine approach; and petrosectomy and radical dissection of the retromandibular fossa), the “Surgical Anatomy” and the “Surgical Technique” are described in great detail. These sections form a unique manual for those planning or undertaking temporal bone dissection courses. In the first chapter, which covers the general topic of subtotal petrosectomy, the authors go into the detail of preparation for an operation generally. Instruments are listed, including the choice of magnifying loupes, microscopes, drills, coagulators, fibrin glue kits, and dressings. Whether the loupe or the microscope is recommended for a particular stage of the operation is noted. facial nerve repair, grafting, and re-routing, as well as descriptions of the ‘donor sites’ for the harvesting of suitable nerve grafts. Also in this first chapter is an extremely valuable section dealing with the selection of the surgical approach most appropriate for a particular lesion, including cholesteatoma. Subsequent chapters add to the above information, according to the subject being dealt with. Thus, in Chapter 2 , the Cavitron Ultrasonic tumor aspirator is included in the description of instruments used to debulk an acoustic neuroma. Chapters 3, 4, and 5 amply demonstrate Professor Fisch’s disciplined approach to large glomus tumors in the region of the skull base, and the skill needed to piece together diagnostic information from preoperative axial and coronal CT and angiography. Discussing his philosophy in regard to persisting vertigo after unsuccessful medical management, Dr. Fisch obviously has been unimpressed with endolymphatic sac decompression. Although he does not ignore it completely, he will only consider it “if the hearing is normal between attacks and the dizziness is mild.” He puts his faith in vestibular neurectomy, and accepts a 3% incidence of worsened hearing. For vestibular neurectomy he favors an approach to the internal auditory meatus from above, via the middle fossa rather than retrolabyrinthine or retrosigmoid. He considers that these posterior fossa approaches carry an increased risk of severe CSF leaks, meningitis, headache, and permanent facial palsy. Moreover, the approach he advocates from above is to the eighth nerve, where there is already a natural separation into cochlear and vestibular entities. Expertise gained in the superior approach adds to the surgeon’s ability to handle facial nerve complications. With the nerve both proximal and distal to the geniculate ganglion, thus exposed it is rational to use electromyography to help localize the size at which neural transmission is blocked. This monumental textbook deserves the highest praise.

99.00.

These properties of speech are related to the important factors of hearing loss (attenuation and distortion). The next chapters consider the epidemiology of hearing loss in the United Kingdom and the pathophysiology of the cochlea. The chapter on assessment of hearing briefly discusses all the standard tests. Discussions of frequency resolution, intensity coding, and temporal analysis are interesting, but again the reader needs some background; for instance, psychophysical tuning curves are described in two paragraphs. The same chapter presents the objective measurement of hearing (tympanometry and brain stem audiometry). I found the chapter on audiovisual speech perception both readable and informative. It discusses lipreading of both consonants and vowels, the complementary nature of audio and visual information, and the relative merits of “top-down’’ vs. “bottom-up” constraints in models of speech perception. Another chapter is devoted to speech production in postlingual deafness. It is generally assumed that the postlingually deaf retain their speech with little degeneration; however, this is not always the case, and the author presents an hypothesis to explain the degeneration. The last two chapters are devoted to hearing aids. The first of these discusses the effects of acoustic parameters (frequency-responses, dynamic range) and signal processing. This chapter was admittedly difficult reading, but it considers the limits to auditory correction and the theoretical means of correction. The last chapter attempts to assess rehabilitation and hearing aid needs in the United Kingdom, Europe, and North America. As I have implied, this book is not introductory or casual reading. It is well referenced and documented. Although it is not a “how-to” book for hearing aid fitting, it has considerable background and theoretical material that should be digested by those seriously interested in hearing aid prescription and distribution.

Book Review: Larynx - Microlaryngoscopy and HistopathologyLarynx - Microlaryngoscopy and Histopathology by LehmannW., PidouxJ.M., and WidmanJ.J.. 129 pages with illustrations. Inpharzam Medical Publishers, Cadempino, Switzerland, 1981.

AN ATLAS OF PEDIATRIC NEUROSURGlCAL OPERATIONS, by John Shillito and Donald D. Matson, illustrations by Mildred B. Codding and Grant S. Lashbrook. Philadelphia, WB Saunders Co, 1981. Price

Book Review: Physiology and Pathophysiology of the Eustachian Tube and Middle EarPhysiology and Pathophysiology of the Eustachian Tube and Middle Ear, International Symposium, Freiburg, edited by MunkerG. and ArnoldW.. New York, Thieme-Stratton, 1980. Price

160. The book i s loosely organized into four sections: (1) normal physiology of the eustachian tube, (2) etiologies of tubal dysfunction, (3) morphology, immunology, and biochemistry of middle ear mucosa, and (4) treatment of tuba1 dysfunction. It is richly and effectively illustrated with line drawings and photomicrographs, and a small number of color photographs are used toi llustrate some nasopharyngoscopic findings. Each paper contains a summary paragraph that can be skimmed prior to in-depth reading where desired. This atlas is a magnificent effort at detailed, clear portrayal of a large number of procedures dealing with pediatric neurosurgery, Many general procedures are outlined, such as diagnostic and emergency procedures. Preparation of the patient, including saphenous vein cutdown, i s described and various surgical positions, with and without skeletal fixation, are delineated. The atlas also contains a section of basic surgical techniques with marvelous, clear illustrations of scalp incisions and their closure. A minor criticism is that the description of the microsurgical setup is out of date.