G. Slaughter Fitz-Hugh

Sinusitis of the Maxillary Antrum

Twenty-four adults with clinical evidence of sinusitis were studied by 65 needle punctures of the maxillary antrum. Fourteen of 15 sinuses with normal transillumination and 19 of 26 that were dull had normal aspirates, whereas 24 of 24 that were opaque had abnormal aspirates (P less than 0.001). Marked mucosal thickening as determined radiologically (Waters view) was associated with abnormal aspirates whereas lesser mucosal thickening was not (P less than 0.001). In acute sinusitis, there was a strong correlation between high aspirate leukocyte counts (greater than 1000 per cubic millimeter) and infection as manifested by bacterial titers of greater than 10(5) per milliliter or the isolation of virus fungus (P greater than 0.001). Anterior-nasal-swab cultures correlated poorly with direct aspirate culters. Organisms frequently recovered from the sinus included Haemophilus influenzae, Strepto coccus pneumoniae, and anaerobic bacteria. Rhinovirus was recovered twice. Antibiotics were usedful in patients with acute sinusitis if the organism was sensitive in vitro (P less than 0.001).

Platysma myocutaneous flap for intraoral reconstruction

Fourteen patients were treated for intraoral epidermoid carcinoma with a single stage reconstructive technic employing a myocutaneous flap based upon the platysma muscle. This flap carries on its distal tip a portion of isolated cervical skin to be used for intraoral replacement of the resected tissue. The flap has proved to be highly reliable and has significant benefits over many other technics commonly employed for head and neck reconstruction.

Low-grade papillary adenocarcinoma of the palate

Low‐grade papillary adenocarcinoma of the palate is a rare but distinctive neoplasm. This tumor progresses slowly and is often misdiagnosed and inadequately treated initially. Although its slow growth may allow the clinician a second chance at curative surgery even years after the original excision, the axiom of adequate total excision by the initial surgeon is still important, since this carcinoma will recur locally and will metastasize to regional lymph nodes. However, in each of the two cases presented in this report, the metastasis was almost “inclusion‐like:” it involved only a single cervical lymph node.

Esthesioneuroblastoma: Diagnosis and Treatment

Esthesioneuroblastoma is a nasal tumor which arises from cells of neural crest origin. It is a difficult tumor to diagnose clinically and histopathologically. First described in 1924, approximately 160 cases have been reported with over 125 of these in the last 15 years. This reflects an increased awareness of the tumor by physicians rather than an increased incidence. In the past 17 years, 12 cases of esthesioneuroblastoma have been treated at the Department of Otolaryngology and Maxillofacial Surgery of the University of Virginia Medical Center. Reviewing these cases and the literature leads us to make the following recommendations for diagnosis and treatment: The diagnosis of esthesioneuroblastoma can be made by 1) the clinician who suspects it in any patient with a nasal mass causing unilateral obstruction; 2) the finding of plexiform intercellular fibrils by light microscopy (rosettes and pseudorosettes are not as common as reported); 3) the finding of secretory granules and neurites by electron microscopy of the highly undifferentiated tumors; and 4) formaldehyde-fume-induced fluorescence. Combined therapy with preoperative irradiation followed by craniofacial resection of the tumor to include the cribriform plate is recommended. This treatment should result in a five-year survival in excess of 50% of patients.

Cancer of the posterior hypopharyngeal wall.

Thirty-five patients with cancer of the posterior pharyngeal wall treated at the University of Virginia Hospital since 1956 have been reviewed. A minimum follow-up of five years was available in all patients. These have been analyzed by stage and treatment modality, and the crude and determinate three and five year survival figures presented. In contradistinction to results reported for other hypopharyngeal sites, radiotherapy alone has proved the most effective treatment in the posterior wall, particularly for T1 and T2, NO lesions, where the crude and determinate survival after 5 years were 45 and 50% respectively. For advanced lesions no treatment approach has approved efficacious, although 2 or 10 (20%) patients treated initally by radiotherapy alone survived disease free for 3 years with subsequent surgical removal of residual nodal disease.

High dose pre-operative radiotherapy and surgery for cancer of the larynx.†‡

High dose pre‐operative radiotherapy has played an increasing role in the treatment of advanced cancer of the larynx at the University of Virginia Hospital since 1966. The results of treatment of 72 cases treated in this fashion are compared with 151 cases treated by surgery alone. Employing the actuarial method for calculating survival, there would appear to be a distinct improvement in the group receiving pre‐operative radiotherapy. Local recurrence was reduced to 15 percent following radiotherapy from a level of 30 percent with surgery alone; however, this is a retrospective study, and the two groups are not strictly comparable by age, sex and race. Comparison by stage demonstrates that the more advanced cases received pre‐operative radiotherapy. Morbidity from the combined approach was not increased with a dose of 5,000 rads delivered in five weeks.

Mycotic Carotid Artery Aneurysm

A painful, pulsatile neck mass with associated fever should suggest the presence of a mycotic carotid artery aneurysm. Diagnosis can be confirmed from angiograms. Broad spectrum antibiotics are indicated, and an operation should be performed promptly. The lack of tissue planes uninvolved by infection will almost always prevent vascular reconstruction. Carotid artery ligation with excision of the aneurysms is recommended.

Bilateral Synchronous Mixed Tumors of the Parotid Gland

A 62-year-old man had bilateral parotid masses. This case represents a rare occurrence of bilateral synchronous mixed tumors of the parotid gland. We discuss this case, including preoperative evaluation, reason for rarity, treatment, and a review of the literature.

Fourteen years' experience with Cobalt‐60 radiation therapy in the treatment of early cancer of the true vocal cords

The results of treatment and reasons for failure are analyzed for a group of 110 patients with early (T1 and T2) squamous cell carcinoma of the true vocal cords, all treated with a Cobalt‐60 source. The report covers a period from 1956 through 1969, and presents 5‐year survival figures for over 50% of the patients in the series. For 55 Tl patients, the 5‐year absolute and relative survival rates were 80% and 94%, respectively. Similarly, for 12 T2 patients, the respective figures were 67% and 100%. Employing the actuarial method, the cure rates for radiotherapy alone were calculated utilizing the entire group of 85 Tl patients and 25 T2 patients. The cure rate for Tl lesions was 91%, for T2 lesions, 80%. Only eight radiotherapy failures were discovered in the combined group, and five of these have been salvaged by laryngectomy and now are alive and well. There were no significant complications attributed to the radiation therapy, and, in the five patients who came to surgery, the laryngectomy was carried out with no added morbidity. In six of the eight radiotherapy failures, technical reasons were discovered which may have contributed to the poor results in these patients. The results are compared with a large series of patients recently reported in a review article by Vermund.

Immediate complications of laryngectomy following high-dose preoperative radiotherapy.

During the most recently completed academic year (July 1969 to July 1970), 24 laryngectomies were performed for squamous cell carcinoma of the larynx. Twenty‐two of these laryngectomies followed high‐dose preoperative radiotherapy. Of this latter group, 14 represented a planned course of preoperative radiotherapy (5,000 rads in 5 weeks) followed by laryngectomy after a waiting period of 4 to 6 weeks. The remaining eight cases represented the surgical salvage of radiation failures. No mortality or major complications were recorded. Five minor complications were noted; however, of this group, none required a second surgical procedure, and, in all cases, a well‐healed surgical field was obtained. With careful teletherapy and meticulous surgical technique, it is possible and feasible to perform low morbidity major head and neck surgery on heavily irradiated tissues.