George T. Simpson

Fulminant aspergillosis of the nose and paranasal sinuses: A new clinical entity†‡

Fulminant aspergillosis of the nose and paranasal sinuses represents a new clinical entity occurring in individuals with depressed immunological responses. It is marked by a rapid malignant course, requiring early recognition, aggressive surgery and chemotherapy. Clinical manifestations include a rapidly progressive gangrenous mucoperiostitis advancing relentlessly to destruction of the nasal cavity and the paranasal sinuses within a few days. The recent emergence of this form of aspergillosis appears to be directly related to the increased intensity of chemotherpay and immunosuppression in the treatment of previously fatal neoplastic diseases. Control of this disease process requires aggressive therapy. This may include radical sinus ablation, debridement of nasal structures, chemotherapy and possible correction of immunological deficits, i.e., bone marrow transplantation. Four cases are discussed in detail to present the clinical spectrum of this new disease entity.

Predictive Factors of Success or Failure in the Endoscopic Management of Laryngeal and Tracheal Stenosis

Stenosis of the larynx and/or trachea presents perplexing problems. No one technique has proved totally satisfactory in the management of all varieties of stenosis. Recent reports have described the successful use of the CO2 laser in the endoscopic management of stenosis of the larynx and trachea. Failures of this technique need emphasis to assure appropriate selection of therapeutic method. Retrospectively, 49 cases of laryngeal stenosis, 6 cases of tracheal stenosis and 5 cases of combined laryngeal and tracheal stenosis were studied (total 60 patients) following treatment at the Boston University Affiliated Hospitals. Follow-up ranged from 1 to 8 years. Multiple procedures were required in 35 laryngeal patients. Of the laryngeal patients 39 were successfully managed (average number of procedures in successful cases 2.18). Of 11 tracheal patients with combined laryngeal and tracheal procedures, 3 were successfully managed (average number of procedures in successful cases 6). Failures in laryngeal stenosis included four patients in whom an adequate airway was not established though voice was present while maintaining tracheostomies. Thirteen patients failing endoscopic management required open surgery with good result. Factors associated with poor result or failure include circumferential scarring with cicatricial contracture, scarring wider than 1 cm in vertical dimension, tracheomalacia and loss of cartilage, previous history of severe bacterial infection associated with tracheostomy, and posterior laryngeal inlet scarring with arytenoid fixation. In these circumstances, multiple procedures, more extensive alternative open surgical techniques, or maintenance of tracheostomy were necessary. In successful cases only three or fewer procedures on average were required. The factors associated with failure or success of endoscopic methods in the management of laryngotracheal stenosis, including use of the CO2 laser and soft Silastic stents, are analyzed.

Localized Amyloidosis of the Head and Neck and Upper Aerodigestive and Lower Respiratory Tracts

Seven cases of localized amyloidosis limited to structures of the head and neck and upper aerodigestive and lower respiratory tracts evaluated and treated at Boston University Hospitals in a recent 7-year period were reviewed. Negative Congo red staining of abdominal adipose aspiration biopsy or rectal biopsy specimens established that the amyloidosis was not systemic. Localized amyloidosis occurred in discrete masses in a variety of sites in the aerodigestive tract including the orbit, nasopharynx, lips, floor of mouth, tongue, larynx, and tracheobronchial tree. Five patients required surgical excision because of significant airway obstruction or organic dysfunction. Amyloid deposits completely excised with the carbon dioxide laser have not recurred, though other amyloid masses may appear elsewhere within the same organ or region. Amyloidosis may occur primarily or secondarily to other disease states. Localized amyloidosis has not been chemically identified but is usually defined by the absence of systemic features. While rare, amyloidosis must be recognized and understood by the otolaryngologist head and neck surgeon to allow appropriate diagnostic and therapeutic planning.

Acute paranasal sinusitis related to nasotracheal intubation of head-injured patients

One hundred eleven head-injured patients were examined for paranasal sinusitis during early convalescence. Glascow coma scale (GCS) was less than 8 in 79 patients. Ninety-three patients had sustained blunt injuries, and 18 had penetrating ones. Sixty-five orotracheal intubations (OTI) and 31 nasotracheal intubations (NTI) were performed at the scene or on hospital arrival. Fifteen patients were not tracheally intubated. Paranasal sinus air fluid levels (AFL) were present in 30 patients on their admitting computerized tomography scans.Paranasal sinusitis developed in 19 patients with a mean GCS of 5.4 ± 3.3 (SD). Sixteen of the 19 had NTI, and three had OTI (p < .05). Of 30 patients with AFL, sinusitis occurred in 13. Ten of these 13 had NTI, and three had OTI (p < .05). Penetrating injury did not increase the risk of sinusitis (p > .1). Seventeen of the 19 infections were polymicrobial. Sinusitis after head trauma is related to NTI, AFL, and severity of head injury.

Natural history and management of keratosis, atypia, carcinoma in situ, and microinvasive cancer of the larynx

Keratosis, atypia, carcinoma in situ, and microinvasive cancer occurring as white or red patches on the vocal cords are part of the diathesis of cancer of the aerodigestive tract and represented a sequential continuum. Excisional biopsy is the preferred treatment for identification and potential cure of the lesion. If the margins of excision are inadequate, further treatment options are either reexcision or radiotherapy. Radiotherapy should be used only when the need for voice conservation prevails. Cessation of smoking does not remove the potential for progression of the disease, therefore, all patients must be followed indefinitely. Excisional biopsy of keratosis, carcinoma in situ, and microinvasive cancer of the larynx offers an excellent prognosis for voice preservation and survival.

Laser Epiglottectomy: Endoscopic Technique and Indications

Endoscopic epiglottectomy (epiglottidectomy) may be performed with relative ease and minimal morbidity by using standard microlaryngoscopy techniques and the CO2 laser. Depending on the indications, the removal may be partial or complete. Indications for 51 epiglottectomies included treatment of supraglottic airway obstruction— 30 cases; discovery of benign or malignant neoplasm (diagnosis and staging)—20 cases; treatment of malignant neoplasm—7 cases; glottic visualization—4 cases; and treatment of chronic inflammatory conditions—1 case. It is not unusual for a patient to have more than one indication for this procedure. Some epiglottic cancers invade the pre-epiglottic space. This crucial information may not be detectable by MRI or CT scanning techniques. Laser epiglottectomy provides a method to explore and perform a biopsy of the pre-epiglottic space and thereby stage these lesions accurately. There are no significant problems with postoperative alimentation, airway, or voice. Any form of primary or adjuvant therapy can be started without delay.

The use of the carbon dioxide laser in the pediatric airway.

Congenital and acquired lesions of the pediatric airway present difficulties in management. Until recently, correction of these problems frequently involved an external approach to the larynx and trachea. Development of fiberoptic instrumentation, as well as the introduction of the Zeiss operating microscope, has now given the surgeon a new means to visualize the larynx and trachea. Soon after its development, the carbon dioxide surgical laser was coupled to these instruments to permit an extremely precise form of tissue excision and ablation. Its unique properties, including an extraordinary hemostatic effect, as well as minimal postoperative edema and scarring, make it an ideal tool for management of lesions of the pediatric airway. It has been employed successfully in the treatment of 177 lesions.

Middle Ear Pressure Changes after Nitrous Oxide Anesthesia and Its Effect on Postoperative Nausea and Vomiting

Objectives/Hypothesis: This study was designed to explore the relationship between changes in middle ear pressure associated with inhalational anesthesia and the incidence of postoperative nausea and vomiting (PONV).

Benign Tumors and Lesions of the Larynx in Children Surgical Excision by CO2 Laser

Benign lesions of the airway in infants and children may endanger the airway and compromise laryngeal function. The CO2 laser provides an elegant method of transoral surgical excision without compromising laryngeal function or airway competence. It avoids the risks of such other treatment modalities as external surgical approaches, prolonged steroid therapy, and radiation. It is applicable to a wide variety of lesions without the necessity of tracheotomy. Hospitalization is minimized. Ten cases are presented to show the wide applicability of this technique. Gross pathology and pre- and postoperative findings are demonstrated and discussed, as is the safety and efficacy of the laser soft-tissue interaction.

Clinical Characteristics of Nosocomial Sinusitis

Paranasal sinusitis is an important source of sepsis and morbidity in head injury victims and requires aggressive pursuit and therapy. Of 208 head-injured patients, 24 developed paranasal sinusitis. The Glasgow Coma Scale score of the sinusitis patients was 7.1 ± 3.9. Nineteen patients were intubated nasotracheally, and five were intubated orally. Sinus air fluid levels, indicative of bleeding into the sinus, were seen on 17 initial computed tomographic scans. Maxillary sinus suppuration occurred in 23 patients; in 20 it was the initial sinus involved. Twenty-one patients developed polymicrobial sinusitis. Coexisting infections were common. In 15 patients with concurrent tracheobronchitis or pneumonia, organisms identical to those in sinus aspirations were recovered from the sputum. Seven patients had associated bacteremia. Meningitis in six patients shared a common pathogen with their sinusitis. Nonoperative management successfully resolved sinus infection in 19 cases. Five patients required open sinusotomy.