James H. Whicker

Juvenile angiofibroma: Review of 120 Cases

Summary All young males with nasal obstruction or nose-bleed (or both) should be suspected of having juvenile angiofibroma. This awareness, as well as a good physical examination and history taking, is essential. Plain roentgenograms of the sinus, with submentovertical views, and tomograms should be sufficient adjuncts for diagnosis. Knowledge of the point of origin in the posterior nasal cavity and the natural history of extension of the tumor into the nasal cavity, nasopharynx, sphenoid sinus, pterygomaxillary and infratemporal fossae, and cranial cavity is essential in planning treatment. Angiography for diagnostic purposes should be used only in unusual circumstances. The use of hormones, cryotherapy, carotid ligation, or hypotensive anesthesia probably will not be of any help in controlling hemorrhage at operation. Our experience with patients who have received irradiation and who still had the angiofibroma—with the ever present risk of irradiation [ 15 ] in the preadult patient—has caused us to be skeptical of this modality as a primary form of treatment. However, the radiotherapist is a member of the team managing the treatment of patients with this most difficult tumor. (Figure 9.) All operations presently used to obtain surgical exposure of the angiofibroma and its extension may be inadequate when the tumor bleeds excessively on manipulation. We believe-lateral rhinotomy, in one procedure, allows the surgeon to expose the extensions of the tumor and to remove the tumor from its point of origin in the posterior nasal cavity without disturbing facial growth or causing facial deformity. Intracranial extension indicates advanced disease and is not unusual [ 13, 16 ]. We have successfully removed angiofibromas involving the middle fossa, but four of our patients who died had evidence of intracranial angiofibroma.

Surgical treatment of squamous cell carcinoma of the base of the tongue.

One hundred two patients with squamous cell carcinoma of the base of the tongue were treated by surgery. The grade of the tumor did not influence survival; however, survival was influenced by the stage of the disease and the operation selected. Operations that provided wider access decreased the incidence of local recurrence. Of the 102 patients, 23 percent required either total or partial laryngectomy. The survival curves of the 23 patients suggest that management of the larynx is a key factor in treating larger cancers. Overall, the five‐year survival rate for the 102 patients was 42 percent. Surgery is the treatment of choice in squamous cell carcinoma of the base of the tongue.

Diagnostic and therapeutic problems in extracranial meningiomas

Summary Extracranial meningiomas, either primary or secondary, may present in numerous sites about the head and neck. We have described primary extracranial meningiomas of the middle ear and jugular foramen-parapharyngeal regions. Surgical extirpation of such meningiomas should provide a good prognosis if removal is complete. For tumors in the infratemporal region, preliminary total parotidectomy exposes the facial nerve so that the surrounding tumor may be removed without injuring the nerve. With patients who have extracranial extensions of intracranial meningiomas, the surgeon may be reluctant to excise the extracranial component. However, follow-up study of cases in which extracranial excision was performed suggests that long-term relief from pain and disfiguration may be expected. The intracranial component may be removed at a second-stage procedure, or in certain instances, the patient may be observed. Consultation with a neurosurgeon is essential in determining the appropriate therapeutic course.

Surgical treatment of squamous cell carcinoma of the tonsil

From 1960 through 1968, we examined 117 patients with carcinoma of the tonsil. Of these 117 patients a choice of the primary treatment modality existed for 96 patients, and 68 percent had surgery as their initial treatment. The absolute five‐year survival for all patients undergoing surgical procedures designed to cure was 48 percent. Tonsillar cancers are neither anaplastic nor markedly radiosensitive. The incidence of local recurrence in seven published series in which the primary tonsillar cancer was treated with radiation averaged 49 percent. We believe that the local recurrence rate of 19 percent in our surgical series reflects our dependence on frozen tissue examination and suggests that surgery offers a good chance of eradicating operable tonsillar carcinoma.

Long-Term results of thornell arytenoidectomy in the surgical treatment of bilateral vocal cord paralysis†

Unilateral or bilateral Thornell arytenoidectomy provided relief from laryngeal obstruction in 135 of 147 patients (92 percent). Twelve patients required contralateral arytenoidectomy an average of six and one‐half years after an initially successful unilateral procedure. Voice preservation was excellent in all but six patients (4 percent). Complications in seven patients included the formation of granulation polyps (five) and webs (two); corrective procedures rehabilitated all seven.

An anatomic study of the hypotympanic branch of Jacobson's nerve.

Microscopic dissection of 20 human temporal bones revealed that the nerve of Jacobson gave rise to a hypotympanic branch in 50% of the specimens. The fact that the branch was frequently covered by promontory bone and was difficult to approach by the standard tympanotomy technique may explain the 21% failure rate as reported in the literature.