John Conley

Sternocleidomastoid muscle transfer and superficial musculoaponeurotic system plication in the prevention of Frey's syndrome

Parotidectomy may be associated with a significant depression in the retromandibular region and a significant incidence of gustatory sweating (Freys syndrome). Superiorly and inferiorly based sternocleidomastoid flaps and posterior plication of the superficial musculoaponeurotic system were evaluated for their ability to ameliorate both consequences. Sixteen patients with sternocleidomastoid flaps and 16 patients with superficial musculoaponeurotic system plication were compared to a control group of 104 patients. The incidence of Freys syndrome was 47.1% in the control group, 12.5% (P = 0.025) in the sternocleidomastoid flap group, and 0% (P = 0.005) in the superficial musculoaponeurotic system plication group. The surgical techniques are described. The prevalence of Freys syndrome is discussed with respect to age, sex, radiation therapy, and the type of parotidectomy performed. The indications and contraindications of the three surgical techniques are described.

Adenoid cystic carcinoma involving the external auditory canal a clinicopathologic study of 16 cases

Sixteen patients with a rare tumor, adenoid cystic carcinoma (ACC) involving the external auditory canal, have been studied. Clinically, most patients complained of ear pain, often of several years duration. On physical examination, a mass or a nodule usually was identified in the ear canal. In most cases, treatment consisted of a wide surgical resection of the auditory canal and adjacent structures. Histologically, these neoplasms had the same appearance as ACC originating in salivary glands. In eight cases, the tumor was confined to the ear canal wall and unquestionably arose in this area, probably within the ceruminous glands. When incompletely excised, these lesions usually recurred locally. Nine patients had a total of 26 local recurrences. Most recurrences were found within two years of the preceding treatment, but the interval in some cases was long, ranging up to 14 years. Of the 16 patients, seven had no evidence of recurrence following surgical resection, two were living with recurrent, unresectable tumor, five had died of disease, one had died of other causes, and one was lost to follow‐up. Some patients died of tumor after a prolonged clinical course with multiple recurrences. Death usually was caused by intracranial extension by the tumor, or by pulmonary metastases. Radiotherapy did not appear to cure the lesion, but probably resulted in palliation. An increased incidence of recurrent, unresectable tumor or of death from the neoplasm correlated with the following histologic features: demonstration of tumor on the lines of surgical excision, involvement of the parotid gland, extension into bone, perineural invasion and local recurrence of tumor.

Sublabial approach to the nasal and nasopharyngeal cavities

A sublabial transnasal degloving approach to the mid-face, nasal cavity, septum, paranasal sinuses, and nasopharynx is described. This approach provides adequate exposure and ample facility for management of tumors in these areas. The pterygomaxillary space and infratemporal fossa ard readily accessible for hemostasis and management of tumor extensions. Children, adolescents, and women with benign and low-grade malignant tumors of these areas are the ideal candidates for this procedure. Twenty-six patients have been managed in this fashion, with no major complication. The cosmetic results have been excellent. This approach to the mid-third of the face, nasal, paranasal, and nasopharyngeal cavities should receive more attention and use.

Carcinoma of the maxillary sinus following thorotrast instillation

Summary The long term latent carcinogenic effect of residual radioactive thorium dioxide in the maxillary sinus is reviewed. Seven of the eleven cases noted previously in the world literature have been treated at the Columbia Presbyterian Medical Center. Despite the rarity of these cases, an additional three patients have since been treated. The relatively few cases thus far reported may be due to the long latent period from instillation to malignancy. Thirteen of the fourteen patients developed cancers of the maxilla and adjacent paranasal sinuses. Of the ten patients with malignancy treated by radical surgery at the Columbia Presbyterian Medical Center, three are alive and free of disease from seven to eighteen years. One of the three surgical survivals was a radiation failure salvaged by radical maxillectomy. One patient had benign sinusitis diagnosed thirteen years following instillation of the thorotrast, then treated by removal of all the contrast material and the mucosal lining, and has been free from evidence of malignancy for the succeeding ten years. No patient was successfully treated by irradiation alone. A program for all patients known to have intrasinusal thorotrast is proposed.

Reconstruction of radical parotidectomy defects

Abstract The technique of microvascular free dermis-fat flaps is an efficient method of restoring cervicofacial contour after ablative head and neck surgery. Our success in six consecutive patients, including three who had received irradiation, establishes this as a reliable technique associated with gratifying results and minimal complications.

Treatment of massive deep lobe parotid tumors.

Abstract Because of the anatomy of the deep lobe of the parotid and its restrictive boundaries, retromandibular tumors may be asymptomatic until reaching a massive size. Removal by an intraoral approach may not only be disappointing but could be disastrous with disintegration of the tumor and generalized spillage in the wound. Our experience suggests that the most comfortable approach to any type of tumor in this region is through the upper lateral cervical tissues with consideration of a mandibular osteotomy if the tumor extends into the retropharynx or the nasopharynx. This review of 12 patients who required osteotomy indicates a high success rate with minimal complications.

Carcinoma of the maxillary sinus following Thorotrast instillation: A further report

Abstract 1. 1. Three new cases of carcinoma of the maxillary sinus developing fifteen to twenty years following instillation of Thorotrast into the maxillary sinus are presented. 2. 2. The carcinogenic effect of the radioactivity of thorium and its decay products is discussed. 3. 3. The need for investigation of radiopaque material in the maxillary sinuses is re-emphasized.

A Quantum Mechanical Model of Spherical Supermembranes

We present a quantum mechanical model of spherical supermembranes. Using superfields to represent the cartesian coordinates of the membrane, we are able to exactly determine its supersymmetric vacua. We find there are two classical vacua, one corresponding to an extended membrane and one corresponding to a point-like membrane. For the = 2 case, instanton effects then lift these vacua to massive states. For the = 4 case, there is no instanton tunneling, and the vacua remain massless. Similarities to spherical supermembranes as giant gravitons and in Matrix theory on pp-waves is discussed.

Cervical lesions of branchial origin

Abstract A brief review of the developmental background of the lateral cervical sinuses, fistulas, cysts and auricles has been presented. In all likelihood they are of branchial cleft origin. Surgical excision is the recommended treatment as shown in the cases described.

MANAGEMENT OF MALIGNANT TUMORS OF THE SCALP

The scalp is a unique region of the body warranting analysis as a specialized organ. This epithelial surface presents anatomic and physiologic characteristics quite different from any other surface covering. Its biologic response to tumor growth encompasses not only the complete gamut of neoplasia, but imposes specialized manifestations in respect to local growth and metastasis. The management of these malignant tumors, therefore, embraces a selective set of rules applicable to each of the various neoplasms. The anatomy of the scalp has much to do in determining the growth characteristics and metastasizing potential of these tumors. The true hair-bearing area of the scalp contains five layers. The epithelium is thick and rests upon a tough cushion of deeply set hair follicles, glands, fat, fibrous tissue, lymph channels, and vascular systems, richly interlaced in a great interlocking conduit system. This dynamic portion of the scalp is supported on a tough aponeurotic layer which loosely covers the periosteum of the skull. Between these two latter structures is a subaponeurotic space which permits the scalp its mobility on the cranium. Primary tumors of the scalp may arise from epithelial, glandular, or somatic tissue elements. A tumor may appear in the scalp as a metastatic focus from another primary carcinoma in the body or may appear as a direct extension from the calvarium, brain, or regional structures. These circumstances present a concentrated potpourri of histogenetic possibilities of neoplasia in the scalp. In spite of this high histogenetic potentiality the general incidence of maliganant tumors in the scalp is only slightly over two per cent. The biologic factors which give this epithelial surface its relative immunity to tumor growth are not apparent. The basic etiologic factors precipitating cancer of the scalp are not known. Atrophic scars, old burns, chronic inflammation, keratosis, excessive exposure to sunlight, postradiation atrophy, chronic skin disease and irritation, and the occasional association with sebaceous cysts are well recognized as predisposing conditions for cancer. Atrophic changes associated with the loss of hair and eventual baldness indicate a significant diminution in the vascular supply to the scalp. This physiologic change does not appear to influence or control the incidence of cancer. Although 65 per cent of the carcinomas appeared in men, where baldness is a much more common clinical entity, there was no relative increase in the frontal and parietal regions involved in the balding process. Paradoxically, the predominant number of melanomas and basal-cell carcinomas appeared in the region of the temple which was rarely affected by baldness. The other malignant neoplasms of the scalp were distributed throughout the various regions without predilection. Malignant neoplasia have been associated with neurofibromatosis and Paget’s disease, bearing out a relationship between congenital abnormality and new growth in this region.