Mark S. Persky

Extracranial Repair of Cerebrospinal Fluid Fistulas: Technique and Results in 37 Patients

Although neurosurgeons have traditionally preferred intracranial repair for the management of cerebrospinal fluid (CSF) fistulas, this approach is associated with the complications of a craniotomy, anosmia, and a high incidence of recurrent fistulas. Extracranial repair, on the other hand, produces no central nervous system morbidity, preserves olfaction, and is associated with a low incidence of recurrence. Although there have been several reports of extracranial repair of CSF fistulas by otorhinolaryngologists, this approach has received scant mention in the neurosurgical literature. We report here our experience with 37 patients with CSF rhinorrhea or otorrhea who underwent extracranial repair. The etiology of the fistula was postoperative in 22, traumatic in 6, and spontaneous in 9. The fistulas were repaired using one of four techniques: external ethmoid-sphenoid in 18 patients, transmastoid in 9, transseptosphenoid in 7, and osteoplastic frontal sinusotomy in 3. In 32 of the 37 patients (86%) the fistulas were successfully repaired with the initial procedure. Of the 5 patients requiring a second operation, the fistula was successfully closed in 4 for an overall success rate of 97%. Complications were few and consisted of a transient facial paresis in a patient undergoing transmastoid repair and one death from meningitis. The authors conclude that because of low morbidity and mortality and a high success rate in closing fistulas, extracranial repair is the preferred technique for the operative management of CSF rhinorrhea and otorrhea.

Internal jugular vein thrombosis

Internal jugular vein thrombosis is a vascular disorder that is easily overlooked or misdiagnosed. It occurs in a variety or clinical settings which disrupt normal blood flow through the internal jugular vein. Intravenous drug abusers represent a high risk group in this study. Diagnosis is readily made by computed tomography. Seven patients are presented, with discussion of the pathogenesis, clinical findings, radiologic features, potential complications, and treatment rationale.

Metastatic Cutaneous Squamous Cell Carcinoma of the Head and Neck Region

Cutaneous squamous cell carcinoma has a relatively low metastatic rate (0.5% to 16%), but patients with the disease should always be evaluated for possible regional nodal involvement. We reviewed the records of 37 patients with metastatic disease among the 388 patients with head and neck cutaneous squamous cell carcinoma who were treated at New York University Medical Center between 1961 and 1992. In this group of patients the most common primary site was the cheek or preauricular region and the most common metastatic site was the level I neck lymph nodes. Seven patients (18%) had metastases at initial presentation. Among the remaining patients the average time to the development of metastases was 19 months. Nineteen patients (51%) had recurrence at the primary site before metastasis; 11 (30%) developed metastases with control of the primary tumor. Analysis of the records of 31 patients treated for cure revealed that 13 were treated by surgery, 2 by radiation therapy, and 16 by a combination of surgery and radiation therapy. During the mean follow‐up period of 49 months, 11 (35%) of these 31 patients died of their disease. Recurrence of the primary tumor appeared to increase the risk for nodal and distant metastases.

Congenital vascular lesions of the head and neck

There is no universally acceptable classification method of treating congenital vascular lesions of the head and neck. An historical perspective, the hemodynamics of arteriovenous fistulas, and the various modalities of treatment are presented. The importance of superselective angiography in studying these lesions is emphasized. Embolization represents a major advance in the treatment of these patients and cooperation between head and neck surgeon and the vascular radiologist is encouraged. The evaluation and treatment of 66 patients with congenital head and neck vascular lesions are presented. The rationale for various types of treatment is reviewed.

Cricopharyngeal myotomy: A review of surgical results in patients with cricopharyngeal achalasia of neurogenic origin†‡

Cricopharyngeal myotomy is an effective procedure for the treatment of swallowing disorders due to dysfunction of the upper esophageal sphincter and pharyngeal musculature. Eight patients with documented pharyngeal and sphincteric dysfunction have undergone myotomies with significant improvement in swallowing associated with restoration of oral feeding without aspiration in 5, while 3 patients have not improved. The preoperative work‐up and evaluation is discussed as well as criteria that may identify those patients most likely to benefit from this treatment.

Embolization in the treatment of epistaxis after failure of internal maxillary artery ligation

Internal maxillary artery ligation is effective in treating epistaxis. Occasionally a patient may continue to hemorrhage after this procedure. Evaluation of postoperative angiograms reveals several factors accounting for the failure of internal maxillary artery ligation. These factors include incomplete ligation of vessels, alternative dominance of vessels, and reconstitution of flow through collaterals. Eleven such patients have been successfully treated with angiography and embolization. There was one complication of skin slough in the region of the columella. Embolization is a useful modality in the management of these difficult cases.

Extracranial repair of cerebrospinal fluid otorhinorrhea

Forty-eight patients with cerebrospinal fluid leaks comprise this retrospective study. There were 39 traumatic and 9 spontaneous leaks. Nine patients were initially managed with bed rest and spinal drainage, but 3 patients in this group ultimately required surgical intervention for repair of their persistent leaks. Thirty-nine patients had surgery as initial therapy, with 33 extracranial repairs, 2 intracranial repairs, and 4 combined approaches. The extracranial approach was used in 36 of 42 patients, with an initial success rate of 86%.

Metastatic basal cell carcinoma of the head and neck

Metastases are occasionally associated with cutaneous squamous cell carcinoma but only rarely with basal cell carcinoma. There are approximately 200 cases of metastases from basal cell carcinoma reported in the world literature. We describe 6 additional cases. All of our patients demonstrated recurrence at the primary site before they developed their metastases. Metastases presented in subcutaneous tissue, cervical lymph nodes, bone, and lung between 1.5 and 14 years after initial treatment of the primary lesion. The long interval seen in these patients between the initial treatment of the primary and the development of metastases underscores the need for long‐term follow‐up in what is often thought to be a nonaggressive, nonmetastasizing malignancy.

Laser Endoscopic Treatment of Laryngoceles and Laryngeal Cysts

The laryngocele and saccular cyst are uncommon anomalies of the larynx. Two patients, one with an Intemal laryngocele and one with a saccular cyst, were successfully treated by endoscopic laser marsupialization of their lesions. Since neither patient was found to be a suitable candidate for prolonged general anesthesia, the patients did not require a tracheotomy and were discharged the day after surgery. Both patients are doing well, with remarkable Improvement in their voices persisting in their three year follow-up. The signs, symptoms, diagnosis, treatment, and Indications for endoscopic laser treatment of Intemal laryngoceles and saccular cysts are discussed. Laser marsupialization of Intemal laryngoceles appears to be an acceptable mode of treatment.

Evaluation of malignant invasion of the carotid artery by CT scan and ultrasound

Carcinoma adherent to the carotid artery may be present in advanced head and neck cancers. Angiography, ultrasound, computerized tomography (CT), and magnetic resonance imaging (MRI) are available for the preoperative evaluation of the carotid artery. This study demonstrates that CT is not accurate in demonstrating malignant invasion of the carotid artery. Ultrasonography appears to be the best modality for assessing carotid artery invasion. Magnetic resonance imaging may prove helpful in this determination.