Robert A. Sofferman

Angiogenesis as a Prognostic Marker in Early Head and Neck Cancer

Experimental evidence suggests that tumor growth beyond the earliest stages is dependent on angiogenesis, or neovascularization, and that angiogenesis may also promote metastasis. Recent clinical studies demonstrate that angiogenesis is a prognostic marker in breast, lung, and prostate cancer. To investigate whether tumor angiogenesis also correlates with metastasis and survival in early head and neck carcinoma, we quantified the microvascularity of 106 primary carcinomas prior to treatment and correlated the counts with eventual outcome after 3 to 15 years of follow-up. Microvessels were stained immunocytochemically for von Willebrand factor and then counted by light microscopy. Microvessels were counted per 200x and 400x fields, and their density was graded from 1 to 4, in the area of most intense neovascularization. We found that neither microvessel counts nor density grades correlated with metastatic disease, local recurrence, or survival in early head and neck carcinoma. These results are in contradistinction to those recently reported for other tumor sites.

Sphenoethmoid approach to the optic nerve

Five percent of all head injuries affect some portion of the visual system, and the most common locus of injury is the canalicular segment of the optic nerve. The classic surgical approach to this area is via the transfrontal craniotomy, although the Japanese have utilized an external ethmoidal technique to provide limited extracranial access to the optic canal. Harvey Cushing utilized the transsphenoidal hypophysectomy principally for pituitary tumors causing visual deficits. This paper presents a variation of the transsphenoidal hypophysectomy technique which will allow exposure of the optic nerve from the orbital apex to the optic chiasm through the use of microsurgical instrumentation. A detailed step‐wise description of the surgical methodology is presented, along with drawings to define the approach fully. Four case reports and representative pre and postoperative radiographs illustrate the actual approach in the clinical setting.

Minimal-access parathyroid surgery using intraoperative parathyroid hormone assay.

Objectives: Review the most current preoperative localization imaging techniques in patients with primary hyperparathyroidism and demonstrate their applicability to targeted tumor removal with intraoperative parathyroid hormone (PTH) monitoring. Study Design: Retrospective review of 40 consecutive patients undergoing parathyroid surgery with intraoperative PTH assay as the principal determinant of correction of the hyperparathyroid state. Details of the technology, cost analysis, and comparison with other management methods are discussed. Methods: The standard intact PTH chemiluminescent assay (Nichols Diagnostics) and modifications to allow accelerated intraoperative results are discussed in detail. The time intervals between completion of parathyroid excision and postremoval assay and subsequent laboratory investigation present a practical therapeutic algorithm. Results: Forty consecutive patients with hyperparathyroidism were treated surgically with intraoperative PTH as the determinant of satisfactory resolution of the disease state. In most instances, the surgical field was reduced to the targeted pathology identified by preoperative localization, and all patients became eucalcemic when this method was employed. Approximately half of eligible patients were treated under local anesthesia. Conclusions: Intraoperative PTH assay has added a new dimension to primary and revision parathyroid surgery. It is cost‐effective and accurate and may reduce the morbidity of surgical intervention in revision procedures. Laryngoscope, 108:1497–1503, 1998

The nasogastric tube syndrome

The nasogastric tube can produce sudden, life‐threatening bilateral vocal cord paralysis and is often an unrecognized cause of this clinical entity. The pathophysiologic mechanism is thought to be paresis of the posterior cri‐coarytenoid muscles secondary to ulceration and infection over the posterior lamina of the cricoid. Since our initial report of this entity in 1981, several cases have been photo‐documented. Study of whole organ sections of an involved larynx have demonstrated the histopathology. Diabetic renal transplant patients appear to be particularly susceptible to the condition, due to prolonged gastroparesis and requirement for nasogastric tube drainage. Esophagoscopy should be performed promptly in these patients when pha‐ryngodynia, hoarseness, or evolving stridor present in the postoperative period.

Use of the linear stapler for pharyngoesophageal closure after total laryngectomy

INTRODUCTION In 1972 Paches et al. published their experience in the Russian literature with the use of a stapling device during laryngectomy. However, this technique has not been used in the United States, although internal stapling methods have received recent popularity in the treatment of Zenker’s diverticulum. Between October 1995 and October 1999 the senior author (R.A.S.) has performed 19 of 24 laryngectomies with the Ethicon (Somerville, NJ) linear stapler. Most closures were performed as “closed techniques” in which the larynx is not separated from the pharyngoesophagus until closure is completed. Once the larynx is skeletonized and definitive resection is imminent, the organ resection and stapled closure are accomplished in 5 to 10 minutes. This method is efficient, produces a reliable and secure suture line, and offers the theoretical advantage of the closed technique of avoiding salivary contamination from the oropharynx into the operative field.

Transoral unilateral facetectomy in the management of unilateral anterior rotatory atlantoaxial fracture/dislocation: a case report.

An unusual case of unilateral anterior rotatory atlantoaxial fracture/dislocation with neurological deficit is presented. The injury could not be reduced by skeletal traction, but was successfully reduced by partial facetectomy at C-1, C-2 accomplished through a transoral exposure of the atlantoaxial region combined with labiomandibularglossotomy. To the best of our knowledge, this is the first instance of an injury of this type to be so managed. The details of the operative procedure are described, and the subject of rotatory atlantoaxial dislocation is reviewed.

Lost Airway During Anesthesia Induction: Alternatives for Management

Pediatric and adult patients with upper airway obstruction pose several challenges to the anesthesiologist and otolaryngologist‐head and neck surgeon. The initiation of general anesthesia and endotracheal intubation may progress to complete life‐threatening respiratory decompensation with failure to achieve endotracheal intubation or mask ventilation. Hurried invasive maneuvers such as large‐bore needle tracheal entry and cricothyrotomy are recognized salvage techniques, but other modes of extratracheal ventilation are now possible before surgical airway procedures are required. The laryngeal mask airway and esophagotracheal Combitube (Kendall Sheridan Health Care Products Co., Argyle, NY) are described, with examples of their clinical application. The combined technique of anterior commissure laryngoscopy and intubation with the gum elastic bougie is the preferred alternative for achieving tracheal entry when extratracheal ventilation cannot be accomplished. An algorithm for joint management of the problem airway by anesthesiologist and otolaryngologist‐head and neck surgeon is illustrated.

The Septal Translocation Procedure: An Alternative to Lateral Rhinotomy

Lesions deep in the nasal vault with contiguous sinus involvement often require a lateral rhinotomy for exposure. This procedure affords excellent surgical access, but requires a significant external incision. An alternative sublabial technique, with dislocation of the nasal septum into the opposite nasal passage, provides excellent surgical exposure for these same lesions, while external facial incisions are avoided. The text outlines the surgical technique and representative uses in optic nerve decompression, inverted papilloma, giant rhinolith, angiofibroma, and a variety of nasosinus and nasopharyngeal malignant lesions.

Adenoid cystic carcinoma of the nasopharynx after previous adenoid irradiation

In 1978, Prntt challenged the otolaryngology community to identify an incidence of malignancy in individuals who have previously received radium therapy to the nasopharyngeal lymphoid tissues. This case report is a direct response to that quest and presents a well documented adenoid cystic carcinoma evolving 23 years after radium applicator treatment to the fossa of Rosenmuller. Although a cause‐and‐effect relationship cannot be scientifically proven, the case history raises several important questions concerning the stimulating effects of radiation on the later onset of frank malignancy.

Overcoming obstacles to setting up office-based ultrasound for evaluation of thyroid and parathyroid diseases†

Ultrasound is an integral part of the preoperative workup for patients who are being evaluated for thyroid and parathyroid surgery. It helps improve the accuracy of a fine‐needle aspiration biopsy and complements other imaging modalities used for planning the extent of surgery. It also allows imaging of vital structures in relation to the thyroid and parathyroid. The compact nature and portability of ultrasound machines in recent years has made it easier for motivated surgeons (head and neck, general, and endocrine surgeons) to incorporate them into their practice. However, successfully setting up such a service needs adequate planning and an understanding of the obstacles that are involved. We aim to discuss these obstacles in detail, with practical suggestions on how to overcome them. This review may serve as a resource when dealing with issues such as purchasing equipment, training, credentialing, billing, documentation, and collaboration. Although these are discussed with respect to surgeons with an interest in endocrine disease, with some modifications they may also apply to any surgeon who uses ultrasound frequently. Laryngoscope, 2011