Robert F. Aarstad

Posterior Glottic Stenosis Mechanism and Surgical Management

Posterior glottic stenosis with arytenoid fixation is an uncommon complication of laryngeal injury. Though etiologies vary; the most common is prolonged intubation. Patients with this problem are tracheotomy dependent and have compromised voice production. There has been no acceptable approach to reconstruction of the larynx, the majority of patients being treated with some type of vocal fold lateralization. The success rate with this approach varies, and this procedure does not take advantage of the intact neuromuscular status of the larynx. Over the past 3 years we have utilized an alternative approach, to repair the stenosis and mobilize the arytenoids in 10 patients. Our surgical technique involves laryngeal exposure via a laryngofissure, the removal of posterior glottic cicatricial tissues, and the application of an autologous graft. Subsequently, all but one of the patients were able to be decannulated. Subjective postoperative voice analysis showed improved voice production. The pathophysiology for this disorder and a review of different treatment modalities are discussed.

Rhinophyma: A New Approach to Hemostasis

Rhinophyma is a benign tumor of the nose. It possesses both functional and cosmetic implications. The pathophysiology of the disease is reviewed to illustrate the basis for the treatment options. Many different therapeutic modalities have been reported in the literature, each with reasonable success. A new treatment approach to this condition is developed using a combination of the Weck blade and the argon beam coagulator. This modality is found to be relatively simple and less traumatic than all the other techniques used by the senior author.

Screening bone scintigraphy in the staging of locally advanced head and neck cancer

A retrospective determination of the yield from screening bone scintigraphy in detecting bone metastasis when used for disease staging of 93 asymptomatic patients with locally extensive head and neck cancer was undertaken. The bone scintigraphy findings were correlated with observations from other radioimaging studies done within 1 month of head and neck cancer diagnosis. Bone scintigraphy did not reveal a single case of bone metastasis outside the head and neck region. On the other hand, 3 cases (8%) of resectable and 2 cases (5%) of non-resectable bone metastasis located within the head and neck area were observed among the 40 patients with abnormal bone scintigraphy. Old rib fracture or degenerative disease was responsible for the increased radionuclide uptake in bony areas below the clavicle in less than half of the remaining 35 cases. We conclude that the routine use of bone scintigraphy for disease staging in asymptomatic patients with locally advanced head and neck cancer is not warranted because the positive yield is low.

Induction chemotherapy followed by concomitant chemoradiation-induced regression of advanced cervical lymphadenopathy in head and neck cancer as a predictor of outcome

OBJECTIVE: We sought to determine whether induction chemotherapy followed by concomitant chemoradiation (ICCR)-induced advanced neck disease regression could predict outcome, especially the need for complete neck dissection in patients with N2-3 stage IV head and neck cancer (HNC). METHODS: A retrospective study of 339 patients evaluated for treatment of stage IV HNC during the years 1988 to 1997 revealed 36 individuals with N2-3 cervical lymphadenopathy who were treated with ICCR. Responses to treatment, patterns of failure, and survival rates were analyzed. RESULTS: Primary and regional tumor regressions were complete in 21 patients (58%), partial in 9 (25%), and absent in 6 (17%); the corresponding local failure rates were 5%, 44%, and 33% (P < 0.02). The regional failure rates were 24%, 89%, and 83%, respectively (P < 0.001); distant failure rates were 10%, 0%, and 0% (P > 0.99). The estimated 2-year survival rates for complete and partial/nonresponders were 57% and 20%, respectively (P < 0.02). CONCLUSION: Patients with advanced regional metastases of HNC who respond completely to ICCR have an excellent chance for survival. However, such ICCR-induced complete regression of regional tumor cannot reliably predict ultimate neck disease control.

Evaluation of Bilateral Vocal Fold Dysfunction: Paralysis Versus Fixation, Superior Versus Recurrent, and Distal Versus Proximal to the Laryngeal Nerves

The initial finding of reduced movement or immobility of the bilateral vocal folds may be caused by different etiologies. Bilateral vocal fold dysfunction (BVFD) could originate from neurological, myogenic, or articular causes, each treated by routine examination and completely different surgical procedures. In clinical practice, laryngoscopy rarely indicates the underlying causes of BVFD. Cases with straightforward etiologies may undergo changes in pathophysiologic status and present more complex clinical pictures. A battery of methods have been used to evaluate BVFD including fiberoptic laryngoscopy, videostroboscopy, spirometry, laryngeal electromyography (LEMG), and magnetic resonance imaging (MRI). LEMG plays an important role in determining the diagnosis in terms of laryngeal paralysis, laryngeal joint fixation or dislocation, or posterior commisure synechiae. Bilateral vocal fold paralysis (BVFP), though uncommon, has a multitude of etiologies and is a potentially life-threatening condition. BVFP is often caused by iatrogenic lesions in adults and by congenital anomalies in infants and children. Neurological lesions are the second most common cause of BVFP in adu1ts.l

Spinal epidural compression in head and neck cancer: report of five cases

Patients with newly diagnosed head and neck cancer (HNC) during a 13-year period were retrospectively studied for the development of spinal epidural compression (SEC). Of the 759 patients studied, 5 developed epidural compression (1%), 4 of whom were relatively young. SEC occurred simultaneously with HNC in 2 patients and long after the diagnosis of HNC in 3 individuals. There was no observed tendency to involve a particular segment of the spine. Local control of HNC following definitive treatment along with regained ability to walk after palliative radiotherapy in a patient was associated with long-term survival. Recommendations are made for aggressive treatment of SEC to achieve a satisfactory outcome.

Laryngeal Evoked Brainstem Responses in Humans: A Preliminary Study

Laryngeal evoked brainstem responses (LBRs) were recorded in normal human subjects in an attempt to develop a central laryngeal function test and enhance our understanding of neurolaryngologic disorders. The results showed that the human LBR consists of five positive peaks and five negative peaks reproducible within 10 ms after a vibratory stimulation to the superior laryngeal nerve (SLN). The waveform reproducibility was verified by blocking the SLN and topically anesthetizing the hypopharyngeal cavity. The morphology and latency of peak 5 were similar to results obtained in animal LBR experiments. It was concluded that a vibratory stimulation to the SLN was a noninvasive method to elicit far‐field potentials from the central laryngeal pathway. These findings encourage further effort to establish normative data and explore clinical correlations.

Salvage treatment of recurrent skin cancer of the midface.

Nine patients with recurrent cutaneous cancers of the midface were treated by definitive surgery (with adjuvant radiotherapy in five individuals). The clinical courses were marked by local and regional relapses in six cases. Although the prognosis may be generally poor, aggressive therapy, as feasible, seems warranted in these patients because death was not typically rapid after reappearance of disease in several patients.

Complications of Aesthetic Facial Surgery

Educational objectives: To recognize and understand the causes of many common aesthetic facial surgery complications and, through this understanding, to be better able to prevent and treat these complications.

68: Physiological Testing of Facial Paralysis: A Combination of the Acoustic Reflex and Electroneurography

after the opera t ion . There was only one report (The Laryngoscope, November 1993, from Switzerland) that revealed a normal laryngeal growth after this operation. Methods: Three patients aged 9, 6, and 6 years underwent this operation in March, May, and June 1989 due to an inability to find a lumen of the subglottic stenosis. Results: There was no immediate complication, and the patients were decannulated shortly after the operation. We were able to follow up the third patient in August 1995. It revealed a normal growth of the larynx. Conclusion: This finding supports the previous report regarding laryngeal growth. We had a 100% success rate in three children, and we consider the operation useful for children.