Stanley E. Thawley

Complications of combined radiation therapy and surgery for carcinoma of the larynx and inferior hypopharynx.

A group of 554 patients was studied to determine and compare the complications of combined preoperative radiation therapy with surgery and combined surgery with postoperative radiation therapy when used for treatment of carcinoma of the larynx and inferior hypopharynx. The complications recorded were infection, slough, carotid blowout, glottic insufficiency, pharyngeal stricture, operative death, chondritis, fistula, and margins of resection involved with tumor. The highest complication rates were in the partial laryngopharyngectopy‐postoperative radiation group (63.6%) and in the supraglottic laryngectomy‐postoperative radiation group (52.9%). Most of the increase in total complication rate was attributable to higher rates of glottic insufficiency and margins involved with tumor categories. The lowest complication rates were in the hemilaryngectomy with no radiation group (4.5%) and the total laryngectomy‐postoperative radiation group (12.8%). The complication rate for the supraglottic laryngectomy‐postoperative radiation group (52.9%) was significantly higher than for the preoperative radiation‐supraglottic laryngectomy group (26.4%). Within the partial laryngopharyngectomy group, there was no significant difference in total complication rate between the use of preoperative (47.2%) or postoperative radiation (63.6%). Within the total laryngectomy group there was no significant difference between complication rates when either preoperative or postoperative radiation was employed. There was no significant difference in the rate of carotid blowout, chondritis, operative death, slough, or fistula, between preoperative or postoperative radiation in any of the surgical groups. In general, patients with conservation surgery seem to tolerate postoperative radiation without a prohibitive increase in complications.

Supernumerary nasal tooth

A tooth presenting in the nasal cavity is an unusual phenomenon. Supernumerary teeth usually occur in the upper incisor area. Other locations may be the maxillary third molar and the mandibular bicuspid areas. Nasal teeth are a rare form of supernumerary teeth. They may be asymptomatic or may present with nasal obstruction and infection. They may be removed through a nasal approach.

Basal cell adenoma of the salivary glands.

Basal cell adenoma is an unusual type of salivary gland tumor which has only recently been classified as a separate entity. Four cases are presented. Three were discovered by reviewing a series of adenoid cystic carcinomas and mixed tumors, and one was diagnosed originally. Three cases involved the parotid; one, the submaxillary gland. There was no facial nerve involvement in any case. Treatment was local excision. Follow‐up from two to nine years revealed no recurrence. The lesions typically are slow growing, firm, non‐tender, asymptomatic masses present for several years before treatment. The average age of the patients is generally older than those with mixed tumors. They are most often found in the parotid gland, but have been reported from the submaxillary and minor salivary glands of the upper lip, cheek, and palate. Microscopically the tumor consists of monomorphic basaloid cells with an absence of myoepithelial cells. Myoepithelial cells play an important role in salivary gland tumors. Their range of activity and products determine to a certain degree the morphology of adenoid‐cystic and mixed tumors. They resemble muscle cells as demonstrated by electron microscopy studies and also by functioning as contractile elements. The cell of origin is unknown. The tumors may closely resemble adenoid cystic carcinoma and mixed tumors; therefore, diagnostic and therapeutic questions may arise. The tumors are benign. No malignancy has been reported. The lesions can be unencapsulated; therefore, the best treatment is adequate local excision rather than enucleation, tumor may contribute more knowledge concerning the histogenesis of certain salivary gland tumors.

Air in the neck

Air in the neck is normally found in the pharynx, larynx and trachea. Free air may enter the neck by direct opening of potential fascia spaces, dissection within the fascia spaces from the head or mediastinum and by injury to the upper respiratory or alimentary tracts. The sources for free air in the neck are numerous and varied and range from the rectum to the sinuses. The otolaryngologist should have a thorough knowledge of the differential diagnosis for air in the neck since the definitive therapy depends on the etiology.

Wegener's granulomatosis: unusual indication for orbital decompression.

Wegeners granulomatosis (WG) is characterized by granulomatous vasculitis of the upper and lower respiratory tract together with glomerulonephritis. The majority of cases have ocular, sinus and ear symptomatology. A case is presented with severe granulomatous disease of the sinuses with contiguous spread to the orbit producing exophthalmos and decreased vision. An orbital decompression relieved the pressure and preserved vision. The definitive medical therapy for WG is cyclophosphamide. Emergency orbital decompression may be necessary to preserve vision in WG in patients with rapidly decreasing vision secondary to high intraocular pressure produced by the granulomatous process.

Posterior tracheal laceration: A rare complication of tracheostomy.

Tracheostomy is an operation with a long history and many potential complications. Two case reports of acute posterior tracheal wall laceration, a rare complication, are presented. Although previously described as being secondary to inadvertent knife contact with the posterior tracheal wall, both of these cases are thought to be due to insertion of the tube with excessive force against tissue made friable by previous radiation. The diagnosis should be suspected if poor ventilation follows insertion of an endotracheal or tracheal tube. The offending tube should be removed and an oral endotracheal tube inserted. After treatment of any accompanying pneumothorax, the site should be evaluated under direct vision as the endotracheal tube is withdrawn proximal to the tracheotomy. If a tear is found, esophagoscopy is performed to insure the integrity of the esophagus. Repair of the tracheal wall is done with a single layer closure through the tracheotomy alternating suturing with ventilation. A generous tracheotomy, soft tubes and care in insertion of tubes into the trachea are suggested preventive measures.

Health care costs of laryngeal surgery

The total costs of various laryngeal surgeries were considered from initial visit through one year postoperatively. For the four most widely used procedures, average costs were: laryngoscopy with biopsy,

Chylous fistula prevention and management

1,000.00; hemilaryngectomy,

Epiglottic reconstruction of the vocal cord following hemilaryngectomy

5,035.00; total laryngectomy,

“HOW I DO IT” — Otology and neurology: A specific issue and its solution how to decrease postoperative mastoid cavity problems

6,010.00; and supraglottic laryngectomy and neck dissection,