Peripharyngeal space invasion of head and neck cancer--incidence, mechanisms, and management

We studied the incidence and mode of development of peripharyngeal invasion from head and neck cancers by both retrospective examination of our 127 patients and tracing the dynamics of lymph flow from the hypopharyngeal wall to the peripharyngeal space. We also presented three experiences of the surgical approach to the peripharyngeal invasion by our modification of Attia's technique. Peripharyngeal space invasions occur frequently in a direct or indirect way when meso- or hypopharyngeal or posterior oral cancer invades deeply into the muscle layers and extends to the palatine arch, retromolar region, pharyngoepiglottic fold, pharyngeal tongue, or posterior buccal mucosa. The lymph flow was revealed to move quickly from the lateral hypopharyngeal wall to the base of the skull and occasionally to the opposite side. The peripharyngeal space invasions were successfully removed under a wide surgical field without injuring the important nerves and vessels and with preservation of mandibular function. We should cover all routes for extension of head and neck cancers, including the peripharyngeal space, in the diagnosis and management of these conditions.

The effect of pericardium on the end-systolic pressure-segment length relationship in canine left ventricle in acute volume overload

The effect of the pericardium on the end-systolic pressure-segment length relationship in the left ventricle was examined with an ultrasonic miniature gauge in open-chest dogs. In 12 dogs, blood was infused until left ventricular (LV) end-diastolic pressure reached about 20 mm Hg, and then the pericardium was opened widely. In the other 12 dogs a pericardiectomy was performed without blood infusion. Stroke volume was measured in six dogs in the former group and in seven dogs in the latter group. After blood infusion, LV systolic, end-systolic, and end-diastolic pressures increased from 120 +/- 14 to 162 +/- 16 mm Hg (mean +/- SD), from 106 +/- 13 to 146 +/- 17 mm Hg, and from 8 +/- 2 to 19 +/- 2 mm Hg, respectively (all p less than .01). End-systolic and end-diastolic segment lengths increased from 8.9 +/- 2.1 to 10.6 +/- 2.2 mm and from 11.6 +/- 2.5 to 14.9 +/- 2.7 mm, respectively (both p less than .01). After pericardiectomy, the segments were further lengthened by 8.9 +/- 4.4% and by 10.0 +/- 6.2%, respectively (both p less than .01). Heart rate, LV systolic and end-systolic pressures, and peak positive dp/dt did not change, although end-diastolic pressure fell from 19 +/- 2 to 18 +/- 2 mm Hg (p less than .01). Stroke volume rose from 13.1 +/- 3.7 to 23.9 +/- 5.0 ml due to volume loading and further increased by 26.7 +/- 9.0% after pericardiectomy.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of oxygen breathing on pulmonary vascular input impedance in patients with pulmonary hypertension

The effect of oxygen breathing on the stiffness of the large pulmonary artery has not been elucidated. We analyzed the proximal pulmonary arterial impedance with a multisensor catheter in ten patients with pulmonary arterial hypertension (PAH), eight patients with pulmonary venous hypertension, and six control subjects. The stiffness of the vessel was quantified by the characteristic impedance (Zo) and compared with the plasma norepinephrine level. Ten minutes of high-oxygen breathing decreased the Zo (from 78 +/- 18 to 57 +/- 14 dynes.sec.cm-5, p less than 0.01) and pulmonary arterial resistance in all the cases with PAH. In this group, norepinephrine also decreased (from 381 +/- 89 to 319 +/- 77 pg/ml, p less than 0.01) following the correction of hypoxemia. Yet, those parameters did not change in the other two groups. These results indicate that in patients with PAH, oxygen breathing can reduce the stiffness of the main pulmonary artery because of the sympatholytic effect.

Assessment of the magnitude of aortic regurgitation by dye injection into the descending aorta

A technique simpler than the angiographic method for estimating aortic regurgitant volume was tried with 31 patients with aortic insufficiency. During cardiac catheterization, we injected dye into the descending aorta while recording the dye dilution curve in the left ear. The distance between the aortic arch and the tip of the catheter at the lowest point from which the injected dye could be detected in the left ear was rated in terms of the number of corresponding vertebral bodies. This "distance score" closely correlated with the regurgitant stroke volume and with the fraction to total stroke volume, which were measured by angiocardiography (r = 0.927, p less than 0.001; and r = 0.900, p less than 0.001, respectively). The correlation coefficients of the aortographic grade to those parameters were not as high as they were in the relationship of the score to the same parameters. Therefore, these results indicate that the "distance score" is a practical method for assessing the magnitude of aortic regurgitant volume.

Echocardiographic and morphological features of the pulmonic valve in patients with primary pulmonary hypertension and those with secondary pulmonary hypertension resulting from left-to-right shunt

In 11 patients with primary pulmonary hypertension (PPH) and 16 with secondary pulmonary hypertension due to left-to-right shunt (SPH), echocardiographic and morphological features of the pulmonic valve were studied. Mean ages of these patients were 27 and 31 years, respectively. The echo intensity of the pulmonic leaflet was graded as either "strong" or "not strong" by comparison with the adjacent tissue. In the PPH group, the valve echo was "not strong", while it was "strong" in the majority of the cases of SPH. In autopsy, there were no morphological changes in the pulmonic valves in the former, while these valves were definitely hypertrophic in the latter. The average thicknesses of the valve edges in the two groups of patients were 0.5 and 1.6 mm, respectively. The results suggest that the different echo intensities reflect the morphological differences of the pulmonic valve; and this provides a diagnostic value for differentiating the two conditions.

Norepinephrine levels in the coronary sinus in patients with cardiovascular diseases at rest and during isometric handgrip exercise

In order to evaluate cardiac sympathetic nerve activity, plasma norepinephrine levels in the coronary sinus (NECS) and in the artery (NEA) were determined in 24 subjects with cardiovascular diseases and in six with functional murmur. The resting NECS was greater than NEA in 14 subjects with normal left ventricular end-diastolic pressure (LVEDP) (p < 0.001) and/or in 22 with normal cardiac index (p < 0.04), whereas NECS was not significantly different from NEA in the remaining patients with elevated LVEDP and/or with reduced cardiac index. Isometric handgrip exercise increased both NECS and NEA (p < 0.001). When subjects were divided into two groups according to the slope of the ventricular function curve (delta stroke work index/delta LVEDP), NECS during exercise was greater then NEA in the group having slopes of 1.0 or more (p < 0.01), but neither values significantly differed in the group with slopes of less than 1.0. In the latter group, cardiac NE overflow rat calculated from the difference between NECS and NEA multiplied by coronary sinus plasma flow, was significantly less than that of the former group before and during handgrip (p < 0.05 and p < 0.01, respectively). These results suggest that cardiac norepinephrine release into the coronary sinus is reduced in patients with impaired cardiac function.

Cineventriculographic analysis of left ventricular dynamics during sustained handgrip exercise

In order to evaluate the effect of handgrip on left ventricular dynamics, cineventriculography was performed in 16 patients with heart disease and 5 normal subjects at 30% of maximal voluntary contraction. No patient had ventriculographic evidence of asynergy or valve regurgitation. During exercise, left-ventricular end-diastolic volume (LVEDV) insignificantly increased, left ventricular end-systolic volume (LVESV) decreased, and hence stroke volume (SV) and ejection fraction (EF) rose in the normal group, while in the patient group a similar change in LVEDV was associated with increased LVESV, resulting in unchanged SV and decreased EF. It is notable that during exercise LVEDV increased in both groups, despite a shortened diastolic filling period. Mean velocity of fiber shortening (mean VCF) increased in the normal group and remained unchanged in the patient group. The changes in mean VCF during exercise were correlated with the alterations in SV and EF (r=0.46, p less than 0.05 and r=0.90, p less than 0.001), respectively). These data signify that an increased afterload induced by handgrip leads to an enhanced left ventricular myocardial contraction in addition to an increase in preload in the normal group, while the Frank-Starling mechanism is mainly utilized in the patient group.

Trisomy 12p syndrome: de novo occurrence of mosaic trisomy 12p in a mentally retarded boy

The first case of trisomy of probable 12p mosaicism originated de novo is presented. Comparison of the clinical findings of this patient with those of previously described cases of 12p trisomy derived from translocated chromosomes indicates that the symptoms of 12p trisomy are: (1) normal birth weight and physical development, (2) severe psychomotor retardation and generalized hypotonia, (3) peculiarly round face with prominent cheeks, hypertelorism, epicanthus, broad, flat nasal bridge, short nose with anteverted nostrils, large philtrum, broad, prominent lower lip, and (4) poly(syn)dactyly of feet.

Cineventriculographic analysis of the ventricular septal motion during stimulation of various pacemaker sites

By means of cineventriculography, contraction pattern of the ventricular septum was studied during electrical stimulation of the right atrium (RA), outflow tract (RVO) and apex (RVA) of the right ventricle and apex (LVA) and lateral wall (LVL) of the left ventricle. RA pacing produced a monophasic shortening of the septal hemiaxes after initial lengthening for about 40 msec from R wave of ECG. In contrast, ventricular stimulation near the septum (i.e. RVO, RVA and LVA) resulted in a biphasic and decreased contraction of the septal wall, in which an early preejection shortening was followed by a brief lengthening and second shortening. LVL pacing showed a monophasic and increased contraction of the septal wall. The biphasic motion of the septal wall was likely to be related to the abnormal mechanical contraction caused by the abnormal conduction sequence of ventricular depolarization. On the other hand, the lateral wall demonstrated a biphasic and decreased contraction during LVL pacing, and a monophasic and increased contraction during RVO, RVA and LVA pacing. Thus, the biphasic and diminished contraction at the site of electrical stimulation was compensated by the monophasic and forceful contraction of the contralateral wall. It is considered that the ventricular septum plays an important functional role in regulation of cardiac performance.

Metabolic effects of glucose-insulin-potassium in the ischemic myocardium

This investigation was designed to explore the metabolic, hemodynamic, and electrocardiographic effects of glucose-insulin-potassium (GIK) solution in a model of segmental myocardial ischemia with significant but incomplete restriction of coronary blood flow. An open-chest anesthetized canine model was utilized including 11 GIK and 6 saline control experiments. The anterior descending coronary artery (LAD) was partially occluded causing an average 71% reduction in its blood flow. Thirty min following occlusion GIK or saline was infused for 30 min at 3 ml/min into a femoral vein. Statistically significant effects of GIK included: increased glucose uptake by the ischemic myocardium, reduced arterial free fatty acid (FFA) concentration, reduced myocardial FFA uptake, decreased coronary arterio-venous oxygen content difference, increased myocardial lactate extraction, decreased myocardial potassium egress, and reduced epicardial ST segment elevation. Heart rate, aortic and left ventricular end-diastolic pressures, and developed force in the ischemic area were unchanged. The results indicate a potentially favorable effect of GIK on the metabolism of the ischemic myocardium which may be due to the shift of substrate utilization from free fatty acids to glucose.

Plasma norepinephrine concentration in the coronary sinus in cardiomyopathies

In order to evaluate the cardiac sympathetic nerve tone in cardiomyopathies, plasma norepinephrine concentration in the coronary sinus (NE(CS)) and artery (NE(A)) was measured by THI method in five patients with the hypertrophic type (HCM) and in seven with the congestive type (CCM); six patients with functional murmur served as controls. NE(CS) was 182 +/- 39 ng/liter (SEM) in HCM, 288 +/- 47 in CCM, and 306 +/- 65 in controls. The NE(CS) - NE(A) difference (delta NE) was 9 +/- 22 ng/liter in HCM, -57 +/- 34 in CCM, and 81 +/- 29 in controls. Norepinephrine overflow into the coronary sinus,which was calculated by multiplying coronary sinus plasma flow by delta NE, was 0.54 +/- 0.86 ng/min/100gm, -2.81 +/- 1.47, and 3.73 +/- 1.77, respectively. Norepinephrine overflow and delta NE were significantly lower in CCM than in controls. The results suggest than an excessive sympathetic discharge does not exist in HCM and that cardiac sympathetic activity is reduced in CCM.

Pulmonary arterial pressure-flow characteristics in atrial septal defect: comparative study with ventricular septal defect and patent ductus arteriosus

Pulmonary arterial pressure-flow relation was studied in 142 patients with artrial septal defect (ASD) and was compared with that of 139 patients with ventricular septal defect (VSD) and was compared with that of ductus arteriosus (PDA). The incidence of pulmonary arterial mean pressure (PAm) over 25 mmHg was 21 percent in ASD, 36 percent in VSD and 43 percent in PDA, and that over 40 mmHg was 3 percent, 23 percent and 19 percent, respectively. Large left to right shunt over 50 percent was found more frequently in ASD (58 percent) than in VSD (22 percent) and PDA (30 percent). When patients were separated into 2 groups at a PAm of 40 mmHg, lower pressure group showed a positive correlation between PAm and left-to-right shunt in each disease, although the correlation was poor in ASD (r equals 0.23) as compared with VSD (r equals 0.49) and PDA (r equals 0.47). The slope of the regression line was less steep in ASD (0.08) than in VSD (0.17) and PDA (0.14). It is considered that pulmonary hypertension in ASD develops on the basis of pulmonary vascular changes caused by prolonged hyperkinetic circulation.

Regional contraction patterns of the left ventricle during ventricular pacing

Ten mongrel dogs were used to assess regional myocardial function in response to electrical pacing form the inflow (RVI), outflow tracts (RVO), and apex (RVA) of the right ventricle and apex (LVA) and lateral wall (LVL) of the left ventricle. Strainguauge arches were sutured to the epicardial segments of the apical and lateral walls of the left ventricle and their mechanical shortening was measured during right artial (RA) and during ventricular pacing. The onset of shortening of two segment did not differ significantly in RA and RVI pacing, while the stimulation of RVA and LVA caused the initial contraction of the apical segment, and RVO and LVL pacing caused that of the lateral segment; i.e. RVA and RVO pacing resulted in left ventricular asynchrony of contraction similar to LVA and LVL pacing, respectively. Asynchrony of contraction was not accompanied by a uniform change in peak tension of regional myocardial segments, but prejection tension rose and ejection tension fell at the pacing site. The reduction in mean aortic pressure inversely correlated with the prolongation of the time interval between the onset of shortening of two segments during left ventricular pacing. The decrease in cardiac performance observed during ventricular pacing was related to the severity of asynchrony rather than the direction of the ventricular depolarization or change in regional myocardial tension.

Effects of isometric handgrip exercise on coronary sinus blood flow in idiopathic cardiomyopathy

Coronary sinus blood flow (CSBF) was measured by the dye dilution method in 18 patients with idiopathic cardiomyopathy including 13 with hypertrophic type and 5 with congestive type, and the capacity for increasing CSBF in response to handgrip exercise was studied in 14 patients. CSBF at rest ranged from 41 to 236 ml/min/M2. Average CSBF of 114 +/- 12 ml/min/M2 (112 +/- 14 in hypertrophic type and 119 +/- 25 in congestive type) was significantly larger than control value of 77 +/- 6 presented previously (p less than 0.01). Handgrip exercise at 30% maximal effort for 3 min resulted in the increase in CSBF, averaging 23 +/- 8 ml/min/M2 (22 +/- 8%). However, in about one-half of cases, the percent increase in CSBF was much smaller than the percent increase in effort index which represents myocardial oxygen demand. The change of CSBF was not correlated with the changes of left ventricular systolic pressure, cardiac output, and stroke work. The diminished response of CSBF to isometric handgrip exercise was ascribed to the decreased coronary vascular reserve in this disorder.

Effects of pacing location on coronary circulation in dogs

In 13 open chest dogs, the right atrium and various ventricular sites (i.e. the inflow and outflow tracts and apex of the right ventricle, apex and lateral wall of the left ventricle) were stimulated electrically at a given rate, ranging from 140 to 210 per min. Coronary circulation and cardiodynamics in response to ventricular pacing were compared with those to right atrial pacing at equivalent heart rate. Stimulation of the ventricle except lateral wall of the left ventricle produced no significant changes in coronary sinus blood flow and myocardial oxygen consumption despite decreased blood pressure and cardiac output. The minor change of coronary sinus blood flow was related to the decrease in coronary vascular resistance. Oxygen content of coronary sinus blood decreased during ventricular pacing, while arterial oxygen saturation remained constant. The response of coronary circulation to ventricular pacing did not differ essentially at faster and slower heart rates. It was considered that when stimuli were applied to the ventricular surface, the relatively constant myocardial oxygen consumption in the presence of lowered cardiac performance was attributed to the asynchrony of fractionate contractions of the ventricular muscle.

Effects of varying pacemaker sites on left ventricular performance

The hemodynamic effects of the site of the artificial cardiac stimulation were studied in 17 open chest dogs. The right atrium and five ventricular sites (the inflow and outflow tracts and apex of the right ventricle, apex and lateral wall of the left ventricle) were stimulated electronically at a given rate, ranging from 130 to 190 per min. When cardiac performance during ventricular pacing was compared with those during right atrial pacing, the former uniformly caused a diminution of cardiac output and systemic blood pressure, without reduction of left ventricular end-diastolic pressure. Ventricular function curves, in which left ventricular stroke work was related to left ventricular end-diastolic pressure, shifted downwards and to the right during ventricular pacing. Stimulation frequency did not alter these variables. It was considered that the left ventricular dysfunction in ventricular pacing resulted from the absence of atrial contribution to ventricular filling, mitral regurgitation present and asynchronous ventricular contraction. No significant difference of cardiac performance was demonstrated by changing the site of ventricular pacing, suggesting that the mode of ventricular depolarization itself was not relevant to a decrease in cardiac performance.

Plasma catecholamine levels in the coronary sinus, aorta and femoral vein of subjects undergoing cardiac catheterization at rest and during exercise

Plasma catecholamine (CA) levels in the coronary sinus (CS), aorta (Ao) and femoral vein (fv) were simultaneously measured in 22 patients with various heart diseases at rest and during handgrip exercise (IHG). The mean resting levels of plasma norepinephine (NE) in CS, Ao and FV were 359 +/- 49 (SEM) pg/ml, 290 +/- 27 and 234 +/- 24, respectively. The corresponding values of epinephrine (E) were 127 +/- 18 pg/ml, 186+/- 30 and 97 +/- 11, respectively. The E values in Ao were significantly greater than those in CS and in FV (p less than 0.05). IHG exercise induced an obvious elevation of plasma CA levels in every portion of the circulation studied. The mean increments of NE concentration were 81%, 54% and 67% of the resting levels at CS, Ao and FV, respectively, while IHG induced elevation of E were 70% of the resting values at each portion studied. Significant correlations were observed between individual CA concentrations in CS and in Ao, and also between those in Ao and in FV at rest. Under raised sympathoadrenal conditions, however, individual values of NE in CS failed to correlate signficantly to those in Ao and in FV, respectively. The NE output from CS was limited to only 3% and 5% of those in Ao at rest and during IHG, respectively. An actual mean increment of NE on its passing through the coronary circulation was only 2% or less of NE output in ao at both stages. It appears, thus, to be untenable that the cardiac tissue is one of the major source of circulating CA at physiological condition. From these reasons, the direct measurement of NE levels in CS may be mandatory, when plasma CA assay is designed for the purpose of studying the role of the sympathetic nerve activity in the regulation of cardiac function.

Reduced response of cardiac norepinephrine release to isometric handgrip exercise in heart failure

In order to evaluate the relation of cardiac norepinephrine (NE) release to left ventricular function, blood was taken simultaneously from the coronary sinus (CS) and the aorta (A) in 19 patients with heart diseases, at rest and during isometric handgrip exercise (IHG) at 30% of their maximal contraction. Plasma NE was analyzed by Renzini's THI method. The concentrations of plasma NE at rest were 397 +/- 66 (S.E.M.) ng/liter in CS and 292 +/- 50 in A. IHG significantly increased NE to 578 +/- 88 in CS and to 462 +/- 85 in A (p less than 0.001). Estimated NE release from the heart (deltaNE = NECS - NEA) correlated inversely to left ventricular end-diastolic pressure at rest (r = -0.520, p less than 0.05) and during IHG (r= -0.689, p less than 0.01). The changes in deltaNE induced by IHG correlated to the slope of the left ventricular function curve (r=0.618, p less than 0.01). It is concluded that the response of cardiac NE release to exercise is reduced in patients with depressed cardiac function.

Regional difference of respiratory changes in pleural pressure between left and right thoraxes in dogs

Respiratory changes in pleural pressure were recorded simultaneously from the left and right pleural spaces in 6 anesthetized closed-chest dogs in the supine, prone, left lateral and right lateral positions. Saline-filled radiopaque catheters connected to strain-gauge manometers were inserted percutaneously in the left and right pleural spaces by an air tight technique and their tips were placed in the mid-thoracic plane. The esophageal pressure was also recorded with the saline-filled system. The value of respiratory pressure amplitude (deltap, the difference between end-expiratory and minimal inspiratory pressures) in the pleural spaces was significantly greater in the left thorax than in the right in the supine, prone and right lateral positions. In 4 body positions, deltap in pleural pressure was significantly greater than in esophageal pressure. It is concluded that respiratory variations in pleural pressure of the left and right thorax are not the same and that postural change does not produce significant regional difference of the respiratory variations.