Contracture of the deltoid muscle. Results of distal release

We prospectively studied the results of distal release, performed between February 1989 and December 1994 for the treatment of a contracture of the deltoid muscle, in forty patients (forty-nine shoulders). Forty-seven contractures (in thirty-eight patients) developed after multiple intramuscular injections of various medications. The two remaining contractures (in two patients) were congenital. The average age at the onset of the symptoms was thirty-two years (range, birth to fifty-eight years). The primary symptoms included pain around the neck and the shoulder girdle, dimpling of the skin, a palpable fibrous band, winging of the scapula, difficulty in combing the hair or reaching the contralateral side of the body for grooming, and inability to bring the arm adjacent to the body. The average age at the time of the operation was thirty-nine years (range, fifteen to sixty-three years). The average duration of follow-up was three years and eleven months (range, two years to six years and six months). After the distal release of the contracture, but on the same day, the patients started a physical-therapy program. Postoperatively, the pain, dimpling of the skin, palpable fibrous band, and winging of the scapula resolved in forty-eight shoulders (thirty-nine patients). Six patients (six shoulders) no longer had difficulty in combing the hair or adducting the shoulder. There were no infections or neuromuscular complications. Forty-seven (96 per cent) of the forty-nine shoulders (thirty-eight of the forty patients) had a good clinical result, and two shoulders (two patients) had a poor result. Anterosuperior subluxation of the humeral head, noted on preoperative radiographs of twenty-three shoulders (eighteen patients), was not present postoperatively. Drooping of the acromion, seen in six patients (six shoulders) in whom the contracture had developed before they were sixteen years old, improved postoperatively in five shoulders (five patients). Rotation of the scapula, seen in five shoulders (five patients), resolved after release of the contracture in all five. There were no clinical or radiographic signs of osteoarthrosis due to long-term anterior translation of the shoulder joint in the four patients (six shoulders) who had had the contracture for at least twenty years (average, twenty-three years; maximum, twenty-seven years).

A 10-year longitudinal study of tubal function in patients with nasopharyngeal carcinoma after irradiation

OBJECTIVE

To follow up the chronological change of tubal function in patients with nasopharyngeal carcinoma for 10 years after irradiation.

DESIGN

Patients with nasopharyngeal carcinoma were subjected to eustachian tube function tests before irradiation and 6 months, 5 years, and 10 years after irradiation.

SETTING

University hospital.

PATIENTS

Ten patients (20 ears), 7 men and 3 women.

RESULTS

Twelve (60%) of the ears had patulous tubes 10 years after irradiation, which might result from atrophy of peritubal tissues. The occurrence of a patulous tube was independent of the radiation dosage, but it was related to the interval since irradiation.

CONCLUSIONS

Development of a patulous tube is associated with correction of organic obstruction of the eustachian tube. Resolution of the inflammatory reaction plays the most important role in recovery of function of the tube. Therefore, the prevalence of middle ear complications is low 10 years after irradiation.

Undifferentiated carcinoma of the major salivary glands

BACKGROUND

Undifferentiated carcinoma of the salivary glands is a rare disease, the incidence of which is highest among the Inuit of Greenland and North America. It was demonstrated to be closely related to Epstein- Barr virus (EBV) infection. However, the relation of EBV to this tumor has not been studied to any great extent here in Taiwan because of the small number of cases.

METHODS

Twelve cases of undifferentiated carcinoma of the salivary glands from the period 1977-1996 were retrieved from the cancer registry at National Taiwan University Hospital. The clinical data were analyzed retrospectively based on the medical records. Eleven formalin fixed, paraffin embedded tissue sections were used for in situ hybridization with an antisense probe complementary to EBV-encoded RNA 1 (EBER1).

RESULTS

Ten of 12 tumors originated from the parotid gland and 2 from the submandibular gland. The patients' ages ranged from 22 to 63 years, with an average of 38.1 years. One patient was lost to follow-up, 2 patients died of metastatic disease, and the remaining 9 patients were all alive and disease free at last follow-up. The actuarial 5-year survival rate was 79.8%. In situ hybridization demonstrated EBER1 in 9 of the undifferentiated carcinomas with lymphoid stroma, but EBER1 was not demonstrated in the other 2 tumors without lymphoid stroma.

CONCLUSIONS

Undifferentiated carcinoma with lymphoid stroma of the major salivary glands is closely associated with EBV. The mainstay of treatment is surgery and postoperative radiotherapy. The outcomes in this series were good except for two elderly patients who died of rapid and progressive distant metastases.

Pyogenic granuloma--an uncommon complication of nasal packing

Nasal packing is a very common procedure in the otolaryngologic service for nasal bleeding and postoperative hemostasis. However, a pyogenic granuloma complicated from nasal packing has not been reported in the literature. A 50-year-old man underwent nasal packing by use of vaseline gauze due to nasal bleeding. Two weeks later, a dark brown nasal tumor was found in his nasal cavity. He underwent partial turbinectomy for removal of the tumor. The pathology demonstrated a pyogenic granuloma. It is the first case of a confirmed pyogenic granuloma complicated from nasal packing in the literature. To prevent complications and decrease the discomfort, we strongly recommend the use of inflatable balloons or nontraumatic materials for nasal packing.

Salvage surgery for recurrent nasopharyngeal carcinoma

OBJECTIVE

To assess the efficacy of salvage surgery for patients with recurrent nasopharyngeal carcinoma (NPC) at the primary site after radiotherapy.

DESIGN

Retrospective analysis of 24 patients treated by transpalatal, transmaxillary, or transmandibular approach to resect the recurrent tumor, with maximum follow-up of 50 months.

SETTING

Academic tertiary referral center.

RESULTS

Radiotherapy before salvage surgery included 1 to 3 courses of radiation to the nasopharynx, with doses ranging from 60 to 190 Gy. Eighteen (75%) of the patients relapsed within 2 years, and 6 (25%) relapsed more than 6 years after the last irradiation. In 4 of 6 late-relapsing cases, the histopathological type changed to keratinizing squamous cell carcinoma, which is rare in cases of NPC in Taiwan. Fourteen patients (58%) survived for 8 to 50 months after surgery (median, 18 months). The surgical complications were tolerable.

CONCLUSIONS

Salvage surgery is feasible in selected patients with recurrent disease at the primary site. Thus, we can offer alternative retreatment in addition to external irradiation for patients with recurrent NPC.

Screening of Carnation Cultivars for Resistance to Meloidogyne incognita

A total of 33 carnation cultivars cultured in Korea were screened for resistance to the southern root-knot nematode, Meloidogyne incognita. Carnations were tested by either inoculating with 5,000 eggs or by transplanting into a mixture of bedding medium and soil infested with an average of 435 second-stage juveniles/300 cm(3) soil. Cultivars, Desio, Castelaro, Kappa, Rara, Izu Pink, Target, and Antalia were highly resistant to M. incognita. Twelve cultivars were moderately resistant, and the remaining 14 cultivars were susceptible. These results were similar to those obtained when the cultivars were subjected to field populations of the condition on a carnation farm.

Surgical treatment of complex fracture of the proximal humerus

Sixteen patients aged 19 to 63 years (average, 52 years) were observed from 1.8 to 5.6 years (average, 3.8 years) after open reduction and internal fixation with or without external fixation of 3- and 4-part displaced fractures of the proximal humerus. There were 12, 3-part displaced greater tuberosity and surgical neck fractures with 6 concomitant dislocations. Four cases were 4-part fractures with 3 concomitant dislocations. Fixation was achieved with heavy sutures or wire that incorporated the rotator cuff tendon, tuberosities, and shaft combined with threaded pins or Hoffmann external fixation to enhanced stability for early rehabilitation. According to Neer's criteria, 14 (87%) of the 16 patients had satisfactory or excellent results. Two (13%) of the 16 had unsatisfactory results. The use of a technique of limited soft tissue dissection and internal fixation with or without external fixation achieved good fracture stability and a high percentage of satisfactory results. The limitations of the procedure include (1) patients who could not tolerate anesthesia, (2) complex displaced fractures in older patients with osteoporotic bone that cannot hold pins or external fixation, (3) older patients with 4-part fracture dislocations in which avascular necrosis of the humeral head occurs frequently and in which a subsequent endoprosthesis insertion is inappropriate if osteosynthesis fails, and (4) head splitting fractures. The described approach provides an alternative method for the treatment of complex displaced fractures of the proximal humerus.

Radiation-induced malignant fibrous histiocytoma in patients with nasopharyngeal carcinoma

OBJECTIVE

To evaluate the prevalence, 15-year cumulative incidence, time interval, and prognosis of radiation-induced malignant fibrous histiocytoma of the head and neck in long-term survivors of nasopharyngeal carcinoma.

DESIGN

Cohort.

SETTING

Tertiary care hospital.

PATIENTS

Eight long-term survivors of nasopharyngeal carcinoma with malignant fibrous histiocytoma in the maxillary sinus or nasal cavity.

MAIN OUTCOME MEASUREMENT

Survival of postirradiation malignant fibrous histiocytoma in patients with nasopharyngeal carcinoma.

RESULTS

The prevalence of radiation-induced malignant fibrous histiocytoma in long-term survivors of nasopharyngeal carcinoma was 0.38%. The 15-year cumulative incidence was 2.2%. Most tumors occurred in the maxillary sinus and were characterized by spindle-shaped tumor cells with plump nuclei arranged in a whorl or storiform pattern in a fibrous stroma. The mean interval between malignant fibrous histiocytoma and nasopharyngeal carcinoma was 121 months. Local recurrence developed in all cases within 9 months after surgery. Six patients died of disease without distant metastasis within 30 months. Two patients were alive with disease for 20 and 32 months, respectively.

CONCLUSIONS

Radiation-induced malignant fibrous histiocytoma in the head and neck region in long-term survivors of nasopharyngeal carcinoma is rare. It takes a long time to occur after irradiation and is locally invasive with poor prognosis.

Otitis media with effusion in patients with nasopharyngeal carcinoma, postirradiation

Eighteen patients with nasopharyngeal carcinoma were subjected to eustachian tube function testing before and 6 months and 5 years after irradiation at the university hospital to investigate the chronological changes of tubal function induced by irradiation and to study the development of otitis media with effusion after irradiation. Improvement of tubal function was found 5 years after irradiation in those ears without otitis media. However, in patients who had otitis media with effusion after irradiation, deterioration of tubal function was persistent, and inflammatory reaction was detected in the upper respiratory tract, including the maxillary sinus and nasopharynx. Thus, the development of otitis media with effusion after irradiation in patients with nasopharyngeal carcinoma is attributable to both tubal and inflammatory factors. Insertion of a ventilatory tube in ears can relieve tubal obstruction but can possibly aggravate the inflammatory process. Therefore, it is our opinion that myringotomy plus local treatment may be preferable to insertion of a ventilatory tube in patients with nasopharyngeal carcinoma who have otitis media with effusion.

Soluble interleukin-2 receptor as a clinical parameter for nasopharyngeal carcinoma

We evaluated whether the serum soluble interleukin-2 receptor (sIL-2R) may be a parameter to monitor the efficacy of treatment for nasopharyngeal carcinoma (NPC). There were 177 NPC patients and 24 healthy controls. The level of sIL-2R was measured with a sandwich ELISA kit. Higher levels of sIL-2R than for controls were found in NPC patients before treatment and in patients with distant metastasis (p < 0.001). There was, however, no difference in sIL-2R levels between controls and NPC patients after radiotherapy in relapse-free or in primary relapse. The sIL-2R levels in sequential testing revealed good correlation with clinical response. The sIL-2R levels were found to be elevated when distant metastasis was detected. Two patients had elevated sIL-2R level up to 5 months before clinical detection of metastasis. These results indicate that serial measurements of sIL-2R levels are worthwhile for NPC patients in their clinical course. The sIL-2R level proved to be an adjunct clinical parameter to monitor the efficacy of treatment of NPC.

"Trapdoor" procedure for osteonecrosis with segmental collapse of the femoral head in teenagers

Osteonecrosis of the femoral head in adolescents often leads to serious destructive changes in the hip with resulting significant disability. Between March 1981 and June 1990 we treated 13 teenagers (14 hips) using the "trapdoor" bone grafting procedure for severe femoral head osteonecrosis with articular surface collapse. Nine cases (10 hips) had the trapdoor procedure combined with containment osteotomy of the femur and acetabulum. Thirteen of the 14 hips had adequate follow-up to be included in this report. The main focus of this report is the 10 hips treated with a trapdoor bone grafting plus containment procedure (femoral osteotomy, acetabular osteotomy, or both). At an average follow-up of 4 years 5 months, clinically seven cases (eight hips) had a good result and two had a fair result. Radiographic evaluation showed six hips with a good result, three hips with a fair result, and one with a poor result. None of these 10 hips has yet required hip fusion or replacement arthroplasty, suggesting that trapdoor bone grafting plus containment can serve as a procedure to delay the need for hip fusion in femoral head avascular necrosis in teenagers.

Epstein-Barr virus harboring in the parotid gland without tumor association

The purpose of this study is to clarify the relationship between Epstein-Barr virus (EBV) and tumors of the major salivary gland. EBV DNA was detected by polymerase chain reaction (PCR) in parotid secretions in 56% of patients (n = 32) regardless of the presence of tumors in the parotid gland and in tumor tissues in 19% of surgical specimens (n = 21). By Southern blot-hybridization analysis, we found type A EBV in three patients and type B EBV in one patient. In situ hybridization for EBV genome was positive in surgical specimens of salivary glands in 33% of patients (n = 21). Our results suggest that this virus may not play a role in the pathogenesis of most tumors of the major salivary gland. However, two patients with lymphoepithelial carcinoma were found to have a close relationship to EBV as shown by high titers of antibodies in the sera against EBV related antigens by standard immunofluorescent technique and by the presence of many copies of EBV genome in tumor cells using in situ hybridization.

Association between bleomycin genotoxicity and non-constitutional risk factors for head and neck cancer

Sensitivity of phytohaemagglutinin-stimulated lymphocytes to bleomycin clastogenicity is increased in patients with tumours in organs and tissues that are in direct contact with the external environment, such as the mucosa of the head and neck. Sensitivity to bleomycin may reflect a genetically determined hypersensitivity to certain genotoxicants and therefore may be important in the carcinogenic process. In this study the applicability of bleomycin genotoxicity was investigated in cultured lymphocytes of forty individuals without a tumour history. No correlations were observed with increasing age or the well-known head and neck cancer risk factors alcohol and tobacco consumption. Since inter-individual variation in sensitivity greatly exceeded intra-individual variation, our results suggest that an elevated bleomycin clastogenicity score may identify individuals who have a constitutional hypersensitivity towards certain genotoxicants and may show an increased cancer susceptibility.

Multiple schwannomas of the foot: report of a case

Schwannoma, a relatively common tumor of the nerve sheath, rarely involves the foot. A review of the literature disclosed that most reports of schwannoma of the foot were solitary tumors. There has been only one reported case of multiple schwannomas of the foot. We report a case of multiple schwannomas involving both the medial and lateral plantar nerves of the right foot. The patient had been treated for plantar fasciitis for the previous eight years. After excision of one tumor, magnetic resonance imaging (MRI) was used in the diagnosis, revealing four additional tumors. These tumors were also successfully excised and the patient's symptoms relieved. Patients with prolonged intractable pain and tenderness of the foot may require examination by MRI or sonography to search for deep tumors impinging upon the plantar nerves.

Elevated levels of soluble interleukin 2 receptor and tumor necrosis factor in nasopharyngeal carcinoma

Depressed cell-mediated immunity as a measure of the mitogenic response of mononuclear cells in patients with nasopharyngeal carcinoma is well documented, but the mechanism is still unclear. The enzyme-linked immunosorbent assay was used to measure soluble interleukin 2 receptor and tumor necrosis factor levels in 295 patients with nasopharyngeal carcinoma and 97 age-matched control subjects. Soluble interleukin 2 receptor levels in patients with nasopharyngeal carcinoma were elevated and correlated with clinical staging. Higher soluble interleukin 2 receptor levels were found in patients with bone metastasis but not in patients with intracranial involvement. The levels of tumor necrosis factor in nasopharyngeal carcinoma were higher than in control subjects but did not correlate with clinical staging. These data suggest that soluble interleukin 2 receptor levels might be more useful than soluble tumor necrosis factor levels that indicate tumor bulk. Soluble interleukin 2 receptor serves as a blocking factor that competes with interleukin 2 function, resulting in a decreased mitogenic response in patients with nasopharyngeal carcinoma. The usefulness of the levels of soluble interleukin 2 receptor to monitor the efficacy of treatment in patients with nasopharyngeal carcinoma with bone metastasis requires further study.

[Serum B-protein in patients with nasopharyngeal carcinoma]

B-protein is an acidic glycoprotein that appears in the serum of cancer patients, although it is not produced by cancer cells. It is not a cell surface antigen but can serve as a biological marker for detecting malignancies and monitoring cancer therapy. From January to August 1987, serum samples were collected from 133 patients with nasopharyngeal carcinoma (NPC) and 19 patients without cancer as the control group. The positive rates of B-protein in NPC patients without distant metastasis (107) and with distant metastasis (26) were 78.5% and 84.6% respectively. The overall positive rate of B-protein in NPC patients was 79.7%, which did not correlate with tumor stage and sex. The positive rate of B-protein in the control group was 5.3%. The difference in positive rates between NPC and the control group was significant (p less than 0.001). The quantitative changes of B-protein did not correlate with the tumor burden of NPC patients. Therefore, B-protein assay is not recommended in monitoring the treatment of NPC.

[Detection of serum gamma interferon in nasopharyngeal carcinoma patients using reversed passive hemagglutination method]

In order to detect the difference in serum gamma-interferon levels between patients with nasopharyngeal carcinoma (NPC) and normal controls, the reversed passive hemagglutination (RPHA) method was used. Serum gamma-interferon level was determined in 93 patients with NPC, of these, 47 were newly diagnosed, untreated patients. Of the treated patients, 15 had received radiotherapy but were proved later to have distant metastasis. Thirty-one patients had received radiotherapy and survived over 5 years without local recurrence or distant metastasis. Another 47 healthy subjects, age and sex matched with fresh NPC cases, were used as control group. The results revealed that the concentration of gamma-interferon in the serum of neither males nor females showed significant difference (p greater than 0.1). Among the NPC fresh cases, the concentration of gamma-interferon also showed no significant difference in patient serum in either early stages (stages I and II) or later stages (stages III-V) (p greater than 0.1). The serum gamma-interferon level was significantly increased in fresh NPC patients compared with normal controls (p less than 0.05). Concerning the irradiated patients, serum gamma-interferon level was not increased in patients who survived over five years, without relapse, compared with normal controls (p greater than 0.1). However, the serum gamma-interferon level in patients with distant metastasis was higher than in normal controls (p less than 0.05). Also, the serum gamma-interferon level was significantly increased in distant metastatic patients compared with patients without relapse (p less than 0.05).

A cephalometric appraisal of edgewise Class II nonextraction treatment with extraoral force

The purpose of this study was to determine the treatment effects of nonextraction edgewise therapy combined with cervical headgear on Class II, Division 1 malocclusions. Data from a sample of 43 treated patients with a mean age of 11 years 11 months and a mean treatment time of 2 years 8 months were recorded. A cephalometric appraisal was done and the initial and final measurements of points, lines, and angles based on accepted cephalometric analyses were compared. Student's t test for paired cases was used to evaluate the significance of all measurement changes. The significant findings were as follows: the inhibition of forward growth of the maxilla, downward tipping of the anterior part of the palate, reduction of flaring of the maxillary incisors, reduction of the facial convexity, and extrusion and mesial movement of maxillary and mandibular first molars. The overall results tend to indicate the efficacy of this treatment modality in the treatment of the Class II, Division 1 malocclusion.