Partial laryngectomy and radiotherapy for supraglottic cancer: a conservative approach

This is a retrospective study of 33 patients with supraglottic cancer treated with partial laryngectomy and moderate-dose radiotherapy at the University of Virginia from 1967 through 1986. All patients had a 2-year minimum follow-up. Ten patients received preoperative radiotherapy, and 23, postoperative radiotherapy. The 2-year adjusted survival rate was impressive at 97%. Local control at 2 years was 96%, including one patient who was salvaged with total laryngectomy. Control of the neck was 90% at 2 years. Ninety percent of the patients alive at 2 years had a functional voice. One patient required a completion laryngectomy for chronic aspiration. Conservation surgery with radiotherapy provides excellent survival as well as locoregional control rates with preservation of function in selected patients with supraglottic cancer. This approach may be especially helpful in the management of bulky T2 lesions as well as T4 lesions with minimal vallecula or base of tongue involvement.

Role of fine needle aspiration in the diagnosis of lesions of the oral cavity, oropharynx, and nasopharynx

The oral cavity, oropharynx and nasopharynx are readily accessible to fine needle aspiration (FNA). This study reviews the author's experience with 93 FNA from these sites: 76 from the oral cavity, eight from the oropharynx, and eight from the nasopharynx. Thirty-nine (42%) of the FNA were positive for malignancy with no false-positive diagnoses. In 15 cases the FNA provided the initial diagnosis of cancer and in 24 cases documented recurrence. Five (5%) of the FNA interpreted as suspicious for malignancy were subsequently proven malignant by biopsy. There were 33 (36%) negative FNA with seven false-negative diagnoses confirmed by biopsies. Fifteen FNA (16%) were unsatisfactory and malignancy was found by biopsy in two of these cases. These results emphasize the importance of repeating the FNA or recommending biopsies in negative and unsatisfactory FNA when clinically indicated to assure accuracy in diagnosis. A positive FNA may be regarded as a definitive diagnostic test and treatment instituted accordingly. No complications resulted from these FNA. This study demonstrates the application, safety, and accuracy of FNA in these anatomic sites.

Clinicopathologic features of cutaneous squamous cell carcinomas of the head and neck in patients with chronic lymphocytic leukemia/small lymphocytic lymphoma

The clinicopathologic features of 32 cutaneous squamous cell carcinomas of the head and neck in 12 patients with chronic lymphocytic leukemia/small lymphocytic lymphoma were examined to determine the frequency of clinically aggressive and histologically poorly differentiated carcinomas in this group of patients. Two thirds of the neoplasms were multiple and 56% were high grade (grade 3 or 4). One of the 12 patients had recurrent carcinoma, two patients had recurrent and metastatic disease, and two patients had metastatic tumor without recurrence. Two patients died of tumor, one patient is alive with extensive recurrent and metastatic disease, and one patient died of an uncertain type of carcinoma. An additional patient with squamous cell carcinoma of the face died of cutaneous squamous cell carcinoma that arose on the chest. This study shows that cutaneous squamous cell carcinomas of the head and neck in patients with chronic lymphocytic leukemia/small lymphocytic lymphoma are often high grade and have the potential for recurrence and metastasis.

Intranasal tolerance and histopathologic effects of a novel synthetic interferon, rIFN-alpha Con1

In a double-blind trial 119 adults were randomly assigned to receive daily sprays of placebo (N = 30) or rIFN-alpha Con1 3 MU (N = 29), 9 MU (N = 30), or 30 MU (N = 30) per day for 25 consecutive days. Fifty-nine subjects were removed from treatment because of abnormal nasal exams (N = 56) or irritative symptoms (N = 3). The fraction of drop-outs in the placebo group (30%) was significantly different (P less than 0.05) from that in the 3 MU (55%), 9 MU (57%), or 30 MU (67%) groups. Nasal mucosal biopsies collected 1-2 days after completing spray use detected moderate or marked lymphocytic infiltration in 10% of placebo (N = 10), 90% of 3 MU (N = 9), 85% of 9 MU (N = 13), and 70% of 30 MU (N = 10) subjects (P less than 0.05, placebo vs each rIFN-alpha Con1 group). All 3 dose levels of rIFN-alpha Con1 were associated with significant clinical and histopathologic signs of nasal irritation. The findings suggest that intranasal rIFN-alpha Con1 does not have a more favorable therapeutic index than rIFN-alpha 2 and that the risk of nasal irritation relates more closely to the anti-viral activity than the protein content of the rIFN-alpha administered.

Coding of acute myocardial infarction. Clinical and policy implications

STUDY OBJECTIVE

To evaluate the appropriateness of diagnostic coding of acute myocardial infarction across teaching and nonteaching hospitals.

DESIGN

Retrospective review of a random sample of medical records to find evidence of the occurrence and active treatment of acute myocardial infarction during the admission.

SETTING

Five tertiary teaching, five other teaching, and five nonteaching hospitals in metropolitan Boston.

CASES

Random sample of hospital admissions assigned a discharge diagnosis of acute myocardial infarction between October 1984 and September 1985.

MEASUREMENT AND MAIN RESULTS

Of the 1003 cases reviewed, 260 did not meet the clinical criteria for acute myocardial infarction. At tertiary hospitals, 175 (41.7%) failed to qualify, compared with 25 (9.1%) at nonteaching facilities. In a large fraction of the disqualified cases, the patients had been admitted to exclude the diagnosis of acute myocardial infarction; although explicitly "ruled out," an acute myocardial infarction code was assigned. Sixty-six cases from teaching hospitals did not qualify because the patient had been admitted only for coronary angiography after an uneventful postmyocardial infarction course. Almost one-third of these patients had had their infarcts from 5 to 8 weeks before the angiography admission.

CONCLUSIONS

Cases with an inappropriate discharge diagnosis of acute myocardial infarction may be concentrated in teaching hospitals. This finding could have implications for Medicare's diagnosis-related group payment system and governmental and other research efforts that use these data for such purposes as drawing inferences about the quality of hospital care.

The role of exercise testing in evaluation of arrhythmias

Exercise testing has been widely applied for the evaluation of patients with coronary artery disease. The principles underlying its use for this indication make it a useful adjunctive technique, when combined with ambulatory monitoring, to diagnose arrhythmias and monitor antiarrhythmic drug therapy. During exercise, there is a withdrawal of vagal tone and a marked increase in circulating catecholamines and sympathetic inputs to the heart. These changes may directly cause arrhythmias (e.g., catecholamines can enhance automaticity and delayed afterpotentials and can shorten myocardial conduction time and refractory periods). However, they also augment myocardial oxygen demands by increasing myocardial inotropy, heart rate and blood pressure. Such changes may cause ischemia in patients with heart disease, which is a powerful stimulus for arrhythmia, or lead to dysfunction in left ventricular contraction and increased myocardial wall stress, factors that also may precipitate arrhythmia. In approximately 10% of patients with a history of serious arrhythmia, exercise represents the only means for exposing arrhythmia. Importantly, this technique is useful for evaluating the effect of antiarrhythmic drugs. These agents work by reducing membrane automaticity, slowing impulse conduction through the myocardium and prolonging membrane refractoriness. In contrast, catecholamines, which are secreted in response to exercise, have the opposite effect. Thus, exercise may negate the important effects of the antiarrhythmic drugs. Additionally, exercise testing may expose potentially serious toxic drug reactions that may not be obvious at rest. These include conduction abnormalities, negative inotropic effects, congestive heart failure and aggravation of arrhythmia. Although the presence and frequency of arrhythmia with exercise is highly variable in patients with benign arrhythmia, results are more consistent in patients with a history of serious arrhythmia. If arrhythmia is reproducibly provoked with exercise, this technique can be used to judge drug effect. Thus, exercise testing is an important, reliable and helpful technique for exposing arrhythmia, evaluating drug efficacy and identifying potentially serious toxic drug effects.

Therapeutic and diagnostic benefits of intentional crosstalk mediated ventricular output inhibition

Ventricular output inhibition due to crosstalk is generally considered unsafe and something that should be avoided. Special circuits have been incorporated in some dual chamber pacing systems to absolutely prevent this from happening. However, in patients with intact atrioventricular conduction, crosstalk mediated ventricular output inhibition can be beneficial to the evaluation and management of the patient. Utilizing this technique, one can achieve single chamber atrial paced rates which greatly exceed the rates allowed by lower rate limit programming to facilitate an assessment of the integrity of AV nodal conduction and to both convert and suppress some pathological tachyarrhythmias. The methods of achieving crosstalk and its utilization in four patients is discussed in this report.

Tolerance and efficacy of intranasal administration of recombinant beta serine interferon in healthy adults

We performed two studies to determine the dose-related tolerance and the efficacy of recombinant beta serine interferon (rIFN-beta ser) in experimental rhinovirus infection. In the tolerance study, 120 healthy adults received intranasal sprays of rIFN-beta ser or placebo daily for 25 d. No differences in nasal symptoms were found. Rhinoscopy detected more mucosal bleeding sites in high-dose (38%) versus low-dose (12.5%) or placebo (12.5%) recipients. There were more subepithelial lymphocytes in nasal biopsy specimens in the high-dose (54%) than the low-dose (17%) or placebo (17%) groups. In the efficacy study, 34 volunteers received daily nasal drops of IFN, beginning 36 h before challenge and for three days afterwards. The numbers of infections and days of shedding of virus were not reduced, but colds occurred less often in the high-dose (25%) than in the low-dose (55%) or placebo (64%) recipients. Nasal mucus weights were lower in the high-dose (mean +/- SD g per five days; 5 +/- 4) than placebo (31 +/- 37) recipients. Thus, rIFN-beta ser may have a more favorable therapeutic ratio than do previously tested alpha interferons.

Preservation of the eye in paranasal sinus cancer surgery

Forty-one patients undergoing surgery between 1977 and 1985 for malignant tumors of the paranasal sinuses abutting or eroding the orbital walls were studied for the need to remove the orbital contents. All patients had preliminary computed tomographic scans to delineate the extent of orbital invasion. All were treated with preoperative radiotherapy. If the tumor mass could be peeled from the periorbita, the eye was saved. Preservation of eyes in the patients without periosteal invasion did not alter survival. Frozen-section control may be used to determine periorbital involvement. If the periorbita was minimally involved, it was locally resected. If invasion of the periorbita was extensive, an orbital exenteration was done. Only five of 41 patients required exenteration. Local recurrence of disease in the orbit has not occurred in these patients.

Small-cell carcinoma of the parotid gland with neuroendocrine features

An 82-year-old woman had a small-cell carcinoma of the parotid gland with cells containing neuroendocrine secretory granules. To our knowledge, these dense-core granules have been identified in only three other major salivary gland small-cell carcinomas. The findings of histologic and ultrastructural evaluations of this neoplasm suggested a salivary duct cell origin. The tumor appears to arise from cells of the salivary duct system that differentiate into cells with either neuroendocrine or epithelial features. Electron microscopy to determine the type of small-cell carcinoma should be performed, as this may have prognostic significance. Aggressive therapy should be undertaken, since small-cell carcinomas of the major salivary glands appear to have a better prognosis than bronchogenic or laryngeal small-cell carcinomas have.

Tumor invasion of the anterior skull base: a comparison of MR and CT studies

Seven patients who had tumors arising in the anterior face or paranasal sinuses and invasion of the anterior skull base were evaluated with magnetic resonance (MR) and high resolution CT. Magnetic resonance was superior in evaluating tumor encasement of the carotid artery and invasion of the cavernous sinus; for assessing the relationship of the tumor to the anterior brain, optic nerves, and optic chiasm; in providing coronal images free from dental artifact; and in determining tumor extent within the infratemporal fossa. Bone destruction was more easily observed on CT than MR.

Sinonasal undifferentiated carcinoma: a distinctive and highly aggressive neoplasm

Eleven cases of sinonasal undifferentiated carcinoma were treated between 1975 and 1986. This distinctive neoplasm involved the orbital cavity in 6 of 11 patients (55%) and the cranial cavity in 7 of 11 patients (64%) at the time of presentation. Of the eight patients (73%) who died of disease, six died within 13 months after the diagnosis. One patient has no evidence of disease 10 months after therapy, and two are alive with disease after 15 and 22 months.

AO compression plating technique for treating fractures of the edentulous mandible

The treatment of fractures of the edentulous mandible has posed a significant problem to all physicians treating trauma patients because of the absence of teeth. Dynamic compression plating has been proven over the years by the experience of fracture apposition and excellent fragment immobilization in this difficult group.

MRI vs. high-resolution CT scanning: evaluation of the anterior skull base

While magnetic resonance imaging (MRI) is no longer a tool of the future, its availability is limited. Most hospitals still use high-resolution computed tomography (CT) scanning as their major imaging modality. Although numerous articles point to the improved diagnostic uses of MRI--as compared to high-resolution CT--a change from high-resolution CT scanning to MRI scanning throughout the United States would cost billions of dollars. We should, therefore, delineate those clinical situations in which magnetic resonance imaging is distinctly superior to high-resolution CT scanning. It is already an accepted fact that MRI provides improved imaging of the central nervous system, but, while recent articles maintain the superiority of MRI head and neck imaging, the advantages to the clinician are less clear. We present representative cases of large malignant tumors of the frontal, ethmoid, and sphenoid sinuses, in which the full extent of the disease which involved intracranial structures and the orbit was better defined on the MRI scan than it was on the high-resolution CT scan. Decisions concerning the involvement of the infratemporal fossa, the cavernous sinus, the optic chiasm, the pituitary, and the frontal lobes were more easily made when based upon magnetic resonance imaging, while the tumor involvement as evaluated by CT scanning was much less clear. Establishment of the problem regions of the head and neck--when magnetic resonance imaging is superior to high-resolution CT scanning--will assist in identification of the true need for this tool in the practice of the otolaryngologist--head and neck surgeon.

Sinonasal undifferentiated carcinoma. An aggressive neoplasm derived from schneiderian epithelium and distinct from olfactory neuroblastoma

Eight cases of a highly aggressive undifferentiated carcinoma of the nasal cavity and paranasal sinuses are described. The patients, who ranged in age from 30-77 years, had multiple sinonasal symptoms, and each had involvement of the nasal cavity, maxillary antrum, and ethmoid sinus. Six tumors extended into the orbital bones, and five penetrated the cranial cavity. Five patients died of disease from 1 to 41 months after diagnosis (median: 4 months), and three are alive with tumor less than 1 year following diagnosis. Microscopically, the neoplasms formed nests, trabeculae, and sheets containing medium-sized cells with small to moderate amounts of eosinophilic cytoplasm. A high mitotic rate, tumor necrosis, and prominent vascular permeation were characteristic. Seven neoplasms were immunoreactive for cytokeratin, five for epithelial membrane antigen, and four for neuron-specific enolase. Ultrastructurally, occasional small desmosomes and rare membrane-bound, dense-core granules were observed. Sinonasal undifferentiated carcinoma is a distinctive clinicopathologic entity that must be distinguished from other, less aggressive sinonasal neoplasms.

Esthesioneuroblastoma: the University of Virginia experience 1960-1985

Twenty-six cases of esthesioneuroblastoma were treated by the Department of Otolaryngology-Head and Neck Surgery from 1960 to 1985. This period was divided into the precraniofacial period (1960 to 1975) and the craniofacial period (1976 to 1985) to denote the transition to a more aggressive combined therapeutic approach. Of the eight patients in the precraniofacial group (group I), only 37.5% are alive without disease. In group II (the craniofacial group), 82% of the patients are alive without disease with an average follow-up of 4 years. This latter survival rate compares favorably with the survival rate of group I and the cure rate of 10% to 67% as stated in other studies.

Electrocautery and pacemakers: management of the paced patient subject to electrocautery

Electrocautery, commonly used during surgery to maintain hemostasis, can have significant detrimental effects in the paced patient. Damage to the pulse generator, reprogramming of the pacemaker, changes in the capture threshold, and ventricular fibrillation can all be induced by electrocautery. Familiarity with the particular pacemaker in use is critical in minimizing these adverse effects. Preoperative evaluation of the patient's dependence on the pacemaker and evaluation of pacemaker function should be performed and documented. We recommend close intraoperative monitoring of heart rate and rhythm, and suggest that a pacemaker programmer be on hand in the surgical suite during the operation. A postoperative check of pacemaker function should be carried out so that electrocautery-induced pacemaker malfunction will not go unnoticed or uncorrected. Three cases are presented which clearly illustrate these points.

Blunt esophagectomy and gastric interposition for tumors of the cervical esophagus and hypopharynx

Between April 1982 and June 1984, 17 patients underwent blunt esophagectomy and gastric interposition for squamous carcinoma of the cervical esophagus or hypopharynx. There was one operative death; no bleeding complications required thoracotomy or re-exploration. In two patients, a previously unknown carcinoma of the resected esophagus was discovered at the time of surgery. Blunt esophagectomy with gastric interposition is a safe technique for cervical esophageal reconstruction, as it has the added benefit of removing the entire esophagus, which has a propensity for later or synchronous carcinoma in patients with head and neck malignancies.

Normal and abnormal rhythms associated with dual-chamber pacemakers

Except for the unique eccentricities of individual devices, most dual-chamber paced rhythms, both normal and abnormal, are readily understood and lend themselves to analysis if the programmed parameters are known. Although they may appear intimidating, this need not be the case if the physician is initially willing to devote both time and effort to understanding them. Learning is not a passive exercise. It is therefore suggested that when the patient is clearly stable and doing well and there is no active concern about a possible pacing system malfunction, the physician should obtain and carefully analyze selected tracings. This analysis should include the diagramming of all pertinent intervals (atrial escape interval, AV delay interval, maximum tracking rate interval, postventricular atrial refractory period, blanking period, and ventricular refractory period) by placing these cycles under the respective P and R waves and atrial and ventricular pacing pulses on the selected rhythm strips. Then, if something does not appear to fit or make sense, a colleague or the manufacturer can be contacted for clarification. These exercises will help develop one's ability to handle these rhythms. This exercise is preferable to first attempting such an analysis when presented with a patient in whom a problem is already suspected. Despite this effort, confusing rhythms will occasionally be encountered. In these cases, the added features of telemetry, enabling interrogation of programmed and measured data (see Fig. 30), endocardial electrograms (see Fig. 2), and generation of marker pulses are proving to be extremely valuable in the rapid and accurate assessment of the more complex pacemaker rhythms.

Reconstruction of large nasal defects with a subcutaneous pedicle nasolabial flap. An underutilized technique

The cosmetic repair and camouflage of large full-thickness defects of the nasal bridge and lower nasal skin can be an arduous task. The standard techniques of split- or full-thickness skin grafts provide for a poor color match and inadequate tissue mass, and other flap techniques do not have the versatility, tissue bulk, and ability to hide the donor site that the subcutaneous nasolabial pedicle flap does. This technique has versatility in treating larger lower nasal bridge defects.