The role of pars flaccida in human middle ear sound transmission

The role of the pars flaccida in middle ear sound transmission was studied with the use of twelve otoscopically normal, fresh, human temporal bones. Peak-to-peak umbo displacement in response to a constant sound pressure level at the tympanic membrane was measured with a noncontacting video measuring system capable of repeatable measurements down to 0.2 micron. Measurements were made before and after pars flaccida modifications at 18 frequencies between 100 and 4000 Hz. Four pars flaccida modifications were studied: (1) acoustic insulation of the pars flaccida to the ear canal with a silicone rubber baffle, (2) stiffening the pars flaccida with cyanoacrylate cement, (3) decreasing the tension of the pars flaccida with a nonperforating incision, and (4) perforation of the pars flaccida. All of the modifications (except the perforation) had a minimal effect on umbo displacement; this seems to imply that the pars flaccida has a minor acoustic role in human beings.

Modification of the deltopectoral flap for pharyngoesophageal reconstruction

These modifications minimize flap loss, fistulae, and stenosis, and make the final stage easier to perform. The need for periodic dilation with Maloney dilators may be required; however, we do not consider this a significant complication. The goal is a predictable result with a low complication rate so that oral feedings can begin 5 weeks after laryngopharyngectomy, and postoperative radiotherapy may be started at 6 weeks. The need for three stages may appear excessive; however, three planned stages are better than three or more unplanned stages that result in flap loss or dehiscence.

Correlation of the in vivo anticoagulant, antithrombotic, and antimetastatic efficacy of warfarin in the rat

Fibrin formation has been hypothesized to be an element of the metastatic process in cancer, and pharmacological interference with such fibrin formation has been proposed as a means of antimetastatic therapy. We have tested this hypothesis through an in vivo study of warfarin in two independent rat disease models--a model of chemical-injury-induced arterial thrombosis, and a model of spontaneous metastasis. We found 0.50 mg/kg-day warfarin to be uniformly lethal after two weeks treatment. The chronic dose of 0.25 mg/kg-day was non-toxic and produced effective anticoagulation and marked antithrombotic and antimetastatic activity. The 0.125 mg/kg-day dose produced a reduction in factor IIc (50%) and factor VIIc (70%), and resulted in statistically significant antithrombotic and antimetastatic activity. The 0.0625 mg/kg-day dose failed to reduce the vitamin K-dependent clotting factors, and failed to produce any antithrombotic or antimetastatic effects. The substantial correlation (very similar dose-response effects) among the anticoagulant, antithrombotic and antimetastatic efficacies of warfarin in the rat suggests that anticoagulation provides the pharmacological mechanism underlying both the antithrombotic and the antimetastatic effects. The poor therapeutic index we observed in the rat may be the attribute which limits the efficacy of warfarin in the treatment of human cancer.

Surgical treatment of the "marginal mandibular lip" deformity

Unilateral permanent paralysis of the lower lip after section or compression of the marginal mandibular branch of the facial nerve is not rare. It may occur after trauma or as a result of parotid, ear, or upper neck surgery. Surgical treatment of the deformity--which we term the marginal mandibular lip--is indicated to improve cosmesis and restore oral competence during eating and speech. We describe our experience with partial resection of the paralyzed lower lip as an effective yet simple method of surgical correction. We also review the alternate methods of treatment for comparison.

Cranial bone grafts for post-traumatic facial defects

Recent interest in onlay cranial bone grafts has shown it to be a preferred technique in the reconstruction of facial defects. This paper reports seven patients in whom outer table cranial bone grafts were used to reconstruct post-traumatic facial deformities. These included orbital and zygomatic deformities (2 patients), maxillary defects (2 patients), mandibular defects (2 patients), and nasal deformity (1 patient). A brief review of the development of membranous bone grafting for maxillofacial reconstruction is given. Good cosmetic results were obtained in six of seven patients with no evidence of graft resorption. One patient required removal of the graft because of inadequate soft tissue coverage. No patient suffered any significant donor site morbidity. In summary, this technique is extremely useful in treating post-traumatic bony deformities of the facial skeleton. The excellent graft survival and ease in harvesting the graft make this technique preferable to traditional endochondral grafts taken from the iliac crest and rib.

Stapes vibration produced by the output transducer of an implantable hearing aid. Experimental study

The function of the output transducer of an implantable hearing aid was assessed by applying it to the stapes head in seven fresh human cadaver temporal bones while observing vibration of the stapes under a microscope with the use of a stroboscope and a video measuring system. The transducer was a 5 X 1.2 X 0.6-mm piezoelectric ceramic bimorph with attached metal holder. Transmission changed with the amount of force holding the transducer tip on the head of the stapes. An optimal connection between the vibrator and stapes produced better transmission than a tight or loose connection. Gluing the connection with cyanoacrylate cement decreased transmission in the optimal connection, produced no change in the tight connection, and improved transmission in the loose connection. Comparison of stapes displacement produced by the vibrator at 1 kHz with that produced by normal middle-ear sound transmission revealed that the vibrator-induced stapes displacement for a 1 V peak-to-peak input was equivalent to that produced by a sound stimulus of 90-dB sound pressure level at the tympanic membrane.

Pharmacologic enhancement of composite graft survival

The use of composite grafts in facial reconstruction has been limited by a history of unpredictable survival beyond a radius of 1 cm. Numerous pharmacologic agents have been employed to improve the survival of random skin flaps but, to our knowledge, have not been studied in composite grafts. Three agents that have demonstrated efficacy in random skin flap survival, intravenous heparin sodium, topical nitroglycerin, and intramuscular methylprednisolone sodium succinate, were investigated for their effect on composite graft survival. Using a rabbit model, full-thickness auricular composite grafts were created, rotated 180 degrees, and reattached. At 21 days, all grafts were assessed for area of survival and postexcisional weight. Animals receiving 30 mg/kg of intramuscular methylprednisolone sodium succinate daily, during the first four postoperative days, demonstrated a significant increase in graft survival compared with controls. Heparin and nitroglycerin produced no change compared with controls. Furthermore, the only grafts to achieve 100% survival were found in the group treated with methylprednisolone.

Treatment of cervical esophageal stenosis with a long-term indwelling prosthesis

Intubation of the cervical esophagus with a long-term indwelling prosthesis is described to palliate malignant strictures, and manage benign strictures in high-risk patients. The inner cannula of a Moore design tracheostomy tube was used as the prosthesis. Over a 10-year period, seven cases were managed in this fashion. The tube remained in place in five of seven patients for periods of 1.5 to 11 months, while a pureed or well-masticated soft diet was tolerated. There were no major complications in this small series. Retrograde displacement was the most common minor complication; displacement did not occur in the last two cases after addition of a silicone sponge ring to the distal end of the prosthesis. Pain and discomfort was experienced in two cases, requiring temporary removal in one patient.

Measurement of the ossicular vibration ratio in human temporal bones by use of a video measuring system

Vibration modes of the ossicles and the lever function were studied in human cadaver temporal bones with an intact cochlea. After placing tiny steel spheres on the ossicles, ossicular vibration to a sound stimulus was measured by observing the displacements of the spheres under a microscope with strobe illumination by means of a video measuring system. The lever ratio varied from 1.9 at 0.6 kHz (minimum) to a peak of 6 near 2 kHz. This relatively high lever ratio at higher frequencies was considered to be caused by a shift of the malleus-incus rotation axis secondary to the loading of the cochlear fluid on the ossicular system. Dependence of the lever ratio on frequency indicated that the rotation axis of the ossicles was not fixed, but variable according to frequency due to a relative increase in the translational movements of the rotation axis of the malleus and incus with frequency.

Effects of middle ear pressure changes on umbo vibration

Effects of middle ear pressure changes on umbo vibration were studied in 5 fresh human temporal bones taken from cadavers. Umbo vibration to a constant sound pressure of 120 dB SPL at the tympanic membrane was measured with an MTI 1000 Fotonic Sensor. The results showed that there was a loss of umbo vibration at lower frequencies below 2 kHz; 5.0 +/- 1.0 dB loss at -100 mmH2O, 9.2 +/- 1.3 dB loss at -200 mmH2O, and 13.1 +/- 1.8 dB loss at -300 mmH2O. In contrast, there was a slight increase in umbo vibration at around 2-3 kHz. The effect was considered to be mainly due to increased stiffness of the tympanic membrane and decreased air volume in the middle ear cavity.

Abnormal Pap smear: colposcopy and cryosurgery

Colposcopic evaluation of patients with abnormal Papanicolaou smears permits the physician to visualize cervical lesions and determine the extent of intraepithelial neoplasia. Through the use of colposcopy with cryotherapy, many patients with cervical intraepithelial neoplasia may avoid a more invasive form of treatment. Family physicians should become familiar with colposcopic technique so that they can select patients who are suitable for local treatment with cryotherapy.

Effect of middle ear modification on umbo vibration. Human temporal bone experiments with a new vibration measuring system

The effects of aditus blockage, decrease of tympanic cavity volume, and resection of the tensor tympani muscle on umbo displacement were studied in human temporal bones using a new non-contacting video measuring system. This system, combined with stroboscopic illumination, allowed measurement of umbo vibration down to 0.3 micron in the 0.1- to 4.5-kHz frequency range for a constant 124-dB sound pressure level at the tympanic membrane. Aditus blockage caused a mean increase of 5.4 dB with a peak at 2.8 kHz and a mean decrease of 3.4 dB below 1.6 kHz. Decrease of the tympanic cavity volume by 30% to 42% showed an improvement of 2.2 dB in the 1.4- to 3-kHz range and a similar loss below 1 kHz. Resection of the tensor tympani muscle produced a slight improvement of 1.7 dB at 1.8 kHz.

Mesenchymal-epithelial interactions as factors influencing male accessory sex organ growth in the rat

Mesenchyme (UGM) and epithelium (UGE) isolated from the urogenital sinuses (UGS) of 17-day male and female rat embryos were separated by using a trypsinization procedure, grown on soft agar, transplanted into syngeneic pubertal male hosts as subcapsular renal grafts, and then collected after 29-30 days. Neither UGM nor UGE underwent prostatic morphogenesis when grown under these conditions. However, tissue recombinants composed of UGM + UGE grew and produced prostatic glands with acinar secretory material. Further, UGM + UGE recombinants were made by varying the proportions of mesenchymal and epithelial tissues. The size of the implants was a function of the absolute amount of mesenchyme; increasing the absolute amount of UGM produced larger specimens whereas varying the UGE had no effect. The UGM was also found to be essential for supporting the growth of small glandular elements derived from the ventral prostate of pubescent rats. Segments isolated from the terminal vesicles (TIPs) and from prostatic tissue adjacent to the urethra (PDCT) regressed when implanted alone under the kidney capsule. However, combination of the prostatic segments with UGM produced prostatic glands with relative wet weight and DNA content responses of the following order: UGM + TIP greater than UGM + PDCT = UGM + UGE. Two-dimensional gel electrophoretic protein patterns from UGM + PDCT and UGM + TIP specimens had differential expression of three protein regions unique to the ventral prostate Quantitative and qualitative responses of the TIP and PDCT segments to UGM inductive influences indicate that differences exist between the epithelia of the TIP and PDCT regions of the ventral lobes of the rat prostate.

Incendiary characteristics of a new laser-resistant endotracheal tube

Endotracheal tube fires are the most frequent complication of laser surgery of the larynx. We investigated the incendiary characteristics of a new laser-resistant endotracheal tube, compared to polyvinyl chloride (PVC) and red rubber (RR) tubes, with different gas mixtures. A CO2 laser was focused on each tube and the probability of fire was assessed with oxygen fractions (FiO2) of 30%, 40%, 50%, 70%, and 100%, the balance being N2 or N2O. The laser-resistant tube could not be penetrated by a single laser pulse, regardless of laser energy or gas composition. PVC and RR tubes were readily ignited, the probability of ignition being related to oxygen concentration and laser energy. Nitrous oxide readily supported combustion. We suggest that laser surgery of the larynx can be most safely performed with a laser-resistant endotracheal tube and with gas mixtures containing the minimal safe O2 concentration (without nitrous oxide).

Clinical evaluation of a new nonelectronic all-in-the-ear hearing device for mild hearing loss

A new, nonelectronic hearing aid was studied in 112 patients with mild sloping sensorineural hearing loss. The device, worn all in the ear and made of clear plastic, produced a mean functional gain of 9.6 dB at 1500 Hz, 12.4 dB at 1750 Hz, and 9.1 dB at 2000 Hz, with lesser gains at adjacent frequencies between 1000 and 2500 Hz. Speech discrimination in quiet and in noise was improved. Patient acceptance of the device (in a group of 884 patients) was 76%. The device appears to be useful in the treatment of mild hearing loss.

Inhibitory effect of warfarin on the metastasis of the PAIII prostatic adenocarcinoma in the rat

The PAIII rodent metastatic prostatic adenocarcinoma model was employed to evaluate the effects of dietary warfarin, a prototypic antagonist of thrombin generation on the lymphatic and pulmonary metastases of the tumor from the tail site of subcutaneous transplantation in male Lobund Wistar (LW) rats. In addition, the anticoagulant effects of warfarin were determined in the same animals. Warfarin, administered in the diet at concentrations equivalent to 0.063, 0.125 or 0.250 mg./kg. b.w. for 30 days had no effect on final body weight, gluteal or iliac lymph node weights. Significant (p less than 0.05) dose-dependent extensions of whole blood prothrombin (WBPT), activated partial thromboplastin (WBAPTT) and clotting times (WBCT) over control values were observed with warfarin treatment. Preliminary studies demonstrated that the 0.500 mg./kg. dose produced 50 per cent mortality at +14 days. Warfarin produced significant (p less than 0.05) dose-dependent decreases in the number of PAIII pulmonary metastases as indicated by reductions in dry lung weights and lung colony numbers when compared to untreated tumor-bearing controls. While the therapeutic index of warfarin is a limiting factor in clinical use as an antimetastatic agent, these results suggest that compounds capable of altering hemostatic mechanisms may be potential inhibitors of tumor metastasis. The PAIII prostatic adenocarcinoma model may be a useful system to quantitatively evaluate potential antimetastatic and cytotoxic agents.

Metastatic spread of the PAIII prostatic adenocarcinoma after implantation in the tail of the rat

The spontaneous metastatic spread of a suspension of PAIII prostatic adenocarcinoma cells from the tail site of implantation was analyzed over a period of 5 weeks in male Lobund-Wistar (LW) rats. Following subcutaneous injection of the PAIII cells, the tumor metastasized through the primary lymphatic drainage. PAIII microfoci were evident in the gluteal and iliac lymph nodes prior to colonization of the lungs. Growth of the primary tumor was evidenced by significant weight differences of the tails of PAIII-bearing and control rats 1 week after tumor implantation. Time-dependent sequential spread of the adenocarcinoma was quantitated. Significant differences were noted between PAIII-bearing and control animals with respect to the gluteal lymph node weights (+2 weeks), iliac lymph node weights (+3 weeks), dry lung weights, and lung colony numbers (+4 weeks) after tumor implantation. During the course of these studies, the whole blood prothrombin, activated partial thromboplastin, and recalcification times for the PAIII-bearing animals were similar to those of the control group. These findings indicate that there were no gross changes in systemic blood coagulation accompanying the metastasis of PAIII cells from the primary tumor. The tumor in LW rats produced a consistent pattern of growth and metastasis that is suitable for quantitation. The PAIII prostatic adenocarcinoma is a sensitive and reproducible system that may be useful to evaluate potential antimetastatic and cytotoxic agents for the treatment of hormone-insensitive prostatic cancer.

Iodine 125 suture implants in the management of advanced tumors in the neck attached to the carotid artery

Between 1975 and 1982, 38 patients with locally advanced head and neck cancer attached to the carotid artery underwent surgical excision followed by iodine 125 vicryl suture implant in the neck. Most patients had neck masses that were greater than 6 cm and stage IV disease without clinically evident distant metastases. Twelve patients had received no previous therapy while 26 underwent an implant for recurrent disease. The local control rate in the implant volume was 79%. The local and regional control rate in all head and neck sites was 53%. The mean survival was 11 months. The overall complication rate was 26%. There was no significant correlation of local control or complications with the minimum total dose, volume implanted, individual 125I seed strength, or total seed strength. In patients with large masses attached to the carotid artery, surgical resection followed by a 125I implant for residual disease is a viable alternative to resection of the carotid artery.

Surgery of the incompetent nasal valve

One of the causes of nasal airway obstruction during inspiration is an incompetent nasal valve. An incompetent valve is one that collapses during quiet normal breathing due to narrowing of the valve area, a loss of upper and/or lower lateral cartilage support, or a combination of these. The most common etiology is a previous rhinoplasty; trauma and aging are other causes. Treatment is surgical and consists of replacing what is missing with similar tissue. If only the vestibular skin is scarred, a skin graft is used. If cartilage alone is missing, a cartilage graft is inserted. If both skin and cartilage are absent, a composite graft from the concha is the best choice.

192Ir pharyngoepiglottic fold interstitial implants. The key to successful treatment of base tongue carcinoma by radiation therapy

Twenty-eight patients with squamous carcinomas of the base tongue were seen and evaluated in a conjoint Head and Neck Tumor Board at Stanford between 1976 and 1982. Fourteen patients were treated by combined external beam and interstitial irradiation, 11 of whom had Stage III and IV carcinomas (American Joint Committee). An initial dose of 5000 to 5500 rad was first delivered by external beam irradiation in 5 to 5.5 weeks, followed approximately 3 weeks later by an iridium 192 (192Ir) interstitial implant boost by the trocar and loop technique. The key to successful treatment of these neoplasms was found to be the use of a lateral percutaneous cervical technique, which placed horizontal loops through the oropharyngeal wall above and below the hyoid bone; the superior loop included the pharyngoepiglottic fold and the tonsilloglossal groove. Standard multiple loop implants (submentally inserted) of the base tongue from the vallecula anteriorly to the circumvallate papillae were also used routinely. This approach has been successful, since 10 of the 14 patients (71%) remain without evidence of disease (mean follow-up, 32 months). There have been only two local recurrences, both on the pharyngoepiglottic fold in patients who did not receive the now standard pharyngoepiglottic fold/lateral pharyngeal wall implants. No patients have relapsed after 18 months. The other 14 patients were treated prospectively during the same period by combining initial resection, radical neck dissection, and postoperative irradiation. In this group, there were more locoregional failures compared to the group treated with radiation therapy alone (5 tongue recurrences and 7 neck relapses); in addition, more severe complications were noted in these 14 patients who received surgery and postoperative irradiation. The authors believe that combined external beam and interstitial irradiation is effective treatment for base tongue carcinomas, especially when the high-dose distribution includes the adjacent tonsilloglossal groove, pharyngoepiglottic fold, and oropharyngeal wall to and below the level of the hyoid bone, in addition to treating an adequate base tongue volume.

Heat myringotomy

Heat myringotomy using a commercially available, battery powered device produced an opening in the tympanic membrane that persisted 1 to 3 weeks. The procedure was performed to treat chronic otitis media with effusion (COME) in lieu of ventilation tubes in 10 pediatric and 15 adult ears under office iontophoretic anesthesia. These patients were followed for a minimum of 3 months to assess efficacy. Fifty percent of pediatric ears were controlled, eliminating the need for general anesthesia and tube insertion. Forty percent of adult ears were controlled with heat myringotomy. A description of the procedure, discussion of possible reasons for failure, and analysis of potential cost savings are included.

Combined surgery and postoperative irradiation in the treatment of cervical lymph nodes

One hundred seventy-three patients with squamous carcinomas of the laryngopharynx, oral cavity, and oropharynx received planned, combined resection of the primary neoplasm and radical neck dissection (when N1, N2, or N3 lymphadenopathy was present) followed by megavoltage irradiation to the primary sites and bilateral cervical regions between 1975 and 1982. Radical neck dissections were performed in all patients with N2 and N3 cervical lymphadenopathy, in 90% of those with N1 necks, but in only 4% whose necks were staged NO. Neck failures occurred in 10%, 22%, 19%, and 38% of patients with stages N0, N1, N2, and N3 necks, respectively. The most ominous pathologic feature was soft-tissue extension in the radical neck dissection specimen. Initially clinically benign contralateral lymph nodes became involved in only 9% of these patients.

Intraoperative iodine 125 implants. Their use in large tumors in the neck attached to the carotid artery

Twenty-nine patients with large masses attached to the carotid artery underwent surgical resection, preservation of the artery, and intraoperative iodine 125 implantation via an absorbable suture. Eighteen were treated for recurrent neoplasms, having failed prior surgery and/or irradiation therapy. Eleven were treated primarily. With a minimum follow-up of one year, 76% were disease free in the implant volume and 62% were disease free in the entire neck. Distant metastases occurred in 45%. Mean survival was 15 months in the primary group (range, two to 50 months) and 12 months in the recurrent group (range, four to 26 months). This technique shows promise in providing local control without necessity for sacrifice of the carotid artery.