The effects of anesthesia on middle-ear effusions

Surgeons occasionally note a discrepancy between preoperative assessment of middle-ear effusion and operative observation during the placement of ventilating tubes in children's ears. This study was designed to determine whether this variance is secondary to the effects of inhalation anesthesia or misinterpretation of the preoperative exam. Observations were recorded by three distinctly different methods of measurement: the surgeon, the MD-2 Impedance Analyzer, and the Acoustic Otoscope immediately before and after induction of anesthesia. These results were then analyzed and compared with the operative findings. Anesthetic induction was shown to cause alteration in the presence of middle-ear fluid in less than 10% of cases.

T-cell subsets and natural killer cell function with squamous cell carcinoma of the head and neck

Twenty-two patients with squamous cell carcinoma of the head and neck were studied to assess potential abnormalities in total T lymphocytes, T4/T8 ratios, and natural killer cell function. Total T-cell counts were reduced for the entire group with the greatest reduction occurring in individuals with hypopharyngeal tumors and/or stage IV disease. Helper to suppressor ratios were within the norm for the total group, but specific site variances were detected in patients with oral cavity and hypopharyngeal primary carcinomas. Similarly altered T4/T8 ratios were noted with stage III disease. Substantive differences in natural killer cell activity were not observed. These data suggest that perturbations in T-lymphocyte subsets can be associated with decreased survival.

Fragmented care of facial fractures

The treatment of facial trauma currently falls within the purview of several surgical subspecialties, including plastic surgery, oral and maxillofacial surgery, otolaryngology, ophthalmology, and neurosurgery. The complexity of facial anatomy and the newer techniques for skeletal and soft-tissue reconstruction demand interdisciplinary, rather than multidisciplinary, care for these injuries. Interdisciplinary cooperation benefits the patient with a complex facial fracture by: minimizing chances for inadequate primary therapy, promoting discussion of controversial therapy, and providing the optimal therapy. Examples are given of unfavorable results following treatment of facial fractures. Recommendations are made to foster communication between the concerned surgical subspecialties.

Childhood irradiation of pharyngeal lymphoid tissue: management considerations

Childhood irradiation to the head and neck increases the probability of developing regional glandular neoplasia. Life-long follow-up of these patients is warranted.

Obstructive sleep apnea in Down syndrome children: a surgical approach

Obstructive sleep apnea is considered in five Down syndrome children. All had altered anatomy consistent with this syndrome involving the oropharynx, cranium, and midface. Based on earlier work, it was established that, except for specific isolated instances, routine tonsillectomy and adenoidectomy would not reverse obstructive respiratory patterns in this patient population. A modified pharyngopalatal surgical approach has been successful in alleviating upper airway sleep obstruction in Down syndrome.

Voice rehabilitation following laryngectomy. Myomucosal tracheoesophageal shunt

Surgical procedures for speech rehabilitation following laryngectomy lack wide support owing to tumor recurrence, aspiration, stenosis of the fistula, and multiple surgical stages of limited usefulness in irradiated patients. The recent prostheses and their modifications have approximately a 70% success rate but similarly remain limited by the requisite maintenance and soilage. A mucosa-lined tracheoesophageal fistula with a functioning proximal muscle sphincter, created in one stage at laryngectomy, is described. This myomucosal unit can function with or without a prosthesis and potentially eliminates aspiration. Evolution of the flap design in an animal model is delineated and the clinical trial in six patients high-lighted. Five of the six have an excellent vocal quality without an associated air leak on phonation. Three function without a prosthesis.

Kartagener's syndrome. A blinded, controlled study of cilia ultrastructure

We investigated respiratory mucosa cilia ultrastructure in patients homozygous for the gene for Kartagener's syndrome (KS) and patients apparently phenotypic for KS who had bronchiectasis and sinusitis but without situs inversus. Parents, as obligate carriers of the recessive KS gene, were also evaluated among other control groups. The four patients with KS had significantly fewer cilia outer dynein arms than normal subjects or parents of patients with KS. Two of five patients apparently phenotypic for KS demonstrated distinctive ultrastructural changes. No other subjects demonstrated explicit ultrastructural abnormalities. Internal control specimens showed that the number of outer dynein arms was consistent within a subject compared with variation between subjects. The outer dynein arm serves as a dependable ultrastructural marker. Carriers of KS do not demonstrate distinctive morphologic cilia abnormalities. Not every patient with chronic bronchiectasis and sinusitis demonstrates abnormal cilia ultrastructure.

Immunomodulating activity in supernatants from EBV immortalized lymphocytes

Our earlier work has demonstrated that EBV immortalized B lymphocytes are involved in a factor dependent autostimulatory cycle. Soluble growth stimulating activity was released into culture supernatants by these growing B cells. Growth enhancing (GE) media from B lymphocyte lines, immortalized by EBV infection, contained soluble factor(s) which modulated the Con A response of normal human mononuclear cells. Conditioned media from these lines affected the Con A response in a biphasic manner, stimulating the blastogenic response at lower concentrations, while inhibiting at higher concentrations. At stimulatory concentrations, the blastogenic response to Con A began earlier than in controls and was markedly enhanced by day 2. GE media reduced the initial response of purified B cells to pokeweed mitogen. GE media did not support growth of IL-2 dependent cells. GE media from some EBV-carrying B cell lines had measurable IL-1 activity in the mouse thymocyte PHA response. GE media from LPS stimulated B lymphocyte lines produced significant IL-1-like effects on stimulated mouse thymocytes. These results suggested that these B cell lines may produce IL-1-like factors that cooperate in T cell responses. The possibility that such factors may play a role in B lymphocyte transformation by EBV is discussed.

Airway obstruction and sleep apnea in Hurler and Hunter syndromes

The Hurler and Hunter syndromes are two forms of mucopolysaccharidosis. Although the diseases are rare, those afflicted commonly require otolaryngologic consultation. Upper airway obstruction is often severe, progressive, and not infrequently the suspected cause of death in these patients. Four patients with these problems are presented. In all of the children, obstructive sleep apnea was a major management problem. This and other upper airway difficulties are detailed with clinical and pathological correlates.

Choanal atresia. Clinical considerations for management

Taking cognizance of the embryology and newer diagnostic techniques, the transpalatal route is strongly recommended as the optimal surgical procedure for the management of choanal atresia. It should be performed as soon as general anesthesia can be safely administered. In selected instances, but particularly when a patient is at increased surgical risk, necessitating surgical brevity, the endonasal puncture technique should be considered as the initial procedure. Parents must be appraised of the potential for subsequent growth deficiencies, mental retardation, and crossbite.

Bilateral congenital middle ear cholesteatomas

Congenital middle ear cholesteatomas remain of interest because of their relative rarity and unknown origin. A 4-month-old child presenting with bilateral congenital middle ear cholesteatomas forms the basis for this report. The nature of the epithelial debris found suggests an external origin. An extended transcanal tympanotomy approach for removal, based upon an operative experience of 11 similar ears, will be discussed.

Osteosclerotic plasmacytoma of maxillary bone (orbital floor)

Plasma cell neoplasms have been classified as multiple myeloma, solitary plasmacytoma and extramedullary plasmacytoma. They are usually considered as osteolytic lesions of bone except for the rare occurrence of osteosclerotic lesions. This paper describes the first reported osteosclerotic plasmacytoma of the maxillary bone and orbital floor. The difficulties in establishing a diagnosis and the relationship to other plasma cell neoplasms are discussed. Osteosclerotic plasmacytomas are a rare variant of plasma cell tumors which usually produce osteolytic lesions rather than bony sclerosis. Sixty-eight patients with the osteosclerotic variant have appeared in the world literature, with an overall incidence of about 1 per cent in a large series of plasma cell neoplasms (Dreidger and Pruzanski, 1979). There have been only six previous cases of solitary osteosclerotic plasmacytomas reported (Morley and Schweiger, 1964; Roberts et al., 1974; Rodriguez et al. 1976; Rushton, 1965; Schneinker, 1938; Brigham Medical Review, 1961) involving spine, sternum, or rib. None have previously been reported in the head and neck area. Plasma cell tumors have been classified into multiple myeloma, solitary plasmacytomas of bone, and extramedullary plasmacytomas. Multiple myeloma is a disseminated plasma cell malignancy characterized by the production of homogeneous immunoglobulins (whole or fragments) which appear in the serum and urine. Plasma cell tumors can also occur as solitary plasmacytomas, usually in bone, but also in soft tissue. With time, most solitary plasmacytomas develop disseminated disease with all the characteristics of multiple myeloma (Wiltshaw, 1976). Extramedullary plasmacytomas arise in soft tissue rather than bone, and primarily occur in the head and neck region. Clinically, they remain localized and less frequently develop into disseminated myeloma.

Cryotherapy of subglottic hemangioma

The natural history of the hemangioma is spontaneous regression; therefore, most lesions require no treatment. The large occlusive subglottic hemangioma which presents before the age of 6 months, however, may be life-threatening. Two infants with subglottic hemangiomas with complete upper airway obstruction were treated successfully with cryotherapy, after tracheostomy. In each case the cryoprobe was placed transbronchoscopically on the subglottic hemangioma at -80 degrees C. for 30 to 45 seconds, the freezing interval varying with the age of the patient. One infant is asymptomatic and has had the tracheostomy tube removed. The other infant, after successful cryosurgical treatment, died from an unrelated illness. The histopathology of the larynx 3 1/2 months after cryotherapy of the hemangioma showed tracheal reepithelialization, active regeneration of cartilage with maintenance of luminal diameter, minimal submucosal fibrosis, and minimal residual hemangioma. Cryotherapy for subglottic hemangiomas offers many advantages including hemostasis, controlled local surgical injury, subsequent rapid healing of tissues with minimal fibrosis, and preservation of lumen without stricture. Previous forms of therapy which have been supplanted include radiotherapy, injection of sclerosing substances, systemic steroids, and surgical excision. Carbon dioxide laser is an effective therapeutic modality that we reserve for selected smaller hemangiomatis lesions of the subglottic area.

Infarcted tongue

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Interferon and natural killing of human lymphoma cell lines after induction of the Epstein Barr viral cycle by superinfection

Interferon (IFN) production during natural killer (NK) cell assays with Raji, an EBV-carrying human lymphoma-derived cell line, was studied to determine whether IFN generated by effectors in vitro acted in target cell lysis. In 4-hr tests, Raji is insensitive to NK but becomes susceptible after superinfection with the P3HR-1 strain of EBV. IFN was not detectable by bioassay in supernatants from 4-hr assays, and the addition of antibody to IFN did not prevent the lysis of the superinfected Raji cells. In 18-hr tests the NK sensitivity of the superinfected Raji cells was markedly elevated, and a percent of the normal Raji cells was also killed. IFN alpha was found in supernatants from 18-hr tests. Antibody to IFN alpha markedly reduced the killing of superinfected Raji and slightly reduced cytotoxicity against control Raji in 18-hr tests. Taken together these results indicate that what is referred to as natural killing has IFN-related and IFN-nonrelated components.

Interferon and natural killing of human lymphoma cell lines after induction of the Epstein Barr viral cycle by superinfection

Interferon (IFN) production during natural killer (NK) cell assays with Raji, an EBV-carrying human lymphoma-derived cell line, was studied to determine whether IFN generated by effectors in vitro acted in target cell lysis. In 4-hr tests, Raji is insensitive to NK but becomes susceptible after superinfection with the P3HR-1 strain of EBV. IFN was not detectable by bioassay in supernatants from 4-hr assays, and the addition of antibody to IFN did not prevent the lysis of the superinfected Raji cells. In 18-hr tests the NK sensitivity of the superinfected Raji cells was markedly elevated, and a percent of the normal Raji cells was also killed. IFN alpha was found in supernatants from 18-hr tests. Antibody to IFN alpha markedly reduced the killing of superinfected Raji and slightly reduced cytotoxicity against control Raji in 18-hr tests. Taken together these results indicate that what is referred to as natural killing has IFN-related and IFN-nonrelated components.

Pseudomonas rhinosinusitis

Although rare in the otherwise healthy patient, pseudomonas rhinosinusitis is encountered most frequently in the immunocompromised host or severely traumatized patient. Intravenous antibiotic therapy in conjunction with aggressive surgical drainage is required. Two cases are documented that are typical of this philosophy. A third patient with isolated nasal involvement, because of multiple medical disabilities, was treated with local debridement and topical therapy alone and responded.

Rehabilitative surgery for aspiration. A clinical analysis

Operative intervention for refractory aspiration necessitates an understanding of its prognostic implications. The closure procedures most often performed are evaluated, comparing and rating technical difficulty, degree of closure, reversibility, and vocalization, both immediately and after reconstruction. The epiglottic over-sew was shown to have merit. Its distinctive features include the potential for postclosure phonation as well as the opportunity for sequential reversal. Both of these features make mastering the technique worthwhile.

Adult epiglottitis

Seventy-five patient-episodes of adult epiglottitis were analyzed retrospectively. Six tracheotomies were performed, and no deaths occurred. In a large subset of patients, viral pathogenesis was suggested by benign clinical courses that included normal or mildly elevated temperatures and minimally elevated leukocyte counts with relative lymphocytosis. Hospitalization may not be indicated for adults with epiglottitis of viral etiology as it is for patients with signs of bacterial infections.

Increased sensitivity to natural killing in Raji cells is due to effector recognition of molecules appearing on target cell membranes following EBV cycle induction

Previous studies demonstrated that NK resistant Epstein-Barr virus (EBV) carrying human lymphoblastoid cell lines become sensitive to NK cell-mediated destruction following induction of the viral cycle by superinfection with the P3HR-1 substrain of EBV or chemicals. In the present report we analysed the cellular membrane changes that were related to the development of sensitivity to NK activity in Raji cells with metabolic inhibitors. NK sensitivity does not develop in P3HR-1 superinfected Raji cells that are cultured in the presence of the RNA synthesis inhibitor actinomycin D and drops to half the amount usually detected in superinfected cells that are grown with the protein synthesis inhibitor cyclohexamide. In experiments with cyclohexamide blocks removed after 24 h, the target cell sensitivity to NK returns to normal levels. Control Raji cells cultured with the same inhibitors for up to 72 h do not develop any sensitivity to NK cell activity. These findings suggest that the development of sensitivity to NK destruction in Raji cells following superinfection is due to the addition to the cell membrane of a virally promoted molecule(s) that requires active RNA and protein synthesis.

Self-stimulating growth factor production by B-cell lines derived from Burkitt's lymphomas and other lines transformed in vitro by Epstein-Barr virus

Kinetics of cell growth of human B-lymphocyte lines derived from Burkitt's lymphomas and lines derived from the Epstein-Barr virus transformation of normal adult lymphocytes were studied. Cells seeded at high densities (5 X 10(4)/ml) grew in an exponential manner; those seeded at low densities (5 X 10(3) to 1 X 10(4) began to grow exponentially only after a lag period of 3 to 4 days. Transfer of stationary low-density cell populations into filtered media from growing high-density cultures (conditioned media) stimulated cell growth, as determined both by increased cell numbers and [3H]thymidine incorporation. Enhanced cell growth occurred in conditioned media at all cell seeding concentrations that grew in normal media. Furthermore, cultures seeded at very low cell concentrations that do not grow in normal media proliferated in conditioned media. Media from a series of B-cell lines tested with one exception were autostimulatory. Reciprocal cell transfer experiments showed that media from B-cell lines cross-stimulated cells in other B-cell lines. Media from the non-B-cell lines tested were not autostimulatory and did not stimulate growth of the B-cell lines, and conversely these non-B-cell lines were not growth enhanced by the conditioned media. Absorption of growth-enhancing media with preincubated cell lines seeded at low density removed the enhancing capacity. These results demonstrate that B-cell lines from Burkitt's lymphomas and B-cells transformed in vitro by Epstein-Barr virus produce absorbable growth-enhancing factor(s) that may be essential to the development of perpetual growth in culture.