Intraoperative transcranial Doppler ultrasound in head and neck surgery: a preliminary report

PURPOSE

To evaluate the possible role of intraoperative cerebral emboli in the origin of perioperative stroke during major head and neck surgical procedures.

MATERIALS AND METHODS

Eleven patients undergoing major head and neck surgery that involved direct manipulation of the carotid sheath were the participants in this study. Transcranial Doppler (TCD) ultrasound was used intraoperatively to detect possible cerebral emboli. The presence or absence of intraoperative cerebral emboli in each patient was assessed by the presence or absence of typical embolic signal patterns within the TCD waveform.

RESULTS

No intraoperative cerebral emboli were noted in the series, nor did any patient have a postoperative stroke.

CONCLUSIONS

No intraoperative cerebral emboli were noted by using TCD ultrasound for embolus monitoring in patients undergoing major head and neck surgery involving carotid sheath manipulation. This detection system is easily used in appropriate head and neck cases and allows real-time, noninvasive intraoperative monitoring.

Relationship between psychological status and compliance in a sample of patients treated for cancer of the head and neck

BACKGROUND

the psychological status of patients treated for advanced head and neck cancer is an area of patient care that has not received sufficient attention from caregivers and can be influential in terms of patient outcomes.

METHODS

Thirty patients participated in this study designed to evaluate areas of psychological distress associated with treatment of advanced head and neck cancer. Patients completed a set of questionnaires related to various psychosocial variables including anxiety, depression, social support, health locus of control, adjustment to illness, illness-related behaviors, and compliance.

RESULTS

Moderate levels of depression and anxiety, disability, and psychological distress characterize this sample of patients. Additionally, patient self-report of compliance reveals different variable combinations to be related to overall diet and medication compliance, and different levels of each compliance type were observed.

CONCLUSION

Head and neck cancer therapy presents a unique set of challenges for patients. Awareness of the impact of the illness and the psychological distress that are experienced should improve patient compliance and medical outcome.

Capitation Essentials for Otolaryngologists

Educational objectives: To assess opportunities and risks in capitated contracts and to determine practice costs for capitation.

Perioperative stroke in patients undergoing head and neck surgery

The risk of perioperative strokes has been demonstrated to be very low in general surgical procedures, and somewhat higher in cardiac and carotid artery procedures. We describe 5 patients who underwent major head and neck procedures not requiring carotid ligation and who postoperatively suffered strokes. These occurred between the first and ninth postoperative days. Four of the patients were thought to have had emboli, 3 to the cerebral hemispheres (2 ipsilateral and 1 contralateral to the neck dissections), and another to the lower brain stem. Hypoperfusion was thought to have caused the stroke in the fifth patient. All patients had risk factors for stroke. The cases in our series were difficult to diagnose because of the delayed onset and subtle nature of symptoms, as well as masking of speech and communication due to the operative involved. Thrombogenesis within the internal carotid and vertebral artery systems due to patient positioning and intraoperative cervical manipulation may be an important etiologic factor in this form of stroke.

Cavernous sinus involvement in head and neck cancer

Spread of tumor to intracranial structures is an infrequent and late manifestation of head and neck cancers. We recently encountered six patients with a distinct clinical syndrome due to involvement of the cavernous sinus, which forms the basis of this report. This syndrome was a source of significant morbidity and mortality, with a mean survival of only 4 months. The diagnosis is often elusive, but is now made more commonly than previously. Whether this reflects increased incidence (due to alterations in the natural history of disease by therapy) or improved diagnosis (due to modern imaging modalities) is unknown. Cavernous sinus involvement may be the first evidence of distant disease in head and neck cancer. Although survival is poor, palliation is worthwhile. Awareness of this syndrome can lead to earlier diagnosis and alteration of treatment.

Comparison of electroglottographic and acoustic analysis of pitch perturbation

Pitch perturbation is a measure of the cycle-to-cycle variation in vocal fold vibration. Perturbation can be assessed by means of electroglottographic or acoustic signals. The purpose of this study was to determine if these two analysis techniques are equivalent measures. The Laryngograph, an electroglottograph, and the Visi-Pitch, an acoustic analyzer, were used to measure pitch perturbation in 80 dysphonic subjects. Both instruments use Koike's formula to calculate relative average perturbation. While intra-subject variability appeared erratic, statistical analysis of intersubject data indicated that the two instruments provided an equivalent measure of pitch perturbation.

Acoustic characteristics of post-thyroplasty patients

This study investigated changes in voice quality after thyroplasty type I in eight adults with unilateral vocal fold paralysis. A silicone rubber implant was inserted through a window in the thyroid ala and placed between the inner and outer perichondrium to externally medialize the abducted vocal fold. Measures of fundamental frequency (vocal pitch), pitch range, maximum phonation time, s/z ratio, pitch perturbation (vocal jitter), and amplitude perturbation (vocal shimmer) were made 1 to 2 weeks preoperatively and 1 month postoperatively. Postoperative voice quality was characterized by an improved pitch range, phonation time, s/z ratio, and pitch and amplitude perturbation. No change was noted in fundamental frequency. Changes in postoperative voice quality were unrelated to the subjects' preoperative age, sex, etiology, and duration of the paralysis.

Carotid artery resection for head and neck cancer

Occasionally, the head and neck surgeon encounters a patient whose malignancy involves the carotid artery. In these patients, curative or palliative surgery may require excision of the common or the internal carotid artery. However, the high complication and death rates dissuade many surgeons from undertaking carotid artery resection. This study reviews the outcomes in 20 patients treated between 1979 and 1985 at the Department of Otolaryngology-Head and Neck Surgery, The University of Iowa Hospitals and Clinics, with resection of the carotid artery for head and neck cancer. The carotid artery was electively resected in 16 patients, while 4 patients underwent emergent carotid artery ligation. In the group of patients studied the stroke rate was 25%, the death rate 20%, and the combined stroke and death rate 30%. Of the patients who survived the procedure, all but 1 died of complications caused by tumor recurrence. These results are discussed, and compared with results from other studies.

Communication status following laryngectomy: the Iowa experience 1984-1987

Data regarding treatment and outcome for a consecutive series of 73 total laryngectomy patients were collected from clinical records with a follow-up period of 30 to 78 months postoperatively. Notable findings were that 27% were women; 75% reported hoarseness or a voice change as an early symptom; and 22% reported combined heavy use of both cigarettes and alcohol. Of the 73 patients, 38 (52%) died during the follow-up period; 18 of the 38 died within 1 year postoperatively. Thirty-nine (53%) of the 73 had received a surgical tracheoesophageal fistula (TEF) for voice restoration, as either a primary or a secondary procedure. Of the 39, 75% were using the TEF at last examination, with no failures attributed to sphincter spasm. Of the total group, the primary communication modality was reported to be use of a TEF by 44% and use of an electrolarynx by 50%. Limitations of the study and directions for future investigations are discussed.

Comparison of biomaterials for facial bone augmentation

We compared the gross behavior of and microscopic response to implant materials currently in clinical use for facial bone augmentation at different sites in dogs. Materials evaluated include porous polytetrafluoroethylene carbon (Proplast), large-pore high-density polyethylene (Medpor), solid medical-grade silicone rubber (Silastic), polyamide mesh (Supramid), and autogenous rib bone. The subjects were 12 mixed-breed dogs and the materials were implanted directly on bone with periosteum removed at one of three sites in the dog's face (malar eminence, nasal dorsum, and chin). Animals were killed 3 months after surgery and stability of the implants was graded by manual manipulation. Blocks of tissue, including the study materials and underlying bone, were examined microscopically after sectioning. Stability results are tabulated and histologic appearance is described by site for each material evaluated. These data demonstrate marked variability of stability and cellular response depending on the site of implantation. From these data one may conclude that the site of implantation and implant movement are essential factors in determining the nature of the tissue response and fate of an implant. Solid and porous alloplastic materials show an acceptable tissue response, but neither demonstrates the ability to consistently provide an implant that is stable on underlying bone.

Adenoid cystic carcinoma. A clinicopathologic study with flow cytometric analysis

Forty-five patients with adenoid cystic carcinoma (ACC) of salivary glands were retrospectively studied to determine the prognostic use of DNA ploidy analysis compared with clinicopathologic features. Nuclear suspensions were prepared from 37 of these tumors by the Hedley technique on paraffin-embedded material. The DNA content was analyzed by flow cytometry after propidium iodide staining. Thirty-five tumors were diploid and 2 were tetraploid. Mean survival was 117 and 52 months for the diploid and tetraploid patients, respectively. The median S-phase fraction (Spf) of the 35 diploid tumors was 4.45%. Of the 17 diploid patients who died of disease, there were 11 tumors with high Spf (greater than 4.45%) and 6 tumors with a low Spf (P less than 0.05 chi-square test). The presence of more than 30% of a solid pattern in the tumor was strongly associated with poor median survival in Kaplan-Meier survival curve analysis (P less than 0.05 log rank test). Grade, stage, recurrence, and metastases were also found to be important prognostic factors. Because few tumors were nondiploid, these results suggest that S-phase fraction analysis may be a more useful prognostic indicator than ploidy classification.

Deferoxamine decreases necrosis in dorsally based pig skin flaps

Deferoxamine, a free radical scavenger and iron chelator, has been shown to improve skin flap survival in ischemic flap surgery in rats. The present study investigates the value of deferoxamine in ischemic flap surgery in the porcine model. Four 4 x 12 cm flaps, 3 cm apart and 3 cm from the dorsal midline, were elevated on each of six female pigs, weighing 50 to 60 pounds each. The animals were divided into two test groups. Group 1 received six 1 gm doses of deferoxamine in 4 ml of sterile water intramuscularly every 6 hours preoperatively for five doses, followed by the administration of 1 g every 6 hours for the first 6 days postoperatively. Group 2 received 4 ml of normal saline administered intramuscularly as above. The percentage of flap necrosis was assessed on postoperative day 7 by the weighing paper technique. Group 1 had 17.1% necrosis and group 2 had 33% necrosis (p less than 0.005). Deferoxamine has decreased flap necrosis in the porcine model and may be of use in augmenting the surviving length of flaps in human beings.

Cancer of the cheek

The combined skills of the micrographic surgeon and the head and neck surgeon offer excellent cure rates and reconstructive techniques for primary cutaneous tumors of the cheek. In most instances, structures crucial to facial function and appearance can be preserved or rehabilitated. This interspecialty approach to such tumors results in the best care for the patient and a high sense of professional satisfaction for the surgical team.

Phonosurgery: indications and pitfalls

Twenty-five patients underwent type 1 thyroplasty (external medialization of abducted true vocal cord) during a 2-year period 1986 to 1988) at the University of Iowa. The most common indication for thyroplasty was post-thyroidectomy vocal cord paralysis. Eighteen patients (72%) had either a good or an excellent initial result. Five patients were revised. Postrevision, 21 patients (84%) had achieved either a good or an excellent result. Complications were limited to one case of significant vocal cord edema and another instance of vocal cord hemorrhage. No patient required a tracheotomy. No prosthesis extruded. We feel that phonosurgery has the advantages over traditional Teflon injection of allowing the patient's head to be in a neutral position during the operation; of allowing local anesthesia; of permitting a predictable, graduated end point of the procedure; and of being infinitely adjustable, with preservation of the vocal cord mucosal wave.

Salivary gland carcinosarcoma: true malignant mixed tumor

True malignant mixed tumor, or carcinosarcoma, of salivary gland origin is rare. Only 19 cases have been reported in the literature and a review of cases seen at the University of Iowa over the last 60 years yielded only two. In one case the mesenchymal component of the tumor contained both osteosarcoma and chondrosarcoma. In the second case, the history and the histology suggest a progression from carcinoma ex pleomorphic adenoma to a carcinosarcoma. These features are documented in this report and literature review.

Botryomycosis of the oral cavity

Botryomycosis is a bacterial infection characterized histologically by granules containing bacteria. Usually there is surrounding granulomatous inflammation with occasional extension into muscle or bone. While there are several hypotheses regarding the pathogenesis of botryomycosis, the exact mechanism is unclear. Botryomycosis has been associated with a variety of aerobic and anaerobic bacteria, usually endogenous flora and low virulence organisms. Oral lesions appear to be uncommon despite continuous exposure to endogenous oral flora. Treatment should include surgical excision and antibiotic therapy.

The effects of pentoxifylline on random skin flap survival

Random skin flaps are an important and frequently used technique in head and neck reconstruction. Pentoxifylline has been shown to improve the deformability of red blood cells by increasing their intracellular adenosine triphosphate content and, therefore, improving their flow properties. This is especially important in ischemia and low blood flow states present in the distal portions of random skin flaps. The rheologic properties of pentoxifylline were studied in the swine model. Swine in group I (eight flaps) served as controls with no pharmacologic manipulations. Swine in group II (16 flaps) received pentoxifylline (20 mg/kg/d) for ten days preoperatively and ten days postoperatively. Necrosis in swine in group I (controls) averaged 32.6%, which substantiated previous reports. Necrosis in swine in group II (pentoxifylline) averaged 2.57%. This study has shown a statistically significant enhancement of random skin flap survival using pentoxifylline in a swine model.

The use of composite auricular grafts in nasal reconstruction

Composite auricular grafts are extremely valuable in head and neck reconstruction. They are most commonly used in reconstruction of the ear, eyelid, and nose. Composite grafting provides a relatively simple technique of reconstruction with excellent cosmetic and functional results. The advantage of a one-stage reconstruction is particularly valuable to the patient.

Effects of Oxypherol-ET on random skin-flap survival in the swine model

Random skin flaps are an important and frequently used technique in head and neck reconstruction. Fluorocarbons (Oxypherol-ET) have a low viscosity and high oxygen solubility that allow them to enhance the microcirculation and reduce skin-flap necrosis. These properties were evaluated using the swine model. Group 1 (four flaps) served as controls, with no hematologic or pharmacologic manipulations. Group 2 (16 flaps) had 20% of their blood volume removed and replaced with an equal amount of lactated Ringer's solution. Group 3 (16 flaps) also had 20% of their blood volume removed and replaced with an equal amount of Oxypherol-ET. Necrosis in group 1 (controls) averaged 32.6%; in group 2 (lactated Ringer's solution), 27.8%; and in group 3 (Oxypherol-ET), 8.34%. This study has shown a statistically significant enhancement of random skin-flap survival in the swine model with Oxypherol-ET.

Irradiated homologous cartilage grafts. Long-term results

The use of irradiated homologous cartilage for the restoration of facial contour defects remains a controversial issue in reconstructive surgery. Both favorable and unfavorable reports can be found in the literature. Some basic research concerning the rate and mechanism of resorption has been completed but has failed to resolve the issue of the usefulness of this material in day-to-day practice. One frequently cited reference concerning the use of irradiated homologous cartilage in reconstructive surgery was coauthored by two of the present investigators ten years ago. In an effort to place this study in a long-term perspective, we examined 42 of the original 107 patients who formed the initial population base. Sixty-two of the original 145 irradiated homologous cartilage grafts have been followed up for an average of nine years, with an average resorption rate of approximately 75%. Eighteen of 24 grafts followed up from 11 to 16 years completely resorbed. In spite of complete graft resorption, some patients have maintained satisfactory facial contour with fibrous tissue replacement of the cartilage.

Infratemporal fossa meningioma: CT and MR findings

We report an unusual case of an extracranial meningioma presenting as a large facial mass. The CT and magnetic resonance findings and a brief review of extracranial meningiomas are presented.

Tissue expansion in the treatment of giant congenital melanocytic nevi

Treatment of giant facial congenital melanocytic nevi (CMN) is recommended due to the potential for malignant degeneration, although therapy may be complicated because of cosmetic and functional considerations and the results problematic. We present the case of a 2-year-old child with a giant CMN of the scalp, excision of which was facilitated by the use of a tissue expander. This technique allows the creation of skin similar in appearance and type to that immediately adjacent to the defect. The giant CMN, which covered approximately one third of the scalp, was excised and simultaneously resurfaced with the remaining expanded normal scalp.

Effects of neutralizing agents on esophageal burns caused by disc batteries

The sequelae associated with ingested disc batteries that lodge in the esophagus may include tracheoesophageal fistula, esophageal perforation, stricture formation, or death. The focus of the current investigation is on whether medical therapy can arrest or lessen the severity of the injury during the time required to transport the patient to a center for treatment. A case of esophageal damage from the ingestion of a 1.5-V manganese dioxide disc battery in a 3-year-old boy is reported also. A two-phase study was completed in which the initial phase was an in vitro experiment to identify potable solutions that might neutralize the alkali contained in disc batteries. An in vivo study in 24 cats was undertaken to determine if bolus administration of these solutions would arrest or lessen the severity of the esophageal injury. None of the solutions tested demonstrated a significant difference in the degree of gross or histologic esophageal damage when compared to controls.

Non-Hodgkin's lymphoma of the head and neck: the University of Iowa experience

The evaluation of a patient with a mass in the head and neck may require the consideration of lymphoma in the process of differential diagnosis. Non-Hodgkin's lymphoma is a well-described heterogeneous group of lymphoid malignancies characterized by a natural history ranging from indolent to aggressive growth. Little has been written, however, concerning the specific features of this disease in the head and neck. Between 1974 and 1984, 287 patients were treated for non-Hodgkin's lymphoma presenting in the head and neck. A multivariant analysis of these cases forms the basis of this report. All case material was reviewed and classified according to the working formulation of the National Cancer Institute and the Ann Arbor Classification System for lymphomas. Sites of initial presentation, methods of diagnosis, choice of therapy and subsequent response to treatment were related to the manifestations of non-Hodgkin's lymphoma in the head and neck. Of particular interest to the head and neck surgeon is the constellation of presenting signs and symptoms which point one to the possibility of non-Hodgkin's lymphoma.

The trapezius myocutaneous flap. Dependability and limitations

Many reports of the trapezius myocutaneous flap have centered on a single form of the flap. However, three distinct myocutaneous segments, the superior, the lateral island, and the extended island flaps, can be harvested from the trapezius muscle and its overlying skin. Fifty-five patients underwent reconstruction for head and neck defects using 56 trapezius myocutaneous flaps consisting of 28 superior, 24 lateral island, and four extended island flaps. The four vascular supplies of the trapezius muscle are discussed, with emphasis on the variable nature of the transverse cervical and dorsal scapular arteries. Major complications developed in two of 28 superior, five of 24 lateral island, and one of four extended island flaps. The superior flap, although the most dependable, has the most limited range of application. Both the lateral and extended island flaps have a broader range of clinical application, but their usefulness may be limited by previous neck surgery or occult neoplasm in the neck, as well as by the variable vascular supply. Due to the above limitations, 30% of our attempts to utilize the lateral island flap had to be aborted at the time of surgery and an alternate means of reconstruction used. The trapezius myocutaneous flaps are excellent reconstructive tools for selected defects.

Calvarial bone grafting of facial defects

Bony defects of the face continue to challenge the reconstructive surgeon. Traditional sources of autologous bone from the rib or pelvis have been associated with the limitations of pain at the donor site, the need for a second operative field, variable "take" of the graft with poor eventual survival and, ultimately, less than optimal reconstruction. Calvarial bone grafting provides a readily accessible source of bone from an inconspicuous donor site, usually within the same operative field. The morbidity is minimal. The calvarial bone graft is especially useful in repair of the frontal sinus, orbital floor, nasal and malar regions, as well as in certain instances of cleft palate with alveolar involvement.

Surgical anatomy of the scapular spine in the trapezius-osteomuscular flap

Measurements of the spine of the scapula in relationship to the trapezius-osteomuscular flap were made in a series of cadavers. These measurements enable estimation of the amount of available bone present and give the reconstructive surgeon a series of guidelines for using the trapezius-osteomuscular flap in correcting mandibular defects. A related phase of this investigation was the development of a roentgenographic technique using the 30 degree cephalic view of the shoulder for preoperative assessment of the spine of the scapula.

Tagliacotian cross-arm flap reconstruction of facial defects

The tagliacotian cross-arm flap finds its basis in one of the oldest reconstructive techniques known, the brachial flap of Gaspar Tagliacozzi. Although not commonly employed today, it remains useful in difficult orbital and nasal reconstructions. Our report deals with the historic development, applicability, timing, and technique of this procedure and is well illustrated by a case report. Advantages of the tagliacotian flap include no additional scarring in the exposed area and a hidden donor site. A considerable amount of usually non-hair-bearing tissue can be transferred without sacrifice of valuable muscle and without special surgical techniques. The tagliacotian cross-arm flap should be considered when local and regional tissue supply is inadequate, when aesthetic desires of the patient preclude additional local scarring, and when time allows for the training and transfer of this flap.