Intercostal pedicled flap in esophageal atresia.
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Esophageal Atresia↗
Biomedical subjects
L D Holinger
Publications and source records attributed to L D Holinger.
Superselective embolization of laryngeal hemangioma.
Diffuse upper respiratory hemangiomas are extremely rare lesions. Unlike the much more common congenital subglottic hemangiomas, diffuse upper respiratory hemangiomas do not resolve spontaneously and may prove quite recalcitrant to conventional forms of therapy. Superselective embolization, a highly successful technique for the management of head and neck vascular lesions, was used to effectively control an obstinate laryngotracheal hemangioma. Superselective embolization appears to provide yet another viable therapeutic option in the management of laryngeal hemangiomas.
Child↗
Concomitant therapy with infusion of cisplatin and 5-fluorouracil plus radiation in head and neck cancer.
We have combined cisplatin, 5-fluorouracil infusion, and radiation in an every-other-week schedule in a phase I-II study of 44 patients with head and neck cancer to assess toxicity and response. Ten patients were treated palliatively with 2 to 6 cycles of therapy, and 34 were treated curatively with a planned 7 cycles. Of 34 patients treated curatively, all were initially controlled. Three died during treatment (1 myocardial infarction, 1 bowel perforation, and 1 renal failure after amino-glycoside antibiotics). Four patients have had regional recurrences, 7 failed at distant sites (follow-up 2 to 5 yr). Thirty-three percent of 20 patients with complete clinical disappearance of all evidence of their cancer have had a recurrence, as have 38% of 14 (P greater than .1) with some residual abnormalities (partial responders) following treatment. All failures were in the 25 patients with T4 and/or N3 disease. None of the 9 patients with lesser stage IV or stage III disease who were followed for 24 months or more had recurrences. Eighteen patients (53%) survive with a projected 3-year survival of 63% (95% confidence interval 47% to 77%). Nine (27%) have died of disease, 1 (3%) died of a second primary in the head and neck, 3 (9%) of intercurrent disease at 15 to 45 months, and 3 (9%) during treatment. Of the 10 patients treated palliatively, 1 died during treatment with hepatic failure, 6 had complete responses, and 2 had partial responses.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Right middle lobe syndrome in children.
Right middle lobe syndrome (RMLS) is characterized by a spectrum of diseases from recurrent atelectasis and pneumonitis to bronchiectasis of the middle lobe. It has been described among all age groups, although the diagnosis in pediatrics may be delayed or missed because of non-specific symptoms or findings. Twenty-one children with RMLS were evaluated during the past 10 years with particular attention to the history, bronchoscopic and pathologic findings. Most of these patients had asthma or a family history of atopic disorders; 3 patients had a family history of RMLS. Only two of the 21 patients had sufficient obstruction on bronchoscopy to account for their disease. Four had evidence of concomitant laryngeal pathology. The various theories of pathogenesis are discussed. In this series, the non-obstructive (impaired collateral ventilation) theory appeared to be most plausible. Bronchoscopy was performed in all instances to rule out obstruction due to foreign body or tumor. It was therapeutic in two-thirds of the cases. Resolution occurred promptly in one-third, and eventually in another third. Of the remaining patients, 4 required lobectomy and were cured; two have decreased but persistent symptoms. An aggressive medical management following bronchoscopy is warranted in all cases, especially when there is a possibility of asthma.
Asthma↗
Acquired subglottic cysts in premature infants.
Advances in the management of premature infants have resulted in improved survival. However, long-term intubation may produce associated laryngeal complications. We report 12 infants and children who developed subglottic cysts following long-term intubation as newborns. The majority of the cysts were in the posterior subglottic larynx. Laser excision of the cysts was undertaken in 8 patients and 3 underwent removal with cupped forceps. Recurrent cysts in 3 patients required more than one endoscopic procedure. The differential diagnosis of stridor in infants who have required long-term intubation includes subglottic cysts. The cysts are not always obvious at endoscopy and indeed may be buried below the mucosa within a soft tissue subglottic stenosis. Their presence may be suspected when tiny beads of mucus are released when laser surgery of a soft tissue stenosis is applied. Successful management of these cysts includes early precise diagnosis, with careful identification of these cysts to differentiate them from other types of subglottic stenosis. An initial attempt of conservative management with endoscopic excision is made. If this fails, an anterior cricoid split may be indicated in cases where the cysts are associated with soft tissue subglottic stenosis. Tracheostomy may be unavoidable in some cases.
Cysts↗
Treatment of advanced head and neck cancer with concomitant radiation and chemotherapy.
Forty-four patients with predominantly inoperable or recurrent head and neck cancers were treated with combined chemotherapy (CT) and radiation therapy (RT) in a Phase I/II study. CT and RT were combined in a concomitant fashion to take advantage of radiosensitizing properties of the chemotherapeutic agents. Each treatment cycle consisted of cisplatin 60 mg/M2 on day 1, 5-FU infusion at a dose of 800 mg/M2 per day continuously for 5 days and RT at 200 cGy per day, days 1 through 5. The treatment cycle was repeated every 2 weeks for 7 cycles in patients treated curatively and for 2 to 6 cycles in patients treated palliatively due to prior radiation therapy or the presence of metastatic disease. Regional control was achieved in 98% of the patients. Regional control has persisted in 87% of the patients treated curatively with a minimum follow-up of 24 months. Distant failure occurred in 23% of this group. Actuarial survival of 2 years for the curative group is 66%. Concomitant combination of radiation with radiation potentiating chemotherapeutic agents shows promise of increase in local control.
Antineoplastic Combined Chemotherapy Protocols↗
Anterior cricoid split: the Chicago experience with an alternative to tracheotomy.
Twenty-six infants and children underwent anterior cricoid split (ACS) in an attempt to avoid tracheotomy. Twenty (77%) were extubated successfully without tracheotomy;six (23%) failed and required tracheotomy. Our experience corroborates that reported in the literature. To date, 106 (77%) of 138 patients who have undergone ACS have been extubated successfully without tracheotomy. These results substantiate the validity of the operation when done for the proper indications. Substantive glottic and tracheal pathology indicate a high likelihood of failure of ACS.
Child, Preschool↗
Voice change after barium enema: a clinical sign of extraperitoneal colon perforation.
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Barium Sulfate↗
Surgical complications in patients with head and neck cancer receiving chemotherapy.
We evaluated postoperative complications in a randomized series of patients with head and neck cancer who received preoperative chemotherapy. Forty-two patients with advanced squamous carcinoma of the head and neck were randomized to receive either high-dose methotrexate with leucovorin calcium rescue (23 patients) or no chemotherapy (19 patients) prior to definitive conventional treatment. The two groups of patients were balanced by sex, disease site, stage, histologic grade, and prior therapy. Sixteen of the 23 patients receiving preoperative chemotherapy had postoperative complications, whereas only eight of 19 patients not receiving chemotherapy had postoperative complications. Surgical complications included wound infections, orocutaneous fistulas, and flap necrosis.
Antineoplastic Combined Chemotherapy Protocols↗
Glottic cancer. Surgical salvage for radiation failure.
Radiation therapy is a well-established treatment for early squamous cell carcinoma of the glottic larynx. However, the management of patients suspected to have persistent or recurrent disease may present both diagnostic and therapeutic dilemmas, particularly when laryngeal edema persists months after conclusion of radiation therapy. We reviewed the outcome of 212 patients with T1s, T1, and T2NOMO carcinoma of the glottic larynx who had been treated for cure with radiation therapy, with surgical salvage reserved for radiation failures. Twenty-four patients (11%) had recurrences after radiation therapy, 13 (59%) of whom had successful salvage by surgery. The five-year, recurrence-free survival in this series was 92% for T1s and T1 and 69% for T2. We conclude that T1s, T1, T2NOMO carcinoma of the glottic larynx is effectively managed by radiation therapy and surgical salvage for radiation failure. Total laryngectomy usually was necessary for surgical salvage.
Actuarial Analysis↗
Chronic cough in infants and children.
Chronic cough is an important, sometimes frustrating problem, often encountered by the otolaryngologist-head and neck surgeon. Thirty-eight infants and children under age 16 with a normal chest roentgenogram were evaluated for chronic cough persisting for longer than 4 weeks. Specific therapy (rather than symptomatic treatment) of chronic cough lead to a resolution or control of the cough in 33 (87%). Cough-variant asthma was by far the most common cause of chronic cough, followed by sinusitis, aberrant innominate artery, psychogenic cough, and subglottic stenosis. In addition to a detailed history, physical examination, and chest roentgenogram, endoscopy, paranasal sinus roentgenograms, and pulmonary function studies with methacholine challenge testing were particularly effective for establishing a precise diagnosis. Chronic cough is best managed by determining the precise cause of the cough, then specifically treating the underlying disorder. Children with persistent cough and a normal chest roentgenogram should be referred promptly for evaluation by an otolaryngologist when the primary physician's initial efforts at diagnosis and treatment are unsuccessful. Endoscopy is under-utilized in practice and its importance is understated in the literature. It is particularly helpful in establishing a precise diagnosis in infants under 18 months of age.
Adolescent↗
Endoscopic sizing: an attempt at uniformity.
The inside and outside diameters of all endoscopes and tracheotomy tubes in the endoscopy suite were systematically measured. These measurements were correlated with the manufacturer's stated size and comparisons noted. A lack of uniformity was noted often among and between all product lines. In addition, endoscopes and tracheotomy tubes were not uniformly labeled with inside and outside diameters. As a result, the proper choice of a tracheotomy tube or endoscope for a patient's size and age may be confusing. A chart was developed and included in order to allow quick and accurate recognition of tracheotomy tube and endoscope sizes across product lines to aid in the proper selection of tracheotomy tubes and endoscopic equipment.
Bronchoscopes↗
Management of an infant with prenatal ultrasound diagnosis of upper airway obstruction.
We report a case in which a cervical teratoma was diagnosed antenatally in the mid third trimester. In anticipation of potential upper airway obstruction, resources were mobilized to the operating room at the time of the planned cesarean section. The neonate was unable to breathe, but his airway was secured without delay. There was no evidence of cerebral anoxia initially or at one year follow-up. As prenatal diagnosis by ultrasound becomes more refined, the otolaryngologist will play an increasing role in perinatal decision making and anticipated emergencies at the time of delivery. Airway obstruction of various causes will be the most urgent problem.
Airway Obstruction↗
A randomized trial of adjuvant chemotherapy in head and neck cancer.
Ninety-five patients with squamous cell carcinoma of the head and neck were entered into a randomized study testing a two-week course of induction chemotherapy with methotrexate and leucovorin given prior to regional therapy. In addition, following regional therapy, patients randomized to chemotherapy were to receive similar methotrexate courses every three months for one year. Poor tolerance to this regimen after radiation and surgery led to a change in the chemotherapy following regional therapy to a combination of Adriamycin (Adria Laboratories, Columbus, Ohio) and cisplatin every three weeks for four cycles after the first 35 patients had been entered. Nine cases were ineligible and four lacked any follow-up data, leaving 82 analyzable cases. Using Cox regression analysis, no differences in the percentage of patients achieving disease control, the relapse-free survival, or the overall survival were identified between any treatment group. As has been described in many pilot studies of induction chemotherapy of head and neck cancer, chemotherapy responders had a more favorable disease-free survival than chemotherapy nonresponders in the total group of patients receiving adjuvant chemotherapy. However, correcting for imbalances in the expected three year disease-free survival of these patients, based on their disease site and stage, erased this difference, indicating tumor response to this regimen of chemotherapy is not an independent factor affecting disease outcome. The division of patients into arbitrary prognostic categories based on the expected outcome for each specific tumor site and stage proved to be a useful method for balancing treatment groups, given the multiple site-stage combinations within the upper aerodigestive tract. The defined prognostic categories were the single most sensitive predictors of relapse-free and overall survival.
Antineoplastic Combined Chemotherapy Protocols↗
Improved control in advanced head and neck cancer with simultaneous radiation and cisplatin/5-FU chemotherapy.
Chemotherapy with cisplatin plus 5-FU infusion was given simultaneously with radiation therapy; both were administered every other week. Twenty-seven patients with stage IV disease and three with stage III disease were treated; 57% had T4, 33% had N3, and 10% had M1 disease. Of these patients, 17 (57%) achieved complete response and the rest achieved partial response. However, whether or not a clinically complete response occurred had no effect on subsequent risk for disease recurrence. With a median follow-up of 16 months (range, 6-35), only 11 patients (37%) have had disease recurrence and eight (27%) have died. Of those patients who recurred, six failed in distant sites only, one developed a second head and neck primary, and four (36% of all failures) failed regionally. Normally, greater than 50% of patients who are initially controlled (usually less than 60% of stage IV patients) would have failed within the first 12 months and greater than or equal to 75% of these would be expected to fail regionally. Nine patients who had received previous treatment or who had M1 disease accounted for six of the recurrences and four of the deaths. Because of the excellent local control, we have cautiously limited surgery to conserve laryngeal, tongue, and mandibular function in selected cases. Neither immediate nor long-term toxicity from radiation appeared increased. Although no patient with such advanced disease can be considered cured at this time, these results seem to represent a substantial improvement in the quality of life and degree of local control over other approaches. Controlled trials of the sequencing of radiation and chemotherapy in head and neck cancer appear indicated.
Aged↗
Endoscopic evaluation of the patient with head and neck cancer.
Endoscopic evaluation of the patient with head and neck cancer is important in the precise diagnosis and staging of the disease, as well as in ruling out synchronous disease. Various types of instruments and techniques may be employed in this evaluation. Endoscopic surgery for malignant disease may play a role in the treatment of selected lesions.
Anesthesia↗
Anesthetic management and gas scavenging for laser surgery of infant subglottic stenosis.
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Air Pollution↗
A specimen mount for small laryngeal biopsies.
Accurate histologic interpretation of small laryngeal biopsies is often obfuscated by tangential sectioning of the specimen. The natural tendency of the tissue specimen to curl and suboptimal orientation of the specimen account for the tangential cuts. Use of a biopsy specimen mount eliminates this problem. The biopsy specimen mount also permits accurate determination of tumor involvement of deep and peripheral margins, a useful feature in the management of small areas of leukoplakia of the vocal cords. The biopsy specimen mount is therefore helpful in the endoscopic surgical management of small areas of leukoplakia of the vocal cords. The biopsy specimen mount is therefore helpful in the endoscopic surgical management of early glottic malignancy (T1s, T1), since therapy can be individualized and planned rationally with precise determination of margin involvement.
Biopsy↗