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P Gullane

Publications and source records attributed to P Gullane.

At least 37 records · Page 2Linked to original sources
PubMed1997

Biophysics of airflow within the airway: a review.

An understanding of the fundamental principles that govern flow through the airway, like anatomy and physiology, is essential for the practising otolaryngologist. Failure to grasp these principles prevents the clinician from understanding why certain things happen clinically and why certain treatments are effective. This review presents the basic concepts of fluid mechanics as applied to the airway, using commonly encountered clinical situations to further illustrate ideas. Since air is a gaseous fluid, a review of the gas laws initiates the reader. Laminar and turbulent flow is discussed as well as the method used to distinguish between the two. Also included is a brief review of the air/liquid interface inside an alveolus, as well as a discussion of airflow through an endotracheal tube.

Airway Obstruction↗
PubMed1996

Multidisciplinary management controversies in laryngeal cancer.

While the primary goal of laryngeal cancer management is to save life, the preservation of structure and function also holds a very prominent position in the decision making for this disease. Although the therapeutic options to achieve these goals exist for most patients presenting with laryngeal carcinoma, they are not applied to a significant number of patients. In this paper we will summarise some of the disagreements which exist about optimal management and demonstrate that the opinions of experts trained to treat this disease have been shaped by non-evidence based approaches. In large part the specialty of practice and the geographic location of specialists have the greatest influence on the type of treatment recommended to an individual patient with a given stage of disease; medical knowledge, or more correctly the lack of it when comparing treatment options, seems to have a lesser influence on the decision process. We will consider the principal opportunities available to attempt to resolve controversies in laryngeal cancer. The discussion will include attention to randomised clinical trials, patient preferences, economic issues, and techniques to avoid the problems of selection bias when comparing outcomes for different treatments.

Carcinoma↗
PubMed1996

Subglottic resection with primary tracheal anastomosis: including synchronous laryngotracheal reconstructions.

Subglottic stenosis is defined as an obstructing lesion in the upper airway lying at a level between the base of the vocal cords superiorly and the lower border of the cricoid cartilage below. Symptoms of upper airway obstruction are characterized by inspiratory and expiratory stridor and dyspnea. Because most of these injuries follow translaryngeal intubation and assisted ventilation with or without tracheostomy, symptoms usually appear within a few weeks of extubation. This article reviews the management, techniques of reconstruction such as laryngofissure, stenting and endoscopic therapy, and the clinical experience (October 1973 through October 1995) gained with the operation of segmental subglottic resection and primary thyrotracheal anastomosis in 80 consecutive patients with benign disease.

Anastomosis, Surgical↗
PubMed1995

Clinico-pathological predictors of recurrence for acinic cell carcinoma.

The biological behaviour of acinic cell carcinomas, even if well differentiated, is unpredictable. We studied 45 patients with acinic cell carcinoma followed-up from 10 to 379 months (5 year recurrence-free and survival rate of 69% and 81% respectively), and compared clinico-pathological parameters with outcome. The presence of a predominately solid architecture was strongly associated with a poor outcome (P < 0.01) and this was the only independent prognostic variable when log rank testing was performed. Tumour size (> 2.75 cm) was a significant predictor of recurrent deep parotid lobe involvement, the presence of cervical nodal disease and lymphocytic infiltration, although not significant, factors showed a tendency towards recurrence. For acinic cell carcinoma, the predominant solid architecture would appear to be a strong predictor of recurrence.

Adolescent↗
PubMed1994

The role of surgery following radiotherapy failure for advanced laryngopharyngeal cancer. A prospective study.

BACKGROUND: To comment on the use of surgery following radiotherapy failure for advanced laryngopharyngeal cancer. METHODS: Of 212 participants, 88 underwent potentially curative surgical salvage following radiotherapy failure. These 88 patients were followed up prospectively for a median of 4.4 years following surgery; complications, recurrences, tumor measures, and survival were documented to facilitate a critical analysis. RESULTS: Surgical complications developed in 48% of the patients, were most prevalent following pharyngectomy (P = .03), and were not influenced by the addition of a neck dissection (P = .76). Postsurgical survival was statistically associated with the TNM stage of the recurrent tumor and the site of recurrence (local or regional vs both), but was not associated with the TNM stage of the original tumor, time to recurrence, age, sex, or primary site. The overall 5-year postsurgical survival for this cohort was 35%. Utilizing a policy of primary radiotherapy, reserving surgery for radiotherapy failures, 41% of our patients retained functional larynges without reducing their overall survival. CONCLUSIONS: We suggest that recurrent tumors be restaged, as the measures of the recurrent tumor, not the tumor at original presentation, correlate best with survival following surgical intervention for tumor recurrence.

Aged↗
PubMed1994

An assessment of prognostic factors in soft-tissue sarcoma of the head and neck.

OBJECTIVE: This study evaluates the outcome, patterns of failure, and prognostic factors in head and neck soft-tissue sarcoma in the adult. DESIGN: A retrospective evaluation of 73 patients treated recently for this rare disease. The minimum follow-up for all patients was 3 years with the living patients having a mean follow-up of 4.6 years. SETTING: All patients were treated between January 1980 and December 1988, at the Princess Margaret Hospital-Ontario Cancer Institute, Toronto, the major sarcoma referral center for a population in excess of 3 million. PATIENTS OR PARTICIPANTS AND INTERVENTIONS: Fifty-two patients were treated with curative intent: 10 by surgery without radiotherapy and 42 with surgery and radiotherapy. Twelve patients received adjuvant chemotherapy. OUTCOME MEASURES: Five-year cause-specific survival, local relapse, and distant failure rates were calculated by the product limit method. Comparisons between survival curves were carried out by the log-rank statistic and Cox regression analysis was performed to assess the influence of prognostic factors. RESULTS: The 5-year cause-specific survival was 62%, with a local relapse rate of 41% and distant relapse rate of 31%. Extension to adjacent structures, high grade, and large lesion size were associated with poorer survival. Gross residual tumor also was associated with high local failure (75% failure) despite the addition of radiation therapy. Those with clear surgical margins or only microscopic involvement fared much more favorably and had similar local control rates (26% and 30% failure, respectively) provided adjuvant radiotherapy was given. However, 68% of patients dying as a result of their sarcoma had uncontrolled local disease because of the high incidence (27%) of gross residuum following surgery in this series. CONCLUSIONS: This series highlights the absolute necessity for resection of all overt disease with planned adjunctive radiotherapy and appropriate reconstruction in most cases. This is achieved more easily in the setting of a specialized sarcoma treatment unit.

Adolescent↗
PubMed1994

Internal jugular vein blowout complicating head and neck surgery.

Internal jugular venous rupture after head and neck surgery is a rare but important condition to recognize. The Toronto General Hospital experience of this condition, together with its identification and management is reported. Jugular vein rupture should be considered in patients undergoing primary tumour excision with modified or functional neck dissection complicated by a pharyngo-cutaneous fistula. Typically, bleeding is venous and occurs repeatedly. However, haemorrhage may be substantial and life-threatening. Treatment requires exploration and ligation of the venous system. The carotid artery should be assessed and protected at surgery, since there is a likelihood of a carotid blowout as the conditions have a common aetiology. It is important to distinguish jugular vein haemorrhage from carotid arterial rupture, since the former has a far better outcome if treated properly.

Adult↗
PubMed1994

The through-and-through oromandibular defect: rationale for aggressive reconstruction.

Through-and-through oral cancer (T4+) involving contiguous mucosa, mandible, and skin is a devastating disease with poor prognosis and represents one of the most difficult reconstructive challenges in head and neck surgery. Thirty-eight patients underwent immediate microvascular reconstruction following surgical tumor ablation. The purpose of the present review was to assess the value of microvascular reconstruction in these essentially palliative reconstructive efforts. The iliac crest osteocutaneous flap was used in the majority of patients and was found to be ideal for the reconstruction of large bony and soft-tissue defects present in this group of patients. Other methods, including pectoralis major, forehead, and latissimus dorsi flaps, also were used in the soft-tissue reconstruction. The mean follow-up was 16 +/- 2 months, and the mean hospitalization was 43 +/- 22 days. The majority of patients succumbed to recurrent or related diseases, yet a few went on to survival despite the initial advanced stage of disease. A number of complications were observed. However, most patients developed normal or easily intelligible speech (65 percent), and most (78 percent) had their tracheostomies closed and sustained themselves on an oral soft diet (84 percent). Bony union was noted in the majority of patients (73 percent). Although the prognosis in full-thickness oral carcinoma is grim, it appears that palliative surgery in these cases is well justified. The goals are to shorten the duration of hospitalization, reduce morbidity, and improve the remaining quality of life. Microvascular tissue transfer offers a means to achieve these goals in a single, reliable procedure. We feel that immediate one-stage bone and soft-tissue reconstruction restores dignity and relieves suffering in this unfortunate group of individuals.

Adult↗
PubMed1994

Reinnervated lateral antebrachial cutaneous neurosome flaps in oral reconstruction: are we making sense?

Eight patients who underwent a partial glossectomy and associated floor of the mouth resection for squamous cell carcinoma were reconstructed with a sensate radial forearm flap in which the lateral antebrachial cutaneous nerve was anastomosed to the (divided) lingual nerve. The patients were compared prospectively with matched controls who received noninnervated forearm flaps for the same defect. A "blinded" therapist performed detailed sensory testing at least 6 months following surgery. In all modalities examined, the sensate proved superior to the nonsensate flap and not statistically different from the opposite side of the tongue. Two-point discrimination and pressure sensitivity were much greater in the innervated forearm flaps than in the forearms from which they came. The results are discussed with reference to the density of sensory receptors, the degree of cortical representation, and the subcortical anatomy of the neurosensory tracts. It appears that the density of sensory receptors is not directly related to the sensory potential in a given tissue transfer and that this potential is more related to the cortical fidelity of the recipient nerve. A historical matched cohort of 10 patients receiving pectoralis flaps for similar defects also was examined. Although the follow-up was longer, reinnervation was of a very low order--even worse than with noninnervated forearm flaps. This work supports the concept that sensory reinnervation should be attempted whenever possible following ablative oral surgery. This would include suture or grafting of major sensory nerves as well as the reinnervation of flaps.

Aged↗
PubMed1993

Recipient vessels in head and neck microsurgery: radiation effect and vessel access.

Historical cohort analysis compared free-flap survival rates in 226 irradiated and 108 nonirradiated head and neck reconstructions. The failure rate for the irradiated flaps (3.5 percent) did not differ significantly from that for the nonirradiated group (2.9 percent). A case-control study of the failed irradiated flaps revealed infection and lag time between radiotherapy and surgery as the only factors significantly associated with free flap failure. Salvage techniques (vein grafting, cephalic transposition, and Corlett looping) for recruiting recipient vessels into radically ablated head and neck beds are reviewed.

Adult↗
PubMed1993

Horner's syndrome following a thyroidectomy.

A case of Horner's syndrome following a thyroidectomy for a benign multinodular goiter is presented, the literature reviewed, and possible explanations are discussed. Theories to explain this phenomenon include: local trauma to the sympathetic chain during retraction of the carotid sheath, anatomical variations which leave a patient susceptible to damage to the sympathetic chain, postoperative hematoma compressing the sympathetic chain, and ischemic damage to the sympathetic chain.

Aged↗
PubMed1993

A re-evaluation of radical total glossectomy.

Total glossectomy, with or without accompanying total laryngectomy, in many respects represents the radical extreme of the treatment spectrum for oral cavity/oropharyngeal carcinoma. It necessarily impacts greatly upon the functions of speech and deglutition and thereby upon the patient's quality of life. The candidates for this surgical procedure are, however, already severely debilitated with respect to these functions due to the extent of their disease and tumor-induced pain. When considering the alternatives, radical surgery becomes more acceptable, for, at the very least, it offers substantial palliation. This article reviews the current literature regarding the procedure itself, potential outcomes and presents a small case series of reconstructive options.

Aged↗
PubMed1992

Accuracy of pathologic diagnosis in thyroid lesions.

Although there is much literature devoted to the role that fine-needle biopsy plays in the management of the thyroid mass, only a handful of studies deal with the diagnostic accuracy of the frozen section and final paraffin section of thyroid lesions. Fine-needle biopsy results, frozen-section diagnoses, final paraffin-section diagnoses, and panel review diagnoses were recorded for 137 consecutive patients who underwent thyroidectomy procedures. The overall accuracy of fine-needle biopsy, frozen-section, and paraffin-section diagnoses was 81%, 87%, and 94%, respectively. The high positive predictive value and specificity of both the fine-needle and frozen-section modalities suggests that intraoperative pathology consultation, given that the preoperative needle aspirate is positive for malignant neoplasia, can offer little further in the treatment of the patient. Statistical analysis of the accuracy of the three modalities suggests strategies for accurate treatment of the thyroid nodule.

Adolescent↗
PubMed1992

Pleomorphic adenoma: a preliminary histopathologic comparison between tumors occurring in the deep and superficial lobes of the parotid gland.

Twenty-four cases of pleomorphic adenoma of the parotid gland were retrospectively reviewed. The histopathological features of capsular thickness, penetration and completeness, tumoral cell population and mitotic activity were analyzed in twelve superficial lobe and twelve deep lobe tumors. The capsules were found to be significantly thicker and less likely to be penetrated by tumor in the deep lobe group. No significant differences in completeness of encapsulation, cell population or mitotic activity were found between the two groups. This may explain the clinical suggestion that the less aggressive surgical approach which is often performed does not compromise the prognosis for recurrence in the deep lobe lesions.

Adenoma↗
PubMed1991

A comparison of the results following oromandibular reconstruction using a radial forearm flap with either radial bone or a reconstruction plate.

Fifteen cases of oromandibular reconstruction using a radial osteocutaneous flap were compared with 16 in which the mandible was replaced with a reconstruction plate and a forearm flap was used for intraoral lining. All cases involved oral cancer; most had been irradiated. Nine survived in each group. Complications included one infected nonunion in addition to two bone exposures in the bone group, compared with three cases of plate exposure and two bone exposures in the plate group. Functional results were similar in both, but osteointegrated implants were possible only in the patients receiving bone. Cosmesis seemed somewhat better in the plate group. Donor-site problems were common but minor, and long-term forearm function was slightly reduced in both groups. Although the sample sizes were small, the reconstruction plate together with a radial forearm flap appeared to provide effective reconstruction following composite resection. However, we would not recommend this for the younger patient or in benign disease.

Adult↗
PubMed1990

Liposarcoma: report of a case and review of the literature.

Liposarcoma of the head and neck region is extremely rare. An additional case of pleomorphic liposarcoma of the buccal mucosa is reported, representing an even rarer combination. The importance of combined radiation and radical surgical therapy as a means of improving survival is emphasized.

Aged↗
PubMed1990

The iliac crest and the radial forearm flap in vascularized oromandibular reconstruction.

Sixty cases (59 patients) of oromandibular reconstruction using vascularized iliac crests were compared with 13 in which radial osteocutaneous flaps were used. These patients were reviewed from the standpoint of cosmetic results and function as well as their operative and postoperative courses. In both groups, the results were generally good. However, revisionary surgery was more frequent in those receiving the iliac crest. This group also had a higher incidence of intraoral wound breakdown and bone exposure. Nevertheless, the sheer size of the iliac crest made it ideal for massive oromandibular defects, just as its natural curvature lent itself to precise replication of the mandible in bone-only reconstructions. Its bulk proved a major obstacle in small composite defects. The radial forearm flap carried thin, pliable, well-vascularized skin that was superior to groin skin for oral lining. Bone gaps of up to 9 cm could be handled with ease, thus making it complementary to the iliac crest over the wide spectrum of mandibular reconstruction.

Adolescent↗