Biomedical subjects
Publications and source records attributed to W E Fee.
We describe a useful technique for local brow-lift operation. We discuss the results and outline procedural modifications that minimize postoperative scarring. The operation may be performed in conjunction with blepharoplasty or other cosmetic surgery.
Trigeminal neurinomas may produce atypical facial pain, loss of facial sensation, facial palsy, hearing loss, nystagmus, or vertigo, and thus may be confused with nasopharyngeal carcinomas or acoustic neurinomas. The diagnosis can be made by the clinical presentation together with radiographic features showing widening of the foramen ovale and/or smooth destruction of the anteromedial portion of the peterous apex. Tomography, pneumoencephalography, angiography, and other diagnostic procedures are sometimes helpful. Treatment is removal by transtemporal craniotomy and offers an excellent prognosis.
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MacFee (double horizontal) incisions have often been criticized for transecting the dominant blood supply of the central bipedicled cervical flap. To assess the viability of this flap we reviewed our recent surgical data. Ninety-three patients who underwent 100 radical neck dissections were evaluated retrospectively for cervical skin viability after surgery. MacFee incisions were used in 50 of these; in the remaining 50 a variety of other incisions were used. With MacFee incisions no ischemic tissue loss resulted. By contrast, six patients (12%) in the comparison group experienced partial flap necrosis due to ischemia. Chi-square analysis shows this difference to be statistically significant (P less than 0.01). This study shows the bipedicled cervical flap to be durable, dependable, and sufficiently vascularized to prevent ischemic tissue loss, even when incisions were previously placed in the ipsilateral neck or antecedent radiation therapy was delivered.
Our experience with reexploration of the parotid wound following parotid gland surgery is presented. There is scant information in the literature to guide the head and neck surgeon in deciding when, and indeed whether, he can safely reexplore the parotid wound following parotidectomy for the removal of residual disease or for determination of neural integrity. The authors treated six patients at Stanford University (Stanford, CA), all of whom underwent reexploration of the parotid wound. Four patients were reexplored to remove residual disease, and two patients were reexplored to evaluate the integrity of the facial nerve after evidence of neural degeneration. Reexploration was undertaken from seven to 23 days after the primary surgical procedure. In all cases, no difficulty was encountered in identification and repair of the facial nerve or removal of residual disease. Five of these patients have fully recovered facial nerve function; one is awaiting recovery after a facial nerve grafting procedure. We recommend early reexploration of the parotid wound following parotidectomy for the removal of residual disease and to assess the integrity of the facial nerve in instances of neural degeneration. Reexploration may be easily and safely accomplished within 3 weeks of initial surgery without significant risk of further neural damage.
Alveolar soft part sarcoma is a rare malignancy. To our knowledge, 13 cases in the head and neck have been reported previously. It occurs more commonly in the extremities, where it is associated with a poor prognosis. Its clinical course resembles that of adenoid cystic adenocarcinoma in that late metastases often cause death in 10 to 15 years. A 5-year-old girl with alveolar soft part sarcoma was successfully treated with partial glossectomy and is free of disease at two-year follow-up.
Laryngeal coccidioidomycosis with severe upper airway obstruction occurred in a 5-year-old boy. Diagnosis was confirmed by positive serum precipitin and complement fixation titers, pathologic demonstration of typical Coccidioides spherules in biopsy specimens from subglottic tissue and paratracheal lymph nodes, and culture of C. immitis from the subglottic tissue specimen. The child was treated successfully with tracheostomy and intravenously administered amphotericin B (total dose of 60 mg/kg).
The purpose of these experiments was to determine the incidence of the middle ear reflex in response to several nonacoustic (tactile and air jet) stimuli among subjects with normal hearing who had an acoustic reflex and selected patients with severe hearing loss. The results demonstrate that the incidence of response to tactile stimulation increases as the facial area stimulated approaches the auricle. The response to an air jet stimulus directed toward the eye is high; however, the clinical utility of the air jet may be limited because it often results in a startle reaction and head movement, and the response appears to fatigue easily. In normal listeners the response to auricular air jet stimulation probably results from both acoustic and tactile stimulation. The presence of a reflex to tactile stimulation, together with normal tympanometry constitutes strong evidence of a normal middle ear; but the absence of a reflex to acoustic or tactile stimuli still leads to an ambiguous determination of potential stapedial muscle function.
A new method of permanent tracheal fenestration is reported, utilizing cervical skin and tracheal flaps. It has been performed on four patients without complications and has the advantage of being a quick, simple, one-stage operation that is reversible should conditions change. The procedure is utilized in patients with posttraumatic or postirradiation fibrosis of the larynx, chronic obstructive pulmonary disease and patients with sleep apnea.
A double-blind, parallel investigation was undertaken to evaluate the efficacy of transdermally delivered scopolamine hydrobromide in acute vertigo as compared to meclizine hydrochloride and placebo. Statistical analysis of subjective patient responses and clinical observations suggested that both scopolamine and meclizine are more effective than placebo. Both have significant, but different, side effects.
A 58-year-old man was evaluated for a 42-year complaint of a pharyngeal foreign body sensation whenever he ate. Examination revealed normal anatomy at rest but diffuse hypopharyngeal distension with Valsalva's maneuver. His past history was remarkable for an infectious illness, possibly diphtheria. We speculate that this unusual case most likely represents a postdiphtheritic selective pharyngeal paralysis and present his case, radiographic findings, and a discussion of the differential diagnosis.
Conradi-Hunerman syndrome, a variant of chondrodysplasia punctata, rarely presents with primary manifestations relevant to the head and neck surgeon. Usually, the disease is evidenced by malformation of the extremities, cataracts, cutaneous lesions, and an unusual facies. We have followed a child with Conradi-Hunerman syndrome for 7 years whose primary manifestation of the disease is respiratory compromise secondary to calcification of the laryngotracheobronchial tree. In addition, he has a conductive hearing loss thought to be secondary to ossicular chain fixation.
Sixteen patients with advanced head and neck carcinomas were treated with cis-diaminedichloro platinum chemotherapy; seven preoperatively and nine for recurrent disease. Cis-platinum was given by 24-hour infusions of 80 mg/m2 every three weeks. There was 50% regression in 38% (6) of the patients; another 38% (6) had 25% to 50% regression. Toxicity was minimal, with vomiting occurring in 75% (12) of the courses, renal toxicity in 6% (2), leukopenia in 13% (4), thrombocytopenia in 9% (3), and anemia in 31% (10). Of the seven patients who had serial audiograms, only one experienced ototoxicity. Cis-platinum, given by 24-hour infusion, was effective in reducing tumor bulk in 75% (12) of the patients, with advanced head and neck carcinomas, without undue morbidity.
Angiosarcomas are uncommon tumors of the skin and soft tissues, but occur in endothelial cells of almost any internal organ. When they occur in the skin, the head and neck are the most common sites of origin. Nothing is pathognomonic about their clinical presentation, and the pathologic diagnosis can only be established by biopsy. The frequent multicentric nature of the tumor and propensity for extensive subcutaneous spread require wide treatment fields, whatever the modality of therapy, and account for the low survival reported. Four cases and their outcome are reported, with only one patient achieving an apparent cure following irradiation therapy. Based on experience and extensive review of the literature, a best therapeutic approach cannot be recommended. Since the outlook for cure is so unfavorable, there appears to be a need for cooperative studies using surgery, irradiation, and perhaps, chemotherapy.
Synovial chondromatosis is an uncommon disease of cartilaginous transformation of synovial membrane with formation of loose bodies within the joint space. A case involving the temporomandibular joint (TMJ) is presented. In the TMJ, this disorder occurs more often in females and is usually on the right side. Symptoms include preauricular swelling, pain, and tenderness. Radiographs of the TMJ may be normal, but frequently show multiple, partially calcified loose bodies within the joint. Treatment consists of removal of the loose bodies together with all affected synovium. If the meniscus is excised, reconstruction with a Silastic prosthesis is recommended.
Frontal sinus trephination with removal of the intersinus septum has been found to be an effective therapy in selected cases of chronic unilateral frontal sinusitis; in addition, it may be combined with unilateral duct reconstruction in the treatment of chronic bilateral sinusitis. It may also be performed as a prophylactic measure when nasofrontal duct injury occurs during unilateral nasal or maxillary sinus surgery. The authors' experience with the procedure in 20 cases is described.
Nasopharyngeal tumors in the newborn are exceedingly rare. Typically, initial symptoms are breathing or eating difficulties. A case is presented of a patient in whom bleeding began following diagnostic passage of nasopharyngeal catheters. Surgical excision was required on the third day of life, and histologic review revealed a squamous cell proliferative lesion consistent with squamous cell carcinoma. The infant's postoperative course was uneventful. Specimens from a nasopharyngeal biopsy done six weeks later revealed only reactive lymphoid hyperplasia and a 6 months of age, the child's condition was normal. After review of the available literature and this patient's pathologic condition, it is believed that this lesion represents an otherwise unclassifiable squamous cell proliferation previously not described.
Follicular lymphoid hyperplasia of the hard palate is a slowly growing, soft, nontender swelling that may grow to involve the entire hard palate. The overlying mucosa is normal. This appearance naturally prompts biopsy, and both clinically and microscopically might be confused with lymphoma. Four case histories are presented with histologic description: normal palatal submucosal structures are replaced with benign reactive lymphoid tissue replete with well-developed germinal centers. Surrounding these centers are dense populations of small, regular, bland lymphocytes. Minor salivary glands, except for some atrophied residue, are notably absent; also absent are the epimyoepithelial islands characteristic of the benign lymphoepithelial lesion (Mikulicz's disease). Etiologic factors remain obscure. One of our patients had two recurrences following local excision; in another patient nodules of benign lymphoid hyperplasia developed in the cheek and upper neck. These four patients are alive and free of any malignant process 4, 7, 9, and 12 years after the onset of their palatal swellings. We urge caution in distinguishing these lesions from palatal lymphoma, and recommend local excision as the treatment of choice.