RESUMEN
OBJECTIVE: To describe the clinical manifestations of latex allergy in otolaryngology patients. DESIGN: Descriptive case series. SETTING: Tertiary academic otolaryngology practice. PATIENTS: Otolaryngology patients with documented allergic reactions to latex during surgery and confirmatory laboratory test results for latex allergy. MAIN OUTCOME MEASURES: Clinical description of latex reactions; identification of risk factors for latex allergy. RESULTS: We describe 3 patients, 2 children and 1 young adult, with severe latex allergy manifested by intraoperative cardiorespiratory changes and confirmed by positive latex-specific IgE test results. A 9-year-old boy with a tracheotomy and a history of multiple procedures for laryngeal stenosis developed a rash and unexplained bronchospasm during an open laryngeal procedure. Surgery was aborted, and subsequent surgery was performed uneventfully 4 weeks later using a latex-safe environment. A 13-year-old boy with recurrent respiratory papillomatosis and a ventriculoperitoneal shunt had sudden unexplained arterial oxygen desaturation and a rash during laser endoscopy. He was then treated successfully using latex-safe protocols. A 23-year-old man with a parotid malignancy developed unexplained hypotension and ventilatory difficulties in the operating room during preparation for surgery. He responded to medical treatment for anaphylaxis. CONCLUSION: The otolaryngologist should share in the increased awareness of latex allergy. Our patients who have had multiple surgical procedures or who are exposed to latex on a long-term basis may be at increased risk. Latex allergy should be considered when unexplained cardiorespiratory compromise occurs during surgery.
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Complicaciones Intraoperatorias/inmunología , Hipersensibilidad al Látex/diagnóstico , Procedimientos Quirúrgicos Otológicos , Adolescente , Adulto , Niño , Fibromatosis Agresiva/cirugía , Humanos , Intubación Intratraqueal , Masculino , Papiloma/cirugía , Neoplasias de la Parótida/cirugía , Neoplasias del Sistema Respiratorio/cirugía , TraqueotomíaRESUMEN
Despite many operative procedures focused on vocal fold lateralization, none has achieved an acceptable level of dependability. Bilateral vocal fold abductor paralysis is treated by arytenoidectomy, cordotomy, suture lateralization, or partial cordectomy. Tracheotomy remains the gold standard for maximizing the airway and preserving phonatory function. We have developed a device that is minimally invasive, tunable, and reversible, with the potential for lateralization or medialization of the vocal process. The device consists of a polyethylene collar, a Vitallium cam, and a double-helix core for engaging soft tissue. It is introduced through a circular opening in the thyroid cartilage by a modified thyroplasty approach. Both the first and second iterations of this device have been evaluated for clinical effectiveness in 9 sheep by means of photographic and video documentation. Effectiveness in humans is currently being assessed. The results of the animal study permit us to have substantial optimism with respect to the clinical application of this device.
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Fonación/fisiología , Parálisis de los Pliegues Vocales/cirugía , Factores de Edad , Animales , Tecnología de Fibra Óptica/métodos , Laringoscopía/métodos , Laringe Artificial , Procedimientos Quirúrgicos Mínimamente Invasivos , Implantación de Prótesis , Ovinos , Cartílago Tiroides/cirugíaAsunto(s)
Neoplasias Esofágicas/diagnóstico , Esofagoscopía , Esófago/diagnóstico por imagen , Neoplasias de Cabeza y Cuello/patología , Neoplasias Primarias Múltiples/diagnóstico , Neoplasias Esofágicas/diagnóstico por imagen , Humanos , Neoplasias Primarias Múltiples/diagnóstico por imagen , Neoplasias Primarias Múltiples/patología , RadiografíaRESUMEN
This study evaluates the soft tissue response in rabbits following laryngeal implantation for medialization using hydroxylapatite prostheses, carved silicone rubber prostheses, and injectable Teflon. Sixteen rabbits underwent left recurrent laryngeal nerve section for denervation and laryngeal implantation with hydroxylapatite. At 1, 3, 6, and 12 months, 4 animals were painlessly sacrificed and processed for histology. Similarly, animals were implanted with carved silicone rubber prostheses or with Teflon injected through a flap in the thyroid lamina for comparison at 1, 3, and 6 months. In animals implanted with hydroxylapatite, histologic findings include limited acute inflammatory response, thin fibrous encapsulation, and osteogenesis in the region of the fenestra, with lamellar bone bridging the space between the implant and thyroid lamina. With silicone rubber prostheses, there is a limited inflammatory response and fibrous encapsulation of the implant without evidence of osteogenesis. Animals implanted with Teflon demonstrated a classic foreign body reaction with multinucleated giant cells, granuloma formation, and migration of Teflon into surrounding muscle. With respect to soft tissue response, both hydroxylapatite and silicone rubber are less reactive than Teflon. The osteogenesis observed in the presence of hydroxylapatite increases implant stability and minimizes the risk of migration. Conversely, the presence of bone growth may limit the reversibility of medialization procedures performed with hydroxylapatite.
Asunto(s)
Durapatita , Laringe/cirugía , Politetrafluoroetileno/efectos adversos , Prótesis e Implantes , Siliconas/efectos adversos , Animales , Cuerpos Extraños/complicaciones , Granuloma/etiología , Osteogénesis , ConejosRESUMEN
Medialization thyroplasty is generally considered a phonosurgical procedure for voice augmentation in patients with glottic insufficiency. This article addresses specifically the issue of dysphagia and aspiration in patients with laryngeal paralysis. A retrospective review of patients undergoing medialization thyroplasty is performed. From 1991 to 1995, 84 patients at The Johns Hopkins Medical Institutions underwent medialization thyroplasty for unilateral vocal fold motion impairment. At presentation 48 patients had isolated recurrent laryngeal nerve injury, 26 with combined superior laryngeal nerve/recurrent laryngeal nerve injury and 10 with idiopathic nerve injury. Sixty-one percent of patients had swallowing difficulties. The severity of symptoms is greater in the superior laryngeal nerve/recurrent laryngeal nerve group. Before surgery 13 patients were dependent on feeding tubes. Nine patients improved to the point at which all alimentation was taken by mouth and tube feedings were discontinued after medialization thyroplasty. One patient was subsequently converted to a full oral diet after cricopharyngeal myotomy. Three patients remained dependent on feeding tubes. The pathophysiology of dysphagia including clinical and experimental observations is reviewed. In addition, the nonsurgical and surgical approaches to treatment of patients with laryngeal paralysis are reviewed.
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Trastornos de Deglución/cirugía , Cartílago Tiroides/cirugía , Trastornos de Deglución/complicaciones , Trastornos de Deglución/fisiopatología , Femenino , Humanos , Inhalación , Masculino , Persona de Mediana Edad , Prótesis e Implantes , Procedimientos Quirúrgicos Operativos/métodos , Parálisis de los Pliegues Vocales/complicacionesRESUMEN
A review of the table of contents of the program for the fourth International Conference on Head and Neck Cancer permits one to conclude that there is high energy in virtually every aspect of either the diagnosis or therapy concerning head and neck cancer. There is, in addition, an emerging interest (in fact, emphasis) on a more global restitution of the head and neck cancer patient, such that rehabilitation, both physical and emotional, as well as a greater acceptance of the benefits of less orthodox methods for treatment can be seen affecting outcomes.
Asunto(s)
Neoplasias de Cabeza y Cuello/terapia , Humanos , Calidad de la Atención de SaludAsunto(s)
Internado y Residencia , Otolaringología/educación , Docentes Médicos/estadística & datos numéricos , Cirugía General/educación , Hospitales de Enseñanza , Humanos , Relaciones Interinstitucionales , Internado y Residencia/estadística & datos numéricos , Medicina Militar/educación , Población , Edición , Facultades de Medicina , Consejos de Especialidades , Estados Unidos/epidemiología , Recursos HumanosAsunto(s)
Política de Salud , Nicotiana , Plantas Tóxicas , Adolescente , Adulto , Comercio , Femenino , Humanos , Masculino , Fumar , Tabaquismo/epidemiología , Estados Unidos/epidemiologíaRESUMEN
OBJECTIVES: To use concurrent chemoradiotherapy as primary treatment for resectable head and neck squamous cell carcinoma to (1) demonstrate the feasibility of an organ preservation approach for nonlaryngeal sites; (2) evaluate the toxic reactions and response to a new combination of two platinum compounds; and (3) monitor the effect of therapy on oral and pharyngeal function. DESIGN: Case series, a prospective single-armed trial. SETTING: Tertiary referral center. PATIENTS: Twenty-two patients with head and neck squamous cell carcinoma of the oral cavity, oropharynx, and hypopharynx for whom surgery would significantly compromise function were entered in this trial. INTERVENTION: Standard fractionation external-beam radiation therapy (2 Gy/Fx; total, 70 Gy) was given during a 9-week period, including a 2-week break after 40 Gy, concurrently with eight weekly doses of carboplatin and three doses of cisplatin (100 mg/m2) at 3-week intervals. A biopsy was performed 12 weeks after the completion of chemoradiotherapy to assess clinical response. All patients presenting with nodes greater than 3 cm had planned neck dissection. MAIN OUTCOME MEASURES: Tumor response, toxic reactions, survival, and oral and pharyngeal function. RESULTS: Overall complete response was 86%. Estimated overall 2-year survival was 64%, and disease-specific survival was 71% (median follow-up time, 25 months). Five patients have died of disease and two of unrelated causes. Treatment was completed by all, with toxic reactions including myelosuppression, mucositis, and dysphagia. Half of the patients required gastrostomy. CONCLUSIONS: Concurrent chemoradiotherapy using two platinum analogues was tolerated with good local control and survival. Notable dysphagia was common. This study provides pilot data for randomized clinical trials to confirm the usefulness of chemoradiotherapy for nonlaryngeal organ preservation.
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Carcinoma de Células Escamosas/tratamiento farmacológico , Carcinoma de Células Escamosas/radioterapia , Neoplasias de la Boca/tratamiento farmacológico , Neoplasias de la Boca/radioterapia , Neoplasias Faríngeas/tratamiento farmacológico , Neoplasias Faríngeas/radioterapia , Adulto , Anciano , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Carcinoma de Células Escamosas/fisiopatología , Quimioterapia Adyuvante/efectos adversos , Deglución/fisiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Neoplasias de la Boca/fisiopatología , Neoplasias Faríngeas/fisiopatología , Proyectos Piloto , Estudios Prospectivos , Dosificación Radioterapéutica , Radioterapia Adyuvante/efectos adversos , Habla/fisiología , Resultado del TratamientoRESUMEN
This paper reviews a new technique to develop high-resolution three-dimensional (3-D) images of the larynx using histological sections. Three-dimensional computer-reconstructed histological sections of the cat are used in this study to evaluate the recurrent laryngeal nerve (RLN) in its true anatomic course, with emphasis on its relationship to surrounding structures (laryngeal framework). A cat model was used because of specimen availability and technical ease of tissue preparation. Computer-reconstructed serial histologic sections add a new dimension to the study of laryngeal anatomy, laryngeal trauma, and growth patterns of laryngeal cancer. The technical aspects of three-dimensional reconstruction and future applications are discussed.
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Procesamiento de Imagen Asistido por Computador/métodos , Laringe/anomalías , Animales , Gatos , Técnicas Histológicas , Laringe/citologíaRESUMEN
None of the consultants was comfortable with the idea of proceeding with the biopsy of a neck mass in an outpatient clinic setting. All warned about the possible relationship of the mass with important anatomic structures. With regard to needing further information, physicians requested an imaging study of the neck, thoracic cavity, and mediastinum (Dr. Cummings); pelvic examination, breast examination with mammography, chest x-ray, and CBC (Dr. Weymuller); flexible endoscopy, chest x-ray, CBC, and MRI (Dr. Woodson). All three experts advised her to put IVF on hold. After the work-up, they would proceed with a biopsy of the mass and send the tissue to the pathologist in saline. In addition, tissue should be examined for fungus and AFB (Drs. Weymuller and Woodson). Because the patient proceeded with IVF and became pregnant, two experts advised her to abort and proceed with treatment for her Hodgkin's disease (Drs. Cummings and Woodson). The other option was for her to continue her pregnancy and proceed with radiotherapy to her neck, with shielding of the abdomen (Dr. Weymuller).
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Cuello/patología , Complicaciones del Embarazo/diagnóstico , Adulto , Biopsia , Diagnóstico Diferencial , Femenino , Fertilización In Vitro , Neoplasias de Cabeza y Cuello/diagnóstico , Neoplasias de Cabeza y Cuello/radioterapia , Enfermedad de Hodgkin/diagnóstico , Enfermedad de Hodgkin/radioterapia , Humanos , Planificación de Atención al Paciente , Embarazo , Complicaciones Neoplásicas del Embarazo/diagnóstico , Complicaciones Neoplásicas del Embarazo/radioterapiaRESUMEN
Laryngeal implantation for medialization has improved our ability to manage the patient with vocal fold motion impairment. We present preliminary data evaluating the use of preformed hydroxylapatite laryngeal implants and instrumentation for rapid determination of implant size and position. A window in the thyroid ala is created by means of a standard fenestra template. One of 5 prosthesis templates is inserted through the window for determination of correct size and position. The corresponding implant is then inserted and secured with a hydroxylapatite shim. Thirty-five patients have been implanted for vocal fold paralysis, and 4 patients were implanted for soft tissue deficits or bowing. Thirty-one of 35 patients have reported subjective improvement (89%). Improvement was demonstrated in 13 of 15 (87%) patients with complete preoperative and postoperative objective voice function measurements. Complications include 1 implant extrusion and 1 case of airway obstruction secondary to edema. Preliminary results indicate that prefabricated hydroxylapatite implants are effective for medialization thyroplasty. Advantages include a readily available implant selection, rapid determination of correct size and position, and improved implant stabilization with a hydroxylapatite shim.
Asunto(s)
Laringe/cirugía , Prótesis e Implantes , Parálisis de los Pliegues Vocales/cirugía , Adulto , Durapatita , Femenino , Humanos , Laringe/fisiopatología , Masculino , Métodos , Persona de Mediana Edad , Fonación , Complicaciones Posoperatorias , Reoperación , Parálisis de los Pliegues Vocales/fisiopatologíaRESUMEN
Twenty patients with vocal fold motion impairment were reviewed to correlate the findings of electromyography (EMG) and stroboscopy. The causes of motion impairment were idiopathic, previous surgery with recurrent laryngeal nerve injury, neck and skull base trauma, and neoplasm. The EMG studies were analyzed to assess the status of innervation of the immobile vocal fold. The presence or absence of the mucosal wave prior to therapeutic intervention was determined with stroboscopic examination. Eight of 10 patients with EMG evidence of reinnervation or partial denervation were found to have mucosal waves, and 3 of 10 patients with EMG evidence of denervation were found to have mucosal waves. Six patients developed mucosal waves after surgical medialization, despite evidence of denervation by EMG criteria. These findings support the premise that tension and subglottic pressure, rather than status of innervation, determine the presence of the mucosal wave.
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Electromiografía , Laringoscopía , Parálisis de los Pliegues Vocales/fisiopatología , Adulto , Anciano , Femenino , Humanos , Laringe/fisiopatología , Masculino , Persona de Mediana Edad , Parálisis de los Pliegues Vocales/etiología , Parálisis de los Pliegues Vocales/cirugíaRESUMEN
Partial necrosis of a skin flap can complicate reconstructive surgery. We performed a double-blinded crossover study to determine if pentoxifylline improves perfusion and survival of a myocutaneous flap. Ten 20-kg pigs were fed pentoxifylline (400 mg three times a day) or placebo for 1 week before and after raising a 5 x 30 cm panniculus carnosus flap on one flank. After 1 week of washout, each pig began the opposite drug treatment and the surgery was repeated on the opposite flank. Immediately after surgery, perfusion dermofluorometry and laser Doppler velocimetry demonstrated a significant increase in the perfusion of pentoxifylline-treated flaps compared to control flaps. On postoperative day 7, the mean area of clinical necrosis was 39.7 +/- 4.7 cm2 on the placebo sides and 30.1 +/- 4.6 cm2 on the pentoxifylline sides (t = 2.21, p < 0.05). We conclude that pentoxifylline improves perfusion and survival of myocutaneous flaps in pigs. Clinical trials appear to be indicated on the basis of the findings of this experiment.
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Pentoxifilina/farmacología , Colgajos Quirúrgicos , Supervivencia Tisular/efectos de los fármacos , Administración Oral , Animales , Método Doble Ciego , Evaluación Preclínica de Medicamentos , Femenino , Fluorometría , Flujometría por Láser-Doppler , Modelos Lineales , Masculino , Músculos/irrigación sanguínea , Pentoxifilina/administración & dosificación , Distribución Aleatoria , Piel/irrigación sanguínea , Porcinos , Factores de TiempoRESUMEN
Graves' ophthalmopathy (thyroid eye disease) can result in progressive visual loss. The University of Washington (Seattle) experience in orbital decompression was reviewed for the years 1983 through 1990 to determine overall safety and outcome. Twenty patients underwent transantral decompression of 36 orbits for either steroid therapy failure, steroid therapy intolerance, or recurrence of optic neuropathy with tapering of the steroid therapy. Decompression successfully improved visual function in 33 of the orbits (92%) and a second decompression procedure was successful in another two (5%) of the orbits (6%). There were no major complications or cases of decreased visual function. Diplopia, present preoperatively in 17 patients (85%), was improved in eight patients (47%) and unchanged in nine patients (53%). However, of the three patients without preoperative diplopia (15%), one had development of new-onset diplopia postoperatively. Transantral decompression of the orbit offers a safe and effective therapeutic modality for vision-threatening Graves' ophthalmopathy.
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Enfermedad de Graves/cirugía , Enfermedades Orbitales/cirugía , Corticoesteroides/efectos adversos , Corticoesteroides/uso terapéutico , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Enfermedad de Graves/clasificación , Enfermedad de Graves/complicaciones , Hospitales Universitarios , Humanos , Presión Intraocular , Análisis de los Mínimos Cuadrados , Masculino , Persona de Mediana Edad , Enfermedades Orbitales/clasificación , Enfermedades Orbitales/complicaciones , Servicio Ambulatorio en Hospital , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Resultado del Tratamiento , Trastornos de la Visión/diagnóstico , Trastornos de la Visión/etiología , Agudeza Visual , Washingtón/epidemiologíaRESUMEN
OBJECTIVE: --To analyze the working environment and work hours of a cohort of otolaryngology--head and neck surgery residents. DESIGN: --Environmental analysis questionnaire and a log of daily activities. SETTING: --Residents were on a clinical rotation system. PARTICIPANTS: --Fifty-nine residents from six programs, including three public and three private institutions, from geographically diverse regions of the country were involved in the study. Residents were equally distributed from their second year through their fifth year of postgraduate work. All eligible residents participated in and completed the study. INTERVENTION: --The environmental analysis survey was designed to elicit resident perception of different aspects of their working environment. The daily activity log required the resident to report on activities for each half-hour period for 7 consecutive days. RESULTS: --Residents were on call an average of 52.8 hours (2.2 days) and worked 79.4 hours per week. Seventy-five percent believed that the level of faculty supervision and the degree of resident responsibility was about right. Two major inefficiencies were the time involved in completion of paperwork and the lack of nonmedical support services. Thirty-one percent of the residents responded that fatigue resulted in substandard patient care 10% of the time. Forty-seven percent responded that their educational experience was substandard 25% of the time secondary to fatigue. Two thirds responded that the demands of residency training had a negative impact on their family and personal life. CONCLUSIONS: --Seventy percent of the otolaryngology--head and neck surgery residents surveyed at six institutions believe that an 80-hour workweek, including being on call every third night with no more than 24 hours of continuous work without sleep, approximates a reasonable, maximum work schedule. Residents working the longest hours expressed concern about rendering substandard care and developing negative attitudes toward patients. Noneducational inefficiencies were identified and solutions were proposed. Demands of residency training, even within guidelines established as reasonable, can have detrimental effects on residents' educational activities and personal life.
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Internado y Residencia , Otolaringología/educación , Análisis y Desempeño de Tareas , Actitud , Humanos , Relaciones Interpersonales , Tolerancia al Trabajo ProgramadoRESUMEN
In most cases of posterior epistaxis, the terminal branches of the internal maxillary artery (IMA)--principally the sphenopalatine artery--are believed to be the source of hemorrhage. However, we recently treated three patients in which unexpected or aberrant vascular anatomy resulted in persistent posterior epistaxis.
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Epistaxis/etiología , Cara/irrigación sanguínea , Arteria Maxilar/anomalías , Anciano , Arterias/anomalías , Senos Etmoidales/irrigación sanguínea , Femenino , Humanos , Masculino , Persona de Mediana Edad , Cavidad Nasal/irrigación sanguíneaRESUMEN
OSB can occur in the absence of an obvious contiguous source of infection. When a patient has persistent unilateral headache, elevated ESR, and radiographic evidence of a lytic skull-base lesion, the clinician should consider OSB as a potential diagnosis. A baseline gallium scan should be obtained before biopsy, since surgery or trauma can also produce positive results on radionuclide scans. Technetium-phosphate bone scans should also be performed before any surgical manipulation. However, positive results from a gallium or technetium scan in this setting are not conclusive evidence of infection. At biopsy, the otolaryngologist-head and neck surgeon should consider sending a specimen to the microbiology department for culture in addition to the specimen sent for routine pathologic study; this procedure could minimize delay in diagnosis. Establishing the diagnosis in these patients without obvious contiguous infection can be difficult, demanding perseverance and an appropriate index of suspicion. Once the diagnosis is confirmed, intravenous antibiotic therapy should begin immediately. The duration of therapy must be individualized; patients may require from 4 weeks to several months of treatment. Response to therapy is indicated by resolution of symptoms, normalization of ESR, and reversal of abnormalities on radionuclide scans. Serial gallium scans are particularly useful in following response to treatment.