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The objective of this study was to assess the value of preoperative fiberoptic nasopharyngoscopy with the Müller maneuver (FNMM) and cephalometric radiography in predicting response to uvulopalatopharyngoplasty (UPPP) in patients with obstructive sleep apnea syndrome. Fifty-three such patients having significant obstruction at the soft palatal level and variable degrees of obstruction at the base-of-tongue level underwent both diagnostic procedures before UPPP. Outcome was assessed by the apnea-plus-hypopnea index (AHI) as determined by polysomnography, which was performed before and after surgery. As a group, patients exhibited a significant 10-point reduction in AHI (46.5 to 36.7). However, 17 (32.1%) were judged to be responders as defined by a reduction of the AHI by an increment of 50% or greater with respect to baseline. Of all the cephalometric variables assessed, soft palate length was the only one that differed between responders and nonresponders (45.5 mm versus 42.6 mm, respectively). However, this difference only approached significance (P = .067). Similarly, FNMM results did not discriminate between responders and nonresponders. These results indicate that preoperative cephalometric radiography and FNMM cannot be reliably used to enhance surgical success.

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Nasal packing is considered routine by most physicians and patients at the completion of nasal and septal surgery. Yet the rationale for this maneuver is not clearly defined by reported investigation or logical analysis. We discuss 75 consecutive nasal surgical procedures completed without packing. There were two postoperative episodes of bleeding, both from pyriform aperture incisions for lateral osteotomy and both managed in the recovery room with an absorbable gelatin sponge. Technical refinements such as scrupulous preoperative history taking, through-and-through suturing of the entire septal flaps, small-caliber osteotomy, meticulous closure of all intranasal incisions, and proper application of a conforming dressing are essential for hemostasis. We offer specific procedural guidance to minimize the risk of postoperative nasal bleeding.

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Large tumors of the paranasal sinuses can be removed thoroughly with a craniofacial approach that provides for good visualization. With this approach, some tumors previously considered inoperable may be removed and in some cases cured. We report three cases of tumors managed by means of a craniofacial procedure. One case involved an extensive inverting papilloma of the ethmoid sinus that invaded the orbit and coursed over the globe around the optic nerve. The second patient had a large squamous cell carcinoma of the paranasal sinuses that involved the cribriform plate, dura, and a portion of frontal lobe. The third case involved a meningioma that invaded the sphenoid wing, orbit, pterygomaxillary space, and infratemporal fossa. The craniofacial surgical technique and adjunctive therapies are discussed.

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The hypoglossal nerve is frequently involved in head and neck afflictions as a result of its long course. Hypoglossal nerve paralysis, rarely occurs as the initial presenting symptom. Clinical situations, where the hypoglossal nerve paralysis was an early symptom, are discussed. The anatomy of the nerve from the brain stem to the tongue is elaborated upon.

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Radiation therapy is an integral part of treatment for head and neck cancer, but its use is not without complications. We describe the first reported sternoclavicular-tracheal fistula resulting from osteoradionecrosis (ORN) at the medial clavicle. This ORN resulted from definitive radiation therapy for a primary pyriform sinus squamous cell carcinoma. The diagnosis of ORN was made by fiberoptic bronchoscopy. The physiologic damage of ORN is based on a compromised blood supply and altered metabolism of bone formation secondary to effects of ionizing radiation. Treatment requires meticulous hygiene, antibiotics, and debridement as conservative therapy. Radical surgery and reconstruction may be indicated in refractory cases. A thorough preirradiation assessment of patients is mandatory to decrease the incidence of radiation-induced ORN.

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Spontaneous pneumomediastinum with subcutaneous emphysema is a well-documented phenomenon which usually follows a benign course and rarely results in circulatory collapse and death. The condition is caused by a sustained increase in the intra-alveolar and intrabronchial pressure with air dissecting along the perivascular spaces of the mediastinum. The majority of patients respond to conservative therapy and rarely require aggressive surgical intervention. Three cases are presented. The anatomy, etiology and the pathophysiology of the disease are reviewed, and the treatment options discussed.

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Granular cell tumors are rare neoplasms that arise in different regions of the body. Their cell of origin is still debated among many pathologists, but recent authors consider them to be neurogenic. These tumors are believed to be benign; however, local recurrences after excision and multifocality arouse suspicions for malignancy. In the head and neck, granular cell tumors occur most frequently in the tongue. In the laryngotracheobronchial tree, most tumors reported have been in the larynx and the next most in the bronchi. Only six cases of true tracheal occurrences have been reported previously; two additional cases are reported in this paper. The literature of the cell of origin of these tumors is reviewed, the different theories are presented, and diagnosis, treatment, and follow-up are discussed.

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