Biomedical subjects
Publications and source records attributed to D D Caldarelli.
Experience with the transnasal microsurgical correction of bilateral congenital choanal atresia is presented. Four case reports are presented to illustrate the advantages of this surgical approach utilizing standard otosurgical instruments and supplemental fiberoptic nasopharyngeal visualization.
Hemangiopericytoma is a vascular tumor that typically occurs in the soft tissues of the extremities and trunk, and only rarely occurs in the paranasal sinuses and nasal cavity. We report a case of hemangiopericytoma of the maxilla and review the pertinent literature. Based on a propensity for local recurrence and occasional metastasis, a radical excision was performed.
Cleft lip and palate patients, 16 years and older, selected at random, were studied to determine the type and frequency of middle ear disease. Various morphologic and physiologic factors interrelating to cleft form and otopathology are discussed.
Explore the source record for details and available documents.
Explore the source record for details and available documents.
BACKGROUND: Cerebrospinal fluid leaks from defects in the anterior cranial fossa present a difficult management problem. Particularly when the defects are large, conventional techniques may not be sufficient to close them. We describe a new technique for treating such CSF leaks using a composite mucochondral flap from the nasal septum. METHODS: We treated five patients with the composite mucochondral flap. All patients were women aged 29-60 years. Two patients had an encephalocele, one had an esthesioneuroblastoma, and one had adenocarcinoma; one leak was spontaneous. RESULTS: The CSF leak was successfully closed in all five patients. No patients have experienced recurrence; the longest follow-up has been 39 months. The donor site on the septum healed without complication in all patients. CONCLUSIONS: The composite flap is useful for repairing large defects or after radiotherapy or trauma. The advantage of skeletal support to counter the pressure exerted by CSF seems clear.
In a review of 80 patients with hypopharyngeal squamous-cell carcinoma, 43 patients were found to have had lesions arising in the pyriform sinus, 34 had lesions arising on the postcollateral wall of the hypopharynx, and 3 had lesions in the postcricoid area. Therapeutic modalities included radical radiation therapy in 56 patients, radiation plus surgery in 13 patients, and planned combined therapy in 11 patients. The five-year determinate survival rate of all the patients was 20%. Patients with posterolateral wall tumors had a 23% rate of cure, but those with pyriform sinus tumors had only a 13% rate of cure. The five-year determinant survival rate was 12.5% for patients undergoing radical radiation therapy, 15.4% for those undergoing unplanned radiation and surgery (salvage therapy), and 55.6% for those with planned combined therapy. Over 40% of the patients had a recurrence of their disease; an additional 20% developed distant metastatic spread which usually occurred within the first year. The type of therapy did not alter the rate of recurrence but did affect the rate of distant metastatic spread, with planned combined therapy greatly improving control of the primary lesion. This study suggests that, even with advanced disease, the most effective therapy for hypopharyngeal carcinoma is planned combined radiation therapy and surgery.
Laryngeal wound healing is essential following laryngotracheal surgery. Patients with poor wound healing develop poor epithelial closure and increased granulation tissue which cause a stenosis of the repaired airway. Transforming growth factor-beta3 has been shown to enhance wound healing in cutaneous wounds, but has never been used in the airway. This study utilized a rabbit laryngeal wound-healing model that has been shown to be reproducible with limited morbidity. Thirty-four rabbits underwent a cricoid-split operation with collagen sponge insertion. All animals were classified randomly into three groups: local administration of placebo (Group G1, n = 13), 0.18 microg transforming growth factor-beta3 (Group G2, n = 11) and of 1.0 microg transforming growth factor-beta3 (Group G3, n = 10). All animals survived the postoperative period without respiratory distress. The airway was harvested six days after surgery and assessed by light microscopy. Histologic evidence for healing was subjectively graded by two blinded, independent investigators, and the results were statistically analyzed for significance. A significant improvement in the epithelial closure (p < 0.01) and subepithelial connective tissue closure (p < 0.005) was found in the 1.0 microg transforming growth factor-beta3 group (G3) compared with the placebo group (G1). Analysis of the 0.18 microg transforming growth factor-beta3 group (G2) did not reveal any significant differences compared with the placebo group (G1). These results suggest an application for transforming growth factor-beta3 in accelerating wound healing in the larynx.
Explore the source record for details and available documents.
Cholesteatomas of the frontoethmoid region must always be considered in the differential diagnosis of a mass in the frontoethmoid region. A painless, slow-growing mass, often accompanied by proptosis and diplopia, but without history of trauma or infection, should make one suspect of this pathologic entity. Although histologically a benign lesion, the keratinizing squamous epithelial lining will continue to desquamate and expand, leading to erosion of surrounding structures which could be life-threatening. In order to prevent recurrence, complete removal of the cyst lining is mandatory. Cosmetic reconstruction, often requiring obliteration of the surgical cavity, should be delayed for one year to insure against recurrence of the covering of active squamous tissue adjacent to dura, cribriform plate or ocular structures.
An occasional patient with metastatic or recurrent malignant disease develops intraluminal masses in the trachea and/or the main bronchi. The accuracy of the application, absence of bleeding, slight reaction, and rapid healing make the CO2 laser applied through the open bronchoscope a valuable palliative treatment for the relief of obstructive dyspnea. This patient is reported because he demonstrated the reduced bleeding which occurred with the bronchoscopic CO2 lasing as compared to bronchoscopic forceps removal.
One-lung and two-lung high frequency ventilation (HFV) through a 2-mm internal diameter catheter was evaluated in 22 patients during endoscopic laser excision of stenotic lesions of larynx, trachea, and bronchi. High frequency ventilation at 80 to 250 breaths per minute using air during two-lung HFV and using air-oxygen at an inspired oxygen concentration of 25% during one-lung HFV maintained adequate alveolar ventilation and oxygenation in all patients. The use of HFV through a catheter allowed continuous control of ventilation and provided maximal surgical exposure for endoscopic laser surgery. The continuous outflow of HFV gases through the endoscope also prevented lung contamination with blood and debris. The potential of HFV polyvinylchloride catheter ignition by laser was also evaluated in the laboratory during continuous flow of air-oxygen and oxygen-nitrous oxide. The laser ignited polyvinylchloride tubes in all the mixtures of oxygen and nitrous oxide within 3 to 7 seconds. Oxygen at 30% mixed with nitrogen 70% was safe and all such tubes were not ignited by the laser. The ability of HFV to provide adequate oxygenation during endoscopic laser surgery using air-oxygen at an FiO2 below 30% also avoids the hazard of catheter and airway fire.
Eighteen paragangliomas of the head and neck (11 carotid body tumors, four glomus tympanicum tumors, three glomus jugulare tumors) were studied retrospectively. Tissue from each of these tumors was immunostained for the presence of serotonin, a variety of neuropeptide hormones, and the enzyme neuron-specific enolase (NSE). Seven tumors were studied by electron microscopy. The clinical and laboratory records were reviewed for evidence of endocrine activity or metabolic imbalance. All tumors displayed diffuse and intense immunostaining for NSE. In addition, a wide variety of hormonal substances could be identified. Those most frequently demonstrated were serotonin and leu-enkephalin. Ten of the 11 carotid body tumors demonstrated immunoreactivity for multiple hormones. By electron microscopy all tumors contained a heterogeneous population of membrane-bound neurosecretory granules. None of these tumors was associated with a clinically apparent endocrine syndrome. We conclude that paragangliomas of the head and neck are neuroendocrine tumors that are capable of synthesizing a variety of hormonal substances. These hormonal substances rarely elicit a clinically apparent endocrine or metabolic imbalance. All of the tumors demonstrated immunostaining for NSE. Future studies on serum levels of NSE may provide useful diagnostic and follow-up data.
Conservation of physiologic values of circulating parathormone is a surgical objective in those instances in which a hyperfunctional parathyroid state exists as well as in those instances in which cervical evisceration employed as an ablative measure for the management of neoplastic disease threatens to impose postoperative tetany. Because the parathyroid glands may vary in number and in anatomic sites, a predictable and reproducible surgical approach that permits the operator an avenue of access to these structures is used. The viscerovertebral angle provides a surgical modality which facilitates the operative effort. The method has been applied in more than 70 patients.
The pterygomaxillary space (PMS) is a potential reservoir for expansion of the neoplasms originating in the epipharynx. Palatotomic and mandibulotomic approaches to this secluded site have been reported. The advantages of surgical palatomaxilloschisis are twofold. First, the exposure of the operative field is panoramic. Second, the carotid arterial system is identifiable prior to surgical intervention. The triangular pterygomaxillary recess is bounded superiorly by the greater wing of the sphenoid, posteriorly by the pterygoid process and anteriorly by the dorsal convexity of the posterior wall of the maxilla. Ascending laterally to the PMS in its route to penetrate the temporal bone is the internal carotid artery. In particular, juvenile angiofibromas which originate in the epipharynx may in their growth encroach upon the bounds of the PMS. The surgical objective is not only to extirpate the neoplasm but also to safeguard the carotid arterial system which may be displaced by the new growth and thereby become a surgical hazard. A clinical experience illustrates the applicability of this approach.
Although nasal polyposis is a common entity, it is seldom considered a cause of bony destruction with consequent ophthalmologic and neurologic sequelae. Acute bilateral visual loss developed suddenly in a young, healthy woman with nasal polyps. Evaluation revealed erosion of the floor of the anterior cranial fossa, with compression of the optic nerves secondary to extensive paranasal and nasal polyposis. The clinical course, treatment, and histopathologic findings are discussed.
Endoscopic frontal sinus surgery, once the last frontier in the evolution of endoscopic sinus surgery, is considered difficult, risky to the patient, and likely to result in a high failure rate. We clarify the surgical anatomy for frontal sinus surgery that, based on a review of our data, provides safe and predictable access to the frontal sinus. We studied 200 consecutive patients with respect to indications, endoscopic and radiographic findings, results, and complications. The study will describe the technique in detail, including the following points: 1) computed tomography identification of the superior attachment of the uncinate process; 2) complete removal of the uncinate process, including its superior attachments, by using the microdebrider; 3) removal of the agger nasi cell, if present; and 4) verification of an open frontal sinus by a transillumination or image-guided system. Postoperative assessment of patients' symptoms and the confirmation of a patent frontal sinus by office endoscopy and transillumination indicated a 90% patency for short-term follow-up (average 12.2 months). There were no major complications. Postoperative complications included frontal recess stenosis, polypoid mucosa occluding the frontal recess, and middle turbinate lateralization. All of these situations may lead to recurrence of infection and symptoms. In-depth understanding of anatomic variations of the uncinate process and precise surgical removal of its superior attachments provide surgical access to the frontal sinus that is based on the natural ostia and is, therefore, more likely to remain patent.
Sixteen patients (32 ears) with diagnoses of mandibulofacial dysostosis were reviewed. The characteristic otologic manifestations of the syndrome were delineated, found to be bilateral, and consist of the following: 1. Mild symmetric deformity of the auricle (grade 1 microtia). 2. Agenesis or hypoplastic development of the mastoid and mastoid antrum. 3. Absence of the external auditory canal. 4. Marked narrowing or agenesis of the middle ear cleft. 5. Agenesis or severe malformation of the malleus and incus. When present, the malleus and incus are most often rudimentary, fused to form a conglomerate mass, and ankylosed to either the atretic plate, epitympanum, or both. 6. Stapedial malformations which usually consist of a deformed suprastructure. 7. Frequently the tegmen assumes a more inferior (low lying) position than normal. 8. Occasionally, the facial nerve pursues an abnormal course and is located more anteriorly than would be expected. 9. A normal inner ear. 10. Normal bone conduction with a marked (greater than 50 dB) conductive hearing loss. 11. Marked disparity between the degree of auricular deformity (mild; grade 1 microtia) and the degree of deformity of the remaining first and second branchial arch derivatives that constitute the external and middle ears (severe).