Biomedical subjects
Publications and source records attributed to M S Robertson.
Computerized tomographic (CT) imaging provides detailed information on the paranasal sinuses and is now well established as an alternative to standard radiographs. The planning and safety of surgery to the paranasal sinuses is greatly improved by CT imaging. We describe a new CT protocol comprising a limited coronal and axial scan series, based on our experience with the previously described 'CT-Mini-series'.
Fine needle aspiration cytology has been performed on patients presenting with head and neck masses in Christchurch since mid-1985. The results of an initial 120 aspirations were reviewed. Histology was available to compare with the cytology result in 58% of cases. Clinical review was used to assess the accuracy of the cytology result in the remaining cases. The majority of the masses aspirated were of benign origin (72%). The cytological diagnosis was accurate in 79% of cases. Of the remaining aspirates, 13% were inaccurate and 8% nondiagnostic. The sensitivity for malignant lesions was 100%, with 86% specificity (for benign lesions). Particular diagnostic difficulty was found in the differentiation between some salivary gland tumours, and the assessment of aspirates from neck masses after combined therapy (radiotherapy and surgery). Fine needle aspiration cytology is of considerable value in the management of head and neck masses.
Total glossectomy is the most crippling of all oral cavity resections. Speech problems are unavoidable and post-operative aspiration is often severe. Two patients are presented who have had tongue reconstructions following near-total glossectomies. In each case a quilted, split-skin grafted pectoralis major muscle flap was used. The speech and swallowing results of these two patients are compared with two patients who underwent a hemiglossectomy and total glossectomy respectively without tongue reconstruction. Only if the suprahyoid and extrinsic tongue muscles are preserved can an active oral phase of swallowing and usable speech be regained by tongue reconstruction.
Pectoralis major muscle flaps have rarely been used on their own for head and neck reconstruction. Some of the problems experienced with myocutaneous flaps can be avoided by the judicious use of muscle flaps. These include suture line separation, excessive bulk, hair growth from the flap, and alteration of breast position. In contrast to the pectoralis major myocutaneous flap, the pectoralis major muscle flap is light and pliable. When it is employed for reconstruction in the oral cavity, oropharynx, or hypopharynx, it can be covered by a "quilted" skin graft or used on its own. We believe that pectoralis major muscle flaps provide a valuable alternative to the more bulky myocutaneous flaps in head and neck reconstruction.
From June 1980 to June 1985 51 pectoralis major muscle flaps have been used for one-stage reconstruction of extensive defects in the head and neck following cancer surgery. The pectoralis major muscle was used as a myocutaneous flap on 28 occasions, as a muscle covered with split thickness skin on 17 occasions, and as a muscle-only flap six times. The muscle, in its various forms, was used for reconstruction of the pharyngooesophageal segment, the tongue, floor of the mouth and oropharynx, to replace the skin of the face and neck, and to provide a well vascularized recipient bed for a split-rib graft, used to replace a defect of the anterior arch of the mandible. Many of the problems associated with the use of a pectoralis major myocutaneous flap can be avoided by the judicious use of a muscle flap on its own or covered by a split thickness skin graft.
Conservative measures are rarely effective in treating the habitual snorer. A new operation called a uvulopalatopharyngoplasty has been successful in curing snoring in seven patients.
Current methods of pharyngoesophageal reconstruction have in common the creation of an epithelial lined pharynx. We performed eight cases of pharyngoesophageal reconstruction with a pectoralis major muscle flap. In the first six cases, split-thickness skin was quilted onto the muscle. In the last two cases, pectoralis major muscle alone was used, allowing epithelialization to occur from adjacent mucosa. The results with this simplified technique have been as good as when a skin-grafted muscle flap was used. We prefer a pectoralis major muscle flap, with or without split-thickness skin, to a pectoralis myocutaneous flap. There is no hair growth, it is easy to tube, and a thin-walled pharynx is produced. This is an advantage for the development of an esophageal voice, and tracheoesophageal puncture can be easily performed if no voice is achieved. All of our patients received full-dose, preoperative radiotherapy. One patient developed a fistula that closed spontaneously. There have been no strictures at the pharyngoesophageal junction. All patients quickly established a good oral intake.
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Preauricular sinus is a common congenital condition which does not always cause symptoms. It is often misdiagnosed, can be difficult to treat surgically, and recurrences are common. The results of treatment in twelve Christchurch patients are discussed and a surgical technique is described.
Pharyngoesophageal reconstruction continues to be a problem in the management of cancer involving the hypopharynx. In our experience, the use of deltopectoral and pectoralis major myocutaneous flaps for total reconstruction has been disappointing. We report four cases of immediate near-total reconstruction using a quilted , skin-grafted pectoralis major muscle flap. All cases had received full dosage preoperative irradiation. A thin-walled pharynx was created that has allowed early development of a good esophageal voice. There has been no stricture formation. All patients have experienced no difficulty in establishing a good oral intake.
The methods of finding the facial nerve at parotidectomy are reviewed. The surgical anatomy of the tympanomastoid fissure and relevant segment of the facial nerve is described in detail. The authors' technique for finding the nerve using the tympanomastoid fissure as a guide is described.
A case is presented of a chondrosarcoma arising in the nasal septum and extending into the maxillary sinuses. This tumour is unusual in the head and neck and rarely arises in the nasal septum. Diagnostic difficulties are discussed. The treatment was radical surgery with removal of a major portion of the upper jaw, necessitating reconstruction with a maxillo-facial prothesis.
The late presentation of head and neck malignancies is often attributable to failure by the patient and the doctors to appreciate the significance of early symptoms. The presenting features of 522 cases are summarised. They emphasize that the following clinical features are significant, especially in a patient who smokes or drinks: local pain, pain referred to the ear, hoarseness, dysphagia, dyspnoea and stridor, persistent sore throat, nasal obstruction, bleeding, problems fitting dentures and a neck lump. An adequate history and ability to examine the head and neck region are prerequisites to early diagnosis. A knowledge of the presenting features of head and neck malignancies could be stressed more adequately by public health authorities.
A retrospective study of 262 patients with malignancy in the head and neck was undertaken. 15.6 percent of these patients presented with a metastatic gland in the neck as the only symptom. Forty-four percent of the nasopharyngeal tumours presented solely with a metastatic cervical node; as did 26 percent of hypopharyngeal tumours and 24 percent of tumours of the oropharynx. The problem of a patient presenting with a suspected malignant cervical gland as the only symptom is one which demands careful evaluation.
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The closure of a pharyngocutaneous fistula by the use of a posteriorly based tongue flap is described. The use of such a flap for this purpose has not been previously recorded in the literature.
Tongue flaps can provide up to 100 square centimeters of mucosal surface for the repair of defects in the oral cavity or upper pharnyx. They provide an acceptable alternative to the use of pedicled skin flaps for the repair of many small to medium sized defects which occur following radical cancer surgery.