Esophagography and esophagoscopy.
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Esophageal Neoplasms↗
Biomedical subjects
R J Toohill
Publications and source records attributed to R J Toohill.
Histopathologic changes in snoring and obstructive sleep apnea syndrome.
The pathophysiologic events that lead to the loss of airway compensation in obstructive sleep apnea (OSA) are poorly understood. The development of airway instability may be secondary to changes in neurologic control, airway morphology, or both. To identify potential histopathologic features of pharyngeal tissues that may contribute to OSA, transverse sections of the distal soft palate and uvula were qualitatively compared using light and electron microscopy from 4 severe apneics (greater than 50 apnea/hour), 4 severe snorers (less than 20 apnea/hour), and 4 nonsnorers. Light microscopy of both apneics and snorers revealed mucous gland hypertrophy with ductal dilation and focal squamous metaplasia, disruption of muscle bundles by infiltrating mucous glands, focal atrophy of muscle fibers, and extensive edema of the lamina propria with vascular dilation. Severe snorers did not differ qualitatively from apneics in the characteristic changes found; however, some snorers had less extensive changes. No distinctive histopathologic findings could be associated with the development of apnea. Electron microscopy of severe apneics identified frequent focal degeneration of myelinated nerve fibers and axons. The finding of similar histopathologic changes in apneics and severe snorers supports previous speculation of a common etiology not directly related to apnea, such as vibratory trauma to pharyngeal tissues. Degenerative changes in peripheral nerves, identified on electron microscopy, however, may contribute to airway instability and the development of obstructive apnea by impairing pharyngeal reflexes.
Atrophy↗
Microtrapdoor flap repair of laryngeal and tracheal stenosis.
Twenty patients have undergone repair of laryngeal and tracheal stenosis by microtrapdoor accessing of scar or soft tissue and removal with the carbon dioxide laser. A total of 34 flap procedures were performed in the 20 patients. Follow-up ranged from 8 months to 4 years, and 30 of these flaps were considered successful on the basis of improvement of the airway. The only complications were postoperative granulation tissue in 2 patients that responded to endoscopic removal.
Adult↗
The endo-extralaryngeal needle carrier.
A laryngeal needle holder has been devised. This instrument will allow endoscopic insertion of sutures for lateralization of a paralyzed vocal cord or for fixation of endoscopically inserted stents or keels in laryngotracheal stenosis. The suture material is delivered by a curved nontraumatic cutting needle. After the needle is inserted in the desired endoscopic area, the tip protrudes through the anterior neck skin. The needle and distal suture are then pulled through the skin and the needle holder is withdrawn. The proximal portion of the suture is then inserted in the same fashion. Both ends of the suture are then fixed over buttons on the neck. The technique avoids the blind and cumbersome method of placing suture material from the skin to airway and back out to skin again.
Humans↗
Clinical experience with the Lichtenberger endo-extralaryngeal needle carrier.
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Adult↗
Trigeminal nerve neurofibroma: case report.
A case of left trigeminal nerve neurofibroma is presented. The location of the lesion required a multidisciplinary surgical effort for total excision. A vertical ramus osteotomy allowed access to the infratemporal space and base of skull. The frequency and clinical features of trigeminal nerve tumors are discussed.
Bone Plates↗
Treatment-related toxicities with Fluosol-DA 20% infusion during radiation in advanced head and neck malignancies.
Fluosol-DA 20%, a synthetic perfluorocarbon emulsion first developed as a blood substitute, is currently being investigated as a radiation sensitizer. Theoretically, an oxygen-carrying perfluorocarbon emulsion combined with oxygen inhalation might be able to increase tumor response by decreasing the relative proportion of hypoxic tumor cells. Twenty-one patients with advanced head and neck malignancies receiving primary radiation therapy were evaluated for treatment-related toxicity. Mucosal reactions and weight loss during treatment in the group of patients who received the perfluorocarbon emulsion and the group who did not were comparable. Late sequelae appeared comparable. No patient in either group who completed radiation therapy required an interruption of the treatment course. We conclude that Fluosol-DA 20% is a tolerated adjunct to primary radiation therapy. Further study is needed to determine whether the agent will improve local/regional tumor control.
Blood Substitutes↗
Surgery for sinusitis and aspirin triad.
An 11-year retrospective study was conducted to evaluate the surgical treatment of sinusitis in aspirin-triad patients. Twenty-five patients were selected for surgery when their sinus disease and asthma progressed despite intense medical treatment. Sixteen patients had radiographic evidence of severe ethmoid disease, and their initial surgical procedures were limited (i.e., bilateral intranasal ethmoidectomies). Of these 16 patients, 6 required subsequent surgery for recurrent sinusitis. Nine of the 25 patients had radiographic evidence of severe antral, as well as ethmoid, disease. Their initial surgical procedures were radical, i.e., bilateral Caldwell-Luc operations with intranasal and transantral sphenoethmoidectomies. None of these 9 patients required further surgical treatment for control. This review indicates that if antral and sphenoid disease are detected in association with ethmoid involvement, a radical surgical approach is the operation of choice.
Adolescent↗
Laryngotracheal reconstruction with composite nasal septal cartilage grafts.
The composite nasal septal graft has been used successfully by us to reconstruct patients with high tracheal and laryngotracheal stenosis. We have treated ten patients and have been able to decannulate seven of these patients. When these ten cases are added to the six original cases presented in an earlier report (1981), certain conclusions can be drawn. The success or failure of these procedures, which is judged by the ability to decannulate the patient, appears to be related to the extent of the initial injury. We discuss the indications for the composite nasal septal graft and the use of additional treatment, including stents, steroid injections, dilatations, and flaps. In conclusion, the addition of these ten cases to the original six cases of composite nasal septal grafts now provides the opportunity to review indications and contraindications for the use of this graft in the management of advanced laryngotracheal stenosis.
Adult↗
Anterior pituitary involvement in Wegener's granulomatosis.
Wegener's granulomatosis rarely involves the pituitary, and is limited to the posterior gland. A young woman developed sinusitis, otitis media, asymptomatic pulmonary density, blindness, and anterior pituitary hormone deficiency over 7 years. Mucosal biopsies showed only chronic necrotizing inflammation without vasculitis. Since her clinical course suggested an atypical presentation of Wegener's granulomatosis, cyclophosphamide was finally added to corticosteroid therapy. All symptoms but monocular blindness and hypopituitarism remitted.
Adrenal Cortex Hormones↗
Esthesioneuroblastoma masquerading as extramedullary plasmacytoma.
Nine years after biopsy and radiation therapy for an extramedullary plasmacytoma of the nasal cavity, a 64-year-old man developed locally recurrent tumor. Repeat biopsy revealed tumor identical in hematoxylin and eosin stain (H & E) appearance to that found originally, leading to the diagnosis of recurrent extramedullary plasmacytoma. Neither the original tumor or its recurrence demonstrated features characteristic of esthesioneuroblastoma (e.g., nests, rosettes, ganglion cells, or fibrillary background). However, Gremilus staining and neuron specific enolase tests (immunoperoxidase method), done strictly as a teaching exercise, were strongly positive and eventually resulted in an altered diagnosis to esthesioneuroblastoma. This case underscores the difficulty that may be encountered in distinguishing these two pathologic entities of the nasal cavity solely on the basis of H & E staining. In view of differences in staging, evaluation, prognosis, and management, accurate differentiation of these two relatively uncommon tumors of the nasal cavity is of immediate clinical importance. These observations suggest that care should be taken to exclude the possibility of esthesioneuroblastoma before making the histologic diagnosis of extramedullary plasmacytoma of the nasal cavity.
Diagnosis, Differential↗
Cisplatin and fluorouracil as neoadjuvant therapy in head and neck cancer. A preliminary report.
A randomized, prospective trial utilizing cisplatin and fluorouracil as neoadjuvant chemotherapy in the treatment of advanced squamous cell carcinomas of the upper aerodigestive tract was initiated in January 1983. Sixty patients were stratified by site (oral cavity, 19; larynx, 14; hypopharynx, 14; oropharynx, 11; nasopharynx, one; and paranasal sinuses, one) and by stage (III, 19; IV, 41), and then randomized to receive either standard treatment (defined as preoperative irradiation followed by radical excision or irradiation alone) or adjuvant chemotherapy followed by standard treatment. An additional three patients were entered into the study, but withdrew. Chemotherapy consisted of three cycles for those patients in whom an objective tumor response was observed; nonresponders received standard treatment. Response to chemotherapy was complete in five and partial (greater than 50%) in 18 patients, for an overall response rate of 85%. The follow-up for surviving patients was a minimum of 24 months and a maximum of 44 months. Survival was compared for patients in both treatment groups according to the method of Lee and Desu. Despite excellent tumor response, actuarial survival was 70% in the standard treatment group as opposed to 56% in the experimental group. It was therefore evident that the high response rates reported in previous pilot studies do not necessarily result in improved survival in these cancers.
Carcinoma, Squamous Cell↗
The effects of delay in standard treatment due to induction chemotherapy in two randomized prospective studies.
It is often suggested that tumors will respond to induction chemotherapy and result in improved survival for patients with squamous cell carcinoma of the head and neck. Two regimens of induction chemotherapy were studied in separate randomized, prospective trials over the last 6 years. Eighty-three patients with advanced disease were entered into the first study (43/chemotherapy; 40/control), and 60 into the second (27/chemotherapy; 33/control). Patient randomization was stratified by stage (III/IV) and site (oral cavity, oropharynx, nasopharynx, hypopharynx, larynx, paranasal sinuses). The first study utilized bleomycin, Cytoxan, methotrexate and 5-fluorouracil in two cycles (one cycle if no tumor response), followed by standard treatment which consisted of combined irradiation and surgery or, in some instances, primary irradiation alone. The second study utilized cisplatin and 5-fluorouracil in three cycles prior to standard treatment. An objective tumor response to chemotherapy was observed in 68% in the first study and 85% in the second. The patient survival in both studies (at 24 months in the first; at 19 in the second) was better in the control than that in the experimental groups (43% to 31%; 69% to 46%). In the second study, the average length of delay of standard treatment was longer than in the first study (95 days vs. 66 days; P less than .02). Results combining the P-values of both studies indicate that the relative risk of having persistent disease was 2.9 times greater for patients who received chemotherapy. While toxicity to chemotherapy was not a factor in survival, the number of patients who withdrew from the studies and those who did not comply with treatment were greater in the chemotherapy groups. Except for new drug regimens of exceptional promise, it is recommended that future studies be designed so that chemotherapy is given concurrent with, or following the completion of standard treatment.
Antineoplastic Combined Chemotherapy Protocols↗
The diagnostic accuracy of pharyngoesophagram compared to esophagoscopy in patients with head and neck cancer.
Two hundred and fifty-four patients with head and neck cancer were entered into a prospective study comparing the results of pharyngoesophagram to esophagoscopy. All patients had pharyngoesophagram deemed adequate to evaluate the esophagus and rigid esophagoscopy to at least 30 cm from the upper incisor teeth. In 239 (94.1%) patients both the pharyngoesophagram and esophagoscopy were negative. Four esophageal tumors were found. Only one of these tumors (25%) was detected on pharyngoesophagram. We believe that the pharyngoesophagram should be a part of the initial work-up of every head and neck cancer patient and should precede esophagoscopy. However, the barium swallow cannot be relied upon exclusively to detect small simultaneous second primary esophageal malignancies.
Aged↗
The microtrapdoor technique for the management of laryngeal stenosis.
The use of the carbon dioxide laser as an endoscopic microsurgical instrument has stimulated interest in treating laryngeal and tracheal stenosis. Dedo and Sooy (1984) reported a significant improvement in the management of posterior commissure, subglottic, and high tracheal stenoses with the use of a microtrapdoor flap. A recent laboratory investigation of this method supported the clinical efficacy of this technique. Six patients are evaluated in this report, three with posterior commissure stenosis and three with subglottic or high tracheal lesions. All six patients had a tracheotomy present or performed at the time of their surgical procedures, and each patient had only one procedure. All six had improved airways after the microtrapdoor flaps. Five have been decannulated and one patient with associated hypopharyngeal stenosis still has a tracheostomy because of mild aspiration, although the airway lumen is moderately improved. It is felt that, as a group, the subglottic and high tracheal lesions respond to this technique better than the posterior commissure stenoses. Details of the technique are presented. This brief clinical report supports the efficacy of the microtrapdoor flap procedure in selected laryngeal and tracheal stenoses.
Adolescent↗
A randomized study of adjuvant chemotherapy for cancer of the upper aerodigestive tract.
A prospective, randomized trial of induction chemotherapy in advanced squamous cell carcinomas of the upper aerodigestive tract (UAD) was conducted between July 1979 and September 1982. Eighty-three patients with locally advanced Stage III-IV tumors received standard treatment (STD RX; defined as preoperative irradiation and radical excision or irradiation alone), or induction chemotherapy (CTX) followed by STD RX. Chemotherapy consisted of two cycles of bleomycin (30 units/day by continuous infusions Days 1-4), cyclophosphamide (200 mg/m2 IV Days 1-5), methotrexate (30 mg/m2 Days 1 + 5), and 5-fluorouracil (400 mg/m2 IV Days 1-5). Response to CTX was complete in 2 and partial (greater than 50% reduction) in 27; the overall response rate was 68%. Tumor clearance was documented in 30/40 STD RX patients at completion of irradiation and/or surgery and in 24/43 CTX patients (17/29 responders, 7/14 non-responders). Freedom from local-regional disease was noted at 2 years in 53% STD RX and 35% CTX patients (p less than .06). CTX patients had a higher proportion of local-regional persistence and recurrence. The difference was apparent only in the subset of patients treated with primary irradiation; local-regional control following irradiation and surgery was equal in STD RX and CTX groups. Survival at 2 years was 43% STD RX and 31% CTX. Disease-free survival in those with clearance was 64% STD RX and 59% CTX. Induction chemotherapy did not improve tumor clearance or survival in this series. Caution regarding local-regional control with CTX and primary irradiation is noted.
Bleomycin↗
The radiological appearance of the post-Caldwell-Luc maxillary sinus.
A review of the radiographic findings in 19 patients who had undergone unilateral or bilateral Caldwell-Luc procedures for chronic maxillary sinusitis revealed improvement in the radiographic appearance of the sinuses in 13 and lack of improvement, progression or recurrence of disease in six. Eight of the patients had changes which could be attributed directly to surgery. These included fibro-osseous proliferation in five, antral contraction in four and compartmentalisation in two. Follow-up studies, including pluridirectional tomography and computed tomography, can reliably distinguish post-operative changes from recurrent disease in the patient who has undergone this type of radical maxillary antrostomy.
Follow-Up Studies↗