Biomedical subjects
Publications and source records attributed to S J Wetmore.
There seems to be a consensus in the surgical literature that wound infections after surgery for cancer have a favorable effect on the course of certain malignant diseases. In a review of laryngeal cancer during a 10-year period, the recurrence rate was statistically lower in the group that suffered wound infections than in the group that did not have a wound infection.
A number of different approaches can be used to expose the facial nerve. The route taken will depend on the pathology and the portion of the nerve that requires exposure. When performing a parotidectomy approach to the extratemporal portion of the facial nerve, the tragal pointer is a key landmark, but other landmarks also should be used to identify the facial nerve safely. The lateral semicircular canal, the chorda tympani nerve, the digastric ridge, and the cochleariform process are some of the useful landmarks in the mastoid and middle ear. When performing a middle fossa approach, the superior semicircular canal, the greater petrosal nerve, and a window through the tegmen tympani into the attic are useful guideposts. The surgeon should use as many of the available landmarks as feasible to perform safe facial nerve surgery.
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Sinusitis due to unusual fungal pathogens is thought to occur primarily in immunocompromised individuals. However, the fungi Curvularia, Drechslera, and others produce sinusitis in healthy young adults. The signs and symptoms produced by these organisms are usually considered to be complications of sinusitis. Of the three cases that we report, two manifested decreased visual acuity, and the third presented with acute onset of seizures. Computed tomography scans were helpful in delineating the extent of disease and in following the results of therapy. Aggressive surgical treatment is necessary; indeed, two of our cases required a second operation to eradicate all disease. If histopathology shows tissue invasion by the fungus, intravenous amphotericin B is recommended. Fungal cultures and smears should be obtained when healthy patients present with complications of sinusitis.
Mohs micrographic surgery has been highly successful in treating skin cancers that grow in a contiguous manner. The technique requires removal of involved tissue in thin layers and histographic mapping to pinpoint residual tumor. This process is repeated until all of the tumor is resected. This allows 100 percent of all margins to be examined and is very tissue conservative, attributing to its unsurpassed cure rates and excellent cosmetic results. Since it is done as an outpatient procedure under local anesthetic, it also is safe and efficient.
Perinephric rabbit fat was divided into small particles with scissors and razor blades and then injected subcutaneously into the donor rabbit. The injected fat was compared with surgically implanted fat. Subcutaneous augmentation with both types of fat resulted in similar findings. Grossly, 40% of injection and implantation sites were palpable after 16 to 36 weeks of observation. Histologically, fat was present at practically every site, but with a variable amount of fat cell destruction. This study demonstrates that the author's method for dividing and injecting fat produces comparable results in terms of soft tissue augmentation to those obtained by surgically implanting fat. Although injected fat does not fulfill the criteria as the ideal substance for soft tissue augmentation, fat injection may prove to be a clinically useful means for improving body contour.
The presence of anterior and posterior nasal packs in patients with epistaxis is known to be associated with cardiorespiratory problems and sometimes death, although the mechanism has not been well understood. To determine the incidence and severity of obstructive sleep apnea in patients with epistaxis treated with both anterior and posterior nasal packs, we obtained polysomnograms on twelve patients while the packs were in place. Ten of these patients demonstrated obstructive sleep apnea. The apnea index (apneas/hour sleep) ranged from 1 to 83, with a mean of 29; the hypopnea index (hypopneas/hour sleep) ranged from 9 to 33, with a mean of 20; and the lowest oxygen saturation (SaO2) ranged from 17% to 91%, with a mean of 77%. Ten patients returned for another polysomnogram after removal of the packs. These baseline studies showed improvement in the apnea index and in the lowest SaO2 in all patients, although four patients still demonstrated at least mild obstructive sleep apnea. This study demonstrates that nasal packs used for the treatment of epistaxis may induce obstructive sleep apnea or markedly exacerbate underlying obstructive sleep apnea and, therefore, contribute to the sudden deaths that have been reported in epistaxis patients.
Auditory brainstem response (ABR) has been used by several investigators to study the role of the brain stem in the pathophysiology of obstructive sleep apnea (OSA). These studies have produced conflicting results. We studied 27 preoperative OSA patients and 17 controls using click stimuli presented at a slow (11.7/second) rate and at a fast (57.7/second) rate. ABR was repeated postoperatively in 18 patients. There were no statistically significant differences in the ABRs of preoperative OSA patients when compared with the control group. However, the preoperative recordings showed statistically significant prolonged latencies for wave III (p less than 0.01) and interpeak latency (IPL) I-III (p less than 0.01) when compared to postoperative recordings. Rapid-rate testing was not helpful. Although normal sleep does not cause ABR abnormalities, the pathological sleepiness seen in OSA patients may cause brainstem dysfunction manifested by prolonged ABR latencies. These abnormalities may resolve with treatment of OSA.
Spontaneous cerebrospinal fluid (CSF) otorrhea is rare. We present four new cases and an analysis of the literature. Two distinct subtypes occur. Seventy-two percent of cases are the childhood type with congenital defects of the otic capsule. Meningitis, usually pneumococcal and frequently recurrent, occurs in 92% of these cases. CSF otorrhea follows myringotomy for a presumed serous effusion. The child usually has unilateral and sometimes bilateral absence of cochlear and vestibular function and commonly exhibits a Mondini deformity. CSF usually enters the inner ear through a dural defect in the lateral aspect of the internal auditory canal and exists through the oval window. Treatment should consist of stapedectomy and packing of the vestibule with muscle or subtotal petrosectomy. Twenty-eight percent of cases of spontaneous CSF otorrhea are the adult type characterized by bony dehiscenses, most commonly of the tegmen tympani or tegmen mastoideum and less commonly of the posterior fossa plate. The meningeal defects are either meningoencephaloceles or simply holes in the dura. Therapy should consist of a mastoidectomy in conjunction with a transtemporal supralabyrinthine (middle fossa) approach if a meningoencephalocele of the tegmen is found.
We treated 21 previously untreated T1 or tumor in situ squamous cell carcinomas of the true vocal cords by carbon dioxide laser excision. The mean follow-up was 42 months, with a range of 26 to 64 months. Recurrent vocal cord carcinomas, with an average interval to recurrence of 21 months developed in four patients. Three of the four recurrences involved the anterior portion of the true vocal cord, including the anterior commissure. One of the patients with recurrence was treated again with the laser, and the other three underwent radiotherapy. All four patients are alive and have retained their larynges. Laser excision of selected T1 and in situ carcinomas of the true vocal cords is a cost-effective and viable alternative to radiotherapy or more radical surgical therapy.
Thirty-six patients with stage IV squamous cell carcinoma of the head and neck were treated with cisplatin (15 mg/m2), administered synchronously with high-dose radiation therapy. Of the original 36 patients, 26 are dead of disease. Although previous reports of an 88% response to this regimen were noted, the disease-free intervals in this 36-patient group were short. The interval of time between treatment and death ranged from two to 27 months, with an average survival time of 10.7 months. It appears that although cisplatin potentiation to radiation therapy offers an encouraging clinical response initially, persistent clinical regression of disease is unlikely. Further studies of cisplatin sensitization of radiation therapy vs radiation therapy alone and chemotherapy alone need to be performed before this regimen can be considered strong enough to stand on its own merits.
The standard ABB remains the most popular test of vestibular function. The use of air caloric irrigations or the closed loop water system seem to be scientifically sound alternatives to the use of open water irrigation. Although controversy still surrounds the use of monothermal warm calorics as a screening test, several studies have shown its reliability. The Torok monothermal differential caloric test seems to be a good alternative to the ABB, but more studies need to be done showing its results in other hands. Some of the other tests mentioned in this report may be helpful as ancillary tests for use in patients in whom the standard tests produce inconsistent findings.
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Uvulopalatopharyngoplasty (UPPP) is an operation that is frequently performed for the treatment of obstructive sleep apnea (OSA). While UPPP usually eliminates or decreases snoring and often reduces excessive daytime sleepiness, the decrease in the number of episodes of apnea and hypopnea, and the improvement in oxygen saturation (SaO2) have been less predictable. We compared preoperative and postoperative polysomnography (PSG) in 27 patients with OSA and found that no single PSG parameter could accurately reflect the changes in respiration seen after UPPP. We suggest that a combination of indices including the apnea index, the apnea and hypopnea index, the frequency and severity of decreases in SaO2, and the lowest SaO2 be used to assess the effect of UPPP. Using this combination we determined that 30% of our patients were markedly improved, 33% were somewhat improved, and 37% were unimproved. To rely solely on the patient's subjective improvement often results in overestimating the therapeutic results of surgery, whereas to rely only on one PSG parameter may underestimate or overestimate the degree of improvement.
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We report a 64% long-term success rate in our series of 66 patients who have undergone the tracheoesophageal puncture (TEP) procedure with follow-up ranging from one to 3 1/2 years. Poor motivation and compliance were the most common factors noted in patients who failed to obtain or maintain tracheoesophageal speech. Other problems causing failure were technical problems relating to the TEP and medical problems. The success rate in the last 24 cases of our series has improved to 83%. The "collared" prosthesis, more careful patient selection, and emphasis on a team approach seem to be important factors for the higher success rate. The Blom-Singer TEP procedure is a safe, simple, and effective means of alaryngeal communication for selected patients.
Thirty-three patients with inoperable squamous cell carcinoma of the head and neck were treated with cisplatin, 15 mg/sq m, administered synchronously with high-dose radiation therapy. Twenty-nine patients (88%) responded to the regimen; of these, 20 had complete regression of all disease. Eight of the 20 had a relapse in less than one year of their treatment. Among those patients who did not have a relapse, the follow-up period was short. It is concluded that a clinical regression response is more likely with this treatment regimen than with radiation therapy alone, and that that response may be a better palliation. Further study of this combination of treatment modalities is warranted.
The Singer-Blom tracheoesophageal puncture procedure for surgical-prosthetic voice restoration has proved to be a viable option for alaryngeal speech rehabilitation. Following tracheoesophageal puncture, occlusion of the tracheostoma shunts pulmonary air through the Blom-Singer prosthesis into the cervical esophagus. The pulmonary air passing through the cervical esophagus and into the hypopharynx causes a portion of the upper alimentary tract to vibrate in a manner similar to that of the pharyngoesophageal segment during the production of esophageal speech. To study the location and shape of the vibratory segment in tracheoesophageal speakers, videofluoroscopy and simultaneous voice recording were performed with 16 patients. To analyze the vibratory segment(s), photographs were made of the videotaped image while it was stopped during the patients' production of the /a/ sound. The most frequent location of the vibratory segment was in the lower third of the neck, which corresponds to cervical vertebrae C5 through C7. Five of the subjects had two separate vibratory segments and two other subjects had long vibratory segments. The vibratory segment(s) in tracheoesophageal speakers was found to be similar to the vibratory segment(s) in esophageal speakers.