A PREVIOUSLY HEALTHY 43-YEAR-OLD WOMAN presented with a 2-month history of a mass in the right side of her neck. The mass had started as a small lesion that the patient attributed to a possible bug bite. Shortly thereafter, the lesion enlarged and became extremely painful and tender. Also, there was a small amount of spontaneous purulent drainage. During the ensuing 2 months, the mass continued to grow slowly but was no longer causing pain. The patient noted no further drainage and complained only of mild irritation caused by collared shirts. She had received no treatment and had undergone no diagnostic workup before consultation. She denied having fevers, chills, night sweats, weight loss, or other neck masses. Her medical history was otherwise unremarkable, and a review of systems revealed no other abnormalities. The findings of a comprehensive head and neck examination were remarkable only for a 3-cm firm skin mass that was situated anterior to the right sternocleidomastoid muscle. The mass, which had a central scar, was mildly tender to palpation and was not affixed to the deep neck structures. An ultrasound probe confirmed the presence of a partially cystic heterogeneous skin mass, which was further evaluated with a fineneedle aspiration (FNA) biopsy. The FNA sample showed multiple lymphocytes, multinucleated histiocytes, and granulomas in a necrotic background but was nondiagnostic. Stains were negative for acid-fast bacilli and fungal organisms. The results of purified protein derivative testing were also negative, and a chest x-ray film revealed no abnormalities. A 10-day course of clindamycin therapy was initiated, but the lesion failed to improve. Therefore, an excisional biopsy was performed. Intraoperatively, the lesion appeared confined to the skin and seemed well encapsulated. Histopathologic examination of the specimen revealed an infiltrative growth pattern, with basaloid cells showing marked mitotic activity (4-7 mitoses per high-power field) and cytologic atypia (Figure 1). There were large areas of necrosis en masse with ghost (or shadow) cells and matrical cells (Figure 2). Invasion of the surrounding tissue was also noted. Special stains were negative for acid-fast bacilli, fungal, aerobic, and anaerobic organisms. What is your diagnosis?
A PREVIOUSLY HEALTHY 43-YEAR-OLD WOMAN presented with a 2-month history of a mass in the right side of her neck. The mass had started as a small lesion that the patient attributed to a possible bug bite. Shortly thereafter, the lesion enlarged and became extremely painful and tender. Also, there was a small amount of spontaneous purulent drainage. During the ensuing 2 months, the mass continued to grow slowly but was no longer causing pain. The patient noted no further drainage and complained only of mild irritation caused by collared shirts. She had received no treatment and had undergone no diagnostic workup before consultation. She denied having fevers, chills, night sweats, weight loss, or other neck masses. Her medical history was otherwise unremarkable, and a review of systems revealed no other abnormalities. The findings of a comprehensive head and neck examination were remarkable only for a 3-cm firm skin mass that was situated anterior to the right sternocleidomastoid muscle. The mass, which had a central scar, was mildly tender to palpation and was not affixed to the deep neck structures. An ultrasound probe confirmed the presence of a partially cystic heterogeneous skin mass, which was further evaluated with a fineneedle aspiration (FNA) biopsy. The FNA sample showed multiple lymphocytes, multinucleated histiocytes, and granulomas in a necrotic background but was nondiagnostic. Stains were negative for acid-fast bacilli and fungal organisms. The results of purified protein derivative testing were also negative, and a chest x-ray film revealed no abnormalities. A 10-day course of clindamycin therapy was initiated, but the lesion failed to improve. Therefore, an excisional biopsy was performed. Intraoperatively, the lesion appeared confined to the skin and seemed well encapsulated. Histopathologic examination of the specimen revealed an infiltrative growth pattern, with basaloid cells showing marked mitotic activity (4-7 mitoses per high-power field) and cytologic atypia (Figure 1). There were large areas of necrosis en masse with ghost (or shadow) cells and matrical cells (Figure 2). Invasion of the surrounding tissue was also noted. Special stains were negative for acid-fast bacilli, fungal, aerobic, and anaerobic organisms. What is your diagnosis?
To the Editor .—In a recent commentary, Brummett 1 drew attention to a common, yet potentially life-threatening, drug interaction between nonselective β-adrenergic blockers and epinephrine. However, there were some serious typographical errors in his article and misleading recommendations as to the appropriate clinical response. First, β 1 and β 2 have been transposed throughout the commentary. The β 1 -receptors, not the β 2 , are those found in the heart, which, when stimulated, increase heart rate and contractility. 2 Epinephrine activates both α- and β 2 -receptors in blood vessels to mediate the opposing effects of vasoconstriction (α) and vasodilation (β 2 ). The net effect of low doses of epinephrine in healthy patients is only an increase in heart rate because of β 1 stimulation. 3 Higher doses of epinephrine produce systolic hypertension as well as tachycardia. 3 If the β 1 - and β 2 -receptors are blocked by a
To the Editor.—Distortions in the normal position of the human larynx have often been noted in observations and descriptions of the usual roentgenographic study of the chest, and these are usually noted along with the associated pulmonary and thoracic variations. To my knowledge, however, the phenomenon of the "twisted larynx" as a clinical syndrome has not been noted. These distortions may be divided into two types, theextrinsicand theintrinsic. Years ago I was requested to perform a tracheotomy in an elderly patient with laryngeal obstruction. The larynx could not be found by palpation, but it was finally located by applying a stethoscope circumferentially around the neck until breath sounds could be heard. The displacement or twist was such that the trachea was under the left mastoid process. This was the area where a successful and adequate tracheotomy was performed. The intrinsic is a rotary twist and
To the Editor.—I was pleased with the article by Adamson et al1in the MayArchives. The authors pointed out that beveling scalp incisions parallel with the hairshafts improves the scarline. May I point out that in any such scalp procedure, be it facelift, temporal lift, or forehead lift, it is best to make the more superior incision perpendicular to the surface of the scalp, and then bevel the more inferior (or anterior, in the case of forehead lift) incision parallel to the hair shaft. This ensures that some intact follicles are present along the cut margin of the superior flap edge, and that the new hair shafts produced by these follicles will tend to grow through the hairline and help to disguise it.
Seventeen healthy male volunteers received 15 mL of 2% solution (300 mg) of lidocaine hydrochloride every three hours for eight consecutive doses. Modes of administration were as follows: (A) each dose washed throughout the oral cavity, then spit out without swallowing; (B) each dose washed, then swallowed; and (C) each dose swallowed directly. Plasma levels of lidocaine and its two metabolites (monoethylglycinexylidide [MEGX] and glycinexylidide [GX]) were measured during and after the period of dosage. In trial A, levels of all three compounds were very low, in no case exceeding 0.3 microgram/mL. During trial C, the mean peak levels of lidocaine and MEGX, respectively, were 0.5 and 0.6 microgram/mL after the first dose, and 0.8 and 1.3 microgram/mL after the eighth dose. Both compounds were essentially undetectable by 12 hours after the last dose. Levels in trial B were very similar to those in trial C. Thus, recommended topical oral cavity use of 2% lidocaine leads to negligible systemic levels of lidocaine and metabolites. Even when doses are swallowed, systemic levels do not approach a toxic range.
Forty patients with head and neck cancer had a computed tomographic (CT) scan followed by lymphadenectomy and pathologic confirmation. The overall accuracy of clinical examination of the neck was 70% vs 93% by CT. The CT correctly "upstaged" the neck in nine patients. One was upstaged from NO to N1, and four each from NO to N2 and N1 to N2. It correctly "downstaged" the neck in one patient (from N2 to N1). Eight patients had extranodal disease on CT confirmed by pathology. The CT findings were correct in ten of 11 previously treated patients. Because CT is more accurate than the clinical examination, it should be included in the staging of not only the primary tumor but also nodal disease of the neck. It can have an important role in the management of head and neck cancer.
Malignant salivary gland tumors of the base of the tongue are unusual lesions and optimal treatment has not been established. As a group, these tumors tend to be diagnosed at an advanced stage, and consequently carry a grave prognosis. Fourteen patients were treated at UCLA between 1954 and 1984. Twenty-three percent of the patients have survived longer than ten years, although only one patient is free of disease. Eight of 14 patients developed distant metastases. Salivary tumors in this location are difficult to completely excise and surgical margins are frequently positive. Treatment using a planned combined approach is advocated.
Verrucous carcinoma of the larynx is a distinct and uncommon variant of well-differentiated squamous cell carcinoma. By DNA hybridization techniques, we clearly demonstrated human papillomavirus (HPV-16-related) sequences in five patients with this neoplasm. In addition, HPV-16-related sequences were found in adjacent normal tissues. The DNAs from squamous cell carcinomas of the larynx were negative when hybridized to HPV-6, -11, or -16. Postirradiation anaplastic transformation of verrucous carcinoma has been described. We believe that radiotherapy should not be given unless the potential consequences are fully explained because of its potential to activate or alter HPV-16-related sequences.
Total ophthalmoplegia is a serious complication of internal maxillary artery ligation. Although serious complications of transantral surgery of the pterygopalatine space are rare, they remain a very real possibility and should be considered before undertaking arterial ligation for treatment of posterior epistaxis.
A group of 24 patients with recurrent and/or metastatic cancers were treated with photodynamic therapy using hematoporphyrin derivative (HpD) to study feasibility of this new technique. This experience demonstrated that photodynamic therapy is possible for head and neck cancer and that the toxic reactions and complications are minimal. The short durations of response in this group of patients most probably are a reflection of current lack of understanding about what represents maximal tolerable doses of HpD and frequencies of treatment.
The management of the ear canal in the treatment of tumors occurring in the area of the head and neck is a highly specialized problem. The material for this report is a derivative of the treatment of tumors involving the auricle, tragus, the skin of the cheek, temple, mastoid, parotid gland, ear canal, and middle ear. The extensive variety of histopathologic conditions and positions of the various tumors creates special problems in preserving and reconstructing the ear canal, saving the tympanic membrane, and rehabilitating the area of the ear canal when these structures have had to be resected. Six basic techniques have been used in rehabilitating this unique area, by using regional skin, free skin grafts, regional flaps, cervical flaps, combinations of these techniques, and large cutaneous and myocutaneous chest and back flaps for the larger ablations.
The identification of cartilage involvement in laryngeal carcinoma implies advanced stage T4 disease. Although computed tomography (CT) provides the most accurate method of assessing these cartilages, subtle cartilage invasion may go undetected. The major pitfall in detecting tumor involvement is the incomplete calcification of these structures, which may simulate cartilage destruction. High-resolution CT now allows the evaluation of the medullary space of these cartilages. The CT finding of abnormal soft tissue in the central medullary space in addition to a focal cortical defect allows the confident diagnosis of cartilage involvement.
Primary infection of the laryngeal cartilages has become rare in the antibiotic era. However, trauma, irradiation, a foreign body, or cancer may initiate the infection, particularly in the immunocompromised patient. We encountered three cases of perichondritis and abscess associated with airway intubation, nasogastric intubation, and external beam radiotherapy. Laryngeal perichondritis and abscess remain serious potential causes of laryngeal deformity and dysfunction.
Forty patients underwent pharyngoesophageal reconstruction with a free jejunal interposition graft (FJIG). Three categories of disease were treated: (1) primary upper aerodigestive tract carcinomas, (2) recurrent carcinomas, and (3) benign pharyngoesophageal stenosis. There were no intraoperative graft failures. Postoperative complications included four perioperative deaths, eight late graft failures, three transient fistulas, eight distal graft strictures, one prolonged ileus, two postoperative hematomas, one abdominal wound dehiscence, one abdominal abscess, and one hypoglossal nerve palsy. Of the eight patients with late graft failures, three underwent successful jejunal reimplantation, yielding an overall success rate of 88% (35/40). The advantages of an FJIG are as follows: (1) a single-stage procedure for large defects, (2) a jejunal segment approximately the size of the pharyngoesophagus, (3) tissue that is able to tolerate radiation therapy, (4) maintenance of near-physiologic swallowing mechanism, (5) denervated small-bowel model, (6) excellent palliative procedure, and (7) shortened hospitalization. Disadvantages include (1) microvascular surgical technique, (2) abdominal procedure, and (3) limited esophageal speech.
Snoring has been shown to be the primary sign of a potentially serious medical condition, ie, obstructive sleep apnea. Traditionally, the otolaryngologist has been the primary resource for patients with snoring problems although, until recently, little was known about the now-acknowledged serious complications of this phenomenon. Among the primary treatments for this condition, the most commonly used to-date involve surgical procedures routinely performed by the otolaryngologist, ie, tracheostomy and uvulopalatopharyngoplasty. Thus, the practicing otolaryngologist has been thrust into the forefront of diagnosis and management of obstructive sleep apnea, and it behooves the modern practitioner to be cognizant of the multidisciplinary approach to the diagnosis and management of this problem. The utilization of information obtained during the sleep study determines the management of the sleep apneic patient.
Full-thickness eyelid defects resulting from trauma, tumor destruction, surgical excision, or congenital anomalies present a dilemma to the reconstructive surgeon. Full-thickness eyelid replacement requires composite grafting of skin, muscle, tarsal support or its substitute, and mucosa. A temporalis fascia sling hammock can be used to support the reconstructed eyelid. This static suspension assists in maintaining proper globe apposition to the eyelid and in preventing sagging of the reconstructed structures.
