Otolaryngology–Head and Neck SurgeryVolume 133, Issue 4 p. 635-636 Clinical Photograph Tympanic Membrane Perforation and Retained Metal Slag after a Welding Injury Jeffrey P. Simons MD, Jeffrey P. Simons MD Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PennsylvaniaSearch for more papers by this authorDavid E. Eibling MD, Corresponding Author David E. Eibling MD [email protected] Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PennsylvaniaReprint requests: David E. Eibling, MD, Department of Otolaryngology, University of Pittsburgh School of Medicine, Eye and Ear Institute Pavilion, 200 Lothrop Street, Suite 500, Pittsburgh, PA 15213. E-mail address: [email protected].Search for more papers by this author Jeffrey P. Simons MD, Jeffrey P. Simons MD Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PennsylvaniaSearch for more papers by this authorDavid E. Eibling MD, Corresponding Author David E. Eibling MD [email protected] Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PennsylvaniaReprint requests: David E. Eibling, MD, Department of Otolaryngology, University of Pittsburgh School of Medicine, Eye and Ear Institute Pavilion, 200 Lothrop Street, Suite 500, Pittsburgh, PA 15213. E-mail address: [email protected].Search for more papers by this author First published: 17 May 2016 https://doi.org/10.1016/j.otohns.2005.05.007Citations: 1AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat No abstract is available for this article. References 1Fisher EW, Gardiner Q. Tympanic membrane injury in welders: Is prevention neglected? J Soc Occup Med 1991; 41: 86–8. 10.1093/occmed/41.2.86 CASPubMedGoogle Scholar 2Panosian MS, Dutcher Jr. PO Transtympanic facial nerve injury in welders. Occup Med 1994; 44: 99–101. 10.1093/occmed/44.2.99 CASGoogle Scholar 3Stage J, Vinding T. Metal spark perforation of the tympanic membrane with deafness and facial paralysis. J Laryngol Otol 1986; 100: 699–700. 10.1017/S0022215100099916 CASPubMedWeb of Science®Google Scholar 4McMillan GH. Welding, fumes and inhalational fevers. In: PJ Baxter, PH Adams, TC Aw, et al., editors. Hunter's diseases of occupations. 9th ed. London: Arnold Publishers; 2000. p. 179–94. Google Scholar 5Burgess WA. Potential exposures in the manufacturing industry—their recognition and control. In: RL Harris, editor. Patty's industrial hygiene. 5th ed. New York: John Wiley and Sons, Inc.; 2000. p. 1257–340. Google Scholar 6Mertens J, Bubmann M, Reker U. Schweissperlenverletzungen des Ohres: Beobachtungen am eigenen Krankengut [German]. Laryngo-Rhino-Otol 1991; 70: 405–8. 10.1055/s-2007-998063 CASPubMedWeb of Science®Google Scholar 7Frenkiel S, Alberti MB. Traumatic thermal injuries of the middle ear. J Otolaryngol 1977; 6: 17–22. CASPubMedWeb of Science®Google Scholar Citing Literature Volume133, Issue4October 2005Pages 635-636 ReferencesRelatedInformation

CONTEXT:Reductions in the length of acute care hospitalizations have resulted in earlier transfer of patients with significant neurologic disease, such as head injury or stroke, to inpatient rehabilitation facilities. In many instances, these patients arrive at the rehabilitation hospital with multiple unresolved acute processes, including undetected or inadequately evaluated dysphagia. These patients may be at significant risk for the development of aspiration pneumonia, especially if elderly or debilitated.OBJECTIVE:To review the role of otolaryngologic consultation in the management of inpatients in two rehabilitation hospitals.DESIGN AND SETTING:Retrospective review of 1046 consultations performed by two otolaryngologists over a 4-year period at two long-term inpatient rehabilitation hospitals in the Pittsburgh, PA, metropolitan area.RESULTS:A total of 833 patients were evaluated. Three hundred were seen for a variety of common disease processes, including hearing loss, and cerumen removal. A total of 548 consultations were for recommendations regarding swallowing dysfunction. Fibre-optic endoscopic examination of swallowing function was performed in 478 patients. Two hundred consultations were for assistance in decannulation of patients who were transferred from the acute care hospital with an indwelling tracheostomy tube.CONCLUSIONS:The detection and evaluation of the aspiration risk of dysphagic patients in rehabilitation hospitals are enhanced by an onsite dysphagia team with access to instrumented measures of swallowing, especially videofluoroscopy or videoendoscopy. Otolaryngologic consultation can provide considerable benefit for many inpatients in rehabilitation hospitals, even those with apparent "minor" dysfunction. The otolaryngologist-head and neck surgeon is uniquely qualified to provide consultation in the management of those inpatients with complex clinical problems involving the upper aerodigestive tract. Consultation may be critical for some patients, assessing the cause and severity of dysphagia and assisting in the safe decannulation of those with indwelling tracheostomy tubes.

Background. During the past decade, laryngeal framework surgery has become the treatment of choice for the management of adductor paralysis of the vocal fold. The primary impetus for the use of this technique has been on the rehabilitation of voice. The purpose of this study was to ascertain the effectiveness of laryngeal framework surgery, including medialization laryngoplasty with silicone (MLS), with or without arytenoid adduction (AA), on eliminating aspiration, improving diet, and aiding in the subsequent decannulation of individuals with glottic insufficiency secondary to vocal fold palsy.Methods. A retrospective chart review was performed on all patients initially seen with vocal cord paralysis who were treated with laryngeal framework surgery from June 1992 to April 1996. The study comprised 70 patients, including 31 women and 39 men, with a median age of 57 years. Clinical information was obtained regarding the etiology of the lesion, characteristics of the vocal cord deficit, history of aspiration, the presence of other neurologic deficits or concurrent pulmonary disease, treatment, and outcome. To determine the effectiveness of MLS, with or without AA, we assessed the final outcome regarding the presence and degree of aspiration, diet, history of aspiration pneumonia, and decannulation.Results. Seventy patients underwent 77 MLS (three bilateral, four revisions), and 21 AA. Decreased aspiration was obtained in 96% of our patients. Seventy-five percent of those patients who had required a tracheotomy were decannulated.Conclusions. These results support the use of laryngeal framework surgery for the effective treatment of aspiration in selected patients initially seen with deficits of the glottic closure secondary to vocal fold paralysis or paresis. (C) 1999 John Wiley & Sons, Inc.

Purpose: The purpose of this study is to ascertain the effectiveness of laryngeal framework surgery, including medialization thyroplasty (MT), with or without arytenoid adduction (AA), on preventing aspiration, improving diet, and aiding in the subsequent decannulation of individuals with high vagal lesions.Patients and Methods: A retrospective chart review was performed on each patient presenting with a high vagal lesion who was treated with laryngeal framework surgery from June 1992 to April 1996 at a university medical center. Thirty-five patients were identified; there were 20 women and 15 men, with a median age of 51. Information regarding etiology of the lesion, characteristics of the vocal cord deficits, degree of aspiration, the presence of other neurologic deficits and concurrent pulmonary disease, treatment, and outcome was obtained. The final outcome regarding voice, the presence and degree of aspiration, diet, and decannulation following MT, with or without AA, was assessed to determine the effectiveness of these procedures.Results: Thirty-five patients underwent 40 MTs and 19 AAs. Ninety-four percent of patients who experienced aspiration improved, and 79% who had required tracheotomy were decannulated. Ninety percent of patients were noted to have subjective improvement in voice postoperatively.Conclusion: Laryngeal framework surgery improves airway, deglutition, and voice in individuals suffering from high vagal lesions, and facilitates the rehabilitation of these patients. Copyright (C) 1998 by W.B. Saunders Company.

Background. There is a need to evaluate the effectiveness of laryngeal fracture repair using rigid adaptation plates.Methods. A retrospective chart review of patients undergoing open repair of laryngeal fractures using metal alloy plates, from 1987 to 1995, was performed. Postoperative airway, deglutition and voice were assessed. Postoperative follow-up ranged from 1 to 58 months (median, 27 months). All 10 patients sustained blunt or penetrating laryngeal trauma. After patients were resuscitated according to the ABC principles recommended by the American College of Surgeons, each underwent open repair of laryngeal fractures using rigid adaptation plates.Results. Outcome was measured by perceptual analysis of the postoperative airway, swallowing, and voice, as well as biocompatibility. Ten patients underwent repair and stabilization of the larynx using adaptation plates. Nine patients sustained blunt trauma, and one patient sustained penetrating trauma. Voice was subjectively graded as good if it resembled the preinjury status, fair if it differed, and poor ii it represented aphonia, whisper; or unintelligible speech. Airway was graded as good ii it resembled preinjury status, fair ii mild exercise intolerance or aspiration existed, and poor ii the patient could not be decannulated. Nine patients had a good airway following repair, and six of seven patients requiring tracheotomy were decannulated. All patients tolerated the plates well and suffered no surgical complications.Conclusion. Repair of the laryngeal framework using adaptation plates provides adequate, immediate stabilization with restoration of function and is an alternative to traditional methods of repair. (C) 1998 John Wiley & Sons, Inc.

Lower cranial nerve deficits following skull base surgery can be accompanied by significant morbidity, especially if the vagus nerve has been sacrificed or injured. Loss of pharyngeal function and glottic closure can result in dysphagia and aspiration. Left untreated, these can result in the major morbidity for the patient following skull base surgery. The authors discuss the management of lower cranial nerve deficits, with emphasis on rehabilitation of swallowing function and prevention of aspiration following vagal injury.

The relationship between tracheostomy and swallowing dysfunction has been long recognized. Often this dysfunction is manifested by aspiration, for which a number of etiologic factors may be responsible. Disruption of glottic closure has been previously demonstrated in association with the presence of an indwelling tracheostomy tube. The plugging or removal of the tracheostomy tube, or the use of an expiratory air valve, has been demonstrated to decrease aspiration and improve swallowing function. Measurement of subglottic pressure through an indwelling tracheostomy tube during swallowing demonstrated pressure peaks occurring concomitant with swallowing and laryngeal elevation. This presentation will review the evidence supporting the role of subglottic pressure rise in swallowing efficiency. Current investigational activity will be reviewed, and new areas for study will be suggested.

A retrospective analysis of formalin-fixed, paraffin-embedded tissue from patients with histologically confirmed metastatic squamous cell carcinoma was performed using flow cytometry. Ninety-eight sets of specimens from previously untreated patients with an oral cavity or oropharyngeal tumor and a simultaneous cervical metastatic deposit were analyzed. Normal mucosa and cervical lymph nodes were processed identically and run as controls, All patients underwent surgical resection at Wilford Hall USAF Medical Center or The Eye and Ear Hospital of Pittsburgh between 1980 and 1986. The specimens from 94 patients were technically adequate for interpretation. Diploid histograms in both the primary and metastatic tumors were present in 49 (52%) of 94 patients, Aneuploid histograms in either the primary or metastatic tumors were noted in 45 (47%) of 94 patients, In this group of 45 patients, the primary tumor and cervical metastasis were both aneuploid in 21 (46%), and aneuploid histograms occurred with equal incidence in either the primary or metastasis in the remaining 24 cases. No statistically significant prediction of survival could be made from any correlation with the histograms of either the primary or metastasis, The potential technical problems and limitations of flow cytometry in the determination of DNA content of formalin-fixed, paraffin-embedded tissue and the selection of patients with advanced disease warrant caution in the interpretation of results.

OBJECTIVE:To analyze serial measurements of squamous cell carcinoma antigen (SCCAg) to determine its prognostic significance in squamous cell carcinoma of the head and neck (SCCHN).DESIGN:Retrospective analysis of serial SCCAg measurements in 75 patients with squamous cell carcinoma of the head and neck. Serum samples were obtained preoperatively and at postoperative intervals ranging from 1 week to 36 months. Serum SCCAg levels were determined by radioimmunoassay.SETTING:Oncologic head and neck practice at a tertiary referral hospital.PATIENTS:Tumor Registry data of 75 consecutive patients with at least three postoperative SCCAg determinations were reviewed to provide equal numbers of patients with and without recurrent disease. All patients who remained disease-free were followed up for at least 2 years. All patients were previously untreated and underwent surgical therapy.MAIN OUTCOME MEASURES:Association of postoperative SCCAg levels and 2-year disease-free survival.RESULTS:No differences in preoperative levels were noted, but SCCAg levels predicted 2-year disease-free survival at 6, 9, and 12 months after surgery. The ratio of post-operative SCCAg levels to preoperative and early post-operative levels also provided prognostic information.CONCLUSIONS:Serial measurements of SCCAg postoperatively in patients with head and neck cancer predict outcome and may allow for earlier detection of recurrent disease. Further studies are needed to determine if earlier detection can be translated into improved survival.

The nasal septal hemangioma or ''bleeding polyp,'' first reported by Ash and Old(1) in 1950, is an uncommon lesion of the nasal cavity. Histological confirmation of the diagnosis is crucial to make the appropriate diagnosis and institute definitive treatment because these tumors often mimic malignancy. We present an unusual case of a patient with a nasal septal hemangioma that originated on the osseous nasal septum rather than the more commonly described anterior cartilaginous septum. Computed tomography (CT) and early biopsy assisted in definitive treatment planning.

(Editorial Comment: The authors emphasize the potential importance of jugular vein reconstruction in patients with advanced bilateral cervical metastasis in whom a bilateral radical neck dissection obviates potential for preservation of a single jugular vein.) Simultaneous bilateral modified neck dissections are well tolerated by head and neck cancer patients and the use of dissections in the management of palpable and occult metastatic disease of the upper aerodigestive tract is increasingaIm The low morbidity associated with these procedures is secondary to the ability to preserve important structures such as the internal jugular vein (IJV), spinal accessory nerve, and the sternocleidomastoid mus-cle.4 Maintenance of at least one internal jug- jugular vein in these bilateral lymphadenectomies is helpful in reducing the complicationsof interrupting the venous drainage of the head. Massive postoperative head and neck edema,4-” increased intracranial pressure,7 orsure, or syndrome of inappropriate antidiuretic hor-mone secretion (SIADH)’ may occur if both IJVs are surgically occluded5- despite the presence of collateral venous drainage. Severe intracranial sequelae such as stroke, blindness,g and even death7 have been reported [Table

Biological markers of disease enhance the ability to diagnose, treat and evaluate results of therapy and are especially intriguing for their potential use in the management of malignant tumours. The serum levels of various biochemical substances have been shown to be abnormal for many cancers and are utilised in the management of affected patients. Several markers have been thoroughly investigated for potential clinical utility in head and neck carcinoma. Although no single marker has been found to be adequately sensitive and specific, combinations of markers may improve the utility for some aspects of patient management. This review highlights the literature to date in the realm of circulating markers for head and neck carcinoma. A discussion of the potential usefulness and limitations of such markers follows.

Hoarseness indicates an abnormality at the level of the glottis. This symptom may result from either structural or physiologic disorders. The differential diagnosis is lengthy and includes both benign and malignant diseases. History taking and physical examination, particularly laryngeal visualization, provide key clues. Careful and complete examination is always recommended, because airway obstruction can in some situations quickly follow hoarseness.

Thirty-six patients with unresectable squamous cell carcinoma of the head and neck were entered into a phase Ib trial evaluating the toxicity, maximally tolerated dose (MTD), and immunomodulating effects of locally administered interleukin-2 (IL-2). Patients received daily IL-2 injected perilesionally in divided doses in each of four quadrants and bilaterally into the superior jugular lymph nodes. The dose of IL-2 began at 200 U/day and was escalated to 4 x 10(6) U/day in groups of six patients. Overall, regionally administered IL-2 was well tolerated. The most frequently encountered toxicities were fever, hepatotoxicity, and hypotension. Dose-limiting toxicity was encountered at 4 x 10(6) U. Of the 36 patients treated, 2 partial responses were noted at 2,000 and 4 x 10(6) U. We conclude that regionally administered IL-2 is well tolerated in patients with head and neck cancer and that the MTD is 2 x 10(6) U/day, similar to what has been reported with systemically administered IL-2. Although the overall response rate was low, it may be improved with prolonged administration of IL-2 or by combining it with other biologic or cytotoxic agents.

Multiple reports now demonstrate the technical feasibility of combined intra- and extracranial procedures for the excision of malignancy involving the anterior skull base-Anatomic proximity to vital structures in this region often precludes en bloc resection, however, and margins are often measured in millimeters. Nevertheless, multiple cases of prolonged survival following craniofacial excision of high-grade malignancies have been reported. These are usually included in larger series that encompass tumors of various histologic characteristics and grade. A meta-analysis of the reported outcome of craniofacial resection for squamous cell and undifferentiated carcinoma was performed. Ninety-six articles on craniofacial resection were reviewed and a total of 425 patients who had undergone craniofacial resection were identified in 30 of these. Of 89 patients with squamous cell carcinoma in whom follow-up data were available from seven larger series, the disease-free survival at 2 or greater years was 64%. Forty-one patients with undifferentiated carcinoma were identified who had undergone surgical excision, and 45% were disease-free at 2 or greater years (range, 2 to 24 years). This meta-analysis suggests that high-grade carcinoma involving the anterior cranial base is amenable to surgical excision with acceptable disease-free survival in selected patients at 2 years.

An ideal tumor marker should be sensitive in tumor-bearing patients while having adequate specificity so that controls do not demonstrate the marker. To date, a single circulating marker has not been identified for squamous cell carcinoma of the head and neck. This study evaluates a panel including squamous cell carcinoma radioimmunoassay, lipid-associated sialic acid, carcinoembryonic antigen, and CA-125. In this population of patients with cancer, serum samples from 101 patients and 88 controls were evaluated. The squamous cell carcinoma radioimmunoassay was the most sensitive marker identified (47.5%), while carcinoembryonic antigen level was elevated in 40.6%, lipid-associated sialic acid level in only 16.8%, and CA-125 level in 7.9%. False-positive results were found with all markers, including squamous cell carcinoma radioimmunoassay (18.2%), carcinoembryonic antigen (18.2%), lipid-associated sialic acid (10.2%), and CA-125 (15.9%). Various combinations of markers did not significantly improve either specificity or sensitivity. Available tumor markers are inadequate for diagnostic purposes in patients with squamous cell carcinoma of the head and neck.

A patent internal carotid artery (ICA) is essential in most patients. Management of skull base lesions often requires translocation, balloon embolization, or resection of this vessel. Preoperative tests to assess the availability of collateral flow have not been uniformly accurate. A new test that significantly increases the safety of surgical removal of the ICA is described. One hundred thirty-six patients were studied with temporary balloon occlusion (TBO) of the ICA and determination of stable xenon-enhanced computed tomography cerebral blood flow (Xe/CT CBF) measurements. Eleven patients failed TBO and were determined to be at very high risk of stroke with loss of the ICA. Ninety-six of the patients were predicted to be at minimal risk with permanent loss of the ICA by Xe/CT CBF studies. Twenty-one patients in this group had either permanent balloon occlusion (PBO) or surgical resection of the ICA with no permanent neurologic sequelae. Our studies show that the combination of preoperative TBO and Xe/CT CBF studies significantly increases the safety of ICA resection.

Reconstruction of surgical defects in 30 patients undergoing surgery of the anterior cranial base was performed using pericranial, galeopericranial, and galeal scalp flaps. Twenty-seven patients had resection of neoplasms, the majority of which were malignant. Fifty-seven percent of patients received prior therapy consisting of surgery and/or radiotherapy. Adequate healing of the cranial base was noted in all cases without persistent cerebrospinal fluid leaks, meningitis, or brain herniation. Mucosalization of the intranasal surface was noted. No skin grafts were used. At a median follow-up of 13 months, 67% of patients were alive with no evidence of disease. The pericranial, galeopericranial, and galeal flaps are highly reliable, versatile, and well suited for reconstruction of the anterior cranial base.

A reliable circulating tumor marker, appropriate for head and neck malignancy, is not yet available. This manuscript reports the efficacy of using circulating squamous cell carcinoma antigen in evaluating patients with squamous cell carcinoma of the head and neck. Serum samples from 89 patients with squamous cell carcinoma of the head and neck were obtained before treatment and at intervals following treatment. Squamous cell carcinoma antigen levels were determined by radioimmunoassay. Elevated pretreatment serum levels of squamous cell carcinoma antigen were identified in 39 of 89 patients (44%) who had head and neck squamous cell carcinoma. Of the 16 patients evaluated from this group with recurrent or persistent disease, 15 (93.5%) demonstrated elevated levels of squamous cell carcinoma antigen. However, of the 21 evaluable patients who remained disease free, only 10 (48%) had post-therapy levels within the normal range. The possible use of this marker in aiding the clinical follow-up of head and neck cancer patients is discussed.

Curability of skull base tumors is related to the ability to achieve a complete resection. Resection of the internal carotid artery with the tumor puts the patient at risk for catastrophic cerebral injury. Autogenous vein grafting is not always technically or physiologically possible. We present eight patients with tumors eroding the cranial base who underwent safe resection or occlusion of the internal carotid artery as predicted by three tests: 1. carotid arteriography, 2. temporary balloon occlusion of the internal carotid artery, and 3. xenon computerized tomography cerebral blood flow mapping. No patient suffered permanent central nervous system injury.