Faculty Bibliography

The causes of nasopharyngeal obstruction are described. The diagnosis and treatment of each type of nasopharyngeal obstruction are presented in detail.

Few reports describing manual strangulation injury to the neck are found in the otolaryngologic literature. Since most victims sustain immediate fatal asphyxiation, brain anoxia, or cardiac arrest, they are usually examined by a forensic pathologist. When strangulation attempts are nonfatal, neck injuries can lead to delayed airway obstruction. If not managed in a timely fashion, these injuries can be fatal or cause permanent laryngotracheal sequelae. We describe a patient who 36 hours following manual strangulation developed acute upper airway obstruction and neck abscess necessitating tracheotomy, neck exploration, and drainage. Patients suffering this unique type of compression injury may present initially with deceptively benign symptoms and signs. We discuss the overall management of these patients, stressing the need for early imaging studies, endoscopic assessment, and continued airway monitoring in an intensive care unit.

This is a report comprised of 78 cases of melanoma of the mucous membrane of the head and neck and is part of a larger study of 995 cases of head and neck melanoma. These cases represent a review of patients over a 55-year period from the Pack Medical Foundation. Melanoma of the mucous membrane is a rare condition and the most serious of all head and neck melanomas. Its highest incidence is in the oral cavity, followed by the nasal and pharyngeal cavities. It usually occurs during the fifth decade of life. In its early stages it is asymptomatic and often located in areas difficult to see upon visual examination and technically inaccessible. These facts lead to a delay in diagnosis, which reduces curability to 8%. In spite of these negative factors, there has been a significant improvement in the extension and quality of life for patients with melanoma of the mucous membrane. The biological characteristics of this disease are analyzed and a philosophy of management is offered.

The purpose of this study was to review a large series of patients with adenoid cystic carcinoma of the parotid gland in order to develop clinical criteria for sacrifice versus selective sparing of the seventh nerve. We studied 43 patients followed over 36 years. Study patients were grouped according to the preoperative status and intraoperative management of the facial nerve. Criteria for choosing various management strategies are discussed.

Massive fibro-osseous lesions of the frontal and ethmoidal sinuses are rare. If left untreated, these lesions can produce chronic infection, orbital complications, and/or intracranial events. In the past, resection of these lesions has usually been subtotal and a risk of damage to intracranial structures existed, particularly to the dura, due to poor exposure, and a high recurrence rate was also present. We have treated eight such lesions with a combined craniofacial approach for total resection with resolution of symptoms, without recurrence, and without occurrence of cerebrospinal fluid leak, damage to the orbital contents or intracranial structures, or resultant cosmetic deformity.

Adductor spastic dysphonia (SD) is a laryngeal dystonia characterized by a choked, constrained voice pattern with breaks in vocal flow. Treatment with a variety of therapies including speech and pharmacotherapy have minimal benefit; only one-third of patients undergoing recurrent laryngeal nerve section have benefitted at 3 years. We have used local injections of botulinum toxin (Botox) bilaterally into vocalis muscles in 42 patients with SD. Injections were through a teflon-coated hollow electromyography (EMG) recording needle. Unilateral small doses (2.5-3.75 U) were of no clinical benefit. Bilateral small doses resulted in sustained improvement lasting 84.4 +/- 9.3 days. The degree of improvement was 61.1 +/- 4.6%. Common side-effects included a brief period of breathy hypophonia (8.5 +/- 2.5 days) and a mild sensation of choking/aspiration of fluids (1.7 +/- 0.6 days); there were no serious adverse effects. Vocal cord paralysis was not necessary for benefit. Follow-up vocalis muscle EMGs revealed denervation. All patients responded to retreatment (longest follow-up 3.5 years). Patients with prior recurrent laryngeal nerve surgery and residual uncomplicated dysphonia had similar results. Our results indicate that local injection of low-dose Botox is the treatment of choice for SD.

Granulomatous disorders of the larynx can take on many forms and usually represent the end stage of chronic disease. In the past, laryngeal granulomas were much more prevalent primarily because of the frequency of tuberculosis. Seldom is the larynx the site of origin for granulomatous disease, but it is usually a manifestation of a pulmonary entity such as histoplasmosis, blastomycosis, sarcoidosis, or tuberculosis. The actual diagnosis is frequently arrived at while trying to rule out carcinoma. Laryngeal tuberculosis, although rare in the United States, remains the most common granulomatous disease of the larynx. Its increasing incidence has paralleled the diminished incidence of tuberculosis in the general population. Specific clinical characteristics for diagnosis are few and diagnosis is arrived at through a high index of suspicion and biopsy. When biopsy is carried out, adequate tissue should be obtained for both histological sections, cultures, and sensitivities.

The hearing sensitivity of 9427 railroad train crew members, determined during the first year of a company-wide hearing conservation program, was compared with hearing sensitivity in a control population not exposed to occupational noise. The hearing sensitivity of the trainmen did not differ significantly from that of the control population. Multiple regression analysis, which considered separately the effects of age and years of service, showed significant differences in hearing levels due to age, but no differences in hearing levels due to years of service. Evaluation of the data by risk categories developed by the National Institute for Occupational Safety and Health indicate that this group of trainmen had no risk of occupational noise-induced hearing loss. These analyses, combined with studies of locomotive cab noise, show clearly that trainmen are not typically exposed to hazardous occupational noise.