Faculty Bibliography

Angiography is useful in following selected patients with chemodectoma of the head and neck treated by radiotherapy. Comparison of preradiotherapy and post radiotherapy angiograms in three patients revealed a decrease in the following: size of feeding arteries, size of tumor, intensity of tumor opacification, and degree of venous shunting. When chemodectomas are not amenable to physical examination and when the question of radiotherapy complication vs further growth of tumor arises, postradiotheraphy angiography may be of particular value.

An extended area of stenosis of the upper mediastinal trachea, which normally would require extensive thoracic mobilization for primary anastomosis, was corrected by resection of the manubrium with the creation of a trough. This was closed in several stages utilizing embedded Marlex mesh and regional skin flaps. The development and modifications of this technique are discussed.

A technique is described whereby limited soft tissue defects may be cosmetically improved using autogenous fascial strips. These strips of fascia lata are threaded onto a cadaveric needle that is tunneled subdermally, in a "basket weaving," criss-crossed fashion, augmenting the soft tissue defect and separating the scar from the underlying tissue. There are minimal incisions in the skin for this augmentation and there is very little local tissue reaction.

The aggressive initial treatment of external auditory canal and middle ear malignancies using ablative surgery in the form of temporal bone resection combined with postoperative curative doses (6,000 rads) of irradiation has resulted in meaningful palliation and a seeming increase in cure rates for these lesions. This combined therapy regimen has placed new demands on the wound of the temporal bone resection and subsequently necessitated development of a more substantial reconstructive effort. Hypoglossal nerve crossover has proved to be an efficient means of facial reanimation following temporal bone resection, with minimal morbidity associated with the loss of motor function to one half of the tongue. The composite posterior cervical flap, including a portion of trapezius musculature, has satisfied both the functional and cosmetic needs of this combined therapy program.

This paper reviews 13 cases of chordoma in the cervical spine and base of the skull which have been seen at the Pack Medical Foundation over the past 25 years. Chordomas are dysonto genetic, malignant, slow-growing neoplasms that arise in remnants of the embryonic notochord. Concealed along the axial skeleton, these slow-growing tumors are usually well entrenched before they are accurately diagnosed. The majority of the chordomas of the spine occur in the sacroccygeal region. Of the 13 cases in the area of the cervical spine, 39% occurred in the region of the base of the skull and 61% in the area of the cervical spine. The treatment of the cervical tumors consisted of laminectomy to relieve the pressure on the cord and to remove as much of the neoplasm as possible. Some of the tumors at the base of the skull were nonresectable and were treated with radiotherapy. Radiotherapy was ultimately used in every case, either in combination with surgery or as a primary or subsequent method of management. The overall prognosis for palliation was fair but ineffective for cure.

Polarization between proponents of intact canal wall tympanoplasty and radical (modified) mastoidectomy in the treatment of cholesteatoma and other irreversible temporal bone lesions can be avoided in many cases by the use of one or more special techniques. These include (a) Gelfilm (no-graft) induction of tympanic membrane regrowth; (b) the use of tragal cartilage and perichondrium in columellization and in Type III neomyringostapediopexy; (c) the use of laboratory-prefabricated ossicular homografts to correct malleal-capitulum and malleal-footplate discontinuities more precisely; and (d) the circumferential approach (circumnavigation of patient's head) and anterior position of the surgeon in order to visualize the sinus tympani, retropyramidal, and retrofacial areas, obviating extensive posterior tympanotomy bone dissections. These techniques make possible a third alternative to the choice of either combined-approach tympanoplasty or radical or modified radical mastoidectomy in the treatment of a number of advanced temporal bone lesions.

Although the cochlear toxicity of dihydrostreptomycin (DHSM) is well-recognized in man, it has always proved difficult to demonstrate in animals. Hearing thresholds in M. nemestrina monkeys remained essentially unchanged after DHSM 100 mg/kg im daily for 8 months, but E. patas monkeys were severely deafened by DHSM 20 mg/kg for 90 days, a regimen formerly used in treating human tuberculosis. The patas monkey may prove to be the animal model of choice for evaluating aminoglycoside ototoxicity.