Showing papers in "Laryngoscope in 1972"

Newer concepts of first branchial cleft defects

Abstract: Duplication embryological anomalies of the first branchial cleft are reported. Six cases are presented which were treated since 1963. A classification of these cases is suggested wherein there are Type I and Type II lesions. Type I is of ectodermal origin and is considered a duplication of the membranous external auditory canal. Initial infection and subsequent infection often necessitate repeated incision and drainage. Only one of the five cases of Type I did not show infection. Characteristically, these lesions occur medial to the concha and frequently extend to the postauricular crease. They pass anterior and deep to the ear lobe, superior to the facial nerve, parallel to normal external auditory canal and finally end in a cul-de-sac on a bony plate at the level of the mesotympanum. Microscopically, these lesions are cystic, have a squamous epithelium lining, form keratin and may or may not show accessory skin structures. Surgical excision is the treatment of choice. The surgery must be performed during remission from infection and consists mainly of parotid gland and facial nerve dissections. After the lesion is excised, the normal membranous external auditory canal is incised lengthwise, and an iodoform pack is placed in the area of the excised anomaly and brought out externally through the recently incised membranous external auditory canal and the meatus. During the first few days postoperatively, the pack is gradually removed and the bed of the wound repacked if necessary. Such a technique enhances wound healing. Type II are duplication anomalies of the membranous external auditory canal and pinna; they contain skin (ectoderm )and cartilage (mesoderm). These anomalies likewise are usually diagnosed after infection has taken place and after incision and drainage of an abscess at a point below the angle of the mandible. The upward extension of this lesion passes over the angle or horizontal ramus of the mandible. It continues upward passing either lateral or medial to the facial nerve and in rare instances may split its main trunk. It may end inferior to the membranous external auditory canal or form a sinus in that location. The middle ear is normal. Only one case with such anomaly is reported here, but in 1963, Work and Proctor reported five of six cases as Type II anomalies. Wide surgical excision is curative. The facial nerve must be preserved intact. Types I and II anomalies are not associated with pretragal cysts or sinuses.

Laser surgery of the vocal cords. An experimental study with carbon dioxide lasers on dogs.

Abstract: In experiments on dogs, a focused beam from a continuous wave surgical carbon dioxide laser integrated with an operating microscope was used selectively to evaporate predetermined amounts of normal vocal cord tissue through a laryngoscope. This mode of tissue removal was precise, rapid and practically bloodless. Microscopic laryngoscopy examinations and histological work-up one, two and three weeks postoperatively indicated normal healing similar to that of clean surgical wounds.

Physiology of the eustachian tube in the pathogenesis and management of middle ear effusions.

Abstract: Eustachian tube function studies were carried out in patients with concurrent or recent middle ear effusions. Radiographic techniques were employed in assessing tubal response to liquid flow. Studies of air flow and air pressure were carried out using a Madsen bridge, and depended on the presence of either a perforation or a tympanostomy tube. Most of the Eustachian tubes studied showed varying degrees of obstruction or abnormal distensibility or both, often depending on the direction of flow, or on whether pressures were increased or reduced. Quite apart from other factors which may contribute to intrinsic oxextrinsic obstruction of the Eustachian tube, its compliance appears to play an important role in determining its function. In particular, compli. ance appears to be an important factor in the response of the Eustachian tube to increased positive or to negative pressures. Elimination of the causes of both nasal obstruction and abnormal nasopharyngeal secretions may alleviate problems in the function of the Eustachian tube which seem attributable to increased tubal compliance.

Symposium on basic ear research. II. Strial atrophy in clinical and experimental deafness

Abstract: The hair cells and the first-order neurons of the cochlear nerve are usually considered to be the primary targets of traumatic, ototoxic, and degenerative processes affecting the inner ear. The purpose of this paper is to show that several forms of sensori-neural deafness are associated with atrophy of the stria vascularis, and that strial atrophy often precedes and may indeed be an important cause of hair cell loss. Strial atrophy was found: 1. in presbycusis; 2. in hereditary deafness in Dalmatian dogs; 3. after noise exposure; and 4. after ototoxic drugs. The technique used was that of dissecting the cochlea, stained with Osd4, into surface preparations. Special attention was given to the spiral ligament and the-stria vascularis. In man, sensori-neural degeneration with aging was invariably associated with strial atrophy. There appeared to be a direct relation between severity of strial atrophy and hair cell loss. The findings in two old animals were similar to those in man. We found no cases with obvious strial atrophy and a normal hair cell population. Four litters of deaf Dalmatian dogs were studied. Two litters were from deaf parents and two were from a deaf bitch and a hearing male. Animals sacrificed at various ages displayed a series of changes involved in cochleosaccular degeneration. The following phases were observed: 1. strial atrophy; 2. a. sagging of Eeissner's membrane and onset of hair cell degeneration, b. collapse of Reissner's membrane, ductus reuniens, and the membranous wall of the saccule; 3. complete hair cell degeneration, involving first the outer hair cells, then the inner hair cells; and 4. nerve degeneration. The offspring of deaf parents showed bilateral degeneration, occurring mainly during the first two to three weeks postnatally. In the litter from a deaf female and a hearing male, several pups had complete cochleo-saccular degeneration on one side, with partial involvement on the opposite side. Four of these pups had strial atrophy in the middle and apical turns, and recent outer hair cell degeneration in the corresponding area. This finding suggests a close relation between strial atrophy and hair cell degeneration. The capillaries in the atrophic stria were narrow and had markedly thickened walls. Cats were given high doses of neomycin and ethacrynic acid. Guinea pigs were given gentamicin, also in high doses. All three drugs caused strial atrophy, which was most severe in the basal turn but was also pronounced in the apical turn in the neomycin and ethacrynic acid-treated animals. The neomycin- and gentamicin-treated animals showed severe to total hair cell degeneration, but ethacrynic acid-treated cats showed virtually no hair cell loss despite severe strial changes. With one exception the neomycin-treated animals had the most severe changes, with only an epithelium and network of empty, atrophic capillaries and strands remaining in the most affected areas. The stria of the ethacrynic acid-treated animals had a distinctive appearance, with swollen osmiophilic cells clumped around the capillaries and severe atrophy between the blood vessels. Twelve guinea pigs were exposed to a wide-band noise at 120 db SPL for eight, 30 and 110 hours. In one 110-hour animal and two 30-hour animals, ultrastructural changes were observed in the stria vascularis. The marginal cells displayed marked loss of cell processes and their nuclei were pyknotic. The basement membrane of the strial capillaries was thickened. Strial atrophy appears to be a common denominator in sensory degeneration. It is suggested that the atrophy alters the composition of the endolymph, and may thus cause hair cell degeneration; however, the temporal relationship between stria atrophy and hair cell loss is still to be ascertained.

The influence of ischemia upon the energy reserves of inner ear tissues

Abstract: Ischemic changes in the levels of glucose, glycogen, ATP and P-creatine are determined under “closed system” conditions in the organ of Corti, stria vascularis, ganglion spirale, cochlear nerve and vestibular sensory epithelia. From the resting levels of these compounds the total energy reserve in terms of equivalents of high energy phosphate, both preformed and potentially available from anaerobic glycolysis, is computed. The energy reserves are highest in the organ of Corti, intermediate in stria vascularis, spiral ganglion and vestibular structures, and lowest in the cochlear nerve. The rate of depletion of these energy reserves in ischemia is used as an indicator of the energy requirements of the respective tissues. The metabolic rate is by far the highest in the stria vascularis, intermediate in ganglion spirale and cochlear nerve and lowest in the organ of Corti and vestibular structures. There is no correlation between the total energy reserve and the initial energy use rates. The obtained data are compared with the dynamic patterns of the corresponding biopotentials and with pertinent results of enzymatic and respirometric studies; in addition, ischemic changes in glucose and lactate levels of perilymph are described.

Location of small cochlear lesions by phase contrast microscopy prior to thin sectioning.

Abstract: A new technique for the study of the inner ear is described. Cochleae are fixed, dehydrated and infiltrated with plastic while their bony walls are intact except for small holes at the third turn and near the round window. After the plastic polymerizes, the cochlear bone is removed so that half turns of cochlear duct can be separated from the modiolus. These specimens are re-embedded in a thin layer of plastic after trimming so that their basilar membrane sides lie close to the surface of the plastic layer. Using phase contrast microscopy, the entire organ of Corti is examined by focusing through the surface of the plastic and through the specimens from the basilar membrane up to the tectorial membrane. Segments of organ of Corti containing small lesions are divided in such a way that cross-sections of those areas for study by light and electron microscopy are obtained readily using an ultrotome.

Facial nerve neuroma.

Abstract: Facial nerve neuromas are uncommon, slow growing, and readily treatable when detected. Fourteen patients with facial nerve neuromas are reported here. These tumors can occur within any part of the intratemporal course of the facial nerve. Occurrence and progression of the symptoms depend on the site of origin of the tumor and are those of facial nerve paralysis, hearing loss, or vertigo; occasionally there may be no symptoms at all. Initial facial paralysis may recover leading to a mistaken diagnosis of Bell's palsy. All patients with facial paralysis should be seen by an otologist whose examination would include audiogram for pure tones and speech, positional and caloric vestibular examination and roentgenogram of the temporal bone. If the possibility of intracranial extension exists, a pre-operative myelogram of the posterior fossa should be made. Early diagnosis, prompt surgical removal, and graft or end to end anastomosis of the facial nerve would be the goal in the treatment of facial nerve neuromas.

Symposium on meniere's disease.: I. Meniere's disease: Results of a two and one‐half‐year study of etiology, natural history and results of treatment

Abstract: The results of a two and one-half year study of 120 patients with Meniere's disease has revealed multiple but specific etiology for 36 percent of the patients: 1. allergy, 14 percent; 2. congenital or acquired syphilis, seven percent; 3. adrenal pituitary insufficiency, six percent; 4. myxedema, three percent; 5. stenosis of the internal auditory canal, three percent; and 6. trauma, acoustic or physical, three percent. Emotional or psychiatric factors are not involved in etiology of this disease. The vestibular and cochlear aqueduct on both temporal bones of patients with Meniere's disease could not be visualized in a significantly greater number than a normal control group suggesting an anatomic predisposition to the development of Meniere's disease. Preliminary immunologic viral investigation suggests the possibility of viral etiology in the remaining group considered idiopathic. Medical treatment with vasodilators is effective in many cases. The endolymphatic subarachnoid shunt operation was the treatment of choice for patients unresponsive to medical treatment and it is effective in controlling symptoms in 62 percent of cases. It is hoped that this study will encourage other investigators to criticize and help intensify our efforts to solve the questions remaining about Meniere's disease.

Surgical treatment of squamous cell carcinoma of the base of the tongue.

Abstract: One hundred two patients with squamous cell carcinoma of the base of the tongue were treated by surgery. The grade of the tumor did not influence survival; however, survival was influenced by the stage of the disease and the operation selected. Operations that provided wider access decreased the incidence of local recurrence. Of the 102 patients, 23 percent required either total or partial laryngectomy. The survival curves of the 23 patients suggest that management of the larynx is a key factor in treating larger cancers. Overall, the five-year survival rate for the 102 patients was 42 percent. Surgery is the treatment of choice in squamous cell carcinoma of the base of the tongue.

The presence of melanocytes in the human larynx.

Abstract: During the study of serially sectioned cancerous and irradiated larynges, a unique case of extensive melanosis of the laryngeal mucosa was encountered. While pigmented neoplasms in the larynx had been reported repeatedly, to our knowledge the presence of melanocytes had not been demonstrated at that site; consequently, we initiated a study to ascertain whether melanocytes were present in the human larynx as an explanation for the histogenesis of these neoplasms. We adopted the technique of Epstein for stripping the laryngeal mucosa, and of Nigogosyan and coworkers for embedding and sectioning the ribbons of tissue. In an ongoing study, using non-selected adult larynges removed at autopsy, scattered foci of melanocytes were found in an appreciable number of Caucasian and Negro specimens. With the Masson-Fontana silver procedure for melanin, they appear as dendritic cells containing black granular pigment, situated in the basal layer of the squamous epithelium and subjacent connective tissue. While the origin of melanomas from pigment containing cells in the skin, eye and leptomeninges is well established, the histogenesis of those tumors arising in non-integumentary and extra-ocular sites remains obscure, because with few exceptions melanocytes have not been demonstrated in these organs. Melanocytes have been observed in the esophagus, oral cavity, vagina, and now larynx. Theories attempting to explain their presence at nonectodermal sites include the migration of melanoblasts with mesoderm to visceral sites, the transformation of neural crest elements into melanocytes and nevus cells, as well as the metaplasia of both squamous and glandular epithelium into pigment producing cells.

Cochlear microvasculature in normal and damaged ears

Abstract: The minute vessels of the cochlea were examined post mortem in normal guinea pigs and in others exposed to intense noise or treated with the ototoxic drugs gentamicin and quinine. The benzidine stain was used to display the capillary networks, and osmic acid for surface preparations, “thick” sections, and ultrathin sections for electron microscopic examination. The capillaries of the spiral ligament, i.e., the so-called arteriovenous anastomoses, do not show the characteristics of the muscular shunts described by Chambers and Zweifach. They are divided into two groups, the adstrial capillaries closely applied to the basal surface of the stria vascularis, and the poststrial capillaries which supply the tissue of the spiral ligament. Continuing beneath the floor of the external sulcus they form an alternating pattern with the root cells, and are surrounded by a specialized pericapillary tissue which resembles that found around the capillaries of the spiral prominence. These tissues are readily destroyed by gentamicin and other ototoxic aminoglycosidic antibiotics. Vasoconstriction of the outer and inner spiral vessels in response to noise and quinine appears to involve both contraction of pericytes and swelling of the endothelial cells. After prolonged exposure to noise or treatment with gentamicin, degeneration of capillaries with formation of intervascular strands and avascular channels is found in the suprastrial network of the spiral ligament. Similar capillary changes are seen in presbycusis, and in the deaf Dalmatian dog.

Presurgical internal maxillary artery embolization in juvenile angiofibroma.

Abstract: Embolization of the internal maxillary artery with barium impregnated silastic spheres was performed in four patients with juvenile angiofibroma of the nasopharynx. Three of the cases were done prior to the initial surgical resection to reduce operative hemorrhage. The fourth case was a postoperative recurrence, and embolization was performed to evaluate the clinical response of the tumor. The technical aspects of the procedure, the rationale for embolization and pertinent literature are reviewed.

Treatment of aberrant carotid arteries in the middle ear: a report of two cases.

Abstract: Two cases are described in which aberrant carotid arteries were encountered in the middle ear. The course of the arteries through the tympanum was from posterior to anterior at the level of the promontory. In both cases a bony defect was present in the promontory, below the cochlea. Pre-operative evaluation included carotid arteriograms and jugular venograms. Polytomograms of the middle ear showed the bony defect of the promontory. The technique of repair stressed maintenance of carotid blood flow. The arteries were covered by a temporalis fascia graft, then compressed into the promontory defect or canal with a bone graft obtained from the posterior wall of the ear canal. The bone graft was then covered by another fascia graft. Because carotid blood flow is not interrupted, danger of cerebrovascular accidents and neurologic sequelae are minimized in this operation. One patient has an unexplained neurosensory hearing loss, while the other has a mild conductive loss. They suffer no other ill effects and have returned to full function. Reference is made to possible anomalous development of the internal carotid artery.

Occult regional metastasis: carcinoma of the oral tongue.

Abstract: Review of charts of 158 patients with carcinoma of the oral tongue revealed 108 (68 percent) were clinically free of cervical metastasis upon presentation. Patients who were found to have microscopic metastases after elective neck dissection and patients who developed cervical metastases but never a local recurrence were said to have occult regional metastases. The incidence of occult metastases was 23 percent with no difference between T1, T2, and T3 lesions. Determinant survival rates of the T1N0M0 groups were 83 percent and 57 percent at two and five years respectively. Survival rates of the T1N0M0 patients who had occult metastases were comparable (82 percent and 50 percent respectively). Survival rates of patients with T2N0M0 and T3N0M0 lesions with occult metastases were lower than for all patients in each of the two groups. The incidence of local recurrence in these same 108 patients was 27 percent with the incidence highest in the T2N0M0 group (31 percent). Survival rates of these patients, especially of those who developed regional metastases, were lower in all three groups of patients. The combined use of pre-operative irradiation with cobalt 60 followed by en bloc resection of the primary tumor with the regional lymphatics has been very effective to date. The following conclusions are based on retrospective study of carcinoma of the oral tongue. 1 The incidence of occult regional metastasis is the same for T1 and T2 primary cancers of the oral tongue. 2 To date, combined therapy is resulting in higher survival rates in patients with larger oral tongue carcinomas. 3 To increase the probability of cure, elective treatment of regional lymphatics either by radical neck dissection or irradiation should be considered in the treatment of T1N0M0 epidermoid carcinoma of the oral tongue.

Complicated acute sinusitis

Abstract: The incidence of complications of paranasal sinusitis have been progressively decreasing since the advent of antibiotics. Most of the complications that have occurred are secondary to sub-acute or chronic sinusitis. A few patients, however, still present with a complication of an acute sinusitis infection. Four cases are presented in detail and 14 cases are summarized which presented with an acute complication as the primary presenting complaint. Sinusitis was not an obvious component in most of these cases, and none of the 18 patients had any previously known sinus disease. The paper was limited to a discussion of complications involving the orbit, the tissues surrounding the sinuses, and the intracranial cavity. Basic information regarding these topics was reviewed. The first case report described a young boy with cellulitis of the orbit and cheek secondary to a maxillary sinusitis. Neither the cellulitis nor the sinusitis responded to the medical treatment until trephine and irrigation of the sinus was performed. The second case report described a young man with a frontal subperiosteal abscess and orbital cellulitis secondary to frontal sinusitis. His treatment consisted of drainage of the abscess and performance of a frontal sinus trephine. The third case described a young man with maxillary, ethmoid and sphenoid sinusitis and a secondary cavernous sinus thrombosis. The maxillary sinuses were drained and the patient was given high doses of intravenous antibiotics and decongestants but he was not anticoagulated. Apart from the central retinal artery thrombosis resulting in the left eye, recovery was complete. The fourth case report described a young lady who had undergone a renal transplant and was maintained on immunosuppressant medications. She developed a meningitis secondary to maxillary sinusitis. Complete recovery occurred on medical treatment alone. The other 14 cases were summarized in a table. These cases were then discussed and recommendations were made regarding management of these complications. It was concluded that with antibiotics in adequate closes, it is now safe to perform a sinus trephine much earlier in the course of the disease than has previously been advocated. Eight of the 18 were drained in the acute phase and there was no evidence of osteomyelitis or other sequella secondary to this procedure. Indeed, six of these patients required surgical drainage before the fever or the complications would respond to therapy. It is suggested that immediate surgical drainage and irrigation is indicated when sinusitis does not respond or becomes clinically worse after 24-48 hours of treatment with systemic antibiotics and decongestants; or when acute suppurative local infection or septic intracranial complications are present. The sinuses should be irrigated frequently with saline until the return remains clear for 48 hours. The majority of the organisms isolated were staphylococci, coagulase negative and coagulase positive. Four cultures grew no organisms but since routine cultures for anaerobic organisms were not performed these could not be eliminated as a factor in the infection. The majority of cases were treated with high doses of intravenous antibiotics and these were only given intramuscularly 24 to 48 hours after the fever had subsided and the clinical symptoms were resolving. The total duration of antibiotic treatment varied considerably within this series. It is recommended that complicated acute sinusitis should be treated as though an osteomyelitis is actually present. The systemic antibiotics should be continued for a full week after fever disappears before changing to oral antibiotics. The total duration of antibiotic therapy should be for four to six weeks. In treating meningitis, high doses of broad spectrum antibiotics were used until culture sensitivities were available. Examination of cerebrospinal fluid was emphasized. On adequate treatment the C.S.F. sugar levels should rise above the initial values and no demonstrable micro-organism should be present after 24 hours. It was noted that intracranial abscesses can occur with minimal symptoms and that fever is not necessarily present. If any doubt exists an arteriogram or other investigations should be performed.

A comparative analysis of endotracheal intubation in neonates, children and adults: complications, prevention and treatment.

Abstract: The use of endotracheal tube to provide a prolonged airway and as an adjunct to artificial ventilation continues to be a controversial subject. With this controversy in mind, a six-year survey was undertaken in utilizing three private hospitals to evaluate the number of patients requiring prolonged endotracheal intubation, their incidence of complication, and particularly to record the diagnosis for which this form of artificial airway was required. At the same time, primary and secondary tracheostomies were evaluated as to mortality, morbidity, and complications. There were 205 premature and newborns evaluated, with 108 of these neonates requiring endotracheal intubation for 48 hours or longer. The average duration was five and one-half days. There were 26 survivors of 108 infants with one serious complication, or an incidence of 4 percent. The incidence of mortality and morbidity for tracheostomy in the neonate is much higher than that of endotracheal intubation and intubation should be the method of choice. Over 500 children requiring intensive care were evaluated. Of these, 64 cases required endotracheal intubation of 24 hours or longer with 43 survivors. There was one death with a mortality of 1.4 percent. In evaluating the diagnoses requiring endotracheal intubation, it is statistically significant that those patients other than post-surgical or medically clean had an incidence of complication of 23 percent. There were over 1,200 adult patients who required some form of artificial ventilation with 454 requiring endotracheal intubation of 24 hours duration or longer. The average duration was 61 hours. Immediate and minor complications, such as cord granulomas, lacerations, laryngeal edema, etc., were not included. There were 11 adult complications which could be classified as serious with stenotic changes of the larynx or trachea. This gives an overall incidence of complication of 2.4 percent with no mortality. These statistics are better than those for tracheostomy; however, the severely anoxic, toxic, or infected patient was the one which had a significant incidence of complications. The suicide patient had an incidence of 17.5 percent, patients with pulmonary infection 12.3 percent, and the stroke patient, 5.6 percent. A comparative study of tracheostomies continues to indicate that there is a higher incidence of mortality and early complications in tracheostomy than endotracheal intubation; however, both endotracheal intubation and secondary tracheostomies following prolonged intubation show a much higher incidence of delayed complications. Treatment should be one of prevention with the proper choice of tube and cuff, more than just adequate nursing care with definite proper follow-up of those patients who have had prolonged intubation. Frequent use of endoscopy and indirect laryngoscopy in these patients is mandatory for early treatment of delayed complications. Once these complications have manifested themselves, then treatment should follow the course as prescribed by the various authors finding success in the treatment of these lesions.

Chondrosarcomas of the facial region

Abstract: Less than 100 chondrosarcomas originating in the facial skeleton have been reported. Information regarding chondrosarcomas in the facial region is fragmentary. The largest series collected transcend a long period of time containing changes in surgical technique and philosophy. Precedence for therapy and prognostic information is not readily available. Three patients with facial chondrosarcomas are reported. All were diagnosed within a four-year time span. The aforementioned adequately depict the protean manifestations of this tumor and the aggressive therapy required. Correlation is made with the existing body of information regarding this entity.

Current concepts of frontal sinus surgery: an appraisal of the osteoplastic flap-fat obliteration operation.

Abstract: . The osteoplastic flap-fat obliteration operation has been utilized in a variety of clinical problems (osteomas, chronic infection, mucocele, extensive trauma) for the past eight years. The experience suggests that in carefully selected patients it is an effective operative procedure for the surgical control of these problems. Two failures, which were probably preventable, occurred in the 53 patients operated upon by this technique. Long term animal experiments and clinical experience support the merit of using fat as an obliterating material in the infected sinus. The only unfavorable long term result in otherwise successful patients has been the forehead embossment that has occurred over the frontal sinus osteoplastic flap area.

High dosage pre‐operative radiation and surgery for carcinoma of the larynx and laryngopharynx — a 14‐year program.

Abstract: A carefully planned clinical program of combined pre-operative radiation and surgery has been conducted by the Department of Otolaryngology at The Mount Sinai Hospital for the past 14 years in an effort to improve the survival rates for advanced cancer of the larynx and laryngopharynx. The Combined Therapy Program, introduced in 1958, encompassed three separate but interdependent phases. The first stage consisted of a strict protocol of 5,500 rads of Cobalt 60 teletherapy administered over a five to six-week period. The second stage involved a rest period of three to six weeks to allow for proper healing of radiation reactions. The third stage comprised the radical procedure which included a wide field laryn-gectomy, ipsilateral hemithyroidectomy and radical neck dissection. Whenever indicated, a contralateral neck dissection was performed as soon as feasible. The protocol described above was applied only to those patients who fit all the criteria that categorized them as having advanced cancer of the larynx and laryngopharynx. In this study all patients had a biopsy proven diagnosis of squamous cell carcinoma. A very careful statistical analysis has been made of the survival experience of this series of cases. The three and five-year survival rates have been computed by the actuarial method,1 which when compared to the direct method, adds more reliability to the results. The direct method removes those cases not treated at least three and five years ago in computing three and five-year survival rates, while the actuarial procedure includes all cases in the computation of survival rates. Between November, 1958, and March 1, 1972, 64 patients had been treated by combined therapy. According to the American Classification2 the 64 cases are composed of 20 Stage II (T2N0 excluded), 12 Stage III and 32 Stage IV cases. According to the actuarial method the absolute survival rates for all cases were 77 percent and 59 percent for three and five years respectively. The corresponding determinate rates were 88 percent and 86 percent. Analyzing the results according to stages, the three-year determinate rates ranged from 100 percent for Stage II to 79 percent for Stage IV. The corresponding absolute rates ranged from 89 percent to 70 percent. The five-year determinate rates ranged from 100 percent to 74 percent, while the absolute five-year survival rates ranged from 50 percent for Stage II to 66 percent for Stage IV. This apparent reversal is far from being statistically significant because of considerable sampling error. The complications seen in patients treated with combined therapy have been essentially the same as those patients who undergo radical surgery without pre-operative radiation. Several preventive measures have been utilized during surgery, and it is to be emphasized that there have been no deaths related to complications, and all patients ultimately healed completely. The important controversy which exists in the- combined method of therapy concerns the question of using low dosage pre-operative radiation in the order of 1,000 to 3,000 rads or high dosages of radiation. It is our contention that serial section studies of biopsied laryngeal specimens labelled with tritiated thymidine tend to disprove the claims made favoring the value of low dosage radiation. The in vitro tritiated thymidine studies demonstrated that active DNA synthesis was observed in cancer cells in an appreciable number following dosages of 3,500 and also 5,500 rads.3 A further significant factor to be considered, we believe, is the effect of high dose pre-operative radiation on the incidence of cervical recurrence. In this series, 44 patients had clinically palpable nodes pre-operatively. There were six patients who developed local cervical recurrence, a rate of 14 percent. In conclusion, our statistics seem to indicate that our combined method of therapy has improved the survival rates of patients with advanced cancer of the larynx and laryngopharynx.

Osteoplastic obliteration of the frontal sinuses. A review of 100 patients.

Abstract: One hundred consecutive osteoplastic frontal sinus operations were reviewed. The obliteration of the frontal sinus was achieved by natural bony obliteration instead of by operative fat obliteration. The operation was performed for 6 cases of trauma, 13 cases for an osteoma, 56 cases for frontal sinusitis without previous frontal sinus surgery and 25 cases for frontal sinusitis with previous frontal sinus surgery. Headaches were the presenting chief complaint of all cases, and 93 of them had some degree of frontal sinusitis. Localized osteomyelitis of the frontal sinus was present in 42 cases. Although 85 patients were completely satisfied with the results of the operation, 15 continued to have frontal headaches. Complete bony obliteration of the frontal sinus occurred in 93 cases. The seven patients who had incomplete bony obliteration of the frontal sinus are being followed closely for signs and symptoms of recurrent frontal sinus disease.

The presbycusis component in occupational hearing loss

Abstract: In the evaluation of suspected occupational hearing losses, an expanding part of current otologic practice, the otologist is expected to differentiate noise sequelae from other types of ear pathology and to estimate the extent to which each abnormality contributes to the total hearing disability. The audiometric identification of acoustic trauma is possible only in early cases. When the noise effects are more advanced and when they are combined with aging, the pure tone curves are nonspecific. The standard battery of audiologic tests does not help in the quantitative separation of acoustic trauma from presbycusis. Most authorities consider that when acoustic trauma and presbycusis are concomitant, the effects of each are independent and that the influences of each upon auditory acuity are simply additive. There are significant individual differences in susceptibility to acoustic trauma and in the degree of hearing deterioration which occurs with aging. While it is not yet possible to make retrospective determinations of these variances, it is feasible to make age corrections of noise-induced hypoacusis if one averages acoustic vulnerability and aging effects. Such averaging results in some inequalities in individual cases, but the validity of this approach in large numbers of cases is justifiable because of the absence of alternatives. The authors have modified the prebycusic data of Spoor (which combine several important hearing surveys conducted in the United States and in western Europe) by changing the calibration from ASA-1954 to ANSI-1969 and have prepared curves which demonstrate mean aggregate hearing levels at specified frequencies according to age and sex. Two formulae for age correction are presented along with examples of each formula and the authors' evaluation.

Acoustic neuroma: Primary arising in the vestibule

Abstract: As more information on acoustic tumors is accumulated, it is apparent that the lesions may have several sites of origin. A case of an acoustic tumor arising primarily in the vestibule is presented. This case, which has been followed for seven years, supports the proposed theory that the tumor may develop from the nerves to either the saccule or the utricle.

Symposium on prophylaxis and treatment of middle ear effusions.: I. The morphological basis for understanding middle ear effusions.: An electron microscopic, cytochemical, and autoradiographic investigation†‡§

Abstract: An attempt was made to elucidate the cytological nature of the defense mechanisms of the normal middle ear with special emphasis on the secretory system. Autoradiography was performed with the use of isotope-labeled glucose in order to determine the rate of glucose uptake by middle ear cells, particularly by secretory cells. Mucus-secreting glands in the guinea pig eustachian tube incorporated a large amount of glucose, while the demilune cells (serous) incorporated only a moderate amount. Some simple squamous epithelium of the bulla also took up a large amount of glucose. Since the mucous blanket of the bulla was labeled after only one hour, it is speculated that these flat cells are of the secretory type. A cytochemical demonstration of the enzyme acid phosphatase was done in order to determine the localization of this lysosomal enzyme in the middle ear cells. A strong reaction was consistently noted in the cytoplasm of both light (mucous) and dark (serous) secretory cells. This reaction appears to take place on the outer surface of the secretory granules, but, occasionally, it takes place inside the granules. The strongest reaction was noted in the lysosomal bodies. A weak reaction was frequently noted in the nuclear chromatin of the secretory cells. An immunofluorescent study demonstrated the presence of immunoglobulin-producing cells in the eustachian tube and in the guinea pig middle ear mucosa. Fluorescein-labeled cells (round cells) were numerous, particularly in the eustachian tube near the glands. It can be suggested from the foregoing that the middle ear is provided with mucociliary, enzymatic, and immunological (secretory and serum) defense systems. The pathological characteristics of human serous otitis were also reviewed. Evidence was shown of an increase in the number of secretory and ciliated cells, of free macrophages, and of the round cells of the submucosal connective tissue. Evidence of the free escape of transudate through intercellular spaces of the epithelial cells and capillary wall damage in the submucosal layer was also noted in pure serous effusion cases. These changes are identical to those that take place in inflammatory reactions. The middle ear effusion, therefore, can be looked upon as the result of enhanced middle ear defense mechanisms occurring in different phases.

The superior laryngeal nerve and the interarytenoid muscle in humans: an anatomical study.

Abstract: The course and distribution of the rami perforantes of the superior laryngeal nerve was studied in 12 human larynges. Dissections utilized a Zeiss operating microscope. All branches were found to perforate the muscle; none terminated in the muscle. This eliminates anatomically any possibility of motor supply to the mterarytenoid muscle from the superior laryngeal nerve. The rami perforantes also contribute to mucosal innervation on the posterior surface of the larynx. Histologic studies of whole fetal larynges corroborated the findings from the dissections. No evidence of innervation across the midline was found. No extra-laryngeal division of the recurrent laryngeal nerve into abductor and adductor branches was found. A ganglion around the superior laryngeal nerve was described.

Traumatic perforations of the tympanic membrane: Observe or repair?†

Abstract: Traumatic perforations of the tympanic membrane deserve the same careful attention as any other injury, and healing should not invariably be left to chance. Sometimes early repair is clearly indicated. A foreign object rupturing the posterosuperior quadrant may cause obscure damage to the ossicular chain, a perilymphatic leak, or leave an unsuspected foreign body in the middle ear. All very large traumatic perforations and all perforations in the posterosuperior quadrant should be repaired promptly to reduce the incidence of permanent impairment. Small perforations in less vulnerable quadrants can be treated in the traditional expectant manner. Steroid-containing ear drops inhibit healing and are contraindicated in the-treatment of traumatic perforations.