Many institutions require that tracheotomies be performed in the operating room. Movement of critically ill patients dependent on multiple life support systems is technically difficult, labor intensive, and potentially dangerous for the patients. Between 1983 and 1992, 1088 tracheotomies were performed on patients ages 1 week to 94 years at the University of Rochester affiliated hospitals on critically ill patients as isolated procedures. The procedure was performed in the Intensive Care Units (ICU) on 996 patients, (92.9%), whereas 92 patients (7.1%) had tracheotomies in the operating room (OR1). An additional 346 tracheotomies took place in the operating room in conjunction with other head and neck procedures (OR2). Incidence of perioperative bleeding (within 48 hours) was 2.3% in the ICU group, 2.1% in the ORI group, and 2.0% in the OR2 group. Incidence of stomal infection was also similar among the three groups at 1.8%, 2.1%, and 1.5%, respectively. Tube dislodgement in all groups was a complication. No statistical differences were noted among the three groups (ICU, OR1, OR2) at the p < 0.01 level. Criteria for performing the tracheotomy in the ICU are delineated and discussed.
Fifty-four of 103 malignancies of the paranasal sinuses treated at the Cleveland Clinic Foundation between 1977 and 1986 were squamous cell carcinomas. Six arose from the ethmoid sinus and 48 from the maxillary sinus. Of the maxillary sinus patients, 11 presented with T1 or T2 lesions, 20 with T3, 16 with T4, and 7 of these had nodal disease. Treatment was surgery and/or radiation therapy. There was local recurrence in 25 of 48 maxillary sinus patients and in 1 of 6 ethmoid patients. Overall 5-year survival was 38.2% in the maxillary sinus group: T1, 100.0%; T2, 85.7%; T3, 31.8%; and T4, 6.7%. Three of six patients with ethmoid tumors were cured. There was a statistical trend for better prognosis in those patients presenting with ethmoid primaries, with early lesions, treated with both radiation and surgery, and with history of inverting papilloma. There were complications of treatment in 10 patients, four of which resulted in death. Local control was the major problem for these patients; therefore, early detection and aggressive local treatment are desirable.
\s=b\A previous report reviewed the technique and indications for near-total laryngectomy with epiglottic reconstruction in the management of squamous cell carcinoma of the glottis. This approach permits removal of most of both vocal folds, with immediate reconstruction using the epiglottis without the need for stenting or multistage procedures. Forty-eight patients underwent the procedure and were followed up for at least 2 years or until death. Seventeen underwent the surgery for recurrence after failure of radiation therapy for cure. Complications included one wound infection and one laryngocutaneous fistula. All patients underwent decannulation, with little or no compromise of swallowing. All but 1 now have functional voices. Of 8 patients with recurrence, 6 have been salvaged. Two patients died of disease. The value of near-total laryngectomy with epiglottic reconstruction for management of glottic cancer is reviewed.In the past, squamous cell carcinoma involving both true vocal folds was frequently managed by total lar¬ yngectomy either as the primary mode of therapy or for recurrence after failed radiation therapy. Verti¬ cal partial laryngectomy (hemilaryngectomy) can result in satisfactory cure rates for glottic carcinomas12 limited essentially to one vocal cord. However, when extended vertical par¬ tial laryngectomy is performed for more extensive tumor, inadequate air¬ way can result in permanent tracheostomy, and multistaged reconstruc¬ tion is often necessary. The 2-year survival rate may be as low as 60% for such procedures.34Tucker et al5 described near-total laryngectomy with epiglottic recon¬ struction as a single-stage procedure for managing squamous cell carcino¬ ma involving both true vocal folds, either as the initial treatment, in a planned combination with radiothera¬ py, or as a salvage procedure after radiation therapy failure in carefully selected cases.This article is an analysis of the initial results and long-term followup of 48 patients who underwent neartotal laryngectomy with epiglottic reconstruction. PATIENTS AND METHODSAll patients admitted to the Department of Otolaryngology and Communicative Disorders, Cleveland (Ohio) Clinic Founda¬ tion, who underwent near-total laryngec¬ tomy with epiglottic reconstruction for squamous cell carcinoma and who had at least 2 years of follow-up or who died within the first 2 years of treatment were included in this study. Criteria previously estab¬ lished for this procedure5 are listed in Table 1, although selected patients with T3 le¬ sions or more than 1.0 cm of subglottic ex¬ tension were also included. Patients whose disease was classified as T3 because of ap¬ parent fixation of the vocal fold but who were found not to have direct invasion of cartilage on exploration of the larynx were considered amenable to near-total laryn¬ gectomy with epiglottic reconstruction, providing (1) that the cricoarytenoid joint was not involved and (2) that there was no extension of disease through the cartilage to the external perichondrium.Of the 48 patien...
Most attempts at laryngeal reconstruction have sought to reestablish skeletal support. Bone and cartilage grafts have been used for this purpose, but they have often failed to maintain position in the larynx and/or trachea following reconstruction, and they tend to be reabsorbed. The rotary door flap can provide an undelayed, one-stage epithelial resurfacing of the larynx and trachea while simultaneously restoring luminal support without the need for transfer of cartilage or bone. Luminal support for the trachea is provided by the bulk, turgor, and anterior traction of the intact sternohyoid muscle, which serves as the carrier for the rotated skin island. During inspiration the intact muscle, whose points of attachment are anterior to the plane of the larynx and trachea, contracts and tends to open the airway to provide dynamic luminal support. The need for internal stenting is minimized. The technique is described and experience in 20 patients is presented.
Five patients suffering from recurrent syncope in association with metastatic squamous cell carcinoma of the head and neck were examined. Two patients had exhaustive diagnostic work-up for syncope, which eventually disclosed previously undiagnosed, recurrent squamous cell carcinoma. Case reports describe glossopharyngeal neuralgia, a well recognized cause of syncope in the head and neck cancer patient, characterized by acute unilateral head or neck pain preceding each syncopal episode. The literature on the diagnosis of syncope is reviewed, and the syncopal mechanisms unique to the head and neck cancer patient are analyzed and discussed. A diagnostic approach to syncope in head and neck cancer is proposed.
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