Frontal sinus infections can spread to the intracranial space so fast that the clinical situation often becomes far advanced before a complication is recognized. Retrograde septic thrombophlebitis is the most common pathway of extension. A review of recent experiences with fulminating frontal sinusitis and its intracranial complications such as subdural empyema, brain abscess, epidural abscess, and meningitis is presented. Neurologic features of intracranial invasion are interpreted. Good results have been achieved by immediate and aggressive surgical and medical measures.

Between January 1957 and June 1974, 173 patients with carcinoma of the supraglottic larynx were treated by an integrated approach at the University of California in San Francisco. The policy was to use radiotherapy or surgery alone for Stage I and II disease, radiotherapy combined with either supraglottic laryngectomy or total laryngectomy for resectable Stage III and IV disease, and radiotherapy alone for advanced unresectable disease. Control of the disease in the primary site was achieved in 92% of T1a, 88% of T1b, 80% of T2, 79% of T3 and 56% of T4 lesions. Of the 36 patients with late Stage I and resectable Stages III and IV disease treated by combined preoperative radiotherapy and supraglottic or total laryngectomy, the primary lesion was controlled in 33 (92%). Recurrent disease in the primary site after radiotherapy alone, when detected early, was usually controlled by subsequent surgery, whereas recurrent disease after surgery was not controlled by radiotherapy. Preservation of a functioning vocal apparatus was achieved in 44% of the patients whose primary lesion was controlled. Control of cervical lymph node metastasis was achieved in 71% of N1, 38% of N2, and 25% of N3 disease. No disease recurred in the radically dissected neck which received preoperative radiotherapy. Radiotherapy also reduced the incidence of subsequent neck disease in patients without cervical lymph node metastasis initially from 23% to 14%.

The management of large juvenile nasopharyngeal angiofibromas with intracranial extension is controversial. We review our experience since 1980 with eighteen patients with juvenile nasopharyngeal angiofibroma. A diagnostic and treatment approach consisting of preoperative magnetic resonance imaging, embolization of feeding branches from the external carotid artery, and attempted complete resection was used in seven patients with intracranial disease since 1987. Serial magnetic resonance images were used for followup. Intracranial disease that was persistent or recurrent and demonstrated subsequent growth was irradiated (35 to 45 cGy). Extracranial tumor recurrences were reexcised. We advocate this approach as a safe and effective alternative to primary irradiation and its sequelae.

Seventeen patients with advanced or recurrent salivary gland cancer were treated with cisplatin, doxorubicin, and 5-fluorouracil combination chemotherapy (PAF). Two patients achieved a complete response and four patients achieved a partial response, for an overall response rate of 35%. Six of the nine patients who received PAF in the neoadjuvant setting did not respond and proceeded to surgery and/or radiation therapy. No difference in response rate was found between those patients treated for recurrent disease v those treated with neoadjuvant chemotherapy. All three patients with adenocarcinoma responded. The response duration in patients with metastatic or recurrent disease ranged from 6 to 15 months. The PAF regimen was delivered primarily in the outpatient setting and was associated with acceptable toxicity. PAF demonstrates activity in salivary gland malignancies, and further evaluation of this combination seems warranted.

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