Dermatofibrosarcoma protuberans

OtolaryngologyHead and Neck Surgery

Scientific Posters P221

Volume 121 N u m b e r 2

TMJ are rare but represent a challenging diagnostic problem. They are notable for their atypical and misleading presentations that usually mimic much more common disorders. Patients with 3 months or more of recalcitrant TMJ swelling or pain require radiographic imaging to rule out these rare neoplasms. This may lead to earlier intervention and improved outcome.

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A Simulation Study of Vocal Tract in Laryngectomy SOO-GEUN WANG MD PHD; EUI-KYUNG GOH MD PHD; KYONG-MYONG CHON MD PHD; CHANG-SU KIM MD; Pusan South Korea

Objectives: The rehabilitation of voice after total laryngectomy has been suggested through the correct estimation and simulation of patients' vocal tracts. Methods: We studied the shape of the vocal tract during the phonation of 5 Korean vowels /u, o, a, e, i/ in tracheoesophageal shunt patients by MRI. The same vocal tract was determined in each vowel from MRI. First, speech data produced by them were analyzed and also checked for speech intelligibility. Then we tried to synthesize vowels from the vocal tract area of each vowel and from the expanded pharyngeal section of the vocal tract. Results: (1) The sounds of/a/,/e/, a n d / i / w e r e similar to natural sounds in the speech of actual patients. The sound of /o/was heard as/3/. The sound o f / u / w a s heard as a strained /u/. (2) The synthesized vowels o f / a / a n d / e / f r o m MRI were heard as natural sounds. The sounds of/u/,/o/, a n d / i / w e r e heard as other sounds. (3) The synthesized vowel by the expanded pharyngeal section of 3 times in vowel/o/was more naturally heard than that of 2 times. The synthesized vowel from Formfrek was more naturally heard than that from AreatoFormant. Conclusion: Some of the synthesized sounds from MRI disagree with the actual sounds produced by the subjects. This could be best identified by the synthesis from the area data. Future MRI studies should consider this problem for more accurate measurements. Also, pharyngeal areas with varied sizes should be experimented with to secure better speech output because the correct shapes of the vocal tract ensure correct vowel pronunciation. 62

Improvement of Operative Efficiency in Endoscopic Sinus Surgery ERICA R THALER MD; ANDREW N GOLDBERG MD; DONALD C LANZA MD; DAVID W KENNEDYMD; Philadelphia PA

Objectives: The introduction of clinical "pathways" or preset allocation of human and material resources with structured time and resource utilization targets has been recognized by

many in the health care industry to be a means of improving operative efficiency. This study evaluates change in operative efficiency in terms of case length as well as labor and material cost through use of an operative pathway for endoscopic sinus surgery (FESS). Methods: One hundred twenty-one patients who underwent FESS were entered in a clinical pathway designed to improve operative efficiency. Data about case length, labor cost, and material cost were collected for each case and compared with historic data. Cases were categorized as bilateral FESS (BFESS), unilateral FESS (UFESS), and bilateral FESS with septoplasty (BFESS/S). Results: In all 3 categories, case length was shortened (BFESS by 20%, UFESS by 5%, BFESS/S by 24%). Labor cost was reduced in each category (BFESS by 18%, UFESS by 10%, BFESS/S by 22%), Materials cost was also reduced in each category (BFESS by 6%, UFESS by 7%, BFESS/S by 20%). Conclusion: The introduction of an operative pathway for FESS, in a teaching hospital, resulted in significant improvement in efficiency through reduction in case length, as well as labor and materials cost reduction. It would appear that similar savings should be possible in other settings.

63 Dermatoflbrasarcoma Pratuberans DANIEL J HALL MD; RICK D G R O S S MD; J O N A T H A N PONTELL MD; Honolulu HI; Kailua HI; TriplerArmy M e d Ctr HI

Objectives: Dermatofibrosarcoma protuberans (DFSP) is an unusual, easily misdiagnosed tumor of the head and neck. Local recurrences can lead to extensive local disease and distant metastases, causing significant morbidity. Our objective is to review the pathology and treatment of DFSP utilizing serial photographs in a case report format. Methods: Through pictorial case-study format, we present a case of recurrent scalp DFSP treated by Mohs' micrographic surgery (MMS) and reconstruction using tissue expanders. This tumor had been previously misdiagnosed and excised 3 times prior to referral. Results: Recent dermatology literature presents convincing evidence that DFSP is best treated with MMS, while the otolaryngology literature advocates wide local excision of DFSP. Our case study illustrates the MMS technique for treatment of DFSP, as well as serial photographs of the staged reconstruction of the resultant scalp defect using tissue expanders. Conclusion: DFSPs grow in an asymmetric fashion, with pseudopod-like microscopic extensions, and have a high rate of local recurrence when treated with wide local excision. Despite growing evidence of the efficacy of MMS in control of disease, the otolaryngology literature lags behind the dermatology literature in the advocacy of MMS as the preferred treatment modality. Through this case study, the diagnosis,

P222

OtolaryngologyHead and Neck Surgery August 1999

Scientific Posters

pathology, and treatment of DFSP is presented with the use of intraoperative, postoperative, and serial reconstruction photographs. Special emphasis is made on the role of MMS and the use of tissue expanders in reconstruction of the hair-bearing scalp. 64

Frontal Sinus Obliteration with the Pericranial Flap

bilateral vestibular aplasia who showed a transient geotropic DCPN with normal cochlear development. We used routine audiometry, electronystagmography, and radiologic evaluation. Results: In electronystagmography, we noted directionchanging positional nystagmus. We also noted congenital vestibular aplasia on CT. Other tests showed normal results. Conclusion: The authors report that congenital vestibular aplasia can be one cause of DCPN and report its possible mechanism.

AFSHIN PARHISCAR MD; GADY HAR-EL MD; Brooklyn NY; Fresh Meadows NY

Objectives: To introduce the technique of obliteration of the frontal sinus with the pericranial flap and to review our experience. Methods: The records of 10 patients who underwent frontal sinus obliteration with the pericranial flap were reviewed. Demographics, indications for frontal sinus obliteration, frontal sinus size, pericranial flap size, immediate and late complications, and long-term outcome were recorded. These results were then compared with those published in the current literature. Results: Ten sinuses were obliterated by the pericranial flap. Indications included frontal sinus mucoceles, mucopyoceles, frontal sinus osteomyelitis, and frontal sinus fractures. The mean sinus size was 10.7 cm3, the mean pericranial flap size was 24.8 cm2, and the median follow up was 3 years. There was 1 short-term complication of persistent headaches for 1 month. There was asymptomatic recurrence of a "netfrontal" sinus in 1 case. Conclusions: Frontal sinus obliteration with the pericranial flap is an effective alternative to other available options. The pericranial flap is a vascularized flap that is easily harvested. The use of the pericranial flap prevents donor site morbidities associated with free fat or cancellous bone grafts. The pericranial flap works best in smaller sinuses. 65

Congenital Vestibular Aplasia with Direction-Changing Positional Nystagmus WOON KYO CHUNG MD; JUNG PYOE HONG MD; Seoul South Korea

Objectives: Direction-changing positional nystagmus (DCPN) is defined as nystagmus that changes its direction with change in head and body positions. In the past, DCPN has been believed to be the sign of a central vestibular system lesion. But recently there have been some reports that the existence of DCPN does not always indicate the site of lesion to be in the central vestibular pathway; more often it indicates a peripheral vestibular lesion site. Until now, congenital vestibular aplasia has not been reported to be a cause of DCPN. Methods: Recently, we treated a 17-year-old patient with

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Surgery in Advanced Oral Cavity Carcinoma after Chemotherapy CHING-YI YIU MD; HUI-CHEN HSU MD; CHEN-YI HSU MD; JINCHING LIN MD; Taichung Taiwan (Republic of China)

Objectives: Combination therapy has been proved to be a standard treatment for advanced, unresectable oral cavity carcinomas. Induction chemotherapy with several combined drugs followed by radical surgery seems to achieve excellent results. Using the disease-free interval and 5-year survival rate, this study retrospectively evaluates the role of radical surgery in advanced oral cavity carcinoma after induction chemotherapy. Methods: Thirty-five advanced oral cavity carcinoma patients who received induction chemotherapy with CDDP 25 mg/m2, 5-FU 1000 mg/m2, bleomycin 10 mg/m2, methotrexate 30 mg/m2, and epirubicin 30 mg/m2 alternately biweekly. Radical surgery as previously planned was given 2 weeks later after induction chemotherapy was completed. The diseasefree interval and 5-year survival rate were calculated by the Kaplan-Meier method. Results: In the complete response group after induction chemotherapy, the median disease-free interval was 60 months, and the 5-year survival rate was 88%. However, in the partial response group, the median disease-free interval was 11 months, and the 5-year survival rate was 56%. Conclusion: Radical surgery still plays a role in advanced, unresectable oral cavity carcinoma patients after induction chemotherapy. If a complete response is achieved after chemotherapy, the disease-free interval and 5-year survival rate will be significantly better than if a partial response is achieved. 67

Acinic Cell Carcinoma of the Nasal Septum MICHAEL E JASIN MD; ROBERT HUTCHUNSON MD; Tampa FL

Objectives: Acinic cell carcinoma is a neoplasm uncommonly found in the minor salivary glands. Presented is the first report of a case of aciuic cell carcinoma arising from the nasal septum. Methods: This is a report of a 44-year-old white woman