Intracerebral hematoma complicating split calvarial bone-graft harvesting

ABSTRACTS from postpolio syndrome (defined as a new weakness in the limbs) were examined for oropharyngeal dysfunction. Of the 32 patients, 14 had new swallowing difficulties and 18 were asymptomatic. Twelve had a previous history of bulbar involvement during the acute polio attack. Swallowing function was objectively assessed by videofluoroscopy. The authors found that all but one of the 32 patients, regardless of whether they had new symptoms or previous bulbar involvement, had some objective abnormality of oropharyngeal function. Only two patients had aspiration. Videofluoroscopy showed abnormalities of varying severity,including bolus transport, pooling in the pyriform sinuses, and delayed pharyngeal constriction. Four patients who were re-examined 2 years later had objective signs of worsening oropharyngeal function with no corresponding symptoms. This article emphasizes the need for careful history taking in patients with a new onset of dysphagia, particularly since polio may have occurred in prior years with no other signs or symptoms. Objective assessment of swallowing dysfunction is also necessary to document progression or stabilization of disease. Symptomatic patients may be treated by modifications in swallowing position, changes in diet, or other compensatory techniques. This is an interesting article that warrants attention by anyone caring for patients with dysphagia.

Induction Chemotherapy Plus Radiation Compared with Surgery Plus Radiation in Patients with Advanced Laryngeal Cancer. The Department of Veterans Affairs Laryngeal Cancer Study Group. N Engl J Med 1991; 324:1685-1690 This article is a report of a prospective randomized study in patients with previously untreated advanced laryngeal squamous cell carcinoma. It was performed to compare the results of induction chemotherapy followed by radiation therapy compared with conventional laryngectomy and postoperative radiation therapy. Three hundred thirty-two patients were randomly assigned to receive three doses of chemotherapy (cisplatin and fluorouracil) and radiation therapy or surgery and radiation therapy. Clinical tumor response was assessed after two cycles of chemotherapy, and patients with a response received a third cycle followed by definitive radiation therapy. Patients in whom no tumor response was seen or who had locally recurrent cancers after chemotherapy and radiation therapy underwent laryngectomy. After two cycles of chemotherapy tumor response was complete in 31% of the patients and partial in 54%. After follow-up period of 33 months, the estimated Z-year survival rate was 68% for both treatment groups. Patterns of recurrence differed significantly between the two groups with more local recurrences and fewer distant metastases seen in the chemotherapy group. Thirty-six percent of the patients in the chemotherapy group required total laryngectomy. The larynx was preserved in 64% patients overall, and 64% of patients were alive and free of disease. This is a startling and extremely interesting article. A major finding is that the larynx could be successfully preserved in 64% of the patients with locally advanced

243 disease who were randomly assigned to receive induction chemotherapy combined with radiation therapy. This was achieved without reducing the estimated X-year survival rate compared with the survival rate obtained with conventional treatment of laryngectomy followed by postoperative radiation therapy. No significant differences in duration of survival were detected between the two treatment groups. This new approach requires a high level of skill incorporating various disciplines. Adequate compliance and careful documentation of tumor extent is necessary. This is a preliminary report, but it suggests that chemotherapy may play a role in advanced laryngeal cancer for organ preservation.

Intracerebral Hematoma Complicating Split Calvarial Bone-Graft Harvesting. VL Young, RH Schuster, LW Harris. Plast Reconstr Surg 1990; 86:763-765 Split calvaria bone grafts are safe, reliable, and good material for facial reconstructions. The usual donor site complications include hematoma and seroma. Rare problems include dural tears and intracerebral hemorrhage, yielding a 1% incidence of serious complications. This is an interesting case report documenting an unusual complication in a patient who required cranial bone graft. Successful elevation of the cranial bone graft was performed in standard fashion and was described as being atraumatic. At the end, the inner table was intact. On awakening, the patient had a clear mental status, but was not using her right arm or leg. A computed tomography scan of the head showed a sizeable left hemispheric intracerebral contusion with hematoma in the region of the bone graft. The patient showed significant improvement over several hours without neurosurgical intervention. It is possible that energy transmitted from the bone-harvesting process may have caused vascular disruption. This mechanism of injury is analogous to that which may be seen in tangential injuries due to high-velocity missiles. Cushing termed such injuries “gutter wounds,” noting that glancing and nonpenetrating blows to the cranium could produce neurologic injury without skull fractures. This is an important case report of a potentially devastating complication of cranial bone grafts.

The Use of Periosteal Flaps in Scalp and Forehead Reconstruction. W Terranova. Ann Plast Surg 1990; 25:450-456 Scalp and forehead defects following tumor excision or trauma may produce exposed bone. Small defects can easily be handled by rotational flaps. Since 1983, scattered case reports have surfaced proposing the use of periosteal flaps in scalp reconstruction. This is a report of a series of eight patients who suffered small to moderate-sized scalp defects with bone exposed and reconstructed using flaps of periosteum alone covered by skin grafts. Most of the flaps were based anteriorly or anterolaterally. Flaps ranged in size from 7 x 4 to 12 x 7 cm. Periosteal flaps were raised and transposed to cover exposed bone and split-thickness skin grafts were