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Positron emission tomography in a patient with multiple paragangliomas of the head and neck
Otolaryngology Head and Neck Surgery Volume 115 Number 2
derwent TMERS emphasized that they were totally free from running ear discharge. Otolaryngologists may consider this surgical procedure as one of the best choice for patients with postoperative cavity problems. 44 The Effect of the $tom-Vent 2 "Artificial Nose" Prosthesis In Laryngectomy Patients JOHN D, GOLDENBERG, MD, BARRYL. WENIG, MD, MPH, and LOUISG. PORTUGAL, MD, Chicago, III.
The negative impact of a total laryngectomy to the quality of life of larynx cancer patients is well known to the head and neck surgeon. These include loss of voice, a permanent cervical stoma, and loss of the humidification process normally provided by the nose and paranasal sinuses. Heat and moisture exchange devices have been devised to compensate for this and serve as an "artificial nose" for the laryngectomized patient. This study sought to determine the effect of the Stom-Vent 2 prosthesis in a cohort of laryngectomy patients. The inclusion criteria was as follows: 3 or more months postoperative; no local wound complications such as a pharyngocutaneous fistula, severe radiation dermatitis, or requirement for a laryngectomy tube secondary to stomal narrowing; and an ability to understand and follow through with the requirements of the trial. After complete medical and surgical histories were obtained, each patient completed a questionnaire before and after the trial relative to general health issues, respiratory information, and communication status. The patients were also objectively evaluated in the tumor clinic throughout the 6-week trial to ensure study compliance. We found a significant portion of our study population embraced the "artificial nose" prosthesis and reported subjective improvement relative to tracheal secretions and overall comfort. Furthermore, patients utilizing a tracheoesophageal prosthesis for voice rehabilitation did not experience difficulties using both devices concurrently. We conclude that the Stom-Vent 2 prosthesis can have a beneficial effect on the quality of life of laryngectomy patients. 45 The Endoscopic Approach for Juvenile Angloflbromas WOLFGANG LUXENBERGER, MD, HEINZ STAMMBERGER, MD, KLAUS GREISTORFER,MD, and WOLFGANG ANDERHUBER, MD, Graz, Austria
Objective: In recent years a number of advanced applications for endoscopic sinus surgery were developed. We present two cases of juvenile angiofibromas that could be managed endoscopically. Methods: Both angiofibromas were operated on endoscopically in a combined approach through the nose and transorally after retraction of the soft palate, but without discontinuation of the integrity of the soft and hard palates. Preoperatively, angiographic embolization of the internal
Scientific Posters
P 175
maxillary artery was performed in both cases. IMAs were the only blood supply of the angiofibromas in these cases. Results and conclusions: The two angiofibromas could be removed without complications and without major blood loss. No packing or blood transfusion was necessary. The surgical technique presented may be ideally suited for class 1 and 2 angiofibromas. Its limitations in larger angiofibromas are discussed. Advantages include but are not limited to an excellent cosmetic result with no external incision, minimal trauma to the patient, no risks for complications like vestibular stenosis, oroantral fistula, nasolacrimal damage, or facial deformation. 46 Chromium Induced Nasal Lesions: Why Do They Remain So Common? ELICZIA HELENA DE LIMA, OSWALDO LACRClO MENDON(~,(~,A CRUZ, CARLOS SI~RGIO DA SILVA, and SlGNE SCHUSTER GRASEL, SOo Paulo, Brazil
Chromic acid containing hexavalent chromium is a toxic and carcinogenic substance to the respiratory tract mucosa. It produces ulceration and perforation of the nasal septum, common findings in chrome workers during the first half of this century. Modernization of the plating industries and vigorous environmental control have reduced the incidence of these lesions in most countries. We observed, however, an unacceptably high prevalence of nasal lesions in Brazilian chrome workers even after a short exposure time. In a prospective study we evaluated 459 workers from 22 electroplating plants in S~o Paulo, Brazil. Twenty-two workers from five plants were exposed to no other metal than hexavalent chromium. Maximum chromic acid concentration in air samples was 5 ~g]m3(ACGIH limit, 50 Hg/m3). Ischemic changes (41%), ulceration (27%), and perforation (9%) were the major findings. Histopathology performed in five cases confirmed the clinical data showing erosion, ulceration, infiltration of inflammatory cells, hyperkeratosis, and regular squamous metaplasia. No dysplastic lesions were found. We discuss the prevalence of nasal lesions in chrome workers and its relationship to air chromium concentration, exposition time, and histopathologic changes. Conclusion: Poor environmental conditions remain the principal reason for the elevated number of nasal lesions in chrome workers that may develop within few weeks of exposition time. Otolaryngologists should be aware of occupation-induced nasal lesions. 47 Positron Emission Tomogrophy in a Patlent With Multlple Paragangliomas of the Head and Neck PHILLIP T. NICHOLS, MD, NARESH GUPTA, MD, and MARK K. WAX, MD, Morgantown, W.Va., and Buffalo, N.Y.
Positron emission tomography (PET) is a new imaging modality that has shown great promise in the evaluation of
Otolaryngology Head and Neck Surgery P 176
August 1996
Scientific Posters
head and neck tumors. Surveillance for recurrent disease, detection of subclinical neck metastasis, and the identification of unknown primary tumors are the areas of focus for most ongoing research. In general, PET has not added to more conventional techniques such as CT or MRI. PET detects tumors due to their accelerated metabolic rate when compared with normal surrounding tissues. Thus it may be useful in the imaging of any hypermetabolic tumor, be it malignant or benign. Head and neck paragangliomas are highly vascular tumors of neural crest origin. Most paragangliomas are solitary and benign, but occasionally they may be multiple in number. Local invasiveness and lymph node metastasis have been reported in 10% of solitary cases. In this article we describe a patient with multiple paragangliomas of the head and neck. The patient presented with bilateral cervical lymphadenopathy and was referred to us for further management after a lymph nose biopsy that was suspicious for paraganglioma. The issue of metastatic paraganglioma, and from which tumor it had originated, was raised. PET demonstrated three paragangliomas in the neck (bilateral carotid body tumors and a glomus vagale). There was no evidence of metastatic disease. Excision of two of the paragangliomas, with multiple negative lymph node biopsies, confirmed the PET findings. This is the first reported application of PET in a patient with paragangliomas of the head and neck.
48 Comparative Analysis of Findings In PNS CT and Endoscopic Sinus Surgery KWON SOO LIM, MD, TAE HYUN KIM, MD, YOUNG CHAE YU, MD, and JAE SHIK CliO, MD, Kwangju, Korea
Objective: The purpose of this study is to find out the degree of accuracy of PNS CT in describing the pathologic conditions and to find out the conditions for determining the extent of endoscopic sinus surgery by comparative analysis of PNS CT and operative findings. Methods: We analyzed 62 patients (120 sides) who had undergone surgery for chronic sinusitis. We performed CT scans using 3-mm coronal and axial sections. CT findings were classified into negative, mucosal thickening, polypoid hypertrophy, partial, and total opacification. Operative findings analyzed by videorecording of the operation were classified into normal, mucosal thickening, polyp or cyst, and secretion. Results: The rate of correspondence between preoperative CT findings and operative findings was 89% in the operated 62 patients (120 sides). The important conditions for determining the extent of endoscopic sinus surgery are as follows: (1) in all cases, anterior and posterior ethmoidectomy should be completely performed and the maxillary sinus ostium should be opened wide; (2) the widening of the frontal sinus opening should be performed when CT indicates the pathologic findings in the frontal sinus or around the
frontal sinus opening; and (3) sphenoidectomy should be performed when CT indicates the pathologic findings in the sphenoid sinus or in the posterior part of the posterior ethmoid sinus, or when the pathologic secretion is found around the natural ostium of the sphenoid sinus in endoscopic sinus surgery. Conclusions: We suggest that the extent of surgery should not be determined only by the CT findings because some cases are pathologic in operative findings, although CT findings indicate them as negative. 49 Congenital Canal Atresia Reconstruction with Dental Impression Material PETERC. WEBER, MD, WARREN Y, ADKINS, Jr, MD, and BETSY DAVIS, MD, Charleston, S.C.
Medium density viscosity dental impression material has recently been used after repair of an atretic canal to stent open the newly created external auditory canal for 2 weeks, followed by a hard plastic stent. This may provide some additional benefits over traditional packing, but caution must still be used. We recently have used the dental impression material to help in the reconstruction of four ear canals. The medium-viscosity impression material hardens quickly and provides a solid, nonmobile stent to enhance skin graft take. It will usually pull out without difficulty in approximately 2 weeks. The stent that is removed may then be used by our prosthodontist to fashion a hard, plastic, removable stent to be worn for the next month or two. This hard stent is used to prevent further stenosis. As with any technique, complications may arise and, through experience, common mistakes that can hinder a good outcome can be avoided. We will report four cases with illustrated tips on how to avoid complications using this technique. 5O Nd:YAG Laser In the Treatment of Eplstaxis in Heredltary Hemorrhagic Telanglectasla HASSAN H. RAMADAN, MD, FACS, Morgantown, W.Va.
Osler-Weber-Rendu is a rare disease that causes morbidity to those patients inflicted by it. This is mainly due to epistaxis that these individuals encounter and the number of blood transfusions that they require. The treatment has been surgical and mainly involves intranasal dermoplasty and local intranasal flap rotations. The physicians, as well as the patients, have been frustrated with those surgical procedures because the telangiectasias infiltrate the graft, and then the bleeding starts again. We have used the neodymium:yttriumaluminum-garnet (Nd:YAG) laser for photocoagulation of intranasal telangiectasias to control epistaxis that is refractory to traditional surgical therapies. The technique involves using a fiberoptic YAG laser along with an endoscope, and we usually stage the procedure by side. Use of the technique in three patients during the past four years has resulted in a
derwent TMERS emphasized that they were totally free from running ear discharge. Otolaryngologists may consider this surgical procedure as one of the best choice for patients with postoperative cavity problems. 44 The Effect of the $tom-Vent 2 "Artificial Nose" Prosthesis In Laryngectomy Patients JOHN D, GOLDENBERG, MD, BARRYL. WENIG, MD, MPH, and LOUISG. PORTUGAL, MD, Chicago, III.
The negative impact of a total laryngectomy to the quality of life of larynx cancer patients is well known to the head and neck surgeon. These include loss of voice, a permanent cervical stoma, and loss of the humidification process normally provided by the nose and paranasal sinuses. Heat and moisture exchange devices have been devised to compensate for this and serve as an "artificial nose" for the laryngectomized patient. This study sought to determine the effect of the Stom-Vent 2 prosthesis in a cohort of laryngectomy patients. The inclusion criteria was as follows: 3 or more months postoperative; no local wound complications such as a pharyngocutaneous fistula, severe radiation dermatitis, or requirement for a laryngectomy tube secondary to stomal narrowing; and an ability to understand and follow through with the requirements of the trial. After complete medical and surgical histories were obtained, each patient completed a questionnaire before and after the trial relative to general health issues, respiratory information, and communication status. The patients were also objectively evaluated in the tumor clinic throughout the 6-week trial to ensure study compliance. We found a significant portion of our study population embraced the "artificial nose" prosthesis and reported subjective improvement relative to tracheal secretions and overall comfort. Furthermore, patients utilizing a tracheoesophageal prosthesis for voice rehabilitation did not experience difficulties using both devices concurrently. We conclude that the Stom-Vent 2 prosthesis can have a beneficial effect on the quality of life of laryngectomy patients. 45 The Endoscopic Approach for Juvenile Angloflbromas WOLFGANG LUXENBERGER, MD, HEINZ STAMMBERGER, MD, KLAUS GREISTORFER,MD, and WOLFGANG ANDERHUBER, MD, Graz, Austria
Objective: In recent years a number of advanced applications for endoscopic sinus surgery were developed. We present two cases of juvenile angiofibromas that could be managed endoscopically. Methods: Both angiofibromas were operated on endoscopically in a combined approach through the nose and transorally after retraction of the soft palate, but without discontinuation of the integrity of the soft and hard palates. Preoperatively, angiographic embolization of the internal
Scientific Posters
P 175
maxillary artery was performed in both cases. IMAs were the only blood supply of the angiofibromas in these cases. Results and conclusions: The two angiofibromas could be removed without complications and without major blood loss. No packing or blood transfusion was necessary. The surgical technique presented may be ideally suited for class 1 and 2 angiofibromas. Its limitations in larger angiofibromas are discussed. Advantages include but are not limited to an excellent cosmetic result with no external incision, minimal trauma to the patient, no risks for complications like vestibular stenosis, oroantral fistula, nasolacrimal damage, or facial deformation. 46 Chromium Induced Nasal Lesions: Why Do They Remain So Common? ELICZIA HELENA DE LIMA, OSWALDO LACRClO MENDON(~,(~,A CRUZ, CARLOS SI~RGIO DA SILVA, and SlGNE SCHUSTER GRASEL, SOo Paulo, Brazil
Chromic acid containing hexavalent chromium is a toxic and carcinogenic substance to the respiratory tract mucosa. It produces ulceration and perforation of the nasal septum, common findings in chrome workers during the first half of this century. Modernization of the plating industries and vigorous environmental control have reduced the incidence of these lesions in most countries. We observed, however, an unacceptably high prevalence of nasal lesions in Brazilian chrome workers even after a short exposure time. In a prospective study we evaluated 459 workers from 22 electroplating plants in S~o Paulo, Brazil. Twenty-two workers from five plants were exposed to no other metal than hexavalent chromium. Maximum chromic acid concentration in air samples was 5 ~g]m3(ACGIH limit, 50 Hg/m3). Ischemic changes (41%), ulceration (27%), and perforation (9%) were the major findings. Histopathology performed in five cases confirmed the clinical data showing erosion, ulceration, infiltration of inflammatory cells, hyperkeratosis, and regular squamous metaplasia. No dysplastic lesions were found. We discuss the prevalence of nasal lesions in chrome workers and its relationship to air chromium concentration, exposition time, and histopathologic changes. Conclusion: Poor environmental conditions remain the principal reason for the elevated number of nasal lesions in chrome workers that may develop within few weeks of exposition time. Otolaryngologists should be aware of occupation-induced nasal lesions. 47 Positron Emission Tomogrophy in a Patlent With Multlple Paragangliomas of the Head and Neck PHILLIP T. NICHOLS, MD, NARESH GUPTA, MD, and MARK K. WAX, MD, Morgantown, W.Va., and Buffalo, N.Y.
Positron emission tomography (PET) is a new imaging modality that has shown great promise in the evaluation of
Otolaryngology Head and Neck Surgery P 176
August 1996
Scientific Posters
head and neck tumors. Surveillance for recurrent disease, detection of subclinical neck metastasis, and the identification of unknown primary tumors are the areas of focus for most ongoing research. In general, PET has not added to more conventional techniques such as CT or MRI. PET detects tumors due to their accelerated metabolic rate when compared with normal surrounding tissues. Thus it may be useful in the imaging of any hypermetabolic tumor, be it malignant or benign. Head and neck paragangliomas are highly vascular tumors of neural crest origin. Most paragangliomas are solitary and benign, but occasionally they may be multiple in number. Local invasiveness and lymph node metastasis have been reported in 10% of solitary cases. In this article we describe a patient with multiple paragangliomas of the head and neck. The patient presented with bilateral cervical lymphadenopathy and was referred to us for further management after a lymph nose biopsy that was suspicious for paraganglioma. The issue of metastatic paraganglioma, and from which tumor it had originated, was raised. PET demonstrated three paragangliomas in the neck (bilateral carotid body tumors and a glomus vagale). There was no evidence of metastatic disease. Excision of two of the paragangliomas, with multiple negative lymph node biopsies, confirmed the PET findings. This is the first reported application of PET in a patient with paragangliomas of the head and neck.
48 Comparative Analysis of Findings In PNS CT and Endoscopic Sinus Surgery KWON SOO LIM, MD, TAE HYUN KIM, MD, YOUNG CHAE YU, MD, and JAE SHIK CliO, MD, Kwangju, Korea
Objective: The purpose of this study is to find out the degree of accuracy of PNS CT in describing the pathologic conditions and to find out the conditions for determining the extent of endoscopic sinus surgery by comparative analysis of PNS CT and operative findings. Methods: We analyzed 62 patients (120 sides) who had undergone surgery for chronic sinusitis. We performed CT scans using 3-mm coronal and axial sections. CT findings were classified into negative, mucosal thickening, polypoid hypertrophy, partial, and total opacification. Operative findings analyzed by videorecording of the operation were classified into normal, mucosal thickening, polyp or cyst, and secretion. Results: The rate of correspondence between preoperative CT findings and operative findings was 89% in the operated 62 patients (120 sides). The important conditions for determining the extent of endoscopic sinus surgery are as follows: (1) in all cases, anterior and posterior ethmoidectomy should be completely performed and the maxillary sinus ostium should be opened wide; (2) the widening of the frontal sinus opening should be performed when CT indicates the pathologic findings in the frontal sinus or around the
frontal sinus opening; and (3) sphenoidectomy should be performed when CT indicates the pathologic findings in the sphenoid sinus or in the posterior part of the posterior ethmoid sinus, or when the pathologic secretion is found around the natural ostium of the sphenoid sinus in endoscopic sinus surgery. Conclusions: We suggest that the extent of surgery should not be determined only by the CT findings because some cases are pathologic in operative findings, although CT findings indicate them as negative. 49 Congenital Canal Atresia Reconstruction with Dental Impression Material PETERC. WEBER, MD, WARREN Y, ADKINS, Jr, MD, and BETSY DAVIS, MD, Charleston, S.C.
Medium density viscosity dental impression material has recently been used after repair of an atretic canal to stent open the newly created external auditory canal for 2 weeks, followed by a hard plastic stent. This may provide some additional benefits over traditional packing, but caution must still be used. We recently have used the dental impression material to help in the reconstruction of four ear canals. The medium-viscosity impression material hardens quickly and provides a solid, nonmobile stent to enhance skin graft take. It will usually pull out without difficulty in approximately 2 weeks. The stent that is removed may then be used by our prosthodontist to fashion a hard, plastic, removable stent to be worn for the next month or two. This hard stent is used to prevent further stenosis. As with any technique, complications may arise and, through experience, common mistakes that can hinder a good outcome can be avoided. We will report four cases with illustrated tips on how to avoid complications using this technique. 5O Nd:YAG Laser In the Treatment of Eplstaxis in Heredltary Hemorrhagic Telanglectasla HASSAN H. RAMADAN, MD, FACS, Morgantown, W.Va.
Osler-Weber-Rendu is a rare disease that causes morbidity to those patients inflicted by it. This is mainly due to epistaxis that these individuals encounter and the number of blood transfusions that they require. The treatment has been surgical and mainly involves intranasal dermoplasty and local intranasal flap rotations. The physicians, as well as the patients, have been frustrated with those surgical procedures because the telangiectasias infiltrate the graft, and then the bleeding starts again. We have used the neodymium:yttriumaluminum-garnet (Nd:YAG) laser for photocoagulation of intranasal telangiectasias to control epistaxis that is refractory to traditional surgical therapies. The technique involves using a fiberoptic YAG laser along with an endoscope, and we usually stage the procedure by side. Use of the technique in three patients during the past four years has resulted in a