摘要:

AbstractAir in the neck is normally found in the pharynx, larynx and trachea. Free air may enter the neck by direct opening of potential fascia spaces, dissection within the fascia spaces from the head or mediastinum and by injury to the upper respiratory or alimentary tracts. The sources for free air in the neck are numerous and varied and range from the rectum to the sinuses. The otolaryngologist should have a thorough knowledge of the differential diagnosis for air in the neck since the definitive therapy depends on the etiology.

ISSN:0023-852X    

DOI:10.1288/00005537-197409000-00001

出版商:John Wiley&Sons, Inc.    

年代:1974

数据来源: WILEY

摘要:

AbstractThree rather complicated cervical tracheo‐esophageal problems and their appropriate management, are described. In each case, a tracheal defect required repair. In one case, fascia lata was used to close a defect in the posterior tracheal wall. In another, this type of repair was unsuccessful in one‐stage closure of a large tracheo‐esophageal fistula. A 7 cm defect of esophagus in heavily irradiated tissues was successfully reconstituted with transposed colon. The co‐existing postirradiation tracheo‐esophageal fistula was repaired at an earlier stage to ensure that the patient's recovery from the laparotomy would not be complicated by aspiration pneumonitis. Thoracotomy was not required, but resection of the clavicular head and mobilization of the origin of the sternomastoid were used to improve the transcervical exposure of the superior mediastinum.In the second case, a tracheal defect that involved the tracheal cartilage was repaired by sleeve resection and end‐to‐end anastomosis. In revision surgery of chronic cervical tracheal and subglottic stenosis, one can anticipate massive local scar formation. The densely fibrosed common wall between the trachea and the esophagus should be left completely with the esophagus and only the lateral and anterior remnants of the trachea excised to avoid iatrogenic recurrent nerve paralysis or inadvertent perforation into a traction diverticulum of the esophagus. One should anticipate the use of the laryngeal drop procedure to make up the tracheal defect. The suprathyroid tissues will be virgin, whereas the previous tracheal procedures will have reduced the length attainable below from tracheal remobilization. Suturing the chin toward the chest is an effective and well‐tolerated prophylactic measure that prevents both extension of the neck after the operation and undue tension on the tracheal anastomosis.In the third case, closure of a vertical tracheal‐esophageal fistula and repair of a tracheal defect were undertaken simultaneously. The procedure involved mobilizing the larynx from its hyoid attachments, dropping the larynx, and bringing the margins of the esophageal defect together transversely, as in a pyloroplasty. This application of the laryngeal drop procedure, not previously describ

ISSN:0023-852X    

DOI:10.1288/00005537-197409000-00002

出版商:John Wiley&Sons, Inc.    

年代:1974

数据来源: WILEY

摘要:

AbstractThe otolaryngologist is frequently consulted by patients with a confusing array of complaints of pain in the head and neck region. It is the purpose of this paper to re‐introduce the problem of the temporomandibular joint pain dysfunction syndrome and stress its frequent occurrence.Costen in 1934 and 1944 brought to the attention of otolaryngologists the problem of temporomandibular joint dysfunction. In his 1944 report he stated that the diagnosis of tic doloreaux had been frequently made in patients with temporomandibular joint pain dysfunction syndrome. The number of cases included in this report are those collected over the past six months. Between June and December of 1973, 25 patients with the diagnosis of temporomandibular joint pain dysfunction syndrome were asked to fill out a questionnaire covering the history and symptomatology of their problem. Just over 50 percent were under the age of 50, with the largest number between the ages of 30 and 49. No patients had symptoms less than three months and most of the patients had symptoms from three months to one year. Unilateral symptoms were present in all but four cases, and the right side was most frequently involved. Many physicians were consulted and averaged 2.3 for each patient. All but two patients described pain in multiple areas, the most frequent combinations being the joint, ear and lower jaw; however, most patients were unaware of joint pain primarily. One patient complained only of throat pain and one complained only of pain in the lower jaw. Eight patients described “popping” in the joint, and eight had a history of teeth clenching or bruxing. Thirteen complained of fullness or pressure along with tinnitus and vertigo on an intermittent basis. Four case histories are presented to exemplify certain problems.The history is one of many nerve roots involved with pain in and around the ear, pain down the side of the neck, a gnawing aching tight feeling under the jaw to a burning sensation down the skin of the neck. In most all patients treatment has often been given by many doctors. They frequently present to the examiner as an individual with a large psychosomatic overlay.Physical examination reveals subjective pain and tenderness in the joint, clicking or crepitation upon auscultation of the joint, spasm of the external pterygoid, tenderness of the masseter muscle, deviation of the mandible on opening, impaired motion of one or both condyles and a generalized sensitiveness of the skin in the involved region.Representative X‐rays are presented. Intra‐articular injection of 1 cc. of 2 percent lidocaine will relieve some or all of the symptoms the patient is experiencing. Complications of the injection have been minimal. A small number of patients obtained complete relief of their head and neck pain after three to five injections. A possible mechanism to explain the genesis of the syndrome is presented. Treatment is varied and not agreed upon. Three patients have been treated by the insertion of a temporomandibular joint p

ISSN:0023-852X    

DOI:10.1288/00005537-197409000-00003

出版商:John Wiley&Sons, Inc.    

年代:1974

数据来源: WILEY

摘要:

AbstractBecause of the high incidence of alcoholism in patients with cancer of the laryngopharynx and oral cavity, alcoholic withdrawal syndromes are a frequent postoperative complication in head and neck surgery. Delirium tremens, the most severe form of alcohol withdrawal, is characterized by a progressive symptom complex: anxiety, irritability, confusion, nausea, tremors, hallucinations, hyperpyrexia, convulsions, and delirium. It usually develops 48‐72 hours after the abrupt cessation of prolonged heavy alcoholic drinking but it may occur up to 10 days later. Delirium tremens usually persists for two or three days but there is considerable individual variation in the severity and the intensity of the reaction.Delirium tremens is caused by a rapidly falling blood alcohol level but the exact pathophysiological mechanism is unknown. Numerous theories have been proposed. Walder, et al., feel that one of the breakdown products of ethanol, possibly acetaldehyde, is the cause based on recent hemodialysis studies. Mays, et al., feel that an elevated serum free fatty acid level is causative. Albumin usually binds the fatty acids but when the albumin levels are low, the fatty acids circulate freely and are cytotoxic.In head and neck surgery, delirium tremens usually occurs in the postoperative period. An early diagnosis is difficult because the symptoms usually begin subtly on the second to fourth postsurgical day with agitation and confusion. Twenty‐four hours later when hallucinations, convulsions and delirium occur, the diagnosis is self‐evident.Except for hemodialysis therapy which is complex and not universally available, the treatment of delirium tremens is largely symptomatic and supportive but should begin promptly to minimize or prevent the later more severe symptoms. Paraldehyde and the psychotropic drugs such as chlordiazepoxide (librium) and diazepan (valium) are the most commonly used sedatives. The use of intravenous alcohol is contraindicated because of its short duration of action and narrow margin of safety. Maintaining proper fluid and electrolyte balance is most important. Since some alcoholic patients are dehydrated and some over‐hydrated, the usual parameters and indices for fluid and electrolyte replacement must be closely observed. Restraints, urinary catheters and close observation for lung, liver and gastrointestinal complications are necessary.The irrational, hallucinating, combative and delirious patient is difficult to manage in the postoperative period and is prone to many complications. Needles, feeding tubes, drainage tubes, tracheotomy tubes, wounds, dressings and skin flaps may be molested or removed. Optimum body positioning is impossible. Tracheal aspirations are increased and pneumonitis is likely. Sudden death from fatty emboli is possible.The mortality rate for delirium tremens is approximately 10 percent and when a complicating medical or surgical problem co‐exists, the mortality rate increases to 25 percent. Several case reports are presented to illustrate that delirium tremens in the postoperative period is not only a serious threat to the patient but a difficult challenge for the physician.In order to minimize the high postoperative morbidity and mortality of delirium tremens, the head and neck surgeon should be suspicious of the alcoholic patient, recognize the high risk patient, delay surgery when necessary and begin withdrawal therapy

ISSN:0023-852X    

DOI:10.1288/00005537-197409000-00004

出版商:John Wiley&Sons, Inc.    

年代:1974

数据来源: WILEY

摘要:

AbstractAn audiologic study of 290 hemodialysis and renal transplant patients revealed that in 43 of these patients significant hearing loss developed which could be directly attributed to the therapy of the kidney problem.The clinicopathologic findings in 16 temporal bones of eight chronic hemodialysis and renal transplant patients were presented. The five patients treated with 59 or less hemodialyses had no subjective hearing loss; on the other hand, the three patients receiving 264 or more hemodialyses and multiple transplants, complained of hearing and vestibular difficulties. The pathologic findings common to all 14 temporal bones of the seven patients who underwent transplantation were blue stained concretions in the stria vascularis and/or vestibular receptors. The cochlear changes noted ranged from mild loss of outer hair cells and spiral ganglion cells in patients with few hemodialyses and transplants to complete absence of the organ of Corti in patients receiving more than 264 hemodialyses and multiple transplants; thus, the severity of the clinical and histopathological temporal bone findings was directly proportional to the number of hemodialyses and transplants to which the patient had been subjected. This seems to suggest that numerous hemodialyses or recurrent kidney transplants can induce electrolytic, osmotic, biochemical, vascular and/or immunological changes in the inner ear which can lead to severe audioves‐tibular symptoms and patholog

ISSN:0023-852X    

DOI:10.1288/00005537-197409000-00005

出版商:John Wiley&Sons, Inc.    

年代:1974

数据来源: WILEY

摘要:

AbstractThis is the first report of a red chorda tympani nerve observed in association with Bell's palsy. A prospective study was designed to determine the frequency and significance of this sign in association with Bell's palsy. Twenty‐eight patients were evaluated within two days of onset of paralysis. The red chorda tympani sign was correlated with alterations in chorda tympani function in terms of taste and submandibular salivary flow as well as response of the extracranial facial nerve to the maximal stimulation test. The chorda tympani was red in 10 of 20 patients (50 percent) where the nerve could be seen through the tympanic membrane. This finding is discussed in terms of a viral‐inflammatory involvement of the chorda tympani as part of the pathogenesis of Bell's palsy. In addition, the red chorda tympani sign was clinically significant. It indicated a more severe involvement of the chorda tympani than in those patients where the nerve was normal. The patients with the finding had a greater incidence of loss of taste by history and testing. In addition, 4 of the 10 patients with a red chorda tympani on the side of the facial paralysis had a salivary flow of less than 25 percent as compared to only 1 of 10 patients with a normal chorda tympani on the ipsilateral side. The study suggested a worse prognosis for patients with a red chorda tympani, although the difference was not statistically significant. The most important clinical significance of the red chorda tympani was its exclusive association with Bell's palsy and, therefore, may be an important diagnostic s

ISSN:0023-852X    

DOI:10.1288/00005537-197409000-00006

出版商:John Wiley&Sons, Inc.    

年代:1974

数据来源: WILEY

摘要:

AbstractThe traditional approach in establishing the doctor‐patient relationship is that of “taking the history.” This is fundamental to medical records, but it is a performance seldom re‐explored after the formative period in one's medical education. The patient's history remains fundamental and with systems analysis of patient care, the information furnished by this is designated as a part of the data base, in accord with principles elucidated by Weed and previously reported by our SARCI group specifically for otolaryngology.Our prior report described the struggle with language related to the things we examine and try to describe in terms understandable to a computer. The next consideration has been the evaluation of what kind and how much information would be accumulated for each patient to constitute the standard data base for the otolaryngologist. For greatest computer help, it is clearly required that the same information be gathered on every patient before proceeding to define any additional data which will be used only for further definition of an individual patient's problem. Almost endless sets of patient history data are available to us and our problem has been to select and decide what set would constitute our standard data base for most patients in otolaryngology.Certain principles concerning the concept and content of the data base have become evident. These are as followsEvaluation of the information in the history of a patient taken and recorded by different physicians was conducted and analyzed. The overall result can be summarized to the effect that there was more variation within the results of any one physician than between physicians. Knowing of such variability in contrast to the standardization required to mesh with the computer led us to evaluate questionnaires.Patient questionnaires need not imply leaving a patient alone with a form or a video display tube staring at him. A paper and pencil format needs no time limits and even computer controlled questionnaires can work at the patient's place. Both of these systems gain information that is as complete as we care to make it; but having the same approach to each patient makes the information comparable. We wanted a combination of questions so as to elicit a “signal” whenever there was a need for further physician evaluation. A format containing 65 “Inquiry by Systems” questions was found. It has been tried on seven population samples and has been modified four times during the course of these trials. Any such tool needs evaluation for reproducibility of results and for validity. As an example, we compared positive answers in the ear, nose and throat area with the findings recorded in the medical record. This gave a mean agreement of 75 percent with a mean error of 16 percent.Classical narrative form for recording the patient's history requires a change in language for the computer. At the present time a “yes” and “no” or numbered answer to a question is required to make the potential of the computer useful to the physician. We have established to our own satisfaction that questionnaires are likely to generate useful information consistently and easily, but the physician's judgment is required to deal with false positives as

ISSN:0023-852X    

DOI:10.1288/00005537-197409000-00007

出版商:John Wiley&Sons, Inc.    

年代:1974

数据来源: WILEY

摘要:

AbstractThe literature on ethmoiditis was reviewed emphasizing the diagnostic and therapeutic aspects of the disease.The records of 47 patients with chronic inflammatory nasoethmoid disease, treated by polypectomy and intranasal ethmoidectomy, were reviewed to determine the effectiveness of the operative procedure.There has been follow‐up of two years or more on 26 patients. The records were analyzed with attention to etiologic factors, diagnostic criteria, surgical procedure and results.We have found that the preoperative sinus roentgenograms frequently do not reveal the extent and severity of the disease noted at the time of surgery.Our review supports the intranasal ethmoidectomy as an effective procedure for chronic nasoethmoid inflammatory disease, especially with recent emphasis on total resection of the middle turbinat

ISSN:0023-852X    

DOI:10.1288/00005537-197409000-00008

出版商:John Wiley&Sons, Inc.    

年代:1974

数据来源: WILEY

摘要:

AbstractA facial nerve coursing inferior to the oval window niche was injured during a stapedectomy. In this location, the nerve did not have normal gross characteristics and was not recognized as a vital structure.The relationship between the facial nerve and the stapes is determined by the fourth week of fetal life. Even when the nerve lies inferior to the stapes, it is postulated that a normal bony facial canal and stapedial muscle can develop.

ISSN:0023-852X    

DOI:10.1288/00005537-197409000-00009

出版商:John Wiley&Sons, Inc.    

年代:1974

数据来源: WILEY

摘要:

AbstractGranular cell myoblastoma is a relatively uncommon lesion but one important to remember because of the diagnostic difficulty it may present. Six cases over a 15‐year period were reviewed. The lesions occurred more in females (five to one) in the fourth and fifth decades. Most were symptomatic with hoarseness. Half (three) of the lesions were located on the posterior true vocal cord, two on the mid cord and one on the anterior cord, and all were removed endoscopically. Follow‐up of six months to six years has revealed no recurrences. Microscopically the lesions consist of pink cells with the characteristic granules. The cell of origin is probably the Schwann cell. A problem in diagnosis is the frequently present overlying epithelial layer of pseudoepitheliomatous hyperplasia which must not be mistaken for carcinoma. The lesions are benign. Although a few malignant cases have been reported, there have been none in the larynx. Endoscopic local excision is usually adequate, although very large lesions may require laryngofissure or hemilaryngectomy. Even total laryngectomies have been repor

ISSN:0023-852X    

DOI:10.1288/00005537-197409000-00010

出版商:John Wiley&Sons, Inc.    

年代:1974

数据来源: WILEY