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Cis-diamminedichloroplatinum has been proven to be an effective neoplastic agent. Nephrotoxicity and ototoxicity are two prominent side effects of this drug. Investigation of ototoxicity has been limited to auditory function. This report details the first known case of vestibular toxicity following platinum therapy. In addition, a prospective vestibular testing program is reported.

• In order to compare the efficacy of permucosal needle drainage with that of incision and drainage in the outpatient management of peritonsillar abscess, 52 patients with aspiration-proven peritonsillar abscess were entered into a randomized, prospective protocol. A symptomatic scale scoring system was employed to evaluate treatment results. In the needle drainage group, 92% (22/24) were cured with a single aspiration. Ninety-three percent (26/28) of the patients in the incision and drainage group were cured on the initial attempt. The remainder of the patients in both groups were cured with a single retreatment. Only one patient required hospitalization, and no patients required tonsillectomy to resolve the abscess. These data indicate that outpatient permucosal needle drainage of peritonsillar abscess is an acceptable, inexpensive treatment comparing favorably with incision and drainage. ( Arch Otolaryngol Head Neck Surg 1988;114:296-298)

• From the records of the Veterans Administration Hospital and the American Cancer Society, 357 patients who had undergone laryngectomy had their conditions evaluated retrospectively to see if they had acquired alaryngeal speech. Despite the efforts of highly qualified speech pathologists and the favorable implications of previous reports, only 24.4% of the entire patient population achieved functional esophageal speech. The addition of other treatment modalities did not substantially affect the results. It is concluded that if obtaining esophageal speech is the primary goal in successful rehabilitation of the alaryngeal patient, then there is a profound need to reassess the previous directions in restoration of postlaryngectomy communication. (Arch Otolaryngol1982;108:647-649)

Six patients with adductor spasmodic dysphonia were evaluated for evidence of brainstem dysfunction using the auditory brainstem response (ABR). In four, abnormally large increments in wave V latencies were found at high stimulus repetition rates. Latency increments exceeded three standard deviations above the mean in a normative adult population. A fifth patient had the prolonged interpeak latencies described previously by other investigators. In five of six patients the capacity of the auditory brainstem to conduct impulses was compromised. These results suggest a central nervous system abnormality in adductor spasmodic dysphonia.

Temporal bone histopathology was studied in five patients (aged 51–67) who received cis-diamminedichloroplatinum (DDP) chemotherapy for head and neck squamous cell carcinoma. In each case, a sensorineural hearing loss occurred during the course of treatment and temporal bones were acquired 3–5 hours postmortem for anatomical study. Scanning electron microscopy revealed acute degenerative changes in cochlear hair cells that appeared to be the result of drug treatment. However, the presence of age-related degeneration made it difficult to unequivocally identify hair cell loss due solely to ototoxicity. In one patient, a decrement in vestibular function was observed during DDP treatment. Postmortem examination showed severe degeneration of the maculae and cristae which could be correlated with the absence of caloric response seen after chemotherapy.

The management of 120 laryngeal injury patients at a major trauma center over 23 years is presented in the form of two patient populations. The first population consists of 52 previously analyzed and reported laryngeal trauma patients who served as the basis for the subsequent refinement of treatment of a second population of 68 patients. Collectively, these patients form a series unique in that 1) it comprises the largest number of such injuries treated at one institution, 2) the management principles remained the same throughout the entire 23 years, and 3) the majority of the patients were managed by one physician. The experience gained from these patients is examined in the hope of resolving prevailing controversies about the treatment of the acutely injured larynx.

A 13-year retrospective review of 53 patients with laryngeal trauma seen between 1965 and 1975 at the University of Texas Health Science Center at Dallas affiliated hospitals is presented. Patient management fell into four groups: observation following direct laryngoscopic examination or observation alone (7 patients), direct laryngoscopic examination and tracheostomy (5 patients), open reduction of fractures without stenting (14 patients), and open reduction of fractures with stenting (27 patients). These cases were analyzed according to initial signs and symptoms, duration between time of injury and surgery as pertains to success of management, indications for open reduction of laryngeal fractures, and associated injuries.

Twelve patients with various parotid masses were prospectively studied by both nuclear magnetic resonance (NMR) imaging and intravenously enhanced computed tomography (CT). These imaging techniques were then correlated with the disease process and clinical relevance of both forms of imaging assessed. Our results suggest high resolution, spin-echo NMR offers several advantages over CT, and is likely to become the preferred method of evaluating a parotid mass.

• A sample of 5,392 students were surveyed using a 42-item, multiple-choice questionnaire from a population of 19,040 Texas school-age children. The geographic distribution was 70% urban and 30% rural, with a representative sampling of the various racial and ethnic groups within Texas. The results of the survey indicated that 486 (9%) of the students regularly used smokeless tobacco, 810 (15%) regularly smoked cigarettes, and 4,096 (76%) used no tobacco products. Further, 77% perceived cigarette smoking as very harmful, while only 40% perceived smokeless tobacco as very harmful. Age of initiating use indicated that 55% of smokeless tobacco users started before the age of 13 years, whereas only 36% of cigarette smokers began that early. ( Arch Otolaryngol 1985;111:639-642)

• Patients undergoing radical surgical treatment of head and neck neoplasms often are seen with a history of cirrhotic liver disease, electrolyte abnormalities, and other stigma of chronic disease. Despite skillful thyroid surgical technique performed as an isolated procedure or in combination with other procedures such as laryngectomy, hypocalcemia can occur. Common causes of lowered serum calcium levels secondary to removal of parathyroid glands, blood transfusions, hypoalbuminemia, gastrointestinal malabsorption, and renal insufficiency are well known. Less well known is the recently elucidated role of dependence of calcium metabolism on magnesium. Recently, it has been well documented that alcoholism directly lowers serum magnesium levels in both human and animal models without prior liver disease or malabsorption. The fact that three mechanisms are needed to explain calcium homeostasis implies that the magnesium-calcium interdependence is not clearly understood. (Arch Otolaryngol104:263-266, 1978)

Stabilization, reconstruction, and rehabilitation of certain mandibular fractures or continuity defects may be facilitated by external skeletal fixation. The utilization of a convenient and inexpensive monophasic extraskeletal fixation appliance in select instances of mandibular trauma or head and neck surgery is described herein and illustrated with case reports.

This case study exemplifies successful diagnosis through stroboscopic fiberoptic examination, illustrates the critical importance of a careful case history, and demonstrates potential hazards of supposedly benign environmental substances for hypersensitive individuals.

Since laryngoceles are usually asymptomatic, their incidence is probably higher than the literature suggests. With the advent of computed tomography, the incidence and significance of the asymptomatic laryngocele in a general head and neck practice can be addressed. To this end, 304 consecutive patients with a variety of otolaryngic diagnoses were studied prospectively by computed tomography of the neck from January 1983 to February 1985. Thirty-eight (12.5%) of the patients had asymptomatic laryngoceles, defined as air-containing structures in the supraglottic region extending more than 5 mm above the superior border of the thyroid cartilage during normal breathing. The incidence of laryngoceles associated with laryngeal cancer (29%) was higher than that for laryngoceles associated with other diseases (9%). No patient with an asymptomatic laryngocele not associated with laryngeal cancer showed evidence of a subsequent laryngeal neoplasm during close follow-up of 10 to 36 months.

• Spasmodic dysphonia (SD) is a low-incidence voice disorder of unknown origin. A subgroup of seven patients with SD from our larger pool of 70 report vocal symptoms subsequent to head injury. This article is a case report of the neurodiagnostic findings, including computed tomography, magnetic resonance imaging, auditory brain-stem response, brain electrical activity mapping, and single photon emission computed tomography for three such patients. For each patient, two or more tests revealed positive neurologic findings. Each test, except computed tomography, demonstrated abnormalities in one or more patients. Two principles of clinical management are derived: (1) information regarding head trauma sustained before SD symptom onset is significant; (2) the absence of neuropathology on a single measure of central nervous system function should not be considered conclusive evidence that no neurologic lesions exist. (Arch Otolaryngol Head Neck Surg1987;113:1107-1110)

Spasmodic dysphonia is a devastating voice disorder of unknown etiology, with a variable clinical presentation and response to treatment. Three independent evaluations of brain stem function were performed on spasmodic dysphonic patients, and age and sex-matched controls. Statistically significant (p less than 0.01 approximately 0.05) differences were noted between these groups, and the findings were consistent with impairment of somatic and visceral brain stem pathways. A significant correlation (p less than 0.05) was found between the severity of tested central nervous system impairment and vocal tremor, number of associated neurologic signs and duration of illness. Possible etiologies (viral or traumatic), age, and sex, did not correlate with the severity of brain stem impairment. Clinical signs and the brain stem findings appeared to stabilize 3 to 5 years after onset of dysphonia. The investigation of other spasmodic cranial nerve disorders afforded insight into the etiology and therapy for spasmodic dysphonia. Drawing upon previous observations and the results of the brain stem tests, two models are proposed for neuronal processing in spasmodic dysphonia, and future strategies are discussed. The evidence cited in this research project are consistent with spasmodic dysphonia being one of several spasmodic brain stem disorders with variable presentation which are known by the cranial nerve nuclei or pathways of major clinical involvement.

Mucoceles of the paranasal sinuses extending into the epidural space are both uncommon and difficult to surgically manage. To best overcome the problem of recurrent disease, we have adopted a combined otorhinolaryngologic-neurosurgical approach which emphasizes removal of as much as possible of the mucocele and marsupialization, or permanent drainage, of the disease site into the nasal cavity. Recently, we have modified this procedure in selected cases to include resection of involved dura and isolation of the epidural space from the nasal cavity. The indications and results of both forms of management are now reported in ten patients.

The management of 87 laryngeal trauma patients over the past 17 years is reported. During the last four years, 35 of these patients were prospectively studied by the author after drawing upon the treatment policies of the earlier experience. The results of this study demonstrate a successful program to preserve or restore the phonatory and airway function of the acutely injured larynx.

Recently, American otolaryngologists have become increasingly interested in endoscopic paranasal sinus surgery. This trend has been beneficial, because it has enhanced the understanding of the anatomy and pathophysiology of the sinuses. However, as with the introduction of any new surgical technique, it takes both time and experience to acquired the skills necessary to perform this procedure. To evaluate the state of endoscopic sinus surgery, we analyzed the experience of one of the authors with 100 consecutive patients undergoing therapeutic endoscopic sinus surgery over 23 months. With an average follow-up of 5 months (range: less than 1 month to 20 months), 14 patients had minor complications. The most common complication was synechia between the middle turbinate and the lateral nasal wall (six patients), resulting in revision surgery in four patients. Eighty-three patients were judged as having significantly improved after surgery, while ten were improved but had one episode of sinusitis postoperatively. The results of this series suggest that endoscopic paranasal sinus surgery is an efficacious advance in the treatment of sinusitis, given the limitations discussed in this report.

Stenosis of the posterior laryngeal commissure with arytenoid fixation following intubation trauma or laryngeal fracture poses a treatment dilemma. Over the past 2 1/2 years we have managed four patients with this problem by mobilization of the fixated cricoarytenoid joint, arytenoid-pharyngeal mucosal advancement flap, brief splinting of the arytenoids in the fully abducted position, and early speech therapy. As of this time, three of the four patients have been both decannulated and have achieved adequate to near normal voices. Most significantly, the previously fixated arytenoids are now mobile, confirming the efficacy of the principles presented herein.

A case of cerebrospinal fluid rhinorrhea is presented in which routine diagnostic evaluation failed to disclose the site of leakage. Computerized tomography (CT) scanning with metrizamide, a nonionic contrast medium, provided not only documentation of the leak but also demonstrated the actual sinus involved. Metrizamide cisternography with CT scanning is a valuable technique in the evaluation of CSF rhinorrhea. It may only be used when an active leak is present. The patient described in this report lost several drops of CSF from the nose per minute in the face-down position. Neurotoxicity may be avoided by routine pre-examination medication with valium or phenobarbital. Mixing of the contrast agent with CSF. is diminished by injecting in the subarachnoid space at C1-C2. The methods used in this examination and their indications are described, and the literature concerning metrizamide toxicity and pharmacologic properties reviewed.

At the January meeting of the Western Section of the Triological Society, Drs Goding and Cummings and Mr Trachy presented the results of their work measuring the effects of controlled skin expansion on blood flow. Cutaneous blood flow was measured by a dermofluorometer in 28 subcutaneous pockets placed in seven pigs, which were divided into three groups. The first group underwent expansion of the subcutaneous pocket with a 200-mL tissue expander over 12 days, followed by deflation and observation for an additional six days. The second group had a noninflated 200-mL tissue expander placed, and the third group served as a control. In group 1 there was no significant change in blood flow prior to skin expansion. Inflation of the expander on the fourth day resulted in decreased blood flow with return of that flow at the time of second expansion on the eighth day, and overall increase in flow

At the American Laryngological Association annual meeting, Steven Zeitels, MD, C. W. Vaughn, MD, and G. T. Simpson, MD, of Boston University, reported their experience in managing various supraglottic pathologies in 49 patients by laser epiglottectomy. Utilizing general endotracheal anesthesia, the majority of patients (23) were treated for supraglottic airway obstruction caused by benign or malignant tumors, inflammatory processes, and postradiation edema. Other indications for laser epiglottectomy included diagnosis and staging of supraglottic carcinoma (18 patients), debulking advanced tumors (14 patients), and treatment of localized carcinomas and improvement of glottic visualization due to epiglottic obstruction following trauma or radiation (four patients). This unique series is enhanced by the investigators' concise elaboration of the actual surgical technique. Such a report provides useful information to both the novice and experienced laryngeal surgeon. The lack of significant postoperative problems with alimentation, airway, or voice, attest to the skill of these investigators and the

In Reply .—The question raised regarding the accuracy of either CT or random biopsies in 20 patients who were initially seen with unknown primary malignant neoplasms and clinical cervical adenopathy. Of these 20 patients, the primary site was identified in 15 instances. In one patient with extensive nasopharyngeal carcinoma it was identified by CT scan; the initial biopsy result was normal. In another patient, the CT scan was normal and, on panendoscopy, a positive biopsy specimen was obtained from a superficial lesion of the piriform sinus. In two other patients, the CT scan showed a submucosal lesion at the piriform sinus that we were unable to confirm by repeated panendoscopy. Three patients with inapparent tumors at the tonsil on CT scan and physical examination had positive random biopsy specimens at this site for squamous cell carcinoma. The remaining eight patients had tumors which were identified at CT and confirmed

The clinical course of five patients with varying degrees of laryngeal trauma are presented to illustrate the predictive value of computed tomography (CT) in the management of laryngeal trauma. Computed tomography visualizes well the laryngeal skeleton, soft tissues and airway in the injured larynx. Cost effectiveness of CT scanning is an important consideration, and the authors have chosen their case examples to restrict this examination to selected patients.

• Computed tomographic (CT) scans were prospectively obtained on 68 patients with previously untreated stages III and IV squamous cell carcinoma of the oral and pharyngeal cavity. We report herein the results of CT evaluation of primary disease arising in these sites, improvements in contrast-enhancement techniques, and CT assessment of the patient's condition after radiation or chemotherapy treatment. (Arch Otolaryngol1982;108:688-692)

At the 1988 annual meeting of the American Laryngological Association in West Palm Beach, Fla, Dr M. D. Kelly and colleagues, University of Virginia, Charlottesville, presented their results on a study of radiotherapy treatment for stage I and II carcinoma of the glottis. This report included 148 patients treated initially by definitive radiotherapy over a 12-year period. All patients underwent radiotherapy employing megavoltage equipment with a dose range of 6000 to 6600 cGy. At three years, 93.6% of the stage I patients and 75.5% of the stage II patients were free of disease. In the stage I group, surgical salvage consisted of partial laryngectomy in four patients, total laryngectomy in one patient, and radical neck dissection in another patient. In the stage II group, 13 of 14 radiation failures were managed by partial laryngectomy (one patient), total laryngectomy (11 patients), and radical neck dissection (one patient), with a salvage rate

Steven Schaefer, MD, Ben Watson, PhD, Frances Freeman, PhD, et al, of The University of Texas Southwestern Medical School, Dallas, and The University of Texas at Dallas and Arlington reported the results of their electromyographic study of seven spasmodic dysphonic patients and five normal controls to the American Speech and Hearing Association National Meeting. This report was unique in that: (1) vegetative, paralinguistic, and linguistic tasks elicited activity in different regions of the brain; (2) control subjects were used to check the validity of the observations in the spasmodic dysphonic subjects; (3) multiple laryngeal, vagally innervated, nonlaryngeal vagally innervated, and nonvagally innervated muscles were assessed by indwelling electrodes; and (4) digital processing techniques were used to provide both qualitative and quantitative assessment of electromyographic signals. The results of this study offer several new insights into spasmodic dysphonia. First, the presence of abnormal neuromotor activity within the levator palatini demonstrates that

Gastroesophageal reflux (GER) is a common condition with many manifestations which are of interest to the otolaryngologist. Factors predisposing to GER include anatomic abnormalities of the esophagus and pharynx, neurogenic disease and diet induced decreased lower esophageal sphincter pressure. Three interesting cases are reported, including subglottic stenosis which has not previously been thought to be a complication of GER. A literature review of otolaryngologic symptoms, the problems of diagnosis, and a suggested treatment plan are presented.

The types of temporal bone fractures, longitudinal and transverse, are reviewed. All cases of bilateral temporal bone fractures at Parkland Memorial Hospital in Dallas over a 10-year period from 1968 to 1978 are reivewed and discussed by the authors. One hundred sixty patients with the diagnosis of base of skull fractures were studied. Fifty-nine of these were temporal bone fractures and 17 of the 59 were bilateral. Of all the base of skull fractures, 10% were bilateral temporal bone fractures and 29% of all temporal bone fractures were bilateral. For each case the method of injury, the extent of damage to hearing and facial nerve function, presence of CSF otorrhea, X-ray findings, and additional complications are summarized and the results discussed. The operative findings of facial nerve decompressions are carefully reviewed. The authors' method of caring for temporal bone fractures is presented.

To improve our management of optic neuropathy from thyroid eye disease, we have refined the external ethmoidectomy approach, which permits the removal of the medial orbital wall and adjacent floor. We now report our experience with six patients (11 eyes) selected for this surgical technique. These patients are part of a larger population of patients with thyroid eye disease who have been surgically managed by us over the last 6 years.

Benign and malignant neoplasms of the upper aerodigestive tract that invade the middle cranial fossa are frequently considered unresectable due to the proximity of the cavernous sinus and internal carotid artery, and to the inaccessibility of this region via conventional surgical approaches. We report our experience using a combined, lateral intracranial and infratemporal fossa procedure for the management of these tumors in four patients. Successful removal of neoplasm associated with minimal morbidity was accomplished in 3 patients, 2 with angiofibromas and 1 with an adenoid cystic carcinoma. The postoperative course of the fourth patient was complicated by meningitis which resulted in the patient's death five months following resection of an adenocarcinoma.