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Nasopharyngeal stenosis and oropharyngeal stenosis are rare and challenging problems in the pediatric population. The most common etiology is currently the surgical trauma associated with adenotonsillectomy. Stenosis can vary from a thin band to a complete obstructing cicatrix. Presenting symptoms range from mild hyponasal speech to severe airway obstruction. We present a series of eight children with varying degrees of stenosis and associated symptoms. Choice of treatment varied with the severity of disease. In our series, successful interventions included triamcinolone acetonide injection, lysis of adhesions, rotational and advancement mucosal flaps, and jejunal free flap. Preoperative evaluation and individualized surgical repair are essential for successful treatment.

Magnetic resonance imaging (MRI) of the airway has recently emerged as a diagnostic tool for evaluating tracheobronchial obstruction in pediatric patients. Computer-assisted reconstructions of transaxial images have enabled three-dimensional reconstructions of the airway to be manipulated in any plane and visualized in relation to adjacent anatomical structures. Eight patients in whom magnetic resonance imaging was used to diagnose a variety of airway obstructive lesions are presented. A protocol for the evaluation of pediatric tracheobronchial obstruction is presented, with the role of three dimensionally reconstructed MR imaging emphasized.

Purpose: To describe the appearance of recurrent malignant neoplasms in patients who have undergone resection of primary head and neck tumors with flap reconstruction., Methods: Thirty-two examinations, 26 CT and 6 MR scans, were retrospectively reviewed in 25 patients with documented recurrent malignant neoplasms. Confirmation of disease was by biopsy or disease progression. The flaps included 15 myocutaneous, 6 free composite, 2 jejunal free grafts, and 2 combined jejunal and myocutaneous flaps., Results: The most common location of recurrence was in the primary tumor bed involving the undersurface or suture line of the reconstruction flaps, 14 of 32 scans; both nodal and flap recurrence was seen in 12 of 32 scans., Conclusions: When examining patients who may have recurrent disease after flap reconstruction, the radiologist should be aware of the type of flap used and the expected appearance. Tumor recurrence in this patient population is manifest either as a focal recurrent mass at or near the suture line of the reconstruction flap, or nodal disease, usually in the contralateral neck.

The neonatal laryngocele is a congenital pathologic entity originating in the saccule of the laryngeal ventricle. This entity may present as an uncommon cause of neonatal airway obstruction. We present two cases of this condition and the management undertaken. Both patients demonstrated significant airway distress. Evaluation of each patient included either plain x-ray films of the neck, ultrasound, or computed tomography of the neck. A cystic mass, containing air and fluid, was identified causing external compression of the airway in each case. Surgical intervention required airway endoscopy and an external approach to excise the mass. Tracheotomy was avoided in both cases; however, one infant required further surgery for laryngomalacia. Both children have done well in follow-up.

Mandibular fracture management has evolved over several decades, and controversies exist over ideal approaches for individual fractures. Treatment choices include closed versus open techniques, reduction methods and repair, and decision concerning intermaxillary fixation. Both the patient and the fracture characteristics have an impact on these choices. Patient factors include age, mandibular bone quality, dentition, patient reliability, and associated injuries. Fracture characteristics include favorability versus unfavorability, single versus multiple, location, and infection. This study was undertaken to develop and evaluate a management algorithm to determine the best treatment of mandible fractures. Sixty-seven patients were managed at the Grady Memorial Hospital otolaryngology service. Ages ranged from 3 to 68 years and included 55 male patients and 12 female patients. Forty-three patients had multiple fractures, while 24 had single fractures. Sixty-four patients were successfully managed and had normal function on follow-up examination. Eleven patients (16.4%) had complications. These included three infections, one malunion, two malocclusions, and five marginal nerve pareses. Multiple fractures did not have a higher incidence of complication. This protocol allows an orderly approach to the successful outcome of mandibular fractures.

Objective: This article summarizes the phase-specific nature of a cell surface, 44-kd tumor-associated transplantation antigen glycoprotein expressed during early and middle gestation in a portion of rodent and human fetal cells during normal fetal tissue development and illustrates how this glycoprotein is consistently recrudesced in primary and established human squamous cell carcinomas and other human and rodent tumors. The oncofetal antigen was not detectable in any human or rodent term fetal tissue or normal adult tissues tested. The tumor-associated transplantation antigen was tumor specific, yet not germ-line specific (expressed in lymphomas, sarcomas, and carcinomas) in human or rodent cancers. Rodent model tumor studies have shown 44-kd oncofetal antigen can act as a tumor-associated autoantigen of potential use in cancer detection and therapy., Design: The oncofetal antigen was detected by immunogenicity, flow cytometry, and Western blotting in syngeneic rodent tumor recipients and by the last two methods in humans with progressive cancer. Syngeneically derived mouse monoclonal antibody (MoAb 115) was used to identify 44-kd oncofetal antigen. Early to middle gestation, oncofetal antigen-positive, mouse embryo/fetal cells used to stimulate the hybridoma were tested for immunogenicity as a tumor-associated transplantation antigen in syngeneic hosts., Setting and Patients: Patients presenting with head and neck squamous cell carcinoma (N = 25) and other carcinomas at the University of South Alabama Medical Center, Mobile, underwent a biopsy, and the tumors were mechanically dispersed and were then tested for oncofetal antigen expression directly in flow cytometry. The tumors were also cultured and tested as squamous carcinoma cell lines. Growing squamous carcinoma cells and uncultured tumor cells were stained with MoAb 115 or control MoAb. Extracts of the cells were banded by electrophoresis in gels, Western blotted, and reacted with MoAbs and enzyme-linked immunosorbent assay second antibody. Time-mated mouse fetus and human fetal cells were also stained with MoAb 115 or control antibody and analyzed in the flow cytometer., Results: Eight- to 13-day mouse fetal cells conferred protection against syngeneic tumor challenge. Term 18- to 21-day fetal or neonate or adult mouse cells were nonprotective. All head and neck squamous cell carcinomas tested expressed 44-kd oncofetal antigen by flow cytometric analysis and in Western blots as did ATCC cell lines of these tumors, whereas normal control tissues were negative. Second trimester human fetal cells were 44-kd oncofetal antigen positive. A large spectrum of rodent sarcomas and lymphomas express the OFA., Conclusions: Shared 44-kd oncofetal antigen OFA offers promise as a tumor detection marker in human squamous cell carcinoma and other human carcinoma development, and syngeneic mouse tumors are good model systems to explore oncofetal antigen antigenicity.

Methods of treating malignant tumors of the extracranial portion of the head and neck have become more sophisticated. Cross-sectional imaging is extremely important in the evaluation of patients with a tumor in the head or neck. Although the complexities of head and neck radiology may be overwhelming, a uniform approach that first determines the location and extent of the primary tumor and then examines the nodal chains for metastatic adenopathy takes much of the mystery out of the process. MR imaging allows improved soft-tissue contrast and direct multiplanar acquisition of data, two advantages over CT. This review describes the current role of imaging in the clinical assessment of a patient with a malignant tumor in the head and neck, including the questions that must be answered before surgery and when MR imaging is the preferred technique.

Purpose: To report our experience with the radiographic evaluation of severe complications resulting from the functional endoscopic sinus surgery (FESS) procedure., Patients: Ten major complications were reviewed retrospectively., Findings: Ten major complications occurred. Eight of 10 had injury to the floor of the anterior cranial fossa, fovea ethmoidalis (roof of the ethmoid sinus), or roof of the sphenoid sinus. Six patients presented with meningitis or rhinorrhea, two presented with headache and massive pneumocephalus; one patient who presented with meningitis had a large nasal frontal encephalocele. Noncontrast brain CT that included the paranasal sinuses adequately evaluated the source of pneumocephalus. Thin-section coronal CT accurately predicted the site of leak in five patients. Both coronal sinus CT and MR imaging were useful to confirm the nasal encephalocele. Two of 10 had vascular injury secondary to FESS. One patient presented with subarachnoid hemorrhage seen on noncontrast CT and cerebral angiography demonstrated an aneurysm of the anterior cerebral artery. The second patient suffered severe intraoperative hemorrhage. Emergency angiography revealed a pseudoaneurysm of the cavernous carotid artery, and balloon occlusion of the artery was performed. No deaths occurred in this series., Conclusion: Radiologists should be familiar with the rare, but potential complications of this commonly performed procedure in order to help direct the work-up in an efficacious manner.

Oncofetal antigens (OFA) are proteins expressed during periods of embryonal/fetal development and on malignant cells. Previous investigations detected the presence of phase-specific 44- and 200-kd OFA, using a monoclonal antibody (MoAb 115). This study will determine if primary head and neck squamous cell carcinomas express the 44-kd OFA, and will assess the possible role of OFA in oncogenesis. Fifteen primary human head and neck squamous cell carcinomas (HNSCC) and six HNSCC cell lines were tested for OFA expression. Thirteen primary cancers and three cell lines demonstrated various degrees of OFA positivity. Oncofetal antigens are proposed to represent a proto-oncogene active during fetal development and malignant growth in head and neck squamous cell carcinomas.

Radiation-induced changes within skeletal muscle may be seen on follow-up CT or MR scans in patients who have undergone postoperative radiation therapy for head and neck tumors. Because they may mimic recurrent disease, these changes should be borne in mind.

From 1979 to 1989, 21 patients underwent craniofacial resection for malignancies involving the anterior skull base. Histologic types included 8 squamous cell carcinomas, 3 chondrosarcomas, 2 melanomas, 2 basal cell carcinomas, 2 adenocarcinomas, 2 poorly differentiated carcinomas, 1 malignant schwannoma, and 1 malignant hemangiopericytoma. Survival was 57%, with follow-up of 41 months. A 50% complication rate included osteomyelitis, cerebrospinal fluid rhinorrhea, meningitis, brain abscess, epidural abscess, and syndrome of inappropriate antidiuretic hormone. Recurrent disease occurred in 9 patients (41%), the most reliable predictor being dural invasion indicated preoperatively by CT scan or at operation. Patients demonstrating dural involvement (N = 9) had a 22% survival rate, while patients without (N = 12) had a survival rate of 83%. The impact of dural invasion on long-term survival is emphasized. Though complications were frequent, long-term results were favorable.

Patients with recurrent neoplasms of the head and neck present perplexing management problems, and accurate preoperative assessment of their disease is crucial. Thirty-eight patients with suspected recurrent neoplasms comprise this study: 30 had computed tomography scans, 4 had magnetic resonance images, and 4 patients underwent both computed tomography and magnetic resonance imaging to assess the anatomical extent of pathology in 34 malignant and 4 benign tumors. Contrast enhancement was essential for detecting disease on computed tomography scan. Differentiation of recurrent tumor was more difficult when the patient had undergone radiation. Magnetic resonance imaging demonstrated superior visibility in recurrent parotid and paranasal sinus neoplasm, but was less helpful in laryngeal and pharyngeal recurrences. Computed tomography demonstration of a mass with infiltration of normal fat or tissue planes or lymphadenopathy correlated highly with recurrent disease. Imaging techniques and fine points for determining recurrent neoplasms are presented.

Penetrating head and neck trauma in children causes uncommon and potentially life-threatening injuries. We reviewed the charts of 21 patients who sustained penetrating injuries to the face or upper neck. Seventeen males and 4 females, aged 32 weeks' gestation to 19 years (mean = 10.2 years) comprised the study population. There were 15 gun-shot wounds, 1 shotgun injury, and 5 stab wounds. Significant problems included 7 vascular injuries, 6 central nervous system injuries, 5 ocular injuries, 3 airway compromises, 2 facial nerve injuries, 1 cervical esophageal penetration, and 2 cases of pneumothorax. Three deaths occurred, but the majority of the patients survived and sustained minimal permanent disability. Included in this review is a unique case of an intrauterine gunshot wound to the face at approximately 32 weeks' gestation. The treatment protocol, differences from adult patients, and management highlights are reviewed.

The purpose of this study was to review mechanisms, etiologies, associated injuries, and treatment of maxillofacial trauma in children and to compare them to similar adult injuries. Thirty blunt injuries (1984-1986) comprised the children's group, and 176 injuries, the adult group. Multiple associated injuries were more common in children, the most frequent being CNS and orthopedic injuries. Detailed anatomy of mandibular fractures required pleuridirectional tomography in 63% of the pediatric cases compared to 12% in adults. In the children's group, the mandibular fractures were favorable in 56% of cases compared to 15% in adults. Children required shorter periods of intermaxillary fixation with no child requiring reapplication of fixation. Based on these comparisons, a protocol for the management of pediatric maxillofacial injuries has been developed.

Three nasofrontal encephalocoeles managed at the University of South Alabama Medical Center are presented. Each consisted of abnormal brain originating from one frontal lobe, although the amount of cerebral tissue and the accompanying skin and meningeal layers varied. The encephalocoeles protruded through a defect in the anterior skull base near the cribiform plate. Repair in the neonatal period was required in two of the infants because of the size of the lesion and obstruction of the nasal airway. The operative approach utilized a bifrontal craniotomy with resection of the encephalocoele intradurally, repair of the anterior cranial fossa dura and osteoplastic repair of the foramen cecum defect. The closure of the facial defect depended upon the nature of the skin covering the herniation; either absence or excess of skin occurred. The preoperative evaluation disclosed associated congenital deformities in 2 of 3 patients in this series. Computerized tomographic scanning was of importance in preoperative planning. The operative technique can be modified to allow for each child's unique anatomy. Repair of nasofrontal encephalocoeles in the neonatal period may simplify the required operative procedures.

The major source of controversy that surrounds the use of radiation for glomus tumors is the finding of persistent chief cells years after completion of the treatment. Questions have been raised as to the viability of the irradiated chief cell and its capacity to proliferate. The radiotherapists consider a stable glomus tumor a radiation "cure," whereas skull base surgeons are fearful that these lesions will continue to slowly grow and cause problems 20 to 30 years later. We have recently managed a patient who was not a candidate for surgery, with a catecholamine-secreting glomus jugulare tumor. After 4750 rad of radiation therapy, no changes in tumor size or in catecholamine secretion have been observed (at 20 months of followup). The implications of the case are discussed.

Laryngotracheal trauma is rare and complications are frequent. Twelve major series totalling 392 cases have been published over the past decade, with complication rates as high as 40%. We have treated over 30,000 trauma victims at our Level I Trauma Center over the past 5 years, of which 109 had neck injuries, but only 12 suffered cervical laryngotracheal trauma. The mechanism of injury was penetrating in eight and blunt trauma in four. The time to tracheostomy decannulation varied from 7 to 60 days. Airway patency was assured without stenosis or significant granulation tissue in 10 of the 12 patients. Three patients suffered permanent voice changes. Based on review of the 392 previously reported cases and a critical analysis of our 12 cases, a detailed management algorithm is proposed.

Most primary human carcinomas uniformly express an oncofetal epitope which has not been demonstrated previously in established human carcinoma cell lines. We successfully derived several low-passage cell lines of human squamous cell carcinoma (SCC) from head and neck tumors using an in vitro adaptation procedure, characterized these lines, and examined them for expression of a 44-kilodalton (kD) polypeptide (PP) oncofetal antigen (OFA) at the cell surface. Newly established an in vitro-passaged SCC cells retained characteristic microvilli, numerous desmosomes and tonofilaments, abundant rough endoplasmic reticulum, osmophilic keratohyaline granules, and other features of the primary SCC cells. These new cell lines and two long-term, established SCC lines (FaDu and Detroit 562) displayed OFA at the cell surface, as determined by flow cytometry using monoclonal antibody (MoAb) 115. While the FaDu and Detroit 562 lines exhibited aneuploidy during flow cytometric analysis, the new, low-passage SCC lines that we developed remained diploid as were the primary SCC cells from which they were derived. We propose that the expression of a 44-kD OFA is a common feature of human SCC. This marker may prove useful in the detection and treatment of these tumors.

A retrospective search of the Duke University Melanoma Clinic patients identified 399 cases with primary malignant melanoma located in the head and neck region. Ninety-five percent of the deaths in this series were from metastatic melanoma. Various clinical and pathological data were examined and their effects on survivability and disease-free intervals were evaluated. The characteristics noted included sex, age, depth of the invasion, thickness, site of the lesion, histologic type, and nodal status. A multivariate regression analysis identified the following factors as having a negative effect on survival: nodular histologic type, scalp primary, increasing Clark level, and male sex. In comparing head and neck, extremity, and truncal primary sites, the median survival for patients with head and neck malignant melanomas was notably less. These differences correlated with a higher incidence for male patients, for patients with thicker lesions, and for patients with an increased frequency of nodular histologic type.

Competition between otolaryngologists and anesthesiologists for the limited space of the airway results in compromised control for both concerns. The surgeon desires an unobstructed view, whereas the anesthesiologist must ensure adequate ventilation. The drawbacks of standard methods include inadequate airways, inadequate visualization, and operating room contamination from inspired gases. Since 1984, we have developed a technique utilizing jet ventilation delivered through a metal delivery system providing a relatively safe, ignition-free environment. A total intravenous anesthetic technique is used to avoid any environmental contamination. The newer short acting, high potency narcotic, sufentanil citrate, combined with a short acting muscle relaxant, atracurium besylate or vecuronium bromide, have made this technique an ideal one for our needs. The pulse oximeter provides an invaluable margin of safety. This technique has been employed in 36 microlaryngeal procedures performed on 21 patients with a uniformly smooth perioperative course and only one complication. The technique, possible pitfalls, and applications are discussed.

Penetrating wounds of the face present a spectrum of injuries and multiple management dilemmas. The surgeon's first concern remains the establishment of a proper airway and control of life-threatening injuries. Selected ancillary diagnostic procedures should be used to confirm vascular, aerodigestive, or central nervous system injuries. Diagnosis of injuries may require arteriography, endoscopic examination, barium studies, computerized tomography, and detailed ophthalmologic examination. We review 16 cases of penetrating facial trauma treated at the University of South Alabama Trauma Center over a one-year period. The injuries resulted from 13 gunshot wounds and three stab wounds. Injuries of the central nervous system occurred in three patients, mandibular fractures in four, optic nerve or globe injury in three, and maxillary sinus fracture in seven. Our experience with these patients demonstrates the spectrum of injuries and serves as a basis for a management algorithm.

Basal cell carcinomas involving the ear represent a spectrum of diseases, from a small superficial auricular lesion to an advanced destructive malignancy invading the temporal bone. The biologic activity of the morphea-form basal cell carcinoma variant of tumor and a postauricular location predispose to an aggressive biologic pattern. Management requires a thorough evaluation with determination of the degree of cranial and possible intracranial invasion. These lesions usually can be managed with partial temporal bone resections, although prognosis for patients with advanced lesions may be poor.

The management of pediatric upper airway disorders requires rapid assessment of the patient's status and prompt airway support. The recent development and popularity of pulse oximetry in the management of patients having general anesthesia for surgical procedures has proved the efficacy of this technology. The University of South Alabama Division of Otolaryngology has managed 18 children with upper airway disorders over the past year using pulse oximetry as adjunctive monitoring. The outcome was excellent in all 18 cases. The second-to-second monitoring of oxyhemoglobin saturation provided excellent measurement of the patient's ventilatory status. The advantages include noninvasive monitoring, serial second-to-second display, easy interpretation by nursing personnel, absence of false-negative results, and excellent patient acceptance.

Many otolaryngologic procedures can be performed safely on an ambulatory basis. Complications can be minimized by careful patient and procedure selection. This article describes common procedures adaptable to outpatient surgery and addresses the surgeon's added responsibility in this setting.

The first step in trauma care is establishing an adequate airway. With laryngotracheal injuries the airway itself is injured, making this primary task more difficult. Several areas of management for patients with laryngotracheal trauma are controversial, and treatment dilemmas exist. These dilemmas include initial airway management, indications for computed tomography, operative approach, and utilization of stents. This institution has utilized a standard protocol which addresses each of these management dilemmas for the past 3 years. Twenty-one patients are reported. Voice results were good in 13, fair in six, and poor in two. Airway results were good in 16, fair in three, and poor in two. Complications included two wound infections and one death. The protocol and management dilemmas for these injuries are discussed in detail.

The management of advanced squamous cell carcinomas of the head and neck has shown disappointing results with surgery and radiation alone. Chemotherapy offers a third method of managing these patients. A background of basic tumor biology and cell cycle kinetics is essential in designing an effective head and neck chemotherapeutic protocol. The principles of the cell cycle, stem cell regulation, and doubling times are discussed. The kinetic classification of chemotherapeutic agents and experimental hypotheses of clinical relevance are reviewed.