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Home , Laryngectomy, Rhinoplasty

and excision of malignant vocal cord lesions while they are still extremely small. HERBERT H. DEDO, M.D.

REFERENCES Jako GJ: Laryngoscope for microscopic observation, and pho- tography. Arch Otolaryngol 91:196-199, Feb 1970 Hurzeler D: Microsurgery of the larnyx. Arch Otolaryngol 93:521- In the past few years, more emphasis is being 524, May 1971 placed on conservation techniques in the surgical Kleinsasser 0: Microlaryngoscopy and Endolaryngeal Microsurgery. treatment of nasal deformity. Incisions are now Philadelphia, W.B. Saunders Co. 1968 planned to offer maximum exposure of the in- ternal structures of the nose with minimum de- struction of the and , thus lessening atrophy and the formation of tissue. Conservation Surgery of the Better understanding of the physiologic func- Conservation surgery is the term given to the tion of the with the relationship of laryngeal procedures which totally remove ma- the nasal pyramid is being stressed. Not only is lignant lesions in selected cases while preserving cosmetic result important, but the maintenance one or both and thus the patient's of a functional airway is emphasized. The ana- voice. Two such procedures are vertical hemi- tomic relationship of the upper and lower lateral and supraglottic laryngectomy. with the nasal septum and how they Vertical hemilaryngectomy can be used to re- affect breathing are important considerations. move a localized lesion that is limited to the In the ideal result the patient has excellent superficial layers of the true vocal cord, occa- nasal function as well as a good cosmetic appear- sionally even after a full course of radiation ance. Therefore, the accomplished rhinologist therapy has failed. Supraglottic laryngectomy strives to attain function as well as beauty. can be used to remove limited to the MEYER SCHINDLER, M.D. false cord, aryepiglottic fold, , base of tongue and piriform sinus. It is usually preceded by a partial dose of radiation therapy when the REFERENCES lesion involves the pharyngeal mucosa. Since so Anderson JR: New approach to rhinoplasty-A five-year reappraisal. Arch Otolaryngol 93:284-291, Mar 1971 many of the patients with supraglottic malignant Martin H: Surgery of the crooked nose. Arch Otolaryngol 92:583- 587, Dec 1970 disease are in active middle life and anxious to Diamond HP: Rhinoplasty technique. Surg Clin North Am (Cos- return to work, preservation of the voice is es- metic Surg): 51, 2:317-331, Apr 1971 pecially desirable. HERBERT H. DEDo, M.D.

REFERENCES Ogura JH, Saltzstein SL, Spjut HJ: Experiences with conservation surgery in laryngeal and pharyngeal carcinoma. Laryngoscope 71:258- 276, Mar 1961 Microscopic Dedo HH: Supraglottic laryngectomy indications and techniques. In the last three years, fiberoptically illumi- Laryngoscope 78:1183-1194, Jul 1968 nated laryngoscopes have been developed which, by their brilliant light and improved design, permit use of the operating microscope during laryngeal surgical procedures. The operating microscope, with stereoscopic magnification, as- Audiologic Evaluation in Newborns sists in the precise removal of lesions such as Identification of hearing impairment as early singer's nodules, polyps and leukoplakia, from in life as possible has been recognized and im- the vocal cords. Magnification of 6 to 10 times plemented in numerous newborn nurseries in the favors complete removal while preserving the . substance of the vocal cord. Use of the operat- Downs and Hemingway (1969) found the in- ing microscope also permnits early identification cidence of hearing loss at birth to be one in

74 SEPTEMBER 1972 * 1 17 * 3 1,000 in their study of 17,000 newborn infants. , drooling, and the appearance of a Another estimate (Downs and Sterrit, 1964) large, rounded, cherry-red epiglottis visible above found that peripheral hearing impairment may the posterior third of the tongue. Since these are appear in one of every 2,000 babies. usually streptococcal , large doses of The Joint Committee on Newborn Hearing penicillin administered promptly are most effec- Screening Program, February, 1971, issued the tive. Corticosteroids have no place in the treat- following statement on the subject of newborn ment of acute epiglottis. If is not testing: "Review of data from limited number performed, the airway must be watched very of controlled studies which have been reported closely until the subsides. to date has convinced us that results of mass Acute laryngitis. This is characterized by screening programs are inconsistent and mis- hoarseness or complete'loss of voice. There is no leading." respiratory distress since there is an adequate However, the final recommendations of the glottic' airway. This type of edem'a involves the conference do include identification of newborns true vocal cords and is usually caused by voice by prenatal history and postnatal physical as- abuse or chemical irritation of the vocal cords. sessment of the infant. This would include ba- The treatment consists of sinple voice rest, ab- bies who have a family history of deafness, ru- solute abstinence from smoking, and occasional bella, congenitXal malformnations of the external steamn inhalations. Corticosteroids are used only , cleft lip or palate, infants having a bilirubin in severe cases where rapid resolution is neces- value of 20 mg percent or more, who had ex- sary-for example, in the treatment of opera change transfusions at high risk of bilirubin singers. encephalopathy, all infants under 1,500 grams of Acute laryngo-tracheo-bronchitis (croup). This weight, and all infants with abnormal otoscopic is an inflammatory disease of the lower respira- findings. tory tract consisting of severe inflammatory ede- In view of the controversy of infant testing, ma of the cpnus elasticus regiQn just below the there appears to be a general consensus that we true vocal cords. The onset of the condition is do need some kind of auditory screening or an characterized by rapidly developing inspiratory auditory high risk register at the time of birth stridor, the typical barking sound pf a croupy to detect early deafness. cough, and the presence of a relatively normal JANICE R. SIEGEL, M.A. voice. It is in this condition that the proper administration of corticosteroids is extremely REFERENCES important and will nearly always obviate tra- Downs MP, Hemingway WG: Report on the hearing screening of cheotomy. 17,000 neonates. International Audiology 8:72-76, Jan 19 9 Downs MP: The identification of congenital deafness, Trans Am The treatment of acute laryngo-tracheo-bron- Acad Ophthalmol Otolaryngol 74:1208-1214, Nov-Dec 1970 chitis consists of the use of a cold mist croup tent (croupette), , and . Since the infectious organism is most commonly alpha- hemolytic streptococcus, Hemophilqs influenzae, beta-hemolytic streptococcus, and Staphylococcus albus, in that order of incidence, ampicillin is the drug of choice. Corticosteroids shoi4d be Laryngeal Edema and administered intravenously or intramuscularly in Corticosteroid Therapy large shock doses. Since adrenal suppression is There are three major types of laryngeal not a factor to be considered here and since the edema which need to be differentiated before treatment is aimed at rapid resolution of tissue therapy can be begun. These vary according to edema, the initial dose should not be less than the location of the obstructive edema. 100 mg of soluble hydrocortisone (Solu-Cortef®) Acute epiglottis. This is an acute infectious or 40 mg of methylprednisolone (Solu-Medrol®), edema of the epiglottis. When it occurs in chil- even in small infants. If the initial dose fails to dren it represents an emergency and usually re- relieve the respiratory stridor, a second dose of quires tracheotomy. It is characterized by in- equal strength should be given one hour later. spiratory as well as expiratory stridor, diffici4ty A "maintenance dose schedule" is ineffective and

CALIFORNIA 75 The Western Journal of Medicine