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EDITOR'S NOTE: The best surgical approaches for the treatment of chronic inflammatory frontal sinus disease have been hot ly d e b a t e d ove r the las t 100 years. The pendulum has been swinging back and forth between i n t r anasa l and e x t e r n a l approaches. This "Di f f icul t Decisions" article is dedicated to this topic. Four cases have been presented to two authorities in this field, Dr. Jonas Johnson and Dr. Steven Schaefer. The following issues are discussed: radiologic findings; pathophysiology; medical and surgical treatment; advantages and disadvantages of techniques; complications; and followup. Representative CT images are presented; however, not all the images provided to the authors are i nc l uded . We hope the reader will f ind the discussion stimulating and educational. Note: The following abbreviations are used in the illustrations accompanying the CT scans: FS, frontal sinus; C, crista galli; MT, middle turbinate; NS, nasal sinus; MS, maxillary sinus; LP, lamina papyracea; IT, inferior turbinate.

The posterior approach to sphenoethmoidectomy represents an alternative to the better known modifications of endoscopic paranasal sinus surgery. We present our modifications and experience with this technique over the last 4 years, and explain our rationale for selection of patients to be managed by this approach. This operation has proven useful in patients with extensive sinus disease, and/or previous surgery that has resulted in loss of normal anatomic landmarks to the sinuses.

The acute surgical management of the severely injured larynx is among the more demanding problems in laryngology, with early treatment decisions determining the outcome of both the airway and voice. To assist the physician with such decision-making, we report the rationale and operative techniques used at our institution to surgically manage 62 of 120 patients with acute laryngeal injuries for more than two decades. Such experience hopefully will also serve to help resolve several of the prevailing controversies over the care of such patients.

For 11 years, we primarily relied on frontal sinus oblit­ eration with fat via an osteoplastic flap approach to treat the majority of patients with medically refractive, chronic frontal sinusitis. For the past 4 years, we have primarily used an endoscopic, intranasal approach for initial surgi­ cal management of patients with disease similar to those treated in the earlier ll-year period. We made this tran­ sition to endoscopic frontal sinusotomy because of the following: 1. The advent of rigid fiberoptic endoscopes provides excellent visualization of the frontal recess and medial frontal sinus. 2. Recognition of the role of the anterior ethmoids in recurrent frontal sinusitis and the ability afforded to op­ erate at this site by endoscopes. 3. Knowledge of such surgery being used in Europe. 4. Our desire to minimize the surgical technique for the initial treatment of medically refractive disease.l" Last year, we reported our initial experience with en­ doscopic frontal sinusotomy. This article updates that experience and better describes our surgical technique. 1