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Objective: To characterize the otolaryngologic manifestations of amyloidosis; classify patients with amyloidosis by specific location and type of underlying disease; and compare disease presentation and long-term outcome in these patients. Design: Retrospective review of biopsy specimens recorded as amyloidosis. Setting: Tertiary care referral center serving a diverse patient base. Patients: Of 141 patients with biopsy-verified amyloidosis who met the inclusion criterion for the study, 27 (19%) had head and neck manifestations. Outcome Measures: Good functional outcome and survival of patients with amyloidosis. Results: The tongue was the most commonly affected site of the head and neck. Distinct differences exist in functional outcome and long-term survival in patients with the localized form of amyloidosis when compared with patients with systemic amyloidosis. Conclusion: Because amyloidosis often affects the head and neck, otolaryngologists need to be familiar with this disease. (Arch Otolaryngol Head Neck Surg. 1995;121:778-782)

Molecular biology of the vestibular system has been limited by a number of technical difficulties including fixation, decalcification of the temporal bone and the small size of specific structures relative to their surroundings. In situ hybridization histochemistry and immunoelectron microscopy allow the subcellular study of gene expression and gene products, respectively. We developed the methodologies necessary to apply these techniques to the central and peripheral vestibular systems. The central and temporal bone distributions of the neuropeptide calcitonin gene-related peptide (CGRP) mRNA and two genes coding for gap junction proteins, connexin C32 and C43 mRNA, were studied. The cellular distributions of these mRNAs are presented. In addition, examples of pre-embedding and postembedding immunoelectron microscopy are presented demonstrating the usefulness of these techniques in studying the subcellular localization of specific antigens. The ultrastructural innervation of the vestibular periphery by the efferent neuropeptide CGRP and ultrastructural evidence of glycoprotein secretion by the human endolymphatic sac is presented.

Evaluating the extent of tumor invasion of the mandible is clinically important in the management of mandibular tumors. Conventional imaging studies including panoramic radiography, bone scans, and computed tomography, as well as clinical evaluation can be unreliable in defining the extent of neoplastic marrow invasion. This study presents the initial UCLA, Los Angeles, Calif, experience with magnetic resonance imaging in evaluating mandibular invasion by benign and malignant neoplasms. Magnetic resonance imaging, using T1 and T2 images, was compared with conventional imaging methods in 11 patients with malignant lesions and nine patients with benign lesions. In all cases, magnetic resonance imaging most accurately determined the full extent of tumor invasion in the mandibular marrow spaces. Magnetic resonance imaging appears to be superior to offer clear benefits over conventional imaging methods, including computed tomography, for the evaluation of tumor invasion of the mandible.

Intralaryngeal injections of botulinum toxin (Botox), under electromyographic guidance, have emerged as an effective treatment for adductor spasmodic dysphonia. To remain effective, these injections must be repeated every 3 to 9 months as the symptoms recur. One drawback to the current method is the need for electromyographic confirmation of needle placement into the thyroarytenoid muscle. This report describes an anatomic approach to Botox injection that requires only flexible nasopharyngeal endoscopy and careful evaluation of the anatomic landmarks. This technique has been used successfully on 13 patients, and objective pretreatment and posttreatment measures are reported.

There are a variety of methods for treating unilateral vocal cord paralysis, but to date there have been few studies that compare these phonosurgical techniques by using objective measures of voice improvement. Vocal efficiency is an objective voice measure that is defined as the ratio of the acoustic power produced by the larynx to the subglottic air power. Vocal efficiency has been found to decrease with glottic disorders such as vocal cord paralysis and carcinoma. This study compared the effects of vocal fold medialization by surgical augmentation to those of arytenoid adduction on the vocal efficiency, videostroboscopy, and acoustics (jitter, shimmer, and signal-to-noise ratio) of a simulated unilateral vocal cord paralysis in an in vivo canine model. Arytenoid adduction was superior to surgical augmentation in vocal efficiency, traveling wave motion, and acoustics.

A series of 238 patients with laryngeal paralysis seen during a six-year period (1976–1982) were studied with serial 16-mm motion picture filmstrips. There were 39 cases in which no etiological disease process could be found responsible for the paralysis; these were called “idiopathic.” In all 39 cases, both the superior and recurrent laryngeal nerves were paralyzed indicating that the lesion involved the central (nuclear) lower motor neurons of the dorsal and ventral nucleus ambiguus. The high incidence of upper respiratory infections suggests a viral etiology in many cases. The ability to separate a pure recurrent from a combined superior and recurrent laryngeal paralysis on morphological indirect endoscopic appearance has significant diagnostic and therapeutic implications.

Tracheostomy during infancy often results in serious complications and even death. The current policy in many medical centers is to recommend extended hospitalization of an infant whenever tracheostomy is necessary. Almost all obstructing diseases of the infant larynx are treated by tracheostomy because of the concern that surgical intervention of the larynx may result in impaired laryngeal growth inadequate for airway or phonation. Since no applicable clinical or experimental reports could be found in the literature, a study was designed to determine the effect of laryngofissure on laryngeal development and function. Six five-week-old dogs underwent an anterior laryngofissure, three of which had placement of a Teflon® keel. The keels were removed six weeks later. Four five-week-old dogs served as controls. At maturity eight months later the ten animals were sacrificed just after direct laryngoscopy. Full vocal cord mobility was found, and the glottic aperture, including the anterior commissure, appeared to be normal. The larynges were excised and found to have the same dimensions and weight as did the controls. Microscopic studies revealed little scarring at the anterior commissure, and the thyroid lamina were bridged by fibrous and cartilaginous tissue with minimal displacement of the lamina. The results of this study suggest that the infant larynx may be divided by a midline vertical thyrotomy without impairment of laryngeal development or function.

Voice dysfunction is associated with neuromuscular impairment of laryngeal control and is often difficult to diagnose by indirect examination of the larynx. The newer techniques, currently used in the UCLA—Veterans Administration Medical Center Laboratories, provide some methods that aid in the diagnosis of voice impairment by providing documented objective data. Illustrative case reports of disorders of neuromuscular dysfunction of the larynx are presented and future research needs and direction are discussed.

This article discusses the importance of the evaluation and diagnosis of objective tinnitus (tinnitus heard by the patient and the physician). Intracranial arteriovenous communications and vascular anomalies are most frequently responsible for the tinnitus and auscultable bruits and are highly amenable to current surgical treatment. While the otolaryngologists may initially see these patients and be responsible for the diagnosis of their problem, the surgical correction of the intracranial lesions is usually the province of the neurosurgeon. Illustrative cases of extracranial causes are presented. Particular emphasis is placed on the diagnosis and treatment of venous hum. Formerly called cephalic bruit and essential objective tinnitus, venous hum is now a recognized nosological entity that is amenable to treatment by ligation of the internal jugular vein.

The juvenile nasopharyngeal angiofibroma, a rare neoplasm of adolescent males, is histologically benign but often clinically malignant. Although spontaneous regression of this tumour has been reported (Dane, 1954; Martin, Erhlich and Abels, 1948), this is not the usual clinical course and aggressive treatment is necessary to control symptomatic lesions. Surgical resection has been generally regarded to be the treatment of choice (Pressman, 1962; Rodriguez, 1966, English, Hemenway and Cundy, 1972). However, it has been our experience (Kadin, 1974), as well as that of others (Patterson, 1965), that results of attempted resection of angiofibromas which have extended widely beyond the nasopharynx have been poor. Because of this experience, a patient with an extensive nasopharyngeal angiofibroma was treated with radiation therapy with pre-and post-arteriographic studies to evaluate the extent of the tumour and the results of therapy. A 14-year-old Japanese-American male presented with a four-month history of n...

• Angioblastic lymphoid hyperplasia with eosinophilia, or Kimura's disease, is a clinically and histopathologically recognized entity that is characterized by cutaneous nodules, proliferating blood vessels with atypical histiocyte-like endothelial cells, and numerous eosinophils. It has been treated with steroids and by surgical excision, irradiation, cryotherapy, and electrodesiccation. Persistent residual disease and local recurrence are frequent. We review the literature and report two cases that involve the ear. We present the histopathologic and clinical results of laser removal of a conchal and external canal lesion. (Arch Otolaryngol1981;107:316-319)

• Neuromuscular dysfunction of the cricopharyngeus muscle is becoming increasingly recognized as a cause of dysphagia, particularly in the growing geriatric population. The disorder may occur primarily, or as part of a generalized neurologic syndrome. This debilitating and potentially lethal type of dysphagia, formerly managed by nasogastric tube or gastrostomy feeding, is usually correctable by simple section of the cricopharyngeus muscle. We report a series of six successfully managed patients to illustrate important aspects of diagnosis and treatment. ( Arch Otolaryngol 101:726-729, 1975)

A grantsman is usually considered to be a person who successfully writes grant applications. The term carries a connotation that the writer of the grant has some particular ability or inside track on the method needed to apply for and successfully acquire funds to support a project. There is also a negative aura that surrounds the term grantsmanship, which has been built up primarily by those unsuccessful in competing for funds. This negative connotation has been promulgated in the form of myths that are untrue stories without a base of reality. The purpose of this article is to dispel some of these misconceptions and untruths that are counterproductive in the preparation of a quality research grant application. In the preparation of this article, discussions have been held with a number of persons including grant applicants, former study section members, council members, and members of the National Institute of Neurological and

This study was conducted specifically to determine and document the various possible causes of postoperative aspiration. Such information may assist in better selection of candidates as well as provide insights that facilitate improvement of operative techniques for conservation surgery for cancer of the larynx. The major significant information derived from this study is the recognition and delineation of the part played by paralysis of the superior and recurrent laryngeal nerves as causes for aspiration following conservation laryngeal surgery.

Two cases with laryngeal manifestations of systemic lupus erythematosus presented demonstrate the value of serial indirect laryngeal photography and results of treatment for the mucosal and serosal effects of the disease.Systemic lupus erythematosus is an autoimmune collagen vascular disease which produces widespread damage to connective tissue, blood vessels, serosal surfaces and mucous membranes (Rodman et ah, 1973). It is no surprise that with such a widespread disorder the upper airways too may show involvement.Estimates of the number of patients with laryngeal involvement have ranged from one percent by Dubois (1966) to one-third of patients by other authors (Babich and Tranaov, 1970; Minchina et al., 1971).Systemic lupus erythematosus may cause laryngeal symptoms referrable to an active mucosal, submucosal or serosal process. With acute flares of the disease, mucosal ulceration, edema, and submucosal hematomas may result in hoarseness and throat pain (Scarpelli et al., 1959). One case of epiglottitis caused by increased mucosal swelling has been reported (Toomey et al., 1974). As the disease progresses, late effects of mucosal disease including corditis, mucosal thickening, laryngeal scarring with stenosis and laryngitis with dry, thickened vocal cords may appear (Babich and Tramaov, 1970; Smith and Ferguson, 1976). With serosal involvement, the patient may demonstrate perichrondritis, cricoarytenoid arthritis or actual vocal cord paralysis (Dubois, 1966; Montgomery and Lofgren, 1963).Histopathologic study of involved mucosa along with cultures of the tissue is not diagnostic of systemic lupus erythematosus but can help to rule out other disorders similar in appearance such as tuberculosis and rhinoscleroma. Klebsiella rhinoscleromata infections particularly can cause a similar early inflammatory mucosal and late scarred picture.Microscopic sections of mucosa from a patient who died of laryngeal edema secondary to systemic lupus erythematosus appeared similar to mucosa from a patient with subglottic stenosis (Smith and Ferguson, 1976) with an infiltration of histiocytes, lymphocytes, plasma and mast cells.The following two cases demonstrate the differences in the course of serosal and mucosal airways disease.

The development of fiberoptic endoscopes and the discovery of a new system of telescope optics have dramatically revolutionized endoscopy. These advances are discussed, and the superior photographic documentation that is now possible through these instruments is presented.

Presentation of Case First admission. A 24-year-old woman was admitted to the Massachusetts Eye and Ear Infirmary because of discomfort in the throat, hoarseness and nocturnal dyspnea and stridor. Four months previously she began to notice fullness in the throat. Six weeks before admission she became increasingly hoarse, particularly on awakening in the morning, and experienced dyspnea on exertion and difficulty in swallowing. She received tetracycline, without relief. One month before entry numerous cervical lymph nodes became enlarged. Three weeks later examination at another hospital revealed edema of the larynx and left side of the palate. She failed to . . .

Recent studies on the fate of pedicle osteocutaneous grafts have shown that they remain viable and may be actively involved in the mechanics of bone repair. This communication reports on a series of experiments aimed to clarify the role of periosteum in the survival of pedicle-assisted bone grafts. Osteocutaneous grafts were developed in dogs in such a manner as to isolate the implant from normal recipient bone. Free bone grafts were used as controls and a group of pedicle periosteal grafts were studied as potential sources of bone formation. Specimens were evaluated at regular intervals over a 40-week period. The pedicle bone grafts maintained their viability and developed vigorous osteoneogenesis. The process was progressive and eventually resulted in partial substitution of the original graft by new bone of periosteal origin. The free bone grafts were resorbed and no bone formation was obtained in pedicle periosteum specimens. The study provides clear evidence that under experimental conditions no bone contact is needed to maintain the viability of pedicle osteocutaneous grafts. It also shows that the periosteum has the leading role in the restructuring process of these grafts.

Objective measurement of vocal function is important in evaluating phonatory disorders, planning treatment, and documenting the effects of therapy. Glottographic measurement, ie, measures that describe glottal movement, can be performed and analyzed relatively easily, and can be related to the pathophysiology of vocal dysfunction. In our clinic, simultaneous recording of acoustic, photoglottographic and electroglottographic signals is being used in the evaluation of patients with voice disorders associated with neurologic impairments. Our experience with these measures indicates that they may provide detailed information about the vibratory patterns of the vocal folds, which appears to differentiate some phonatory characteristics among patients with differing types of disorders.

Recurrent tumor in or around the tracheal stoma following laryngectomy almost always terminates in a fatal outcome. Several investigators have attempted to determine the factors that predispose a patient to stomal recurrence, but their conclusions are not entirely in agreement. The records of 251 consecutive laryngectomy patients treated at the UCLA Hospital between 1955 and 1977 were reviewed. The variables evaluated included type of operation, preoperative tracheostomy, interval from operation to recurrence, presence of neck metastases, performance of thyroidectomy, site of lesion, and control of tumor margins. While certain events, such as preoperative tracheostomy, appeared more frequently than others in the stomal recurrence patients, no single factor or group of factors could explain all the recurrences. It appears that stomal recurrences arise from heterogeneous causes. Good planning and utilization of the principles outlined should reduce the incidence of this dreaded complication.

A new method of permanent tracheal fenestration is reported, utilizing cervical skin and tracheal flaps. It has been performed on four patients without complications and has the advantage of being a quick, simple, one-stage operation that is reversible should conditions change. The procedure is utilized in patients with posttraumatic or postirradiation fibrosis of the larynx, chronic obstructive pulmonary disease and patients with sleep apnea.

The suitability of cosmetic augmentation mentoplasty with percutaneous injection of polytef (Ethicon PTFE) paste for injection was studied in five monkeys. Six month observation and histologic sections of the mandible, chin, and adjacent lymph nodes shows this to be a potentially simple, safe, and effective method for correcting the receding chin. Augmentation mentoplasty by polytef paste injection has produced satisfactory short-term results in five patients.

The loss of a slight-to-moderate amount of perilymph during stapes surgery is not uncommon. A few cases have been encountered in which there was a massive welling up of fluid from the vestibule that filled the middle ear and external canal. Since the volume of the perilymphatic spaces is small, it is likely that this excessive fluid came from the subarachnoid space, possibly by a new pathway. The purpose of this paper is to postulate and attempt to demonstrate histologically how a new communication between the perilymphatic and subarachnoid spaces might occur. The close anatomical relationships of the oval-window region are discussed, and measurements of the distances between the various structures and the stapes footplate are presented. Very little has been said in the literature about the loss of perilymph during stapes surgery, except to caution against aspirating it from the vestibule after footplate fracture or removal. In general, the

THE MEDICAL literature contains numerous articles on the subject of branchial cleft cysts. Their origin and significance has been discussed from many points of view. By far the most common anatomical site for the occurrence of branchial cleft cysts is in the cervical area, generally anterior to the sternocleidomastoid muscle in the upper or middle portion of the neck. Review of the available literature revealed no cases resembling branchial cleft cysts occurring in the mediastinum. Among the large series of primary mediastinal tumors reported, no reference could be found to either a branchial cleft sinus or branchiogenic cyst by name or the histologic description of a lesion which resembles such a tumor. Though the possibility of a branchial cleft cyst in the mediastinum has been discounted by some and ignored by most, the diagnosis of such a lesion seems reasonable if certain criteria are met. If the histology is that

Cervical esophagostomy is an effective method of providing long-term tubal alimentation for the chronically ill and debilitated patient. Elimination of an unsightly feeding tube and unpleasant irritation to the nose and upper-airway passages contributes to the patient's comfort and wellbeing. Cervical esophagostomy eliminates the inconveniences of gastrostomy and is not accompanied by skin irritation caused by regurgitation of food. The technique is superior to and should, in the future, replace gastrostomy for patients with swallowing problems. The many advantages discussed far surpass the few complications encountered. New modifications of the technique have lessened the incidence of complications, which should lead to greater acceptance of the procedure.

THROUGHOUT the history of medicine, physicians have sought to restore anatomically deficient areas of the human body by autogenous, homologous, and synthetic materials. Beyond any doubt, the preferable substances as far as tissue tolerance is concerned continues to be autogenous materials. While physiologically more acceptable, autogenous materials suffer from many disadvantages. These include availability, the necessity for surgical acquisition and implantation, and the problem of reabsorption. The search for well-tolerated synthetic material has been underway almost as long as has the search for the fountain of youth and has been as elusive as the pot of gold at the end of the rainbow. The desire stems from the advantages that an ideal synthetic implant would provide. These include immediate availability, ease of sculpturing and molding, elimination of need for donor or donor site, and diminution or absence of resorption. The use of an injectable type synthetic implant also eliminates the

• Varicosities or swollen veins of the periorbital temporal and frontal areas are uncommon except when tumor or inflammatory diseases involve the orbit. The recent surge of interest in cosmetic appearance has created a new concern in some patients about dilated veins of the periorbital area that have previously been considered normal. These engorged vessels are considered as cosmetic blemishes and thus present the physician with a problem. A new successful technique of electrothrombosis with an insulated 27-gauge needle is described, and the experience in three cases is discussed. ( Arch Otolaryngol Head Neck Surg 1987;113:286-288)

• Controversy surrounding the surgical treatment of thyroid cancer is discussed. The various approaches are lobectomy, isthmusectomy and lobectomy, subtotal thyroidectomy (sparing the capsule and some tissue on the contralateral side in an effort to decrease the complications of bilateral recurrent nerve paralysis and hypoparathyroidism), and total thyroidectomy. The surgical treatment options for each histologic type of thyroid gland malignancy are also discussed. For well-differentiated carcinomas of the thyroid, a strong case is made for total thyroidectomy. ( Arch Otolaryngol Head Neck Surg 1986;112:1204-1206)

• A further miniaturization of the lens telescopes (Hopkins Rod) has resulted in a telescope (length, 6 cm; diameter, 2.7 mm) that is suitable for pediatric otoscopy. The adaptation of otoscopic specula, a lightweight motor-driven remote flash camera, and movie and video photography to this telescope has resulted in a system that represents a significant advance in the examination of the ear. In this study, we document ear diseases in children with the use of color photographs. (Arch Otolaryngol105:431-433, 1979)

Observations of patterns of laryngeal dysfunction in patients with known as well as unrecognized neurological disease have provided the basis for a new classification. Representative patients are used to describe typical patterns of laryngeal dysfunction which occur with afferent and efferent (upper motor neuron, extrapyramidal, cerebellar and nuclear pathways) neurological disorders. The value of cinephotography in documenting and avoiding the pitfalls of brief indirect laryngoscopy is emphasized as a factor in achieving a correct diagnosis in patients with laryngeal diseases of central origin.

The diagnosis and management of carotid body tumors are discussed, including the importance of good arteriography which allows visualization of all major feeding vessels. These include the carotid bulb, internal and external carotid arteries and the often neglected but important vertebral and ascending cervical arteries. Emphasis is placed on the importance of establishing tourniquet control of the common, internal and external carotid arteries. Surgeons removing carotid body tumors should be experienced in arterial wall repair by means of vascular shunts, end-to-end arterial anastomosis, and vein graft replacement of a segment of arterial wall.

A comparison was made between the phase of vestibulo-ocular reflex (VOR) responses to sinusoidal rotatory tests and the phase of the subjective sensation (SS) to rotation. A parallelism was found between the results of both sets of data such that they behaved in accordance with the prediction of the pendulum model of vestibular function. The time constant of the VOR (17.5 seconds) was longer, however, than that of the SS (13 seconds). Measurements in patients with unilateral labyrinthine pathology also showed comparable changes in both responses. One group of patients with complete unilateral labyrinthine paralysis showed an advance of the phase of the VOR and of the SS. However, phase measurements in the group of patients with only partial unilateral labyrinthine paralysis were not significantly different statistically from those of normal subjects.

Myocutaneous flaps have become increasingly popular in reconstructive head and neck surgery. As surgeons have gained familiarity with them, many of the advantages, limitations, and complications of these flaps have become apparent. A rare but serious complication of myocutaneous flaps is recurrent tumor within the pedicle. Three cases of squamous cell carcinoma involving three different myocutaneous flaps are presented and the literature is reviewed. Possible mechanisms of tumor metastasis to myocutaneous flap pedicles are discussed. Surgeons must be aware of the possibility of tumor involvement of reconstructive flaps to facilitate early diagnosis and aggressive treatment.

• Despite the use of strict morphologic criteria, some head and neck neoplasms remain classified as "poorly differentiated" or "undifferentiated." To circumvent this diagnostic quandary, newer techniques primarily based on immunocytochemistry are being utilized to study tumor specimens. These methods rely on the binding of specific antibodies to cellular antigens in order to better define the tumor according to cell type. We treated six patients in whom a definitive pathologic diagnosis could not be obtained without the use of immunohistologic stains. In each case, the definition of a specific tumor category altered patient management. The approach to the evaluation of patients with undifferentiated head and neck neoplasms is important. Close cooperation between the clinician and pathologist is necessary in such cases; this is assisted by a knowledge of the uses and limitations of the current diagnostic modalities being used, as well as proper tissue handling and processing. ( Arch Otolaryngol Head Neck Surg 1987;113:506-509)

• A new argon beam coagulator system promises a radically different form of electrocoagulation. Rarely does a tool make such an important contribution to the surgical armamentarium. This instrument reduces blood loss by up to half via rapid superficial coagulation, even when severe bleeding occurs. It causes minimal tissue damage, coagulates large vessels (2 to 3 mm in diameter), reduces the risk of postoperative hemorrhage, and markedly reduces operative time. Since the coagulation is superficial, healing appears to be unimpaired. We describe our experience with this new instrument (video tape recordings demonstrating its use in surgical procedures are available). ( Arch Otolaryngol Head Neck Surg. 1989;115:921-923)

Fibromatoses are uncommon, locally aggressive lesions that may involve the structures of the head and neck. They are most commonly found in and along the fascial planes of the neck muscles but can involve other structures, including the oral cavity, nose, nasopharynx or paranasal sinuses. An unusual case of an extra-abdominal desmoid tumor is presented and a review of the anatomical, clinical and pathological features of these tumors is discussed.

Coccidioidomycosis is a fungal disease endemic to the southwestern United States. The primary form of the disease is relatively benign and many patients, after exposure by inhalation of the sapyrophytic form of the organism, convert from negative to positive skin testing without significant clinical symptoms. The less common disseminated form represents a serious life-threatening disease and can present with granulomatous changes in the larynx. The authors' experience with disseminated coccidioidomycosis presenting in the larynx of adults and infants successfully treated with amphotericin B are presented and discussed.

An experiment was designed to determine the frequency with which the stapes could be visualized radiographically. Ten human temporal bones were radiographically sectioned before and after stapedectomy using three routine views, and with lead-coated stapes replaced in the oval window. Five human temporal bones were radiographically sectioned before and after stapedectomy using the Guillen view, that is, with the tympanic cavity viewed through the orbit, and with the head tilted 15 degrees to the side under investigation. The Guillen view proved to be superior for evaluating the foot-plate and superstructure of the stapes because it placed these structures in a favorable position for contact with the x-ray beam.

Characteristic patterns of laryngeal dysfunction due to central neurologic disease are documented by 16 mm cine photography. Representative patients are used to describe typical patterns of abnormal laryngeal function which occur in upper motor neuron, extrapyramidal, cerebellar, nuclear and mixed foci of lesions. The pitfall of brief indirect laryngoscopy without visual documentation is emphasized as a factor in misdiagnosis of patients with laryngeal disease of central origin. The value of more careful evaluation of similar patients is emphasized in relation to better understanding of laryngeal function and improved patient care.

• Differentiation of brown tumors of primary or secondary hyperparathyroidism, giant-cell reparative granulomas, and the "true" giant-cell tumors requires consideration of the clinical presentation, anatomic location, roentgenographic features, and results of metabolic studies. These lesions are indistinguishable by histologic appearance alone. Of the 32 giant-cell lesions of bone that were treated at UCLA during the preceding 20 years, seven were from the head and neck region. Four giant-cell reparative granulomas were easily accessible and were treated by local excision. The three "true" giant-cell tumors were found to be in inaccessible locations and thus were treated with full course irradiation. This resulted in tumor shrinkage, but it is probably not curative. Tumor type, location, and clinical setting are important in planning treatment of these lesions. ( Arch Otolaryngol 104:186-190, 1978)