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The exposure obtained using the degloving approach is superb and the absence of resultant facial scar or deformity provides a dramatic new addition to the otolaryngologist's surgical repertoire. The advantages of the degloving technique in exposure of the midface, nasal cavities, paranasal sinuses, nasopharynx, skull base, and clivus have led to its increasing importance in the otolaryngology literature. Within 2 years of the technique's introduction in our department, it had been used 48 times for a wide variety of problems, including inverting papilloma, juvenile angiofibroma, chordoma and selected cases of fungal disease of the sinuses. This article describes the procedure, reports the results from a panel of 48 patients, and discusses potential complications. The authors' experience with this procedure indicates that it should become a procedure of choice for management of inverting papilloma and juvenile angiofibroma, as well as a major alternative method in many other circumstances.

alpha-Difluoromethylornithine is a new antineoplastic and antiparasitic drug that inhibits the synthesis of polyamines. It causes a sensorineural hearing loss in humans. We have established an animal model for alpha-difluoromethylornithine-induced hearing loss. The time course for onset and recovery of the hearing loss in animals was similar to that seen in humans. Electrophysiologic and histologic data suggest that the anatomic site of alpha-difluoromethylornithine-induced hearing loss is the organ of Corti. Unlike other drugs with ototoxic effects, the specific enzymatic site of action of alpha-difluoromethylornithine is known, making it a potentially important tool in auditory research.

Preoperative adjuvant chemotherapy is being used with increasing frequency in advanced head and neck cancer; however, the effects of chemotherapy on wound healing have not been fully elucidated. To evaluate the effect of preoperative chemotherapy, experimental animals were given chemotherapeutic drugs, wounded, and the subsequent wound breaking strength determined. Rats received a single dose of intravenous tumoricidal drugs (adriamycin or or dihydroxyanthracenedione) either one week before or simultaneously with wounding. Wound breaking strength of treated animals and control animals receiving no chemotherapy was measured one and two weeks after wounding. All wounds, regardless of treatment, were stronger at two weeks than at one week after wounding. Wound breaking strength was reduced at both times when chemotherapy was administered one week before wounding. Wound breaking strength in animals that were simultaneously wounded and received chemotherapy was similar to controls. Both adriamycin and dihydroxyanthracenedione have a deleterious effect on one parameter of wound healing--wound breaking strength--when administered one week before wounding.

High-dose cisplatin (40 mg/m2 every day X5) was administered to 14 patients (11 men, three women) with locally advanced or metastatic head and neck cancer not curable by surgery or refractory to previous chemotherapy and/or radiation therapy. All 14 patients were evaluable for toxicity; one patient was inevaluable for response due to early death. A total of 24 courses of therapy were administered. The dose-limiting toxicity was myelosuppression with 73% of patients experiencing Grade III or IV neutropenia. Grade II or above thrombocytopenia occurred in 30% of the patients. Renal and neurologic toxicity was minimal. Two patients experienced laryngeal edema from vigorous hydration with one of them requiring a tracheostomy for respiratory compromise. Partial responses were seen in six patients (46%). Two of the six patients had received previous treatment with standard dose cisplatin. Two patients achieved long-term responses (54+, 44+ months, respectively). Both of these patients were previously untreated, inoperable (T4N3M0, T3N1M0), and subsequently received radiation therapy after two cycles of chemotherapy. Median duration of response in the remaining responders was 3 months (range, 3-10 months). High-dose cisplatin may benefit selected patients with inoperable, advanced head and neck tumors. However, further randomized trials need to be conducted before firm conclusions can be established.

Initial evaluation of patients with tinnitus presents a challenge to the otolaryngologist's skills, knowledge, and judgment. History-taking, physical examination, and the ordering of initial laboratory tests should be orchestrated to efficiently evaluate patients with tinnitus. By the end of this initial evaluation, major decisions have to be made in regard to the employment of additional expensive and possibly invasive diagnostic tests. We present an outline to expedite the initial evaluation of patients with tinnitus as their major concern.

Although the Mohs technique is most often applied to moderate and large lesions, with appropriate modifications it can also be applied to massive lesions. Reconstructive procedures after resection of large defects are also discussed.

Over the past two decades, the emphasis on the management of acoustic neuromas has turned from the single goal of preserving the patient's life to early diagnosis and functional preservation of cranial nerves.

The diagnosis of cancer has a profound emotional effect on the patient. We report the two-year experience of a weekly support group attended by 142 hospitalized head and neck cancer patients and 33 family members. The major goal for the group was to provide an open forum for discussion of any problems that faced the patient. Group size was usually four to eight patients and two to four therapists. Weekly data sheets documented attendance and major themes for the group. The most common theme was anticipation of and reaction to treatment. Initial difficulties with the group included ambivalence by the professional staff, low attendance, and logistical problems. Subjective impressions of the staff were that the group improved patients' morale, patient to patient support, compliance, and decreased the rate of discharge against medical advice.

Simultaneous concentrations of total plasma platinum, filterable platinum, intact cisplatin, and total tumor platinum were measured for 24 hours after an intravenous bolus of cisplatin in five patients. Tumor concentrations of drug were greater than could be explained on the basis of circulating plasma platinum at the time of biopsy. Intratumor platinum concentrations derived from this study provide guidance for selection of the appropriate drug concentrations for in vitro chemosensitivity testing of head and neck cancer in humans.

The laser-ignited airway explosion is a shocking emergency. Techniques available for prevention of an airway fire minimize the risk, but they are not applicable in all circumstances. The severity of the patient's injury depends on the duration and intensity of the burn. Prompt, appropriate management is facilitated if the operating team has previously discussed and "rehearsed" this potential disaster. The distal airway burn produced by an ignited endotracheal tube differs from an inhalation burn in character and severity. The anatomic and respiratory effects occurring subsequent to the laser-induced burn are examined. Emergency care requires immediate elimination of the fire, removal of the tube and any foreign body or debris, and usually a tracheostomy. A program of medical and endoscopic management is suggested.

Bilateral transection and reanastomosis of the main trunk of the facial nerve was performed on 18 rats. On one side of each rat, all peripheral branches except the mandibular branch were ligated with silk suture and divided distal to the ligatures. Axon counts after 1, 3, and 6 months showed a statistically significant increase in the number of axons in both the mandibular branch and the main trunk on the side with the peripheral ligation. These data indicate that peripheral branch ligation is a useful adjunct in facial nerve rehabilitation.

A hurdle in the evaluation of any therapy of ISHL has previously been proposed-a spontaneous recovery of satisfactory hearing of 63% of patients. The hurdle has yet to be convincingly passed by any drug therapy. The intent here is not to denigrate the use of drugs in this syndrome; on the contrary, it remains likely that some subgroups of ISHL would benefit from specific medical management. For instance, a systemic viremia would be most logically treated with anti-inflammatory agents and a thrombotic event with anticoagulants. However, prospective studies in which patients are divided into prognostic categories before treatment with adequate control groups must be performed.

The feasibility and usefulness of chemosensitivity testing with the soft agar cloning assay was tested in 20 patients with advanced head and neck cancer. Pretreatment biopsy specimens could be obtained on only 13 of 20 patients, and chemosensitivity testing could be performed in only two patients. As currently used, the soft agar cloning assay does not contribute to the management of patients with advanced head and neck cancer.

Functional endoscopic surgery affords the potential for dramatically reducing operative morbidity of surgery for paranasal sinus mucoceles by offering a minimally invasive approach under local anesthesia. Following surgery, direct endoscopic visualization of the area enables accurate follow-up. Unlike sinus obliteration, the ability to accurately image the sinus by CT is also preserved. This paper presents our preliminary experience with 18 mucoceles in which endoscopic sinus surgery was attempted. Five patients had preoperative proptosis and diplopia, three had Pott's puffy tumor and five had erosion of the posterior table of the frontal sinus. Fifteen patients were satisfactorily treated endoscopically, two lesions could not be satisfactorily approached and required external surgery, and one patient had persistent disease. No disease recurrence has been noted to date with endoscopic follow-up of up to 42 months.