A comparison of three methods for estimating the requirements for medical specialists: the case of otolaryngologists

OBJECTIVE

To compare three methods of computing the national requirements for otolaryngologists in 1994 and 2010.

DATA SOURCES

Three large HMOs, a Delphi panel, the Bureau of Health Professions (BHPr), and published sources.

STUDY DESIGN

Three established methods of computing requirements for otolaryngologists were compared: managed care, demand-utilization, and adjusted needs assessment. Under the managed care model, a published method based on reviewing staffing patterns in HMOs was modified to estimate the number of otolaryngologists. We obtained from BHPr estimates of work force projections from their demand model. To estimate the adjusted needs model, we convened a Delphi panel of otolaryngologists using the methodology developed by the Graduate Medical Education National Advisory Committee (GMENAC).

DATA COLLECTION/EXTRACTION METHODS

Not applicable.

PRINCIPAL FINDINGS

Wide variation in the estimated number of otolaryngologists required occurred across the three methods. Within each model it was possible to alter the requirements for otolaryngologists significantly by changing one or more of the key assumptions. The managed care model has a potential to obtain the most reliable estimates because it reflects actual staffing patterns in institutions that are attempting to use physicians efficiently.

CONCLUSIONS

Estimates of work force requirements can vary considerably if one or more assumptions are changed. In order for the managed care approach to be useful for actual decision making concerning the appropriate number of otolaryngologists required, additional research on the methodology used to extrapolate the results to the general population is necessary.

Otolaryngology-head and neck surgery

Molecular analysis of surgical margins may provide greater accuracy in predicting local recurrence. The high frequency of associated p53 mutations implicates tobacco in the molecular progression that eventuates in head and neck squamous cell carcinoma.

Warthin's tumor: a 40-year experience at The Johns Hopkins Hospital

Warthin's tumor previously has been thought to occur much more commonly in men than in women and rarely in African Americans. One hundred thirty-two cases of Warthin's tumor treated at The Johns Hopkins Hospital from 1952 to 1992 were retrospectively reviewed. There were 90 (68%) men and 42 (32%) women, with an overall man-to-woman ratio of 2.2:1. The number and percentage of women with Warthin's tumor increased over each consecutive decade: 1952 to 1962, 5 (21%); 1963 to 1972, 6 (29%); 1973 to 1982, 11 (31%); and 1983 to 1992, 20 (39%). A positive smoking history was found in 88% of the men and in 89% of the women with a Warthin's tumor. Eleven (8%) African Americans and 1 (0.75%) Asian American were diagnosed to have a Warthin's tumor. Also, the incidence of African Americans with a Warthin's tumor increased over each decade: 0 (0%), 1 (4.8%), 2 (5.5%), and 8 (16%). This study's results indicate a progressive increase in the occurrence of this tumor in women and in African Americans and a higher overall incidence in African Americans than previously reported.

Otolaryngology--head and neck surgery

p53 mutations are early events in the development of carcinoma of the head and neck. Cochlear implantation continues to influence rehabilitation of the profoundly deaf. Replacing cocaine with a combination of lidocaine and oxymetazoline for nasal procedures avoids potential abuse.

Carcinoma of the major salivary glands treated by surgery or surgery plus postoperative radiotherapy

From 1975 to 1987, 87 patients with carcinomas of the major salivary glands (70 parotid and 17 submandibular) were treated at our institution by either surgery or surgery followed by postoperative radiotherapy (RT). Surgical procedures included superficial (24%) or total (56%) parotidectomies and submandibular gland resection (20%). Postoperative RT usually began 2 to 4 weeks following surgery. Using 4 MV photons or, infrequently, 60Co, the majority of patients received 6000 cGy in 6 weeks to the parotid region (ranged from 4500 to 7000 cGy). Determinant actuarial survival was 74% at 5 years and 71% at 10 years. For patients with previously untreated disease, 5 of 19 (26%) treated by surgery alone experienced local recurrence, whereas only 2 of 50 (4%) recurred locally following surgery plus postoperative RT (p = 0.01). For patients presenting with recurrent disease, 4/4 (100%) failed locally following surgery as opposed to 3/14 (21%) following surgery plus postoperative RT (p = 0.01). The determinant 5-year actuarial survival for patients receiving postoperative RT was 75% versus 59% for surgery alone. Results were analyzed by multivariate methods using determinant survival or recurrence as endpoints. Five important prognostic factors were identified. (a) Facial nerve paresis was predictive of poor outcome (p less than 0.001) with 3-year relapse free survival of 13%. (b) Undifferentiated histology was associated with decreased survival (p = 0.002). (c) Male sex was associated with poor outcome (p = 0.008). (d) Skin invasion resulted in decreased survival (p = 0.012). (e) Radiotherapy was associated with improved survival (p = 0.014). In addition, postoperative RT was effective in preventing local recurrence (p less than 0.001). The data demonstrate the efficacy of postoperative RT in improving survival and local control for patients with carcinomas of the major salivary glands.

Stage T1 glottic carcinoma: results of radiation therapy or laser excision

A retrospective analysis was made of the data on 60 patients with stage T1 glottic carcinoma (43 T1a, 17 T1b) who received radiation therapy and 17 patients with T1a disease who underwent laser excision as the primary treatment modality. Patients who received radiation therapy achieved 3- and 5-year actuarial local control rates of 92% and 89% for T1a and 77% and 77% for T1b disease, respectively. In patients who underwent laser excision (all with T1a disease), the 3-year local control rate was 77%. Of the 42 evaluable irradiated T1a patients, 31 (74%) had a normal to near-normal voice, eight (19%) had mild or intermittent hoarseness, and three (7%) had persistent hoarseness. Of the 13 evaluable patients in the laser-excision group, four (31%) had a normal to near-normal voice, five (38%) had mild or intermittent hoarseness, and four (31%) had persistent hoarseness. The difference in the quality of voice between these two groups is statistically significant (P = .012), although the ultimate local control rate after salvage therapy for irradiated patients (97%) was similar to that for laser-excision patients (94%).

Esophageal reflux and secondary malignant neoplasia at laryngoesophagectomy

Pathologic evidence of gastroesophageal reflux demonstrated by either Barrett's esophagus or esophagitis was present in 33% of patients undergoing laryngopharynoesophagectomy, while secondary esophageal squamous cell carcinomas were present in 25% of the specimens. Overall, 54% of all the patients undergoing laryngopharyngoesophagectomy had esophageal disease. This incidence of reflux and secondary esophageal malignant neoplasia is higher than in the general population. Careful assessment of the patient's preoperative history for gastroesophageal reflux, contrast swallowing studies, and esophagoscopies correctly diagnosed most but not all of the esophageal lesions found on pathologic examination. Interestingly, all of the esophageal carcinomas removed in the laryngopharyngoesophagectomy specimens were small and sometimes not evident clinically. Although gastroesophageal reflux has been postulated as an additional etiologic agent in the development of laryngeal carcinoma, all the patients in our study had heavy alcohol and tobacco consumption, and therefore reflux could not be evaluated separately as a risk factor.

Bilateral parotid enlargement in HIV-seropositive patients

Bilateral enlargement of the parotid glands has been noted in five patients who are seropositive for antibody to the human immunodeficiency virus. A characteristic cystic appearance has been noted in these lesions on clinical and radiographic examination. A benign lymphoepithelial infiltrate with cystic degeneration is found in parotid specimens from these patients. The presence of human immunodeficiency virus ribonucleic acid in inflammatory cells infiltrating the parotid specimen was confirmed by an in situ hybridization technique. The clinical manifestations of sicca syndrome were not present nor were opportunistic infections diagnostic for the acquired immunodeficiency syndrome.

Current management of salivary gland tumors. Part 2

The authors base their treatment of salivary gland malignancies on the size of the primary and the histopathologic diagnosis. Group 1 includes smaller tumors in the T1 and T2 classification with cell types that are associated with slow growth. A parotidectomy is usually sufficient therapy for tumors in this group. Group 2 contains T1 and 2 tumors with more aggressive behavior. Total parotidectomy is indicated here, with postoperative radiotherapy. T3 tumors and patients with nodal metastasis or recurrent tumors make up group 3. Radical parotidectomy with sacrifice of the facial nerve is usually required for a sufficient tumor-free margin in these patients, and postop radiotherapy is also necessary. Group 4 includes T4 lesions. Extent of disease dictates magnitude of excision and amount of postop radiotherapy.

Incidence, diagnosis, and classification of salivary gland tumors. Part 1

The diagnosis of salivary gland tumors is complicated by their relative infrequency, the limited amount of pretreatment information usually available, and the wide range of biologic behaviors seen with different histopathologic types. Most salivary gland neoplasms originate in the parotid, 10-15% arise from the submandibular glands, and the rest occur in the sublingual and minor salivary glands. The probability of a salivary gland neoplasm being malignant is inversely proportional to the size of the gland. The authors discuss two major theories of histogenesis, itemize the various benign and malignant varieties of tumor, discuss the presentation and prognosis for each type, and present a list of factors that influence survival. They also discuss the newest staging system.

Fungal sinusitis: diagnosis with CT and MR imaging

Of 293 patients who underwent computed tomography (CT), surgery, and pathologic examination for chronic sinusitis, 25 had a diagnosis of fungal sinusitis at pathologic examination. Of these, 22 had foci of increased attenuation at CT (in four patients the mean representative CT number [Hounsfied unit] was 122.2 HU [SD, 8.2 HU]), and three did not. Of the 22, 19 patients (76%) met the CT criterion of this study (there was a 12% false-positive and a 12% false-negative diagnostic rate). Six of the 19 patients and one additional patient underwent magnetic resonance (MR) imaging, and all demonstrated remarkably hypointense signal characteristics on T2-weighted images. The findings at MR imaging therefore appear more characteristic of fungal sinusitis than the findings at CT. Furnace atomic absorption spectrometry showed increased concentrations of iron and manganese in mycetoma compared with their concentrations in bacterially infected mucus. This finding and the presence of calcium in the fungal concretion may explain the hypointense T2-weighted signal on MR images.

The pericranial flap for reconstruction of anterior skull base defects

In 1981, the senior author first reported the use of the pericranial flap for support of the brain following resection of the anterior skull base. Since the initial report, considerable experience has been gained with this flap. It is currently deployed via a bifrontal craniotomy and is placed primarily as a support beneath the frontal lobes. The pericranial flap may also be used to repair dural laceration and defects. The sinonasal surface is routinely grafted with split-thickness skin or dermis. This technique provides an excellent barrier between the sinonasal cavity and the cerebrospinal fluid, establishing a tough, fibrous platform. Herniation of intracranial contents has not occurred. One major complication has been reported in which radiation necrosis occurred during postoperative therapy, leading to progressive devitalization of the pericranial flap. Ultimately, dural repair and closure with a latissimus dorsi free flap was required. The pericranial flap repair of anterior skull base defects has a 90% complication-free and 95% overall success rate. It is simple and extremely effective. Bone grafting has not been necessary in our experience.

3-D CT for cranial facial and laryngeal surgery

Three-dimensional imaging is a new digital technology which interpolates two-dimensional computer tomography information to render a "life-like" anatomic display of the diagnostic information. We have found that this new methodology significantly improves the assessment and therapy of patients undergoing surgical procedures of the head and neck. The technique has been used in cranial-facial and laryngeal pathology, and in preoperative planning of tumor resection, particularly skull-base neoplasms. The use of three-dimensional computer tomography improves the display of the location and volume of pathology and affords accurate therapeutic and surgical planning. The choice and extent of surgery is better defined, and precise bone removal can be performed. In reconstructive surgery, an accurate prefabricated model of the bony defect can be made to aid reconstruction. Representative cases demonstrating the use of three-dimensional computer tomography in head and neck surgery, and its benefits in saving operative time and improving the postoperative result, will be discussed.

MR imaging of normal nasal cycle: comparison with sinus pathology

Sequential MR examinations of the nasal cavity and paranasal sinuses were performed within a 6-8 h period in five normal volunteers. The nasal mucosal volume and signal intensities (T2 weighted) were shown to alternate from one side to the other during this period. When a topical vasoconstrictor was applied, this cycle was interrupted. These cyclical changes were limited to the mucosa of the turbinates, nasal cavity, and ethmoid sinus, representative of the nasal cycle. The maxillary, frontal, and sphenoid sinuses were not affected. The hyperintensity of the nasal cycle on T2-weighted images was similar to that shown by inflammatory mucosa. Squamous cell carcinoma within the nasal cavity and paranasal sinuses has characteristically demonstrated a lower signal intensity on T2-weighted images. Awareness of these cyclical nasal and paranasal appearances reduces the likelihood of inflammatory disease being confused with normal physiologic changes within the nasal area.

Physiologic mucosal changes within the nose and ethmoid sinus: imaging of the nasal cycle by MRI

Magnetic resonance studies frequently demonstrate increased T2-weighted signal in the nasal area. To further evaluate this phenomenon, several MRI examinations of the nasal cavity were performed within an 8- to 12-hour period. The study demonstrated that changes alternated from side to side and were interrupted by the administration of topical vasoconstriction, confirming imaging of the normal nasal cycle. Changes were also observed within the ethmoid sinuses. Signal intensity on T2-weighted images during the congested phase was similar to inflammatory mucosa. Occasionally, these changes make interpretation of the extent of pathology difficult in patients with sinus disease, and raise the possibility of inflammatory pathology in asymptomatic patients. Awareness of MRI imaging of nasal cycle should reduce the likelihood of diagnostic errors and provides another method for study of this physiologic phenomenon.

Tumors of the major salivary glands in children

During the 30-year period 1955-1985, 21 children with neoplasms of the major salivary glands were treated at the Johns Hopkins Hospital. A thorough review of the English literature revealed an additional 472 cases. The cases were studied as to age, sex, site, histopathologic characteristics, mode of treatment, and results. The majority of the patients were between 8 and 20 years of age. There was a female preponderance of 1.42:1. The parotid gland was the site of origin in 85.1%, the submandibular in 11.7%, and the sublingual in 3.2%. An equal incidence of benign (50.1%) and malignant (49.9%) lesions is noted. Pleomorphic adenoma was the most common benign neoplasm and mucoepidermoid carcinoma the most common malignant neoplasm. The final prognosis seems to be similar with superficial or total parotidectomy, provided the tumor has been completely removed at the initial surgery. Re-excision is recommended for tumor recurrence, and the use of radiation therapy should be individually determined in cases of aggressive malignancies.

The versatile midface degloving approach

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.

Indomethacin sensitive suppressor-cell activity in head and neck cancer patients. The role of the adherent mononuclear cell

Head and neck cancer (H&N CA) patients have known depression of cell-mediated immunity. There is suggestive evidence that prostaglandin (PGE2)-secreting cells may be a major factor. The authors have sought to determine the role of PGE2-releasing monocytes-macrophages in this immune depression by determining the effects of adherent cell depletion and by measuring the effects of indomethacin, a PGE2 synthetase inhibitor, on selected tests of lymphocyte function. Lymphocyte stimulation with phytohemagglutinin (PHA) (T-cell stimulant) and Staph phage lysate (SPL) (B-cell stimulant) was done in the presence of varying concentrations of indomethacin; the effect of adherent cell depletion also was determined. The study population included 45 patients with localized or locoregional squamous CA of the H&N and 40 controls. Results included the following: (1) lymphocyte stimulation responses to PHA and SPL were generally depressed in the CA patients versus controls; (2) incubation with indomethacin produced bivalent effects in both controls and CA patients, depending on the concentration of indomethacin and lymphocyte stimulant; incubation with optimum concentrations of indomethacin generally produced augmented responses in both study groups whereas high concentrations of indomethacin were suppressive; (3) the immune potentiating effects were not observed in older patients with advanced disease; and (4) removal of adherent leukocytes (mainly monocytes) also restored depressed lymphocyte responses. Although other factors also are operative, our data suggest that PGE2-secreting monocytes-macrophages may have a major role in the immune depression of H&N CA patients. Age and host effects of the cancer and the malnutrition common to these patients probably are involved also, although their singular contribution has not been measured. This depression is largely reversible by a PGE2 synthesis inhibitor, indomethacin, which suggests the potential value of in vivo administration of indomethacin to H&N CA patients as an adjunct.

In vitro hyperdiploidy in head and neck cancer. A genetic predisposition?

The role of heredity in the cause of head and neck cancer has not been clarified. Contrary to the autosomal-dominant heritable cancer syndromes, there is no clear genetic pattern seen in oropharyngeal or laryngeal squamous cell carcinoma. Pedigree data demonstrating clusters of affected relatives suggest that some head and neck squamous cell cancers result from an interaction between environmental factors and germinal predisposition. Though no genetic marker has been described for head and neck epidermoid carcinomas, some heritable single tumor syndromes demonstrate increased amounts of hyperdiploidy (defined as a metaphase with more than 46 chromosomes exclusive of 92) in in vitro cultures of dermal fibroblasts. In the present study, dermal fibroblasts were cultured from 30 patients with biopsy-proved oropharyngeal and laryngeal squamous cell cancer. Compared with the percentage of cells with in vitro hyperdiploidy (IVH) of 0% to 1% in 155 clinically normal individuals without a family cancer history, 13 (43%) of these 30 patients had significantly elevated (7% to 12%) IVH. Six of the seven clinically affected women had IVH, a proportion significantly greater than that for the men. In vitro hyperdiploidy remained stable for each assayed cell line from the third through sixth passage. Each patient's IVH percentage of dermal and oropharyngeal fibroblasts remained nearly constant varying 0% to 1%. The stability of the hyperdiploid fraction independent of the biopsy site eliminates local factors as the sources of the elevated IVH.(ABSTRACT TRUNCATED AT 250 WORDS)

Selective, histamine-mediated immunosuppression in laryngeal cancer

Immunosuppression observed even in the earliest laryngeal cancers can be, in part, reversed with H2 histamine antagonists. In an effort to explain this, we tested whether histamine could evoke changes in endogenous antitumor lymphokine production using tonsil lymphocytes as test cells. We have observed that lymphocytes, treated in vitro with histamine, display a significant suppression of lymphokine production and mixed lymphocyte proliferation response following galactose oxidase treatment. Interferon gamma production was reduced to less than 2% of control value in the presence of histamine. In contrast, the lymphokine-activated killer cell activity induced by purified, natural interleukin-2 was not affected by similar concentrations of histamine. Histamine appears to exert its inhibitory effect by stimulating the production of a substance released by suppressor T cells. The suppressive effects observed could be reversed by concomitant or sequential treatment with cimetidine or ranitidine and not by H1 histamine antagonists, indicating that it occurs through an H2 histamine receptor. These experiments suggest that histamine may have a profound suppressive effect on the lymphocyte population studied.

Anterior extraoral approach to the atlas and axis

A transcervical extraoral approach was utilized to achieve exposure to the upper cervical spine in five patients, four of whom required bone graft placement. Excellent exposure was achieved in all patients, and the postoperative course was uncomplicated. The anterior extraoral approach is a reliable technique in treatment of pathology of the atlas and axis.

Immature teratoma of the larynx

Teratomas are unusual tumors which occasionally occur in the head and neck. The tumor consists of the three basic germ-cell layers, in various degrees of maturation. Because of its malignant potential in adults, complete surgical excision is recommended. The patient we have described is believed to provide the first reported case of laryngeal teratoma in the English literature.

[Surgical treatment of chronic recurrent sinusitis--the Caldwell-Luc versus a functional endoscopic technic]

More than 50 patients who underwent intranasal or radical (Caldwell-Luc) antrostomy for chronic recurring sinusitis and who had still the same symptoms as before the operation, were examined by endoscopy and polytomography/CT. More than 50% still had polypoid changes of the maxillary sinus mucosa. No correlation was found between the degree of the patient's symptoms and the degree of the maxillary sinus pathology or the patency of the naso-antral window. CT demonstrated anterior ethmoid disease in all of the patients, correlating well with the endoscopic findings and the patient's symptoms. This again proves that the anterior ethmoid holds the key position for re-infection or cure of the larger dependent sinuses. Functional endoscopic sinus surgery therefore aims at the primary infective foci in the anterior ethmoid and usually cures disease in the larger sinuses without an attack upon the latter sinuses.

Multiple primary malignancies in head and neck cancer

Multiple primary (MP) malignancies were found in 9.7% of 1961 patients with primary head and neck cancer diagnosed at The Johns Hopkins Hospital, Baltimore, during the years 1975 to 1985. The index tumors were divided into six main groups. Out of the 190 MP malignancies, 46.9% were synchronous and 53.1% were metachronous. Seventy-four percent of MP lesions were noted during the first year after diagnosis of the index primary tumor. Patients with an index tumor in the upper aerodigestive tract had a significantly increased risk of developing a second cancer in the head and neck area. This risk was 5.94 for the oral cavity, 6.98 for the pharynx, 3.57 for the larynx, and 7.02 for the esophagus. Patients with an index tumor in the salivary gland or the thyroid gland had, respectively, a 3.59 and a 7.38 higher risk than the general population of developing a second tumor. Efforts aimed at improving the survival of patients with head and neck cancer must incorporate strategies for the prevention, early detection, and treatment of MP neoplasms.

Chemotherapy for salivary gland cancer

Because of the scarcity of such lesions, little is known about the efficacy of chemotherapy for advanced salivary gland cancers. Although surgery and irradiation are the mainstays of treatment, patients with recurrent tumors and those with unresectable or metastatic cancer are not candidates for this usual approach. Ten patients with recurrent, metastatic, or unresectable salivary gland tumors were treated with combination chemotherapy, primarily with cisplatin, doxorubicin hydrochloride (Adriamycin), and cyclophosphamide, or cisplatin with 5-fluorouracil. In patients whose tumors exhibited no response, second-line drugs were used. The overall response rate was 50%--with one complete response--but the duration of response was short. This report contributes to the growing data base that demonstrates definite chemosensitivity of these tumors. To date, 116 patients have been reviewed. Adenocarcinoma-like cancers respond best to cisplatin, doxorubicin hydrochloride, and 5-fluorouracil. High-grade mucoepidermoid carcinoma may show a sensitivity similar to that of squamous cell carcinoma. Multi-institutional protocols need to be developed to assess the roles of adjuvant and palliative chemotherapy in the treatment of salivary gland cancer.

Compression plates in the treatment of advanced anterior floor of mouth carcinoma

Advanced anterior floor of mouth squamous cell carcinoma has been traditionally treated with wide excision in conjunction with mandibulectomy and radical neck dissection. This has resulted in significant mandibulofacial defects with functional and cosmetic significance. Efforts at primary reconstruction in the past using bone grafts, osteomyocutaneous flaps, and other methods have yielded unsatisfactory results. A history of prior irradiation has made this problem even more refractory. We present a series of 11 patients who underwent composite resection for advanced anterior floor of mouth carcinoma (T2-T4), with primary reconstruction using a dynamic compression plating system in conjunction with local and regional tissue flaps. The clinical courses, complications, and surgical techniques are discussed. The issues of reconstruction at primary treatment, irradiation with a metal plate in the field, and the early restoration of oral function are addressed. Experience in this series shows that compression plates can be an effective method of primary reconstruction for advanced anterior floor of mouth lesions.

Multiple primary neoplasms in patients with salivary gland or thyroid gland tumors

The exact risk of multiple primary neoplasms in patients with salivary gland or thyroid gland malignancies is difficult to ascertain from the data available in the literature. This study examines, retrospectively, 198 patients with a first malignancy of the salivary gland and 186 patients with a first malignancy of the thyroid gland, treated over a 10-year period. Fourteen cases of second tumors were found in the first group and 29 cases in the latter. Patients whose second neoplasm was a skin cancer or who had a previous neoplasm at a site other than those selected for study were excluded. The risk of a second tumor compared to the expected number of second cancers from the Combined National Cancer Institute Registry Data, and the results indicated an increased risk in males with a first malignancy of the salivary gland and in both men and women with a first thyroid malignancy. The salivary glands, larynx, and colon were the most common sites of second tumors after a first salivary cancer. The adrenals, brain, lymphatic system, and breast were the most common site after a first thyroid cancer. The previously reported association of cancers of the thyroid and the breast in females is confirmed here in men and women. The excess of brain tumors and lymphomas has not been reported previously.

Lesions of the oral mucous membranes

This article has not attempted to exhaustively review mucosal diseases of the oral cavity. We have, however, described some oral mucous membrane lesions which need to be kept in mind during the head and neck examination.

Functional endoscopic sinus surgery. Theory and diagnostic evaluation

The keys to functional endoscopic sinus surgery are an understanding of the underlying mechanisms of paranasal sinus disease and the ability to diagnose the causes accurately. Previously unrecognized causes of recurrent acute sinusitis and of chronic sinus symptomatology can now be identified by careful diagnostic evaluation. Systematic nasal endoscopy and high-resolution computed tomographic imaging provide complementary diagnostic information that can allow for the recognition of problems not identifiable by other means. The ability to diagnose these problems and to correct them with functional endoscopic surgery heralds new possibilities in the field.

Interferon sensitivity of fibroblast cell cultures derived from patients with neoplasms of the head and neck

Interferon (IFN) is a protein with antiviral activity that has been shown to inhibit the growth of many different types of cells. We have measured the IFN sensitivity of nine cell cultures isolated from patients with squamous cell carcinoma and one with malignant melanoma of the head and neck. Normal-appearing fibroblast cultures isolated from these tissues appear quite sensitive to the antiviral effects of IFN. When the encephalomyocarditis virus yield reduction assay is used, these diploid cells are as sensitive to IFN-alpha as are newborn foreskin fibroblast cultures. A similar antiviral effect is seen with IFN-gamma. These cells are relatively insensitive to the antigrowth effect of both IFN preparations as measured by 3H thymidine incorporation and direct observations of cell growth. This is the same relative sensitivity as fibroblasts derived from normal patients. Since these cells are at least 100 times less sensitive to the antigrowth action of the IFNs, it appears unlikely that the IFNs play a significant role in the control of normal fibroblast growth, in contrast to the sensitivity of malignant cell lines.

Infralabyrinthine approach to skull-base lesions

New surgical techniques have extended the head and neck surgeon's domain to include various skull-base lesions. The infralabyrinthine approach incorporates these techniques and can be used to resect benign and malignant tumors involving the base of the temporal bone. Lesions of the internal carotid artery near the carotid foramen are also readily accessible. The main surgical steps in the infralabyrinthine approach include (1) mastoidectomy, (2) anterior transposition of the facial nerve, (3) neck dissection, (4) removal of the lateral tympanic bone, (5) exposure of the jugular foramen, and (6) exposure of the intratemporal carotid artery. Details of the infralabyrinthine approach are illustrated by photographs of surgical and cadaver dissections. Examples of various lesions successfully treated by this technique are presented. The important surgical anatomy of the infralabyrinthine compartment of the skull base is reviewed, with particular attention paid to the internal carotid artery, which, like the facial nerve, demands an intimate familiarity on the part of the temporal bone surgeon.

Mitomycin and fluorouracil with concomitant radiotherapy in head and neck cancer

Forty-two previously untreated patients with predominantly stage IV (35) head and neck squamous cell carcinoma were treated preoperatively with mitomycin and fluorouracil and concomitant radiotherapy with 5,000 to 6,000 rad using a split-course technique. Toxic reactions were acceptable. Five patients developed severe mucositis. The white blood cell count fell to 1,500/cu mm in two patients; the platelet count fell to 100,000/cu mm in three. Other complications occurred in three patients. Eighty-six percent of patients completed advised treatment. Complete response, assessed clinically and with histologic correlation, was 79% at primary sites and 69% at nodal sites. Twenty-seven patients had a complete response (64%). Follow-up currently is between ten and 24 months. Though analysis of disease-free intervals and survival data is premature, the high complete response rates in this study are encouraging.

Prophylactic efficacy and tolerance of low-dose intranasal interferon-alpha 2 in natural respiratory viral infections

The prophylactic activity of intranasal human interferon-alpha 2 (HuIFN-alpha 2) was determined in a randomized, double-blind, placebo-controlled study. Healthy, working adults self-administered sprays of HuIFN-alpha 2(1.25 X 10(6) IU; n = 142) or placebo (n = 145) twice daily. Drug administration was stopped after 12 days because of the frequent occurrence of nasal irritation manifested by blood-tinged nasal mucus (44% HuIFN-alpha 2 versus 15% placebo, P less than 0.001) and associated nasal mucosal abnormalities. Over 80% of volunteers had participated in a similar field trial conducted 7 months earlier; no evidence of cumulative toxicity was detected. HuIFN-alpha 2 administration did not decrease the occurrence of illnesses associated with rhinorrhea, cough, or feverishness as compared to placebo, but the number of laboratory-documented respiratory viral infections was small (6 HuIFN-alpha 3 placebo). Intranasal HuIFN-alpha 2 1.25 X 10(6) IU twice daily was associated with significant local intolerance.