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• The development of new experimental methods and test equipment has permitted a study of the mechanical characteristics of unembalmed human cadaver skin. Excised tissue specimens were exposed to dynamic, biaxially applied displacements and forces in order to quantify the skin's anisotropic, viscoelastic stress-strain response. In addition to monotonically increasing displacement-time loadings, experiments were performed to measure the tissue's stress relaxation characteristics resulting from a suddenly applied displacement. Data are presented that demonstrate a nonlinear stress-strain relationship for the skin that is notably influenced by displacement boundary conditions imposed on the tissue specimen. Results indicate that the skin is a viscoelastic material whose mechanical loading response is dependent on the anatomic direction in which the strains are applied.(Arch Otolaryngol 1984;110:329-333)

• Microscopic fingers of epidermoid cancer can extend submucosally 1 to 3 cm from grossly discernible borders of upper aerodigestive tract cancers. These fingers are best detected by sectioning all surgical margins parallel to the margins. Microscopic disease was found at the original excisional margins in 75% of 70 cases. Using this principle for frozen-section evaluation, and reexcising further tissue as indicated, local disease was completely controlled in all 24 patients eligible for two-year follow-up.(Arch Otolaryngol 1984;110:193-196)

• Lateral canthopexy using permanent suspending sutures to shorten the lateral canthal tendon helps prevent scleral show, increased sloping of the upper lid, and inferomedial displacement of the lateral canthus following lower lid blepharoplasty. While these complications usually are prevented by flap suspension techniques, in which more skin is excised above and lateral to the commissure than below it, sutures running from the inferomedial part of the lateral canthal tendon to its superolateral aspect and to periosteum just inside the orbit still further reduce the tendency toward the complications mentioned. We report technical aspects and results. After several years of clinical experience, we have the impression that the technique is a useful adjunct, even though it may produce more swelling and inflammation and a longer recuperative period.(Arch Otolaryngol 105:601-604, 1979)

• Face lift surgery almost always is elective; and, because its purpose is to diminish aging problems, it most often is done in those who are aged. Local and general risks, therefore, should be minimized. Wide undermining dictates flaps dissected more deeply and wounds closed well short of the limits of stretch of skin. Less radical undermining described here produces much smaller total wounds, lessens hazards of hematoma, considerably shortens operative and anesthetic times, reduces risks to nerves and ducts, and allows snugger closures.Details of operative technique, including platysma plication, are demonstrated. Short- and long-term results are shown. They indicate improvement sufficient to justify expanded use of the suggested techniques, particularly in view of diminished morbidity and risks to the general condition of those in the older age group.(Arch Otolaryngol 102:657-662, 1976)

• This paper presents the authors' experiences with 111 treated mandibular fractures and 16 cases of complication. Pertinent data on the fresh fractures are given, but the major part of the study deals with cause, diagnosis, and treatment of the complications of mandibular fractures. These are divided into four categories—infection, nonunion, malunion, and temporomandibular joint ankylosis, although only infection and temporomandibular joint ankylosis are included here. Unique mandibular fracture complications are reviewed.(Arch Otolaryngol 102:627-630, 1976)Never strike another man's fist with your chin.Anonymous

• An approach to the evaluation and the preferred methods of treatment of congenital facial paralysis is presented. The expected results from testing procedures and the limitations of their usefulness in acquired v developmental palsies are discussed. We recommend that the auditory brain-stem response test be included in the initial evaluation of patients with congenital facial paralysis.(Arch Otolaryngol 1983;109:145-151)

• The effects of halothane and nitrous oxide narcotic anesthesia on bleeding were studied. Coagulation parameters were examined preoperatively and a half hour after induction. There were no notable changes with either anesthetic technique, and there were no substantial differences between the two anesthesias. A clinical comparison of bleeding, surgical exposure, blood pressure, and duration of surgery also was made. The two anesthetic techniques tested had no notable differences in the previously mentioned parameters on septorhinoplasty.(Arch Otolaryngol 1982;108:83-86)

• Nasal profiles are altered in almost every rhinoplasty operation. Often neglected in diagnosis and surgery are alterations in profiles of the cheeks and upper lip that should be made at the same time. We show aesthetic effects produced by alterations in these structures and describe how we measure and record the adjustments. A few examples of results are presented to indicate the techniques used and the importance of including changes in profiles of the cheeks and upper lip in cosmetic rhinoplastic diagnosis and treatment.(Arch Otolaryngol 104:16-21, 1978)

• Lateral osteotomies performed posteriorly enough to avoid step-like prominences at the sides of the nose may allow medial displacement of bone to impinge on the airways. This obstruction near the floor of the nasal passageway is prevented by leaving a triangular piece of bone at the pyriform aperture intact just superior to the level of the inferior turbinate. A curved lateral osteotomy, as described here, cuts bone posteriorly only where aesthetic narrowing is required in rhinoplasty. Techniques providing the recommended curved or angulated lateral osteotomies with osteotomes are demonstrated in the cadaver and in patients.(Arch Otolaryngol 103:454-458, 1977)

BACKGROUND: Smell impairment affects 1% to 2% of Americans and leads to frequent physician visits. Olfactory testing is available in chemosensory centers, but not as part of a routine cranial nerve examination. The alcohol sniff test (AST), which uses the standard 70% isopropyl alcohol pad, was developed as a quick, reliable measure of olfactory function. METHODS: Sixty-four patients and 36 healthy control subjects (N=100) were tested with the AST and with a standard butanol threshold test. RESULTS: The AST reliably, consistently, and correctly measured olfactory function. CONCLUSION: The AST is a rapid, reliable olfactory test that can be used for screening olfactory function and should be incorporated in the routine cranial nerve examination.Arch Otolaryngol Head Neck Surg. 1997;123:591-594

• Different scar revision techniques are compared on similar scars, all on the same patient. Comparison of the final results is unique and interesting and provides insight into choosing the "optimal" technique for these procedures. Historical perspective is provided.(Arch Otolaryngol Head Neck Surg. 1991;117:200-204)

Two cases of medial orbital fracture with medial rectus muscle entrapment are reported, one a bona fide blowout fracture. Review of the literature reveals six previous cases.Clinically, patients complain of diplopia with lateral gaze and forced duction tests confirm medial rectus entrapment. Radiographic confirmation is best obtained with hypocycloidal tomography. Surgical therapy is indicated for diplopia or enophthalmus.

• Infections caused by Pasteurella occur most frequently after domestic animal bites or scratches and in individuals with agricultural or veterinary contact with animals. A serious Pasteurella infection developed in an agricultural worker following tumor extirpation of a head and neck neoplasm. Review of Pasteurella infections in humans disclosed that 31 of 446 reported infections involved head and neck structures. The most serious of these involved the adjacent central nervous system. Surgical drainage combined with parenteral penicillin remains the treatment of choice in these infections. Aminoglycosides are not effective in treating this organism.(Arch Otolaryngol Head Neck Surg 1986;112:207-209)

The acquired immunodeficiency syndrome (AIDS) epidemic continues. The number of patients with AIDS continues to grow. Surgeons have a responsibility to protect themselves and the operating room team in such a way as to minimize the inadvertent transmission of human immunodeficiency virus (HIV) from patient to health-care team. Otolaryngologists are required to suspect and diagnose AIDS because 40% to 60% of patients with AIDS present with disease involving the head and neck. Second, virtually all patients with AIDS develop head and neck infections or tumors during their disease and, again, the otolaryngologist is required to diagnose and assist in treatment.HIV can be transmitted to health-care team members by inadvertent sticks, cuts, and splashes at the time of surgery. It behooves every surgeon and every operating room team to have a program to minimize the risk of transmitting AIDS and hepatitis B virus (HBV). The following are the guidelines recommended

To the Editor.—There is currently a great deal of alarming discussion about recertification. I, for one, abhor the thought of once again having to go before some eminent body, which might with a simple pass or fail vote decide whether or not I will continue the practice of medicine.While I feel reasonably certain that the combination of the endorsement from my residency director, passing a written examination and then passing an oral examination, was a fair and reasonable means of assessing my knowledge and ability to go into the practice of medicine, I do not believe an examination 7, 14, 21, 28, 35, or even 42 years later can possibly be a meaningful assessment of my ability to continue as an effective practitioner.Why then are we even discussing this matter? The answer, I assume, is that it is perceived that a small number of our medical group

In Reply.—It is refreshing to see others thinking creatively about improving our ability to trace and excise tumor. There is very little doubt that a major cause of local recurrence is incomplete tumor excision. Parallel histologic sectioning is time-consuming. The idea proposed by Jako et al would greatly simplify tumor identification and excision and is therefore worth pursuing.I am hopeful that others will also apply their ingenuity to develop techniques for detecting, tracing, and excising microscopic extensions of locally aggressive neoplasms.

In Reply.—Dr Byers' letter highlights the fact that there is some confusion about how pathologists orient tissue for frozen-section determination. The traditional technique, which we would describe as perpendicular to the surgical surface and the one used by Byers and his colleagues, is a sampling process. Typically, this orientation would sample 0.1% of the actual margin. Even if multiple additional sections were made, the percentage would only be increased slightly. The orientation described by Frederick Mohs and the one we applied is parallel to the surgical margin and if properly performed, examines 100% of the surgical margin. This is 1,000 times more thorough.Using this approach, I think, we learned something new about the growth patterns of epidermoid carcinoma. This tumor has fingerlike extensions that can be detected by parallel histologic sectioning. Using this technique, this microscopic spread can be detected, traced, and excised. This will ultimately reduce the

Living in San Diego, Calif, I have been privileged to be part of the good, the bad, and the ugly of managed care. I have also had the opportunity to assist our department of surgery in developing capitation rates for general and subspecialty surgery. The following are observations that I believe important for those just beginning this process.Capitation means that a physician or group of physicians agrees to take care of a group of patients for a fixed fee. If the patient group is healthy and requires little medical and surgical care, one can profit. Conversely, if the group is sick, a tremendous amount of work and resources may be required.Those who recommend a capitation agreement mostly come from business and legal backgrounds. The physician is advised to know the age, sex, and sickness of the group for which he or she is capitating. Except for simple divisions