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Morris raises an extremely valid issue in his letter analyzing my comments regarding the guidelines for the treatment of otitis media published by the Agency for Health Care Policy. 1 There is no question that otolaryngologists find themselves in a dilemma under the new schemes of health care delivery being devised across the United States. For more than three decades, our specialty has attempted to convince the public, as well as our colleagues in medicine that, in fact, we are highly trained specialists dealing with a multiplicity of disorders of the head and neck. Now we find ourselves trying to convince the public that we are, in fact, primary care physicians. This certainly has the potential of depicting otolaryngologists as somewhat schizophrenic. There is no question that many otolaryngologists throughout the United States spend a significant portion of their practice day treating primary care problems of the head and neck.

To the Editor. —I am deeply troubled by the article by Dr Kleinman and colleagues 1 regarding appropriateness of tympanostomy tubes. There are several issues of significant concern. Their article compares criteria developed by a panel of "experts" retained by VHS with indications for tympanostomy tube insertion found in the charts of a number of otolaryngologists across the United States. It then concludes, based on these criteria, that approximately 25% of proposed tympanostomy tube insertions did not meet VHS criteria. Of interest is that VHS selected a panel of individuals, declared them experts, and then asked them to write criteria for the use of tympanostomy tubes. In addition, the authors state that participation in the expert panel should not infer that all those individuals uniformly endorsed the proposed criteria. One must be mindful of the fact that VHS is a for-profit organization that sells software packages to third-party payers who

Congenital stridor is frequently a perplexing clinical problem. The diagnosis is often elusive and can prove challenging. Two case presentations illustrate the difficulties involved when more than one lesion is present. The need for complete evaluation of the airway including laryngoscopy, bronchoscopy and barium swallow is stressed.

This article describes the symptomatology of the most commonly encountered malignancies of the head and neck in children. Information is being made available on practically a daily basis from the areas of cytogenetics, tumor markers, and oncogenes. The role of surgery and radiation in the management of these malignancies is also considered and reevaluated.

1. 1. Carcinoma of the palatine arch is part of a regional diathesis of carcinoma of the mucosa of the upper aerodigestive tract and this concept has a definite influence on the choice of treatment. 2. 2. Surgery has an important role in the management of both the primary tumors and the regional metastatic nodes. 3. 3. Radiation therapy is indispensible in the management of carcinoma of the tonsillar crypts, stage IV tumors of the palatine arch, and primary tumors of the palatine arch with certain specific extensions. 4. 4. Comprehensive management of carcinoma of the palatine arch requires careful evaluation of each patient and his disease, vigorous application of the chosen method of treatment by either the surgeon or the radiotherapist, and continuous follow-up study and supportive treatment for the rest of the patient's life.

The carbon dioxide laser has been used in a variety of otolaryngologic conditions. Its specific advantages have particularly lent themselves to its use in the airway. The role of laser endoscopic treatment in subglottic and tracheal stenosis will continue to expand and aid in the successful management of these difficult cases.

A case of melanotic neuroectodermal tumor of infancy has been presented, and the etiology, clinical presentation, and management of this rare tumor have been discussed. The tumor may not be familiar to most otolaryngologists and should be included in the differential diagnosis of pediatric head and neck neoplasms.

Ataxia is rarely attributed to lesions of the peripheral vestibular system. In 1973, the first case of ataxia and hearing loss secondary to a labyrinthine fistula was reported. Until now, this syndrome has not been reported in patients under the age of 10 years. A case is presented of a 5-year-old boy with symptoms of ataxia and hearing loss as well as vertigo and tinnitus after head trauma. Three physical findings appear to be most characterisitic of patients with perilymphatic fistulas: a positive fistula response, positive positional testing with the involved ear down, and evidence of vestibular ataxia when testing station and gait. The absolute diagnosis of perilymphatic fistula can only be established by exploration of the middle ear space. If a fistula is found, it may be sealed with soft tissue and, if this fails, actual stapedectomy may be required.

Benign lesions of the airway in infants and children may endanger the airway and compromise laryngeal function. The CO2 laser provides an elegant method of transoral surgical excision without compromising laryngeal function or airway competence. It avoids the risks of such other treatment modalities as external surgical approaches, prolonged steroid therapy, and radiation. It is applicable to a wide variety of lesions without the necessity of tracheotomy. Hospitalization is minimized. Ten cases are presented to show the wide applicability of this technique. Gross pathology and pre- and postoperative findings are demonstrated and discussed, as is the safety and efficacy of the laser soft-tissue interaction.

Malignant tumors of the head and neck in childhood can present a perplexing diagnostic and therapeutic challenge. The advent of advanced chemotherapeutic and radiotherapeutic techniques has both enhanced survival rates and changed the role of surgical intervention in many of the tumors in this age group. Recent studies employing an interdisciplinary approach have demonstrated that mutilating surgery for head and neck tumors can often be avoided. A prolonged disease free survival and a probable cure can be anticipated in 50 to 70 per cent of the patients. Higher survival rates have been achieved in some tumors, such as stage I Hodgkin's disease and localized rhabdomyosarcoma in some series. The surgeon plays a key role in delineating and diagnosing the initial disease. He must also be attentive to regular follow-up, inasmuch as many patients frequently die of local recurrence, which may go undetected in early stages if vigilance is not maintained. All members of the treatment team must exercise regular conscientious surveillance if these devastating problems are to be overcome.

The fourth branchial cleft anomaly has long been postulated. A case in which a lower neck sinus tract extended under the clavicle near the subclavian vessels is presented. The distinguishing features of bronchogenic and branchogenic anomalies are discussed. It appears that unless a complication (e.g., abscess, inflammatory process) of the fourth branchial cleft sinus tract occurs within the mediastinum, mandating full exploration, the complete form of the anomaly may continue to remain undocumented.

To the 28 cases of rupture of the inner ear windows reported during the past five years, 19 cases are now added. Many have resulted from accidental trauma or barotrauma, with initial manifestation of gait disturbance, ataxia, episodic vertigo, and sensorineural hearing loss of varying severity. The finding of positional nystagmus, a positive Romberg or fistula sign with a sensory hearing loss makes the diagnosis of an inner ear window rupture most probable. Surgical exploration of the middle ear is necessary to identify and close the fistula.

Infection of the supraglottic larynx is a well-recognized clinical entity in both adults and children. The anatomical relationships of the various components of the larynx have been studied extensively, especially as they relate to the spread of malignant disease. However, the relationship of these spaces and compartments in inflammatory disease has not been heretofore appreciated. This report describes for the first time histologic evidence that infection of the supraglottic larynx may spread to the paraglottic space, thus causing compromise of the glottic region. This potential carries significant implications for planning the appropriate therapeutic measures.

Congenital subglottic hemangioma is a potentially life-threatening lesion which frequently presents before the age of 6 months. Many forms of therapy have been advocated for the treatment of this difficult lesion. The use of the carbon dioxide laser has been advocated in the past and this report represents an update in treating 31 patients from 1975 to 1983. The success rate was 94 % and the complication rate was 6.5%. This form of therapy is an effective and valuable addition to those already available for this troublesome lesion.

It is only through meticulous attention to detail that complications in the use of lasers can be avoided. Lasers can be efficient, safe, and effective tools for the head and neck surgeon. However, it is imperative that the surgeon take all precautions so that the incidence of complications, uniquely attributable to laser energy, will be kept to a minimum. Inattention to detail may expose the patient to an unnecessary risk of complications.

Stenosis of the larynx and/or trachea presents perplexing problems. No one technique has proved totally satisfactory in the management of all varieties of stenosis. Recent reports have described the successful use of the CO2 laser in the endoscopic management of stenosis of the larynx and trachea. Failures of this technique need emphasis to assure appropriate selection of therapeutic method. Retrospectively, 49 cases of laryngeal stenosis, 6 cases of tracheal stenosis and 5 cases of combined laryngeal and tracheal stenosis were studied (total 60 patients) following treatment at the Boston University Affiliated Hospitals. Follow-up ranged from 1 to 8 years. Multiple procedures were required in 35 laryngeal patients. Of the laryngeal patients 39 were successfully managed (average number of procedures in successful cases 2.18). Of 11 tracheal patients with combined laryngeal and tracheal procedures, 3 were successfully managed (average number of procedures in successful cases 6). Failures in laryngeal stenosis included four patients in whom an adequate airway was not established though voice was present while maintaining tracheostomies. Thirteen patients failing endoscopic management required open surgery with good result. Factors associated with poor result or failure include circumferential scarring with cicatricial contracture, scarring wider than 1 cm in vertical dimension, tracheomalacia and loss of cartilage, previous history of severe bacterial infection associated with tracheostomy, and posterior laryngeal inlet scarring with arytenoid fixation. In these circumstances, multiple procedures, more extensive alternative open surgical techniques, or maintenance of tracheostomy were necessary. In successful cases only three or fewer procedures on average were required. The factors associated with failure or success of endoscopic methods in the management of laryngotracheal stenosis, including use of the CO2 laser and soft Silastic stents, are analyzed.

Congenital choanal atresia frequently demands immediate recognition in the newborn, and provision of a nasal airway as soon as possible. A variety of techniques are available to correct this problem, but none is entirely satisfactory. Transpalatal procedures are associated with significant morbidity in the newborn, and transnasal microsurgical procedures are less predictable when a thick bony plate is present in the choanal obstruction. Transnasal resection with the CO2 laser has been carried out in seven patients (ten sides), whose ages ranged from 16 hours to 14 years. From this early experience, it appears that the procedure is entirely feasible and convenient. It seems to have significant advantages over conventional microsurgical techniques. Eight out of ten choanae have remained patent for four months or more. A lumen keeper is needed during the immediate postoperative period for at least two to three weeks. The procedure is associated with minimal morbidity.

A reliable sliding chest wall flap, allowing extensive resection of tumors invading the anterior cervical skin is described. There has been no instance of failure or significant complication in the use of this flap in this small series of cases presented. It is believed that its use has allowed more extensive resection of tumor without any increase in morbidity, and may account for the prolonged survival seen in four out of six patients.

Otitis media with effusion is the most common cause of hearing loss in children. Prior studies have indicated that viable bacteria may be present in this process. A controlled clinical trial was therefore undertaken to assess the efficacy of antimicrobial agents in the treatment of this disease entity over a four week period. It appears that the use of antibiotics significantly improves the outcome in patients treated for four weeks when compared with patients observed over the same time period.

Recurrent respiratory papillomatosis is most common in childhood but it affects all age groups; it represents a diathesis of the aerodigestive tract so that lesions may develop at various sites — the nares, lips, pharynx, nasopharynx, larynx, tracheobronchial tree, and the lungs. Ablation of all visible papillomas with the surgical laser achieved remissions in approximately one-third of patients for one year or more; since relapses may occasionally occur 2 to 20 years later, cure can never be assumed. At the present time, management is directed towards total ablation of all visible papilloma consistent with preservation of the airway and voice; reduction of the tumor burden to minimal proportions is thought to allow the maximum opportunity for remission. As the host-papilloma relationship is unraveled, it may be possible in the future to provoke an immune response so that remissions can be predicted and produced consistently.

Rhabdomyosarcoma represents the most common soft-tissue neoplasm of the head and neck found in children. The tumor is most commonly seen in Caucasian children under the age of 12, usually presenting as a painless mass. Distant metastases are frequently present, especially in regional lymph nodes, lung, and bone marrow. All patients suspected of having this disorder should have a thorough examination of the head and neck, as well as a complete radiographic evaluation of the primary region. Histologic disagnosis should be made as rapidly as possible. Once this has been accomplished, a thorough search for metastatic disease can be undertaken. Therapy must be individualized, and a team approach is advocated. The roles of surgery, radiation therapy, and chemotherapy are discussed. A staging system and a treatment-therapy plan are outlined.

Transoral microsurgery of the larynx has now made it possible to treat multiple lesions heretofore only treatable by external approach. The introduction of the surgical carbon dioxide laser has been the single greatest advance in transoral surgery of the airway in the past 15 years. This modality of therapy offers many features not found in any other known form of surgery. It is especially useful in the pediatric airway where the avoidance of edema and the need for minimal scarring is most critical. Its unique aspects make this form of treatment most desirable in the pediatric laryngotracheal region.

This article describes the normal anatomy and physiology of the infant suck-swallow and discusses some dis-orders of swallowing that occur in infancy.

Recurrent respiratory papillomatosis is a relentless disease of viral origin in which squamous papillomas frequently obstruct the respiratory tract of children and young adults. No therapy has been proved to be curative for this process. Recent reports have suggested that interferon may cure or dramatically control airway papillomatosis. We evaluated the efficacy of human leukocyte interferon in the treatment of respiratory papillomatosis. One hundred twenty-three patients were randomly assigned to receive treatment with either surgery plus interferon or surgery alone. Interferon (2 X 10(6) IU per square meter of body-surface area) was given daily for one week, then three times per week for one year; treatment was followed by a year of observation, without the drug. Both study groups underwent serial endoscopy to remove papillomas and to document the efficacy of treatment during the two years of study. During the first six months, the growth rate of papillomas in the interferon group was significantly lower than in the control group (P = 0.0007). This difference diminished during the second six months and was no longer statistically significant (P = 0.68). Our data do not show that interferon is either curative or of substantial value as an adjunctive agent in the long-term management of recurrent respiratory papillomatosis. The initial benefit of interferon is not sustained.

A new microlaryngeal instrument set has been developed for phonatory surgery in adults and for pediatric laryngology. This 20-instrument set consists of forceps (cupped and alligator type) and scissors with 1-mm distal grasping and cutting tips. Open tip and whistle tip variety suction instruments with tip diameters of 1.0,1.5, and 2 mm are also available. Included as well are fine (1.0-mm) probes for palpation and laser welding and smoke evacuation double-action grasping forceps. This microlaryngeal instrument set has been extremely useful in more than 80 clinical applications.

Acute epiglottitis is a true pediatric emergency. The intense inflammation of the supraglottic larynx may completely obstruct the larynx within several hours. This infection is secondary to infiltration of Hemophilus influenzae type b (HIB), and 90% to 95% of patients have positive blood cultures. During this period of generalized septicemia HIB involvement of other soft tissue sites may occur. The goal of this article is to alert otolaryngologists to the possibility of extraepiglottitic HIB involvement. In particular, HIB meningitis, concurrent with supraglottitis, will be discussed. Although the overall incidence of multiple site involvement is relatively low, it is important to be aware of the possibility, since the outcome may be significantly altered.

Congenital and acquired lesions of the pediatric airway may lead to significant morbidity and mortality. A review of 616 endoscopic procedures, carried out over a 2-year period, was undertaken. Of these procedures, 270 were diagnostic and 346 were therapeutic. This paper outlines the clinical indications, the role of radiology, and the diagnoses revealed by this retrospective review. Of particular interest was the fact that 11.5% of the patients had lesions in more than one anatomic site in the upper aerodigestive tract. The complications were divided into intraoperative, immediate postoperative, and delayed. In total, there was a 1.6% complication rate.

• Kawasaki disease (KD) is an acute illness of unknown cause that affects infants and children. The diagnosis is confirmed in patients with prolonged fever and four of the following clinical features: (1) nonexudative conjunctivitis; (2) oral cavity changes; (3) rash; (4) extremity changes; and (5) cervical adenopathy. Complications of KD include coronary artery aneurysms, which may lead to myocardial infarction, chronic coronary insufficiency, or death. We describe a series of 83 patients with KD in whom 43 (52%) of 83 developed cervical adenopathy during their acute illness. Eighteen (42%) of these 43 patients were initially misdiagnosed as having cervical adenitis and were treated with antibiotics. The otolaryngologist may see these patients in referral and should consider the diagnosis of KD in patients with cervical adenopathy, prolonged fever, signs of mucosal inflammation, or rash. Early diagnosis and intravenous treatment with high-dose γ-globulin is effective in reducing the prevalence of coronary artery abnormalities. (Arch Otolaryngol Head Neck Surg1989;115:512-514)

Cystic fibrosis (mucoviscidosis; fibrocystic disease of the pancreas) is an inherited autosomal recessive disorder that results in generalized dysfunction of exocrine glands. Chronic pansinusitis with nasal polyposis occurs frequently in this disease. Polypectomy and sinus drainage procedures are often required in those cases refractory to medical therapy. Recurrence of nasal polyps following removal is common. Controversy exists regarding the timing and extent of surgery. The management of 40 children with cystic fibrosis who underwent nasal polypectomy, intranasal ethmoidectomy, and Caldwell-Luc procedures to treat extensive sinusitis and nasal polyposis forms the basis for this report. Follow-up data indicate that fewer recurrences and longer symptom-free intervals result when intranasal ethmoidectomy and Caldwell-Luc procedures are combined with polypectomy.

Otitis media with effusion is the leading cause of hearing loss in children. The pathogenesis of this disease process continues to be controversial. Diagnosis requires precise otoscopic evaluation coupled with audiometric investigation. Therapy has traditionally included medical and surgical regimens. Recent findings indicate that some basic changes may be required in both these therapeutic avenues. Aggressive therapeutic intervention may be required in patients presenting with complications of otitis media with effusion. Available information strongly indicates that a more intensified research effort must be undertaken to better identify and treat this difficult disease process.

A controversy has existed in recent years regarding the ideal method of establishing and maintaining an airway in the pediatric patient with acute supraglottitis. Nasotracheal intubation has been used as the sole method of airway management of acute supraglottitis at The Children's Hospital, Boston, since 1970. This paper reviews our experience with 80 children with acute supraglottitis presenting at our institution during the years 1980 to 1985.

The carbon dioxide laser was used to treat a group of pediatric patients with benign lesions of the upper aerodigestive tract exclusive of the larynx Prior to development of the CO2 laser, excision of these lesions by conventional means often resulted in incomplete removal, significant bleeding, and postoperative edema resulting in airway obstruction. The CO2 laser, with its unique properties of precise excision, hemostatic effect and minimal postoperative edema, has become the instrument of choice in the removal of these lesions.

Serous otitis media is the most common cause of hearing loss in childhood. Traditionally, this entity has been felt to be a sterile process. This study was undertaken to determine the incidence of infected middle ear fluid in patients with asymptomatic middle ear effusions. The external auditory canal, nasopharynx and middle ear fluids of 57 patients undergoing myringotomy were cultured. Of 57 patients, 26 had positive cultures; 67% of patients less than 36 months of age had positive culture, with a bacterial flora closely resembling that of acute otitis media. Further investigation is required to determine the significance of such infection together with the optimum therapy for chronic effusions of the middle ear in young children.

Congenital and acquired lesions of the pediatric airway present difficulties in management. Until recently, correction of these problems frequently involved an external approach to the larynx and trachea. Development of fiberoptic instrumentation, as well as the introduction of the Zeiss operating microscope, has now given the surgeon a new means to visualize the larynx and trachea. Soon after its development, the carbon dioxide surgical laser was coupled to these instruments to permit an extremely precise form of tissue excision and ablation. Its unique properties, including an extraordinary hemostatic effect, as well as minimal postoperative adema and scarring, make it an ideal tool for management of lesions of the pediatric airway. It has been employed successfully in the treatment of 177 lesions.

VEHICULAR accidents represent the single greatest cause of death and injury to people under the age of 35 in the United States. Approximately 75 per cent of these accidents involve injuries to the ...

A working protocol is presented which has developed to help the clinician in the diagnosis and management of patients suffering from the sleep apnea syndrome associated with various types of upper airway obstruction.

Surgery of the nasal septum has long been discouraged in the pediatric population. Concerns about growth and development of the nose have led surgeons to adopt an extremely cautious attitude toward the correction of nasal septal deformities in childhood. More recently, studies have shown that with proper preservation of septal cartilage, surgery can be safely undertaken in this area. Frequently, however, exposure to the nasal septum is limited in small children due to the size of the nasal vestibule. Sublabial septoplasty has been safely carried out now in ten patients ranging in age from 4 to 9 years. This approach allows for complete access to the nasal septum while avoiding any external cosmetic deformity. The nasal septum has been preserved in all cases through morsalization and repositioning. Growth and development of the nose has been followed for up to 60 months without evidence of deformity or alteration. Sublabial septoplasty would, therefore, appear to be a safe and cosmetically acceptable approach to the correction of severe nasal septal deformities of childhood.

The CO2 laser was first introduced for surgery of the aerodigestive tract in 1971. Since that time, great advances in application have been made in both the adult and pediatric population. Recent reports of isolated complications have appeared in the literature. However, a realistic complication rate in a large series of patients has yet to be reported. This report relates the combined experience of the authors in a total of 4416 cases during the 11-year period from 1971 to 1982. There were nine instances of complications, representing a complication rate of 0.2%. These complications provided a unique learning experience for the authors, and led to the establishment of certain basic principles that should be followed in all laser operations. This survey indicates that the CO2 laser is a safe, extremely useful surgical modality in the aerodigestive tract.

• Microlaryngoscopy for the diagnosis and treatment of laryngeal pathology is a commonly performed procedure in otolaryngology. The use of this technique continues to increase in frequency due to the availability of laser surgery for the management of laryngeal disease. Ventilation during microlaryngoscopy, however, poses a problem as the airway must be shared by the anesthesiologist and the otolaryngologist. Although many techniques of ventilation during microlaryngoscopy are used, the use of high-pressure Venturi jet ventilation, especially during laser surgery, is most frequent. Complications during high-pressure Venturi jet ventilation are uncommon but may occur suddenly and present the surgeon with a life-threatening emergency. Hypoventilation, pneumomediastinum, pneumothorax, severe abdominal distention, and death (directly attributable to various methods of jet ventilation) have been described. (Arch Otolaryngol1985;111:127-131)

Five antigenically distinct serotypes of human papillomavirus (HPV) cause various cutaneous verrucae with distinct clinical features. Laryngeal and other mucosal papillomas, also suspected to have a viral etiology, were examined for the presence of a genus-specific (common) antigen of HPV using a peroxidase-antiperoxidase (PAP) technique. The primary antiserum used was reactive against laryngeal papillomas from 26 of 35 randomly selected patients (74%); overall, 49 of the 102 squamous papillomas stained were positive for HPV (48%). HPV antigen was not demonstrated within frankly dysplastic squamous cells. Nuclear localization of virus was confirmed by electron microscopy in 3 cases positive for HPV. PAP localization of HPV is rapid and more efficient than routine electron microscopy. Our data indicate a common pathogenesis for some papillomas and cutaneous verrucae and suggest a future role for immunohistochemistry in evaluating the epidemiology and pathobiology of laryngeal papillomatosis.

Two cases of bifid epiglottis are presented: one with an associated laryngeal cyst and another with an associated cricoid stenosis. The occurrence of multiple laryngeal anomalies in association with bifid epiglottis has not previously been described. The occurrence of an extra digit is noted to be statistically significant both in the current series and in a review of the literature. A brief review of the embryologic classification and staging by the Carnegie System, and the correlation of the time sequence of development of the epiglottis is presented. No correlation is made as to the mechanism of the origin of this laryngeal anomaly, as adequate embryologic knowledge of the development of the pharynx is not available at this time.