Major Ambulatory Surgery of the Otolaryngologic Patient

Major Ambulatory Surgery of the Otolaryngologic Patient

Major Ambulatory Surgery 0039--6109/87 $0.00 + .20 Major Ambulatory Surgery of the Otolaryngologic Patient Gerald S. Gussack, M.D.,* and William ...

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Major Ambulatory Surgery

0039--6109/87 $0.00

+

.20

Major Ambulatory Surgery of the Otolaryngologic Patient

Gerald S. Gussack, M.D.,* and William R. Hudson, M.D.t

The specialty of otolaryngology-head and neck surgery-lends itself well to ambulatory surgery. Perhaps as many as 75 per cent of surgical procedures can be performed on an outpatient basis. This includes most facial trauma, the majority of otologic procedures, nasal and sinus surgery, limited procedures on the neck, selected oral cavity and laryngeal lesions, and cosmetic facial plastic surgery. The surgical procedure in question is not the only determining factor in electing ambulatory surgery. Third party carriers have developed specific lists of approved outpatient procedures. Deviations from this list result in denials and delays, necessitating further documentation and appeals. Little consideration is giver). to extenuating factors affecting patient safety. These factors include: (1) the medical status of the patient; (2) the quality and proximity of care following discharge; (3) the physical facilities of the surgical unit; (4) the quality and training of the personnel in the unit; and (5) the availability of an acute care unit for transfer if necessary. Safe ambulatory surgery places more demands on the surgeon. Careful preoperative planning is essential. One does not have the luxury of correcting errors of omission in the preoperative evaluation as can be done in the hospitalized patient. Laboratory data and indicated consultations must be obtained prior to the day of surgery. Discussions with the patient and the family must also address postoperative care. This includes fluid and dietary requirements, pain management, activities, and possible complications. The patient and his or her family should have specific instructions as to who to call for questions and emergencies, Calls from the surgeon's office during the immediate postoperative days are not only reassuring to the patient but may help anticipate complications. Certain categories of surgical procedures withir). each specialty have a predictably high incidence of complications. The head and neck area i~ *Assistallt Professor and Chief, Division of Otolaryngology, University of South Alabama Medical Center, Mobile, Alabama tProfessor and Chief, Division of Otolaryngology, Duke University Medical Center, Durham, North Carolina

Surgical Clinics of North America-Vol. 67, No.4, August 1987

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extremely vascular, and bleeding, particularly when the airway is endangered, can be life-threatening. This is of major concern in nasal surgery and in tonsillectomies. Edema with airway obstruction may follow laryngeal surgery. Dehydration may accompany dysphagia. The patient and the family must be carefully instructed to recognize these potentially lethal complications. Leaflets are advised for patient review. Safety should never be compromised for reasons of cost or convenience. Unanticipated emergencies and complications do occur, but by carefully considering all the variables the astute surgeon can keep these to a minimum.

ANESTHESIA The choice of anesthetic agents for the ambulatory otolaryngologic and head and neck procedures is dependent on many factors, including the age of the patient, physical status, level of anxiety, patient's preference, surgeon's preference, length of the procedure, and capabilities of the facility. Most procedures in otolaryngology are suitable for local or topical anesthesia, or both. The addition of intravenous sedation under the auspices of anesthetic personnel, or "monitored anesthesia," is preferable in many situations. Local and topical anesthetics alone are ideally suited for ambulatory situations because a prolonged period of convalescence and postoperative monitoring is not required. The most commonly used topical agent is cocaine. Cocaine can be applied to the mucosal surfaces in a 2 to 10 per cent solution or in the form of a paste. Cocaine is rapidly absorbed from the mucosal surfaces and the toxic potential of this drug must be kept in mind at all times. Maximum adult doses of 200 mg should not be exceeded during any 1 hour. Toxicity is usually manifested as central nevous system irritability and seizures. Resuscitation equipment and drugs such as barbiturates and diazepam should be available at all times. Other topical agents in use for nasal and laryngeal procedures include lidocaine and tetracaine. These agents offer reasonably good topical anesthesia but lack the vasoconstrictive properties of cocaine. Their lower potential for abuse and lack of popularity as recreational drugs makes them preferable to cocaine in certain situations. Lidocaine is effective either locally or topically. Solutions of 1 to 2 per cent are commonly used for local anesthesia, and the addition of 1:100,000 or 1:200,000 epinephrine decreases local bleeding and prolongs the anesthetic effect. The maximum safe dose for lidocaine is 500 mg. Its toxicity may manifest by cardiovascular instability and arrhythmias. Marcaine is another useful local agent when prolonged anesthesia is anticipated. The vasoconstrictor effect of topical cocaine and local lidocaine with epinephrine is of particular benefit in surgery of the vascular areas of the head and neck. This provides a relatively blood-free field for the surgeon and may decrease the need for blood transfusions. Nasal procedures are particularly suited for this combination of topical and local anesthetics. In an ambulatory setting adequate preoperative medication is necessary. The medications given should be individualized according to the age, weight, and physical status of the patient along with the type and length of

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the procedure to be performed. Good communication with the anesthesiologist, who will be attending the surgical procedure, is of importance. Medications may be given fo the patient to take home prior to the surgery and may be taken before arrival. This provides time for the drug to achieve its full sedative effect and for the patient to enter the ambulatory unit in a relaxed frame of mind. Barbiturates and diazepam are given preoperatively not only to decrease patient anxiety but to decrease the likelihood of a toxic reaction to local and topical agents. The availability of general anesthesia in an ambulatory setting greatly increases the scope and variety of procedures that can be done. The concept of general anesthesia being used on an outpatient basis is being utilized more and more frequently. Often the types of anesthetic agents that are utilized do not differ remarkably from those used in general inpatient procedures. The main difference is a frame of mind that is undertaken by both the anesthesiologist and the surgeon. Use of agents that provide a prolonged mode of action and long recovery period should be avoided. The recent introduction and popularity of the short-acting narcotic agents such as sufentanil citrate provide deep levels of anesthesia and a very high rate of metabolism. This allows the anesthesiologist to administer a deeper level of general anesthesia and still have the patient awake and alert after the drug has been metabolized completely within 30 to 40 minutes. The authors have also found the use of a combination of ketamine along with sufentanil to produce a deep level of anesthesia and analgesia without the need for endotracheal airway management. The patient is alert and responsive during the procedure with a high level of analgesia, although patients report some disassociative types of symptoms. The authors have found this to be an ideal type of anesthetic for procedures such as the removal of appliances for mandibular fixation or resection of small intraoral lesions. Closed reductions of nasal fractures have also been undertaken using this technique.

SURGERY OF T1IE EAR Surgery of the external ear is easily included in the scope of ambulatory procedures. A wide variety of procedures is included in this category. This may include drainage of hematomas, resection of preauricular fistulas, removal of small ear malignancies, cosmetic otoplasties, and keloid removal. Some of these will be discussed in further detail.

SURGERY OF THE EXTERNAL EAR Hematoma Hematomas result from trauma to the auricle and are formed from the accumulation of blood between the skin and the perichondrium. This produces a smooth, characteristically rounded swelling of the pinna without evidence of inflammation as might be seen in the patient with perichondritis. If found in the acute stage, aspiration of the hematoma may return the

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ear to its normal anatomic configuration. Care must be taken to carry this out under aseptic conditions to avoid infection. Incomplete evacuation usually results in reformation of the hematoma. If this is allowed to occur chronically, then a cauliflower-ear type of deformity may develop. Often large hematomas are not amenable to aspiration and a more definitive procedure must be undertaken. This should be performed by making an incision in the fold of the helix and evacuating the blood in a sterile fashion. A curette may be used to remove any adherent clot to the perichondrium. This is followed by copious irrigation. Postoperative care is facilitated by applying rolls of Vaseline-impregnated cotton, molded to the contours of the ear, and applying a mastoidal pressure dressing. The use of throughand-through stay sutures tied over antibiotic-impregnated dental rolls on both sides of the auricle is another alternative. Care must be taken not to tie these sutures too tightly, or necrosis of the skin and cartilage may ensue. Careful and frequent follow-up to look for perichondritis or necrosis should be taken into consideration in the management of all hematomas of the ear to avoid complications. Keloids Keloids of the ear are commonly seen in the black population and are secondary to an overgrowth of connective tissue. This usually follows the trauma of ear piercing. Simple re-excision of keloids usually results in recurrence of a larger keloid within a short period of time. Good success has been obtained in the management of keloids with repeated injections with 1 ml of steroids (40 mg of Kenalog suspension, ER Squibb, Princeton, New Jersey) repeated at weekly to monthly intervals in an attempt to soften the hypertrophic tissue and decrease the size. Four to six preoperative injections of the steroid, followed by a conservative type of resection leaving a small rim of the skin overlying the keloid, often yields a good result. Some centers follow excision with 300 rads of radiation therapy, but controversy exists as to the efficacy of this type of therapy. Lesions of the Pinna The pinna is a common site for basal and squamous cell carcinoma because of its exposure to sunlight in susceptible populations. Small lesions along the helix should be removed by a wedge resection. A relaxing type of incision with a smaller resection of a portion of the remaining auricular cartilage is often helpful in preventing a protrusion or cup-like deformity of the pinna. If larger lesions are encountered, a variety of more extensive incisions can be undertaken to resect the carcinoma. These are illustrated in Figure 1. The pinna has a smaller appearance but generally an excellent cosmetic result is obtained. Every attempt is made to preserve the superior portion of the pinna in patients who wear eyeglasses. Surgeons should be aware that larger lesion!! require a thorough physical examination to rule out early metastatic disease of the neck. SURGERY OF THE TYMPANIC MEMBRANE AND MIDDLE EAR

Myringotomy with Tympanostomy Tubes The management of recurrent otitis media remains a major portion of the otolaryngologist's practice. One of the most common ambulatory surgical

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c Figure 1. Subtotal auriculectomies for maligf,lant lesions of the pinna. A, Incisions for resection. B, Placement of mattress sutures. C, Final closure. (From Hudson WR, Gussack GS: Otolaryngology-head and neck surgery. In Davis JE (ed): Major Ambulatory Surgery. Baltimore, Williams & Wilkins Co, 1986; with permission.)

procedures performed by the otolaryngologist is a myringotomy and the placement of a tympanostomy tube for establishment of ventilation of the middle ear. Controversy obviously surrounds the exact indications for this procedure, but they may include: the presence of serous, amber-colored fluid in the middle ear; recurrent otitis media with inability of the middle ear to return to its normal physiologic appearance between attacks; acute suppurative otitis media with exudate under pressure; and eustachian tube dysfunction secondary to cleft palate or other cranial facial anatomic deformities. Anesthetic techniques for myringotomy and tube placement should be tailored to the clinical situation. In a cooperative adult patient, the external auditory canal may be injected in four quadrants with 1 to 2 ml of lidocaine with epinephrine. This is similar to the technique employed in anesthesia

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for a tympanomeatal flap in a stapedectomy or middle ear exploration. The technique of iontophoresis utilizing 1 ml of 4 per cent lidocaine is also applicable. This technique utilizes an electric current to drive the solution through the intact epithelium of the external auditory canal and tympanic membrane. The procedure has the disadvantages of requiring 15 to 30 minutes for optimal results. The level of anesthesia may be variable. In young children, inhalation anesthetic by means of a volatile agent such as halothane is well tolerated and effective. This may often be performed without the use of any supplemental intravenous agent. The anesthetist must be cognizant of an intact airway, especially on turning the patient's head to the side as the surgeon performs the operative procedure. Technique. The technique of myringotomy involves the incision of the tympanic membrane with a small sharp knife. The incision should be confined to the pars tensa and should avoid the posterior-superior quadrant and underlying round window and ossicular chain. The incision should be large enough to allow evacuation of the middle ear fluid and snug placement of the flange of the tympanostomy tube. This is illustrated in Figure 2. A straight pick is often helpful for tube manipulation. Tympanoplasty Closure of chronic perforations can be an outpatient procedure. Ideally this is performed on a dry, noninfected middle ear. The extent of the surgery is dependent on the size and position of the perforation. Small perforations can be closed utilizing transcanal procedures; larger perforations (especially anterior perforations) or total perforations require a postauricular approach. Anesthesia can be local as previously described or general. This will depend on the age of the patient and the extent of the procedure. Transcanal Techniques. After adequate anesthesia, the perforation is visualized and margins of the perforation are freshened. The underlying mucosal surfaces of the drum are then roughened with angled picks. A small piece of temporalis muscle fascia is harvested from the postauricular area and placed into a graft press. After this has dried, it is trimmed to the appropriate size. A bed of Gelfoam is then made in the middle ear and the graft is placed in an underlay technique. The graft is then covered with Gelfoam or a small piece of Silastic sheeting, as illustrated in Figure 3. Postauricular Approach. Large or total perforations require more extensive surgery, and general anesthesia is usually preferred. Postauricular approaches provide better exposure of the anterior annulus and allow a more definitive examination and exploration of the ossicular chain. The incision is made in a postauricular crease and is carried down to the mastoid portion of the temporal bone. Periosteal elevators are utilized to expose the posterior canal wall. A posterior canal wall incision is then made and the middle ear can be visualized through the postauricular incision. Microsurgical instruments are employed to remove the margins of the perforation and prepare the drum remnant for the graft. The tympanomeatal flap is elevated down to the level of the annulus of the tympanic membrane and the middle ear is exposed. The integrity of the ossicular chain and the presence of the round window membrane reflex are assessed. A bed of

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Figure 2. Myringotomy and tube placement. A, Radial incision is made in the anteriorinferior quadrant. 8, Fluid is removed with suction. C, Placement of tympanostomy tube. D, Appearance at conclusion. (From Hudson WR, Gussack GS: Otolaryngology-head and neck surgery. In Davis JE (ed): Major Ambulatory Surgery. Baltimore, Williams & Wilkins Co, 1986; with permission.)

Gelfoam is placed in the middle ear and the temporalis fascia is then placed in an underlay technique. Careful measurement of the size of the perforation allows for the exact trimming of the size of the fascia graft and facilitates better graft placement. Care is taken to have the graft tucked well up under the anterior margins of the annulus and then extend up on the bony posterior canal wall. Replacement of the posterior canal wall skin aids in providing a vascular supply. Packing is then placed with added pieces of Gelfoam and antibiotic ointment. The postauricular incision is closed in a standard fashion and a mastoid dressing is placed.

SURGERY OF THE NOSE Nasal surgery for the well-adjusted adult patient is ideal for ambulatory management. This includes both internal and external procedures, or

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Figure 3. Myringoplasty. A, Incisions in the external canal wall skin and preparation of the margins of the perforation. B, Inspection of the ossicular chain. C, Placement of the fascial graft. D, Gelfoam placed in the middle ear to support graft. E, Final placement of the graft. F, Replacement of the tympanomeatal flap. (From Hudson WR, Gussack GS: Otolaryngology-head and neck surgery. In Davis JE (ed): Major Ambulatory Surgery. Baltimore, Williams & Wilkins Co, 1986; with permission.)

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combinations. The use of local anesthetics and topical cocaine may be supplemented by intravenous sedation.

SEPTOPLASTY

Septoplasty is an operation performed to straighten a deformed or deviated nasal septum while preserving important cartilaginous supporting functions of the septal cartilage. Current operations are more conservative and dynamic than the standard submucous resection of the septal cartilage that was performed in the past. A successful septoplasty is dependent on a careful preoperative evaluation of the distinct anatomic deformities. Deformities of the nasal septum may be divided into three basic groups, which may occur as isolated deformities or in any combination: (1) caudal septal deformities; (2) deformities of the anterior septum and maxillary crest; and (3) deformities of the posterior cartilaginous and bony septum. The anesthetic technique for each is similar and employs packing of the nose with pledgets impregnated with cocaine solution followed by the injection of lidocaine with epinephrine. The injection of lidocaine along the septum produces elevation of the mucoperichondrium and allows easier dissection later. Injections are made along the floor of the nose and the base of the columella. The goal of the modern septoplasty is complete exposure of the bony and cartilaginous skeleton of the nose with accurate resculpturing and refinement of the deformities. This occurs along with minimal sacrifice of supporting elements of the nose, which is in sharp contrast to the submucous resection that has been advocated in the past. The surgical approach to all these deformities begins with the same basic incision in all dissections. This is the hemitransfixion incision. It is usually made along the convex edge of the nasal septum about 2 to 3 mm from the caudal end of the septum. It may also be placed directly on the caudal end of the septum and the same result is achieved. The key to proper elevation of the mucoperichondrial flaps lies in achieving the proper plane of dissection. This is the plane between the cartilage of the septum and the perichondrium. Deformities of the caudal end of the septum are repaired by elevating the flaps bilaterally to free this aspect of the septum and carrying the incision down to the floor of the nose, with careful dissection along the nasal spine and maxillary crest. The aim is to achieve total mobilization of the caudal portion of the septum by detaching it from the surrounding mucosal attachments. A small portion of the cartilage underlying the base of the septum may be resected to achieve full mobilization. The septum is allowed to swing free over the midline of the maxillary crest and is then reattached to the nasal spine with a figure eight or mattress suture. A small amount of the leading edge of the septum may be removed, but this should be kept to a minimum to avoid retraction of the tip of the nose. Deformities of the anterior septum and maxillary spine usually result from old trauma in which the septal cartilage has become subluxed off the maxillary crest, forming a characteristic spur. Again, management of these defects begins with elevation of the mucoperichondrial flap along the entire

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length of the septum back to the perpendicular plate of the ethmoid. The flap is elevated down onto the deformity at the base of the septum and maxillary crest. An inferior tunnel is then elevated along the floor of the nose and the two tunnels are connected to expose the deformity. A combination of blunt and sharp dissection is used and care must be taken to avoid tearing the flaps in this area. The deformity is removed by resecting the overhanging portion of the cartilage and possible resection of the wing of the maxillary crest by using a small osteotome. Periodic replacement of the flap and examination of the nasal airway with the flaps in place allow the surgeon to assess the progress and adequacy of the repair. Deformities of the posterior cartilaginous bony septum are common and result from developmental or post-traumatic deformities. Management of these deformities is straightforward and among the easiest of the septoplasty procedures to be performed. The flap is elevated on the ipsilateral side onto the posterior septum and face of the sphenoid. A contralateral mucoperichondrial flap is then elevated by incising the cartilaginous septum in a vertical manner at the bony cartilaginous junction, achieving access to the plane immediately below the periosteum of the perpendicular plate of the ethmoid bone and vomer. Once adequate exposure is obtained, the perpendicular plate is removed above the deformity with a double-action cutting rongeur of the Jansen-Middleton variety. Care is taken to avoid any rocking motion that may injure the cribriform plate and result in cerebrospinal fluid rhinorrhea. The spur is then removed with a Takahashi type forceps. After this procedure has been carried out, the surgeon may still be dissatisfied as to the adequacy of the repair. Persistent septal deflections can be removed by utilizing resculpturing techniques including shave excision, small elliptical excisions, and cartilage morselization. All of these techniques are designed to increase the flexibility of the cartilage and allow it to return to the midline without loss of a major amount of cartilaginous support. An extremely conservative attitude should always be exercised in performing these procedures, as loss of nasal support results in severe functional and cosmetic deformities. At the completion of the septoplasty, the nose is carefully examined and any blood, loose bone, or cartilage removed. Tears in the mucoperichondrial flaps are repaired with sutures of 4-0 chromic ca.tgut. The procedure is then completed by closing all the incisions with interrupted sutures of 4-0 chromic catgut.

SURGERY OF THE PARANASAL SINUSES

Ambulatory surgery of the paranasal sinuses should be primarily limited to surgery of the maxillary sinuses or endoscopic procedures of the ethmoid sinuses .. The potential intracranial complications from frontoethmoid or sphenoid surgery require careful postoperative monitoring because of the risk of cerebrospinal fluid leaks or meningitis. More extensive sinus procedures should be considered as inpatient procedures. The maxillary sinus is the largest of the paranasal sinus and is most often involved with infectious complications. Indeed, it is unusual to see

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involvement of the other sinuses without some evidence of maxillary sinus disease. Procedures performed for surgery of the maxillary sinus are usually instituted after a failure of conservative medical treatment for the patients' symptoms. Frequently surgery on the maxillary sinuses is performed in conjunction with other intranasal surgery such as septoplasty or turbinate reductions. For multiple intranasal and sinus procedures, we again believe that inpatient therapy is best. Antral Puncture

The first of the surgical procedures to be discussed is the nasal antral irrigation or antral puncture. These are usually performed with a combination of topical 4 or 5 per cent cocaine solution supplemented with 1 per cent lidocaine with epinephrine. The site for puncture is usually below the inferior turbinate and the area to be anesthetized is on the lateral wall of the nose and the inferior meatus. A wait of 10 to 15 minutes after the institution of anesthesia ensures both a good anesthetic effect and increased vasoconstrictive effect. Puncture of the maxillary antrum is then carried out with the use of a straight thin Lichtwizc needle or similar type of instrument with a stylet in place. The site of puncture is at least 0.5 to 1 cm behind the leading edge of the inferior turbinate. The surgeon should constantly be aware of the position of this needle and keep a second finger externally on the nose to palpate the piriform aperture and avoid inadvertent subcutaneous injection. The needle is introduced through the lateral wall of the nose and directed toward the lateral canthus. The needle should be aspirated to check for proper position prior to any irrigation. The sinuses are then gently irrigated with warm normal saline solution while the patient holds his or her head over a basin and allows the solution to run out of the nose and mouth. Intranasal Antrostomy

A well-performed intranasal antrostomy offers an excellent chance of providing effective drainage with minimal complication in the treatment of maxillary sinus inflammatory disease. The anesthetic technique is similar to that for a nasal antral irrigation. The nasal wall is anesthetized and the turbinate is usually infractured with a broad-based Freer or Cottle type of elevator. The nasal speculum is then positioned to enable visualization of the lateral wall of the nose. The lateral wall is perforated with a suitable instrument and the antrostomy is enlarged with the use of a Kerrison bonebiting rongeur anteriorly and a Takahashi rongeur posteriorly. The most common reason for failure of an intranasal antrostomy is an opening that is not of adequate size. The opening should be at least 1.5 to 2 cm in diameter and the overlying mucosa should also be removed. The sinus cavity can then be inspected and any abnormal tissue removed. Endoscopic Sinus Surgery

The past 2 to 3 years have witnessed a marked increase in popularity of endoscopic sinus procedures. The theory behind this procedure is that diseased areas in the ethmoid and maxillary sinus can be better visualized

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and removed, while areas of the ethmoid sinus that are not diseased can be preserved. The theory that has been popularized by Messerklinger is that the anterior ethmoidal middle meatal complex is a primary source of disease for the maxillary, ethmoid, and frontal sinuses. Inflammation and obstruction in this area may cause secondary obstruction in the other mentioned sinuses and lead to recurrent sinus infections. The procedure is best undertaken after the patient has undergone a detailed radiographic evaluation of the paranasal sinuses with the use of hypocycloidal, conventional tomography, or a direct coronal computed tomographic analysis. These studies identify problems in the anterior ethmoids that can lead to extensive secondary disease in the maxillary and frontal sinuses. It is hoped that these endoscopic procedures will reduce the need for more extensive maxillary and frontal sinus surgery. This technique obviously requires experience, a special set of instruments, and specialized instruction in the use of these procedures. Briefly, endoscopic surgery may be undertaken in the following fashion. The patient is first examined carefully at the time of the initial consultation after the nose has been treated with a topical vasoconstrictor and anesthetic. This is correlated with the tomographic appearance of the patient's sinuses, and a decision regarding endoscopic sinus surgery may then be made. If an endoscopic sinus procedure is elected, this may be undertaken under general anesthesia or a combination of local and topical anesthesia. The infundibulum of the anterior ethmoid sinus is opened slightly anterior to and inferior to the insertion of the middle turbinate. The medial wall of the infundibulum is then removed. The area of the bulla ethmoidalis may be examined. The theory of endoscopic sinus surgery is that only the diseased cells are removed. The maxillary sinus ostium is then widened in its physiologic position using a special instrument. Postoperative care is similar to that for standard nasal surgery and requires humidification and cleansing of the nose. The advantages of this technique for outpatient surgery are that it is considered less invasive and has decreased morbidity over standard intranasal surgical approaches. Radical Antrostomy (Caidwell-Luc) The gold standard for access and evaluation for surgery of the maxillary sinus is a radical antrostomy or Caldwell-Luc procedure. The indications for this may be chronic maxillary sinusitis, antral disease of dental origin with an associated oral-antral fistula, diagnostic exploration if a tumor is suspected, trauma or fracture of the antral walls, malar or orbital floor, or access to the pterygomaxillary space. An important part of the operation is to provide a large intranasal antrostomy for drainage into the nose. Local anesthesia may be tolerated in select individuals. However, general anesthesia is usually the preferred technique. After general anesthesia is obtained, the upper lip is elevated in the canine fossa, and the buccal sulcus is injected with lidocaine with epinephrine. An incision is made above the alveolar ridge and carried down to the anterior face of the maxilla. The soft tissue and periosteum is then elevated to the level of the infraorbital nerve. Obviously, care is taken to avoid injury to this structure, as postoperative hypoesthesia may occur. An

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osteotome or drill is then used to make a hole in the face of the maxillary antrum and fragments of b9ne are removed. Kerrison rongeurs are then utilized to enlarge the opening. Once a large enough opening is obtained, the maxillary sinus may be inspected and definitive treatment of the diseased tissue may be undertaken. Following this, a large opening is made into the inferior meatus by removing the bone on the medial wall of the sinus and preserving the nasal mucosa. A flap of mucosa based inferiorly is then created covering the cut edge of the bone and extending into the antrum. Packing is usually not necessary but may be brought out through the intranasal antrostomy if required. The Caldwell-Luc is the starting point for several other procedures including transantral ethmoidectomy, exploration of the pterygomaxillary space, and exploration of the floor of the orbit.

FRACTURES OF THE FACIAL SKELETON Management of facial fractures on an ambulatory basis should be limited to isolated injuries. Complex maxillofacial fractures should be cared for on an inpatient basis with close postoperative follow-up. In managing any injury of the facial bones, injuries coexistent to the central nervous system, orbital structures, and upper airway must be ruled out. A thorough history and physical examination should be undertaken. Specific information concerning any change in mental status or loss of consciousness must be elicited. The physical examination should include a complete neurologic examination with particular reference to the cranial nerves, examination of the ears to rule out a hematotympanum, and careful examination of the oropharynx to rule out foreign bodies such as fractured teeth or dentures. The coexistence of chest, abdominal, or limb trauma should be searched for in any patient sustaining motor vehicular trauma. The majority of facial fractures can be managed surgically after waiting 5 to 7 days for subsequent ecchymosis and edema to subside. This~ may simplify the operative technique without compromising a good postoperative cosmetic result.

NASAL FRACTURES

Nasal fractures are by far the most common facial bone injuries. These may occur as an isolated injury or in conjunction with other fractures of the zygomaticomaxillary or frontoethmoid complex. As mentioned previously, evidence of other trauma to the head and neck should be looked for and ruled out. Examination should include palpation of all of the bones of the facial skeleton, palpation of the nose for crepitance, and palpation for the presence of subcutaneous emphysema. Palpation of the orbital floors and rims may reveal a step deformity or a depressed or rotated zygomatic arch. Visual acuity should be documented in all facial injuries. The range of extraocular muscle movements and examination of the fundus should also be well documented prior to any surgical intervention. Any evidence of decreased or changing vision should be evaluated by an ophthalmologist

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on an emergency basis. Evidence of a disrupted medial or lateral canthal ligament should also be sought to prevent later complications of pseudohypertelorism. The front teeth and maxillary alveolus should be grasped and moved in an anteroposterior direction to assess the stability of this area. If any evidence of other injury, airway compromise, neurologic deficit, or doubt as to the patient's reliability is present, the patient should be admitted. It is the authors' opinion that simple nasal fractures may be easily managed on an outpatient basis. A set of high-quality nasal x-rays is helpful in demonstrating the fracture and looking for associated injuries. Radiographic studies should include a Waters x-ray and lateral nasal film. Projection of the nasal bones in an anterosuperior fashion may be made by placing an occlusal x-ray film in the mouth beneath the hard palate. Regarding interpretation of the x-ray, it should be noted that characteristic vascular markings that run parallel to the nasal bone often mimic fractures. Any lines observed running perpendicular to the axis of the nasal bones most likely are nasal fractures; any depression of the dorsum may also represent a nasal fracture. The nose should be visually inspected for evidence of lacerated mucosa, septal hematomas, and septal fractures. The latter two conditions account for the majority of long-term post-traumatic nasal complications. These can result in prolonged nasal obstruction, septal abscess, or septal perforation. Diagnosis of a septal hematoma should be made by noting a swollen or fluctuant area along the nasal septum. These are best managed by an incision through the septal mucoperichondrium and evacuation with suction. Mucoperichondrial flaps may be packed against the septum with gauze packing impregnated with an antibiotic ointment. Septal fractures are best managed with definitive repair using a standard septoplasty technique as previously discussed. Reduction of Nasal Fractures. Adequate anesthesia is of paramount importance in obtaining an acceptable functional and aesthetic result. Fractures in children and uncooperative adults should be reduced under general anesthesia. In the cooperative patient, adequate anesthesia is easily obtained by packing the nose with cocaine solution followed by the injection of 1 per cent lidocaine with epinephrine. A subcutaneous injection, made via an intercartilaginous approach along the junction of the nasal bones and the frontal bones, gives adequate anesthesia to the superior aspects of the nasal pyramid. This may be supplemented with injections at the base of the columella and laterally to block the infraorbital nerves. Again, waiting an adequate period of time between the instillation of anesthesia and the initiation of the operative procedure enhances the anesthetic and vasoconstrictive effects. Technique. As in the reduction of any other fracture, the anatomy of the distal and proximal segments must be studied. The nasal bones may be displaced medially or laterally, superiorly or inferiorly, or impacted into the frontoethmoid sinuses. A common sequela from a lateral blow to the nose is a medially displaced fracture of one nasal bone and a concomitant laterally displaced fracture of the opposite bone. The instruments used for reduction of nasal fractures should include an Asch forceps and a straight nasal elevator. If the latter is not available a number 3 scalpel handle often suffices. A laterally displaced nasal bone may be reduced by firm bidigital

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pressure on the affected side. The medially displaced fracture or depressed tip fractures are reduced by placing the first nasal elevator intranasally and, with an upward and outward motion, elevating the bone with guidance from the opposite hand using external palpation. A severely comminuted or impacted fracture may be reduced by placing one blade of the Asch forceps inside the nostril and one outside the nostril and elevating and distracting the fractured segments. Care is taken to maintain the nose in a midline position. After the reduction of the nasal fracture has taken place, it is imperative to inspect the nose and assess the following: (1) adequate airway; (2) absence of septal hematoma; (3) good cosmetic alignment of the nasal pyramid; and (4) midline alignment of the cartilaginous septum and nasal spine. An external splint should be applied for 5 to 7 days.

FRACTURES OF THE ZYGOMA

The zygomatic bone forms the prominence of the cheek. It articulates with the temporal bone posteriorly, the greater wing of the sphenoid laterally, the frontal bone superiorly, and the maxillary bone inferiorly. It also forms the lateral margin and a portion of the inferior margin of the orbit. The majority of zygomatic fractures are caused by direct trauma to the cheek, such as a blow from the fist or trauma resulting from an automobile accident. The signs and symptoms include periorbital ecchymosis, flattening of the cheek, subconjunctival hemorrhage, a step deformity of the orbital rim, subcutaneous emphysema, or hypoesthesias in the distribution of the infraorbital nerve. When these are combined with fractures of the orbital floor, a decrease in the range of motion of the extraocular muscles may be noted. Such damage usually results from entrapment of the inferior rectus muscle, resulting in a restriction of upward gaze. A common finding in zygomatic fractures is a reduction in the patient's ability to open the mouth completely. This limited excursion is secondary to an impingement by the lractured zygomatic arch on the coronoid process of the mandible and subsequent decrease in excursion. Determination of the presence of muscle entrapment is essential, as this will influence decision-making for surgical management of orbital floor fractures. A distinct decrease in limitation of upward gaze at the physical examination is indicative of entrapment of the inferior rectus muscle. A forced duction test may occasionally be necessary to determine inferior rectus muscle entrapment. This should be carried out gently and without undue tension or pull on the eye. The eye is then anesthetized with a topical anesthetic agent and the tendon of the inferior rectus muscle is gently grasped below its insertion into the globe. Gentle traction is applied in an anterior and superior fashion. If the globe does not move freely, entrapment is demonstrated by a reduction of the upward ocular motion. Again, caution should be exercised in performing this test and on physical examination should be relied on as the mainstay of diagnosis. Other signs and symptoms of an orbital floor fracture include enophthalmos secondary to herniation of the infraorbital fat into the maxillary sinus. Exophthalmos may also occur if an infraorbital hematoma is present. Diplopia is often

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seen in orbital fractures and should alert to the existence of a more extensive type of injury than a simple zygomatic arch fracture. Technique. A variety of approaches may be used in the reduction of zygomatic fractures. The selected approach should be dictated by the extent of displacement. Local anesthesia is occasionally satisfactory; however, general anesthesia is often necessary. One method of reduction may be accomplished through an incision in the gingivobuccal sulcus by a CaldwellLuc approach. A curved elevator is passed posteriorly to the maxillary tuberosity and sufficient force is applied on the zygomatic bone from a medial to lateral fashion to return the bone to its anatomic position. This approach involves intraoral contamination and does not provide access for direct wiring of the fracture site. It does offer the advantage of adequate fixation without any external incisions. Simple fractures may also be reduced by a percutaneous route, which utilizes a variety of instruments including a towel clip. The zygoma is grasped percutaneously and the depressed arch is maneuvered into a normal position. A Gilles approach via the temporal area provides the benefit of a cosmetically acceptable incision in the hairline along with the mechanical advantage in reducing the displaced zygomatic fracture. The incision is carried down in the hair-bearing area to the infratemporal fossa and the elevator is passed deep to the fascia of the temporalis muscle and superficial to the muscle itself. The fascia will guide the elevator below the zygomatic arch onto which the fascia is attached. The elevator may then be directed laterally to reduce the zygomatic fracture and return it to its normal anatomic position. Care must be taken to avoid using the temporal bone as a fulcrum because an inadvertent skull fracture may occur. Placing a rolled gauze sponge in the area allows a fulcrum effect without direct pressure on the skull itself. Again, no direct wiring of the fracture is possible through this approach; however, a Penrose drain or a similar type of material may be packed beneath the zygomatic arch to maintain its position. This may then be removed through the incision in the temporal scalp. When a stable reduction cannot be obtained in a closed fashion, open reduction and internal fixation may be necessary. Direct interosseous wiring in the region of the zygomaticofrontal suture and in the infraorbital area may be required for more extensive zygomatic injuries. If the fracture is impacted or the floor of the orbit is disrupted, it may be necessary to perform a Caldwell-Luc procedure for adequate reduction. Packing of the antrum may also be required to help support the orbital floor. A Foley catheter balloon placed through an intranasal antrostomy may also be of benefit.

MANDIBULAR FRACTURES

Mandibular fractures are second only to nasal fractures as the most common facial bone injury. Proper management of mandibular fractures is essential, not only to avoid cosmetic sequelae but also for the prevention of malocclusion. The scope of mandibular fractures may range from an isolated fracture of the coronoid that may require little therapy to multiple

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open comminuted fractures that require a great deal of innovation to achieve correction. In this text, discussion will be limited to the management of simple mandibular fractures capable of being treated with closed reduction by means of intermaxillary fixation. Mandibular fractures of the body of the mandible are usually classified as favorable or unfavorable. Favorable fractures are those in which the pull of the pterygoid and temporalis muscles aids in the reduction of the fracture. In unfavorable fractures, the direction of the muscle pull opens the fracture site and often requires open reduction and internal fixation. The outpatient management of mandibular fractures should be limited to the management of those injuries that are either favorable or in which an anatomic reduction may be obtained in a closed fashion. Fractures of the body of the mandible usually occur in patients with teeth, and the treatment of choice is intermaxillary fixation with dental arch bars. Periods of fixation are usually 5 to 6 weeks, followed by a trial without fixation but with the arch bars in place. If the fracture appears stable and there is no pain at the fracture site, the bars may be removed in 1 to 2 weeks. If pain occurs at this site, the patient is again placed in intermaxillary fixation for 2 to 4 weeks. Technique. The technique of arch bar application is as follows. The arch bars are measured to the appropriate length and positioned to run from the posterior-most molar teeth on each side. Care must be taken that the hooks on the arch bar are oriented in the proper fashion before the arch bars are wired in place. Pieces of 24 and 26 gauge wire, approximately 6 inches in length, are used to secure the arch bar to the neck of each stable tooth. The wire is first inserted below the arch bar between two teeth in an intraoral direction and one loop of the wire is passed under the cingulum or neck of the tooth. Care must be taken that the wire is above the height of contour of the tooth to prevent slipping. The end of the wire is then passed back through the interdental space to the opposite side of the tooth to the extraoral direction existing above the arch bar. The ends of the wire are crossed and grasped with a needle holder and twisted clockwise. The wires are twisted until a secondary spiral begins to form and then cut to a length of 5 to 7 mm. They are then folded up in a pigtail fashion and bent snugly against the arch bar to avoid irritation to the gums and lips. Arch bars are placed in the maxillary teeth in a similar manner. When the arch bar appears stable on the mandible and maxilla, reduction may be undertaken by the application of rubber bands or wires placed from the hooks of the mandibular to the maxillary arch bar. The wires and rubber bands may be used to adjust the pull between mandibular and maxillary arch bars to facilitate a good reduction of the fractured segments. Care must be taken that the buccal groove of the maxillary first molar articulates well with the lower lingual cups of the mandibular first molar. The patient should be checked in 1 week to ascertain that the mandibular fracture is still stable and that no motion is present at the fracture site. Instructions for adequate care and hygiene of the teeth in fixation should be given; follow-up with a dentist is recommended. Mouthwash and irrigations with half-strength peroxide are also advisable.

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SURGERY OF THE LARYNX AND ORAL CAVITY LARYNGEAL SURGERY

Potential airway complications are of prime importance in considering ambulatory laryngeal surgery. The possibility of postoperative airway obstruction secondary to hemorrhage, edema, or laryngospasm must be a major consideration. The personnel and equipment for immediate airway management are therefore required. Facilities and equipment for immediate reintubation or tracheostomy are necessary. This possibility significantly limits the extent of ambulatory laryngeal surgery. Most laryngeal surgery requires general anesthesia and microscopic control. Experienced anesthesia and recovery room personnel are essential. Direct laryngoscopy for diagnostic purposes can be safely done on outpatients. The popularity and availability of modern fiberoptic equipment for office use has greatly reduced the need for more direct bronchoscopic and laryngoscopic procedures. Microlaryngoscopic Techniques Removal of small nodules and polyps or stripping of the vocal cord is greatly facilitated by the use of the operating microscope. As small an endotracheal tube as feasible is utilized. This endotracheal tube can be manipulated to be moved in an anteroposterior position for better visualization. The microscope is coupled with a 400 mm objective providing excellent binocular vision. After adequate anesthesia is obtained, the laryngoscope is introduced and utilized with a suspension apparatus. The operating microscope is then brought into the field. Appropriate microlaryngeal instruments can be employed at this point to remove or biopsy lesions or to strip the vocal cords. The anterior commissure must be respected as an area prone to scarring and care should also be taken to avoid exposure of the arytenoid cartilages. Laser Procedures The increasing popularity and applicability of the carbon dioxide laser for microlaryngeal surgery has opened the way for a greater use of outpatient laryngoscopic procedures. The laser has the distinct advantage of allowing a precise microscopic resection of the lesions in question without significant damage and swelling to surrounding tissue. The use of the carbon dioxide laser requires alterations in anesthetic techniques to maintain a low inspired oxygen content. Adequate protection of the endotracheal tube must be provided to avoid inadvertent ignition by a stray laser beam.

SURGERY OF THE ORAL CAVITY

A variety of lesions of the oral cavity are safely managed on an outpatient basis, including lesions of the floor of the mouth, the anterior tongue, alveolar ridge, palate, and buccal mucosa. Stones in the subman-

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dibular duct or gland can be extracted intraorally. Local anesthesia is usually adequate, although at times general anesthesia may be preferred. Large or extremely vascular lesIons should be inpatient procedures because hemorrhage and edema can rapidly compromise the airway.

Tonsillectomy The advisability of outpatient tonsillectomies is still subject to debate. Some otolaryngologists have found this to be a safe and effective outpatient procedure, whereas others insist that the patient remain in the hospital overnight. The major complication, hemorrhage, occurs in the immediate postoperative period or about a week later when the eschar sloughs. Complications are more common in adults and some surgeons insist on postoperative overnight stays for them but perform ambulatory surgery on children. Tonsillectomies may be done with the surgeon standing beside the patient or seated at the head of the patient. The latter is generally preferred because this provides improved exposure and permits better control of the endotracheal tube. With the surgeon at the head of the table, a suspended McIvor or Davis-Crowe mouthgag is used to expose the oropharynx. The tonsil is grasped with a tenaculum and retracted medially, and an incision is made in the mucosa of the anterior pillar as illustrated in Figure 4. The tonsil capsule is identified. Care must be taken to maintain this plane outside the capsule. With sharp and blunt dissection the tonsil is freed down to the inferior pole. The posterior pillar must be carefully preserved. A snare is then used to remove the tonsil. Meticulous electrocautery control of bleeding points is essential. Some surgeons prefer to perform the entire procedure with the electrocautery. Sutures or ligatures are rarely needed.

Adenoidectomy Adenoidectomies are frequently done in conjunction with a tonsillectomy. Specific indications for an adenoidectomy include recurrent otitis media, either suppurative or non suppurative, and persistent nasal obstruction with chronic sinusitis or nasopharyngitis. The role of chronic nasal obstruction in facial development indentation is controversial. Many orthodontists and otolaryngologists advocate an adenoidectomy as an important part of nasal airway control. In patient selection, a short palate or a submucous cleft must be ruled out because removal of the adenoid pad may result in palatal incompetence. Palpation of the palate, particularly in the presence of a bifid uvula, may reveal a cleft, and unless the indications are overwhelming surgery should not be done. Endotracheal anesthesia is utilized. With the surgeon at the head of the patient, the area is exposed in a manner similar to that discussed for tonsillectomy. The palate is retracted and the nasopharynx exposed. Adenoid curettes of appropriate size are used to remove the major mass, sweeping from above downward. Ethmoid rongeurs are angled. Punch forceps are used to remove remaining tissue from around the tubal cartilage. A nasopharyngeal mirror is helpful in visualizing this tissue. Care must be taken not to injure the tubal cartilage or the soft palate mucosa posteriorly

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Figure 4. Technique of tonsillectomy. A, McIver mouthgag in place with initial dissection of tonsil. B, Further resection of the tonsil before removal with a snare or with the electrocautery. (From Hudson WR, Gussack GS: Otolaryngology-head and neck surgery. In Davis JE (ed): Major Ambulatory Surgery. Baltimore, Williams & Wilkins Co, 1986; with permission.)

because the major complications are stenosis of the eustachian tube orifice or nasopharyngeal stenosis. Bleeding is controlled with the electrocautery and pressure packs. Occasionally it may be necessary to leave a pack in place with an attached string. This can be removed in the recovery room.

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SURGERY OF THE NECK Select lesions of the neCK are suitable for ambulatory surgery. The major problem is determining the nature of the lesion and assessing the extent of the proposed surgery. The diagnosis in some situations may be obvious: for example, a neck abscess requiring incision and drainage. Even in this case one must be aware of the possibility of a deep neck extension requiring a more extensive exploration and prolonged hospitalization. A common indication for ambulatory surgery of the neck is an open biopsy of a lymph node or a group of nodes for the diagnosis of a malignant or inflammatory disease. Prior to proceeding with surgery careful consideration should be given to the probable etiology. The age of the patient, location and growth rate of the mass, history and other physical examination findings, presence of tenderness and/or fluctuation, and mobility of the mass are all important diagnostic parameters. In children and young adults differentiation is usually between reactive lymphoid hyperplasia, inflammatory disease, or primary disease of the lymphatic system, such as lymphomas or Hodgkin's disease. If the mass is cystic, a congenital lesion, such as a branchial cleft cyst, thyroglossal duct, or laryngocele must be considered. Removal of cystic masses should not be undertaken on an ambulatory basis because the surgery required might be long and extensive. Neck masses in patients over 40 years of age must be considered metastatic carcinoma until proved otherwise. A careful search of the upper airway or digestive tract should be made in an attempt to identify a possible primary. This workup requires indirect laryngoscopy with attention to occult areas, such as the tonsil, base of tongue, nasopharynx, and piriform sinus. Suspicious lesions in the oral and upper airway and the digestive tract should be biopsied prior to biopsy of any lymph node. X-rays, barium swallows, computed tomograms, and a search for an occult primary should be undertaken. With a known primary the preferred treatment is to undergo an en bloc dissection, such as a classic or modified radical neck dissection, for definitive therapy of the metastatic lesion. The handling of lymph nodes for pathologic evaluation obtained at the time of biopsy has greatly improved over the past several years. No longer is a routine hematoxylin-eosin stain pathologic evaluation of the lymph node the standard for the diagnosis of complex lymphatic disorders. Specimen is obtained for special studies such as immunohistology, electron microscopy, flow cytometry, and lymphocyte subset population analysis. If such a specimen is placed in formaldehyde at the time of biopsy, these evaluations are not possible. The personnel in the ambulatory center should be aware of the proper handling of lymph node specimens and steps should be undertaken to expedite proper pathologic processing. The submandibular gland may be excised in an ambulatory setting if the involvement is secondary to chronic sialadenitis or sialolithiasis. If a tumor is suspected, inpatient management is advised. Technique. The technique of excision of the submandibular gland illustrates a number of points in surgery of the neck. A 5 cm sickle-shaped incision is placed 1 cm below the mandible from the angle of the mandible to the cornu of the hyoid bone. The platysma is divided and the facial

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arteries are identified at the inferior edge of the mandible. Identification of the ramus mandibularis of the facial nerve must be made to prevent injury and subsequent asymmetry of the mouth. The artery and vein can be ligated approximately 1 cm inferior to the mandible and retracted superiorly to preserve this nerve. The facial vein is identified as it passes over the gland and ligated above the gland. The gland can then be elevated and dissected from medial to lateral. The mylohyoid muscle is retracted medially, exposing the anterior digastric triangle. This allows identification of Wharton's duct, the lingual nerve, and the hypoglossal nerve. The duct is ligated and sectioned and the submandibular ganglion is ligated and sectioned with care to preserve the lingual nerve. With retraction, the posterior aspect of the gland can be visualized and the facial artery identified posteriorly, doubly ligated, and divided. Careful hemostasis is then obtained and a Penrose drain is inserted and the wound closed in layers. It must be remembered during the removal of any salivary gland that a mixed tumor may be present. Spillage of the contents of the mixed tumor may lead to local recurrence of the disease. Removal of tumors of the parotid gland should not be done on an outpatient basis. Almost without exception such surgery requires identification of the facial nerve and associated superficial parotidectomy.

REFERENCES 1. Converse JM: Reconstructive Plastic Surgery. Edition 2. Philadelphia, WB Saunders, 1977 2. Lore JM Jr: An Atlas of Head and Neck Surgery. Edition 2. Philadelphia, WB Saunders, 1973 3. Mathog RH: Maxillofacial Trauma. Baltimore, Williams & Wilkins, 1984 4. Naumann HH: Hand and Neck Surgery: Indications, Techniques, Pitfalls. Philadelphia, WB Saunders, 1980 5. Shabaugh GE, Glasscock ME: Surgery of the Ear. Edition 3. Philadelphia, WB Saunders, 1980

William R. Hudson, M.D. Division of Otolaryngology Department of Surgery Duke University Medical Center Durham, North Carolina 27710