Multiple- and single-period courses

COST FOR INSTRUCTION COURSES The price for all courses will be $20.00 per hour.

Multiple- and single-period courses Sunday, September 7, 1997 COURSE 1501-2 Two-Period Course ($40)

R o o m MOS-101 12:30-2:45

COURSE 1502-2 Two-Period Course ($40)

Room MOS-I02 12:30-2:45

Status of T & A and Tympanostomy Tubes--1997

Surgical Management of Snoring and Sleep Apnea

Charles D Bluestone M D Pittsburgh, PA

Samuel A Mickelson MD; B Tucker Woodson M D Dunwoody, GA; M e n o m o n e e Falls,Wl

Educational Objectives: 1. Provide guidelines for selection of children who might potentially benefit from surgery. 2. Improve outcome of surgery.

Educational Objectives: 1. Form a treatment plan for patients with mild, moderate, or severe sleep apnea or nonapneic snoring. 2. Understand surgical technique of LA UP, UPPP, midline glossectomy, lingual plash, and genioglossal and hyoid advancement.

Tonsillectomy, adenoidectomy, and tympanostomy tube insertion are still the most common operations performed on children today. Otolaryngologists must be informed about the most recent information on the indications of these procedures. This course will present the results of randomized clinical trials that have been conducted in the United States and Great Britain, including the most recent findings from the tonsillectomy and adenoidectomy studies conducted at the Children's Hospital of Pittsburgh. The indications will be discussed for tonsillectomy for recurrent throat infections, adenoidectomy for nasal obstruction, and adenoidectomy (with or without tonsillectomy) for otitis media. The results of randomized clinical trials of the efficacy of myringotomy/tympanostomy tube, either alone or in conjunction with adenoidectomy, will also be presented. The results of the studies will be related to the impact of managed care, practice guidelines, the emergence of resistant bacteria, and implications for medical malpractice in the 1990s.

This course will focus on the surgical treatment of OSAS and nonapneic snoring. We will present our approach for deciding who to operate on, which operation to do, and in what sequence and combination to do the procedures. We will briefly discuss the diagnostic tests needed to make these decisions. Procedures that will be covered include septoplasty, turbinectomy, UPPP, LAUP, transpalatal advancement, midline glossectomy and lingualplasty, epiglottidectomy, and genioglossus and hyoid advancement. We will briefly touch on the indications for bimaxillary advancement. We will cover success rates for these procedures, specific indications, risks, potential complications, variations in technique, preoperative and postoperative care, and ways to avoid complications. This course is designed for the individual who is actively involved in the management of sleep-disordered breathing and will present an in-depth discussion of surgical management.

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instructionCourses-- Sunday

COURSE 1503-2 Two-Period Course ($40)

Room MOS-103 12:30-2:45

The Glycolic Acid Peel for Facial Skin Enhancement Sigmund L Sattenspiel MD; F Candy Langan RN Freehold, NJ Educational Objective: Use practical and technical aspects of

glycolic acid peeling and maintenance and the glycolic acid program to build and enhance the facial plastic aspects of the otolaryngologic practice. The glycolic acid peel has demonstrable histologic and clinical benefits to facial skin consistency. Glycolic acid preparations are not cosmetics. They are preparations that are chemically formulated to provide effective therapeutic value to the skin. This presentation discusses the needs of the patient as well as the most appropriate indications and uses of glycolic acid, focusing on the glycolic acid peel procedure and the glycolic acid maintenance program. The didactic session also includes a how-to-do-it live demonstration, a video presentation format, and a practical handson experience on simulated patients to guide the physician through the step-by-step process of the peeling procedure. Patient management, including preparation and aftercare, are discussed. Glycolic skin care maintenance is elaborated. The Glycolic program offers an indispensable addition to the armamentarium of the otolaryngologist practicing facial plastic surgery. The practice-enhancing advantages of this program to the surgical practice are stressed.

COURSE 1504-2 Two-Period Course ($40)

Room MOS-104 12:30-2:45

FESS: What Is New? David W Kennedy MD; Donald C Lanza MD; Reuben C Setliff III MD; Eugenia M Vining MD; Hiroshi Moriyama MD Philadelphia, PA; Philadelphia, PA; Sioux Falls, SD; Wallingford, CT; Minato-ku Tokyo, Japan

Educational Objectives: 1. Understand changing concepts and techniques in FESS. 2. Improve knowledge and familiarity with critical anatomy and emerging technology. This session is for the otolaryngologist who is familiar with and currently practicing FESS. The aim of the workshop is to provide participants with the current emerging concepts and to demonstrate the role of technologic advancements. The experienced faculty will highlight the most important aspects of technique, par-

ticularly with regard to mucosal preservation and surgery on the frontal sinus. Relative anatomy will be reviewed. Particular attention will be directed toward decision- making in frontal recess surgery and the role of the transseptal approach to the frontal sinus. The role of microdebriders and their role in mucosal preservation will be presented. Methods of avoiding complications will be highlighted and technical advances, including the role of interactive intraoperative imaging, will be discussed. The program will include panel discussion and allow adequate time for audience questions.

COURSE 1505-2 Two-Period Course ($40)

Room MOS-105 12:30-2:45

Clinical Applications of Otoacoustic Emissions Brenda L Lonsbury-Martin PhD; Thomas J Balkany MD; Glen K Martin PhD; Fred F Telischi MD Miami, FL Educational Objectives: I. Understand thefundamentals of the

cochlear generation of otoacoustic emissions. 2. Gain a working appreciation of the interpretative strengths and weaknesses of emissions testing. The purpose of this course is to provide an overview of the benefits of otoacoustic emissions testing in clinical practice. The role of acoustic emissions in our current understanding of the actions of the peripheral ear in the normal processing of sound will be discussed. Further information will include up-to-date knowledge concerning the practical utility of transient-evoked and distortion-product otoacoustic emissions in screening, diagnosing, and monitoring of ear disease. Also, the potential contribution of emissions testing in furthering our understanding of the pathogenesis and satisfactory patient rehabilitation of such puzzling ear diseases as Meniere's disease and sudden idiopathic sensorineural hearing loss will be discussed. Other information will include how the study of otoacoustic emissions can assist in planning treatment strategies for acoustic neuromas and for use of evoked emissions as an intraoperative monitoring procedure during surgery of the cerebellopontine angle. Additionally, the usefulness of emissions testing in patient populations that include newborn and older infants and young children will be addressed, with a particular emphasis on the application of evoked emissions testing as a newborn screening technique. Finally, examples of specific limitations that interfere with the interpretation of test results will be presented to provide an overall appreciation of the strengths and weaknesses of emissions testing in clinical practice.

OtolaryngologyHead and Neck Surgery Volume 116 Number5

COURSE 1506-2 Two-Period Course ($40)

InstructionCourses--Sunday

Room MOS-106 12:30-2:45

COURSE 1507- I One-Period Course ($20)

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R o o m MOS-200 12:30-I :30

Partnership Dynamics in the Age of Managed Care

Forensic Audiology: Assessment of the Patient/Litigant

Stephen R Levinson MD; Alan J Gill MD; Tom K Coffey MD; Steven B Levine MD; Neil Gordon MD Fairfield, CT

Marc B Kramer PhD N e w York, NY

Educational Objectives: 1. Understand the methods of successful decision making in group practice. 2. Learn how to apply these principles to economic and business decisions to ensure a healthy group dynamic.

This course presents a set of fundamental principles of group practice dynamics. These are then applied to practice decisions involving productivity, expense allocation and income division, retirement buy-outs and semiretirement cost sharing, new partner contracts and buy-ins with consideration of noncompete covenants, and the economic evaluation of office ownership. These areas of interest are now reviewed with respect to both the indemnity insurance world and the managed care and capitation environment. We establish guidelines for decision making and agreements. These facilitate a mutually enriching and rewarding practice experience for all the partners at each stage of their careers, and they create a blueprint for future success of the practice. Our discussion will employ an open-forum approach, allowing participants to construct the various management issues that are met in group practice. Participants also will help to analyze alternative solutions to these issues and their consequences, both positive and negative. Participants will have the opportunity to assume different roles such as entering, established, or senior physician, exploring situations from the perspective of each. Our goal is a heightened awareness of the issues challenging medical groups, with delineation of a set of principles that can be used to generate successful working solutions in our changing medical environment. Topics to be covered include (1) principles of decision making for successful long-term group interaction, (2) retirement funding, (3) income division, (4) insurance and attorneys, (5) retirement for senior associates, (6) bringing in a new physician, (7) pros and cons of restrictive covenants, and (8) property ownership.

Educational Objectives: 1. Better identify the existence of exaggerated (functional) hearing loss. 2. More effectively review audiologic assessments with respect to the validity and reliability of the responses volunteered.

With increasing frequency, otologists are called upon to render expert opinions regarding the auditory status of litigants. Such opinions must be based on a thorough examination of all the pertinent facts and rely heavily on the audiometric data. Whereas patients generally seek relief from pain and suffering or improvement in their hearing, in litigation the patient/litigant may seek recovery in a monetary form, the magnitude of which may depend on the clinical history offered and responses on audiometric testing. It is the ability of the expert to evaluate the efficacy of both the audiologic results and the assessment procedure itself that is crucial to the formulation of a carefully considered opinion. The course will draw on more than two decades of clinical experience in evaluating hearing loss litigants and their claims. The course will review a variety of procedures that should be considered to accurately assess these patients and to identify (or rule out) functional components. Relevant examples will be drawn from patient/litigant experiences. This course should prove to be of equal value to both the examining clinician and the reviewing expert. Topics to be covered include potential exaggeration: a realistic view; an index of suspicion: the concept; possible indications of exaggeration found during patient assessment; classic audiologic findings suggestive of exaggeration; the use of special tests; recommended procedures to expedite the identification of exaggeration; and the clinical resolution of discrepancies.

COURSE 1508-2 Two-Period Course ($40)

R o o m MOS-208/210/212 12:30-2:45

CSF Leaks: Comprehensive Diagnosis and Management Daniel W Nuss MD; Peter D Costantino M D N e w Orleans, LA; N e w York, NY

Educational Objectives: 1. Understand mechanisms of CSF leakage and initiate diagnostic studies to confirm presence and extent of a CSFfistula. 2. Institute appropriate surgical therapy and adjunctive measures to definitively repair CSFfistulas.

The modern era of skull base surgery has brought with it a number of innovations that have enhanced our ability to diagnose and successfully repair CSF fistulae. Such

Head

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innovations have amplified the role of the otolaryngologist in solving these challenging and sometimes vexing clinical problems previously considered mainly within the domain of the neurosurgeon. This course will address each of the following topics concerning diagnosis: • Causes of CSF leaks and their influence on treatment • Clinical observations that confirm CSF drainage • Utility and futility of testing for glucose and protein • Use of specific Beta-2-transferrin assay for definitive CSF detection • Imaging studies for fistula detection and localization, including CT, MRI, CT-cisternography, and radio-isotopic scans • Nonradiologic studies such as endoscopic-fluorescein method Discussion of issues relevant to definitive repair of CSF leaks will include: • Review of traditional neurosurgical methods • Use of fascia grafts and intranasal mucosal flaps • Use of newer vascularized soft tissue flaps • Biomaterials useful for closing difficult leaks • Endoscopic repair of ethmoid and sphenoid leaks • Methods for management of multirecurrent fistulae • Adjunctive use of lumbar subarachnoid drainage • Pharmacologic and anesthetic techniques, as well as postoperative strategies to improve results

COURSE 1510-1 One-Period Course ($20)

R o o m MOS-220 12:30-1:30

Cutaneous Laser Surgery and the Facial Plastic Surgeon Mary A Fazekas-May MD; Milton Waner M D N e w Orleans, LA; LittleRock, AR Educational Objectives: 1. Understand the mechanisms of skin resurfacing. 2. Understand the differences between the lasers.

Although lasers gained wide popularity in the treatment of rhytids, a comparison with previously used modalities has still not been undertaken. Furthermore, an ever-increasing number of laser devices have become available, each proclaimed to be superior in one aspect or another. A comprehensive review of the technology as well as instructions on its use will help the physician understand the true role of lasers in skin resurfacing as well as decipher the difficult terminology associated with lasers. Preoperative and postoperative strategies will be discussed also.

COURSE 1511-I One-Period Course ($20)

R o o m MOS-222 12:30-I :30

Practical Guidelines for Young Physicians Interested in Inner Ear Research A h m e d M Soliman M D East Setauket, NY Educational Objectives: 1. Know how to start a scientific otologic research project (topic selection, experimental design, funding, supervision, techniques). 2. Learn the basic techniques, concepts, and applications of immunofluorescence and electrophysiology as applied to inner ear otology research.

Electrophysiology and immunohistochemistry are two important tools of research in the field of otology. Practical guidelines for the basic concepts, techniques, applications, and recent improvements in both fields are mandatory for young physicians interested in inner ear research. The author, a young physician involved in inner ear research over the last 10 years, would like to share his experience in starting a research project. Emphasis will be on experimental electrophysiology and immunofluorescence. The specific aims of this course are (1) to link clinical training and scientific research in the domain of otology, (2) to specifically learn the basic techniques, applications, and improvements in inner ear immunofluorescence, and (3) to highlight experimental electrophysiology, with emphasis on methodology and applications.

COURSE 1512-I One-Period Course (S20)

R o o m MOS-224 12:30-I :30

Pediatric Otology: Surgical and Medical Dilemmas Margaret A Kenna MD; Nancy Sculerati M D Boston, MA; N e w York, NY Educational Objectives: I. Better diagnose and treat common and uncommon pediatric otologic problems and have a better handle on the chronic draining ear in children. 2. Have surgical options for common~uncommon pediatric otologic problems.

Pediatric otologic problems often differ from those in adults in acuteness and severity of presentation, as well as optimal solutions. Infectious diseases, such as otitis media, and difficult audiologic issues, such as rapidly progressive sensorineural hearing loss, are common in children. Appreciation of the otologic issues in relation

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to the whole child, including other associated diseases, is needed for long-term successful management. This course provides a practical overview of decision making in pediatric otology. Specific operative indications and methods of management of complications will be discussed. The topics covered will include myringotomy and tube insertion, exploratory surgery for perilymph fistula, and cochlear implantation. Both surgical and medical management of the draining ear will be addressed in depth; attention is given to timing and type of surgery, use of autograft and synthetic reconstructions, canal wall up versus down procedures, and need/ timing of "second-look" procedures. The management of retraction pockets and cholesteatoma is discussed.

COURSE 1513-1 One-Period Course ($20)

Room MOS-226 12:30-1:30

Cancer Treatment Planning: Integrating Old and New Concepts Sharon L Collins MD MS Maywood, IL

Educational Objectives: 1. Assess multimodality therapy regimens for head and neck cancer on a scientific basis. 2. Realize the importance to the patient of maintaining surgery in the initial treatment plan.

Perennial treatment controversies persist in HNC, and treatment planning remains largely empiric based on personal training and experience. Since 1992 a dramatic change has occurred in the apparent "standard of care" for advanced HNC. Quality as well as length of life are now primary treatment planning end points, and traditional, "mutilating" HNC operations are in disfavor, moving surgery more often from initial treatment to the salvage context. Increasingly toxic combinations of chemoradiotherapy are in vogue to attempt to control locoregional cancer and to substitute for surgery but are poorly tolerated in the fragile HNC population. Better function of preserved organs is largely undocumented. The major current controversy of adding chemotherapy to the treatment of advanced HNC is put into perspective by presenting principles of action and interaction of the major treatment modalities and discussing the impact of treatment on patterns of cancer spread and several clinically important tumor/host biologic processes. Because surgery remains the most effective way to control bulky locoregional disease, the major determinant of improved survival, the strategy of organ preservation surgery for advanced HNC is presented as a viable alternative to nonsurgical treatments. Such considerations are particularly germane in this era of payorbased allocation of medical resources.

COURSE 1514-1 One-Period Course ($20)

Room MOS-228/230 12:30-1:30

Functional Neck Dissection Javier Gavilan MD; Jesus Herranz-Gonzalez MD; Cesar Gavilan MD Madrid, Spain; La Coruna, Spain; Madrid, Spain

Educational Objectives: 1. Describe the step-by-step surgical technique of functional neck dissection. 2. Understand the rationale, indications, and results offunctional and selective neck dissections.

Functional neck dissection (FND), also known as "modified neck dissection," was described by Osvaldo Sufirez in the early 1960s. The operation is based on the fascial compartmentalization of the neck. Although initially controversial, the procedure has been proved to be oncologically safe and has gained worldwide acceptance among head and neck surgeons. The functional and cosmetic advantages of FND are meritorious. The course is based on experience with more than 1500 FNDs performed since 1969. This is a surgically oriented course that will emphasize the technical aspects of the operation. A step-by-step description of the surgical technique will be illustrated with high-quality slides and a videotape. The rationale, indications, and results of the procedure will also be discussed. Handouts will be given to attendees to reduce the need for note-taking and to provide a valuable reference for later review. The handouts will include the slide elements as well as several articles with the rationale, surgical technique, results, and complications of the operation. Ample time will be allotted for discussion.

COURSE 1515-I One-Period Course ($20)

Room MOS-232/234 12:30-1:30

Combined Micro and Endoscopic Surgery (Comet) for Sinus Disorders Manuel Pais Clemente MD Porto, Portugal

Educational Objective: Review the surgical principles of sinus using both micro and endoscopic techniques to achieve good results with less complications. In recent years the endoscopic sinus procedure has been the most up-to-date treatment for chronic sinus disorders. However, we believe, as do many other otolaryngologists, that microsurgical techniques also play an important role in the surgical management of these diseases. Although we recognize that endoscopic sinus surgery is a very innovative technique that is performed well by

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excellent surgeons around the world, we also believe that it is a very difficult technique for beginners who are essentially trained for microsurgical procedures. The combined microscopic and endoscopic techn i q u e - C O M E T surgery--is an approach to the surgical management of sinus disorders that combines the advantages of both techniques, provides the possibility for the surgeon to decide in the future which technique he or she is more comfortable with, and provides better results with less complications. For the past 10 years we have performed more than 700 surgical procedures using the microscope as our main surgical equipment, and we were able to achieve excellent functional results without major complications. Use of the microscope provides surgical, optical, and ergonomic advantages. Mainly, a better anatomic view of the surgical field is obtained under magnification while one is sitting in a comfortable position with both hands free; in addition, with adequate training it is difficult to get "lost" as with a routine otologic procedure. The endoscopes are mainly used for a more precise diagnosis and for surgical treatment of difficult and inaccessible areas. We will also describe current management of other disorders using the same COMET surgery for dacryocystorhinostomy, closure of small CSF fistulas, orbital decompression, and assisting craniofacial resection.

COURSE 1517-2 Two-Period Course ($40)

Room MOS-238 12:30-2:45

Decision Making in the Management of the Aspirating Patient David E Eibling MD; Ricardo L Carrau MD; Jonathan E Aviv MD; Thomas Murry PhD Pittsburgh, PA; Pittsburgh, PA; New York, NY; Pittsburgh, PA

Educational Objectives: 1. Learn which of the evaluation techniques are valuable in the assessment of the aspirating patient. 2. Use patient history and evaluation to select appropriate therapeutic modalities for specific patients with morbid aspiration.

Nabil S Fuleihan MD; Norman J Pastorek MD; Robert L Simons MD Boston, MA; New York, NY; Miami, FL

Morbid aspiration is a common problem afflicting a wide variety of patients, especially those who have undergone extirpative head and neck surgery or have neurologic impairment of pharyngeal function. Decision making in the management of these patients often is difficult because optimal outcome must be achieved within the context of patient desires and the primary disease process. This course will review a variety of diagnostic modalities, especially the use of the modified barium swallow (MBS) and direct endoscopic observation during swallowing (FEES). Newer techniques for sensory evaluation of the pharynx also will be presented. A number of therapeutic options will be discussed, including vocal fold medialization, cricopharyngeal myotomy, tracheostomy tube valving, and laryngeal closure procedures. Decision making will be presented by the use of selected case studies and will include participant evaluation of specific videotapes of FEES and MBS and open discussion of decision making processes. Audience participation will be encouraged during the case presentations.

Educational Objectives: I. Understand the dynamics of endonasal techniques used in the treatment of various primary and revision nasal deformities. 2. Have a better understanding of the decision-making process in tip surgery.

COURSE 1518-2 Two-Period Course ($40)

COURSE 1516-2 Two-Period Course ($40)

Room MOS-236 12:30-2:45

Endonasal Rhinoplasty Techniques

This is an advanced course designed to give the participants a better understanding of dynamics of endonasal rhinoplasty techniques. Emphasis will be placed on indications and long-term results. Specific tip and dorsal deformities will be addressed by each faculty member, who will stress formulation of judgment and rationales for use of various techniques. A 45-minute panel discussion will address difficult tip and dorsal deformities.

Room MOS-250 12:30-2:45

Treatment--Anterior Floor of Mouth Carcinoma Joseph P Atkins MD; William M Keane MD; David Reiter MD DMD Philadelphia, PA

Educational Objectives: 1. Understand the anatomy and pathophysiology of the development offloor of mouth carcinoma. 2. Understand surgical approaches and reconstructive techniques used in treating floor of mouth carcinoma.

Surgery of the anterior floor of the mouth continues to be a challenge in modern-day head and neck practices because the cancer is close to the tongue and mandible, which are the cornerstones of oral function. Cure of cancer and functional rehabilitation are most important in treating patients with cancer of the floor of the mouth.

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Newer techniques in the management of cancer of this area, including conservation surgery of the mandible, modified neck dissections, and reconstructive flap procedures such as nasolabial and platysma myocutaneous flaps, have greatly enhanced our ability to resect cancer adequately and rehabilitate oral function, speech, mastication, and swallowing function. The course is intended to discuss the issues and indications for conservation procedures and to outline a method of surgery and rehabilitation for patients with cancer of the anterior floor of the mouth. The issues of resection will be discussed. There will be a strong focus on reconstructive aspects. Special attention will be paid to microvascular osteomyocutaneous flaps, particularly fibula flaps.

COURSE 1519-2 Two-Period Course ($40)

Room MOS-252/254/256 12:30-2:45

The Actor and Singer as Patients of the Laryngologist Hans van Leden MD; Robert T Sataloff MD; William Riley DMA; David M Alessi MD; Michael S Benninger MD Los Angeles, CA; Philadelphia, PA; New York, NY; Los Angeles, CA; Detroit, MI

Educational Objectives: 1. Assist the singer and actor in a vocal emergency. 2. Pattern surgical indications and contraindications to the special problems of entertainers. The nationwide expansion of theatrical and musical programs is causing increasing numbers of actors and singers to seek the aid of laryngologists. Frequently the otolaryngologist is not well prepared to deal with entertainers who expect expert advise on their professional problems. The voices of singers and actors are based on a fine balance of physiologic and psychologic factors that may be impaired by any pathologic changes or emotional trauma. A panel of laryngologists with special expertise in handling the problems of singers and actors, as well as a distinguished vocal artist, will discuss the care of entertainers' voices in the practice of our specialty, with emphasis on points of practical importance: 1. The vocal management of entertainers before and during performances 2. Guidelines regarding singing and acting in vocal emergencies 3. Helpful diagnostic aids 4. Special requirements of singers 5. The use of voice rest and specific medications 6. Substance abuse/surgical problems in entertainers 7. The influence of hormones and drugs on the voice 8. The care of singers' nodes 9. Laryngeal problems of the rock singer 10. Teamwork among laryngologists, singing teachers and voice coaches

COURSE 1520-1 One-Period Course ($20)

Room MOS-262 12:30-1:30

Orbital Surgery for Head and Neck Surgeons Robert A Weisman MD; J David Osguthorpe MD San Diego, CA; Charleston, SC

Educational Objectives: 1. Conceptualize surgical anatomy and surgical approaches to the orbit. 2. Know the differential diagnosis of proptosis and the classification of orbital diseases, including medical and surgical treatment options. The orbit is a complex anatomic region that presents many challenges to the physician faced with treating its pathologic conditions. Those diseases and conditions that compress the orbit, causing proptosis, compromised vision, or nasolacrimal duct obstruction, are of' greatest importance to head and neck surgeons. The pathologic and physiologic Characteristics of such disorders and the surgical procedures with which a head and neck surgeon can benefit patients with these orbital problems are the focus of this course. The differential diagnosis of proptosis in children and adults will be reviewed. Graves' orbitopathy, the most common cause of preptosis in adults, will be discussed thoroughly, including diagnosis and nonsurgical management. Surgical techniques for orbital decompression, including traditional open approaches through the paranasal sinuses, the transconjunctival approach, and the endoscopic endonasal approach, are demonstrated with illustrative cases. Second, a systematic approach to orbital tumors, classified both by tissue type and location within the orbit, is outlined for the participants and illustrated with representative cases. Lateral orbitotomy, a mainstay of orbital tumor surgery, will be shown in detail, and the surgical procedure clearly defined. Medial, inferior, superior, and craniofacial approaches to orbital tumors also are illustrated and discussed. Nasolacrimal duct obstruction, a common complication of orbital diseases and injuries, is presented as an important adjunct to the treatment arsenal of the head and neck surgeon undertaking orbital surgery. Traditional open approaches and the endoscopic endonasal approach are demonstrated.

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COURSE 1521-1 One-Period Course ($20)

Room MOS-270 12:30-1:30

Medicine in Developing Countries: How You Can Help James D Smith MD Singapore, Singapore

Educational Objectives: 1. Arrange a trip to help those less fortunate in a developing country with medical and surgical needs of the head and neck. 2. Be prepared to experience the cultural differences and medical needs of operating in a foreign country.

Many opportunities are available to help needy people in developing countries. Many of us do not know how to make contacts or what to expect in doing pro bono work in a Third World setting. The purpose of this course is to help participants make wise choices as they consider the many opportunities to help in a developing country. We will present ways to help in a developing country. We will present opportunities available and how to make contacts to arrange your own project. The second section will deal with the preparation that is necessary before leaving. A planning schedule for travel documents, immunizations, licenses, surgical equipment, supplies, etc., will be discussed. We will present potential sources for donations of supplies and their shipping. The third section will help the participant understand how to deal with culture shock and cultural differences. Finally, the special needs of anesthesia, surgical equipment, sterilization, and aseptic technique will be discussed. Ideas on how to overcome language barriers in the operating room setting will be discussed. Course participants should be able to find and have a fascinating and rewarding experience helping those less fortunate. All it takes is sensitivity and a keen interest in others, a sense of adventure, curiosity about other cultures, and above all a sense of humor and flexibility to adapt to the unexpected.

COURSE 1522-1 One-Period Course ($20)

Room MOS-272 12:30-1:30

Tympanoplasty: Augusta to Beziers William H Moretz MD; Jean-Bernard Causse MD Augusta, GA; Colombiers, France

Educational Objectives: I. Gain deeper understanding of the principles involved in successful ossicular chain reconstruction. 2. Understand the indications, use, and technical considerations of a variety of prostheses and instruments in various situations requiring ossicular chain reconstruction.

The rationale, techniques, and results of ossicular chain reconstruction techniques using malleus strut and hydroxylapatite cap prostheses in tympanoplasty, as used at the Southern Otologic Clinic in Augusta, Georgia,

and the Causse Otology Clinic in B6ziers, France, will be presented. Refinements of established techniques and introduction of new prostheses and techniques along with a detailed analysis of long-term results highlight this course. The didactic portions of the session will be complemented with 35 mm slide and videotape material. An extensive syllabus outlining the techniques discussed will be given to course participants.

COURSE 1523-2 Two-Period Course ($40)

Room MOS-274 12:30-2:45

Understanding Disease--Temporal Bone Histology & Histopathology Hosakere K Chandra Sekhar MD; Sujana S Chandrasekhar MD New York, NY; Newark, NJ

Educational Objectives: l. Correctly identify structures in the temporal bone on vertical and horizontal histologic sections, and on axial CT scan images. 2. Understand manifestations and treatment of common and unususal ear diseases via histopathologic sections.

A thorough understanding of the histology, radiographic anatomy, and histopathology of the ear enables the clinician to be able to appreciate the manifestations of ear disease. The first hour of this course is devoted to a detailed description of the horizontal and vertical histological anatomy of the temporal bone. The horizontal sections are paired with matching axial CT scan images to enable clinical appreciation of the anatomy. The vertical sections are described as with lateral surgical approaches to the temporal bone, with which the clinicians attending the course are more familiar. The second hour of the course concentrates on the histopathologic appearance of common and uncommon diseases of the external ear, tympanic membrane, middle ear, inner ear, and VII and VIII nerve. Discussion proceeds in a detailed fashion, from lateral to medial, and diseases are divided by category, such as infectious, metabolic, neoplastic, etc. Descriptions of these clinical disorders are given, along with histopathologic slides. In addition, medical and/or surgical treatments for these disorders are discussed. This course was successfully expanded from 1 hour to 2 hours at the 1996 Centennial meeting. Attendees appreciated the detailed nature of the course and the clinical and radiographic correlations. We received an overall score of 4.2.

Otolaryngology Head and Neck Surgery Volume 116 Number5

COURSE 1524-2 Two-Period Course ($40)

InstructionCourses--Sunday P39

Room MOS-276 12:30-2:45

Otolaryngic Allergy "How to Do It" Update 1997 Hamilton S Dixon MD; Barbara Jane Dixon BS Rome, GA Educational Objectives: 1. Set up an allergy department in the office, whether the otolaryngologist is a newly practicing physician or has been in practice for many years. 2. Understand and be able to perform skin endpoint titration (SET), even though the physician elects to mainly use some other form of lgE.

I.

lI.

IlL

IV.

V.

VI.

The patient A. Evaluation 1. How to take an "allergy history" 2. Other necessary tests (radiographs, etc.) 3. Nasal cytology B. Preparation of patient (patient education before becoming involved in allergy testing and treatment) Test preparation A. Physical plant--where to do it B. Supplies---essential for entire allergy department C. Mixing--testing sets 1. SET--in vivo 2. Radioallergosorbent test (RAST)--in vitro Test methods A. SET B. RAST-to-SET conversion C. Problems in testing A. Computing results 1. From SET 2. From RAST B. Preparing individual patient treatment vials C. Dosage schedules and records Food allergies (overview only) A. Provocative food testing B. Oral challenge feeding testing C. Managing known food allergies without testing D. Rotation diet The follow-up A. Case reports B. Instructions for out-of-town physicians C. How to mail out prescriptions D. Other allergy needs and necessities

COURSE 1525-1 One-Period Course ($20)

Room MOS-300 12:30-1:30

Creating and Managing the Single Specialty ENT Network Michael D Weiss MD, ira D Papel MD; Lindsay I Golden MD Owings Mills, MD; Owings Mills, MD; Silver Spring, MD Educational Objectives: 1. Have a basic understanding and tools necessary, to organize a network in a cost-efficient manner. 2. Have a better understanding of the more common management issues. 3. Have a better understanding what differentiates a good capitated contract from one that is unsatisfactory.

This course is designed to provide a review of issues involved in creating and managing a single specialty network or IPA. While providing a "how-to" approach for physicians to organize themselves in a marketable fashion, this course will also provide a forum in which to share ideas with others from around the country, thereby enhancing the participants' own efforts to develop and market their respective IPAs. For those groups with specialty networks already being developed or in place, this course will go beyond our original course by addressing problems commonly encountered in network development and administration. After completing this course, it is hoped that the participants will have increased their knowledge with regard to developing and managing similar entities in their own communities.

COURSE 1526-2 Two-Period Course ($40)

Room MOS-301 12:30-2:45

Using Microsoft Access to Manage Data in Clinical and Academic Practice Kimberly Reed; Mark K Wax MD; Anthony Nguyen MD Buffalo, NY; Buffalo, NY; Cheektowaga, NY Educational Objectives: 1. Understand the principles behind data collection and manipulation. 2. Extract useful information from a database on OME, referral sources, and other information. 3. Design a simple database for prospective/ retrospective studies.

Computerized databases are used for the collection, storage, and utilization of data. The ability of a database program to manipulate and generate reports from vast quantities of data is useful in both academic and clinical practices. Oftentimes the clinician is "afraid" of using a database or is unsure as to how it can help them. In this course we will introduce basic concepts concerning databases in a hands-on format. Sample databases will be used to demonstrate a variety of subjects. These databases will focus on topics pertinent to both academic and clinical practitioners and will include compiling records of continuing medical education and track-

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ing referral sources by location, speciality, etc. Prospective and retrospective research studies will be utilized to demonstrate the case and the necessity of using Microsoft Access for extraction of data. Understanding how a database needs to be set up will allow the attendee to better answer research questions. Familiarity with personal computers and the Windows platform is required. A number of instructors will teach this interactive course, using preloaded software (Microsoft Access for Windows).

treatment available. These methods of treatment will be discussed in the course and will include medications, surgery, biofeedback, tinnitus maskers, heating aids, and electrical stimulation.

COURSE 1529-I

One-Period Course ($20)

R o o m MOS-304 12:30-1:30

Electronic Medical Records: Myths and Realities Duncan S Postma MD; Michael Y Parker M D Tallahassee, FL; Raleigh, N C

COURSE 1527-I One-Period Course ($20)

R o o m MOS-302 12:30-I:30

Oral Manifestationsof Systemic Disease William Lawson M D DDS; Anthony J Reino M D N e w York, NY Educational Objectives: I. Recognize lesions of the oral cav-

ity. 2. Order appropriate diagnostic tests and select therapy. Systemic disease within the oral cavity may selectively involve the dental structures, gingiva, oral mucosa, or alveolus. Etiologic agents include genetic, metabolic, inflammatory, infectious, and neoplastic disorders. Despite the diverse causes of oral disease, the clinical manifestations are limited to keratotic, pigmented, erosive, hypertrophic, and destructive lesions. The differential diagnosis of each group will be discussed. The anatomic variants found within the oral cavity must be understood also because they may be confused with pathologic changes. Slides of more than 100 representative cases will be presented.

COURSE 1528-I One-Period Course ($20)

R o o m MOS-303 12:30-1:30

Tinnitus: Evaluation and Treatment John W House MD; M Jennifer Derebery M D Los Angeles, C A Educational Objectives: 1. Understand and perform the evalu-

ation of patients suffering from tinnitus including understanding the differential diagnosis and importance of the evaluation. 2. Learn the various treatment options in managing the patient with severe unrelenting tinnitus. Tinnitus has long been a problem for the patient and the otolaryngologist. Approximately 80% of ear disorders are associated with tinnitus. Usually the tinnitus is subjective, but a small percentage may be objective. About 95% of our patients with tinnitus do not consider the tinnitus to be a major problem. About 5% of the patients fall into the group that find the tinnitus an extreme hardship. For this reason it is important for the otolaryngologist to understand the causes of tinnitus, the evaluation of tinnitus, and the various methods of

Educational Objectives: I. Analyze their needs for electronic

medical records. 2. Understand the strengths and limitations of electronic medical records. 3. Compare different EMR systems to fit their needs. Two single-specialty ENT groups present their experience during the past 2 years with a complete electronic medical record (EMR) system. We will discuss the practical reasons to consider the purchase of an EMR system, the pitfalls in implementation, and the enhancements it can bring to your practice. The in-depth experience of two different practices with two different EMR systems should help you analyze your goals, enhance your experience, and encourage your group to move toward complete seamless office computerization.

COURSE 1530-2

Two-Period Course ($40)

R o o m MAR-Salon I/2 12:30-2:45

Advanced Rhinoplasty Peter A Adamson M D Toronto ON, C a n a d a Educational Objectives: 1. Have a thorough knowledge of nasal

anatomy and surgical techniques applicable to advanced rhinoplasty. 2. Apply this knowledge in surgical practice to achieve superior rhinoplasty results. This course presents advanced rhinoplasty techniques illustrated through the use of the open rhinoplasty approach. Both cosmetic and reconstructive problems are discussed. A videotape demonstrates nasal anatomy and surgical dynamics through the open approach. The various advanced techniques that are useful in correction of deformities of the septum, columella, tip, and dorsum are discussed from the perspective of accurate diagnosis and graduated corrective maneuvers. Tip techniques presented include tip grafting, horizontal and vertical cartilage division, struts, battens, alar base narrowing, and soft-tissue flaps and excisions. Dorsal techniques reviewed include transverse and double osteotomies, augmentation, spreader grafting, onlay grafting, and management of polybeak deformities. Functional treatment

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of septal deformities with cartilage excisions, scoring, castellation, and shaving is outlined. Diagrams of representative patients that illustrate the techniques applied show the results of integrating these maneuvers. Results of a large patient review are presented. This course emphasizes a thorough understanding of nasal anatomy and surgical dynamics. By combining accurate diagnosis and application of the techniques presented, the rhinoplasty surgeon can improve his or her surgical results.

COURSE 1531-1 One-Period Course ($20)

Room MAR-Salon 3/4 12:30-1:30

Bad Results in Endoscopic Sinus Surgery Frederick A Kuhn MD; Scott M Graham MD, Martin Citardi MD Savannah, GA; Iowa City, IA; Savannah, GA Educational Objectives: 1. Understand the comprehensive

theory of functional endoscopic sinus surgery and thereby identify the contributing factors of poor surgical outcomes. 2. Develop specific techniques for the management of specific anatomic structures within the paranasal sinuses.

Persistent or worsening chronic sinusitis after endoscopic sinus surgery frustrates the patient, his or her family, and the operating surgeon. This course deals with the causes of recurrent or persistent sinusitis and poor surgical results or outcomes after endoscopic sinus surgery by addressing the theory and technique of functional endoscopic sinus surgery (FESS). Particular attention is paid to anatomic problem areas associated with mechanical causes of recurrence. Inadequate management of the original anatomic deformities may precipitate worsening or persistent disease. For this reason the discussion will include the surgical management of the uncinate process, the middle turbinate, the maxillary ostium, the frontal recess, and the Onodi and Haller cells. The philosophy of FESS incorporates not only surgical procedures that recognize the natural physiology of the paranasal sinuses but also a comprehensive understanding of preexisting medical conditions that may contribute to sinusitis. Immunologic issues, gram-negative sinusitis, allergic fungal sinusitis, and nasal polyposis will be discussed also. Last, clinical cases, including the patient's history, computed tomographic scans, and nasal endoscopy, will be presented to illustrate the systematic application of FESS principles in patients with refractory disease. By examining these cases of surgical failure, course participants will learn to avoid specific pitfalls in the practice of FESS.

COURSE 1532-2 Two-Period Course ($40)

Room MAR-Salon 5/6 12:30-2:45

Microsurgery of the Larynx--1997 Robert H Ossoff MD; Stanley M Shapshay MD Nashville, TN; Boston, MA Educational Objectives: 1. Better appreciate the new instru-

mentation for this type of surgery. 2. Better understand the newer laser and nonlaser techniques and their indications for microlaryngeal surgery.

The development of delicate, new microlaryngeal instrumentation and laser microspot micromanipulators has facilitated a renewed interest in microsurgery of the larynx. Several new surgical techniques have been modified and/or refined. This course will review laryngeal anatomy and histopathology from a microsurgical viewpoint. The instructors' approach to managing patients with benign and malignant laryngeal disease will be reviewed; both laser and nonlaser techniques will be discussed, and the relative benefit of both techniques will be compared and contrasted. Appropriate preoperative and postoperative documentation of voice will also be discussed. Finally, the instructors will present representative laser and nonlaser cases illustrating the new and modified surgical techniques in the form of a panel discussion for review and critique. Course registrants are invited to bring cases that they would like to be included in this panel discussion.

COURSE 1533-I One-Period Course ($20)

Room MAR-Salon 10/11 12:30-1:30

Endoscopic Ear Surgery Dennis S Poe MD; Kevin X McKennan MD Boston, MA; Sacramento, CA Educational Objectives: 1. Explain the expanding uses of

endoscopes for diagnostic and therapeutic use in the operating room and office. 2. Understand the indications, applications, potential problems, risks, and future role of endoscopes in otologic neurologic service.

Endoscopy is now being used routinely for surgery of the middle ear, mastoid, and internal auditory canal. Endoscopes deliver the surgeon's view into the operative field and permit inspection and dissection under direct visualization beyond the normal line-of-sight limitation of surgical microscopes. In the office the middle ear may be visualized in its undisturbed state, free of any surgically produced transudate or injected anesthetics. Examinations may be done rapidly and thoroughly in an office setting with minimally invasive techniques. Risks and recovery are minimized compared with surgical procedures. Endoscopic exploration has been useful for the evalu-

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ation of conductive hearing loss, perilymphatic fistula, middle ear masses, cholesteatoma, eustachian tube disease, and other middle ear or tympanic membrane disease. It has been used both in place of a surgical exploration and as an adjunct to the preoperative assessment. Endoscopic middle ear and mastoid surgery can reduce morbidity significantly. Second-look endoscopic procedures are performed routinely to minimize the surgical incision, operating time, and morbidity rate. Primary cholesteatoma often can be excised from the epitympanum, sinus tympani, and oval window with endoscopes through postauricular approaches, but sparing the patient from conventional mastoidectomy. Canal wall-down procedures may be averted by the ability to visualize surgical dissection directly in these recesses. Acoustic neuroma surgery has been improved with the endoscope's ability to look far laterally into the internal auditory canal, allowing removal of remnants of tumor during suboccipital approaches. Open-air cells can be seen directly and sealed to aid in the prevention of cerebrospinal fluid leaks, dramatically reducing our incidence of leak. Indications, techniques, potential problems, and results of endoscopic surgery will be presented.

COURSE 1534-2 Two-Period Course ($40)

Room MAR-Salon 12 12:30-2:45

Conservation Surgery of the Larynx Byron J Bailey MD; Gary L Schechter MD Galveston, TX; Norfolk, VA

Educational Objectives: 1. Understand the concepts behind conservation surgery and the methods of preoperative evaluation. 2. Understand the methods of sophisticated reconstruction of the larynx after conservation surgical pro£eduges.

The basic concepts of conservation surgery of the larynx have been established, but there have been ongoing refinements in thinking related to tumor resection and reconstruction. In this course, the broad range of conservation surgical procedures of the larynx will be presented including cord stripping for superficial cancers, laser cordectomy, standard and extended hemilaryngectomy, laser supraglottic laryngectomy, standard supraglottic laryngectomy, partial laryngopharyngectomy, and extended resections requiring cricohyoidosupraglottoplasty (CHEP) or cricohyoidoplasty (CHP). The diagnostic needs for specific anatomic sites, that is, vocal cord, supraglottis, pyriform fossa, are outlined, and treatment principles for each site are covered individually. The full range of available reconstructive procedures, including cartilage, bone and muscle laryngoplasty, and epiglottic reconstruction, will be presented. Particular emphasis is given in this course to advanced reconstruction and management techniques.

COURSE 1535-1 One-Period Course ($20)

Room MAR-Salon 13 12:30-1:30

Cutaneous Melanoma: Current Advances and Controversies James C Alex MD Chicago, IL

Educational Objectives: I. Properly diagnose and stage cutaneous melanoma and understand the rationale and efficacy of current treatment options. 2. Becomefamiliar with the most recent advances in management, such as radionuclide lymphatic mapping, their appropriate application, and the controversies that surround them.

Recent advances in the evaluation and treatment of cutaneous melanoma of the head and neck are dramatically reshaping the traditional therapeutic approach to this lethal disease. These advances have also added to the controversy regarding what constitutes the optimal diagnosis and management of head and neck melanoma. The course will begin with a basic review of the risk factors, histologic features, diagnostic evaluation, and accepted staging of melanoma. In the major part of the course, the evolution in thinking during the past 10 years regarding the management of the primary tumor, the regional lymphatics, and distant metastases will be discussed. Controversies such as the extent of tumor margin, the efficacy of elective lymphadenectomy, and the role of radiation therapy, chemotherapy, and immunotherapy will be discussed. In particular, on the basis of a 5-year ongoing experience, this course will highlight the origins of the sentinel node theory, its application to regional lymphatic mapping, the pros and cons of vital dye mapping versus radionuclide mapping of the sentinel node, and how these new developments may radically alter the traditional management of the regional lymphatics. Finally, the course will examine the effect of prognostic factors, tumor stage, and treatment modality on survival. A handout detailing the major points of the course will be provided.

COURSE 1536-1 One-Period Course ($20)

Room MAR-Salon 14 12:30-1:30

Management of Facial Trauma with Minimal External Incisions Kevin A Shumrick MD Cincinnati, OH

Educational Objective: Perform extended access internal approaches for the management of facial trauma.

The two most significant recent developments in the treatment of facial trauma are the introduction of various plating systems and the development of facial degloving techniques that allow wide exposure of the en-

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Volume 116 Number5

tire facial skeleton. It is now possible to expose the entire facial skeleton and treat fractures through incisions and approaches that are virtually completely camouflaged. These approaches are: hemi-coronal and bi-coronal flaps, the sublabial approach of the mid-face, the trans-conjunctival approach to the orbital floor and orbital rim, and the intraoral management of mandibular fractures. While these approaches are becoming standard techniques for managing facial trauma, each one has definite technical points that need to be adhered to in order to assure their success. In addition, there are situations where these approaches are not appropriate and, in fact, may even be detrimental. This course details our approach to facial trauma using these extended access/internal approaches and discusses the important technical factors of each approach. Extensive use of the anatomic drawings and cadaver dissections as well as intraoperative photographs are used to illustrate the important concepts and techniques of these extended access approaches. In addition, case presentations with long-term follow-up are presented to illustrate the superiority of these approaches over conventional techniques.

COURSE 1537-1 One-Period Course ($20)

Room MAR-Salon 15 12:30-1:30

Complications of Otologic Surgery: Management and Prevention

COURSE 1538-1 One-Period Course ($20)

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Room MAR-Nob Hill A 12:30-1:30

Facial Nerve Surgery Jack L Pulec MD Los Angeles, CA Educational Objectives: 1. Select and recommend to patients

specific surgical procedures for facial nerve problems. 2. Aceurately perform facial nerve surgery depending on their basic level of surgical competence.

The surgical approaches and techniques for treating lesions of the facial nerve have been perfected to provide effective and predictable results. The objectives of this course are to demonstrate the philosophy, principles, and current techniques to manage all facial nerve problems. The course will be illustrated by slides and videotapes. The methods for exposing and identifying the facial nerve anywhere between the brainstem and the parotid gland will be described. The method for doing facial nerve decompression without surgical complication will be demonstrated. The technique for facial nerve grafting as well as the procedure for excision of the geniculate ganglion and nervus intermedius for the treatment of geniculate ganglion neuralgia will be reviewed. The surgical management of hemifacial spasm will be described. The surgical technique for complete removal of cholesteatoma from the facial nerve without producing injury to the nerve will be described.

John T McElveen Jr MD; Bradley S Thedinger MD; David M Barrs MD Raleigh, NC; Kansas City, MO; Colorado Springs, CO Educational Objectives: 1. Be aware of medical management

of chronic otitis media. 2. Be aware of and be able to perform the surgical options in treating the chronically draining ear.

Despite the best intentions of all otolaryngologists, complications may arise during an otologic surgical procedure. It is essential that the surgeon be able to deal with the particular complication in a manner that will minimize any further risk to the patient. It is also essential that the surgeon develop techniques that will prevent such complications from occurring in the future. The intent of this 1-hour course is to accomplish that. The areas to be covered will be facial nerve injuries, labyrinthine trauma, vascular insults, and dural injuries. Although particular emphasis is directed toward the proper management of these problems, techniques designed to prevent these complications are also reviewed.

COURSE 1539-2 Two-Period Course ($40)

Room MAR-Nob Hill B 12:30-2:45

Head and Neck Reconstruction Without Free Flaps David E Schuller MD; Ronald C Hamaker MD; William R Panje MD Columbus, OH; Indianapolis, IN; Chicago, IL Educational Objectives: 1. Identify and understand the vari-

ables important to the determination of the optimal reconstructive technique for an array of reconstructive problems without reliance on free flaps. 2. Understand modifications of surgical reconstructive techniques that enhance the structural and functional results.

This 2-hour course has been designed by three individuals who have broad clinical experience and who have published extensively on the course content. The primary objective of the course is to discuss how reconstructive techniques other than free flaps can be used for a variety of reconstructive tasks and achieve beneficial results in restoring structure and function. Reconstructive techniques will include skin grafts, local, regional, and musculocutaneous flaps, and prosthetic rehabilitation. The course will also include discussion about those reconstructive tasks (i.e., anterior mandibular defects) that are felt by the instructors to be more effectively

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resolved by free flaps rather than by alternative approaches. The course will include an interactive session in which attendees will be involved in case- study problem solving, which uses knowledge gained during the course. The anatomic areas that will be discussed include facial and neck soft tissue defects, oral cavity, oropharyngeal, hypopharyngeal, cervical esophageal, laryngopharyngeal, and cranial base defects. The course will also include descriptions of modifications of standard techniques for particular tasks that the instructors have developed that provide for improved reconstructive results. Attendees will receive the instructors reprints about this course content, and an outline of the course will be provided for each attendee at the time of the course.

COURSE 1540-1 One-Period Course ($20)

Room MAR-Nob Hill C 12:30-1:30

Food Allergy and Its Relationship to Otolaryngology John H Boyles Jr MD Centerville, OH

Every organ system in the human body is capable of an immunologic response and is therefore capable of developing allergic dysfunction and clinical disease. It follows that practitioners of every specialty of medicine will have to develop the expertise to recognize, diagnose, and treat these allergic syndromes. The general otolaryngologist deals with perhaps the most common short organ of allergic disease, the upper respiratory tract, in particular the nose and the paranasal sinuses. The otolaryngologist is therefore ideally suited to function as a regional allergist treating both the medical and surgical disorders caused by immunologic dysfunction. Many otolaryngologists, through the excellent teaching of the American Academy of Otolaryngic Allergy, have mastered the proper diagnostic and treatment modalities necessary to control sensitivities to biologic inhalants. Although this approach is efficacious for allergic rhinitis, it will only partially contribute to the complete resolution of many other otolaryngic disorders. Problems such as Meniere's disease, fluctuating tinnitus, chronic external otitis, chronic headache, migraine headaches, chronic pharyngitis, and many other chronic head and neck symptoms will only fully respond if the otolaryngologist can effectively diagnose and treat food allergy. Unfortunately, there is no simple blood test to identify foods the patient may be sensitive to; only a clear understanding of the natural history of food allergy and the ability to properly perform the modalities of challenge feeding tests and provocative neutralization test will enable the practitioner to identify incriminating foods. Once identified, the proper treatment of elimination, rotary diversified diet, or neutralization therapy will relieve the patient of chronic symptoms.

COURSE 1541-1 One-Period Course ($20)

Room MAR-Nob Hill D 12:30-1:30

Parotid Tumors and Parotidectomy Richard D Nichols MD Detroit, MI

Educational Objectives: 1. Differentiate between true tumors and other intraparotid disease. 2. Treat parotid tumors effectively and safely with concise paradigm based on clinical presentation.

This course is an overview of the management of parotid neoplasms. Ten percent will be on differential diagnosis because non-neoplastic intraparotid and paraparotid disease can simulate true neoplasms. Fifteen percent of parotidectomy specimens contain unexpected pathology other than epithelial tumors of the gland. Careful clinical evaluation, which should identify nearly all true tumors, will be emphasized with discussion of ancillary studies and their appropriate application in selected cases. Other subjects to be presented include (1) the importance of preoperative clinical assessment of the nature of the tumor (clinically benign or clinically malignant) and the importance of that assessment in overall management; (2) processes for identification and protection of the facial nerve, including visualization, indications for magnification and the use of nerve stimulators and nerve monitors; (3) the importance of clinical decision making intraoperatively regarding the appropriate extent of operation, management of the facial nerve and use of frozen section; (4) management of aggressive tumors including extended en bloc parotidectomy; (5) indication for and types of radiation therapy for parotid tumors; and (6) cosmetic considerations, including placement of surgical incisions and intraoperative augmentation of the surgical bed. Etiology and histopathology of parotid tumors and management of recurrent pleomorphic adenoma will be given less emphasis. A review of the important current year's literature on parotid neoplasms will be included in the course syllabus.

COURSE 1542-1 Room MAR-Golden Gate Hall A3 One-Period Course ($20) 12:30-1:30 Pediatric Sinusitis: Is FESS the Answer? Ramzi Younis MD; Rande H Lazar MD Germantown, TN; Memphis, TN

Educational Objectives: l. Define the current indications and advantages of FESS in children. 2. Evaluate children with sinusitis and decide on an optimal management plan.

Pediatric sinusitis, once unrecognized or underdiagnosed, is currently a common disease entity requiring frequent attention and care, Pediatric functional endoscopic sinus surgery (FESS) has been accepted widely as the surgical

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Volume116 Number5

procedure of choice for chronic or recurrent sinusitis. However, since its introduction, many changes and modifications have been introduced. Our current approach to sinusitis in children is different. Subsequently, we are achieving better outcomes with fewer complications. Multiple variables need to be addressed in children as compared with adults. These may include age, day care, smoking, allergy, immunologic work-up, ciliary function, adenoidal or tonsillar hypertrophy, and duration of symptoms and treatment. After 10 years of experience, we developed clear and restrictive indications for FESS that may secure superior results. However, failure still exists, and we have developed an approach to manage failure and guidelines for revision FESS. FESS is not the solution for every child with chronic or recurrent sinusitis. We will discuss our 10-year experience with pediatric FESS. The current technique, workup, indications, and outcome of pediatric and revision FESS will be detailed.

COURSE 1543-2 Room MAR-Golden Gate Hall A1 Two-Period Course ($40) 12:30-2:45 Supraomohyoid and Lateral Neck Dissection James I Cohen MD: Randal S Weber MD Portland, OR; Philadelphia, PA

Educational Objective: Understand the step-by-step approach to the performance of a supraomohyoid and lateral neck dissection and the management of malignancies of the upper aerodigestive tract. Supraomohyoid and lateral selected neck dissections are assuming an ever-increasing role in the management of malignancies of the upper aerodigestive tract, particularly for patients with limited neck disease. Unfortunately, little is written about the technical aspects of performing this surgery, and yet these dissections are, if anything, more difficult than the more traditional comprehensive radical neck dissection. The purpose of this course is to instruct the participants in how to perform these neck dissections. Emphasis will be entirely on the indications and technical aspects of the procedures. Slides and videotape will be used to demonstrate the techniques involved. A handout outlining the technical details of these operations will be supplied.

COURSE 1544-1

Room MAR-Golden Gate Hall A2 One-Period Course ($20) 12:30-1:30

Diagnostic and Management Challenges in Pediatric Otolaryngology Brian J Wiatrak MD; Charles F Koopmann Jr MD Birmingham, AL; Ann Arbor, MI

Educational Objective: Better understand the diagnostic aspects of airway and inflammatory diseases in children and the therapeutic options in the management of pediatric airway and inflammatory disorders. This course is designed to discuss diagnostic and management challenges in pediatric otolaryngology, with emphasis on areas of inflammatory diseases and obstructive airway pathology. The discussion will include rhinology and sinusitis, the role of functional endoscopic sinus surgery in the treatment of sinusitis, and the diagnosis and management of chronic rhinorrhea. Airway problems would include evaluation and treatment of patients with stridor, laryngomalacia, subglottic hemangiomas, and stenosis. Finally, a discussion of topics such as tonsillectomy, adenoidectomy, and inflammatory neck masses will be presented. Videotape presentations will be used to illustrate airway problems. Throughout the course the audience will be invited to participate in a dialogue with the presenters and with other members of the audience.

COURSE 1607-1 One-Period Course ($20)

Room MOS-200 1:45-2:45

Forensic Otology: The Expert Witness Marc B Kramer PhD New York, NY

Educational Objectives: 1. Participate with greater confidence, knowledge, and self-assurance in the medical~legal (litigative) arena. 2. Better understand the litigative process and the potential roles that may be assumed by the otologist in this process. The formulation of a considered medical opinion after examining a patient/litigant and reviewing the pertinent clinical assessments is often only the first step in the litigative process in which the physician is asked to participate. An understanding of this process and the roles played by the medical expert is essential not only to effective participation, but also to the physician's own comfort in the unfamiliar legal environment. This course will draw on over two decades of experience dealing with the legal process as it relates to the expert medical witness. It will address the form of the litigative process per se, as well as the numerous roles that a physician may be required to play in the courtroom. (e.g., fact, opinion, treating, corroborating witness, etc.) and the roles that one may play in other aspects of the

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process in general (e.g., educator, investigator, evaluator, interpreter, etc.). It will endeavor to provide guidanc e in establishing a personal code of behavior and will also provide specific recommendations with regard to the manner in which testimony might be prepared. The content of this course is suitable not only to practitioners who have specific interest in participating in the litigative process, but to all whose paths may at some time cross that of a patient who becomes a subsequent litigant.

COURSE 1610-1 One-Period Course ($20)

Room MOS-220 1:45-2:45

Endoscopic and External Sinus Surgery: Anatomy and Technique Frank N RiMer MD; Jeffrey E TerreU MD Ann Arbor, MI

Educational Objectives: 1. Understand the anatomy of the

paranasal sinuses pertinent for external or endoscopic sinus surgery 2. Understand congenital and acquired anatomic variants of the sinuses and the key principles to avoid complications during sinus surgery. Every surgeon relies heavily on a keen knowledge of the original anatomy during the performance of a surgical operation. This is especially true regarding the paranasal sinuses where congenital or developmental changes, infection, neoplasm, bleeding injury, or prior surgery may distort the salient landmarks and increase the risk of complications. This course stresses the precise anatomic landmarks to guide the surgeon performing external or endoscopic sinus surgery. Slides of cadaver dissections, CT scans, and endoscopic dissections will be used to stress the important landmarks for the sinus surgeon. Special attention will also be given to the relevant anatomy specific to endoscopic sinus surgery, as well as pertinent anatomic and clinical pearls for external or endoscopic control of epistaxis, orbital decompression, optic nerve decompression, and endoscopic DCRs. This is a practical course with time for open discussion, questions, and answers.

COURSE 1611-1 One-Period Course ($20)

Room MOS-222 1:45-2:45

Management of Sudden Hearing Loss with Best Practice Ideas Frederick M Byl Jr MD Oakland, CA

Educational Objectives: I. Better understand the etiology and

natural history of sudden sensorineural hearing loss. 2. Develop a practical and cost-effective management plan. Sudden sensorineural hearing loss (SHL) is an anxiety-provoking medical event with severe psychological

overtones: What caused it? Is it part of a more serious life-threatening process? Will it happen to the other ear? This often leads to unnecessary expensive tests and at times inappropriate and dangerous treatment. This course offers a systematic guide to the evaluation of patients with SHL starting with a definition, historic milestones, natural history, discussion of probable etiology, diagnostic options, therapeutic alternatives, and a practical cost-effective management protocol based on evaluation and treatment of more than 400 patients in our Sudden Hearing Loss Clinic established in 1975. Best Practice Ideas will be discussed. Course attendees can expect to be fully informed about the emotional, as well as the medical aspects of SHL. Guidelines for frequency of follow-up visits and the need for consultation and treatment will be offered. Pitfalls to be avoided will be emphasized, and a method of predicting prognosis will be presented. A syllabus with a selected bibliography will be provided.

COURSE 1612-I One-Period Course ($20)

Room MOS-224 1:45-2:45

Reading Between the Lines in Medical Journals Richard M Rosenfeld MD MPH Brooklyn, NY

Educational Objective: Help journal readers, peer reviewers,

and journal editors critically evaluate published and unpublished manuscripts. Do you believe most things you read in medical journals? Do you rely on peer review as an assurance of high quality? Are you tempted to read only the abstract and conclusion of an article to save time? Does the clash of P-values and data tables with the human mind induce a state of blissful acquiescence? If so, then read on! In this informative but entertaining course, you will learn how to critically evaluate five types of journal articles; how to recognize five common flaws in study design; how to interpret the six most popular statistical procedures in otolaryngology journals; how to spot seven ways that investigators can deceive you with statistics; and how to judge the real importance of any study by using five simple criteria. This course is designed for consumers, producers, and peer-reviewers of the otolaryngology literature. A background in statistics and epidemiology is not required. From case reports to outcomes research you will increase your ability to critically interpret journal articles and to derive meaningful conclusions from your own research and clinical observations.

Otolaryngology Head and Neck Surgery Volume 116 Number5

COURSE 1613-1 One-Period Course ($20)

InstructionCourses--Sunday P47

Room MOS-226 1:45-2:45

Breaking the Rules in Head and Neck Cancer Surgery Sharon L Collins MD MS; Robert W Bastian MD Maywood, IL

Educational Objectives: 1. Be aware of the pressing need for surgeons to develop "nonmutilating" operations that allow them to stay competitive in the initial management of head and neck cancer (HNC) for the benefit of the patient. 2. Be aware of modifications of radical operations that allowfunctionally and oncologically sound "organ preservation" for advanced cancers in a variety of HNC sites. Surgery is the best method to control bulky locoregional head and neck cancer (HNC); but traditional "mutilating" operations are in disfavor, and quality of life/organ preservation considerations are being used as the basis for substituting increasingly toxic combinations of chemoradiotherapy for initial surgery. Surgery for HNC is being relegated more often to a "salvage" context for persistent or recurrent cancer, which is a dangerous trend because most patients who have been cured of their disease have had surgery as part of their initial treatment. HNC surgeons must provide alternatives to the traditional radical operations for HNC to maintain surgery in the initial management of HNC so that locoregional control can be optimized. This course presents examples of the use of initial "organ preservation" surgery for advanced HNC in several difficult sites, with favorable oncologic and functional outcomes based on a 10-year experience of the instructors: • Transoral or endoscopic excision of large tumors (oral cavity, oropharynx, hypopharynx) • "Extended" partial laryngopharyngectomy • "Mucosa-preserving" total or near-total laryngectomy • Avoidance of segmental mandible resection of the mandible for posterior oral cavity (BOT)/oropharynx tumors • Larynx-preserving pharyngectomy • Use of local tissue to avoid free flap/visceral interposition reconstruction of hypopharynx and total laryngopharyngectomy defects

COURSE 1614-I One-Period Course ($20)

Room MOS-228/230 1:45-2:45

Supraglottic Laryngectomy--Fundamentals and Technique Jesus Herranz-Gonzalez MD; Javier Gavilan MD La Coruna, Spain; Madrid, Spain

Educational Objectives: 1. Provide a detailed description of the surgical technique of supraglottic laryngectomy. 2. Explain the rationale, indications, and results of supraglottic laryngectomy. The oncologic safety of supraglottic laryngectomy results from embryological reasons. The bottom of the ventricle acts as a true barrier, preventing the lower spread of supraglottic carcinomas into the vocal cords. Supraglottic laryngectomy is a safe and oncologically sound procedure, allowing the preservation of all laryngeal functions: voice, breath, and swallow. Although more than 50% of all laryngeal tumors at our institutions arise in the supraglottis, only one third of them are suitable cases for supraglottic laryngectomy,~, This low rate is probably due to the fact that these tumors remain "silent" until neighboring structures are invaded. When supraglottic laryngectomy is performed in cases with extension to neighboring structures, there is a high rate of laryngeal dysfunction. Complete and safe tumor removal must be the first and main goal of treatment; functional concerns come next. Careful patient selection is the key to good results. This is a surgically oriented course in which the main steps of the operation will be illustrated with slides and a detailed videotape. The embryological and anatomical bases for supraglottic laryngectomy, as well as the selection criteria for suitable cases, will also be discussed. A course outline will be given to the attendees and ample time will be allotted for discussion.

COURSE 1615-I One-Period Course ($20)

Room MOS-232/234 1:45-2:45

Partial Vertical Laryngectomy Kerry D Olsen MD Rochester, MN

Educational Objectives: 1. Review the indications and treatment results of partial vertical laryngectomy for select T1 glottic cancer. 2. Understand the three major surgical procedures performed for T1 glottic cancer via an open approach. Squamous cell carcinoma of the larynx is the cancer that most frequently involves the upper air and food passages. Glottic cancers, those arising on the two vocal folds, constitute about 75% of all laryngeal cancers. Hoarseness invariably accompanies the development of glottic cancer; therefore glottic cancer often can be diagnosed while

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the tumor is still confined to the vocal fold(s). Because the diagnosis can be made early, successful treatment can be expected. We have found that the laryngofissure and cordectomy operation and its variations, including removal of thyroid cartilage, is an expeditious and highly successful means of eradicating glottic cancer, even though some think of the procedure as obsolete. Rather than an obsolete operation, this operation, we believe, can be considered a reference standard by which other forms of treatment can be compared when the results of treating early glottic carcinoma are analyzed. Approximately 50% of the T1 glottic carcinomas seen at the Mayo Clinic are treated with an open procedure. The operations are as follows: laryngofissure and cordectomy when the anterior commissure is not involved; partial vertical laryngectomy when the anterior commissure is involved; and the anterior commissure procedure for tumors confined to the anterior commissure. A hemilaryngectomy is not done for these tumors. The indications, limitations, and surgical technique for each of these procedures will be presented in detail. The incidence of local recurrence is less than 5%. In our discussions we will present voice results. That discussion, the expediency of biopsy and excision of the tumor at the same time, a description of tumors that are inappropriate for transoral removal, and the high incidence of cure are major considerations in the decision to remove the tumor by use of the laryngofissure cordectomy operation and its variations.

COURSE 1620-1 One-Period Course ($20)

Room MOS-262 1:45-2:45

Evaluation and M a n a g e m e n t of CSF Fistulae Mark C Weissler MD; Harold C Pillsbury III MD Chapel Hill, NC

Educational Objectives: 1. Properly evaluate clinically and

radiologically the patient with suspected CSFfistulas. 2. Have a working knowledge of techniques for closing CSFfistulas at various sites. Cerebrospinal fluid fistulas may occur both traumatically and nontraumatically. The proper evaluation and treatment of these patients depend on the cause and mode of presentation of the leak. Although CSF leaks resulting from blunt head trauma will often heal spontaneously or with the assistance of a lumbar drain, iatrogenic and spontaneous leaks often require surgical closure. Effective surgical closure is dependent on appropriate preoperative evaluation to determine the precise site of the leak. Techniques used to evaluate the site of the leak range from the use of intrathecal dyes to high-resolution CT and radionuclides scans, the use of intrathecal contrast agents, and in some special cases the use of overpressure studies. Methods of evaluating and closing leaks from various sites are discussed.

COURSE 1621-1 One-Period Course ($20)

Management

R o o m MOS-270 1:45-2:45

of Incus Problems

Edward L Applebaum M D Chicago, IL

Defects of the incus are common sequelae of chronic otitis media and trauma. These defects range from minute erosions of the lenticular process to complete absence of a usable incus. If the incus problem can be seen through a transparent tympanic membrane or a perforation, or if it is large enough to be visualized with computed tomography, then diagnosis and preoperative planning are not problematic. At times, however, incus problems are diagnosed only at surgery, so ear surgeons must be prepared to manage them effectively when tympanoplasty is attempted. This course presents the author's methods of managing the most common incus problems. A systematic, simple, and predictable approach uses two prostheses designed by the author and readily available. The incudostapedial joint prosthesis is used for defects of the long process, and the incus replacement system is used when no useful incus remains. Both prostheses are made of hydroxyapatite. Slides and surgical videos will be used to facilitate discussion of the indications and techniques of tympanoplasty for these implants.

COURSE 1622-I One-Period Course ($20)

R o o m MOS-272 1:45-2:45

Botulinum Toxin in Hyperfunctional Head and Neck Disorders Andrew Blitzer M D DDS; Mitchell F Brin MD; Christy L Ludlow PhD N e w York, NY; N e w York, NY; Bethesda, M D

Educational Objectives: 1. To learn about pathophysiology of

hyperfunctional syndromes. 2. To learn about botulinum toxin and how to use botulinum toxin for the management of hyperfunctional syndromes. Hyperfunction of muscle groups in the head and neck may cause pain and dysfunction. Conditions that produce hyperfunction include dystonia, tremor, tics, muscle tension disorders, myoclonus, hemifacial spasm, and hyperfunctional facial movements. The faculty is multidisciplinary: otolaryngology, neurology, and speech and language pathology. The course will review in detail the pathophysiology of the disorders that produce dysfunctional and painful muscle hyperfunction. An outline of the evaluation process and differential diagnosis of these conditions will be discussed. A review of traditional management of these conditions including systemic therapy, physical therapy, and prosthetic devices will be presented.

Otolaryngology Head and Neck Surgery Volume 116 Number5

InsITucfionCou~es--Sunday P49

We will then review the pharmacology and techniques for delivery of Botulinum toxin injection for the management of hyperfunctional syndromes of the head and neck including adductor and abductor spasmodic dysphonia, hemifacial spasm, post-Bell's facial synkinesis, facial tics, stuttering, oromandibular dystonia, torticollis, blepharospasm, temporomandibular disease, vocal tremor, palatal myoclonus, cricopharyngeal achalasia, hyperfunctional facial lines and wrinkles, and others. We will review the results, possible complications and adjunctive techniques.

COURSE 1625-1 One-Period Course ($20)

Room MOS-300 1:45-2:45

Use and Abuse of Ventilation Tubes Michael M Paparella MD; Michael S Morris MD Minneapolis, MN; North Potomac, MD

Educational Objectives: 1. Identify various otologic diseases; the pathogenesis and how ventilation tubes can assist with treatment of these diseases. 2. Have an understanding of the use and abuse of ventilation tubes as related to the above.

In this course the generic use and abuse of ventilation tubes for various otologic diseases, most notably for otitis media, will be discussed. Indications for the use of ventilation tubes include most frequently chronic otitis media with effusion (OME) and especially mucoid otitis media (MOM); however, ventilation tubes have also proved useful for treatment of frequent recurrent acute purulent otitis media (POM), plus as an adjunct in certain cases for treating chronic miffs media (COM) with tympanoplasty or tympanomastoidectomy and for treatment of sequelae of otitis media, such as atelectasis or retraction pockets. Other otologic diseases that have benefitted from the use of ventilation tubes include patent eustachian tube, endolymphatic sac enhancement for intractable Meniere's disease, and recurrent barometric pressure problems including middle ear/inner ear interaction. Abuse refers to the many otological diseases for which use of ventilation tubes have no role, and complications associated with their use. These too will be discussed. Complications mostly include otorrhea and TM perforations. Technical considerations include tube design (short, long, small, or large and type of material) and application (site on the TM). Important underlying middle ear anatomical-pathological considerations that can result in tube success or failure will be discussed.

COURSE 1627-1 One-Period Course ($20)

Room MOS-302 1:45-2:45

Penetrating Trauma of the Head and Neck Michael G Stewart MD; Newton J Coker MD Houston, TX

Educational Objectives: l. Understand the evaluation and treatment protocols for penetrating trauma of the head and neck, including the temporal bone. 2. Use entry zone and weapon-~pe information to direct evaluation and treatment of penetrating injuries of the head and neck.

With the increase in violent crime in many cities across the United States, otolaryngologists-head and neck surgeons are often called on to evaluate patients with penetrating injuries of the head and neck. We describe the management protocols for penetrating head and neck trauma used at the Ben Taub General Hospital (BTGH), an urban level I trauma center in Houston, Texas. In a retrospective review of 78 patients with penetrating midface injuries treated at BTGH over a 3-year period, we found that injury patterns differ significantly depending on (1) type of weapon and (2) zone of entry. We discuss the midface zoning system and its implications for airway complications, intracranial penetration, globe injury, and vascular injury, as well as delayed complications. We describe the three entry zones of the neck and present protocols for evaluation and management of penetrating trauma to each zone. Although in the past all neck injuries penetrating the platysma underwent mandatory surgical exploration, at BTGH more neck injuries are evaluated with endoscopy, arteriography, radiography, and observation with equivalent results. We discuss the controversy between mandatory neck exploration versus observation in selected injuries. We also describe the management of temporal bone injury secondary to penetrating trauma, including debridement and reconstruction of the middle ear. We will discuss in detail the immediate management of traumatic facial nerve injury, including prognostic testing and the indications for emergency surgical exploration and repair including the use of nerve autografis.

Otolaryngology Head and Neck Surgery PSO

May 1997

Instruction Courses-- Sunday

COURSE 1628-1 One-Period Course ($20)

Room

MOS-303 1:45-2:45

Surgical and Medical Management of Otosclerosis Jean-Bernard Causse MD; Robert Vincent M D Colombiers, France

Educational Objectives: 1. Know from the experience of the authors, the tips and tricks to perform an easier and safer stapes surgery. 2. Talk to two surgeons, performing five cases a day of otosclerosis surgeryfor the senior author and three cases a day for the junior author, and discuss the difficult situations. An average of seven to eight cases of stapes surgery is performed each day in the Causse Clinic in ColombiersB6ziers. In this course the senior and junior authors are pleased to pass on all the tips and tricks they have learned as the result of the experience with more than 51,000 cases of stapes surgery performed in the clinic, and they will also demonstrate with videotapes how to make the surgery safe and as easy as possible. For instance, use of a preshaped vein graft is making the rebuilding of a buffering system around the lower tip of the piston extremely easy. Surgery for otosclerosis can be difficult in case of obliterative otosclerosis or prolapsing facial nerve, but tips can transform this surgery into a much easier one. Rebuilding the stapedius tendon is also explained. The rationale for medical treatment is explained and developed in this course.

It is a proven product ready for use by any medical specialty. It improves the quality of care by providing the physician a better view of the patient's status. It offers flexibility in entering patient information. Having one source for charts allows simultaneous, unhindered access. The physician's efficiency is improved by decreasing documentation time and fatigue. At the same time, the system increases decision-making time and allows the physician to see more patients. Office administration also improves by eliminating the need to look for charts, a chronic problem in many offices. Revenues increase by the improved efficiency, the decreased payroll, and the productive use of the space used to store charts. Several safeguards are built into the system, including medical alert, pending test reminder, confidential codes, no-show control, incomplete chart control, appointment recall, and daily back-up of records. The system has been enhanced to include prescription writing, schedulers, and report generation for research and practice management. Supplements to the system include an automatic dialer, document file, system interface with sources of medical information outside of the practice, word processing, a calculator, electronic mail, and drug interaction monitoring.

COURSE 1631-I

Room

One-Period Course ($20)

MAR-Salon 3/4 1:45-2:45

The Micro-Debrider System in FESS Stanley E Thawley MD; Jay F PiccirilloM D COURSE 1629-1 One-Period Course ($20)

Room MOS-304 1:45-2:45

Computerized Medical Records: Tomorrow's Systems Today Dino E Flores MD FACS

Bethesda, MD

Educational Objective: Understand the benefits of computerizing the medical records and the management of clinical information; it improves quality of care, increases the efficiency of the physician and the office administration, and increases practice revenues. SMART CHART MD is the software used for demonstration during this course. The system, called SMART CHART, MD, was developed during a 12-year period using thousands of active medical records. The computerized medical record is the central element in the clinical information management system, which has four groups of functions. They include the different ways to use the record's contents to extract information needed at the moment, aids for the physician, system safeguards, and communications with other parties.

Saint Louis, M O

Educational Objectives: 1. Understand the concepts behind the micro-debrider in functional endoscopic sinus surgery. 2. Recognize clinical situations in which the microsurgical debrider will augment traditional and functional endoscopic sinus surgery. With the introduction of endoscopic sinus surgery, the surgical approaches to the paranasal sinuses have become more refined. New approaches and modifications to the original technique are reported routinely. One new technique uses a powered microsurgical arthroscopy system. The microsurgical debrider, or "hummer," was introduced originally for the controlled removal of soft tissues (polyps) within the nose and paranasal sinuses. It has now been used for a variety of other paranasal procedures. This session will focus on the description of the microsurgical debrider, its capabilities within the nose and paranasal sinuses, its indications for use, case presentations, and outcomes of its use. The attendees will understand the utility of this new addition to endoscopic sinus surgery.

OtolaryngologyHead and Neck Surgery Volume 116 Number5

COURSE 1633-1 One-Period Course ($20)

InstructionCourses--Sunday P51

Room MAR-Salon 10/11 1:45-2:45

Diagnosis and Management of Acute Facial Paralysis Using ENOG Bruce J Gantz MD Iowa City, IA

Educational Objectives: 1. Understand and perform electroneurography in patients with acute facial paralysis. 2. Use information obtainedfor electroneurography to manage patients with acute facial paralysis.

The management of acute facial nerve paralysis is one of the more confusing subjects confronting otolaryngologists. Contributing to this confusion is the uncertain reliability of routine topognostic and electrodiagnostic testing methods, and reports that decompression of the fallopian canal through the mastoid does not alter the natural history of Bell's palsy. In view of the above, an electrodiagnostic test, electroneurography, has become a reliable method of obtaining information about the status of the injured facial nerve. The objective measurements made with this technique are useful in planning a treatment regimen. The objectives of this instruction course are to (1) review the pathophysiologic characteristics of acute facial nerve injury, (2) describe the technique of electroneurography, emphasizing procedures that can influence the test results, and (3) discuss, based on electroneurographic findings, the clinical management of acute facial nerve paralysis resulting from Bell's palsy, trauma, infection, and tumors.

COURSE 1635-1 One-Period Course ($20)

Room MAR-Salon 13 1:45-2:45

Clinical Applications of Central Auditory Evoked Potentials Alan G Micco MD; Dawn B Koch PhD; Richard J Wiet MD FACS Lemont, IL; Evanston, IL; Hinsdale, IL

Educational Objectives: 1. Understand the neurophysiologic origins, recording paradigms, and waveform morphologies of the auditory middle latency response, P300, and the mismatch negativity. 2. Appreciate the potentials clinical uses for thalamic and cortical evoked potentials in a clinical pracrice.

Historically, clinical use of early auditory evoked potentials has focused on estimating hearing sensitivity and diagnosing lesions in the auditory system peripheral to the thalamus. The auditory brainstem response and the middle latency response (MLR) have gained widespread use in assessing the configuration and the degree of peripheral hearing loss and in identifying retrocochlear lesions. However, it is clear that auditory evoked potentials can be elicited from many other loca-

tions along the auditory pathway and that those potentials reflect different aspects of auditory processing. Because hearing encompasses more than just the detection of sound, those evoked responses hold potential as tools for evaluating complex auditory processing in location central to the eighth nerve. This course describes three auditory evoked potentials, the MLR, the P300, and the mismatch negativity (MMN). The MLR has become an accepted clinical tool that is used primarily for estimating lower frequency hearing thresholds and asymmetric damage to the thalamocortical areas of the brain. In combination with auditory brainstem response, it provides a measure of hearing sensitivity across the audiometric range. The P300 is a cortical evoked potential that reflects the cognitive processes involved in detecting and responding actively to stimulus differences. It can be elicited with sound or visual or somatosensory stimuli and originates in multiple auditory and nonauditory centers. The MMN, on the other hand, is a measure of the brain's response to small acoustic differences and is thought to represent a measure of fine auditory discrimination. It may serve as a tool for evaluating auditory processing in individuals whose hearing is normal but whose behavior indicates central processing problems. Case studies will be presented to illustrate the potential uses of the MLR, MMN, and P300 in a clinical practice.

COURSE 1636-1 One-Period Course ($20)

Room MAR-Salon 14 1:45-2:45

Management of Subglottic Stenosis in Infants and Children Lauren D Holinger MD Chicago, IL

Educational Objectives: 1. Have a basic understanding of the etiology and histopathology of congential and acquired subglottic stenosis. 2. Be able to take a rational approach to the diagnosis and management of subglottic stenosis in infants and children.

Rational therapy for laryngotracheal stenosis is based on a determination of the histopathology and the precise location and extent of the stenosis. This course includes a discussion of the histopathology of congenital and acquired subglottic stenosis and its classification, using examples from the collection of the Laryngeal Development Laboratory at the Children's Memorial Hospital in Chicago. The course also presents the differential diagnosis, evaluation, and treatment of subglottic stenosis. Emphasis is placed on proper indications and specific surgical techniques. In addition to horizontal sections from the Laryngeal Laboratory, illustrations will include endoscopic photographs, standard radiographs, intraop-

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erative photographs, and detailed line drawings of the various surgical procedures. The following alternative strategies for avoiding tracheotomy in infants and children with severe upper airway obstruction will be detailed: laryngotracheal decompression (anterior cricoid split), laser, resectoscope, dilation, and laryngotracheal reconstruction.

COURSE 1637-I One-Period Course ($20)

Room MAR-Salon 15 1:45-2:45

Canalplasty: An Essential Part of Otologic Procedures Timothy T K Jung MD; Marcos V Goycoolea MD PhD Loma Linda, CA; Santiago, Chile

Educational Objectives: 1. Understand indications and stepby-step operative procedures of canalplasty. 2. Avoid pitfalls and incorporate canaloplasty into his or her clinical practice.

Canalplasty is a procedure that repairs abnormality of external auditory canal (EAC) by removing abnormal bony growth, such as anterior overhang or exostosis, removing and replacing intractably infected skin of the canal, or enlarging and straightening a severely stenotic and tortuous canal. Meatoplasty may be performed at the same time. Canalplasty can be done as a primary procedure to correct specific problems in the EAC or as a part of other otologic procedures, such as tympanomastoidectomy or even exploratory tympanotomy. Whenever narrow EAC prevents satisfactory visualization, canalplasty becomes an essential part of otologic procedure. Thus every otologic surgeon should know the indications and methods of performing a good canalplasty. This 1-hour course will discuss step-by-step operative procedures of canalplasty. A different method of canalplasty for exostosis, anterior bony overhang, intractable external otitis, and severely stenotic canal will be discussed. Surgical approaches for tumors in the EAC will be briefly discussed. It will be emphasized that canalplasty is an essential part of other otologic procedures, such as tympanomastoidectomies. Illustrative materials include slides of step-by-step operative procedures and videotape of surgical procedures. The goal of this course is to enable each participant to incorporate canalplasty into his or her clinical practice. It is hoped that the attendants will be confident to perform canalplasty whenever indicated in the management of otologic disorders.

COURSE 1638-1 One-Period Course ($20)

Room MAR-Nob Hill A 1:45-2:45

Severe Maxillofacial Trauma: Evaluation, Stabilization, and Reconstruction Gerry Funk MD; Robert E Johnson MD Iowa City, IA; Honolulu, HI

Educational Objectives: 1. Apply advanced trauma life support (ATLS) principles to the management of severe head and neck trauma in the emergency room setting. 2. Plan the reconstruction of complex soft tissue and bony injuries of the craniomaxillofacial area.

The otolaryngologist-head and neck surgeon often is called to the emergency department to treat patients with severe injuries of the head and neck area. The potential for serious airway compromise coupled with severe hemorrhage in a patient with a mutilating injury of the face can be daunting to even the experienced surgeon. A clear-minded, organized approach to these patients is critical. The course instructors will draw from their extensive experience at busy, level I trauma centers to present a comprehensive, stepwise, and practical approach to the management of severe head and neck injuries. The basic principles of advanced trauma life support will be applied to describe an organized method for evaluation and stabilization of these injuries, with particular emphasis on airway management. We will briefly discuss the interdisciplinary treatment of associated injuries and consider how their presence and management impact the timing of head and neck reconstructive procedures. The definitive management of complex injuries involving tissue loss in the craniomaxillofacial area will be discussed in detail. Emphasis will be placed on an organized approach to reconstruction, to include the need for multiple, staged procedures. Color slides will be used to demonstrate a wide array of reconstructive techniques, including facial skeletal fixation, bone and cartilage grafting, and local, regional, and free tissue transfer techniques. Cases will be presented that demonstrate reconstructive approaches to the orbit, midface and nose, lips and oral cavity, and the mandible and maxilla. A course handout will be provided.

Otolaryngology Head and Neck Surgery Volume 116 Number5

COURSE 1640-1 One-Period Course ($20)

Inst~cfionCourses--Sunday P53

Room MAR-Nob Hill C 1:45-2:45

Perioperative Management Issues in Free Flap Surgery Ara A Chalian MD; John E Gooey MD; Gregory K Hartig MD Philadelphia, PA; Brookline, MA; Madison, Wl

Educational Objectives: 1. Apply the principles learned to optimize flap donor site, position, and pedicle geometry to maximize outcomes in microvascular reconstruction. 2. Understand the advantages and disadvantages of intra- and perioperative monitoring, pharmacologic management, and salvage technology to maximally optimize microvascular flap outcome.

Microvascular flap reconstruction is the state of the art for reconstruction of extensive and composite defects of the head and neck after resection of carcinomas or trauma. As the enthusiasm and popularity of microvascular flap reconstruction have increased, the number of surgeons using this technique has increased. Although flap options are well described, the pertinent points in preoperative, intraoperative and postoperative management and decision making are less well articulated. To assist in use of these reconstructive techniques, the course will outline important points for consideration. The discussion will be broken down into physical and anatomic issues of respective flaps, changes in the softtissue envelope of the neck by previous surgery and radiation, and recipient vessel options and pedicle geometry. Pharmacologic and microvascular issues, including vessel handling and preparation techniques, anastomotic techniques, and pharmacotherapy will be reviewed and discussed. The final segment will focus on flap monitoring and salvage techniques to optimize outcomes and success. We will discuss flap-monitoring options, flapsalvage timing and techniques, and the role of pharmacotherapy and leeches. These techniques will help surgeons optimize the perioperative management and outcomes of microvascular flap reconstruction.

COURSE 1641-1 One-Period Course ($20)

Room MAR-Nob Hill D 1:45-2:45

Cosmetic Surgery to the Latin Nose William Lawson MD DDS; Anthony J Reino MD; Laurence Milgrim MD New York, NY; New York, NY; Grapevine, TX

Educational Objective: Comprehensively understand, analyze, and correct the different deformities with noses from different Latin American Countries.

The nature of the deformities of Latin noses relative to their Caucasian counterparts will be analyzed and meth-

ods of correction presented. These include autogenous, alloplastic, and autoalloplastic grafting of the dorsum, endonasal tip repair with dome binding and vertical dome division techniques, and surgery of the columella to augment caudal septal deficiency, gain projection of the tip, and achieve nasolabial enhancement. The latter involves the placement of cartilage, bone, and silicone rubber struts and modification of the medial crura. Moreover, surgery of the ala to modify the nasal base will be addressed. Illustrated cases will be presented.

COURSE 1642-I Room MAR-Golden Gate Hall A3 One-Period Course ($20) 1:45-2:45 Diagnosis and Treatment of Pediatric Cervicofacial Masses David E Tunkel MD; Steven M Kelly MD Baltimore, MD; Salt Lake City, UT

Educational Objectives: 1. Understand differential diagnosis of head and neck masses in young children and use costand time-efficient evaluation. 2. Understand medical and surgical therapies of congenital~inflammatory neck masses in children.

The causes of pediatric cervicofacial masses include chronic and acute inflammatory conditions, congenital abnormalities, and benign and malignant neoplasms. The diagnostic evaluation of head and neck masses in young children includes trials of antimicrobial therapy, imaging with CT and MRI scans, and excisional or incisional biopsy. We have used fine-needle aspiration biopsy for cytology and culture as an early step in the evaluation of these masses in children. A full discussion of the differential diagnosis of cervicofacial masses in young children will be presented. Emphasis on history and examination to determine the most prudent and efficient steps to eventual diagnosis and treatment will be detailed. Emphasis will be placed on surgical treatment of recurrent bronchial cleft and thyroglossal duct cysts, to outline variations in techniques to reduce complications/recurrences. The use of fine-needle aspiration of young children in the outpatient setting will be detailed. The utility and limitations of this technique will be fully described. Treatment of childhood mycobacterial adenitis will be addressed, with full descriptions of techniques of surgical excision and curettage. Use of fine-needle aspiration biopsy for early diagnosis of this condition is also addressed. Patient presentations will be used to illustrate a streamlined approach to diagnosis and treatment.

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COURSE 1644-I Room MAR-Golden Gate Hall A2 One-Period Course ($20) 1:45-2:45 Closed Structure Universal Tiplasty Geoffrey W Tobias MD; William J Binder MD FACS Englewood, NJ; Los Angeles, CA

Educational Objectives: 1. Better understand rhinoplas~. 2.

Describe an endonasal tiplas~ technique based on ''structure fundamentals" of tip reconfiguration that is an effective alternative to the open o1"external approach. The "structure" concept of rhinoplasty emphasizes nasal tip recontouring via minimal cartilage resection with preservation of natural support mechanisms. The inherent structural integrity or shape of the lower lateral cartilages is modified in a precise, predictable, and reversible manner through a progressive sequence of steps. Tip cartilage is reconfigured through the use of multiple sutures, incisions, and grafts. The open or external rhinoplasty has generated much interest in this practical approach because of one's ability to directly visualize and modify nondistorted tip anatomy. An alternative endonasal or "closed structure technique" will be discussed that achieves similar results while avoiding certain drawbacks typically associated with open procedures. Technical aspects of the closed structure procedure will be presented, and it will be shown how it can successfully be applied to the wide variations of presenting nasal tip anatomy, the key to a true universal tiplasty. Shorter operative time, more concise intraoperative assessment, and simple surgical steps underscore advantages of this technique. The presentation will include discussion of how the underprojected, overprojected, asymmetric, and revision tip is effectively modified in order to achieve esthetic, functional and enduring results.

COURSE 1701-2 Two-Period Course ($40)

Room MOS-101 3:00-5:15

Rhinoplasty Overview William E Silver MD; William H Friedman MD; Fred J Stucker MD FACS Atlanta, GA; Saint Louis, MO; Shreveport, LA

Educational Objectives: 1. Evaluate patients for specific rhi-

noplastic procedures and how they should be performed. 2. Understand the anatomic and physiologic aspects of rhinoplas~ and evaluate. This course is designed to take the rhinoplastic surgeon from the initial consultation, reviewing the evalu-

ation, indication, and surgical planning, including the facial aesthetics, to help with the planning. The steps of rhinoplasty will then be outlined. The following areas will then be reviewed, including functional nasal surgery-septoplasty, turbinectomy, nasal valve and spreader graft, followed by addressing the problems of the nasal dorsum, including augmentation and reduction, followed by the problems of nasal tip surgery. The final portion will include special problems such as twisted nose, saddle deformity, asymmetrical tip, and acute nasal trauma. A review of indications for open rhinoplasty versus endonasal approach will then finalize the program. Review of anatomy and nasal dynamics will be included in each of the approaches.

COURSE 1702-I One-Period Course ($20)

Room MOS-102 3:00-4:00

The Parotid Gland: Diagnosis, Medical, and Surgical Approaches David W Eisele MD; Dale H Rice MD Baltimore, MD; Los Angeles, CA

Educational Objectives: l. Evaluate parotid gland disorders

both nonneoplastic and neoplastic. 2. Properly manage parotid gland disorders both medically and surgically. The parotid gland serves as a target for infections as well as inflammatory, immunologic, congenital, traumatic, and neoplastic disorders. The differential diagnosis of disorders affecting this gland is extensive. A thorough understanding of the classification and pathologic characteristics of the neoplastic and nonneoplastic processes affecting the parotid gland is essential for a rational approach to therapy. The complexity of the treatment of these various disorders is enhanced by the intricate relationship of the gland to cranial nerves, arteries, and veins and the cervical-facial musculature. This course will cover the classification, pathologic characteristics, factors influencing treatment, medical and surgical approaches, pitfalls, and complications of treatment of parotid disease, both neoplastic and nonneoplastic. The purpose of this course is to provide the otolaryngologist-head and neck surgeon with a body of knowledge that will allow him or her to systematically evaluate parotid gland diseases, to discuss with his or her pathologist the histopathologic appearance of the disease process, and to properly manage parotid gland disorders both medically and surgically.

Otolaryngology Head and Neck Surgery Volume 116 Number5

InstructionCourses--Sunday P55

Steven L Neal MD Pendleton, OR

Each attendee will receive a complete workbook including all the forms, surveys, practice prospectuses, and newsletters used by the instructor in his daily practice. A detailed discussion of total quality management and continuous quality improvement in a busy community-based otorhinolaryngology practice will be presented. An open forum is planned. Bring your ideas!

Educational Objectives: 1. See the advantages in facial plastic surgery by taking up art. 2. Experience using the right side of the brain in aesthetic analysis through laboratory exercises provided.

COURSE 1705-I One-Period Course ($20)

COURSE 1703-2 Two-Period Course ($40)

Room MOS-103 3:00-5:15

What Every Facial Plastic Surgeon Should Know About Art

There are no secrets in facial plastic surgery. Every technique is freely taught in today's professional environment. Why then do some facial plastic surgeons consistently have better results than others? This happens because they see patients differently than the rest of us. Attendees will learn how the visual arts can help us improve our aesthetic analysis--indeed, the very way to visualize our patients. Interesting hands-on demonstrations will provide insight and direction in a life-long invitation to improving our surgical results.

COURSE 1704-2 Two-Period Course ($40)

Room MOS-104 3:00-5:15

Surviving and Thriving as an Independent Practitioner Steven F Isenberg MD Indianapolis, IN

Educational Objectives: 1. Improve patient services and referral services. 2. Implement outcomes studies and understand continuous quali~ improvement. 3. lmprove practice management through improved management with data and analysis of the process of care.

In this 2-hour course the attendees will systematically go through a workbook and review several issues that are extremely important to otorhinolaryngologists in today's health care environment: • Patient services • Referral services • Outcomes: the best tool in your bag • Employment process • Implementing change • Managing managed care • How to improve revenues and control costs • Capitation • Mergers • Continuous quality improvement • The practice prospectus

Room MOS-105 3:00-4:00

Newer Perspectives in Laryngeal Paralysis Roger L Crumley MD Irvine, CA

Educational Objectives: 1. Understand the many current procedures available for the management of unilateral laryngeal paralysis (vocal fold/cord paralysis) and when each is most appropriate. 2. Obtain new knowledge regarding usage of arytenoidectomy, laryngeal reinnervation, and the still experimental PCA stimulator/implant procedure.

This course is designed to update otolaryngologists regarding newer aspects of the treatment of laryngeal paralysis on the basis of today's latest concepts in laryngeal physiology and pathophysiology. With regard to unilateral paralysis, the current status of injectables (Teflon, Zyplast-Phonogel, Gelfoam, liquid silicone, Gelfoam paste, and other newer materials) will be reviewed. While currently serving a reduced role in management of laryngeal paralysis, certain patients are still most appropriately treated with one of the above injectables. Several variations of thyroplasty will also be discussed. The various procedures' phonatory results, from the literature and from the author's experience over 20+ years, will be presented. Bilateral laryngeal paralysis and the much more common bilateral vocal fold motion impairment are still most frequently treated with arytenoidectomy and/or tracheotomy. The history of laryngeal reinnervation for bilateral paralysis, clinical data from the instructor's series of phrenic nerve-PCA reinnervations, and the newest experimental treatment modality (posterior cricoarytenoid implant/stimulation) will be detailed. Previously misunderstood intralaryngeal motor nerve anatomy may play a role in refining reinnervation and/or implant procedures. In addition, laryngeal synkinesis will be thoroughly covered in the course, since it appears to be the best explanation for certain glottic dystonias, apparent airway obstruction occasionally seen in unilateral paralysis, and normal phonation sometimes seen in patients with unilateral paralysis.

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COURSE 1706-2 Two-Period Course ($40)

Room MOS-106 3:00-5:15

Management of External Ear Diseases Frank E Lucente MD; Simon C Parisier MD; Mark J Levenson MD; Dennis I Bojrab MD; Donald B Kamerer MD Brooklyn, NY; New York, NY; New York, NY; Royal Oak, MI; Pittsburgh, PA

Educational Objectives: I. Understand rationale for manage-

ment of infections and inflammation of the external auditory canal. 2. Prescribe appropriate primary and secondary therapy for infections of the external auditory canal. This course focuses on infections and inflammations of the external auditory canals and auricle. A brief introduction regarding the anatomy and physiology of the external ear will stress the natural gross and microscopic protective mechanisms in this region. Among the clinical topics that wilt be presented are refractory diffuse external otitis, otomycosis, mycobacterial infections, malignant (progressive necrotizing) external otitis, infectious eczematoid dermatitis, and psychocutaneous diseases. We also shall discuss the various dermatoses that present in this region. Surgical treatment of external canal stenosis and other conditions will be illustrated in videotapes and slides. The problem-case discussion approach will be used. There will be ample time for other case discussions, and audience members are encouraged to bring cases for presentation.

COURSE 1707-1 One-Period Course ($20)

Room MOS-200 3:00-4:00

Basic Dental Sciences for the Otolaryngologist David D Hamlar Jr MD DDS; Sherard A Tatum MD; Mario J Imola MD DDS Eagan, MN; Syracuse, NY; Eden Prairie, MN

Educational Objectives: 1. Discuss the functional anatomy of

the orthognathic system and the morbidity encountered by dentoalveolar infection, pathology, trauma, or oncologic resection of its components. 2. Make dental casts and bite registration to fabricate occlusal stents and splints. Learn acrylic~wire bonding techniques for tooth stabilization. Today's practice of otolaryngology/head and neck surgery covers a wide spectrum of disciplines, one of which involves the oral cavity and orthognathic system. Otolaryngologists find it necessary to negotiate this complex area whether it be general otolaryngology, oncology, trauma, or plastic and reconstructive surgery. Mastery of the basic sciences as they relate to the dentoalveolar structures is essential. A review of oral and dental anatomy is necessary to aid explanation of the occlusion and its relation to the temporomandibular joint. This is important when considering differential diagnoses and treatment for oral

myofunctional disorders as well as plastic and prosthetic reconstruction following maxillofacial trauma or oncologic resection. Hands-on fabrication of dental stents and splints by means of impression techniques will be used. Many of the problems faced by otolaryngologists carry comorbidity that simple techniques borrowed from our dental colleagues easily manage. A review of dentoalveolar pathologic mechanisms and their treatment will precede a hands-on session to learn acrylic/wire bonding techniques to stabilize loose or avulsed teeth. Discussion will include International Classification of Diseases--ninth revision and Current Procedural Terminology codes for the procedures. In addition to augmenting a current practice, the course is designed to help communications with potential and referring colleagues.

COURSE 1708-2 Two-Period Course ($40)

Room MOS-208/210/212 3:00-5:15

Life Threatening Infections of the Head and Neck George L Adams MD; Robert H Maisel MD; Frank L Rimell MD Minneapolis, MN

Educational Objectives: 1. Identify and manage advanced in-

fections caused by resistant organisms. 2. Recognize and manage infections in immunocompromised patients. Life-threatening infections are those that will cause death in 24 to 72 hours if not appropriately addressed immediately by both surgical and medical management. The use of antibiotics has modified the classic presentation of serious head and neck infections. Immunocompromised patients, diabetic patients, and patients receiving chemotherapy may develop rapidly fulminating infections, particularly fungal infection. Necrotizing fasciitis is classically described in patients who are diabetic or elderly. Recent experience with seven relatively healthy patients who had mixed aerobe and facultative infections will be discussed. Their predisposing factors, the role of hyperbaric oxygen, and the importance of immediately involving a thoracic surgeon and multidisciplinary support for both children and adults are discussed. Postoperative infections include wound infections, aspiration pneumonia, and C. difficile infections. Postoperative wound infections after major head and neck cancer surgery require drainage of abscesses, rerouting of fistulous tracts, and protection of the carotid artery. Multiple risk factors and their implications for wound infections are given. Perioperative antibiotic use has changed the organisms responsible for postoperative wound infections. Antibiotic selection suggestions for the most likely responsible organisms are given. In children, airway compromise and mediastinal and pulmonary extension as well as intracranial complications require special consideration.

Otolaryngology Head and Neck Surgery Volume116

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COURSE 1710-I One-Period Course ($20)

Room MOS-220 3:00-4:00

Functional and Cosmetic Approaches to Mid-Face Reconstruction

COURSE 1711-I One-Period Course ($20)

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R o o m MOS-222 3:00-4:00

Practical Imaging of the Temporal Bone

Neal D Futran M D DMD; Craig S Murakami M D Seattle, W A

Barry E Hirsch MD; Lorenz F Lassen MD; Jane L Weissman M D Pittsburgh, PA; Chesapeake, VA; Pittsburgh,PA

Educational Objectives: 1. Identify and describe specific techniques that optimize functional and aesthetic reconstruction of mid-face defects. 2. Develop a logical and sequential approach to achieve superior results in reconstructing the midface.

Educational Objectives: 1. Understand the principles and practical aspects of radiographic imaging of the temporal bone and the relevant radiographic anatomy. 2. Proceed with a logical and comprehensive CT and~or MRI workup of temporal bone disease.

The midface or orbit-nasal-maxillary complex is an intricate three-dimensional entity with important functional and esthetic purpose. Defects in this region result in significant disfigurement and in disability in speech, mastication, and swallowing. In addition, loss of both the vertical dimension and projection of the midface, as well as malposition of the affected eye, results in significant esthetic impairment. Because each defect has different reconstructive requirements, selection of the reconstructive methods must be highly individualized. The maxim of the last decade that the best reconstruction of the midface was obtained with a prosthesis has now been replaced by a much more aggressive approach to appearance and function by replacement of component tissue with a variety of vascularized and nonvascularized tissues. One must rely on techniques that are both cosmetic and reconstructive in nature. The incorporation of knowledge gained from the fields of rhinoplasty, face-lift, liposuction surgery, and microvascular free tissue transfer is a tremendous asset in these complex cases. Assessment of the need for an adaptive prosthesis then can be considered. The goals of this course are initially to identify the pertinent functional anatomy and conduct detailed defect analysis. Attention then will be paid to the bony requirements of the midface. Specific nonvascularized and vascularized bone grafts (cranial, fibular, and scapular) will be discussed with regard to reconstruction of the bony framework of the orbit midface and/or palate. A variety of free and locoregional soft-tissue transfers will be described to achieve optimal nasal, orbital, and cheek contour, as well as to seal the palate. Finally, secondary cosmetic procedures to further optimize the overall results will be discussed.

The practicing general otolaryngologist may feel unsure about how to proceed with radiographic workup of otologic symptoms and temporal bone diseases. In addition, either by necessity or by choice, otolaryngologists often rely on their own abilities to interpret radiographic studies in conjunction with the clinical findings and pathology. The first portion of this course reviews the basic principles and findings of CT and MR imaging of the temporal bone. The radiographic anatomy will be correlated with the relevant surgical anatomy. The strengths and shortcomings of each imaging technique will be discussed. We will then present interesting examples of common temporal bone diseases (congenital anomalies, chronic otitis media, cholesteatoma, cholesterol granuloma, otosclerosis, vestibular schwannoma, facial nerve and vascular lesions, and trauma). In conjunction with the radiologists, we will decide how to proceed in the radiographic workup. This course will provide a basic introduction to the powerful and essential diagnostic tools that radiology now offers to the practicing otolaryngologist.

COURSE 1712-I One-Period Course ($20)

Room MOS-224 3:00-4:00

Gene Therapy Technology & Clinical Implications in Otolaryngology Bert W O'Malley Jr MD; Marion E Couch M D Baltimore, M D

Educational Objectives: 1. Understand the basic concepts and principles of gene delivery and immunotherapies. 2. Understand the rationale for using gene and molecular therapies as applied to otolaryngology-head and neck surgery, including reconstructive surgery. The surge of molecular biology and the new understanding of genes and the products of their expression have allowed the emergence of a rising field heralded as gene therapy. Novel gene transfer technology is being used in immunotherapy to augment antitumor responses and has opened other avenues of clinical investigation.

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It is important to understand traditional methods of gene transfer such as electroporation and calcium phosphate precipitation and the inherent limitations of these methods that preclude efficient clinical use. Newer technology such as the rise of both viral- and lipid-mediated delivery systems has overcome these limitations but raises other clinical issues such as safety, duration of gene expression, and feasibility. During this course, discussion will include not only the commonly chosen retroviral, adenoviral, and vaccinia viral delivery systems but also naked DNA, receptor-mediated, and recently reported gene-transfer technology. The rationale for developing both the in vivo and ex vivo strategies with these systems is critical for understanding their use in human clinical trials. Examples of specific applications in otolaryngologyhead and neck surgery include the use of "suicide genes," cytokine gene-transduced tumor vaccines, and tumor suppressor genes for treating head and neck tumors. We will discuss clinically relevant animal models and stress the importance of careful preclinical scientific evaluation of gene therapy strategies. The final presentation in this course will be an update of present clinical trials in otolaryngology and a summary of future directions, including gene therapy in reconstruction surgery.

COURSE 1713-1 One-Period Course ($20)

Room MOS-226 3:00-4:00

Congenital Airway Disorders George H Zalzal MD Washington, DC

Educational Objectives: 1. Recognize and assess severity of a congenital airway problem, formulate a differential diagnosis, and proceed with a structured workup. 2. Implement safe management, surgical or otherwise, with a clear understanding of expectations and limitations of treatment.

Neonatal and pediatric stridor can cause significant stress for the practitioner. This course should help practitioners become more comfortable in dealing with this problem. Congenital airway disorders present with a variety of symptoms related to breathing, feeding, and voice production. Presentation does not necessarily occur at birth, and a variable course of progression of symptoms occurs, depending on the type and severity of the lesion. Tips on how to obtain relevant history, what to look for in a physical examination, and the indications for and value of radiologic procedures relevant to various airway disorders will be presented. The indications and technique for flexible and rigid endoscopy will be discussed briefly. A practical approach to diagnosis and management of congenital airway lesions will be detailed, with representative cases of craniofacial anoma-

lies, choanal atresia, oropharyngeal and hypopharyngeal cysts and tumors, laryngomalacia, laryngeal webs, laryngeal atresia, vocal cord paralysis, laryngeal cysts, h e m a n g i o m a , subglottic stenosis, laryngeal cleft, tracheomalacia, vascular rings, tracheoesophageal fistula, and congenital tracheal rings.

COURSE 1714-1 One-Period Course ($20)

Room MOS-228/230 3:00-4:00

Advances and Surgical Management of Nasoethmoidal, Mid-face Zygoma Complex Fractures: 550 Cases Joram Raveh MD DMD; Kurt Laedrach MD DMD; Jon B Turk MD Bern, Switzerland; Bern, Switzerland; Brooklyn, NY

Educational Objectives: 1. Become acquainted with the correct three-dimensional reduction of thefractures and the best choice of various plating systems. 2. Become acquainted with the management of severe soft and bone tissue lesions and the indication for bone grafts, flaps, and canthal ligament adjustment.

The reconstruction of this area is quite controversial. Particularly in complex fractures, reproduction of the correct pretraumatic symmetry still represents a challenge. The reduction of the zygoma, orbital floor and walls, and the midface fractures and the indication for cartilage and bone grafting will be emphasized. Different aspects and techniques designed to avoid zygoma prominence, asymmetry, enophthalmus, and double vision will be evaluated. The simultaneous management of zygoma fractures with concomitant skull base lesions will be pointed out. Indications, limitations, and the best choice of plating systems will be demonstrated. Various aspects and techniques for the reconstruction of severe combined nasoethmoidal and orbital disruption as well as optimal reduction of the canthal ligaments will be highlighted. This region is of utmost importance because the dislocated, multifragmentary, inward-telescoped nasal buttress and frontal region, if not meticulously reconstructed, often leads to postoperative telecanthus and further asymmetries. In cases with bone and soft-tissue defects the indication and choice of free bone grafts, pedicled external table grafts, or soft-tissue reconstruction, including free revascularized flaps, is crucial to optimize outcomes and will be discussed extensively. The thrust of this course is to enhance the participant's experience in the treatment of various fracture patterns, while introducing pitfalls in the management of these fractures. We hope to share our experience in regard to the best choice of surgical approaches and methods, including the latest advance in facial fracture management.

Otolaryngology Head and Neck Surgery Volume 116 Number5

COURSE 1715-I One-Period Course ($20)

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Room MOS-232/234 3:00-4:00

Postlaryngectomy Vocal and Pulmonary Rehabilitation: The Provox System Frans J Hiigers MD A m s t e r d a m , Netherlands

Educational Objectives: 1. Understand the prospects of postlaryngectomy prosthetic voice rehabilitation with an indwelling voice prosthesis system, and related appliances. 2. Understand the prospects of postlaryngectomy pulmonary rehabilitation with the use of heat and moisture exchangers (HMEs).

Consistently high success rates with prosthetic voice rehabilitation have been reported in the past 16 years. An increasing number of patients achieve a useful voice, making prosthetic voice rehabilitation the method of choice. Two types of voice prosthesis can be distinguished: non-indwelling devices, which can be removed and replaced by the patient, and indwelling devices, which stay in place permanently and must be removed and replaced by a qualified health care provider at the end of the device life. This is mostly determined by incompetence of the valve and leakage. Based on our experiences with surgical and prosthetic voice rehabilitation since 1979, we prefer indwelling devices, because they require less dexterity of the patient. In 1988, we developed an indwelling, low-resistance silicon voice prosthesis, Provox. This has been successfully used in our Institute for the past eight years in all laryngectomized patients. Primary insertion at the time of total laryngectomy, making stenting of the TE-fistula superfluous, is preferred, although secondary application is also easily accomplished. The clinical results, which can be obtained with this voice prosthesis and the adverse events and their solutions with prosthetic voice rehabilitation, are the subject of this course. The recently developed second- generation Provox voice prosthesis for bidirectional, that is, anterograde and retrograde, insertion (Provox 2) will be presented as well. This device has considerably decreased the discomfort of the retrograde replacement procedure for the patient and is also easier applied by speech therapists. Besides vocal rehabilitation, focus will be on the importance of pulmonary rehabilitation after total laryngectomy. Prevention and treatment of the frequently encountered pulmonary complaints after laryngectomy with a heat and moisture exchanger (HME) will be discussed.

COURSE 1716-1 One-Period Course ($20)

Room MOS-236 3:00-4:00

Technical Decisions in Rhinoplasty Norman J Pastorek MD New York, NY

Educational Objectives: 1. Choose approach to rhinoplasty incisions and use suture reformation of lower lateral cartilages. 2. Use autogenous cartilage grafts for revision surgery.

The successful rhinoplasty surgeon knows that technical decisions concerning the nasal tip remain the key to consistently good results. The use of various approaches and techniques are totally dependent on the initial examination, including observation and palpation. At surgery, a good result is dependent on totally reliable surgical techniques. The instruction course offers the author's systematic approach to nasal tip surgery and the reasons for an evolution of methods over a 24-year period. The range of nasal tip problems includes the underprojecting tip, the overprojecting tip, the hanging columella, and use of tip grafts in secondary and primary rhinoplasty.

COURSE 1717-1 One-Period Course ($20)

Room MOS-238 3:00-4:00

Steroids in Otolaryngology: Indications, Efficacy, and Safety Daniel G Deschler MD; Todd T Kingdom MD Philadelphia, PA; Atlanta, GA Educational Objectives: l. Understand the basic physiology of corticosteroids and the potential complications of their use. 2. Review the pertinent literature concerning the use of steroids in otolaryngology and develop an approach to their safe usage.

For more than 50 years, corticosteroids have been used for the treatment of a wide variety of disorders in the specialty of otolaryngology-head and neck surgery. Only recently have the possible complications of steroid use become well recognized and their use drastically curtailed. While it is clear that steroids are extremely valuable for the reduction of inflammation in many clinical situations encountered by otolaryngologists, the use of steroids in the management of many disease processes remains controversial. Therefore, the practitioner requires an understanding of the indications and contraindications for using corticosteroids and their potential complications. This course will review basic steroid physiology and the problems associated with both short and long-term steroid therapy. The common uses of steroids in otolaryngology will be reviewed, focusing on the scientific evidence of their efficacy and the complications associ-

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ated with their use. In particular, the role of steroids in the management of idiopathic facial palsy, sudden sensorineural hearing loss, laryngotracheobronchitis, and surgical procedures will be discussed. The goal of the presentation will be toward helping the practitioner develop a strategy for safe steroid use in clinical situations arising in his or her otolaryngology practice.

COURSE 1719-1 One-Period Course ($20)

Room MOS-252/254/256 3:00-4:00

Rigid and Contact Video Endoscopy--Assessment of Laryngeal Pathology Mario Andrea MD; Oscar Dias MD Lisbon, Portugal

Educational Objective: Perform this endoscopic technique. COURSE 1718-1 One-Period Course ($20)

Room MOS-250 3:00-4:00

Management of Pediatric Tracheal Stenosis and Compression Frank L Rimell MD; James D Sidman MD Minneapolis, MN

Educational Objectives: l. Accurately diagnose and differentiate the various types of pediatric tracheal compressions and stenosis. 2. Understand better how to manage each type of stenosis and compression.

Most otolaryngologists will encounter at sometime an infant or child who presents with tracheal stenosis or compression. Although many of these children are referred eventually to a tertiary pediatric institution, the initial diagnosis and management is performed by the primary otolaryngologist. The purpose of this course is to review the current diagnosis and management of pediatric tracheal stenosis and compression. Information on new diagnostic and repair techniques as practiced by the instructors will be discussed. The course will begin with a review of the differential diagnosis and cover both intrinsic forms of tracheal stenosis and the various forms of extrinsic vascular tracheal compression commonly encountered in the infant and child. Newly described variants of pulmonic arterial tracheal compression will be presented. In-depth discussions will follow on the radiologic work-up, including the usefulness of high-kilovoltage films, fluoroscopy, echocardiography, computed tomography, angiography, and particular attention to the use of magnetic resonance imaging. The role and method of diagnostic rigid and flexible endoscopy will be presented. The last portion will be devoted to innovative repair techniques, including the use of the extracorporeal membrane oxygenation, cardiac bypass, costal cartilage grafting, pericardial patch technique, end-to-end anastomosis, and the use of the various laser in both rigid and flexible bronchoscopy.

The evaluation of benign and malignant lesions of the larynx, namely, those of the vocal cord, have benefited by the systematic use of rigid endoscopes (0, 30, 70, and 12 degree) during microlaryngoscopies (REMS). Besides the access to particular areas of the endolarynx-anterior commissure, inferior surface and border of the vocal cord, and subglottis--all laryngeal disease is evaluated with higher magnification and definition. The form, dimensions, limits, extension, color, relief, and vascular abnormalities are valued with greater detail. Contact endoscopy (CEMS) by use of 60x and 150x magnification and a vital colorant (methylene blue) gives direct access to the cells, producing an in vivo and in situ study of the superficial epithelium of the larynx. The regularity of the epithelium, dimensions and color of the nucleus, nucleus-cytoplasmic ratio, contours, and presence of nucleolus, mitosis, cytoplasmic inclusions, or keratosis allow the definition of normal and specific epithelial patterns--chronic laryngitis, Reinke's edema, dysplasia, papilloma, and malignant tumors. With CEMS, microvascular patterns of the larynx in normal and pathologic conditions are observed, and with 150x magnification, blood flow can be studied. REMS and CEMS techniques have repercussions in e p t i o p a t h o l o g y , diagnosis, performance of biopsies, treatment, and follow-up.

COURSE 1720-1 One-Period Course ($20)

Room MOS-262 3:00-4:00

Olfactory and Gustatory Disorders: Diagnosis and Treatment Michael H Stevens MD; Bruce W Jafek MD Salt Lake City, UT; Denver, CO

Educational Objectives: 1. Diagnose and evaluate olfactory and gustato©' disorders. 2. Treat these disorders.

Olfactory and gustatory disorders can have a significant impact on individuals either as a presenting symptom of serious underlying disease or by affecting their quality of life. They can also cause significant disability for persons in certain occupations. In this course the physiologic and anatomic basis of olfaction will be presented. We will discuss the use of the UPSIT as a simple office test of olfaction, and testing the sense of taste. A differential diagnosis and treatment of these disorders will also be outlined.

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COURSE 1721-1 One-Period Course ($20)

Instruction C o u r s e s - - Sunday

Room MOS-270 3:00-4:00

Diagnostic Evaluation for Dizziness: A Physiological Approach Douglas D Backous MD; Lloyd B Minor MD Baltimore, MD

Educational Objectives: 1. Perform a physiologically based, focused, and time-effective evaluation of a patient complaining of dizziness. 2. Know the indications for specific vestibular tests and therapeutic interventions.

This instruction course will discuss recent advances in the understanding of vestibular and oculomotor physiology as they relate to clinical manifestations of peripheral vestibular disturbances. An approach to complete history and bedside examination of patients with the complaint of dizziness will be described as a guide for m a k i n g a d i a g n o s i s and i m p l e m e n t i n g a p p r o p r i a t e therapy. Techniques for the office evaluation of dynamic visual acuity, pursuit, spontaneous and g a z e - e v o k e d nystagmus, vestibulo-ocular reflex (VOR) cancellation, head-shaking nystagmus, and testing of the high-frequency spectrum of the VOR with the head-thrust maneuver will be presented in lecture and video formats. A basic vestibulospinal examination focusing on static (tandem and sharpened Romberg) and dynamic (Fukuda and tandem walking) testing will be outlined. Guidelines for a p p r o p r i a t e use of v e s t i b u l a r tests (electronystagmography, rotatory chair, posturography) and laboratory and radiologic screening will be proposed. The material will be integrated into a stepwise plan for evaluation that is based on symptoms and findings on examination.

COURSE 1722-1 One-Period Course ($20)

Room MOS-272 3:00-4:00

Laryngeal Electromyography Steven M Parnes MD; Glendon M Gardner MD; Neil Laya MD Albany, NY; Bloomfield Hills, MI; Albany, NY

Educational Objectives: l. Perform a laryngeal electromyography. 2. Apply the results to more effective clinical management in both diagnostic and prognostic capacities.

Laryngeal electromyography (LEMG) is a useful clinical tool for evaluating patients with vocal cord dysfunction. Analogous to its counterpart, conventional EMG, it is valuable in determining the site of neurogenic lesions (upper vs. lower motor neurons), as well as differentiating myopathy or mechanical fixation from neuropathy and functional disturbance from organic. More specifically, it can provide delineation of specific nerves affected (superior vs. recurrent laryngeal) based on objective data rather than subjective interpretation derived from the position

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of cords noted on laryngoscope. The LEMG also provides prognostic indicators that aid the clinician in the management of patients with vocal cord abnormalities. Two techniques are used that will be described. The first is a simple method of percutaneous laryngeal EMG permitting access to the primary areas of innervation, the superior laryngeal nerve and the recurrent laryngeal nerve. This test may be performed on an outpatient basis in a conventional EMG laboratory. The second method is used in some children or noncompliant patients. Under general anesthesia the electrodes are inserted directly into vocal cords to access the intrinsic muscles of the larynx by means of direct laryngoscopy. We will describe our experience with these techniques, demonstrating its clinical applications and its use in patients with spasmodic dysphonia who do not tolerate the percutaneous technique.

COURSE 1723-I One-Period Course ($20)

Room MOS-274 3:00-4:00

Stapedectomy With Vein Graft and Teflon Piston John J Shea Jr MD Memphis, TN

Educational Objectives: 1. Understand otosclerosis, its natural history, how to make the diagnosis, etc. 2. Know how to do stapedectomy, prevent revisions, manage complications, etc.

Otosclerosis is a progressive disorder of the temporal bone that causes ankylosis of the stapes footplate and conductive hearing loss. The otosclerotic focus usually begins in the fissura ante fenestra, just in front of the oval window, as a remodeling of bone, that enlarges and eventually invades and fixes the stapes footplate. The diagnosis is made by the typical history of a progressive, low-tone conductive hearing loss, often with a family history of similar hearing loss, and a fiat, type A tyrnpanogram, with an absent stapedial reflex. In ears with localized or widespread otosclerosis, a small fenestra is made in the thin central part of the footplate with an argon laser and hand probe, and a Teflon piston inserted, after a small piece of compressed vein, removed from the back of the hand, is interposed. Results with this technique of operation have been good, with permanent closure of the air bone gap in 90% and further hearing loss in no more than 1%. Postoperative hearing results will be explained, together with the most important complications, and how to avoid and manage them if they occur. A VHS tape of the laser stapedectomy with vein graft and Teflon piston will be distributed to all attendees.

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COURSE 1724-1 One-Period Course ($20)

Room MOS-276 3:00-4:00

Contemporary Pharmacotherapy for Allergic Rhinitis James A Hadley MD; Berrylin J Ferguson MD Rochester, NY; Pittsburgh, PA

Educational Objectives: l. Understand relationships of new medications for rhinitis. 2. Use knowledge of physiology to appropriately manage patients with rhinologic complaints. The interaction of inhalant allergens on the mast cell leads to the release of chemical mediators that initiate a bi-phase reaction in the mucosa of the upper respiratory tract. Early phase reactions due to the release of histamine and other kinins lead to complaints of sneezing, watery rhinitis, and pruritis. Subsequent cellular infiltration in the late phase brings in new mediators of inflammation, prolonging the initial reaction. This second stage has a different set of mediators that have recently been categorized. Contemporary pharmacotherapy has changed with the new knowledge obtained from studies of these reactions. The classic sedating H-1 antihistamines are useful but lead to a reduced productivity due to sedation. Some newer nonsedating H-1 antihistamines recently developed and introduced have additional indications that make them more effective for the patient. Concurrent research is directed at i m m u n o m o d u l a t o r s and leukotriene antagonists that will be introduced to the clinician. The introduction of topical nasal steroids has revolutionized pharmacotherapy for this disorder. These medications are ever- changing, and some have improved onset of action with the addition of reduction of ocular symptoms along with reduction of nasal symptoms. Complications and intolerances can occur with the use of these and other medications. These issues are discussed in this instructional course and will give the practitioner the proper tools and information for appropriate contemporary medical management of rhinologic complaints.

COURSE 1725-2 Two-Period Course ($40)

Room MOS-300 3:00-5:15

Improving the Bottom Line by Managing Accounts Receivable Karen A Zupko Chicago, IL

Educational Objectives: l. Review your accounts receivable decisively and diagnose a myriad of common problems. 2. Reduce the dollars owed your practice by applying recommended principles. Otolaryngologists with a proactive bent in all types of practice settings will find this session valuable and prof-

itable. Revised for 1997, this course will illustrate how otolaryngology practices with receivable problems made significant improvements by using the recommended techniques described in this session. Topics covered include: 1. Reports: which ones to run and what to look for 2 . F l o w charting the b i l l i n g process: l o o k i n g for landmines 3. Preoperative financial counseling 4. Improving patient registration 5. The managed care payment black holes

COURSE 1726-2 Two-Period Course ($40)

Room MOS-301 3:00-5:15

Introducing Windows '95 Raymund C King MD; Russell A Faust MD PhD O k l a h o m a City, OK; Minneapolis, MN

Educational Objectives: l. Know the basic features of the Windows '95 operating system and have hands-on experience with Windows '95 applications. 2. Customize their own personal computer using the special features of Windows '95 .]'or optimal peJJ~rmance. This will be a 2-hour hands-on course in the computer laboratory. Fifteen IBM-compatible computers will accommodate two persons per computer. The course is designed as an introduction to the Windows '95 operating system, with the assumption that the attendee has used a Windows operating system (Windows 3.×) on a personal computer and would like to become familiar with and optimize his or her use of the Windows '95 operating system. Use of some commercially available interactive tutorial software and multimedia programs will give the course participant a good foundation for learning more about Windows '95. The instructors have used this operating system in their practices. However, the course will intentionally avoid office management and concentrate more on computer use for personal purposes. Most of the session will be spent working on the computers, and the instructors will be available for discussions about personal computer use. Furthermore, advanced "tips and tricks" with Windows '95 will be discussed for interested attendees. A brief lecture will precede the selfpaced portion of the course, and a handout will be supplied.

Otolaryngology Head and Neck Surgery Volume 116 Number5

COURSE 1727-1 One-Period Course ($20)

InstructionCourses- - Sunday

Room MOS-302 3:00-4:00

Surgical Rejuvenation of the Aging Forehead and Brow Tom D Wang MD Portland, OR

Educational Objectives: l. Evaluate the patientfor surgery for the upper aging face. 2. Select the appropriate surgical approach to perform surgery of the upper face.

The aging face syndrome involves the forehead and eyebrow in a specific pattern, including the development of forehead rhytids, brow ptosis, and redundancy of upper eyelid skin. The constellation can lead to functional impairment, including restriction of the visual fields. A variety of procedures have been described in the literature to address brow elevation. This course will discuss each of these procedures and place it in a context relative to the appropriate indications for the individual patient. The functional surgical anatomy, as well as the relative advantages and disadvantages of each procedure, will be addressed. The surgical techniques will be thoroughly reviewed. Preoperative and postoperative patient photographs of each technique discussed will be candidly evaluated. The role of endoscopic brow elevation will be addressed and placed in perspective in relation to more traditional techniques. This course will allow participants to appropriately evaluate and diagnose patients with problems related to the aging upper face. In addition, based on this evaluation, the participants will be able to select an appropriate approach for correction of the conditions encountered.

COURSE 1728-2 Two-Period Course ($40)

Room MOS-303 3:00-5:15

necessary in these children, including assessment for allergic disease, gastroesophageal reflux, immune deficiency, cystic fibrosis, and congenital abnormalities, will be described. The role of adenoidectomy as well as alternate forms of sinus surgery will also be reviewed. The focus of the course will be to discuss current controversial issues, including the actual definition of chronic sinusitis in children, the symptom complex and disease process of the child, the appropriate albeit limited role of the physical examination on the young child, and a thorough discussion of "maximal medical therapy" for the young child with symptomatic chronic sinusitis. An extensive discussion of issues relating to the radiographic approach to the assessment and decision-making for surgery in these children will also be reviewed. Multiple CTs will be shown to demonstrate a variety of abnormalities in young children as well as the significant changes that can be seen once appropriate therapeutic measures are instituted. The second hour of the course will focus on the surgical approach used in small children with sinus disease. The preoperative consultation will be described in detail. Controversial issues such as the timing of surgery, extent of surgery, and ancillary surgery will all be discussed. Current pediatric sinus instrumentation as well as "powered" instrumentation will be discussed. Video tapes of "small hole surgery" demonstrating the miniFES technique with powered instrumentation will be presented. Postoperative management issues will also be described. A variety of "pearls" for how to approach this procedure in small children and "how to stay out of trouble" will also be discussed. Finally, the impact and benefits of surgery on children with a variety of conditions such as asthma, allergy, and CF will be reviewed.

COURSE 1729-2 Two-Period Course ($40)

Chronic Sinusitis and Endoscopic Sinus Surgery in Young Children

Uncovering the Personal Computer

Seth M Pransky MD; Max M April MD

C l e v e l a n d , OH; Springfield, MO

San Diego, CA; N e w York, NY

Educational Objectives: 1. Understand the approach, evaluation, and workup of the young child with chronic sinusitis. 2. Understand the approach to and technique of functional endoscopic sinus surgery in young children. 3. Appreciate the various controversies involving FESS in young children.

This course will discuss the indications for endoscopic sinus surgery in young children. With the burgeoning use of this technique throughout the country, great care is needed in choosing the appropriate surgical candidate when the child is very young. This is particularly important in view of the lack of clearly described indications for sinus surgery in this age group. The extensive and cost-effective preoperative medical evaluation

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Room MOS-304 3:00-5:15

David W Stepnick MD; Allan L Allphin MD

Educational Objectives: 1. Understand basic computer terminology and its impact on the selection of computers and computer software. 2. Have a better understanding of potential applications for the computer and its use linked in the Internet as a valuable educational, marketing, and communications tool.

Personal computers are an inescapable reality in today's world and have dramatically changed the operations of many otolaryngology practices in the United States. Many feel that advancing technology is "leaving them behind"; others remain skeptical about the potential benefits to be gained by embracing this technology. The standard approach to educating would-be computer users/owners traditionally involved technical explanations of the intricacies of operating systems and programming: much of this

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information is unnecessary for the vast majority of physicians to learn and understand. By attaining basic knowledge of computer systems, software, and their potential uses, as well as developing a good understanding of the medical uses of the Internet, physicians can comfortably optimize their use of this resource. This course is designed for the computer novice. The first hour of this course defines and explains concepts such as memory, viruses, and networks in a way that persons unfamiliar with computers should understand. A brief discussion of some of the potential applications of various computer software as it relates to the otolaryngologist's practice, including a look at multimedia learning tools, presentation graphics, surgical case logs, and pharmaceutical database programs, will conclude the first half of the course. The second hour will provide information to participants about Internet "linguistics," an explanation of methods to access and navigate "the Net," and explore how the Worldwide Web can be used as a valuable educational, marketing, and communications tool.

COURSE 1730-1 One-Period Course ($20)

Room MAR-Salon 1/2 3:00-4:00

Pediatric Sinusitis: Medical and Surgical Management

COURSE 1731-2 Two-Period Course ($40)

Room MAR-Salon 3/4 3:00-5:15

The Possibilities of Powered Instrumentation in FESS Reuben C Setliff III MD Sioux Falls, SD

Educational Objectives: 1. Provide a surgical comfort level with the use of powered instrumentation in FESS. 2. Provide a framework for a standardized surgical approach that addresses the cause of chronic sinusitis. This course covers the use of powered instrumentation from its beginning in August 1992 to the development of minimally invasive "small hole" surgery. The latter has been in continuous use in more than 1500 cases since February 1993. A model for the pathogenesis of chronic sinusitis is combined with four cardinal surgical landmarks and three critical transition spaces. The result is a standardized surgical approach offering many advantages for both the patient and surgeon.

COURSE 1732-2 Two-Period Course ($40)

Room MAR-Salon 5/6 3:00-5:15

Is It a Normal Larynx? The Spectrum of Normal in Videolaryngoscopy

Rodney P Lusk MD; Harlan R Muntz MD; David S Parsons MD Saint Louis, MO; Saint Louis, MO; Columbia, MO

Karen M Kost MD; David E Eibling MD Westmount PQ, Canada; Pittsburgh, PA

Educational Objectives: 1. Describe the etiology and underly-

Educational Objectives: 1. Know variations of normal endo-

ing factors causing pediatric sinusitis and discuss the medical and surgical treatment options. 2. Describe the technique used by the instructors to perform pediatric endoscopic sinus surgery.

scopic anatomy. 2. Recognize subtle anatomic andfunctional abnormalities.

The diagnosis of pediatric acute and chronic sinusitis is being made with increasing frequency by otolaryngologists, pediatricians, family practitioners, and pediatric allergists. The symptoms and methods of diagnosis remain controversial. We present our experience and describe how we make the diagnosis. The validity of plain sinus films is discussed and compared with coronal CT scans in a prospective study of 70 patients. The location of chronic sinus disease in children is described, as documented with 116 CT scans. The incidence and significance of congenital pediatric abnormalities is discussed. The literature evaluating tonsillectomy, adenoidectomy, sinus lavage, and nasal antral windows is critically reviewed. A detailed discussion of the pathophysiology of osteomeatal complex obstruction and pediatric chronic sinusitis is reviewed and used as a rationale for functional endoscopic surgery. A detailed review of the surgical techniques developed by the instructors in the endoscopic treatment of chronic pediatric sinusitis will be given. Special emphasis is placed on the surgical instrumentation developed for pediatric sinus endoscopy.

Videostroboscopy has resulted in improved imaging of the larynx and increased our understanding of the mechanics of vocal fold movement. The wide variations in normal laryngeal symmetry, color, and motion, which may now be appreciated as a result of improved imaging abilities, may lead to confusion in distinguishing normal variants from abnormalities. The ability to make this distinction is important because it carries implications with respect to diagnosis and treatment. This course is aimed primarily at the otolaryngologist with limited experience in this area. The basis of laryngeal videostroboscopy and the parameters that can be assessed with its use will be reviewed. A large number of cases will be used to demonstrate the transition from "textbook normal" to normal variants and to subtle abnormalities. More obvious abnormalities will be illustrated and discussed also. The audience will be encouraged to participate in the discussion and analysis of videotapes.

OtolaryngologyHead and Neck Surgery Volume116 Number5

COURSE 1733-I One-Period Course ($20)

InstructionCourses--Sunday

R o o m MAR-Salon 10/11 3:00-4:00

COURSE 1735-I One-Period Course ($20)

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R o o m MAR-Salon 13 3:00-4:00

Pediatric Otology

Down's Syndrome and the Otolaryngologist

Antonio De la Cruz MD; William M Luxford M D Los Angeles, C A

Eric M Kraus M D Greensboro, N C

Educational Objectives: 1. Order the proper evaluation for children with otologic disorder. 2. Understand indications for medical and surgical treatment of pediatric patients.

Educational Objectives: 1. Have acquired in-depth, updated knowledge concerning the otolaryngologic problems associated with Down syndrome and practical, clinical recommendations for management. 2. Understand effective, safe, outpatient sedation techniques to aid in the head and neck examination of individuals with Down syndrome.

Pediatric otologic problems represent a significant part of every otolaryngologist's practice. This course emphasize the diagnosis and treatment of middle ear effusions, timing of tympanoplasty, surgical correction of congenital atresias, evaluation and management of progressive sensorineural hearing loss, and pitfalls in auditory evaluation in children. Included will be a discussion of the recent advances in patient selection, results, and complications of cochlear implants in children.

COURSE 1734-1 One-Period Course ($20)

Room MAR-Salon 12 3:00-4:00

Maximizing Treatment of the N3 Neck John U Coniglio MD; Lee Reussner MD; Alexis Carras MD Rochester, NY; Lawrence, KS; Rochester, NY

Educational Objectives: 1. Determine surgical candidacy for those patients with N3 neck metastases. 2. Demonstrate the ability to preoperatively assess the resectability of the carotid artery. 3. Plan appropriate reconstruction. The N3 neck presents the head and neck surgical oncologist with many challenging evaluation and management decisions. Treatment for these patients usually is aimed at palliation, given the poor prognosis. Primary surgical management of the N3 neck will be discussed, with the goals being to inform the patient that cure is difficult to achieve but that palliative effects as well as curative possibilities do exist. The involvement of surrounding structures including the mandible, base of skull, skin, clavicle, deep muscles of the neck, and carotid artery are the norm in patients with N3 neck disease. Carotid artery involvement does not make the tumor unresectable, and the role of the carotid artery assessment will be discussed from the simple Matas maneuver to single-photon emission computed tomography. The treatment of 33 patients yielded an overall 2year survival of 39%. We believe our successful outcomes are the result of careful patient selection, assessment of the carotid artery before surgery, revascularization of the artery when involved, and use of reconstructive free or pedicled muscle flaps.

As otolaryngologists, we frequently are involved in diagnosing and managing the ear, nose, and throat problems associated with Down syndrome. Proper recognition and management of these problems have become imperative as the American paradigm for interacting with the differently abled has matured from that of segregation to that of inclusion. Many individuals with Down syndrome are now being mainstreamed into American society and are entitled to the same standard of medical care as that provided to their temporarily abled peers. This course is designed to update your knowledge about Down syndrome and to provide you with useful clinical information that you can apply in your daily practice. Specifically, this 1-hour course will discuss the following: 1. Basic science: A brief review of our current knowledge of the genetics and biochemistry of chromosome 21, including new information concerning prenatal screening, will be presented. 2. Ear disease: Guidelines for aggressive otologic management will be discussed, including indications for hearing screening, transtympanic tubes, stapedectomy, canal plasty, auditory brain stem response, OAEs, hearing aids, central auditory processing, and early auditory intervention. 3. Upper airway issues: Indications, precautions, and controversies concerning tonsillectomy and adenoidectomy, uvulopalatopharyngoplasty, management of chronic obstructive sleep disorder, partial glossectomy, drooling, subglottic stenosis, and atlantoaxial subluxation will be presented. 4. Facial cosmetic procedures: Controversies concerning the role of facial cosmetic surgery will be discussed: what, why, and when. 5. Additional topics: The management of chronic rhinosinusitis, hypothyroidism, infantile spasms, and antibiotic resistance will be reviewed. Practical suggestions for working with pediatric and adult patients will be provided, including recommendations for outpatient sedation techniques. A comprehensive bibliography, published article, Down syndrome growth charts, and guidelines for preventive medical care will be provided to each participant.

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COURSE 1736-I One-Period Course ($20)

R o o m MAR-Salon 14 3:00-4:00

Clinical Electrocochleography and Brainstem Audiometry Derald E Brackrnann MD; Manuel Don PhD Los Angeles, C A

Educational Objectives: I. Order the proper audiometric studies for neurotologic diagnosis. 2. Understand the basics of electrocochleography and brainstem audiometry for neurotologic diagnosis. Electric response audiometry, particularly brainstem audiometry, has become an important clinical tool. This course demonstrates how these techniques are used in clinical practice. The first portion of the course deals with the basic principles and techniques of electric response audiometry. The uses of electrocochleography as a threshold test and for measurement of cochlear potentials in Meniere's disease are described. The major emphasis of the course is on the uses of brainstem audiometry. Determination of auditory threshold in infants and uncooperative adults is first described. Auditory brainstem responses are the most accurate noninvasive means of detecting acoustic tumors. This technique is described in detail. Finally, the use of auditory brainstem responses in neurologic diagnosis is described. This course is supplemented by a detailed handout covering the material presented.

COURSE 1737-1 One-Period Course ($20)

R o o m MAR-Salon 15 3:00-4:00

Laser Stapedotomy Rodney C Perkins M D Palo Alto, C A

Educational Objectives: 1. Have requisite knowledge of back-

ground and techniques used in laser stapedotomy. 2. Understand techniques for dealing with difficult situations in the otosclerotic patient. The laser stapedotomy operation, which was developed in 1978, has since has been proved to be a safe and effective treatment for otosclerosis and has become the method of choice for many otologists. This course is designed to familiarize the surgeon with the basics and refinements of the operation and to provide information pertinent to the successful execution of the procedure. The material covered will include: 1. Historical background 2. Rationale

3. Instrumentation 4. Pertinent laser fundamentals 5. Patient preparation and local anesthesia 6. Surgical technique 7. Results 8. Control of thermal effect 9. Floating footplate 10. Difficult situations • Obliterated footplate technique • Overhanging facial nerve • Narrow oval window niche A highly illustrated, integrated syllabus will facilitate note taking and provide a valuable reference for later review.

COURSE 1738-I One-Period Course ($20)

R o o m M A R - N o b HillA 3:00-4:00

The Unknown Primary Ashok R Shaha M D N e w York, NY

Educational Objectives: 1. Understand the diagnosis, evaluation, and workup of a patient with metastatic cancer in the neck. 2. Understand the role of blind biopsies, treatment approaches, and role of surgery and radiation therapy in the management of unknown primary including metastatic adenocarcinomas. An unknown primary is considered as presence of metastatic cancer in the neck with no obvious primary documented in the upper aerodigestive tract. Evaluation of a patient presenting with suspected metastatic cancer in the neck is always complicated. Occasionally a million dollar workup is performed; however, most of the time, limited workup is quite sufficient. A good clinical examination and a thorough head and neck examination are vitally important in the evaluation of a patient presenting with suspected metastatic cancer in the neck. The role of fine needle evaluation is paramount in the evaluation of a neck mass. This instruction course will discuss the role of needle biopsy, the possible sites of primary tumors in the head and neck and structures below the clavicle, role of endoscopy, and controversial issues related to blind biopsies. The role of immunofluorescence and other state-of-the-art pathological evaluations will be discussed. The course will also discuss the treatment approaches in the management of unknown primary. The controversy regarding radical versus modified radical neck dissection will be discussed and the role of postoperative radiation therapy will be defined. The extent of radiation therapy will be discussed in detail.

OtolaryngologyHead and Neck Surgery Instruction Courses-- Sunday

Volume 116 Number5

COURSE 1739-1 One-Period Course ($20)

R o o m MAR-Nob HillB 3:00-4:00

COURSE 1740-1 One-Period Course ($20)

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R o o m MAR-Nob HillC 3:00-4:00

Predicting Wound Healing after Mohs' Surgery of the Face

Interdisciplinary Management of Surgical Parathyroid Disease

Gary D Becker MD; Lawrence Adams MD Panorama City, C A

Phillip K PellitteriDO; Ronald P Monsaert M D

Educational Objectives: 1. Understand the variables affecting secondary intention healing. 2. Anticipate the cosmetic result after Mohs surgery.

Educational Objectives: 1. Have a greater understanding of parathyroidology as it relates to preoperative assessment and surgical decision making. 2. Provide comprehensive care to patients with surgical disease of the parathyroid glands using an interdisciplinary head and neck endocrine clinic.

Facial skin defects resulting from Mohs surgery may be closed surgically or allowed to heal by secondary intention. Immediate reconstruction of full-thickness skin defects is a commonly accepted surgical principle used to preserve function and minimize cosmetic deformity. However, healing by secondary intention offers various advantages, and in selected cases, comparable or even superior cosmetic results. Accurate prediction of the final cosmetic and functional result after secondary intention healing is essential for selection of appropriate management. For purposes of documentation, the face was divided into the following units; forehead, lip and chin, nasal and perinasal, ear and cheek. Each facial unit was further subdivided into subunits." The wound location by subunit, size in millimeters, geometric configuration, and depth in millimeters and by anatomic layer was recorded. Cosmetic and functional results were recorded as acceptable or unacceptable by consensus of the authors. This course explores the dynamics of wound healing as influenced by defect location, size, depth, configuration and skin laxity. These variables interact in a predictable manner during secondary intention healing and allow one to anticipate, with a high degree of accuracy, the final cosmetic and functional result. On the basis of observations of more than 5000 patients, recommendations are made regarding defects in each subunit as to which would benefit by surgical or nonsurgical intervention. Extensive photographic documentation of lesions in each subunit from initial surgical resection to final cosmetic result are documented and discussed.

Danville, PA

This course will outline an interdisciplinary approach to the management of parathyroid gland disorders in which patients are evaluated concurrently by the endocrinology and head and neck services in a combined clinic. The course is presented by a head and neck endocrine team composed of a head and neck surgeon and endocrinologist experienced in treating parathyroid disorders. Pathophysiologic and embryologic aspects of parathyroidology as they pertain to surgical exploration and decision making will be discussed. The presentation has been updated and modified in order to highlight recent developments in the management of surgical parathyroid disease, including the use of localization imaging studies for detection of hyperfunctional parathyroid tissue, as well as the use of a rapid intraoperative determination of serum parathyroid hormone levels. The discussion format will feature a series of case vignettes dealing with a number of surgical parathyroid disorders including primary hyperparathyroidism and the hyperparathyroidism associated with multiple endocrine neoplasia and renal failure. A cost-effective diagnostic and therapeutic algorithm will be offered. The course participant will have a greater understanding of parathyroidology as it relates to preoperative assessment and surgical decision making. In addition, head and neck physicians attending the course will be able to provide comprehensive care to patients with surgical disease of the parathyroid glands using an interdisciplinary head and neck endocrine clinic.

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COURSE 1741-2 Two-Period Course ($40)

Room MAR-Nob Hill D 3:00-5:15

The Management of Hemangiomas and Vascular Malformations of the Head and Neck Milton Waner MD; James Y Suen MD; Stanley M Shapshay MD Little Rock, AR; Little Rock, AR; Boston, MA

Educational Objectives: I. Appropriately classify hemangiomas and vascular malformations. 2. Determine appropriate surgical interventions and laser therapies of these lesions.

The major obstacle to our understanding and management of vascular lesions has been nomenclature. The array of histologic and descriptive terms currently found in most texts lends little, if any, insight into their etiology, natural history, and management. A recently proposed biologic classification based on their clinical behavior and cellular kinetics recognizes two distinct groups of vascular lesions, hemangiomas and vascular malformations. Hemangiomas refer to specific groups of pediatric tumors that present at or soon after birth. These lesions proliferate within the first year of life and involute over a variable period. Vascular malformations on the other hand, are always present at birth although they may not be clinically obvious. Furthermore, they grow in proportion to the child and never involute. Recent developments in laser technology have enabled us to develop new guidelines for the management of these conditions. Using these devices in conjunction with conventional surgical techniques, we have successfully treated a wide variety of these lesions. Details of the classification and natural history of these lesions will be presented, followed by a brief description of the surgical indications and the techniques in which these lasers are used, both alone and in conjunction with conventional surgical dissection will also be presented.

COURSE 1742-2 Room MAR-Golden Gate Hall A3 Two-Period Course ($40) 3:00-5:15 Surgical Treatment of Pediatric Airway Lesions Robin T Cotton MD Cincinnati, OH

Educational Objective: Diagnose and treat pediatric airway lesions. During the past 3 decades, improvements in medical technology, anesthesia, and surgical techniques have resulted in the ability to treat certain pediatric airway lesions endoscopically. Other conditions, however, are still best managed by open surgical techniques. This presentation discusses both endoscopic and open surgical treatment of airway lesions in children. After introductory remarks on diagnosis, treatment of a wide variety of congenital and acquired supraglottic,

glottic, subglottic, and tracheal abnormalities is presented. Indications, surgical techniques, complications, and outcomes are presented. The material contained in this course has been acquired over many years of experience with pediatric airway diseases and will provide the audience with a fund of knowledge that should help in the diagnosis and planning for treatment.

COURSE 1743-2 Room MAR-Golden Gate Hall A1 Two-Period Course ($40) 3:00-5:15 Surgery of the Skull Base for Head and Neck Neoplasm Paul J Donald MD; Bernard M Lyons FRACS; Joao J Maniglia MD Sacramento, CA; Melbourne, Australia; Curitiba PR, Brazil

Educational Objectives: 1. Understand the relationship of deep facial structures to the cranial base and the pertinent intracranial anatomy. 2. Perform the comprehensive workup required by skull base surgery patients. 3. Acquire a working knowledge of the basic skull procedures in the anterior, middle, and posterior cranial fossa. Surgery of the skull base is one of the most rapidly advancing areas of endeavor in both head and neck and neurologic surgery. Tumors, especially malignancies involving the cranial base, have heretofore been considered to be hopelessly inoperable or to carry at best a very poor prognosis. Modem techniques of surgery in this area now carry a 45% or 65% 2-year and longer survival rate. The course includes the anatomy, presentation, preoperative diagnostic work-up, surgery, and management of complications of both benign and malignant cranial base neoplasms. The surgery covers the various head and neck and neurosurgical approaches to the anterior, middle, posterior, midline, and far lateral areas. Concentration will be on internal carotid evaluation and management; surgery of the cavernous sinus, sphenoid sinus, and clivus; and reconstruction of the surgical defects of the skull base. Survival figures and complication rates are given.

COURSE 1744-2 Room MAR-Golden Gate Hall A2 Two-Period Course ($40) 3:00-5:15 Acupuncture and Alternative Medicine in Otolaryngology Jack J Wazen MD; Benjamin F Asher MD New York, NY; Montpelier, VT

Educational Objectives: 1. Understand the history and principles of acupuncture and other alternative medicine disciplines. 2. Identify certain conditions amenable to such therapy.

It is estimated that 22 million Americans have sought the care of an alternative medical practitioner. Alterna-

Otolaryngology Head and Neck Surgery Volume 116 Number5

InstructionCourses-- Sunday

tive medicine has not only captured the attention of the American public but also the medical community. Approximately 40 medical schools in this country are now offering courses on alternative medicine, and universities and major medical centers throughout the country are opening alternative therapy medical clinics. Insurers are being required to pay for alternative medical treatments in some states. The purpose of this course is to review the different "alternative medicine" methods available to our patients, including acupuncture, biofeedback, herbal medicine, aroma therapy, and others. By educating ourselves about these methods, we may be able to better advise our patients about their effectiveness or lack of effectiveness under different circumstances. A video presentation of acupuncture, biofeedback, and other techniques is also presented.

COURSE 1802-1 One-Period Course ($20)

Room MOS-102 4:15-5:15

Pharyngeal Space Tumors: A Clinical and Radiological Guide Jonas T Johnson MD; Jane L Weissman MD Pittsburgh, PA

Educational Objectives: 1. Identify normal imaging landmarks of the parapharyngeal space. 2. Indicate a variety of surgical approaches to removing these tumors. The patient with a parapharyngeal space mass presents a diagnostic and therapeutic dilemma. The precise location of the mass determines the differential diagnosis. Prestyloid parapharyngeal space masses are almost always of salivary origin. Poststyloid parapharyngeal space masses arise from the carotid neurovascular bundle, and most are glomus tumors and neurilemmomas. The location (and histology) of the tumor determine the surgical approach and influence preoperative patient counseling. MR and CT studies readily distinguish between prestyloid and poststyloid parapharyngeal space masses. These studies also identify clinical "mimics," masses arising from adjacent spaces (masticator space or tonsillar pillar). Familiarity with basic imaging anatomy is the key to this valuable information. The course will present clinical examples (including physical examinations), discuss accompanying CT or MR findings in detail, and describe surgical technique. The course will emphasize collaboration between surgeon and radiologist to arrive at a management plan for challenging tumors of the parapharyngeal spaces and adjacent structures.

COURSE 1805-1 One-Period Course ($20)

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Room MOS-105 4:15-5:15

Management of Cancer of the Supraglottic Larynx Eugene N Myers MD Pittsburgh, PA Educational Objectives: 1. Understand the etiology and diag-

nostic and staging systems used in the treatment of patients with cancer of the supraglottic larynx. 2. Understand the medical and surgical techniques used in the management of this disease, together with the risks and benefits. Cancer of the supraglottic larynx is usually discovered in more advanced stages of the disease and is best managed surgically. Conservation surgery in the form of supraglottic laryngectomy can be applied, in many cases achieving local control no different than in patients treated with total laryngectomy. A high degree of sophistication in patient selection is required not only with respect to management of the primary tumor but also in considering the management of regional lymph node metastasis and the patient's physiologic condition. The objectives of this course will be to emphasize the history and physical examination, the use of diagnostic imaging, and the importance of precise staging in selecting a management program for these patients. Another objective is to have the audience understand the surgical technique involved in supraglottic laryngectomy. Of particular importance is the management of the neck in supraglottic cancer. I will present data on what we believe is the appropriate management of the neck based on outcome studies done in our department. Emphasis will also be placed on rehabilitation of the patient's swallowing following supraglottic laryngectomy. Also discussed will be the use of adjunctive therapy following surgery. The course is designed to help otolaryngology-head and neck surgeons in the management of cancer of the supraglottic larynx in order to maximize the therapeutic effect of this program and enhance the survival and quality of life in this patient population.

COURSE 1807-1 One-Period Course ($20)

Room MOS-200 4:15-5:15

Allergic Fungal Sinusitis: A Medical and Surgical Disease Richard L Mabry MD; Bradley F Marple MD Dallas, TX Educational Objectives: 1. Accurately diagnose allergic fun-

gal sinusitis. 2. Be aware of the role of surgery, immunotherapy, and other modalities in the treatment of AFS. In little more than a decade, allergic fungal sinusitis has gone from a medical curiosity to one of the more perplexing problems to challenge the otorhino-

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laryngologist. It is now apparent that this disorder has an immunologic basis and that the symptoms are driven at least in part by the continued formation of allergic mucin within the involved sinuses. At The University of Texas Southwestern Medical Center we use the following approach. It is our opinion that each element of this regimen is extremely important. (1) Adequate preoperative evaluation and medical preparation (2) Appropriate surgery (3) Immunotherapy with relevant fungal and nonfungal antigens (4) Medical management including topical and systemic corticosteroids when necessary (5) Irrigation and self-cleansing by the patient (6) Close clinical follow-up with endoscopically guided debridement when necessary The course will cover in detail our approach to the management of patients with this challenging disorder.

cade, new knowledge gained in the field of growth factors has grown immensely. The potential of therapeutically utilizing growth factors in wound healing and otolaryngology is tremendous. Presently, these signal proteins are rapidly assuming a prominent role in clinical research and in clinical medicine. This course will provide an overview of the most studied factors: fibroblast growth factors (FGF), transforming growth factors (TGF), epidermal growth factor (EGF), platelet-derived growth factor (PDGF), and bone morphogenic proteins (BMPs). Particular emphasis will be placed on how they relate to soft tissue and bony wound healing. Their possible therapeutic potential in wound healing will also be discussed.

COURSE 1810-1 One-Period Course ($20)

Collin S Karmody MD; Lucinda A Halstead MD Boston, MA; Charleston, SC

Room MOS-220 4:15-5:15

Mandibular Fractures: Putting Principles into Practice William D Clark MD DDS; John M Morehead MD San Antonio, TX; Lackland AFB, TX

Educational Objectives: 1. Determine the appropriate tech-

niques to treat a variety of mandible fractures. 2. Access the special circumstances of the patient with a mandibular fracture and modify treatment accordingly. Decision making when treating mandibular fractures has become complex in recent years. The maxillofacial surgeon must choose from among several options to treat these fractures and should consider the special circumstances of each patient. Each modality of treatment will be addressed, with emphasis on the application of sound principles rather than on the details of operative technique. Adjunctive measures such as splinting and supported maxillomandibular fixation will also be discussed.

COURSE 1811-1 One-Period Course ($20)

Room MOS-222 4:15-5:15

Growth Factors in Wound Healing: An Overview David B Horn MD; Peter D Costantino MD Minneapolis, MN; New York, NY

Educational Objectives: 1. Better understand the current knowledge of polypeptide growth factors. 2. Gain insight into the future therapeutic potential of growth factors. This course is an introduction to the emerging science of growth factors in wound healing. During the past de-

COURSE 1812-I One-Period Course ($20)

Room MOS-224 4:15-5:15

Surgical Management of Congenital Anomalies of the Neck

Educational Objectives: 1. Grasp the fundamentals of the

embryology of the neck and recognize and understand the clinical presentation of the associated anomalies. 2. Formulate a practical approach to the management of anomalies of the neck based on the appropriate diagnostic maneuvers and using safe, efficient surgical techniques. Congenital anomalies of the components of the head and neck are surprisingly common. Nevertheless, they may be considerably difficult to diagnose, and management can be problematic even to the experienced surgeon. The nuances in diagnosis of the more common anomalies will be presented and discussed. The practical points of surgical management are emphasized. Particular attention is given to the surgical approach, intraoperative identification of important structures, potential intraoperative problems, and avoidance of complications. The course begins with a short but practical outline of the embryology of the neck. The surgical management of the anomalies are then discussed by tissue layers, and the bronchial apparatus is discussed in detail. The material is extensively illustrated with clinical photographs, intraoperative photographs, diagnostic imaging studies, and schemas of the anatomy, embryology, and surgical techniques. The material is from the Center for Birth Defects at Boston's Floating Hospital for Children and the pediatric otolaryngologic practice of the Medical University of South Carolina.

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COURSE 1813-1 One-Period Course ($20)

Room MOS-226 4:15-5:15

Free Oxygen Radical Biology and Otolaryngologic Disorders Michael D Seidman MD FACS; Leonard P Rybak MD West Bloomfield, MI; Springfield, IL

Educational Objectives: 1. Understand the involvement offree oxygen radicals (FOR) in otolaryngology, including noiseinduced hearing loss, cis-platin ototoxicity, presbycusis, myocutaneous free flaps, neural injury, and aging. 2. Develop a potential intervention for the damaging effects of FOR in relation to otolaryngologic disorders.

Free oxygen radicals (FOR) are continuously formed in the body through a series of normal biochemical and physiological processes. A primary mechanism for the formation of FOR is cellular respiration. Furthermore, ionizing radiation, environmental contaminants, and ischemia followed by reperfusion add to the barrage of FOR that attack living systems each second. FOR are molecules that contain an odd number of electrons, thereby making them chemically reactive. They are implicated in all processes of ischemia-induced damage, that is, myocardial infarction and cerebrovascular accident. More recently we have demonstrated their deleterious effects in sudden hearing loss, noise-induced hearing loss, cis-platin ototoxicity, and presbycusis. They are also involved in free flap failure, neural injury, and ultimately the aging processes. We have successfully intervened with FOR scavengers, blockers, and lazaroids to attenuate the damage caused by these radicals. This course will address the mechanisms of FOR biochemistry, tissue injury, and potential medicinal interventions that may attenuate damage associated with these highly destructive molecules.

COURSE 1814-1 One-Period Course ($20)

Room MOS-228/230 4:15-5:15

Endoscopic Dacryocystorhinostomies Manuel S Bernal-Sprekelsen MD; Manuel D TomasBarberan MD Palma de Mailorc, Spain; Madrid, Spain

Educational Objectives: 1. Know about the anatomic sites, localize the lacrimal sac, perform lacrimal probing, use the correct preoperative testings, and make correct indication for surgery. 2. How to perform endoscopically the exposition of the lacrimal sac and its opening. 3. How tofollow-up patients who have undergone surgery.

Endonasal dacryocystorhinostomy (DCR) is less aggressive than any external approach and it is becoming popular among ENT surgeons. This course pretends to

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offer a survey of the indications and a thorough description of the surgical procedure, its complications, and the steps of the follow-up, based on the experience of more than 370 cases. Slides and videos will demonstrate the surgical technique. The following items will be presented and discussed: 1. Anatomy: how to find the lacrimal sac endoscopically, based on anatomical references 2. The tests that are preoperatively the most useful to confirm a sacal or a postsacal problem 3. Minimal instrumentation; handling of forceps and burrs; how to expose the sac (visual support) 4. Dilatation of the canaliculi; how to use the lacrimal probes; how to avoid via falsa and endoscopic disorientation; annular catheterization and its importance 5. Complications and their management 6. The importance of close postoperative care: aspirations, preventions of synechiae, control and when to remove the annular probe In more than 85% epiphora disappears, and it improves in another 10%.

COURSE 1815-1 One-Period Course ($20)

Room MOS-232/234 4:15-5:15

Tracheotomy: Surgical and Percutaneous Pavel Dulguerov MD; Claudine Gysin MD Geneva, Switzerland

Educational Objectives: I. Perform a percutaneous tracheotomy and be familiar with its problems and their solution. 2. Improve their skills in traditional surgical tracheotomy.

Classical surgical tracheotomy has been a gold standard since its formal standardization by C. Jackson at the beginning of the century. Nevertheless, numerous reports issued from departments other than otolaryngology and published within the last 30 years have described a high rate of complications; this has prompted the development of alternative surgical techniques such as percutaneous tracheotomy. An extensive critical review of publications on the complication rates of surgical tracheotomy published during the past 30 years will be presented. While serious complications such as hemorrhage, pneumothorax, desaturation, or tube malposition have been commented on extensively, emphasis will be placed on means to prevent less serious but more frequent problems. Small incisions and minimal tissue dissection tend to decrease postoperative bleeding and local infections. Bjork-type tracheotomy allows securing of the anterior tracheal wall to the skin and decreases false passages and tube malposition. Similarly, all publications on percutaneous tracheotomy are reviewed and the complications rates are compared with surgical tracheotomy. This permits an objec-

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tive answer to the claims of the percutaneous technique literature. The surgical technique of the different percutaneous tracheotomy sets will be demonstrated and the pitfalls of this operation discussed. Specific practical advice for initiating use of this technique will be given.

COURSE 1816-I One-Period Course ($20)

Room MOS-236 4:15-5:15

Rhinogenic Headache: Its Endoscopic Diagnosis and Treatment Allen M Seiden MD; James M Chow MD Cincinnati, OH; M a y w o o d , IL

Educational Objectives: 1. Discuss appropriate diagnostic evaluation in patients with chronic headache. 2. Discuss nasal and sinus pathology that may be associated with chronic headache. Traditional teaching holds that headache pain is an uncommon symptom of chronic sinusitis. However, as we learn more about the pathophysiology of sinus inflammation, we have learned that pressure headaches and atypical facial pain in fact are frequent manifestations of chronic nasal and sinus disease, sometimes in the absence of associated congestion and drainage. This makes diagnosis potentially quite difficult. Patients with chronic headaches often are mislabeled as migraine sufferers and therefore undergo a variety of inappropriate therapies. The otolaryngologist is frequently called on to rule out underlying sinus disease as a potential etiologic factor. This course will discuss the endoscopic examination of these patients, emphasizing those findings that can be associated with pain symptoms. The pathophysiology of rhinogenic and sinogenic pain will be discussed, as well as appropriate avenues of therapy. Case examples covering diagnosis, therapy, and appropriate follow-up will be presented.

COURSE 1817-1 One-Period Course ($20)

Room MOS-238 4:15-5:15

Modified Radical Mastoidectomy: Problems and Pitfalls John F Kveton MD; Myles L Pensak MD New Haven, CT; Cincinnati, OH

Educational Objectives: I. Recognize the common causes of failure of canal wall down mastoidectomy. 2. Develop a systematic approach for successful modified radical mastoidectomy. Successful modified radical mastoidectomy requires strict adherence to bony and soft tissue surgical techniques. A thorough understanding of temporal bone anatomy is critical to the development of a successful method of surgical dissection of the temporal bone. Re-

current drainage most commonly occurs through deficient surgical technique involving the epitympanum, sinodural angle, facial recess and facial ridge, perilabyrinthine region, and mastoid tip. Poor development of the bony transition between the external auditory canal and the tegmen tympani superiorly and the mastoid tip inferiorly often results in debris accumulation and recurrent superficial infection. Inappropriate management of ossicular chain remnants during tympanoplasty often results in retraction pocket formation. Deficient soft tissue technique leads to inadequate meatoplasty, which prevents proper aeration of the mastoid defect and allows for collection of debris medial to the meatus. These major pitfalls of modified radical mastoid surgery will be discussed through focused, serial highlights of videotape case studies. The authors will summarize by providing a systematic approach to modified radical mastoidectomy that can be used routinely to obtain a lasting dry ear.

COURSE 1818-1 One-Period Course ($20)

Room MOS-250 4:15-5:15

Telescopic Laryngeal and Pharyngeal Surgery William J Richtsmeier MD PhD; Richard L Scher MD Durham, NC

Educational Objectives: 1. Understand the principles underlying the techniques of telescopic laryngeal and pharyngeal surgery, for a variety of conditions of the larynx and pharynx. 2. Understand the indications for it and advantages of this technique compared with traditional microscopic-based microsurgery of the larynx and pharynx and the limitations of these procedures. This course will present new techniques based on the experience of the senior instructor and co-instructor. Microscopic surgery of the hypopharynx and larynx followed invention of suspension laryngoscopy and introduction of the operating microscope, which provided magnification, enhanced illumination, and an environment for surgical intervention. Our familiarity with endoscopic sinus surgery with angled telescopes, particularly in the frontal sinus recess and maxillary sinus, encouraged us to extend these instruments to interventional procedures in the larynx and pharynx. These instruments provide perspective that in many cases cannot be achieved with the operating microscope. We have extended these techniques to procedures not exclusively performed with telescopes but we believe that the telescopic visualization and perspective significantly adds to the otolaryngologist's interventional armamentarium. Techniques described will include standard excision and laser excision of lesions of the larynx and pharynx, laryngeal cordotomy, laryngeal ventriculotomy, pharyngotomy (and closure), and endoscopic staple-assisted esophagodiverticulostomy for Zenker's

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diverticulum. Numerous instruments developed for endoscopic procedures in other areas of the body can be directly adapted to surgery of the pharynx and larynx, including hemostatic devices, angled lasers, and instruments. Current limitations include necessity for the surgeon to hold the telescope with one hand, the threedimensional view of the operating microscope being superior to the telescope if it is in a fixed position, and the necessity for a video support. Our management of these limitations will be discussed. We believe that the advantages of telescopic surgery, including excision, performed perpendicular to the laryngeal or pharyngeal wall can initiate an enthusiasm for a variety of endoscopic extrapolative and reconstructive procedures.

COURSE 1820-I One-Period Course ($20)

Room MOS-262 4:15-5:15

Hair Replacement: More Than Just Plugs Daniel E Rousso MD Birmingham, AL Educational Objectives: 1. Identify appropriate candidates for

surgical hair replacement. 2. Understandmultiple techniques for hair replacement and their appropriate use in various different patterns of hair loss.

Since the introduction of hair transplantation more than 50 years ago, there has been a virtual explosion in the number of different procedures used in hair replacement surgery. There are standard grafts, minigrafts, micrografts, scalp reductions, flaps, tissue expanders, scalp extenders, and extensive scalp-lifting operations. For the physician interested in performing this type of surgery, it can often be confusing to decide which procedures to use and when to use them. This course is designed to familiarize the practicing otolaryngologist with the various types of hair loss and to describe and illustrate the different techniques used in hair replacement surgery. Emphasis will be placed on candidate selection, hairline placement, and coordination of various procedures. Detailed intraoperative illustrations, "how to" tips, and patient results will be demonstrated for each of the various methods presently used. Particular attention will be placed on some of the newer techniques, including micrographs, minigraphs, scalp extenders and flaps.

COURSE 1821-1 One-Period Course ($20)

Room MOS-270 4:15-5:15

Improving Exposure in Tympanoplasty and Middle Ear Surgery Raleigh O Jones Jr MD; Herbert Silverstein MD Lexington, KY; Sarasota, FL Educational Objectives: 1. Describe various techniques used

to improve exposure in tympanoplasty. 2. Apply variety of exposure techniques to appropriate disease entities.

Exposure of the middle ear is critical for successful middle ear surgery. Inadequate exposure may lead to incomplete removal of disease, improper placement of graft, difficulty in ossicular chain reconstruction, and failure of the procedure. A technique of enlarging the external canal circumferentially allows exposure of the attic, eustachian tube orifice, hypotympanum, and sinus tympani via the external canal while preserving the posterior canal wall. This technique is useful in chronic ear surgery, glomus tumor removal, singular neurectomy, transcanal labyrinthectomy, and transcanal VIII nerve section. Surgical video tapes, slides, and temporal bone dissection photographs will accompany the didactive presentation.

COURSE 1822-1 One-Period Course ($20)

Room MOS-272 4:15-5:15

Education of Hearing Impaired Children: Methods and Controversies H Alexander Arts MD; Teresa Zwolan PhD Ann Arbor, MI Educational Objectives: 1. Provide an understanding of the

various schools of thought regarding the education of severely hearing impaired children and the controversies surrounding them. 2. Provide an understanding of how the various methods of hearing impaired education affect the performance of children with cochlear implants.

The importance of early intervention for prelingually deaf children has recently received considerable attention, largely because of technological advances in the diagnosis (i.e., otoacoustic emissions) and rehabilitation (i.e., cochlear implants) of severe to profound hearing impairment. Cochlear implants have clearly been extremely beneficial for many of these children. The child's educational environment, however, remains critical to the development of speech and language skills, as well as academic skills, even in children with implants. For years, heated controversy has persisted regarding the ideal mode of communication and education of profoundly hearing impaired children (auditory-oral, manual, total communication, cued speech, etc.). The

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controversies are not close to being resolved, and little objective data are available. Typically these decisions are based largely on. clinician bias, parental preference, and program availability. On the other hand, the choice of communication mode and the child's educational environment clearly has a major impact on the remainder of their lives, not only affecting their academic and communication skills, but to a certain extent determining their cultural identify. In children with implants, there is mounting evidence that the educational methods employed have a profound effect on implant performance. In spite of the obvious importance of these educational issues on the hearing-impaired child's ultimate quality of life, little attention has been given to them in otolaryngologic training. The otolaryngologist typically plays a central role in the identification and management of hearing-impaired children and should have a basic understanding of these issues. In this course we will present a brief review of the theories and controversies in the field of education of profoundly hearing impaired children. Special emphasis will be placed on how these issues affect the performance of children with cochlear implants and how otolaryngologists can assist families in finding an appropriate educational environment for their child. Our experience with more than 160 children with implants will be reviewed.

COURSE 1823-I One-Period Course ($20)

Room MOS-274 4:15-5:15

COURSE 1824-1 One-Period Course ($20)

Room MOS-276 4:15-5:15

Fine-Needle Aspiration: Technique and Pearls for the Otolaryngologist C Ron Cannon MD; Doug Richardson MD Jackson, MS

Educational Objectives: 1. Know the background and use of

fine-needle aspiration biopsy as a diagnostic adjunct in the practice of head and neck surgery. 2. Understand methods of improving cellular yield and adequately preparing slides for cytologic study.

Fine-needle aspiration biopsy (FNA) has become a widely accepted procedure in the diagnosis of neoplasms and inflammatory conditions of the head and neck. FNA is easily performed in the office or outpatient setting, is minimally invasive, and is associated with few complications. Although the procedure is simple, various technical considerations influence the diagnostic yield of FNA. The simple equipment required for FNA is described, along with a new technique for enhancing cellular yield in aspirating smaller lesions. The importance of adequate slide preparation is emphasized, and easily mastered procedures for making smears that are optimal for interpretation are detailed. Clinical correlation of cytologic resuits and close cooperation with the pathologist are emphasized. Personal techniques and "pearls" for enhanced clinical usefulness of the procedure are shared with the course participant.

Reconstruction of the Lip Gregory J Renner MD; Robert P Zitsch MD C o l u m b i a , MO

Educational Objectives: 1. More properly choose from among

a variety of reconstructive techniques. 2. Have a greater understanding of the advantages and consequences of various methods of lip reconstruction.

The lips together are a well-defined facial structure that have important motor, sensory, and cosmetic functions. A remarkable number of flap designs have been described dealing with reconstruction of lip tissue. In most situations reconstruction is best done with tissue from within the anatomic lip unit. With larger defects it becomes more necessary that graft or flap tissue is brought in to the lip unit from adjacent or distant sites. This course will involve detailed discussion of the principle methods of lip reconstruction. It will also present a variety of special situations. The course will include a mix of didactic presentation and audience participation. In the end, the participant should be capable of determining a logical progression of lip reconstruction with an understanding of the functional and cosmetic results of each.

COURSE 1827-I One-Period Course ($20)

Room MOS-302 4:15-5:15

Branchial Cleft (Pharyngeal Pouch) Remnants: Evaluation and Surgical Management Harvey M Tucker MD; James E Arnold MD Cleveland, OH

Educational Objectives: 1. Correctly evaluate and diagnose

congenital neck masses in children and young adults. 2. Predict the anatomic relationships of any branchial cleft remnant and thus carry out surgical removal of such lesions without damage to adjacent structures.

Branchial cleft (pharyngeal pouch) remnants continue to challenge the diagnostic and surgical capabilities of otolaryngologists. Although the majority of masses in the head and neck among children and young adults are of inflammatory origin, congenital remnants are not uncommon and may not become symptomatic until relatively late in life. Too frequently a branchial cleft remnant is presumed to be a neck abscess for some time before the correct diagnosis is suspected. The developmental anatomy of branchial cleft rein-

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Volume116 Number5

nants is quite well understood, and this knowledge will permit otolaryngologists to predict the important anatomic relationships of any such mass to major neurologic and/or vascular structures. Such an understanding encourages accurate diagnosis and is most important in preventing complications and ensuring complete surgical removal of these lesions. A step-by-step review of developmental anatomy of each type of remnant is presented. Several representative cases of 1st, 2nd, 3rd, and 4th branchial cleft remnants, as well as mediastinal "cysts" that are probably of branchial cleft origin, are demonstrated, including details of their surgical management.

COURSE 1830-I One-Period Course ($20)

R o o m MAR-Salon I/2 4:15-5:15

Revision of Pediatric Endoscopic Sinus Surgery Rodney P Lusk MD; David S Parsons MD; Harlan R Muntz M D Saint Louis, MO; Columbia, MO; Saint Louis, M O Educational Objectives: I. Identify the most frequent causes of

failure in pediatric endoscopic sinus surgery. 2. Understand the priniciples most important in preventing scarring and recurrent sinusitis. The basic techniques espoused by Messerklinger for functional endoscopic sinus (FES) surgery have been modified for use in children. Recent advances in instrumentation have further improved these techniques. This course will address the more difficult surgical procedures such as FES surgery in subperiosteal orbital abscess, extensive allergic sinusitis, and revision surgery. Special emphasis is placed on pediatric revision surgery and powered instrumentation. The techniques and maneuvers used to prevent surgical complications are presented. The causes of primary FES failure are discussed in detail by the instructors and illustrated through case presentations. Anatomical areas discussed in detail are the middle meatal antrostomy, frontal recess, and sphenoid sinus. The collective experience with complicated acute and revision endoscopic surgery in both adults and children is used as a basis to discuss surgical techniques and philosophy. Postoperative management in children is discussed in detail.

COURSE 1833-I One-Period Course ($20)

R o o m MAR-Salon 10/11 4:15-5:15

Videostrobolaryngoscopy Peak W o o M D N e w York, NY Educational Objectives: I. Provide an understanding of the

capabilities and limitations of stroboscopy examination of the larynx 2. Incorporate stroboscopy into clinical practice by appropriately selecting patients for examination, performing the basic examination, and dictating and reporting stroboscopy findings. Laryngostroboscopy is a valuable tool for examination of vocal fold vibratory function. It is an especially valuable evaluation tool in singers with voice complaints or dysphonic patients with no obvious lesions, and in assessment of laryngeal lesions that result in a pathologic voice. Practically, stroboscopy can be used in all phases of laryngology to assess the effectiveness of medical, surgical, and speech therapy treatment. This includes (1) diagnosis of small subcordal vocal fold lesions, (2) evaluation of vocal fold paralysis, (3) evaluation of laryngeal carcinoma as to depth of invasion, (4) assessment of mucosal hygiene, and (5) feedback on phonosurgical results. Although the stroboscopy examination is much like standard mirror examination, the examiner must set vocal tasks for the patient to standardize the examination. After the examination the stroboscopy video must be evaluated with a critical eye to judge mucosal vibratory function. The mucosal fold symmetry, edge, amplitude, wave, phase, and periodicity are rated as part of the report. This course is for the otolaryngologist who is incorporating stroboendoscopy into his or her practice. It will demonstrate a simplified protocol for assessment of vocal fold function. This will be followed by samples of interpretation. With the use of videotapes and slides, I will present case studies to demonstrate the various features that are altered with normal and abnormal vocal fold function. We will focus on pretreatment and posttreatment stroboscopy findings.

COURSE 1834-I One-Period Course ($20)

R o o m MAR-Salon 12 4:15-5:15

Glomus Tumors and Skull Base Surgery Derald E Brackmann MD; Antonio De la Cruz M D Los Angeles, C A Educational Objectives: 1. Order the proper evaluation for

patients presenting with vascular masses in the middle ear. 2. Know the proper management for glomus tumors of the temporal bone. Great strides have been made in the evaluation and surgical management of glomus tumors. High-resolu-

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tion computerized cranial tomography makes possible exact preoperative delineation of the extent of these tumors. Magnetic resonance imaging allows evaluation of the involvement of the internal carotid artery. With new surgical techniques, en bloc resection even of large tumors is possible. We will present all aspects of the diagnosis and management of glomus tumors. The importance of preoperative studies including computerized cranial tomography, magnetic resonance imaging, and arteriography will be discussed. The role of preoperative embolization will also be discussed. We will outline therapy on the basis of the classification of tumors as glomus tympanicum or glomus jugulare. Surgical techniques are described and illustrated by movies and slides. The indications for radiation therapy and the response one may expect will be given. The infratemporal fossa approach has revolutionized management of large glomus tumors and other tumors involving the skull base. We will describe and discuss the advantages of this new approach.

COURSE 1835-I One-Period Course ($20)

Room MAR-Salon 13 4:15-5:15

ABR in the MRI Era: An Introduction Douglas L Beck MA F-AAA; Eric W Sargent MD Manchester, MO; Saint Louis, MO

Educational Objectives: I. Understand the principles associated with hearing loss detection and estimation with ABR. 2. Understand the role of ABR in detecting retrocochlear pathology.

Auditory brainstem response (ABR) testing is an important tool in the assessment of the auditory system. ABR serves two essential functions: 1. To study patients with suspected retrocochlear hearing loss 2. To estimate auditory thresholds During this course, the physiology of ABR will be discussed. Pitfalls in testing will be analyzed, and practitioners will learn how to determine whether a test has been done properly. The clinical roles of ABR will be elaborated on. A rational approach to evaluating a possible retrocochlear disorder (such as acoustic neuroma or multiple sclerosis) with ABR will be discussed. Handouts will be distributed and a question-and-answer period provided.

COURSE 1836-I One-Period Course ($20)

Room MAR-Salon 14 4:15-5:15

Management of Suppurative Complications of Otitis Media Edgar L Chiossone MD; Simon I Angeli MD; Juan A Chiossone BA Boca Raton, FL; Caracas, Venezuela; Caracas, Venezuela

Educational Objectives: 1. Recognize the different presentations of intratemporal and intracranial complications of otitis media. 2. Develop a practical approach for the management of these complications.

The incidence of suppurative complication of otitis media has decreased in industrialized nations as primary health care improves. This has prevented many physicians from gathering enough experience in the various and serious presentations of complicated otitis media. In developing countries, however, the opposite is true. We will present our experience with the diagnosis and management of complicated otitis media based on our work at the largest tertiary health care center and a major children's hospital in Venezuela. The different clinical entities will be individually considered (mastoiditis, petrositis, facial palsy, labyrinthitis, neck abscess, meningitis, extradural abscess, lateral sinus thrombophlebitis, otitic hydrocephalus, and brain abscess). Graphic materials and real-case presentation s will illustrate the discussion. Emphasis will be placed on helping course attendants develop a practical approach to early diagnosis and a cost-efficient use of diagnostic modalities, and on prompt institution of medical and surgical treatments.

COURSE 1837-1 One-Period Course ($20)

Room MAR-Salon 15 4:15-5:15

Dexamethasone, Streptomycin, and Lidocaine Perfusion for Meniere's Disease John J Shea Jr MD; Michael J Ruckenstein MD Memphis, TN

Educational Objectives: l. Understand the natural history, of Meniere's disease and how to make the diagnosis. 2. Understand when to do dexamethasone, streptomycin, or lidocaine perfusion to control Meniere's disease.

In many patients with Meniere's disease, there is an immune-mediated trigger. The immune basis for Meniere's disease will be explained, together with the audiologic, vestibular, and immunologic tests to make the diagnosis.

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By perfusing the inner ear through the round window with dexamethasone dissolved in hyaluronan, it is possible to stop the dizzy spells, reduce the fullness and low-frequency tinnitus in most patients, and improve the hearing in about a third. The risk of further hearing loss is very small. In those patients who continue to have dizzy spells after dexamethasone perfusion, it is possible to stop the dizzy spells in most with combined low-concentration streptomycin and dexamethasone perfusion, but the risk of further heating loss is greater. In those patients in whom tinnitus is a major complaint, combined lidocaine dexamethasone perfusion will usually relieve the tinnitus. Dexamethasone, streptomycin, and lidocaine perfusion through the round window are the first treatment of choice in Meniere's disease.

COURSE 1838-1 One-Period Course ($20)

Room MAR-Nob Hill A 4:15-5:15

Cochlear Implantation in Children: The European Way Thomas H Lenarz MD PhD; Gerard M O'Donoghue FRCS; Alain Uziel MD PhD Hanover, Germany; N o t t i n g h a m , England (UK); Montpellier, France Educational Objectives: Better understand selection criteria,

the place of electrophysiological testing before, during, and after surgery, and factors influencing the outcome.

Three major European pediatric cochlear implant centers will present their experience of managing over 800 children. The course will concentrate on four major issues. 1. Selection criteria: Audiological assessment including marginal hearing aid users, speech and language abilities, and educational and psychosocial considerations. 2. Electrophysiological testing: Transtympanic EABR, intraoperative testing (electrically evoked CAP, EABR, stapedius testing, integrity testing), and telemetry. 3. Educational issues: Educational setting, mode of communication and rehabilitation. 4. Predictive outcome factors: The main determinants of outcome will be analyzed, including duration of deafness, age at implantation, etiology, mode of communication (auditory, oral sign, total) and educational placement.

COURSE 1839-1 One-Period Course ($20)

Room MAR-Nob Hill B 4:15-5:15

Nasal and Sinus Neoplasms: Surgical Management Decisions J David Osguthorpe MD; Robert A Weisman MD Charleston, SC; San Diego, CA Educational Objectives: 1. Appropriately and cost effectively

evaluate paranasal sinus neoplasms and to understand the options in treatment. 2. Conceptualize the options in tumor extirpations and defect reconstructions and select among them for a particular tumor and patient situation.

A cost-effective evaluation and preoperative preparation of patients with paranasal neoplasms is presented, including the indications for computed tomography, magnetic resonance imaging, and arteriography with or without balloon occlusion or embolization. Our approach to selecting the optimal therapy(ies), from surgery to irradiation or chemotherapy, is explained. The main thrust of the course is the many options in surgical approaches that afford in toto extirpation yet preserve form and function when oncologically sound. Endoscopic resection of nasal wall lesions; midfacial degloving access to the paramedian nasal region; lateral rhinotomy for full maxillary, nasal vault, and orbital access; mandibular and/or lateral facial splits for pterygomaxillary, nasopharyngeal, or sphenoid tumor extensions; and bifrontal or pterional craniotomy for skull base encroachments will be detailed. Options in reconstruction from regional or free flaps to osseointegrated prostheses are briefly presented.

COURSE 1840-1 One-Period Course ($20)

Room MAR-Nob Hill C 4:15-5:15

Management of Hemangiomas and Angiofibromas William R Panje MD Chicago, IL Educational Objectives: 1. Better understand how to differen-

tiate the various types of vascular neoplasms and identify those that will need subsequent treatment. 2. Gain insight into what is currently available for the treatment of head and neck hemangiomas.

Vascular tumors of the head and neck present unique considerations in diagnosis and management. Frequently hemangioma in the pediatric age group will undergo spontaneous regression; however, some of these benign tumors can become "malignant" by their location. The CNS invasion, airway compromise, and bleeding frequently require aggressive surgical intervention. The use of hormones, pressure, irradiation, and embolization have been advocated as alternate ways in managing these vascular tumors. Recurrences, failure to spontaneously involute, and local infiltrative characteristics are more a

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reflection of (1) anatomic site, (2) size and extent of lesion, and (3) selection of the primary treatment. The purpose of this course is to present state-of-the-art methods in the differential diagnosis and selection of subsequent treatment for head and neck hemangiomas. This

course will present rational, current techniques and resuits in managing juvenile angiofibroma, cavernous hemangioma, mixed hemangiomas, capillary hemangiomas, reparative granulomas and malignant tumors of the head and neck.

American Academy of Otolaryngology-- Head and Neck Surgery Foundation, Inc. Using only a phone, you can automatically request your information and receive it in an instant over your own fax machine. Pre-meeting automated fax-on-demand service

Call toll-free 1-888-292-2703 To obtain additional registration forms, simply dial 1-888-2922703 and punch in the code numbers of the information you want. For international calls, please call 1-573-402 - 1374 (long distance charges will apply).

101st Annual Meeting: September 7-10 San Francisco, CA , Meeting Housing/Transportation Information • Registration and Instruction • Instruction Course Listing Sunday, September 7 and Monday, September 8 • Instruction Course Listing Tuesday, September 9 and Wednesday, September 10 • Scientific Program Overview • Spouse/Guest Tour Registration Information

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2nd US/UK Joint Otolaryngology Meeting: July 23-26, 1997 Boston, MA • Meeting Housing/Transportation Information • Registration Form

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2nd Conjoint Symposium: Aesthetic and Reconstructive Rhinoplasty: July 24-27 Boston, MA • Meeting Housing/TransportationInformation • RegistrationInformation

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