Ebook Cummings Otolaryngology Head and Neck Surgery PDF Full Chapter PDF

Cummings otolaryngology : head and
neck surgery - eBook PDF

Visit to download the full and correct content document:
https://ebooksecure.com/download/cummings-otolaryngology-head-and-neck-surgery
-ebook-pdf/
Cummings
Otolaryngology
Head and Neck Surgery Seventh Edition
Paul W. Flint, MD, FACS University of South Florida K. Thomas Robbins, MD

Professor and Chair Tampa, Florida; Professor Emeritus
Department of Otolaryngology– Adjunct Professor Division of Otolaryngology–
Head and Neck Surgery Department of Surgery Head and Neck Surgery
Oregon Health & Science University University of Auckland Faculty of Health Executive Director Emeritus
Portland, Oregon Sciences Simmons Cancer Institute at SIU
Auckland, New Zealand Simmons Endowed Chair of Excellence
Howard W. Francis, MD, MBA, in Oncology
FACS Marci M. Lesperance, MD
Southern Illinois University School
Richard Hall Chaney Sr. Professor and Chair Professor of Medicine
Department of Head and Neck Surgery Department of Otolaryngology– Springfield, Illinois
and Communication Sciences Head and Neck Surgery
Duke University School of Medicine Chief, Division of Pediatric Otolaryngology J. Regan Thomas, MD
Durham, North Carolina University of Michigan Health System Professor, Facial Plastic Surgery
Ann Arbor, Michigan Department of Otolaryngology–
Bruce H. Haughey, MBChB, MD, Head and Neck Surgery
FACS, FRACS Valerie J. Lund, CBE, MBBS, MS,
Northwestern University Feinberg School
Medical Director, Oncology
FRCS, FRCS(Ed), FACS(Hon)
of Medicine
Advent Health Celebration Professor Emeritus Chicago, Illinois
Otolaryngology Head and Neck Surgery Rhinology and Anterior Skull Base Surgery
Advent Health Medical Group University College London and Royal
Orlando, Florida; National Throat, Nose, and Ear Hospital
Collaborative Professor London, UCLH
Department of Otolaryngology– London, United Kingdom
Head and Neck Surgery
Morsani School of Medicine
1600 John F. Kennedy Blvd.
Ste. 1600
Philadelphia, PA 19103-2899
CUMMINGS OTOLARYNGOLOGY–HEAD AND NECK Standard Edition ISBN: 978-0-323-61179-4

SURGERY, SEVENTH EDITION International Edition ISBN: 978-0-323-61216-6
Copyright © 2021 by Elsevier Inc.
All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any
means, electronic or mechanical, including photocopying, recording, or any information storage and
retrieval system, without permission in writing from the publisher. Details on how to seek permission,
further information about the Publisher’s permissions policies, and our arrangements with organizations
such as the Copyright Clearance Center and the Copyright Licensing Agency can be found at our website:
www.elsevier.com/permissions. This book and the individual contributions contained in it are protected
under copyright by the Publisher (other than as may be noted herein).
Previous editions copyrighted 2015, 2010, 2005, 1998, 1993, 1986.
Notices
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical treatment
may become necessary. Practitioners and researchers must always rely on their own experience and
knowledge in evaluating and using any information, methods, compounds, or experiments described
herein. In using such information or methods they should be mindful of their own safety and the safety
of others, including parties for whom they have a professional responsibility. With respect to any drug
or pharmaceutical products identified, readers are advised to check the most current information
provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to
verify the recommended dose or formula, the method and duration of administration, and
contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge
of their patients, to make diagnoses, to determine dosages and the best treatment for each individual
patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the
Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to
persons or property as a matter of products liability, negligence or otherwise, or from any use or
operation of any methods, products, instructions, or ideas contained in the material herein.
The Publisher
Library of Congress Control Number: 2019942176
Content Strategist: Jessica McCool

Senior Content Development Specialist: Deidre Simpson
Publishing Services Manager: Catherine Jackson
Senior Project Manager: John Casey
Senior Book Designer: Amy Buxton
Printed in Canada
9 8 7 6 5 4 3 2 1
Contributors
Dunia Abdul-Aziz, MD Seth A. Akst, MD, MBA William B. Armstrong, MD

Instructor Anesthesiologist and Critical Care Professor and Chair
Department of Otolaryngology Physician Department of Otolaryngology–Head
Harvard Medical School TeamHealth Anesthesia and Neck Surgery
Massachusetts Eye and Ear Department of Anesthesiology University of California, Irvine
Boston, Massachusetts Sibley Memorial Hospital Irvine, California
Johns Hopkins Medicine
Waleed M. Abuzeid, MD Michelle G. Arnold, MD
Washington, DC
Clinical Instructor Staff Otolaryngologist
Department of Otolaryngology–Head W. Greer Albergotti, MD Naval Medical Center
and Neck Surgery Assistant Professor, Head and Neck San Diego, California
Stanford Sinus Center Surgery
Moises A. Arriaga, MD, MBA
Palo Alto, California Medical College of Georgia
Clinical Professor and Director of
Augusta University
Meredith E. Adams, MD, MS Otology and Neurotology
Augusta, Georgia
Associate Professor Department of Otolaryngology and
Department of Otolaryngology–Head Sheri L. Albers, DO, FAOCR Neurosurgery
and Neck Surgery Director Louisiana State University Health
University of Minnesota Radiology Research and Consultation Sciences Center
Minneapolis, Minnesota Sacramento, California Medical Director
CNC Hearing and Balance Center
Peter A. Adamson, OOnt, MD, FRCS(C), Clint T. Allen, MD
Culicchia Neurological Clinic
FACS Associate Professor
Medical Director
Professor, Division of Facial Plastic and Department of Otolaryngology–Head
Cochlear Implant Program
Reconstructive Surgery and Neck Surgery
Children’s Hospital
Department of Otolaryngology–Head Johns Hopkins University
New Orleans, Louisiana;
and Neck Surgery Baltimore, Maryland
Medical Director
University of Toronto Faculty of
Abdulmalik S. Alsaied, MD LSU–Our Lady of the Lake Hearing and
Medicine
Otolaryngologist Balance Center
Toronto, Ontario, Canada
Department of Otolaryngology–Head Our Lady of the Lake Regional Medical
Edem S. Agamah, MD, MS and Neck Surgery Center
Associate Professor of Clinical Medicine Medical College of Georgia Baton Rouge, Louisiana
Division of Hematology and Oncology Augusta University
H. Alexander Arts, MD, FASCS
Department of Internal Medicine Augusta, Georgia;
Professor
Southern Illinois School of Medicine King Fahd University Hospital
Departments of Otolaryngology and
Springfield, Illinois Khobar, Saudi Arabia
Neurosurgery
Yuri Agrawal, MD Mohamedkazim Alwani, MD University of Michigan School of
Associate Professor Resident Surgeon Medicine
Department of Otolaryngology–Head Department of Otolaryngology–Head Ann Arbor, Michigan
and Neck Surgery and Neck Surgery
Joan C. Arvedson, PhD
Johns Hopkins University School of Indiana University School of Medicine
Clinical Professor
Medicine Indianapolis, Indiana
Department of Pediatrics
Baltimore, Maryland
Jennifer Christy Alyono, MD Medical College of Wisconsin
Faisal I. Ahmad, MD Clinical Assistant Professor Program Coordinator, Feeding and
Fellow Department of Otolaryngology–Head Swallowing Services
Head and Neck Surgery and Neck Surgery Departments of Speech Pathology and
University of Texas MD Anderson Cancer Stanford University School of Medicine Audiology
Center Stanford, California Children’s Hospital of Wisconsin
Houston, Texas Milwaukee, Wisconsin
Carryn Anderson, MD
Mostafa M. Ahmed, MD Clinical Associate Professor Yasmine A. Ashram, MD
Assistant Professor Department of Radiation Oncology Professor
Carl R Darnall Army Medical Center University of Iowa Hospitals and Clinics Department of Physiology
Fort Hood, Texas Iowa City, Iowa Consultant, Intraoperative
Neurophysiologist
Faculty of Medicine
Alexandria, University
Alexandria, Egypt
v
vi Contributors
Nafi Aygun, MD Pete S. Batra, MD, FACS Mukul Bhattarai, MD, FACP
Associate Professor Stanton A. Friedberg MD Chair in Assistant Professor
Russel H. Morgan Department of Otolaryngology Department of Internal Medicine
Radiology Professor and Chairman Southern Illinois University
Johns Hopkins University School of Section Head, Rhinology, Sinus Surgery, Springfield, Illinois
Medicine and Skull Base Surgery
Benjamin S. Bleier, MD
Baltimore, Maryland Co-Director, Rush Center for Skull Base
Associate Professor
and Pituitary Surgery
Douglas D. Backous, MD, FACS Director of Otolaryngology Translational
Secretary, American Rhinologic Society
Medical Director Research
Department of Otorhinolaryngology–
Center for Hearing and Skull Base Director of Endoscopic Skull Base
Surgery Surgery
Rush University Medical Center
Swedish Neuroscience Institute Co-Director of Center for Thyroid
Chicago, Illinois
Swedish Medical Center Disease and Orbital Surgery
Seattle, Washington Beth M. Beadle, MD, PhD Department of Otolaryngology–Head
Associate Professor and Neck Surgery
Shan R. Baker, MD
Department of Radiation Oncology Harvard Medical School
Professor Emeritus
Stanford University Massachusetts Eye and Ear
Facial Plastic and Reconstructive Surgery
Stanford, California Boston, Massachusetts
Department of Otolaryngology–Head
and Neck Surgery Nicholas A. Beckmann, DO Nikolas H. Blevins, MD
University of Michigan Resident Larry and Sharon Malcolmson Professor
Ann Arbor, Michigan Department of Otolaryngology–Head Department of Otolaryngology–Head
Thomas J. Balkany, MD, FACS, FAAP
University of Tennessee Health Science Stanford University School of Medicine
Hotchkiss Professor and Chairman
Center Stanford, California
Emeritus
Memphis, Tennessee
Department of Otolaryngology Andrew Blitzer, MD, DDS
University of Miami Miller School of James R. Bekeny, MD Professor Emeritus of Otolaryngology–
Medicine Surgeon Head and Neck Surgery
President, Institute for Cochlear Implant Department of Otorhinolaryngology– Columbia University College of
Training Head and Neck Surgery Physicians and Surgeons
Miami, Florida Advent Health Adjunct Professor of Neurology
Celebration, Florida Icahn School of Medicine at Mt. Sinai
Leonardo Balsalobre, MD, PhD
Director, NY Center for Voice and
Staff of Rhinology Division Diana M. Bell
Swallowing Disorders
Sao Paulo ENT Center Associate Professor
Co-Founder and Director of Research,
Edmundo Vasconcelos Hospital Department of Pathology
ADN International
Sao Paulo, Brazil The University of Texas MD Anderson
New York, New York
Cancer Center
Fuad M. Baroody, MD, FACS
Houston, Texas Kofi Boahene, MD
Professor of Surgery
Professor
Section of Otolaryngology–Head and Elizabeth Bradford Bell, MD
Neck Surgery Assistant Professor
and Neck Surgery
Professor of Pediatrics Department of Otolaryngology–Head
Johns Hopkins University School of
Director, Otolaryngology Residency and Neck Surgery
Medicine
Program University of Nebraska Medical Center
Baltimore, Maryland
Director of Pediatric Otolaryngology Omaha, Nebraska
The University of Chicago Medicine and Lauren A. Bohm, MD
Michael S. Benninger, MD
The Comer Children’s Hospital Assistant Professor
Chicago, Illinois Department of Otolaryngology–Head
Lerner College of Medicine of Case
and Neck Surgery
Robert W. Bastian, MD Western Reserve University
University of Michigan
Founder and Director Chairman, Head and Neck Institute
Ann Arbor, Michigan
Bastian Voice Institute Cleveland Clinic
Downers Grove, Illinois Cleveland, Ohio Michael M. Bottros, MD
Associate Professor
Gregory J. Basura, MD, PhD Heidi J. Bernknopf, AuD, BS
Associate Chief of Pain Management
Assistant Professor Audiologist
Department of Anesthesiology and Pain
Department of Otolaryngology–Head Department of Speech and Hearing
Medicine
and Neck Surgery Robert Wood Johnson University
Director, Acute Pain Service
University of Michigan Hospital
Washington University School of
Ann Arbor, Michigan New Brunswick, New Jersey
Medicine in St. Louis
Daniel M. Beswick, MD St. Louis, Missouri
Assistant Professor
Department of Otolaryngology
University of Colorado
Aurora, Colorado
Contributors vii
Derald E. Brackmann, MD Bena Brown, BSpPath, PhD Paolo Campisi, MD, MSc, FRCS(C)
Clinical Professor of Otolaryngology Health Research Fellow Professor and Vice Chair, Education
Head and Neck Surgery Centre for Functioning and Health Department of Otolaryngology–Head
University of California School of Research and Neck Surgery
Medicine Metro South Hospital and Health Service University of Toronto
Associate, House Ear Clinic Department of Speech Pathology Staff Otolaryngologist
Los Angeles, California Princess Alexandra Hospital Department of Otolaryngology–Head
Senior Lecturer and Neck Surgery
Carol R. Bradford, MD
School of Health and Rehabilitation Hospital for Sick Children
Executive Vice Dean for Academic Affairs
Sciences Toronto, Ontario, Canada
and Professor
University of Queensland
Department of Otolaryngology–Head John P. Carey, MD
Brisbane, Queensland, Australia
and Neck Surgery Professor and Division Chief for Otology,
University of Michigan Medical School Cameron L. Budenz, MD Neurotology, and Skull Base Surgery
Ann Arbor, Michigan Assistant Professor Department of Otolaryngology–Head
Department of Otolaryngology–Head and Neck Surgery
Gregory H. Branham, MD
and Neck Surgery Johns Hopkins University School of
Professor and Chief, Facial Plastic and
Department of Neurosurgery Medicine
Reconstructive Surgery
New York Medical College Baltimore, Maryland
Valhalla, New York;
and Neck Surgery Eric T. Carniol, MD, MBA
ENT and Allergy Associates, LLP
Washington University School of Division Chief
Sleepy Hollow, New York
Medicine in St. Louis Department of Otolaryngology–Head
St. Louis, Missouri Clare Burns, PhD, BSpPath and Neck Surgery
Advanced Speech Pathologist Milford Regional Medical Center
Barton F. Branstetter IV, MD, FACR
Department of Speech Pathology and Director, Facial Plastic Surgery
Chief of Neuroradiology
Audiology etc aesthetic surgery
Department of Radiology
Royal Brisbane and Women’s Hospital Milford, Massachusetts
University of Pittsburgh Medical Center
Clinician Research Fellow
Professor Simon D. Carr, MD, FRCS (ORL-HNS)
Metro North Hospital and Health
Departments of Radiology, Clinical Fellow
Service
Otolaryngology, and Biomedical Department of Otolaryngology–Head
Lecturer
Informatics and Neck Surgery
School of Health and Rehabilitation
University of Pittsburgh Hospital for Sick Children
Sciences
Pittsburgh, Pennsylvania Toronto, Ontario, Canada
Jason A. Brant, MD Brisbane, Queensland, Australia Geoffrey C. Casazza, MD
Assistant Professor Resident Physician
J. Kenneth Byrd, MD
Department of Otorhinolaryngology– Division of Otolaryngology–Head and
Associate Professor
Head and Neck Surgery Neck Surgery
Hospital of the University of University of Utah
Medical College of Georgia at Augusta
Pennsylvania Salt Lake City, Utah
University
Philadelphia, Pennsylvania
Augusta, Georgia Keith Casper, MD
Scott E. Brietzke, MD, MPH Assistant Professor
Patrick Byrne, MD
Affiliate Professor of Surgery Department of Otolaryngology–Head
Director
Charles E. Schmidt College of Medicine and Neck Surgery
Division of Facial Plastic and
Florida Atlantic University University of Michigan
Reconstructive Surgery
Boca Raton, Florida; Ann Arbor, Michigan
Johns Hopkins University School of
Joe DiMaggio Children’s Hospital at
Medicine Paolo Castelnuovo, MD, FRCS(Ed),
Memorial
Baltimore, Maryland FACS
Hollywood, Florida
Professor and Head of
Yi Cai, MD
Jennifer Brinkmeier, MD Otorhinolaryngology
Resident Physician
Assistant Professor Department of Biotechnology and Life
Department of Otolaryngology–Head Science (DBSV)
and Neck Surgery
and Neck Surgery University of Insubria
University of California, San Francisco
Division of Pediatric Otolaryngology Director, Head and Neck Surgery and
San Francisco, California
Saint Louis University Forensic Dissection Research Center
St. Louis, Missouri Hollin Calloway, MD Director, Surgical Specialties
Otolaryngologist, Facial Plastic and Circolo-Varese Hospital
Hilary A. Brodie, MD, PhD
Reconstructive Surgeon Varese, Lombardy, Italy
Professor
ENT and Allergy Associates, LLP
Department of Otolaryngology–Head Ivette Cejas, PhD
Hoboken, New Jersey
and Neck Surgery Associate Professor
University of California Davis Medical Director, Family Support Services
Center Department of Otolaryngology
Sacramento, California University of Miami
Miami, Florida
viii Contributors
Kay W. Chang, MD Richard A. Chole, MD, PhD Mark S. Courey, MD

Professor Professor Professor
Department of Otolaryngology Department of Otolaryngology Department of Otolaryngology–Head
Stanford University Washington University School of and Neck Surgery
Palo Alto, California Medicine in St. Louis Chief, Division of Laryngology
St. Louis, Missouri Director, Grabscheid Voice and
Burke E. Chegar, MD
Swallowing Center
Medical Director Baishakhi Choudhury, MD
Vice Chair of Quality
Chegar Facial Plastic Surgery Assistant Professor
Carmel, Indiana Otology/Neurotology and Lateral Skull
and Neck Surgery
Base Surgery
Alan G. Cheng, MD Mount Sinai Health System
Associate Professor New York, New York
and Neck Surgery
Loma Linda University Healthcare Renee Cover, BSN, RN, CPHRM
and Neck Surgery
Loma Linda, California Risk Manager
Stanford University
Johns Hopkins Hospital
Stanford, California James M. Christian, DDS, MBA, FACS
Baltimore, Maryland
Professor
Alan T.L. Cheng, MD, FRACS
Department of Oral and Maxillofacial Daniel R. Cox, MD
Clinical Associate Professor
Surgery Fellow in Rhinology
Discipline of Child and Adolescent
University of Tennessee Health Science Department of Otolaryngology–Head
Health
Center and Neck Surgery
University of Sydney
Memphis, Tennessee Emory University School of Medicine
Sydney, NSW, Australia;
Atlanta, Georgia
Department of Paediatric ENT Robert H. Chun, MD
The Children’s Hospital at Westmead Associate Professor Benjamin T. Crane, MD, PhD
Westmead, NSW, Australia Department of Pediatric Otolaryngology Professor
Medical College of Wisconsin Departments of Otolaryngology,
Douglas B. Chepeha, MD, MSPH
Milwaukee, Wisconsin Bioengineering, and Neuroscience
Professor
University of Rochester
Department of Otolaryngology–Head Martin J. Citardi, MD
Rochester, New York
and Neck Surgery Professor and Chair
University of Toronto Department of Otorhinolaryngology– Francis X. Creighton Jr, MD
Toronto, Ontario, Canada; Head and Neck Surgery Assistant Professor
Adjunct Professor University of Texas Health Science Department of Otolaryngology–Head
Department of Otolaryngology–Head Center at Houston and Neck Surgery
and Neck Surgery Chief of Otorhinolaryngology Division of Otology, Neurotology, and
University of Michigan Memorial Hermann–Texas Medical Skull Base Surgery
Ann Arbor, Michigan Center Johns Hopkins University School of
Houston, Texas Medicine
Wade W. Chien, MD
Baltimore, Maryland
Associate Professor Andrew Michael Compton, MD
Department of Otolaryngology–Head [Ch 17] Matthew G. Crowson, MD, MPA,
and Neck Surgery Associate Professor FRCSC
Johns Hopkins University School of Department of Otolaryngology–Head Clinical Fellow, Neurotology
Medicine and Neck Surgery Department of Otolaryngology–Head
Baltimore, Maryland; Oakland University William Beaumont and Neck Surgery
Staff Clinician School of Medicine Sunnybrook Health Sciences Center
National Institute On Deafness and Royal Oak, Michigan; University of Toronto
Other Communication Disorders Physician-Owner Toronto, Canada
National Institutes of Health Oakland ENT, LLC
Frank Culicchia, MD
Bethesda, Maryland West Bloomfield, Michigan
David G. Kline Professor and Chairman
Oliver Y. Chin, MD Maura K. Cosetti, MD Department of Neurosurgery
Resident Physician Associate Professor Louisiana State University School of
Department of Otolaryngology–Head Department of Otolaryngology–Head Medicine
and Neck Surgery and Neck Surgery New Orleans, Louisiana
University of California Davis Medical Icahn School of Medicine
Charles W. Cummings, MD
Center New York Eye and Ear Infirmary of
Distinguished Service Professor
Sacramento, California Mount Sinai
New York, New York
Sukgi S. Choi, MD, MBA and Neck Surgery
Attending Physician M. Laurin Council, MD Johns Hopkins Medical Institutions
Otolaryngology and Communication Associate Professor Baltimore, Maryland
Enhancement Departments of Internal Medicine and
Boston Children’s Hospital Dermatology
Senior Lecturer Washington University School of
Department of Otolaryngology Medicine in St. Louis
Harvard Medical School St. Louis, Missouri
Boston, Massachusetts
Contributors ix
Calhoun D. Cunningham III, MD Charles C. Della Santina, PhD, MD David W. Eisele, MD, FACS
Associate Professor Professor Andelot Professor and Director
Co-Director, Duke Raleigh Skull Base Departments of Otolaryngology–Head Department of Otolaryngology–Head
and Cerebrovascular Center and Neck Surgery and Biomedical and Neck Surgery
Department of Head and Neck Surgery Engineering Johns Hopkins University School of
and Communication Sciences Johns Hopkins University School of Medicine
Duke University Medical Center Medicine Baltimore, Maryland
Durham, North Carolina Baltimore, Maryland
Laurie Eisenberg, PhD
Sharon L. Cushing, MD, MSc, FRCS(C) Joshua C. Demke, MD Professor of Research Otolaryngology
Associate Professor Associate Professor Tina and Rick Caruso Department of
Department of Otolaryngology–Head Facial Plastic and Reconstructive Surgery Otolaryngology–Head and Neck
and Neck Surgery Department of Otolaryngology Surgery
University of Toronto Texas Tech Health Sciences Center University of Southern California Keck
Staff Physician Lubbock, Texas School of Medicine
Department of Otolaryngology–Head Los Angeles, California
Craig S. Derkay, MD
and Neck Surgery
Professor and Vice-Chairman Mark El-Deiry, MD, FACS
Archie’s Cochlear Implant Laboratory
Department of Otolaryngology–Head Associate Professor
Hospital for Sick Children
and Neck Surgery Department of Otolaryngology–Head
Eastern Virginia Medical School and Neck Surgery
Brian C. Dahlin, MD Director Emory University School of Medicine
Associate Professor Pediatric Otolaryngology Atlanta, Georgia
Department of Radiology Children’s Hospital of the King’s
Edward El Rassi, MD
University of California, Davis Daughters
Assistant Professor
Sacramento, California Norfolk, Virginia
Sam J. Daniel, MD, CM, FRCS(C) Nicholas A. Dewyer, MD and Neck Surgery
Hugh Hallward Chair Assistant Professor University of Oklahoma Health Sciences
Department of Pediatric Surgery Department of Otolaryngology–Head Center
McGill University and Neck Surgery Oklahoma City, Oklahoma
Director, Pediatric Otolaryngology–Head University of Arizona College of
Hussam K. El-Kashlan, MD
and Neck Surgery Medicine
Professor and Associate Chair
Montreal Children’s Hospital Tucson, Arizona
Montreal, Quebec, Canada
Rodney C. Diaz, MD and Neck Surgery
Camila Soares Dassi, MD Professor Director, Division of Otology and
Otolaryngology-Rhinology and Skull Department of Otolaryngology–Head Neurotology
Base Surgery and Neck Surgery University of Michigan
Sao Paulo ENT Center University of California Davis Medical Ann Arbor, Michigan
Edmundo Vasconcelos Hospital Center
Anila B. Elliott, MD
Sao Paulo, Brazil Sacramento, California
Assistant Professor
Terry A. Day, MD Amanda E. Dilger, MD University of Michigan
Professor Fellow Department of Anesthesiology
Director, Head and Neck Tumor Center Facial Plastic and Reconstructive Surgery CS Mott Children’s Hospital
Medical University of South Carolina Beverly Hills/Roseville, California Ann Arbor, Michigan
Charleston, South Carolina
Lynn E. Driver, MS, CCC-SLP Ravindhra G. Elluru, MD, PhD
Kavita Dedhia, MD Pediatric Speech-Language Pathology Professor and Chair
Assistant Professor Department of Pediatric Otolaryngology Department of Otolaryngology
Department of Otolaryngology–Head University of Michigan, Michigan Wright State Boonshoft School of
and Neck Surgery Medicine Medicine
University of Pennsylvania Perelman Ann Arbor, Michigan Director, Division of Pediatric
School of Medicine Otolaryngology
Alison B. Durham, MD
Division of Otolaryngology Dayton Children’s Hospital
Assistant Professor
Children’s Hospital of Philadelphia Dayton, Ohio
Department of Dermatology
University of Michigan Susan D. Emmett, MD, MPH
Matthew M. Dedmon, MD, PhD Ann Arbor, Michigan Assistant Professor of Surgery and Global
Assistant Professor Health
Avraham Eisbruch, MD
Department of Otolaryngology–Head Department of Head and Neck Surgery
Professor
and Neck Surgery and Communication Sciences
Department of Radiation Oncology
University of North Carolina at Chapel Duke University School of Medicine
Hill School of Medicine Duke Global Health Institute
Attending Physician
Chapel Hill, North Carolina Durham, North Carolina
Hospital of the University of Michigan
Nicholas L. Deep, MD Ann Arbor, Michigan
Fellow in Neurotology
NYU Langone Health
New York, New York
x Contributors
Donovan Eu, MBBS, MMed, FAMS Paul W. Flint, MD, FACS Andres Gantous, MD, FRCS(C), FACS
Associate Consultant Professor and Chair Associate Professor and Head
Department of Otolaryngology–Head Department of Otolaryngology–Head Division of Facial Plastic and
and Neck Surgery and Neck Surgery Reconstructive Surgery
National University Hospital Oregon Health and Science University Department of Otolaryngology–Head
Singapore Portland, Oregon and Neck Surgery
University of Toronto
Samer Fakhri, MD Elizabeth M. Floyd, MD
Professor and Chair Assistant Professor
Department of Otorhinolaryngology Department of Otolaryngology Bruce J. Gantz, MD
American University of Beirut Northwell Health Professor and Chair
Beirut, Lebanon Great Neck, New York Department of Otolaryngology–Head
and Neck Surgery
Carole Fakhry, MD, MPH Wytske J. Fokkens, MD, PhD
University of Iowa
Associate Professor Department of Otorhinolaryngology
Iowa City, Iowa
Department of Otolaryngology–Head Amsterdam University Medical Centres
and Neck Surgery Amsterdam, The Netherlands C. Gaelyn Garrett, MD, MMHC
Johns Hopkins University School of Professor and Vice Chair
Howard W. Francis, MD, MBA, FACS
Medicine Department of Otolaryngology
Richard Hall Chaney Sr. Professor and
Baltimore, Maryland Guy M. Maness Chair in Laryngology
Chair
and Voice
Edward H. Farrior, MD Department of Head and Neck Surgery
Vanderbilt University
Affiliate Associate Professor, Voluntary and Communication Sciences
Medical Director
Faculty Duke University School of Medicine
Vanderbilt Voice Center
Department of Otolaryngology–Head Durham, North Carolina
Nashville, Tennessee
and Neck Surgery
David R. Friedland, MD, PhD
University of South Florida M. Boyd Gillespie, MD, MSc
Professor and Vice-Chair
Tampa, Florida; Professor and Chair
Chief, Division of Otology and Neuro-
Visiting Clinical Associate Professor Department of Otolaryngology–Head
otologic Skull Base Surgery
Otolaryngology and Communication
and Neck Surgery University of Tennessee Health Science
Sciences
University of Virginia Center
Medical College of Wisconsin
Charlottesville, Virginia Memphis, Tennessee
Milwaukee, Wisconsin
David Feller-Kopman, MD, FACP Douglas A. Girod, MD, FACS
Oren Friedman, MD
Director, Bronchoscopy and Professor
Associate Professor
Interventional Pulmonology Department of Otolaryngology–Head
Director, Facial Plastic Surgery
Division of Pulmonary and Critical Care and Neck Surgery
Otorhinolaryngology
Medicine University of Kansas School of Medicine
University of Pennsylvania
Professor of Medicine, Anesthesiology, Kansas City, Kansas;
Otolaryngology–Head and Neck Chancellor
Surgery Rick A. Friedman, MD, PhD University of Kansas
Johns Hopkins Hospital Vice Chief of Otolaryngology–Head and Lawrence, Kansas
Baltimore, Maryland Neck Surgery
Hannah Glick, AuD, PhD, CCC-A
Charles B. Felts, DDS Department of Speech, Language, and
Director of University of California San
Former Chief Resident Hearing Science
Diego Acoustic Neuroma Program
Department of Oral and Maxillofacial Institute of Cognitive Science
University of San Diego
Surgery Center for Neuroscience
San Diego, California
University of Tennessee Health Science University of Colorado
Center John L. Frodel Jr, MD Boulder, Colorado
Memphis, Tennessee Atlanta Medispa and Surgicenter, LLC
John C. Goddard, MD
Atlanta, Georgia;
Daniel S. Fink, MD Division Head of Otology and
Geisinger Center for Aesthetics and
Assistant Professor, Laryngology and Neurotology
Cosmetic Surgery
Voice Disorders Physician Director of Audiology
Danville, Pennsylvania
and Neck Surgery Ian Ganly, MD, PhD, MSc Northwest Permanente, PC
University of Colorado School of Professor Portland, Oregon
Medicine Head and Neck Surgery
George S. Goding Jr, MD
Aurora, Colorado Memorial Sloan Kettering Cancer Center
Professor
Professor
Kenneth C. Fletcher Jr, MD Department of Otolaryngology
Otolaryngology–Head and Neck Surgery
Assistant Professor University of Minnesota Medical School
Weill Cornell Medical College
Department of Otolaryngology–Head Faculty, Department of Otolaryngology
New York, New York
and Neck Surgery Hennepin County Medical Center
Vanderbilt University Minneapolis, Minnesota
Contributors xi
Andrew N. Goldberg, MD, MSCE, FACS Stephen T. Green, MD Jennifer F. Ha, MBBS (Hons), FRACS
Professor and Director, Division of Resident Physician Pediatric Otolaryngologist
Rhinology and Sinus Surgery Department of Otolaryngology–Head Pediatric Otolaryngology–Head and
Department of Otolaryngology–Head and Neck Surgery Neck Surgery
and Neck Surgery Louisiana State University School of Perth Children’s Hospital
University of California, San Francisco Medicine Otolaryngologist
San Francisco, California New Orleans, Louisiana Murdoch ENT
St. John of God Murdoch Hospital
David Goldenberg, MD, FACS Vincent Grégoire, MD, PhD, FRCR
Pediatric Otolaryngologist
Steven and Sharon Baron Professor and Professor
Department of Surgery
Chair Department of Radiation Oncology
University of Western Australia
Department of Otolaryngology–Head Centre Léon Bérard
Nedlands, Western Australia
and Neck Surgery Lyon, France
Pennsylvania State University College of Patrick K. Ha, MD
J. Fredrik Grimmer, MD
Medicine Irwin Mark Jacobs and Joan Klein Jacobs
Professor
Hershey, Pennsylvania Distinguished Professor
Division of Otolaryngology–Head and
Chief, Division of Head and Neck
Nira A. Goldstein, MD, MPH Neck Surgery
Surgical Oncology
Professor, Attending Physician University of Utah
Department of Otolaryngology Director of the Vascular Anomalies
and Neck Surgery
State University of New York Center
Downstate Medical Center Primary Children’s Hospital
Attending Physician Salt Lake City, Utah
Department of Otolaryngology Natalia M. Hajnas, MD
Catherine A. Gruffi, MD
Kings County Hospital Center Department of Otolaryngology–Head
Clinical Lecturer
Brooklyn, New York and Neck Surgery
University of Illinois at Chicago
Nathan J. Gonik, MD, MHSA Department of Pediatric Anesthesiology
Chicago, Illinois
Assistant Professor CS Mott Children’s Hospital
Department of Otolaryngology–Head Ann Arbor, Michigan Bronwyn E. Hamilton, MD
and Neck Surgery Professor and Director of Head and
Samuel P. Gubbels, MD, FACS
Wayne State University Neck Radiology
Associate Professor
Assistant Professor Department of Radiology
Department of Pediatric Otolaryngology Oregon Health and Science University
and Neck Surgery
Children’s Hospital of Michigan Portland, Oregon
University of Colorado School of
Detroit, Michigan
Medicine Grant S. Hamilton III, MD
Debra Gonzalez, MD Director, UCHealth Hearing and Balance Associate Professor
Assistant Professor Clinics Department of Otolaryngology–Head
Department of Otolaryngology Aurora, Colorado and Neck Surgery
Washington University School of Mayo Clinic
Piyush Gupta, MBBS, MS
Medicine in St. Louis Rochester, Minnesota
Research Fellow
St. Louis, Missouri
Head and Neck Surgery, Department of Marc Hamoir, MD
Christine G. Gourin, MD, MPH, FACS Surgery Professor and Head
Professor Memorial Sloan Kettering Cancer Center Department of Head and Neck Surgery
Department of Otolaryngology–Head New York, New York Université Catholique de Louvain,
and Neck Surgery Louvain-la-Neuve, Belgium;
Richard K. Gurgel, MD
Johns Hopkins University School of Chairman of the Executive Board
Associate Professor
Medicine King Albert II Cancer Institute
Division of Otolaryngology–Head and
Baltimore, Maryland St Luc University Hospital
Neck Surgery
Brussels, Belgium
M. Elise Graham, MD, FRCS(C) University of Utah
Assistant Professor Salt Lake City, Utah Ehab Y. Hanna, MD, FACS
Department of Otolaryngology–Head Professor and Director of Skull Base
Jose G. Gurrola II, MD
and Neck Surgery Surgery
Assistant Professor
London Health Sciences Centre and Vice Chairman
Western University Department of Head and Neck Surgery
and Neck Surgery
London, Ontario, Canada University of Texas MD Anderson Cancer
Center
Glenn E. Green, MD San Francisco, California
Houston, Texas
Professor
Department of Otolaryngology–Head Jeffrey J. Harmon Jr, MD
and Neck Surgery Graduated Resident
University of Michigan Department of Otolaryngology–Head
Ann Arbor, Michigan and Neck Surgery
University of Cincinnati College of
Medicine
Cincinnati, Ohio
xii Contributors
Ulrich Harréus, MD Frans J.M. Hilgers, MD, PhD Jeffrey J. Houlton, MD

Professor and Chair Chairman Emeritus Associate Professor
Department of Otolaryngology–Head Department of Head and Neck Oncology Department of Otolaryngology
and Neck Surgery and Surgery University of Washington
EVK Duesseldorf Academic Hospital of The Netherlands Cancer Institute–Antoni Seattle, Washington
Heinrich-Heine University van Leeuwenhoek
John W. House, MD
Duesseldorf, Germany Professor Emeritus for Oncology-Related
Clinical Professor
Voice and Speech Disorders
Renee Banakis Hartl, MD, AuD Department of Otolaryngology–Head
Amsterdam Center for Language and
Resident Physician and Neck Surgery
Communication
Department of Otolaryngology University of Southern California
University of Amsterdam
University of Colorado Clinical Professor
Amsterdam, The Netherlands
Aurora, Colorado Department of Otolaryngology–Head
Justin D. Hill, MD and Neck Surgery
Richard Harvey, MD, PhD, FRACS
ENT Specialists University of California, Los Angeles
Professor and Program Head
Salt Lake City, Utah Los Angeles, California
Rhinology and Skull Base Research
Group Alexander T. Hillel, MD Timothy E. Hullar, MD
University of New South Wales Associate Professor Professor
Professor Department of Otolaryngology–Head Departments of Otolaryngology–Head
Faculty of Medicine and Health Sciences and Neck Surgery and Neck Surgery and Neurology
Macquarie University Anesthesia and Critical Care Medicine Oregon Health and Science University
Sydney, NSW, Australia Johns Hopkins University School of Portland, Oregon
Medicine
Bruce H. Haughey, MBChB, MD, FACS, Thomas Hummel, MD
Baltimore, Maryland
FRACS Professor
Medical Director, Oncology Michael L. Hinni, MD Smell and Taste Clinic
Advent Health Celebration Professor Department of Otorhinolaryngology
Otolaryngology Head and Neck Surgery Department of Otolaryngology–Head Technische Universität Dresden
Advent Health Medical Group and Neck Surgery Dresden, Germany
Orlando, Florida; Mayo Clinic College of Medicine
Joseph O. Humtsoe, PhD
Collaborative Professor Consultant
Assistant, Professional Research
Department of Otolaryngology–Head Department of Otolaryngology–Head
and Neck Surgery
Morsani School of Medicine Mayo Clinic Arizona
University of South Florida Phoenix, Arizona
Tampa, Florida;
Kellie J. Hirce, AuD
Adjunct Professor Peter H. Hwang, MD
Clinical Audiologist
Department of Surgery Professor
Speech and Hearing
University of Auckland Faculty of Health Department of Otolaryngology–Head
Robert Wood Johnson University
Sciences and Neck Surgery
Hospital
Auckland, New Zealand Stanford University
New Brunswick, New Jersey
Stanford, California
Peter Hawkins, MD
Henry T. Hoffman, MD, FACS
Radiation Oncology Stacey L. Ishman, MD, MPH
Professor
University of Michigan Professor
Ann Arbor, Michigan Department of Otolaryngology–Head
University of Iowa
and Neck Surgery
Peter Hellings, MD, PhD Iowa City, Iowa
University of Cincinnati
Clinic Head
Ashlee E. Holman, MD Surgical Director, Upper Airway Center
Department of Otorhinolaryngology
Assistant Professor Divisions of Otolaryngology and
University Hospitals Leuven
University of Michigan Pulmonary Medicine
Leuven, Belgium
Department of Anesthesiology Cincinnati Children’s Hospital Medical
John W. Hellstein, DDS, MS CS Mott Children’s Hospital Center
Professor and Head Ann Arbor, Michigan Cincinnati, Ohio
Department of Oral Pathology
David B. Hom, MD, FACS Jad Jabbour, MD, MPH
University of Iowa
Professor of Surgery Pediatric Otolaryngology
Iowa City, Iowa
Co-Director, Facial Plastic and Charlotte Eye Ear Nose and Throat
Kurt Herzer, MD, PhD Reconstructive Surgery Associates, PA
Director Head and Neck Surgery Charlotte, North Carolina;
Population Health University of California San Diego Lecturer, Department of Otolaryngology
Oscar Health School of Medicine Harvard Medical School
New York, New York San Diego, California Associate Scientific Research Staff
Claire Hopkins, BMBCh, MA(Oxon),
Boston Children’s Hospital
FRCS(ORL-HNS), DM
Professor of Rhinology
ENT Department
Guy’s Hospital
London, United Kingdom
Contributors xiii
Robert K. Jackler, MD Timothy M. Johnson, MD Bradley W. Kesser, MD

Chair Professor Professor
Department of Otolaryngology–Head Departments of Dermatology, Department of Otolaryngology–Head
and Neck Surgery Otolaryngology, and Surgery and Neck Surgery and Pediatrics
Stanford University University of Michigan University of Virginia School of Medicine
Stanford, California Ann Arbor, Michigan Charlottesville, Virginia
Neal M. Jackson, MD Dipti Kamani, MD Majid Khan, MBBS, MD
Resident Physician Research Director Associate Professor
Lousiana State University Health Division of Thyroid and Parathyroid Radiology Division of Neuroradiology
Sciences Center Surgery Director of Non-Vascular Spine
New Orleans, Louisiana Massachusetts Eye and Ear Interventions
Boston, Massachusetts Johns Hopkins Hospital
Adrian L. James, DM, FRCS(ORL-HNS)
Baltimore, Maryland
Professor William E. Karle, MD
Department of Otolaryngology–Head Clinical Instructor Paul R. Kileny, PhD, FAAA, FASHA,
and Neck Surgery Department of Otolaryngology–Head BCS-IOM
University of Toronto and Neck Surgery Professor
Pediatric Otolaryngologist Oregon Health and Science University Department of Otolaryngology–Head
Hospital for Sick Children Portland, Oregon and Neck Surgery
Toronto, Ontario, Canada Academic Program Director
Robert T. Kavitt, MD, MPH
Audiology and Electrophysiology
Brian Jameson, MD Associate Professor of Medicine
University of Michigan, Michigan
Department of Endocrinology Director, Center for Esophageal Diseases
Medicine
Geisinger Health System Section of Gastroenterology, Hepatology,
Ann Arbor, Michigan
Geisinger Wyoming Valley Medical and Nutrition
Center University of Chicago Jennifer Kim, MD
Wilkes-Barre, Pennsylvania Chicago, Illinois Associate Clinical Professor
Taha A. Jan, MD David M. Kaylie, MD
and Neck Surgery
Fellow Professor of Surgery
University of Michigan, Michigan
and Neck Surgery and Communication Sciences
Medicine
Stanford University Duke University Medical Center
Ann Arbor, Michigan
Stanford, California Durham, North Carolina
Adam J. Kimple, MD, PhD
Herman A. Jenkins, MD Robert M. Kellman, MD, FACS
Assistant Professor
Professor and Chair Professor and Chair Emeritus
Department of Otolaryngology–Head Department of Otolaryngology and
and Neck Surgery
and Neck Surgery Communication Sciences
University of North Carolina
University of Colorado School of SUNY Upstate Medical University
Chapel Hill, North Carolina
Medicine Staff Physician
Aurora, Colorado St. Joseph’s Health Ericka F. King, MD
Syracuse, New York Pediatric Otolaryngology
Nicole T. Jiam, MD
Mary Bridge Children’s Hospital
Resident Physician David W. Kennedy, MD
Tacoma, Washington
Department of Otolaryngology–Head Professor
and Neck Surgery University of Pennsylvania Perelman Diana N. Kirke, MBBS, MPhil, FRACS
University of California, San Francisco School of Medicine Assistant Professor
San Francisco, California Philadelphia, Pennsylvania Department of Otolaryngology–Head
and Neck Surgery
Hong-Ryul Jin, MD, PhD Robert C. Kern, MD
Icahn School of Medicine at Mount Sinai
Director George A. Sisson Professor of
New York, New York
Otorhinolaryngology Otolaryngology
Dr. Jin’s Premium Nose Clinic Chair, Department of Otolaryngology– Elizabeth Knecht, MD
Seoul, Republic of Korea Head and Neck Surgery Department of Otolaryngology–Head
Northwestern University Feinberg and Neck Surgery
Christopher M. Johnson, MD
School of Medicine Pediatric Otolaryngology
Staff Surgeon
Chicago, Illinois University of Michigan, Michigan
Medicine
Naval Medical Center Julia L. Kerolus, MD
Ann Arbor, Michigan
San Diego, California; Clinical Assistant Professor
Assistant Professor Department of Otolaryngology–Head Raymond J. Konior, MD
Department of Surgery and Neck Surgery Chicago Hair Institute
Uniformed Services University of the University of Illinois at Chicago Medical Director
Health Sciences Chicago, Illinois Oakbrook Terrace, Illinois
Bethesda, Maryland
xiv Contributors
Shannon M. Kraft, MD Devyani Lal, MD Kevin P. Leahy, MD, PhD

Associate Professor Professor of Otolaryngology Assistant Professor
Department of Otolaryngology–Head Mayo Clinic College of Medicine Department of Otorhinolaryngology–
and Neck Surgery Consultant Head and Neck Surgery
University of Kansas Health System Department of Otolaryngology University of Pennsylvania Perelman
Kansas City, Kansas Mayo Clinic School of Medicine
Phoenix, Arizona Philadelphia, Pennsylvania
Russell W.H. Kridel, MD
Clinical Professor Anil K. Lalwani, MD Daniel J. Lee, MD, FACS
Department of Otorhinolaryngology– Professor and Vice Chair for Research Director, Pediatric Otology and
Head and Neck Surgery Department of Otolaryngology–Head Neurotology
University of Texas Health Science and Neck Surgery Associate Professor
Center and McGovern Medical School Columbia University Vagelos College of Department of Otology and Laryngology
at Houston Physicians and Surgeons Massachusetts Eye and Ear
Private Practice Medical Director Harvard Medical School
Facial Plastic Surgery Associates Perioperative Services Boston, Massachusetts
Houston, Texas NewYork–Presbyterian Hospital
Edward R. Lee, MD
New York, New York
Edward C. Kuan, MD, MBA Physician
Assistant Professor Derek J. Lam, MD, MPH Department of Otolaryngology–Head
Department of Otolaryngology–Head Associate Professor and Neck Surgery
and Neck Surgery Department of Otolaryngology–Head University of California, San Francisco
University of California, Irvine and Neck Surgery San Francisco, California
Orange, California Oregon Health and Science University
Nancy Lee, MD
Portland, Oregon
Parvesh Kumar, MD Attending and Vice Chair
Professor and Chair, Department of Paul R. Lambert, MD Department of Radiation Oncology
Radiation Oncology Professor and Chairman Memorial Sloan Kettering Cancer Center
Vice Dean of Research Department of Otolaryngology–Head New York, New York
University of Nevada Las Vegas School and Neck Surgery
Marci M. Lesperance, MD
of Medicine Medical University of South Carolina
Professor
Las Vegas, Nevada Charleston, South Carolina
Melda Kunduk, PhD Christopher G. Larsen, MD, FACS and Neck Surgery
Professor Associate Professor University of Michigan Health System
Department of Communication Sciences Department of Otolaryngology–Head Ann Arbor, Michigan
and Disorders and Neck Surgery
Laeben Lester, MD
Louisiana State University Division Director General
Assistant Professor
Baton Rouge, Louisiana; Otolaryngology
Departments of Anesthesiology and
Adjunct Professor University of Kansas Medical Center
Critical Care Medicine and Emergency
Department of Otolaryngology–Head Kansas City, Kansas
Medicine
and Neck Surgery
Richard E. Latchaw, MD Associate Medical Director
Louisiana State University Health
Professor Johns Hopkins Medicine
Sciences Center
Department of Radiology Multidisciplinary Airway Programs
New Orleans, Louisiana
Division of Neuroradiology Johns Hopkins University School of
Ollivier Laccourreye, MD University of California, Davis Medicine
Professor Sacramento, California Baltimore, Maryland
Claire M. Lawlor, MD Jessica Levi, MD
Pediatric Otolaryngologist Associate Professor
Hôpital Européen Georges Pompidou
Department of Otolaryngology Otolaryngology Head and Neck Surgery
Université Paris-Descartes
Children’s National Health System Boston University/Boston Medical
Sorbonne Paris-Cité, AP-HP
Assistant Professor of Pediatrics and Center
Paris, France
Surgery Boston, Massachusetts
Stephen Y. Lai, MD, PhD George Washington University School of
James S. Lewis Jr, MD
Professor Medicine and Health Sciences
Professor
Departments of Head and Neck Surgery, Washington, DC
Department of Pathology, Microbiology,
Radiation Oncology, and Molecular
Colleen G. Le Prell, PhD and Immunology
and Cellular Oncology
Emilie and Phil Schepps Professor of Vanderbilt University Medical Center
University of Texas MD Anderson Cancer
Hearing Science Nashville, Tennessee
Center
School of Behavioral and Brain Sciences
Houston, Texas Daqing Li, MD
University of Texas at Dallas
Professor and Attending Physician
Dallas, Texas
University of Pennsylvania Health
System
Contributors xv
Timothy S. Lian, MD Valerie J. Lund, CBE, MBBS, MS, Jeffery C. Markt, DDS
Professor FRCS, FRCS(Ed), FACS(Hon) Professor
Chief, Division of Facial Plastic Surgery Professor Emeritus Department of Otolaryngology–Head
Department of Otolaryngology Rhinology and Anterior Skull Base and Neck Surgery
University of Florida College of Surgery University of Nebraska Medical Center
Medicine University College London and Royal Omaha, Nebraska
Gainesville, Florida National Throat, Nose, and Ear
Michael Marsh, MD
Hospital London, UCLH
Whitney Liddy, MD [Ch 178]
London, United Kingdom
Assistant Professor President
Department of Otolaryngology–Head Lawrence R. Lustig, MD Otolaryngology
and Neck Surgery Professor and Chair Arkansas Center for Ear, Nose, Throat,
Northwestern University Department of Otolaryngology–Head and Allergy
Chicago, Illinois and Neck Surgery Fort Smith, Arkansas
Columbia University
Charles J. Limb, MD Davide Mattavelli, MD
New York, New York
Francis A. Sooy Professor Assistant Professor
Chief, Division of Otology, Neurotology Anna Lysakowski, PhD Unit of Otorhinolaryngology–Head and
and Skull Base Surgery Professor Neck Surgery
Director, Douglas Grant Cochlear Departments of Anatomy and Cell Department of Medical and Surgical
Implant Center Biology and Otolaryngology–Head and Specialties, Radiological Sciences, and
Departments of Otolaryngology–Head Neck Surgery Public Health
and Neck Surgery and Neurosurgery University of Illinois at Chicago University of Brescia
University of California San Francisco Chicago, Illinois Brescia, Italy
School of Medicine
Robert H. Maisel, MD, FACS Douglas E. Mattox, MD
Professor William Chester Warren Jr MD
Frank R. Lin, MD, PhD Department of Otolaryngology–Head Professor and Chair
Professor and Neck Surgery Department of Otolaryngology–Head
Department of Otolaryngology–Head University of Minnesota and Neck Surgery
and Neck Surgery Hennepin County Medical Center Emory University School of Medicine
Johns Hopkins University School of Minneapolis, Minnesota Atlanta, Georgia
Medicine
Fawaz Makki, MD, MSc, FRCS(C) Hilary C. McCrary, MD, MPH
Director, Cochlear Center for Hearing
Staff Surgeon Resident Physician
and Public Health
Alberta Health Services Department of Otolaryngology— Head
Johns Hopkins Bloomberg School of
Calgary, Alberta, Canada; and Neck Surgery
Public Health
University of Alberta University of Utah School of Medicine
Baltimore, Maryland
Edmonton, Alberta, Canada Salt Lake City, Utah
Gary Linkov, MD
Devinder S. Mangat, MD, FACS JoAnn McGee, PhD
Medical Director
Professor for Facial Plastic Surgery Senior Research Scientist
City Facial Plastics
Department of Otolaryngology–Head VA Loma Linda Healthcare System
New York, New York
and Neck Surgery Loma Linda, California;
Thomas Loh, MBBS, FRCS University of Cincinnati Medical Center Adjunct Faculty
Associate Professor Cincinnati, Ohio; Department of Speech-Language-
Department of Otolaryngology–Head Private practice Hearing Sciences
and Neck Surgery Vail, Colorado University of Minnesota
National University Health System Minneapolis, Minnesota;
Daniele Marchioni, MD
Singapore Adjunct Faculty
Professor
Department of Biomedical Sciences
Kai Johannes Lorenz, MD, PhD Department of Otolaryngology–Head
Creighton University School of Medicine
Deputy Head and Neck Surgery
Omaha, Nebraska;
Department of Otorhinolaryngology, University Hospital of Modena
Adjunct Faculty
Head and Neck Surgery Modena, Italy
Department of Special Education and
German Federal Armed Hospital, Ulm
Lynette J. Mark, MD Communication Disorders
Baden-Württemberg, Germany
Associate Professor University of Nebraska
David G. Lott, MD Department of Anesthesiology and Lincoln, Nebraska
Professor Critical Care Medicine
Johnathan D. McGinn, MD
Department of Otolaryngology–Head Joint Appointment, Department of
Professor and Vice Chair
and Neck Surgery Otolaryngology–Head and Neck
Mayo Clinic College of Medicine Surgery
and Neck Surgery
Consultant Founder, Difficult Airway Response Team
Pennsylvania State University College of
Department of Otolaryngology–Head (DART) Program
Medicine
and Neck Surgery Johns Hopkins University School of
Hershey, Pennsylvania
Mayo Clinic Arizona Medicine
Phoenix, Arizona Baltimore, Maryland Kinneri Mehta, MD
Resident
University of Connecticut
Farmington, Connecticut
xvi Contributors
Jeremy D. Meier, MD Lloyd B. Minor, MD Wojciech K. Mydlarz, MD

Associate Professor Carl and Elizabeth Naumann Professor Assistant Professor
Division of Otolaryngology–Head and for the Dean of the School of Medicine Director, Head and Neck Surgery,
Neck Surgery Professor of Otolaryngology–Head and National Capitol Region
University of Utah Neck Surgery Department of Otolaryngology–Head
Salt Lake City, Utah Professor of Neurobiology and of and Neck Surgery
Bioengineering, by courtesy Johns Hopkins University School of
Albert L. Merati, MD
Stanford University Medicine
Professor and Chief
Stanford, California Baltimore, Maryland
and Neck Surgery Stephanie Misono, MD, MPH Sahar Nadimi, MD
University of Washington Assistant Professor Assistant Professor
Seattle, Washington Director, Lions Voice Clinic Department of Otolaryngology–Head
Barbara P. Messing, MA, CCC-SLP,
and Neck Surgery Loyola University Medical Center
BCS-S, FASHA
University of Minnesota Maywood, Illinois
Director
Minneapolis, Minnesota
The Milton J Dance Jr Head and Neck Joseph B. Nadol Jr, MD
Center Jenna L. Mitchell, MD Distinguished Professor
Johns Hopkins Head and Neck Surgery Texas A&M Health Science Center Department of Otolaryngology
Johns Hopkins Voice Center Round Rock, Texas Harvard Medical School
Greater Baltimore Medical Center Boston, Massachusetts
Steven Ross Mobley, MD
Baltimore, Maryland;
Mobley MD Facial Plastic Surgery James G. Naples, MD
PhD Candidate
Clinical Adjunct Associate Professor Beth Israel Deaconess Medical Center
Department of Otolaryngology–Head Harvard Medical School
and Neck Surgery Division of Otolaryngology–Head and
Anna H. Messner, MD, FACS, FAAP University of Utah School of Medicine Neck Surgery
Professor and Chief of Pediatric Salt Lake City, Utah Boston, Massachusetts
Otolaryngology
Eric J. Moore, MD Paul S. Nassif, MD, FACS
Professor Assistant Clinical Professor
and Neck Surgery
Department of Otolaryngology Department of Otolaryngology–Head
Baylor College of Medicine
Mayo Clinic and Neck Surgery
Texas Children’s Hospital
Rochester, Minnesota University of Southern California
Houston, Texas
Los Angeles, California;
Nadia K. Mostovych, MD
Anna Meyer, MD Director, Nassif MD, Inc and Associates
Associate Professor Beverly Hills, California
Graduate Fellow, ABFPRS
Department of Plastic Surgery Matthew R. Naunheim, MD, MBA
and Neck Surgery
Belcara Health Instructor
Division of Pediatric Otolaryngology
Department of Otolaryngology–Head Department of Otolaryngology
and Neck Surgery Massachusetts Eye and Ear
University of Maryland Boston, Massachusetts
Michelle Mierzwa, MD St. Joseph Medical Center
Gregory S. Neel
Associate Professor Baltimore, Maryland
Radiation Oncology
Sarah Mowry, MD, FACS and Neck Surgery
Associate Professor Mayo Clinic Arizona
Ann Arbor, Michigan
Residency Program Director, CWRU Phoenix, Arizona
Henry A. Milczuk, MD ENT Residency
Marc E. Nelson, MD, MS
Professor Medical Director, UH Cochlear Implant
Associate Professor
Department of Otolaryngology Program
Oregon Health and Sciences University Department of Otolaryngology–Head
Pediatric ENT Center
Portland, Oregon and Neck Surgery
Akron Children’s Hospital
Case Western Reserve University
Jennifer L. Millar, MSPT Akron, Ohio
University Hospitals Cleveland Medical
Physical Therapist
Center Rick F. Nelson, MD, PhD
Department of Physical Medicine and
Cleveland, Ohio Assistant Professor
Rehabilitation
Otolaryngology–Head and Neck Surgery
Johns Hopkins University School of Harlan R. Muntz, MD, FACS
Indiana University
Medicine Professor
Indianapolis, Indiana
Baltimore, Maryland Division of Otolaryngology–Head and
Neck Surgery Piero Nicolai, MD
Michelle Miller-Thomas, MD
University of Utah Professor
Associate Professor
Salt Lake City, Utah Unit of Otorhinolaryngology–Head and
Department of Neuroradiology
Neck Surgery
Mallinckrodt Institute of Radiology
Department of Medical and Surgical
Specialties, Radiological Sciences, and
Public Health
St. Louis, Missouri
University of Brescia
Brescia, Italy
Contributors xvii
Carrie L. Nieman, MD, MPH Bert W. O’Malley Jr, MD Albert H. Park, MD

Assistant Professor Professor and Chair Chief, Pediatric Otolaryngology
Department of Otolaryngology–Head Department of Otolaryngology–Head Professor, Division of
and Neck Surgery and Neck Surgery Otolaryngology–HNS
Johns Hopkins University School of University of Pennsylvania Health University of Utah
Medicine System Salt Lake City, Utah
Core Faculty Philadelphia, Pennsylvania
Stephen S. Park, MD
Cochlear Center for Hearing and Public
Robert C. O’Reilly, MD Professor
Health
Division of Otolaryngology Department of Otolaryngology–Head
Johns Hopkins Bloomberg School of
Children’s Hospital of Philadelphia and Neck Surgery
Public Health
Professor, Department of University of Virginia
Baltimore, Maryland
Otorhinolaryngology–Head and Neck Charlottesville, Virginia
Richard J. Noel, MD, PhD Surgery
Matthew S. Parsons, MD
Associate Professor and Chief Perelman School of Medicine at the
Associate Professor
Division of Pediatric Gastroenterology, University of Pennsylvania
Hepatology, and Nutrition Philadelphia, Pennsylvania
Duke University Medical Center
Richard R. Orlandi, MD St. Louis, Missouri
Durham, North Carolina
Professor
G. Alexander Patterson, MD, FRCS(C),
S.A. Reza Nouraei, BChir, PhD, FRCS Division of Otolaryngology–Head and
FACS
Robert White Professor of Laryngology Neck Surgery
Joseph C Bancroft Professor
Consultant Laryngologist and Tracheal University of Utah School of Medicine
Surgeon Salt Lake City, Utah
The Robert White Centre for Airway
Hilary L.P. Orlowski, MD Medicine in St. Louis
Voice and Swallowing
Assistant Professor St Louis, Missouri
Poole Hospital, NHS Foundation Trust
Poole, Dorset, United Kingdom Phillip K. Pellitteri, DO, FACS
Chair
Ajani Nugent, MD Washington University School of
Department of Otolaryngology–Head Medicine in St Louis
and Neck Surgery
and Neck Surgery St. Louis, Missouri
Guthrie Health System
Emory University School of Medicine
Giancarlo Ottaviano, MD, PhD Sayre, Pennsylvania;
Atlanta, Georgia
Department of Neurosciences—ENT Clinical Professor
Daniel W. Nuss, MD, FACS Section Department of Otolaryngology–Head
George D. Lyons MD Professor and University-Hospital of Padova and Neck Surgery
Chairman Padova, Italy Temple University School of Medicine
Department of Otolaryngology–Head Philadelphia, Pennsylvania;
Nitin A. Pagedar, MD, MPH
and Neck Surgery Clinical Professor
Associate Professor
Louisiana State University School of Department of Surgery
Medicine Geisinger Commonwealth School of
and Neck Surgery
New Orleans, Louisiana Medicine
University of Iowa
Scranton, Pennsylvania
Brian Nussenbaum, MD, MHCM, FACS Iowa City, Iowa
Executive Director Jonathan A. Perkins, DO, FACS
James N. Palmer, MD
American Board of Otolaryngology–Head Professor
Professor
and Neck Surgery Department of Otolaryngology–Head
Houston, Texas and Neck Surgery
University of Washington School of
Rick M. Odland, MD, PhD University of Pennsylvania Perelman
Medicine
Professor School of Medicine
Director, Vascular Anomalies Program
Department of Otolaryngology Philadelphia, Pennsylvania
Seattle Children’s Hospital
University of Minnesota
Blake C. Papsin, MD, MSc, FRCS(C), Seattle, Washington
Chief
FAAP, FRCS
Department of Otolaryngology Stephen W. Perkins, MD, FACS
Professor
Hennepin Healthcare Clinical Associate Professor
Minneapolis, Minnesota Department of Otolaryngology–Head
and Neck Surgery
and Neck Surgery
Richard G. Ohye, MD Faculty of Medicine
Indiana University School of Medicine
Edward L. Bove MD Professor of University of Toronto
President
Cardiac Surgery Otolaryngologist-in-Chief
Meridian Plastic Surgeons
Head, Section of Pediatric Cardiovascular Department of Otolaryngology–Head
Indianapolis, Indiana
Surgery and Neck Surgery
University of Michigan Medical School The Hospital for Sick Children Bailey Pierce, BS
Ann Arbor, Michigan Toronto, Ontario, Canada Charles E. Schmidt College of Medicine
Florida Atlantic University
Boca Raton, Florida
xviii Contributors
Shirley S.N. Pignatari, MD, PhD Reza Rahbar, DMD, MD Lou Reinisch, PhD
Associate Professor Professor Associate Provost
Department of Otorhinolaryngology– Department of Otolaryngology Academic Affairs
Head and Neck Surgery Harvard Medical School New York Institute of Technology
Federal University of São Paulo Associate Otolaryngologist-in-Chief New York, New York
São Paulo, Brazil McGill Chair in Pediatric
Eleni Rettig, MD
Otolaryngology
Steven D. Pletcher, MD Instructor of Otolaryngology–Head and
Department of Otolaryngology and
Associate Professor Neck Surgery
Communication Enhancement
Department of Otolaryngology–Head Harvard Medical School
Boston Children’s Hospital
and Neck Surgery Associate Surgeon
University of California, San Francisco Brigham and Women’s Hospital and
San Francisco, California Virginia Ramachandran, AuD, PhD Dana-Farber Cancer Institute
Education and Training Specialist Boston, Massachusetts
Dennis S. Poe, MD, PhD
Oticon, Inc.
Professor Matthew H. Rigby, MD, MPH, FRCS(C)
Somerset, New Jersey
Department of Otolaryngology Assistant Professor
Harvard Medical School Vijay R. Ramakrishnan, MD Department of Otolaryngology–Head
Boston Children’s Hospital Associate Professor and Neck Surgery
Boston, Massachusetts Department of Otolaryngology Dalhousie University
University of Colorado School of Halifax, Nova Scotia, Canada
Aron Popovtzer, MD
Medicine
Head of Head and Neck Unit Alejandro Rivas, MD
Department of Neurosurgery
Vice Chair, Oncology Center Associate Professor
University of Colorado School of
Davidoff Cancer Center Department of Otolaryngology–Head
Medicine
Rabin Medical Centet and Neck Surgery
Aurora, Colorado
Tel Aviv University Medical School The Otology Group of Vanderbilt
Petah Tikva, Israel Gregory W. Randolph, MD, FACS, Vanderbilt University
FACE Nashville, Tennessee
Gregory N. Postma, MD
Director, General and Thyroid/
Professor and Vice Chairman K. Thomas Robbins, MD
Parathyroid Endocrine Surgical
Department of Otolaryngology–Head Professor Emeritus
Divisions
and Neck Surgery Division of Otolaryngology–Head and
Massachusetts Eye and Ear
Medical College of Georgia at Augusta Neck Surgery
Professor of Otolaryngology–Head and
University Executive Director Emeritus
Neck Surgery
Augusta, Georgia Simmons Cancer Institute at SIU
Claire and John Bertucci Endowed Chair
Simmons Endowed Chair of Excellence
James C. Prueter, DO in Thyroid Surgical Oncology
in Oncology
Otology and Skull Base Surgery Fellow Harvard Medical School
Southern Illinois University School of
Swedish Neuroscience Institute Boston, Massachusetts
Medicine
Seattle, Washington
Krishna Rao, MD, PhD Springfield, Illinois
Michael P. Puglia II, MD, PhD Associate Professor
Daniel S. Roberts, MD, PhD
Lecturer Division of Hematology/Medical
Assistant Professor
University of Michigan Oncology
Department of Anesthesiology Department of Internal Medicine
University of Connecticut
CS Mott Children’s Hospital Simmons Cancer Institute
Farmington, Connecticut
Ann Arbor, Michigan Southern Illinois University School of
Medicine Brianne Roby, MD
Z. Jason Qian, MD
Springfield, Illinois Assistant Professor
Resident
Department of Otolaryngology–Head Lesley Rao, MD
University of Minnesota
and Neck Surgery Assistant Professor
Minneapolis, Minnesota;
Stanford University School of Medicine Department of Anesthesiology and Pain
Pediatric Otolaryngologist
Stanford, California Management
Pediatric ENT and Facial Plastic Surgery
Alicia M. Quesnel, MD Children’s Hospitals and Clinics of
Assistant Professor Minnesota
St. Louis, Missouri
Department of Otolaryngology St. Paul, Minnesota
Massachusetts Eye and Ear Christopher H. Rassekh, MD
J. Thomas Roland Jr, MD
Harvard Medical School Professor
Mendik Foundation Chairman and
Boston, Massachusetts Department of Otorhinolaryngology–
Professor
University of Pennsylvania
and Neck Surgery
NYU Langone Medical Center and NYU
Lisa M. Reid, MD School of Medicine
Associate Professor New York, New York
Cooper University Hospital
Camden, New Jersey
Contributors xix
Ohad Ronen, MD Thomas J. Salinas, DDS Anne G.M. Schilder, MD, PhD
Director Professor Professor
Head and Neck Surgery Unit Department of Dental Specialties evidENT
Department of Otolaryngology–Head Mayo Clinic Ear Institute
and Neck Surgery Rochester, Minnesota University College London
Galilee Medical Center National Institute of Health Research
Sandeep Samant, MD
Nahariya, Israel; University College London Hospitals
Chief, Division of Head and Neck and
Azrieli Faculty of Medicine Biomedical Research Centre
Skull Base Surgery
Bar-Ilan University London, United Kingdom
Professor and Vice-Chairman
Safed, Israel
Department of Otolaryngology–Head Joshua S. Schindler, MD
Kristina W. Rosbe, MD and Neck Surgery Associate Professor
Professor and Chief of Pediatric University of Tennessee Health Science Department of Otolaryngology
Otolaryngology Center Oregon Health and Science University
Department of Otolaryngology–Head Memphis, Tennessee Medical Director
and Neck Surgery OHSU–Northwest Clinic for Voice and
Robin A. Samlan, PhD
University of California, San Francisco Swallowing
Associate Professor
San Francisco, California Portland, Oregon
Department of Speech, Language, and
Richard M. Rosenfeld, MD, MPH, MBA Hearing Sciences Cecelia E. Schmalbach, MD, MSc,
Distinguished Professor and Chairman Assistant Professor FACS
Department of Otolaryngology Department of Otolaryngology–Head David Myers MD Professor and Chair
SUNY Downstate Medical Center and Neck Surgery Department of Otolaryngology– Head
Brooklyn, New York University of Arizona and Neck Surgery
Tucson, Arizona Director, Temple Head and Neck
Bruce E. Rotter DMD, MS
Institute
Professor and Dean Guri S. Sandhu, MBBS, MD, FRCS,
Lewis Katz School of Medicine at Temple
Southern Illinois University FRCS (ORL-HNS)
University
School of Dental Medicine Consultant Otolaryngologist/Airway
Edwardsville, Illinois Surgeon
Department of Otolaryngology–Head Scott R. Schoem, MD, MBA
Christopher R. Roxbury, MD
and Neck Surgery Director
Assistant Professor
Charing Cross Hospital Department of Otolaryngology
Rhinology and Endoscopic Skull Base
Imperial College Healthcare NHS Trust Connecticut Children’s Medical Center
Surgery
London, United Kingdom Hartford, Connecticut;
University of Chicago
Clinical Professor
Chicago, Illinois Kathleen M. Sarber, MD
Assistant Professor
Michael J. Ruckenstein, MD University of Connecticut School of
Professor Health Sciences
F. Edward Hébert School of Medicine
Department of Otolaryngology–Head Farmington, Connecticut
Uniformed Services University of the
and Neck Surgery
Health Sciences Michael C. Schubert, PT, PhD, FAPTA
Hospitals of the University of
Bethesda, Maryland Professor
Pennsylvania
Departments of Otolaryngology–Head
Philadelphia, Pennsylvania Cara L. Sauder, PhC, CCC-SLP
and Neck Surgery
Speech Pathologist
Christina L. Runge, PhD and Physical Medicine and Rehabilitation
Department of Speech and Hearing
Professor Johns Hopkins University School of
Sciences
Chief, Division of Communication Medicine
University of Washington
Sciences Baltimore, Maryland
Seattle, Washington
Director, Koss Cochlear Implant
Joseph Schulte, MD
Program Richard L. Scher, MD, FACS
Fellow
Department of Otolaryngology and Professor Emeritus
Communication Sciences Head and Neck Surgery and
Johns Hopkins University
Medical College of Wisconsin Communication Sciences
Baltimore, Maryland
Milwaukee, Wisconsin Duke University Health System
Durham, North Carolina; Yehuda Schwarz, MD
Leonard P. Rybak, MD, PhD
Executive Director Director of Pediatric Otolaryngology
Research Professor
ENT Procedure Innovation and Service
Development Department of Otolaryngology–Head
Southern Illinois University School of
Olympus Corporation and Neck Surgery
Medicine
Southborough, Massachusetts Samson Assuta Ashdod University
Springfield, Illinois
Hospital
Robert Saadi, MD Faculty of Health Sciences
Resident Ben Gurion University of the Negev
Department of Otolaryngology Be’er Sheva, Israel;
Hershey Medical Center Senior Physician
Hershey, Pennsylvania Department of Otolaryngology–Head
and Neck Surgery
Shaare Zedek Medical Center
Jerusalem, Israel
xx Contributors
James J. Sciubba, DMD, PhD Clough Shelton, MD, FACS William H. Slattery III, MD
Professor (Retired) C. Charles Hetzel Jr MD and Alice President
Department of Otolaryngology–Head Barker Hetzel Presidential Endowed House Ear Clinic
and Neck Surgery Chair in Otolaryngology Clinical Professor
Johns Hopkins School of Medicine Professor and Chief, Division of Department of Otolaryngology–Head
Consultant Otolaryngology–Head and Neck and Neck Surgery
The Milton J. Dance Head & Neck Surgery University of California, Los Angeles
Center University of Utah Clinical Professor
The Greater Baltimore Medical Center Salt Lake City, Utah Department of Otolaryngology
Baltimore, Maryland University of Southern California
Seiji B. Shibata, MD, PhD
Los Angeles, California
Anthony P. Sclafani, MD, FACS Clinical Fellow in Otology/Neurotology
Director Department of Otolaryngology–Head Kristine A. Smith, MD
Department of Facial Plastic Surgery and Neck Surgery Assistant Professor
Weill Cornell Medical Center University of Iowa Hospitals and Clinics Rhinology and Skull Base Surgery
Professor Iowa City, Iowa Department of Otolaryngology–Head
Yelizaveta Shnayder, MD, FACS
and Neck Surgery University of Manitoba
Professor
Weill Cornell Medical College Winnipeg, Manitoba, Canada;
New York, New York Department of Otolaryngology–Head
and Neck Surgery
and Neck Surgery
Hadi R. Seikaly, MD, MAL, FRCS(C) University of Kansas School of Medicine
University of Utah School of Medicine
Professor of Surgery and Oncology Kansas City, Kansas
Salt Lake City, Utah
Director, Division of Otolaryngology–
Elizabeth A. Shuman, MD
Head and Neck Surgery Richard J.H. Smith, MD
Resident Physician
Zone Clinical Department Section Chief Sterba Hearing Research Professor
of Otolaryngology–Head and Neck Department of Otolaryngology–Head
and Neck Surgery
Surgery and Neck Surgery
Department of Surgery Carver College of Medicine
University of Alberta and Alberta Health University of Iowa
Services Douglas R. Sidell, MD Iowa City, Iowa
Edmonton, Alberta, Canada Assistant Professor
Ryan M. Smith, MD
Samuel H. Selesnick, MD Assistant Professor
and Neck Surgery
Professor and Vice Chairman Department of Otorhinolaryngology–
Division of Pediatric Otolaryngology
Department of Otolaryngology–Head Head and Neck Surgery
Stanford University
and Neck Surgery Section of Facial Plastic and
Weill Cornell Medical College Reconstructive Surgery
New York, New York Parul Sinha, MBBS, MS Rush University Medical Center
Resident Chicago, Illinois
Brent A. Senior, MD, FACS, FARS
Professor Timothy L. Smith, MD, MPH
Department of Otolaryngology–Head Professor and Director
and Neck Surgery Oregon Sinus Center at OHSU
University of North Carolina Department of Otolaryngology–Head
St. Louis, Missouri
Chapel Hill, North Carolina and Neck Surgery
Davud B. Sirjani, MD, FACS Oregon Health and Science University
Anu Sharma, PhD
Associate Professor Portland, Oregon
Professor
Department of Speech, Language, and Zachary M. Soler, MD, MSc
Stanford University
Hearing Science Associate Professor
Institute of Cognitive Science Department of Otolaryngology–Head
Center for Neuroscience Jonathan R. Skirko, MD, MHPA, MPH and Neck Surgery
University of Colorado Assistant Professor Medical University of South Carolina
Boulder, Colorado Division of Otolaryngology–Head and Charleston, South Carolina
Neck Surgery
Jeffrey D. Sharon, MD Matthew E. Spector, MD, FACS
University of Utah
Assistant Professor Assistant Professor
Salt Lake City, Utah
Department of Otolaryngology–Head Department of Otolaryngology–Head
and Neck Surgery Heidi K. Slager, AuD and Neck Surgery
University of California, San Francisco Audiologist University of Michigan, Michigan
San Francisco, California Department of Otolaryngology Medicine
University of Michigan Ann Arbor, Michigan
A. Eliot Shearer, MD, PhD
Ann Arbor, Michigan
Clinical Fellow in Pediatric Steven M. Sperry, MD
Otolaryngology Head and Neck Surgeon
Department of Otolaryngology and Department of Otolaryngology–Head
Communication Enhancement and Neck Surgery
Boston Children’s Hospital Advocate Aurora Health
Boston, Massachusetts Milwaukee, Wisconsin
Contributors xxi
Brad A. Stach, PhD Angela Sturm, MD, FACS S. Mark Taylor, MD, FRCS(C), FACS
Director, Division of Audiology Clinical Assistant Professor Professor and Head
Department of Otolaryngology–Head Department of Otolaryngology–Head Department of Otolaryngology–Head
and Neck Surgery and Neck Surgery and Neck Surgery
Henry Ford Hospital McGovern Medical School at UT Health Dalhousie University
Detroit, Michigan Clinical Assistant Professor Halifax, Nova Scotia, Canada
University of Texas Medical Branch at
Robert P. Stachecki Rod A. Teasley, MD, JD
Galveston
Assistant Professor Attending Otolaryngologist
Mallinckrodt Institute of Radiology Tacoma, Washington
and Neck Surgery
Washington University Medical Center
Private Practice Steven A. Telian, MD
St. Louis, Missouri;
Facial Plastic Surgery Associates John L. Kemink Professor of
Department of Radiology
Houston, Texas Neurotology
Barnes-Jewish St. Peters Hospital
Division of Otology-Neurotology
St. Peters, Missouri Melanie Subramanian, MD, MPHS
Resident Physician
Aldo Cassol Stamm, MD, PhD and Neck Surgery
Cardiothoracic Surgery
Chief, Department of Otolaryngology University of Michigan Medical School
Sao Paulo ENT Center Ann Arbor, Michigan
Co-Director, Skull Base
St. Louis, Missouri David J. Terris, MD
Sao Paulo Skull Base Center
Regents’ Professor
Sao Paulo, Brazil John B. Sunwoo, MD
Director of Head and Neck Cancer
James A. Stankiewicz, MD and Neck Surgery
Research
Former Chair and Professor Medical College of Georgia at Augusta
Department of Otolaryngology–Head University
and Neck Surgery and Stanford Cancer
and Neck Surgery Augusta, Georgia
Institute
Loyola University/Trinity Medical Center
Stanford University School of Medicine Aaron L. Thatcher, MD
Maywood, Illinois
Stanford, California Assistant Professor
Jeffrey T. Steitz, MD Department of Otolaryngology–Head
Robert A. Swarm, MD
Facial Plastic and Reconstructive Surgeon and Neck Surgery
Professor
St. Louis Facial Plastic Surgery University of Michigan
Department of Anesthesiology
Synergy ENT Specialists Ann Arbor, Michigan
Chief, Division of Pain Management
St. Louis, Missouri
Washington University School of J. Regan Thomas, MD
Shawn M. Stevens Medicine in St. Louis Professor, Facial Plastic Surgery
Assistant Professor St. Louis, Missouri Department of Otolaryngology–Head
Barrow Neurologic Institute and Neck Surgery
Jonathan M. Sykes, MD
Associate Northwestern University Feinberg
Professor Emeritus
Neurotology Otology and Skull Base School of Medicine
Department of Otolaryngology–Facial
Surgery Chicago, Illinois
Plastic Surgery
Arizona Otolaryngology Consultants
UC Davis Medical Center Sherry R. Timmons, DDS, PhD
Phoenix, Arizona
Sacramento, California Associate Dean for Education
David L. Steward, MD Department of Oral Pathology,
Noah P. Syme, MD
Professor Radiology, and Medicine
Assistant Professor, Head and Neck
Department of Otolaryngology–Head University of Iowa College of Dentistry
Oncology
and Neck Surgery Iowa City, Iowa
Division of Endocrinology
Division of Otolaryngology Tjoson Tjoa, MD
University of Cincinnati College of
University of New Mexico Assistant Professor
Medicine
Albuquerque, New Mexico Department of Otolaryngology–Head
Cincinnati, Ohio
and Neck Surgery
M. Eugene Tardy Jr., MD
David G. Stoddard Jr, MD University of California, Irvine
Professor Emeritus of Otolaryngology–
Rhinologist Irvine, California
Spokane ENT
Department of Otolaryngology Dean M. Toriumi, MD
Spokane, Washington
University of Illinois Medical Center Head, Division of Facial Plastic and
Janalee K. Stokken, MD Chicago, Illinois Reconstructive Surgery
Head and Neck Institute Department of Otolaryngology–Head
Sherard A. Tatum III, MD
The Cleveland Clinic and Neck Surgery
Professor and Interim Chair
Cleveland, Ohio University of Illinois at Chicago
Department of Otolaryngology and
Chicago, Illinois
Pediatrics
SUNY Upstate Medical University Matteo Trimarchi, Prof, MD
Medical Director Associate Professor
Cleft and Craniofacial Center Department of Otorhinolaryngology
Golisano Children’s Hospital IRCCS San Raffaele Hospital
Syracuse, New York Vita-Salute San Raffaele University
Milan, Italy
xxii Contributors
Terance T. Tsue, MD Roderick P. Venekamp, MD, PhD Rohan R. Walvekar, MD

Douglas A. Girod Endowed Professor of Assistant Professor Clinical Professor
Head and Neck Surgical Oncology Julius Center for Health Sciences and Mervin L Trail Endowed Chair for Head
Department of Otolaryngology–Head Primary Care and Neck Oncology
and Neck Surgery General Practice Department of Otolaryngology–Head
University of Kansas School of Medicine University Medical Center Utrecht, and Neck Surgery
Vice President and Physician in Chief Utrecht University Louisiana State University School of
University of Kansas Cancer Center Utrecht, The Netherlands Medicine
Vice President of Physician Services New Orleans, Louisiana
Sunil P. Verma, MD
The University of Kansas Health System
Assistant Professor Jennifer R. Wang, MD, ScM
Kansas City, Kansas
Department of Otolaryngology–Head Assistant Professor
Nathan C. Tu, MD, MHS and Neck Surgery Department of Head and Neck Surgery
Clinical Neurotology Fellow University of California, Irvine School of University of Texas MD Anderson Cancer
Michigan Ear Institute Medicine Center
Farmington Hills, Michigan Irvine, California; Houston, Texas
Director
Michael D. Turner, DDS, MD Tom D. Wang, MD
University Voice and Swallowing Center
Associate Professor Professor and Director
UC Irvine Medical Center
Chief, Division of Oral and Maxillofacial Division of Facial Plastic and
Orange, California
Surgery Reconstructive Surgery
Icahn Mount Sinai Medical School Jennifer A. Villwock, MD Oregon Health and Science University
New York, New York Assistant Professor Portland, Oregon
Ravindra Uppaluri, MD, PhD Bryan K. Ward, MD
and Neck Surgery
Associate Professor Assistant Professor
University of Kansas Medical Center
Harvard Medical School Department of Otolaryngology–Head
Kansas City, Kansas
Director, Head and Neck Surgical and Neck Surgery
Oncology Esther X. Vivas, MD Johns Hopkins University School of
Brigham and Women’s and Dana-Farber Associate Professor Medicine
Cancer Institute Department of Otolaryngology–Head Baltimore, Maryland
Boston, Massachusetts and Neck Surgery
Randal S. Weber, MD
Emory University School of Medicine
Michael F. Vaezi, MD, PhD, MSc Professor
Atlanta, Georgia
Professor of Medicine and Clinical Department of Head and Neck Surgery
Director David Vokes, BHB, MBChB, FRACS University of Texas MD Anderson Cancer
Division of Gastroenterology and Consultant Otolaryngologist and Head Center
Hepatology and Neck Surgeon Houston, Texas
Director, Center for Swallowing and Department of Otorhinolaryngology–
Richard O. Wein, MD, FACS
Esophageal Disorders Head and Neck Surgery
Associate Professor
Director, Clinical Research Auckland City Hospital
Vanderbilt University Medical Center Auckland, New Zealand
and Neck Surgery
P. Ashley Wackym, MD Tufts Medical Center
Kathryn M. Van Abel, MD Professor and Chair Boston, Massachusetts
Assistant Professor Department of Otolaryngology–Head
Gregory S. Weinstein, MD
Department of Otolaryngology and Neck Surgery
Professor and Vice Chair
Mayo Clinic Rutgers Robert Wood Johnson Medical
Rochester, Minnesota School
New Brunswick, New Jersey
Michiel W.M. van den Brekel, MD, PhD The University of Pennsylvania
Chairman, Department of Head and Edward J. Walsh, PhD Philadelphia, Pennsylvania
Neck Oncology and Surgery Senior Research Scientist
Erik K. Weitzel, MD
The Netherlands Cancer Institute–Antoni VA Loma Linda Healthcare System
Deputy Commander
van Leeuwenhoek Loma Linda, California;
US Army Institute of Surgical Research
Professor for Oncology-Related Voice Adjunct Faculty, Department of Speech-
Director, AirMed Research Program
and Speech Disorders Language-Hearing Sciences
Professor of Surgery, USUHS
Amsterdam Center for Language and University of Minnesota
Bethesda, Maryland;
Communication Minneapolis, Minnesota;
Otolaryngology/Rhinology/Skull Base
University of Amsterdam Adjunct Faculty, Department of
Surgery
Amsterdam, The Netherlands Biomedical Sciences
Joint Base
Creighton University
Laura Van Gerven, MD, PhD San Antonio, Texas
Adjunct Faculty, Department of
Assistant Professor
Otolaryngology
Research Group, Experimental
University of Nebraska Medical Center
Otorhinolaryngology
Omaha, Nebraska;
Department of Neurosciences
Adjunct Faculty, School of Natural
Clinical Department of
Resources
Otorhinolaryngology
University of Nebraska
Lincoln, Nebraska
University Hospitals
Leuven, Belgium
Contributors xxiii
D. Bradley Welling, MD, PhD Laurelie R. Wishart, BSpPath(Hons), Carol H. Yan, MD

Walter Augustus LeCompte Professor PhD Assistant Professor
and Chair Research Workforce Development Division of Otolaryngology–Head and
Department of Otology and Laryngology Officer (Allied Health) Neck Surgery
Harvard University Centre for Functioning and Health University of California, San Diego
Chief of Otolaryngology Research San Diego, California
Massachusetts Eye and Ear Metro South Hospital and Health Service
Charles D. Yingling, PhD
Massachusetts General Hospital Lecturer
Clinical Professor
Boston, Massachusetts School of Health and Rehabilitation
Sciences
Katherine Lisa Whitcroft, MBChB and Neck Surgery
(Hons), BSc (Neuroscience), MRCS, Stanford School of Medicine
DOHNS Stanford, California
ENT Specialty Registrar Erika Woodson, MD, FACS
Diana H. Yu, MD
Yorkshire and Humber Deanery Section Head, Otology/Neurotology
Assistant Professor of Clinical Medicine
United Kingdom; Medical Director, Hearing Implant
Director, Interventional Pulmonology
Research Fellow Program
Research
Smell and Taste Clinic Head and Neck Institute
Division of Pulmonary, Critical Care, and
Department of Otorhinolaryngology Cleveland Clinic Foundation
Sleep Medicine
Technische Universität Dresden Clinical Assistant Professor
Keck School of Medicine, University of
Dresden, Germany; Department of Otolaryngology–Head
Southern California
PhD Candidate and Neck Surgery
Los Angeles, California
Ear Institute The Cleveland Clinic Lerner School of
University College, London Medicine Yao Yu, MD
Associate Research Fellow Cleveland, Ohio Assistant Attending
Centre for the Study of the Senses Department of Radiation Oncology
Gayle Ellen Woodson, MD
School of Advanced Study Memorial Sloan Kettering Cancer Center
Adjunct Professor
London, United Kingdom New York, New York
Richard H. Wiggins III, MD Drexel University College of Medicine Bevan Yueh, MD, MPH
Professor, Director of Head and Neck Philadelphia, Pennsylvania George L. Adams Chair for Leadership
Imaging in Otolaryngology
Peter J. Wormald, MD
Departments of Radiology, Associate Dean for Strategy and
Chairman and Professor
Otolaryngology–Head and Neck Innovation
Surgery, and BioMedical Informatics Professor
and Neck Surgery
Division of Otolaryngology–Head and Department of Otolaryngology–Head
Professor, Skull Base Surgery
Neck Surgery and Neck Surgery
University of Adelaide
University of Utah University of Minnesota
Adelaide, South Australia
Salt Lake City, Utah Minneapolis, Minnesota
Douglas M. Worrall, MD
Brent J. Wilkerson, MD Mark E. Zafereo, MD
Resident
Assistant Professor Associate Professor
Icahn School of Medicine at Mount Sinai
and Neck Surgery University of Texas MD Anderson Cancer
New York, New York
San Antonio Military Medical Center Center
San Antonio, Texas Bozena B. Wrobel, MD, FARS Houston, Texas
Associate Professor of Otolaryngology
Eric P. Wilkinson, MD Renzo Zaldivar, MD
and Neurosurgery
Surgeon/Partner Oculofacial Plastic Surgeon
Chief, Division of Rhinology and Skull
House Clinic Oculofacial Plastic Surgery Consultants,
Base Surgery
House Ear Institute PA
USC Caruso Department of
Los Angeles, California Cary, North Carolina
Otolaryngology–Head and Neck
Melissa L. Wingo, MS, PA-C Surgery Adam M. Zanation, MD
Physician Assistant University of Southern California Associate Professor
Laryngology Los Angeles, California Department of Otolaryngology–Head
Bastian Voice Institute and Neck Surgery
Mary Jue Xu, MD
Downers Grove, Illinois University of North Carolina
Resident Physician
Sarah K. Wise, MD, MSCR Department of Otolaryngology–Head
Professor and Neck Surgery Carlton J. Zdanski, MD, FAAP, FACS
Department of Otolaryngology–Head University of California, San Francisco Herbert H. Thorp and Julian T. Mann
and Neck Surgery San Francisco, California Distinguished Professor
Director, Residency Program Department of Otolaryngology–Head
Thomas R. Yackel, MD, MPH, MS, MBA
Emory University School of Medicine and Neck Surgery
Professor
Atlanta, Georgia Surgical Director, The North Carolina
Department of Internal Medicine
Children’s Airway Center
VCU School of Medicine
University of North Carolina School of
Richmond, Virginia
Medicine
xxiv Contributors
David S. Zee, MD Marc S. Zimbler, MD David Zopf, MD, MS

Professor Assistant Clinical Professor Assistant Professor
Departments of Neurology, Department of Otolaryngology–Head Department of Otolaryngology–Head
Ophthalmology, and Otolaryngology– and Neck Surgery and Neck Surgery
Head and Neck Surgery, and NYU Langone Medical Center Pediatric Otolaryngology
Neuroscience New York, New York University of Michigan, Michigan
Johns Hopkins University School of Medicine
S. James Zinreich, MD
Medicine Ann Arbor, Michigan
Professor
Baltimore, Maryland
Russell H. Morgan Department of Teresa A. Zwolan, PhD, CCC-A
Daniel M. Zeitler, MD, FACS Radiology and Radiologic Sciences Professor and Director
Staff Surgeon Johns Hopkins Hospital Department of Otolaryngology
Department of Otolaryngology–Head Baltimore, Maryland University of Michigan Cochlear Implant
and Neck Surgery Program
Virginia Mason Medical Center Ann Arbor, Michigan
Clinical Instructor
and Neck Surgery
University of Washington
Seattle, Washington
Preface
As with all specialties, otolaryngology–head and neck surgery the text. This content includes a 29-slide deck of labeled temporal
continues to evolve as the result of evidence-based medicine, our bone sections arranged in series, providing a valuable educational
ability to understand the immune response to cancer and introduc- resource for understanding ear anatomy and associated function.
tion of targeted therapies, unlocking the genetic basis of disease, We continue to keep the text concise, yet representative of the
and advances in technology across the spectrum of surgical major and notable developments in the field. As with the last
procedures. In response, the seventh edition of Cummings Otolar- edition, the seventh features access to an eBook and the Expert
yngology – Head and Neck Surgery has added 12 new chapters in Consult website, which includes enhanced text and images from
addition to expanding the archive of narrated video clips. Video the book, a full reference list for each chapter, as well as videos
clips, now totaling 73 (up from 49), are cited in the text with live demonstrating ACGME (Accreditation Council for Graduate
links to eBook and Expert Consult. Medical Education) Key Indicator Procedures, and more. The video
New chapters in the otology and skull base section reflect the component provides residents and practitioners the opportunity
growing acceptance of middle ear endoscopy and eustachian tube to visualize and better understand the critical elements of these
surgery in daily clinical practice and the increasing recognition core procedures.
of the public health importance of hearing, vestibular disorders, Our goal is to further the education of those now associated
and geriatric otology. New insights into allergy, chronic rhinosi- with otolaryngology and head and neck surgery and provide a
nusitis, and facial pain are highlighted. New chapters in pediatric foundation for the next generation to follow. Our editors and
diseases include pediatric cochlear implantation, advances in contributors, by tradition, have worldwide representation, thus
otologic surgery, vestibular disorders, and pediatric speech disorders. reflecting the global contributions to the field. Through the
Pediatric airway management includes new chapters on laryngeal combined effort of all contributors, the seventh edition will continue
cleft surgery and management of pediatric tracheostomy. Changes to be the definitive resource of our specialty.
in the epidemiology, science, novel staging, and treatment of
HPV-related head and neck cancer are detailed in updated chapters. Paul W. Flint
In addition, new chapters highlight computer-simulated and Howard W. Francis
modeled dentomandibular reconstruction and advances in the Bruce H. Haughey
technology and approaches to transoral surgery for upper aerodiges- Marci M. Lesperance
tive tract tumors. Valerie J. Lund
New material is now available on our digital platform, Expert K. Thomas Robbins
Consult, to complement several otology and neurotology chapters in J. Regan Thomas
xxv
Acknowledgments
As senior editor, I dedicate this edition to Mark Richardson and serve in this profession at the full extent of my abilities, including
John Niparko, both former editors, colleagues, and friends who my wife, Sarah, my children, Natalie and Ben, and my parents,
met untimely deaths. Here are a few thoughts to share. Millicent and Howard.
John Niparko and I started our faculty careers together under
the mentorship of Charlie Cummings. We arrived at Johns Hopkins Howard W. Francis
a week apart and soon shared a lab, both interested in the central
connections affecting diseases in our areas of interest, the cochlear It continues to be a distinct honor and pleasure to be part of
nucleus for John and the nucleus ambiguous for me (by definition the editorial team assembled for this seventh Edition of Cummings
I was faced with the more daunting challenge). We learned together Otolaryngology–Head and Neck Surgery. The publishers and authors
about the challenges of collaboration and we grew together as a have been tireless in their work to produce chapters that are
result of this relationship. Over time, I realized I would be the comprehensive in scope and depth. My sincere thanks go to each
true beneficiary in this partnership. As we both moved on to our author and their family, who inevitably have put up with liberal
clinical calling, John soon became recognized as the leader in amounts of “burning the midnight oil.” I must also acknowledge
outcomes research in cochlear implantation, mentoring numerous my assistant, Sarah Pete, my PA, Vanessa Hernandez, and our
future leaders now coming of age. In a generation, there are only office staff, who hold the fort for clinical matters while one is
a handful of individuals that succeed in influencing both the practice working on academic projects. Similarly, the fellows and my
of medicine and economics of medicine across their specialty. colleagues at Advent Health Celebration Otolaryngology–Head
John stands tall among them. & Neck Surgery have been highly supportive. Thank you Scott
After 2 years of general surgery, Mark Richardson was my first Magnuson, MD, Michael Seidman, MD, Jim Bekeny, MD, and
otolaryngology attending at the University of Washington. His all the Celebration Florida crew.
compassion for pediatric otolaryngology and empathy for his The ability to purvey knowledge starts with one’s education.
patients was infectious, and at the same time life balance was key My thanks go to my late parents, Thomas and Marjorie Haughey,
to Mark…I worked hard, yet we had many laughs together in my teachers, medical professors, and otolaryngology residency
clinic and OR. I somehow survived the rotation, and so did Mark. and fellowship mentors in both Auckland, New Zealand and at
We crossed paths again at Johns Hopkins, where Mark and Ellen the University of Iowa, Iowa City, IA.
became dear friends with the Flints and the opportunity to assume My family has unswervingly endorsed the time away required
the chair at OHSU under Dean Richardson was an honor. We for this project, so heartfelt love and thanks go to my wife, Helen,
shared a hallway at the oral board exams. We butted heads over as well as to each of my children and grandchildren.
the budget. Our friendship grew. Over the years, I could see the As we enjoy the content of this book and its online components,
influence Mark had on the specialty and beyond. As Chair, he I keep in mind the ultimate source of all knowledge and truth: in
attracted the best and brightest residents. Mark was a superb dean the words of Proverbs 26: “… The Lord gives wisdom and from
and leader in academic medicine and was able to guide the school his mouth come knowledge and understanding.” My sincere hope
of medicine through rocky times. I still admire his ability to deal is that readers learning to and practicing otolaryngology–head
with heated board issues and somehow find the simple solution and neck surgery will benefit from this textbook, better accomplish-
to complex problems. ing our specialty’s goal of top-quality patient care.
It is my sincere privilege to dedicate this textbook to two great
leaders in otolaryngology–head and neck surgery. Bruce H. Haughey
Paul W. Flint It is again my pleasure to serve as editor of the pediatric

otolaryngology chapters for the premier textbook in otolaryngol-
I would like to thank Paul Flint for this opportunity to par- ogy–head and neck surgery. I am grateful to Dr. Flint and Dr.
ticipate in the continuing legacy of the Cummings text. My role Cummings for the opportunity.
as editor of the otology, neurotology, and skull base section brings I owe a debt of gratitude to the authors for sharing their
my career full circle, and as such, I devote my efforts in honor of wealth of experience to benefit future generations of otolaryngolo-
all the teachers, mentors, and sponsors that I have had along my gists. These chapters represent many hours of reviewing the lit-
academic and professional journey from Montego Bay, Jamaica, erature, gathering images, writing and revising, often during
to Los Angeles, Boston, Baltimore, and Durham, NC. Charles evenings and weekends after clinical and other obligations are
Cummings and John Niparko, in particular, loom large in the met. Finally, I thank my husband, Edward Karls, and my children,
development of my professional identity as an academic otolar- Matthew, Michelle, Maria, and Melanie, for their love, patience
yngologist and neurotologist. As their past resident, fellow, and and support.
junior colleague, there is no greater honor than to be entrusted
with continuing their legacy in this role. I thank my work colleagues Marci M. Lesperance
and the wider community of otolaryngologist–head and neck
surgeons who continue to inspire me for their commitment to I thank Paul Flint and his colleagues for my continued involve-
the highest standards of excellence and also the values of compas- ment in this prestigious project, the publishers for their exemplary
sion, inclusivity, and fairness that will keep our specialty innovative, efficiency in its management, and my husband, David Howard,
intellectually vibrant, and increasingly relevant in broader con- for his constant support and encouragement.
siderations of population health. Finally, I would like to acknowledge
the shared sacrifice of my family in making it possible for me to Valerie J. Lund
xxvi
Acknowledgments xxvii
In previous editions of the book, I have used this important serves as a recognizable source of up-to-date information and a
opportunity to memorialize my parents and honor my beloved key reference for modern patient treatment. As an individual who
family, respected colleagues, mentors, and the numerous trainees has been privileged to maintain a career within an academic
with whom I have connected. However, among those I have environment, this textbook provides a solid source of expertise
previously acknowledged is my dearest wife, Gayle Woodson, and information for my residents and fellows in training.
who deserves an acknowledgment encore. Over many years It is particularly rewarding for me as an individual whose career
together, she has excelled as a caring partner, insightful advisor, has been focused on a subspecialty within otolaryngology to provide
and dedicated soulmate. While becoming highly successful within outstanding insight and information into the areas of facial plastic
her own career, she has unselfishly supported my endeavors and reconstructive surgery. I am greatly appreciative to the
throughout our many years in academic medicine. Thank you, contributing authors of this volume for providing their expertise
Gayle. and sharing their experience.
My wife, Rhonda Churchill Thomas, deserves my ongoing
K. Thomas Robbins appreciation and gratitude for her enthusiastic and always present
support for my professional activities. Likewise, I offer my sincere
I am genuinely honored to again have the privilege of serving appreciation to my children, Ryan, Aaron, and Evan, for their
as an editor of this outstanding and internationally recognized inspiration and example.
textbook. As the otolaryngology specialty knowledge and informa-
tion base continues to expand and grow, this multivolume textbook J. Regan Thomas
Contents
VOLUME I 15 Sleep Apnea and Sleep Disorders, 215

Kathleen M. Sarber, Derek J. Lam, and Stacey L. Ishman
PART I
Measuring Outcomes and Performance PART III
1 Outcomes Research, 1
Stephanie Misono and Bevan Yueh
SECTION 1 Facial Surgery
2 Interpreting Medical Data, 8 16 Aesthetic Facial Analysis, 236
Richard M. Rosenfeld
Marc S. Zimbler
3 Evidence-Based Performance Measurement, 24 17 Recognition and Treatment of Skin Lesions, 248
Thomas R. Yackel
Gary Linkov, M. Laurin Council, Andrew Michael Compton, and
Gregory H. Branham
PART II 18 Scar Revision, Keloids, and Camouflage, 260
General Otolaryngology Hilary C. McCrary and Steven Ross Mobley
4 History, Physical Examination, and the 19 Facial Trauma: Soft Tissue Lacerations and
Preoperative Evaluation, 34 Burns, 269
Ericka F. King Justin D. Hill, David G. Stoddard Jr, Grant S. Hamilton III
5 General Considerations of Anesthesia and 20 Maxillofacial Trauma, 286
Management of the Difficult Airway, 49 Robert M. Kellman
Lynette J. Mark, Alexander T. Hillel, Laeben Lester, Seth A. Akst,
Renee Cover, and Kurt Herzer 21 Reconstruction of Facial Defects, 311
Shan R. Baker
6 Surgical Management of the Difficult Adult
Airway, 73 22 Hair Restoration: Medical and Surgical
William E. Karle and Joshua S. Schindler Techniques, 331
Raymond J. Konior and Sahar Nadimi
7 Tracheotomy, 81
Shannon M. Kraft and Joshua S. Schindler 23 Management of Aging Skin, 351
Stephen W. Perkins and Elizabeth M. Floyd
8 Overview of Diagnostic Imaging of the Head and
Neck, 90 24 Rhytidectomy and Facial Liposuction, 371
Devinder S. Mangat and Nadia K. Mostovych
Majid Khan, Joseph Schulte, S. James Zinreich, and Nafi Aygun
9 Deep Neck and Odontogenic Infections, 141 25 The Aesthetic Brow and Forehead, 388
Paul S. Nassif and Julia L. Kerolus
James M. Christian, Charles B. Felts, Nicholas A. Beckmann,
and M. Boyd Gillespie 26 Blepharoplasty, 402
Oren Friedman, Renzo A. Zaldivar, and Tom D. Wang
10 Head and Neck Manifestations in the
Immunocompromised Host, 155 27 Mentoplasty, 416
Jose G. Gurrola II, Steven D. Pletcher, and Andrew N. Goldberg Jonathan M. Sykes, Amanda E. Dilger, John L. Frodel Jr
11 Laryngeal and Tracheal Manifestations of Systemic 28 Otoplasty, 432

Disease, 180 Eric T. Carniol, Peter A. Adamson, Andres Gantous
Kevin P. Leahy
SECTION 2 Rhinoplasty
12 Oral Manifestations of Systemic Diseases, 185
Michael D. Turner 29 The Nasal Septum, 439
Russell W. H. Kridel and Angela Sturm
13 Otolaryngology in the Elderly, 198
Susan D. Emmett 30 Nasal Fractures, 457
Burke E. Chegar and Sherard A. Tatum III
14 Pain Management in the Head and Neck
Patient, 206 31 Rhinoplasty, 470
Michael M. Bottros, Lesley Rao, and Robert A. Swarm Anthony P. Sclafani, J. Regan Thomas, and M. Eugene Tardy Jr
xxix
xxx Contents
32 Special Rhinoplasty Techniques, 510 PART V Laryngology and

Edward H. Farrior Bronchoesophagology
33 Non-Caucasian Rhinoplasty, 532 53 Laryngeal and Pharyngeal Function, 799
Stephen S. Park and Hong-Ryul Jin Gayle Ellen Woodson
34 Revision Rhinoplasty, 544 54 Visual Documentation of the Larynx, 808
Jeffrey T. Steitz, Natalia M. Hajnas, and Dean M. Toriumi Robin A. Samlan and Melda Kunduk
PART IV Sinus, Rhinology, and 55 Voice Evaluation and Therapy, 819

Allergy/Immunology Robin A. Samlan
35 Allergy and Immunology of the Upper 56 Neurologic Evaluation of the Larynx and
Airway, 558 Pharynx, 827
Daniel R. Cox, Sarah K. Wise, and Fuad M. Baroody Gayle Ellen Woodson, Andrew Blitzer, and Diana N. Kirke
36 Olfactory Function and Dysfunction, 586 57 Neurologic Disorders of the Larynx, 832
Katherine Lisa Whitcroft and Thomas Hummel Andrew Blitzer and Diana N. Kirke
37 Objective Assessment of Nasal Function, 603 58 The Professional Voice, 839

Giancarlo Ottaviano and Laura Van Gerven Matthew R. Naunheim, Daniel S. Fink, and Mark S. Courey
38 Imaging of Nose and Sinuses, 616 59 Laser Surgery: Basic Principles and Safety
Majid Khan, S. James Zinreich, and Nafi Aygun Considerations, 854
C. Gaelyn Garrett, Lou Reinisch, and Kenneth C. Fletcher Jr
39 Nonallergic Rhinitis, 636
Carol H. Yan and Peter H. Hwang 60 Benign Vocal Fold Mucosal Disorders, 868
Robert W. Bastian and Melissa L. Wingo
40 Acute Rhinosinusitis: Pathogenesis, Treatment, and
Complications, 643 61 Acute and Chronic Laryngopharyngitis, 897
Michael S. Benninger, Christopher R. Roxbury, Clint T. Allen, Brian Nussenbaum, and Albert L. Merati
and Janalee K. Stokken
62 Medialization Thyroplasty, 906
41 Pathogenesis of Chronic Rhinosinusitis, 649 Paul W. Flint, Joshua S. Schindler, and Charles W. Cummings
Robert C. Kern, Whitney Liddy, and Peter Hellings
63 Arytenoid Adduction and Abduction, 916
42 Chronic Rhinosinusitis: Evidence-Based Medical Gayle Ellen Woodson
Treatment, 660 64 Laryngeal Reinnervation, 922
Kristine A. Smith, Richard R. Orlandi George S. Goding Jr
43 Chronic Rhinosinusitis: Outcomes of Medical and 65 Chronic Aspiration, 930
Surgical Treatment, 667 Elizabeth A. Shuman, Steven D. Pletcher, and David W. Eisele
Daniel M. Beswick, Zachary M. Soler, Claire Hopkins,
and Timothy L. Smith 66 Laryngeal and Esophageal Trauma, 939
S.A. Reza Nouraei and Guri S. Sandhu
44 Primary Sinus Surgery, 677
Devyani Lal and James A. Stankiewicz 67 Surgical Management of Upper Airway
Stenosis, 952
45 Causes of Failure, Revision Surgery for Robert A. Saadi, David Goldenberg, and Johnathan D. McGinn
Rhinosinusitis, and Management of Complications
in Endoscopic Sinus Surgery, 711 68 Diseases of the Esophagus, 964
Vijay R. Ramakrishnan, Benjamin S. Bleier, and David W. Kennedy Robert T. Kavitt and Michael F. Vaezi
46 Management of the Frontal Sinuses, 719 69 Transnasal Esophagoscopy, 992

Wytske J. Fokkens and Richard Harvey Abdulmalik S. Alsaied, Christopher M. Johnson,
and Gregory N. Postma
47 Epistaxis, 733
Edward C. Kuan and James N. Palmer 70 Zenker Diverticulum, 997
Richard L. Scher
48 Cerebrospinal Fluid Rhinorrhea, 745
Martin J. Citardi and Samer Fakhri 71 Tracheobronchial Endoscopy, 1007
Diana H. Yu and David Feller-Kopman
49 Sino-Orbital Interface, 759
Edward El Rassi, Erik K. Weitzel, Benjamin S. Bleier, Peter J. Wormald
PART VI Head and Neck Surgery
50 Benign Tumors of the Sinonasal Tract, 773 and Oncology
Piero Nicolai, Davide Mattavelli, and Paolo Castelnuovo
51 Systemic Disease of the Nose and Sinuses, 788 SECTION 1 General Considerations
Pete S. Batra, Bozena B. Wrobel, and Matteo Trimarchi
72 Fundamentals of Molecular Biology and Gene
52 Facial Pain, 795 Therapy, 1016
Adam J. Kimple and Brent A. Senior Waleed M. Abuzeid, Bert W. O’Malley Jr, and Daqing Li
Contents xxxi
73 Biology of Head and Neck Cancers, 1032 90 Benign Tumors and Tumor-Like Lesions of the
Mary Jue Xu, Joseph O. Humtsoe, and Patrick K. Ha Oral Cavity, 1283
Timothy S. Lian
74 Human Papillomavirus and the Epidemiology of
Head and Neck Cancer, 1043 91 Malignant Neoplasms of the Oral
Eleni Rettig, Christine G. Gourin, and Carole Fakhry Cavity, 1289
Richard O. Wein and Randal S. Weber
75 Radiotherapy for Head and Neck Cancer:
Radiation Physics, Radiobiology, and Clinical 92 Reconstruction of the Mandible, 1316
Principles, 1049 James R. Bekeny, Fawaz Makki, and Hadi R. Seikaly
Aron Popovtzer and Avraham Eisbruch
93 Prosthetic Management of Head and Neck
76 Chemotherapy and Targeted Biologic Agents for Defects, 1331
Head and Neck Cancer, 1070 Jeffery C. Markt and Thomas J. Salinas
Mukul Bhattarai, Edem S. Agamah, and Krishna Rao
94 Malignancies of the Paranasal Sinus, 1363
77 Skin Flap Physiology and Wound Piyush Gupta, Adam M. Zanation, and Ian Ganly
Healing, 1085
Hollin Calloway, Michelle G. Arnold, and Rick M. Odland
SECTION 4 Pharynx and Esophagus
78 Free Tissue Transfer, 1098
Yelizaveta Shnayder, Douglas A. Girod, and Terance T. Tsue
95 Benign and Malignant Tumors of the
Nasopharynx, 1391
79 Integrating Palliative and Curative Care Strategies Donovan Eu and Thomas Loh
in the Practice of Otolaryngology, 1119
Debra Gonzalez
96 Malignant Neoplasms of the
Oropharynx, 1402
80 Management of Cutaneous Head and Neck Parul Sinha and Ulrich Harréus
Melanoma, 1124
Cecelia E. Schmalbach, Alison B. Durham, Timothy M. Johnson,
97 Transoral Approaches to Malignant Neoplasms of
and Carol R. Bradford the Oropharynx, 1423
Eric J. Moore and Kathryn M. Van Abel
98 Reconstruction of the Oropharynx, 1444

VOLUME II Matthew H. Rigby, Bruce H. Haughey, and
S. Mark Taylor
SECTION 2 Salivary Glands
99 Swallowing Function and Implications in Head
81 Physiology of the Salivary Glands, 1139 and Neck Cancer, 1466
Ravindhra G. Elluru Barbara P. Messing, Clare Burns, Laurelie Wishart,
and Bena Brown
82 Diagnostic Imaging and Fine-Needle Aspiration of
the Salivary Glands, 1149 100 Diagnostic Imaging of the Pharynx and
Hilary L. P. Orlowski and Michelle Miller-Thomas Esophagus, 1474
Barton F. Branstetter IV
83 Inflammatory Disorders of the Salivary
Glands, 1157 101 Neoplasms of the Hypopharynx and Cervical
Neal M. Jackson, Jenna L. Mitchell, and Rohan R. Walvekar Esophagus, 1503
Matthew E. Spector and Ravindra Uppaluri
84 Benign Neoplasms of the Salivary Glands, 1171
Jennifer R. Wang, Diana M. Bell, and Ehab Y. Hanna 102 Radiotherapy and Chemotherapy of Squamous Cell
85 Malignant Neoplasms of the Salivary Carcinomas of the Hypopharynx and
Glands, 1189 Esophagus, 1519
Davud B. Sirjani, James S. Lewis Jr, Beth M. Beadle, Keith Casper, Michelle Mierzwa, Peter Hawkins
and John B. Sunwoo 103 Reconstruction of the Hypopharynx and
Esophagus, 1528
SECTION 3 Oral Cavity Douglas B. Chepeha
86 Physiology of the Oral Cavity, 1213

Mohamedkazim M. Alwani, Fawaz M. Makki, SECTION 5 Larynx
and K. Thomas Robbins
104 Diagnostic Imaging of the Larynx, 1542
87 Oral Mucosal Lesions, 1230 Matthew S. Parsons and Robert P. Stachecki
James J. Sciubba
105 Malignant Tumors of the Larynx, 1564
88 Odontogenesis, Odontogenic Cysts, and William B. Armstrong, David E. Vokes, Tjoson Tjoa,
Odontogenic Tumors, 1254 and Sunil P. Verma
John W. Hellstein and Sherry R. Timmons
106 Management of Early Glottic Cancer, 1596
89 Temporomandibular Joint Disorders, 1276 Noah P. Syme, Henry T. Hoffman, Carryn Anderson,
Bruce E. Rotter, Fawaz Makki and Nitin A. Pagedar
xxxii Contents
107 Transoral Laser Microresection of Advanced PART VII Otology, Neurotology, and Skull
Laryngeal Tumors, 1617 Base Surgery
Michael L. Hinni, David G. Lott, and Gregory S. Neel
108 Conservation Laryngeal Surgery, 1635 SECTION 1 Basic Science

Steven M. Sperry, Gregory S. Weinstein, and Ollivier Laccourreye
126 Anatomy of the Temporal Bone, External Ear, and
109 Total Laryngectomy and Middle Ear, 1928
Laryngopharyngectomy, 1660 Howard W. Francis
Christopher H. Rassekh and Bruce H. Haughey
127 Neuroanatomy of the Auditory System, 1938
110 Radiation Therapy for Cancer of the Larynx and Christina L. Runge and David R. Friedland
Hypopharynx, 1677 128 Physiology of the Auditory System, 1945
Parvesh Kumar
Wade W. Chien and Daniel J. Lee
111 Vocal and Speech Rehabilitation After 129 Anatomy of the Vestibular System, 1958
Laryngectomy, 1696 Anna Lysakowski
Frans J.M. Hilgers, Michiel W.M. van den Brekel, and
Kai Johannes Lorenz 130 Anatomy and Physiology of the Eustachian
Tube, 1977
112 Diagnosis and Management of Tracheal Robert C. O’Reilly and Jessica Levi
Neoplasms, 1716
Melanie Subramanian and G. Alexander Patterson 131 Clinical Evaluation and Management of the
Eustachian Tube, 1984
Bryan K. Ward and Dennis S. Poe
SECTION 6 Neck
132 Cortical Neuroplasticity in Hearing
113 Differential Diagnosis of Neck Masses, 1732
Elizabeth Bradford Bell, Ajani Nugent, Mark W. El-Deiry
Loss, 1996
Anu Sharma and Hannah Glick
114 Ultrasound Imaging of the Neck, 1739
Jeffrey J. Houlton and David L. Steward
133 Geriatric Otology: Population Health and Clinical
Implications, 2011
115 Neoplasms of the Neck, 1755 Carrie L. Nieman, Frank R. Lin, and Yuri Agrawal
Terry A. Day and W. Greer Albergotti
116 Lymphomas Presenting in the Head and SECTION 2 Diagnostic Assessment

Neck, 1773
Mukul Bhattarai and Krishna Rao 134 Diagnostic Audiology and Electrophysiologic
Assessment of Hearing, 2021
117 Radiation Therapy and Management of the Paul R. Kileny, Teresa A. Zwolan, and Heidi K. Slager
Cervical Lymph Nodes and Malignant Skull Base
Tumors, 1786 135 Neuroradiology of the Temporal Bone and Skull
Vincent Grégoire, Nancy Lee, Marc Hamoir, and Yao Yu Base, 2042
Geoffrey C. Casazza, Richard H. Wiggins III, Richard K. Gurgel,
118 Neck Dissection, 1806 Bronwyn E. Hamilton, and Clough Shelton
Ohad Ronen, Sandeep Samant, and K. Thomas Robbins
136 Interventional Neuroradiology of the Skull Base,
119 Complications of Neck Surgery, 1831 Head, and Neck, 2063
Wojciech K. Mydlarz and David W. Eisele Richard E. Latchaw, Sheri L. Albers, and Brian C. Dahlin
120 Penetrating and Blunt Trauma to the 137 Otologic Symptoms and Syndromes, 2080
Neck, 1840 Erika Woodson and Sarah Mowry
David B. Hom, Jeffrey J. Harmon Jr, and Robert H. Maisel
SECTION 3 External Ear

SECTION 7 Thyroid/Parathyroid
138 Infections of the External Ear, 2093
121 Disorders of the Thyroid Gland, 1852 James G. Naples, Jason A. Brant, and
Phillip K. Pellitteri, David Goldenberg, and Brian Jameson Michael J. Ruckenstein
122 Management of Thyroid Neoplasms, 1869 139 Topical Therapies of External Ear
Faisal I. Ahmad, Mark E. Zafereo, and Stephen Y. Lai Disorders, 2101
123 Management of Parathyroid Disorders, 1899 Kinneri Mehta, Daniel J. Lee, and Daniel S. Roberts
Lisa M. Reid, Dipti Kamani, and Gregory W. Randolph
124 Surgical Robotics in Otolaryngology, 1909 SECTION 4 Middle Ear, Mastoid, and
David J. Terris and J. Kenneth Byrd Temporal Bone
125 Management of Thyroid Eye Disease (Graves 140 Chronic Otitis Media, Mastoiditis, and
Ophthalmopathy), 1917 Petrositis, 2118
Jennifer A. Villwock, Douglas A. Girod, and Christopher G. Larsen Richard A. Chole and Jeffrey D. Sharon
Contents xxxiii
141 Complications of Temporal Bone 160 Cochlear Implantation: Patient Evaluation and
Infections, 2135 Device Selection, 2413
Cameron L. Budenz and Hussam K. El-Kashlan P. Ashley Wackym, Kellie J. Hirce, Heidi J. Bernknopf,
and Howard W. Francis
142 Tympanoplasty and Ossiculoplasty, 2155
Meredith E. Adams and Hussam K. El-Kashlan 161 Medical and Surgical Considerations in Cochlear
Implantation, 2425
143 Mastoidectomy: Surgical Techniques, 2166 Thomas J. Balkany and Daniel M. Zeitler
Shawn M. Stevens and Paul R. Lambert
162 Cochlear Implantation in Adults: Results,
144 Middle Ear Endoscopic Surgery, 2178 Outcomes, Rehabilitation, and Education, 2439
Matthew M. Dedmon, Daniele Marchioni, and Alejandro Rivas
Nicole T. Jiam and Charles J. Limb
145 Clinical Assessment and Surgical Treatment of 163 Auditory Brainstem Implantation, 2448
Conductive Hearing Loss, 2186 Baishakhi Choudhury, Nicholas L. Deep, Eric P. Wilkinson,
James C. Prueter, Rod A. Teasley, and Douglas D. Backous and J. Thomas Roland Jr
146 Otosclerosis, 2197 164 Hearing Aid Amplification, 2455
John W. House and Calhoun D. Cunningham III Brad A. Stach and Virginia Ramachandran
147 Management of Temporal Bone
Trauma, 2207 SECTION 7 Vestibular Disorders
Brent J. Wilkerson, Hilary A. Brodie, and Mostafa M. Ahmed
165 Principles of Applied Vestibular
Physiology, 2466
VOLUME III John P. Carey and Charles C. Della Santina
166 Evaluation of the Patient With Dizziness, 2495

SECTION 5 Inner Ear Timothy E. Hullar, David S. Zee, and Lloyd B. Minor
148 Cochlear Transduction and the Molecular Basis of 167 Peripheral Vestibular Disorders, 2517
Auditory Pathology, 2221 Benjamin T. Crane and Lloyd B. Minor
JoAnn McGee and Edward J. Walsh
168 Central Vestibular Disorders, 2536
149 Genetics of Ear Disorders, 2269 Benjamin T. Crane and David M. Kaylie
Nathan C. Tu and Rick A. Friedman
169 Surgery for Vestibular Disorders, 2551
150 Genetic Sensorineural Hearing Steven A. Telian and Gregory J. Basura
Loss, 2279
A. Eliot Shearer, Seiji B. Shibata, and Richard J.H. Smith 170 Vestibular and Balance Rehabilitation Therapy:
Program Essentials, 2563
151 Otologic Manifestations of Systemic Jennifer L. Millar and Michael C. Schubert
Disease, 2293
Joseph B. Nadol Jr and Alicia M. Quesnel
SECTION 8 Facial Nerve Disorders
152 Sensorineural Hearing Loss in Adults, 2311
H. Alexander Arts and Meredith E. Adams
171 Tests of Facial Nerve Function, 2574
Oliver Y. Chin and Rodney C. Diaz
153 Tinnitus and Hyperacusis, 2328
Douglas M. Worrall and Maura K. Cosetti
172 Clinical Disorders of the Facial Nerve, 2587
Douglas E. Mattox and Esther X. Vivas
154 Noise-Induced Hearing Loss, 2342
Colleen G. Le Prell
173 Intratemporal Facial Nerve Surgery, 2598
Rick F. Nelson, Samuel P. Gubbels, and Bruce J. Gantz
155 Infections of the Labyrinth, 2356
John C. Goddard and William H. Slattery III
174 Rehabilitation of Facial Paralysis, 2611
Ryan M. Smith, Kofi Boahene, and Patrick Byrne
156 Autoimmune Inner Ear Disease, 2365
James G. Naples, Jason A. Brant, and Michael J. Ruckenstein SECTION 9 Cranial Base
157 Vestibular and Auditory Ototoxicity, 2370 175 Surgical Anatomy of the Lateral Skull Base, 2624
Leonard P. Rybak Nikolas H. Blevins, Samuel H. Selesnick, and
Jennifer Christy Alyono
158 Pharmacologic and Molecular Therapies of the
Cochlear and Vestibular Labyrinths, 2381 176 Surgery of the Anterior and Middle Cranial
Anil K. Lalwani and Z. Jason Qian Base, 2634
Stephen T. Green, Rohan R. Walvekar, Frank Culicchia,
SECTION 6 Auditory Prosthetic Stimulation, and Daniel W. Nuss
Devices, and Rehabilitative Audiology
177 Transnasal Endoscopic-Assisted Surgery of the
159 Implantable Hearing Devices, 2396 Anterior Skull Base, 2662
Francis X. Creighton Jr, Lawrence R. Lustig, Aldo Cassol Stamm, Shirley S.N. Pignatari, Leonardo Balsalobre,
and Charles C. Della Santina and Camila Soares Dassi
xxxiv Contents
178 Temporal Bone Neoplasms and Lateral Cranial SECTION 3 Hearing Loss and Pediatric Otology
Base Surgery, 2678
Samuel P. Gubbels, Renee Banakis Hartl, Matthew G. Crowson, 192 Pediatric Otologic Surgery, 2881
Herman A. Jenkins, and Michael Marsh Simon D. Carr, Adrian L. James, Sharon L. Cushing,
and Blake C. Papsin
179 Neoplasms of the Posterior Fossa, 2699
Moisés A. Arriaga and Derald E. Brackmann 193 Early Detection and Diagnosis of Infant Hearing
Impairment, 2887
180 Intraoperative Monitoring of Cranial Nerves in M. Elise Graham, Kavita Dedhia, Albert H. Park
Neurotologic Surgery, 2729
Yasmine A. Ashram and Charles D. Yingling 194 Congenital Malformations of the Inner Ear, 2898
Taha A. Jan, Alan G. Cheng, and Robert K. Jackler
181 Radiation Therapy of Benign Tumors of the
Cranial Base, 2746 195 Microtia Reconstruction, 2917
Nicholas A. Dewyer, Dunia Abdul-Aziz, and D. Bradley Welling David Zopf, Elizabeth Knecht, and Jennifer Kim
196 Pediatric Cochlear Implantation, 2926

PART VIII Pediatric Otolaryngology Howard W. Francis, Carlton J. Zdanski, Ivette Cejas,
and Laurie Eisenberg
SECTION 1 General
197 Evaluation and Management of Congenital Aural
182 General Considerations in Pediatric Atresia, 2935
Otolaryngology, 2754 Bradley W. Kesser and Kay W. Chang
Alan T.L. Cheng
198 Evaluation and Management of Pediatric Vestibular
183 Pediatric Speech Disorders, 2767 Disorders, 2950
Lynn E. Driver and Marc E. Nelson Sharon L. Cushing and Blake C. Papsin
184 Anesthesia in Pediatric Otolaryngology, 2772
Michael P. Puglia II, Ashlee E. Holman, Anila B. Elliott, SECTION 4 Infections and Inflammation
and Catherine A. Gruffi
199 Acute Otitis Media and Otitis Media with
185 Nonobstructive Pediatric Sleep Disorders, 2794 Effusion, 2956
Bailey Pierce and Scott E. Brietzke Anne G.M. Schilder, Richard M. Rosenfeld, and
Roderick P. Venekamp
186 Evaluation and Management of Pediatric
Obstructive Sleep Apnea, 2798 200 Pediatric Chronic Rhinosinusitis, 2970
Nira A. Goldstein Fuad M. Baroody
201 Pediatric Infectious Disease, 2979

SECTION 2 Craniofacial Yi Cai and Anna Meyer
187 Craniofacial Surgery for Congenital and Acquired
Deformities, 2808 SECTION 5 Head and Neck
Joshua C. Demke and Sherard A. Tatum III
202 Congenital and Inflammatory Neck Masses in
188 Cleft Lip and Palate, 2833 Children, 2989
Tom D. Wang and Henry A. Milczuk Aaron L. Thatcher
189 Velopharyngeal Dysfunction, 2850 203 Vascular Anomalies of the Head and
Harlan R. Muntz, Cara L. Sauder, Jeremy D. Meier, Neck, 3002
Jonathan R. Skirko M. Elise Graham, Jonathan A. Perkins, and
J. Fredrik Grimmer
190 Congenital and Acquired Malformations of the
Nose and Nasopharynx, 2859 204 Pediatric Head and Neck Neoplasms, 3020
Ravindhra G. Elluru Jennifer Brinkmeier, Aaron L. Thatcher
191 Pediatric Facial Fractures, 2871 205 Salivary Gland Disease in Children, 3035
Lauren A. Bohm and Brianne Roby Sam J. Daniel and Yehuda Schwarz
SECTION 6 Pharynx, Larynx, Trachea, 211 Aerodigestive Foreign Bodies and Caustic
Ingestions, 3119
and Esophagus Scott R. Schoem, Kristina W. Rosbe, Edward R. Lee
206 Evaluation and Management of the Pediatric 212 Pediatric Swallowing, Laryngopharyngeal and
Airway, 3053 Gastroesophageal Reflux Disease, Eosinophilic
Douglas R. Sidell and Anna H. Messner
Esophagitis, and Aspiration, 3132
207 Ankyloglossia and Tight Maxillary Frenula, 3068 Robert H. Chun, Richard J. Noel, and Joan C. Arvedson
Anna H. Messner and Jennifer F. Ha
213 Pediatric Tracheotomy and Decannulation, 3139
208 Recurrent Respiratory Papillomatosis, 3076 Nathan J. Gonik
Craig S. Derkay and Paolo Campisi
214 Laryngotracheal Clefts, 3146
209 Glottic and Subglottic Stenosis and Related Voice Jad Jabbour, Sukgi S. Choi, and Reza Rahbar
Disorders, 3092 Appendix: Temporal Bone Anatomy in Serial Sections
Claire M. Lawlor, Reza Rahbar, and Sukgi S. Choi
(available online only at Expert Consult)
210 Diagnosis and Management of Tracheal Anomalies
and Tracheal Stenosis, 3107
Glenn E. Green and Richard G. Ohye
Video Contents xxxv
Video Contents
24.1 Rhytidectomy, Part I 49.1 Endoscopic Dacryocystorhinostomy

24.2 Rhytidectomy, Part II 50.1 Endoscopic Resection of Juvenile Angiofibroma
25.1 Augmentation of the Temple with Fat 54.1 Stroboscopy: Normal
28.1 Otoplasty 54.2 Stroboscopy: Cyst
32.1 Soft Tissue Augmentation in Thin-Skinned Nasal Tips 54.3 Stroboscopy: Cyst 1
32.2 Upper Lateral Cartilage Turn-in Flap 54.4 Stroboscopy: Nodules
32.3 Diced Cartilage in Temporalis Fascia for Dorsal 54.5 Stroboscopy Polyp 1
Augmentation
54.6 Stroboscopy: Polyp
44.1 Preoperative CT Review
54.7 Stroboscopy: Vocal Fold Scar
44.2 Diagnostic Nasal Endoscopy
54.8 Stroboscopy: Unilateral Vocal Fold Motion
44.3 Vasoconstrictor Injection Impairment
44.4 Maxillary Antrostomy 54.9 Paradoxical Vocal Cord Dysfunction/Vocal Cord
Dysfunction
44.5 Complete Ethmoidectomy (Anterior and Posterior
Ethmoidectomy) 54.10 LHSV: Cyst
44.6 Sphenoidotomy 54.11 LHSV: Nodules
44.7 Skull Base Dissection 54.12 LHSV: Polyp
44.8 Suture Medialization of Middle Turbinates 54.13 LHSV: Vocal Fold Scar
44.9 Primary Endoscopic Sinus Surgery 54.14 LHSV: Scar 1
44.10 Allergic Fungal Sinusitis (Left Side Dissection) 54.15 LHSV: Unilateral Vocal Fold Motion Impairment
44.11 Well-Healed Sinuses after ESS 60.1 Hemorrhagic Polyp
xxxv
xxxvi Video Contents
60.2 Mucous Retention Cyst 128.1 Left Superior Canal Dehiscence Repair
60.3 Mucous Retention Cyst 2 131.1 Examination of the Nasopharynx of a Normal
Eustachian Tube
67.1 Microdebrider Resection of Laryngeal Papilloma
131.2 Example of a Balloon Dilation of the Cartilaginous
69.1 Example of TNE Procedure
Portion of the Eustachian Tube in a Patient with Right
97.1 Transoral Lateral Oropharyngectomy Obstructive Eustachian Tube Dysfunction
97.2 Base of Tongue in Transoral Resection 131.3 Example of Medial and Lateral Excursions of the Left
Tympanic Membrane in a Patient with Patulous
106.1 Microdirect Laryngoscopy with Resection of
Eustachian Tube Dysfunction
Leukoplakia—“Floating the Lesion”
131.4 Example of a Shim Insertion in a Patient with Right
109.1 Laryngectomy (Key Indicator Video)
Patulous Eustachian Tube Dysfunction
111.1 Patient Speaking with Automatic Valve (counting and
131.5 Example of Injecting Hydroxyapatite Bone Cement
telling the days in the week in Dutch)
into the Eustachian Tube of a Patient with Left-Sided
111.2 Animation of Provox Vega System Insertion Patulous Eustachian Tube Dysfunction
111.3 Animation of Provox Vega Tube Insertion 142.1 Tympanoplasty (Key Indicator Video)
111.4 Animation of Provox Vega Capsule Insertion 144.1 Trimming of Ear Canal Hairs to Minimize Endoscope
“Smudging”; Vascular Strip Injection
111.5 Animation of Provox Vega Overshooting–System
Insertion 144.2 Incision Placement and Hemostasis Techniques During
Flap Elevation
111.6 Animation of Provox Vega Overshooting–Tube
Insertion 145.1 Stapedectomy (Key Indicator Video)
111.7 Primary Tracheoesophageal Puncture with Provox 146.1 Laser Stapedotomy
Vega Puncture Set
169.1 Transmastoid Labyrinthectomy
111.8 Short Myotomy of Upper Esophageal Sphincter
169.2 Retrolabyrinthine Vestibular Nerve Sectioning
111.9 Sectioning of Sternocleidomastoid Muscles
173.1 MCF Approach to Facial Nerve Decompression
111.10 Secondary Tracheoesophageal Provox Vega 174.1 Intraoperative Video of Masseteric Nerve Dissection
Puncture Set and Masseteric to Facial Nerve Transfer for Treatment
of Facial Paralysis
111.11 Videofluoroscopy of Tracheoesophageal Voicing
Appendix: Temporal Bone Anatomy in Serial Sections
114.1 Head and Neck Cineloops
Vertically sectioned normal temporal bone arranged in
114.2 Thyroid Ultrasound & FNA sequence at variable intervals; 29 slides show relevant
structures, and anatomic relationships are pointed out
118.1 Selective Neck Dissection: Levels II through IV (Key
and labeled.
Indicator Video)
PART
I Measuring Outcomes and Performance
1 Outcomes Research
Stephanie Misono, Bevan Yueh
KEY POINTS measured using survival, costs, and physiologic measures, as well
as health-related quality of life (HRQOL).
• Outcomes research, or clinical epidemiology, is the study To gain scientific insight into these types of outcomes in the
of treatment effectiveness or the success of treatment observational (nonrandomized) setting, outcomes researchers and
in the nonrandomized, real-world setting. It allows care providers relying on evidence-based medicine (EBM) need
researchers to gain knowledge from observational data. to be fluent in methodologic techniques that are borrowed from
a variety of disciplines, including epidemiology, biostatistics,
• Bias and confounding can affect researchers’ economics, management science, and psychometrics. A full descrip-
interpretation of study data. Accurate assessments of tion of the techniques in clinical epidemiology3 is beyond the
baseline disease status, treatment given, and outcomes of scope of this chapter. The goal of this chapter is to provide a
treatment is critical to sound outcomes research. primer on the basic concepts in effectiveness research and to
• Many types of studies are available to evaluate treatment provide a sense of the breadth and capacity of outcomes research
effectiveness and include randomized trial, observational and clinical epidemiology.
study, case-control study, case series, and expert
opinions. The concept of evidence-based medicine uses
the level of evidence presented in the aforementioned
HISTORY
studies to grade diagnostic and treatment In 1900, Dr. Ernest Codman proposed to study what he termed
recommendations. Meta-analyses can summarize the “end-results” of therapy at the Massachusetts General Hospital.4
findings across multiple studies and provide important He asked his fellow surgeons to report the success and failure of
insights into the body of literature. each operation and developed a classification scheme by which
• Outcomes in clinical epidemiology can be difficult to failures could be further detailed. Over the next two decades, his
quantify, and thus instruments measuring these attempts to introduce systematic study of surgical end-results were
outcomes must meet criteria of the Classical Test scorned by the medical establishment, and his prescient efforts
Theory (reliability, validity, responsiveness, and burden) to study surgical outcomes gradually faded.
or the Item Response Theory to be considered Over the next 50 years, the medical community accepted the
psychometrically valid. randomized clinical trial (RCT) as the dominant method for
evaluating treatment.5 By the 1960s, the authority of the RCT
• Many outcomes instruments have been created to assess was rarely questioned.6 However, a landmark 1973 publication by
health-related quality of life. These scales are generic or Wennberg and Gittelsohn spurred a reevaluation of the value of
disease specific, including assessment of head and neck observational (nonrandomized) data. These authors documented
cancer, otologic disease, rhinologic disease, pediatric significant geographic variation in rates of surgery.7 Tonsillectomy
disease, voice disorders, sleep disorders, and facial plastic rates in 13 Vermont regions varied from 13 to 151 per 10,000
surgery outcomes. persons, even though there was no variation in the prevalence of
tonsillitis. Even in cities with similar demographics and similar
access to health care (Boston and New Haven), rates of surgical
procedures varied tenfold. These findings raised the question of
whether the higher rates of surgery represented better care or
INTRODUCTION unnecessary surgery.
The time when physicians chose treatment based solely on their Researchers at the Rand Corporation sought to evaluate the
personal opinions of what was best is past. This era, although appropriateness of surgical procedures. Supplementing relatively
chronologically recent, is now conceptually distant. In a health sparse data in the literature about treatment effectiveness with
care environment altered by abundant information on the internet expert opinion conferences, these investigators argued that rates
and continual oversight by managed care organizations, patients of inappropriate surgery were high.8 However, utilization rates
and insurers are now active participants in selecting treatment. did not correlate with rates of inappropriateness and therefore
Expert opinions are replaced by objective evidence representing did not explain all of the variation in surgical rates.9,10 To some,
multiple stakeholders, and the physician’s sense of what is best is this suggested that the practice of medicine was anecdotal and
being supplemented by patients’ perspectives on outcomes after inadequately scientific.11 In 1988 a seminal editorial by physicians
treatment. from the Health Care Financing Administration argued that a
Outcomes research (clinical epidemiology) is the scientific study fundamental change towards study of treatment effectiveness was
of treatment effectiveness. The word “effectiveness” is critical necessary.12 These events subsequently led Congress to establish
because it pertains to the success of treatment in populations the Agency for Health Care Policy and Research in 1989 (since
found in actual practice in the real world, as opposed to treatment renamed the Agency for Healthcare Research and Quality [AHRQ]),
success in the controlled populations of randomized clinical trials which was charged with “systematically studying the relationships
in academic settings (“efficacy”).1,2 Success of treatment can be between health care and its outcomes.”
1
CHAPTER 1 Outcomes Research 1.e1
Abstract Keywords
1
Outcomes research or clinical epidemiology is the study of treat- Outcomes research
ment effectiveness or the success of treatment in the nonrandom- clinical epidemiology
ized, real-world setting. It allows researchers to gain knowledge health services research
from observational data. Bias and confounding can affect research- bias
ers’ interpretation of study data, and an accurate assessment of outcomes instruments
baseline disease status, comorbidities, treatment given, and outcomes
of treatment is critical to sound outcomes research. Outcomes
can be evaluated in terms of efficacy or effectiveness. Many types
of studies are available to evaluate treatment effectiveness and
include the randomized trial, observational study, case-control
study, case series, and expert opinions. The concept of evidence-
based medicine uses the level of evidence presented in the
aforementioned studies to grade diagnostic and treatment recom-
mendations. Meta-analyses can summarize findings across multiple
studies and provide important insights into the body of literature.
Outcomes in clinical epidemiology can be difficult to quantify,
and thus instruments measuring these outcomes must meet criteria
of the Classical Test Theory (reliability, validity, responsiveness,
and burden) or the Item Response Theory to be considered psycho-
metrically valid. Many outcomes instruments have been created,
which assess health-related quality of life. These scales are generic
or disease specific, including assessment of head and neck cancer,
otologic disease, rhinologic disease, pediatric disease, voice dis-
orders, sleep disorders, and facial plastic surgery outcomes.
2 PART I Measuring Outcomes and Performance
In the past decade, outcomes research and the AHRQ have this is often incomplete. Inclusion criteria should include all relevant
become integral to understanding treatment effectiveness and portions of the history, the physical examination, and laboratory
establishing health policy. Randomized trials cannot be used to and radiographic data. For example, the definition of chronic
answer all clinical questions, and outcomes research techniques sinusitis may vary by pattern of disease (e.g., persistent vs. recurrent
can be used to gain considerable insights from observational data acute infections), duration of symptoms (3 months vs. 6 months),
(including data from large administrative databases). With current and diagnostic criteria for sinusitis (clinical exam vs. ultrasound
attention on EBM and quality of care, a basic familiarity with vs. CT vs. sinus taps and cultures). All of these aspects must be
outcomes research is more important than ever. delineated to place studies into proper context.
In addition, advances in diagnostic technology may introduce
a bias called stage migration.13 In cancer treatment, stage migration
KEY TERMS AND CONCEPTS occurs when more sensitive technologies (such as CT scans in
The fundamentals of clinical epidemiology can be understood by the past, and PET scans nowadays) may “migrate” patients with
thinking about an episode of treatment: a patient presents at baseline previously undetectable metastatic disease out of an early stage
with an index condition, receives treatment for that condition, (improving the survival of that group) and place them into a stage
and then experiences a response to treatment. Assessment of baseline with otherwise advanced disease (improving this group’s survival
state, treatment, and outcomes are all subject to forces that may as well).14,15 The net effect is that there is improvement in stage-
influence how effective that treatment appears to be. We will specific survival but no change in overall survival.
begin with a brief review of bias and confounding.
Disease Severity. The severity of disease strongly influences
response to treatment. This reality is second nature for oncologists,
Bias and Confounding who use TNM stage to select treatment and interpret survival
Bias occurs when “compared components are not sufficiently outcomes. It is intuitively clear that the more severe the disease,
similar.”3 The compared components may involve any aspect of the more difficult it will be (on average) to restore function.
the study. Selection bias exists if there are systematic differences Interestingly, however, criteria for staging do evolve over time,
between people in the comparison groups. For example, selection and therefore it is critical to understand not just stages of severity
bias may occur if, in comparing surgical resection to chemoradiation, but also how the stages are defined.
oncologists avoid treating patients with kidney or liver failure. Integration of the concept of disease severity into the study
This makes the comparison biased because on average the surgical and practice of common otolaryngologic diseases such as sinusitis
cohort will accrue more ill patients and this may influence survival and hearing loss is also developing. Recent progress has been
or complication rates. This can be addressed through random made in sinusitis. Kennedy identified prognostic factors for suc-
assignment of participants to different treatment groups, known cessful outcomes in patients with sinusitis and encouraged the
as randomization. Information bias exists if there are systematic development of staging systems.16 Several staging systems have
differences in how exposures or outcomes are measured. Informa- been proposed, with most systems relying primarily on radiographic
tion bias can include observer bias, in which data are not collected appearance.17-20 Clinical measures of disease severity (symptoms,
the same way across comparison groups, and recall bias, in which findings) are not typically included. Although the Lund-Mackay
inaccuracies of retrospective assessment can influence findings. staging system is reproducible,21 often radiographic staging systems
Observer bias can be reduced by using blinded data collection, have correlated poorly with clinical disease.22-26 As such, the Zinreich
in which measurements are made without knowledge of which method was created as a modification of the Lund-Mackay system,
comparison group they are for; single blinding means participants adding assessment of osteomeatal obstruction.27 Alternatively, the
do not know which group they are in, and double blinding means Harvard staging system has been reproducible21 and may predict
study staff who collect and/or interpret data do not know which response to treatment.28 Scoring systems have also been developed
study participants are in which group (until blinding is removed for specific disorders such as acute fungal rhinosinusitis,29 and
at the end). Recall bias can be reduced by using prospective data clinical scoring systems based on endoscopic evaluation have
collection, in which measurements are made as participants move likewise been developed.30 The development and validation of
forward through time as opposed to attempting to remember what reliable staging systems for other common disorders, and the
happened in the past. integration of these systems into patient care, are pressing challenges
Similar to bias, confounding also has the potential to distort the in otolaryngology.
results. However, confounding refers to specific variables. Con-
founding occurs when a variable thought to cause an outcome is Comorbidity. Comorbidity refers to the presence of concomitant
actually not responsible, because of the unseen effects of another disease unrelated to the “index disease” (the disease under con-
variable. Consider the hypothetical (and obviously faulty) case sideration), which may affect the diagnosis, treatment, and prognosis
where an investigator postulates that nicotine-stained teeth cause for the patient.31-33 Documentation of comorbidity is important
laryngeal cancer. Despite a strong statistical association, this because the failure to identify comorbid conditions such as liver
relationship is not causal, because another variable—cigarette failure may result in inaccurately attributing poor outcomes to
smoking—is responsible. Cigarette smoking is confounding because the index disease or treatment being studied.34 This baseline variable
it is associated with both the outcome (laryngeal cancer) and the is most commonly considered in oncology because most models
supposed baseline state (stained teeth). of comorbidity have been developed to predict survival.32,35 The
Adult Comorbidity Evaluation 27 (ACE-27) is a validated instru-
ment for evaluating comorbidity in cancer patients and when used
Assessment of Baseline has shown the prognostic significance of comorbidity in a cancer
Most physicians are aware of the confounding influences of age, population.36,37 Given its impact on costs, utilization, and QOL,
gender, ethnicity, and race. However, accurate baseline assessment comorbidity should be incorporated in studies of nononcologic
also means that investigators should carefully define the disease diseases as well.
under study, account for disease severity, and consider other
important variables such as comorbidity.
Assessment of Treatment
Definition of Disease. It would seem obvious that the first step Control Groups. Reliance on case series to report results of
is to establish diagnostic criteria for the disease under study. Yet surgical treatment is time honored. Although case series can be
CHAPTER 1 Outcomes Research 3
informative, they are inadequate for establishing cause and effect

relationships. A recent evaluation of endoscopic sinus surgery
FUNDAMENTALS OF STUDY DESIGN 1
reports revealed that only 4 of 35 studies used a control group.38 A variety of study designs are used to gain insight into treatment
Without a control group, the investigator cannot establish that effectiveness. Each has advantages and disadvantages. The principal
the observed effects of treatment were directly related to the trade-off is complexity versus rigor because rigorous evidence
treatment itself.3 demands greater effort. An understanding of the fundamental differ-
It is also particularly crucial to recognize that the scientific ences in study design can help to interpret the quality of evidence,
rigor of the study will vary with the suitability of the control which has been formalized by the EBM movement. EBM is the
group. The more fair the comparison, the more rigorous the results. “conscientious, explicit, and judicious use of current best evidence
Therefore a randomized cohort study, where subjects are randomly in making decisions about the care of individual patients.”43 EBM
allocated to different treatments, is more likely to be free of biased is discussed in detail elsewhere in this textbook but is mentioned
comparisons than observational cohort studies, where treatment here because of its overlap with clinical epidemiology. We will
decisions are made by an individual, a group of individuals, or a summarize the major categories of study designs, with reference
health care system. Within observational cohorts, there are also to the EBM hierarchy of levels of evidence (Table 1.1).43,44
different levels of rigor. In a recent evaluation of critical pathways
in head and neck cancer, a “positive” finding in comparison with
a historical control group (a comparison group assembled in
Randomized Trial
the past) was not significant when compared with a concurrent RCTs represent the highest level of evidence, particularly if a
control group.39 group of RCTs can be examined together in a meta-analysis, because
the controlled, experimental nature of the RCT allows the investiga-
tor to establish a causal relationship between treatment and
Assessment of Outcomes subsequent outcome. The random distribution of patients also
Efficacy. The distinction between efficacy and effectiveness, briefly allows unbiased distribution of baseline variables and thus minimizes
discussed earlier, illustrates one of the fundamental differences the influence of confounding. Although randomized trials have
between randomized trials and broader outcomes research. Efficacy generally been used to address efficacy, modifications can facilitate
refers to whether a health intervention, in a controlled environment, insight into effectiveness as well. RCTs with well-defined inclusion
achieves better outcomes than does placebo. Two aspects of this criteria, double-blinded treatment and assessment, low losses to
definition need emphasis. First, efficacy is a comparison to placebo. follow-up, and high statistical power are considered high quality
As long as the intervention is better, it is efficacious. Second, RCTs and represent Level 1 evidence. Lower-quality RCTs are
controlled environments shelter patients and physicians from rated Level 2 evidence.
problems in actual clinical settings. For example, randomized
efficacy trials of medications may provide continuing reminders
for patients to use their medications and may even provide the
Cohort Study
medications, whereas in “real life,” patients are responsible for In cohort studies, patients are identified at baseline before treatment
obtaining medications and remembering to take them as directed. (or “exposure,” in standard epidemiology cohort studies investigating
risk factors for disease), similar to randomized trials. However,
Effectiveness. An efficacious treatment that retains its value under these studies accrue patients who receive routine clinical care.
usual clinical circumstances is effective. Effective treatment must Inclusion criteria are substantially less stringent, and treatment is
overcome a number of barriers not encountered in the typical assigned by the provider in the course of clinical care. Maintenance
trial setting. For example, disease severity and comorbidity may of the cohort is also straightforward because there is no need to
be worse in the community because healthier patients tend to be keep patients and providers double blinded.
enrolled in (nononcologic) trials. Patient adherence to treatment The challenge in cohort studies is to find an appropriate control
may also be imperfect. Consider CPAP treatment for patients group. Rigorous prospective and retrospective cohort studies with
with obstructive sleep apnea. Although the CPAP is efficacious a suitable control group represent high-quality studies and can
in the sleep laboratory, the positive pressure is ineffective if the represent Level 2 evidence. To obtain insight into comparisons
patients do not wear the masks when they return home.40 Studies of treatment effectiveness, these studies need to use sophisticated
of surgical treatments may have additional challenges, including statistical and epidemiologic methods to overcome the biases
differences in individual technique or skill, and more strongly discussed in the prior section. Even with these techniques, there
held opinions (less equipoise) about what approach is superior.41,42 is the risk that unmeasured confounding variables will distort the
TABLE 1.1 Summary of Study Designs

Design Advantages Disadvantages Level of Evidence
Randomized clinical trial (RCT) • Only design to prove causation • Expensive and complex 1, if high-quality RCT
• Unbiased distribution of confounding • Typically targets efficacy 2, if low-quality RCT
• Potentially limited generalizability
Observational (cohort) study • Cheaper than RCT • Difficult to find suitable controls 2, with control group
• Clear temporal directionality from • Confounding 4, if no control group
treatment to outcome
Case-control study • Cheaper than cohort study • Must rely on retrospective data 3
• Efficient study of rare diseases or • Directionality between exposure
delayed outcomes and outcome unclear
Case series • Cheap and simple • No control group 4
• No causal link between treatment
and outcome
Expert opinion N/A N/A 5
comparison of interest. Poor-quality cohorts without control groups, but Level 2 or 3 evidence (observational study with a control
or inadequate adjustment for confounding variables, are considered group, or case-control study) exists, the treatment recommendations
Level 4 evidence because they are essentially equivalent to a case are ranked as Grade B. The presence of only a case series would
series (see later). result in a Grade C recommendation. If even case series are
unavailable and only expert opinion is available, the recommenda-
tion for the treatment is considered Grade D.
Case-Control Study
Case-control studies are typically used by traditional epidemiologists
to identify risk factors for the development of disease. In such
MEASUREMENT OF CLINICAL OUTCOMES
cases the disease becomes the “outcome.” In contrast to randomized Clinical studies have traditionally used outcomes such as mortality
and observational studies, which identify patients before “exposure” and morbidity or other “hard” laboratory or physiologic end
to a treatment (or a pathogen) and then follow patients forward points,59 such as blood pressure, white cell counts, or radiographs.
in time to observe the outcome, case-control studies use the opposite This practice has persisted despite evidence that interobserver
temporal direction. This design is particularly valuable when variability of accepted “hard” outcomes such as chest x-ray findings
prospective studies are not feasible, either because the disease is and histologic reports are high.60 In addition, clinicians rely on
too rare or because the time interval between baseline and outcome “soft” data, such as pain relief or symptomatic improvement to
is prohibitively long. determine whether patients are responding to treatment, but
For example, a prospective study of an association between a because it has been difficult to quantify these variables, these
proposed carcinogen (e.g., asbestos) and laryngeal cancer would outcomes have until recently been largely ignored.
require a tremendous number of patients and decades of observa-
tion.45 However, by identifying patients with and without laryngeal
cancer and comparing relative rates of carcinogen exposure, a
Psychometric Validation
case-control study can be an alternative way to assess the same An important contribution of outcomes research has been the
question. It should be noted that because the temporal relationship development of questionnaires to quantify these “soft” constructs,
between exposure and outcome is not directly observed, no causal such as symptoms, satisfaction, and QOL. Recommendations for
judgments are possible (and this particular association remains scale development procedures are constantly evolving, but a rigorous
controversial).46,47 These studies are considered Level 3 evidence. psychometric validation process is typically followed to create
these questionnaires (more often termed scales, or instruments).
These scales can then be administered to patients to produce a
Case Series and Expert Opinion numeric score. Components of validation are briefly summarized
Case series are the least sophisticated format. As discussed earlier, below; a more complete description can be found elsewhere.61-63
no conclusions about causal relationships between treatment and Three major steps in the process are the establishment of reliability,
outcome can be made because of uncontrolled bias and the absence validity, and responsiveness; in addition, increasing consideration is
of any control group. These studies are considered Level 4 evidence. also given to burden.
If case studies are unavailable, then expert opinion is used to
• Reliability. A reliable scale reproduces the same result in a precise
provide Level 5 evidence.
fashion. For example, assuming there is no clinical change, a
scale administered today and next week should produce the same
Other Study Designs result. This is called test-retest reliability. Other forms of reliability
include internal consistency and interobserver reliability.63,64
There are numerous other important study designs in outcomes
• Validity. A valid scale measures what it is purported to measure.
research, but a detailed discussion of these techniques is beyond
This concept is initially difficult to appreciate. Because these
the scope of this chapter. Meta-analyses48,49 are summaries of
scales are designed to measure constructs that have not previ-
evidence that have rigorous criteria for study inclusion, assessment,
ously been measured and because the constructs are difficult
and data analysis and can offer important insights into conclusions
to define in the first place (what is QOL?), how does one
that can be drawn from multiple studies in the literature Other
determine what the scales are supposed to measure? The
common approaches include decision analyses,50,51 cost-identification
abbreviated answer is that the scales should behave in the
and cost-effectiveness studies,52-54 and secondary analyses of
hypothesized way. A simple example of an appropriate hypothesis
administrative databases.55-57 Literature on these techniques are
is that a proposed cancer-specific QOL scale should correlate
referenced for further reading.
strongly with pain, tumor stage, and disfigurement but less
strongly with age and gender. For more complete discussion,
Grading of Evidence-Based several excellent references are listed.61-65
Medicine Recommendations • Responsiveness. A responsive scale is able to detect clinically
important change.66 For instance, a scale may distinguish a
EBM uses the levels of evidence described previously to grade
moderately hearing impaired individual from a deaf individual
treatment recommendations (Table 1.2).58 The presence of high-
(the scale is “valid”), but to be considered responsive, it also
quality RCTs allows treatment recommendations for a particular
needs to detect whether an individual’s hearing improves
intervention to be ranked as Grade A. If no RCTs are available
after surgery. Alternatively, the minimum improvement in
score that represents a clinically important change might be
provided.67,68
• Burden. Burden refers to the time and energy that patients
TABLE 1.2 Relationships Between Grades of Recommendation and
Level of Evidence176
must spend to complete a scale, as well as the resources necessary
for observers to score the questionnaire. A scale should not be
Grade of Recommendation Level of Evidence an excessive encumbrance to a patient, caregiver, or provider
A 1 using it.
B 2 or 3
More recently, Item Response Theory (IRT) has been used to
C 4
D 5
create and evaluate self-reported instruments. A full discussion of
IRT is beyond the scope of this chapter. In brief, IRT uses
mathematic models to draw conclusions based on the relationships TABLE 1.3 Examples of Outcomes Measures Relevant
between patient characteristics (latent traits) and patient responses to Otolaryngology 1
to items on a questionnaire. In addition to a general requirement
Disease Category Examples
for larger sample sizes than classical test theory, a critical limitation
is that IRT assumes that only one domain is measured by the Generic Health Status SF-3675
scale. This may not fit assumptions for multidimensional QOL Quality of Life WHO-QOL80
scales, which may necessitate modifications of typical IRT analyses. Utility QWB76
However, if this assumption is valid, IRT-tested scales have several Head and Neck General UWQOL,89 FACT,90
advantages. IRT allows for the contribution of each test item to Cancer EORTC,86 HNQOL92
be considered individually, thereby allowing the selection of fewer Radiation Specific QOL-RTI/H&N94
test items which more precisely measure a continuum of a Clinician Rated PSS91
characteristic.69-72 Therefore IRT lends itself easily to adaptive Otologic General HHIE103
computerized testing, allowing for significantly diminished testing Conductive Loss HSS106
time and reduced test burden.69 Adaptive testing is increasing in Amplification APHAB,107 EAR177
use, and IRT will likely be the basis for more new questionnaires Dizziness DHI117
Tinnitus THI118
evaluating outcomes including QOL. Cochlear Implants Nimigen,110 CAMP111
Rhinologic Nasal Obstruction NOSE128
Categories of Outcomes Chronic Sinusitis SNOT-20,119 CSS,120
RhinoQOL127
In informal use, the terms health status, function, and QOL are Rhinitis mRQLQ,124 ROQ125
frequently used interchangeably. However, these terms have
important distinctions in the health services literature. Health status Pediatric Tonsillectomy TAHSI140
Otitis Media OM-6136
describes an individual’s physical, emotional, and social capabilities
Sleep Apnea OSD-6,138 OSA-18137
and limitations, and function refers to how well an individual is
able to perform important roles, tasks, or activities.62 QOL differs Laryngologic Swallowing MDADI,160 SWAL-QOL161
Voice VHI,144 VOS,145 VRQOL156
because the central focus is on the value that individuals place on
Upper Airway Dyspnea DI163
their health status and function.62
Because many aspects of overall QOL are unrelated to a patient’s Sleep Adult Sleep Apnea FOSQ,164 SAQLI165
health status (e.g., income level, marital and family happiness), Facial Plastics Aesthetic FACE-Q,174 RHINO175
outcomes researchers typically focus on scales that measure only Functional RHINO,175 NOSE129
HRQOL (health-related QOL). HRQOL scales may be categorized Refer to text for additional scales.
as either generic or disease specific. Generic, or general, scales are
used for QOL assessment in a broad range of patients. The principal
advantage of generic measures is that they facilitate comparison
of results across different diseases (e.g., how does the QOL of a
heart transplant patient compare with that of a cancer patient?).
Generic Scales
On the other hand, disease-specific scales are designed to assess specific The best-known and most widely used outcomes instrument in the
patient populations. Because these scales can focus on a narrower world is the Medical Outcomes Study Short Form-36, commonly
range of topics, they tend to be more responsive to clinical change called the SF-36.75 This 36-item scale is designed for adults and
in the population under study. To benefit from the advantages of surveys general health status. It produces scores in eight health
each type of scale, rigorous studies often use both generic and a constructs (e.g., vitality, bodily pain, limitations in physical activi-
disease-specific scales to assess outcomes. ties), as well as two summary scores on overall physical and mental
In addition to these measures, a number of other outcomes health status. Normative population scores are available, and the
are increasingly popular. These include patient satisfaction, costs scale has been translated into numerous languages. Reference to
and charges,53,54 health care use, and patient preferences (utilities, instructions, numerous reference publications, and other related
willingness to pay).53,73,74 Descriptions of these methods are ref- information can be found at the SF-36 website (www.sf36.com).
erenced for further information. A variety of other popular, generic scales are available as well.
The Quality of Well-Being (QWB)76,77 and the Health Utilities
Index (HUI)78,79 measure patient preferences, or utilities. The World
Examples of Outcomes Measures Health Organization has developed a QOL scale (WHO-QOL)80 as
As mentioned previously, one of the principal contributions of a measure of generic QOL as well as the International Classification
outcomes research has been the development of scales to measure of Functioning, Disability, and Health (ICF) to evaluate a patient’s
HRQOL and related outcomes. Scale development and validation functioning and disability.81 The ICF has been used not only as
are complex processes but are important to ensure that scales an instrument itself but also as a stand-alone reference by which
actually measure what they are intended to measure. Common to evaluate other measures of QOL and functioning.82,83
pitfalls include lack of literacy level assessment and lack of clarity The Patient-Reported Outcomes Measurement Information
regarding what to do with missing data. System, developed by the National Institutes of Health (NIH), is
We will briefly highlight a variety of scales that are relevant another rich resource for measuring patient-reported outcomes.
to otolaryngology. Widely used scales in each category are listed Scales offered by this system include global health measures as
in Table 1.3. Unless otherwise indicated, the scales in this chapter well as a wide variety of other measures focused on specific aspects
are completed independently by the patient, although numerous of health and can be delivered in multiple ways, including on
scales also exist that are rated by observers. The references contain paper and online.84
details about validation data, and most also include a listing of
sample questions and scoring instructions. The concept of minimal
important difference67 (i.e., the smallest numeric score change
Disease Specific Scales
that is associated with a meaningful change for the patient) is very Head and Neck Cancer. In 2002 the NIH sponsored a confer-
important for understanding scores within the relevant clinical ence to achieve consensus on the methods used to measure and
context. report QOL assessment in head and neck cancer.85 There was
agreement that an adequate number of scales already exist to scales, there are several excellent, validated scales that assess other
measure general QOL in head and neck cancer patients. The three aspects of otologic disease, including dizziness117 and tinnitus.118
most popular scales at this time are the European Organization
for Research and Treatment of Cancer Quality of Life Question- Rhinologic Disease. The ability to assess outcomes in chronic
naire (EORTC-HN35),86 the University of Washington Quality rhinosinusitis has dramatically improved with the development of
of Life scale (UW-QOL),87-89 and the Functional Assessment of disease-specific scales. Among the most widely used scales are the
Cancer Therapy Head and Neck module (FACT-HN).90 Both Sinonasal Outcome Test (SNOT-20)119 and the Chronic Sinusitis
the EORTC and FACT instruments offer additional modules Survey (CSS).120 The SNOT-20 has 20 items, has been extensively
that measure general cancer QOL in addition to the head and validated, and is a shortened version of the 31-item Rhinosinusitis
neck cancer–specific modules but are longer than the 12-item Outcome Measure.121 It is responsive to clinical change and has
UW-QOL scale. established scores that reflect minimal important differences. The
A clinician-rated (i.e., the clinician completes the scale, rather CSS is a shorter scale consisting of two components. The severity-
than the patient) scale that has achieved widespread use is the based component has four items, and the duration-based component
Performance Status Scale, a three-item instrument that correlates asks about duration of both symptoms and medication use. In
well with many of the aforementioned cancer scales.91 A number addition to the SNOT and CSS, there are a number of other
of other excellent, validated patient-completed scales are also excellent validated sinusitis scales.122,123 Some of these scales focus
available, including the Head and Neck Quality of Life (HNQOL)92 on rhinitis specifically, including the Mini Rhinoconjunctivitis
and the Head & Neck Survey (H&NS),93 although these scales QOL Questionnaire,124 the Rhinitis Outcome Questionnaire,125
have not been used as widely. Several validated scales that focus and the Nocturnal Rhinoconjunctivitis Questionnaire,126 whereas
on QOL of patients undergoing radiation are also in use.94,95 others focus on rhinosinusitis specifically. The Rhinosinusitis
A few measures focus on symptom inventory and symptom Quality of Life survey (RhinoQOL) has been validated for both
distress directly related to head and neck cancer. These include acute and chronic sinusitis.127 Additional new rhinologic scales
the Head and Neck Distress Scale (HNDS)96 and the MD Anderson continue to be developed.
Symptom Inventory, Head and Neck Module.97 In 2003 the American Academy of Otolaryngology-Head and
Several new instruments have been developed as disease-specific Neck Surgery Foundation commissioned the National Center for
measures within the field of head and neck cancer. For example, the Promotion of Research in Otolaryngology (NC-PRO) to
to assess the impact of cutaneous malignancy on QOL, the Skin develop and validate a disease-specific instrument for patients
Cancer Index has been validated and found to be sensitive and with nasal obstruction for a national outcomes study. The Nasal
responsive,98,99 and the Patient Outcomes of Surgery—Head/Neck Obstruction Symptom Evaluation (NOSE) scale is a five-item
(POS-Head/Neck) has been newly developed to assess surgical instrument that is valid, reliable, and responsive.128,129
outcomes in cutaneous malignancy.100 In addition, an instrument
has been developed to assess QOL after treatment of anterior Pediatric Diseases. An important difference between measuring
skull base lesions.101 A questionnaire has also been developed to outcomes in adults and children is that younger children may be
evaluate outcomes directly related to the use of voice prostheses unable to complete the scales by themselves. In these cases the
after total laryngectomy.102 instruments need to be completed by proxy, typically a parent or
other caregiver. This difference in perspective should be kept in
Otologic Disease. The most widely used validated measure to mind when interpreting the results of pediatric studies. A good
quantify hearing-related QOL is the Hearing Handicap Inventory generic scale, similar to the SF-36 in adults, is the Child Health
in the Elderly (HHIE), a 25-item scale with two subscales that Questionnaire (CHQ).130 This is also a widely used instrument
measure the emotional and social impact of hearing loss.103,104 The that has been extensively validated and translated into numerous
minimum change in score that corresponds to a clinically important languages. It is a health status measure designed for children 5
difference has been established.105 However, the scale does not years of age and older and can be completed directly by children
distinguish between conductive or sensorineural loss. The Hearing 10 and older. Other generic QOL assessments for children include
Satisfaction Scale (HHS) is specifically designed to measure the Pediatric Quality of Life Inventory (PedsQL) and the Child
outcomes after treatment for conductive hearing loss. It therefore Health and Illness Profile—Child Edition (CHIP-CE).131,132 The
addresses side effects or complications of treatment and is brief Glasgow Children’s Benefit Inventory is a validated measure which
(15 items).106 evaluates the benefit a child receives from an intervention and is a
Numerous validated measures exist to assess outcomes after general measure which was developed with otolaryngologic disease
hearing amplification. One popular scale is the Abbreviated Profile in mind.133 The Caregiver Impact Questionnaire has been used
of Hearing Aid Benefit (APHAB).107 This 24-item scale measures to evaluate the impact of disease on the child’s caregivers.134,135
four aspects of communication ability. Values corresponding to There are a number of excellent, validated disease-specific scales
minimal clinically important change have also been established.108 for children. A number of instruments have been developed to
The Effectiveness of Auditory Rehabilitation (EAR) scale addresses assess the impact of otitis media. The most widely used OM-6 is
comfort and cosmesis issues associated with hearing aids that are a brief, six-item scale useful for the evaluation of otitis media–related
overlooked in many hearing aid scales. There are two brief 10-item QOL in children.136 It has been shown to be reliable, valid, and
modules: the Inner EAR addresses intrinsic issues of hearing loss responsive and has been widely adopted. Two scales are pertinent
such as functional, physical, emotional, and social impairment, to children with obstructive sleep disorders, the Obstructive Sleep
and the Outer EAR covers extrinsic factors such as the comfort, Apnea-18 (OSA-18),137 which has been found to be valid, reliable,
convenience, and cosmetic appearance.109 and responsive, and the OSD-6.138,139 A scale has also recently
Effects of cochlear implantation on HRQOL have also recently been developed for studying tonsil and adenoid health in children.140
begun to be measured. The Nijmegen Cochlear Implant Question- Voice-related QOL has also been evaluated in children via the
naire has been used for this purpose,110 whereas the University of Pediatric Voice Outcomes Survey and the Pediatric Voice-Related
Washington Clinical Assessment of Musical Perception (CAMP) Quality-of-Life survey (PVQOL).141-143
has been developed to assess perception of music in cochlear
implant recipients.111 Voice. Numerous instruments have been developed to assess
Individuals interested in pursuing research on hearing amplifica- outcomes in voice, with varying psychometric properties.144-146
tion should also be aware of a number of other validated scales; The Voice Handicap Index is one of the most widely used instru-
only a partial listing is referenced here.112-116 In addition to these ments; its original form was 30 items144 and also exists as a 10-item
shortened version (VHI-10).147 It evaluates the psychosocial impact Facial Plastic Surgery. Finally, numerous instruments have been
of dysphonia and has been validated by both Classical Test developed to assess outcomes in facial plastic surgery.172,173 These 1
Theory112,148 and IRT.149 Normative values150 and data on minimal include the FACE-Q,174 which measures patient opinion of their
important difference on the VHI-10151,152 are also available. The appearance and can be used in rhinoplasty, and the RHINO,175
Voice Symptom Scale (VoiSS),153,154 the Vocal Performance which incorporates data on both aesthetic and functional out-
Questionnaire, and the Voice-Related Quality of Life Instrument comes after rhinoplasty. The NOSE129 scale can also be useful
are also frequently used.155,156 These instruments provide inde- for assessing functional outcomes in rhinoplasty. Various other
pendent useful data that complement clinician performed perceptual instruments exist for self-ratings of appearance, satisfaction, and
evaluation.157,158 In addition, the Singing Voice Handicap Index other outcomes.
has been created and found to valid and reliable for assessing With all of these options, there is a tension between using
vocal problems specific to singers.159 existing, widely utilized scales, which can facilitate comparisons
and combined analyses, versus specific or newly developed scales
Swallow and Other Throat Symptom Scales. Several scales that may have better content validity or other psychometric
specific to swallowing are available, including MD Anderson properties. Practitioners and researchers therefore need to balance
Dysphagia Inventory (MDADI),160 a brief, 20-item scale intended competing considerations when choosing generic and disease-
to measure dysphagia in head and neck cancer patients. The specific measures.
SWAL-QOL is longer (44 items) but validated for use in a more
general population.161 Multiple scales exist for examining symptoms
related to laryngopharyngeal reflux, with the most frequently cited
SUMMARY AND FUTURE DIRECTIONS
being the Reflux Symptom Index.162 The Dyspnea Index was Outcomes research is the scientific analysis of treatment effective-
developed specifically for adults with upper airway dyspnea (e.g., ness. In recent decades, it has contributed substantially to the
paradoxical vocal fold motion)163 and has very good psychometric national debate on health resource allocation. Outcomes research
properties. provides insight into the value of otolaryngology treatments and
methods for quantifying important outcomes, particularly from
Sleep. Several validated scales are in use to assess HRQOL in the patient’s perspective. Better appreciation for outcomes research
adults with obstructive sleep apnea. The most widely used are the will improve the level of evidence about important treatments
30-item Functional Outcomes of Sleep Questionnaire (FOSQ)164 and operations.
and the 50-item Calgary Sleep Apnea Quality of Life Index The impact of outcomes research is currently beginning to
(SAQLI).165,166 In addition, the Quebec Sleep Questionnaire (QSQ) extend into deliberations about quality of care, as the health
was recently validated as an additional OSA instrument.167 Clinicians care system moves to establish standards for patient safety. The
interested in a more brief instrument may wish to consider the Leapfrog Group, a coalition of the largest public and private
Symptoms of Nocturnal Obstruction and Respiratory Events organizations that provide health care benefits for its employees,
(SNORE-25).168 The eight-item Epworth Sleepiness Scale (ESS) uses its collective purchasing power to ensure that its employees
is commonly used to assess the degree of daytime sleepiness.169 have access to, and more informed choices about, quality health
Although perhaps one of the widely used tools in sleep outcomes, care. Policymakers will increasingly look to outcomes research
a study found that its clinical reproducibility may be limited,170 for insight into how to measure quality and safety, in addition to
and a number of studies have shown wide variability in correlation effectiveness.
between the ESS and objective measures of sleep apnea severity. It is imperative that clinicians be familiar with these basic
As sleepiness and fatigue can be difficult to differentiate on QOL principles. Otolaryngologists should participate in local and national
instruments and in clinical practice, more recently the Empirical outcomes research efforts to improve the evidence supporting
Sleepiness and Fatigue Scales were created (using a number of successful otolaryngology interventions and to provide informed
items from the ESS). These scales were found to have internal physician perspective in a health care environment that is increas-
consistency and good test-retest reliability and will likely aid in ingly driven by third party participants.
the evaluation of patients with OSA who are more likely to endorse
sleepiness variables.171 For a complete list of references, visit ExpertConsult.com.
CHAPTER 1 Outcomes Research 7.e1
REFERENCES in chronic sinusitis?, Otolaryngol Head Neck Surg 123(1 Pt 1):81–84,

1. Brook RH, Lohr KN: Efficacy, effectiveness, variations, and quality. 2000. 1
Boundary-crossing research, Med Care 23(5):710–722, 1985. 29. Ponikau JU, Sherris DA, Weaver A, Kita H: Treatment of chronic
2. Flay BR: Efficacy and effectiveness trials (and other phases of rhinosinusitis with intranasal amphotericin B: a randomized,
research) in the development of health promotion programs, Prev placebo-controlled, double-blind pilot trial, J Allergy Clin Immunol
Med 15(5):451–474, 1986. 115(1):125–131, 2005.
3. Feinstein AR: Clinical epidemiology: the architecture of clinical research, 30. Wright ED, Agrawal S: Impact of perioperative systemic steroids
Philadelphia, 1985, W. B. Saunders Company. on surgical outcomes in patients with chronic rhinosinusitis with
4. Codman EA: The product of a hospital, Surg Gynecol Obstet 18:491–496, polyposis: evaluation with the novel Perioperative Sinus …. Laryn-
1914. goscope [Internet], 2007. Available from: http://onlinelibrary.wiley.
5. Hill AB: The clinical trial, Br Med Bull 7:278–282, 1951. com/doi/10.1097/MLG.0b013e31814842f8/full.
6. Weinstein MC: Allocation of subjects in medical experiments, 31. Feinstein AR: The pre-therapeutic classification of comorbidity in
N Engl J Med 291:1278–1285, 1974. chronic disease, J Chronic Dis 23:455–469, 1970.
7. Wennberg J: Small area variations in health care delivery, Science 32. Charlson ME, Pompei P, Ales KL, MacKenzie CR: A new method of
182(117):1102–1108, 1973. classifying prognostic comorbidity in longitudinal studies: development
8. Winslow CM, Solomon DH, Chassin MR, et al: The appropriate- and validation, J Chronic Dis 40(5):373–383, 1987.
ness of carotid endarterectomy, N Engl J Med 318(12):721–727, 33. Piccirillo JF: Importance of comorbidity in head and neck cancer,
1988. Laryngoscope 110(4):593–602, 2000.
9. Chassin MR, Kosecoff J, Park RE, et al: Does inappropriate use 34. Pugliano FA, Piccirillo JF: The importance of comorbidity in staging
explain geographic variations in the use of health care services? A upper aerodigestive tract cancer, Curr Opin Otolaryngol Head Neck
study of three procedures, JAMA 258(18):2533–2537, 1987. Surg 4:88–93, 1996.
10. Leape LL, Park RE, Solomon DH, et al: Does inappropriate use 35. Piccirillo JF, Lacy PD, Basu A, Spitznagel EL: Development of a new
explain small-area variations in the use of health care services?, JAMA head and neck cancer-specific comorbidity index, Arch Otolaryngol
263(5):669–672, 1990. Head Neck Surg 128(10):1172–1179, 2002.
11. Gray BH: The legislative battle over health services research, Health 36. Piccirillo JF, Costas I, Claybour P, et al: The measurement of
Aff 11:38–66, 1992. comorbidity by cancer registries, J Registry Manag 30(1):8–15, 2003.
12. Roper WL, Winkenwerder W, Hackbarth GM, Krakauer H: Effective- 37. Piccirillo JF, Tierney RM, Costas I, et al: Prognostic importance of
ness in health care. An initiative to evaluate and improve medical comorbidity in a hospital-based cancer registry, JAMA 291(20):2441–
practice, N Engl J Med 319(18):1197–1202, 1988. 2447, 2004.
13. Feinstein AR, Sosin DM, Wells CK: The Will Rogers phenomenon. 38. Lieu J, Piccirillo JF: Methodologic assessment of studies on endoscopic
Stage migration and new diagnostic techniques as a source of mislead- sinus surgery, Arch Otolaryngol Head Neck Surg 2003. in press.
ing statistics for survival in cancer, N Engl J Med 312(25):1604–1608, 39. Yueh B, Weaver EM, Bradley EH, et al: A critical evaluation of critical
1985. pathways in head and neck cancer, Arch Otolaryngol Head Neck Surg
14. Champion GA, Piccirillo JF: The Impact of Computer Tomography 129(1):89–95, 2003.
on Pretherapeutic Staging of Patients with Laryngeal Cancer: 40. Weaver EM: Sleep apnea devices and sleep apnea surgery should be
Demonstration of the Will Rogers’ Phenomenon. Submitted. compared on effectiveness, not efficacy, Chest 123(3):961–962, author
15. Schwartz DL, Rajendran J, Yueh B, et al: Staging of head and neck reply 962, 2003.
squamous cell cancer with extended-field FDG-PET, Arch Otolaryngol 41. Ergina PL, Cook JA, Blazeby JM, et al: Challenges in evaluating
Head Neck Surg 2003. in press. surgical innovation, Lancet 374(9695):1097–1104, 2009.
16. Kennedy DW: Prognostic factors, outcomes and staging in ethmoid 42. McCulloch P, Taylor I, Sasako M, et al: Randomised trials in surgery:
sinus surgery, Laryngoscope 102(12 Pt 2 Suppl 57):1–18, 1992. problems and possible solutions, BMJ 324(7351):1448–1451, 2002.
17. Lund VJ, Mackay IS: Staging in rhinosinusitus, Rhinology 31(4):183–184, 43. Sackett DL, Rosenberg WM, Gray JA, et al: Evidence based medicine:
1993. what it is and what it isn’t, BMJ 312(7023):71–72, 1996.
18. Gliklich RE, Metson R: A comparison of sinus computed tomography 44. Cook DJ, Guyatt GH, Laupacis A, Sackett DL: Rules of evidence
(CT) staging systems for outcomes research, Am J Rhinol 291–297, and clinical recommendations on the use of antithrombotic agents,
1994. Chest 102(Suppl 4):305S–311S, 1992.
19. Lund VJ, Kennedy DW: Staging for rhinosinusitis, Otolaryngol Head 45. Offermans NSM, Vermeulen R, Burdorf A, et al: Occupational asbestos
Neck Surg 117(3 Pt 2):S35–S40, 1997. exposure and risk of pleural mesothelioma, lung cancer, and laryngeal
20. Newman LJ, Platts-Mills TA, Phillips CD, et al: Chronic sinusitis. cancer in the prospective Netherlands cohort study, J Occup Environ
Relationship of computed tomographic findings to allergy, asthma, Med 56(1):6–19, 2014.
and eosinophilia, JAMA 271(5):363–367, 1994. 46. Peng W-J, Mi J, Jiang Y-H: Asbestos exposure and laryngeal cancer
21. Metson R, Gliklich RE, Stankiewicz JA, et al: Comparison of sinus mortality, Laryngoscope 126(5):1169–1174, 2016.
computed tomography staging systems, Otolaryngol Head Neck Surg 47. Ferster APO, Schubart J, Kim Y, Goldenberg D: Association between
117(4):372–379, 1997. laryngeal cancer and asbestos exposure: a systematic review, JAMA
22. Bhattacharyya T, Piccirillo J, Wippold FJ, 2nd.: Relationship Otolaryngol Head Neck Surg 143(4):409–416, 2017.
between patient-based descriptions of sinusitis and paranasal sinus 48. Feinstein AR: Meta-analysis: statistical alchemy for the 21st century,
computed tomographic findings, Arch Otolaryngol Head Neck Surg J Clin Epidemiol 48(1):71–79, 1995.
123(11):1189–1192, 1997. 49. Rosenfeld RM: How to systematically review the medical literature,
23. Stewart MG, Sicard MW, Piccirillo JF, Diaz-Marchan PJ: Severity Otolaryngol Head Neck Surg 115(1):53–63, 1996.
staging in chronic sinusitis: are CT scan findings related to patient 50. Pauker SG, Kassirer JP: Decision analysis, N Engl J Med 316(5):250–
symptoms?, Am J Rhinol 13(3):161–167, 1999. 258, 1987.
24. Hwang PH, Irwin SB, Griest SE, et al: Radiologic correlates 51. Kassirer JP, Moskowitz AJ, Lau J, Pauker SG: Decision analysis: a
of symptom-based diagnostic criteria for chronic rhinosinusitis, progress report, Ann Intern Med 106(2):275–291, 1987.
Otolaryngol Head Neck Surg 128(4):489–496, 2003. 52. Russell LB, Gold MR, Siegel JE, et al: The role of cost-effectiveness
25. Bhattacharyya N: Radiographic stage fails to predict symptom analysis in health and medicine. Panel on Cost-Effectiveness in Health
outcomes after endoscopic sinus surgery for chronic rhinosinusitis, and Medicine, JAMA 276(14):1172–1177, 1996.
Laryngoscope 116(1):18–22, 2006. 53. Gold MR, Siegel JE, Russell LB, Weinstein MC: Cost-Effectiveness in
26. Hopkins C, Browne JP, Slack R, et al: The Lund-Mackay staging health and medicine, New York, NY, 1996, Oxford University Press.
system for chronic rhinosinusitis: how is it used and what does it 54. Kezirian EJ, Yueh B: Accuracy of terminology and methodology in
predict?, Otolaryngol Head Neck Surg 137(4):555–561, 2007. economic analyses in otolaryngology, Otolaryngol Head Neck Surg
27. Kennedy DW, Kuhn FA, Hamilos DL, et al: Treatment of chronic 124(5):496–502, 2001.
rhinosinusitis with high-dose oral terbinafine: a double blind, placebo- 55. Mitchell JB, Bubolz T, Paul JE, et al: Using Medicare claims for
controlled study, Laryngoscope 115(10):1793–1799, 2005. outcomes research, Med Care 32(Suppl 7):JS38–JS51, 1994.
28. Stewart MG, Donovan DT, Parke RB, Jr, Bautista MH: Does the 56. Feinstein AR: Para-analysis, faute de mieux, and the perils of riding
severity of sinus computed tomography findings predict outcome on a data barge, J Clin Epidemiol 42(10):929–935, 1989.
7.e2 PART I Measuring Outcomes and Performance
57. Hoffman HT, Karnell LH, Funk GF, et al: The National Cancer first wave of adult self-reported health outcome item banks: 2005–2008,
Data Base report on cancer of the head and neck, Arch Otolaryngol J Clin Epidemiol 63(11):1179–1194, 2010.
Head Neck Surg 124(9):951–962, 1998. 85. Yueh B: Measuring and Reporting Quality of Life in Head and Neck
58. Centre for Evidence-Based Medicine [Internet]. Centre for Evidence- Cancer. McLean, Virginia, 2002.
Based Medicine. Available from: www.cebm.net. 86. Bjordal K, Hammerlid E, Ahlner-Elmqvist M, et al: Quality of
59. Feinstein AR: Clinical biostatistics. XLI. Hard science, soft data, life in head and neck cancer patients: validation of the European
and the challenges of choosing clinical variables in research, Clin Organization for Research and Treatment of Cancer Quality of Life
Pharmacol Ther 22(4):485–498, 1977. Questionnaire-H&N35, J Clin Oncol 17(3):1008–1019, 1999.
60. Elmore JG, Wells CK, Lee CH, et al: Variability in radiologists’ 87. Hassan SJ, Weymuller E, Jr: Assessment of quality of life in head
interpretations of mammograms, N Engl J Med 331(22):1493–1499, and neck cancer patients, Head Neck 15(6):485–496, 1993.
1994. 88. Deleyiannis FW, Weymuller EA, Jr, Coltrera MD: Quality of life of
61. Stewart AL, Ware JE: Measuring functioning and well-being: the medical disease-free survivors of advanced (stage III or IV) oropharyngeal
outcomes study approach, Durham, 1992, Duke University Press. cancer, Head Neck 19(6):466–473, 1997.
62. Patrick DL, Erickson P: Health status and health policy: quality of life in 89. Rogers SN, Gwanne S, Lowe D, et al: The addition of mood and
health care evaluation and resource allocation, New York, 1993, Oxford anxiety domains to the University of Washington quality of life scale,
University Press. Head Neck 24(6):521–529, 2002.
63. Streiner DL, Norman GR: Health measurement scales: a practical guide 90. Cella DF, Tulsky DS, Gray G, et al: The Functional Assessment of
to their development and use, ed 2, Oxford, 1995, Oxford University Cancer Therapy scale: development and validation of the general
Press. measure, J Clin Oncol 11(3):570–579, 1993.
64. McDowell I, Jenkinson C: Development standards for health measures, 91. List MA, D’Antonio LL, Cella DF, et al: The Performance Status Scale
J Health Serv Res Policy 1(4):238–246, 1996. for Head and Neck Cancer Patients and the Functional Assessment
65. Feinstein AR: Clinimetrics, New Haven, Connecticut, 1987, Yale of Cancer Therapy-Head and Neck Scale. A study of utility and
University Press. validity, Cancer 77(11):2294–2301, 1996.
66. Deyo RA, Diehr P, Patrick DL: Reproducibility and responsiveness 92. Terrell JE, Nanavati KA, Esclamado RM, et al: Head and neck cancer-
of health status measures. Statistics and strategies for evaluation, specific quality of life: instrument validation, Arch Otolaryngol Head
Control Clin Trials 12(Suppl 4):142S–158S, 1991. Neck Surg 123(10):1125–1132, 1997.
67. Juniper EF, Guyatt GH, Willan A, Griffith LE: Determining a minimal 93. Gliklich RE, Goldsmith TA, Funk GF: Are head and neck specific
important change in a disease-specific Quality of Life Questionnaire, quality of life measures necessary?, Head Neck 19(6):474–480, 1997.
J Clin Epidemiol 47(1):81–87, 1994. 94. Trotti A, Johnson DJ, Gwede C, et al: Development of a head and
68. Jaeschke R, Singer J, Guyatt GH: Measurement of health status. neck companion module for the quality of life-radiation therapy
Ascertaining the minimal clinically important difference, Control Clin instrument (QOL-RTI), Int J Radiat Oncol Biol Phys 42(2):257–261,
Trials 10(4):407–415, 1989. 1998.
69. Hulin CL, Drasgow F, Parsons CK: Item response theory: application 95. Browman GP, Levine MN, Hodson DI, et al: The head and neck
to psychological measurement, 1983, Dorsey Press. radiotherapy questionnaire: a morbidity/quality-of-life instrument
70. Santor DA, Ramsay JO: Progress in the technology of measure- for clinical trials of radiation therpy in locally advanced head and
ment: applications of item response models, Psychol Assess 10(4):345, neck cancer, J Clin Oncol 11:863–872, 1993.
1998. 96. Jones HA, Hershock D, Machtay M, et al: Preliminary investigation of
71. Cooke DJ, Michie C: An item response theory analysis of the Hare symptom distress in the head and neck patient population: validation
Psychopathy Checklist–Revised, Psychol Assess 9(1):3, 1997. of a measurement instrument, Am J Clin Oncol 29(2):158–162, 2006.
72. Hays RD, Morales LS, Reise SP: Item response theory and health 97. Rosenthal DI, Mendoza TR, Chambers MS, et al: Measuring head
outcomes measurement in the 21st century, Med Care 38(Suppl and neck cancer symptom burden: the development and validation
9):II28–II42, 2000. of the MD Anderson symptom inventory, head and neck module,
73. Weinstein MC, Siegel JE, Gold MR, et al: Recommendations of Head Neck 29(10):923–931, 2007.
the Panel on Cost-effectiveness in Health and Medicine, JAMA 98. Rhee JS, Matthews BA, Neuburg M, et al: Validation of a quality-of-life
276(15):1253–1258, 1996. instrument for patients with nonmelanoma skin cancer, Arch Facial
74. Nease RF, Jr, Kneeland T, O’Connor GT, et al: Variation in patient Plast Surg 8(5):314–318, 2006.
utilities for outcomes of the management of chronic stable angina. 99. Rhee JS, Matthews BA, Neuburg M, et al: The skin cancer index:
Implications for clinical practice guidelines, JAMA 273:1185–1190, clinical responsiveness and predictors of quality of life, Laryngoscope
1995. 117(3):399–405, 2007.
75. Ware JE: SF-36 health survey manual and interpretation guide. 100. Cano SJ, Browne JP, Lamping DL, et al: The Patient Outcomes
Boston: The Health Institute, 1993. of Surgery—Head/Neck (POS-Head/Neck): a new patient-based
76. Kaplan RM, Atkins CJ, Timms R: Validity of a quality of well-being outcome measure, J Plast Reconstr Aesthet Surg 59(1):65–73, 2006.
scale as an outcome measure in chronic obstructive pulmonary disease, 101. Gil Z, Abergel A, Spektor S, et al: Development of a cancer-
J Chronic Dis 37(2):85–95, 1984. specific anterior skull base quality-of-life questionnaire, J Neurosurg
77. Kaplan RM, Ganiats TG, Sieber WJ, Anderson JP: The Quality of 100(5):813–819, 2004.
Well-Being Scale: critical similarities and differences with SF-36, 102. Kazi R, Singh A, De Cordova J, et al: Validation of a voice prosthesis
Int J Qual Health Care 10(6):509–520, 1998. questionnaire to assess valved speech and its related issues in patients
78. Feeny D, Furlong W, Boyle M, Torrance GW: Multi-attribute health following total laryngectomy, Clin Otolaryngol 31(5):404–410, 2006.
status classification systems. Health Utilities Index, Pharmacoeconomics 103. Ventry IM, Weinstein BE: The hearing handicap inventory for the
7(6):490–502, 1995. elderly: a new tool, Ear Hear 3(3):128–134, 1982.
79. Furlong WJ, Feeny DH, Torrance GW, Barr RD: The Health Utilities 104. Weinstein BE, Ventry IM: Audiometric correlates of the Hearing
Index (HUI) system for assessing health-related quality of life in Handicap Inventory for the elderly, J Speech Hear Disord 48(4):379–384,
clinical studies, Ann Med 33(5):375–384, 2001. 1983.
80. The WHOQOL Group: Development of the World Health Orga- 105. Newman CW, Jacobson GP, Hug GA, et al: Practical method for
nization WHOQOL-BREF quality of life assessment, Psychol Med quantifying hearing aid benefit in older adults, J Am Acad Audiol
28(3):551–558, 1998. 2(2):70–75, 1991.
81. World Health Organization: International Classification of Function- 106. Stewart MG, Jenkins HA, Coker NJ, et al: Development of a
ing, Disability and Health: ICF. World Health Organization, 2001. new outcomes instrument for conductive hearing loss, Am J Otol
82. Cieza A, Geyh S, Chatterji S, et al: ICF linking rules: an update 18:413–420, 1997.
based on lessons learned, J Rehabil Med 37(4):212–218, 2005. 107. Cox RM, Alexander GC: The abbreviated profile of hearing aid
83. Stucki A, Cieza A, Schuurmans MM, et al: Content comparison of benefit, Ear Hear 16(2):176–186, 1995.
health-related quality of life instruments for obstructive sleep apnea, 108. Cox RM: Administration and Application of the APHAB, 1996.
Sleep Med 9(2):199–206, 2008. 109. Yueh B, McDowell JA, Collins M, et al: Development and validation
84. Cella D, Riley W, Stone A, et al: The Patient-Reported Outcomes of the effectiveness of [corrected] auditory rehabilitation scale, Arch
Measurement Information System (PROMIS) developed and tested its Otolaryngol Head Neck Surg 131(10):851–856, 2005.
Another random document with
no related content on Scribd:
argumento que pueda
desbaratarla, la cual os quiero
poner en término que me podáis
responder á ella si hallareis qué
poder decir para confundirla.
Antonio.—Proponed, que yo iré
respondiendo como supiere,
aunque, según la habéis
encarecido, desde agora me
puedo dar por concluso; pero
todavía tengo creído que no
faltará respuesta, y mejor de la
que vos pensáis.
Albanio.—Decidme: si un
religioso reza sus horas
canónicas con mucho cuidado y
devoción, y un seglar hace lo
mismo y en la misma igualdad,
¿cuál de ellos merecerá mayor
premio y será digno de más
gloria?
Antonio.—Paréceme que el
religioso, porque assí como
tendría mayor pena y mayor
castigo no cumpliendo con la
obligación que tiene sobre sí, assí
es justo que se le dé mayor
premio por hacerlo que es
obligado; que de otra manera
sería notorio agravio el que
recibiese, y como Dios sea juez
tan justo, quiere que sean iguales
en la gloria y en la pena, para que
el que fuere digno de más crecida
pena también lo sea para llevar
más crescida la gloria.
Albanio.—Lo cierto habéis
respondido, y de vuestra
respuesta sale la razón que he
dicho, y así me responded á lo
que diré: ¿cuál es digno de mayor
infamia, uno que es de muy buen
linaje y hace alguna vileza ó cosa
fea de que pueda ser
reprehendido, ó uno que ha
alcanzado valor por su sola
persona y comete la misma vileza
haciendo lo que no debe?
Antonio.—El que ha ganado el
merecimiento y valor por su
persona.
Albanio.—Pues ¿cómo puede
ser esso, que vos mesmo os
contradecís, porque esta razón
tiene la mesma fuerza que la
pasada? Claro es y notorio á
todos que mayor obligación tiene
un bueno á obrar cosas buenas y
virtuosas que uno que no lo es
tanto, digo en la calidad y linaje, y
así por esta obligación que tiene
sobre sí merece mayor premio y
honra en ser bueno siguiendo la
virtud de sus pasados, que no el
que es de bajo y oscuro linaje;
porque éste no está tan obligado
á usar de aquella bondad, y así
como al bueno se le ha de dar
mayor premio por esto, es digno
de mayor infamia si se desvía del
camino que fundó el que dió
principio á su linaje y siguieron los
que dél han procedido, y si es
digno de mayor infamia faltando á
su obligación, justo será que se le
dé mayor honra sin contradicción
ninguna.
Antonio.—Hermosa y fuerte
razón es la que, señor Albanio,
habéis traído, y argumento muy
aparente, aunque no dexa de
tener respuesta bastante, porque,
como suelen decir, debaxo de la
buena razón á veces está el
engaño, y asi lo está debaxo
desto que vos habéis dicho
cuando quisiéredes bien
entenderlo, porque yo no niego
que al que es de buen linaje y hijo
de buenos padres se le debe
mayor honra, siendo bueno, que
al que es de humilde linaje
aunque sea bueno; pero esto se
entiende cuando son igualmente
buenos, que bien podría ser
bueno el que es de buen linaje y
tener mayor bondad el que es de
más bajo estado; y en este caso
todavía me afirmo en que es
digno de mayor honra el que
mayor bondad tuviere; esto
podréis mejor entender por lo que
agora diré. Notorio es que
muchos romanos de oscuros y
bajos linajes hicieron hechos tan
valerosos que por ellos
merecieron ser recebidos en
Roma con muy honrados y
sumptuosos triunfos, y á algunos
dellos se les pusieron públicas
estatuas en los lugares públicos y
fueron tenidos y estimados como
dioses que decian, héroes entre
los hombres. No faltaban
juntamente en Roma algunos
hombres de antiguos y claros
linajes, muy virtuosos y sin
mancilla que les pudiese
embarazar la honra; pero con no
igualar en los hechos, ni en la
fortaleza y virtud del ánimo con
los otros, no se igualaban con
ellos en la honra que se les hacía,
antes eran tenidos y estimados en
menos. El rey David, pastor fué
que guardaba ganado, y en su
tiempo muchos varones sanctos y
virtuosos hubo que descendían
de sangre de reyes, á los que no
les faltaba virtud ni fortaleza; pero
con no igualarse en ellas ni en las
hazañas tan valerosas,
principalmente cuando mató á
Golias, no fueron tan honrados ni
tan estimados de las gentes como
lo fué el rey David. Y así podría
traeros otros diversos exemplos,
los cuales dexo por la prolixidad y
porque entre nosotros lo vemos
cada día; que dos hijos de un
padre y de una madre igualmente
buenos, si á algunos dellos por
permisión y voluntad de Dios
ayuda y le favorece la industria en
poder acabar y salir con hechos
más hazañosos, le tenemos y
estimamos por más honrado que
al otro.
Jerónimo.—Desa manera al
acaecimiento se ha de atribuir la
honra de los hombres y en él está
darla á los unos y quitarla á los
otros.
Antonio.—Principalmente se ha
de atribuir á Dios, pues todas las
cossas se gobiernan por su
summo poder y voluntad. Pero
con esto permite que algunos
sean más bien empleados que
otros, y así cuando unos se
ensalzan, otros se humillan y
abaten, que no pueden estar
todos en una igualdad. Y así
resolviendo me digo, que cuando
dos hombres, el uno de buen
linaje y el otro de no tan bueno,
fueren igualmente buenos, que ha
de ser preferido y antepuesto en
la honra el de buen linaje al otro,
y si no son iguales, siendo mejor
en virtud y fortaleza el que es
inferior en linaje ha de ser más
estimado y preferido; y conforme
á esto se ha de entender el
decreto sobredicho, porque la
razón que habéis dicho de que
merece mayor pena el bueno,
haciendo lo que no debe, que el
que no es tal como él, yo os lo
confieso que así es digno de
mayor gloria. Pero (como en lo
que arriba he dicho bien á la clara
yo he probado) el que tiene más
virtud y valor, aunque sea
desigual en linaje, ya se ha hecho
tan bueno con ello como el otro, y
aun mejor. Y así está ya puesto
debajo de la mesma obligación de
usar la virtud y bondad, y obligado
á la mesma pena. Lo que
entenderéis por un ejemplo que
diré: Si un fraile ha que es fraile
cuarenta años, y otro no ha más
de uno que hizo proffesión, ¿no
estará éste obligado á los
preceptos de la orden como el
otro? ¿y no pecará igualmente?
Albanio.—Aunque en parte le
relevaría no estar tan habituado á
las observancias de la orden;
pero si no es pecado por
inorancia, eso no puede negarse.
Antonio.—Pues lo mesmo es en
lo que tratamos; que cuando uno
se ensalza y engrandece con
virtudes y hazañas, hace
profesión en la orden de la honra,
de manera que tan obligado
queda á guardar los preceptos
della y conservarla como aquel
que de antiguo tiempo tiene esta
obligación, pues que á todos nos
obliga la naturaleza igualmente á
ser virtuosos, no quiero decir en
un mesmo grado, sino que nos
obliga á todos sin excetar alguno,
dexando la puerta abierta para
que sea vicioso, y á lo mesmo la
verdadera ley christiana que
tenemos y seguimos nos obliga
juntamente á todos, y desta
manera, si bien lo consideramos,
no tenemos por qué decir que es
más obligado á sustentar la honra
de sus antepasados uno que
desciende de claro y antiguo
linaje que uno que por si mesmo
la ha ganado de nuevo.
Albanio.—En fin, la común
opinión es contraria de lo que
decís, porque tienen en tanto una
antigua y clara sangre, que el que
della participa, siempre es
juzgado digno de mayor honra.
Antonio.—No entendemos qué
cosa es ser buena y clara la
sangre, pues ya conocemos qué
cosa es ser antigua. Por cierto á
muchos juzgamos de buena
sangre que la tienen inficionada y
corrompida de malos humores, y
dexando de ser sangre se vuelve
en ponzoña que, bebiéndola,
bastaría á matar á cualquier
hombre, y algunos labradores hay
viles y que no sabiendo apenas
quiénes fueron sus padres tienen
una sangre tan buena y tan pura
que ninguna mácula hay en ella.
Esta manera de decir de buena
sangre es desatino y un impropio
hablar. Pero dexando esto, yo
estoy espantado de las
confusiones, novedades,
desatinos que cada día vemos en
el mundo acerca desto de los
linajes; pluguiesse á Dios que
tuviesse yo tantos ducados de
renta en su servicio para no vivir
pobre, como hoy hay hidalgos,
pecheros y villanos que no
pechan, que en esto hay algunos
que se saben dar tan buena
maña, que gozan del privilegio
que no tienen, y otros hay tan
apocados y tan pobres, que no
son bastantes á defender su
hidalguía cuando los
empadronan, y assí la pierden
para sí y para sus descendientes.
Y assí hemos visto dos hermanos
de padre y madre ser el uno
hidalgo y pechar el otro, y ser el
uno caballero y el otro no
alcanzar á ser hidalgo. Algunos
de los que son hidalgos no hallan
testigos que juren de padre y
agüelo, como la ley lo manda;
otros que no lo son, hallan cien
testigos falsos que por poco
interese juran. Y assí anda todo
revuelto y averiguada mal la
verdad en este caso.
Jerónimo.—Así es, señor
Antonio, como vos lo decís, que
muchas veces lo he considerado
y aun visto por experiencia. Pero
decidme, ¿qué diferencia hay
entre hidalgo y caballero, que yo
no lo alcanzo?
Antonio.--Yo os la diré. En los
tiempos antiguos, los reyes
hacían hidalgos algunos por
servicios que les hacían ó por
otros méritos que en ellos
hallaban; á otros armaban
caballeros, que era mayor
dignidad, porque gozaban de más
y mejores essenciones; pero esto
se entendía en sus vidas, porque
después sus descendientes no
gozaban de más de ser hidalgos.
Los que eran caballeros se
obligaban á cumplir ciertas cosas
cuando recebían la orden de
caballería, como aun agora
parece por algunas historias
antiguas, y en los libros de
historias fingidas, que tomaron
exemplo de lo verdadero, se trata
más copiosamente, y por esta
causa eran en más estimados.
Agora no se usa aquella orden de
caballería, y así hay muy pocos
caballeros á los cuales nuestro
emperador ha dado este
previlegio ó por sus virtudes ó por
otros respetos, y con ser la mayor
dignidad de todas en la milicia,
puede tanto la malicia de las
gentes, que si antes que
hubiessen la orden de caballería
no eran de buen linaje, los llaman
por despreciados caballeros
pardos ó hidalgos de privilegio,
paresciéndoles que por ser en
ellos más antigua la hidalguía
tiene mayor valor, y dexando de
guardar en esto la verdadera
orden que se ha de tener. A los
hidalgos ricos llaman caballeros, y
á lo que creo es porque tienen
más posibilidad para andar á
caballo, que yo no veo otra causa
que baste, porque tan hidalgo es
un hidalgo que no tiene un
maravedí de hacienda como un
señor que tiene veinte cuentos de
renta, si, como he dicho, no es
armado caballero; y hay tan
pocos caballeros en Castilla, que
aunque el rey ha dicho algunos,
no sería muy dificultoso el número
dellos, y con todo esto no veréis
otra cosa, ni oiréis entre los que
presumen sino á fe de caballero,
yo os prometo como caballero, sin
que tengan más parte con ser
caballeros que quien nunca lo fué
ni lo soñó ser, ó diremos que
toman este nombre en muy ancho
significado porque el vulgo tiene
por caballero que es hombre rico
que anda á caballo. Desta
manera son todas las otras cosas
que tocan á esto de la honra, que
ningún concierto ni orden hay en
ellas, sino que cada uno juzga y
defiende como le parece y como
más hace á su apetito.
Albanio.—¿Sabéis, Antonio, qué
veo? Que cuando comenzamos
esta materia prometisteis de no
sentenciar en ella, y á lo que he
visto, por más que sentenciar
tengo vuestras palabras, pues
ningún lugar habéis dejado con
ellas para ser más estimados los
herederos de la honra que los que
por sí la ganaron, y no os veo tan
desapasionado en esto que
queráis volver atrás de lo que
habéis dicho en ninguna cosa.
Antonio.—Yo digo lo que siento,
y no por esso dejo de pensar que
habrá otros que lo sientan
differentemente y de manera que
tengan otras muchas razones
contrarias para contradecir lo que
he dicho, y así me pongo debaxo
de la correción de los que más
sabios fueren y mejor lo
entendieren; pero esto ha de ser
no les yendo en ello su propio
interese, que desta manera
podrán ser buenos jueces, como
vemos que lo fué Salustio que
cuando competía con Marco
Tulio, porque le iba su propia
pasión, fué del parecer vulgar,
mas cuando habló desapasionado
y como filósofo moral en la batalla
que escrebió del rey Ingurta dice
asi:
Quanto vita majorum plæclarior
est,
tanto posterorum socordia flagitior
est.
que quiere decir: cuanto la vida
de los antepasados fué más
illustre, tanto la pereza de los
descendientes es más culpada.
Y pues que ya hemos dicho
brevemente todo lo que alcanza á
nuestros claros juicios, y yo he
cumplido lo que quedé mejor que
he sabido, justo será que nos
vamos, que ya el sol tiene tanta
fuerza que no basta el frescor de
la verdura para resistirla.
Jerónimo.—Es ya casi medio día
y con el gusto de la cuestión no
hemos sentido ir el tiempo.
Caminemos, porque no hagamos
falta, que ya el conde habrá
demandado la comida.
Finis.
COLLOQUIO
PASTORIL
En que un pastor llamado

Torcuato cuenta á otros dos
pastores llamados Filonio y
Grisaldo los amores que tuvo
con una pastora llamada
Belisia. Va compuesto en
estilo apacible y gracioso y
contiene en sí avisos
provechosos para que las
gentes huyan de dexarse
vencer del Amor, tomando
enxemplo en el fin que
tuvieron estos amores y el
pago que dan á los que
ciegamente los siguen, como
se podrá ver en el proceso
deste colloquio.
Á LOS LECTORES DICE LAS

CAUSAS QUE LE
MOVIERON Á PONER ESTE
COLLOQUIO CON LOS
PASSADOS.
Bien cierto estoy que no faltarán
diferentes juicios para juzgar esta
obra, como los hay para todas las
otras que se escriben, y que
aunque haya algunos á quien les
parezca bien, habrá otros que
tendrán otro parecer diferente y
murmurarán diciendo que no fué
bien acertado mezclar con los
colloquios de veras uno de burlas,
como es el que se sigue, y que yo
debiera excusarlo assí, y quiero
decir los motivos que para ello
tuve y me parecieron bastantes,
en los cuales pude acertar y
también he podido engañarme,
que creo que habrá assimesmo
en esto diversos pareceres como
en lo pasado. Lo primero que me
movió, fué que, dirigiendo este
libro al Sr. D. Alonso Pimentel, y
estando su señoría en edad tan
tierna, cuando viniese á leer
cosas más pesadas que
apacibles, como son las que se
tratan en estos colloquios, que
por ventura se enfadaría dellas, y
convenía hallar en qué mudar el
gusto para tomar más sabor en lo
que se leyese, y así quise poner
por fruta de postre la que también
podrá servir en el medio cuando
entre manjar y manjar quisiere
gustar della; y demás desto, no
dexa de tener en sí este colloquio
muy buenos enxemplos y dotrina,
pues se podrá entender por él el
fin que se sigue de los amores
que se siguen con vanidad, y
cuán poca firmeza se suele hallar
en ellos. También en la segunda y
tercera parte se hallarán algunas
cosas que, considerándolas, se
sacará dellas muy gran provecho,
pues tienen más sentido en sí del
que en la letra parece; y sin estas
causas que he dado, parecióme
que podría yo hacer lo que otros
autores muy graves hicieron sin
ser reprehendidos por ello, y que
tenía escudo y amparo en su
enxemplo contra las lenguas de
los que de mí por esta causa
murmurar quisiessen.
El primero es el poeta Virgilio, que
con los libros de La Eneida,
siendo obra tan calificada, no le
pareció mal poner las Bucólicas,
que tratan cosas de amores, y los
Parvos, que son todos de burlas y
juegos. El poeta Ovidio también
mezcló con sus obras el de Arte
amandi y el de Remedio amoris.
Eneas Silvio, que después se
llamó el papa Pío, escribió cosas
muy encarecidas y con ellas los
Amores de Eurialo Franco y
Lucrecia Senesa. Luciano, autor
griego, con los colloquios de
veras mezcló algunos de burlas y
donaires, y también puso con
ellos los libros en que escribe el
Mundo nuevo de la luna,
fingiendo que hay en ella
ciudades y poblaciones de gentes
y otras cosas que van pareciendo
disparates. Petrarca muchas
obras escribió en que se mostró
muy gran teólogo y letrado, y no
por esto dexó de poner entre ellas
la que hizo sobre los amores que
tuvo con madona Laura, y así yo
pude escribir el colloquio que se
sigue con los pasados, teniendo
por mi parte tantos autores con
quien defenderme de lo que fuere
acusado. Y si estas razones y
excusas no bastaren, bastará
una, y es que á los que les
pareciere mal no lo lean y hagan
cuenta que aquí se acabaron los
colloquios, que para mí basta
solamente que á quien van
dirigidos se satisfaga de mi
intención, la cual ha sido de
acertar á servir en esto y en todo
lo que más pudiere hacerlo, como
soy obligado.
Torquemada.
COLLOQUIO PASTORIL
En que se tratan los amores de

un pastor llamado Torcato con
una pastora llamada Belisia: el
cual da cuenta dellos á otros
dos pastores llamados Filonio
y Grisaldo, quexándose del
agravio que recibió de su
amiga. Va partido en tres
partes. La primera es del
proceso de los amores. La
segunda es un sueño. En la
tercera se trata la causa que
pudo haber para lo que Belisia
con Torcato hizo.
INTERLOCUTORES
Grisaldo.—Torcato.—Filonio.
Filonio.—¿Qué te parece,
Grisaldo, de las regocijadas y
apacibles fiestas que en estos
desposorios de Silveida en
nuestro lugar hemos tenido, y con
cuánto contento de todos se ha
regocijado? Que si bien miras en
ello, no se han visto en nuestros
tiempos bodas que con mayor
solemnidad se festejasen, ni en
que tantos zagales tan bien
adrezados ni tantas zagalas tan
hermosas y bien ataviadas y
compuestas se hayan en uno
juntado.
Grisaldo.—Razón tienes,
Filonio, en lo que dices, aunque
yo no venga del todo contento,
por algunos agravios que en ellas
se han recibido, que á mi ver han
sido en perjuicio de algunos
compañeros nuestros, que con
justa causa podrán quedar
sentidos de la sinrazón que
recibieron. Y porque no eres de
tan torpe entendimiento que tu
juicio no baste para haber
conocido lo que digo, dime, así
goces muchos años los amores
de Micenia y puedas romper en
su servicio el jubón colorado y
sayo verde con la caperuza azul y
zaragüelles que para los días de
fiesta tienes guardados, ¿no fué
mal juzgada la lucha entre
Palemón y Melibeo dándose la
ventaja á quien no la tenía y
poniendo la guirnalda á quien no
la había merecido; que si tuviste
atención no fué pequeña ventaja
la que tuvo el que dieron por
vencido al que por vencedor
señalaron?
Filonio.—Verdaderamente,
hermano Grisaldo, bien
desengañado estaba yo de que el
juicio fué hecho más con afición
que no con razón ni justicia;
porque puesto caso que Palemón
sobrepujase en fuerzas á
Melibeo, no por eso se le debía
atribuir la victoria, pues nunca le
dió caída en que ambos no
pareciesen juntamente en el
suelo, y demás desto, si bien
miraste la destreza de Melibeo en
echar los traspiés, el aviso en
armar las zancadillas, la buena
maña en dar los vaivenes,
juzgarás que no había zagal en
todas estas aldeas que en esto
pudiese sobrepujarlo; y cuando
Palemón con sus fuertes brazos
en alto lo levantaba, así como
dicen que Hércules hizo al
poderoso Anteo, al caer estaba
Melibeo tan mañoso que, apenas
con sus espaldas tocaba la tierra,
cuando en un punto tenía á
Palemón debaxo de sí, que quien
quiera que le viera más
dignamente le juzgara por
victorioso que por vencido. Pero
¿qué quieres que hiciese el buen
pastor Quiral, puesto por juez,
que por complacer á su amada
Floria le era forzado que, con
justicia ó sin ella, diese la
sentencia por Palemón su
hermano?
Grisaldo.—Si al amor pones de
por medio, pocas cosas justas
dexarán de tornar injustamente
hechas. Y dexando la lucha, no
fué menos de ver el juego de la
chueca, que tan reñido fué por
todas partes, en el cual se mostró
bien la desenvoltura y ligereza de
los zagales, que en todo un día
no pudieron acabar de ganarse el
precio que para los vencedores
estaba puesto; ni en la corrida del
bollo se acabó de determinar cuál
de los tres que llegaron á la par lo
había tocado más presto que los
otros, y en otras dos veces que
tomaron á correr, parecía que
siempre con igualdad habían
llegado.
Filonio.—Bien parece que con
faltar Torcato en estos regocijos y
fiestas, todos los pastores y
mancebos aldeanos pueden tener
presunción que cuando él
presente se hallaba, ninguno
había que con gran parte en
fuerzas y maña le igualase; todas
las joyas y preseas eran suyas,
porque mejor que todos lo
merecía y en tirar á mano ó con
una honda, en saltar y bailar á
todos sobrepujaba, en tañer y
cantar con flauta, rabel y
cherumbela, otro segundo dios
Pan parecía. No había zagala
hermosa en toda la comarca que
por él no se perdiese; todas
deseaban que las amase, y, en
fin, de todas las cosas de buen
pastor á todos los otros pastores
era preferido; mas agora yo no
puedo entender qué enfermedad
le trae tan fatigado y abatido, tan
diferente del que ser solía, que
apenas le conozco cuando le veo
su gesto, que en color blanca con
las mejillas coloradas á la blanca
leche cubierta de algunas hojas
de olorosos claveles semejaba,
agora flaco, amarillo, con ojos
sumidos, más figura de la mesma
muerte que de hombre que tiene

Ebook Cummings Otolaryngology Head and Neck Surgery PDF Full Chapter PDF

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Ebook Cummings Otolaryngology Head and Neck Surgery PDF Full Chapter PDF

Uploaded by

Copyright:

Available Formats

Cummings otolaryngology : head and

neck surgery - eBook PDF

Paul W. Flint, MD, FACS University of South Florida K. Thomas Robbins, MD

CUMMINGS OTOLARYNGOLOGY–HEAD AND NECK Standard Edition ISBN: 978-0-323-61179-4

Previous editions copyrighted 2015, 2010, 2005, 1998, 1993, 1986.

Library of Congress Control Number: 2019942176

Content Strategist: Jessica McCool

Dunia Abdul-Aziz, MD Seth A. Akst, MD, MBA William B. Armstrong, MD

Kay W. Chang, MD Richard A. Chole, MD, PhD Mark S. Courey, MD

Ulrich Harréus, MD Frans J.M. Hilgers, MD, PhD Jeffrey J. Houlton, MD

Robert K. Jackler, MD Timothy M. Johnson, MD Bradley W. Kesser, MD

Shannon M. Kraft, MD Devyani Lal, MD Kevin P. Leahy, MD, PhD

Jeremy D. Meier, MD Lloyd B. Minor, MD Wojciech K. Mydlarz, MD

Carrie L. Nieman, MD, MPH Bert W. O’Malley Jr, MD Albert H. Park, MD

Terance T. Tsue, MD Roderick P. Venekamp, MD, PhD Rohan R. Walvekar, MD

D. Bradley Welling, MD, PhD Laurelie R. Wishart, BSpPath(Hons), Carol H. Yan, MD

David S. Zee, MD Marc S. Zimbler, MD David Zopf, MD, MS

Paul W. Flint It is again my pleasure to serve as editor of the pediatric

VOLUME I 15 Sleep Apnea and Sleep Disorders, 215

11 Laryngeal and Tracheal Manifestations of Systemic 28 Otoplasty, 432

32 Special Rhinoplasty Techniques, 510 PART V Laryngology and

PART IV Sinus, Rhinology, and 55 Voice Evaluation and Therapy, 819

37 Objective Assessment of Nasal Function, 603 58 The Professional Voice, 839

46 Management of the Frontal Sinuses, 719 69 Transnasal Esophagoscopy, 992

98 Reconstruction of the Oropharynx, 1444

86 Physiology of the Oral Cavity, 1213

108 Conservation Laryngeal Surgery, 1635 SECTION 1 Basic Science

116 Lymphomas Presenting in the Head and SECTION 2 Diagnostic Assessment

SECTION 3 External Ear

166 Evaluation of the Patient With Dizziness, 2495

196 Pediatric Cochlear Implantation, 2926

201 Pediatric Infectious Disease, 2979

24.1 Rhytidectomy, Part I 49.1 Endoscopic Dacryocystorhinostomy

informative, they are inadequate for establishing cause and effect

TABLE 1.1 Summary of Study Designs

REFERENCES in chronic sinusitis?, Otolaryngol Head Neck Surg 123(1 Pt 1):81–84,

En que un pastor llamado

Á LOS LECTORES DICE LAS

En que se tratan los amores de

You might also like