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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
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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.
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Content Strategist: Jessica McCool

Senior Content Development Specialist: Deidre Simpson
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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
4 PART I Measuring Outcomes and Performance
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
Another random document with
no related content on Scribd:
The Fox and Raven;
a fable.
A raven was once sitting upon a tree with a nice bit of cheese in
his mouth. A fox near by, being hungry, approached the raven with
the design of getting the bit of cheese, if he could. So he began to
speak as follows:
“Good morning, Mr. Raven! How fine you look to-day! I never saw
your coat so rich and glossy before. Pray give me a bit of that
cheese; I am very fond of cheese.”
“Hem!” said the raven, taking care not to open his mouth, and
seeming to think that he was not such a ninny as to be flattered out
of his cheese by a fox. But reynard is a sort of natural lawyer, who
knows the weak points of people, and has a faculty, as well as a
disposition, to turn them to account. He thought to himself, “Now the
raven has a hoarse, croaking voice; and the way to flatter any one is
to praise that in which he is most deficient.” So he began:
“Well, my dear Raven, I told you I wanted the cheese—but, in
point of fact, I care nothing about it. I hate cheese, for it spoils the
breath; but I really wanted to hear you sing, and the cheese stops up
your mouth. I beg of you to sing me a little French or Italian air; you
execute those things so deliciously.”
The raven, like many other silly people who have odious voices,
fancied that he sang divinely; so he dropped the cheese, and began;
whereupon the fox picked up the cheese, and holding his bursting
sides, ran away, saying to himself, “O, flattery, flattery; it is the key
that unlocks all hearts. You have only to use the right kind, and you
can make a fool of anybody. But as to these people with croaking
throats, who pretend to sing French and Italian airs, bah! it is too
much!”
I don’t see why.
I know a little girl who has a very pleasant home, and the very
kindest of parents, and who is yet often discontented and unhappy.
She pouts her lips, and throws her arms about, and sulks, and
stamps with her feet, and makes a strange noise in her throat,
between a growl and a cry. It is not because she has not enough to
eat of good, wholesome food; nor because she has no time to play,
and playthings in abundance, and brothers to play with her. She is
not blind, nor lame, nor deformed in any way, but has health and
strength, and everything which any little girl could wish, to make her
happy in this world, but a good heart.
What was it, then, that made her fretful? Why, she had a kind
mother, who told her what she must do, and what she must not do. I
will tell you what I heard one day.
“Caroline, you must not take my scissors, my dear.”
“Why, mother? I have no scissors to cut off my thread,” said
Caroline, pettishly.
“Well, my dear, I will give you a pair, but you must not take mine.”
“I am sure I don’t see why; it’s only just to cut my thread.”
Now, these scissors were of the finest kind, and highly polished,
and Caroline’s mother knew that it would soil them if she should
handle them; and that if she had them once, she would want them
again. Caroline’s duty was to obey cheerfully, whether she saw the
reason why, or not.
“Caroline, my dear, you must not climb upon the chair to reach
your work. You must ask some one to get it for you.”
“I am sure I don’t see why. It is less trouble to get it myself than to
ask anybody for it.”
“Very well, my child, you shall do it in your own way, and see.”
That very afternoon, Caroline mounted on a chair to get her work.
She reached too far, and over went the chair, and Caroline with it.
Her work was scattered over the floor—the needlebook in one
direction, and the thimble in another, and the spools in another; and,
what was worse than all, her head struck the edge of the door, and a
gash was cut in her forehead. She cried sadly, and did not get over
the hurt for weeks. Was it less trouble to get it herself?
If she had trusted her mother, she would have saved herself all
this pain; but for the sake of knowing the reason why she could not
get upon the chair, she cost herself a severe wound, and a great
deal of shame and sorrow.
It is a good rule, through life, to do what God requires of us,
whether we see why or not. One of the things he requires of us to
do, is to obey our parents. (Eph. vi. 1. Col. iii. 20.)
There is a chapter in the Bible, of which you cannot read three

verses without crying.—What chapter is it?
Sketches of the Manners, Customs, and History
of the Indians of America.
CHAPTER VIII.
Character of the Indians.—Employed in the mines.—Story of a
pickaxe.—Mr. Temple’s conduct considered.—Humanity of the
Indians to him.—His reflections.—Dress of the Indian men;—
of the women.
In 1825, Edmund Temple, a young Englishman, went out to

Potosi as agent for a mining company formed in London. From his
“Travels” I shall select such remarks and incidents as tend to
illustrate the present character and condition of the native Indians.
We shall then be better able to judge what they have gained by their
intercourse with Europeans.
“The Peruvian Indians are a strong, healthy race, though not very
tall, and generally laborious, for every kind of labor is performed by
them. In Potosi, however, the miners, all Indians, have acquired a
character for habits of idleness and a propensity to defraud their
employers, which it must be admitted is not altogether without
foundation, though I think the cause of the evils complained of may
be traced to harsh treatment, or to unwarrantable exactions of some
sort, aggression being as frequent on one side as delinquency on
the other.
“I know from experience, that, by proper management, their faults
and the disadvantages arising from them may be guarded against,
and in a great degree corrected. A worm, or, if it be thought more
applicable, the adder, will turn when trod upon, and will then resent
the injury; so has it been with these Indians before now; but, with
kind usage, fair remuneration for their services, and an impartial
conduct towards them, they are perfectly tractable, and may become
good, faithful, and willing servants.
“During my residence at Potosi I have had occasion to employ
many Indians, as well miners as those of other trades and
occupations; there is no want of hands, as it has been generally
supposed, and I cannot say that I have any cause of complaint
against them; they performed the work for which they were engaged
to the best of their abilities, and at the completion of it I paid them
their hire.
“Sunday, after the hour of early mass, is the customary time of
paying the miners, and all persons employed in the ingenios; this
practice I did not adhere to, having preferred settling all such
matters, so far as I had control, on Saturday evening.
“At the appointed hour they assembled in the court before my
office, accompanied sometimes by their wives and children, and if I
happened to be engaged in any business, (despatching the couriers,
for instance, when, in the absence or illness of my companions, I
have been employed many hours of the day ‘writing against time’)
these people would remain, without evincing the slightest
impatience, and never approach to ask to be settled with till called by
name as they stood upon the list of the major-domo.
“They always expressed their thanks when they received their
wages, upon which subject we never had the most trifling
misunderstanding, and only once upon another, namely, upon the
subject of a pickaxe that had been stolen out of our ingenio. It was
worth fifteen shillings at Potosi, and might have been worth five in
England; but the example, not the value, determined me upon giving
a color of infinite importance to the case.
“After the depredation had been made known to me, and when
the workmen had assembled to receive their week’s wages, two
shillings per diem each man, I called them all into my office, merely
for the sake of exhibiting myself in the highest possible degree of
dignity, (a clerk never looks so dignified as behind his own counter,)
and whilst they stood like culprits in humility before me, with their
hats off, I sat proudly elevated upon my judgment-seat, with my hat
on, and in my hand a pen—a just emblem of my office, it is true, and
at the same time calculated to convey terror to the mind of the thief,
who knew that, if detected, I should instantly employ it in an
application to the alcade for the infliction of fine and imprisonment.
“When I had fixed the attention of the party, I commenced the
dread inquisition. Alas! many of their forefathers, for crimes of as
little note, or even the bare suspicion of them, had been condemned
by a more horrible inquisition, and before judges less disposed to
render justice and mercy than their present one, although it will
appear that even he was obdurately relentless. I put the question,—
“‘Who stole my pickaxe?’—Dead silence, each looked at each,
and all looked at me.
“‘Who stole my pickaxe, I say?’
“‘Quien sabe?’ (who knows?) said a low voice in the crowd.
“‘Who knows?’ said I; ‘why, some of you know; and I, too, must
know, before I pay you one rial of your wages.’ I then proceeded to
question each individual by name.
“‘Gregorio Medrano, did you steal the pickaxe?’
“‘No, Señor.’
“‘Bernandino Marquete, did you steal the pickaxe?’
“‘Casimiro Chambi, did you?’
“And so on through the whole list with the same profitless result.
“The Indians, like the lower class of Irish, preserve inviolable
secrecy respecting their own concerns; an informer is looked upon
as a wretch unworthy to live among honest men, or if permitted to
live is loathed as a demon. Assured, therefore, that I should never
succeed in detecting the exact thief, although we all well knew he
was one of the party present, I proceeded to judgment upon all of
them.
“‘Know, then, hermanos mios, (dear brothers,) that my sentence is
this; that the major-domo do now, immediately, and on the spot, put
into his hat as many grains of mais as there are of you here present;
that those grains shall be all white save one, which shall be black;
and he who draws that black grain shall pay for a new pickaxe.’
“Here consternation became general and evident, but, from the
natural darkness of the Indian complexion, it was impossible to
discover the delinquent from any change produced on his
countenance by the inward workings of his mind.
“‘Now, señor major-domo, shake your hat well—shake it! I say,
that no suspicion of partiality may be entertained. Let each man in
succession put his hand in and take one grain of mais, then withdraw
it, taking care to keep his hand shut, and not to open it until ordered
so to do.’
“This being done, they all stood before me with their right arms
stretched out at full length, and the hand firmly closed.
“‘Now for the detection of the thief! Open! Que es eso? (what is all
this?) Major-domo! what is the reason of this?’ said I, for to my
astonishment every hand was empty.
“‘I really don’t know, sir; they must have drawn the grains and
swallowed them, for not a single one remains in my hat!’ said the
major-domo, turning his hat-mouth downwards to prove that nothing
was there.
“Amazement was at its height; it was evidently a case of bruxeria,
(witchcraft.) Inaquinte Sambrano observed that it was the miraculous
interference of Saint Dimas,[1] to prove that there was no thief
among them. But, notwithstanding my surprise and confusion, I
determined that the saint should not keep my pickaxe without paying
for it.
“I desired the major-domo to give me his hat; upon examining it
the witchcraft was explained. In obeying my orders ‘to shake the hat
well,’ every grain of maize had absconded through a rent in the
crown, and the floor being covered with thick straw matting, they fell
upon it unheard.
“We therefore proceeded with more caution to a second drawing,
when the black bean appeared, on the show of hands, in that of
Basil Calamayo, from whose wages I directed the major-domo to
purchase the best pickaxe that could be had in Potosi. From that
hour I never heard of any pilfering.”
I do not record this procedure of Mr. Edmund Temple as a pattern
of justice. Mr. Temple, in taking the worth of the pickaxe in the
manner he did, from Basil Calamayo, without doubt punished an
innocent person, and excited the superstitious fears of the ignorant
Indians; both, very wrong actions. Still he pities the poor natives, and
when his own interest does not interfere, speaks very kindly of their
character. And well he might when he had such instances as the
following to record.
“When I have arrived weary and faint at a Peruvian hut, with what
pure feelings of gratitude have I made my acknowledgments to the
family, who, from sheer benevolence, have ceded to me the only
little store they possessed. Often have I alighted from my horse at an
unseasonable hour and asked for milk, offering dollars.
“The answer invariably was, ‘No hai! no hai, Señor!’ They would
not take the trouble of getting it for money.
“But when I said, ‘I am very unwell, my brother; do me the favor
and God will repay you,’ my feeble voice, pale cheek, and sunken
eye, bearing testimony to what I said, the sire of the family, or the
matron, twisting her ball of thread from the silken wool of the vicuña,
would mutter something in Quichua, (the language of the country,)
when instantly an earthen ware pipkin would be seized by one of the
younger members, who would glide away in pursuit of the flock, and
returning quite breathless from the haste he used, would present me
with the milk, without a question as to the payment.
“And this is savage hospitality! could I expect more among the
most polished people of the earth? Should I always have obtained as
much?”
In another place Mr. Temple observes, “I felt no apprehension of
losing a single article of my baggage; it had been entrusted to the
Indians, and in their charge required neither guards, nor swords, nor
pistols, to protect it, or to insure its safe delivery.
“On the whole, I believe I am not singular in the opinion that the
worst qualities of the Peruvian Indians have been imported, and that
their virtues are their own. They possess a peaceable, unoffending
spirit, free from even an accusation of those great moral crimes
which disgrace civilized nations.
“The dress of the men, excepting the hat, which is precisely the
shape of Don Quixote’s helmet without the niche in it, reminded me
of that of the peasantry of Connaught. They wear coarse brown
frieze cloth breeches, with the waistband very low, and always open
at the knees, the buttons being for ornament, not for use. Shirts are
seldom worn; the legs are bare, with the exception of pieces of hide
under the soles of the feet, tied sandal-fashion round the instep and
toes.
“The dress of the female Indians consists of a petticoat, worn
much shorter by the unmarried than by those that are married, and a
scarf of sundry colors round the shoulders, which is pinned on one
side of the chest with a topa, a large silver pin; but sometimes they
use a spoon, the handle of which being pointed serves as a pin.
“Cholas, those descended from Spanish and Indian parents, are
very fond of dress. I have seen them with topas of gold, set with
pearls and precious stones of considerable value.”
[1] The patron saint of robbers.

Charles and his Mother.
a dialogue.
Charles. Mother, may I play with the baby a little while before I go
to school?
Mother. She is asleep now, my son; but you may go softly and
look at her.
C. She is just going to wake up, mother! she is smiling and
moving her little hands.
M. No, she is only dreaming; don’t hold the curtain back so far,
the sun shines on her face.
C. I wonder what she is dreaming about; she looks very sober
now; what a pity she can’t tell us when she wakes! Mother, I shall be
glad when Susan grows a little bigger, and can run about, and talk,
and play with me; I don’t think a little baby is good for much.
M. And what if she should never grow up, Charles?
C. What! be always a little baby?
M. No, my son; what if she should die?
C. Die! O, that can’t be; she has only just begun to live.
M. Who made her live?
C. God, you told me.
M. And cannot God make her die when he pleases?
C. I suppose he can; but he never does, does he? Does he ever
kill such little babies as Susan?
M. They very often die, Charles.
C. I never heard of that before; I hope Susan will not die. How old
is she, mother?
M. Eight months.
C. O, mother, mother, that is too young to die; I am sure she
won’t. Here am I, seven years old, and I am not dead yet.
M. And I am twenty-seven, my dear boy; but for all that, you and
Susan may both die before I do, if it should please God.
C. What makes the tears come in your eyes, mother? we shan’t
die, I know. See how Susan keeps stirring about! see how red her
cheeks are!
M. She is not well; she is feverish, Charles. Do you know there
are two little white teeth trying to get through her gums, and they
give her a great deal of pain? I shall send for the doctor to-day. The
clock is striking nine, Charles, and you must go to school.
C. O dear! and where is my little satchel? and where is my
spelling-book, I wonder?
M. You had better look in the breakfast-room; and, Charles, be
sure you shut the window; it is very damp this morning.
C. Yes, mother. I wonder what I did with my cap.
M. Don’t bang the door, Charles—and don’t forget to shut the
window. I must take the baby down this morning.
tuesday morning.
Charles meets the doctor coming out of his mother’s chamber.
C. Are you the doctor, sir?
D. Yes, my little man.
C. Is the baby almost well again?
D. O no! no!
C. Why, they told me you were coming to cure her, and you came
three times yesterday; for I saw your old horse out of the school-
room window.
D. But she is very sick, little boy; somebody left a window open
yesterday when it was almost raining, and the nursery maid carried
her into a damp room while they were sweeping the nursery.
C. O, doctor, what shall I do? what shall I do?
D. Don’t cry, my little fellow; what is the matter, now?
C. It was I, it was I, that left the window open! mother told me to
shut it, and I was hunting for my cap and forgot all about it.
D. Well, that was wrong; but hush up; if your mother hears you
sobbing so bitterly she will feel much worse. It was a pity you forgot
the window.
C. O, my poor little sister! will you cure her? you can cure her sir,
can’t you sir?
D. I will try, but God must help us.
C. And won’t he help you? do you think he will make Susan die?
D. I cannot tell, indeed; but you must ask him to make her well.
C. How can I ask him?
D. In your prayers; do you not say your prayers every night?
C. Yes, the Lord’s prayer, and two other prayers; but there is
nothing in them about Susan’s being sick.
D. And can’t you make a little prayer on purpose?
C. I don’t know; I never tried.
D. Then go up into your chamber, my dear child, and kneel down
where you always say your prayers every night, and pray to God just
as if you could see him in the room with you. You may depend upon
it. He is there.
C. Shall I ask him to help you cure Susan?
D. Ask him to cure her if it is best she should get well.
C. Why, it is best certainly. And will it be wrong to tell him how
sorry I am that I forgot the window, and ask him to forgive me?
D. No, it will be quite right.
C. Then I will go this minute. You must come again before dinner
—won’t you?
D. Yes, I must indeed.
wednesday morning.
Charles comes softly into his mother’s chamber, half dressed.
C. Mother, are you there? it is so dark I cannot see you.
M. I am here, sitting by the bed, my son.
C. The fire is out, and the candle is just going out; may I open the
shutter a little way, so that I can see the baby, mother? I won’t wake
her.
M. She is not asleep, my dear boy. But what made you wake at
day-break?
C. I kept thinking of Susan when I was asleep, mother. What
makes her so still? is the pain better?
M. It is all gone, Charles; she will never feel it again; open the
shutters wide and come here.
C. O, mother, mother! (burying his face in her lap,) I do not wish to
look at her.
M. What is the matter, Charles? tell me.
C. She is dead—she is dead! the tears keep rolling down your
cheeks—and she is lying just like my little canary bird—and I do
believe she is dead!
M. Yes! my baby is dead, Charles! and—
C. Don’t cry, don’t cry! dear mother; you did not cry when I came
in—I will leave off crying if you will, mother.
M. Look at her little pale face, Charles;—why are you unwilling to
look at her?
C. I do not know. Will you take her off the bed? are you afraid to
hold her in your arms?
M. O, no; I have held her a great while to-night, Charles, and she
died in my lap.
C. And were you all alone?
M. No, there were two or three people with me then, and they
were very kind; but I sent them all away at last.
C. Why, mother?
M. Because sometimes I wanted to cry, and sometimes to pray,
and I liked better to be alone. I was praying when you came in,
Charles.
C. Mother, I prayed yesterday about Susan, but God did not mind
it. What makes you pray now that she is dead?
M. I was praying that I might remember how happy little Susan’s
soul is, and that I might not be so wicked as to complain because
God had taken her away again; and that I might be a better woman
now, and think more of heaven.
C. You need not pray for that, mother; you are a very good
woman, the best woman in the world.
M. Nobody can be good without praying, my son; and I had a
great many things to beg of God. I was asking him to make the little
boy who is spared to me, a good child.
C. Ah, mother, that is because I forgot the window!
M. No, my child, I was not thinking of that then; but if you should
pray to God to help you to cure your faults, you will find it becomes
much easier for you.
C. Then why did he not cure Susan’s sickness when I begged him
so hard?
M. Are you sure it would have been better for Susan to live?
C. I don’t know; she would have cried sometimes, I suppose.
M. But she never will cry now, Charles; her soul is with God in
heaven, and her body cannot feel pain now.
C. But it would have been better for us if she had lived to grow up,
mother. What makes you cry again?
Enter Aunt Catherine.
C. I am glad you have come, aunt; I have made mother cry again,
and I cannot help crying too. I do think it would have been better for
us if Susan had not died.
A. Your mother thought so at first, Charles; but now she knows it
would have been wrong to have wished little Susan here just for her
own pleasure, when the little creature is happier in heaven. Besides,
God would not have taken her if it had been for your mother’s real
good to let her stay.
C. I cannot understand that, do you mother?
M. I do! I do! but I cannot talk about it now.
C. So sudden! three days ago she was well!
A. Come, my dear child, come and let me finish dressing you, and
your mother will talk to you about Susan very often; kiss the dear
baby’s cheek, Charles,—your mother is holding her up to you.
C. O, if she could only be made alive again!
A. Hush—do not sob so loud! come with me, Charles, and I will
tell you how we think God has already made her alive in heaven.
John Doree.
We must not always judge of a thing by first sight. Here is a

picture of a fish called John Doree; and a fierce looking fellow he is;
but in point of fact, he seems to be a quiet sort of fish, behaving as
well as others of his race. It is difficult to get at the characters of
creatures down in the deep where John lives; but as he is gaily
marked with gold spots, we may believe that he passes for a kind of
fop among his fellows. His name, John Doree, means the same as
Gilded John. Out of the water and cooked, this fish is much
esteemed for his flavor; and in England he is a favorite upon the
table.
☞ The publishers express their hearty thanks to the writers of

the following, and hope the example here set may be followed by
many other black-eyed and blue-eyed friends of Robert Merry.
Carmel, N. Y., June 23, 1841.
Gentlemen:—We have seen several interesting notices of
your little Magazine in the Saturday Courier, and in other
papers, which give it such good recommendation, that we
have determined to send for it. We have no doubt that if you
would send a subscription paper to this village, many
subscribers could be obtained for the Museum. We have
enclosed money enough to take the Museum for eight
months, and if it proves equal to our expectations we will take
it much longer. It is difficult to enclose $1.50 in a letter, but if
we can obtain some subscribers for you, this difficulty can be
remedied. You may be curious enough to know why the term
we is used. We will explain. A short time since, during the
winter, it was proposed in the family to which we belong, by
one of the members, to do something to help pass away the
long evenings more agreeably. One proposed one thing,
another proposed another, but finally all determined to
subscribe for some other paper, although we already took
four; none of which, however, except the Ladies’ Garland,
seemed to suit the younger portion of the family. Instead of
going immediately to our father for the “money,” we thought
the better way would be to obtain it by our own industry. So
we went to work. Each was to put in at least a penny a week,
and more if we thought proper. This method incited the little
ones to industry. In a short time we had money sufficient to
pay for any Magazine. We sounded around some time to find
one which would blend instruction with delight. We sought in
vain among the mammoth sheets; for such trash as they
contained we thought unworthy to be let loose among the
youthful portion of any family. After a while, looking over the
Saturday Courier, we came across a notice of Merry’s
Museum, and, from the hearty recommendations given, we
thought we had found the very thing for which we had before
sought in vain. And now we, the members of this family, send
the cash necessary to take this paper for the time before
named; and please direct it to
E. L., Carmel, N. Y.
Bees.—When a swarm of bees settle in a hive, the first thing they

do is to build cells which serve for cradles; and then they lay by
something which is called bee-bread. This is gathered from the
flowers like honey; and the use of this bee-bread is to feed the young
bees. It is said that bees know the persons who are kind to them.
I have heard of a lady who attended a great deal to her bees, and
they seemed to be pleased to hear her voice. Sometimes, after a
storm, she would gather them up and wipe them, and lay them in her
warm hand till they recovered; and they would never sting her, but
would buzz about her as if they were pleased and grateful.

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Handbook of Otolaryngology: Head and Neck Surgery 2nd

CURRENT Diagnosis & Treatment Otolaryngology Head and

Cummings Review of Otolaryngology 1st Edition Harrison

Plastic Surgery-Craniofacial, Head and Neck Surgery-

Head and neck 3rd Edition Bernadette L. Koch

Head, Neck and Dental Anatomy 4th Edition, (Ebook PDF)

Head and Neck Pathology 3rd Edition Lester D.R.

Head, Neck and Dental Emergencies 2nd Edition Edition

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

There is a chapter in the Bible, of which you cannot read three

In 1825, Edmund Temple, a young Englishman, went out to

[1] The patron saint of robbers.

We must not always judge of a thing by first sight. Here is a

☞ The publishers express their hearty thanks to the writers of

Bees.—When a swarm of bees settle in a hive, the first thing they

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