Otolaryngology Basic Science and Clinical Review pot

Otolaryngology
Basic Science and Clinical Review
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Otolaryngology
Basic Science and Clinical Review
Thieme
New York • Stuttgart
EDITOR
Thomas R.Van De Water, Ph.D.
Director
Cochlear Implant Research Program
University of Miami Ear Institute
Professor
Department of Otolaryngology
Miller School of Medicine
University of Miami
Miami, Florida
ASSOCIATE EDITOR
Hinrich Staecker, M.D., Ph.D.
Director
Otology and Neurotology Program
Associate Professor
Department of Otolaryngology–Head and Neck Surgery
University of Maryland School of Medicine
Baltimore, Maryland
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Thieme Medical Publishers, Inc.
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New York, NY 10001
Editor: Esther Gumpert
Associate Editor: Birgitta Brandenburg
Vice President, Production and Electronic Publishing:Anne T.Vinnicombe
Production Editor: Print Matters, Inc.
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Printer: Maple-Vail Book Manufacturing Group
Library of Congress Cataloging-in-Publication Data
Otolaryngology : basic science and clinical review / [edited by] Thomas R.Van De Water,
Hinrich Staecker.
p. ; cm.
Includes bibliographical references and index.
ISBN 0-86577-901-5 (US)—ISBN 3-13-124651-0 (GTV)
1. Otolaryngology. 2. Ear—Physiology. 3. Respiratory organs—Physiology.
[DNLM: 1. Otorhinolaryngologic Diseases. 2. Ear—physiology. 3. Otorhinolaryngologic
Surgical Procedures. 4. Respiratory Physiology. WV 150 088 2005] I. Van De Water,
Thomas R. II. Staecker, Hinrich.
RF46.07525 2005
616.5'1—dc22 2005050640
Copyright ©2006 by Thieme Medical Publishers, Inc. This book, including all parts thereof, is legally protected by copyright. Any use, exploitation, or
commercialization outside the narrow limits set by copyright legislation without the publisher’s consent is illegal and liable to prosecution.This applies in
particular to photostat reproduction, copying, mimeographing or duplication of any kind, translating, preparation of microfilms, and electronic data processing
and storage.
Important note: Medical knowledge is ever-changing.As new research and clinical experience broaden our knowledge,changes in treatment and drug therapy
may be required.The authors and editors of the material herein have consulted sources believed to be reliable in their efforts to provide information that is
complete and in accord with the standards accepted at the time of publication. However, in view of the possibility of human error by the authors, editors, or

publisher of the work herein or changes in medical knowledge, neither the authors, editors, or publisher, nor any other party who has been involved in the
preparation of this work, warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors
or omissions or for the results obtained from use of such information. Readers are encouraged to confirm the information contained herein with other
sources. For example, readers are advised to check the product information sheet included in the package of each drug they plan to administer to be certain
that the information contained in this publication is accurate and that changes have not been made in the recommended dose or in the contraindications for
administration.This recommendation is of particular importance in connection with new or infrequently used drugs.
Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or proprietary names even though
specific reference to this fact is not always made in the text.Therefore, the appearance of a name without designation as proprietary is not to be construed as
a representation by the publisher that it is in the public domain.
Printed in the United States of America
5 4 3 2 1
TMP ISBN 0-86577-901-5
GTV ISBN 3 13 124651 0
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This book is dedicated to the memory of Maxwell Abram-
son, M.D., husband, father, physician, educator, re-
searcher, scholar, and friend. Max was an extraordinary
human being whose life reflected his core humanitarian
values. He was a gifted healer, creative scientist, and tal-
ented teacher in the discipline of otolaryngology. He pos-
sessed both a strong desire and an unbridled enthusiasm
to pass along his knowledge of the basic science and clini-
cal foundations of otolaryngology to the fellows, resi-
dents, and medical students at the Columbia University
College of Physicians and Surgeons, where he was chair-
man of the otolaryngology department from 1977 until
his untimely death in 1991. Max greatly loved both his
family and his chosen profession.He was a valued friend to
many of us in the otolaryngology community, and his ab-
sence is felt by all of us.I know that Max would be pleased

to have this book dedicated to his memory because it con-
tinues the dissemination of basic and clinical sciences
knowledge of otolaryngology.
Thomas R.Van De Water,Ph.D.
Maxwell Abramson,M.D. (1935–1991)
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P
REFACE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
F
OREWORD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
Thomas J. Balkany, M.D., F.A.C.S., F.A.A.P.
C
ONTRIBUTORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv
P
ART IT
HE B
ASIC PRINCIPLES
C
HAPTER 1S
URGICAL HEMOSTASIS
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Christopher Hartnick and Hinrich Staecker
C
HAPTER 2W
OUND H
EALING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Jane A. Petro, Mark D. Suski, and Howard D. Stupak
C

HAPTER 3B
ASIC
PRINCIPLES OF A
LLERGIC DISEASES
. . . . . . . . . . . . . . . . . . . . . 32
David Rosenstreich, Ashok Vaghjimal, and Golda Hudes
C
HAPTER
4H
EAD AND
NECK MANIFESTATIONS OF RHEUMATOLOGICAL DISEASES . . . . . 43
Derek D. Sloan and Jeffrey P. Harris
C
HAPTER
5P
ULMONARY
PHYSIOLOGY AND
M
ECHANICAL VENTILATION . . . . . . . . . . . 59
Karen B. Zur and Gregory J. Schilero
C
HAPTER 6B
IOLOGY AND TREATMENT OF SLEEP APNEA . . . . . . . . . . . . . . . . . . . 71
Hector P. Rodriguez and Diana V A. Berggren
C
HAPTER 7MICROBIOLOGY,VIROLOGY, AND MECHANISMS OF INFECTION . . . . . . . . . 83
Ruy Soeiro and Bettie Steinberg
C
HAPTER
8P

RINCIPLES OF
P
HARMACOLOGY
. . . . . . . . . . . . . . . . . . . . . . . . . . 98
Christopher J. Hartnick, Alexander W. Gotta, and Ira M. Leviton
C
HAPTER 9O
TOTOXICITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Leonard P. Rybak, John S.Touliatos, and Kathleen Campbell
C
HAPTER
10A O
NCOLOGY OF
H
EAD AND
NECK
TUMORS . . . . . . . . . . . . . . . . . . . . 137
Elizabeth Franzmann, Scott Lilly, David Huang, Giovana Thomas
C
HAPTER
10B I
MMUNOBIOLOGY AND IMMUNOTHERAPY OF HEAD
AND
N
ECK S
QUAMOUS
C
ARCINOMA . . . . . . . . . . . . . . . . . . . . . . . 150
Giovana Thomas,William J. Richtsmeier, and Hari Nadiminti
Contents

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CHAPTER 11 CLINICAL RADIATION BIOLOGY AND RADIOTHERAPY . . . . . . . . . . . . . . 158
Steven R. Isaacson and Lanny Garth Close
C
HAPTER 12 ENVIRONMENTAL EFFECTS ON THE UPPER AIRWAY . . . . . . . . . . . . . . . . 164
Andrew Blitzer
C
HAPTER 13 HOW TO CONDUCT CLINICAL RESEARCH . . . . . . . . . . . . . . . . . . . . 168
Steven D. Rauch
C
HAPTER
14 BASIC PRINCIPLES AND CURRENT APPLICATIONS OF LASERS IN HEAD
AND
N
ECK SURGERY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
Daniel B. Kuriloff
C
HAPTER 15 MOLECULAR BIOLOGY FOR THE OTOLARYNGOLOGIST . . . . . . . . . . . . . . 192
Jeffrey Wolfe, Hinrich Staecker, and Thomas R.Van De Water
C
HAPTER 16 PHYSIOLOGY OF THE PEDIATRIC PATIENT . . . . . . . . . . . . . . . . . . . . . 199
Lewis P. Singer
C
HAPTER 17 BRANCHIAL
CLEFT ANATOMY AND CONGENITAL NECK MASSES . . . . . . . . 207
Gerald B. Healy
C
HAPTER 18 PATHOPHYSIOLOGY OF
STRIDOR AND AIRWAY DISEASE . . . . . . . . . . . . . 212
John H. Greinwald and Robin T. Cotton

C
HAPTER 19 C
LINICAL GENETICS IN
OTOLARYNGOLOGY
. . . . . . . . . . . . . . . . . . . . 225
Simon I. Angeli, Nancy Sculerati, and Thomas R.Van De Water
P
ART II T
HE
EAR,H
EARING,
AND BALANCE
CHAPTER 20 E
MBRYOLOGY OF THE
OUTER,M
IDDLE, AND
INNER E
AR . . . . . . . . . . . . 251
Thomas R.Van De Water and Hinrich Staecker
C
HAPTER
21 A
COUSTICS AND
MIDDLE EAR MECHANICS FOR OTOLARYNGOLOGY . . . . . . 259
John J. Rosowski and Saumil N. Merchant
C
HAPTER 22 SURGICAL ANATOMY OF THE TEMPORAL BONE . . . . . . . . . . . . . . . . . . 275
Hinrich Staecker and Adrien A. Eshraghi
C
HAPTER 23 H

ISTOLOGY AND
HISTOPATHOLOGY OF THE TEMPORAL BONE . . . . . . . . . 283
Joseph B. Nadol, Jr.
C
HAPTER 24 ULTRASTRUCTURAL ANATOMY OF THE COCHLEA . . . . . . . . . . . . . . . . 313
David J. Lim
C
HAPTER
25 H
AIR C
ELL
FUNCTION
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 332
Peter G. Gillespie
C
HAPTER
26 A
UDITORY PROCESSING IN SENSORINEURAL HEARING LOSS . . . . . . . . . . . 340
M. Charles Liberman
C
HAPTER
27 P
ATHWAYS OF
HEARING AND BALANCE . . . . . . . . . . . . . . . . . . . . . . 350
Alan D. Legatt
C
HAPTER
28 A
SSESSMENT OF
CENTRAL AUDITORY FUNCTION . . . . . . . . . . . . . . . . . 361

Philippe P. Lefebvre and Alan D. Legatt
viii CONTENTS
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CHAPTER 29 LANGUAGE AND THE PLASTIC BRAIN . . . . . . . . . . . . . . . . . . . . . . . . 368
Robert J. Ruben
C
HAPTER 30 PRINCIPLES OF AUDIOMETRY . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374
Jackson Roush and John Grose
C
HAPTER 31 HEARING AIDS,BONE-ANCHORED HEARING AIDS,
AND
COCHLEAR IMPLANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 385
Adrien A. Eshraghi, Susan B.Waltzman, Joseph G. Feghali,
Thomas R.Van De Water, and Noel L. Cohen
C
HAPTER 32 MECHANISM OF NOISE-INDUCED HEARING LOSS
AND
OTOPROTECTIVE STRATEGIES . . . . . . . . . . . . . . . . . . . . . . . . . 395
Richard D. Kopke, John K.M. Coleman, Jianzhong Liu, Ronald L. Jackson,
and Thomas R.Van De Water
C
HAPTER 33 VESTIBULAR SYSTEM PHYSIOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . 409
John Carey
C
HAPTER 34 T
ESTING BALANCE AND THE
VESTIBULAR SYSTEM . . . . . . . . . . . . . . . . 415
Hinrich Staecker
C
HAPTER 35 M

ORPHOPHYSIOLOGY OF THE
FACIAL
NERVE
. . . . . . . . . . . . . . . . . . . 421
K. Paul Boyev and Adrien A. Eshraghi
C
HAPTER 36 R
ADIOLOGY OF THE
TEMPORAL B
ONE . . . . . . . . . . . . . . . . . . . . . . 431
Barbara Zeifer
P
ART III T
HE NOSE,O
LFACTION
, AND THE
SINUSES
CHAPTER 37 D
EVELOPMENT OF THE
N
OSE . . . . . . . . . . . . . . . . . . . . . . . . . . . 449
Bradley J. Goldstein and Thomas R.Van De Water
C
HAPTER
38 S
URGICAL
ANATOMY OF THE
NOSE
AND
PARANASAL

S
INUSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 455
Dinesh Mehta and Walter M. Ralph Jr.
C
HAPTER 39 NASAL AND PARANASAL SINUS PHYSIOLOGY . . . . . . . . . . . . . . . . . . . 472
Erich P.Voigt and David R. Edelstein
C
HAPTER 40 T
HE B
IOLOGY AND TESTING OF OLFACTORY DYSFUNCTION . . . . . . . . . . 485
James E. Schwob, Daniel B. Kurtz, and Bradley J. Goldstein
P
ART IV THE LARYNX,VOICE, AND NECK
C
HAPTER 41 THE BRANCHIAL ARCHES AND THEIR DERIVATIVES . . . . . . . . . . . . . . . . 499
Jeffrey T. Laitman, Joy S. Reidenberg, Armand Balboni,
Andrew Bergemann, and Peter Som
C
HAPTER
42 M
ORPHOPHYSIOLOGY OF THE LARYNX . . . . . . . . . . . . . . . . . . . . . . 505
Joy S. Reidenberg and Jeffrey T. Laitman
C
HAPTER
43 N
EUROLOGICAL
D
ISORDERS OF THE
LARYNX . . . . . . . . . . . . . . . . . . . 516
Abigail Arad-Cohen and Andrew Blitzer

CONTENTS ix
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CHAPTER 44 BASICS OF VOICE PRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . 524
John S. Rubin and Ronald C. Scherer
C
HAPTER 45 PRINCIPLES OF PHONOSURGERY . . . . . . . . . . . . . . . . . . . . . . . . . . 536
Peak Woo
C
HAPTER 46 SURGICAL ANATOMY OF THE PHARYNX AND ESOPHAGUS . . . . . . . . . . . . 552
Dorothy Frenz and Richard V. Smith
C
HAPTER
47 THE BIOLOGY OF SWALLOWING . . . . . . . . . . . . . . . . . . . . . . . . . . 566
Soly Baredes and Kristine Mosier
C
HAPTER 48 LARYNGEAL PATHOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 574
Marjorie Brandwein-Gensler
C
HAPTER 49 ORIGINS AND SPECIFICATION OF CRANIOFACIAL MUSCULOSKELETAL TISSUES . . . 592
Drew M. Noden
C
HAPTER 50 SURGICAL ANATOMY OF THE NECK AND CLASSIFICATION OF DISSECTIONS . . . 598
Richard V. Smith and Dorothy Frenz
C
HAPTER 51 SURGICAL
ANATOMY OF THE SKULL BASE AND CRANIAL NERVES . . . . . . . . 610
Joseph Feghali and Dorothy Frenz
P
ART VT
HE O

RAL CAVITY
,T
ASTE, AND THE
GLANDS OF THE
NECK
CHAPTER 52 B
ASIC S
CIENCE OF THE
ORAL C
AVITY AND G
USTATION
. . . . . . . . . . . . . 627
Charles P. Kimmelman
C
HAPTER 53 M
ORPHOPHYSIOLOGY OF THE
S
ALIVARY
GLANDS . . . . . . . . . . . . . . . . . 634
Richard J.Wong and Gregory W. Randolph
C
HAPTER 54 MORPHOPHYSIOLOGY OF THE THYROID AND PARATHYROID GLANDS . . . . . . 643
Carl E. Silver and Lane Krevitt
C
HAPTER 55 P
ATHOBIOLOGY OF THE
THYROID GLAND . . . . . . . . . . . . . . . . . . . . . 650
Marjorie Brandwein-Gensler
P
ART

VI F
ACIAL
PLASTICS AND
M
ISCELLANEOUS
CHAPTER 56 IMAGING OF THE NECK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 667
Adam Silvers
C
HAPTER 57 T
HE A
GING FACE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 682
Ivan Wayne and Brian Jewett
C
HAPTER 58 VASCULAR ANATOMY OF THE HEAD AND NECK . . . . . . . . . . . . . . . . . 693
Jane A. Petro
C
HAPTER
59 T
HE B
IOLOGY OF
F
LAPS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 704
Neal Futran
C
HAPTER 60 IMPLANTS IN OTOLARYNGOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . 709
G. Richard Holt
A
NSWERS TO
S
ELF-TESTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 715

I
NDEX
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 719
x CONTENTS
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For otolaryngology–head and neck surgeons in training as
residents and fellows, it is a difficult task to keep up with
all of the advances in the basic and clinical sciences that
impact the medical and surgical practice of their specialty.
It is also pertinent to the practice of otolaryngology–head
and neck surgery for interested medical students and lec-
turers in medical school faculties who teach students and
resident physicians to have a reference book that clearly
presents the basic principles.This book serves as an excel-
lent resource for residents preparing for board exams,
students studying for exams, and a refresher for praction-
ers and all other interested parties. It is a natural by-prod-
uct of a Basic Sciences in Otolaryngology course that was
taught at the New York Academy of Medicine.This course
was first organized as a Saturday teaching program, and at
the behest of Professors Max Abramson (chairman of the
Department of Otolaryngology, College of Physicians
and Surgeons, Columbia University) and Bob Ruben
(chairman of the Department of Otolaryngology, Albert
Einstein College of Medicine,Yeshiva University), I reor-
ganized and expanded the scope of the course and became
the academic director for over 15 years. Six New York and
one New Jersey otolaryngology–head and neck surgery
residency training programs participated in this basic sci-
ences course on Tuesday evenings at the New York Acad-

emy of Medicine.The course became very comprehensive
and covered almost all of the basic and clinical science as-
pects of otolaryngology–head and neck surgery. In 1991,
I renamed this resident teaching program the Maxwell
Abramson Basic Sciences Course in Otolaryngology to
honor Max after his untimely and tragic death.The con-
tent and relevancy of this course have been continually
improved by responding to the critiques and suggestions
provided by the attending residents, medical students, fel-
lows, residency program directors, program chairs, and
lecturers. It remained current by the hard work of the in-
vited lecturers who continually incorporated contempo-
rary advances into the talks they gave that covered their
respective fields of expertise.The subject matter and infor-
mation presented in this book are a product of that
process of updating and refinement.
Because this book attempts to cover the entire field of
otolaryngology–head and neck surgery, it is very compre-
hensive and therefore is composed of 60 chapters.These
chapters are arranged into six broadly defined sections.
Chapters 1 to 19 comprise Section I,The Basic Principles;
Chapters 20 to 36 form Section II,The Ear, Hearing, and
Balance; Chapters 37 to 40 comprise Section III,The Nose,
Olfaction, and the Sinuses; chapters 41 to 51 cover section
IV,The Larynx,Voice, and Neck; Chapters 52 to 55 rep-
resent section V,The Oral Cavity,Taste, and the Glands of
the Neck; and Chapters 56 to 60 are Section VI, Facial
Plastics and Miscellaneous.
The authors invited to write each chapter were se-
lected because they are leaders and experts in their sub-

ject areas and for their ability to confer their knowledge
in a clear and concise format that is appropriate for the
targeted audience.There are over 100 authors who have
contributed to Otolaryngology:Basic Science and Clinical Re-
view. These authors come from such diverse fields as
anatomy, auditory physiology, pharmacology, radiology,
general otolaryngology, molecular biology, molecular ge-
netics, plastic surgery, infectious diseases, pediatrics, otol-
ogy, neurotology, phonosurgery, voice, head and neck
surgery, and oncology.They hold such diverse degrees as
Ph.D.s, Au.D.s, and M.D.s, but a uniting factor is that
they are all teachers with a desire to educate, who con-
sider it both their duty and a privilege to pass on their ac-
cumulated knowledge to interested students, residents,
and fellows.
This book is dedicated not only to the memory of Pro-
fessor Maxwell Abramson, who was both a caring physi-
cian and a gifted teacher, but also to the many residents,
medical students, and fellows who have participated in
this course over the years and whose intelligent and
thoughtful input improved the content of the Maxwell
Preface
13978_FM.qxd 8/19/05 3:10 PM Page xi
Abramson Basic Sciences in Otolaryngology course and
therefore the final content of this book.We also thank the
many authors who spent countless hours writing, rewrit-
ing, and updating their chapters, for without their dedica-
tion and hard work, none of this would have been
possible.
No book is accomplished without many hours that

turn into days and then into weeks and months stolen
from our families with their knowledge and assent.We ac-
knowledge this sacrifice and express our deep gratitude
to our wives, Jeanette Van De Water and Danielle
Staecker, for both their understanding and generosity of
spirit.
Otolaryngology: Basic Science and Clinical Review could
never have seen the light of day without the very able
assistance and help from our editor, Esther Gumpert, and
our very capable, committed, and multitalented associate
editor, Birgitta Brandenburg, at Thieme Medical Publish-
ers in New York.
Thomas R. Van De Water,Ph.D.
Hinrich Staecker,M.D.,Ph.D.
xii PREFACE
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Otolaryngology: Basic Science and Clinical Review fills a
unique requirement for a contemporary, definitive text-
book that covers the expansive fields of basic and clinical
sciences in otolaryngology.
The education of medical students and residents to be-
come practicing otolaryngologists is a primary function
of any department of otolaryngology–head and neck sur-
gery.To become skilled clinicians and surgeons, residents
must have a firm understanding of the scientific precepts
that form the bases for the clinical and surgical practice of
their chosen specialty.
This textbook is the natural outgrowth of a basic science
in otolaryngology course that was organized and taught by
Thomas Van De Water, Ph.D., at the New York Academy of

Medicine for over 15 years.The textbook benefits from re-
finements and the continuous updating of that course in re-
sponse to feedback from students, residents, and faculty.
Knowledge is presented in a clear and comprehensive for-
mat written by experts in each of the disciplines who have
kept their targeted audience in mind.
There is at present no other textbook in the specialty
of otolaryngology–head and neck surgery that brings to-
gether all of the basic and clinical science knowledge
needed for a comprehensive understanding of this surgi-
cal/medical specialty.As the first of its genre, Otolaryngol-
ogy: Basic Science and Clinical Review fills a much needed
place in the education of residents, provides a resource
for medical students interested in pursuing a career in this
specialty, and acts as a study guide for recent graduates of
training programs.This ambitious text—detailing the ex-
plosion of knowledge underpinning a highly diverse spe-
cialty—is destined to become both required reading for
residents and an authoritative reference for practicing
otolaryngologists. Professor Van De Water and associate
editor Hinrich Staecker, M.D., Ph.D., along with the ex-
pert authors gathered here, are to be congratulated for
this outstanding contribution to our specialty.
Thomas J. Balkany, M.D.,F.A.C.S.,F.A.A.P.
Foreword
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Contributors
EDITOR

Thomas R.Van De Water, Ph.D.
Director
Cochlear Implant Research Program
University of Miami Ear Institute
Professor
Department of Otolaryngology
Miller School of Medicine
University of Miami
Miami, Florida
ASSOCIATE EDITOR
Hinrich Staecker, M.D., Ph.D.
Director
Otology and Neurotology Program
Associate Professor
Department of Otorhinolaryngology–
Head and Neck Surgery
University of Maryland School of
Medicine
Baltimore, Maryland
CONTRIBUTORS
Simon I. Angeli, M.D.
Associate Professor
Department of Otolaryngology
Miller School of Medicine
University of Miami
Miami, Florida
Abigail Arad-Cohen, M.D.
Shoham, Israel
Armand Balboni, J.D., M.Phil.
(A.B.D.)

Department of Anatomy and Morphology
Mount Sinai School of Medicine
New York, New York
Thomas J. Balkany, M.D., F.A.C.S.,
F.A.A.P.
Hotchkiss Professor and Chairman
Department of Otolaryngology
Professor of Neurological Surgery and
Pediatrics
Miller School of Medicine
University of Miami
Miami, Florida
Soly Baredes, M.D., F.A.C.S.
Chairman
Department of Otolaryngology
University of Medicine and Dentistry of
New Jersey
Newark, New Jersey
Andrew Bergemann, Ph.D.
Department Of Pathology
Mount Sinai School of Medicine
New York, New York
Diana V A. Berggren, M.D., Ph.D.
Chairman
Department of Otolaryngology
Professor
Departments of Clinical Science,
Otorhinolaryngology
Umeå University
Umeå, Sweden

Andrew Blitzer, M.D., D.D.S.
Professor
Department of Otolaryngology
College of Physicians & Surgeons
Columbia University
Presbyterian Hospital
New York, New York
K. Paul Boyev, M.D.
Associate Professor
Department Of Otolaryngology
University of South Florida
Tampa, Florida
Marjorie S Brandwein-Gensler, M.D.
Professor
Departments of Pathology and
Otolaryngology
Mount Sinai School of Medicine
Mount Sinai Medical Center
New York, New York
Kathleen Campbell, Ph.D.
Professor and Director of Audiology
Research
Department of Surgery
Southern Illinois University School of
Medicine
Springfield, Illinois
John Carey, M.D.
Associate Professor
Department of Otolaryngology–
Head and Neck Surgery

The Johns Hopkins University School of
Medicine
Baltimore, Maryland
13978_FM.qxd 8/19/05 3:10 PM Page xv
Lanny Garth Close, M.D.
Howard W. Smith Professor and Chair
Department of Otolaryngology–
Head and Neck Surgery
College of Physicians & Surgeons
Columbia University
Presbyterian Hospital
New York, New York
Noel L. Cohen, M.D.
Chairman Emeritus
Department of Otolaryngology
New York University School of
Medicine
New York, New York
John K. M. Coleman, Ph.D.
Senior Research Scientist
Department of Otolaryngology
Naval Medical Center–San Diego
San Diego, California
Robin T. Cotton, M.D.
Professor
Department of Otolaryngology
Children's Hospital Medical Center
University of Cincinnati College of
Medicine
Cincinnati, Ohio

David R. Edelstein, M.D., F.A.C.S.
Chief
Division of Otolaryngology/Nasal Sinus
Disease/Endoscopy
Manhattan Eye, Ear and Throat Hospital
New York, New York
Adrien A. Eshraghi, M.Sc., M.D.
Associate Professor
Department of Otolaryngology
Miller School of Medicine
University of Miami
Jackson Memorial Hospital
Miami, Florida
Joseph Feghali, M.D., F.A.C.S.
Adjunct Professor
Department of Otolaryngology and
Neurological Surgery
Albert Einstein College of Medicine
Montefiore Medical Center
Bronx, New York
Elizabeth J. Franzmann, M.D.
Assistant Professor
Department of Otolaryngology
Miller School of Medicine
University of Miami
Miami, Florida
Dorothy Frenz, Ph.D.
Director
Otolaryngology Research
Professor

Departments of Otolaryngology and
Anatomy and Structural Biology
Albert Einstein College of Medicine
Bronx, New York
Neal Futran, M.D.
Assistant Professor
Department of Otolaryngology–Head
and Neck Surgery
University of Washington
Seattle,Washington
Peter G. Gillespie, Ph.D.
Professor of Otolaryngology and Cell
Biology
Oregon Hearing Research Center
Oregon Health and Sciences University
Portland, Oregon
Bradley J. Goldstein, M.D., Ph.D.
Assistant Professor
Department of Otolaryngology–Head
and Neck Surgery
The Johns Hopkins University School of
Medicine
Baltimore, Maryland
Alexander W. Gotta, M.D.
Chairman Emeritus
Department of Pharmacology
Downstate Medical Center
State University of New York
Brooklyn, New York
John H. Greinwald, Jr., M.D.

Associate Professor of Otolaryngology
and Pediatrics
Department of Otolaryngology
Division of Pediatric Otolaryngology
Children's Hospital Medical Center
University of Cinncinati College of
Medicine
Cincinnati, Ohio
John H. Grose, M.D.
Department of Otolaryngology–
Head and Neck Surgery
University of North Carolina at Chapel
Hill
Chapel Hill, North Carolina
Jeffrey P. Harris, M.D.
Chairman
Department of Otolaryngology
Head and Neck Surgery Clinic
University of California–San Diego
Medical Center
La Jolla, California
Christopher J. Hartnick, M.D.
Assistant Professor
Department of Otology and
Laryngology
Harvard Medical School
Massachusetts Eye and Ear Infirmary
Boston, Massachusetts
Gerald B. Healy, M.D.
Professor

Department of Otology and
Laryngology
Children’s Hospital
Harvard Medical School
Boston, Massachusetts
G. Richard Holt, M.D.,
M.S.E., M.P.H.
University of Texas Health Science
Center
San Antonio,Texas
David Huang, M.D., Ph.D.
Department of Radiation Oncology
Miller School of Medicine
University of Miami
Miami, Florida
Golda Hudes, M.D., Ph.D.
Assistant Professor
Department of Medicine (Allergy &
Immunology)
Department of Otolaryngology
Albert Einstein College of
Medicine
Montefiore Medical Center
Bronx, New York
xvi CONTRIBUTORS
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Steven R. Issacson, M.D., F.A.C.S.
Associate Professor
Departments of Radiation Oncology
and Otolaryngology

College of Physicians & Surgeons
Columbia University
Presbyterian Hospital
New York, New York
Ronald Jackson, Ph.D.
Senior Scientist
Department of Otolaryngology
Naval Medical Center
San Diego, California
R. L. Jackson, M.D.
Department of Defense Spatial
Orientation Center
Naval Medical Center
San Diego, California
Brian Jewett, M.D.
Assistant Professor
Department of Otolaryngology
Division of Facial Plastic Surgery
Miller School of Medicine
University of Miami
Miami, Florida
Charles P. Kimmelmann, M.D.,
M.B.A., F.A.C.S.
Associate Clinical Professor
Department of Otorhinolaryngology
Weill Cornell Medical Center
New York, New York
Richard D. Kopke, M.D., F.A.C.S.
Clinical Professor
Department of Otorhinolaryngology

University of Oklahoma Health
Sciences Center
Director, Hough Ear Institute
Oklahoma City, Oklahoma
Lane Krevitt, M.D.
Adjunct Clinical Instructor
Department of Otolaryngology
Albert Einstein College of Medicine
Montefiore Medical Center
Bronx, New York
Daniel B. Kuriloff, M.D., F.A.C.S.
Associate Professor
Department of Otolaryngology–Head
and Neck Surgery
College of Physicians & Surgeons
Columbia University
Presbyterian Hospital
New York, New York
Daniel B. Kurtz, Ph.D.
Assistant Professor
Department of Biology
Utica College
Utica, New York
Jeffrey T. Laitman, Ph.D.
Professor and Director
Center for Anatomy and Functional
Morphology
Professor, Department of
Otolaryngology
Mount Sinai School of Medicine

New York, New York
Philippe P. Lefebvre, M.D., Ph.D.
Professor and Chairman
Department of Otolaryngology and
Audiophonology
University of Liège
Liège, Belgium
Alan David Legatt, M.D., Ph.D.
Professor
Department of Neurology
Albert Einstein College of Medicine
Director, EEG Laboratory
Director, Evoked Potential Laboratory
Director, Intraoperative Neurophysiology
Montefiore Medical Center
Bronx, New York
Ira M. Leviton, M.D.
Department of Internal Medicine
Division of Infectious Diseases
Albert Einstein College of Medicine
Montefiore Medical Center
Bronx, New York
M. Charles Liberman, Ph.D.
Professor
Department of Otology and Laryngology
Harvard Medical School
Director
Eaton Peabody Laboratory
Massachusetts Eye and Ear Infirmary
Boston, Massachusetts

Scott Lilly, D.D.S., M.D.
Oklahoma Oncology, Inc.
Tulsa, Oklahoma
David J. Lim, M.D.
Executive Vice President of Research
Head, Gonda Department of Cell and
Molecular Biology
House Ear Institute
Adjunct Professor
University of Southern California
Los Angeles, California
Jianzhong Liu, M.D.
Department of Otorhinolaryngology
University of Oklahoma Health
Sciences Center
Hough Ear Institute
Oklahoma City, Oklahoma
Dinesh Mehta, M.D., F.A.C.S.,
F.R.C.S.
Clinical Associate Professor
Department of Otolaryngology–
Head and Neck Surgery
Albert Einstein College of
Medicine
Montefiore Medical Center
Bronx, New York
Saumil N. Merchant, M.D.
Associate Professor
Department of Otology and
Laryngology

Harvard Medical School
Massachusetts Eye and
Ear Infirmary
Boston, Massachusetts
Kristine Mosier, D.M.D., Ph.D.
Assistant Professor
Department of Radiology
Indiana University School of
Medicine
Indianapolis, Indiana
Joseph B. Nadol, Jr., M.D.
Professor and Chairman
Department of Otology and
Laryngology
Harvard Medical School
Massachusetts Eye and Ear Infirmary
Boston, Massachusetts
CONTRIBUTORS xvii
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Hari Nadiminti, M.D.
Resident, Internal Medicine
Harvard Medical School
Massachusetts General Hospital
Boston, Massachusetts
Drew M. Noden, Ph.D.
Professor of Embryology and Animal
Development
Department of Biomedical Sciences
College of Veterinary Medicine
Cornell University

Ithaca, New York
Jane A. Petro, M.D., F.A.C.S.
Professor
Department of Surgery
Division of Plastic Surgery
New York Medical College
White Plains, New York
Walter M. Ralph, Jr., M.D., Ph.D.
Department of Surgery
Division of Ololaryngology
St Johns Queens Hospital
Elmhurst, New York
Gregory W. Randolph, M.D.
Department of Otology and
Laryngology
Harvard Medical School
Massachusetts Eye and Ear Infirmary
Boston, Massachusetts
Steven D. Rauch, M.D.
Associate Professor
Department of Otolaryngology
Harvard Medical School
Massachusetts Eye and Ear Infirmary
Boston, Massachusetts
Joy S. Reidenberg, Ph.D.
Associate Professor
Center for Anatomy and Functional
Morphology
Mount Sinai School of Medicine
New York University School of Medicine

New York, New York
William J. Richtsmeier, M.D.
Chief
Otolaryngology Service
Bassett Healthcare
Cooperstown, New York
Hector P. Rodriguez, M.D.
Assistant Professor
Department of Otolaryngology–Head
and Neck Surgery
Director of Rhinology
College of Physicians and Surgeons
Columbia University
Presbyterian Hospital
New York, New York
David Rosenstreich, M.D.
Department of Medicine
Albert Einstein School of Medicine
Montefiore Medical Center
Bronx, New York
John J. Rosowski, Ph.D.
Professor
Department of Otology and
Laryngology
Harvard Medical School
Massachusetts Eye and Ear Infirmary
Boston, Massachusetts
Jackson Roush, Ph.D.
Professor and Director
Division of Speech and Hearing

Sciences
School of Medicine
University of North Carolina at
Chapel Hill
Chapel Hill, North Carolina
Robert J. Ruben, M.D.
Distinguished University Professor
Department of Otolaryngology–
Head and Neck Surgery
Albert Einstein College of Medicine
Montefiore Medical Center
Bronx, New York
John S. Rubin, M.D., F.A.C.S.,
F.R.C.S.
Consultant Surgeon
The Royal National Throat, Nose and
Ear Hospital
Division of The Royal Free N.H.S.Trust
London, United Kingdom
Leonard P. Rybak, M.D., Ph.D.
Distinguished Professor
Department of Surgery
Division of Otolaryngology
Southern Illinois University School of
Medicine
Springfield, Ilinois
Ronald C. Scherer, Ph.D.
Professor
Department of Communication Disorders
Bowling Green State University

Bowling Green, Ohio
Gregory J. Schilero, M.D.
Assistant Professor
Department of Medicine
Mount Sinai School of Medicine
Mount Sinai Medical Center
New York, New York
James E. Schwob, M.D, Ph.D.
Professor and Chair
Department of Anatomy and
Cellular Biology
Tufts University School of Medicine
Boston, Massachusetts
Nancy Sculerati, M.D.
Pediatric Otolaryngologist (retired)
New York University School of Medicine
New York, New York
Carl E. Silver, M.D.
Professor
Department of Surgery–Head and Neck
Albert Einstein College of Medicine
Montefiore Medical Center
Bronx, New York
Adam Silvers, M.D.
Director of Neuroradiology
Next Generation Radiology
Great Neck, New York
Lewis P. Singer, M.D.
Professor
Department of Pediatrics

Albert Einstein College of Medicine
Children's Hospital
Montefiore Medical Center
Bronx, New York
xviii CONTRIBUTORS
13978_FM.qxd 8/19/05 3:10 PM Page xviii
Derek D. Sloan, M.D.
Senior Postdoctoral Fellow
Department of Laboratory Medicine
University of Washington
Seattle,Washington
Richard V. Smith, M.D.
Vice Chairman
Associate Professor
Department of Otolaryngology–
Head and Neck Surgery
Medical Arts Pavilion
Albert Einstein College
of Medicine
Montefiore Medical Center
Bronx, New York
Ruy Soeiro, M.D.
Professor
Department of Medicine
Albert Einstein College
of Medicine
Montefiore Medical Center
Bronx, New York
Peter Som, M.D.
Professor

Department of Radiology and
Otolaryngology
Director
Head and Neck Radiology
Mount Sinai School of Medicine
Montefiore Medical Center
New York, New York
Bettie Steinberg, Ph.D.
Associate Director
Institute for Medical Research at
North Shore
Professor, Department of
Ololarnyngology
Long Island Jewish Medical Center
New Hyde Park, New York
Howard D. Stupak, M.D.
Private Practice
Facial Plastic Surgery
New Haven, Connecticut
Mark D. Suski, M.D.
Private Practice
Westlake Village, California
Giovana Thomas, M.D.
Assistant Professor
Department of Otolaryngology–
Head and Neck Surgery
Division of Head and
Neck Surgery
Miller School of Medicine
University of Miami

Miami, Florida
John S.Touliatos, M.D.
Private Practice
Memphis,Tennessee
Ashok Vaghjimal, M.D.
Private Practice
Allergy,Asthma, and Infectious Disease
Northport,Alabama
Eric P.Voigt, M.D.
Clinical Instructor
Department of Otolaryngology
New York University School of
Medicine
NYU Medical Center
New York, New York
Susan B Waltzman, Ph.D.
Professor
Department of Otolaryngology
Director
Cochlear Implant Program
New York University School of Medicine
New York, New York
Ivan Wayne, M.D.
Department of Otorhinolaryngology
University of Oklahoma Health
Sciences Center
Oklahoma City, Oklahoma
Jeffrey Wolfe, M.D.
Assistant Professor
Department of

Otorhinolaryngology–Head and
Neck Surgery
University of Maryland School of
Medicine
University of Maryland Medical
Center
Baltimore, Maryland
Richard J.Wong, M.D.
Memorial Sloan-Kettering Cancer
Center
New York, New York
Peak Woo, M.D.
Professor
Department of Otolaryngology
Mount Sinai School of Medicine
Mount Sinai Medical Center
New York, New York
Barbara A. Zeifer, M.D.
Vice Chairman
Department of Radiology
Beth Israel Medical Center
New York, New York
Karen B. Zur, M.D.
Assistant Professor
Department of
Otorhinolaryngology–Head and
Neck Surgery
University of Pennsylvania School of
Medicine
Children's Hospital of Philadelphia

Philadelphia, Pennsylvania
CONTRIBUTORS xix
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1. S
URGICAL HEMOSTASIS
2. WOUND HEALING
3. BASIC PRINCIPLES OF ALLERGIC DISEASES
4. HEAD AND NECK MANIFESTATIONS OF
RHEUMATOLOGICAL DISEASES
5. PULMONARY PHYSIOLOGY AND
MECHANICAL VENTILATION
6. BIOLOGY AND TREATMENT OF SLEEP APNEA
7. MICROBIOLOGY,VIROLOGY, AND MECHANISMS
OF
INFECTION
8. PRINCIPLES OF PHARMACOLOGY
9. OTOTOXICITY
10A. ONCOLOGY OF HEAD AND NECK TUMORS
10B. IMMUNOBIOLOGY AND IMMUNOTHERAPY OF
HEAD AND NECK SQUAMOUS CARCINOMA
11. C
LINICAL RADIATION BIOLOGY AND
RADIOTHERAPY
12. ENVIRONMENTAL EFFECTS ON
THE
UPPER AIRWAY
13. HOW TO CONDUCT CLINICAL RESEARCH
14. BASIC PRINCIPLES AND CURRENT APPLICATIONS

OF
LASERS IN HEAD AND NECK SURGERY
15. MOLECULAR BIOLOGY FOR THE
OTOLARYNGOLOGIST
16. PHYSIOLOGY OF THE PEDIATRIC PATIENT
17. BRANCHIAL CLEFT ANATOMY AND
CONGENITAL NECK MASSES
18. PATHOPHYSIOLOGY OF STRIDOR AND
AIRWAY DISEASE
19. CLINICAL GENETICS IN OTOLARYNGOLOGY
Part I
The Basic Principles
13978_C01.qxd 8/9/05 8:55 AM Page 1
1. S
URGICAL HEMOSTASIS
2. WOUND HEALING
3. BASIC PRINCIPLES OF ALLERGIC DISEASES
4. HEAD AND NECK MANIFESTATIONS OF
RHEUMATOLOGICAL DISEASES
5. PULMONARY PHYSIOLOGY AND
MECHANICAL VENTILATION
6. BIOLOGY AND TREATMENT OF SLEEP APNEA
7. MICROBIOLOGY,VIROLOGY, AND MECHANISMS
OF
INFECTION
8. PRINCIPLES OF PHARMACOLOGY
9. OTOTOXICITY
10A. ONCOLOGY OF HEAD AND NECK TUMORS
10B. IMMUNOBIOLOGY AND IMMUNOTHERAPY OF
HEAD AND NECK SQUAMOUS CARCINOMA

11. C
LINICAL RADIATION BIOLOGY AND
RADIOTHERAPY
12. ENVIRONMENTAL EFFECTS ON
THE
UPPER AIRWAY
13. HOW TO CONDUCT CLINICAL RESEARCH
14. BASIC PRINCIPLES AND CURRENT APPLICATIONS
OF
LASERS IN HEAD AND NECK SURGERY
15. MOLECULAR BIOLOGY FOR THE
OTOLARYNGOLOGIST
16. PHYSIOLOGY OF THE PEDIATRIC PATIENT
17. BRANCHIAL CLEFT ANATOMY AND
CONGENITAL NECK MASSES
18. PATHOPHYSIOLOGY OF STRIDOR AND
AIRWAY DISEASE
19. CLINICAL GENETICS IN OTOLARYNGOLOGY
Part I
The Basic Principles
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Chapter 1
Surgical Hemostasis
CHRISTOPHER HARTNICK AND HINRICH STAECKER
CLINICAL EVALUATION OF A PATIENT FOR
POTENTIAL HEMOSTATIC DISORDER
LABORATORY EVALUATION
TESTS FOR PLATELET EVALUATION

TEST OF COAGULATION PATHWAY
COMMONLY SEEN BLEEDING ABNORMALITIES
PLATELET DISORDERS
DISORDERS OF THE COAGULATED SYSTEM
EVALUATION AND MANAGEMENT OF PERIOPERATIVE
BLEEDING
SUGGESTED READINGS
SELF-TEST QUESTIONS
Surgical hemostasis is described in Schwartz’s Textbook of
Surgery as a “complex process that prevents or terminates
blood loss from the intravascular space, provides a fibrin
network for tissue repair,and ultimately,removes the fibrin
when it is no longer needed.” This chapter begins with an
overview of the process by way of review and then provides
some guidance toward pre-,intra-,and postoperative man-
agement of a given patient with a potential bleeding event.
The process of hemostasis begins at the moment of in-
jury to the endothelial lining of the vascular bed. Left
undisturbed, the endothelial cells themselves act within a
complex series of events to prevent clotting.When the en-
dothelial wall is disrupted, the various elements of the
blood are exposed to the underlying collagen.After this ini-
tial event, several events rapidly occur to stem the flow of
blood from the wound.The first process is that of vasocon-
striction at the level of the capillary bed.This process is de-
pendent upon the local contraction of smooth muscle and
is influenced by the next event in the cascade of hemostasis;
namely, platelet aggregation, as thromboxane A2, a power-
ful vasoconstrictor, is produced by the release of arachi-
donic acid from platelet membranes during aggregation.

Within 15 seconds after the onset of vasoconstriction,
platelets begin to aggregate as they stick to the exposed
collagen.The platelets adhere to the wound bed and begin
to form a plug, which is the initial matrix upon which
fibrin will eventually deposit.As the platelets are beginning
to aggregate and adhere to the subendothelial collagen,the
intrinsic and extrinsic pathways of the coagulation system
are also activated by damage to the endothelium, and the
two cascades move toward the end point where prothrom-
bin is converted to thrombin, which in turn catalyzes the
conversion of fibrinogen to fibrin. Insoluble fibrin is de-
posited in and around the platelet plug, and a more fully
developed clot is formed. At any point on the path from
endothelial injury to thrombus formation, a host of factors
can derail the process of hemostasis and can produce a po-
tential for prolonged bleeding.
CLINICAL EVALUATION OF A
PATIENT FOR POTENTIAL
HEMOSTATIC DISORDER
All patients who are scheduled for surgery or who
present with an episode of bleeding should be evaluated
for a potential occult bleeding disorder.The first and
perhaps most sensitive screen to identify a bleeding
disorder is the taking of a careful history. A pattern
of easy bruising, of prolonged bleeding after minor
or major surgery or after tongue biting, of heavy men-
strual bleeding, or of any family history of excessive
bleeding all warrant further pursuit of an underlying
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