Abstracts, Book Reviews

ABSTRACTS

Needle aspiration biopsy of major salivary gland tumors: its value, P O'Dwyer, WB Farrar, AG James, W Finkelmeier, DP McCabe. Cancer 57:554-557, 1986

The value of needle aspiration biopsy in the diag- nostic evaluation of abnormal masses throughout the body is controversial. This is particularly true in eval- uation of salivary gland masses, in which some sur- geons continue to use open biopsy as a diagnostic procedure in cases difficult to evaluate clinically. Open biopsy involves the risk of an operative proce- dure and makes contamination of the operative field with tumor cells likely, although this method almost always predicts accurately the histologic features of such masses. Needle aspiration biopsy is safe and easy to perform and causes little discomfort to the pa- tient. Critics have faulted a high incidence of false- negative results with the use of needle aspiration biopsy in the salivary gland and believe it is probably unnecessary to distinguish between benign and ma- lignant tumors preoperatively in the clinically ob- vious salivary gland tumor. Because of the diversity of opinion concerning the merits of needle aspiration biopsy, the authors reviewed 341 patients who under- went needle aspiration biopsy preoperatively in an ef- fort to establish its precise role in diagnosis and oper- ative decision-making in patients with major salivary gland tumors.

The 341 needle aspiration biopsies considered were performed over a 32-year period. Eighty per cent of tumors were benign, and 20 per cent were malignant. Preoperative needle aspiration biopsy findings were compared with pathologic diagnosis of the surgically resected specimen. Of 63 aspirates from malignant tumors, 46 were correctly diagnosed by needle aspira- tion biopsy, establishing a sensitivity of 73 per cent. Of 265 aspirates from benign tumors, 249 were cor- rectly diagnosed, establishing a specificity of 94 per cent. Overall accuracy was 90 per cent. Diagnostic error or difficulty in clinically localizing the tumor to the salivary gland was encountered in 64 patients with parotid tumors and 12 patients with submandib- ular tumors. Needle aspiration biopsy correctly local- ized over 85 per cent of these tumors to the salivary gland, thus enabling both immediate and correct deci- sion-making concerning subsequent management.

Both accuracy and specificity were high in this study, and false-positives, the most common cause of which is atypia in a benign mixed tumor, were re- ported infrequently. Poor correlation between diag- nosis and precise histologic type in malignant tumors was similar to that reported in other studies. As cyto- pathologists gain experience, diagnostic accuracy im- proves.

The authors believe that needle aspiration biopsy specimens are particularly helpful in the diagnosis of clinically unsuspected or clinically questionable sali- vary gland tumors. Similar difficulty is encountered

in differentiating enlarged submandibular lymph nodes from tumors of the submandibular gland. Cor- relation between needle aspiration biopsy diagnosis and precise histologic type in malignant tumors is poor. The authors conclude that needle aspiration biopsy needs to be defined as a diagnostic tool that aids in the evaluation of a salivary gland mass and not a histologic procedure on which operative decisions can be based. Its high percentage of false-negative re- sults and its low predictive value for malignancy make it unreliable when used alone for this purpose. However, when combined with clinical judgment and frozen section evaluation, which can also be unreli- able, it may help in making such decisions.

The authors believe their review demonstrates the value of needle aspiration biopsy as a diagnostic tool that aids in establishing a diagnosis in the assessment of the clinically questionable salivary gland tumor. This is a safe, reliable, easy-to-perform, cost-effective office procedure, which, when used with an experi- enced cytopathologist, can provide the surgeon with valuable information that otherwise could be ob- tained only by surgical exploration.

Acute epiglottitis in children: a conservative ap- proach to diagnosis and management, DD Vernon, AP Sarnaik. Crit Care Med 14:23-25, 1986

The best methods of diagnosis and management for acute epiglottitis, a potentially lethal condition, re- main undecided. Swollen supraglottic structures can be demonstrated either by lateral neck x-ray films or by direct pharyngoscopy in the emergency depart- ment. Airway management may consist of nasotra- cheal in tubat ion, t racheos tomy, or observat ion without an artificial airway. The authors described a conservative approach to the diagnosis and treatment of acute epiglottitis in children.

Of 60 children with epiglottitis, 42 were admitted via the emergency department at the authors' institu- tion, and 18 were transferred there after initial airway management elsewhere. Patients managed primarily at the authors ' inst i tut ion had lateral neck x-ray studies perfarmed, which were diagnostic in each case, and underwent nasotracheal intubation in the operating room. There was no mortality or permanent morbidity in this group. Transferred patients were managed in a variety of ways at their referring institu- tions, sometimes without an artificial airway. Compli- cations in this group included transient hypoxic en- cephalopathy in three children and permanent severe encephalopathy in one child; four other children died. Blood cultures were positive for Hemophilus in- fluenzae type b in 96 per cent of the entire series.

The morbidity and mortality seen in the referred patients illustrate the importance of a consistent, well-organized approach to the diagnosis and man- agement of epiglottitis, the reliability of a lateral neck x-ray study, the high incidence of H. influenzae bac- teremia, and the efficacy of nasotracheal intubation

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ABSTRACTS, BOOK REVIEWS

for maintaining airway patency in this disease. The authors do not advocate lateral neck radiographs in children with clinically severe airway obstruction as manifested by cyanosis, severe retractions, and de- pressed sensorium. Such patient should be taken im- mediately to the operating room for laryngoscopy and emergency airway management. Because it is impos- sible to predict which children will experience ob- struction and because emergency intubation of the obstructed airway may be difficult, the authors be- lieve that every patient should be intubated elec- tively. In this study, every patient who underwent elective intubation was normal at discharge.

Re-irradiation of advanced tumors of the head and neck with fast neutrons, RD Errington, M Catterall. Int J Radiat Oncol Biol Phys 12:191-195, 1986

Over 9,000 patients have been treated with fast neutrons, but the investigation so far has been ad- versely affected by the clinical quality of the neutron beam. The effects are mechanical rather than biolog- ical, yet they produce significant clinical effects that act against possible benefits from neutron therapy. Complications are increased, and the ability to deliver adequate doses to the tumor is reduced. Thus, neu- tron beams have not been comparable with photon beams from modern megavoltage x-ray apparatus, with their deep penetration, sharp definition, sparing of the skin, and infinitely variable field sizes and shapes. The advantages of fast neutrons in the treat- ment of solid tumors are based on radiobiological data concerning the variability of sensitivity according to the phase in the cell cycle, the histological type, and the degree of hypoxia. In all of these, neutrons have a greater tumoricidal effect. There is much less resis- tance to neutrons as a result of histological type, and neutrons are more effective against hypoxic cells than are photons. The authors analyzed a group of patients retrospectively who appeared to be particularly suit- able for assessing neutron therapy, partly because they had "radioresistant" tumors and partly because these tumors were growing in poorly perfused tissues. These patients had advanced tumors of the head and neck, which had already received treatment with megavoltage, x-ray or gamma-ray therapy. Many of the tumors had also been treated surgically, which contri- buted to changes in the surrounding tissues that com- promise tolerance to any subsequent treatment by ra- diation therapy.

Twenty-eight patients had received radical treat- ment with x-rays to tumors of the head and neck. Only one of them had a tumor less than 30 cm 2 with no involvement of bone or skin. Twenty-three of them had also undergone surgery, and ten had more than one operat ion. Seven had also received chemo- therapy. They were treated with neutrons to a tumor dose of 1,560 cGy in 12 fract ions over 26 days. Twenty-three of the tumors (82 per cent) underwent complete regression that was maintained in 15 for at least 12 months. Despite the damage done to the

normal tissues by the previous radiation and surgery, 15 patients had no complications following neutron therapy. In six patients, there was major necrosis, and in seven others, this was minor. Eight tumors re- curred. Five patients experienced partial regression of their tumors. The median survival was 20 months (range, 4 to 69 months).

These patients had actively growing tumors in tissues that had been compromised by extensive pre- vious treatments and were therefore presumably hyp- oxic. These patients were considered too advanced for further conventional treatment of any type. This study showed a greater destruction of malignant cells than normal cells by neutrons. The high control rate by neutrons and the comparable rate of necrosis to that seen with re-irradiation by photons may be explained by the greater efficacy of neutrons on hypoxic condi- tions and the reduced ability of malignant cells to re- pair damage induced by neutrons. That this damage was far greater to the malignant tissue than to the normal tissues, although these were severely compro- mised, is evidence of the efficacy of neutron therapy in the dose and techniques used.

Tympanometry in children with treated acute otitis media, MTK Wheeler. Lancet 1:529-531, 1986

The duration of pathologic changes after resolution of acute otitis media is uncertain. These changes have been implicated as a cause of deafness, and long- lasting effusion is thought to be a causal factor in chronic serous otitis media. Methods for study of the sequelae of acute otitis media include interpretation of the state of the tympanic membrane, in which ob- server variation is wide, and the presence of middle ear pathology as identified by deafness, for which there is no universal definition. Tympanometry has been used little in the study of acute otitis media, al- though this technique gives information on several el- ements in the condi t ion-- the patency of the eusta- chian tube, the state of the tympanic membrane and ossicular chain, and the presence of fluid in the middle ear. The authors undertook this study to iden- tify by tympanometry the middle ear changes that arose during and after the acute infection in children.

Tympanometry was used to identify middle ear changes in 154 children with otitis media during and after treatment. Acute otitis media was defined as ear- ache and an acute inflammation involving at least two thirds of the tympanic membrane. Deafness and aural discharge were confirmatory signs when present, but were not essential for diagnosis.

In each episode, infected and noninfected ears were examined by tympanometry at presentation. Tympan- ometry was repeated at the first, third, and seventh weeks after presentation and every four weeks there- after until the findings returned to normal. If the sta- pedial reflex was not present in both ears, tympa- nometry was repeated at intervals until the reflexes were present.

In 215 episodes, 242 infected and 196 noninfected

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ABSTRACTS, BOOK REVIEWS

American Journal of Otolaryngology

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ears were examined. Of the 155 effusions, all but 17 were followed up until they had resolved. Fifty per cent and 90 per cent of effusions had resolved by the end of the first and seventh weeks, respectively, and none remained indefinitely. In episodes of unilateral acute otitis media, 56 children (28.6 per cent) had an effusion in the noninfected ear, 71 (36.2 per cent) had compliance reduction (including ears with effusions), and 132 (67.3 per cent) had pressure reduction (in- cluding ears with effusions). Those children with per- sistent or recurrent effusions were not at special risk of infection.

The results suggested that chronic serous otitis media is not a consequence of acute otitis media. Per- sistence of middle ear effusion is unlikely to predis- pose to recurrent acute otitis media, and unilateral otitis media abnormalities are often present in both ears. The fact that, after resolution of the acute infec- tion, all the effusions ultimately resolved suggests that the middle ear effusion that follows acute otitis media, even if present in the noninfected ear, is dis- tinct from chronic serous otitis media. This should be remembered when surgery is contemplated for a child with middle ear effusion and a history of acute otitis media. This study has given no support to the theory that a persistent effusion predisposes to recurrent acute otitis media.

Neonatal screening with auditory brainstem re- sponses: results of follow-up audiometry and risk factor evaluation, S Duara, CM Suter, KK Bessard, RL Gutberlet. J Pediatr 108:276-281, 1986

Routine auditory brainstem response (ABR) tests of all newborn infants would detect only a very small number with impaired hearing. Investigations have focused on special groups of infants at increased risk for developing neurosensory hearing loss. Factors such as low birth weight, congenital infections, con- genital malformations, and perinatal asphyxia have a reportedly high association with hearing impairment and are some of the suggestive indications for evalua- tion of hearing in infants. The purposes of this study were to determine the predictive value of clinical in- dicators to screen both healthy and sick newborn in- fants with the ABR test and to attempt the identifica- tion of a risk group with the highest likelihood for hearing loss after discharge from the nursery.

To determine the incidence and outcome of neuro- sensory hearing loss in infants, without selection bias, volunteers screened all infants from intensive care and well-baby nurseries of a tertiary care center for risk factors over a one-year period. Infants with suffi- cient risk factors were screened by ABR testings. In- fants with abnormal findings received audiometric follow-up.

At initial follow-up audiometry, at a mean postnatal age of 13 months, 17 of the 27 infants who failed the initial screening had normal hearing, and ten had ab- normal hearing (mild loss in one, moderate loss in five, and severe loss in four). Four continued to have severe persistent hearing loss. This represents a 14.6 per cent incidence of confirmed hearing loss in the

infants who failed the nursery ABR screen and were examined at follow-up. The infants with confirmed hearing loss were from the intensive care nursery and represent a 2.5 per cent incidence of hearing loss in the intensive care nursery population receiving the ABR screen (four of 159). None of the infants screened in the well baby nursery deve loped pe rmanen t hearing loss. Risk factor evaluation revealed a 17 per cent incidence of neurosensory hearing loss in a sub- group of infants with multiple risks, such as birth weight below 1,500 g, perinatal asphyxia, subsequent hypoxemia, and hospital stay of over two months. All four infants with permanent hearing loss had all four of these factors.

Cricoarytenoiditis: CT assessment in rheumatoid ar- thritis, L Brazeau-Lamontagne, B Charlin, R-Y Le- vesque, A Lussier. Radiology 158:463-466, 1986

The cricoarytenoid joint is a true diarthrodial joint that can be affected by rheumatoid disease. Rheuma- toid involvement of the cricoarytenoid joint deserves attention for two major reasons: the apparent increase in clinical incidence and the serious clinical implica- tions. The purposes of this investigation were to rec- ognize and define the rheumatoid changes of the cri- coarytenoid joint seen on high-resolution CT and to propose a laryngeal staging to be used whenever a pa- tient needs evaluation of the extent of rheumatoid disease.

Direct fiberoptic laryngoscopy and high-resolution CT were used to assess the larynx in 32 rheumatoid patients. High-resolution CT showed abnormalities in 72 per cent. No laryngeal symptoms could be found predictive of CT findings, however, and laryngoscopy and laryngeal CT scanning appeared to be comple- mentary investigations, as laryngoscopy tends to allow better evaluation of mucosal and functional in- tegrity, whereas CT scanning enables evaluation of structural integrity. Erosion-luxation of the cricoary- tenoid joint and surrounding soft t issue swelling could be demonstrated on high-resolution CT scans. The authors propose a radiologic grading of the rheu- matoid larynx (grade I = thickening, grade II = ero- sion, grade I I I = luxation, and grade IV = subocclu- sion of the larynx), stressing that accurate evaluation of the larynx should be part of the diagnostic evalua- tion of every rheumatoid arthritic patient, given the high frequency of occurrence of rheumatoid laryn- gitis. Endoscopy and CT laryngeal evaluations of rheumatoid arthritis patients are particularly impor- tant if general anesthesia is contemplated. Rheuma- toid involvement of the cricoarytenoid joint of the larynx can be a hazard to the airway.

Cancer of the tonsil: improved survival with combi- nation therapy, KS Dasmahapatra, MA Mohit-Taba- tabai, BF Rush Jr, GJ Hill, M Feuerman, M Ohanian. Cancer 57:451-455, 1986

Treatment of patients with squamous cell cancer of the tonsil remains controversial. The results of treat-

ABSTRACTS, BOOK REVIEWS

ment in patients with stage I and II disease appear to be equally good with either radiation therapy or sur- gery, with five-year survival rates ranging from 63 per cent to 100 per cent in stage I and from 18 per cent to 73 per cent in stage II. No conclusive data show the surperiority of any type of treatment modality in pa- tients with advanced disease. The authors evaluated retrospectively the results of treatment of tonsillar cancer over a 20-year period, with special emphasis on the outcome of stage III and IV disease.

A total of 174 cases of squamous cell cancer of the tonsil were reviewed. Radiation therapy alone was used in 81 patients, surgery alone in 19 patients, pre- operative radiation therapy and surgery in 49 pa- tients, and chemotherapy in 25 patients. The five-year survival rate was 88 per cent in stage I (n = 21), 72 per cent in stage 2 (n = 19), 23 per cent in stage III (n = 34), and 15 per cent in stage IV (n = 100). Radia- tion therapy and surgery were equally effective in stages I and II. In stage III, the five-year survival rate for radiation therapy plus surgery was 31 per cent versus 11 per cent for radiation therapy alone. In stage IV, the respective three- and five-year survival rates after radiation therapy plus surgery were 24 per cent and 15 per cent versus 6 per cent and 0 per cent, re- spectively, for radiation therapy alone. There was an 84 per cent response rate to chemotherapy, and the patients who completed chemotherapy plus radiation therapy and surgery had three- and five-year survival rates of 41.7 per cent and 32 per cent, respectively.

The five-year survival rate for stage IV patients during the first ten-year period was 7 per cent, for the next five-year period, 14 per cent, and for the last five-year period, 22 per cent.

The authors believe their results indicate that for stage I and II tonsillar cancer, there is no statistically significant difference in the outcome between those treated with either surgery or radiation therapy. The combination of radiation therapy and surgery appears to offer better survival rates than radiation therapy alone for stage III and IV squamous cell cancer of the tonsil. The high response rate in early survival data seen with chemotherapy plus radiation therapy and surgery suggests a promising role for this approach.

Stapes prosthesis: evaluation with CT, JD Swartz, AK Lansman, AS Berger, RJ Wolfson, G Bell, GL Popky, NG Swartz. Radiology 158:179-182, 1986

Computed tomography has been valuable for iden- tification of the complications of stapedectomy with prosthesis insertion, and complex motion tomog- raphy has been used to describe instances of disloca- tion and subluxation involving the stainless steel prostheses. Computed tomography (CT) provides a unique perspective in this regard owing to its ability to delineate adjacent soft tissue changes.

Computed tomography was used to evaluate 44 pa- tients who had undergone stapedectomy with inser- tion of a prosthesis (44 were wire, 12 were Teflon, and eight were stainless steel). Several patients had poor surgical results, including recurrent conduc t ive hearing loss, vertigo, and sensorineural hearing loss.

Conductive hearing loss occurring immediately after the procedure was most often caused by anatomic limitations or surgical technique. Causes of delayed or recurrent conductive hearing loss included reparative granuloma formation, incus necrosis (at the attach- ment of the wire), prosthesis subluxation (most often posterior), and regrowth of otosclerosis, which occa- sionally was further complicated by incus disloca- tion.

Retrospective evaluation of the cases in which the prostheses functioned normally indicated that the de- vice need not be centrally located within the oval window and that provided at least four to six weeks have passed since surgery, no soft tissue should be present in the oval window niche. Delayed or recur- rent conductive hearing loss has several causes, most of which were highly recognizable on CT scans. These include incus dislocation, prosthesis subluxation, granuloma development, postoperative tympanic fi- brosis, and regrowth of otosclerotic bone. The authors found that CT was often diagnostic when these com- plications occurred. Immediate sensorineural hearing loss or vertigo can be self-limited if caused by serous labyrinthitis. When delayed, these symptoms may be caused by perilymph fistula. If caused by the latter, CT may not yield abnormal findings unless subluxa- tion of the prosthesis into the vestibule has occurred.

The authors believe that CT is important in evalua- tion of complications of prosthetic stapedectomy, provided proper technique is used. Findings are often not specific, and careful clinical correlation is neces- sary.

Electrocardiographic changes suggestive of cardiac ischemia in a patient with esophageal food impac- tion, J Yackee, A Lipson, AG Wasserman. JAMA 255:2065-2066, 1986

Patients with chest pain thought to be of cardiac or- igin may actually have esophageal disease as an alter- native or additional cause of their complaints. Elec- trocardiography (EGG) is generally considered to be a reliable means of distinguishing between esophageal and cardiac pain. The authors described a patient who developed EGG changes suggestive of cardiac ischemia secondary to esophageal food impaction.

The patient was a 57-year-old woman who was ad- mitted to the hospital with the chief complaint of chest discomfort and dysphagia. She had underlying esophageal disease and no evidence of coronary artery disease. The EGG taken on admission revealed ST- segment depression and T-wave inversion in the infe- rior and anterolateral leads. A barium swallow exami- nation showed an irregularly contoured, intraluminal, esophageal filling defect proximal to the gastroesoph- ageal junction. Administration of sublingual nitro- glycerin and intravenous glucagon failed to resolve the symptoms. Esophagoscopy revealed a large piece of meat impacted in the distal esophagus at 35 cm. After administration of sublingual nifedipine, the meat bolus was mechanical ly advanced into the stomach. There was no evidence of an esophageal stricture. An ECG soon after endoscopic disimpaction

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American Journal of Otoloryngology

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showed marked improvement of the ST-T-wave changes.

The mechanism by which esophageal meat impac- tion might cause ST-T-wave changes is speculative. A vagal mechanism for similar changes observed in gas- troenterologic conditions, such as pancreatitis and cholecystitis, has been proposed.

The authors believe this is the first reported case of ST-T-wave changes attributable to esophageal food impaction. It adds evidence that the ECG is not always a reliable means of differentiating chest pain of cardiac and esophageal etiologies.

Lymph nodes of the neck: evaluation with US [ultra- sound], PC Hajek, E Salomonowitz, R Turk, D Tscholakoff, W Kumpan, H Czembirek. Radiology 158:739-742, 1986

Correct assessment of tumorous and inflammatory lymph nodes of the neck is essential for diagnosis and therapy of patients with malignant disease of the head and neck. Inspection and palpation of the neck are unreliable, and computed tomography is the method of choice for both demonstration of primary tumors and staging of cervical lymph nodes. Among the drawbacks of CT, however, is its inability to depict the longitudinal diameter of enlarged lymph nodes and to differentiate the margins of lymph nodes and adjacent structures, specifically adjacent vessels. The authors described their analysis of the role of small- parts ultrasound in the depiction of lymph nodes, demonstration of their location, size, and anatomic relationships, and delineation of adjacent structures.

A total of 99 patients was included in the study. Twenty-five patients were admitted for evaluation of the cervical lymph node changes in the course of in- flammatory diseases, including suspected toxoplas- mosis, tularemia, tuberculosis , and nonspecif ic lymph node abscesses. Nineteen patients had malig- nant systemic lymphoma; 55 patients had malignant head and neck tumors including cancers of the epi- pharynx, hypopharynx, larynx, tonsils, tongue, and thyroid. Sonograms were obtained with real-time sector scanners and high-resolution scan heads. The neck was examined longitudinally and transversely in a continuous-sweep technique covering the neck re- gion from the thoracic outlet and scalenus muscles to the submental and retroparotid regions. The retro- pharyngeal space was evaluated in its bordering structure, and the longus colli muscle was demon- strated. Special care was taken to assess the relation of a lymph node to adjacent muscles and vessels.

Ultrasound proved highly effective as an adjunctive procedure to other imaging modalities, specifically CT, for detection, localization, and delineation of en- larged lymph nodes of the neck. Infiltration of adja- cent structures, specifically the common, internal, and external carotid arteries, and the neck muscles was reliably demonstrated. Benign and malignant lymph node enlargement could not be differentiated.

Ultrasound examinations changed the operative course of 56 per cent of patients studied. In 41 per

cent, a more radical operative procedure was per- formed than was previously planned; in 14 per cent, the original plan of a supraomohyoid procedure was changed in favor of functional neck dissection. In an- other 14 per cent, ultrasound demonstrated inopera- bility, and instead of bilateral neck dissection, radia- tion therapy was performed. Of patients with no ab- normal clinical findings, 27 per cent demonstrated enlarged cervical lymph nodes on ultrasound scans, necessitating a neck dissection procedure.

The authors have concluded that small-parts ultra- sound is a very useful adjunct to current imaging techniques of cervical lymph node disease. The au- thors advise that the investigation must be performed by a well-trained clinician knowledgeable about de- tails of cervical anatomy.

BOOK REVIEWS

The Facial Nerve. M May. New York, Thieme- Stratton, 1985, 832 pages, $98.00

A definitive and most up-to-date text has arrived regarding The Facial Nerve. This 832-page text repre- sents a compilation of Dr. Mark May's 20 years' expe- rience dealing with facial nerve pathology in over 1,500 patients. The text is almost entirely written by Dr. May, except for the sections on management of hyperkinesis and some parts of surgery of the facial nerve. These two sections are written by an interna- tional panel of experts in otolaryngology, ophthal- mology, and neurosurgery.

The text is divided into seven sections, with the first two sections being most basic and least contro- versial. Section I regards applied basic science, and these 181 pages are excellent. The material presented is clearly written and very clinically oriented. Very good use is made of diagrams to depict the topo- graphic diagnosis of facial nerve abnormality and the ability to locate the site of injury (e.g., supranuclear versus infranuclear). The chapter, "Anatomy of the Facial Nerve for the Clinician," is exceptional and should be read by all who deal with this nerve. Like- wise, the photomicrographs accompanying "Histopa- thology of the Facial Nerve" are excellent and cer- tainly illustrate many of the pathologic problems en- countered with the nerve in its temporal bone course.

The second section deals with evaluation of facial nerve function, and here the basic tests for topo- graphic diagnosis are discussed. The emphasis is clinical and centers around the use of the history, physical examination, and laboratory tests including the various electrical tests to aid in diagnosis.

Section three discusses in detail the management of facial paralysis starting with the office management. This is followed by a very good discussion of facial nerve disorders of viral origin with special emphasis on Bell's palsy. Dr. May definitely feels that Bell's palsy is a result of infection by the herpes simplex type I virus with paralysis resulting from an inflam- matory immune response to the viral agent. A thor-