Office-based esophagoscopy: a preliminary report.

OBJECTIVE: Preliminary study that describes unsedated, transnasal esophagoscopy (TNE) in an office setting. STUDY DESIGN AND SETTING: TNE was prospectively performed on 14 consecutive out-patients with dysphagia whose initial oropharyngeal dysphagia evaluation was insufficient to reveal the cause of their swallowing problem. TNE was carried out without conscious sedation while the patients were sitting in an examining chair. Ease of endoscope insertion, optical quality of images, and examination findings were assessed. Heart rate before and after the procedure and incidence of epistaxis and airway compromise was also determined. Patients were asked to rate the level of discomfort of TNE on a validated 10-point scale (1 representing none/well tolerated and 10 severe/poorly tolerated). RESULTS: All patients completed TNE with the esophagus readily intubated and esophageal mucosa clearly visualized. Findings included esophageal stricture, patulous upper esophageal sphincter, and Zenker's diverticulum. There were no incidences of epistaxis or airway compromise and no significant changes in heart rate. Overall tolerance of TNE was rated by the patients as 2.0 (SD, 1.2). CONCLUSIONS: TNE is well tolerated and can be safely performed in patients with dysphagia in an office setting. TNE may have a role in the comprehensive evaluation of the dysphagic patient in the office.

Cost-effectiveness of two types of dysphagia care in head and neck cancer: a preliminary report.

We conducted a prospective, preliminary study to compare the cost-effectiveness of two different instrument-based techniques for diagnosing and managing dysphagia in 30 consecutive hospitalized patients with head and neck cancer. The two techniques are videofluoroscopy via modified barium swallow (MBS) and videoendoscopy via flexible endoscopic evaluation of swallowing with sensory testing (FEESST). Medicare was the primary insurer of all patients. Fifteen of these patients had their dysphagia diagnosed and managed by MBS and the other 15 by FEESST. Cost-effectiveness was assessed by determining the average Medicare reimbursement for each procedure. We found that the mean reimbursements were $451.01 (+/- $50.55) for MBS and $321.23 (+/- $3.01) for FEESST. The mean reimbursement for FEESST was significantly lower than that for MBS (p < 0.0001; Mann-Whitney U test). We conclude that FEESST appears to be more cost-effective than MBS for the inpatient management of dysphagia in patients with head and neck cancer.

Expression of p75NTR and its associated protein NADE in the rat cochlea.

OBJECTIVES/HYPOTHESIS: To investigate the expression of the low-affinity neurotrophin receptor p75 (p75NTR) and its associated protein NADE in the cochlea of the developing and the adult rat. Studies such as this one will help to predict the functional role of p75NTR and NADE in cochlear development. STUDY DESIGN: Histochemical evaluation of p75NTR and NADE in the rat cochlea was performed. METHODS: Immunohistochemical analysis was used to localize p75NTR and NADE in the rat cochlea at postnatal (PN) days PN0, PN2, PN4, PN6, PN8, PN10, and PN13 and in the adult. Confocal laser scanning microscopy was used to analyze whole-mount specimens. RESULTS: Immunoreactivity of both p75NTR and NADE was observed in pillar cells. However, these proteins displayed reciprocal expression patterns. Expression of p75NTR was detected at PN0 and PN2, but disappeared after PN4. In contrast, NADE expression was initially detected at PN2 and persisted into adulthood. CONCLUSIONS: The neurotrophin receptor p75NTR and NADE have distinct and independent roles in developing and mature cochlea.

Laryngopharyngeal sensory deficits in patients with laryngopharyngeal reflux and dysphagia.

There are no reliable means of quantifying the edema that results from acid exposure to the posterior larynx in patients with laryngopharyngeal reflux (LPR). However, it is possible to quantify laryngopharyngeal sensitivity in these patients by endoscopic administration of air pulses to the laryngeal mucosa in order to elicit the laryngeal adductor reflex. The purpose of this study was to determine whether patients with LPR have sensory deficits in the laryngopharynx, and whether treatment of these patients with a proton pump inhibitor (PPI) results in resolution of sensory deficits. Flexible endoscopic evaluation of swallowing with sensory testing was prospectively performed in 54 patients with dysphagia without neurologic disease and in 25 healthy controls. The laryngopharyngeal sensory level, posterior laryngeal edema, and LPR were assessed. We defined LPR as passage of food material from the esophageal inlet retrograde into the hypopharynx. Patients with LPR were placed on 3 months of omeprazole or lansoprazole and then retested. Patients without LPR were placed on H2 blockers for 3 months and then retested. In the dysphagia group, 48 of 54 patients (89%) had edema of the posterior larynx, and 42 of 54 (78%) had laryngopharyngeal sensory deficits. We noted LPR in 38 of 54 (70%). In the control group, 1 of 25 subjects (4%) had edema, sensory deficits, and LPR. The differences in incidence of edema, sensory deficits, and LPR between the dysphagia group and the control group were significant (p < .001, chi2 test). Twenty-three patients with LPR placed on a PPI returned for follow-up, with improvement in laryngeal edema in 14 of the 21 (67%) who had pretreatment edema and resolution of sensory deficits in 15 of the 19 (79%) who had pretreatment deficits. In the non-LPR, non-PPI group, 11 of 16 patients returned for follow-up, with improvement in laryngeal edema in none of the 11 and improvement in sensory deficits in 1 of the 11 (9.1%). The differences in improvement in laryngeal edema and sensory deficits between the LPR, PPI group, and the non-LPR, non-PPI group were significant (p < .01, Fisher's exact test). We conclude that patients with dysphagia and edema of the posterior larynx as a result of LPR have sensory deficits in the laryngopharynx. Treatment of these patients with a PPI appears to result in resolution of laryngopharyngeal edema and improvement of sensory deficits, both subjectively and objectively.

Endoscopic evaluation of swallowing as an alternative to 24-hour pH monitoring for diagnosis of extraesophageal reflux.

Patients with symptoms of extraesophageal reflux may not be eager to undergo 24-hour pH probe monitoring for the sake of a definitive diagnosis. It has been anecdotally noted that extraesophageal reflux can be detected during an endoscopic swallowing evaluation. The purpose of this pilot study was to demonstrate that flexible endoscopic evaluation of swallowing with sensory testing (FEESST) can be implemented to identify and subsequently treat patients with extraesophageal reflux. Over a 6-month period, FEESST was prospectively performed in 20 healthy control subjects and in 20 patients with dysphagia. The dysphagic patients did not have a history of stroke or chronic neurologic disease. Attention was specifically directed toward noting the presence or absence of reflux into the laryngopharynx during the endoscopic swallowing evaluation. None of the control subjects were noted to have reflux during FEESST, but 18 of the 20 patients with dysphagia were found to have reflux during the evaluation; this difference was statistically significant (p < .001, Fisher's exact test). We conclude that FEESST is useful as a means of diagnosing extraesophageal reflux in patients with dysphagia.

The safety of flexible endoscopic evaluation of swallowing with sensory testing (FEESST): an analysis of 500 consecutive evaluations.

We assessed the safety of a new office or bedside method of evaluating both the motor and sensory components of swallowing called flexible endoscopic evaluation of swallowing with sensory testing (FEESST). FEESST combines the established endoscopic evaluation of swallowing with a technique that determines laryngopharyngeal sensory discrimination thresholds by endoscopically delivering air-pulse stimuli to the mucosa innervated by the superior laryngeal nerve. Endoscopic assessment of laryngopharyngeal sensory capacity followed by endoscopic visualization of deglutition was prospectively performed 500 times in 253 patients with dysphagia over a 2.5-year period in a tertiary care center. The patients had a variety of underlying diagnoses, with stroke and chronic neurological disease predominating (n = 155). To determine the safety of FEESST, the presence of epistaxis, airway compromise, and significant changes in heart rate before and after the evaluation were assessed. Patients were also asked to rate the level of discomfort of the examination; 498 evaluations were completed. There were three instances of epistaxis that were self-limited. There were no cases of airway compromise. There were no significant differences in heart rate between pre- and posttest measurements (p > 0.05). Eighty-one percent of patients noted either no discomfort or mild discomfort as a result of the examination. In conclusion, FEESST is a safe method of evaluating dysphagia in the tertiary care setting and may also have application for the chronic care setting.

Laryngopharyngeal sensory discrimination testing and the laryngeal adductor reflex.

Laryngopharyngeal sensory capacity has been determined by endoscopically administering air pulse stimuli to the mucosa innervated by the superior laryngeal nerve and asking the patient if he or she feels the stimulus. A potential shortcoming of this psychophysical testing (PT) procedure is that it is a subjective test, and patients with impaired cognition may not be able to perform the required task. In the search for an objective measure of laryngeal sensory function, we have observed that the laryngeal adductor reflex (LAR) is evoked at stimulus intensities similar to those capable of eliciting the psychophysical, or perceptual, response. The purpose of this study is to determine if the threshold for eliciting the LAR is the same as that of the sensory threshold. A specially designed endoscope was used to present air pulse stimuli (range 0.0 to 10 mm Hg) to the laryngopharynx in 20 healthy subjects and in 80 patients with dysphagia, using both PT and the LAR. The patients had a variety of underlying diagnoses, with stroke and chronic neurologic disease predominating (n = 65). In the control group and in the group of patients with dysphagia, there was no statistically significant difference between the median laryngopharyngeal sensory thresholds whether we used PT or the LAR (p>.05, Wilcoxon signed-rank test). The intraclass correlation for the total sample was .999 (U = .999, L = .998). Since psychophysical and sensorimotor reflex thresholds were not statistically significantly different and the intraclass correlation was close to a perfect correlation, we conclude that the LAR can be used as an objective and accurate clinical method of endoscopically assessing laryngopharyngeal sensory capacity.

Identification of a 5-cM region of common allelic loss on 8p12-p21 in human breast cancer and genomic analysis of the hEXT1L/EXTR1/EXTL3 gene in this locus.

The short arm of chromosome 8 is frequently lost in many human carcinomas including breast cancer, suggesting the presence of a tumor suppressor gene(s) in this region. We identified a gene termed hEXT1L/EXTR1/EXTL3 (hEXT1L hereinafter) that was mapped to chromosome bands 8p12-p21 where frequent LOHs of this region was reported in breast cancer. The existence of the third breast cancer susceptibility gene was also suggested in this region by linkage analysis. We further performed LOH analysis in 8p12-p21 in 34 breast cancers and identified a 5-cM region of common allelic loss that overlapped with the locus for positive lod score in familial breast cancer. We further analyzed genomic alterations of hEXT1L in tumors in which frequent LOHs of 8p were reported. A total of 327 cancers (313 primary tumors and 14 cancer cell lines) including 22 primary breast cancers were analyzed, but none of the tumors had somatic mutations: only one thyroid cancer patient without any family history of cancer had a 9-bp insertion in the constitutional DNA. These results suggest that mutations of hEXT1L do not play a major role in the development of sporadic cancers including breast cancer, and that other tumor suppressor gene(s) exists in the 5-cM region identified in this study.

Mutational analysis of the PTEN gene in head and neck squamous cell carcinoma.

Loss of heterozygosity (LOH) at chromosome band 10q23 occurs frequently in a wide variety of human tumors. A recently identified candidate tumor suppressor gene, PTEN located on 10q23, is mutated in multiple advanced cancers. To explore whether PTEN is associated with human squamous cell carcinoma of the head and neck (SCCHN), DNAs from both normal muscle and tumor tissue in 19 SCCHN were used for detecting LOH at chromosome 10q23 and mutational analysis of PTEN by direct polymerase chain reaction (PCR)-DNA sequencing. LOH at 10q23 was identified in 6/15 SCCHN. Mutation of PTEN was identified in 3/19 SCCHN. Of these 3 patients, 2 had stage IV disease; the third patient, with recurrent, metastatic and stage III disease, showed a 36 bp germline heterozygous deletion within intron 7. Furthermore, a missense mutation at codon 501 (TCT --> TTT: Ser --> Phe) in exon 8 was also found in tumor from the same patient. Our results suggest that PTEN may play a role in the genesis of some SCCHNs.

FEESST: a new bedside endoscopic test of the motor and sensory components of swallowing.

We here introduce an office or bedside method of evaluating both the motor and sensory components of swallowing, called fiberoptic endoscopic evaluation of swallowing with sensory testing (FEESST). FEESST combines the established endoscopic evaluation of swallowing with a technique that determines laryngopharyngeal (LP) sensory discrimination thresholds by endoscopically delivering air pulse stimuli to the mucosa innervated by the superior laryngeal nerve. Endoscopic assessment of LP sensory capacity followed by endoscopic visualization of deglutition was prospectively performed 148 times on 133 patients with dysphagia over an 8-month period. The patients had a variety of underlying diagnoses, with stroke and chronic neurologic disease predominating (n = 94). Subsequent to LP sensory testing, a complete dysphagia evaluation was conducted. Various food and liquid consistencies were dyed green, and attention was paid to their management throughout the pharyngeal stage of swallowing. Evidence of latent swallow initiation, pharyngeal pooling and/or residue, laryngeal penetration, laryngeal aspiration, and/or reflux was noted. Recommendations for therapeutic intervention were based on information obtained during the FEESST and often involved the employment of compensatory swallowing strategies, modification of the diet or its presentation, placement on non-oral feeding status, and/or referral to other related specialists. All patients successfully completed the examination. In 111 of the evaluations (75%), severe (>6.0 mm Hg air pulse pressure [APP]) unilateral or bilateral LP sensory deficits were found. With puree consistencies, 31% of evaluations with severe deficits, compared to 5% of evaluations with either normal sensitivity or moderate (4.0 to 6.0 mm Hg APP) LP sensory deficits, displayed aspiration (p < .001, chi2 test). With puree consistencies, 69% of evaluations with severe deficits, compared to 24% with normal or moderate deficits, displayed laryngeal penetration (p < .001, chi2 test). FEESST allows the clinician to obtain a comprehensive bedside assessment of swallowing that is performed as the initial swallowing evaluation for the patient with dysphagia.

Fiberoptic endoscopic evaluation of swallowing with sensory testing (FEESST) in healthy controls.

The purpose of this study was to introduce a new method of bedside assessment of both the motor and sensory components of swallowing called fiberoptic endoscopic evaluation of swallowing with sensory testing (FEESST). This approach combines the established bedside endoscopic swallowing evaluation with a more recently described technique that allows objective determination of laryngopharyngeal (LP) sensory discrimination thresholds by delivering air pulse stimuli to the mucosa innervated by the superior laryngeal nerve via a flexible endoscope. A prospective study was conducted of FEESST in 20 healthy control subjects, mean age of 34 +/- 11 years. LP sensory thresholds were defined as either normal (< 4.0 mmHg air pulse pressure [APP]), moderate deficit (4.0-6.0 mmHg APP), or severe deficits (> 6.0 mmHg APP). Subsequent to LP sensory testing, food of varying consistencies, mixed with green food coloring, was given and attention was paid to spillage, laryngeal penetration, pharyngeal residue, aspiration, and reflux. Therapeutic maneuvers such as postural changes and airway protection techniques were performed on each subject to determine if the assessed swallowing parameters were affected by maneuvers. All patients completed the study; all had normal LP sensory discrimination thresholds (2.9 +/- 0.7 mmHg APP). There were no instances of spillage, laryngeal penetration, or aspiration. Two of 20 subjects had pharyngeal residue and 2 of 20 had reflux. Institution of therapeutic maneuvers resulted in a predictable change in the endoscopic view of the laryngopharyngeal anatomy. FEESST provides comprehensive, objective sensory and motor information about deglutition in the bedside setting and might have implications for the bedside diagnosis and management of patients with dysphagia.

Laryngopharyngeal sensory testing with modified barium swallow as predictors of aspiration pneumonia after stroke.

Improved diagnostic tests that can accurately identify subjects at high risk for aspiration pneumonia (AP) are needed. One measure of this accuracy is the false-negative rate (FNR), which determines the failure of a test to identify a group at high risk. This study compares FNRs for AP among dysphagic stroke patients for two prognostic techniques: modified barium swallow (MBS) alone and MBS combined with laryngopharyngeal sensory discrimination testing (MBS + LPSDT). MBS and LPSDT were performed within 4 weeks of stroke in 20 subjects who were prospectively followed for at least 2 years to identify the frequency of AP. MBS identified 10 patients as not at risk based on the finding of no aspiration on initial MBS; four of these patients developed AP (FNR = 40%). MBS + LPSDT identified five patients as not at risk based on the findings of neither aspiration nor bilateral sensory deficits; none of these patients developed AP (FNR = 0%). The combination of MBS criterion (aspiration) with the LPSDT criterion (bilateral sensory deficits) improves prognostication of outcome in dysphagic stroke patients by identifying a subgroup at high risk for developing AP (nonaspirators with bilateral deficits).

Restoration of laryngopharyngeal sensation by neural anastomosis.

OBJECTIVE: To demonstrate that sensory nerve transposition may be used to reestablish sensation of the laryngopharynx after central nervous system injury and vagal deficit. DESIGN: Prospective preliminary report of 2 patients following brain-stem stroke with aspiration pneumonia confirmed on chest radiography, severe dysphagia and inability to tolerate oral alimentation, and modified barium swallow that demonstrated cricopharyngeal spasm and impaired laryngeal elevation. Both patients also had severe, bilateral laryngopharyngeal sensory deficits as determined by delivery of air pulse stimuli to the mucosa innervated by the superior laryngeal nerve via a fiberoptic telescope. Each patient underwent surgery as part of management of dysphagia after failure of aggressive nonsurgical treatment. INTERVENTION: During a cricopharyngeal myotomy and laryngeal suspension, a unilateral microneurorrhaphy between the greater auricular nerve and the superior laryngeal nerve was performed. OUTCOME MEASURES: Ability to tolerate oral diet without development of aspiration pneumonia and postoperative laryngopharyngeal sensory capacity. RESULTS: By 12 months after surgery, both patients had ipsilateral restoration of laryngopharyngeal sensation, with no further episodes of aspiration pneumonia. CONCLUSIONS: In select cases of severe dysphagia after central nervous system injury, sensory nerve transposition may be a useful adjunct to the surgical rehabilitation of the patient with dysphagia.

Silent laryngopharyngeal sensory deficits after stroke.

Dysphagia and aspiration are two devastating sequelae of stroke. Recent work has shown that laryngopharyngeal (LP) sensory deficits are associated with aspiration in stroke patients with dysphagia. The phenomenon of silent LP sensory deficits, where the patient exhibits no subjective or objective evidence of dysphagia, yet has an LP sensory deficit, has not been previously described. The aim of this study was to evaluate the sensory capacity of the laryngopharynx in stroke patients who had no subjective or objective complaints of dysphagia. We determined the sensory threshold in the laryngopharynx using air pulse stimulation of the mucosa of the pyriform sinus and aryepiglottic fold. Eighteen stroke patients (mean age 65.6 +/- 11.5 years) and 18 age-matched controls were prospectively evaluated. Normal thresholds were defined as < 4.0 mm Hg air pulse pressure (APP). Deficits were defined as either a moderate impairment in sensory discrimination thresholds (4.0 to 6.0 mm Hg APP) or a severe sensory impairment (> 6.0 mm Hg APP). Stroke patients were followed up for 1 year to determine the incidence of aspiration pneumonia (AP) as verified by chest radiography. In 11 of the stroke patients studied, either unilateral (n = 6) or bilateral (n = 5) severe sensory deficits were identified. The elevations in sensory discrimination thresholds were significantly greater than those in age-matched controls (7.1 +/- 0.6 mm Hg APP versus 2.5 mm Hg APP; p < .01, Wilcoxon score). Among patients with unilateral deficits, sensory thresholds were severely elevated in all cases on the affected side compared with the unaffected side (p < .01, Wilcoxon score). Moreover, the sensory thresholds of the unaffected side were not significantly different from those of age-matched controls. Aspiration pneumonia did not occur in the patients with normal LP sensation or in the patients with unilateral severe LP sensory deficits. However, in the 5 patients with bilateral, severe LP sensory deficits, 2 developed AP, both within 3 months of their LP sensory test. The results of this study showed, for the first time, that stroke patients without subjective or objective clinical evidence of dysphagia could have silent LP sensory deficits. These impairments could contribute to the development of AP following stroke. The findings in this study suggest that LP sensory discrimination threshold testing should not be restricted only to patients with clinical dysphagia.

Headaches and disease of the nose and paranasal sinuses.

Headaches resulting from disease of the nose or paranasal sinuses are usually associated with symptoms (congestion, fullness, discharge, obstruction) that point to the site of origin. Occasionally, however, nasal or sinus disease can be manifested solely as headache. In that circumstance, office nasal endoscopy in combination with a computed tomography (CT) scan of the sinuses may demonstrate an abnormality or disease of the nose or paranasal sinus. Recent studies have demonstrated that a neuropeptide (substance P) is likely to be a mediator of pain arising in the nose or paranasal sinuses.

Head and neck surgery workforce in the year 2014.

The head and neck surgery workforce in the United States over the next 20 years is of significant interest to physicians, patients, and others. Using election to fellowship in the American Society for Head and Neck Surgery or the Society of Head and Neck Surgeons, or both, as the criteria for designation as a head and neck surgeon, a mathematical model was designed to project the growth of the head and neck surgery workforce through the year 2014. The current combined active membership of the two societies was analyzed to determine the impact of age distribution on this model. The paradigm assumes 30 new head and neck surgeons each year and includes the appropriate mortality rate for each cohort. Based on this model, the total number of head and neck surgeons should decrease slightly from 1109 in the year 1994 to 1028 in the year 2014. A steady-state supply of head and neck surgeons is therefore predicted.

Sensory recovery in noninnervated flaps used for oral cavity and oropharyngeal reconstruction.

OBJECTIVES: To assess the clinical recovery of sensation in noninnervated flaps used for oral cavity and oropharyngeal reconstruction. To correlate the return of flap sensation to articulation and swallowing. DESIGN: Prospective nonrandomized study. Six months minimum follow-up. SETTING: Tertiary care center. PATIENTS: From April 1, 1991, to May 31, 1993, 12 patients underwent resection of stage III or greater squamous cell carcinoma of the oral cavity or oropharynx. Ten patients were previously untreated; two had failed previous full-course radiation therapy. Reconstruction was performed with either a pedicled musculocutaneous flap (four patients) or a fasciocutaneous free flap (eight patients). Flap sensation to touch, sharp vs dull, two-point discrimination, and warm vs cold was evaluated in each of these patients at monthly intervals by two independent observers. In addition, an extensive evaluation of articulation and swallowing was performed on all 12 patients a minimum of 6 months after surgery. 10 patients (83%) (eight of eight with fasciocutaneous free flaps and two of four with musculocutaneous flaps), with a strong trend for sensory recovery with the fasciocutaneous free flaps over the musculocutaneous flaps (P = .09). Sensory recovery correlated statistically with articulation (P = .045) and oral intake (P = .045). Patients who underwent reconstruction of base of tongue defects had significantly worse articulation and swallowing than those who underwent reconstruction of other sites (P = .04). No statistically significant correlation was found between patient age, flap size, history of irradiation, or length of follow-up (> 6 months) and flap sensation, articulation, or swallowing. CONCLUSIONS: Spontaneous return of flap sensation was documented by clinical testing in the majority (83%) of patients who underwent reconstruction of oral cavity or oropharyngeal defects with noninnervated flaps. Sensory recovery occurred more often in patients with fasciocutaneous free flaps (100%) than in those with musculocutaneous flaps (50%). Articulation and swallowing correlated statistically with the return of flap sensation.

Phase I studies of continuous-infusion paclitaxel given with standard aggressive radiation therapy for locally advanced solid tumors.

Currently available therapies are unsatisfactory for locally advanced solid tumors of the lung, head and neck, and brain. Laboratory data suggest that the addition of paclitaxel (Taxol; Bristol-Myers Squibb Oncology, Princeton, NJ), a microtubule-stabilizing drug, to radiation therapy may result in significant radiation sensitization, perhaps because paclitaxel induces cell cycle arrest at G2/M. Relatively low concentrations, 1 to 10 nmol/L, appear to be optimal for direct cytotoxicity and radiosensitization in vitro. Within this dose range, more prolonged exposure seems to result in higher response rates. We are conducting phase I trials designed to test continuous infusion (24 hours per day, 7 days per week) intravenous paclitaxel combined with standard curative-intent radiation therapy. To date, 22 patients are evaluable, and the maximum tolerated dose of paclitaxel has not been reached at up to 2.5 mg/m2/d. Observed toxicities include anemia, lymphopenia, mucositis, and cutaneous erythema/desquamation.

Endoscopic resection of the intranasal frontal sinus floor.

The current accepted treatment for chronic frontal sinus disease unresponsive to medical management and endoscopic surgery is an external approach to either obliterate the sinus or restore communication to the nasal cavity. Here reported is an endoscopic approach for resection of the intranasal frontal sinus floor, a modification of a procedure first described by Lothrop in 1899. Eleven patients underwent this operation from April 1993 to December 1993. One complication, a cerebrospinal fluid leak treated successfully endoscopically, has occurred. Of the 7 patients followed up 3 months or longer after surgery, only 1 has developed symptoms of recurrent frontal sinusitis. On the basis of this limited preliminary experience, the endoscopic Lothrop procedure shows promise as an effective operation designed to establish a physiologic communication between the frontal sinus and the nasal cavity in selected patients who would otherwise be candidates for an external approach.