This book is a compilation of carefully articulated opinions on the best way to manage more than two dozen commonly encountered clinical problems in which there is uncertainty in otolaryngology—head and neck surgery. Indeed, if there were not, in some degree, a lack of fundamental knowledge about each of these problems, there probably would be a single management strategy agreed upon by all. Dr. Pensak has selected important problems in otology, rhinology, laryngology, facial plastic and reconstructive surgery, head and neck oncology, and skull base surgery. The problems are important because they are either life threatening or severely compromise the quality of life. Many represent substantial socioeconomic impact because of the number of individuals suffering from them. Each of these clinical problems confronts the thoughtful practitioner with alternative approaches that are theoretically appealing. There are no contrived or academic issues; each problem involves real life dilemmas or even a triad of choices.

Dr. Pensak has also selected some of the most distinguished intellectual leaders of their fields to present, based on their expertise and abundant experience, their preferred solutions to these problems. Each author has presented a reasoned advocacy of his or her approach based on the best data available at this time.

Twenty years ago, I edited a book on controversy in oto-laryngology in which a similar number of difficult problems was addressed. It is not surprising that many of the problems are the same, but how great the differences in the solutions. These differences are a tribute to the clinical progress taking place in otolaryngology—head and neck surgery. They are also predicated on the amazing technological progress that has been applied by many of the authors of this book. Furthermore, diseases change over time. In the course of my career, many diseases affecting the practice of otolaryngology—head and neck surgery have been brought under control, including polio, rubella, measles, mumps, Wegener granulomatosis, and Haemophilus influenzae type B meningitis and epigiottitis, but unfortunately the diseases addressed in that book are still with us. Most of the progress in specific diseases is based on public health measures such as immunization, and much more can be accomplished in this way. A vaccine against otitis media should be available in less than a decade. Nevertheless, progress in the management of specific diseases such as Wegener granulomatosis with cyclophosphamide is based on careful clinical observations and the results of clinical trials like those cited in this book.

I am convinced that all disease is genetically determined or at least genetically predisposed. Even trauma may, in most instances, have a genetic basis in the psychological determination of risk taking. Certainly, the susceptibility to infectious diseases is genetically predisposed, and that susceptibility may range within a population from complete immunity to complete susceptibility with many gradations in between. In the case of hearing impediments, it is now being found that there is a genetic basis to forms of hearing loss that were formerly attributed solely to environmental factors. For example, it is now known that the ototoxicity of aminoglycoside antibiotics in some Asian populations is predisposed by a mutation in the 12S RR,VA mitochon (Hal gene, AI555G), and the individual variation in susceptibility to noise-induced hearing loss and pres-byacusis may well be explained by mitochondrial mutations. The magnitude of the coming role of molecular genetics in clinical medicine is difficult to overestimate.

The remarkable progress in molecular biology related to otolaryngology—head and neck surgery will be the driving force providing the basis for the prevention and control of diseases in the future. For example, the discovery of a multitude of disease genes responsible for the autosomal dominant and recessive X-linked and mitochondrial modes of transmission of syndromic and nonsyndromic forms of hereditary hearing impairment will have a profound impact on the clinical management of hearing impairment. Already, many of these genes have been cloned and their protein products identified. Not only will these discoveries elucidate the development, normal structure and function, and maintenance of the various parts of the auditory and vestibular systems, they will provide the basis for rational therapeutic strategies of the next century and beyond.

The marvelous thing about molecular biologic research is that, for the first time, each discovery relates directly to the pathogenesis of the disease and suggests the strategy for intervention in the very pathogenesis of the disease.

These strategies will be tested in the clinical trials of the future. How fortunate is otolaryngology—head and neck surgery to have the financial resources of the National Institute on Deafness and Other Communication Disorders, the National Institute of Child Health and Human Development, the National Institute on Aging, the National Institute of Allergy and Infectious Diseases, the National Institute of Dental and Craniofacial Research, and the National Cancer Institute, as well as many private foundations and professional societies, to support basic and clinical research needed by our patients. From that research, a new millennium of progress in clinical otolaryn-gology-head and neck surgery will flow to the benefit of countless millions of individuals with disorders of human communication and other disabilities throughout the world.

This book presents fresh perspectives on an array of common clinical problems, and these perspectives can truly be characterized as cutting edge and innovative. Not only does it provide a stimulating intellectual journey through the land of the bêtes noires of clinical otolaryngology—head and neck surgery, it is filled with practical advice in the day-to-day practice of this fascinating field. The reader will be challenged to assess the evidence presented by each author supporting his or her point of view, and it is hoped that this process will be both enjoyable and informative.

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