majority of pediatric otolaryngologists are located in academic teaching centers whose main goal is to train residents how to manage pediatrie oto¬ laryngologic problems when they get out into practice. You do not have to be a pediatrie otolaryngologist to practice good pediatrie otolaryngology in the community. As researchers, our goal is to increase and refine the body of knowledge regarding all pediatrie oto¬ laryngologic problems. As clinicians, our goal is to participate in the care of special and difficult problems in the pediatrie population. It is not
intention to create a manage otitis media and adenotonsillar hypertrophy" or to request "routine management of un¬ our
complicated common problems by ter¬ tiary subspecialty groups."
STEVEN D. HANDLER, MD Philadelphia, Pa
Improving Diagnostic Accuracy of Cervical Metastases With Computed Tomography and Magnetic Resonance Imaging To the Editor.\p=m-\Iam writing to take issue with the conclusions and recommendations made by Hillsamer et al, in the November 1990 issue of the Archives1 regarding the preoperative use of computed tomography (CT) and magnetic resonance imaging (MRI) in the evaluation of the clinically negative neck. Their recommendation for the use of CT or MRI in the preoperative evaluation of the clinically negative neck is not at all supported by the authors' data as presented. The results are based on 27 patients who underwent radical neck dissections for head and neck cancer. However, of those 27 patients, 16 had clinically positive necks and in 15 of those 16, pathologic findings confirmed the clinical impression. In case 25, the physical examination results were positive and the pathologic findings were negative. It should be noted that in this situation, the CT was positive and the MRI was negative. There are no data or rationale presented to support the use of CT or MRI in the clinically positive neck. There was another example, case 12, in which the CT and the MRI gave con¬ flicting reports. Also, eight of the 27 cases had either a CT or an MRI that were not done. As previously mentioned, the au¬ thors make recommendations in this article regarding the clinically nega-
tive neck. Only 11 of the 27 patients had clinically negative necks. It seems reasonable that, if the authors are go¬ ing to make recommendations regard¬ ing clinically negative necks, then their results should be based only on the data collected from those patients. Six of the 11 clinically negative necks also proved to be pathologically nega¬ tive. Thus, there were five cases in which the physical examination pro¬ vided false-negative results. In three of those five cases, the CT or MRI results were also false-negative. Thus, there were only two cases, cases 2 and 4, in which the CT and MRI scan cor¬ rected the false-negative physical ex¬ amination results. In addition, in case 14, the CT and MRI results proved to be false-positive. Therefore, in only three cases did the CT and MRI scan change the clinical impression in patients with clinically negative necks. In two of those occasions, cases 2 and 4, it corrected the physical impression. In case 14; the studies proved misleading. The numbers of patients in this study are so small as to preclude statistical analysis. It seems ludicrous for the authors to conclude that "the results of this study support the use of CT or MRI preoperatively in the evaluation of the clinically negative neck." This kind of recommendation translates into mil¬ lions of dollars in unnecessary tests in our already bulging health care bud¬
WILLIAM PORTILLA, MD COLLEEN M. RENIER Duluth, Minn
1. Hillsamer PJ, Schuller DE, McGhee RB Jr, Chakeres D, Young DC. Improving diagnostic accuracy of cervical metastases with computed tomography and magnetic resonance imaging. Arch Otolaryngol Head Neck Surg. 1990; 116:1297-1301.
In Reply.\p=m-\Iam writing to respond to Dr Portilla's letter to the editors concerning our published article entitled "Improving Diagnostic Accuracy of Cervical Metastases With Computed Tomography and Magnetic Resonance
puted tomography and magnetic resonance imaging were found to be superior over physical examination in sensitivity values, false-positive values, false-negative values, and overall efficiency predictive values. However,
these values did not achieve statistical
We then summarized a recent up\x=req-\ to-date literature review from 1984 to present that showed five out of six in-
stitutions were in agreement with
findings. Two of these, Friedman et al1 and Close et al2 were statistically sig-
nificant. At this point in time we feel that this provoking and controversial issue is unfolding to support the side of utilizing either computed tomography or magnetic resonance imaging in the
However, continued evaluation in this area
is still needed. PETER J. HILLSAMER, MD DAVID E. SCHULLER, MD Columbus, Ohio
1. Friedman M. Rationale for elective neck dissection in 1989. Laryngoscope. 1990;100:54-59. 2. Close L. CT evaluation for regional lymph node involvement cancer of the oral cavity and oropharynx. Head Neck Surg. 1989;11:309-317.
Decision Analysis in Head and Neck Cancer
To the Editor.\p=m-\Iwould like to commend CPT Vic Velanovich, MC, USA, on his recently published article, "Choice of Treatment for Stage I Floor-of-Mouth Cancer."1 The use of decision analysis in the field of head and neck cancer is both appropriate and overdue. Dr Velanovich has modeled the clinical situation clearly and accurately. He has drawn from 22 articles to obtain his rates for cure, recurrence, morbidity, and mortality following treatment. Those who would argue with the results of his study should question the database from which the author draws his rates and not the process of decision analysis. The author has identified an area of needed research\p=m-\qualityof life following treatment for head and neck cancer. The effects of various treatment options on the quality of life for the patient with head and neck cancer is sorely lacking. Fundamental research in quality of life will allow more accurate data to be included in future decision analysis models. Due to the lack of such data, an earlier model, which looked at pyriform sinus cancer, used opinions on quality of life from the treating physicians' point of view and not from the point of view of the patients themselves.2 I applaud the Archives for the decision to publish this article. JAY F. PICCIRILLO, MD New Haven, Conn 1. Velanovich V. Choice of treatment for stage I floor-of-mouth cancer. Arch Otolaryngol Head Neck Surg. 1990;116:951-956. 2. Plante DA, Piccirillo JF, Sofferman RA. Decision analysis of treatment options in pyriform sinus carcinoma. Med Decis Making. 1987;7:74-83.
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