LETTERS TO THE EDITOR.

Dear Dr. Pulec:

I read with interest two articles in the September ENT Journal.

"Are we all just stupid?" requires additional elaboration at just how stupid we are. Otolaryngologists are the only ones with our skills. We have permitted the inroads of managed care to force our older colleagues into early retirement and made it impossible for younger doctors to ever pay off their academic and start-up costs. Office visits and procedures are reimbursed at roughly 60% of Medicare, and surgery at levels below 1975. To paraphrase Nancy Reagan, "Just say no to HMO."

A second article about control of anterior epistaxis by suture of the anterior septal artery, "A new ligation approach to the management of chronic epistaxis" by Samuel G. Adornato, MD, reminds me that every physician/surgeon has "tricks of the trade" that should be shared. For 25+ years I have done a transeptal suture of 0000 chromic catgut around the base of both septal arteries for nosebleeds in patients as young as 4 years (in the OR, under general anesthesia, in conjunction with any other procedure) and as old as their mid-90s under topical/local anesthesia in the office and the emergency room. I have showed the technique to other otolaryngologists and ER doctors. I have done hundreds of them with one complication of a septal hematoma in a teenager requiring septoplasty for drainage. The control rate is astonishingly high for many years. Occasionally a patient has returned with a new vessel in a slightly aberrant location, and Dr. Adornato's technique has been used effectively.

I enjoy reading the useful articles in ENT Journal.

Keep up the good work.

William L. Cantor, MD

Woodcliff Lake, NJ

Dear Dr. Pulec:

A nagging problem we have experienced involves the oral mouth gag retractor geometry. Under some circumstances, we have had difficulty reaching the Mayo stand rim with the armature of the mouth gag. This difficulty seems to be caused by a number of factors: the base of the OR table, the patient's shape or size, or when the bed is tilted into a head-down position. Whatever the cause, the Mayo stand tray is then too close to the patient's chest.

We have found a solution to this problem with an instrument we have been using called the Dedo-extension. Developed by an anesthesiologist (who happens to be the son of a well-known otolaryngologist), it bridges the gap between the Mayo stand and the arm of the oral gag retractor. This simple stainless steel inverted J-hook is easy to use and has become a standard instrument in some of our area hospital's T&A packs.

I have recently seen it advertised in Archives of Otolaryngology and the ENT Journal and highly recommend its use for anyone performing oropharyngeal surgery. In fact, our surgical assistants have made its use routine, Not only do we enjoy an increased margin of safety between the Mayo tray and the patient, there is also more room to pass the electrocautery connection, the suction tubing, and laser control lines. For more information or ordering, you can call CANT Corporation at [phone].

J. Kevin Duplechain, MD, FACS

Lafayette, LA