A specific curriculum in facial plastic surgery. Effect on residency training

There has been a dramatic change in the degree of exposure to facial plastic surgery by the otolaryngology resident in the past decade. The amount of this exposure and the method of presentation of aesthetic concepts and procedures varies. We favor a specific curriculum in facial plastic surgery for the residency training program. The effect of this curriculum is measured by statistical analysis of resident-generated aesthetic surgery cases in one year following the introduction of this curriculum into the teaching program. These data are compared with the same period one year prior to the initiation of the program. Tympanoplasty, mastoidectomy, and tonsillectomy case numbers served as controls for statistical comparison over the same time period. These data serve as a guide to residency programs in determining the most effective means of providing optimum facial plastic surgery exposure to their trainees.     

The role of computer imaging in facial plastic surgery consultation: a clinical study

The influence of using computerized visual communication on preoperative communication between the surgeon and the patient was analysed. This was a retrospective study based on a questionnaire completed by 50 patients who had undergone various facial plastic surgical procedures. Prediction tracings and postoperative slides were compared by the surgeon. The role of computer imaging in communication between doctor and patient, as well as the patient–doctor relationship and trust in the judgement of the doctor was considered to be positive by most of the patients. The vast majority of patients thought computer imaging should be a routine part of preoperative evaluation. Both the surgeon and the patients agreed that the representative value of prediction tracing was about 80%. In view of the possible positive influences on communication and relationship in the preoperative phase, computer imaging may help to provide a clear and realistic preoperative informed consent.     

Competency-based resident education

Over the course of the last decade fundamental changes have occurred in residency training. The basis of these changes has been rooted in the desire to simultaneously improve the quality of the learning experience while decreasing the demands of training on resident lifestyle. The ACGME Outcomes Project was initiated in 1999 with the intent of facilitating such change in medical education. Before its introduction, assessment of residency training sites focused on the processes, resources, and reputation of an individual program, but failed to assess how effectively a program used those assets. The stated goal of the ACGME Outcomes Project has been to drive an evolution of this process-oriented form of education to one that is based on outcomes that measure the effect of the educational experience. This article is a brief overview of current efforts to achieve this goal.     

Facial nerve course in congenital aural atresia – identified by preoperative CT scanning and surgical findings

Conclusions. The facial nerve courses shown by preoperative CT imaging coincide with the surgical findings in most congenital aural atresia cases. CT scanning is critical in evaluation of a patient's candidacy for atresia surgery. Objectives. To evaluate the diagnostic value of preoperative CT scanning of the facial nerve course in congenital aural atresia. Subjects and methods. All inpatients (135 cases) with congenital aural atresia had routine preoperative CT examination. The facial nerve courses were observed in the operation and compared with the preoperative CT imaging. Results. CT imaging showed that the mastoid portions of the facial nerves in 57% of cases (77/135) were located at the level of the round window, and 17% (23/135) were located at the levels of the oval window and the cochlea. Differential overlapping of the oval window by the facial nerve could also be shown in most of the cases. In the majority of cases (75%, 61/81) the tympanic portions of the facial nerve on CT imaging could be confirmed by surgical findings. In severe overlapping of the oval window or cases with anterior displacement, stapedectomy or tympanoplasty, respectively, could not be performed as usual.     

Plastic surgical education for the otolaryngologist

Otolaryngology shares responsibility for provision of plastic surgical services involving facial and cervical structures, but many training programs have been weak in this part of the specialty. Some still are. Beginning in 1963 when a national organization was formed, leading facial plastic surgeons and the senior author analyzed the weaknesses and embarked on a program to correct these educational deficits. There was widespread lack of surgical background, woefully inadequate knowledge of soft tissue techniques, and poor understanding of dynamics involved in cosmetic procedures. Annual meetings, international symposia, numerous courses, and extensive videotape and microfiche production, as well as political and academic recognition, have all helped plastic surgical teaching endeavors at both residency and postgraduate levels. However, much remains to be done. Program directors are the “key” people here. Suggestions for future action are presented.     

The otolaryngologist's attitude to facial plastic surgery

Of 453 Canadian otolaryngologist, 226 responded to a questionnaire, indicating significant interest in the state of facial plastic and reconstructive surgery. The majority of these otolaryngologists practised in larger cities and one-quarter received foreign training. Half of the respondents had academic affiliations and three-quarters considered themselves general otolaryngologists. Almost all the otolaryngologists believed that cosmetic and reconstructive surgery should form a major part of their specialty, this being unanimous among current residents. A large majority felt there should be more facial plastic surgical training, this both at the residency and fellowship levels, preferably through increased surgical exposure. With respect to sub-certification, only the resident group was in favor.     

Preoperative appearance of facial muscles on magnetic resonance predicts final facial function after acoustic neuroma surgery.

OBJECTIVE: Several previous studies have shown that muscle appearance on magnetic resonance is a sensitive indicator of muscle denervation. Previous attempts at determining preoperative indicators of final facial function after acoustic neuroma removal has been mostly unsuccessful. The goal of this study was to determine if the appearance of the facial muscles on preoperative imaging is predictive of final facial function after surgical removal of vestibular schwannomas. STUDY DESIGN: We conducted a retrospective chart and magnetic resonance review. SETTING: This study was conducted at a tertiary referral center. PATIENTS: We included all patients who underwent vestibular schwannoma removal between January 1, 1997, and December 31, 2001, with available preoperative magnetic resonance images and a minimum of 12 months follow up. INTERVENTIONS: We used translabyrinthine, middle fossa, and suboccipital approaches for tumor removal. A neuroradiologist, blinded to preoperative or final facial function after tumor removal, retrospectively reviewed preoperative magnetic resonance images. MAIN OUTCOMES MEASURES: Facial muscles were evaluated on magnetic resonance and classified as symmetric or asymmetric. Facial function was graded using the House-Brackmann scale. Preoperative facial function was noted on the preoperative physical examination. Final function was determined at least 12 months postoperatively. RESULTS: A total of 247 patients underwent tumor removal during the study period. One hundred thirty-two patients had adequate preoperative magnetic resonance images. Patients with preoperative facial muscle asymmetry seen on preoperative magnetic resonance indicating muscle atrophy had significantly worse final facial function, regardless of tumor size. CONCLUSION: The preoperative appearance of facial muscles provides valuable insight into the physiology of the facial nerve in the presence of vestibular schwannomas. Patients with pre-operative facial muscle symmetry have significantly better facial function than those with atrophy.     

Petrous bone cholesteatoma: clinical longitudinal study

The object of this retrospective study was to describe a series of patients with petrous bone cholesteatomas, paying particular attention to classification, diagnosis, surgical strategy, results, complications and recurrences. Furthermore, the study was designed to evaluate the impact of imaging techniques on an early diagnosis. Topographically, the petrous bone cholesteatomas of the present series were grouped using Sanna's classification and different surgical approaches were used. High resolution CT and/or MRI were used to follow-up the patients. The case notes of 52 patients with petrous bone cholesteatomas who were referred to our hospital for surgery between 1987 and 2003 were reviewed postoperatively. There were 45 primary cases and 7 recurrences. The facial nerve had been infiltrated and compressed by the cholesteatoma in 18 patients. Fourteen were managed with cable grafts using sural nerve or great auricular nerves. About 26 patients with preoperative grade I confirmed their normal facial function in 23 cases. In the other ten patients, the preoperative facial paralysis was due to compression by the cholesteatoma and its removal provided partial recovery of facial function in four patients. Our study compared two observation periods (1987-1996 and 1997-2003) when the diffusion and the availability of imaging techniques in our national health system had considerably increased. Two important factors emerged: firstly, the number of less extensive surgical approaches was higher in the more recent observation period, proving that cholesteatomas smaller in size had been diagnosed. Secondly, preoperative facial paralysis was less frequent in the same period-falling to 25% of cases of total facial paralysis from the 45.8% of the earlier period-practically half as much. The partial paralyses instead increased slightly, demonstrating that otologists have become more sensitive to and pay more attention to this symptom.     

Haemangiomas of the geniculate ganglion

About 60 cases have been published since Pulec first described hemangiomas of the geniculate ganglion. They usually cause facial weakness even when they are very small. In cases of insidious evolution of facial paralysis, MRI, and CT are very helpful to rule out these tumors. The treatment is based on complete surgical removal, although it has to be individualized, depending on preoperative facial function and the possibility of complete surgical removal with preservation of the facial nerve.     

Die strukturierte HNO-Facharztweiterbildung

A concept for an ORL residency training program is necessary because of personnel bottlenecks, quality assurance and benchmarkings. We have created a 2.5 years' program, which is based on 6 pillars: 1. Acquisition of the necessary specialist knowledge by the resident in self-study. 2. Weekly attendance of training lectures according to a study timetable, a monthly specialist seminar to discuss case examples. 3. Weekly presentation by the resident on an article from the current literature, alternating with a presentation on cases and a morbidity and mortality conference. 4. Annual 60 min learning target test. 5. Definition of a surgical training calendar oriented to the new national ORL training regulations. 6. Internal operation course with preparative exercises in anatomy and visit to an operations course at a renowned otolaryngology clinic each year. After 2.5 years of the training time a revision course is introduced. In this way a basic training will be guaranteed for all residents, which can be assessed by the annual test. Finally, the construction of a further training curriculum should lead to an improved transparent training, a higher standard of quality and improved staff satisfaction.     

导航系统在鼻眶筛复合骨折术中的应用

目的 探讨导航系统在鼻眶筛复合骨折手术中的应用,寻求导航系统的介入对鼻眶筛复合骨折手术复位精准性的帮助及导航系统手术的优势。 方法 62例鼻眶筛复合骨折的患者被纳入试验中。在采集并导入DICOM格式的CT影像学数据后,术前利用计算机辅助设计复合面部对称性的鼻眶筛复合骨折复位方案,术中在导航系统的指导下完成鼻眶筛复合骨折的复位手术,并实时验证复位后位置与术前设计方案的匹配程度。 结果 在导航系统通过注册后,术中的骨折及解剖位置与CT影像学数据精准吻合,计算机的系统误差控制在1 mm之内。所有的手术都在实时导航下顺利完成,术中根据术前的复位方案精准复位,利用导航系统判断复位后骨质与设计方案的匹配程度。患者术后面部外形改善明显,所有纳入的患者对手术复位结果满意。 结论 在计算机辅助下,通过术前测量、模拟、设计,导航技术有利于提高鼻眶筛复合骨折术中复位的精准性、减少手术风险、降低再次手术的发生率、恢复面部对称性。     

Predictors of future success in otolaryngology residency applicants

OBJECTIVE To evaluate the information available about otolaryngology residency applicants for factors that may predict future success as an otolaryngologist. DESIGN Retrospective review of residency applications; survey of resident graduates and otolaryngology clinical faculty. SETTING Otolaryngology residency program. PARTICIPANTS Otolaryngology program graduates from 2001 to 2010 and current clinical faculty from Barnes-Jewish Hospital/Washington University School of Medicine. MAIN OUTCOME MEASURE Overall ratings of the otolaryngology graduates by clinical faculty (on a 5-point scale) were compared with the resident application attributes that might predict success. The application factors studied are United States Medical Licensing Examination part 1 score, Alpha Omega Alpha Honor Medical Society election, medical school grades, letter of recommendation, rank of the medical school, extracurricular activities, residency interview, experience with acting intern, and extracurricular activities. RESULTS Forty-six graduates were included in the study. The overall faculty rating of the residents showed good interrater reliability. The objective factors, letters of recommendation, experience as an acting intern, and musical excellence showed no correlation with higher faculty rating. Rank of the medical school and faculty interview weakly correlated with faculty rating. Having excelled in a team sport correlated with higher faculty rating. CONCLUSIONS Many of the application factors typically used during otolaryngology residency candidate selection may not be predictive of future capabilities as a clinician. Prior excellence in a team sport may suggest continued success in the health care team.     

Use of cross-sectional imaging in predicting facial nerve sacrifice during surgery for parotid neoplasms

BACKGROUND: Neoplasms of the parotid gland are difficult management issues because of the wide variation in their biological behavior and the potential for sacrifice of the facial nerve during resection. Because of the significant associated morbidity, prediction of facial nerve sacrifice is critically important for planning surgical procedures and preoperative counseling of patients. We hypothesize that along with the knowledge of the tumor type we would be able to accurately predict the likelihood of facial nerve sacrifice using cross-sectional imaging. METHODS: All patients included in this study were previously untreated patients with parotid neoplasms operated on between January 1997 and July 2002. Only those patients with an available preoperative imaging were included and this resulted in 44 patients for review. Nine patients with preoperative deficits in facial nerve function were excluded from this study since these patients would require facial nerve sacrifice regardless of the radiological prediction. The prediction of facial nerve sacrifice was determined using a prediction of tumor location and an algorithm. The predicted results were compared to the operative record. RESULTS: For all lesions, cross-sectional imaging predicted the need for sacrifice of the facial nerve with a sensitivity of 0.83 (95% CI, 0.36-0.99), specificity of 0.90 (95% CI, 0.72-0.97), PPV of 0.63 (95% CI, 0.26-0.90), and NPV of 0.96 (95% CI, 0.79-0.99). For malignant lesions only, prediction of sacrifice of the facial nerve had a sensitivity of 0.83 (95% CI, 0.36-0.99), specificity of 0.80 (95% CI, 0.51-0.95), PPV of 0.63 (95% CI, 0.26-0.90), and NPV of 0.92 (95% CI, 0.62-0.99). CONCLUSION: Cross-sectional imaging and application of our algorithm is a sensitive method for identifying patients with parotid neoplasms who require facial nerve sacrifice. CT and MRI have a high negative predictive value for facial nerve sacrifice.     

The effects of computer simulated facial plastic surgery on social perception by others

Previous studies have demonstrated the remarkable impact of facial plastic surgery on the perception of facial features. However, pre- and postoperative differences other than the surgically changed features such as facial expression, hairstyle, make-up etc., have influenced the results of previous studies. To exclude these visual cues a computer composite photograph of the changed feature mounted upon the preoperative photograph, instead of the standard postoperative photograph, was presented to observers in this study. Computer graphic technology was used to superimpose the postoperative, surgically changed facial features such as the nose, ear and chin of 16 patients on standardized preoperative photographs. The randomized preoperative photographs and the ‘postoperative’ composed images were presented to 67 subjects, using a person-perception questionnaire. Multivariate analysis demonstrated a more favourable postoperative judgement in only two patients (12.5%). The exclusive effect of facial plastic surgery on the social perception of patients by others when excluding visual cues, such as facial expression, hairstyle, make-up etc, is limited. It is tentatively assumed that the role played by facial plastic surgery is one of initiating a positive cycle by changing the patient’s self-perception rather than one of direct social impact from the changed features.     

Management of facial nerve schwannoma in patients with favorable facial function

OBJECTIVE: We report six cases of facial nerve schwannomas in which surgical management allowed the preservation of facial nerve function. Specifically, this paper reports that a stripping surgery may provide favorable functional outcomes. STUDY DESIGN: A retrospective review of preoperative and postoperative data for six patients with facial nerve schwannoma that had normal facial nerve function or a House-Brackmann grade II facial palsy before the surgery. METHODS: Stripping surgery, which removed the schwannoma from the remaining nerve fascicle, was attempted on the six patients. Postoperative facial nerve function and imaging (magnetic resonance imaging) were evaluated. RESULTS: Stripping surgery with gross total tumor removal of the mass was performed in four cases. In the two remaining cases, the stripping surgery was not possible, and decompression alone was performed. Favorable preservation of facial function was achieved in all six cases. CONCLUSION: It was possible to preserve facial function after surgery to remove facial nerve schwannoma. We suggest that stripping surgery, focused on the preservation of continuity of the facial nerve, may be attempted for facial nerve schwannoma in which favorable facial function has been preserved.     

Impact of duty hour restrictions on otolaryngology training: divergent resident and faculty perspectives

OBJECTIVES: In 2003, the Accreditation Council for Graduate Medical Education (ACGME) passed a controversial mandate limiting resident work hours. We sought to examine the impact of these restrictions on otolaryngology programs and to explore faculty and resident perspectives. METHODS: Faculty and residents of all 102 ACGME-accredited otolaryngology residency programs were invited to participate in an anonymous online survey. RESULTS: The study population consisted of 460 respondents: 275 residents and 185 faculty (including 41 program directors) representing 57 otolaryngology programs. Sixty-five percent of programs implemented at least one change specifically to comply with duty-hour restrictions. Strategies included tracking work hours electronically (35.7%), utilization of "home call" (33.1%), and hiring additional healthcare professionals (23.1%). When asked if the restrictions have had a negative effect on patient care, 61% of respondents said no, but a surprising 33% said yes. Sixty-nine percent of faculty felt that the restrictions have actually had a negative effect on resident training compared with only 31% of residents (P<.001). Thirty-nine percent of participants felt resident workload was excessive before the restrictions. Opinions on whether duty-hour limits had fostered improvements in resident education, research, or examination scores varied, but most agreed that resident mental health had improved (67%). CONCLUSIONS: Otolaryngology programs have successfully restricted resident duty hours through significant infrastructural changes. Of concern, the majority of residents surveyed appeared to be in favor of the ACGME restrictions, whereas most program directors and faculty were opposed. Further studies are needed to establish whether limited work hours will enhance or hinder the residency training experience.     

Program directors' opinions about surgical competency in otolaryngology residents

OBJECTIVES: The purpose of this study was to determine whether certain surgical procedures could be used as benchmark skills to monitor resident progress in developing surgical competency. STUDY DESIGN: Survey. METHODS: A two-stage survey was sent to otolaryngology residency program directors in the United States. Respondents were given a list of otolaryngology surgical procedures monitored by the American Board of Otolaryngology (ABO) and were asked to indicate whether they felt residents should be able to do each as a primary surgeon. The appropriate level of training for competency in each procedure and estimated number of procedures to competency was indicated by respondents. RESULTS: Respondents selected 16 common procedures they felt residents at different levels of training should be able to perform independently. There were discrepancies between estimated number of procedures needed for competence and the numbers reported by ABO graduates. CONCLUSIONS: Surgical skill is one aspect of clinical competency, and this indicates agreement among program directors with regard to a set of benchmark skills we can use for concentrated evaluation efforts.     

The rhinology experience in otolaryngology residency: a survey of chief residents

Objectives: The development of rhinology as a distinct subspecialty is based on recent advances in the research, clinical, and surgical aspects of the field. The impact of this evolution on the rhinologic experience in otolaryngology residency programs is not currently understood. Methods: An anonymous, web‐based survey of chief residents in otolaryngology residency programs was performed. Participants were asked to rate their residency experience in rhinology in terms of didactics, research opportunities, mentorship availability, clinical care, and surgical experience on an ordinal 5‐point Likert scale with higher scores representing more favorable responses. Results: Forty‐eight respondents completed the survey, yielding a response rate of 17.6%. The overall experience in rhinology was reported as positive (4.3 points). The individual items with statistically lower scores included availability of basic science research (P = .04), comfort level with the medical management of unusual rhinologic issues (P = .0006), and comfort level with advanced sinus procedures (P < .0001). However, overall ratings were high, and even the poorer‐scoring items were still rated favorably. In programs with rhinology fellowships, basic science opportunities were reported as being higher (P = .04) than programs without fellowships. There were no other statistically significant differences in programs with rhinology fellowships. There was no correlation between responses and future career choice. Conclusion: The overall residency training experience in rhinology appears to be positive, and presence of a rhinology fellowship appears not to have a negative impact on resident rhinologic training.