Christine B. Franzese

Diagnosis and Surgical Management of Nasopalatine Duct Cysts

Objectives/Hypothesis: Nasopalatine duct cysts are the most common cystic lesion of nonodontogenic origin of the maxilla. The purposes of the study were to review the epidemiology and clinical presentation, to describe the radiographic and pathological findings, and to discuss surgical management of this entity.

Extremes in Otolaryngology Resident Surgical Case Numbers

Objective Understand (1) significance between minimum, mean, and maximum case numbers for otolaryngology resident surgical procedures; (2) weaknesses of Accreditation Council for Graduate Medical Education (ACGME) resident case log system contributing to inaccurate data/case inflation; and (3) when excessive case load may transform education into service. Study Design Cross-sectional survey using a national database. Setting Academic otolaryngology residency programs. Subjects/Methods Review of otolaryngology resident national data reports from ACGME resident case log system performed from 2004 to 2010. Minimum, mean, standard deviation, and maximum values for total number of resident surgeon cases and for specific surgical procedures were compared. Case unbundling, resident data entry habits, and tracked vs untracked Current Procedural Terminology (CPT) codes were reviewed. Results Mean total number of resident surgeon cases remained constant (1699.5 ± 424.2 to 1772.2 ± 517). Minimum total number of cases ranged from 730 to 811 (approaching 2 standard deviations below the mean). Zero was reported as the minimum case number for some procedures. Maximum for total number of cases increased (3559 to 4857) and surpassed the mean by 4 to 5 standard deviations. Some procedures have maximums greater than 11 standard deviations above the mean. The authors identified untracked CPT codes and variations in resident case log documentation habits. Conclusions Large differences between the minimum, mean, and maximum resident surgeon case numbers exist. Establishing minimum case number requirements for otolaryngology residents should be considered. Educational benefit derived from excessive case load is unclear. Critical examination of the ACGME resident case log system and resident documentation habits is needed to improve accuracy of reporting.

Peritonsillar and Parapharyngeal Space Abscess in the Older Adult

OBJECTIVE To review the presentation and management of peritonsillar (PTA) and parapharyngeal space (PPSA) abscesses in older adults and compare this with the usual presentation and management in the younger patient. STUDY DESIGN An 18-year retrospective review at a tertiary care hospital. METHODS The patient database was searched by using the diagnosis codes for PTA and PPSA. The search included inpatient and outpatient visits of patients 50 years of age and older from 1983 to 2001. The charts were reviewed, and data regarding presentation, management, and outcome were recorded. Comparisons to the current literature were made. RESULTS Fourteen patients were identified, 8 with PTA and 6 with PPSA. The most common symptoms in both groups were sore throat and dysphagia. Only 1 patient in either group was febrile. All vital signs were within normal limits in all other patients. Only 1 patient in each group experienced trismus, and no patients showed drooling. Five of the PTA patients required inpatient care, and 2 were taken to the operating room. CONCLUSIONS PTA and PPSA are uncommon infections in the older adult, with only 14 patients identified at a tertiary care hospital over an 18-year period. Complaints of new onset sore throat and dysphagia of several days duration in patients over 50 years old should alert the evaluating physician to these 2 clinical entities, even in afebrile, nontoxic patients. PTA in this group may be more likely to require inpatient care along with surgical treatment in the operating room.

Pilot study of an objective structured clinical examination (“the Six Pack”) for evaluating clinical competencies

OBJECTIVE: The purpose of this study was to evaluate an Objective Structured Clinical Examination (OSCE) designed to examine all six competencies and provide meaningful results to improve resident performance. STUDY DESIGN: A prospective, observational study. METHODS: The OSCE consists of 1 hour for examination of a simulated patient, documentation, and feedback, with 30 minutes for an evidence-based medicine (EBM) test. Eight otolaryngology residents participated. Digital recordings and written documentation were evaluated on all competencies except practice-based learning. An EBM test was scored to assess practice-based learning. RESULTS: Overall, senior residents scored better. Seniors scored better on performing a focused history, whereas juniors scored better for thoroughness. Seniors coded better than juniors, although seniors tended to undercode and juniors tended to over-code. Two cases of “insurance fraud” were also discovered. CONCLUSIONS: The “Six Pack” successfully evaluated all competencies while providing valuable information. A clinical practicum was added to improve history and physical examination skills. The discussion of coding and a billing seminar also resulted. Residents believed the OSCE was valuable. Faculty members were impressed with the useful information obtained.

Adult outpatient tracheostomy care: Practices and perspectives

Objectives To determine the attitudes, opinions, and current practice of adult outpatient tracheostomy care from the surgeon and primary care physicians perspective. Study Design Multidisciplinary physician survey. Results Found 53.4% (667 of 1250) and 28.9% (404 of 1400) of otolaryngologists and internists responded, respectively; 47% of otolaryngologists lack standardized tracheostomy discharge protocols. General ward nurses most commonly (33%) provide discharge education. A total of 64% of otolaryngologists felt primarily responsible for tracheostomy care and follow-up; 48% expect the primary physician to provide some or all tracheostomy care. Ninety-seven percent of internists received little or no residency training in tracheostomy care, which was significantly associated with decreased comfort (P < 0.0001) and willingness (P < 0.0001) to care for these patients. Conclusions Tracheostomy care is a concerted effort between the patient, surgeon, primary physician, and interdisciplinary team. Otolaryngologists should strive to standardize tracheostomy discharge, education, and follow-up practices. Significance Disparities are highlighted between disciplines in their comfort, willingness, and knowledge of outpatient tracheostomy care.

The Patient with Allergies

Allergic disease affects a sizeable percentage of the general population, has a significant impact on patient quality of life, and exerts a significant financial burden on society. Atopic symptoms from inhalant allergens are among the most frequent complaints in outpatient medical visits. Key history and physical examination findings help to distinguish allergic rhinitis from other forms of chronic rhinosinusitis. Diagnostic testing may not be necessary unless immunotherapy is contemplated.

When to cut? Using an objective structured clinical examination to evaluate surgical decision-making.

Objectives: To create an objective structured clinical examination (OSCE) tailored to surgical residents that uses surgical case scenarios appropriate for the experience level of the resident to evaluate whether residents understand the indications for a specific surgery, identify when indications are met, and make the appropriate decision to proceed with an operation.

Diagnosis of Inhalant Allergies: Patient History and Testing

In the United States, roughly 20% to 25% of the general adult population is afflicted by some form of chronic allergic respiratory disease, making allergy one of the most commonly diagnosed disorders. Among children, allergic disease is more common, with some sources estimating that it affects up to 40% of children. The focus of this article involves making the diagnosis of the most familiar and best understood of the hypersensitivity reactions, type 1 hypersensitivity, also termed immediate hypersensitivity. Although type 1 hypersensitivity can be caused by ingestion of food antigens or pharmaceuticals, this article focuses on IgE-mediated allergic disease caused primarily by inhalant allergens.

Diagnostic Evaluation of Inhalant Allergies: A Cost-effectiveness Analysis:

Background The purpose of this study was to compare the cost-effectiveness of modified quantitative testing (MQT), intradermal dilutional testing (IDT), and in vitro allergy testing as diagnostic methods used in the management of patients with suspected IgE-mediated inhalant allergies. Methods A systematic review was conducted to determine key statistics for analysis, such as prevalence of disease, and sensitivity and specificity of each diagnostic modality. Costs were calculated based on charges from distribution companies to providers. A deterministic cost-effectiveness analysis then was conducted using a decision tree model to evaluate the various diagnostic strategies. After identifying results at baseline, we performed a sensitivity and threshold analysis to assess the strength of recommendations. Results At an allergic rhinitis prevalence of 20%, MQT dominated IDT and in vitro testing, with 85 people correctly diagnosed at a baseline total cost of

Extremes in Otolaryngology Resident Surgical Case Numbers: An Update

6630 for the 100 patients tested. Although in vitro testing had the highest effectiveness, it had an incremental cost-effectiveness ratio of