Liana Puscas

Computer modeling and navigation in maxillofacial surgery.

Purpose of reviewTo review the accuracy and effectiveness of current technology available for computer-aided maxillofacial surgery. Recent findingsNew developments in computer technology can help surgeons with preoperative planning and intraoperative navigation in the management of maxillofacial injuries. SummaryComputer-aided surgery is improving the surgical outcomes in maxillofacial reconstruction, particularly in complex cases. Several recent articles are presented that explore the clinical outcomes using computer-aided surgery, investigate the precision of various intraoperative optical navigation systems, compare several registration strategies and examine the impact of natural facial asymmetry on planning and reconstruction. In all cases, preoperative computed tomography (CT) data are imported to computer modeling programs in which virtual reconstructions can be performed. These reconstructions are then used by intraoperative navigation systems to guide the surgeon and increase the precision of surgical outcomes. Evaluation of various registration strategies used to orient navigation systems to patient anatomical markers demonstrates that the optimum strategy is dependent on injury type. Some degree of error when repairing maxillofacial injuries is negated by the fact that people have naturally asymmetrical craniofacial skeletons.

Otolaryngology Resident In-Service Examination Scores Predict Passage of the Written Board Examination

Objective The purpose of this study was to assess the association between the Otolaryngology Training Examination (OTE) and the passage rate of first-time examinees on the American Board of Otolaryngology (ABOto) Written Qualifying Examination (WQE). Study Design Historical cohort study. Setting De-identified database containing information on examinees who took the WQE in 2007 to 2011 and the OTE in 2005 to 2011. Subjects and Methods One thousand three hundred nine otolaryngology residents took the WQE for the first time in 2007 to 2011 and the OTE in their final and penultimate years of training in 2005 to 2011. Data were analyzed using 1-way frequencies and table analysis. Logistic regression was used to model the relationship between the pass/fail WQE result and the OTE percentile score in the final and penultimate years of training. Data transformation was used to analyze WQE passage as a function of OTE scores by deciles and quartiles. Results There is a significant relationship between OTE score and passage of the WQE on the first attempt. The probability of passing the WQE on the first attempt is 97% if the resident scores in the upper 3 quartiles of the OTE in the final and penultimate years of training compared with 70% if the examinee scores in the bottom quartile both years. Conclusion Residents who score in the bottom quartile in both their final and penultimate years of training are at significantly higher risk of failing the WQE on the first attempt. Remediation efforts should be focused on these individuals.

Qualities of Residency Applicants: Comparison of Otolaryngology Program Criteria With Applicant Expectations

OBJECTIVES To evaluate the criteria used by otolaryngology programs in ranking residency candidates and to compare residency candidate ranking criteria among otolaryngology programs and applicant expectations. DESIGN Cross-sectional, anonymous survey administered during the 2009 and 2010 match cycles. SETTING Otolaryngology residency programs. PARTICIPANTS Otolaryngology residency program applicants (PAs) and otolaryngology program directors (PDs). MAIN OUTCOME MEASURES The PDs were asked to rank the importance of 10 criteria in choosing a residency candidate on a 20-point scale (with 1 indicating utmost importance; 20, not important at all). The PAs were asked to express their expectations of how candidates should be ranked using those same criteria. RESULTS The interview and personal knowledge of the applicant (mean rank, 3.63) were the most important criteria to PDs, whereas the interview and letters of recommendation (mean rank, 3.65) were the most important criteria among PAs. Likelihood to rank program highly and ethnicity/sex were the least valued by PDs and PAs. CONCLUSIONS Although PDs and PAs agree on the least important criteria for ranking otolaryngology residency candidates, they disagree on the most important criteria. This information provides insight into how programs select residency candidates and how this compares with applicant expectations. Furthermore, this information will assist applicants in understanding how they might be evaluated by programs. Improved understanding of the match process may increase the likelihood of having a good fit between otolaryngology programs and matched applicants.

Utility of Intraoperative Frozen Sections during Thyroid Surgery

Objective. To describe the usefulness of intraoperative frozen section in the diagnosis and treatment of thyroid nodules where fine needle aspirate biopsies have evidence of follicular neoplasm. Study Design. Retrospective case series. Methods. All patients have a fine needle aspirate biopsy, an intraoperative frozen section, and final pathology performed on a thyroid nodule after initiation of the Bethesda System for Reporting Thyroid Cytopathology in 2009 at a single tertiary referral center. Sensitivity, specificity, positive predictive value, and negative predictive value are calculated in order to determine added benefit of frozen section to original fine needle aspirate data. Results. The sensitivity and specificity of the frozen section were 76.9% and 67.9%, respectively, while for the fine needle aspirate were 53.8% and 74.1%, respectively. The positive and negative predictive values for the fine needle aspirates were 25% and 90.9%, respectively, while for the frozen sections were 27.8% and 94.8%, respectively. There were no changes in the operative course as a consequence of the frozen sections. Conclusion. Our data does not support the clinical usefulness of intraoperative frozen section when the fine needle aspirate yields a Bethesda Criteria diagnosis of follicular neoplasm, suspicious for follicular neoplasm, or suspicious for malignancy at our institution.

Physician knowledge of and attitudes toward the Patient Protection and Affordable Care Act.

Objective To assess otolaryngology physician knowledge of and attitudes toward the Patient Protection and Affordable Care Act (PPACA) and compare the association of bias toward the PPACA with knowledge of the provisions of the PPACA. Study Design Cross-sectional survey. Setting Nationwide assessment. Subjects Members of the American Academy of Otolaryngology—Head and Neck Surgery. Methods Otolaryngology physicians answered 10 true/false questions about major provisions of the PPACA. They also indicated their level of agreement with 9 statements about health care and the PPACA. Basic demographic information was collected. Results Email solicitation was sent to 9972 otolaryngologists and 647 responses were obtained (6.5% response rate). Overall correct response rate was 74%. Fewer than 60% of physicians correctly answered questions on whether small businesses receive tax credits for providing health insurance, the effect of the PPACA on Medicare benefits, and whether a government-run health insurance plan was created. Academic center practice setting, bias toward the PPACA, and Democratic Party affiliation were associated with significantly more correct responses. Conclusion Overall physician knowledge of the PPACA is assessed as fair, although better than the general public in 2010. There are several areas where knowledge of physicians regarding the PPACA is poor, and this knowledge deficit is more pronounced within certain subgroups. These knowledge issues should be addressed by individual physicians and medical societies.

Facial Fractures in the Aging Population

Background: As the U.S. population ages and life expectancy increases, the number of elderly patients seeking trauma care and treatment for facial fractures will increase. Understanding age-related differences in the pattern, cause, and management of these fractures is essential for improving care. Methods: A retrospective review of adults presenting to a Level I trauma center was performed to evaluate age-related differences in facial fractures. Descriptive statistics were used to compare fracture number, type, cause of injury, management, and adverse events between elderly (older than 64 years) and younger cohorts (aged 18 to 64 years). Logistic regression was used to evaluate the effect of age on fracture type while controlling for potential confounding variables. Results: Two thousand twenty-three adult patients sustained a facial fracture from 2001 to 2011. Two hundred nine patients were elderly and 1814 were younger. Regarding cause of injury, older patients were more likely to fall and younger patients were more likely to be injured through assaults, motor vehicle collisions, or sports (p < 0.0001). Elderly patients sustained a higher incidence of maxillary (16.3 percent versus 11.4 percent; p = 0.0401), nasal (54.1 percent versus 45.3 percent; p = 0.0156), and orbital floor fractures (28.2 percent versus 18.1 percent; p = 0.004) and a lower incidence of mandible fractures (10.1 percent versus 21.3 percent; p = 0.0001). The elderly had significantly less operative intervention (24.9 percent versus 43 percent; p < 0.0001) and were less likely to experience complications (5.3 percent versus 10.5 percent; p = 0.0162). Conclusion: Elderly patients tend to suffer from less severe facial fractures, requiring less need for operative intervention, likely secondary to low-energy mechanisms of injury. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

The role of human papilloma virus infection in the etiology of oropharyngeal carcinoma.

Purpose of reviewEvidence is growing that human papilloma virus is responsible for a subset of head and neck carcinomas. This review analyzes the history and current thinking regarding this relatively new etiologic agent of squamous cell carcinoma. Recent findingsResearch over the past year has confirmed that human papilloma virus is associated with subset of head and neck squamous cell carcinoma, especially tumors arising from the tonsil. Human papilloma virus 16 is the most common strain found in these tumors. Most studies also indicate that patients with human papilloma virus infection are more likely to have a better prognosis, engage in riskier sexual behavior, and have a history of less tobacco and alcohol consumption than patients who have human papilloma virus-negative tumors. Not all studies confirm these findings, however, and human papilloma virus, even the high-risk strains (16, 18, and 33) are found in a certain percentage of healthy individuals. SummaryHuman papilloma virus (especially strain 16) has been recognized as a probable etiologic agent for some head and neck squamous cell carcinomas. Most commonly, human papilloma virus is associated with tumors arising from the tonsillar epithelium. Because a definitive causal relationship is still to be identified, current research aims to delineate the specific mechanism whereby human papilloma virus produces squamous cell carcinoma. It is hoped that a vaccine may be produced in the near future that will serve as adjuvant therapy for patients with human papilloma virus-positive tumors.

Midline cervical cleft: review of an uncommon entity.

Introduction. Midline cervical cleft is a rare congenital malformation which nonetheless has a classic presentation. This study presents one of the largest single series of new patients with MCC and provides an exhaustive review and catalogue of publications from the international literature. Materials and Methods. Retrospective chart review performed in two academic medical centers and literature review performed with primary verification of all quoted references. Results. Ten patients with MCC were identified (8 boys and 2 girls). All patients presented with the classic findings of this congenital anomaly, and the length of the skin defect correlated with an increase in the patients age. Surgical excision was complete in all cases. Thorough international literature review yielded only 195 verifiable previously reported cases. Conclusions. This is one of the largest series of new patients with midline cervical cleft presented in the world literature. Although rare (with less than 200 cases published to date) this entity does have a reliable presentation that should lead to rapid and accurate diagnosis. Complete surgical excision at an early age is appropriate since the anomaly increases in length commensurate with the patients age.

Comparison of complications in free flap reconstruction for osteoradionecrosis in patients with or without hyperbaric oxygen therapy

Hyperbaric oxygen (HBO) therapy induces native tissue oxygenation. The hypothesis was patients with mandibular osteoradionecrosis (ORN) and a history of HBO therapy would have less free flap reconstruction complications than patients without HBO therapy.

Comparison of Applicant Criteria and Program Expectations for Choosing Residency Programs in the Otolaryngology Match

Objective. To evaluate criteria used by residency applicants in ranking otolaryngology residency programs and to compare applicant criteria with program expectations of ranking otolaryngology residency programs. Study Design. Cross-sectional survey. Setting. 2009 and 2010 match cycles. Subjects and Methods. Program applicants and otolaryngology program directors. Main Outcome Measures. Applicants were asked to rank the importance of 10 criteria in choosing a residency program (1 = criterion was of the utmost importance and 20 = not important at all). Program directors were asked to express expectations of how applicants should rank programs using those same criteria. The Mann-Whitney U test was used to analyze responses between groups. Results. Comprehensiveness of subspecialties and resident satisfaction were the most important criteria for both groups; salary, call schedule, and likelihood to rank the resident highly were least valued. Four criteria were significantly different between groups. Applicants significantly valued location (4.36 vs 8.9, P < .0001) and call schedule (9.85 vs 12.73, P = .002) more than program directors did. Program directors valued didactic schedule (6.1 vs 9.18, P < .0001) and comprehensiveness of subspecialties (2.53 vs 3.02, P = .007) more than applicants did. Forty-one of 105 (39%) program directors completed the survey. Conclusion. While applicants and program directors agree on the most and least important criteria for ranking residency programs, there are several significant differences in these criteria. This study provides insight on ranking criteria that may improve the resident match process and subsequent training experience. However, the ability to generalize the results is limited by the low response rate.