Defining the Safe Entry Point in Deep Plane Facelifting with Novel Landmark for the Buccal Branch of the Facial Nerve.

Background: In deep facial surgery, accurate preoperative landmarking of branches of the facial nerve is helpful in avoiding inadvertent facial nerve injury. The objective of our study was to determine the accuracy at which the intersection point of two bisecting lines that join facial surface landmarks can be used to accurately locate the buccal branch(es) of the facial nerve, specifically at the deep plane entry point (ie, intercept landmark). Methods: Thirty-three cadavers were dissected to determine the position of the buccal rami relative to the intercept. Results: Buccal rami crossed the intercept in 12.12% of specimens (0 mm from intercept, n = 4). Buccal rami passed superiorly in 66.67% of specimens (3.71 ±â€…3.28 mm from intercept, n = 7) and inferiorly in 21.21% of specimens (2.44 ±â€…0.92 mm from intercept, n = 7). Noteworthy, buccal rami were located within 1 cm of the intercept landmark with 96.97% accuracy (32/33 cadavers). Conclusions: These data suggest that this novel intercept (1) reliably locates the buccal branch of the facial nerve as it courses distal to the parotid gland, and (2) helps define a "safe zone" for entry into the deep plane where the likelihood of encountering the facial nerve is extremely low.

A national strategy to engage medical students in otolaryngology-head and neck surgery medical education: the LearnENT ambassador program.

BACKGROUND: In the realm of medical education, student-led ambassador programs represent an innovative approach to increase awareness about medical education resources. LearnENT is an internationally recognized otolaryngology-head and neck surgery (OHNS) smartphone app and website designed for medical trainees to learn about OHNS. However, upon the initial launch of the app, there was a lack of medical student awareness and engagement. APPROACH: In this article, we highlight the process and lessons learned from developing an ambassador program to increase the national presence and uptake of LearnENT. Medical students from across Canada were recruited and trained to promote the app at their respective institutions. EVALUATION: Ambassadors hosted events and spearheaded initiatives around the country with the goal of showcasing LearnENT. Furthermore, ambassadors were engaged in scholarly initiatives such as creating educational content for LearnENT and giving presentations at national conferences. REFLECTIONS: Critical factors in the success of a student-led ambassador program include ensuring widespread dissemination of the program, establishing clear expectations for ambassadors, equipping ambassadors with standardized promotional material, and promoting collaboration to collectively work towards addressing challenges. When creating a national student-led group such as an ambassador program, outreach to senior stakeholders can be an effective way to involve students at different institutions, provide mentorship opportunities for students and provide opportunities for educational scholarship. With new medical education innovations constantly surfacing, the LearnENT ambassador program model can be applied in other contexts to increase awareness of medical education resources.

Alternative sources of cautery may improve post-operative hematoma rates but increase operative time in thyroid surgery.

A retrospective risk-adjusted analysis was completed using data from the National Surgical Quality Improvement Program (NSQIP) to (1) compare the risks of post-operative hematoma for thyroid surgery using conventional cautery compared alternative energy devices (defined as LigaSure and Harmonic Scalpel), and (2) compare operative times for the same. The primary outcome variable was post-operative hematoma occurrence. The secondary outcome variable was operative time. The exposure variable was use of conventional or alternative sources of cautery. All adult patients who underwent a total thyroidectomy, subtotal thyroidectomy or completion thyroidectomy between 2016 and 2018 were included. Multivariable linear and logistic regression analyses were performed to control for potentially confounding variables. A total of 13,330 cases were analyzed; 4342 used conventional cautery, and 8988 used alternative sources. There was a statistically significant decrease in post-operative hematoma risk using alternative sources of cautery compared to conventional cautery (OR 0.75; 95% CI 0.58-0.98) (p = 0.04). Use of alternative sources of cautery added 4.95 min onto operative time (95% CI 2.45-7.45) which was statistically significant (p < 0.0001). After controlling for confounding variables, there was a statistically significant lower rate of post-operative hematoma in thyroidectomies performed using alternative sources of cautery compared to those performed with traditional hemostatic methods. Alternative sources of cautery increased operative time by 4.95 min.

LearnENT: The Development of a Free Open Access Medical Education App in Otolaryngology-Head and Neck Surgery.

OBJECTIVE: To describe the successes and challenges associated with developing an otolaryngology-head and neck surgery (OHNS) medical education app and website. DESIGN: From 2010 to 2018, OHNS faculty across Canada contributed to the development of a smartphone app, LearnENT. LearnENT 1.0, was initially launched in 2012 using the Apple iOS 6 platform. The app utilized a novel user interface and interactive features to help learners develop approaches to OHNS clinical problems, review relevant anatomy, history, and physical examination skills. However, the release of iOS 7 necessitated a redesign and relaunch of LearnENT which occurred from 2015 to 2018 to produce the final version of the app, LearnENT 2.0. Through the relaunching process, the LearnENT team redesigned the app's interface, produced a web version of the app, and created a new content management system. SETTING: OHNS departments across Canada. PARTICIPANTS: OHNS faculty members, residents, and medical students. RESULTS: Through this approach, a sustainable, widely accessible, open access OHNS e-Learning resource was developed. Since the relaunch, the LearnENT app has 2728 user accounts and has been widely used across the globe with users in 36 countries outside of North America. LearnENT is currently the official learning app of the Canadian Society of OHNS, has been featured on several different medical education platforms and incorporated into medical school curricula at various institutions. CONCLUSIONS: The authors successfully created a novel e-Learning resource with the goal of improving OHNS medical education both nationally and internationally.

Correction to: Evaluating the effectiveness of adjuvant radiotherapy in addition to surgery versus surgery alone at improving oncologic outcomes for early stage buccal carcinoma: a systematic review.

Following publication of the original article [1], the authors reported that one of the authors' names was spelled incorrectly. In this Correction the incorrect and correct author name are shown. The original publication of this article has been corrected.

Impact of marginalization on tobacco use in individuals diagnosed with head and neck Cancer.

BACKGROUND: Considerable evidence now indicates that individuals living in underprivileged neighbourhoods have higher rates of mortality and morbidity independent of individual-level characteristics. This study explored the impact of geographical marginalization on smoking cessation in a population of individuals with a diagnosis of head and neck cancer. The aims of this study were twofold: (1) assess the prevalence of smoking cessation in those with a previous diagnosis of head and neck cancer, (2) analyze the determinants of smoking alongside area-based measures of socioeconomic status. METHODS: This was a cross-sectional study. We administered a self-reported nicotine dependence package to participants between the ages of 20-90 with a previous mucosal head and neck cancer diagnosis and with a history of tobacco use. Using the Canadian Marginalization (CAN-Marg) Index tool based on 2006 Canada Census data we compared the degree of marginalization to the smoking status. For those individuals who were currently smoking, nicotine dependence and readiness to quit were assessed. A summative score of marginalization was compared to smoking status of individuals. RESULTS: The results from this study indicate that the summative level of marginalization developed from the combined factors of residential instability, material deprivation, ethnic concentration and dependency may be important factors in smoking cessation. CONCLUSIONS: This analysis of determinants of smoking alongside area-based measures of socioeconomic status may implicate the need for targeted population-based smoking cessation interventions.

Evaluating the effectiveness of adjuvant radiotherapy in addition to surgery versus surgery alone at improving oncologic outcomes for early stage buccal carcinoma: a systematic review.

OBJECTIVE: To systematically review the evidence to evaluate oncologic outcomes for patients with early stage buccal squamous cell carcinoma treated with surgery versus surgery and adjuvant radiation therapy. DATA SOURCES: Ovid MedLine, EMBASE, Google Scholar, PubMed. REVIEW METHODS: The primary purpose was to perform a systematic review to determine the published literature comparing oncologic outcomes of patients with early stage (Stages I&II) buccal mucosal squamous cell carcinoma, treated with surgical resection alone versus surgery plus adjuvant radiation therapy. Oncologic outcomes of interest were overall survival, locoregional recurrence, and disease specific survival. The secondary aim was to perform a meta-analysis to quantitively compare and summarize the data on oncologic outcomes between treatments. RESULTS: A total of 1457 studies were screened and five retrospective cohort studies (n = 733 patients) were eligible for quantitative analysis. Overall study quality was moderate to high. Pooled relative risk ratios using a fixed effects model did not reveal any statistically significant difference in overall survival (p = 0.70) or locoregional recurrence rates (p = 0.72) in Stage I and II disease. CONCLUSIONS: These results demonstrate there is sparse evidence comparing oncologic outcomes for early stage buccal squamous cell carcinoma treated with surgery alone versus surgery and adjuvant radiation therapy. Our findings based on a limited body of evidence suggest no obvious benefit in the addition of adjuvant radiation therapy, however robust randomized trials are warranted to reach firm conclusions.

Surgical peripheral nerve decompression for the treatment of painful diabetic neuropathy of the foot - A level 1 pragmatic randomized controlled trial.

AIMS: To assess the efficacy of surgical decompression of lower extremity nerves for the treatment of painful diabetic peripheral sensorimotor polyneuropathy (DPN). METHODS: People with painful diabetic neuropathy were randomized single-blind to a lower extremity decompression surgery (n = 12) or observation (n = 10) for 1 year. RESULTS: Pain was the primary outcome assessed with 2 measures. The McGill pain visual analogue scores over time changed within the groups (p for time < 0.0001), and changed differently over time within the groups (p for group × time = 0.0138). The NeuroQoL pain sensitivity analysis significantly changed from baseline to 12 months comparing intervention to control (p = 0.0079), and the joint effect of group and time on pain scores was statistically significant (p for group × time = 0.0009). At the study end-point of 12 months, intervention group participants had over 3 times the odds of rating their pain as "better" compared to "unchanged" or "worse" in the control group (p = 0.0177). CONCLUSIONS: Surgical decompression of lower limb nerves was an effective treatment for decreasing pain in patients with DPN and superimposed nerve compressions.

Echocardiogram changes following parathyroidectomy for primary hyperparathyroidism: A systematic review and meta-analysis.

The aim of the study is to systematically review the evidence on post parathyroidectomy (PTX) changes as measured by echocardiogram (ECHO) in patients with primary hyperparathyroidism (PHPT).PHPT may increase risk of cardiovascular morbidity/mortality. Conclusions of studies assessing ECHO changes, pre versus post PTX, are inconsistent.A systematic literature search was conducted to locate published and unpublished studies. Randomized control trials, nonrandomized control trials, and observational studies were included. Variables were reported as means and standard deviations. An inverse variance statistical method, with random-effects analysis model, was applied to continuous data. The effect measure was standardized mean difference, confidence interval of 95%. Primary outcome measure was left ventricular ejection fraction (LVEF). Secondary outcome measures were left ventricular mass index (LVMI), peak early over peak late diastolic velocity ratio (E/A ratio), isovolumetric relaxation time (IVRT), intraventricular septal thickness (IVST), and posterior wall thickness (PWT).Fourteen studies were included. Follow-up time ranged 3 to 67 months. No significant differences (P > .05) in primary outcome measure LVEF (SMD = -0.03, CI = -0.24, 0.19), or secondary outcome measures E/A Ratio (SMD = -0.05, CI = -0.24, 0.14), IVST (SMD = 0, CI = 0.31, 0.32), PWT (SMD = 0.01, CI = -0.38, 0.39), LVMI (SMD = -0.18, CI = -0.74, 0.38), and IVRT (SMD = -0.84, CI = -1.83, 0.14) were observed.There was no significant difference in LVEF pre to post PTX. Due to heterogeneity of current literature, we were unable to determine if other outcome measures of cardiac function are affected after PTX in patients with PHPT. We recommend a randomized control trial be conducted to make concrete conclusions.

Otolaryngology exposure in a longitudinal integrated clerkship setting.

BACKGROUND: Although 20-40% of primary care complaints are Otolaryngology-Head and Neck Surgery (OtoHNS) related, little emphasis is placed on OtoHNS instruction at the undergraduate medical education level. An OtoHNS clerkship rotation is not required at most Canadian medical schools. Furthermore, at institutions offering an OtoHNS rotation, less than 20% of students are able to complete a placement. Given that a large percentage of medical students in Canada will pursue primary care as a career, there remains a gap in providing OtoHNS clinical training. During the longitudinal integrated clerkship at the Northern Ontario School of Medicine (NOSM), students are assigned to one of 14 sites, and not all have access to an otolaryngologist. This study looks to quantify the level of exposure students are receiving in OtoHNS at NOSM and to assess their comfort level with diagnosing and treating common otolaryngologic conditions. METHODS: A structured 13-item survey was administered to second, third and fourth year medical students at NOSM. RESULTS: A majority (67.9%) of medical students surveyed had not observed an otolaryngologist. Furthermore, most students (90.6%) reported receiving very little OtoHNS classroom based and clinical instruction during medical school. CONCLUSIONS: A discrepancy exists between the quantity and breadth of OtoHNS training received in undergraduate medical education and the volume of OtoHNS encounters in primary care practice. Although geographic dissemination of students in the distributed learning model may be a challenge, strategies such as standardized objectives and supplemental electronic resources may serve to solidify clinical knowledge.

Spontaneous intrathyroidal hematoma causing airway obstruction: A case report.

INTRODUCTION: Spontaneous thyroid hemorrhage is a rare occurrence that results in pain, discomfort, and occasionally compressive symptoms. Infrequently, extensive thyroid hemorrhage can result in a rapidly expanding hematoma resulting in airway compromise. This is a case of an otherwise healthy young woman, 3 months postpartum, with a slowly expanding spontaneous thyroid hemorrhage that measured at 7 × 5.5 × 5 cm by computed tomography. She ultimately required intubation to manage respiratory distress and subsequently a hemithyroidectomy for definitive treatment. The case presentation is followed by a literature review where known etiologies of thyroid hematoma including traumatic and nontraumatic causes, precipitating anticoagulation, and spontaneous rupture of branches of the external carotid artery are outlined. The potential links to pregnancy are explored. The roles of bedside thyroid ultrasound in the emergency department and lateral neck roentgenogram in diagnosis are explored. The importance of airway management and indications for conservative versus surgical treatments are discussed. CONCLUSIONS: This is a case of a spontaneous intrathyroidal hemorrhage, which progressed over days to ultimately cause airway compromise. It is imperative that physicians are educated on the appropriate detection and management of the potentially life-threatening spontaneous thyroid hematoma.

Buffered lidocaine and bupivacaine mixture - the ideal local anesthetic solution?

The use of injectable local anesthetic solutions to facilitate pain-free surgery is an integral component of many procedures performed by the plastic surgeon. In many instances, a solution that has both rapid onset and prolonged duration of analgesia is optimal. A combination of lidocaine and bupivacaine, plain or with epinephrine, is readily available in most Canadian health care settings where such procedures are performed, and fulfills these criteria. However, commercially available solutions of both medications are acidic and cause a burning sensation on injection. Buffering to neutral pH with sodium bicarbonate is a practical method to mitigate the burning sensation, and has the added benefit of increasing the fraction of nonionized lipid soluble drug available. The authors report on the proportions of the three drugs to yield a neutral pH, and the results of an initial survey regarding the use of the combined solution with epinephrine in hand surgery.

L'injection d'anesthésiques injectables locaux pour favoriser une opération sans douleur fait partie intégrante des nombreuses interventions réalisées par le plasticien. Dans bien des cas, une solution analgésique à action longue et rapide est optimale. Une bithérapie de lidocaïne et de bupivacaïne, seule ou accompagnée d'adrénaline, disponible dans la plupart des milieux de santé canadiens où de telles interventions sont effectuées, respecte ce critère. Les solutions commerciales de ces deux médicaments sont toutefois acides et provoquent une sensation de brûlure à l'injection. L'utilisation d'un tampon de bicarbonate de sodium pour obtenir un pH neutre est pratique pour limiter la sensation de brûlure et a l'avantage supplémentaire d'accroître la fraction de médicament liposoluble non ionisé disponible. Les auteurs rendent compte des proportions des trois médicaments nécessaires pour obtenir un pH neutre et des résultats d'un sondage initial sur l'utilisation de la bithérapie combinée à l'adrénaline pour la chirurgie de la main.

Mycobacterium smegmatis infection of the hand.

We report a case of Mycobacterium smegmatis granuloma in the soft tissues of the first web space of the left hand in a 67-year-old Caucasian woman. She was in good systematic health; there was no recollection of trauma to the hand. A combined regime of prolonged antibiotic therapy and surgical debridement was necessary to ultimately eradicate the infection. The natural history, microbiology, and treatment of this rare hand infection are discussed.