Atraumatic Delayed Orbital Hematoma Sixteen Years After Orbital Floor Fracture Repair With Porous Polyethylene Implant.

Porous alloplastic materials such as titanium mesh and porous polyethylene allow for the ingrowth of fibrovascular tissues into the implant; stabilizing the implant and reducing the risk of extrusion and extrusion-related complications (such as hematoma formation). The literature contains 2 specific reports of delayed atraumatic orbital hematomas occurring 8 months and 3 years after orbital floor reconstruction with porous polyethylene implants. In this study, an atraumatic orbital hematoma occurring 16 years after orbital floor reconstruction with a porous polyethylene implant was presented. The hematoma was evacuated and the implant was removed without replacement of a secondary implant. The remaining fibrovascular tissue on the underside of the implant provided enough support of the orbital soft tissues to achieve excellent anatomic and physiologic outcomes.

Rhinoscleroma presenting as a nasal-palatal mass with airway obstruction.

We report a case of a 45-year-old male with severe rhinoscleroma. The patient presented to the emergency room with dyspnea from a long-standing nasal-palatal mass. A tracheostomy was required for airway control. While dyspnea in the presence of an upper airway mass is typical of malignancy, consideration of non-oncological etiologies is important. We review the epidemiology, pathology, diagnosis, and treatment of rhinoscleroma.

Squamous cell carcinoma of the tonsil masquerading as a peritonsillar abscess.

A 58-year-old man presented to the emergency department with a persistent left-sided sore throat of 2-month duration. The sore throat had not responded to antibiotic therapy. Over the past week, the soreness had increased and was aggravated by opening the mouth. He denied fever but admitted to a 10-lb weight loss. His social history was significant for alcohol and tobacco use. Physical examination revealed a bulging and erythematous left soft palate with a deviated uvula. Areas of the tonsil were noted to be ulcerating through the soft palate. In the upper left neck, a 3-cm, firm, nontender, lymph node was palpated anterior to the sternocleidomastoid muscle. A computed tomography of the neck with contrast revealed an enhancing tonsillar mass as well as enlarged lymph nodes bilaterally. A transoral biopsy returned squamous cell carcinoma.

Self-reported "worth it" rating of aesthetic surgery in social media.

BACKGROUND: A wide variety of surveys have been used to validate the satisfaction of patients who underwent aesthetic surgery. However, such studies are often limited by patient number and number of surgeons. Social media now allows patients, on a large scale, to discuss and rate their satisfaction with procedures. The views of aesthetic procedures patients expressed in social media provide unique insight into patient satisfaction. METHODS: The "worth it" percentage, average cost, and number of respondents were recorded on October 16, 2011, for all topics evaluated on the aesthetic procedure social media site www.realself.com . Procedures were divided into categories: surgical, liposuction, nonsurgical, and dental. For each group, procedures with the most respondents were chosen and ordered by "worth it" score. A literature search was performed for the most commonly rated surgical procedures and the satisfaction rates were compared. RESULTS: A total of 16,949 evaluations of 159 aesthetic surgery topics were recorded. A correlation between cost of the procedure and percentage of respondents indicating that the procedure was "worth it" was not found. The highest-rated surgical procedure was abdominoplasty, with 93 % of the 1,589 self-selected respondents expressing that abdominoplasty was "worth it." The average self-reported cost was $8,400. The highest-rated nonsurgical product was Latisse, with 85 % of 231 respondents reporting it was "worth it" for an average cost of $200. The satisfaction scores in the literature for commonly rated surgical procedures ranged from 62 to 97.6 %. No statistically significant correlations between literature satisfaction scores and realself.com "worth it" scores were found. CONCLUSIONS: Abdominoplasty had the highest "worth it" rating among aesthetic surgical procedures. Aesthetic surgeons should be wary that satisfaction scores reported in the literature might not correlate with commonly achieved results. Social media has opened a new door into how procedures are evaluated and perceived. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the table of contents or the online instructions to authors www.springer.com/00266 .

General surgery and otolaryngology resident perspectives on obtaining competency in thyroid surgery.

OBJECTIVE: General surgery (GS) and otolaryngology (OTO) do not require a minimum number of thyroidectomies to qualify for board certification. No standardized criteria exist for declaring competence in this procedure. A survey was created to assess GS and OTO resident perspectives on becoming competent in thyroid surgery. DESIGN: A survey was electronically mailed to all GS and OTO residents assessing their competence in thyroid surgery. SETTING: National survey of general surgery and otolaryngology residents. PARTICIPANTS: National general surgery and otolaryngology residents. RESULTS: A convenience sample of 526 residents responded (246/280 = GS/OTO). The mean clinical year of training was 3.3 (3.1/3.5). Most residents (50%/41%) performed between 1 and 10 thyroid operations. Residents believed 13 and 25 (GS/OTO) thyroidectomies were required by their respective Boards. Both groups felt that 30 (27/33) thyroid operations were necessary to obtain competence (p < 0.01). The most important feature was operative volume with graduated responsibility, followed by guidance under an expert mentor. Analysis of residents PGY4 and greater showed no significant differences. CONCLUSIONS: While residents of both specialties generally agree on learning methods, the perception of readiness to perform thyroid surgery after training is variable. A disconnect is present between the number of cases required for Board certification, the number of cases residents believe are required, and the number of cases residents believe it takes to achieve competency.

Vocal cord collapse during phrenic nerve-paced respiration in congenital central hypoventilation syndrome.

OBJECTIVE: Phrenic nerve pacing can be used to treat congenital central hypoventilation syndrome (CCHS). We report how the lack of normal vocal cord tone during phrenic paced respiration can result in passive vocal cord collapse and produce obstructive symptoms. METHODS: We describe a case of passive vocal cord collapse during phrenic nerve paced respiration in a patient with CCHS. As far as we know, this is the first report of this etiology of airway obstruction. The patient, a 7-year-old with CCHS and normal waking vocal cord movement, continued to require nightly continuous positive airway pressure (CPAP) despite successful utilization of phrenic nerve pacers. On direct laryngoscopy, the patient's larynx was observed while the diaphragmatic pacers were sequentially engaged. RESULTS: No abnormal vocal cord stimulation was witnessed during engaging of either phrenic nerve stimulator. However, the lack of normal inspiratory vocal cord abduction during phrenic nerve-paced respiration resulted in vocal cord collapse and partial obstruction due to passive adduction of the vocal cords through the Bernoulli effect. Bilateral phrenic nerve stimulation resulted in more vocal cord collapse than unilateral stimulation. CONCLUSIONS: The lack of vocal cord abduction on inspiration presents a limit to phrenic nerve pacers.

Pitfalls in endoscopic treatment of mandibular subcondylar fractures.

OBJECTIVES: The facial trauma surgeon should be able to list indications for endoscopic treatment of mandibular condyle fractures and discuss the limitations and complications of the technique. BACKGROUND: The ideal treatment of mandibular subcondylar fractures continues to be debated. Acceptable results are often obtained with conservative measures such as mandibular maxillary fixation followed by elastics. On the other hand, an open approaches result in potential risk injury to the facial nerve. These 2 arguments have cautioned many surgeons from open treatment of condylar fractures. Recent advances in endoscopic techniques have made the mandibular condyle more accessible with less risk to the facial nerve. As with any new technique, endoscopic treatment of mandibular subcondylar fractures is not without its own limitations and complications. METHODS: This was a retrospective case series. RESULTS: Three patients with mandibular subcondylar fractures with complications following endoscopic treatment were reviewed. There were a total of 4 condylar fractures (1 patient had bilateral fractures). There was 1 incidence of temporary facial nerve paresis, 1 failure of hardware positioning, 1 screw placement into the mandibular foramen, 2 condyles where adequate reduction of the fracture was impossible, and 1 failure to secure a screw into the proximal fracture segment. CONCLUSIONS: Endoscopic management of mandibular subcondylar fractures is a novel treatment with novel types of complications. Although promising, endoscopic treatment of mandibular subcondylar fractures should be approached prudently to avoid potential pitfalls.

Cost-effective dental protection during rigid endoscopy.

We describe a simple method to create a reusable and customizable dental guard using readily available materials. Our method does not require an extra patient visit and does not add operative time. Furthermore, our guard is rigid, which allows force to be distributed over adjacent teeth, unlike soft mouth guards.

The value of otolaryngologists' services in America: a national survey.

OBJECTIVE: To evaluate the perceived monetary value of physician services within the general population and to foster academic discussion about the finances of clinical practice in the setting of recent health care reform. STUDY DESIGN, SUBJECTS, AND METHODS: National survey of 409 members of the general population and review of Centers for Medicare and Medicaid Services data. RESULTS: The perceived monetary values of office visits were comparable to the actual physician reimbursements. However, the average perceived value associated with surgical treatments was significantly higher than the true Medicare reimbursement amount. For example, survey participants said that a reasonable price for a doctor to be paid for performing a tonsillectomy is $955.58, whereas the national average Medicare reimbursement is $257.74. Furthermore, 59% of respondents also believe that insurers, Medicare, and Medicaid pay doctors more than the respondent's perceived value for each service. CONCLUSION: The current patterns of Centers for Medicare and Medicaid Services reimbursement reveal a trend of declining payments for physician services. A survey of a sample of the general population indicated that most people believe that their doctors are paid far more than they actually are. It is important for otolaryngologists and head and neck surgeons to understand and discuss the economic forces that continue to shape our practices, and it is vital that we all play an active role in the discussions surrounding the evolution of the American health care system.

Primary care perceptions of otolaryngology.

OBJECTIVE: To identify diseases of the head and neck for which primary care physicians may underappreciate the role of the otolaryngologist. STUDY DESIGN: Cross-sectional analysis. SETTING: With increasing subspecialization in the world of medicine, there is the potential for confusion about the scope of practice for different specialties by primary care physicians. These clinicians are often faced with patients who have disease processes in which otolaryngologist are trained but may end up referring patients to other specialists. SUBJECTS AND METHODS: A brief, web-based survey was administered via e-mail to resident physicians of family medicine, pediatrics, and internal medicine programs in the United States. The survey asked responders which specialist they believed was an expert for particular clinical entities: allergies, oral cancer, restoring a youthful face, sleep apnea, thyroid surgery, and tracheostomy. Respondents could choose from a dermatologist, general surgeon, ophthalmologist, oral maxillofacial surgeon, orthopedic surgeon, otolaryngologist, and plastic surgeon. The responder was able to choose more than one specialist for each question. RESULTS: A total of 1064 completed surveys were analyzed. The percentage of primary care residents who picked otolaryngologists as experts was 13.8 percent for allergies, 73.6 percent for oral cancer, 2.7 percent for restoring a youthful face, 32.4 percent for sleep apnea, 47.2 percent for thyroid surgery, and 72.5 percent for tracheostomy. CONCLUSION: This study demonstrates that many primary care residents are not aware of the scope of expertise that an otolaryngologist may offer. Increased exposure to otolaryngology during primary care residency training may increase understanding of the specialty among primary care physicians.