Nonmelanoma Skin Cancer.

This article reviews the most common nonmelanoma skin cancers affecting the head and neck region. Although the most common of these malignancies rarely result in mortality, local morbidity caused by the tumors and their extirpation cannot be underestimated. Complete tumor extirpation with pathologically confirmed negative margins is the gold standard. Regional and distant metastases are rare, but must be treated appropriately should they occur. Although reconstructive surgery can be life changing for the patients and rewarding for the clinicians, it behooves the treating surgeons to remain true to oncologic principles above all else.

Primary care specialty career choice among Canadian medical students: Understanding the factors that influence their decisions.

OBJECTIVE: To identify which factors influence medical students' decision to choose a career in family medicine and pediatrics, and which factors influence their decision to choose careers in non-front-line specialties. DESIGN: Survey that was created based on a comprehensive literature review to determine which factors are considered important when choosing practice specialty. SETTING: Ontario medical school. PARTICIPANTS: An open cohort of medical students in the graduating classes of 2008 to 2011 (inclusive). MAIN OUTCOME MEASURES: The main factors that influenced participants' decision to choose a career in primary care or pediatrics, and the main factors that influenced participants' decision to choose a career in a non-front-line specialty. RESULTS: A total of 323 participants were included in this study. Factors that significantly influenced participants' career choice in family medicine or pediatrics involved work-life balance (acceptable hours of practice [P = .005], acceptable on-call demands [P = .012], and lifestyle flexibility [P = .006]); a robust physician-patient relationship (ability to promote individual health promotion [P = .014] and the opportunity to form long-term relationships [P < .001], provide comprehensive care [P = .001], and treat patients and their families [P = .006]); and duration of residency program (P = .001). The career-related factors that significantly influenced participants' decision to choose a non-front-line specialty were as follows: becoming an expert (P < .001), maintaining a focused scope of practice (P < .001), having a procedure-focused practice (P = .001), seeing immediate results from one's actions (P < .001), potentially earning a high income (P < .001), and having a perceived status among colleagues (P < .001). CONCLUSION: In this study, 8 factors were found to positively influence medical students' career choice in family medicine and pediatrics, and 6 factors influenced the decision to choose a career in a non-front-line specialty. Medical students can be encouraged to explore a career in family medicine or pediatrics by addressing misinformation, by encouraging realistic expectations of career outcomes in the various specialties, and by demonstrating the capacity of primary care fields to incorporate specific motivating factors.

Objective Evaluation of Otoscopy Skills Among Family and Community Medicine, Pediatric, and Otolaryngology Residents.

INTRODUCTION: The objective of this study is to evaluate and compare the perceived need for otolaryngology training and otoscopy diagnostic skills in primary care (Family and Community Medicine, Pediatric Medicine), and Otolaryngology Head and Neck Surgery (OTO-HNS) postgraduate trainees. Participant otoscopy skills were evaluated using the OtoSim simulator. METHODS: Family and Community Medicine, Pediatric, and OTO-HNS residents were recruited. Each resident participated in 3 separate otoscopy training and assessment sessions. The ability to correctly identify middle ear pathology was objectively evaluated using OtoSim™. Pretest, posttest, and 3-month retention test results were compared among residents in a paired comparison paradigm. Survey data assessing exposure to OTO-HNS during undergraduate and postgraduate training were also collected. RESULTS: A total of 57 residents participated in the study. All residents reported limited exposure to OTO-HNS during undergraduate medical training. Primary care trainees performed poorly on pretest assessments (30% ± 7.8%; 95% CI). Significant improvement in diagnostic accuracy was demonstrated following a single 1-hour teaching session (30%-62%; p < 0.001). Primary care residents demonstrated a significant decrease in diagnostic accuracy at a 3-month follow-up assessment (62%-52%, p < 0.001). Self-perceived comfort with otology was poorly correlated to pretest performance among primary care trainees (r = 0.26) and showed a stronger positive correlation among OTO-HNS trainees (r = 0.56). CONCLUSIONS: A single teaching session with an otoscopy simulator significantly improved diagnostic accuracy in primary care and OTO-HNS trainees. Improved performance is susceptible to deterioration at 3 months if acquired skills are not frequently used. Self-perceived comfort with otology may not be an accurate predictor of otoscopic diagnostic skill.

The aesthetic unit principle of facial aging.

IMPORTANCE: In youth, facial aesthetic units flow together without perceptible division. The face appears as a single dynamic structure with a smooth contour and very little if any shadowing between different anatomical regions. As one ages, facial aesthetic units slowly become distinct. This process may be a consequence of differences in skin thickness, composition of subcutaneous tissue, contour of the facial skeleton, and location of facial ligaments. Although the impact of aesthetic unit separation is clinically apparent, its fundamental role in perceived facial aging has not yet been defined empirically. OBJECTIVES: To evaluate and define the effect of aesthetic unit separation on facial aging and to empirically validate the rationale for the blending of aesthetic units as a principle for facial rejuvenation. DESIGN, SETTING, AND PARTICIPANTS: We prepared the photographs of 7 women for experimental evaluation of the presence or absence of facial aesthetic unit separation. Photographic stimuli were then presented to 24 naive observers in a blinded paired comparison. For each stimulus pair, observers were asked to select the facial photograph that they considered to be more youthful in appearance. Each stimulus was compared with all others. MAIN OUTCOMES AND MEASURES: We calculated a preference score for the total number of times any photograph was chosen to be more youthful compared with all others. Paired t tests were used to compare the preference scores between the facial stimuli with and without aesthetic unit separation. RESULTS: We generated 4032 responses for analysis. Photographs without facial aesthetic unit separation were consistently judged to be more youthful than their aged original or modified counterparts, with mean preference scores of 0.66 and 0.33, respectively (P ≤ .047). When we selected the paired stimulus that directly compared one photograph with aesthetic unit separation with another with blended aesthetic units (2015 pairs), observers indicated that the photograph with the blended aesthetic unit was younger 95% of the time. Within-rater reliability was found to be very good (r = 0.88). CONCLUSIONS AND RELEVANCE: Our data support the hypothesis that facial aesthetic unit separation influences perceived facial youthfulness among photographs of women. The presence of facial aesthetic unit separation results in a less youthful appearance. Based on these empirical data, the concept of facial aesthetic unit separation appears to play a significant role in perceived facial aging. LEVEL OF EVIDENCE: NA.

Lymphadenopathy: defining a palpable lymph node.

BACKGROUND: The threshold size required to detect lymphadenopathy via palpation has never been formally determined. The purpose of this study was to determine the threshold, sensitivity, and error of node palpation and how this changes with experience. METHODS: Lymphadenopathy models were created using polyvinyl alcohol cryogel (PVA-C) to mimic tissue tactility. Node diameter ranged from 0.5 to 4 cm. Study subjects were medical students, otolaryngology residents, and otolaryngology consultants. Each subject provided 22 estimates of size. Primary outcomes were the sensitivity, error (true vs estimated size), and threshold of palpation. RESULTS: Thirty subjects completed the study. Sensitivity was 60%, 74%, and 86% for students, residents, and consultants, respectively (p < .01). Error was 0.88 cm, 0.61 cm, and 0.57 cm, respectively (p < .05). Palpation threshold was 1.32 cm, 0.83 cm, and 0.75 cm, respectively (p < .05). All participants detected nodes ≥2 cm, whereas consultants detected nodes ≥1 cm. CONCLUSION: Experience is associated with decreased palpation threshold and error, and increased sensitivity. Educational interventions should target nodes <2 cm.

Preoperative concerns of patients undergoing endoscopic sinus surgery.

BACKGROUND: Patient-centered care is recognized as being fundamental to successful medical practice. The effectiveness of patient-centered care has classically been measured by posttreatment outcomes, such as patient compliance and psychosocial responses. Systematic assessment of patient concerns prior to treatment has been limited, to date. Endoscopic sinus surgery (ESS) is an elective procedure for chronic rhinosinusitis that carries a clear, defined set of risks. The objective of this prospective observational study was to determine the concerns of patients undergoing ESS for chronic rhinosinusitis. METHODS: A total of 180 patients undergoing ESS for chronic rhinosinusitis with or without polyposis were recruited at 2 Canadian tertiary care centers. They completed a validated survey assessing their concerns regarding the risks and outcomes of surgery. Data was analyzed using descriptive statistics and analysis of variance. RESULTS: Patients had a low degree of concern prior to undergoing surgery (overall score 2.8/9), though individual variability existed. Subjects felt the greatest level of concern regarding potential need for revision surgery as well as the wait time for surgery. Patients were least concerned about psychological factors (mean = 1.8/9). No differences with respect to age or gender were identified. Mean scores for cerebrospinal fluid leak and orbital injury were 3 and 3.2, respectively. CONCLUSION: Patients' level of concern prior to undergoing elective surgery is generally low. Patients' areas of greatest concern may not align with those perceived by the physician. This study provides insight into patient concerns prior to undergoing elective sinus surgery and emphasizes the importance of the patient-centered approach to care.

Impact of nasal surgery on speech resonance.

OBJECTIVES: The nose and paranasal sinuses contribute to speech resonance and changes to these structures may alter speech nasality. This change may influence one's vocational and social functioning and quality of life. Our investigation explored objective and subjective changes in nasality following nasal surgery in a prospective and longitudinal fashion. METHODS: Recordings of sustained vowel and sentence stimuli and voice-related quality of life measurements were obtained preoperatively and at 2, 4, 8, and 24 weeks postoperatively from individuals undergoing nasal and/or sinus surgery. Objective measures of fundamental frequency, jitter, shimmer, and harmonic to noise ratio (HNR) were determined. Pre- and postoperative speech samples were assessed by 15 naïve listeners. RESULTS: In all, 15 subjects completed the study. Neither speakers nor listeners perceived a subjective change in nasality following surgery. No statistically significant change in microacoustic measures were identified. Although nasal sentences did not reveal differences for 3 microacoustic measures, a difference in HNR was identified. CONCLUSIONS: Patients undergoing nasal surgery did not exhibit subjective changes in resonance postoperatively. Aside from a difference in HNR for the nasal sentence, objective microacoustics remained unchanged. These results demonstrate the stability of oranasal resonance despite nasal surgery and provide valuable data for patient informed decision-making.

Otolaryngology - Head and Neck Surgeon unemployment in Canada: a cross-sectional survey of graduating Otolaryngology - Head and Neck Surgery residents.

OBJECTIVE: Recently graduated Otolaryngology - Head and Neck Surgeons (OTO-HNS) are facing an employment crisis. To date, there has been no systematic evaluation of the factors contributing to this situation, graduating OTO-HNS trainee employment rates, nor the employment concerns of these graduating residents. This investigation sought to empirically evaluate prospective OTO-HNS graduate employment, identify factors contributing to this situation, and provide suggestions going forward. METHODS: A cross-sectional survey of the 2014 graduating cohort of OTO-HNS residents was conducted 6-months prior to graduation, and immediately following residency graduation. Surveyed items focused on the demographics of the graduating cohort, their future training and employment plans, and their concerns relative to the OTO-HNS employment situation. RESULTS: All twenty-nine Canadian medical school graduated OTO-HNS residents completed the initial survey, with 93% responding at the completion of residency. Only 6 (22%) indicated confirmed employment following residency training. 78% indicated that they were pursuing fellowship training. 90% identified the pursuit of fellowship training as a moderately influenced by limited job opportunities. The ability to find and secure full-time employment, losing technical skills if underemployed/unemployed, and being required to consider working in a less-desired city/province were most concerning. 34% of the residents felt that they were appropriately counseled during their residency training about employment. 90% felt that greater efforts should be made to proactively match residency-training positions to forecasted job opportunities. CONCLUSIONS: Canadian OTO-HN Surgeons lack confirmed employment, are choosing to pursue fellowship training to defer employment, and are facing startling levels of under- and unemployment. A multitude of factors have contributed to this situation and immediate action is required to rectify this slowly evolving catastrophe.

Implants in facial skeletal augmentation.

PURPOSE OF REVIEW: Alloplastic implants have demonstrated longstanding utility in the augmentation of the facial skeleton. Although their popularity may have waned in recent years, their established efficacy endures. This review summarizes the techniques, limitations, and complications associated with the use of facial implants. RECENT FINDINGS: Given the recognized utility of facial implants in the augmentation of the facial skeleton, they have received little attention in the recent literature. Contemporary reports have focused on the refinement of techniques--with renewed interest in the vertical transoral approach, and expanding the scope of facial implants--that is, the utility of facial implants as alternatives and/or adjuncts to orthognathic surgery. SUMMARY: Facial augmentation using alloplastic implants remains a tried, tested, and true means of correcting skeletal insufficiencies and abnormalities. Thus, what was once old will be new again, and a renaissance in the use of facial implants will undoubtedly occur.

Stapedial synkinesis causing change in hearing threshold with facial motion.

OBJECTIVE: Synkinetic facial movement after facial nerve regeneration is a well-documented phenomenon. Rarely, patients recovering from facial nerve injury report feelings of auditory ringing, fullness, and a sensation of ear tightness as a result of stapedial muscle involvement. It is exceedingly rare for such synkinesis to produce perceivable changes in hearing threshold. We report a unique case of stapedial synkinesis causing pure-tone changes in hearing threshold with activation of the facial musculature. PATIENT: A single patient is presented who developed stapedial synkinesis after suboccipital resection of a unilateral acoustic neuroma. RESULTS: Despite facial nerve sparing, surgery resulted in House-Brackmann grade V/VI right facial nerve paralysis that improved to Grade III/VI after 7 months. Synkinesis developed that caused eye closure with puckering of the lips. Puckering of the lips likewise caused decreased hearing in the right ear, corresponding to a measured decrease of 10 dB in the PTA. Over the next several months, facial motion continued to improve, and hearing changes became less bothersome, so no intervention was undertaken. CONCLUSION: The changes presented in the hearing threshold fit within the classically described 15-dB attenuation provided by the stapedial reflex. Although no intervention was undertaken in this particular case, some patients with unremitting stapedial synkinesis might benefit from sectioning of the stapedial muscle. Thus, consideration should be made for audiometric evaluation with and without facial muscle contraction in the evaluation of individuals with synkinetic facial movement.

Methicillin-resistant Staphylococcus aureus-associated infections following septorhinoplasty.

Septorhinoplasty is associated with postoperative infection in less than 2% of cases, even without the use of prophylactic antibiotics. However, there is a concern that increasingly prevalent, highly virulent pathogens such as MRSA may predispose to postoperative infections. Over the past several decades, MRSA has emerged as the most important cause of antibiotic-resistant nosocomial infection. MRSA-associated infections related to nasal surgery are underreported in the literature. We present a case of MRSA-associated infection following a routine septorhinoplasty in a health care worker. We discuss the incidence of this complication and contributing risk factors. The classification of MRSA-associated infections into genotypically distinct hospital-acquired and community-acquired subtypes is reviewed, and the associated differences in epidemiology, clinical presentation, and antibiotic susceptibility are discussed. A comprehensive strategy incorporating diagnostic workup, preventative management based upon preoperative risk stratification, and treatment of MRSA-associated soft tissue infections is presented.

Development of a tissue-mimicking neck model for medical education.

BACKGROUND: The ability to palpate neck masses and lymph nodes and appreciate qualities such as size, location, and consistency is critical for patient care and an important clinical skill for all physicians. Medical students currently learn neck palpation by practicing on healthy, standardized patients; however, studies of similar procedures have shown that educational models with simulated pathology help improve technique and confidence. OBJECTIVE: Our goal was to create a tissue-mimicking neck model with palpable masses. METHODS: Iterative design and development of a high-fidelity neck model using polyvinyl alcohol-cryogel (PVA-C), a nontoxic and biocompatible polymer that exhibits favourable tissue-mimicking elastic properties. Model geometries were digitally reconstructed from high-resolution cadaveric magnetic resonance imaging sections to create physical moulds through stereolithography. PVA-C was formulated to mimic the characteristics of human tissue. RESULTS: A life-like neck model was built and consists of these components: muscle, larynx, spine, soft tissue, pathologic nodes, and skin. DISCUSSION: A final neck model prototype has been completed and will be evaluated by otolaryngology consultants and residents for face and construct validity and assessed in a randomized, controlled trial to evaluate how it impacts students' ability to detect neck masses.

The Western Surgical Concern Inventory-Thyroid: development and initial validation.

OBJECTIVE: Patients considering surgery face many uncertainties and concerns. This investigation sought to develop an objective assessment tool for characterizing the areas of greatest concern among those considering thyroidectomy. STUDY DESIGN: Prospective cohort design. SETTING: Tertiary-care otolaryngology practice. SUBJECTS: Participants included individuals presenting with a thyroid nodule found to be of intermediate risk (15%-20%) of cancer based on fine-needle aspiration (FNA) biopsy and amendable to hemithyroidectomy. METHODS: As part of validating a clinical measure concerning perioperative concerns, patients presenting with thyroid nodules amendable to hemithyroidectomy were voluntarily recruited. Thirty individuals (6 men, 24 women) completed a novel 18-item questionnaire during their initial clinical visit and again 3 days later. Outcome measures included descriptive statistics and test-retest reliability. RESULTS: Individual patients have both general and specific preoperative concerns. A wide range of responses was obtained across the entire spectrum of the survey. The questionnaire demonstrated fair-to-excellent test-retest reliability, with correlation values from 0.467 to 0.954. Between-rater reliability was consistent with intraclass correlation coefficient values of 0.52 to 0.86. No relationship between question order and patient response was identified. Women were found to be more concerned about scar appearance (P = .028), and men were conversely more concerned about resuming daily activities (P = .026). CONCLUSIONS: Patients considering thyroidectomy have concerns that remain stable in the early preoperative period. This is the first study to evaluate preoperative patient concerns and preliminarily establishes the Western Surgical Concern Inventory-Thyroid as a means of ensuring adequate patient counseling and a method of evaluating preoperative patient education.

Biomechanical properties of the facial retaining ligaments.

OBJECTIVE: Osteocutaneous facial retaining ligaments play an important role in the aging face. We sought to better characterize the biophysical properties of these ligaments and, in doing so, provide an empirical basis for the natural descent seen in facial aging. METHODS: Five fresh frozen cadaver heads yielding 10 hemifaces were dissected to expose the orbital, zygomatic, buccomaxillary, and mandibular osteocutaneous ligaments. Each ligament was assessed and subjected to biomechanical testing. The main outcome measures included ligament dimensions, stiffness, percentage of elongation, and force to initial and ultimate failure. RESULTS: Initial and ultimate failure testing revealed the zygomatic ligament to be strongest, followed by the orbital, mandibular, and maxillary ligaments. The zygomatic ligament was also stiffest, followed by the orbital, maxillary, and mandibular ligaments. The percentage of elongation acted as a surrogate marker of elasticity, with the greatest elasticity maintained by the mandibular ligament, followed by the orbital, zygomatic, and buccomaxillary ligaments. Ligament dimensions and biophysical properties did not vary relative to cadaveric hemiface, age, or sex. CONCLUSIONS: To our knowledge, this is the first investigation to quantify the biomechanical properties of the facial retaining ligaments. Inherent ligament properties seem to be related to the changes observed in facial aging, although further study is required.

Is three-dimensional videography the cutting edge of surgical skill acquisition?

The process of learning new surgical technical skills is vital to the career of a surgeon. The acquisition of these new skills is influenced greatly by visual-spatial ability (VSA) and may be difficult for some learners to rapidly assimilate. In many cases, the role of VSA on the acquisition of a novel technical skill has been explored; however, none have probed the impact of a three-dimensional (3D) video learning module on the acquisition of new surgical skills. The first aim of this study is to capture spatially complex surgical translational flaps using 3D videography and incorporate the footage into a self-contained e-learning module designed in line with the principles of cognitive load theory. The second aim is to assess the efficacy of 3D video as a medium to support the acquisition of complex surgical skills in novice surgeons as evaluated using a global ratings scale. It is hypothesized that the addition of depth in 3D viewing will augment the learner's innate visual spatial abilities, thereby enhancing skill acquisition compared to two-dimensional viewing of the same procedure. Despite growing literature suggesting that 3D correlates directly to enhanced skill acquisition, this study did not differentiate significant results contributing to increased surgical performance. This topic will continue to be explored using more sensitive scales of measurement and more complex "open procedures" capitalizing on the importance of depth perception in surgical manipulation. Anat Sci Educ. © 2012 American Association of Anatomists.

What are thyroidectomy patients really concerned about?

OBJECTIVE: To better appreciate perioperative concerns affecting patients considering thyroidectomy and to understand how they may vary according to patient characteristics. STUDY DESIGN: Cross-sectional analysis. SETTING: Tertiary referral center. SUBJECTS AND METHODS: The authors recruited patients scheduled for thyroid surgery at the McGill University Thyroid Cancer Center. A total of 148 patients completed the 18-item Western Surgical Concern Inventory-Thyroid (WSCI-T) questionnaire. Psychometrics of the WSCI-T were assessed through a principal component analysis with varimax rotation and reliability analyses. Independent-samples t tests and 2-tailed Pearson correlations were ran, identifying areas of elevated concerns and their relationship to gender, age, and surgical procedure (total vs hemithyroidectomy). RESULTS: The principal component analysis revealed the presence of 3 domains of presurgical concerns on the WSCI-T:Surgery-Related Concerns, Psychosocial Concerns, and Daily-Living Concerns. Reliability coefficients for the WSCI-T Total and subscales were satisfactory. Responses on the WSCI-T indicated on average a moderate overall level of concerns before thyroidectomy. Surgery-Related Concerns was the highest domain of concerns, followed by Daily-Living and Psychosocial Concerns, respectively. Patients were mainly worried about the nodule being cancerous, experiencing a change in voice, and surgical complications. Areas of minor concern included being judged or treated differently, becoming depressed, and feeling embarrassed. Women had higher overall levels of concern than men did. Although there were no significant differences in overall levels of concern according to age and surgical procedure, differences were noted at a subscale and item level. CONCLUSION: This study establishes a mean that will permit adequate physician counseling and a better management of patients' perioperative worries.

Using photodynamic therapy as a neoadjuvant treatment in the surgical excision of nonmelanotic skin cancers: prospective study.

BACKGROUND: Topical photodynamic therapy (PDT) is a successful treatment for nonmelanotic skin cancers (NMSCs). Nevertheless, surgical excision continues to be the gold standard treatment. Cervicofacial excision often results in functional and aesthetic impairment. We hypothesize that topical PDT as a neoadjuvant therapy to surgical excision may reduce tumour size and subsequently decrease local morbidity. OBJECTIVE: To determine the utility of PDT in reducing the NMSC area for the purpose of surgical excision. METHOD: A prospective cohort study. RESULTS: Thirty-three basal cell carcinomas with a mean area of 523.11 ± 120.93 mm² and 26 squamous cell carcinomas with a mean area of 357.53 ± 61.96 mm² were included. Of these lesions, 22 demonstrated a complete curative response after an average of two PDT treatments, which were then confirmed with histologically negative biopsies. The remaining lesions demonstrated a partial response to topical PDT with a maximum reduction in lesion area following an average of three PDT treatments of at least 88% (p < .05). These lesions were then excised with clear histologic margins. Follow-up at 1 year for all lesions demonstrated no locoregional recurrence. CONCLUSIONS: This is the first study to investigate the efficacy of neoadjuvant topical PDT in the management of NMSC. The results suggest that for NMSC not demonstrating a complete curative response to PDT, neoadjuvant PDT can substantially reduce tumour burden, allowing for less morbid surgical excisions with histologically clear margins.

Neoadjuvant use of photodynamic therapy in Basal cell and squamous cell carcinomas of the face.

Background. This preliminary study sought to determine the success of photodynamic therapy (PDT) in reducing lesion size in an effort to assess the potential application of this treatment approach in a neoadjuvant role. Objectives. To quantify the effects of PDT on lesion area (mm(2)) for basal cell and squamous cell carcinomas of the face. Results. Eighteen participants (10 BCC lesions and 8 SCC lesions of the face) were assessed. Four lesions (all from the BCC group) showed a complete response to PDT. Of the remaining 14 lesions, 85.7% (n = 12) showed reductions in lesion area, while two lesions showed increase in lesion area. Proportional reductions for the 12 lesions that did not demonstrate complete response or an increase in area following-PDT were found to range from 13.2% to 85.1% (BCC) and 6.7% to 89.7% (SCC). Conclusions. PDT as a neoadjuvant treatment may provide a simple, efficient, and viable approach to reducing the area of malignant lesions of the face with the advantage of reduced cosmetic and aesthetic morbidities.

Prospective evaluation of preoperative concern among patients considering endoscopic sinus surgery: initial validation.

BACKGROUND: Patients considering surgery face many uncertainties and concerns. This investigation aimed to develop an objective assessment tool for characterizing the areas of greatest concern among patients considering endoscopic sinus surgery (ESS). METHODS: As part of validating a clinical measure concerning perioperative concerns, patients presenting with chronic rhinosinusitis with or without nasal polyposis were voluntarily recruited. A total of 30 individuals completed a novel 19-item questionnaire during their initial clinical visit and again 3 days later. Outcomes included descriptive statistics and test-retest reliability. RESULTS: Data suggest that patient responses did not vary with age or gender. The questionnaire demonstrated strong test-retest reliability, with alpha values from 0.881 to 0.942. Between-rater reliability was consistent, with an average intraclass correlation coefficient (ICC) of 0.913. No relationships between question order and patient response was identified. CONCLUSION: Patients considering ESS have concerns that remain stable in the early preoperative period requiring surgeon-initiated inquiry and counsel. This is the first study to evaluate preoperative patient concerns, and initially establishes the Western Surgical Concern Inventory-ESS (WSCI-ESS) as a means of ensuring adequate patient counseling and a method of evaluating perioperative patient education.