Deformity, etiology, solution, sequence (DESS): Facial analysis in rhinoplasty.

PURPOSE: Rhinoplasty is amongst the most challenging surgeries to perfect and can take decades. This process begins during residency; however, residents often have limited exposure to rhinoplasty during their training and lack a standardized method for systematically analyzing and formulating a surgical plan. The DESS (Deformity, Etiology, Solution, Sequence) is a novel educational format for residents that serves to increase their pre-operative comfort with the surgical evaluation and intraoperative planning for a rhinoplasty. MATERIALS AND METHODS: A qualitative study performed at a tertiary academic institution with an otolaryngology residency program evaluating three consecutive residency classes comprised of four residents per class. A 9-item questionnaire was distributed to measure change in resident comfort after utilizing the DESS during their facial plastics rotation. Questionnaire responses highlighted resident comfort with facial nasal analysis, identifying deformities, suggesting surgical maneuvers, and synthesizing a comprehensive surgical plan. RESULTS: Ten of the twelve residents surveyed responded. Of those that responded, comfort in facial nasal analysis, identification of common nasal deformities, surgical planning, and development of an overall surgical plan were significantly improved after completion of the facial plastic rotation. These residents largely attributed their success to the systematic educational format, with an average score of 4.8/5.0 (SD 0.42). CONCLUSION: While rhinoplasty is a challenging artform to master, systematic approaches to analysis and operative planning are vital for teaching and guiding residents. Through this novel methodology, residents display significant improvement in their comfort with facial nasal analysis and overall surgical preparation.

Clinically significant cancer rates in incidentally discovered thyroid nodules by routine imaging.

BACKGROUND: With widespread use of diagnostic imaging modalities, incidental thyroid nodules are frequently identified in patients for unrelated reasons. If underlying thyroid cancer risk in such patients is significant, further evaluation becomes imperative. This study evaluates the malignancy rate of incidentally discovered compared to clinically apparent thyroid nodules in surgical patients. METHODS: A retrospective review of prospectively collected data of 809 patients who underwent thyroidectomy at a tertiary referral center was performed. The association between incidental discovery of thyroid nodules, malignancy rates, and clinicopathologic characteristics was assessed. RESULTS: Of 809 patients, 12% (n = 98) had incidental thyroid nodules, where malignancy was found in 65 (66%) of these patients. The overall rate of malignancy identified incidentally by routine imaging was 14% (65/466). Most common imaging modalities leading to detection were ultrasound (32%), computed tomography (29%), and magnetic resonance imaging (23%). Of patients with incidental thyroid nodules harboring malignancy, follicular variant papillary thyroid cancer (PTC) (48%), classical variant PTC (18%), tall cell variant PTC (12%), and diffuse sclerosing variant PTC (12%) were most commonly found. Patients with malignant incidental thyroid nodules had more lymphovascular invasion and positive lymph nodes compared to nonincidental malignant thyroid nodules (53% versus 41% and 47% versus 33%, P < 0.05, respectively). CONCLUSIONS: Incidentally discovered thyroid nodules by imaging represent an important group of surgical patients with clinically significant rates of underlying malignancy. Patients with incidentally discovered thyroid nodules by imaging should undergo appropriate evaluation and counseling for further surgical treatment.

Excitatory glutamate is essential for development and maintenance of the piloneural mechanoreceptor.

The piloneural collar in mammalian hairy skin comprises an intricate pattern of circumferential and longitudinal sensory afferents that innervate primary and secondary pelage hairs. The longitudinal afferents tightly associate with terminal Schwann cell processes to form encapsulated lanceolate nerve endings of rapidly adapting mechanoreceptors. The molecular basis for piloneural development, maintenance and function is poorly understood. Here, we show that Nefh-expressing glutamatergic neurons represent a major population of longitudinal and circumferential sensory afferents innervating the piloneural collar. Our findings using a VGLUT2 conditional-null mouse model indicate that glutamate is essential for innervation, patterning and differentiation of NMDAR(+) terminal Schwann cells during piloneural collar development. Similarly, treatment of adult mice with a selective NMDAR antagonist severely perturbed piloneural collar structure and reduced excitability of these mechanosensory neurons. Collectively, these results show that DRG-derived glutamate is essential for the proper development, maintenance and sensory function of the piloneural mechanoreceptor.