Teaching paradigm for decision making in facial skin defect reconstructions.

OBJECTIVE: To present a decision paradigm for facial defect reconstruction, and test the ability of this paradigm to improve resident performance. DESIGN: A decision paradigm for reconstruction of facial skin defects is proposed and explained, with patient examples. The paradigm's usefulness is then tested with residents. SETTING: Otolaryngology residency training program at a tertiary hospital. STUDY PARTICIPANTS: Otolaryngology residents. INTERVENTIONS: Twelve residents took a pretest wherein they were presented with drawings of skin defects and asked to choose the "best" (most aesthetically pleasing) type of reconstruction from a closed set. This paradigm was presented to these residents, and their posttest consisted of choosing again with the same defects and closed set of choices. MAIN OUTCOME MEASURES: Cosmetic outcomes of reconstructive decisions on the pretest and posttest were rated on a scale of 0 to 5 (with 0 indicating poor; 5, excellent). RESULTS: There was a significant improvement in reconstructive choices between the pretest and posttest (P<.001, Student t test). CONCLUSION: This paradigm can be easily modified to accommodate different surgical approaches preferred by individual surgeons and is thus useful in almost any reconstructive teaching situation.

Stapedectomy surgery in residency: KTP-532 laser versus argon laser.

Stapedectomy for otosclerosis is one of the most demanding otologic procedures, especially for residents in training. The reported series in the literature, as well as our own experience with the traditional resident-performed complete stapedectomy, have been disappointing. The number of patients available to train residents in stapedectomy techniques has steadily declined. The challenge to the otologist involved in teaching residents and fellows is to find a method that will be safe and effective. Over the past 5 years, we have had an opportunity at the University of Texas Medical Branch at Galveston to compare two methods of performing a laser stapedotomy. The two methods involve using the KTP-532 laser with a micromanipulator and using the hand-held argon laser. Although the wavelengths of these two lasers are similar, the methods used in applying them are very different. Twenty-five consecutive cases in each group were reviewed with regards to technical difficulty, complication rate, operative time, and air-borne gap closure. The hand-held argon laser emerged as the preferred technique for teaching a routine stapedotomy to residents.

The relationship between the nasal cycle and mucociliary clearance.

Nasal airway resistances were measured bilaterally on subjects at 30-minute intervals over 6 hours using anterior rhinomanometry. The first 10 subjects found to exhibit alternating congestion and decongestion of the nasal mucosa (i.e., the nasal cycle) were included in the study. Using the saccharin method, nasal mucociliary clearance was determined for each subject in both the congested and decongested phases of the cycle. The results were statistically significant at the P less than .09 level, highly suggestive of a difference in nasal mucociliary clearance between the two phases of the cycle, with the congested phase having the more rapid clearance. However, when compared to the mucociliary clearance times in disease states, the difference in transport times between the two phases is probably not clinically significant.

Stapedectomy techniques in residency training.

The KTP-532 laser has decreased the technical difficulty involved in teaching and performing a stapedectomy in our residency program. Use of this laser has resulted in improved hearing and a decreased number of major and minor complications compared to an equal number of large fenestra stapedectomies performed with hand-held instruments. The major disadvantages of the KTP-532 laser are its cost and limited availability, and the inconvenience of a micromanipulator. The laser should not be relied upon entirely in performing a stapedotomy on a thick footplate. The University of Texas Medical Branch experience in training residents in both large and small fenestra stapedectomy is reported.

Interobserver variability in the interpretation of brush cytologic studies from head and neck lesions.

A study was conducted to evaluate the usefulness of brush cytology as a diagnostic tool for lesions of the head and neck. Brush specimens were obtained from patients for whom surgical biopsy was recommended by the Otolaryngology Service of the University of Texas Medical Branch Hospitals, Galveston. Specimens were interpreted independently by three cytologists, and interobserver variability was calculated. If a surgical biopsy was performed, histopathologic diagnosis was used as the reference standard to assess the accuracy of each cytologic interpretation. Correspondence of cytopathologic interpretation with histologic diagnosis was sufficient to conclude that brush biopsy is a useful screening technique for unsuspected or clinically undetected malignant tumors of the upper aerodigestive tract. Because of its ability to sample large surface areas with minimal tissue trauma, brush biopsy can be a useful screening technique in combination with selective surgical biopsy for the detection of cytologic changes of malignant neoplasia. Brush cytology costs less than surgical biopsy, yet its relatively high sensitivity and specificity for both benign and malignant grades support its utility. Brush cytology, furthermore, has a low interobserver variability for the benign and malignant grades, suggesting that in the hands of an experienced cytopathologist it can be relied on with confidence. For grades 2 or 3 (inconclusive), brush cytology, however, demonstrated much higher interobserver variability. Based on the findings of this and other studies, brush cytology can be effective in identifying clinically unsuspected malignant tumors of the upper aerodigestive tract, especially in patients with mucosal changes suggestive of "field cancerization."

Normal nasal airway resistance in noses of different sizes and shapes.

Measurement of nasal airway resistance is becoming a common clinical technique. Accurate definition of the normal range of airflow is critical for maximal usefulness of this technique. Since typical nasal size and shape vary greatly with ethnic background, different norms for different ethnic groups may be appropriate. Nasal airway flow and resistance and external nasal size and shape were measured in 130 asymptomatic subjects (52 black, 56 white, and 22 Hispanic). Nasal length, width, columellar length, and nasolabial angle were similar for whites and Hispanics, but both groups differed significantly from blacks--even when changes attributable to biologic aging were factored out. In spite of these differences, there was no significant difference in any nasal airflow or resistance parameter among groups, suggesting that currently used airflow and resistance standards are valid for these three different ethnic groups.

Interobserver variability in the interpretation of fine-needle aspiration biopsy of head and neck masses.

Fine-needle aspiration biopsy is gaining acceptance as a clinically useful tool. We set out to evaluate the accuracy of fine-needle aspiration biopsy at our institution by measuring the interobserver variability in cytopathologic interpretation, and by measuring the agreement between cytopathologic and histologic diagnosis. In a prospective study, 253 aspirations were performed on head and neck masses by the otolaryngology service. Specimens were interpreted independently by two cytopathologists (V.J.S. and P.Z.), and interpretations were compared with the surgical histopathologic diagnosis when available. The interobserver variability between cytopathologists was 8% with a specificity of 96% and a sensitivity of 97%. We conclude that fine-needle aspiration biopsy is a safe and useful tool in the diagnosis of head and neck masses. In the diagnosis of epithelial cysts and squamous epithelial malignancies, fine-needle aspiration biopsy is as accurate as open biopsy.

Teaching indirect mirror laryngoscopy.

Indirect mirror laryngoscopy is difficult to learn. An anatomic model of the oropharynx and larynx is described here. This model is used to familiarize medical students with the component skills of mirror laryngoscopy. The students progress to competency at mirror laryngoscopy on patients more quickly after initial use of this model.

Laryngeal cancer without spread to the neck: treatment options and outcome.

We examined treatment and outcome variables in patients who had laryngeal cancer without clinical evidence of spread to the neck. In our patient population, there was a 24% overall recurrence rate for N0 laryngeal cancer. Initial manifestations, including stage and location of tumor, did not influence recurrence (P greater than .1). Initial treatment of the primary T3 or T4 tumor with radiotherapy alone was positively correlated with recurrence (P less than .0 for T3, P less than .0 for T4), but initial treatment of the neck did not appear to affect chance of regional or distant recurrence (P greater than .1). Approximately half of the patients who had recurrent disease were salvaged. Neither chance of salvage nor final disease-free status was significantly associated with any of the variables (P greater than .1).

Magnet extraction of frontal sinus foreign body.

We report a metallic foreign body that entered through the anterior table of the frontal sinus, and rolled down to lodge in the nasofrontal duct. An electromagnet was used to remove the foreign body through a trephination.

Olfactory neuroblastoma. Cytodiagnostic features in a case with ultrastructural and immunohistochemical correlation.

In a case of olfactory neuroblastoma, originally misdiagnosed as an undifferentiated carcinoma, cytologic examination of material scraped from the superior nasal vault revealed tumor cells suggestive of neuroblastoma. The most significant cytodiagnostic feature was the presence of a fibrillary cytoplasm with ill-defined borders. Also noteworthy were the smudged hyperchromatic nuclei and structures resembling rosettes or pseudorosettes. The diagnosis was confirmed by electron microscopy, which revealed the presence of dense-core neurosecretory granules, clear vesicles, neurotubules and neurofilaments, and by immunohistochemistry, which showed positive staining for neuron-specific enolase but negative staining for keratin and glial fibrillary acidic protein. Since olfactory neuroblastoma has a relatively good prognosis and aggressive surgical resection may be curative, it is important that this tumor be distinguished from other small cell malignancies arising in the nasal cavity. The present case shows that the diagnosis can be made by the cytologic examination of scrapings from the tumor.

Surgical care of submental gunshot wounds.

The care of patients with self-inflicted facial gunshot wounds is complex and challenging. The magnitude and self-inflicted nature of the injuries naturally give rise to questions about potential for successful rehabilitation. The surgical care and rehabilitation of ten such patients are described. The initial grotesque disfiguration belies the reasonable chances for functional restoration. Patients in this series who completed reconstruction swallow well enough to maintain body weight, speak understandably, breathe without tracheostomy, and have an appearance sufficiently normal that they can interact socially without embarrassment. Guidelines are proposed for multidisciplinary medical care leading to satisfactory functional, aesthetic, social, and psychiatric rehabilitation.

Bacteriology of middle ear effusions.

We studied fluid obtained from middle ear effusions (MEEs) during 908 myringotomy and tube insertion procedures on 495 children aged 4 months to 12 years. Under general anesthesia the external auditory canal was sterilized with povidone-iodine (Betadine) and alcohol, and myringotomy was done. Fluid was aspirated into a Luki tube and sent for culture and sensitivity determination. The median age of patients was 3 years 5 months; 1-year-old children comprised the largest single group. Two thirds of the children were male. Effusion was present in three fourths of the ears; in about 20% of these, culture grew bacteria. Haemophilus influenzae made up almost 50% of the pathogens, with the percentage decreasing with age. Almost 90% of the H influenzae organisms were sensitive to erythromycin, and about three fourths to ampicillin and cephalosporin.

Tumoral calcinosis in the neck.

Tumoral calcinosis manifests soft-tissue calcification, usually near major joints. It variably includes hyperphosphatemia, elevated 1,25-dihydroxycalciferol, and an affected sibling. Serum calcium, alkaline phosphatase, and parathyroid hormone are normal. Tumoral calcinosis of the head and neck is very rare, but this diagnosis should be considered when x-ray film of a poorly defined mass shows irregular soft-tissue calcification.

Reconstruction of the anterior skull base following craniofacial resection.

Reconstruction of the anterior skull base (ASB) following craniofacial resection must seal off the cranial cavity from the upper respiratory tract and provide structural support for the brain. The inferiorly based pericranial flap is strong, pliable, and well vascularized and is especially suited for reconstruction of small-to moderate-sized midline defects of the ASB. Surgical technique of pericranial flap reconstruction used in three cases is described. Indications for this flap and other types of reconstruction are discussed and compared. We believe pericranial flap reconstruction of the ASB is technically easy, cosmetically acceptable, and safe.

Statistical techniques reported in pathology journals during 1983-1985. Implications for pathology educators.

The increasingly scientific basis of medicine challenges pathology educators to incorporate quantitative skills into a very compressed curriculum. One strategy is to focus training on the statistical techniques pathologists will most commonly encounter in their literature. We identified the reporting of statistical techniques in nearly 5200 original articles published during 1983-1985 in 16 journals important to pathology. Our results suggest that a reader familiar with 12 fundamental statistical concepts can evaluate knowledgeably over 95% of the quantitative findings reported in these journals. With the exception of survival analysis and pharmacologic modeling, these techniques are typically encountered in many introductory statistical texts. In numerous articles, failure to identify the statistical methodology used made it impossible to identify the analytic procedures used and, hence, judge the scientific validity of results.

The reporting of statistical techniques in otolaryngology journals.

The domain of this study is the reporting of statistical analyses in the otolaryngology literature during 1983 and 1984. Fewer than ten basic statistical procedures accounted for more than 90% of the statistical techniques reported. Implications for authors, journals, and educators are discussed. We offer suggestions for imparting statistical skills that may be helpful in curriculum design, residency training, and continuing medical education planning.