Faculty Bibliography

Segmental mandibulectomy leads to a great deficit in the form and function of the patient. Vascularised bone flaps have become the choice of the method of reconstruction of the mandible in an oncologic setting. Fibula osseous or oseteocutaneous flaps have become the favored method in centers across the world. This article reviews certain pertinent and practical points with regards to fibula flap reconstruction of the mandible. Methods of osteosynthesis, merits of inclusion of the FHL muscle in the flap and use of osteointegrated implants are discussed in detail. The reader will also be able at the end to understand the role of pre operative vascular imaging, steps taken when there is an irreversible flap failure and steps to maintain and rehabilitate occlusion as practiced in the author's service

PURPOSE: Peer evaluation is underused in medical education. The goals of this study were to validate in a multiinstitutional study a peer nomination form that identifies outstanding students in clinical competency and interpersonal skills, to test the hypothesis that with additional survey items humanism could be identified as a separate factor, and to find the simplest method of analysis. METHOD: In 2003, a 12-item peer nomination form was administered to junior or senior medical students at three institutions. Factor analysis was used to identify major latent variables and the items related to those characteristics. On the basis of those results, in 2004 a simpler, six-item form was developed and administered. Student rankings based on factor analysis and nomination counts were compared. RESULTS: Factor analysis of peer nomination data from both surveys identified three factors: clinical competence, caring, and community service. New survey items designed to address humanism are all weighted with interpersonal skills items; thus, the second major factor is characterized as caring. Rankings based on peer nomination results analyzed by either factor analysis or simply counting nominations distinguish at least the top 15% of students for each characteristic. CONCLUSIONS: Counting peer nominations using a simple, six-item form identifies medical student exemplars for three characteristics: clinical competence, caring, and community service. Factor analysis of peer nomination data did not identify humanism as a separate factor. Peer nomination rankings provide medical schools with a reliable tool to identify exemplars for recognition in medical student performance evaluations and selection for honors (e.g., Gold Humanism Honor Society).

BACKGROUND: Oral tongue strength and swallowing ability are reduced in patients treated with chemoradiotherapy for oral and oropharyngeal cancer. METHODS: Patients with oral or oropharyngeal cancer treated with high-dose chemoradiotherapy underwent tongue strength, swallowing, and dietary assessments at pretreatment and 1, 3, 6, and 12 months posttreatment. Tongue strength was assessed using the Iowa Oral Performance Instrument (IOPI). Oral and pharyngeal residue was evaluated utilizing videofluoroscopy. RESULTS: Mean maximum tongue strength dropped a nonsignificant amount immediately after treatment, and then increased significantly at 6- and 12-months posttreatment completion. Analyses were adjusted for patient dropout. Tongue strength was not significantly correlated with swallow observations of percentage oral and pharyngeal residue. Ability to eat various diet consistencies was reduced after treatment but improved over time at a rate similar to changes in oral intake and type of diet. CONCLUSIONS: Parallel but not significant changes in oral intake, diet, and tongue strength in the first year post chemoradiation therapy need further study in a larger population.

BACKGROUND: Sexual history taking is a core clinical skill for all physicians, yet many medical schools do not adequately address this important topic within the curriculum. This article describes a sexual-history-taking module that was initiated, designed, and presented by 2nd-year medical students for their peers as part of the required Introduction to Clinical Medicine (ICM) course. DESCRIPTION: As part of this module, a group of 2nd-year medical students developed a large-group presentation and small-group role play cases to enhance students' basic sexual-history-taking skills in challenging situations, teach ways to ask nonjudgmental questions, and introduce legal issues that may arise. Under faculty supervision, the students recruited and trained peer and faculty facilitators and designed, developed, and analyzed the survey evaluation tools. EVALUATION: Both the students and facilitators completed an anonymous questionnaire within 1 to 4 weeks of completing the activity. Of the 92 students completing an online survey, 92% rated the large group presentation good or excellent, and 89% rated the small-group role playing activities as good or excellent, as compared to overall ICM course ratings of 68% good or excellent. Facilitators were well prepared for their roles and reported that the students responded to them positively. Participating students reported that having students as teachers positively enhanced their small group learning experience. Students performed better on the sexual-history-taking questions on the final examination (97.5%) than on the final examination overall (89%). CONCLUSIONS: Medical students can successfully create and implement a curriculum module for their peers in a sensitive area such as sexual history taking. Due to changing responsibilities for students as they progress through medical school, sustainability may be challenging.

OBJECTIVE: To evaluate the clinical presentation, operative findings, and surgical management of patients with spontaneous middle fossa encephalocele (SMFE) and cerebrospinal fluid (CSF) leakage repaired using a middle fossa craniotomy (MFC) approach. STUDY DESIGN: Retrospective. SETTING: Tertiary referral center. PATIENTS: Fifteen consecutive patients with 16 SMFE repaired using an MFC approach between January 1999 and April 2006 were included. INTERVENTIONS: Patients were evaluated clinically and radiologically with computed tomography or magnetic resonance imaging. Encephaloceles were approached via MFC, and the cranial base was repaired in multilayered fashion using a variety of materials, including hydroxyapatite cement. Patients were followed clinically after discharge. MAIN OUTCOME MEASURES: Postoperative complications, including CSF leak and the need for surgical revision, are evaluated. Patient factors, diagnostic testing, and operative findings are reviewed. RESULTS: Diagnosis was made using clinical and radiologic evaluation in most patients. Beta2-transferrin testing was occasionally used in the diagnostic workup. Intraoperatively, multiple defects of the floor of the middle fossa were found in more than half of patients. Fifteen SMFE in 14 patients were successfully repaired via MFC alone. One patient required revision with a combined transmastoid/MFC approach due to recurrent CSF leakage. Hydroxyapatite cement was used for repair of the cranial base in 9 patients without complication. CONCLUSION: An MFC approach can be used to repair SMFE with CSF leakage with a high level of success. Hydroxyapatite cement is a safe and useful adjunct to aid in reconstruction of the cranial base defects in cases of SMFE.

The authors report a novel technique for the treatment of cholesterol granulomas. An extradural middle fossa approach was used to access the granuloma, with drainage through silastic tubes into the sphenoid sinus via the anteromedial triangle between V1 and V2. Cholesterol granulomas occur when the normal aeration and drainage of temporal bone air cells is occluded, resulting in vacuum formation and transudation of blood into the air cells. This process results in anaerobic breakdown of the blood with resulting cholesterol crystal formation and an inflammatory reaction. Traditional treatment of this lesion involves extensive drilling of the temporal bone to drain the granuloma cyst and establish a drainage tract into the middle ear. Such drainage procedures can be time consuming and difficult, and potentially involve structural damage to the inner ear and facial nerve. An extradural middle fossa approach provides easy access to the granuloma and anterior petrous bone entry into the granuloma for resection. Granuloma drainage is then achieved using shunt tubing in the sphenoid sinus via a small hole in the anteromedial triangle between V1 and V2. Five patients with symptomatic cholesterol granuloma were treated without complication using this novel extradural middle fossa approach. One patient required reoperation 1-year postoperatively for cyst regrowth and occlusion of the drainage tube. At the 5-year follow-up examination, no patient reported recurrent symptoms. Extradural middle fossa craniotomy and silastic tube drainage into the sphenoid sinus is a viable alternative method for treatment of cholesterol granuloma.

Neurotologic and skull base surgery involves working around important neurovascular and neurotologic structures and can incur unwarranted complications. Knowledge of surgical anatomy, good preoperative planning, intraoperative monitoring, and excellent microsurgical technique contribute to minimizing and avoiding complications. In the event of a complication, however, the neurotologic surgeon should be prepared to manage it. In this article, the authors focus on the management of complications encountered in neurotologic skull base surgery, including hemorrhage, stroke, cerebrospinal fluid leak, extraocular motility deficits, facial paralysis, hearing loss, dizziness, lower cranial nerve palsies, and postoperative headache.

OBJECTIVE: We describe our surgical posterior transpetrosal technique, particularly the transcrusal variant for lesions involving the upper and middle clivus, petroclival regions, and lesions that involve both the posterior and middle fossae. METHODS: An outline of the posterior transpetrosal technique involved, particularly the transcrusal variant, is described. Important superficial landmarks are identified, and a radical mastoidectomy is performed. The antrum is identified and entered, and, upon completion of the mastoidectomy and when Trautman's triangle is defined, the temporal and suboccipital craniotomies are completed. After bone flap elevation, dura opening, and incision along the middle fossa dura, the superior petrosal sinus is ligated and cut. Tentorium cut completion is at the incisura posterior to the trochlear nerve. Watertight dural closure and standard flap replacement and skin closure complete the technique. RESULTS: Clival exposure and the degree of temporal bone resection increase. Operative freedom also increases with increased temporal bone resection, especially when going from the retrolabyrinthine to transcrusal variants. Little is gained in terms of operative freedom and exposure of the clivus with resection of additional temporal bone beyond that of the transcrusal variant, and resection carries the cost of increasing morbidity, especially with respect to VIIth and VIIIth nerve function. CONCLUSION: The posterior transpetrosal approach and the transcrusal variant provide a lateral operative corridor to lesions of the upper and middle clivus. The transcrusal variant provides increased exposure and operative freedom similar to that provided by the transcochlear approach while minimizing cranial nerve morbidity.