Faculty Bibliography

OBJECTIVES: The objectives of this study were to: 1) implement web-based instruments for assessing and documenting the general competencies of otolaryngology resident education, as outlined by the Accreditation Council of Graduate Medical Education (ACGME); and 2) examine the benefit and validity of this online system for measuring educational outcomes and for identifying insufficiencies in the training program as they occur. METHODS: We developed an online assessment system for a surgical postgraduate education program and examined its feasibility, usability, and validity. Evaluations of behaviors, skills, and attitudes of 26 residents were completed online by faculty, peers, and nonphysician professionals during a 3-year period. Analyses included calculation and evaluation of total average performance scores of each resident by different evaluators. Evaluations were also compared with American Board of Otolaryngology-administered in-service examination (ISE) scores for each resident. Convergent validity was examined statistically by comparing ratings among the different evaluator types. RESULTS: Questionnaires and software were found to be simple to use and efficient in collecting essential information. From July 2002 to June 2005, 1,336 evaluation forms were available for analysis. The average score assigned by faculty was 4.31, significantly lower than that by nonphysician professionals (4.66) and residents evaluating peers (4.63) (P < .001), whereas scores were similar between nonphysician professionals and resident peers. Average scores between faculty and nonphysician groups showed correlation in constructs of communication and relationship with patients, but not in those of professionalism and documentation. Correlation was observed in respect for patients but not in medical knowledge between faculty and resident peer groups. Resident ISE scores improved in the third year of the study and demonstrated high correlation with faculty perceptions of medical knowledge (r = 0.65, P = .007). CONCLUSIONS: Compliance for completion of forms was 97%. The system facilitated the educational management of our training program along multiple dimensions. The small perceptual differences among a highly selected group of residents have made the unambiguous validation of the system challenging. The instruments and approach warrant further study. Improvements are likely best achieved in broad consultation among other otolaryngology programs.

The normal auricle has a well-recognized shape, and significant deviation from 'normal' is immediately evident. In particular, prominent ears are readily apparent and are a relatively frequent cause of patient concern. Correction of the outstanding ear requires a careful understanding of the discrete elements that compose the normal ear. Careful anatomic analysis to determine the precise cause allows appropriate preoperative planning for the correction of a protruding ear

The use of injectable agents, specifically soft tissue fillers and botulinum toxin type A, has risen dramatically over recent years, due to the increased demand for minimally invasive techniques. In fact, today they represent the most commonly performed cosmetic procedures in the United States, with botulinum type A injections topping the list. In the treatment of the aging face, these agents, when used individually or in combination, can effectively decrease rhytids and restore lost volume. The result is a fuller, smoother, more youthful appearance. This article provides an overview of botulinum type A (Botox Cosmetic; Allergan, Inc., Irvine, CA) and the two injectable fillers most commonly used in our practice, namely hyaluronic acid (Restalyne; Medicis Aesthetics, Inc., Scottsdale, AZ) and human-derived collagen (Cosmoderm and Cosmoplast; Inamed Aesthetics, Inc., Santa Barbara, CA). Although we commonly use autologous fat as an injectable filler for facial-volume augmentation, its discussion is beyond the scope of this article. Conceptually, the aging face can be divided into upper, middle, and lower thirds. Using this framework, we will discuss our treatment strategies for addressing each facial region. General principles, preinjection evaluation, and specific approaches and techniques for each anatomic region will be discussed, with particular emphasis on the benefit of using dermal fillers in conjunction with botulinum toxin type A to achieve optimal aesthetic results for facial rejuvenation

Ataxia-telangiectasia mutated (ATM), ataxia-telangiectasia Rad3-related (ATR) and the Mre11/Rad50/Nbs1 complex ensure genome stability in response to DNA damage. However, their essential role in DNA metabolism remains unknown. Here we show that ATM and ATR prevent accumulation of DNA double-strand breaks (DSBs) during chromosomal replication. Replicating chromosomes accumulate DSBs in Xenopus laevis egg extracts depleted of ATM and ATR. Addition of ATM and ATR proteins to depleted extracts prevents DSB accumulation by promoting restart of collapsed replication forks that arise during DNA replication. We show that collapsed forks maintain MCM complex but lose Pol epsilon, and that Pol epsilon reloading requires ATM and ATR. Replication fork restart is abolished in Mre11 depleted extracts and is restored by supplementation with recombinant human Mre11/Rad50/Nbs1 complex. Using a novel fluorescence resonance energy transfer-based technique, we demonstrate that ATM and ATR induce Mre11/Rad50/Nbs1 complex redistribution to restarting forks. This study provides direct biochemical evidence that ATM and ATR prevent accumulation of chromosomal abnormalities by promoting Mre11/Rad50/Nbs1 dependent recovery of collapsed replication forks.

Vestibular schwannomas (VSs) are benign tumors that arise from the Schwann cells (SCs) lining the vestibular nerve. VS cells survive and proliferate far from neurons and axonally derived growth factors. We have previously shown that VSs produce the glial growth factor, neuregulin-1 (NRG1), and its receptors, ErbB2 and ErbB3. In the present work, we explore the contribution of constitutive NRG1:ErbB signaling to human VS cell proliferation. We confirm that human VSs, which express markers of immature and denervated SCs, also express endogenous NRG1 and activated ErbB2. We find that a blocking anti-NRG1 antibody and trastuzumab (Herceptin, HCN), a humanized anti-ErbB2 inhibitory monoclonal antibody, effectively inhibit NRG1 induced SC proliferation. Treatment of primary VS cultures with anti-NRG1 or HCN reduces cell proliferation in the absence of exogenous NRG1. Furthermore, conditioned medium from VS cell cultures contains NRG1 and stimulates SC proliferation in SC cultures, an effect that is inhibited by anti-NRG1 and HCN. These data suggest an autocrine pathway of VS growth stimulation involving NRG and ErbB receptors. Inhibition of constitutive NRG:ErbB signaling reduces VS cell proliferation in vitro and may have therapeutic potential for patients with VSs

Cough is the most common presenting complaint in adults seeking medical treatment in an ambulatory setting. Chronic cough (persisting greater than 3 weeks) can be associated with myriad diseases that may overlap multiple medical specialties. For this reason, a thorough assessment of the patient with chronic cough relies on a multidisciplinary approach and close cooperation between pulmonary medicine, gastroenterology, and otolaryngology. Despite this daunting task, success can be achieved in up to 90% of patients with chronic cough if a systematic and thorough approach is used. The purpose of this review is to summarize the state-of-the-art in the diagnosis and treatment of chronic cough for the practicing otolaryngologist

PURPOSE: To retrospectively evaluate the prevalence of pterygoid process sclerosis in patients with untreated nasopharyngeal carcinoma. MATERIALS AND METHODS: This retrospective HIPAA-compliant study was performed after the institutional review board deemed it to be exempt from review and patient informed consent. Contrast material-enhanced computed tomographic (CT) scans of the neck obtained in 31 patients (22 men, nine women; mean age, 42 years; age range, 27-68 years) with untreated nasopharyngeal carcinoma and in 31 control subjects (17 men, 14 women; mean age, 43 years; age range, 19-62 years) were evaluated independently by two neuroradiologists. The presence of sclerosis of the pterygoid process-defined as increased attenuation in the medullary cavity and/or thickening of the cortical bone-was assessed. Other findings noted included pterygoid process erosion, enhancing tumor adjacent to the pterygoid process, and CT evidence of parapharyngeal extension of the tumor. The data were evaluated by using generalized estimating equations based on a binary logistic regression model. RESULTS: The prevalence of pterygoid process sclerosis averaged for the two readers was 60% (37 of 62 subjects) among the patients with nasopharyngeal carcinoma but only 3% (two of 62 subjects) among the control subjects, indicating a highly significantly increased prevalence (P < .001) of this finding in the patients with nasopharyngeal carcinoma. The overall prevalences of pterygoid process erosion, parapharyngeal extension of tumor, and enhancing tumor adjacent to the pterygoid process were 27% (17 of 62 subjects), 47% (29 of 62 subjects), and 77% (48 of 62 subjects), respectively. Pterygoid process sclerosis was the sole skull base abnormality in 36% (11 of 31) of the patients with nasopharyngeal carcinoma. CONCLUSION: Sclerosis of the pterygoid process, which was present in about half of the patients with untreated nasopharyngeal carcinoma, may reflect tumor proximity to or tumor invasion of the pterygoid process

OBJECTIVES: To develop an anatomically and functionally based approach to endoscopic intranasal ethmoidectomy; to develop such an approach using the salient features of the anterior-to-posterior (AP) and posterior-to-anterior (PA) intranasal sinus operations; to assess the safety of this form of ethmoidectomy in a patient population. STUDY DESIGN: Retrospective chart review of patients undergoing ethmoidectomy by the authors or by residents under their direct supervision. SETTING: University teaching hospital. RESULTS: Two thousand three hundred and forty-four patients underwent either unilateral or bilateral ethmoidectomies between April 1992 and August 2005. A complication rate of 0.34% was observed. CONCLUSIONS: Combining an AP approach to conserve sinus anatomy with a PA approach to avoid surgery directed toward the skull base provides a functional and safe procedure, as demonstrated by the reported results.

BACKGROUND: Recent molecular studies have described a number of abnormalities associated with the progression and dedifferentiation of thyroid carcinoma. These distinct molecular events are often associated with specific stages of tumor development. A better understanding of the mechanisms involved in thyroid cancer pathogenesis may help to translate these discoveries toward improvements in patient care. METHODS: We reviewed the literature on the molecular pathogenesis of thyroid cancer and compared clinical, histopathologic, and genetic features important in defining the disease process. RESULTS: The progression of thyroid cancer from well-differentiated to poorly differentiated and undifferentiated carcinoma represents a biological continuum. Specific genetic events serve as early initiating and late triggering events. Poorly differentiated thyroid carcinomas occupy an intermediate position in this progression model. CONCLUSIONS: With sophisticated genetic tools generating a wealth of information, we have gained better insight into the mechanisms driving thyroid tumor progression. Recognition of these features is crucial to the management of patients with thyroid cancer. Novel treatments are being designed based on our enhanced understanding of this disease process