Residency training in the time of COVID-19: A framework for academic medical centers dealing with the pandemic.

BACKGROUND: As cases of COVID-19 climb worldwide, academic medical centers (AMCs) are scrambling to balance the increasing demand for medical services while maintaining safe learning environments. The scale and nature of the current pandemic, limitations on key resources, risks of transmission, and the impact on trainee wellbeing pose additional challenges to AMCs. We propose a framework for AMCs to utilize in facilitating health system, organization and program-level adjustments to meet the needs of medical trainees during the pandemic. APPROACH: In February 2020, we developed a three-level approach to the pandemic response of training programs at our AMC. The first level involved AMC alignment and engagement with regulatory stakeholders. The second level utilized the graduate medical education committee and leveraged organizational functions such as human resources, finance, and clinical departments. The third level of intervention focused on common approaches used by programs to ensure continuity of learning in the context of dynamic changes in workflows and service operations. EVALUATION: Outcomes at each level are reported. These include the co-development of a national framework on medical trainee responses to COVID-19, the composition of an operational guidance document, organizational protocols to accommodate novel challenges posed by the pandemic, and multiple program-level interventions. REFLECTION: This methodical approach, employed during a global crisis, was critical in facilitating interventions required to fulfill the mission of AMCs. Future steps include assessing the impact of these changes on trainee performance and the applicability of the approach in diverse settings.

Rattled: Analysis of Facial Trauma Among Toddlers.

OBJECTIVE: The aim of this study was to determine the national incidence of facial trauma among toddlers and delineate patterns of injury and their causes. METHODS: A retrospective review was designed to explore patterns of maxillofacial trauma within toddler-aged children using the National Electronic Injury Surveillance System from the Consumer Product Safety Commission. The database was searched for emergency department visits involving facial trauma sustained by children 12 months through 3 years of age from 2010 through 2014 and analyzed for patient demographics, primary diagnosis, and associated products/activities. Subset analyses were performed between age groups to determine the relationship between causes of injury and age using extrapolated national incidences. RESULTS: A sample of 45,249 patients extrapolated to an estimated 1.3 million emergency department visits for facial trauma in toddlers from 2010 to 2014, averaging 260,000 annually. Injuries involving foreign bodies and fractures had a higher incidence in toddlers 2 years or older, and fractures comprised fewer than 1% of facial injuries in any age group. Furniture was the most common source of trauma overall, with a higher frequency among toddlers aged 12 to 17 months. Trauma in the setting of sports was more common in toddlers aged 3 years. CONCLUSIONS: The low incidence of facial fractures further supports recommendations against routine imaging in toddler facial trauma and suggests that more focus should be placed on investigating for concurrent traumas and soft tissue injuries where fractures are involved. Our findings highlight prevention opportunities, particularly in furniture-related injuries for toddlers aged 12 to 17 months and sports-related traumas in toddlers aged 3 years. Our study also suggests restricting certain toys from 3-year-old toddlers to decrease the risk of aspiration.

Economic Analysis of Using Free Fat Graft or Acellular Dermis to Prevent Post-parotidectomy Frey Syndrome.

A decision tree was constructed to determine the incremental cost-effectiveness ratio (ICER) of grafting techniques used to prevent Frey Syndrome. The authors performed a sensitivity analysis to calculate what the probability of preventing Frey Syndrome would have to be and maximum costs associated with using grafting techniques to warrant their use as more "cost-effective" choice than using neither. Decision pathways utilized were uses of (1) free fat graft (FFG), (2) acellular dermis, and (3) no grafting. The probability of developing Frey syndrome and costs were extracted from previous studies to construct the decision tree. The primary effectiveness was the ICER of FFG or acellular dermis to prevent Frey syndrome. The initial outcomes included preventing Frey syndrome (effectiveness = 1) or developing Frey syndrome (effectiveness = 0). Compared with not using a graft, the ICER of using FFG and acellular dermis were $10,628 and $50,813, respectively. Frey syndrome was found in 2.6% of patients postoperatively in FFG group, 9.8% of patients in acellular dermis group, and 30.7% of patients who did not have a graft. The ICER shows absolute dominance of FFG with lower cost and high effectiveness over acellular dermis. This economic evaluation strongly supports the use of FFG over acellular dermis as cost-effective approach for prevention of postparotidectomy Frey syndrome.

Analysis of Factors Associated With Rhytidectomy Malpractice Litigation Cases.

IMPORTANCE: This study investigates the financial burden of medical malpractice litigation associated with rhytidectomies, as well as factors that contribute to litigation and poor defendant outcomes, which can help guide physician practices. OBJECTIVE: To comprehensively evaluate rhytidectomy malpractice litigation. DATA SOURCES AND STUDY SELECTION: Jury verdict and settlement reports related to rhytidectomy malpractice litigations were obtained using the Westlaw Next database. Use of medical malpractice in conjunction with several terms for rhytidectomy, to account for the various procedure names associated with the procedure, yielded 155 court cases. Duplicate and nonrelevant cases were removed, and 89 cases were included in the analysis and reviewed for outcomes, defendant specialty, payments, and other allegations raised in proceedings. Data were collected from November 21, 2015, to December 25, 2015. Data analysis took place from December 25, 2015, to January 20, 2016. RESULTS: A total of 89 cases met our inclusion criteria. Most plaintiffs were female (81 of 88 with known sex [92%]), and patient age ranged from 40 to 76 years (median age, 56 years). Fifty-three (60%) were resolved in the defendant's favor, while the remaining 36 cases (40%) were resolved with either a settlement or a plaintiff verdict payment. The mean payment was $1.4 million. A greater proportion of cases involving plastic surgeon defendants were resolved with payment compared with cases involving defendants with ear, nose, and throat specialty (15 [36%] vs 4 [24%]). The most common allegations raised in litigation were intraoperative negligence (61 [69%]), poor cosmesis or disfigurement (57 [64%]), inadequate informed consent (30 [34%]), additional procedures required (14 [16%]), postoperative negligence (12 [14%]), and facial nerve injury (10 [11%]). Six cases (7%) involved alleged negligence surrounding a "lifestyle-lift" procedure, which tightens or oversews the superficial muscular aponeurosis system layer. CONCLUSIONS AND RELEVANCE: In this study, although most cases of rhytidectomy malpractice litigation were resolved in the defendant's favor, cases resulting in payments created substantial financial burden for the defendants. Common factors cited by plaintiffs for pursuing litigation included dissatisfaction with cosmetic outcomes and perceived deficits in informed consent. These factors reinforce the importance of a comprehensive, preoperative informed consent process in which the specific potential risks and outcomes are presented by the surgeon to the patient to limit or avoid postsurgical allegations. Intraoperative negligence and facial nerve injury were significantly more likely to result in poor defendant outcomes. LEVEL OF EVIDENCE: NA.

Facial fracture repair and diabetes mellitus: An examination of postoperative complications.

OBJECTIVES/HYPOTHESIS: Our objectives included using a nationally representative resource to evaluate charges, demographics, and complication rates among diabetics undergoing surgical repair of facial fractures. METHODS: We evaluated the Nationwide Inpatient Sample, a database encompassing nearly 8 million hospitalizations, for patients with a diagnosis of a facial fracture who underwent surgical intervention during their hospitalization. Patients were organized by whether they had a diagnosis of diabetes mellitus (DM). RESULTS: Of 45,509 inpatients included, diabetics had greater costs, longer length of stays, and were significantly more likely to have a host of baseline comorbidities. On multivariate logistic regression corrected for age, race, gender, and preexisting cardiac disease, DM patients had significantly greater odds for cardiac complications (3.3; P < 0.001) and hepatic failure (15.0; P = 0.007). There were no significant differences associated with DM in the rates of enophthalmos, epiphora, and diplopia among patients with orbital fractures. Diabetics did have a significantly greater risk of postoperative infection after mandible repair. CONCLUSION: In addition to a significant association with greater length of stay and increased hospital charges, DM patients undergoing surgical repair of facial fractures had a significantly greater risk of postoperative complications, including cardiac complications. Diabetics undergoing mandible repair had a greater risk of postoperative infection, even upon controlling for demographic factors, suggesting the need for further study evaluating the role of postoperative antibiotic prophylaxis in this patient population. These findings reveal the potential value of developing and using standardized postoperative care algorithms aimed at minimizing complications in this susceptible population. LEVEL OF EVIDENCE: 2c. Laryngoscope, 127:809-814, 2017.

Pediatric pituitary resection: characterizing surgical approaches and complications.

BACKGROUND: Although there has been extensive study evaluating adult pituitary surgery, there has been scant analysis among children. Our objective was to evaluate a population-based resource to characterize nationwide trends in surgical approach, hospital stay, and complications among children undergoing pituitary surgery. METHODS: The Kids' Inpatient-Database (KID) files (2009/2012) were evaluated for pituitary gland excisions. Procedure, patient demographics, length of inpatient stay, inpatient costs, hospital setting, and surgical complications were analyzed. RESULTS: A weighted incidence of 1071 cases were analyzed; the majority (77.6%) underwent transsphenoidal resections. These patients had significantly decreased hospital costs and lengths of stay. Patients undergoing transfrontal approaches had significantly greater rates of postoperative diabetes insipidus (DI) (66.5%), panhypopituitarism (38.8%), hydrocephalus, and visual deficits. Among transsphenoidal patients, males had greater rates of postoperative hydrocephalus (5.5%) and panhypopituitarism (17.5%) than females, and patients ≤10 years old had greater rates of these 2 complications (14.5%, 19.4%, respectively) as well as DI (61.3%). CONCLUSION: A greater proportion of children undergo transfrontal approaches for pituitary lesions than in their adult counterparts. This difference may harbor a potential to influence future sellar resection approaches in children toward a transsphenoidal operation when surgically feasible. Patients undergoing transfrontal procedures have greater risks for many intraoperative and postoperative complications relative to individuals undergoing transsphenoidal resections. Among patients undergoing transsphenoidal approaches, males had significantly greater rates of postoperative hydrocephalus and panhypopituitarism, and younger children had greater rates of postoperative DI, hydrocephalus, and panhypopituitarism. These data reinforce the need for greater vigilance in the postoperative care of younger children undergoing transsphenoidal surgery.

Cost-effectiveness of routine computed tomography in the evaluation of idiopathic unilateral vocal fold paralysis.

OBJECTIVES/HYPOTHESIS: To evaluate the cost-effectiveness of routine computed tomography (CT) in individuals with unilateral vocal fold paralysis (UVFP) STUDY DESIGN: Health Economics Decision Tree Analysis METHODS: A decision tree was constructed to determine the incremental cost-effectiveness ratio (ICER) of CT imaging in UVFP patients. Univariate sensitivity analysis was utilized to calculate what the probability of having an etiology of the paralysis discovered would have to be to make CT with contrast more cost-effective than no imaging. We used two studies examining findings in UVFP patients. The decision pathways were utilizing CT neck with intravenous contrast after diagnostic laryngoscopy versus laryngoscopy alone. The probability of detecting an etiology for UVFP and associated costs were extracted to construct the decision tree. The only incorrect diagnosis was missing a mass in the no-imaging decision branch, which rendered an effectiveness of 0. RESULTS: The ICER of using CT was $3,306, below most acceptable willingness-to-pay (WTP) thresholds. Additionally, univariate sensitivity analysis indicated that at the WTP threshold of $30,000, obtaining CT imaging was the most cost-effective choice when the probability of having a lesion was above 1.7%. Multivariate probabilistic sensitivity analysis with Monte Carlo simulations also showed that at the WTP of $30,000, CT scanning is more cost-effective, with 99.5% certainty. CONCLUSIONS: Particularly in the current healthcare environment characterized by increasing consciousness of utilization defensive medicine, economic evaluations represent evidence-based findings that can be employed to facilitate appropriate decision making and enhance physician-patient communication. This economic evaluation strongly supports obtaining CT imaging in patients with newly diagnosed UVFP. LEVEL OF EVIDENCE: 2c. Laryngoscope, 2016 127:440-444, 2017.

Consumer product ingestion and aspiration in children: A 15-year review.

OBJECTIVES/HYPOTHESIS: Our objectives were to identify consumer product (CP) ingestion and aspiration trends. Our hope is that evaluation of contemporary trends may be useful to physicians and policy makers and further guide preventative measures. METHODS: The Consumer Product Safety Commission's National Electronic Injury Surveillance System was queried for pediatric CP aspiration and ingestion data for the years 2000 to 2014. Data from 2000 to 2004 were compared to 2010 to 2014 data and analyzed for CP and injury occurrence. Injury trends over the past 15 years were identified; patient demographics were analyzed; and patient disposition was reported. RESULTS: Emergency department visits for pediatric CP ingestion increased 41.4% over the 15-year period analyzed and remained relatively stable for aspiration events. In all, an estimated 1.1 million visits occurred during this time frame. Jewelry overtook coins as the most common CP aspirated (29.3%). Coins remained the most frequent ingestion but comprised a smaller proportion of ingestions in recent years than years past. From 2010 through 2014, children under 5 years of age accounted for 89.4% and 77.8% of CP aspiration and ingestion cases, respectively. CONCLUSION: Pediatric aspiration/ingestion remains a frequent occurrence with potentially significant ramifications. Injury demographics and CPs most likely to be involved may represent valuable information to the otolaryngologist who wishes to provide appropriate counseling to patients and parents and continued investigation on injury prevention. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:1202-1207, 2017.

Does formal research training lead to academic success in otolaryngology?

OBJECTIVES/HYPOTHESIS: To evaluate whether formalized research training is associated with higher researcher productivity, academic rank, and acquisition of National Institutes of Health (NIH) grants within academic otolaryngology departments. METHODS: Each of the 100 civilian otolaryngology program's departmental websites were analyzed to obtain a comprehensive list of faculty members credentials and characteristics, including academic rank, completion of a clinical fellowship, completion of a formal research fellowship, and attainment of a doctorate in philosophy (PhD) degree. We also recorded measures of scholarly impact and successful acquisition of NIH funding. RESULTS: A total of 1,495 academic physicians were included in our study. Of these, 14.1% had formal research training. Bivariate associations showed that formal research training was associated with a greater h-index, increased probability of acquiring NIH funding, and higher academic rank. Using a linear regression model, we found that otolaryngologists possessing a PhD had an associated h-index of 1.8 points higher, and those who completed a formal research fellowship had an h-index of 1.6 points higher. A PhD degree or completion of a research fellowship was not associated with a higher academic rank; however, a higher h-index and previous acquisition of an NIH grant were associated with a higher academic rank. The attainment of NIH funding was three times more likely for those with a formal research fellowship and 8.6 times more likely for otolaryngologists with a PhD degree. CONCLUSION: Formalized research training is associated with academic success in otolaryngology. Such dedicated research training accompanies greater scholarly impact, acquisition of NIH funding, and a higher academic rank. LEVEL OF EVIDENCE: NA Laryngoscope, 127:E15-E21, 2017.

Establishing a danger zone: An anatomic study of the lingual artery in base of tongue surgery.

OBJECTIVES/HYPOTHESIS: To contrast the changes in measurement of the hypoglossal/lingual artery neurovascular bundle (HLNVB) to constant surface landmarks in the base of tongue (BOT) during surgically simulated retraction versus resting anatomic position, and to identify a safe zone for BOT robotic surgery to avoid injury to the HLNVB. STUDY DESIGN: Human cadaver study. METHODS: Five fresh-frozen head and neck complexes were obtained, and seven HLNVBs were dissected. A microcaliper was used to measure the distance from the HLNVB to constant surface landmarks in resting and surgically simulated positions using a Feyh-Kastenbauer retractor. RESULTS: Measurements from foramen cecum to palatoglossus muscle (P < 0.042) was significantly different when comparing anatomical to surgically simulated positions. Importantly, the location of the lingual artery in reference to the surface landmarks measured was dramatically altered with tongue retraction. With retraction, the branches of the dorsal lingual artery were not encountered posterior to a horizontal line between midway circumvallate papilla (mCVP). CONCLUSION: Measurements of the HLNVB to surface landmarks in the BOT differs significantly between resting and a surgically simulated tongue position. The dorsal branch of the lingual artery seems more superficial in the BOT than previously described. A safe zone may exist posterior to an imaginary horizontal line between mCVP; however, further studies are needed to confirm this. LEVEL OF EVIDENCE: NA Laryngoscope, 127:110-115, 2017.

Soccer-Related Facial Trauma: A Nationwide Perspective.

PURPOSE: Soccer participation continues to increase among all ages in the US. Our objective was to analyze trends in soccer-related facial injury epidemiology, demographics, and mechanisms of injury. MATERIALS AND METHODS: The National Electronic Injury Surveillance System was evaluated for soccer-related facial injuries from 2010 through 2014. Results for product code "soccer" were filtered for injures to the face. Number of injuries was extrapolated, and data were analyzed for age, sex, specific injury diagnoses, locations, and mechanisms. RESULTS: In all, 2054 soccer-related facial trauma entries were analyzed. During this time, the number of injures remained relatively stable. Lacerations were the most common diagnosis (44.2%), followed by contusions and fractures. The most common sites of fracture were the nose (75.1%). Of fractures with a reported mechanism of injury, the most common was head-to-head collisions (39.0%). Patients <19 years accounted for 66.9% of injuries, and athletes over 18 years old had a higher risk of fractures. CONCLUSIONS: The incidence of soccer-related facial trauma has remained stable, but the severity of such injuries remain a danger. Facial protection in soccer is virtually absent, and our findings reinforce the need to educate athletes, families, and physicians on injury awareness and prevention.

Adding Injury to Insult: A National Analysis of Combat Sport-Related Facial Injury.

OBJECTIVES/HYPOTHESIS: To estimate the incidence of patients presenting to emergency departments (EDs) for facial trauma sustained from participation in combat sports and evaluate injury patterns and patient demographics. METHODS: The National Electronic Injury Surveillance System (NEISS) was evaluated for facial injuries from wrestling, boxing, and martial arts leading to ED visits from 2008 to 2013. Relevant entries were examined for injury mechanism, location, type, as well as other patient characteristics. RESULTS: There were 1143 entries extrapolating to an estimated 42 395 ED visits from 2008 to 2013. Injury rates for boxing, marital arts, and wrestling were, respectively, 44, 56, and 120 injuries per 100 000 participants. Males comprised the majority (93.7%). A plurality of injuries involved lacerations (46.0%), followed by fractures (26.2%) and contusions/abrasions (19.3%). The proportion of fractures was highest among boxers (36.9%). Overall, the most common mechanisms of injury were punching, kicking, and head butting. CONCLUSIONS: The significant number of ED visits resulted from combat sports facial trauma, reinforcing the importance of familiarity with injury patterns among practitioners managing facial trauma. As most injuries involve individuals younger than 19 despite guidelines suggesting children and adolescents avoid combat sports, these findings may be used for patient education and encouragement of the use of personal protective equipment. Furthermore, injury patterns reported in this analysis may serve as an adjunct for enhancing clinical history taking and physical examination.

The Vicious Cycle: Pediatric Facial Trauma from Bicycling.

OBJECTIVES: Although prevention of head injuries through helmet use is widespread, there has been a paucity of inquiry and publicity regarding the potential for facial injury stemming from cycling. Our objectives included estimating the incidence of emergency department (ED) visits for bicycle-related facial trauma among the pediatric population and detailing injury patterns. STUDY DESIGN AND SETTING: Analysis of a nationwide database. METHODS: The National Electronic Injury Surveillance System, offered by the Consumer Product Safety Commission, was accessed for ED visits related to bicycle-related facial trauma among individuals 21 years old and younger. These data were used to estimate national incidence and examine patient demographics and injury characteristics. RESULTS: From 2010 to 2014, there were 5420 entries extrapolating to an estimated 178,457 ED visits for pediatric bicycle-related facial trauma. Median age was 8 years, and 71.9% of patients were male. Lacerations (63.1%), abrasions/contusions (27%), and fractures (7%) were most common, with fractures dramatically increasing in prevalence with age. Nasal fractures were the most common fracture type. Injury patterns varied by age. CONCLUSION: Bicycle-related facial trauma is prevalent among the pediatric population, with nearly 180,000 visits to EDs between 2010 and 2014. Soft tissue injuries predominated among all age groups, although fractures increased significantly with age. Knowledge of injury patterns described may be a useful adjunct assisting history, examination, and decision making regarding the use of medical imaging. There is a clear void in inquiry regarding the use of facial protection, reinforcing the need for further study into prevention and efforts to raise public awareness among youth.

Protecting the airway and the physician: Aspects of litigation arising from tracheotomy.

BACKGROUND: In recent decades, medical malpractice costs have increased and have led to a change in the way physicians practice medicine. Tracheotomies are cases in which complications have a high risk of morbidity and mortality and the potential for litigation. METHODS: The Westlaw legal database was used to gather data on 43 jury verdicts and settlements from 1987 to 2013. Various factors included outcome, defendant specialty, and the reason for litigation. RESULTS: Median settlements were $500,000 and median verdict awards were $2,000,000. Postoperative negligence was alleged most often (81%) followed by intraoperative negligence (27.9%) and permanent injury (18.6%). Otolaryngologists were named as defendants most often (25.6%), with nurses named second most often. Pediatric cases had significantly higher awards and were more often named in favor of the plaintiff. CONCLUSION: An awareness of tracheotomy malpractice litigation has the potential to both help physicians avoid future litigation and improve patient safety.

Burns in the head and neck: A national representative analysis of emergency department visits.

OBJECTIVES/HYPOTHESIS: Head and neck burns (HNBs) engender serious sequelae including airway edema, speech/swallowing dysfunction, sensory deficits, and scarring/disfigurement, often requiring significant reconstructive surgery. We used a nationally representative resource to estimate the number of visits to emergency departments (EDs), analyze burn types and demographic patterns, and identify specific consumer products involved. METHODS: The National Electronic Injury Surveillance System was evaluated for the most recent 5-year period available. HNB ED visits were identified, and patient records were evaluated for consumer products facilitating injury, along with other ED visit and patient characteristics. RESULTS: From 2009 to 2013, 6,326 cases extrapolating to 233,431 ED visits nationally were identified. Males were predominantly impacted (64.1%). Although adults overall comprised the majority of patients (59.7%), children between 1 and 2 years of age had the highest incidence (21,544 ED visits nationally). The most common consumer products facilitating HNB included welding equipment, hot water, gasoline, bleaches, and cookware. Most injuries involved the face (55%), whereas the most common etiologies included thermal (40%), chemical (23%), and scald (22%) burns. Consumer products and injury patterns varied by patient age. CONCLUSIONS: HNBs significantly impact healthcare delivery, as over 200,000 visits reportedly presented to EDs over the 5-year period studied. Consumer products facilitating visits and associated patient demographics described may guide history, clinical examination, and identification of secondary injuries. In particular, age-specific patterns detailed may be included in consumer education and patient counseling to facilitate injury prevention, as office visits provide an opportunity to counsel patients.

Scholarly investigation into otitis media: who is receiving funding support from the National Institutes of Health?

OBJECTIVES/HYPOTHESIS: Otitis media (OM) is highly prevalent and represents a major public health concern. We evaluate National Institutes of Health (NIH) funding support for OM research and examine the role of otolaryngology primary investigators (PIs). STUDY DESIGN: Examination of bibliometrics and funding history of NIH grant recipients. METHODS: The NIH RePORTER database was examined for PIs funded for otitis media-related projects. The specialty, education level, academic department, scholarly impact (as measured by the h-index), and funding levels of PIs were obtained. RESULTS: There were 320 projects funded for 1,102 fiscal years supporting OM research. Since 2000, there has been >$280 million in support. PhDs received 47.5% of awards, more than any single medical specialty. Pediatricians received 54.8% of grants awarded to physicians followed by otolaryngologists (29.9%). Pediatric infectious disease specialists and pediatric otolaryngologists had the greatest funding per PI upon considering subspecialties, whereas non-fellowship-trained otolaryngologists had the lowest funding levels. Funded otolaryngologists had lower scholarly impact than several specialties. Aggregate funding levels to otolaryngologists decreased between 2000 and 2013. CONCLUSIONS: The NIH provided considerable grant support for researchers studying OM as awards to practitioners in numerous specialties exceeded a quarter of a billion dollars since 2000. Although awards to otolaryngologists were significant, the share of grants awarded to otolaryngologists has declined, suggesting that increased recruitment of basic scientists and enhanced cooperation with other specialists may facilitate further scholarship. These findings suggest a need for improving initiatives that prepare otolaryngology trainees interested in translational OM research for the rigorous NIH peer-review grant process.

Craniofacial Surgery and Adverse Outcomes: An Inquiry Into Medical Negligence.

OBJECTIVE: This study aimed to evaluate factors contributing to medical negligence relevant to craniofacial surgery. METHODS: Retrospective analysis of verdict and settlement reports on the Westlaw legal database for outcome, awards, physician defendants, and other specific factors raised in malpractice litigation. RESULTS: Of 42 verdicts and settlement reports included, 52.4% were resolved with either an out-of-court settlement or plaintiff verdict, with aggregate payments totaling $50.1M (in 2013 dollars). Median settlements and jury-awarded damages were $988,000 and $555,000, respectively. Payments in pediatric cases ($1.2M) were significantly higher. Plastic surgeons, oral surgeons, and otolaryngologists were the most commonly named defendants. The most common alleged factors included intraoperative negligence (69.0%), permanent deficits (54.8%), requiring additional surgery (52.4%), missed/delayed diagnosis of a complication (42.9%), disfigurement/scarring (28.6%), postoperative negligence (28.6%), and inadequate informed consent (20.6% of surgical cases). Failure to diagnose a fracture (19.0%) and cleft-reparative procedures (14.3%) were the most frequently litigated entities. CONCLUSION: Medical negligence related to craniofacial surgery involves plaintiffs in a wide age range as well as physician defendants in numerous specialties, and proceedings resolved with settlement and plaintiff verdict involve substantial payments. Cases with death, allegedly permanent injuries, and pediatric plaintiffs had significantly higher payments.

Cleft palate: a clinical review.

Orofacial clefts, including cleft palates (CP), are one of the most common birth defects. CP have a multiplicity of effects on the individual and society in terms of economic costs, loss of productivity, psychosocial effects, and increased morbidity and mortality at all stages of life. Embryological development of the palate is well delineated, with developments in the last decade regarding the biomolecular processes involved. Etiology is complex, involving a number of genetic and environmental factors. Various techniques can be employed for the repair of CP, depending on whether the cleft is of the primary or secondary palate, the width of the cleft, whether lengthening of the palate is necessary, and with regard to concerns of disruption of midfacial growth. All surgical techniques have the goals of restoring functional speech, swallowing, and aesthetics. A multidisciplinary team is necessary for the long-term pre- and postoperative care of CP patients to handle complications, associated anomalies, and to optimize function and quality of life.