OTOLARYNGOLOGY/FACIAL PLASTIC SURGERY-HEAD AND NECK SURGERY

Transcription

1 AMERICAN OSTEOPATHIC ASSOCIATION INSTITUTIONAL SEGREGATED TOTAL LOG FORM OTOLARYNGOLOGY/FACIAL PLASTIC SURGERY-HEAD AND NECK SURGERY Training Institution Mailing Address Daytime Phone ( ) Name of Program Director List hospital(s), clinic(s), and/or office(s) utilized for clinical examination procedures: A. B. C. D. E. F. G. H. You are requested to use the above listing(s) as a way to identify the location of the facility in which each procedure was performed. Use the letter of the facility from above along with the number of procedures as you fill out each area of the segregated totals (i.e., b-3, c-5, etc.) Thus, one would be able to see how many procedures of each type are done in the base or an outside hospital. Total Number of Major Procedures First Assistant Total Surgical Mortalities Performed Under Supervision INSTRUCTIONS: This form is used by AOA-approved hospitals with residency programs in Otolaryngology and/or Facial Plastic Surgery and/or Head and Neck Surgery. For your convenience, this form is compatible with the codes and nomenclature found in the International Classification of Diseases (ICD), 9 th Edition, which is used by medical record administrators. Please complete the form in its entirety. One copy of this report with supporting documentation, if applicable, will be mailed to the American Osteopathic Colleges of Ophthalmology and Otolaryngology-Head and Neck Surgery (AOCOO-HNS), 405 W. Grand Avenue, Dayton, Ohio I certify that the information on this form is correct and accurate. (Signature of Program Director) (Date)

2 Institutional Segregated Total Report for Otolaryngology/Facial Plastic Surgery/Head and Neck Surgery Number of Procedures I. HEAD AND NECK (25 majors per year) A. Salivary Glands 1. *Total parotidectomy with facial nerves preservation *Superficial parotidectomy *Parotidectomy with nerve graft *Submandibular gland excision Other B. Nose and Maxilla 1. *Lateral rhinotomy *Maxillectomy *Radical maxillectomy with orbital exenteration *Excision nasopharyngeal tumor Other C. Lips 1. *Lip shave *Wedge resection primary closure *Excision with flap reconstruction Other D. Oral Cavity 1. Local resection, tumor of oral cavity *Hemiglossectomy *Partial glossectomy w/o neck dissection *Partial glossectomy w/ neck dissection *Composite resection of primary in floor of mouth, alveolus, tongue, buccal region, tonsil, or any combination *Mandibular resection (independent procedure) Other Page 2 - Rev. 9/03

3 E. Neck 1. I & D neck abscess *Neck dissections (count each side) - *Complete *Modified Excision benign lesions ( cm) Cervical node biopsy F. Larynx 1. *Thyrotomy (laryngofissure) *Hemilaryngectomy *Supraglottic laryngectomy *with neck dissection *Total laryngectomy *with neck dissection *Laryngopharyngectomy *Surgical speech fistula *Repair laryngeal fracture *Laryngoplasty (includes laryngotracheoplasty) *Arytenoidectomy, arytenoidpexy G. Other 1. *Thyroid lobectomy *Subtotal thyroidectomy *Total thyroidectomy *Parathyroidectomy *Cricopharyngeal myotomy *Pharyngoesophagectomy *Cervical esophagostomy for feeding *Pharyngeal diverticulectomy/pexy *Tracheotomy *Tracheal resection with repair *Major vessel ligation *Major vessel repair / grafting Other H. Congenital anomalies (5 majors per year) 1. *Branchial cleft anomaly *Thyroglossal duct cyst *Dermoid Page 3 - Rev. 2/04

4 4. *Lymphatic vascular malformation *Anterior skull base surgery , *Teratomas 7. Other (head and neck) TOTAL PROCEDURES FOR SECTION I II. OTOLOGIC (20 majors per year) A. Otologic 1. Myringotomy w/tube *Myringoplasty (simple) 3. *Tympanoplasty I *Tympanoplasty II-IV (w/ ossicular chain reconstruction) *Tympanoplasty w/ mastoidectomy , *Simple mastoidectomy *Modified radical mastoidectomy *Radical mastoidectomy *Stapedectomy *Facial nerve decompression , *Facial nerve graft / repair / substitution , *Repair fistula (OW, RW) 38642, 69666, *Labyrinthectomy , 69905, *Decompression membranous labryinth - Cochleosacculotomy *Endolymphatic sac operation 69805, *Resection cerebellopontine angle tumor *VIII nerve section , *Excision glomus tumor *Reconstruction congenital EAC atresia *Tympanotomy w/me exploration *Petrous apicetomy, includes radical mastoidectomy *Middle & posterior fossa skull base surgery , Page 4 - Rev. 2/04

5 23. *Cochlear implantation *Meatoplasty (for stenosis due to trauma, or infection) Other (otologic) B. Other ear/head & neck 1. Excision pinna *Temporal bone resection Other TOTAL PROCEDURES FOR SECTION II III. PLASTIC AND RECONSTRUCTIVE (35 majors per year) A. Plastic and reconstructive 1. *Otoplasty (included auricular reconstruction) *Rhinoplasty - open closed *Mentoplasty *Rhytidectomy *Blepharoplasty *Liposuction *Chemical peel (full) Dermabrasion (10 per year) (Surgical Planing/Laser) *Repair complex facial lacerations Reduction facial fractures - *frontal nasal *maxilla LeFort I *maxilla LeFort II , 21345, *maxilla LeFort III 21154, 21431, Page 5 - Rev. 9/03

6 - *malar (zygomatic) *orbital blowout *mandibular - closed *open other (fractures) *Pedical flap procedures - local regional myocutaneous microsurgical free flap other (pedical flaps) *Grafts - split thickness skin full thickness skin composite graft dermal-fat-fascia other (grafts) *Facial sling procedures *Oroantral fistula repair *Choanal atresia repair *Cleft lip repair *Cleft palate repair *Pharyngeal flap *Prognathism/Retrognathism correction Excision skin lesions, primary closure *(with flaps) 11446, Scar revision Other (plastic) TOTAL PROCEDURES FOR SECTION III IV. ENDOSCOPY A. Endoscopy 1. Direct laryngoscopy, diagnostic, newborn Direct laryngoscopy, diagnostic, except newborn Direct laryngoscopy, diagnostic, with operating microscope Direct laryngoscopy with dilatation Page 6 - Rev. 9/03

7 5. Direct laryngoscopy with foreign body removal Direct laryngoscopy with biopsy *Direct laryngoscopy, operative, with excision of tumor and/or stripping of vocal folds or epiglottis *Direct laryngoscopy with arytenoidectomy Direct laryngoscopy with injection into vocal folds Esophagoscopy, diagnostic with biopsy with foreign body removal Bronchoscopy, diagnostic with biopsy *- with foreign body removal *- with stricture dilatation Other (endoscopy) TOTAL PROCEDURES FOR SECTION IV V. GENERAL A. General 1. Adenoidectomy Tonsillectomy Tonsillectomy & adenoidectomy *Uvulopalatopharyngoplasty Nasal septoplasty Nasal polypectomy Maxillary antrostomy/sinus wash / Turbinate reduction Caldwell luc *Endoscopic sinus surgery (25 majors per year) (Count each procedure once) - ethmoidectomy maxillary sinusotomy sphenoid sinusotomy frontal sinusotomy *Ligation ethmoid arteries Page 7 - Rev. 2/04

8 12. *Transantral ligation of vessels *Intranasal ethmoidectomy *External ethmoidectomy *Frontoethmoidectomy *Frontal sinus trephine *Osteoplastic frontal sinusectomy with obliteration *Hypophysectomy (transnasal approach) *Dacryocystorhinostomy Other (general) TOTAL PROCEDURES FOR SECTION V VI. SUMMARY OF PROCEDURAL SECTIONS A. Total Procedures for Section I, Head & Neck B. Total Procedures for Section II, Otology C. Total Procedures for Section III, Plastic & Recon. D. Total Procedures for Section IV, Endoscopic E. Total Procedures for Section V, General OVERALL TOTAL PROCEDURES CUMULATIVE SUBCATEGORIZED SUMMARY OF SPECIFIC MAJOR PROCEDURES A. Head and Neck Majors (25/year) B. Congenital Anomalies (5/year) C. Otology (20/year) D. Plastic and Reconstructive (35/year) E. Endoscopic Sinus Surgery (25/year) F. Laser (10/year, pertaining to all categories) PGY-2 PGY-3 PGY-4 PGY-5 TOTALS Page 8 - Rev. 2/04

9 ACCUMULATED TRACKING LOG FORM Otolaryngology/Facial Plastic Surgery Number of Procedures As Surgeon As Assistant Base Hosp. Outside Base Hosp. Outside Resident's Name SUMMARY OF FIRST YEAR RESIDENCY TRAINING (specialty track internship or general surgery) TOTAL ALL 1st YEAR PROCEDURES SUMMARY OF SECOND YEAR RESIDENCY TRAINING Total Procedures for Section I - Head and Neck Total Procedures for Section II - Otologic Total Procedures for Section III - Plastic and Reconstructive Total Procedures for Section IV - Endoscopy Total Procedures for Section V - General TOTAL ALL SECOND YEAR PROCEDURES ADD TOGETHER 1st & 2nd YEAR TOTALS SUMMARY OF THIRD YEAR RESIDENCY TRAINING Total Procedures for Section I - Head and Neck Total Procedures for Section II - Otologic Total Procedures for Section III - Plastic and Reconstructive Total Procedures for Section IV - Endoscopy Total Procedures for Section V - General TOTAL ALL THIRD YEAR PROCEDURES ADD TOGETHER 1st, 2nd & 3rd YEAR TOTALS SUMMARY OF FOURTH YEAR RESIDENCY TRAINING Total Procedures for Section I - Head and Neck Total Procedures for Section II - Otologic Total Procedures for Section III - Plastic and Reconstructive Total Procedures for Section IV - Endoscopy Total Procedures for Section V - General TOTAL ALL FOURTH YEAR PROCEDURES ADD TOGETHER 1st, 2nd, 3rd & 4th YEAR TOTALS SUMMARY OF FIFTH YEAR RESIDENCY TRAINING (if applicable) Total Procedures for Section I - Head and Neck Total Procedures for Section II - Otologic Total Procedures for Section III - Plastic and Reconstructive Total Procedures for Section IV - Endoscopy Total Procedures for Section V - General TOTAL ALL FIFTH YEAR PROCEDURES ADD TOGETHER 1st,2nd,3rd,4th & 5th YEAR TOTALS Page 9 - Rev. 9/03