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PGY4 at the MGH - The Expert Role specific objectives

General Skills
•    Understands medical literature its limitations and can argue based on the published literature
•    Participate in the post-operative ward and office management of patients who have undergone major head and neck ablative and Reconstructive surgery
•    Demonstrate a sophisticated approach to imaging studies including independent interpretation of findings
•    Perform fine needle aspiration of neck lesions
•    Biopsy nasal or oral cavity lesions
•    Insert or change a tracheoesophageal puncture prosthesis
•    Incise and drain a wound abscess including a demonstrated understanding of the indications for the procedure
•    Pack a pharyngocutaneous fistula and provide ongoing wound care/debridement
•    Effectively manage pain associated with surgery and malignancy
•    Demonstrate understanding of the indications for tracheotomy in a critical care setting
•    Promptly and effectively assess patients with airway emergencies including airway obstruction and supervise junior colleagues in this situation
•    Perform open and percutaneous tracheostomies
•    Perform percutaneous tracheostomy/translaryngeal tracheotomy with limited consultant supervision
•    Provide effective counseling for patients regarding tracheotomy/stoma care
•    Effectively manage pain associated with surgery (e.g. mastoidectomy, skull base surgery)
•    Participate in the post-operative ward and office management of patients who have undergone otologic surgery, lateral skull base surgery, and general otolaryngological surgery
•    Interpret X-ray and cross-sectional imaging of temporal bones and soft tissues of the head and neck

Head and Neck Oncologic Surgery
•    Rapidly stage malignancies of the head and neck and develop approach to surgical management
•    Appropriate use and recommendation of alternate/adjuvant therapies for management of malignancies of the head and neck
•    Effectively perform a transnasal esophagoscopy and understand the findings
•    Comprehensive management of complications from Head and Neck surgery with limited consultant intervention
•    Comprehensive understanding and management of Head and Neck emergencies such as airway obstruction and trauma
•    Perform pan-endoscopy independently with accurate interpretation of findings
•    Perform lymph node and neck mass biopsy limited consultant intervention
•    Effectively perform cervical echography and ultrasound guided fine needle biopsy
•    Perform excision of submandibular glands with limited consultant intervention
•    Perform excision of branchial cleft cysts and thyroglossal duct cysts with gradually decreasing degree of consultant intervention
•    Perform parotidectomy with increasing degree of autonomy
•    Perform neck dissections with increasing degree of autonomy
•    Perform thyroidectomy, parathyroidectomy with limited consultant intervention
•    Perform excision of oral cavity lesions with and without laser
•    Perform medial maxillectomy with consultant supervision
•    Perform composite resections as well as pharyngolaryngectomies with increasing degree of autonomy
•    Perform more extensive maxillectomies with consultant supervision
•    Assist at anterior craniofacial resections

Facial Plastic and Reconstructive Surgery
•    Demonstrate sophisticated understanding of the hierarchy of Reconstructive options for defects in the head and neck
•    Formulate plan for reconstruction of head and neck defects with attention to form and function
•    Design and harvest flaps for major Reconstructive surgical procedures with direct consultant supervision
•    Perform or assist at microvascular anastomosis for vessels and nerves in free tissue transfers
•    Perform or assist at microvascular anastomosis for vessels and nerves in free tissue transfers
•    Diagnosis and treatment of facial nerve disorders and reanimation strategies
•    Diagnose, evaluate and perform treatments of cutaneous malignancies including appropriate reconstruction.
•    Observe, assist in and perform various types of local and regional flaps in cervicofacial reconstruction
•    Approach to facial analysis of patient presenting for esthetic surgery
•    Observe, assist in and perform septorhinoplasty including an evaluation of the nasal valve, open vs. closed approaches, as well as grafting techniques
•    Perform septorhinoplasty with direct consultant supervision.
•    Observe, assist in cervicofacial cosmetic surgery such as blepharoplasty, rhytidectomy, forehead lifts, and various facial implants.
•    Observe, assist in and perform Facial reanimation including skin resurfacing, chemical peels, microdermabrasion, and laser peels
•    Observe, assist in and perform cosmetic procedures such as botox injection and soft tissue injectable fillers (hyaluronic acid derivatives, collagen, etc.)
•    Observe, assist in and perform scar revision including techniques such as Z - plasty, W - plasty, and geometric broken line closure, etc.
•    Management of patients suffering from facial trauma including the techniques of soft tissue repair and closed/open reduction of facial fractures and post-operative care.
•    Perform surgical repair of mandible fractures including the use of M-M fixation and plates.
•    Management of mid facial fractures including choice of incisions and repair materials.
•    Perform or assist at repair of orbitozygomatic and frontal sinus fractures

Laryngology
•    Perform indirect rigid laryngoscopy and video-stroboscopy
•    Develop a differential diagnosis and management plan for dysphonia
•    Develop a differential diagnosis and management plan for dysphagia
•    Management of vocal cord paralysis including investigation, medical therapy, and surgical therapy
•    Perform office-based laryngeal procedures
•    Perform rigid suspension laryngoscopy
•    Perform microlaryngeal surgery with microlaryngeal instruments, CO2 Laser, microdebrideur
•    Understanding of intraoperative airway management during microlaryngeal surgery
•    Perform thyroplasty and other laryngeal framework surgeries
•    Perform, with supervision, endoscopic laser resections of early tumors of the larynx
•    Diagnosis and management of airway and aerodigestive trauma
•    Assist at and begin to perform airway reconstruction (e.g. laryngotracheoplasty)

Neurotology / Otology
•    Accurately assess patients suffering temporal bone trauma including ordering appropriate investigations
•    Be able to perform and interpret conventional audiometry and tympanometry in adults
•    Understand the principles and application of auditory brainstem response (ABR) and Otoacoustic Emissions (OAEs)
•    Understand the principles and application of electronystagmography including interpretation of findings
•    Accurately diagnose benign positional vertigo and demonstrate a rational approach to its treatment
•    Perform the particle repositioning maneuver
•    Develop a rational approach to vestibular rehabilitation and participate in delivery of this care
•    Participate in and demonstrate understanding of the indications for surgical treatment of vertigo (includes labyrinthectomy, vestibular nerve section, endolymphatic sac surgery, and posterior canal occlusion)
•    Observe performance of and interpret electrocochleography
•    Perform and interpret electro-diagnostic testing of the facial nerve
•    Elevate a tympanomeatal flap with limited consultant intervention
•    Perform tympanoplasty with limited consultant intervention
•    Perform ossiculoplasty with consultant supervision
•    Perform mastoidectomy with consultant supervision
•    Demonstrate a rational, organized approach to medical management of disorders of the facial nerve
•    Demonstrate a rational approach to selection of patients for cochlear implant surgery
•    Assist in performance of cochlear implant surgery and actively participate in post-operative rehabilitation and assessment
•    Assist at/observe surgery for treatment of otosclerosis
•    Assist at and demonstrate a logical approach to surgery for treatment of lateral skull base lesions including acoustic neuromas, other benign CPA lesions, and petrous apex lesions
•    Attend Skull Base Clinic and understand controversies in patient management
•    Present cases at Skull Base Tumor Board
•    Participate at skull base surgeries and perform some of the procedure under supervision

Rhinology
•    Perform effective rigid nasal and sinus endoscopy
•    Biopsy nasal cavity lesions
•    Participate actively in the post-operative office management of patients who have undergone sinus surgery including pharmacotherapy and debridement
•    Interpret X-ray and cross-sectional imaging of the paranasal sinuses
•    Demonstrate a sophisticated approach to selection of the surgical candidate for treatment of nasal obstruction and chronic rhinosinusitis, including indications for endoscopic sinus surgery and the extent of the procedure to be performed.
•    Effectively prepare patients for endonasal surgery such as septoplasty and endoscopic sinus surgery, including he informed consent process (description of risks/possible complications)
•    Perform nasal septoplasty including choice of incision, method of septoplasty, and closure materials with decreasing degree of direct consultant supervision
•    Perform inferior turbinate reduction with limited consultant supervision
•    Refine knowledge of paranasal sinus anatomy and perform surgical techniques of endoscopic polypectomy, uncinectomy, ethmoidectomy, and middle meatal antrostomy with decreasing degree of direct consultant supervision
•    Perform endoscopic sphenoidotomy and frontal recess dissection with direct consultant supervision
•    Acquire familiarity and assist at endoscopic approaches to the pituitary gland
•    Perform surgical treatments for epistaxis including endoscopic sphenopalatine artery ligation and anterior ethmoid artery ligation as well as internal maxillary artery ligation
•    Acquire familiarity with techniques for the management of benign sinonasal neoplasms such as inverted papilloma (e.g. endoscopic medial maxillectomy)