Oral exam Case 1 Subungual melanoma
Case 2 Multiple facial fractures and nasoorbitoethmoid (NOE)
A 65-year-old woman with a personal history of melanoma presents with pigmentation under the nail of the great toe
Objective 1: The candidate can develop a differential diagnosis. Question 1: What is your differential diagnosis for this lesion? 1. Malignancy a. Subungual melanoma b. SCC 2. Infection a. Fungal b. Bacterial 3. Trauma a. Subungual hematoma 4. Benign pigmented lesion a. Subungual nevus b. Longitudinal melanonychia Objective 2: The candidate can develop a plan for diagnosis. Question 2: What investigations would you initiate at the time of consultation? 1. Removal of the nail 2. Excisional biopsy of lesion if possible 3. Incisional biopsy for diagnosis if excision not possible Objective 3: The candidate can manage the patient. The biopsy shows a 1.2 mm Breslow depth melanoma with ulceration. Question 3: What treatment would you recommend for this patient? 1. Amputation of great toe proximal to the IP joint. 2. Sentinel node biopsy The sentinel node biopsy shows 1 of 3 nodes positive for melanoma. Question 4: What further treatment would you recommend for this patient? 1. Inguinal lymphadenectomy 2. Referral to medical oncologist for consideration of Interferon
Objective 1: The candidate accurately diagnoses facial fractures. Question 1: What fractures/fracture patterns does this CT demonstrate? 1. Right LeFort 3 5. Bilateral Orbital Floor Fractures 2. Right and Left LeFort 2 6. Bilateral NOE Fractures 3. Right and Left LeFort 1 7. Nasal Fractures 4. Palatal Split Objective 2: The candidate can develop a plan for surgical management. Question 2: What must be completed before taking this patient to the operating room for ORIF? 1. Airway management a. Nasal ETT tube exchange or b. Trach or c. Submental intubation 2. C-spine clearance a. Radiographic b. Clinical 3. Opthalmological consultation and assessment Objective 3: The candidate can diagnose and classify NOE fractures. Question 3: How do you classify NOE fractures? • Manson • Type I: MCT is attached to a large central bone fragment • Type II: MCT is attached to comminuted bone fragments • Type III: MCT is avulsed from NOE bone segment Objective 4: The candidate can surgically manage a NOE fracture. Question 4: Describe your method of exposure and the technique used to correct each of the Manson type I, II and III fractures? • Laceration or coronal incision for upper reaches of NOE • Transconjunctival ± transcaruncular or Mid Lid for Lower reaches of NOE • Type I: Bimanual reduction and ORIF with microplates • Type II: Transnasal canthopexy • Type III: Transnasal canthopexy ± ORIF with microplates
Correspondence: Dr Douglas R McKay, Division of Plastic Surgery, Department of Surgery, Queen’s University, Hotel Dieu Hospital, 166 Brock Street, Brock 3R, B3031, Kingston, Ontario K7L 5G2. Telephone 613-544-3400 ext 2494, fax 613-544-3709, e-mail [email protected] 272
©2014 Canadian Society of Plastic Surgeons. All rights reserved
Plast Surg Vol 22 No 4 Winter 2014
Case 2 Multiple facial fractures and nasoorbitoethmoid (NOE)
A 65-year-old woman with a personal history of melanoma presents with pigmentation under the nail of the great toe
Objective 1: The candidate can develop a differential diagnosis. Question 1: What is your differential diagnosis for this lesion? 1. Malignancy a. Subungual melanoma b. SCC 2. Infection a. Fungal b. Bacterial 3. Trauma a. Subungual hematoma 4. Benign pigmented lesion a. Subungual nevus b. Longitudinal melanonychia Objective 2: The candidate can develop a plan for diagnosis. Question 2: What investigations would you initiate at the time of consultation? 1. Removal of the nail 2. Excisional biopsy of lesion if possible 3. Incisional biopsy for diagnosis if excision not possible Objective 3: The candidate can manage the patient. The biopsy shows a 1.2 mm Breslow depth melanoma with ulceration. Question 3: What treatment would you recommend for this patient? 1. Amputation of great toe proximal to the IP joint. 2. Sentinel node biopsy The sentinel node biopsy shows 1 of 3 nodes positive for melanoma. Question 4: What further treatment would you recommend for this patient? 1. Inguinal lymphadenectomy 2. Referral to medical oncologist for consideration of Interferon
Objective 1: The candidate accurately diagnoses facial fractures. Question 1: What fractures/fracture patterns does this CT demonstrate? 1. Right LeFort 3 5. Bilateral Orbital Floor Fractures 2. Right and Left LeFort 2 6. Bilateral NOE Fractures 3. Right and Left LeFort 1 7. Nasal Fractures 4. Palatal Split Objective 2: The candidate can develop a plan for surgical management. Question 2: What must be completed before taking this patient to the operating room for ORIF? 1. Airway management a. Nasal ETT tube exchange or b. Trach or c. Submental intubation 2. C-spine clearance a. Radiographic b. Clinical 3. Opthalmological consultation and assessment Objective 3: The candidate can diagnose and classify NOE fractures. Question 3: How do you classify NOE fractures? • Manson • Type I: MCT is attached to a large central bone fragment • Type II: MCT is attached to comminuted bone fragments • Type III: MCT is avulsed from NOE bone segment Objective 4: The candidate can surgically manage a NOE fracture. Question 4: Describe your method of exposure and the technique used to correct each of the Manson type I, II and III fractures? • Laceration or coronal incision for upper reaches of NOE • Transconjunctival ± transcaruncular or Mid Lid for Lower reaches of NOE • Type I: Bimanual reduction and ORIF with microplates • Type II: Transnasal canthopexy • Type III: Transnasal canthopexy ± ORIF with microplates
Correspondence: Dr Douglas R McKay, Division of Plastic Surgery, Department of Surgery, Queen’s University, Hotel Dieu Hospital, 166 Brock Street, Brock 3R, B3031, Kingston, Ontario K7L 5G2. Telephone 613-544-3400 ext 2494, fax 613-544-3709, e-mail [email protected] 272
©2014 Canadian Society of Plastic Surgeons. All rights reserved
Plast Surg Vol 22 No 4 Winter 2014
