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Figure 1.
Percentage of Congenital Anomalies, Head and Neck Procedures, and Endoscopic Aerodigestive Procedures Managed by the Pediatric Otorhinolaryngology (ORL) Service
Percentage of Congenital Anomalies, Head and Neck Procedures, and Endoscopic Aerodigestive Procedures Managed by the Pediatric Otorhinolaryngology (ORL) Service
Figure 2.
Percentage of Facial Plastics, Otology, Airway, Rhinology, and General Procedures Managed by the Pediatric Otorhinolaryngology (ORL) Service
Percentage of Facial Plastics, Otology, Airway, Rhinology, and General Procedures Managed by the Pediatric Otorhinolaryngology (ORL) Service
Figure 3.
Trends in Pediatric Otorhinolaryngology (ORL) Involvement, 2006-2016
Trends in Pediatric Otorhinolaryngology (ORL) Involvement, 2006-2016

JNA indicates juvenile nasopharyngeal angiofibroma.

1.
Ruben  RJ.  Development of pediatric otolaryngology in North America.  Int J Pediatr Otorhinolaryngol. 2009;73(4):541-546.PubMedGoogle ScholarCrossref
2.
Cunningham  MJ, Lin  AC.  Pediatric otolaryngology: the maturation of a pediatric surgical subspecialty.  Laryngoscope. 2011;121(1):194-201.PubMedGoogle ScholarCrossref
3.
Pediatric fellowship. SF Match Residency and Fellowship Matching Services website. https://www.sfmatch.org/specialtyinsideall.aspx?id=15&typ=1&name=Pediatric. Accessed December 16, 2016.
4.
Fellowship details. American Society of Pediatric Otolaryngology website. http://aspo.us/fellowshipdetails/. Accessed December 16, 2016.
5.
Ramsden  JD, Johnson  AP, Cocks  HC, Watkinson  JC.  Who performs thyroid surgery? a review of current otolaryngological practice.  Clin Otolaryngol Allied Sci. 2002;27(5):304-309.PubMedGoogle ScholarCrossref
6.
Sherick  DG, Buchman  SR, Patel  PP.  Pediatric facial fractures: analysis of differences in subspecialty care.  Plast Reconstr Surg. 1998;102(1):28-31.PubMedGoogle ScholarCrossref
7.
Le  BT, Holmgren  EP, Holmes  JD, Ueeck  BA, Dierks  EJ.  Referral patterns for the treatment of facial trauma in teaching hospitals in the United States.  J Oral Maxillofac Surg. 2003;61(5):557-560.PubMedGoogle ScholarCrossref
Original Investigation
April 2018

Changes in Scope of Procedures Performed by Pediatric Otolaryngologists in the Past Decade

Author Affiliations
  • 1Department of Otolaryngology and Communication Enhancement, Boston Children’s Hospital, Boston, Massachusetts
  • 2Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
  • 3Clinical Research Center, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
JAMA Otolaryngol Head Neck Surg. 2018;144(4):322-329. doi:10.1001/jamaoto.2017.3164
Key Points

Questions  What is the scope of pediatric otolaryngology practice within and outside the United States and how has that changed over the past decade?

Findings  In this survey study of 42 pediatric otolaryngology departments, 33 respondents reported the least involvement in procedures pertaining to facial plastic and reconstructive surgery, aerodigestive endoscopy, and congenital anomalies and the most involvement in otology, airway, rhinology, and general procedures. Most reported that their department’s degree of involvement in each procedure remained the same from 2006 to 2016.

Meaning  Involvement by the pediatric otolaryngology department varies by procedure, but these changes should be monitored to adequately adjust clinical practices.

Abstract

Importance  Monitoring current trends in pediatric otolaryngology will help adjust our training and practice paradigms in a way that ensures the long-term viability of the specialty.

Objectives  To gauge the current scope of pediatric otolaryngology (ORL) practice within and outside of the United States and to identify changes in caseload over the past decade.

Design, Setting, and Participants  An online survey was sent to pediatric ORL chairs and/or fellowship directors at 42 institutions in the United States and abroad. For 59 procedures, respondents were asked to estimate the percentage of cases performed by their department, determine whether this percentage has changed over the past 10 years (2006-2016), and identify any other specialties performing the procedure. Data were collected during a 2-week period in October 2016, from October 7 through 21, and analyzed from November 2016 through February 2017.

Main Outcomes and Measures  Main outcomes included the percentage of operations currently performed by the respondent’s department for each procedure; whether this percentage has decreased, increased, or remained the same over the past decade; other specialties that perform each procedure; and any procedures added to or eliminated from the respondent’s practice over the past decade.

Results  Respondents from 33 of the 42 academic institutions completed the survey (23 in the United States and 10 international; 79% response rate). Respondents reported the least involvement in procedures pertaining to facial plastic and reconstructive surgery, aerodigestive endoscopy, and congenital anomalies. Conversely, a mean (SD) of 91% (7%) reported performing 90% to 100% of otology, airway, rhinology, and general procedures. A mean (SD) of 82% (11%) reported that their department’s involvement in each procedure has remained the same from 2006 to 2016.

Conclusions and Relevance  The specialty of pediatric ORL has evolved over the past decade. There has been a notable decline in involvement in facial plastic and reconstructive surgery and treatment of vascular malformations and esophageal disorders. The management of thyroid disease is in flux. Monitoring current trends to adjust training and practice paradigms will ensure the long-term viability of the specialty.

Introduction

The development of otorhinolaryngology (ORL) as a surgical specialty in North America began in the late 19th century. However, it was not until the 1940s that otolaryngologists began specializing in the care of children.1 Formal organizations and societies, both national and international, were created to bring together practitioners in the field, the first of which was the Society of Ear, Nose, and Throat Advances in Children in 1973.1,2 Today, there are 23 accredited and 12 unaccredited fellowship programs in the United States and Canada.3 Pediatric ORL services exist at almost every children’s hospital in the United States and worldwide.

The field of ORL currently has 8 subspecialties, including pediatric, allergy, head and neck surgery, facial plastic and reconstructive surgery, otology/neurotology, rhinology, laryngology, and sleep medicine. Pediatric ORL covers a wide range of conditions, from common diseases such as recurrent acute otitis media to rare anomalies of the airway and congenital neck masses. In general, pediatric health care systems serve large populations and provide routine and complex ORL care.

It is important to monitor the current trends in pediatric ORL to ensure adequate resident training and foster collaboration with other specialties. Although trainees should receive a comprehensive and extensive education in all areas of the field, residency and fellowship programs should be tailored to match the current day-to-day practice of pediatric otolaryngologists. Training should emphasize conditions and surgical procedures most commonly managed by ORL rather than those typically managed by other departments. Furthermore, trainees and practicing otolaryngologists must recognize which specialties are beginning to perform operations that were previously considered ORL procedures.

For example, not only is pediatric ORL an integral component of general ORL training, but there is substantial overlap with multiple medical and surgical specialties in treatment of the upper aerodigestive tract and craniofacial structures. These include general surgery, facial plastic surgery, oral surgery, gastroenterology, and pulmonology. Because the practice of medicine is dynamic and perpetually growing, we must continually review and redefine the scope of pediatric ORL.

The objectives of the present study were to gauge the current scope of pediatric ORL practice at institutions within and outside of the United States and identify changes in caseload over the past 10 years to highlight areas of loss or stagnancy and discuss the standardization and expansion of training.

Methods

We developed an online survey that asked respondents to estimate the percentage of specific procedures performed by pediatric otolaryngologists at their institutions (eAppendix in the Supplement). Pediatric ORL chairs and/or fellowship directors at 42 academic institutions were identified as potential respondents; 31 institutions were in the United States and 11 were international. Potential participants were emailed a brief description of the study and a link to the online survey, which was hosted on our institution’s REDCap (Research Electronic Data Capture) service. The institutional review board at Boston Children’s Hospital, Boston, Massachusetts, deemed this study exempt from formal approval procedures.

The survey was initially emailed to potential respondents on October 7, 2016, with a follow-up email reminder sent on October 17, 2016. The survey consisted of 181 items and evaluated 59 procedures. Procedures were divided into 8 categories: congenital anomalies, head and neck, otology, airway, aerodigestive endoscopy, rhinology, facial plastic surgery, and general. Main outcomes included the percentage of operations currently performed by the respondent’s department for each procedure; whether this percentage has decreased, increased, or remained the same over the past decade; other specialties that perform each procedure; and any procedures added to or eliminated from the respondent’s practice over the past decade.

Respondents indicated their department’s current involvement in each procedure by choosing one of 6 percentage intervals (0%-9%, 10%-29%, 30%-49%, 50%-69%,70%-89%, or 90%-100%). For each procedure, respondents were asked to judge whether the percentage performed by the department has decreased, increased, or remained the same over the past 10 years. For each procedure with a reported decline, respondents were asked to indicate which specialty performs the majority of cases. Responses to these questions were required; a survey was deemed complete if all required questions were answered. At the conclusion of the survey, respondents were asked to list any procedures that were added or eliminated from the respondent’s practice during the past decade. Respondents were also asked to name the specialty or specialties that previously performed or now perform those procedures, if applicable. Responses to the last 2 questions were optional. Data collection occurred from October 7 through October 21, 2016. Data analysis began in November 2016 and continued through February 2017.

Partially completed surveys were excluded from analysis. Descriptive statistics were performed using SAS, version 9.4 (SAS Institute Inc).

Results
Respondents

Thirty-three respondents of 42 academic institutions (79%) completed the survey. Respondents included pediatric ORL chairs and/or fellowship directors from 23 institutions in the United States and 10 international institutions: 7 in Europe, 2 in Canada, and 1 in Australia. Of the 23 hospitals in the United States, 7 were in the East, 7 in the South, 5 in the Midwest, and 4 in the West. Respondents represented 26 children’s hospitals and 7 general hospitals.

Current Practice and Scope

The procedures with the highest number of institutions reporting that they perform more than half of the surgical caseload were those involving the airway, rhinology, and general procedures. On the other hand, a mean (SD) of 19 institutions (58% [26%]) reported less than 50% involvement in facial plastic surgery procedures. There were no procedures, in any category, for which all 33 institutions reported 90% to 100% involvement.

With regard to the following findings, there were no notable differences between institutions within and outside the United States. There were also no differences between pediatric and general hospitals.

Congenital Anomalies

Management of congenital anomalies is depicted in Figure 1. There were no procedures for which all institutions reported more than 50% involvement. Thirty-two institutions (97%) reported that the pediatric ORL department performs more than half of the caseload for excision of branchial cleft, nasal dermoid, and thyroglossal duct cysts. In addition, 31 respondents (94%) reported that they perform more than half of the excisions of head and neck dermoid cysts and ranulas. Among congenital anomaly procedures, pediatric ORL had the strongest involvement in ranula excision, with 28 institutions (85%) reporting 90% to 100% involvement. Conversely, 21 institutions (64%) reported that they were involved in less than half of hemangioma/lymphatic malformation/venous malformation cases requiring nonsurgical management. Ten institutions (30%) reported that they manage 0% to 9% of these cases.

Head and Neck

Pediatric ORL involvement in the management of head and neck anomalies is depicted in Figure 1. All respondents reported that they manage more than 50% of cases for drainage of neck, retropharyngeal, or parapharyngeal abscesses as well as excision of nasopharyngeal tumors. Thirty-two institutions (97%) reported that they perform 90% to 100% of retropharyngeal/parapharyngeal abscess procedures. On the other hand, 9 institutions (27%) reported that they perform less than 50% of thyroidectomies, with 4 (12%) reporting that they were involved in 0% to 9%.

Aerodigestive

Involvement in aerodigestive procedures is depicted in Figure 1. All respondents reported that they perform more than 50% of endoscopic laryngeal procedures for tumors or vocal cord nodules, cysts, and polyps. Thirty-two institutions (97%) reported 90% to 100% involvement in these cases. In addition, all respondents reported that they perform more than 50% of laryngoscopy cases, and 32 (97%) reported the same for complete or partial arytenoidectomy. These findings were in stark contrast to the results for flexible esophagoscopy, which had more respondents reporting less than 50% involvement than any other procedure (31 institutions [94%]). Twenty respondents (61%) reported that their department performs 0% to 9% of flexible esophagoscopy cases.

Facial Plastic and Reconstructive Surgery

Involvement in facial plastic surgery procedures is depicted in Figure 2. A mean (SD) of 19 respondents (58% [26%]) reported that they perform less than 50% of facial plastic surgery procedures. Of all the procedure categories, facial plastic surgery had the highest mean number of respondents reporting less than 50% involvement. Twenty-nine institutions (88%) reported that they perform less than 50% of mandibular distraction cases, and 26 (79%) reported that they perform 0% to 9% of these operations. Institutions responded similarly for cleft lip, cleft palate, orbital trauma, mandibular trauma, maxillary trauma, and midface trauma. However, temporal bone trauma and nasal trauma had much more involvement from pediatric ORL, with 32 institutions (97%) reporting that they manage more than half of the caseload for temporal bone trauma and 31 (94%) for nasal trauma. Among facial plastic surgery procedures, temporal bone trauma had the highest involvement from pediatric ORL, with 30 institutions (91%) reporting 90% to 100% involvement. There were no procedures in this category for which all institutions reported more than 50% involvement.

Otology, Airway, Rhinology, and General

Results are depicted in Figure 2. A mean (SD) of 30 respondents (91% [7%]) reported that they perform 90% to 100% of otology, rhinology, general, and airway procedures. For each general procedure (tonsillectomy/tonsillotomy, adenoidectomy, and tympanostomy tube placement), 31 institutions (94%) reported that they perform 90% to 100% of cases. For airway procedures, 32 institutions (97%) reported that they perform 90% to 100% of laryngoplasty, laryngotracheal reconstruction, and cricotracheal reconstruction cases.

Trends Throughout Past 10 Years

A mean (SD) of 27 respondents (82% [11%]) reported that, on average, their department’s degree of involvement in each procedure has remained the same across the past decade. A mean (SD) of 2 respondents (6% [5%]) reported a decrease and 4 (12% [9%]) reported an increase in involvement. The procedure with the most variation in trends was thyroidectomy, in which 10 institutions (30%) reported no change, 16 (49%) reported an increase, and 7 (21%) reported a decrease (Figure 3).

Volume Decreases

Overall, the number of institutions reporting a decrease in involvement over the past decade ranged from 0 to 7 (21%). Procedures with the most reports of decline across the past 10 years included excision and nonsurgical management of hemangioma/lymphatic malformation/venous malformation (7 institutions [21%]) and thyroidectomy (7 [21%]). In addition, 5 institutions (15%) reported a decrease in flexible esophagoscopy and cleft lip repair.

For excision of hemangioma/lymphatic malformation/venous malformation, 4 institutions (12%) reported that the pediatric plastic surgery department manages the procedure. For nonsurgical therapy for this condition, 5 institutions (15%) listed the interventional radiology department. Thyroidectomy was reported to be performed by the general surgery department by 6 institutions (18%) and flexible esophagoscopy was managed by the pediatric gastroenterology department (3 [9%]) or general surgery (2 [6%]).

Among facial plastic surgery procedures, institutions reported loss to other specialties for all but 1 procedure (management of temporal bone trauma). Pediatric plastic surgery was most commonly reported as the dominant specialty in this field, particularly for cleft lip repair (4 institutions [12%]), cleft palate repair (3 [9%]), microtia repair (3 [9%]), and otoplasty (3 [9%]). Pediatric plastic surgery was also reported for pharyngoplasty/pharyngeal flap procedure (2 institutions [6%]), nasal trauma (2 [6%]), and repair of complex lacerations (2 [6%]). Oral surgery and plastic surgery were the dominant specialties for managing mandibular trauma (4 institutions [12%]), maxillary trauma (3 [9%]), and midface (Le Fort) trauma (3 [9%]). Finally, respondents reported that neurosurgery (1 institution [3%]) or pediatric plastic surgery (1 [3%]) departments managed frontal sinus trauma, and the ophthalmology and plastic surgery departments (3 [9%]) managed orbital trauma.

Growth

The number of institutions reporting an increase in involvement across the past decade ranged from 0 to 16 (48%) Thyroidectomy was the single procedure with the highest number of institutions reporting an increase (16 institutions [48%]). No institutions reported an increase for flexible esophagoscopy and several facial plastic surgery procedures, including nasal trauma, mandibular trauma, maxillary trauma, frontal sinus trauma, temporal bone trauma, and midface (Le Fort) trauma. Facial plastic surgery had the highest proportion of procedures with no reported increase in involvement.

Procedures Added or Lost During the Past 10 Years

Respondents were asked to report whether any procedures were added to their pediatric ORL practice during the past 10 years. Eighteen respondents (55%) answered yes. These procedures included thyroid or endocrine surgery (8 institutions [24%]), bone-anchored hearing aid (3 [9%]), pharyngeal flap (2 [6%]), and tracheal surgery (2 [6%]). Other procedures included facial/nasal dermoid cyst excision, otoplasty, repair of nasal malformations, robotic surgery, skull base surgery, skull-transsphenoidal and anterior neck surgical approaches, sphincteroplasty, Furlow palatoplasty, and velopharyngeal insufficiency surgery (1 institution [3%] each).

Respondents were also asked to report whether any procedures were eliminated from their pediatric ORL practice during the past 10 years. Twelve respondents (36%) answered yes. These procedures included esophagoscopy (3 institutions [9%]) and mandibular trauma, sclerotherapy, otoplasty, and thyroid surgery (2 institutions [6%] each). Other procedures included laser treatment of cutaneous vascular lesions, needle biopsy, treatment of midface and maxillary trauma, nasal dermoid cyst excision, and rigid bronchoscopy (1 institution [3.0%] each).

Discussion

Pediatric surgical subspecialties have grown rapidly during the past several decades. Applicants for pediatric ORL fellowships on the SF Match website almost tripled from 2001 to 2011 and have exceeded 40 applicants per year since 2008.3 This has paralleled an increase in the number of training programs both nationally and internationally.4

The addition of new procedures and clinical practices should complement the steady rise in the number of pediatric ORL training programs and trainees, enabling the field to grow both in the number of practitioners and in scope. However, our findings suggest that there may be a lack of growth in certain areas of the discipline, such as facial plastic surgery, aerodigestive endoscopy, and congenital anomaly procedures. A number of institutions reported that they manage less than half of the cases in these areas, with the most notable lack of involvement seen in facial plastic surgery procedures. Within each category, there were often specific procedures that had more substantial loss. The most remarkable example was flexible esophagoscopy, which had the highest number of institutions (31) reporting less than 50% involvement. When asked which specialties now perform this procedure, 3 institutions listed pediatric gastroenterology.

Our analysis of trends in pediatric ORL practice over the past decade suggests that the specialty has, on the whole, remained stable. For each procedure, on average, 82% of institutions reported that their department’s degree of involvement has remained the same. The procedure that has undergone the most change is thyroidectomy, with nearly half of respondents (16) reporting an increase in involvement and almost a quarter (7) reporting a decrease in involvement. In accordance with these findings, a study in the United Kingdom previously reported that general surgeons perform 83% of thyroid operations; ORL surgeons perform 15.4%; and plastic surgeons, maxillofacial surgeons, and cardiothoracic surgeons perform the remainder.5

Based on the findings from our survey, pediatric ORL training may also lack craniofacial trauma and cleft lip/palate experience at most institutions. Overall, respondents reported less than 50% involvement for more procedures in facial plastic surgery than any other category. In addition, facial plastic surgery had the highest proportion of procedures with no reported increase in involvement over the past 10 years. Two previous studies have discussed the overlap between ORL and plastic surgery practices, both of which focus on referral patterns for facial trauma.6,7 In both reports, the management of facial fractures was divided between plastic surgery, oral surgery, and ORL departments. Similarly, several respondents to our survey indicated that plastic surgery and oral surgery departments manage the majority of facial plastic surgery procedures at their respective institutions. Although the relative involvement of each specialty in the management of facial plastic surgery cases may vary by physician preferences and institutional protocols, it is important to recognize which cases require collaboration with ORL to optimize clinical outcomes.

Collaboration with the adult ORL department is another point of interest for many pediatric otolaryngologists. The extent to which otolaryngologists who treat adults also treat pediatric patients can vary widely based on the size of the institution at which they practice, the number of otolaryngologists, and the patient load. For the purposes of our study, we considered adult and pediatric otolaryngology to be separate specialties. However, it is important to recognize that otolaryngologists who treat adults also care for children at many institutions, which may contribute to slight discrepancies in the scope of care for pediatric ORL.

Pediatric ORL societies should monitor changes in the percentage of procedures performed. Understanding which procedures other specialties or adult otolaryngologists are taking on is important for maintenance of patient care in the field. This will not only strengthen and unify our clinical practice and training but will help focus research and quality improvement efforts on the procedures that are universally performed by our specialty.

Limitations

The results of this investigation are affected by limitations in study design. For one, the respondents to this survey were nonrandomly selected based on their position at academic medical institutions. This survey was not administered to otolaryngologists based in community hospitals or private practice. Moreover, there were approximately twice as many respondents who practiced in the United States as at international institutions. Another limitation was the restricted set of multiple-choice response options on the survey (eg, 0%-9%, 10%-29%, and 30%-49%). Although it maintained simplicity and brevity, the multiple-choice format limited the possible range of responses to each question. For example, this survey did not collect qualitative information specifying the degree to which involvement in procedures has changed but only if it has increased, decreased, or remained the same.

Conclusions

Pediatric ORL is a highly specialized field that has undergone several changes over the past decade. Current data show that the field is rapidly growing and accepting more trainees than in previous years. It is important for practitioners to monitor current trends in surgical caseload and adjust our training, clinical practice, and research efforts accordingly. Awareness of trends is especially necessary when considering educational factors that can affect them, such as upcoming Certificates of Added Qualification, which may increase the number of qualified physicians outside of pediatric ORL and skew the types of cases seen within the field. Awareness of trends and communication with other specialties will ensure we remain strong in all aspects of our discipline.

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Article Information

Corresponding Author: Reza Rahbar, DMD, MD, Department of Otolaryngology and Communication Enhancement, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115 (reza.rahbar@childrens.harvard.edu).

Accepted for Publication: December 5, 2017.

Published Online: February 22, 2018. doi:10.1001/jamaoto.2017.3164

Author Contributions: Ms Irace and Dr Kawai had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Adil, Rahbar.

Acquisition, analysis, or interpretation of data: Irace, Shank, Cunningham, Kawai, Sideridis.

Drafting of the manuscript: Irace, Shank, Adil, Sideridis, Rahbar.

Critical revision of the manuscript for important intellectual content: Irace, Cunningham, Kawai, Rahbar.

Statistical analysis: Kawai, Sideridis.

Administrative, technical, or material support: Irace, Shank, Rahbar.

Study supervision: Adil, Cunningham, Rahbar.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Meeting Presentation: This study was presented at the American Society of Pediatric Otolaryngology Annual Meeting; May 19, 2017; Austin, Texas.

References
1.
Ruben  RJ.  Development of pediatric otolaryngology in North America.  Int J Pediatr Otorhinolaryngol. 2009;73(4):541-546.PubMedGoogle ScholarCrossref
2.
Cunningham  MJ, Lin  AC.  Pediatric otolaryngology: the maturation of a pediatric surgical subspecialty.  Laryngoscope. 2011;121(1):194-201.PubMedGoogle ScholarCrossref
3.
Pediatric fellowship. SF Match Residency and Fellowship Matching Services website. https://www.sfmatch.org/specialtyinsideall.aspx?id=15&typ=1&name=Pediatric. Accessed December 16, 2016.
4.
Fellowship details. American Society of Pediatric Otolaryngology website. http://aspo.us/fellowshipdetails/. Accessed December 16, 2016.
5.
Ramsden  JD, Johnson  AP, Cocks  HC, Watkinson  JC.  Who performs thyroid surgery? a review of current otolaryngological practice.  Clin Otolaryngol Allied Sci. 2002;27(5):304-309.PubMedGoogle ScholarCrossref
6.
Sherick  DG, Buchman  SR, Patel  PP.  Pediatric facial fractures: analysis of differences in subspecialty care.  Plast Reconstr Surg. 1998;102(1):28-31.PubMedGoogle ScholarCrossref
7.
Le  BT, Holmgren  EP, Holmes  JD, Ueeck  BA, Dierks  EJ.  Referral patterns for the treatment of facial trauma in teaching hospitals in the United States.  J Oral Maxillofac Surg. 2003;61(5):557-560.PubMedGoogle ScholarCrossref
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