Ali Taghi

Construct validity of the ovine model in endoscopic sinus surgery training

To demonstrate construct validity of the ovine model as a tool for training in endoscopic sinus surgery (ESS).

Balloon Sinuplasty™: balloon-catheter dilation of paranasal sinus ostia for chronic rhinosinusitis

More than 100 million patients worldwide suffer from chronic rhinosinusitis, and a considerable amount of money has been spent on research and treatments by healthcare providers. In the northern hemisphere, damp, temperate climates, along with higher concentrations of pollen, are associated with a higher prevalence of chronic rhinosinusitis. Owing to its persistent nature, the disease can become a significant cause of morbidity. If untreated, it can reduce quality of life and productivity. When medical treatment is not effective, surgery may offer an excellent outcome. Although functional endoscopic surgery has proven to be effective, many cases could be managed medically. Recent research has suggested that optimal medical treatment is as effective as surgery in patients with chronic rhinosinusitis at the end of 1 year. Balloon Sinuplasty™ (Acclarent, Inc., CA, USA) is a new technique in the management of sinusitis and is a hotly debated topic. It is a delicate, minimally invasive tool, and early research demonstrates promising outcomes in terms of safety and effectiveness. This novel technique has been approved by the US FDA. Recently, NICE raised no concerns regarding its safety and efficacy but will continue to review this procedure.

Feasibility of a synthetic temporal bone for training in mastoidectomy: face, content, and concurrent validity.

Objective To investigate the face, content, and concurrent validity of the synthetic Pettigrew temporal bone (PTB) for mastoidectomy training as compared with cadaveric temporal bone (CTB). Study Design A prospective evaluation study. Methods Participants were invited to perform a step-by-step modified radical mastoidectomy using both bones and complete a 22-item, 5-point Likert scale questionnaire. The questionnaire is divided into 4 domains: face validity (FV), global content (GC), task-specific content (TSC), and curriculum recommendation (CR). Results Thirty-six experts and 89 trainees completed all tasks, 63 using CTB and 62 using PTB. The PTB median FV was 4 (IQR: 4–5), GC of 4 (IQR: 4–5), TSC of 4 (IQR: 3–4), and CR of 4 (IQR: 4–5). The CTB was rated significantly higher than PTB by both groups in all domains; CTB FV: 5 (IQR: 4–5), GC: 5 (IQR: 4–5), TSC: 5 (IQR: 4–5), and CR: 5 (IQR: 5–5), p < 0.001 for each. Trainees rated PTB significantly higher than experts in all domains. There was no statistically significant difference between experts and trainees in rating the CTB in all domains. PTB gives similar haptic feedback to CTB, allows the use of suction and irrigation, has the important landmarks painted for identification, and contains articulating ossicles. The facial nerve anatomy was found to be inaccurate around the region of the second genu. Conclusion Participants found PTB to be valid for teaching some, yet not all, aspects of mastoid surgery, and experts agreed that it could improve global transferrable otologic skills. It is essential that the facial nerve anatomy is addressed before recommending this model.

An interesting collection of paraneoplastic syndromes in a patient with a malignant thymoma

Paraneoplastic neurological syndromes are conditions that manifest as the remote effects of cancer. These are very rare, occurring in 1/10000 patients with a malignancy, and include Lambert–Eaton myasthenic syndrome, limbic encephalitis, subacute cerebellar ataxia, opsoclonus-myoclonus, Stiff–Person Syndrome, retinopathies, chronic gastrointestinal pseudo-obstruction and sensory neuropathy. This report describes a case of 41-year-old man who presented with elements of multiple paraneoplastic syndromes, including chronic gastrointestinal pseudo-obstruction, myasthenia gravis-Lambert–Eaton overlap syndrome and polymyositis, and who was subsequently found to have a malignant thymoma. There are only three reported cases in the literature describing cases of Lambert–Eaton myasthenic syndrome in association with a thymoma, and only one case of a myasthenia gravis-Lambert–Eaton overlap syndrome in a patient with thymoma. However, there are no documented cases in the literature of this constellation of syndromes in a patient with a malignant thymoma.

Double seal technique to obliterate the eustachian tube orifice: a novel method for the treatment of recalcitrant cerebrospinal fluid leak.

OBJECTIVE To demonstrate a novel and effective surgical technique for the treatment of refractory cerebrospinal fluid rhinorrhoea after skull base surgery. The novel surgical technique is described and the findings of a review of relevant world English-language publications are reported. CASE REPORT A 44-year-old woman, otherwise fit and well, presented with more than a 2-year history of right-sided facial pain. A diagnosis of classical trigeminal neuralgia was made. Surgical treatment was undertaken with a retromastoid suboccipital craniotomy. Post-operatively, the patient showed signs of right-sided cerebrospinal fluid rhinorrhoea which was recalcitrant. In light of a continuous leak and several hospital admissions, a novel technique was performed whereby the eustachian tube orifice was obliterated using an endonasal endoscopic approach. The technique proved to be successful, with no further leakage. CONCLUSION Endoscopic obliteration of the eustachian tube using a double seal technique is a simple, safe and effective procedure in the treatment of a refractory cerebrospinal fluid leak.

A rare case of bilateral nasolabial cysts

Nasolabial cysts are rare non-odontogenic cystic lesions representing around 0.7% of all maxillofacial cysts. They usually present as unilateral painless swellings, sometimes with epiphora and dacryocystitis as well as pain in cases of rapid growth or infection. We have reviewed the literature and present an extremely rare case of bilateral nasolabial cysts in a young Afro-Caribbean man presenting with chronic nasal blockage, epiphora and rhinorrhoea. We describe our successful surgical management using a sublabial approach for complete excision, leading to a disease-free outcome at 6 months follow-up. Other modalities have been described, from endoscopic marsupialisation to simple aspiration. However, with the exception of complete surgical excision, all other surgical techniques are associated with a high recurrence rate. We therefore advocate complete surgical excision as described below for optimal results.

Barotraumatic perforation of the pharyngo-oesophagus secondary to a Lambrini "bottle explosion".

An interesting case of a middle-aged woman who sustained oral lacerations and pharyngeal tear/perforation on opening a bottle of Lambrini sparkling wine with her teeth is presented. The patient presented to the Accident and Emergency (A&E) department with bleeding from the mouth and dyspnoea, and on examination had a neck surgical emphysema and visible laceration to the oropharynx. On further investigation, including a range of imaging modalities, a diagnosis of pharyngeal tear/perforation was made, detected on a gastrograffin swallow test. The patient was subsequently treated conservatively, being kept nil by mouth and fed through a nasogastric tube, with prophylactic antibiotic cover. The patient was re-imaged 1 week later, which displayed complete resolution of the tear, and was subsequently discharged on a normal oral diet.

Binary versus 5-Point Likert Scale in Assessing Otolaryngology Trainees in Endoscopic Sinus Surgery

Objectives: (1) Examine the discriminant validity of 2 validated assessment tools in endoscopic sinus surgery (ESS) training. (2) Compare the binary versus the 5-point Likert-scale tools in ESS assessment. Methods: A cross-sectional study was conducted from February-August 2013. All otolaryngology trainees in the North-London training program were assessed while performing ESS on sheep heads, which previously showed face and content validity. Performance was rated by 2 blinded assessors using 2 validated tools: The Inter-Collegiate-Surgical-Curriculum-Project tool, which utilizes a binary system and is used throughout the UK surgical training system, and the John Hopkins 5-Point Likert scale ESS tool. The tools’ construct validities were tested by comparing performance of experts and novices. The tools were also tested by correlating task-specific and global skills ratings with overall performance level. Results: The binary tool showed higher inter-rater reliability than the Likert scale, both in task-specific (Kappa: 0.89 versus 0.62) and global skills (Kappa: 0.79 versus 0.68) rating. Both tools discriminated between different levels of expertise in global and task-specific skills (Kruskal-Wallis: P < .001 for all). But pairwise comparison showed that Likert scale tool was a better discriminator between novices and trainees, globally (P = .016 versus P < .271) and task-specifically (P = .049 versus P = .449). Likert scale tool also correlated better with overall performance globally (r = 0.903 versus 0.741) and task-specifically (r = 0.833 versus 0.802). Conclusions: While the binary assessment tool may show higher inter-rater reliability and is easier to complete, the Likert scale, when each level is well defined, showed good agreement and better construct validity, which can be useful when monitoring progress in training.

Optimal Endoscopic Management of Sinonasal Inverted Papilloma: Recurrence-Free Experience with Twenty-one Patients

Objectives: 1) Explore developments in endoscopic techniques and their application in the management of Sinonasal Inverted Papilloma (SNIP). 2) Describe 0% recurrence rates with aggressive endoscopic resection of complex SNIP. Methods: Retrospective single-center patient cohort analysis of twenty-one cases of SNIP treated by endoscopic resection at Charing Cross Hospital from December 2002 to September 2012. Pre-operative assessment included tomography or magnetic resonance imaging and biopsies. The origin and extent of the tumor determined the surgical strategy, and a combination of antrostomy, ethmoidectomy, sphenoidotomy, and endoscopic medial maxillectomy (EMM) with the assistance of angled instrumentation were performed. Sub-periosteal dissection followed by diamond burr drilling of the underlying bone were performed in all cases. All patients were followed up by regular endoscopic surveillance. Results: The study group consisted of 12 (57%) male and 9 (43%) female patients with a mean age of 59 years. Eleven patients (52%) had undergone previous surgery. Association with malignancy was seen in 2 patients (excluded from this study). All patients were treated by pure endoscopic means without adjunctive procedures. Completion surgery was performed on 1 patient with residual disease and histological atypia identified early after the operation. No recurrences were observed after a mean follow-up of 25 months. Conclusions: Our experience is one of the largest single-center recurrence-free case series for SNIP treated by pure endoscopic resection. It further supports the efficacy and safety of this technique even in complex recurrent cases and advocates its use as the gold standard first line surgical strategy.