Arvind Singh

Detecting cholesteatoma with non-echo planar (HASTE) diffusion-weighted magnetic resonance imaging

Objective: The purpose of this study was to evaluate the diagnostic performance of half-Fourier-acquisition single-shot turbo-spin-echo (HASTE) diffusion-weighted magnetic resonance imaging (DWMRI) in the detection of cholesteatoma. Study Design: Prospective blinded comparative study. Setting: London teaching hospital. Subjects and Methods: Subjects comprised 32 consecutive patients with suspected primary or residual cholesteatoma. HASTE DWMRI was performed on all patients an average of three months before mastoid surgery and evaluated for the presence of cholesteatoma. Radiological findings were correlated with intraoperative findings. Results: HASTE DWMRI accurately predicted the presence or absence of cholesteatoma in 30 of 32 patients. Residual cholesteatoma was correctly diagnosed by DWMRI in 12 of 14 cases and correctly excluded in six, with two false-negative results caused by movement artifact and keratin pearls less than 2 mm. All primary cholesteatomas were correctly identified. Sensitivity and specificity were 0.93 (95% confidence interval [CI] 0.75-0.99) and 1.00 (95% CI 0.54-1.0), respectively, whereas positive and negative predictive values were 1.00 (95% CI 0.86-1.00) and 0.75 (95% CI 0.35-0.97), respectively. Conclusion: Our study supports the increasing but small body of evidence that non–echo-planar imaging (i.e., HASTE) DWMRI performs well in the detection of cholesteatoma. We propose that HASTE DWMRI should be performed on all patients before their second-look surgery to provide valuable information to the operating surgeon.

Virtual reality simulation training in Otolaryngology

OBJECTIVEnTo conduct a systematic review of the validity data for the virtual reality surgical simulator platforms available in Otolaryngology.nnnDATA SOURCESnOvid and Embase databases searched July 13, 2013.nnnREVIEW METHODSnFour hundred and nine abstracts were independently reviewed by 2 authors. Thirty-six articles which fulfilled the search criteria were retrieved and viewed in full text. These articles were assessed for quantitative data on at least one aspect of face, content, construct or predictive validity. Papers were stratified by simulator, sub-specialty and further classified by the validation method used.nnnRESULTSnThere were 21 articles reporting applications for temporal bone surgery (n = 12), endoscopic sinus surgery (n = 6) and myringotomy (n = 3). Four different simulator platforms were validated for temporal bone surgery and two for each of the other surgical applications. Face/content validation represented the most frequent study type (9/21). Construct validation studies performed on temporal bone and endoscopic sinus surgery simulators showed that performance measures reliably discriminated between different experience levels. Simulation training improved cadaver temporal bone dissection skills and operating room performance in sinus surgery.nnnCONCLUSIONnSeveral simulator platforms particularly in temporal bone surgery and endoscopic sinus surgery are worthy of incorporation into training programmes. Standardised metrics are necessary to guide curriculum development in Otolaryngology.

The value of non-echo planar HASTE diffusion-weighted MR imaging in the detection, localisation and prediction of extent of postoperative cholesteatoma

Clin. Otolaryngol. 2011, 36, 306–312

The follow-up of patients with head and neck cancer: an analysis of 1,039 patients

In all cancer specialities, there has been much debate about the best follow-up regime. The provision of a service that meets high standards whilst being cost-effective is increasingly pertinent. The objectives of the study were to examine: whether routine follow-up facilitates early diagnosis and recurrence; whether there is a cohort of patients who require a more intensive follow-up regime; whether follow-up should be customised to individual patients. A total of 1,039 consecutive outpatient consultations were prospectively analysed in a multicentre study. All adult patients who had undergone multidisciplinary, multimodality management for head and neck cancer were included. The case mix was representative of all head and neck tumour sites and stages. Suspicion of recurrence was noted in 10% (nxa0=xa096/951) of patients seen routinely. This rose to 68% (nxa0=xa060/88) for the subset of patients who had requested an appointment. Most recurrences were found within the first follow-up year (nxa0=xa064/156, 54%). Only 0.3% (nxa0=xa03/1,039) of asymptomatic patients attending routine appointments were suspected of having a recurrence, and two (0.2%) were found to have an actual recurrence following investigation. Of the total number of patients reporting a new suspicious symptom, recurrence was suspected in 56% (nxa0=xa0152/270). Patients thus had a 98.1% sensitivity to raising suspicion for a recurrence based on the reporting of new symptoms with a 99.6% negative predictive value. Our data show that the efficiency of the current follow-up regime at detecting suspected recurrence of head and neck cancer is low, suggesting the need for a customised, more focused follow-up regime, tailored to individual cases. Patient education and close relationships with clinicians and allied health-care professionals are essential for early diagnosis and management of cancer recurrence. Follow-up regimes within the first year should be most intensive as recurrence is most likely within this time, and it serves to alleviate patient anxiety in the early post-treatment period. More research needs to be carried out to investigate the role of patient self-reporting and surveillance of cancer recurrence.

Objective assessment of learning curves for the Voxel-Man TempoSurg temporal bone surgery computer simulator

INTRODUCTIONnSimulators are becoming an increasingly important part of surgical training. Temporal bone surgery is one area in which simulators, such as the Voxel-Man TempoSurg simulator, are likely to play a significant role in training. We present learning curve data from novice trainees using this simulator to learn cortical mastoidectomy, exposure of the sigmoid sinus, and exposure of the short process of the incus.nnnMETHODSnWe measured the time taken to perform the procedures, the volume of reference bone removed, and the structures damaged during dissection.nnnRESULTSnWe found improvement in a number of parameters over the course of the study. The overall scores, structural damage scores and time taken improved, to differing degrees, for each task. The volume of reference bone removed remained constant.nnnCONCLUSIONnThese results indicate that the trainees efficiency improved as they became more proficient at removing a given volume of reference bone.

Evaluation of ApneaGraph in the diagnosis of sleep-related breathing disorders

ApneaGraph relies on measuring pressure and airflow simultaneously at different levels in the pharynx identifying the segment of airway obstruction and providing baseline respiratory parameters. This study aims to evaluate ApneaGraph and correlate results with both sleep nasendoscopy and polysomnography. This was a prospective study of 49 patients with snoring and/or obstructive sleep apnoea. Thirty of the these patients underwent a PSG and an ApneaGraph study simultaneously in the Sleep Lab. Nineteen patients attended the day surgery unit and had a sleep nasendoscopy with a 10-min ApneaGraph analysis. Polysomnography was used to validate the ApneaGraph system. There are no significant differences (independent t test, Pxa0>xa00.15) between ApneaGraph compared to Polysomnography based on the apnoea–hypopnoea index, total number of apnoeic events, average oxygen saturations and maximum desaturation. This suggests that the ApneaGraph can be used to assess OSA. Statistically, there is poor correlation between the two groups (Spearman’s ρ 0.29). In the cases of discordance, ApneaGraph places greater emphasis on a lower pharyngeal contribution. This unique study analyses the ApneaGraph system in the diagnosis of obstructive sleep apnoea and snoring. It demonstrates the benefits of this new system and highlights certain limitations in localizing the site and level of pharyngeal obstruction in patients with sleep disorders.

Virtual reality case-specific rehearsal in temporal bone surgery: A preliminary evaluation

OBJECTIVESn1. To investigate the feasibility of performing case-specific surgical rehearsal using a virtual reality temporal bone simulator. 2. To identify potential clinical applications in temporal bone surgery.nnnDESIGNnProspective assessment study.nnnSETTINGnSt Marys Hospital, Imperial College NHS Trust, London UK.nnnPARTICIPANTSnSixteen participants consisting of a trainer and trainee group.nnnMETHODnTwenty-four cadaver temporal bones were CT-scanned and uploaded onto the Voxelman simulator. Sixteen participants performed a 90-min temporal bone dissection on the generic simulation model followed by 3 dissection tasks on the case simulation and cadaver models. Case rehearsal was assessed for feasibility. Clinical applications and usefulness were evaluated using a 5-point Likert-type scale.nnnRESULTSnThe upload process required a semi-automated system. Average time for upload was 20 min. Suboptimal reconstruction occurred in 21% of cases arising when the mastoid process and ossicular chain were not captured (n = 2) or when artefact was generated (n = 3). Case rehearsal rated highly (Likert score >4) for confidence (75%), facilitating planning (75%) and training (94%). Potential clinical applications for case rehearsal include ossicular chain surgery, cochlear implantation and congenital anomalies. Case rehearsal of cholesteatoma surgery is not possible on the current platform due to suboptimal soft tissue representation.nnnCONCLUSIONnThe process of uploading CT data onto a virtual reality temporal bone simulator to perform surgical rehearsal is feasible using a semi-automated system. Further clinical evaluation is warranted to assess the benefit of performing patient-specific surgical rehearsal in selected procedures.

Staging primary middle ear cholesteatoma with non-echoplanar (half-Fourier-acquisition single-shot turbo-spin-echo) diffusion-weighted magnetic resonance imaging helps plan surgery in 22 patients: Our experience

Dear Editor, A middle ear cholesteatoma is a non-neoplastic lesion that is characterised histologically by desquamated debris surrounded by layers of keratinising squamous epithelium. It is essentially a clinical diagnosis and treated by surgery where possible. High-resolution computed tomography (CT) of the temporal bones is used to assess the extent of primary cholesteatoma, evaluate for complications (bony and ossicular erosion) and provide local anatomical information to plan surgery. Where the middle ear cleft is not completely opacified, the true extent of cholesteatoma may be defined on CT and this may be sufficient for precise surgical planning. However, in cases where the middle ear cleft is completely opacified on CT, it is not possible to determine the true extent of cholesteatoma because of poor ability of CT to differentiate between cholesteatoma and coexisting inflammatory tissue or fluid. Diffusion-weighted magnetic resonance imaging (DWI), in particular non-echoplanar half-Fourier-acquisition single-shot turbo-spin-echo (HASTE) DWI, has been shown to have high diagnostic performance in the detection of recurrent and residual cholesteatoma by exploiting the unique nature of the cholesteatoma itself, restricted diffusion and T2 shine through effect, that gives it a high signal on b1000 images relative to brain tissue and a corresponding low signal on the apparent diffusion coefficient (ADC) map. There is also a good correlation with size and location of recurrent and residual cholesteatoma between HASTE DWI and surgery. We aim to evaluate the performance of non-echoplanar HASTE DWI in staging the extent of primary cholesteatoma when CT demonstrates complete (or almost complete) soft tissue opacification of the middle ear cleft.

Teflon-induced granuloma: a source of false positive positron emission tomography and computerized tomography interpretation.

Patients diagnosed with malignancy often undergo combined positron emission tomography (PET) and computerized tomography (CT) to investigate possible metastases. This report presents a case in which, in the investigation of suspected pulmonary malignancy, combined PET and CT images suggested a malignant lesion at the level of the vocal fold. Biopsy of the lesion, however, confirmed the clinical diagnosis of a Teflon granuloma. The case highlights the potential for a false positive report during scanning of patients who have had vocal fold injection.

Prospective audit of the quality of ENT emergency clinic notes before and after introduction of a computerized template

This study evaluated the accuracy of notes in an ENT urgent referral clinic, based on a standard of note keeping established within the trust. The results initially failed to meet the set standard and a change of practice was initiated by introduction of a computerized template that allowed for easier and more accurate data entry. After re-evaluation, the notes were found to be accurate and to contain relevant demographic data in more than 90 per cent of cases.