Asit Arora

A multicenter cohort study of total thyroidectomy and routine central lymph node dissection for cN0 papillary thyroid cancer

BACKGROUND The role of routine central lymph node dissection (CLND) for papillary thyroid cancer (PTC) remains controversial. The aim of this study was to evaluate the impact of routine CLND after total thyroidectomy (TTx) in the management of patients with PTC who were clinically node negative at presentation with emphasis on stimulated thyroglobulin (Tg) levels and reoperation rates. METHODS This retrospective, multicenter, cohort study used pooled data from 3 international Endocrine Surgery units in Australia, the United States, and England. All study participants had PTC >1 cm without preoperative evidence of lymph node disease (cN0). Group A patients had TTx alone and group B had TTx with the addition of CLND. RESULTS There were 606 patients included in the study. Group A had 347 patients and group B 259 patients. Stimulated Tg values were lower in group B before initial radioiodine ablation (15.0 vs 6.6 ng/mL; P = .025). There was a trend toward a lower Tg at final follow-up in group B (1.9 vs 7.2 ng/mL; P = .11). The rate of reoperation in the central compartment was lower in group B (1.5 vs 6.1%; P = .004). The number of CLND procedures required to prevent 1 central compartment reoperation was calculated at 20. CONCLUSION The addition of routine CLND in cN0 papillary thyroid carcinoma is associated with lower postoperative Tg levels and reduces the need for reoperation in the central compartment.

Virtual reality simulation training in Otolaryngology

OBJECTIVE To conduct a systematic review of the validity data for the virtual reality surgical simulator platforms available in Otolaryngology. DATA SOURCES Ovid and Embase databases searched July 13, 2013. REVIEW METHODS Four 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. RESULTS There 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. CONCLUSION Several 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.

Objective skills assessment and construct validation of a virtual reality temporal bone simulator.

Objectives To evaluate construct validity of the Voxelman TempoSurg Virtual Reality (VR) temporal bone simulator by determining whether generated objective metrics can distinguish experienced otologic surgeons from intermediate and novice surgeons. Design Prospective assessment study. Setting Two university-affiliated teaching hospitals. Participants Sixty-five participants were recruited; 40 novice surgeons, 15 trainees in otolaryngology, and 10 experienced otolaryngology consultants with a specialist interest in otology were individually assessed on a standardized simulated temporal bone task. The task involved identification and delineation of the sigmoid sinus in a virtual left-sided temporal bone. Main Outcome Measures Objective data were produced using a scoring matrix incorporated into the VOXEL MAN TempoSurg software. The simulator measured the total time taken to complete the task, the volume and efficiency of bone removal and error data for excessive force or injury to the facial nerve, dura, and sigmoid sinus. Results Experts and intermediates outperformed novices with respect to the total time taken to complete the task (expert versus novice: p < 0.001; intermediate versus novice: p < 0.001), total volume of bone removed (p < 0.001 and p = 0.03), efficiency of bone removal (p < 0.001 and p < 0.001), time spent with the drill tip obscured (p = 0.002 and p < 0.001), and number of injuries to the sigmoid sinus (p < 0.001 and p < 0.001). The intermediate group injured the sigmoid sinus on more occasions than the experts (p = 0.008) and were less efficient than experienced surgeons (p = 0.005). Conclusion Simulator-generated objective metrics can be used to differentiate individuals of differing levels of experience using a standardized temporal bone task. VR simulation has potential as a training tool and may have a role in both formative and summative assessment.

Robotic-Assisted Parathyroidectomy: A Feasibility Study

Objective. Targeted parathyroidectomy is the gold standard for localized parathyroid disease. A robotic-assisted approach has not been investigated. The aim was to assess the feasibility of a robotic technique that avoids a neck scar. Study Design. Feasibility study. Setting. Tertiary referral center. Subjects and Methods. Eleven patients with primary hyperparathyroidism were prospectively evaluated. Triple modality concordant localization was a prerequisite. All patients underwent robotic-assisted parathyroidectomy (RAP). Outcome variables assessed were operative time, voice change, biochemical cure, and histopathological confirmation. Patient-reported outcome measures (PROMs) included subjective assessment of pain and scar cosmesis, Voice Handicap Index 2, and EQ-5D quality-of-life assessment. Mean follow-up was 6 months (range, 3-12 months). Results. The parathyroid adenoma was successfully excised in all cases with negligible blood loss (<5 mL). There was 1 conversion. There was no voice change in any case. Robot docking time plateaued to 10 minutes after 8 cases. Mean exposure and console times (31 and 51 minutes, respectively) were affected by body habitus. The mean visual analog scale for scar cosmesis was 75% on the first postoperative day, improving to 92% at 6 months and 95% at 1 year. Pain scores decreased to 8% at 2 weeks. All 5 EQ-5D quality-of-life parameters significantly improved following surgery. Conclusion. The robotic approach is feasible for performing targeted parathyroidectomy that avoids a neck scar. The clinical efficacy and cost-effectiveness of the robotic approach compared with conventional targeted parathyroidectomy warrant further evaluation to establish if this represents a viable alternative to the existing targeted techniques.

Improving tracheostomy management through design, implementation and prospective audit of a care bundle: how we do it

1 Hoffman H.T. & McCulloch T.M. (1996) Anatomic considerations in the surgical treatment of unilateral laryngeal paralysis. Head Neck 18, 174–187 2 Remacle M. & Lawson G. (2007) Results with collagen injection into the vocal folds for medialization. Curr. Opinion. Otolaryngol. Head Neck Surg. 15, 148–152 3 Isshiki N., Morita H., Okamura H. et al. (1974) Thyroplasty as a new phonosurgical technique. Acta Otolaryngol. (Stockh) 78, 451–457 4 Laccourreye O., El Sharkawy L., Holsinger F.C. et al. (2005) Thyroplasty type-I with Montgomery implant among native French language speakers with unilateral laryngeal nerve paralysis. Laryngoscope 115, 1411–1417 5 Schneider B., Denk D.M. & Bigenzahn W. (2003) Acoustic assessment of the voice quality before and after medialization thyroplasty using the titanium vocal fold medialization implant (TVFM). Otolaryngol. Head Neck Surg. 128, 815–822 6 McCulloch T.M. & Hoffman H.T. (1998) Medialization laryngoplasty with expanded polytetrafluooethylene: surgical techniques and preliminary results. Annals Otolo. Rhinol. Laryngol. 107, 427–432 7 Zeitels S.M., Mauri M. & Daily S. (2003) Medialisation laryngoplasty with Gore-tex for voice restoration secondary to glottal incompetence: indications and observations. Ann. Otol. Rhinol. Laryngol. 112, 180–184 8 Giovani A., Vallicioni J., Gras R. et al. (1999) Clinical experience with Gore-tex for vocal fold medialization. Laryngoscope 109, 284–288 9 Robinson K., Gatehouse S. & Browning G. (1996) Measuring patient benefits from Otolaryngological surgery and therapy. Ann Otol. Rhinol. Laryngol. 105, 415–422

Driving standards in tracheostomy care: a preliminary communication of the St Mary’s ENT-led multi disciplinary team approach

Objectives:  To assess tracheostomy care and improve standards following the introduction of an ENT‐led multidisciplinary tracheostomy ward round service.

Clinical applications of Telerobotic ENT-Head and Neck surgery.

OBJECTIVE To review the published clinical data in Telerobotic ENT-Head and Neck surgery, evaluate the benefit of existing clinical applications and identify areas for potential development. METHODS A qualitative review was performed of publications in PubMed, Medline and the Cochrane Database identified from the following keyword searches: Telerobotic/Robotic ENT, Otorhinolaryngology, Head and Neck surgery, Thyroid and Parathyroid surgery. Preclinical studies and non-clinical review articles were excluded. RESULTS Forty-five publications were identified including 7 review articles. Transoral robotic surgery (TORS) was reported in 20 clinical studies, robotic-assisted thyroidectomy in 13 studies, parathyroidectomy in 4 studies and skull base surgery in 1 study. The majority of TORS publications relate to oropharyngeal malignancy which were Stage III and IV. Clinical benefits include avoidance or dose reduction of adjuvant chemoradiotherapy and improved swallow function. The primary clinical advantage of robotic-assisted neck surgery is the avoidance of a neck scar. The learning curve for robotic thyroidectomy is 50 cases. Body habitus is an important factor for assessment of robotic feasibility in transoral and neck surgery. CONCLUSION The application of robotic-assisted parathyroidectomy, thyroidectomy and TORS suggests promising improvements in patient care. Randomised control trials are needed to assess clinical outcome, cost effectiveness and patient benefit in the existing applications. Continued development of robotic technology will expand the viable clinical applications in this specialty.

Health outcome measurements in children with sleep disordered breathing.

Objective:  To validate the Child Health Questionnaire, measure quality of life in children with obstructive sleep apnoea and assess the impact of surgery.

Determination of biometric measures to evaluate patient suitability for transoral robotic surgery.

Transoral robotic surgery (TORS) represents a novel treatment for oropharyngeal cancer and obstructive sleep apnea. Appropriate patient selection is crucial. The purpose of this study was to investigate whether anatomic biometric measures are useful to determine the feasibility of performing TORS.

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

OBJECTIVES 1. 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. DESIGN Prospective assessment study. SETTING St Marys Hospital, Imperial College NHS Trust, London UK. PARTICIPANTS Sixteen participants consisting of a trainer and trainee group. METHOD Twenty-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. RESULTS The 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. CONCLUSION The 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.