C. Matthew Stewart

Readmission following primary surgery for larynx and oropharynx cancer in the elderly

To examine 30‐day readmission rates and associations with risk factors, survival, length of hospitalization, and costs in elderly patients with laryngeal and oropharyngeal squamous cell cancer (SCC).

Qualitative synthesis and systematic review of otolaryngology in undergraduate medical education

Although 25% of primary care complaints are otolaryngology related, otolaryngology instruction is not required in most medical schools. Our aim was to systematically review existing literature on the inclusion of otolaryngology in undergraduate medical education.

Effect of distractions on operative performance and ability to multitask—A case for deliberate practice

To measure the effect of distractions on the operative performance and analyze if practice and experience are the factors that can help to overcome the distractions.

Malignant otitis externa caused by Aspergillus fumigatus: a case report.

Malignant otitis externa (MOE) is a life threatening pathology that may affect the external ear and skull base. Despite the nomenclature it is an infective disease process caused by Pseudomonas aeruginosa in up to 98 percent of cases (1). However when appropriate antibiotics fail, other infective organisms such as Aspergillus fumigatus should be considered, especially in the immunecompromised patient.

Temporal bone involvement in Hand-Schuller-Christian disease.

A 29-year-old man with an 18-month history of diabetes insipidus (DI) presented with several months of left otalgia, aural fullness, and otitis media that did not resolve with multiple courses of antibiotics. Otoscopic examination and facial nerve function were normal. Audiometry revealed a mild left conductive hearing loss, absent acoustic reflexes to broadband stimuli presented at 95 dB HL, and 100% word discrimination. A computed tomography (CT) scan of the temporal bones revealed a 2.4 2.3Ycm soft tissue mass within the left mastoid, with erosion through the sigmoid plate (Fig. 1A). Magnetic resonance imaging (MRI) of the skull base revealed a 2.4 2.3Ycm enhancing soft tissue mass with evidence of central necrosis abutting the left sigmoid sinus (Fig. 1B). An MRI from 18 months before workup of DI revealed thickening and enhancement of the pituitary stalk without appreciable T1 intensity within the sella turcica, without any evidence of a soft tissue mass (Fig. 2A). Pertinent laboratory work revealed an eosinophil number/percent of 1020/8.5% (range, 120Y300/1.0Y4.0%). This patient’s clinical presentation, laboratory tests, and imaging findings led to the presumed diagnosis of Langerhans’ cell histiocytosis (LCH). His previous MRI at the time of his initial presentation of DI further clarified the diagnosis as most consistent with Hand-SchullerChristian disease (HSCD). A left transmastoid approach through a postauricular incision for resection was performed (Fig. 2B). Pathology revealed Langerhans’ cells positive for CD1a. A postoperative positron emission tomography scan revealed multiple pulmonary nodules and pulmonary function tests were consistent with obstructive pathology; these findingswere suspicious for systemic disease. Hewas subsequently discharged home, and adjuvant chemotherapy was initiated.

Frailty, hospital volume, and failure to rescue after head and neck cancer surgery

We previously reported that high‐volume hospital head and neck cancer (HNCA) surgical care is associated with decreased mortality, largely explained by reduced rates of failure to rescue. Frailty is an independent predictor of mortality, but is significantly less likely in patients receiving high‐volume care. We investigate whether differences in frailty rates explain the relationship between volume and outcomes in HNCA patients and whether frailty confounds the relationship between failure to rescue and mortality.

Unusual Cause of Scalp Pain in Hearing-Impaired Patient

A n 86-year-old woman with bilateral profound sensorineural hearing loss and a cochlear implant placed 16 years prior presented to her local emergency department with pain near the implant for 1 week, although it functioned normally. A computed tomography scan was obtained, and implant displacement was suspected per the resulting image (Figure 1A). She was referred for neurotology evaluation. Upon examination, the external transmitter was removed, revealing a loose button battery underneath (Figure 1A, arrow), which had eroded through the scalp toward the internal receiver/stimulator magnet. The patient reported changing her battery several weeks prior and recalled possibly losing one. The ulceration (Figure 1B) healed completely with local wound care. This project was determined to be exempt by the Johns Hopkins Medicine Institutional Review Board.

Development and Pilot Testing of an Objective Structured Clinical Examination for Obstructive Sleep Apnea

Objective Our aim was (1) to develop an objective structured clinical examination (OSCE) for obstructive sleep apnea (OSA) and (2) to test the reliability and evaluate the feasibility of this OSCE while assessing residents’ clinical skills in multiple core competencies via the standardized patient methodology. Study Design Development of assessment tool. Setting Johns Hopkins Medicine Simulation Center. Subjects and Methods Residents of the Department of Otolaryngology–Head and Neck Surgery at The Johns Hopkins University School of Medicine were invited to participate. A 2-station OSCE was developed. The first station used a standardized patient, and the encounter was videotaped for later evaluation by medical faculty not familiar with the participants being tested. The second was a computer-based station developed per a modified Delphi technique, based on feedback from otolaryngology and sleep medicine faculty involved in the care of patients with OSA. Checklists were developed for each station to standardize the evaluation of each trainee’s performance. Results The OSCE that we developed is a feasible tool for assessing residents’ performance and skills to diagnose and manage a patient with OSA. Internal consistency, as assessed by Krippendorff’s alpha, was 0.699 for station 1 and 0.95 for station 2. Conclusion This OSCE was found to be feasible for assessment of clinical competency in OSA. Our model provides targeted assessment of multiple competencies and opportunity to improve clinical knowledge and skills.

In response toQualitative synthesis and systematic review of otolaryngology in undergraduate medical education: Letter to the Editor

We thank Dr. Steven et al. for their comments regarding our article and appreciate their bringing the article by Lloyd et al. to our attention. The use of a modified Delphi technique to focus on the topics most important to otolaryngology undergraduate medical education is one that we strongly support and have used in our survey of medical student topics and procedures presented at the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) meeting in 2014. In our study, we found a need for increased exposure to otolaryngology in undergraduate medical education. Data also suggested that a universal otolaryngology medical student curriculum would be valuable and would aid in resource sharing across institutions. These findings are similar to those reported by Lloyd et al., which includes feedback from 159 physicians, including 81 general practitioners as well as otolaryngologists, emergency room physicians, and pediatric consultants. Its comprehensive scope is impressive and was undoubtedly useful in creating the UK national curriculum. Similar to our counterparts in the United Kingdom, we feel that these data need to be put in the context of the undergraduate educational system in which it will be implemented to be most useful. We also agree with Lloyd et al. that any universal curriculum will need to be tailored to individual programs and systems, as some of the topics deemed most important may be adequately covered in other sections of the medical student curriculum, whereas topics such as sudden sensorineural hearing loss may be underemphasized. Moreover, we concur with Steven et al. that the value of an otolaryngology undergraduate medical curriculum should be useful for all medical students. Toward this end, it is our goal to answer the question: “What should every medical student know about otolaryngology before graduating from medical school?” We are working with the AAOHNS to develop a curriculum that addresses this question and look forward to seeing the continuing research in this area by our colleagues in the United Kingdom. We also welcome further comments and collaboration going forward. STACEY L. ISHMAN, MD, MPH Division of Pediatric Otolaryngology–Head and Neck Surgery Division of Pulmonary Medicine Cincinnati Children’s Hospital Medical Center Department of Otolaryngology–Head and Neck Surgery University of Cincinnati College of Medicine Cincinnati, Ohio

Idiopathic Mastoid Osteoma

In this case report, we describe the rare case of an idiopathic mastoid osteoma. A 40 year old woman complained of tenderness over her right mastoid during exercise and changes in head position. Medical treatment was initially offered with topical corticosteroids, capsaicin, and conservative cervical physical therapy. When her symptoms did not ameliorate, surgical management was then offered. Appropriate surgical planning included computed tomography with threedimensional reconstructions. A mastoidectomy through a postauricular incision for resection was then performed. The osteoma was then removed en bloc with final pathology consistent with a benign compact osteoma of the right mastoid.