Matthew K. Steehler

A novel low-cost sinus surgery task trainer.

Sinus surgery simulation has proven to be a valuable teaching tool, yet the cost of many simulators limits the incorporation of this technology into training programs. The authors developed an inexpensive endoscopic sinus surgery task trainer and evaluated its value as a means of developing basic endoscopy and sinus surgery skills. For less than 5 US dollars, the training model was constructed using gelatin and embedded with reusable, recyclable, and readily available materials. Ten attending otolaryngologists performed nasal endoscopy and 5 specific tasks using this model, followed by completion of a survey evaluating the value of the model as a teaching tool. The model scored very well in promoting camera skills, instrumentation, and hand-eye coordination. This easily reproducible, highly rated sinus surgery task trainer can serve as an alternative to more expensive simulators. Studies are under way to determine its validity and effectiveness as both a teaching and assessment tool.

A retrospective review of frenotomy in neonates and infants with feeding difficulties

OBJECTIVES To measure maternal breast feeding benefit after infant frenotomy. To investigate if timing of neonatal/infant frenotomy affects outcome. STUDY DESIGN Cohort survey and retrospective review. METHODS Medical records of neonates and infants suspected to have ankyloglossia between April 2006 and February 2011 were reviewed. Patient demographic data was compiled. A telephone survey was conducted to gather data on this cohort of patients. RESULTS Neonatal and infant consultations (N=367) were performed for feeding difficulties due to suspected ankyloglossia, 302 of these infants underwent frenotomy for ankyloglossia. A total of 91 mothers agreed to participate in a follow-up telephone survey regarding the intervention. Results showed that 80.4% of mothers strongly believed the procedure benefited their childs ability to breastfeed, and 82.9% of mothers were able to initiate/resume breastfeeding after the procedure was performed. The belief that frenotomy significantly benefitted an infants ability to feed significantly differed in patients that had the procedure performed in the first week of life (86%) as compared to infants that had the procedure performed after the first week of life (74%) (p<0.003). CONCLUSIONS Based on maternal observations, when frenotomy is performed on neonates with ankyloglossia and feeding difficulties in the first week of life, there is more benefit than when it is performed after the first week of life. The population of patients with ankyloglossia is predominantly male with a high familial/genetic correlation associated with the phenotypic trait. Frenotomy for ankyloglossia demonstrates a high degree of maternal satisfaction, is well tolerated and has been shown to improve breastfeeding and decrease pain and difficulty associated with breastfeeding.

Teaching and assessing endoscopic sinus surgery skills on a validated low-cost task trainer†‡§¶

To evaluate a previously validated low‐cost sinus surgery task trainer as a means of acquiring basic endoscopic sinus surgery skills and as an objective structured assessment of technical skills (OSATS) to determine procedural competency.

Frameless Fractionated Stereotactic Radiosurgery for Vestibular Schwannomas: A Single-Institution Experience

Objective: To examine tumor control, hearing preservation, and complication rates after frameless fractionated stereotactic radiosurgery (SRS) in patients with vestibular schwannomas (VS). Methods: Thirty-seven patients treated with fractionated SRS from 2002 to 2011 were retrospectively analyzed. Ninety-five percent were treated with 25 Gy in five fractions, targeting a median tumor volume of 1.03 cc (range 0.14–7.60). Results: With a median follow-up of 4.25 years (range, 15 months–9 years), no tumors required an additional treatment resulting in 100% tumor control rate. Radiographic control rate was 91% in 32 patients at a median follow-up of 3 years. Of the 14 patients with serviceable hearing and with audiograms, the hearing preservation rate was 78% at a median follow-up of 18 months. Twenty-six patients with serviceable hearing pretreatment, were evaluated by a phone survey with a hearing preservation rate of 73% at a 5 year median follow-up. There were two cases that developed both new increased trigeminal parasthesias and facial spasms but there were no cases of facial weakness. Patient had 96% of good to excellent satisfaction rate with the treatment at a median follow-up of 5 years. Conclusion: Frameless fractionated SRS treatment of VS results in good rate of tumor control. Hearing preservation rate and rates of cranial nerve toxicity are comparable to what is reported in the literature. Patients choose this modality because of its non-invasive nature and are generally very satisfied with their long term outcome.

Face, Content, and Construct Validity of a Low-Cost Sinus Surgery Task Trainer

Objective. To assess the face, content, and construct validities of a low-cost sinus surgery task trainer in acquisition of skills for endoscopic sinus surgery. Study Design. Prospective validation study. Setting. Tertiary academic center. Subjects and Methods. Attending otolaryngologists, otolaryngology residents at various levels of training, and medical students performed nasal endoscopy and 5 specific tasks using this model. Face and content validities were assessed based on the attendings’ responses to a questionnaire evaluating the task trainer. Construct validity was determined by comparing novice to experienced performance using a validated checklist and globalized rating scale. Results. A total of 77 subjects participated in the study. Attending otolaryngologists responded to a survey after completing the tasks. Eighty percent of evaluators rated the trainer as realistic and agreed that this model correlates with the essential skills needed for endoscopic sinus surgery, 90% felt this model provided adequate training and would increase resident competency, and 90% were interested in using the model to train residents. On the task trainer, experienced otolaryngologists and senior residents scored significantly higher than junior residents and medical students using the objective measures of the globalized rating scale and checklist. Conclusion. This study demonstrates face, content, and construct validity of the low-cost sinus surgery task trainer. This model has the potential to be a valuable tool in endoscopic sinus surgery training for otolaryngology residents.

Benign lymphoepithelial cysts of the parotid: long-term surgical results.

Benign lymphoepithelial cysts are a widely recognized cause of parotid gland swelling in patients infected with the human immunodeficiency virus (HIV). These cysts are pathognomonic for HIV. The cysts frequently grow to be exceptionally large, causing physical deformity and gross asymmetry of facial contour. This clinical commentary analyzes this cosmetically deforming disease entity and the many treatments that accompany it. The patient presented in this paper is a surgical case-control. The case is a microcosm for our findings upon review of the literature. Treatment options for benign lymphoepithelial cysts include repeated fine-needle aspiration and drainage, surgery, radiotherapy, sclerotherapy, and conservative therapy, with institution of highly active antiretroviral therapy medication. Based on this surgical case-control and our review of the literature, it is concluded that surgical intervention offers the best cosmetic result for these patients.

Induction of tracheal stenosis in a rabbit model—endoscopic versus open technique†‡§

To evaluate and compare open versus endoscopic methods of inducing tracheal stenosis in the New Zealand white rabbit model.

Pediatric Head and Neck Complications of Streptococcus pneumoniae before and after PCV7 Vaccination

Objective To discuss pediatric head and neck complications of pneumococcal infections before and after the introduction of the PCV7 vaccine. Study Design Cross-sectional analysis of a national database. Study Setting Kids National Inpatient Database. Methods A retrospective review of the Kids National Inpatient Database yielded 31,738 pediatric reports involving complications of meningitis, mastoiditis, periorbital cellulitis, and Bezold abscesses due to Streptococcus pneumoniae diagnoses. Each report was analyzed for incidence, length of stay, mean hospital cost, and inpatient admittance from the emergency department. Finally, we calculated the expected annual incidence of each complication via variance-weighted analysis to determine the expected incidence if the vaccine was not administered. Results We identified a significant decrease in the incidence of several complications after the introduction of the PCV7 vaccine and also when comparing these findings to our predicted incidence calculations if the vaccine was not administered. Inpatient admittance from the emergency department for Bezold abscess, periorbital cellulitis, mastoiditis, and meningitis was significantly increased in the pediatric age group (ages 1-4; P < .05). Furthermore, there was a significant increase in the cost to provide care for each of the described conditions (P < .05). Conclusions The PCV7 vaccine produced a measurable reduction in head and neck complications associated with S pneumoniae. However, our data suggest that these benefits were also met with increased inpatient admittance from the emergency department, hospital costs, and length of stay, each of which may be attributed to the selection of a more pathogenic subtype.

Management of subglottic cysts with Mitomycin-C—A case series and literature review

OBJECTIVES To describe the management and outcomes of seven infants with subglottic cysts. To assess the role of Mitomycin-C in the management of subglottic cysts. To discuss the relationship of subglottic cysts with gastro-esophageal reflux. To extensively review the literature on subglottic cysts. DESIGN Retrospective case series and literature review. METHODS Case series of seven children with subglottic cysts at a tertiary care hospital. Charts were reviewed to determine birth history, gender, intubation history, comorbidities, age at presentation, presenting symptoms, interventions and follow-up. RESULTS Between 2001 and 2009, seven patients aged 4-13 months were diagnosed with and treated for subglottic cysts. All children had a history of intubation and had evidence of gastro-esophageal reflux. All children were treated with endoscopic marsupialization (CO(2)-laser, cupped forceps) or bronchoscopic rupture; with or without concomitant topical Mitomycin-C therapy. Infants were followed clinically and with interval endoscopy with a minimum follow-up of 6 weeks. No patients receiving topical post-marsupialization Mitomycin-C (0/4) had cyst recurrence. Those patients who did not receive Mitomycin-C therapy recurred more frequently (66% - 2/3). Cysts ruptured with the bronchoscope tip recurred (66% - 2/3) more often than cysts undergoing endoscopic marsupialization (0/6). The one bronchoscopic rupture case that did not recur was the one in which Mitomycin-C was used concomitantly. Patient follow-up was at 2, 4 and 6 weeks post-procedure. CONCLUSION Endoscopic marsupialization is the treatment of choice for subglottic cysts. Gastro-esophageal reflux has a strong association with subglottic cysts. The post-marsupialization application of Mitomycin-C may have a role in reducing the recurrence rate and scarring after surgical treatment of subglottic cysts.

Parental perception of speech and tongue mobility in three-year olds after neonatal frenotomy

OBJECTIVES The goal of this study was to evaluate parental speech outcomes and tongue mobility in children with ankyloglossia who underwent frenotomy by an otolaryngologist during the neonatal period. STUDY DESIGN Cohort study and retrospective telephone survey. STUDY SETTING University Hospital. SUBJECTS AND METHODS Neonates previously diagnosed with congenital ankyloglossia were separated into Surgical Intervention (N=71) and No Surgical Intervention (N=15) Groups. A Control Group (N=18) of patients was identified from the hospital medical record database, which were not diagnosed with congenital ankyloglossia. A survey provided by a certified speech pathologist utilized a Likert scale to assess speech perception and tongue mobility by parental listeners. The questionnaire also analyzed oral motor activities and the medical professionals that identified the ankyloglossia shortly after birth. Statistical analyses were performed with the Wilcoxon Rank Sum Test and Fischers Exact Test in order to determine an effect size=1. RESULTS There was significantly improved speech outcomes designated by parents in the Surgical Intervention Group when compared to the No Surgical Intervention Group [p<0.0001, p<0.0001], respectively. Furthermore, parents designated no difference in speech outcomes between the Surgical Intervention Group when analyzed against the Control Group [p=0.3781, p<0.2499], respectively. CONCLUSIONS There was a statistically significant improvement in speech outcomes and tongue mobility in children who underwent frenotomy compared to individuals who declined the operation. As a result of the data presented within this study, there appears to be a long-term benefit beyond feeding when frenotomy is performed in newborns with ankyloglossia.