Matthew M. Dedmon

Incidence and survival patterns of sinonasal undifferentiated carcinoma in the United States.

Objective To determine trends in sinonasal undifferentiated carcinoma (SNUC) survival patterns in the United States. Design Retrospective review of national database. Participants All cases of SNUC in the National Cancer Institutes Surveillance Epidemiology and End Results program from 1973 to 2010 were examined. Main Outcome Measures Age-adjusted incidence and survival rates were calculated and stratified by demographic information and treatment modality. Cohort analysis was performed to analyze survival patterns over time. Results A total of 318 SNUC cases were identified. Age-adjusted incidence rate (IR) was 0.02 per 100,000. Incidence was greater in males (IR: 0.03) than females (IR: 0.01; p = 0.03). Overall 5- and 10-year relative survival rate was 34.9% and 31.3%, respectively. Overall median survival was 22.1 months. Median survival following surgery combined with radiation was 41.9 months. Five-year relative survival rate following surgery, radiation, or surgery combined with radiation was 38.7%, 36.0%, and 39.1%, respectively. Median survival from 1973-1986 and 1987-2010 was 14.5 and 23.5 months, respectively. Conclusions This study provides new data regarding survival patterns of SNUC in the United States, confirming survival benefit with surgery and radiation as well as identifying a trend toward improved survival in recent decades.

Development and Validation of a High-Fidelity Porcine Laryngeal Surgical Simulator

Objective Design and validate a laryngeal surgical simulator to teach phonomicrosurgical techniques. Study Design Device development and prospective validation. Setting Tertiary medical center. Subjects and Methods A novel laryngeal fixation device and custom laryngoscope were produced for use with ex vivo porcine larynx specimens. Vocal fold lesions such as nodules and keratotic lesions were simulated with silicone injections and epithelial markings. A prospective validation using postsimulation surveys, global rating scales, and procedure-specific checklists was performed with a group of 15 medical students, otolaryngology residents, fellows, and attending laryngologists. Three procedures were performed: vocal fold augmentation, excision of a simulated vocal fold nodule, and excision of a simulated vocal fold keratosis. Results Participants overwhelmingly agreed that the simulator provided a realistic dissection experience that taught skills that would transfer to real operating scenarios. Expert performance was statistically superior to novice performance for excision of simulated vocal fold nodules and keratotic lesions, while no difference was observed for injection laryngoplasty. Conclusion The ability to learn and rehearse surgical procedures in a safe environment is invaluable, particularly for delicate and highly technical phonomicrosurgical operations. We have developed a high-fidelity laryngeal surgical simulator complete with pathological lesions such as nodules and keratoses to teach these procedures. A prospective study demonstrated validity of our global rating scale and checklist assessments for vocal fold nodule and keratosis excision procedures, allowing them to be confidently incorporated into phonomicrosurgical training programs for surgeons of all levels of expertise.

Development of a Temporal Bone Model for Transcanal Endoscopic Ear Surgery.

Transcanal endoscopic ear surgery (TEES) is being increasingly used in chronic ear disease for cholesteatoma removal and middle ear reconstruction, reducing the need for a postauricular incision and mastoidectomy. However, TEES is a challenging technique even for the most experienced otologist, requiring one-handed dissection using angled instrumentation. We have therefore developed a high-fidelity dissection model incorporating key aspects of TEES and cholesteatoma removal to facilitate the acquisition of these skills. Artificial cholesteatoma was implanted into middle ear spaces of a human temporal bone via a facial recess approach. A pilot study was conducted whereby surgeons endoscopically elevated a tympanomeatal flap with artificial bleeding and removed artificial cholesteatoma with angled instrumentation. Surgeons were uniformly satisfied with the experience and felt it would translate into improved performance in the operating room. This study suggests that the TEES dissection model could become an integral tool in the training of emerging TEES techniques.

Prolonged Radiant Exposure of the Middle Ear during Transcanal Endoscopic Ear Surgery

Transcanal endoscopic ear surgery (EES) provides a high-resolution, wide-field view of the middle ear compared with the conventional operating microscope, reducing the need for a postauricular incision or mastoidectomy. Our group has shown in cadaveric human temporal bone studies that radiant energy from the endoscope tip can quickly elevate temperatures of the tympanic cavity. Elevated temperatures of the middle ear are associated with acute auditory brainstem response shifts in animal models. In EES, proposed methods to decrease middle ear temperature include frequent removal of the endoscope and the use of suction to rapidly dissipate heat; however, the routine application of such cooling techniques remains unknown. Herein, we aim to quantify the duration that the tympanic cavity is typically exposed to the endoscope during routine endoscopic middle ear surgery. We find that the tympanic cavity is exposed to the endoscope without a cooling mechanism for a prolonged period of time.

Delayed Endovascular Coil Extrusion following Internal Carotid Artery Embolization

Internal carotid artery injury is a rare and devastating complication of endoscopic sinus and skull base surgery that has an associated mortality rate of 15%. This case describes a patient who developed massive epistaxis following routine sinus surgery and was eventually diagnosed with a pseudoaneurysm of the cavernous internal carotid artery. Endovascular coiling and Onyx (Covidien, Irvine, California, United States) liquid embolization were ultimately used to completely occlude the internal carotid artery with resolution of bleeding; however, the patient had an unexpected late complication of coil extrusion through the pseudoaneurysm sac into the sphenoid sinus and nasal cavity. The endoscopic skull base team safely excised the coils endoscopically without recurrent bleeding. We describe the multidisciplinary operative management of this case of endovascular coil extrusion to increase awareness of this potentially life-threatening complication.

Skull Base Surgery Training and Practice Patterns among Recent Otolaryngology Fellowship Graduates

OBJECTIVE To collect data on skull base surgery training experiences and practice patterns of otolaryngologists that recently completed fellowship training. DESIGN A 24-item survey was disseminated to physicians who completed otolaryngology fellowships in rhinology, head and neck oncology, or neurotology between 2010 and 2014. RESULTS During a typical year, 50% of rhinologists performed more than 20 endoscopic anterior skull base cases, 83% performed fewer than 20 open cases, and were more confident performing advanced transplanum (p = 0.02) and transclival (p = 0.03) endoscopic approaches than head and neck surgeons. Head and neck surgeons performed fewer than 20 endoscopic and fewer than 20 open cases in 100% of respondents and were more confident with open approaches than rhinologists (p = 0.02). Neurotologists performed more than 20 lateral skull base cases in 45% of respondents during a typical year, fewer than 20 endoscopic ear cases in 95%, and were very comfortable performing lateral skull base approaches. CONCLUSION Many recent otolaryngology fellowship graduates are integrating skull base surgery into their practices. Respondents reported high confidence levels performing a range of cranial base approaches. Exposure to endoscopic ear techniques is minimal in neurotology training, and rhinology training appears to offer increased exposure to skull base surgery compared with head and neck training.

Removal of a Wire Brush Bristle from the Hypopharynx Using Suspension, Microscope, and Fluoroscopy

Wire brush bristles are an increasingly recognized hazard that can present as a foreign body in the aerodigestive tract. Due to their small size and tendency to become embedded in surrounding tissue, these small metallic bristles present a unique operative challenge to otolaryngologists. Here we present a case of a 40-year-old woman who underwent endoscopic extraction of a wire bristle from the posterior pharyngeal wall using suspension, microscopy, and C-arm fluoroscopy. We believe this is the first published case of an endoscopic removal of a buried foreign body in the hypopharynx using these methods of localization concurrently. By leveraging multiple techniques for visualization, surgeons can avoid open exploration while ensuring complete removal of the object. Additionally, this case highlights the importance of regulatory oversight and consumer awareness of the hazards of grill brushes.

Hearing Preservation Cochlear Implantation: a Review of Audiologic Benefits, Surgical Success Rates, and Variables That Impact Success

Purpose of ReviewThe objectives of this review are as follows: (1) examine the audiologic benefits of hearing preservation, (2) review rates of successful hearing preservation, and (3) analyze variables that impact hearing preservation success.Recent FindingsHearing preservation has been shown to confer the following audiologic benefits: better speech understanding in complex listening environments, superior sound localization, and improved music appreciation. There is a notable lack of standardized criteria for reporting of hearing preservation outcomes—this leads to considerable heterogeneity across studies. Rates of functional (i.e., aidable) hearing preservation generally range between 50 and 90%. Studies demonstrate higher preservation rates and more durable hearing outcomes with shorter, straight electrode arrays.SummaryWith advances in CI technology and surgical techniques, residual hearing can be preserved after CI surgery in the majority of patients. Cochlear implant recipients with preserved hearing demonstrate better speech understanding, sound localization, and improved music appreciation.

Improving resident familiarity with the translabyrinthine approach to the internal auditory canal

OBJECTIVE To increase otolaryngology resident experience with drilling and dissection of the internal auditory canal (IAC) via a translabyrinthine approach. STUDY DESIGN Pilot study involving temporal bone education and drilling with completion of pre- and post-drilling surveys. METHODS Participants observed an educational presentation on IAC anatomy and drilling, followed by manipulation of IAC nerves using a prosected cadaveric temporal bone. Participants then drilled the IAC and identified nerves using temporal bones with previously drilled mastoidectomies and labyrinthectomies. Pre- and post-drilling 5-point Likert-based surveys were completed. RESULTS 7 participants were included in this study ranging in experience from PGY1 through PGY 5. The median number of times the IAC had been drilled previously was 0. Participants reported statistically significantly improved familiarity with the translabyrinthine approach after the session with median scores increasing from 2 to 3 (p=0.02), and a near-significant increase in familiarity with IAC anatomy with median scores increasing from 3 to 4 (p=0.06). Prior to the session, 71% of participants either disagreed or strongly disagreed that they had an idea of what the procedure would be like in a real operating room, whereas after the session 0% reported disagreement. 100% of participants were very satisfied with the overall experience. CONCLUSIONS An educational session and temporal bone drilling experience using prosected bones significantly increased the reported familiarity with the translabyrinthine approach. Experiences such as this may enhance resident exposure to advanced lateral skull base approaches in a safe environment, and increase comprehension of the complex anatomic relationships of the IAC.

Update on Surgical Outcomes of Lateral Temporal Bone Resection for Ear and Temporal Bone Malignancies

Objectives Review outcomes of lateral temporal bone resections for ear and temporal bone malignancy. Design, Setting, and Participants Retrospective review of all lateral temporal bone resections performed from 2008 to 2015 at a single tertiary care center. Main Outcome Measures Patient demographics, perioperative variables, overall survival, disease‐free survival (DFS), and comparison of Kaplan‐Meier curves. Results Overall, 56 patients were identified with a mean follow‐up period of 2.3 ± 1.8 years. The predominant histopathologic diagnosis was squamous cell carcinoma (SCC, 54%), followed by salivary gland tumors (18%), and basal cell carcinoma (9%). Tumor stages were T1‐T2 in 23%, T3‐T4 in 73%, and two unknown primary lesions. Mean overall survival was 4.6 ± 0.4 years. Comparison of tumors with and without lymph node involvement or perineural invasion approached statistical significance for overall survival (p = 0.07 and 0.06, respectively). DFS was 2.5 ± 0.3 years. Stratification by lymph node status had a statistically significant difference in DFS (p = 0.03). Subgroup analysis of SCC patients did not reveal significant differences. Conclusions Based on our cohort, most patients with temporal bone malignancies present with advanced disease, making it difficult to achieve negative margins. Overall, lymph node status was the strongest predictor of survival in this group.