Michael G. Brandt

The silent sinus syndrome is a form of chronic maxillary atelectasis: a systematic review of all reported cases.

Background The terms chronic maxillary atelectasis (CMA) and silent sinus syndrome (SSS) have been used to describe spontaneous enophthalmos in association with a contracted ipsilateral maxillary sinus. Despite the use of differing taxonomy, it appears that these two terms describe the same clinical entity. Nevertheless, many reports still discuss CMA and SSS in isolation or as distinct conditions. Methods A systematic review of all reported cases of CMA and SSS was performed (1964-2006). Case reports were excluded if they involved facial trauma, diagnosis of mucocele, or previous surgery. Eligible cases were reviewed and entered into a database. Data were evaluated based on literature of publication, reported diagnosis, demographics, ophthalmologic examination, results of imaging, and operative findings. Only complete data sets were included in an additional analysis whereby the diagnostic criteria for CMA and SSS were applied and the data sets were compared. Results Of the 105 cases reviewed, 55 contained complete data sets. Twenty-seven of these cases met the diagnostic criteria for SSS, and 48 could be diagnosed as CMA, with 23 meeting the criteria for both conditions. Comparing the cases across diagnoses, the only difference observed was that of the presence of sinus-related symptoms, which by definition distinguishes CMA III from SSS. Conclusion The entity termed SSS fits within the staging classification of CMA. We propose abandoning the term SSS and recommend universal adoption of the CMA staging system, which uses nomenclature that more accurately portrays the pathophysiology and natural history of this condition.

Biomechanical properties of the facial retaining ligaments.

OBJECTIVE Osteocutaneous facial retaining ligaments play an important role in the aging face. We sought to better characterize the biophysical properties of these ligaments and, in doing so, provide an empirical basis for the natural descent seen in facial aging. METHODS Five fresh frozen cadaver heads yielding 10 hemifaces were dissected to expose the orbital, zygomatic, buccomaxillary, and mandibular osteocutaneous ligaments. Each ligament was assessed and subjected to biomechanical testing. The main outcome measures included ligament dimensions, stiffness, percentage of elongation, and force to initial and ultimate failure. RESULTS Initial and ultimate failure testing revealed the zygomatic ligament to be strongest, followed by the orbital, mandibular, and maxillary ligaments. The zygomatic ligament was also stiffest, followed by the orbital, maxillary, and mandibular ligaments. The percentage of elongation acted as a surrogate marker of elasticity, with the greatest elasticity maintained by the mandibular ligament, followed by the orbital, zygomatic, and buccomaxillary ligaments. Ligament dimensions and biophysical properties did not vary relative to cadaveric hemiface, age, or sex. CONCLUSIONS To our knowledge, this is the first investigation to quantify the biomechanical properties of the facial retaining ligaments. Inherent ligament properties seem to be related to the changes observed in facial aging, although further study is required.

Is three‐dimensional videography the cutting edge of surgical skill acquisition?

The process of learning new surgical technical skills is vital to the career of a surgeon. The acquisition of these new skills is influenced greatly by visual‐spatial ability (VSA) and may be difficult for some learners to rapidly assimilate. In many cases, the role of VSA on the acquisition of a novel technical skill has been explored; however, none have probed the impact of a three‐dimensional (3D) video learning module on the acquisition of new surgical skills. The first aim of this study is to capture spatially complex surgical translational flaps using 3D videography and incorporate the footage into a self‐contained e‐learning module designed in line with the principles of cognitive load theory. The second aim is to assess the efficacy of 3D video as a medium to support the acquisition of complex surgical skills in novice surgeons as evaluated using a global ratings scale. It is hypothesized that the addition of depth in 3D viewing will augment the learners innate visual spatial abilities, thereby enhancing skill acquisition compared to two‐dimensional viewing of the same procedure. Despite growing literature suggesting that 3D correlates directly to enhanced skill acquisition, this study did not differentiate significant results contributing to increased surgical performance. This topic will continue to be explored using more sensitive scales of measurement and more complex “open procedures” capitalizing on the importance of depth perception in surgical manipulation. Anat Sci Educ.

What are thyroidectomy patients really concerned about

Objective. To better appreciate perioperative concerns affecting patients considering thyroidectomy and to understand how they may vary according to patient characteristics. Study Design. Cross-sectional analysis. Setting. Tertiary referral center. Subjects and Methods. The authors recruited patients scheduled for thyroid surgery at the McGill University Thyroid Cancer Center. A total of 148 patients completed the 18-item Western Surgical Concern Inventory–Thyroid (WSCI-T) questionnaire. Psychometrics of the WSCI-T were assessed through a principal component analysis with varimax rotation and reliability analyses. Independent-samples t tests and 2-tailed Pearson correlations were ran, identifying areas of elevated concerns and their relationship to gender, age, and surgical procedure (total vs hemithyroidectomy). Results. The principal component analysis revealed the presence of 3 domains of presurgical concerns on the WSCI-T: Surgery-Related Concerns, Psychosocial Concerns, and Daily-Living Concerns. Reliability coefficients for the WSCI-T Total and subscales were satisfactory. Responses on the WSCI-T indicated on average a moderate overall level of concerns before thyroidectomy. Surgery-Related Concerns was the highest domain of concerns, followed by Daily-Living and Psychosocial Concerns, respectively. Patients were mainly worried about the nodule being cancerous, experiencing a change in voice, and surgical complications. Areas of minor concern included being judged or treated differently, becoming depressed, and feeling embarrassed. Women had higher overall levels of concern than men did. Although there were no significant differences in overall levels of concern according to age and surgical procedure, differences were noted at a subscale and item level. Conclusion. This study establishes a mean that will permit adequate physician counseling and a better management of patients’ perioperative worries.

Computer-assisted teaching of epistaxis management: a Randomized Controlled Trial.

To determine whether computer‐assisted learning (CAL) is an effective tool for the instruction of technical skills.

The Transcrusal Approach: A 10-Year Experience at One Canadian Center

OBJECTIVEThis study reviewed the experience and outcomes of 1 surgical team (L.S.P., S.P.L.) using the transcrusal approach. METHODSTen-year retrospective review of 17 consecutive patients requiring transcrusal exposure of the petrous apex and upper brainstem was performed. The main outcome measures included hearing and facial nerve preservation as measured by standard audiography and postoperative assessment using the House-Brackmann scale. RESULTSOperative indications included meningioma (5 patients), epidermoid/dermoid cyst (3 patients), trigeminal schwannoma (3 patients), giant or large upper basilar artery aneurysm (3 patients), pontine cavernoma (1 patient), chondrosarcoma (1 patient), and clival melanocytoma (1 patient). Average tumor size was 3.6 cm. Complete resection was achieved in 50% of patients with petroclival tumors. Follow-up data were obtained for 14 patients at 20 ± 4 months. Serviceable hearing was preserved in 58%. Sixty-four percent of patients demonstrated House-Brackmann stage I facial nerve function. Two patients died perioperatively (brainstem infarction). Two patients became hemiparetic, with 1 improving substantially. CSF leaks developed in 3 patients. Forty-seven percent of patients demonstrated cranial nerve V deficits. Forty-one percent of patients demonstrated deficits of cranial nerve III, IV, or VI. Vertigo, vestibular disturbance, hydrocephalus, temporal lobe contusion, or hematoma did not develop in any patients. CONCLUSIONThe transcrusal approach provides adequate exposure for most petroclival lesions and giant aneurysms of the upper basilar artery while offering the possibility of hearing preservation. Like all approaches to large tumors and aneurysms in this region, there is a significant risk of morbidity and mortality. However, this approach is an excellent alternative to other techniques that necessitate deliberate sacrifice of ipsilateral hearing.

Septopalatal Protraction for Correction of Nasal Septal Deformity in Cleft Palate Infants

OBJECTIVE: It is proposed to test the practicality of septopalatal protraction in the unilateral cleft palate infant for purposes of straightening the nasal septum and thus relieving nasal airflow obstruction and its detrimental sequelae. METHODS: Alternate infants affected with complete unilateral palatal clefts had septopalatal protraction for a period of 6 to 8 weeks (protraction group; n = 4). Septal deviation was measured by a standardized technique that used computed tomography scans. The remaining infants had no protraction and served as controls (nonprotraction group; n = 5). Septal deviation was measured in the nonprotraction group from palatoseptal dental molds. RESULTS: A total of 9 patients were studied. All patients in the nonprotraction group had worsening of nasal septal deviation over a period of 8 weeks compared with the protraction group, which had complete nasal septal straightening. Differences in septal angle deviation between the protraction group and nonprotraction group at the end of the study were statistically significant (P ≤ 0.01) as measured by the paired Student t test. CONCLUSIONS: Septopalatal protraction in the newborn appears to provide a means for correcting nasal septal deviation in complete unilateral cleft palate infants. Septopalatal protraction in the newborn is relatively easy and safe. EBM RATING: B-2

Objective Evaluation of Otoscopy Skills Among Family and Community Medicine, Pediatric, and Otolaryngology Residents

INTRODUCTION The objective of this study is to evaluate and compare the perceived need for otolaryngology training and otoscopy diagnostic skills in primary care (Family and Community Medicine, Pediatric Medicine), and Otolaryngology Head and Neck Surgery (OTO-HNS) postgraduate trainees. Participant otoscopy skills were evaluated using the OtoSim simulator. METHODS Family and Community Medicine, Pediatric, and OTO-HNS residents were recruited. Each resident participated in 3 separate otoscopy training and assessment sessions. The ability to correctly identify middle ear pathology was objectively evaluated using OtoSim™. Pretest, posttest, and 3-month retention test results were compared among residents in a paired comparison paradigm. Survey data assessing exposure to OTO-HNS during undergraduate and postgraduate training were also collected. RESULTS A total of 57 residents participated in the study. All residents reported limited exposure to OTO-HNS during undergraduate medical training. Primary care trainees performed poorly on pretest assessments (30% ± 7.8%; 95% CI). Significant improvement in diagnostic accuracy was demonstrated following a single 1-hour teaching session (30%-62%; p < 0.001). Primary care residents demonstrated a significant decrease in diagnostic accuracy at a 3-month follow-up assessment (62%-52%, p < 0.001). Self-perceived comfort with otology was poorly correlated to pretest performance among primary care trainees (r = 0.26) and showed a stronger positive correlation among OTO-HNS trainees (r = 0.56). CONCLUSIONS A single teaching session with an otoscopy simulator significantly improved diagnostic accuracy in primary care and OTO-HNS trainees. Improved performance is susceptible to deterioration at 3 months if acquired skills are not frequently used. Self-perceived comfort with otology may not be an accurate predictor of otoscopic diagnostic skill.

Otolaryngology - Head and Neck Surgeon unemployment in Canada: a cross-sectional survey of graduating Otolaryngology - Head and Neck Surgery residents

ObjectiveRecently graduated Otolaryngology - Head and Neck Surgeons (OTO-HNS) are facing an employment crisis. To date, there has been no systematic evaluation of the factors contributing to this situation, graduating OTO-HNS trainee employment rates, nor the employment concerns of these graduating residents. This investigation sought to empirically evaluate prospective OTO-HNS graduate employment, identify factors contributing to this situation, and provide suggestions going forward.MethodsA cross-sectional survey of the 2014 graduating cohort of OTO-HNS residents was conducted 6-months prior to graduation, and immediately following residency graduation. Surveyed items focused on the demographics of the graduating cohort, their future training and employment plans, and their concerns relative to the OTO-HNS employment situation.ResultsAll twenty-nine Canadian medical school graduated OTO-HNS residents completed the initial survey, with 93% responding at the completion of residency. Only 6 (22%) indicated confirmed employment following residency training. 78% indicated that they were pursuing fellowship training. 90% identified the pursuit of fellowship training as a moderately influenced by limited job opportunities. The ability to find and secure full-time employment, losing technical skills if underemployed/unemployed, and being required to consider working in a less-desired city/province were most concerning. 34% of the residents felt that they were appropriately counseled during their residency training about employment. 90% felt that greater efforts should be made to proactively match residency-training positions to forecasted job opportunities.ConclusionsCanadian OTO-HN Surgeons lack confirmed employment, are choosing to pursue fellowship training to defer employment, and are facing startling levels of under- and unemployment. A multitude of factors have contributed to this situation and immediate action is required to rectify this slowly evolving catastrophe.

Development of a new visual analogue scale for the assessment of area scars.

OBJECTIVE Clinical scar assessment lacks standardized methodology and consensus on the most appropriate evaluation instrument. This study empirically evaluated whether area scars could be validly assessed by naive observers with the objective to develop and validate a novel multidimensional visual analogue scale (VAS) for the assessment of area scars. METHODS Standardized digital photographs of radial forearm free flap (RFFF) donor sites were obtained. Naive observers evaluated the images in three sequential psychophysical experiments, which led to the development of the new scar scale. These experiments involved initial evaluation of four dimensions (pigmentation, vascularity, observer comfort, acceptability) using a paired comparison (PC) paradigm and correlation with ratings of overall severity using a VAS, and initial VAS test phase followed by formal debriefing, and, subsequently, evaluation of a VAS for the four dimensions in addition to contour. Validation involved determination of intra- and interrater reliability and correlational analysis. RESULTS Across all three experiments, 56 observers evaluated 101 images, generating 12 720 observations for analysis. PC data demonstrated that observers could assess scars with high reliability and internal consistency for all dimensions (> 95%). Overall (VAS) severity correlated highly with all dimensions, including contour. The new VAS yielded high levels of correlation (r = .72-.98, p < .01). CONCLUSION Comprehensive VAS analysis demonstrates high reliability in mirroring PC results for multiple dimensions of area scars. These data support our novel multidimensional VAS method as a valid, reliable, simple, and time-efficient instrument for clinical and research use. We introduce the Western Scar Index as a new measurement tool with many potential applications.