Neil Tolley

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.

Systematic review and meta-analysis of the adverse effects of thyroidectomy combined with central neck dissection as compared with thyroidectomy alone.

Meta‐analysis to assess the increased morbidity of performing a central neck dissection with thyroidectomy to thyroidectomy alone.

Nasal architecture: form and flow

Current approaches to model nasal airflow are reviewed in this study, and new findings presented. These new results make use of improvements to computational and experimental techniques and resources, which now allow key dynamical features to be investigated, and offer rational procedures to relate variations in anatomical form. Specifically, both replica and simplified airways of a single subject were investigated and compared with the replica airways of two other individuals with overtly differing geometries. Procedures to characterize and compare complex nasal airway geometry are first outlined. It is then shown that coupled computational and experimental studies, capable of obtaining highly resolved data, reveal internal flow structures in both intrinsically steady and unsteady situations. The results presented demonstrate that the intimate relation between nasal form and flow can be explored in greater detail than hitherto possible. By outlining means to compare complex airway geometries and demonstrating the effects of rational geometric simplification on the flow structure, this work offers a fresh approach to studies of how natural conduits guide and control flow. The concepts and tools address issues that are thus generic to flow studies in other physiological systems.

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.

Measuring quality of life in children with adenotonsillar disease with the Child Health Questionnaire: a first U.K. study.

Objective: To validate the Child Health Questionnaire (CHQ) and assess the quality of life of inner-city British children with adenotonsillar disease. Methods: The primary caregiver of a consecutive series of 43 patients referred for adenotonsillar disease to a pediatric otolaryngology clinic completed the Child Health Questionnaire. Questionnaires were analyzed for data quality and completeness, items/scale correlation, internal consistency and discriminant validity, interscale correlation, reliability estimates and external validity. Results: CHQ demonstrated excellent measuring characteristics in our population. In a comparison with healthy children, 11 out of 15 measures of quality of life were significantly depressed in our sample. Compared with children with rheumatoid arthritis, scores were equivalent in most areas, with the exception of the global health subscale and overall physical score, where our sample scored significantly lower. Conclusion: The CHQ (PF 28 version) is an accurate and reliable way of assessing the impact of adenotonsillar disease on the quality of life in children in Britain. This appears to be quite significant in most aspects of a childs life.Objective: To validate the Child Health Questionnaire (CHQ) and assess the quality of life of inner‐city British children with adenotonsillar disease.

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.

Computational modeling of flow and gas exchange in models of the human maxillary sinus

The present study uses numerical modeling to increase the understanding of sinus gas exchange, which is thought to be a factor in sinus disease. Order-of-magnitude estimates and computational fluid dynamics simulations were used to investigate convective and diffusive transport between the nose and the sinus in a range of simplified geometries. The interaction between mucociliary transport and gas exchange was modeled and found to be negligible. Diffusion was the dominant transport mechanism for small ostia and large concentration differences between the sinus and the nose, whereas convection was important for larger ostia or smaller concentration differences. The presence of one or more accessory ostia can increase the sinus ventilation rate by several orders of magnitude, because it allows a net flow through the sinus. Estimates of nitric oxide (NO) transport through the ostium based on measured sinus and nasal NO concentrations suggest that the sinuses cannot supply all the NO in nasally exhaled air.

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.

Dynamics of airflow in a short inhalation.

During a rapid inhalation, such as a sniff, the flow in the airways accelerates and decays quickly. The consequences for flow development and convective transport of an inhaled gas were investigated in a subject geometry extending from the nose to the bronchi. The progress of flow transition and the advance of an inhaled non-absorbed gas were determined using highly resolved simulations of a sniff 0.5 s long, 1 l s−1 peak flow, 364 ml inhaled volume. In the nose, the distribution of airflow evolved through three phases: (i) an initial transient of about 50 ms, roughly the filling time for a nasal volume, (ii) quasi-equilibrium over the majority of the inhalation, and (iii) a terminating phase. Flow transition commenced in the supraglottic region within 20 ms, resulting in large-amplitude fluctuations persisting throughout the inhalation; in the nose, fluctuations that arose nearer peak flow were of much reduced intensity and diminished in the flow decay phase. Measures of gas concentration showed non-uniform build-up and wash-out of the inhaled gas in the nose. At the carina, the form of the temporal concentration profile reflected both shear dispersion and airway filling defects owing to recirculation regions.

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.