Omid Moshtaghi

Using Google Glass to solve communication and surgical education challenges in the operating room.

Laryngoscope, 125:2295–2297, 2015

CyberKnife for Treatment of Vestibular Schwannoma: A Meta-analysis:

Objectives (1) Perform a meta-analysis of the available data on the outcomes of CyberKnife radiosurgery for treatment of vestibular schwannomas (VSs) in the published English-language literature and (2) evaluate the collective outcomes of CyberKnife treatment with respect to tumor control and hearing preservation. Data Sources A thorough literature search of published English-language articles was performed in the PubMed, Ovid, and Cochrane databases. Review Methods A database search was conducted with the keywords “CyberKnife” and “vestibular schwannoma” or “acoustic neuroma.” A total of 25 papers were found and reviewed. Data were extracted for patient demographics, number of patients with neurofibromatosis type 2, pretreatment hearing status, tumor size, margin dose, and follow-up duration. The primary outcome variables evaluated were tumor control and hearing preservation. Results After careful review of the published articles, 11 papers reported data on outcomes of CyberKnife treatment for VS and were included in the analysis, comprising 800 patients studied during 1998 to 2012. The reported mean tumor volume ranged from 0.02 to 19.8 cm3, and the follow-up duration ranged from 6 to 120 months. Margin dose varied from 14 to 25 Gy. The collective mean tumor control rate was 96.3% (95% CI: 94.0%-98.5%). The collective hearing preservation rate was 79.1% (95% CI: 71.0%-87.3%) in 427 patients with measurable hearing. Conclusion Clinical data on outcomes of CyberKnife radiosurgery for treatment of VSs are sparse and primarily limited to single-institution analyses, with considerable variation in tumor volume and follow-up time. This meta-analysis not only provides an in-depth analysis of available data in the literature but also reviews reported outcomes and complications.

Assessment of google glass as an adjunct in neurological surgery

Background: We assess Google Glass (“Glass”) in improving postoperative review (“debriefing”) and augmenting education in Neurological Surgery at a tertiary academic medical center. Methods: This was a prospective study. Participants were patients of Neurological Surgery physicians at a Tertiary Care Level 1 Academic Trauma Center. Resident physicians received a pre-questionnaire immediately following surgery. Next, the resident and attending physicians debriefed by reviewing the Glass operative recording. Then, residents completed a 4-part post-questionnaire. Questions 1–3 assessed: (1) the residents’ comfort level with the procedure, (2) the quality of education provided by their superiors, and (3) their comfort level in repeating the operation. Question 4 assessed: (4) the perceived benefit of debriefing using Glass. Results: Twelve surveys were collected. Scores were based on a 5-point Likert scale, with a higher score corresponding to a more positive response. For Questions 1–3, the average pre- and post-questionnaire scores were 3.75 and 4.42, respectively (P <.05). For Question 4, the average post-questionnaire score was 4.63, suggesting that postoperative Glass review improved their technical understanding of the procedure. Conclusions: Glass significantly improved neurosurgery residents’ comfort level and quality of training, and provided a high fidelity, reliable, and modifiable tool that enhanced residents’ understanding, expertise, and educational experience. Of note, certain limitations such as variable battery life, variable image quality, and subpar compatibility with surgeon loupes must still be overcome for Glass to become a realistic addition to neurosurgical education.

Smartphone-Enabled Otoscopy in Neurotology/Otology

Objective A smartphone-enabled otoscope (SEO) can capture tympanic membrane (TM) images. We sought to compare a SEO to microscopic otoscopy in the detection and evaluation of TM pathology in an otology/neurotology practice. Study Design Prospective single-site study in adults presenting over a 3-month period. Setting Neurotology clinic within a tertiary care academic medical center. Subjects and Methods Following consent, 57 patients underwent a medical and microscopic ear examination. Afterward, clinicians photographed bilateral TMs using a SEO. A second “blinded” neurotologist received a SEO-acquired image of each TM and a brief patient history. Our primary end point was identification of TM pathology (or lack thereof) and the blinded neurotologists’ corresponding diagnosis. Secondary end points included patient-reported SEO comfort levels. Results A single SEO-acquired TM image and brief patient history resulted in correct diagnosis of 96% (23/24) of normal TMs and identification of 100% (33/33) of microscope-confirmed abnormal TMs. When pathology was identified by the “blinded” physician, the diagnosis was identical to that made by the primary treating physician 82% (27/33) of the time. On patient surveys, 93% (53/57) of patients felt “very comfortable” with SEO utilization, and 88% (50/57) reported viewing acquired images was “very useful” in understanding their condition. Conclusion A SEO is 96% specific in identifying normal TMs and 100% sensitive in identifying pathology. Its 97% positive predictive value and small false-positive rate makes it a useful screening tool. Furthermore, patients are receptive to this technology and felt comfortable with its utilization in a health care or possible telemedicine setting.

Management of mal de debarquement syndrome as vestibular migraines

Mal de debarquement syndrome (MdDS) is a balance disorder that typically starts after an extended exposure to passive motion, such as a boat or plane ride. Management is typically supportive (e.g. physical therapy), and symptoms that persist beyond 6 months have been described as unlikely to remit. This study was conducted to evaluate the response of patients with MdDS to management with migraine prophylaxis, including lifestyle changes and medical therapy.

Postoperative Complications and Readmission Rates Following Surgery for Cerebellopontine Angle Schwannomas

Objective: To investigate the 30-day postoperative complication, readmission, and reoperation rates following surgery for cerebellopontine angle (CPA) schwannomas. Study Design: Cross-sectional analysis. Setting: National surgical quality improvement program dataset (NSQIP) 2009 through 2013. Patients: All surgical cases with an International Classification of Diseases, 9th edition, Clinical Modification (ICD-9-CM) diagnosis code of 225.1, benign neoplasms of cranial nerves, and one of the following current procedural terminology (CPT) codes, were included: 61616, 61526, 61530, and 61520. Intervention(s): Surgical resection as indicated by the CPT codes above. Main Outcome Measure(s): Demographics, comorbidities, 30-day postoperative complications, readmission rate, and reoperation rate. Results: Overall, 404 cases were identified, of which 42.6% were men. The average age was 51 years. Comorbidities were present in 45.3%. NSQIP-tracked complications occurred in 9.7% of patients. Most common complications were wound infections including surgical-site infection and wound dehiscence (11 patients, 2.7%), sepsis (10 patients, 2.5%), blood loss (nine patients, 2.2%), and deep vein thrombosis (DVT; seven patients, 1.7%). Mortality occurred in four patients (1.0%). The complication rate was statistically higher in patients with comorbidities versus those without (10.2% versus 4.1%, p = 0.04). Patients with complications were more likely to undergo reoperation (2.5% with versus 4.1% without, p = 0.001). Unplanned readmissions occurred in 41 cases (10.1%) and reoperations occurred in 23 patients (5.7%). Conclusions: Most common NSQIP-tracked complications in excision of CPA neoplasms are infections, sepsis, blood loss, and deep vein thrombosis (DVT). Further, investigation of patients with unplanned readmission and reoperation are warranted. Neurotologists need to take an active role in the data to be gathered in the NSQIP database as it relates to vestibular schwannomas.

Tinnitus Patients Suffering from Anxiety and Depression: A Review

OBJECTIVES To review literature on the link between depression and anxiety in patients suffering from tinnitus. METHOD A systematic review of published English-language literature was performed using PubMed, Ovid, and Cochrane databases. RESULTS Of the 56 eligible abstracts 15 were chosen to be included in the review. All articles showed an association of depression and anxiety in tinnitus patients. CONCLUSIONS Because of the strong association between tinnitus, depression, and anxiety- all tinnitus patients should be screened for psychiatric disorders. Treatment for these complex conditions should involve a multidisciplinary team with cognitive behavioral therapy and possible pharmacological therapy.

Evaluation of an iPhone Otoscope in a Neurotrauma Clinic and as an Adjunct to Neurosurgical Education

Introduction CellScope®, an iPhone-enabled otoscope, was introduced into the neurotrauma clinic at an American College of Surgeons certified Level I trauma center. CellScope is an innovative tool that digitally improves optical clarity of the tympanic membrane, providing the acquisition of HIPPA compliant images. We compared the CellScope to the traditional otoscope in teaching medical students, neurosurgery physician assistants, and neurosurgery residents. In addition, the utility of this device in a neurotrauma clinic was specifically examined because of the high frequency of otologic symptoms after head trauma. Method CellScope examination of the tympanic membranes was introduced as a standard/routine part of the exam of neurotrauma patients. We retrospectively reviewed the clinic charts of the NeuroTrauma patients during a three-month time period to determine if their otologic symptoms correlated with any CellScope visualized abnormalities. Medical students, P.A.s, residents, and attendings were surveyed before and after using CellScope to assess their comfort and skill in completing an otological exam, as well as their opinion on the utility of CellScope in their medical training. Results 18 medical professionals were surveyed before and after the use of CellScope. Surveys were graded on a 1-5 scale and indicated a greater preference for the CellScope (4.7/5.0) versus the otoscope (3.16/5.0). Similarly, there was a preference for the CellScope for medical education (4.7/5.0 versus 2.78/5.0). Finally, surveys showed a greater preference for CellScope in identifying abnormal pathology. The overall score showed a 49% increased preference for CellScope over the traditional otoscope. Six previously undiagnosed abnormalities of the tympanic membrane were identified in a total of 27 neurotrauma patients using CellScope. Conclusion The visualization of the tympanic membrane is an important part of the physical examination of the neurotrauma patient. Smartphone-enabled medical instruments like CellScope may facilitate and remove barriers to routine implementation of this part of the physical examination.

Migraine-Related Aural Fullness: A Potential Clinical Entity

In this case series, we set out to describe the clinical entity of isolated, prolonged aural fullness (AF) and its relationship with migraine. Patients with isolated, persistent AF for 6 months or more were included with all possible etiologies ruled out. Migraine dietary and lifestyle changes and medical migraine prophylactic therapy were prescribed to all. Eleven patients were included (mean age, 52 years). Six (54%) patients fulfilled International Headache Society criteria for migraine with or without aura. Changes in perceived sensation of AF using the visual analog scale and quality of life questionnaires resulted in a statically significant improvement (P < .001, 95% confidence interval [CI], 4.7 to 6.72, and P < .001, 95% CI, −5.3 to −2.7, respectively). As such, an improvement of isolated, prolonged AF with migraine lifestyle changes and prophylactic treatment may suggest an etiological association between migraine and prolonged aural fullness.

The Role of In-Office Ultrasound in the Diagnosis of Neck Masses:

To evaluate the efficacy of otolaryngologist-performed in-office ultrasound (US) in the clinical assessment of lateral neck masses, we performed a retrospective review of patients with lateral neck masses who had both a surgeon-performed US and US-guided fine-needle aspiration (USGFNA) at our tertiary academic center from 2012 to 2015. Fifty-nine patients were included. USGFNA results included 32 (54%) malignant lesions, 23 (39%) benign lesions, and 4 (6%) nondiagnostic lesions. USGFNA demonstrated 85% accuracy. In 22 (37%) patients, in-office US revealed additional findings that were not identified on physical examination (eg, nonpalpable lymph nodes or elucidated anatomical structures), which either assisted in surgical planning or altered treatment. In-office US and USGFNA on initial evaluation by the otolaryngologist augment physical examination and have potential value as the primary imaging and diagnostic modality in the workup of lateral neck masses.