Rickul Varshney

The McGill simulator for endoscopic sinus surgery (MSESS): a validation study

BackgroundEndoscopic sinus surgery (ESS) is a technically challenging procedure, associated with a significant risk of complications. Virtual reality simulation has demonstrated benefit in many disciplines as an important educational tool for surgical training. Within the field of rhinology, there is a lack of ESS simulators with appropriate validity evidence supporting their integration into residency education. The objectives of this study are to evaluate the acceptability, perceived realism and benefit of the McGill Simulator for Endoscopic Sinus Surgery (MSESS) among medical students, otolaryngology residents and faculty, and to present evidence supporting its ability to differentiate users based on their level of training through the performance metrics.Methods10 medical students, 10 junior residents, 10 senior residents and 3 expert sinus surgeons performed anterior ethmoidectomies, posterior ethmoidectomies and wide sphenoidotomies on the MSESS. Performance metrics related to quality (e.g. percentage of tissue removed), efficiency (e.g. time, path length, bimanual dexterity, etc.) and safety (e.g. contact with no-go zones, maximum applied force, etc.) were calculated. All users completed a post-simulation questionnaire related to realism, usefulness and perceived benefits of training on the MSESS.ResultsThe MSESS was found to be realistic and useful for training surgical skills with scores of 7.97 ± 0.29 and 8.57 ± 0.69, respectively on a 10-point rating scale. Most students and residents (29/30) believed that it should be incorporated into their curriculum. There were significant differences between novice surgeons (10 medical students and 10 junior residents) and senior surgeons (10 senior residents and 3 sinus surgeons) in performance metrics related to quality (p < 0.05), efficiency (p < 0.01) and safety (p < 0.05).ConclusionThe MSESS demonstrated initial evidence supporting its use for residency education. This simulator may be a potential resource to help fill the void in endoscopic sinus surgery training.

Use of an endoscopic urology basket to remove bronchial foreign body in the pediatric population

Foreign body (FB) aspiration is a common problem in the pediatric population. Rigid bronchoscopy is considered the treatment of choice for removal of tracheobronchial FB. This is a report of two cases of tracheobronchial foreign body aspiration that were managed using an endoscopic urology basket through a flexible bronchoscope. This reports main purpose is to inform physicians on the benefit of flexible bronchoscopy and of the potential use of the endoscopic urology basket for tracheobronchial FB retrieval. We hope that the flexible bronchoscopy and the endoscopic basket will become a standard tool in FB retrieval kits for pediatric otolaryngologists who deal with this issue on a routine basis.

Coblation technique as an alternative treatment modality for oral lymphangioma

Lymphangiomas of the tongue are relatively uncommon, and traditional treatment modalities carry a high failure rate. We present here a case report of effective treatment of lymphangioma circumscriptum of the oral tongue using radiofrequency coblation, while including a review of the current literature.

The Mcgill thyroid nodule score - does it help with indeterminate thyroid nodules?

BackgroundUltrasound guided fine-needle aspiration (USFNA) biopsy of thyroid nodules often gives a result of indeterminate pathology, placing thyroid specialists in difficult management situations. The aim of this study is to evaluate the incidence of malignancy in patients undergoing surgery and to correlate these results with the McGill Thyroid Nodule Score (MTNS).MethodsWe performed a retrospective study comparing USFNA results, MTNS and histopathology of patients undergoing thyroid surgery between 2010 and 2012. Pre-operative USFNA results were divided into three subgroups: benign, indeterminate and suspicious for/malignant. The indeterminate USFNA subgroup comprised of Bethesda type III (atypia of undetermined significance) and Bethesda type IV (follicular neoplasms, including Hurthle cell neoplasms) lesions. Post-operative histopathology was divided into benign or malignant groups.ResultsOf the 437 patient charts reviewed, 57.0% had an indeterminate USFNA biopsy. Within the indeterminate group, the malignancy rate was 39.8%. For indeterminate USFNA, the median MTNS was 7 (32% risk of malignancy) for benign nodules and 9 (63% risk of malignancy) for malignant nodules on post-operative histopathology (p < 0.05).ConclusionThe rate of malignancy in operated patients with an indeterminate USFNA result was 39.8%. The MTNS can be of value to thyroid specialists in pre-operative decision-making when dealing with an indeterminate result of a thyroid nodule on USFNA.

Chyle leak: A rare complication post-hemithyroidectomy. Case report and review of literature

BACKGROUND Thyroidectomy is one of the common neck surgeries. Well recognized complications include postoperative bleeding, hypocalcaemia and recurrent laryngeal nerve injury. Chyle leak post-thyroidectomy is extremely rare. Most of the reported cases have had a complete central compartment neck dissection. METHODS AND RESULTS This is a case report of a patient who suffered from chyle leak after a left hemithyroidectomy without a complete central compartment neck dissection. The patient was managed conservatively with low fat diet and observation. A protocol for approaching thyroid patients with chyle leak is proposed based on a comprehensive literature review. CONCLUSION Chyle leak post-thyroidectomy for a benign disease is a very rare complication. Nevertheless, head and neck surgeons should consider it in the differential diagnosis of neck swelling post-thyroidectomy.

Castleman's Disease: A rare finding in a pediatric neck

Castlemans Disease is a rare lymphoproliferative disorder. In the literature, only 29 cases, associated with the neck presentation in children, have been reported. This is another case report regarding a 5-year old child who presented with a persistent cervical lymphadenopathy. Final pathology, after undergoing exploratory neck dissection and surgical excision, revealed Castlemans Disease. This report, augmented with a literature review of all the 29 cases, compares the clinical course of this patient with the other cases. In conclusion, although Castlemans Disease carries a favorable prognosis in children, surgical excision is recommended to confirm the diagnosis and to rule out other causes.

Thyroid gland rupture: A rare finding after a blunt neck trauma

This is a case report of a 13 years old boy with a thyroid rupture secondary to a hockey stick blunt trauma to his neck and a literature review focused on diagnosis and management. There are 14 other cases in the literature, 7 of which required surgical intervention mainly to evacuate a hematoma. The case in this review did not develop any complications. This is the first reported case in the literature of thyroid gland rupture due to a blunt trauma in a child. Patients with thyroid gland rupture should be monitored closely for developing a hematoma or thyroid storm.

Ultrasound-guided fine-needle aspiration of thyroid nodules: Does size matter?

PURPOSE Some authors have questioned the benefit of fine-needle aspiration (FNA) of thyroid nodules ≥ 4 cm. They report that the results of the FNA are not as reliable when compared to nodules <4 cm. The aims of this study are to evaluate the accuracy and predictive values of ultrasound-guided FNA (USFNA) of thyroid nodules ≥ 4 cm and compare these findings to nodules <4 cm. METHODS A retrospective study of 998 patients who underwent thyroid surgery between 2006 and 2012 at the McGill University Thyroid Cancer Center was performed. USFNA and post-operative pathology diagnoses of nodules ≥ 4 cm versus those <4 cm were compared. Pre-operative USFNA results were divided into three groups: benign, indeterminate, and malignant/suspicious for malignancy subgroups. Post-operative results were separated into benign and malignant groups. RESULTS There were 225 patients with nodules ≥ 4 cm and 773 patients with nodules <4 cm. The sensitivity, specificity, positive predictive value and negative predictive value for USFNA of nodules ≥ 4 cm were 84.62% (CI 71.91-93.10), 91.49% (CI 79.6-97.58), 91.67% (CI 80.0-97.63) and 84.31% (CI 71.4-92.95), respectively. The sensitivity, specificity, positive predictive value and negative predictive value for USFNA of nodules <4 cm were 90.48% (CI 86.1-93.8), 85.92% (CI 75.6-93.02), 95.8% (CI 92.41-97.96) and 71.76% (CI 60.95-81.0), respectively. The difference in diagnostic accuracy of USFNA between both groups was not statistically significant (p>0.05). CONCLUSION This study shows that the sensitivity, specificity, positive predictive value and negative predictive value for USFNA of nodules ≥ 4 cm are similar to that of smaller nodules. It is therefore suggested that these nodules undergo USFNA.

Curvature coding is tuned for motion direction

We have investigated the global and local motion tuning properties of curvature coding mechanisms using two shape after-effects believed to be mediated by curvature-sensitive mechanisms: the shape-frequency after-effect, or SFAE, and the shape-amplitude after-effect, or SAAE. The SFAE and SAAE are the phenomena in which adaptation to a sine-wave-shaped contour causes a shift in respectively the apparent shape-frequency and apparent shape-amplitude of a test contour in a direction away from that of the adapting stimulus. In the global motion condition the sinusoidal-shaped contours were made to drift within a fixed stimulus window in the direction of their axis of modulation. In the local motion condition the contour was constructed from a string of Gabors, and their carriers but not envelopes moved. We investigated selectivity to motion direction by using adaptor and test contours that moved either in the same or opposite directions. We found that in the global motion condition both the SFAE and SAAE showed selectivity to motion direction, and that for the same-motion-direction condition, both after-effects increased with shape temporal frequency. We then examined the effect of luminance spatial frequency and luminance temporal frequency on global motion direction selectivity. Luminance temporal frequency accounted for some of the increase in after-effect magnitude with shape temporal frequency, but shape temporal frequency also contributed. The local motion after-effects on the other hand were neither selective to motion direction nor increased with luminance temporal frequency. Taken together, the results are best understood by supposing that curvature is encoded by mechanisms that are selective to motion direction and that the directional selectivity best manifests itself psychophysically when there is sufficient spatio-temporal coverage of the stimulus to stimulate the full array of potentially responsive curvature-coding mechanisms.

Hemorrhagic Hairy Polyp Causing Velopharyngeal Dysfunction in a Newborn

Velopharyngeal dysfunction (VPD) can be secondary to anatomic, neurologic, or functional maldevelopment in the pediatric population. We present a case of transient VPD after the removal of a voluminous oropharyngeal hairy polyp in a newborn with an intact palate. This report sensitizes physicians, speech-language pathologists, and occupational therapists not only to the repercussions of oropharyngeal congenital masses, such as hairy polyps, on the feeding mechanisms of a newborn but also to the possibility of conservative management.