Travis J. Pfannenstiel

Difficult Airway Management for Novice Physicians A Randomized Trial Comparing Direct and Video-Assisted Laryngoscopy

Objectives To detect a difference in (1) intubation success and (2) successful intubation times between novice physicians using a Macintosh-style or video-assisted laryngoscope on a difficult airway manikin. Study Design Prospective randomized trial. Setting Academic, tertiary medical center. Methods Forty first-year residents across a variety of disciplines with fewer than 5 total live intubations were recruited for the study. Testing took place during orientation prior to commencement of clinical duties. The entire group was provided training by faculty otolaryngologists and anesthesiologists using both laryngoscope types on a manikin airway simulator in a standard intubating scenario. Subjects were then randomized into 2 testing groups, using either a Macintosh laryngoscope or video-assisted laryngoscope in a difficult intubation scenario. The difficult airway simulation entailed oral cavity/oropharyngeal obstruction using inflation of the tongue, as well as cervical spine immobilization with a rigid collar preventing extension and elevation of the head and limiting oral cavity opening. Success was defined as a confirmed endotracheal intubation by the testing instructor in 120 seconds or less. Results The Macintosh laryngoscope group (n = 19) had an intubation success rate of 47.4% with a mean intubation time of 69.0 seconds (95% confidence interval [CI]: 52.7, 85.2). The video-assisted group (n = 21) demonstrated a significantly higher success rate of 100% (P < .0001) and a decreased mean intubation time of 23.1 seconds (95% CI: 18.4, 27.8; P < .0001). The mean difference in success rate between groups was 52.6% (95% CI: 30.0%, 75.3%). Conclusions Novice physicians with little to no prior intubation experience showed significantly higher intubation success with lower intubation times using a video-assisted laryngoscope in a difficult airway manikin simulator.

Vocal fold immobility following burn intensive care.

OBJECTIVE: To evaluate factors associated with the development of vocal fold immobility in patients surviving burn intensive care. STUDY DESIGN AND SETTING: A retrospective review of patients referred to Department of Speech Pathology by the Burn Intensive Care Unit between June 2002 and November 2004. Patients underwent videostroboscopic examination, and associations of vocal fold immobility with factors related to patient management were examined by using logistic regression. RESULTS: Vocal fold immobility was diagnosed in 25 (48%) of the 52 patients evaluated. A significant association with a history of intubation during overseas aeromedical evacuation (odds ratio 4.5, P = 0.026) was observed. Multivariate modeling demonstrated an increased risk of 3% for each % total body surface area (TBSA) of burn. CONCLUSION: High-altitude transport of intubated patients was a significant risk factor in the development of laryngeal injury. SIGNIFICANCE: This study magnifies the role that endotracheal tube cuff pressure may play in recurrent laryngeal nerve injury.

The otologist's tuning fork examination--are you striking it correctly?

Objective To determine if the manner in which a tuning fork is activated affects its vibrational response. Study Design Diagnostic test assessment. Setting Hearing Center of Excellence laboratory. Subjects and Methods A Polytec OFV-5000 scanning vibrometer was used to measure the vibrational response of 256-Hz, 512-Hz, and 1024-Hz tuning forks after activation. The tuning forks were activated to varying intensities by striking 4 unique surfaces: the head, palm, a metal surface, and a wood table. Results The fundamental frequency of the individual tuning fork was the dominant observed frequency in all testing scenarios. Additional nonharmonic frequencies were noted when the 256-Hz and 512-Hz tuning forks were struck off metal and wooden surfaces. Conclusions Additional nonfundamental sound frequencies produced secondary to striking a tuning fork off a metal object or a wooden table could affect clinical tuning fork examination and complicate decisions regarding surgical candidacy.

The Tuning Fork Examination: Are You Performing It Correctly?

Objectives: The tuning fork remains a useful diagnostic tool in modern otolaryngology practice. Two important variables help describe the sound generated by the tuning fork: frequency and amplitude. We sought to determine whether the manner in which a tuning fork is activated affects its vibrational response. Methods: A Polytec OFV-5000 single point laser Doppler vibrometer was used to obtain direct velocity measurements after activation of 256 Hz, 512 Hz, and 1024 Hz tuning forks with several striking methods: striking the parietal bone, striking the pisiform bone, striking a wood table, and striking a metal surface. Each method was tested using three separate subjective intensities: softly, medium force, and significant force. Data were analyzed using the Polytec Vibrometer Software to produce a velocity spectrum and measurements of frequency and velocity amplitude. Results: The predominant frequency of motion of all tuning forks was their expected fundamental frequency. Additional nonharmonic frequencies were recorded when striking the 256 Hz and the 512 Hz tuning forks against metal or wood. The aberrant frequencies were of lower intensity relative to the fundamental frequency of the tuning fork. Conclusions: No additional frequencies were seen with activation on the head or pisiform bone or with the 1024 Hz fork using any method. For the 256 Hz and 512 Hz tuning forks, striking a hard surface produced additional and potentially misleading frequencies. As some providers use this test to guide surgical candidacy decisions in stapes surgery, this could have significant impact in clinical decisions.

Effects of Tympanomeatal Blunting on Sound Transfer Function

Objective. (1) To measure the peak-to-peak displacement of the round window membrane (RWM) prior to blunting procedure. (2) To evaluate the impact of blunting the anterior tympanomeatal angle (ATA) on middle ear sound transfer function. Study Design. Basic science study. Setting. Cadaveric temporal bone research laboratory. Subjects and Methods. Six fresh human temporal bones were prepared using a mastoidectomy and facial recess approach. Baseline RWM peak-to-peak displacements were obtained by single-point laser Doppler vibrometry (LDV) at 90-dB sound pressure level over a spectrum of 250 to 8000 Hz. Temporalis muscle was harvested and then fashioned into a graft for each temporal bone, mimicking ATA blunting. RWM displacement responses with the blunted ATA were measured using the LDV to judge the impact on middle ear transfer function. Results. For each of the 6 temporal bones, the average displacement decreased across all sound frequencies with the ATA blunting when compared with baseline (no blunting). Baseline velocity measurements for all sound signals averaged 4.5 × 10−3 ± 1.892 × 10−3 (mean ± SEM) mm/s, while measurements averaged 2.2 ± 6.62 × 10−4 mm/s with blunting of the ATA (P < .001). This amounted to a 52% decrease in velocity of the RWM following blunting of the ATA. Conclusion. Blunting of the ATA decreases the sound transfer function of the tympanic membrane and middle ear. Prevention of blunting at the ATA during tympanoplasty should be emphasized.

New Molecular Therapies in Otology

Program Description: Although there are well-established surgical techniques to reconstruct the ossicular chain, these methods remain varied, often based more on local tradition than on scientific research. The increasing number of available prostheses further increases the number of potential surgical variables. Successful ossiculoplasty as a part of tympanoplasty therefore continues to pose a significant challenge to the otolaryngologist. The goal of this miniseminar is to present the current best surgical technique for ossiculoplasty. Toward this end, we have assembled a panel of distinguished otologists who will draw on significant advances in basic research and ossicular prosthesis design, in addition to their vast clinical experience. Following a brief introduction, each panelist will present his preferred surgical technique of ossiculoplasty for reconstruction of the ossicular chain. The remaining time will be devoted to case presentations to identify the best ossiculoplasty method in specific clinical situations. This miniseminar will provide information that should improve the ability of each participant to perform successful ossiculoplasty.

Does Combat Hearing Preservation Equipment Affect Balance

Objective: 1) To investigate whether the occlusion effect produced by Department of Defense (DoD) Combat Arms Ear Plugs (CAEP) affects balance. 2) To investigate whether the noise-canceling Nacre QuietPro system affects balance. Method: Prospective study conducted from June to August 2010. Twenty subjects with normal hearing and balance function were tested with blackened goggles in 3 conditions—no hearing protection, CAEP, and with the Nacre QuietPro. Results: An AMTI Forceplate was used to measure the 20 individuals’ average angular acceleration during a period of 20 seconds. The order of the conditions given was randomized for each individual. The mean angular acceleration for no hearing protection, CAEP, and the Nacre QuietPro conditions were 0.65, 0.69, and 0.70, respectively (1-way ANOVA, P = .706), showing a nonsignificant trend between the unprotected and protected conditions. Conclusion: The components of an intact balance system include a variety of neural inputs, to include visual, auditory, and proprioceptive cues. Both the CAEP and Nacre QuietPro are combat hearing preservation devices currently deployed by the DoD in Afghanistan. Our pilot data show no decrement in balance with their utilization.

P001: Repair of Frontal Sinus Fracture Using Image Guidance

OBJECTIVES: 1. Learn how to apply an image-guided technique to repair frontal sinus fractures. 2. Be able to simplify locating of the frontal sinus for open repair of fractures. METHODS: A 25-year-old male presented with a comminuted anterior table frontal sinus fracture with minimally displaced posterior table. There was no evidence of cerebrospinal fluid leak or intracranial injury. Patient desired open reduction and internal fixation of the depressed anterior table. After raising a bicoronal flap, image guidance was used to confirm the location of the fracture. RESULTS: Using a novel postioning of the image guidance headset the team was able to successfully locate the position of the frontal sinus fracture without inhibiting access for the bicoronal incision. The fracture was successfully reduced and plated without postoperative complications. CONCLUSIONS: Using image guidance technology helps identify the location of the frontal sinus fracture and helps identify the extent of the osteoplastic flap. Using a novel positioning system of the image guidance headset enabled the surgeons to have full access for a bicoronal incision and direct access to the forehead. This technique overcomes the shortcomings of the imprecise plain film Caldwell views or trans sinus illumination techniques.