Simulation-based workshop for emergency preparedness in otolaryngology.

Objectives: This study aimed to evaluate the outcomes of a hands-on simulation-based course with emphasis on procedural techniques, clinical reasoning, and communication skills developed to improve junior Otolaryngology - Head and Neck Surgery (OHNS) residents' preparedness in managing otolaryngologic emergencies. Methods: Junior OHNS residents and faculty from residency programs in California, Nevada, and Arizona participated in this workshop in 2020 and 2021. The stations featured airway management techniques, ultrasound-guided needle aspiration, nasoseptal hematoma evacuation, and facial fracture repair using various models and cadavers. Participants completed a pre-workshop survey, post-workshop survey, and 2-month follow-up survey that assessed resident anxiety and confidence in three OHNS emergency situations across knowledge, manual skills, and teamwork using a 5-point Likert scale. Results: Pre-workshop surveys reported the least anxiety and most confidence in teamwork, but the most anxiety and least confidence in technical skills and knowledge related to foreign body retrieval and airway management. Immediately post-workshop participants reported significant reductions in anxiety and increases in confidence, largest in the manual skills domain, in foreign body retrieval (anxiety: -0.99, confidence: +0.95, p < .01) and airway management stations (anxiety: -0.68, confidence: +1.07, p < .01). Data collected for the epistaxis station showed decreasing confidence and increasing anxiety following the workshop. Conclusion: Our findings demonstrate the effectiveness of a workshop in preparing junior residents in potentially lifesaving otolaryngologic techniques that residents will encounter. Optimizing use of simulation centered training can inform the future of residency education, improving confidence and decreasing anxiety in residents responsible for the safety of patients. Level of Evidence: III.

Postoperative Gabapentin's Effect on Opioid Consumption and Pain Control Following Sinonasal Surgery.

OBJECTIVE: This study investigates the impact of postoperative gabapentin on opioid consumption and pain control following endoscopic sinus surgery (ESS) and/or septoplasty. METHODS: Patients who underwent ESS and/or septoplasty at a single institution from 2021 to 2022 were enrolled. All patients received postoperative hydrocodone-acetaminophen for pain control. Half of the patients were also prescribed gabapentin for the first postoperative day in addition to hydrocodone-acetaminophen. Subjects completed the Revised American Pain Society Patient Outcome Questionnaire 24 h and 7 days after surgery. We conducted a multivariable regression analysis to assess opioid consumption and improvement in pain scores in the first week between gabapentin and non-gabapentin groups. RESULTS: A total of 102 subjects, 51 in each arm, were enrolled. The mean age was 52 years and 53% of participants were female. Controlling for important baseline demographic, clinical, and surgically related variables, the addition of postoperative gabapentin was associated with a 44% (9.5 mg from 21.6 mg) reduction in opioids consumed in the first postoperative week (B = -9.54, 95% C.I. = [-17.84, -1.24], p = 0.025). In addition, patients in both arms exhibited similar improvement in pain severity and sleep interference in the first 7 days (B = -1.59, 95% C.I. = [-5.03, 1.84], p = 0.36). CONCLUSION: To the best of our knowledge, this is the first study to investigate the impact of postoperative gabapentin on opioid consumption and pain control following ESS and/or septoplasty. Our analysis demonstrated that postoperative gabapentin effectively reduced opioid use during the first postoperative week without compromising pain control. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:1065-1072, 2023.

Decontamination Methods for Reuse of Filtering Facepiece Respirators.

Importance: The novel coronavirus disease 2019 (COVID-19) has proven to be highly infectious, putting health care professionals around the world at increased risk. Furthermore, there are widespread shortages of necessary personal protective equipment (PPE) for these individuals. Filtering facepiece respirators, such as the N95 respirator, intended for single use, can be reused in times of need. We explore the evidence for decontamination or sterilization of N95 respirators for health care systems seeking to conserve PPE while maintaining the health of their workforce. Observations: The filtration properties and fit of N95 respirators must be preserved to function adequately over multiple uses. Studies have shown that chemical sterilization using soap and water, alcohols, and bleach render the respirator nonfunctional. Decontamination with microwave heat and high dry heat also result in degradation of respirator material. UV light, steam, low-dry heat, and commercial sterilization methods with ethylene oxide or vaporized hydrogen peroxide appear to be viable options for successful decontamination. Furthermore, since the surface viability of the novel coronavirus is presumed to be 72 hours, rotating N95 respirator use and allowing time decontamination of the respirators is also a reasonable option. We describe a protocol and best practice recommendations for redoffing decontaminated N95 and rotating N95 respirator use. Conclusions and Relevance: COVID-19 presents a high risk for health care professionals, particularly otolaryngologists, owing to the nature of viral transmission, including possible airborne transmission and high viral load in the upper respiratory tract. Proper PPE is effective when used correctly, but in times of scarce resources, institutions may turn to alternative methods of preserving and reusing filtering facepiece respirators. Based on studies conducted on the decontamination of N95 respirators after prior outbreaks, there are several options for institutions to consider for both immediate and large-scale implementation.

Laryngeal Pilar Cyst Masquerading as an Internal/External Laryngocele.

OBJECTIVES: This study aimed to document and describe a case of a laryngeal pilar cyst and to review the literature. METHODS: We describe the case of a 65-year-old woman with a laryngeal pilar cyst presenting with occasional ear pain and positional dyspnea, with imaging studies suggesting external/internal laryngocele. We also review the existing clinical literature. RESULTS: Pilar cysts are adnexal skin lesions most commonly found in the scalp of elderly women. They generally have a benign course, but in rare instances single or multiple foci of proliferating cells can lead to the neoplastic formation of proliferating trichilemmal cysts, which carry malignant potential. Depending on the location of the cyst, pilar cysts may also present functional challenges for the patient. CONCLUSIONS: Herein, we describe a pilar cyst in and around the larynx appearing initially as a laryngocele. Pilar cysts may present surrounding the larynx and may be mistaken for a vast array of pathologies. It is important to keep the differential broad when evaluating laryngeal masses.

Low-cost modular phonosurgery training station: development and validation.

OBJECTIVE: Phonosurgery requires technical precision and careful tissue handling. Typically, phonosurgical procedures require single-operator techniques, making it difficult for novice residents to develop necessary skills. We developed a low-cost phonosurgery simulator to allow practice and acquisition of microlaryngeal skills. STUDY DESIGN: Validation study assessing the simulator's face and content validity in surgical education. METHODS: For construction, the simulator is composed of a simulation station and laryngeal modules, each constructed with inexpensive, easily accessible materials including plywood and polyvinyl chloride pipe. Laryngeal modules were constructed using rubber bands, bacitracin, and plastic wrap to simulate layers of the true vocal fold. Three separate modules were developed to address specific skills: 1) basic instrumentation; 2) papilloma debulking; 3) subepithelial and epithelial lesion excision. Papillomas, subepithelial, and epithelial lesions were simulated with grapefruit, caulk, and suture, respectively. The Kantor-Berci video laryngoscope was used for visualization. For validation, face and content validity were assessed by attending otolaryngologists (n = 16), who performed the three specific skills using the simulation station and completed a 5-point Likert-type postsimulation questionnaire. RESULTS: Most participants (89%) strongly agreed that the simulator incorporates essential phonosurgery skills and that portions of the model simulated an actual case (content validity). All participants (100%) agreed that the simulator is an adequate training device to increase resident competency and would be interested in using it to train residents (face validity). CONCLUSION: This simulator has the potential to be an important component of phonosurgical education and preoperative preparation. Advantages include a realistic experience, modular design, and inexpensive construction. LEVEL OF EVIDENCE: N/A.

Audiovestibular Characteristics of Small Cochleovestibular Schwannomas in Neurofibromatosis Type 2.

OBJECTIVE: Describe the relationship between cochleovestibular schwannoma (CVS) volume, audiovestibular characteristics, and magnetic resonance imaging (MRI) findings in patients with neurofibromatosis type 2 (NF2). STUDY DESIGN: Subgroup analysis of NF2 prospective natural history study from 2008 to 2011. SETTING: Quaternary medical research institute. SUBJECTS AND METHODS: NF2 patients with small treatment-naive CVSs (volume <1000 mm(3)) by ear; N = 49 ears (32 patients). Cross-sectional analysis of the following parameters was performed: tumor size, auditory brainstem response (ABR), 4-frequency pure-tone average (4f-PTA; 0.5, 1, 2, and 4KHz), cervical vestibular evoked myogenic potential (cVEMP), caloric testing, 240° velocity step test (VST), and MRI findings. RESULTS: For all physiologic measures but the 4f-PTA, larger tumors correlated with abnormal responses (P < .05). For abnormal ABR, mean tumor volume was 405 vs 151 mm(3) (P = .0007) for normal ABR. Similarly, larger tumors correlated with weak caloric responses (mean 521 vs 165 mm(3); P = .0007) and weak cVEMP (mean 357 vs 192 mm(3); P = .0262). Tumor volume was not significantly correlated with 4f-PTA. Elevated intralabyrinthine protein on MRI fluid-attenuated inversion recovery sequences was correlated with larger tumor volume (mean 333 vs 55 mm(3); P = .001) and abnormal ABR and 4f-PTA (P < .05) but did not correlate with cVEMP, VST, or caloric responses. CONCLUSION: In our cohort, ABR, caloric response, cVEMP, and elevated intralabyrinthine protein correlated with tumor volume, but 4f-PTA did not. Abnormal ABR and 4f-PTA correlated with elevated intralabyrinthine protein. These findings may provide insight on the effect of small CVS on the inner ear and cochleovestibular nerves, which may aid in their optimal management.

Oncologic benefit of tonsillectomy in stage I and II tonsil cancer: a surveillance epidemiology and end results database review.

IMPORTANCE: Treatment of low-stage tonsil cancer with radiotherapy is common, but the type of diagnostic procedure prior to radiotherapy varies. This study uses the Surveillance Epidemiology and End Results (SEER) registry to determine whether tonsillectomy or other surgical procedures prior to radiotherapy have an impact on outcome. OBJECTIVE: To demonstrate whether tonsillectomy adds oncologic advantage over biopsy alone in stage I or II tonsil cancers prior to definitive radiotherapy. DESIGN: Retrospective study of the SEER program. PARTICIPANTS: A total of 524 patients with stage I and II primary tonsil carcinoma diagnosed during the period 1988 through 2006 who received definitive radiation treatment. MAIN OUTCOMES AND MEASURES: Hazard ratios, 5-year disease-specific survival (DSS), 5-year overall survival (OS), and Kaplan-Meier survival curves. Subgroup univariate and multivariate analysis of survival compared the following variables: sex, T category (T1 vs T2), year of diagnosis (1988-2003 vs 2004-2006), and surgical status (preradiation tonsillectomy vs biopsy only). A log-rank test compared Kaplan-Meier survival analysis for the surgical status subgroups. RESULTS Statistically significant contributors to survival (DSS and OS) included age (P < .001, DSS), surgical status (P = .001, DSS), and year of diagnosis (P = .02, DSS). Treatment with radiation after tonsillectomy yielded a 5-year OS of 83% (95% CI, 77%-88%) and a 5-year DSS of 90% (95% CI, 84%-93%). This compares with an OS of 64% (95% CI, 54%-71%) and DSS of 76% (95% CI, 68%-82%) for radiation therapy after biopsy alone. CONCLUSIONS AND RELEVANCE: SEER data suggest that tonsil resection prior to radiation therapy is associated with improved survival in low-stage tonsil cancer. Although selection bias is a likely factor in this analysis, the effect remains after controlling for age and year of treatment.

Three-dimensional direct laryngoscopy and bronchoscopy: enhanced visualization of the airway.

IMPORTANCE: This is the first description of 3-dimensional (3D) pediatric airway endoscopy in the otolaryngology literature detailing the superior visualization with this technology. Ultimately, enhanced optics may further improve the treatment of airway pathology. OBJECTIVE: To report the first case series examining the use of 3D direct laryngoscopy and bronchoscopy (DLB) in the diagnosis and management of laryngotracheal pathology. DESIGN: Case series. SETTING: Tertiary care pediatric hospital. PARTICIPANTS: Three patients underwent both telescopic 2-dimensional (2D) and 3D DLB for comparison purposes: a 12-year-old boy for visualization of complete tracheal rings, a 23-year-old man for dilation of tracheal stenosis, and a 4-month-old boy for resection of subglottic cysts. MAIN OUTCOME MEASURES: Enhanced visualization of laryngotracheal pathology and facilitated endoscopic surgery. RESULTS: To our knowledge, this is the first case series in the otolaryngology literature examining the use of 3D DLB for the resection of subglottic cysts, dilation of tracheal stenosis, and visualization of complete tracheal rings. We believe that the 3D view offers qualitatively improved depth perception, accuracy of balloon placement, and appraisal of subglottic cyst resection margins. CONCLUSIONS AND RELEVANCE: This emerging technology has vast potential for improving endoscopy, surgical precision in airway interventions, tissue preservation, and methods of teaching. More research is needed in this area regarding the benefits and advantages of 3D compared with 2D endoscopy.

Intraprotein electron transfer in a two-domain construct of neuronal nitric oxide synthase: the output state in nitric oxide formation.

Intersubunit intraprotein electron transfer (IET) from flavin mononucleotide (FMN) to heme is essential in nitric oxide (NO) synthesis by NO synthase (NOS). Previous crystal structures and functional studies primarily concerned an enzyme conformation, which serves as the input state for reduction of FMN by electrons from NADPH and flavin adenine dinucleotide (FAD) in the reductase domain. To favor the formation of the output state for the subsequent IET from FMN to heme in the oxygenase domain, a novel truncated two-domain oxyFMN construct of rat neuronal NOS (nNOS), in which only the FMN and heme domains were present, was designed and expressed. The kinetics of IET between the FMN and heme domains in the nNOS oxyFMN construct in the presence and absence of added calmodulin (CaM) were directly determined using laser flash photolysis of CO dissociation in comparative studies on partially reduced oxyFMN and single-domain heme oxygenase constructs. The IET rate constant in the presence of CaM (262 s(-)(1)) was increased approximately 10-fold compared to that in the absence of CaM (22 s(-)(1)). The effect of CaM on interdomain interactions was further evidenced by electron paramagnetic resonance (EPR) spectra. This work provides the first direct evidence of the CaM control of electron transfer (ET) between FMN and heme domains through facilitation of the FMN/heme interactions in the output state. Therefore, CaM controls IET between heme and FMN domains by a conformational gated mechanism. This is essential in coupling ET in the reductase domain in NOS with NO synthesis in the oxygenase domain.

Direct measurement by laser flash photolysis of intramolecular electron transfer in a two-domain construct of murine inducible nitric oxide synthase.

Intersubunit intramolecular electron transfer (IET) from FMN to heme is essential in the delivery of electrons required for O2 activation in the heme domain and the subsequent nitric oxide (NO) synthesis by NO synthase (NOS). Previous crystal structures and functional studies primarily concerned an enzyme conformation that serves as the input state for reduction of FMN by electrons from NADPH and FAD in the reductase domain. To favor formation of the output state for the subsequent IET from FMN to heme in the oxygenase domain, a novel truncated two-domain oxyFMN construct murine inducible nitric oxide synthase (iNOS), in which only the FMN and heme domains were present, was designed and expressed. The kinetics of the IET between the FMN and heme domains in this construct was directly determined using laser flash photolysis of CO dissociation in comparative studies on partially reduced oxyFMN and single domain heme oxygenase constructs.

Nitric-oxide synthase output state. Design and properties of nitric-oxide synthase oxygenase/FMN domain constructs.

Mammalian nitric-oxide synthases are large modular enzymes that evolved from independently expressed ancestors. Calmodulin-controlled isoforms are signal generators; calmodulin activates electron transfer from NADPH through three reductase domains to an oxygenase domain. Structures of the reductase unit and its homologs show FMN and FAD in contact but too isolated from the protein surface to permit exit of reducing equivalents. To study states in which FMN/heme electron transfer is feasible, we designed and produced constructs including only oxygenase and FMN binding domains, eliminating strong internal reductase complex interactions. Constructs for all mammalian isoforms were expressed and purified as dimers. All synthesize NO with peroxide as the electron donor at rates comparable with corresponding oxygenase constructs. All bind cofactors nearly stoichiometrically and have native catalytic sites by spectroscopic criteria. Modest differences in electrochemistry versus independently expressed heme and FMN binding domains suggest interdomain interactions. These interactions can be convincingly demonstrated via calmodulin-induced shifts in high spin ferriheme EPR spectra and through mutual broadening of heme and FMNH. radical signals in inducible nitric-oxide synthase constructs. Blue neutral FMN semiquinone can be readily observed; potentials of one electron couple (in inducible nitric-oxide synthase oxygenase FMN, FMN oxidized/semiquinone couple = +70 mV, FMN semiquinone/hydroquinone couple = -180 mV, and heme = -180 mV) indicate that FMN is capable of serving as a one electron heme reductant. The construct will serve as the basis for future studies of the output state for NADPH derived reducing equivalents.