Case Report: Thromboembolism and Hemorrhagic Pericardial Effusion-The Janus Face of Primary Pericardial Angiosarcoma.

Background: Primary cardiac angiosarcomas, especially those originating in the pericardium, are extremely rare and aggressive tumors with poor prognosis. These types of malignant tumors have diverse clinical presentations and are often masked by other comorbidities. Case Summary: Our hospital reported a 59-year-old woman who initially presented with pulmonary thromboembolism (PTE) and was subsequently treated with low-molecular-weight heparin. However, she experienced acute pericardial tamponade after anticoagulation therapy, where no obvious mass was primarily identified upon imaging, both in the pericardium or within the heart. Emergency pericardiocentesis and drainage were performed, where a total of 210 mL of bloody effusion was drained. Four months later, she was hospitalized with progressive hemoptysis and dyspnea. A large mixed mass occupying the right pericardium was later identified by coronary computed tomography angiography (CCTA). The mass was consistent with the right atrium, with heterogeneous thickened pericardium and localized moderate pericardial effusion. CCTA and positron emission tomography scans later showed metastases in both lungs and bilateral pleura. Nodules in hilar and mediastinal lymph nodes were also significant. Ultrasound-guided biopsy was performed, and the patient was ultimately diagnosed with an angiosarcoma based on final positive results for both CD31 and CD34 markers. The patient refused chemotherapy and passed away while waiting for her pathology results. The patient survived for 6 months since the first reported episode of PTE. Conclusions: Our case indicates that patients presenting with both embolism and hemorrhage should urgently be channeled to a clinical specialist to confirm any malignant etiology. This would be beneficial to confirm an early diagnosis and lengthen the duration of patient survival. However, the diagnosis of primary cardiac angiosarcoma is still challenging and requires multiple imaging modalities and biopsies in order to assist the accurate diagnosis of disease and achieve effective patient management.

Prolonged hospitalization following tonsillectomy in healthy children.

OBJECTIVE: To determine the incidence and factors that influence prolonged hospitalization in healthy children following tonsillectomy. METHOD: A retrospective analysis was performed of all the children who underwent tonsillectomy with or without other otolaryngological procedures in a tertiary care center. Analysis were carried out on otherwise healthy children who were unexpectedly hospitalized for two nights or more to identify factors that influenced their length of stay as well as readmission to hospital. RESULTS: Out of a total of 1229 children who underwent tonsillectomy within the study period, there were 1129 children who had no significant co-morbidities. Within this group a total of 73 (6.5%) children were unexpectedly hospitalized for two nights or more. There were 45 (62%) males and 28 (38%) females with a mean age of 5.3 yr and mean length of stay of 2.7 days. The most common reasons for prolonged hospitalization were poor oral intake and fever. While gender was not a risk factor, these children were younger compared with those discharged within 24h (5.3 yr versus 6.2 yr, p-value of 0.046). Nine of the children (12%) who required prolonged hospitalization were readmitted, which is significantly higher compared with the readmission rate of 3.9% in children who were discharged within 24h (p-value<0.001). Delayed hemorrhage was the principle cause of readmission. CONCLUSION: A significant proportion of otherwise healthy children require prolonged hospitalization following overnight-stay tonsillectomy. It is unclear whether planned discharge on day of surgery would be beneficial in lowering this rate.

Hemostasis in sinus surgery.

PURPOSE OF REVIEW: Optimization of the surgical field involves a complex interplay of many factors. Although it is agreed that hemostasis is critical to safe, efficient, and successful sinus surgery, a lack of consensus exists as to the best way to achieve it. This review examines the current body of evidence supporting many of the practices surgeons believe to influence hemostasis. RECENT FINDINGS: Although many of the practices discussed in this article have long been considered to influence hemostasis, it is not until recently that high-level evidence supporting their use has been available. Well designed studies now exist supporting the preoperative use of oral steroids in polyp patients, the importance of adequate reverse trendelenburg positioning, the use of flexible laryngeal mask ventilation during general anesthesia, and the increased safety and comparable efficacy of topical epinephrine over other topical and injectable agents. Controversy still exists as to the ideal method of achieving controlled hypotensive anesthesia, although new evidence has emerged as to what hemodynamic parameters should be adhered to, to reduce the risk of cerebral hypoperfusion. SUMMARY: Numerous factors influence hemostasis and so it is important that ENT surgeons have a sound understanding of the evidence supporting their everyday surgical practice. Improved standardization of scoring and reporting of bleeding may increase the power of research studies to draw more definitive conclusions about the role that certain factors have on hemostasis.

Can virtual reality simulator be used as a training aid to improve cadaver temporal bone dissection? Results of a randomized blinded control trial.

OBJECTIVES/HYPOTHESIS: This study aims to determine whether there are improved performances in cadaver temporal bone dissection after training using a VR simulator as a teaching aid compared with traditional training methods STUDY DESIGN: Randomized control trial. METHODS: Twenty participants with minimal temporal bone experience were recruited for this randomized control trial. After receiving the same didactic teaching they were randomized into two groups. The traditional group were to receive addition teaching via traditional teaching methods such as small group tutorials, videos, and models. The VR group received supervised teaching on the VR simulator. At the end of their teaching they were asked to perform a cadaveric temporal bone dissection and had their performance videoed and assessed by blinded assessors. The assessors judged the videos on four domains of assessments looking at the end product, injury size, overall performance, and technique. These assessments were based on the Welling's scale and OSATS. RESULTS: The VR group performed significantly better in the end product of the dissection (VR 80% vs. traditional 45%, P-value <.001) and caused smaller injuries to anatomic structures (VR 19% vs. traditional 36%, P-value = .01). They also did better in the overall performance score (VR 55% vs. traditional 35%, P-value = .04) There were no differences in the technique score. There was a fair to moderate degree of interrater reliability between the assessors (kappa = 0.33-0.47; Intraclass correlation coefficient = 0.34-0.76). CONCLUSION: Supervised teaching using a VR simulator seems to improve cadaveric temporal bone dissection performance compared with traditional teaching methods.

Differentiating levels of surgical experience on a virtual reality temporal bone simulator.

OBJECTIVE: Virtual reality simulation is increasingly being incorporated into surgical training and may have a role in temporal bone surgical education. Here we test whether metrics generated by a virtual reality surgical simulation can differentiate between three levels of experience, namely novices, otolaryngology residents, and experienced qualified surgeons. STUDY DESIGN: Cohort study. SETTING: Royal Victorian Eye and Ear Hospital. SUBJECTS AND METHODS: Twenty-seven participants were recruited. There were 12 experts, six residents, and nine novices. After orientation, participants were asked to perform a modified radical mastoidectomy on the simulator. Comparisons of time taken, injury to structures, and forces exerted were made between the groups to determine which specific metrics would discriminate experience levels. RESULTS: Experts completed the simulated task in significantly shorter time than the other two groups (experts 22 minutes, residents 36 minutes, and novices 46 minutes; P = 0.001). Novices exerted significantly higher average forces when dissecting close to vital structures compared with experts (0.24 Newton [N] vs 0.13 N, P = 0.002). Novices were also more likely to injure structures such as dura compared to experts (23 injuries vs 3 injuries, P = 0.001). Compared with residents, the experts modulated their force between initial cortex dissection and dissection close to vital structures. Using the combination of these metrics, we were able to correctly classify the participants' level of experience 90 percent of the time. CONCLUSION: This preliminary study shows that measurements of performance obtained from within a virtual reality simulator can differentiate between levels of users' experience. These results suggest that simulator training may have a role in temporal bone training beyond foundational training.