Does "Just in Time" teaching of ergonomic principles improve posture of trainees during otologic microscopic surgery?

PURPOSE: Musculoskeletal disorders are prevalent among otolaryngologists and otologists with symptoms starting during residency. Prior data suggested that high-risk joint angles were often adopted at procedure onset, suggesting a detrimental "natural" operating position. Despite its importance, dedicated ergonomic teaching is not systematically introduced into residency training. The objective of this study was to compare initial ergonomic positioning during microscopic temporal bone surgery between those who receive "Just in Time" ergonomic teaching prior to starting dissection with those who did not. MATERIALS AND METHODS: This was a pilot, prospective trial in which otolaryngology residents at an urban, multicenter tertiary care academic institution (n = 14) wore ergonomic sensors (inertial measurement units) during microscopic temporal bone lab drilling. Prior to recording, participants were randomized to receive an instructional presentation on ergonomic principles (n = 8, intervention group) or not (n = 6, control group). The inertial measurement units analyzed neck and back angles for the initial 5 min of drilling. RESULTS: Of 14 trainees, 78.6 % had prior experience with otologic microscopic cases and 14.3 % reported prior surgical ergonomic training or instruction. The groups were matched in trainee height (P = 0.54), handedness (P = 0.83), stage of otolaryngology training (P = 0.64), prior otologic microscopic surgery experience (P = 0.35), prior temporal bone drilling experience (P = 0.35), and prior teaching in ergonomic principles (P = 0.47). Junior trainees (PGY 1-3) who did not receive "Just in Time" teaching adopted a posture with significantly higher risk back flexion compared to junior trainees who received the training (25.3° vs. 5.7°, P = 0.04). There was no difference in back positioning among senior trainees (12.6° vs. -5.7°, P = 0.13). While there was a trend towards those in the intervention group adopting safer procedural posture, there was no significant difference in the overall cohort between the intervention and control groups in both neck positioning (-11.0° vs. -19.1°, P = 0.17) and back positioning (8.6° vs. 19.1°, P = 0.18). CONCLUSIONS: Musculoskeletal related pain is prevalent among otolaryngologists and otologists with data suggesting that symptoms begin during residency. Targeted "Just in Time" teaching of ergonomic principles is feasible and may be effective for development of healthy postural habits, especially among junior trainees.

Defining the Learning Curve for Endoscopic Ear Skills Using a Modular Trainer: A Multi-Institutional Study.

OBJECTIVE: Quantify the learning curve for endoscopic ear skills acquisition in otolaryngology residents using a simulator. The secondary objective was to determine if demographic factors or previous endoscopic experience influenced skill development. STUDY DESIGN: Prospective, multicenter study. Resident participants each completed 10 amassed trials using a validated endoscopic ear skill trainer. SETTING: Two academic teaching hospitals. SUBJECTS: Otolaryngology residents. MAIN OUTCOME MEASURES: Trial completion times; rate of improvement over time. RESULTS: Thirty-eight residents completed the study, 26 from program A and 12 from program B. Fifteen participants were women and 23 were men. Mean age was 30 years old (range 26 to 34 years). Previous experience with otoendoscopy (B = -16.7, p = 0.005) and sinus endoscopy (B = -23.4, p = 0.001) independently correlated with lower overall trial times. Age, gender, postgraduate year, handedness, interest in otology, and video gaming were not associated with trial times. On multivariate logistic regression, resident completion times improved with trial number, and residents without previous endoscopy experience improved at a faster rate than those with experience ( p < 0.001). CONCLUSIONS: Novice surgeons may acquire basic endoscopic ear experience with self-directed simulation training. The learning curve for transcanal endoscopic ear surgery is comparable to those demonstrated for other otologic surgeries, and specific task competencies can be achieved within 10 trials, suggesting that previous experiences, or lack thereof, may not dictate the ability to acquire new skills. There may be a translational value to previous endoscopic sinus experience on learning transcanal endoscopic ear surgery.

Otolaryngology Patient Satisfaction with In-Office Appointments and Virtual Visits Due to COVID-19.

BACKGROUND: The COVID-19 pandemic forced otolaryngologists to seek new methods of providing patient care in a remote setting. The effect of this paradigm shift on patient satisfaction, however, remains unelucidated. This study compares patient satisfaction with telehealth visits during the COVID-19 pandemic to that with in-office visits during the same period in 2019. METHODS: Press Ganey survey responses of patients seen by otolaryngologists within a large, academic, multicenter hospital system were gathered. Responses were included in analyses if they corresponded with a visit that occurred either in clinic March to December 2019 or via telehealth March to December 2020. Chi-Square Test of Independence and Fisher's Exact Test were employed to detect differences between years. Binary logistic regressions were performed to detect the factors most predictive of positive telehealth experiences. RESULTS: Patient overall satisfaction with in-office and telehealth visits did not differ significantly (76.4% in 2019 vs 78.0% in 2020 rated visit overall as "very good," P = .09). Patients seen by a Head and Neck (odds ratio 4.13, 95% confidence interval 1.52-11.26, P = .005), Laryngology (OR 5.96, 95% CI 1.51-23.50, P = .01), or Rhinology (OR 4.02, 95% CI 1.55-10.43, P = .004) provider were significantly more likely to report a positive telehealth experience. CONCLUSIONS: Patients seen via telehealth during COVID-19 reported levels of satisfaction similar to those seen in-office the year prior. These telehealth satisfaction levels, however, are contextualized within the expected confines of a pandemic. Further research is required to determine whether satisfaction remains consistent as telemedicine becomes a ubiquitous component of medical practice.

Ergonomic Analysis of Otologic Surgery: Comparison of Endoscope and Microscope.

OBJECTIVE: The comparative postural health of surgeons performing endoscopic and microscopic otologic surgeries has been a topic of active debate, with many nascent or anecdotal reports suggesting the latter encourages suboptimal ergonomics. Using inertial body sensors to measure joint angles, this study sought to objectively evaluate and compare the ergonomics of surgeons during endoscopic and microscopic otologic surgeries. STUDY DESIGN: Prospective pilot trial. SETTING: Large, multicenter, academic hospital system. Performed 21 otologic operations (10 endoscopic and 11 microscopic) in November 2020 and January 2021. All attendings were fellowship trained in otology/neurotology. SUBJECTS: Eight otolaryngologists (four attendings and four residents) performing 21 otologic surgeries (11 microscopic and 10 endoscopic). INTERVENTION: Approach to otologic surgery: endoscope or microscope. MAIN OUTCOME MEASURES: Surgeons' neck and back angles while wearing ergonomic sensors affixed to either side of each major joint, mental and physical burdens and pain after each surgery (via modified NASA Task Load Index). RESULTS: Residents' necks (9.54° microscopic vs. -4.79° endoscopic, p = 0.04) and backs (16.48° microscopic vs. 3.66° endoscopic, p = 0.01) were significantly more flexed when performing microscopic surgery than when performing endoscopic surgery, although attending neck and back flexion were comparable during microscopic and endoscopic surgeries. Attendings reported significantly higher pain levels after operating microscopically than after operating endoscopically (0.13 vs. 2.76, p = 0.01). CONCLUSIONS: Residents were found to operate with significantly higher risk back and neck postures (as defined by the validated ergonomic tool, Rapid Entire Body Assessment) when operating microscopically. Attendings reported significantly higher levels of pain after operating microscopically versus endoscopically, suggesting that the suboptimal microscopic postures adopted earlier in training may pose an indelible risk later in a surgeon's career.

A Review of Noninfectious Diseases Masquerading as Acute Mastoiditis.

OBJECTIVE: Acute mastoiditis is commonly attributed to infection. Rarely do clinicians encounter cases that do not respond to traditional antibiotics or surgical management. The goal of this study was to systematically review the literature to characterize diseases masquerading as acute infectious mastoiditis. DATA SOURCES: PubMed, Embase, and Scopus. REVIEW METHODS: A systematic review was performed to identify all publications that reported on diseases with presentations mimicking acute mastoiditis, defined as postauricular redness, swelling, and tenderness. We included clinical prospective studies, retrospective studies, and case series/reports. Exclusion criteria included non-English articles, letters/commentaries, abstracts, and review articles. RESULTS: Out of 3339 results, 35 studies met final inclusion criteria. In children, 11 diseases were reported to mimic mastoiditis, including solid tumors, hematologic diseases, and autoimmune/inflammatory diseases. The most common disease in children was Langerhans cell histiocytosis, followed by rhabdomyosarcoma and acute myelogenous leukemia. In adults, 8 additional diseases were reported. The most common disease in adults was squamous cell carcinoma, followed by nasopharyngeal carcinoma and Langerhans cell histiocytosis. Presenting symptoms are reviewed, as well as characteristic radiographic, laboratory, and intraoperative features that may assist with diagnosis. A diagnostic algorithm for atypical cases of acute mastoiditis is proposed. CONCLUSION: A small but significant group of diseases in children and adults can mimic acute mastoiditis. In such cases, history and examination alone may be insufficient to reach a diagnosis, and further investigation may be necessary. Otolaryngologists should always be mindful of the possibility that noninfectious pathologies may present with a constellation of symptoms similar to mastoiditis.

Sharing in-office otoendoscopy recordings may improve patient satisfaction: A prospective cohort study.

OBJECTIVE: Evaluate the impact of sharing otoendoscopy exams on patient satisfaction in the outpatient clinical setting. METHODS: Randomized, prospective cohort study. Consecutive adults presenting to otology clinic at one tertiary referral center were randomized into two groups: standard microscopy (SM) and video otoendoscopy (VO). The SM group had ears examined using a standard, otomicroscope; the VO group had ears examined using a 0° rigid endoscope connected to a video tower. All subjects were counseled on their exam findings in a routine manner; the VO group was concurrently shown a recording of their ear exam. All subjects completed the 18-item Patient Satisfaction Questionnaire (PSQ-18) at the conclusion of their clinic visit. RESULTS: The SM group consisted of 27 patients and VO group consisted of 23 patients. VO subjects reported higher PSQ-18 scores compared to SM subjects within the domains of communication (p = 0.04) and technical quality (p = 0.005). On linear regression models, demographic factors and positive exam findings were not predictive of patient satisfaction. CONCLUSIONS: Sharing otoendoscopy recordings may be a valuable tool that can improve patient satisfaction. PRACTICE IMPLICATIONS: Clinicians should consider sharing recordings of otoscopic exams with patients, particularly when faced with the possibility of surgery.

Diabetes Is Predictive of Postoperative Outcomes and Readmission Following Posterior Lumbar Fusion.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The present study analyzes complication rates and episode-based costs for patients with and without diabetes mellitus (DM) following posterior lumbar fusion (PLF). METHODS: PLF cases at a single institution from 2008 to 2016 were queried (n = 3226), and demographic and perioperative data were analyzed. Patients with and without the diagnosis of DM were compared using chi-square, Student's t test, and multivariable regression modeling. RESULTS: Patients with diabetes were older (63.10 vs 56.48 years, P < .001) and possessed a greater number of preoperative comorbidities (47.84% of patients had Elixhauser Comorbidity Index >0 vs 42.24%, P < .001) than did patients without diabetes. When controlling for preexisting differences, diabetes remained a significant risk factor for prolonged length of stay (OR = 1.59, 95% CI 1.26-2.01, P < .001), intensive care unit stay (OR = 1.52, 95% CI 1.07-2.17, P = .021), nonhome discharge (OR = 1.86, 95% CI 1.46-2.37, P < .001), 30-day readmission (OR = 2.15, 95% CI 1.28-3.60, P = .004), 90-day readmission (OR = 1.65, 95% CI 1.05-2.59, P = .031), 30-day emergency room visit (OR = 2.15, 95% CI 1.27-3.63, P = .004), and 90-day emergency room visit (OR = 2.27, 95% CI 1.41-3.65, P < .001). Cost modeling controlling for overall comorbidity burden demonstrated that diabetes was associated with a $1709 increase in PLF costs (CI $344-$3074, P = .014). CONCLUSIONS: The present findings indicate a correlation between diabetes and a multitude of postoperative adverse outcomes and increased costs, thus illustrating the substantial medical and financial burdens of diabetes for PLF patients. Future studies should explore preventive measures that may mitigate these downstream effects.

Ergonomic Analysis of Functional Endoscopic Sinus Surgery Using Novel Inertial Sensors.

OBJECTIVES/HYPOTHESIS: Suboptimal ergonomics during endoscopic sinus surgery can lead to considerable physical discomfort and fatigue for the surgeon. The purpose of this pilot study is to objectively evaluate the ergonomic positions of trainee and attending surgeons while performing functional endoscopic sinus surgery (FESS). STUDY DESIGN: Pilot prospective trial. METHODS: Six surgeons (two attendings and four trainees) performed FESS while wearing 11 inertial measurement units (IMUs) affixed to either side of each major joint. Screen placement was standardized to be 1 m directly in front of the surgeon and on the patient's left, 0-15° declined from the surgeons' eyes. Bed height was standardized such that the workspace was 0 to 10 cm below the elbows. IMU data were analyzed to calculate joint angles. Ideal joint angles (i.e., <10° for neck and trunk) were determined by the validated Rapid Entire Body Assessment tool. Subjects subsequently completed a modified National Aeronautics and Space Administration Task Load Index to assess cognitive and physical burden and pain. Student's t-test was employed to detect differences between groups. RESULTS: Trainees adopted positions involving significantly greater neck flexion (9.90° vs. -6.48°, P = .03) and reported significantly higher frustration levels (3.04 vs. 1.33, P = .02) while operating than attendings. For both cohorts, increased operative time was significantly correlated with greater back flexion (r = 0.90, P = .02; r = 0.55, P = .04, respectively). CONCLUSIONS: Our data suggest that trainees operate with higher risk neck postures than do attendings. These data indicate high-risk operative postures may be borne of inexperience and present an opportunity for postural interventions at an early stage of training. LEVEL OF EVIDENCE: NA Laryngoscope, 132:1153-1159, 2022.

Clinical Features of Parosmia Associated With COVID-19 Infection.

OBJECTIVE: To characterize the clinical features, risk factors, symptom time-course, and quality of life implications for parosmia among coronavirus disease (COVID)-related olfactory dysfunction patients. METHODS: Individuals with olfactory dysfunction associated with laboratory-confirmed or clinically suspected COVID-19 infection were recruited from otolaryngology and primary care practices over a period from August 2020 to March 2021. Participants completed olfactory dysfunction and quality of life surveys. RESULTS: A total of 148 (64.1%) of 231 respondents reported parosmia at some point. Parosmia developed within 1 week of any COVID-19 symptom onset in 25.4% of respondents, but more than 1 month after symptom onset in 43.4% of respondents. Parosmia was associated with significantly better quantitative olfactory scores on Brief Smell Identification Test (8.7 vs. 7.5, P = .006), but demonstrated worse quality of life scores, including modified brief Questionnaire of Olfactory Dysfunction-Negative Statements and Sino-Nasal Outcome Test-22 scores (12.1 vs. 8.5, P < .001; 26.2 vs. 23.2, P = .113). Participants who developed parosmia at any point were significantly younger and less likely to have history of chronic sinusitis than those who did not develop parosmia (40.2 vs. 44.9 years, P = .007; 7.2% vs. 0.7%, P = .006). CONCLUSION: COVID-19-associated olfactory dysfunction is frequently linked with development of parosmia, which often presents either at onset of smell loss or in a delayed fashion. Despite better quantitative olfactory scores, respondents with parosmia report decreased quality of life. A majority of respondents with persistent parosmia have sought treatment. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:633-639, 2022.

Utility of liquid biopsy in diagnosing isolated cerebral phaeohyphomycosis: illustrative case.

BACKGROUND: Cladophialophora bantiana is a dematiaceous, saprophytic fungus and a rare but reported cause of intracranial abscesses due to its strong neurotropism. Although it predominantly affects immunocompetent individuals with environmental exposure, more recently, its significance as a highly lethal opportunistic infection in transplant recipients has been recognized. Successful treatment requires timely but often challenging diagnosis, followed by complete surgical excision. Next-generation sequencing of microbial cell-free DNA (cfDNA) from plasma is a novel diagnostic method with the potential to identify invasive fungal infections more rapidly and less invasively than conventional microbiological testing, including brain biopsy. OBSERVATIONS: The authors described the case of a recipient of a liver transplant who presented with seizures and was found to have innumerable ring-enhancing intracranial lesions. The Karius Test, a commercially available method of next-generation sequencing of cfDNA, was used to determine the causative organism. Samples from the patient's plasma identified C. bantiana 6 days before culture results of the surgical specimen, allowing optimization of the empirical antifungal regimen, which led to a reduction in the size of the abscesses. LESSONS: The authors' findings suggest that microbial cfDNA sequencing may be particularly impactful in improving the management of brain abscesses in which the differential diagnosis is wide because of immunosuppression.

Gender Trends in Authorship of Original Otolaryngology Publications: A Fifteen-Year Perspective.

OBJECTIVE: To examine trends in female author representation within original otolaryngology research between 2000 and 2015. METHODS: Original research articles published in 11 otolaryngology journals were analyzed for 2000, 2003, 2006, 2009, 2012, and 2015. The genders of the first and last authors for each article were recorded. Overall female authorship was calculated by summing the numbers of the first, last, and both first and last female-authored articles. Student t test and Cochran-Armitage trend test were utilized to determine significance between years and groups. RESULTS: Of the 9,623 research articles published during 5 representative years, 223 were excluded due to one or more gender-indeterminate authors. Female first authorship exhibited a significant upward trend from 2000 to 2015 (P < 0.0001), as did the proportion of literature with female first and last authors (P < 0.0001). Although female senior authorship in literature with an impact factor (IF) greater than 2 did not increase significantly (10.0% in 2000 to 10.1% in 2015; P = 0.738), this metric did increase significantly just within journals with an IF between 1 and 2 (9.7%-12.3%, P = 0.036). The proportion of articles with a female author in the first, last, or both positions increased from 28% to 39% (P < 0.0001). CONCLUSION: Increasing female representation in otolaryngology literature may reflect the rising proportion of women within otolaryngology as well as greater mentorship availability. Despite these auspicious strides, female-authored articles nonetheless represent a smaller proportion of the literature, and female senior authors remain a stark minority. Future studies should identify the barriers to female access and advancement within the field. LEVEL OF EVIDENCE: III Laryngoscope, 130:2126-2132, 2020.

Neuroanatomical Determinants of Secondary Trigeminal Neuralgia: Application of 7T Ultra-High-Field Multimodal Magnetic Resonance Imaging.

BACKGROUND: Seven-Tesla (7T) magnetic resonance imaging (MRI) has demonstrated value for evaluating a variety of intracranial diseases. However, its utility in trigeminal neuralgia has received limited attention. The authors of the present study applied ultra-high field multimodal MRI to two representative patients with secondary trigeminal neuralgia due to epidermoid tumors to illustrate the possible clinical and surgical advantages of 7T compared with standard clinical strength imaging. Techniques included co-registration of multiple 7T sequences to optimize the detection of potential concurrent neurovascular and neoplasm-derived compression. METHODS: 7T MRI studies were performed using a whole body scanner. Two- and three-dimensional renderings of potential neurovascular conflict were created by co-registering time-of-flight angiography and T2-weighted turbo spin echo images in MATLAB and GE software. Detailed comparisons of the various field strength images were provided by a collaborating neuroradiologist (B.D.). RESULTS: 7T MRI clearly illustrated minute tumor-adjacent vasculature. In contrast, conventional, low-field imaging did not consistently provide adequate details to distinguish cerebrospinal fluid pulsatility from vessels. The tumor margins, although distinct from the trigeminal nerve fibers at 7T, blended with those of the surrounding structures at 3T. Two- and three-dimensional co-registration of time-of-flight angiography with T2-weighted MRI suggested that delicate, intervening vasculature may have contributed to these illustrative patients' symptomatology. CONCLUSIONS: 7T provided superior visualization of vital landmarks and subtle nerve and vessel features. Co-registration of various advanced 7T modalities may help to resolve complex disease etiologies. Future studies should explore the extent to which this dual etiology might persist across tumor types and utilize diffusion-based techniques to quantify what microstructural differences might exist between patients with trigeminal neuralgia from varying etiologies.

Discharge Destination as a Predictor of Postoperative Outcomes and Readmission Following Posterior Lumbar Fusion.

BACKGROUND: Posterior lumbar fusions are performed to treat various spinal deformities, degenerative diseases, fractures, infections, and tumors. The possibility of episode-based bundled payments for spine surgery necessitates analysis of the factors predicting readmissions and postoperative complications. METHODS: Patients undergoing posterior lumbar fusion in the American College of Surgeons National Surgical Quality Improvement Program were queried via Current Procedural Terminology codes 22630, 22633, and 22612. Patients were grouped based on discharge destination, either to home/home health care or to a facility. Relevant demographics, comorbidities, perioperative statistics, and predischarge and postdischarge complications were compared. Multivariable logistic regression models for severe postdischarge complications and 30-day readmissions were created with the exposure of nonhome discharge. RESULTS: Patients discharged to nonhome destinations were significantly older (68.42 vs. 58.15 years; P < 0.0001), sicker (68.11% of patients had American Society of Anesthesiologists Physical Status Classification > 2 vs. 44.25%; P < 0.0001), more dependent (5.92% vs. 1.40%; P < 0.0001), and had significantly greater body mass indices (10.60% of patients had body mass index > 40 vs. 7.63%; P < 0.0001) than patients discharged home. Following discharge, patients in the nonhome discharge group experienced higher mortality (0.28% vs. 0.08%; P < 0.0001) and were more likely to experience a severe complication (5.96% vs. 2.85%; P < 0.0001), minor complication (4.59% vs. 1.74%; P < 0.0001), and readmission (8.92% vs. 4.78%; P < 0.0001). Nonhome discharge proved to be a risk factor for both readmission (odds ratio 1.43; 95% confidence interval 1.28-1.60; P < 0.0001) and severe postdischarge complication (odds ratio 1.73; 95% confidence interval 1.52-1.97; P < 0.0001). CONCLUSIONS: Nonhome discharge patients experienced higher rates of complications and 30-day readmissions.

Measuring degeneration of the lateral geniculate nuclei from pituitary adenoma compression detected by 7T ultra-high field MRI: a method for predicting vision recovery following surgical decompression of the optic chiasm.

OBJECTIVE: Predicting vision recovery following surgical decompression of the optic chiasm in pituitary adenoma patients remains a clinical challenge, as there is significant variability in postoperative visual function that remains unreliably explained by current prognostic factors. Available literature inadequately characterizes alterations in adenoma patients involving the lateral geniculate nucleus (LGN). This study examined the association of LGN degeneration with chiasmatic compression as well as with the retinal nerve fiber layer (RNFL), pattern standard deviation (PSD), mean deviation (MD), and postoperative vision recovery. PSD is the degree of difference between the measured visual field pattern and the normal pattern ("hill") of vision, and MD is the average of the difference from the age-adjusted normal value. METHODS: A prospective study of 27 pituitary adenoma patients and 27 matched healthy controls was conducted. Participants were scanned on a 7T ultra-high field MRI scanner, and 3 independent readers measured the LGN at its maximum cross-sectional area on coronal T1-weighted MPRAGE imaging. Readers were blinded to diagnosis and to each other's measurements. Neuro-ophthalmological data, including RNFL thickness, MD, and PSD, were acquired for 12 patients, and postoperative visual function data were collected on patients who underwent surgical chiasmal decompression. LGN areas were compared using two-tailed t-tests. RESULTS: The average LGN cross-sectional area of adenoma patients was significantly smaller than that of controls (13.8 vs 19.2 mm2, p < 0.0001). The average LGN cross-sectional area correlated with MD (r = 0.67, p = 0.04), PSD (r = -0.62, p = 0.02), and RNFL thickness (r = 0.75, p = 0.02). The LGN cross-sectional area in adenoma patients with chiasm compression was 26.6% smaller than in patients without compression (p = 0.009). The average tumor volume was 7902.7 mm3. Patients with preoperative vision impairment showed 29.4% smaller LGN cross-sectional areas than patients without deficits (p = 0.003). Patients who experienced improved postoperative vision had LGN cross-sectional areas that were 40.8% larger than those of patients without postoperative improvement (p = 0.007). CONCLUSIONS: The authors demonstrate novel in vivo evidence of LGN volume loss in pituitary adenoma patients and correlate imaging results with neuro-ophthalmology findings and postoperative vision recovery. Morphometric changes to the LGN may reflect anterograde transsynaptic degeneration. These findings indicate that LGN degeneration may be a marker of optic apparatus injury from chiasm compression, and measurement of LGN volume loss may be useful in predicting vision recovery following adenoma resection.