Medical Ethics in Extreme and Austere Environments.

American society has a history of turning to physicians during times of extreme need, from plagues in the past to recent outbreaks of communicable diseases. This public instinct comes from a deep seated trust in physician duty that has been earned over the centuries through dedicated and selfless care, often in the face of personal risks. As dangers facing our communities include terroristic events physicians must be adequately prepared to respond, both medically and ethically. While the ethical principles that govern physician behavior-beneficence, nonmaleficence, autonomy, and social justice-are unchanging, fundamental doctrines must change with the new risks inherent to terroristic events. Responding to mass casualty disasters caused by terrorists, natural calamities, and combat continue to be challenging frontiers in medicine. Preparing physicians to deal with the consequences of a terroristic disease must include understanding the ethical challenges that can occur.

The Ripple Effect: A Train-the-Trainer Model to Exponentially Increase Organizational Faculty Development.

This article was migrated. The article was marked as recommended. INTRODUCTION: Faculty development is a key component of undergraduate and graduate medical education and is required for accreditation. Many institutions face the challenges of training large numbers of faculty at multiple locations on a recurring basis. In order to meet the faculty development demands of our organization, we implemented a train-the trainer model of faculty development. METHODS: A train-the-trainer program was created using deliberate practice as the theoretical framework. The primary goals of the program were to enhance content knowledge and develop facilitation skills of the participants (called faculty trainers). Two separate cohorts received 40 hours of in-person training consisting of attending the faculty development workshops as a learner, providing feedback to course faculty, facilitating and participating in journal club sessions on relevant content, and practicing facilitation and receiving feedback on the workshops. Cohorts 1 and 2 were trained on how to deliver 6 and 7 workshops, respectively. An additional 16 hours of training and further feedback occurred when faculty trainers delivered the workshops at outside institutions. RESULTS: Twenty-nine faculty trainers from 15 specialties and subspecialties were trained, including 18 in the first cohort (January 2018) and 14 in the second cohort (February 2019) with 3 who participated in both cohorts. From January 2018 to January 2020, faculty trainers delivered 298 workshops to 3742 attendees at 25 locations. For the faculty trainers, 1477 evaluations were completed with 1031 (88.1%) rated as excellent, 141 (9.5%) rated as good, and 8 (0.5%) as average. There were no fair or poor ratings. DISCUSSION: Our train-the-trainer program effectively developed a community of national faculty developers. Faculty trainer output was substantial and early evaluations of performance were positive. The model outlined in this paper serves as a potential sustainable model for other institutions desiring to train a cadre of faculty developers for their organization.

Endoscopic management of cerebrospinal fluid leaks.

Cerebrospinal fluid (CSF) rhinorrhea is an uncommon but important medical condition. It can result from trauma, intracranial hypertension, or be idiopathic in origin. If left untreated, significant sequelae can result including infectious meningitis. Beta-2 transferrin is a sensitive and specific protein marker for CSF. Various radiographic modalities have been used to localize defects, including computed tomography (CT), magnetic resonance imaging, and CT cisternography. In recent years, surgical management of this condition has evolved significantly, primarily being performed endoscopically. Reconstruction can be performed with fat, free mucosal, or fascial grafts, or with vascularized flaps. The endoscopic surgeon should have a thorough understanding of the pathophysiology and diagnosis of CSF rhinorrhea as well as several surgical options in his or her armamentarium available to treat the patient suffering from CSF rhinorrhea.

International assessment of inter- and intrarater reliability of the International Frontal Sinus Anatomy Classification system.

BACKGROUND: Inconsistencies in the nomenclature of structures of the frontal sinus have impeded the development of a validated "reference standard" classification system that surgeons can reliably agree upon. The International Frontal Sinus Anatomy Classification (IFAC) system was developed as a consensus document, based on expert opinion, attempting to address this issue. The purposes of this study are to: establish the reliability of the IFAC as a tool for classifying cells in the frontal recess among an international group of rhinologists; and improve communication and teaching of frontal endoscopic sinus surgery (ESS). METHODS: Forty-two computed tomography (CT) scans, each with a marked frontal cell, were reviewed by 15 international fellowship-trained rhinologists. Each marked cell was classified into 1 of 7 categories described in the IFAC, on 2 occasions separated by 2 weeks. Inter- and intrarater reliability were evaluated using Light's kappa (κ), the interclass correlation coefficient (ICC), and simple proportion of agreement. RESULTS: Interrater reliability showed pairwise κ values ranging from 0.7248 to 1.0, with a mean of 0.9162 (SD, 0.0537). The ICC was 0.98. Intrarater reliability showed κ values ranging from 0.8613 to 1.0, with a mean of 0.9407 (SD, 0.0376). The within-rater ICC was 0.98. CONCLUSION: Among a diverse sample of rhinologists (raters), there was substantial to almost perfect agreement between raters, and among individual raters at different timepoints. The IFAC is a reliable tool for classification of cells in the frontal sinus. Further outcome studies are still needed to determine the validity of the IFAC.

Aerosinusitis: pathophysiology, prophylaxis, and management in passengers and aircrew.

Patients presenting before flight with an upper respiratory infection are at risk for aerosinusitis. Prophylaxis of this condition consists of an oral decongestant before flight and nasal decongestant spray during the flight just prior to descent. Evaluation of the patient presenting with aerosinusitis consists of a careful physical exam with emphasis on diagnosing treatable nasal and sinus pathology. Categorization of the patient into the Weissman classification is important for determining prognostic factors for recovery. Management of this condition is based on the Weissman stage. Stage I or II lesions are generally treated conservatively with a 1-wk course of topical sprays, analgesics, a tapering course of steroids, and oral decongestants. Use of antibiotics is reserved for those cases initiated by bacterial sinusitis. Additionally, antihistamines are reserved for cases where allergies were the inciting cause. Stage III lesions are rarely seen in civilian air travelers due to the relatively low fluctuations in ambient air pressure. Aircrew that suffer Stage III aerosinusitis are at risk for recurrent sinus barotrauma that may require an expertly performed functional endoscopic sinus surgery to successfully manage it.

Single vs multiallergen sublingual immunotherapy in the polysensitized patient: a pilot study.

BACKGROUND: Sublingual immunotherapy (SLIT) has emerged as an effective and exceptionally safe method of treatment of the atopic patient. However, the optimal number of allergens that should be included in the SLIT treatment regimen for the polysensitized patient is not known and practices vary widely. This study aims to compare the efficacy of single-allergen SLIT with pauci-allergen vs multiallergen aqueous SLIT in polysensitized patients. METHODS: Sixteen subjects sensitized to 6+ allergens were enrolled in the study. Subjects were blinded and randomized to SLIT treatment groups that included 1 (single), 3 (pauci), or all sensitized allergens (multi). Allergens selected were those to which the patient was most sensitized and correlated with history. Primary outcomes included daily allergy medication use, weekly Rhinoconjunctivitis Symptom Score (RCSS), and the mini-Rhinoconjuncitivitis Quality of Life Questionnaire (m-RQLQ). All metrics were measured at baseline, 6 weeks, 3 months, 6 months, and 9 months. RESULTS: There were significant decreases from baseline in RCSS and m-RQLQ scores in all study groups at each interval after beginning SLIT (p < 0.05). There was no significant decrease in number of daily allergy medications used regardless of number of allergens in patient's treatment vial (p = 0.50). No significant differences emerged based on number of allergens used. CONCLUSION: Single-antigen, pauci-antigen, and multiantigen aqueous SLIT significantly improved allergy symptoms. There was no significant difference observed in efficacy of single-allergen SLIT vs pauci-allergen or multi-allergen SLIT in polysensitized patients.

Algorithm for Management of the Refractive Aerosinusitis Patient.

Introduction: For some career military aviators, their ability to continue on flight status is limited by the pressure and pain of aerosinusitis, which is present only while in the flying environment. Failure to treat their disease process can mean the end of their flying careers and the loss of valuable assets trained with taxpayer dollars. Because some medications commonly used in treatment of sinus diseases are not allowed in aviation, this presents a unique problem for their medical management. Surgical treatment must be aimed at treating to symptom relief and not solely disease mitigation. One alternative is operating "beyond the scope of disease" present during a one-atmosphere clinic visit. Materials and Methods: A case series of nine career aviators with aerosinusitis treated at one academic military Otolaryngology department in a tertiary care facility. Results from a treatment algorithm that balances symptomatology and staged surgical intervention are reviewed. The primary endpoint was return to flight duty. Results: For patients treated according to this algorithm, the mean time to return to flight duty was 3.8 mo, requiring an average of 1.2 surgeries. To date, 100% of career aviators have returned to flight duty using this method. Conclusion: Refractory aerosinusitis represents a potentially career-ending medical condition for the aviator and lost training costs to the taxpayers. Using the treatment algorithm presented, 100% of aviators were able to return to flight duty; a savings of millions of dollars for taxpayers. Future work will focus on modifications to the surgical techniques to reduce the extent of surgery while maintaining satisfactory results. Additional study should be undertaken to assess generalizability of these results in the broader aviation community.

Teaching frontal sinus anatomy using the frontal sinus masterclass 3- D conceptualization model.

OBJECTIVE: Frontal sinus anatomy is complex and often is a difficult subject to both teach and learn. The traditional surgical dogma of "see one, do one, teach one" is impractical and dangerous in the frontal sinus. Based on the building block three-dimensional conceptualization module, the Frontal Sinus Masterclass (FSMC) was created to teach this anatomy. METHODS: Study was performed at two academic centers among second- to fifth-year otolaryngology residents. A pretest assessed knowledge prior to the course. Computed tomography scans of the sinuses were evaluated in triplanar view, and participants attempted to reconstruct the anatomy. Subsequently, the course instructor explained the anatomy using the building block method and showed a short video of the surgical dissection, pointing out relevant anatomy. Cases progressed in anatomical difficulty and inflammatory load. A posttest determined knowledge after the course. RESULTS: Thirty of 50 participating residents completed the pre- and posttests (14 junior, 16 senior residents). Correct identification of the frontal sinus drainage pathway increased from 42% to 63% correct (P = 0.054). Anatomical assessment increased from 61% to 68% correct (P = 0.047), and overall assessment increased from 52% to 66% correct (P = 0.016). CONCLUSION: Objectively, participants of the FSMC expanded on their ability to recognize cells of the frontal recess on CT scans. Before the class, residents could answer less than half of the answers correctly, and by the end of the class they were answering over two-thirds of these complex questions correctly. Subjectively, participants reported benefit from the course and felt they would be better surgeons. LEVEL OF EVIDENCE: NA. Laryngoscope, 128:1294-1298, 2018.

Teaching Residents Frontal Sinus Anatomy Using a Novel 3-Dimensional Conceptualization Planning Software-Based Module.

BACKGROUND: The Frontal Sinus Masterclass (FSMC) is an effective method for teaching frontal sinus anatomy. A third party developed new software using the same 3-dimensional building block concept. The authors sought to determine whether the use of the software for the educational module yielded similar results to the original FSMC, which used wooden blocks. METHODS: The study was performed at a sinus course for residents. A precourse test assessed the ability to decipher frontal sinus anatomy prior to the course. Computed tomography (CT) scans of the sinuses were evaluated in triplanar view, and participants attempted to reconstruct the anatomy using the new software. Subsequently, the course instructor explained the anatomy and showed a short corresponding surgical video of the frontal sinusotomy. Cases progressed in anatomical difficulty and inflammatory load. A postcourse test determined knowledge after the course. RESULTS: In sum, 50 residents completed the pre- and postcourse tests. Overall scores increased from 60.5% to 65.2% ( P = .004). Subanalysis also demonstrated improved ability to locate the frontal drainage pathway from 32.5% to 46% ( P = .011) and label the frontal recess cell structures from 64% to 67.6% ( P = .045). CONCLUSION: There is minimal literature on proven methods for teaching frontal sinus anatomy. Objectively, participants of the modified FSMC simulation training using new software improved their ability to recognize cells of the frontal recess on CT scans. They especially exhibited better localization of the frontal sinus drainage pathway. Subjectively, participants reported benefit from the course and felt they would be better surgeons.

International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis.

BACKGROUND: Critical examination of the quality and validity of available allergic rhinitis (AR) literature is necessary to improve understanding and to appropriately translate this knowledge to clinical care of the AR patient. To evaluate the existing AR literature, international multidisciplinary experts with an interest in AR have produced the International Consensus statement on Allergy and Rhinology: Allergic Rhinitis (ICAR:AR). METHODS: Using previously described methodology, specific topics were developed relating to AR. Each topic was assigned a literature review, evidence-based review (EBR), or evidence-based review with recommendations (EBRR) format as dictated by available evidence and purpose within the ICAR:AR document. Following iterative reviews of each topic, the ICAR:AR document was synthesized and reviewed by all authors for consensus. RESULTS: The ICAR:AR document addresses over 100 individual topics related to AR, including diagnosis, pathophysiology, epidemiology, disease burden, risk factors for the development of AR, allergy testing modalities, treatment, and other conditions/comorbidities associated with AR. CONCLUSION: This critical review of the AR literature has identified several strengths; providers can be confident that treatment decisions are supported by rigorous studies. However, there are also substantial gaps in the AR literature. These knowledge gaps should be viewed as opportunities for improvement, as often the things that we teach and the medicine that we practice are not based on the best quality evidence. This document aims to highlight the strengths and weaknesses of the AR literature to identify areas for future AR research and improved understanding.

The role of simulation in teaching sinus surgery in otolaryngology residency: A survey of rhinologists.

BACKGROUND: Simulation is currently recognized as an effective surgical training tool. However, no standardized curriculum exists for endoscopic sinus surgery (ESS) simulation training. The goal of this study was to obtain an understanding of current ESS simulation use to aid the future development of an ESS training curriculum. METHODS: A 14-question survey regarding sinus simulation in residency training was developed through the education committee of the American Rhinologic Society. The survey was administered to academic American Rhinologic Society members in the United States, Canada, and Puerto Rico. The participants provided information regarding the type, amount, and effectiveness of simulation use in their residency program. RESULTS: Responses were received from 67 training programs; 45% of the programs endorsed using simulation training, although only 23.9% used ESS simulation, and all the programs used cadavers. Only 12.5% of respondent programs required ESS simulation training before operating on live patients, and trainees had an average of <6 hours of simulation training before live operations. A majority of respondents observed subjective improvement in residents' endoscope handling, dexterity, and understanding of anatomy after ESS simulation. The greatest obstacles identified were associated cost and lack of realistic simulators. CONCLUSION: A majority of responders observed improved surgical technique and knowledge in residents after simulation training. However, <25% of the survey responders used ESS simulation and cited cost and limited availability as the most common barriers. A curriculum of validated simulators has potential to improve the quality of ESS training during residency.

Assessment of asthma severity and control.

BACKGROUND: Asthma is a disease of great variability. Untreated asthma can have lifelong implications in terms of lung growth as well as residual lung function throughout life. Close attention to establishing severity of the disease and level of control established in each patient through treatment are important to achieving the best results. METHODS: Available English-language literature was reviewed. Citations were included based on the quality of the original paper and relevance to the specific aims of this primer. RESULTS: Assessing intrinsic severity of the patient's disease at the first encounter using impairment measures of short-acting beta agonist use, nighttime awakenings, interference of disease with normal activity, and pulmonary function testing, as well as measures of patient risk of acute exacerbations is vitally important. At subsequent patient encounters, adjusting therapy based on both impairment and risk components of control will improve long-term outcomes. CONCLUSION: Any practitioner undertaking to care for asthma patients should be conversant with the degrees of disease severity and levels of disease control on therapy. Application of these principles will maximize patient benefit from asthma care.

Evidence-based medicine in sleep apnea surgery.

Since the first description of sleep apnea as a clinical entity, the understanding of it within the medical community has increased significantly. Much research has explored the causes, assessment, and treatment of this disease. This research has resulted in a variety of tools for assessment and approaches to treatment. As research progresses, new data have shed light on the strengths of traditional approaches and their limitations. This article gives background for current approaches and charts a potential future course for sleep apnea assessment and treatment.

The association between allergy and chronic rhinosinusitis with and without nasal polyps: an evidence-based review with recommendations.

BACKGROUND: The relationship between allergy and chronic rhinosinusitis (CRS) remains ill-defined and controversial. The association between the 2 is unclear, making an evidence-based decision of whether to evaluate and treat allergies in CRS patients difficult. The purposes of this systematic review are to (1) examine the relationship between allergy and CRS without nasal polyps (CRSsNP), (2) examine the same for allergy and CRS with nasal polyps (CRSwNP), and (3) recommend evaluation and treatment based on the evidence. METHODS: A structured literature search was performed to identify articles examining the link between allergy and CRSsNP and CRSwNP. Pertinent articles were examined for evidence for an association between allergy and CRSsNP and/or CRSwNP. RESULTS: A total of 24 articles were found that met the inclusion criteria; 18 articles examined the relationship between allergy and CRSwNP, with 10 articles showing an association, 7 articles showing no association, and 1 article showing a possible association. Nine articles examined the relationship between allergy and CRSsNP, with 4 articles showing an association and 5 articles showing no association. Four studies directly compared the role of allergy in CRSwNP and CRSsNP, and, again, the results were mixed. No articles examined the outcomes of CRSsNP or CRSwNP following allergy treatment. CONCLUSION: The role of allergy in CRSwNP and CRSsNP continues to be controversial, with the level of evidence poor. Based on the available data, the recommendation is that allergy testing and treatment are an option in CRSwNP and CRSsNP.

The validation of an endoscopic sinus surgery skills training model: a pilot study.

BACKGROUND: Performing functional endoscopic sinus surgery (FESS) requires a trainee surgeon to develop both thorough anatomic understanding and new manual dexterity skills. Traditionally, these skills were learned in the operating room setting. In an era of available surgical simulation, this practice introduces ethical concerns about exposing patients to unnecessary risks during surgical skills development. Additionally, cost-effective rhinologic training has become increasingly important. To address these problems, a low-cost, intermediate-fidelity FESS training model was developed, and both speed and accuracy of task completion were measured to assess both immediate and intermediate-term skills retention. METHODS: Preliminary data were collected on 12 medical students and 10 resident-level (PGY1, -2, and -3) learners. Distinct tasks were performed five times on the initial day of testing and repeated after 2 weeks. RESULTS: Both groups attained statistically significant improvement in time to complete both tasks by the second iteration of each task and retained this effect after 2 weeks. Similarly, statistically significant improvement was seen for accuracy relative to the initial attempt by the fifth iteration for residents. This effect was also seen by the third through fifth iterations and after 2 weeks for students. Additionally, when the 2-week follow-up testing was compared with the fifth attempt, the only skills that deteriorated significantly were the resident group with the complex task times and the students with measures of accuracy. However, in both cases a highly significant improvement from initial attempts was maintained (p = 0.02 and p = 0.005, respectively). Residents were significantly faster than medical students at both simple and complex tasks for attempts 1 through 4, but this difference was not significant for attempt 5 and after 2 weeks. Residents had significantly fewer errors for all but the 2-week data point. CONCLUSION: The data from this pilot study support improved FESS skills for both medical students and residents using this low-cost, intermediate-fidelity model.

Comprehensive surgical management of the aerosinusitis patient.

PURPOSE OF REVIEW: Provide a comprehensive overview of the pathophysiology and surgical management strategies of sinus barotrauma with attention to recent advancements in endoscopic surgical technique. RECENT FINDINGS: New endoscopic frontal sinus surgery techniques have been shown to be highly effective with rhinosinusitis management, but these techniques have not been evaluated with sinus barotrauma management. SUMMARY: We discuss the surgical goals and expectations with sinus barotrauma and contrast these to those with chronic rhinosinusitis (CRS). Sinus barotrauma surgery requires anatomic patency of involved sinuses whereas CRS patients are satisfied with a lack of symptoms from any residual mucosal disease.

Safety in endoscopic sinus surgery.

PURPOSE OF REVIEW: Endoscopic sinus surgery techniques and technologies have undergone rapid development over the past two decades. Recently, image guided systems have been implemented in endoscopic sinus surgery, carrying the promise of increased safety during surgery. This review compiles available data regarding the incidence of complications in endoscopic sinus surgery, the trends over time, and the impact of image guided surgery on complication rates. RECENT FINDINGS: Reporting of complications in endoscopic sinus surgery is widely variable, confounding attempts to establish accurate data regarding complication rates. Few prospective, randomized trials exist comparing the safety of functional endoscopic sinus surgery with other surgical techniques. Major complications occur in 0-1.5% of cases and minor complications occur in 1.1-20.8% of functional endoscopic sinus surgery cases. Powered instrumentation does not appear to affect the incidence of complications, but may increase the severity of complications. It is unclear whether image guided surgery results in lower complication rates. Practical and ethical considerations make randomized trials to evaluate this issue problematic. SUMMARY: In order to maximize safety, functional endoscopic sinus surgery surgeons must individually and collectively audit current practice, report complications in a systematic way, utilize available technology appropriately to support safe surgery, and diligently refine surgical technique as well as the systems supporting endoscopic surgical practice.

Medical and surgical considerations in patients with Samter's triad.

BACKGROUND: The aim of this study was to report on objective and subjective outcomes of patients with Samter's triad (ST) treated with functional endoscopic sinus surgery (FESS), and correlate these results with aspirin desensitization (DS) in patients. METHODS: We performed a retrospective analysis of prospectively collected data in 15 patients requiring revision FESS after failing maximum medical therapy and prior sinus surgery for chronic rhinosinusitis in the context of ST. Five patients underwent aspirin DS and 10 patients did not (non-DS). These patients represent a subset of patients previously reported who were treated in a tertiary rhinology setting over a 3-year period (1999-2001). CT scans were graded according to the Lund-Mackay grading scale and symptom scores were assessed using the Sino-Nasal Outcome Test (SNOT-20). Endoscopy was scored according to the Rhinosinusitis Task Force methodology. All patients had a minimum 2-year follow-up. RESULTS: Preoperative CT scores were 20.1+/-1.9 for non-DS patients and 20.4+/-2.0 for DS patients (p = NS). Preoperative and postoperative SNOT-20 scores for non-DS patients were 31.8+/-3.9 and 8.8+/-1.7, respectively, as compared with 32.0 z 3.6 and 7.3 +/-1.7 for DS patients (p = NS). Preoperative and postoperative endoscopy scores for non-DS patients were 7.6+/-1.2 and 2.0+/-0.4, respectively, as compared with 7.6 +/-1.3 and 1.1+/-0.4 for DS patients (p = NS). Of DS patients, none required additional surgery whereas 8 of 10 non-DS patients required additional revision during the follow-up period (p = 0.003). CONCLUSION: Revision FESS benefits patients with ST; however, the addition of aspirin DS decreases the likelihood that patients with ST will require additional surgical intervention over a 2-year period.

Revision functional endoscopic sinus surgery: objective and subjective surgical outcomes.

BACKGROUND: The aim of this study was to report objective and subjective outcomes after revision sinus surgery (RESS) for chronic rhinosinusitis (CRS). METHODS: We performed a retrospective analysis of prospectively collected data in 125 patients requiring revision functional endoscopic sinus surgery after failing both maximum medical therapy and prior sinus surgery for CRS. Patients were seen and treated over a 3-year period (1999-2001) in a tertiary rhinology setting. Computed tomography (CT) scans were graded as per Lund-MacKay and patient symptom scores were recorded using the Sinonasal Outcome Test 20 (SNOT-20) instrument. Individual rhinosinusitis symptoms were evaluated on a visual analog scale (0-10) before and after surgery. All patients had a minimum 2-year follow-up. RESULTS: The mean number of prior sinus procedures was 1.9 +/- 0.1 (range, 1-7) and the mean preoperative CT grade was 13.4 +/- 0.7. Patients with asthma and polyposis had higher CT scores than those without these processes. Preoperative mean SNOT-20 and endoscopy scores were 30.7 +/- 1.3 and 7.3 +/- 0.4, respectively. At the 2-year follow-up, mean SNOT-20 and endoscopy scores improved to 7.7 +/- 0.6 and 2.1 +/- 0.4, respectively (p < 2.8 x 10(-10)). At 12-month follow-up, each individual symptom score decreased significantly. Overall, 10 patients failed RESS and required additional surgical intervention for an overall failure rate of 8.0%. All patients who failed RESS had nasal polyposis. CONCLUSION: Revision functional endoscopic sinus surgery benefits patients that fail maximum medical therapy and prior sinus surgery for CRS by objective and subjective measures.