Optimal Timing of Entry-Level Otolaryngology Simulation.

OBJECTIVE: Appropriate timing of subspecialty simulation is critical to maximize learner benefit and guide resource utilization. We aimed to determine optimal timing of a simulation-based curriculum designed to teach entry-level procedural skills for otolaryngology residency. STUDY DESIGN: Simulation curriculum intervention tested among 3 comparison groups of varying clinical levels. SETTING: Academic otolaryngology training program and medical school. SUBJECTS AND METHODS: We developed a simulation-based technical skills curriculum incorporating the following task trainers: flexible laryngoscopy, peritonsillar abscess drainage, and myringotomy and tube insertion. Preclinical medical students (n = 40), subintern rotators (n = 35), and midyear interns (n = 8) completed the simulation-based curriculum. Pre- and postintervention knowledge/confidence and "level appropriateness" were rated on a 5-point Likert scale, and effect size was calculated. RESULTS: Overall self-reported knowledge/confidence levels improved in all 3 groups preintervention (1.05, 2.15, 3.17) to postintervention (2.79, 3.45, 4.38, respectively; all P < .01). Preclinical medical students uniformly reported very little to no familiarity with the procedures prior to the curriculum, while interns approached independence following the intervention. Large effect sizes were seen in all tasks for preclinical students (d = 3.13), subinterns (d = 1.46), and interns (d = 2.14). Five-point Likert scale measures of level appropriateness (1 = too challenging, 5 = too easy) for preclinical students, subinterns, and interns were 2.70 (95% CI, 2.56-2.84), 3.11 (95% CI, 2.97-3.25), and 3.75 (95% CI, 3.35-4.15), respectively. CONCLUSION: Subinternship may represent the optimal timing for entry-level skills simulation training. The proposed curriculum shows utility for clinical levels ranging from medical students to postgraduate year 1 resident levels, with large effect sizes for all tested groups.

Comprehensive Hearing Aid Intervention at a Free Subspecialty Clinic.

Importance: Providing a model of a comprehensive free audiologic program may assist other health care professionals in developing their own similar program. Objective: To describe the structure, feasibility, and outcomes of a free subspecialty clinic providing hearing aids to develop a paradigm for other programs interested in implementing similar projects. Design, Setting, and Participants: A retrospective case series was conducted from September 1, 2013, through March 31, 2016. In a partnership between a free independent clinic for indigent patients and an academic medical center, 54 indigent patients were referred to the clinic for audiograms. A total of 50 of these patients had results of audiograms available for review and were therefore included in the study; 34 of these 50 patients were determined to be eligible for hearing aid fitting based on audiometric results. Exposures: Free audiometric testing, hearing aid fitting, and hearing aid donation. Main Outcomes and Measures: The number of hearing aids donated, number of eligible patients identified, number of patients fitted with hearing aids, and work effort (hours) and start-up costs associated with implementation of this program were quantified. Results: A total of 54 patients (31 women [57.4%] and 23 men [42.6%]; median age, 61 years; range, 33-85 years) had audiograms performed, and 84 hearing aids were donated to the program. The patients were provided with free audiograms, hearing aid molds, and hearing aid programming, as well as follow-up appointments to ensure continued proper functioning of their hearing aids. Since 2013, a total of 34 patients have been determined to be eligible for the free program and were offered hearing aid services. Of these, 20 patients (59%) have been fitted or are being fitted with free hearing aids. The value of services provided is estimated to be $2260 per patient. Conclusions and Relevance: It is feasible to provide free, comprehensive audiologic care, including hearing aids and fitting, in a well-established, free clinic model. The opportunity for indigent patients to use hearing aids at minimal personal cost is a major step forward in improving access to high-quality care.

Total versus superficial parotidectomy for stage III melanoma.

BACKGROUND: The primary purpose of this study was to describe the parotid recurrence rates after superficial and total parotidectomy. METHODS: A retrospective cohort study was performed on patients with cutaneous melanoma metastatic to the parotid gland who underwent parotidectomy from 1998 through 2014. Primary outcome was parotid bed recurrence. Secondary outcomes were facial nerve function postoperatively and at last follow-up. RESULTS: One hundred twenty-nine patients were included in the study. Thirty-four patients (26%) underwent a total parotidectomy and 95 patients underwent superficial parotidectomy. Twelve patients (13%) developed parotid bed recurrence after superficial parotidectomy alone versus zero after total parotidectomy (P = .035). Facial nerve function, clinically detected disease, stage, and adjuvant treatment were not statistically different between the groups (P = .32, .32, .13, and 0.99, respectively). CONCLUSION: Parotid bed melanoma recurrence was more common after superficial parotidectomy compared to total parotidectomy, and recurrence resulted in significant facial nerve functional deficit. Our results support total parotidectomy when metastatic melanoma involves the parotid nodal basin.

Preoperative ß-blockade and hypertension in the first hour of functional endoscopic sinus surgery.

OBJECTIVES/HYPOTHESIS: Local anesthetic with epinephrine is commonly injected into the nasal mucosa during functional endoscopic sinus surgery (FESS). Systemic absorption of epinephrine following local injection may occur, resulting in a mild sympathetic response. This study seeks to determine whether an exaggerated sympathetic response to epinephrine is demonstrated in patients undergoing FESS treated preoperatively with established pharmacologic beta (ß) adrenoceptor blockade. STUDY DESIGN: A retrospective analysis of adult patients undergoing FESS at a tertiary care university hospital. METHODS: The primary outcome was the occurrence of an exaggerated hypertensive response within the first hour of surgical time defined by a relative increase (>20%) in the first measured intraoperative systolic blood pressure (SBP) prior to induction of anesthesia, or a single SBP value above 200 mm Hg. A mixed effects logistic regression model was developed to identify independent predictors of an exaggerated hypertensive response and describe the variance in the outcome attributable to the surgeon and anesthesiologist. RESULTS: There were 2,051 patients identified. Independent predictors of an exaggerated intraoperative hypertensive event included: preoperative ß-blocker use (adjusted odds ratio [AOR]: 3.33), female gender (AOR: 1.92), body mass index (AOR: 1.03), lower baseline SBP (AOR: 0.93), and advanced age (AOR: 1.03). The C statistic for the model was 0.8881. CONCLUSIONS: Preoperative ß-blocker use is an independent predictor of an exaggerated hypertensive response within the first hour of operative time. An exaggerated hypertensive effect should be anticipated in patients presenting for FESS with established pharmacologic ß-blockade, and caution should be applied to use of epinephrine-containing solutions. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:1496-1505, 2017.