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PURPOSE: To investigate the difference in survival and complication outcomes between patients with a clinically and radiologically N0 neck who received an elective neck dissection at the time of salvage total laryngectomy compared to those who had salvage total laryngectomy alone. MATERIALS AND METHODS: A retrospective chart review was performed on 125 salvage total laryngectomy patients who were clinically and radiologically N0 preoperatively. Performance of an elective neck dissection and other factors were tested for associations with various postoperative complications, disease-free survival, and overall survival. RESULTS: Ninety-eight patients underwent elective neck dissection, of which ten had positive nodal pathology. Elective neck dissection was not significantly associated with complications or survival outcomes. Positive nodal disease was associated with worse disease-free and overall survival on multivariate analysis. CONCLUSIONS: In patients with clinically and radiologically N0 necks undergoing salvage total laryngectomy, an elective neck dissection can provide prognostic information but does not appear to be significantly associated with increased complications or improved survival.
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Carcinoma de Células Escamosas/cirugía , Neoplasias Laríngeas/cirugía , Laringectomía , Disección del Cuello , Complicaciones Posoperatorias/epidemiología , Terapia Recuperativa , Adulto , Anciano , Anciano de 80 o más Años , Carcinoma de Células Escamosas/mortalidad , Carcinoma de Células Escamosas/patología , Supervivencia sin Enfermedad , Femenino , Humanos , Neoplasias Laríngeas/mortalidad , Neoplasias Laríngeas/patología , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Estudios Retrospectivos , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
Deconstructing surgeries into steps and providing instructions with illustrations has been the staple of surgical textbooks for decades. However, it may be difficult for the novice surgeon to interpret 2-dimensional (2D) illustrations into 3D surgeries. The objective of this study is to create operable models that demonstrate the progression of surgery in 3D and allow for mastering the final steps of the operation first. Mastoidectomy was performed in a stepwise fashion to different end points on 5 identical 3D-printed temporal bone models to represent 5 major steps of the operation. The drilled models were computed tomography scanned and the subsequent images were used to create 3D model copies of each step. This is the first study to demonstrate that it is possible to create, scan, and copy stepwise, operable, patient-specific 3D-printed models, which the trainee can both reference as a 3D dissection guide and can operate on repeatedly and in any order.
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With the advent of operable 3-dimensional (3D)-printed models, case preparation could occur outside of the cadaveric laboratory. The objective of this study was to design a mobile drilling station that can be used for surgical practice in a variety of clean workplaces. Using materials obtained from hardware stores and online retailers, a wheelable drilling station was constructed to mimic laboratory conditions while also being easily maneuverable into clinic rooms. The station houses the otologic drill, suction, and irrigation mechanisms, is height adjustable, and has a shielded workspace. The mobile drilling station was moved into a microscope-containing otolaryngology clinic room where faculty and trainees were asked to drill a pediatric 3D-printed temporal bone followed by completing an evaluation survey. This is the first mobile drilling station described in the literature and can be easily constructed, mobilized, and used in an otolaryngology clinic for dedicated surgical practice using 3D-printed models.
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Otolaringología , Impresión Tridimensional , Hueso Temporal , Humanos , Hueso Temporal/cirugía , Otolaringología/educación , Modelos Anatómicos , Diseño de EquipoRESUMEN
OBJECTIVE: To expand and improve upon previously described nasal osteotomy models with the goals of decreasing cost and production time while ensuring model fidelity. To assess change in participant confidence in their understanding of and ability to perform nasal osteotomies following completion of the simulation course. STUDY DESIGN: Prospective study. SETTING: Simulation training course for otolaryngology residents at West Virginia University. METHODS: A combined methodology of 3D printing, silicone molding, and resin casting was used to design a nasal osteotomy model to address material issues such as print delamination. Multiple models were then used in a simulation lab on performing nasal osteotomies. Model utility and impact on participant confidence was assessed at baseline, postlecture, and postsimulation lab. RESULTS: Using a combined manufacturing methodology, we achieved a production time reduction of 97.71% and a cost reduction of 82.02% for this polyurethane resin nasal osteotomy model relative to a previously described osteotomy model. Participants in the simulation course were noted to have a significant improvement in confidence in their understanding of and ability to perform nasal osteotomies from baseline and postlecture and also from postlecture and postsimulation lab (P < .05 for all). CONCLUSION: By incorporating multiple manufacturing modalities (molding and casting) in addition to 3D printing, this study achieved a large reduction in both production time and cost in fabrication of a nasal osteotomy simulator and addressed material limitations imposed by fused deposition modeling printers. This design methodology serves as an example on how these barriers may be addressed in unrelated simulation projects. Model fidelity was improved with addition of a silicone soft tissue midface. Improvement in participant confidence was noted following completion of the simulation lab.
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Dermal metastasis is a rare manifestation of visceral disease, and esophageal adenocarcinomas represent around only 1% of primaries that present with cutaneous metastasis. In this case, we discuss a patient who presented with a painless submental mass and extensive right neck cutaneous induration and erythema. Core needle biopsy demonstrated poorly differentiated adenocarcinoma. Blood testing also demonstrated elevated carbohydrate antigen 19-9, carcinoembryonic antigen, and alkaline phosphatase. PET/CT followed by esophagoscopy led to the diagnosis of esophageal signet-cell adenocarcinoma primary with isolated dermal metastasis. The patient was started on palliative radiotherapy and passed away two months later from a suspected thoracic fistula and hydropneumothorax.
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BACKGROUND: First health care professionals arriving at the bedside in tracheostomy-related emergencies are rarely the surgical subspecialists who placed the tracheostomy and are unfamiliar with the relevant anatomy and tracheostomy specifications for the individual patient. We hypothesized that implementing a bedside airway safety placard would increase caregiver confidence, understanding of airway anatomy, and management of patients with a tracheostomy. METHODS: A prospective survey study was performed by distributing a tracheostomy airway safety survey before and after implementation of an airway safety placard in a 6-month study period. Placards emphasizing critical airway anomalies as well as emergency management algorithm suggestions designed by the otolaryngology team at the time of tracheostomy were placed at the head of the bed and traveled with the patient during transport around the hospital. RESULTS: Of 377 staff members requested to complete the surveys, 165 (43.8%) responses were obtained, and 31 (8.2% [95% CI 5.7-11.5]) paired pre- and post-implementation responses were recorded. Differences were found in the paired responses, including increases in the domains of confidence (P = .009) and experience (P = .01) post implementation. Less experienced providers (≤ 5 y of experience) (P = .005) and providers from neonatology (P = .049) demonstrated improved confidence post implementation, which was not observed in their more experienced (> 5 y) or respiratory therapy counterparts. CONCLUSIONS: Given the limitations of a low survey response rate, our findings suggest that an educational airway safety placard initiative can be a simple, feasible, and low-cost quality improvement tool to enhance airway safety and possibly decrease potentially life-threating complications among pediatric patients with a tracheostomy. The implementation of the tracheostomy airway safety survey at our single institution warrants a larger multi-center study and validation of the survey.
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Personal de Salud , Traqueostomía , Humanos , Niño , Traqueostomía/efectos adversos , Estudios ProspectivosRESUMEN
OBJECTIVES: Three-dimensional printed models created on a consumer level printer can be used to practice mastoidectomy and to discern mastoidectomy experience level. Current models in the literature for mastoidectomy are limited by expense or operability. The aims of this study were (1) to investigate the utility of an inexpensive model for mastoidectomy and (2) to assess whether the model can be used as an evaluation tool to discern the experience level of the surgeon performing mastoidectomy. METHODS: Three-dimensional printed temporal bone models from the CT scan of a 7-year old patient were created using a consumer-level stereolithography 3D printer for a raw material cost of $10 each. Mastoidectomy with facial recess approach was performed by 4 PGY-2 residents, 4 PGY-5 residents, and 4 attending surgeons on the models who then filled out an evaluation. The drilled models were collected and then graded in a blinded fashion by 6 attending otolaryngologists. RESULTS: Both residents and faculty felt the model was useful for training (mean score 4.7 out of 5; range: 4-5) and case preparation (mean score: 4.3; range: 3-5). Grading of the drilled models revealed significant differences between junior resident, senior resident, and attending surgeon scores (P = .012) with moderate to excellent interrater agreement (ICC = 0.882). CONCLUSION: The described operable model that is patient-specific was rated favorably for pediatric mastoidectomy case preparation and training by residents and faculty. The model may be used to differentiate between experience levels and has promise for use in formative and summative evaluations.
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Competencia Clínica , Mastoidectomía/educación , Impresión Tridimensional , Entrenamiento Simulado , Hueso Temporal , Niño , Humanos , Procedimientos Quirúrgicos Otológicos/educaciónRESUMEN
HYPOTHESIS: Aerosols are generated during mastoidectomy and mitigation strategies may effectively reduce aerosol spread. BACKGROUND: An objective understanding of aerosol generation and the effectiveness of mitigation strategies can inform interventions to reduce aerosol risk from mastoidectomy and other open surgeries involving drilling. METHODS: Cadaveric and fluorescent three-dimensional printed temporal bone models were drilled under variable conditions and mitigation methods. Aerosol production was measured with a cascade impactor set to detect particle sizes under 14.1âµm. Field contamination was determined with examination under UV light. RESULTS: Drilling of cadaveric bones and three-dimensional models resulted in strongly positive aerosol production, measuring positive in all eight impactor stages for the cadaver trials. This occurred regardless of using coarse or cutting burs, irrigation, a handheld suction, or an additional parked suction. The only mitigation factor that led to a completely negative aerosol result in all eight stages was placing an additional microscope drape to surround the field. Bone dust was scattered in all directions from the drill, including on the microscope, the surgeon, and visually suspended in the air for all but the drape trial. CONCLUSIONS: Aerosols are generated with drilling the mastoid. Using an additional microscope drape to cover the surgical field was an effective mitigation strategy to prevent fine aerosol dispersion while drilling.
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COVID-19/prevención & control , Mastoidectomía/efectos adversos , Aerosoles , COVID-19/transmisión , Cadáver , Humanos , Mastoidectomía/instrumentación , Mastoidectomía/métodos , SARS-CoV-2RESUMEN
OBJECTIVES: Define aerosol and droplet risks associated with routine otolaryngology clinic procedures during the COVID-19 era. METHODS: Clinical procedures were simulated in cadaveric heads whose oral and nasal cavities were coated with fluorescent tracer (vitamin B2) and breathing was manually simulated through retrograde intubation. A cascade impactor placed adjacent to the nares collected generated particles with aerodynamic diameters ≤14.1 µm. The 3D printed models and syringes were used to simulate middle and external ear suctioning as well as open suctioning, respectively. Provider's personal protective equipment (PPE) and procedural field contamination were also recorded for all trials using vitamin B2 fluorescent tracer. RESULTS: The positive controls of nebulized vitamin B2 produced aerosol particles ≤3.30 µm and endonasal drilling of a 3D model generated particles ≤14.1 µm. As compared with positive controls, aerosols and small droplets with aerodynamic diameter ≤14.1 µm were not detected during rigid nasal endoscopy, flexible fiberoptic laryngoscopy, and rigid nasal suction of cadavers with simulated breathing. There was minimal to no field contamination in all 3 scenarios. Middle and external ear suctioning and open container suctioning did not result in any detectable droplet contamination. The clinic suction unit contained all fluorescent material without surrounding environmental contamination. CONCLUSION: While patients' coughing and sneezing may create a baseline risk for providers, this study demonstrates that nasal endoscopy, flexible laryngoscopy, and suctioning inherently do not pose an additional risk in terms of aerosol and small droplet generation. An overarching generalization cannot be made about endoscopy or suctioning being an aerosol generating procedure. LEVEL OF EVIDENCE: 3.
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Aerosoles/efectos adversos , COVID-19 , Transmisión de Enfermedad Infecciosa/prevención & control , Endoscopía , Otolaringología , Ajuste de Riesgo/métodos , Succión , COVID-19/prevención & control , COVID-19/transmisión , Cadáver , Endoscopía/efectos adversos , Endoscopía/instrumentación , Endoscopía/métodos , Humanos , Otolaringología/métodos , Otolaringología/normas , Evaluación de Resultado en la Atención de Salud , Equipo de Protección Personal/clasificación , Equipo de Protección Personal/virología , Proyectos de Investigación , Medición de Riesgo/métodos , SARS-CoV-2 , Succión/efectos adversos , Succión/instrumentación , Succión/métodosRESUMEN
OBJECTIVE: During the COVID-19 era, a reliable method for tracing aerosols and droplets generated during otolaryngology procedures is needed to accurately assess contamination risk and to develop mitigation measures. Prior studies have not investigated the reliability of different fluorescent tracers for the purpose of studying aerosols and small droplets. Objectives include (1) comparing vitamin B2, fluorescein, and a commercial fluorescent green dye in terms of particle dispersion pattern, suspension into aerosols and small droplets, and fluorescence in aerosolized form and (2) determining the utility of vitamin B2 as a fluorescent tracer coating the aerodigestive tract mucosa in otolaryngology contamination models. METHODS: Vitamin B2, fluorescein, and a commercial fluorescent dye were aerosolized using a nebulizer and passed through the nasal cavity from the trachea in a retrograde-intubated cadaveric head. In another scenario, vitamin B2 was irrigated to coat the nasal cavity and nasopharyngeal mucosa of a cadaveric head for assessment of aerosol and droplet generation from endonasal drilling. A cascade impactor was used to collect aerosols and small droplets ≤14.1 µm based on average aerodynamic diameter, and the collection chambers were visualized under UV light. RESULTS: When vitamin B2 was nebulized, aerosols ≤5.4 µm were generated and the collected particles were fluorescent. When fluorescein and the commercial water tracer dye were nebulized, aerosols ≤8.61 µm and ≤2.08 µm respectively were generated, but the collected aerosols did not appear visibly fluorescent. Endonasal drilling in the nasopharynx coated with vitamin B2 irrigation yielded aerosols ≤3.30 µm that were fluorescent under UV light. CONCLUSION: Vitamin B2's reliability as a fluorescent tracer when suspended in aerosols and small droplets ≤14.1 µm and known mucosal safety profile make it an ideal compound compared to fluorescein and commercial water-based fluorescent dyes for use as a safe fluorescent tracer in healthcare contamination models especially with human subjects.
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COVID-19/transmisión , Transmisión de Enfermedad Infecciosa , Colorantes Fluorescentes , Modelos Biológicos , Nasofaringe/cirugía , Riboflavina , Aerosoles , Cadáver , Endoscopía , Fluoresceína , Humanos , Modelos Anatómicos , Nebulizadores y Vaporizadores , Otolaringología , Procedimientos Quirúrgicos Otorrinolaringológicos/métodos , Tamaño de la Partícula , SARS-CoV-2RESUMEN
OBJECTIVE: To define the aerosol and droplet risks associated with endonasal drilling and to identify mitigation strategies. STUDY DESIGN: Simulation series with fluorescent 3-dimensional (3D) printed sinonasal models and deidentified cadaveric heads. SETTINGS: Dedicated surgical laboratory. SUBJECTS AND METHODS: Cadaveric specimens irrigated with fluorescent tracer and fluorescent 3D-printed models were drilled. A cascade impactor was used to collect aerosols and small droplets of various aerodynamic diameters under 15 µm. Large droplet generation was measured by evaluating the field for fluorescent debris. Aerosol plumes through the nares were generated via nebulizer, and mitigation measures, including suction and SPIWay devices, nasal sheaths, were evaluated regarding reduction of aerosol escape from the nose. RESULTS: The drilling of cadaveric specimens without flexible suction generated aerosols ≤3.30 µm, and drilling of 3D sinonasal models consistently produced aerosols ≤14.1 µm. Mitigation with SPIWay or diameter-restricted SPIWay produced same results. There was minimal field contamination in the cadaveric models, 0% to 2.77% field tarp area, regardless of drill burr type or drilling location; cutting burr drilling without suction in the 3D model yielded the worst contamination field (36.1%), followed by coarse diamond drilling without suction (19.4%). The simple placement of a flexible suction instrument in the nasal cavity or nasopharynx led to complete elimination of all aerosols ≤14.1 µm, as evaluated by a cascade impactor positioned immediately at the nares. CONCLUSION: Given the findings regarding aerosol risk reduction, we strongly recommend that physicians use a suction instrument in the nasal cavity or nasopharynx during endonasal surgery in the COVID-19 era.
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Aerosoles , COVID-19/prevención & control , COVID-19/transmisión , Transmisión de Enfermedad Infecciosa de Paciente a Profesional/prevención & control , Procedimientos Quírurgicos Nasales/efectos adversos , Cirugía Endoscópica por Orificios Naturales/efectos adversos , Cadáver , Humanos , Hidrodinámica , Intubación Intratraqueal , Modelos Biológicos , Equipo de Protección Personal , Impresión Tridimensional , Medición de RiesgoRESUMEN
OBJECTIVE: The American Academy of Otolaryngology-Head and Neck Surgery Foundation's (AAO-HNSF's) 3D-Printed Temporal Bone Working Group was formed with the goal of sharing information and experience relating to the development of 3D-printed temporal bone models. The group conducted a multi-institutional study to directly compare several recently developed models. STUDY DESIGN: Expert opinion survey. SETTING: Temporal bone laboratory. METHODS: The working group convened in 2018. The various methods in which 3D virtual models had been created and printed in physical form were then shared and recorded. This allowed for comparison of the advantages, disadvantages, and costs of each method. In addition, a drilling event was held during the October 2018 AAO-HNSF Annual Meeting. Each model was drilled and evaluated by attending-level working group members using an 15-question Likert scale questionnaire. The models were graded on anatomic accuracy as well as their suitability as a simulation of both cadaveric and operative temporal bone drilling. RESULTS: The models produced for this study demonstrate significant anatomic detail and a likeness to human cadaver specimens for drilling and dissection. Models printed in standard resin material with a stereolithography printer scored highest in the evaluation, though the margin of difference was negligible in several categories. CONCLUSION: Simulated 3D temporal bones created through a number of printing methods have potential benefit in surgical training, preoperative simulation for challenging otologic cases, and the standardized testing of temporal bone surgical skills.
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Modelos Anatómicos , Impresión Tridimensional , Hueso Temporal , HumanosRESUMEN
None: Despite excellent positive airway pressure (PAP) adherence, a subset of patients with obstructive sleep apnea experience residual elevation of the apnea-hypopnea index (AHI). Drug-induced sleep endoscopy during PAP application provides an opportunity to examine the anatomic effect of PAP therapy on the upper airway and to troubleshoot refractory residual AHI elevation. We present a patient who demonstrated persistent moderate-severe AHI elevation during titration polysomnogram and subsequent data download reports despite numerous mask refits, chin strap, positional modifications, and multiple pressure and mode adjustments in both the clinic and sleep laboratory settings. Drug-induced sleep endoscopy was performed with the flexible endoscope passed through the PAP circuit into the upper airway. Jaw laxity and associated mandibular retrusion at sleep onset was found to result in a complete fixed tongue base obstruction that PAP therapy, delivered via the patient's oronasal interface, was unable to overcome. Various strategies to overcome these obstacles are discussed.
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Apnea Obstructiva del Sueño , Endoscopía , Humanos , Polisomnografía , Respiración con Presión Positiva , Apnea Obstructiva del Sueño/terapia , LenguaRESUMEN
INTRODUCTION: Silent sinus syndrome (SSS) is defined as a progressive enophthalmos and hypoglobus associated with maxillary sinus atelectasis. There is extremely limited literature describing SSS in children. The goals of this study are to characterize SSS in children through an IRB approval retrospective chart review of cases identified through a large health system-wide imaging database and to compare the presentation and outcomes of patients who underwent surgery versus those who were observed. METHODS: A radiology database of over 26 million reports from 2003 to 2017 was searched to identify children aged 1-18 years diagnosed with maxillary sinus hypoplasia or SSS on CT scan. Chart review was performed on the identified children including clinical presentation, eye symptoms, surgical treatment, and outcome. RESULTS: Eighty-three children were identified to have maxillary sinus hypoplasia. Eighty-one patients had maxillary sinus opacification and 57 patients had hypoglobus or enophthalmos characteristic of SSS. Thirty-two patients (47%) were seen by a specialist and 19 had surgery. The majority of patients (55%) had headache as their presenting symptom. There were no statistically significant differences in the clinical presentation between those who received surgery and those who were observed clinically. CONCLUSIONS: Silent sinus syndrome can present at any age. The majority of cases of maxillary sinus hypoplasia will have the orbital floor changes characteristic of SSS. Headaches are a common presenting symptom. Close follow up of pediatric patients is advised and early intervention may be favorable to prevent long term orbital changes and complications.
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Enoftalmia , Enfermedades de los Senos Paranasales , Adolescente , Niño , Preescolar , Enoftalmia/complicaciones , Enoftalmia/diagnóstico , Enoftalmia/terapia , Femenino , Cefalea/etiología , Humanos , Lactante , Masculino , Seno Maxilar/cirugía , Enfermedades de los Senos Paranasales/complicaciones , Enfermedades de los Senos Paranasales/diagnóstico , Enfermedades de los Senos Paranasales/terapia , Estudios Retrospectivos , Síndrome , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Espera VigilanteRESUMEN
INTRODUCTION: Two of the most commonly employed bone-anchored hearing implant (BAHI) systems are the BAHA Connect and BAHA Attract. The BAHA Connect uses a skin-penetrating titanium abutment. The BAHA Attract uses an implanted magnet, leaving the overlying skin intact. Limited data is available on the difference in complication rates between the two systems. Our hypothesis was that there would be no difference in complications and audiologic data. METHODS: Retrospective chart review was performed of patients who had BAHA Connect vs. Attract at our tertiary care pediatric hospital from 2006 to 2018. Pre- and post-operative information, including demographics, related diagnoses, outcomes and complications were compared between the systems using Mann-Whitney U tests and Firth logistic regression for one year post-implant. Audiology data was analyzed with Wilcoxon rank-sum and Wilcoxon matched pairs signed rank tests. RESULTS: Twenty-four Attract and 18 Connect BAHA surgeries were identified from 37 patients. Eleven Connect patients had the surgery completed in two stages. Connect patients followed up an average of 6.5 years post-implant and 15 months for Attract. A total of 58.8% of patients with Connect surgeries had complications within a year and 82.4% had a complication by their last follow-up. Aside from magnet strength related issues, there were no major complications with Attract surgery at any time point. Patients with Connect surgeries had significantly more skin overgrowths, cultured infections, times on antibiotics, nursing phone calls, and ENT visits within the first year and for all records, p < .05. The pure-tone average was significantly lower for both Connect [unaided-M(SD) = 61.7(9.8); aided-M(SD) = 26.4(5.5) and Attract (unaided-M(SD) = 66.0(22.5); aided-M(SD) = 25.6(6.1)] after implant, p < .001. CONCLUSION: Implantation of both systems lead to improved hearing outcomes with profoundly different complication rates.
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Prótesis Anclada al Hueso/efectos adversos , Audífonos/efectos adversos , Pérdida Auditiva Conductiva/rehabilitación , Implantación de Prótesis/efectos adversos , Adolescente , Antibacterianos/uso terapéutico , Niño , Preescolar , Femenino , Estudios de Seguimiento , Audición , Humanos , Infecciones/etiología , Masculino , Visita a Consultorio Médico/estadística & datos numéricos , Complicaciones Posoperatorias/etiología , Consulta Remota/estadística & datos numéricos , Estudios RetrospectivosRESUMEN
OBJECTIVES: Oral and oropharyngeal squamous cell carcinoma (OOPSCC) is a debilitating disease. Salivary rinses contain soluble tumor markers including CD44 (solCD44) and total protein (TP) that may aid detection and prognosis of these aggressive tumors. Here we aim to examine the relationship between these salivary biomarkers and tissue markers p16 and CD44 and determine whether these markers can predict progression-free survival (PFS) and overall survival (OS). MATERIALS AND METHODS: Prospective study to update biomarkers using oral rinses and tissues from OOPSC patients enrolled between 2007 and 2012 at an academic tertiary referral center. 64 cases from a 300-subject case-control study with archived tissue for immunohistochemistry were included. RESULTS: 82.8% were male, 84.4% were ever smokers, 70.3% had disease stage T3-T4, and 57.8% presented with nodal disease. Nineteen patients (25%) were p16 positive. The group with strong tissue CD44 expression in membrane and cytoplasm had higher levels of solCD44 (mean 10.73 ng/ml) than other groups (5.47 ng/ml) (p = 0.033). TP levels were significantly reduced in oral rinses from subjects with p16 universal gross tumor tissue staining (mean 0.80 vs. 1.08 mg/ml; p = 0.039). On multivariate analysis, universal CD44 gross tissue staining and TP levels ≥ 1 mg/ml demonstrated poorer PFS, with the latter also affecting OS. Poorer survival was associated with soluble CD44 ≥ 5.33 ng/ml and TP ≥ 1 mg/ml. CONCLUSIONS: Direct associations were found between high solCD44 levels and strong membrane and cytoplasmic CD44 expression, and between high TP levels and peripheral/mixed p16 gross staining. Poorer PFS and OS are significantly associated with higher levels of solCD44 and protein in oral rinses.
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Biomarcadores de Tumor/metabolismo , Receptores de Hialuranos/metabolismo , Neoplasias de la Boca/genética , Neoplasias de la Boca/patología , Neoplasias Orofaríngeas/genética , Neoplasias Orofaríngeas/patología , Saliva/química , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Estudios ProspectivosRESUMEN
INTRODUCTION: Surgical site infection (SSI) following spinal surgery is a major source of postoperative morbidity. Although studies have demonstrated perioperative antimicrobial prophylaxis (AMP) to be beneficial in the prevention of SSI among spinal surgery patients, consensus is lacking over whether preoperative or extended postoperative AMP is most efficacious. To date, no meta-analysis has investigated the comparative efficacy of these two temporally variable AMP protocols in spinal surgery. We undertook a systemic review and meta-analysis to determine whether extended postoperative AMP is associated with a difference in the rate of SSI occurrence among adult patients undergoing spinal surgery. METHODS: Embase and MEDLINE databases were systematically searched for clinical trials and cohort studies directly comparing SSI rates among adult spinal surgery patients receiving either preoperative or extended postoperative AMP. Quality of evidence of the overall study population was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group approach. Random effects meta-analyses were performed utilizing both pooled and stratified data based on instrumentation use. RESULTS: Five studies met inclusion criteria. No individual study demonstrated a significant difference in the rate of SSI occurrence between preoperative and extended postoperative AMP protocols. The GRADE quality of evidence was low. Among the overall cohort of 2824 patients, 96% underwent lumbar spinal surgery. Pooled SSI rates were 1.38% (26/1887) for patients receiving extended postoperative AMP and 1.28% (12/937) for patients only receiving preoperative AMP. The risk of SSI development among patients receiving extended postoperative AMP was not significantly different from the risk of SSI development among patients only receiving preoperative AMP [RR (risk ratio), 1.11; 95% CI (confidence interval) 0.53-2.36; p = 0.78]. The difference in risk of SSI development when comparing extended postoperative AMP to preoperative AMP was also not significant for both instrumented (RR, 0.92; 95% CI 0.15-5.75; p = 0.93) and non-instrumented spinal surgery (RR, 1.25; 95% CI 0.49-3.17; p = 0.65). There was no evidence of heterogeneity of treatment effects for all meta-analyses. CONCLUSION: Preoperative AMP appears to provide equivalent protection against SSI development when compared to extended postoperative AMP. Prudent antibiotic use is also known to decrease hospital length of stay, healthcare expenditure, and risk of complications. However, until higher-quality evidence becomes available regarding AMP in spinal surgery, surgeons should continue to exercise discretion and clinical judgment when weighing the effects of patient comorbidities and complications before determining the optimal duration of perioperative AMP.
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Profilaxis Antibiótica , Cuidados Posoperatorios/métodos , Cuidados Preoperatorios/métodos , Enfermedades de la Médula Espinal/cirugía , Enfermedades de la Columna Vertebral/cirugía , Fracturas de la Columna Vertebral/cirugía , Procedimientos Quirúrgicos Operativos/efectos adversos , Infección de la Herida Quirúrgica , Profilaxis Antibiótica/métodos , Profilaxis Antibiótica/normas , Humanos , Procedimientos Quirúrgicos Operativos/métodos , Infección de la Herida Quirúrgica/etiología , Infección de la Herida Quirúrgica/prevención & controlRESUMEN
HYPOTHESIS: Patient-specific 3D printed models are useful presurgical planning tools because they accurately represent the anatomy and drilling characteristics of the middle cranial fossa (MCF) approach to the internal auditory canal (IAC). BACKGROUND: The MCF approach to the IAC can be challenging due to variability of the bony architecture along the floor of the middle fossa. Patient-specific 3D printed models may enhance surgeon knowledge of a given patient's anatomy when preparing for MCF surgery. METHODS: Six temporal bone models were printed from photoacrylic resin based on CT data obtained from cadaveric specimens using a desktop stereolithography 3D printer. Critical structures to avoid injuring, the facial nerve and membranous labyrinth, were modeled as hollow cavities and filled with indicator paint. Two neurotologists each drilled three 3D printed models and the corresponding cadaveric specimens, and then completed a 41-item visual analog scale questionnaire (score range of each item: 0-10) to assess the model's accuracy, utility, and potential as a training tool. RESULTS: Drilling the model was favorably rated (median score 9.2; range 7.3-9.6) for its ability to provide surgeons with an accurate mental image of the corresponding cadaveric anatomy. Overall similarity of feel of drilling the model in comparison to human bone was moderate (median 7.6; range 6.6-9.0). Surgeons would use this model to prepare for future cases (median 9.4; range 5.1-9.9) and felt it had excellent utility for training purposes (median 9.3; range 8.4-9.9). CONCLUSIONS: Patient-specific 3D printed models provide an anatomically accurate and favorable tool for preparing for MCF surgery.
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Fosa Craneal Media/cirugía , Modelos Anatómicos , Otolaringología/métodos , Medicina de Precisión/métodos , Impresión Tridimensional , Fosa Craneal Media/anatomía & histología , Humanos , Hueso Temporal/anatomía & histología , Tomografía Computarizada por Rayos X/métodosRESUMEN
Importance: Three-dimensional (3-D) printing of temporal bones is becoming more prevalent. However, there has been no measure of the safety of drilling these models to date. It is unknown whether the heat and sheer from the drill may create harmful volatile organic compounds (VOCs). Objective: To determine the level of exposure to airborne contaminants when conducting high-speed drilling on 3-D-printed models and to explore whether there is a need for exposure control measures. Design, Setting, and Participants: In this occupational safety assessment carried out in a temporal bone laboratory, 3 individual 3-D-printed temporal bones were made using 3 different materials commonly cited in the literature: polylactic acid (PLA), photoreactive acrylic resin (PAR), and acrylonitrile butadiene styrene (ABS). Each model was drilled for 40 minutes while the surgeon wore a sampling badge. Sampling was conducted for airborne concentrations of VOCs and total particulate (TP). Monitoring for VOCs was conducted using Assay Technology 521-25 organic vapor badge worn at the surgeon's neckline. Monitoring for TP was conducted using a polyvinyl chloride filter housed inside a cassette and coupled with an SKC AirChek 52 personal air-sampling pump. Samples were collected and analyzed in accordance with NIOSH Method 500. Main Outcomes and Measures: Presence of VOCs and TP count exposures at Occupational Safety and Health Administration (OSHA) actionable levels. Results: Results of the VOC sample were less than detection limits except for isopropyl alcohol at 0.24 ppm for PAR. The TP samples were less than the detection limit of 1.4 mg/m3. The results are below all applicable OSHA Action Levels and Permissible Exposure Limits for all contaminants sampled for. Conclusions and Relevance: Drilling 3-D-printed models made from PLA, ABS, and PAR was safe by OSHA standards. Continued monitoring and safety testing are needed as 3-D-printed technologies are introduced to our specialty.
Asunto(s)
Contaminantes Ocupacionales del Aire/análisis , Exposición Profesional/análisis , Osteotomía , Material Particulado/análisis , Impresión Tridimensional , Hueso Temporal/cirugía , Compuestos Orgánicos Volátiles/análisis , Humanos , Modelos Anatómicos , Salud Laboral , Otolaringología , Prótesis e Implantes , CirujanosRESUMEN
Objectives We analyze the relationship between CD44, epidermal growth factor receptor (EGFR), and p16 expression in oral cavity and oropharyngeal cancers in a diverse population. We also describe whether particular patterns of staining are associated with progression-free survival and overall survival. Study Design Prospective study, single-blind to pathologist and laboratory technologist. Setting Hospital based. Subjects and Methods Immunohistochemistry, comprising gross staining and cellular expression, was performed and interpreted in a blinded fashion on 24 lip/oral cavity and 40 oropharyngeal cancer specimens collected between 2007 and 2012 from participants of a larger study. Information on overall survival and progression-free survival was obtained from medical records. Results Nineteen cases were clinically p16 positive, 16 of which were oropharyngeal. Oral cavity lesions were more likely to exhibit strong CD44 membrane staining ( P = .0002). Strong CD44 membrane and strong EGFR membrane and/or cytoplasmic staining were more common in p16-negative cancers ( P = .006). Peripheral/mixed gross p16 staining pattern was associated with worse survival than the universal staining on univariate and multivariate analyses ( P = .006, P = .030). This held true when combining gross and cellular localization for p16. For CD44, universal gross staining demonstrated poorer overall survival compared with the peripheral/mixed group ( P = .039). CD44 peripheral/mixed group alone and when combined with universal p16 demonstrated the best survival on multivariate analysis ( P = .010). Conclusion In a diverse population, systematic analysis applying p16, CD44, and EGFR gross staining and cellular localization on immunohistochemistry demonstrates distinct patterns that may have prognostic potential exceeding current methods. Larger studies are warranted to investigate these findings further.