Confirmation of no causal relationship between tracheotomy and aspiration status: a direct replication study.

Debate continues regarding an association between tracheotomy and aspiration status. The aim of this research was to perform a direct replication study to investigate further the causal relationship, if any, between tracheotomy and aspiration. Twenty-five consecutive adult hospitalized patients participated. Inclusion criteria were a pretracheotomy dysphagia evaluation, subsequent tracheotomy and tracheotomy tube placement, then a post-tracheotomy dysphagia reevaluation prior to decannulation. Twenty-two (88%) participants exhibited the same aspiration status or resolved aspiration pre- versus post-tracheotomy. Three participants exhibited new aspiration post-tracheotomy due to worsening medical conditions. Conversely, four participants exhibited resolved aspiration post-tracheotomy due to improved medical conditions. Excluding these seven participants, all nine participants who aspirated pretracheotomy also aspirated post-tracheotomy and all nine participants who did not aspirate pretracheotomy also did not aspirate post-tracheotomy (P > 0.05). No statistically significant differences were found between aspiration status and days since tracheotomy (chi (2) = 0.08, P > 0.05) or between age and aspiration status (P > 0.05). The absence of a causal relationship between tracheotomy and aspiration status was confirmed.

Capillary blood gas: a novel means of assessing free flap perfusion in an animal model.

OBJECTIVE: To demonstrate that in comparison to implantable O(2) microelectrodes, capillary blood gas measurements represent a reliable, accessible, and easy method of identifying failing free flaps. STUDY DESIGN: Groin fasciocutaneous flaps were elevated in 10 rats and following venous occlusion, O(2) microelectrode measurements (pO(2) and flow), and capillary blood gas measurements (pO(2), pCO(2), pH, HCO(3)) were obtained at 10-minute intervals. RESULTS: Measurements with capillary blood gas paralleled measurements with O(2) microelectrodes. Average capillary blood gas pO(2) fell from 42.71 to 31.57 mm Hg at 10 minutes and then to 28.67 mm Hg at 20 minutes. Average pH fell from 7.38 to 7.33 at 10 minutes and to 7.30 at 20 minutes. Results were statistically significant with both the paired Student's t test and the Wilcoxon signed rank test. CONCLUSION: While providing users an ability to simultaneously monitor accepted modalities of flap surveillance, pH and pO(2), capillary blood gas is a reliable, accessible, and reproducible marker of flap health.

Long-term complications of septal dermoplasty in patients with hereditary hemorrhagic telangiectasia.

OBJECTIVE: Septal dermoplasty has been recommended as the treatment of choice for life-threatening epistaxis in patients with hereditary hemorrhagic telangiectasia. This study evaluates the complications of septal dermoplasty in the management of transfusion-dependent epistaxis. STUDY DESIGN: Consecutive retrospective study. SUBJECTS AND METHODS: Between 1994 and 2006, septal dermoplasty was performed on 106 consecutive patients with transfusion dependent epistaxis. Of 103 potential patients, 37 either died or were lost to follow-up, which left 66 patients for study. Data on complications and quality of life were collected on 50 (76%) of 66 patients (mean follow-up, 3.75 years) via phone interview. RESULTS: Seventy-eight percent experienced nasal odor; 72% had nasal crusting; 58% had decreased sense of smell; 30% noted worsened sinus infection; 88% could breathe through their nose; 86% stated improved quality of life. CONCLUSION: Septal dermoplasty remains an effective way of treating transfusion dependent epistaxis in patients with hereditary hemorrhagic telangiectasia and subjectively improves their quality of life.

Arterial coupling for microvascular free tissue transfer.

OBJECTIVE: The purpose of this study was to demonstrate the efficacy of arterial coupling. STUDY DESIGN: Retrospective data were collected in a consecutive series of 124 patients undergoing surgical resection of head and neck tumors followed by free tissue transfer (FTT). METHODS AND MEASURES: The Unilink coupling device was used to perform arterial and venous anastomosis. Flap survival and thrombosis of the arterial anastomoses were determined. RESULTS: A total of 124 consecutive patients underwent a total of 127 microvascular FTTs. Reconstruction included 90 radial forearm, 26 fibula, 9 rectus abdominis, and 2 iliac crest myocutaneous free flaps. There were four (3.2%) complications related to arterial insufficiency in our series, three of which were salvageable. There were three (2.4%) flap failures, resulting in an overall free flap survival rate of 97.6 percent. CONCLUSION: The flap survival with the Unilink Microvascular Anastomotic System is similar to that of standard suture techniques. Use of a coupler device is the preferred method in performing microvascular FTT at our institution.

Construct validity of the endoscopic sinus surgery simulator: II. Assessment of discriminant validity and expert benchmarking.

OBJECTIVES: To establish discriminant validity of the endoscopic sinus surgery simulator (ES3) (Lockheed Martin, Akron, Ohio) between various health care provider experience levels and to define benchmarking criteria for skills assessment. DESIGN: Prospective multi-institutional comparison study. SETTING: University-based tertiary care institution. PARTICIPANTS: Ten expert otolaryngologists, 14 otolaryngology residents, and 10 medical students. INTERVENTIONS: Subjects completed the ES3's virtual reality curriculum (10 novice mode, 10 intermediate mode, and 3 advanced mode trials). Performance scores were recorded on each trial. Performance differences were analyzed using analysis of variance for repeated measures (experience level as between-subjects factor). MAIN OUTCOME MEASURES: Simulator performance scores, accuracy, time to completion, and hazard disruption. RESULTS: The novice mode accurately distinguished the 3 groups, particularly at the onset of training (mean scores: senior otolaryngologists, 66.0; residents, 42.7; students, 18.3; for the paired comparisons between groups 1 and 2 and groups 1 and 3, P = .04 and .03, respectively). Subjects were not distinguished beyond trial 5. The intermediate mode only discriminated students from other subjects (P = .008). The advanced mode did not show performance differences between groups. Scores on the novice mode predicted those on the intermediate mode, which predicted advanced mode scores (r = 0.687), but no relationship was found between novice and advanced scores. All groups performed equally well and with comparable consistency at the outset of training. Expert scores were used to define benchmark criteria of optimal performance. CONCLUSIONS: This study completes the construct validity assessment of the ES3 by demonstrating its discriminant capabilities. It establishes expert surgeon benchmark performance criteria and shows that the ES3 can train novice subjects to attain those. The refined analysis of trial performance scores could serve educational and skills assessment purposes. Current studies are evaluating the transfer of surgical skills acquired on the ES3 to the operating room (predictive validity).

Concurrent chemo-radiotherapy with mitomycin C compared with porfiromycin in squamous cell cancer of the head and neck: final results of a randomized clinical trial.

PURPOSE: Previous randomized trials have shown a benefit with concurrent use of the hypoxic cell cytotoxin mitomycin C (MC) and radiation (RT) in the management of squamous cell cancer of the head and neck (SCCHN). We conducted a randomized trial comparing MC with porfiromycin (POR) in combination with RT in the management of SCCHN. METHODS AND MATERIALS: Between 1992 and 1999, 128 patients with SCCHN were enrolled in this prospective randomized trial. Patients were stratified by management intent, and balanced with respect to stage and site of disease. They were randomized to receive MC (15 mg/M(2)) or POR (40 mg/M(2)) on Days 5 and 47 (or last day) of RT. Of 121 evaluable patients, 61 were randomized to MC and 60 to POR. Patients were treated with standard daily RT to a total median dose of 64 Gy over 47 days. Patients were well balanced with respect to management intent, stage, site, age, sex, hemoglobin levels, tumor grade, radiation dose, and days on treatment. RESULTS: There were no significant differences between the two arms with respect to acute hematologic or nonhematologic toxicities. As of January 2003 with a median follow-up of 6.3 years, there have been 19 local relapses (4 MC vs. 15 POR), 21 regional relapses (7 MC vs. 14 POR), 24 distant metastases (11 MC vs. 13 POR), and 66 deaths (33 MC vs. 33 POR). MC was superior to POR with respect to 5-year local relapse-free survival (91.6% vs. 72.7%, p = 0.01), local-regional relapse-free survival (82% vs. 65.3%, p = 0.05), and disease-free survival (72.8% vs. 52.9%, p = 0.026). There were no significant differences between the two arms with respect to overall survival (49.2% vs. 54.4%) or distant metastasis-free rate (79.9% vs. 75.9%). CONCLUSIONS: Despite promising preclinical data, and an acceptable toxicity profile, POR was inferior to MC as an adjunct to RT in the management of SCCHN. This randomized trial emphasizes the need for randomized studies to evaluate new agents in the management of SCCHN.

Arterial coupling for microvascular free tissue transfer in head and neck reconstruction.

OBJECTIVE: To demonstrate the efficacy of arterial coupling. DESIGN: We report our experience in head and neck reconstruction with the Unilink Microvascular Anastomotic System (Synovis MCA, Birmingham, Ala). Data were collected in a consecutive series of 49 patients undergoing composite resection of head and neck tumors followed by free tissue transfer. SETTING: All patient care took place at Yale-New Haven Hospital, New Haven, Conn, a university-based tertiary care facility. PATIENTS: Forty-nine consecutive patients aged 43 to 85 years underwent a total of 50 microvascular free tissue transfers using the Unilink coupling device. There were 18 women and 31 men, and the following 3 types of flaps were performed: radial forearm (n = 36), fibula (n = 12), and rectus abdominus (n = 2). INTERVENTIONS: The Unilink coupling device was used in this case series. Each arterial and venous anastomosis was performed with the coupling device. Free tissue transfers were monitored clinically and outcomes were recorded. MAIN OUTCOME MEASURES: Flap survival and thrombosis of the arterial anastomoses were determined, as was median length of stay. RESULTS: There were no flap failures in the series. Of the 50 coupled arterial anastomoses, the predominant coupler size used was 2.5 mm in diameter. Reconstructions included 36 radial forearm, 12 fibular osteocutaneous, and 2 rectus abdominus myocutaneous free flaps. One intraoperative arterial thrombosis occurred, requiring hand-sewn anastomosis, and another pulled away from the intact coupler in a steroid-dependent patient. There were no complications related to technical performance of the coupling device. The median length of stay was 14 days. CONCLUSION: While hand-sewn anastomoses in free tissue transfer remain the preferred technique for many microsurgeons, use of the coupler is a viable alternative to sutured anastomoses.

Interventional neuroradiology adjuncts and alternatives in patients with head and neck vascular lesions.

Vascular lesions of the head and neck can result from a variety of neoplastic and traumatic conditions that may cause local neurologic symptoms or may compromise the carotid or vertebral arteries, leading to ischemic deficits. Management of lesions involving vascular structures at the skull base may require a temporary balloon occlusion tolerance test or endovascular transarterial embolization as part of the preoperative management. Endovascular techniques can also be used as a salvage measure for severe head and neck bleeding and can assist with the management of vascular injury occurring in the operative or perioperative setting. Familiarity with the role of endovascular techniques in this group of patients may favorably influence patient management and outcome.

Association between Zenker diverticulum and gastroesophageal reflux disease: development of a working hypothesis.

A cause-and-effect relation between gastroesophageal reflux disease and Zenker diverticulum remains unclear. Convincing evidence exists demonstrating that patients with Zenker diverticula have increased resting tone of the cricopharyngeus muscle, and that this may be an important initiating factor for the development of Zenker diverticula. Yet some patients with cricopharyngeus hypertonicity never develop Zenker diverticulum. In this context, we hypothesize that acid-induced esophageal shortening may be an important cofactor. We suggest that acid reflux induces longitudinal esophageal shortening, which in turn increases the risk for the development of herniation between 2 spatially related structures, the pharyngeal constrictors and cricopharyngeus muscles, leading to the development of Zenker diverticulum. This hypothesis awaits clinical verification.

The efficacy of resorbable plates in head and neck reconstruction.

OBJECTIVE/HYPOTHESIS: The advent of malleable macroporous resorbable plates has allowed the surgeon a greater range of reconstructive options and has decreased the morbidity of conventional plating procedures. Completely malleable after warming to 55 degrees C, resorbable plates can readily conform to most morphologic appearances of fractures or defects and provide rigid fixation when cooled. The plating systems used in head and neck reconstruction are described. STUDY DESIGN: Nine patients were selected for reconstruction using a resorbable plating system. The resorbable system was tested under a variety of clinical situations including frontal sinus fractures (three patients), midface fractures (two patients), mandibular defects (two patients), and laryngeal fractures (two patients). METHODS: Each case was evaluated for rigidity of fixation, and ease of plate contouring and application. Furthermore, the postoperative functional and cosmetic results and complications were contrasted between the resorbable plating systems and each surgeon's vast experience with traditional plating systems. RESULTS: The resorbable plating system was found to be as effective as traditional plating systems with respect to rigidity of fixation, functional results, and complications. In addition, the resorbable system was far easier to contour and, consequently, to apply, while producing higher cosmetic satisfaction after plate resorption than traditional plating. CONCLUSIONS: Based on our experience, resorbable plates appear to be safe, easy to contour and apply, as well as effective for a wide range of head and neck reconstructive applications. In addition, the shortcomings of permanently retained plates such as plate migration, bone growth restriction, and imaging artifact are avoided.

Microsurgical free flap reconstruction outcomes in head and neck cancer patients after surgical extirpation and intraoperative brachytherapy.

OBJECTIVES: The management of recurrent or persistent head and neck cancer poses a challenging problem. Salvage surgery for these individuals consists of ablative surgery, interstitial brachytherapy, and microsurgical free flap reconstruction. This study reviews complications after such reconstruction. METHODS: We reviewed 139 consecutive head and neck cancer patients undergoing free flap reconstruction from January 1994 to May 2002. These included 66 patients with recurrent head and neck cancer undergoing intraoperative brachytherapy (IOBT) and free flap reconstruction and 73 undergoing free flap reconstructions only. A total of 142 reconstructions were performed, with three patients in IOBT group receiving two free flap reconstructions per patient, giving us a total of 69 reconstructions in the IOBT group versus 73 in the non-IOBT group. Nine patients were excluded from the IOBT group because of nonsynchronous use of brachytherapy and reconstruction, and 10 patients were excluded from the other group because they had prior radiotherapy or surgical treatment, leaving us with a total of 123 reconstructions, 60 in the IOBT group and 63 in the non-IOBT group. The IOBT group patients received iodine Vicryl seed implants, palladium seed implants, or both, to deliver an average dose of 79.3 +/- 31.8 Gy (mean +/- 1SD) to the surgical bed. RESULTS: All patients were followed for evidence of local wound complications. The IOBT group showed multiple complications in 23 (38.33%) of 60 reconstructions, the most common being wound dehiscence in 11. This, when compared with the non-IOBT group complications (15.87%), was found to be statistically significant (chi test, P <.01). CONCLUSION: IOBT increases the rate of complications in patients undergoing microvascular free tissue transfer. This, however, should not deter or alter the aggressiveness of cancer therapy used for managing recurrent head and neck cancer.

Use of the operating microscope and loupes for head and neck free microvascular tissue transfer: a retrospective comparison.

OBJECTIVE: To analyze whether less cumbersome loupes are as equally efficacious as the microscope for magnification for free tissue transfers in head and neck reconstruction. DESIGN: A 7-year retrospective review of 151 consecutive microvascular free tissue transfers compares the operating microscope with loupe magnification. SETTING: A tertiary care medical center. PATIENTS: A total of 151 consecutive patients undergoing microvascular reconstructions. INTERVENTION: Microvascular reconstruction of ablative head and neck cancer defects using either microscopic or loupe-provided magnification. MAIN OUTCOME MEASURES: Medical records were reviewed for demographic data, preoperative radiation status, type of defect and flap, length of procedure, complications, and length of stay. RESULTS: Two teams shared the reconstructions, with all microvascular anastomoses created or directly supervised by one of us (D.A.R.). One team used the operating microscope for magnification (84 cases), while the other used loupes (67 cases). Complication rates were statistically similar for the 2 techniques, the length of procedure tended to be shorter in the loupe group, and the length of stay was statistically similar in both groups. CONCLUSIONS: A review of the literature validates the usefulness of loupe magnification in free tissue transfer surgery. To our knowledge, this is the largest number of head and neck reconstruction cases presented comparing these techniques. Loupes offer the surgeon comfort and easy access to and uncomplicated visualization of the operating field. Furthermore, loupes may decrease operating time and help avoid complicated equipment. Therefore, loupe magnification should be considered in head and neck reconstruction without the fear of increased morbidity.

Central facilitation of the glottic closure reflex in humans.

The sphincteric function of the larynx, essential to lower airway protection, is most efficiently achieved through strong reflex adduction by both vocal cords. We hypothesize that central facilitation is an essential component of a bilateral adductor reflex and that its disturbance could result in weakened sphincteric closure. Five patients during supraglottic laryngectomy underwent evoked response laryngeal electromyography under 0.5 and 1.0 minimal alveolar concentration (MAC) isoflurane anesthesia. The internal branch of the superior laryngeal nerve was stimulated through bipolar platinum-iridium electrodes, and recording electrodes were positioned in the ipsilateral and contralateral thyroarytenoid muscles. Consistent threshold responses were obtained ipsilaterally from 0.5 to 1.0 MAC anesthesia. However, the contralateral reflex responses approached 0% in successive trials as anesthetic levels approached 1.0 MAC. In human subjects, alteration of central facilitation by deepening anesthesia abolishes the crossed adductor reflex, predisposing to a weakened glottic closure response. A precise understanding of this effect may improve the prevention of aspiration in patients emerging from prolonged sedation or under heavy psychotropic control.

Efficacy of resorbable plates for reduction and stabilization of laryngeal fractures.

We evaluated the efficacy of resorbable reconstruction plates (polylactic acid copolymer) for the open reduction and stabilization of displaced laryngeal fractures. Both MacroPore and Leibinger reconstruction plates were used with equal ease of application in 3 adult male patients. We found the plating system to be especially effective for the reduction of comminuted cricoid fractures. Adequate skeletal stabilization allowed early resumption of phonatory and respiratory function without long-term intraluminal stenting for skeletal support. No complications of hematoma, seroma, or infection were experienced. Resorbable plates appear to be relatively safe and useful for internal fixation of both cartilaginous and ossified parts of the larynx, allowing rapid rehabilitation and return of function.

Glottic closing force: impact of thyroplasty on vocal cord paralysis in a pig model.

Reflex glottic closure is an essential component of a normal swallow. A lesion of the unilateral recurrent laryngeal nerve weakens this reflex response, affecting the essential protective functions of the larynx and potentially resulting in aspiration pneumonia, sepsis, or death. Thyroplasty has been advocated to reduce glottic incompetence due to unilateral vocal cord paralysis (UVCP). Although medialization thyroplasty has traditionally been evaluated in terms of its phonatory effect, its role in improving protective glottic closure has never been studied. The present study was designed to evaluate the effect of UVCP and thyroplasty type I on the glottic closing force (GCF). Five male Yorkshire pigs weighing approximately 40 kg were used in this study. Both internal superior laryngeal nerves were simultaneously stimulated with bipolar platinum-iridium electrodes, and the force of evoked glottic closure was measured with a pressure transducer positioned between the vocal cords. Initial pressure readings (GCF) obtained with bilaterally intact recurrent laryngeal nerves served as a control. The GCF was then measured after the right recurrent laryngeal nerve was sectioned to simulate the conditions of UVCP. Finally, thyroplasty type I was performed on the affected side, and the GCF was measured again to evaluate its quantitative effect on reflex glottic closure. The mean GCF was reduced by UVCP to approximately 22.5% (49.71 mm Hg) of the control GCF (220.25 mm Hg). Thyroplasty enhanced the GCF to 57.7% (127.08 mm Hg) of the control GCF. These measures underscore the profound effect that UVCP exerts on the GCF and the limitations of vocal cord medialization in fully restoring it.

Very low dose bevacizumab for the treatment of epistaxis in patients with hereditary hemorrhagic telangiectasia.

Hereditary hemorrhagic telangiectasia (HHT) is a disease characterized by mucocutaneous telangiectasias and visceral arteriovenous malformations. The genetic mutations that cause this disease result in elevated levels of vascular endothelial growth factor, which is inhibited by bevacizumab. Previous studies have shown bevacizumab treatment to be effective in reducing symptoms, but study protocols have all used oncological dosing parameters, which carry several well-described serious side effects. This study investigates whether drastically lower dosages of bevacizumab than normally used in oncological treatment could control epistaxis in patients with HHT and medically refractory epistaxis. A prospective, open-label, noncomparative study enrolled six patients receiving 0.125-mg/kg infusions of bevacizumab once every 4 weeks for a total of six infusions. Severity of epistaxis was assessed with the epistaxis severity score, and quality-of-life measures were followed with the 20-item Sino-Nasal Outcome Test and 36-item Short Form surveys. A statistically significant improvement was seen in the control of epistaxis severity and frequency, with minimal negative side effects and high patient satisfaction. Very low dose bevacizumab treatment is an effective method of controlling medically refractory epistaxis in patients with HHT and additional investigation to optimize dosing guidelines is warranted.

The Young's procedure for severe epistaxis from hereditary hemorrhagic telangiectasia.

BACKGROUND: Surgical treatment of epistaxis in hereditary hemorrhagic telangiectasia (HHT) has historically been managed with the laser procedure or the septodermoplasty procedure. For transfusion-dependent patients with severe epistaxis we have been performing the Young's procedure or surgical closure of the nostrils. The objective of this study was to report treatment of severe epistaxis related to HHT with the Young's procedure and assess patient outcome. METHODS: Patients with severe iron or blood transfusion-dependent epistaxis who underwent a Young's procedure in three otolaryngology HHT centers were reviewed. Patients were evaluated for postoperative epistaxis and subjective outcome. RESULTS: Forty-three patients underwent a Young's procedure for severe epistaxis and were observed for a mean of 34 months. The procedure was well tolerated by all patients and 30 of 36 patients (83%) experienced complete cessation of bleeding after the Young's procedure. Patients had a mean increase in hemoglobin of 4.68 g/dL after the procedure. The average Glasgow Benefit Inventory score after surgery was 43.56. No patients requested a reversal of the procedure. CONCLUSION: The Young's procedure is a safe and efficacious procedure with complete cessation of epistaxis in most patients with severe epistaxis and HHT.

A prognostic index for predicting lymph node metastasis in minor salivary gland cancer.

PURPOSE: Large studies examining the clinical and pathological factors associated with nodal metastasis in minor salivary gland cancer are lacking in the literature. METHODS AND MATERIALS: Using the Surveillance, Epidemiology, and End Results (SEER) database, we identified 2,667 minor salivary gland cancers with known lymph node status from 1988 to 2004. Univariate and multivariate analyses were conducted to identify factors associated with the use of neck dissection, the use of external beam radiation therapy, and the presence of cervical lymph node metastases. RESULTS: Four hundred twenty-six (16.0%) patients had neck nodal involvement. Factors associated with neck nodal involvement on univariate analysis included increasing age, male sex, increasing tumor size, high tumor grade, T3-T4 stage, adenocarcinoma or mucoepidermoid carcinomas, and pharyngeal site of primary malignancy. On multivariate analysis, four statistically significant factors were identified, including male sex, T3-T4 stage, pharyngeal site of primary malignancy, and high-grade adenocarcinoma or high-grade mucoepidermoid carcinomas. The proportions (and 95% confidence intervals) of patients with lymph node involvement for those with 0, 1, 2, 3, and 4 of these prognostic factors were 0.02 (0.01-0.03), 0.09 (0.07-0.11), 0.17 (0.14-0.21), 0.41 (0.33-0.49), and 0.70 (0.54-0.85), respectively. Grade was a significant predictor of metastasis for adenocarcinoma and mucoepidermoid carcinoma but not for adenoid cystic carcinoma. CONCLUSIONS: A prognostic index using the four clinicopathological factors listed here can effectively differentiate patients into risk groups of nodal metastasis. The precision of this index is subject to the limitations of SEER data and should be validated in further clinical studies.

From virtual reality to the operating room: the endoscopic sinus surgery simulator experiment.

OBJECTIVE: Establish the feasibility of a predictive validity study in sinus surgery simulation training and demonstrate the effectiveness of the Endoscopic Sinus Surgery Simulator (ES3) as a training device. STUDY DESIGN: Prospective, multi-institutional controlled trial. SETTING: Four tertiary academic centers with accredited otolaryngology-head and neck surgery residency programs. SUBJECTS: Twelve ES3-trained novice residents were compared with 13 control novice residents. METHODS: Subjects were assessed on the performance of basic sinus surgery tasks. Their first in vivo procedure was video recorded and submitted to a blinded panel of independent experts after the panel established a minimum inter-rater reliability of 80 percent. The recordings were reviewed by using a standardized computer-assisted method and customized metrics. Results were analyzed with the Mann-Whitney U test. Internal rater consistency was verified with Pearson moment correlation. RESULTS: Completion time was significantly shorter in the experimental group (injection P = 0.003, dissection P < 0.001), which, according to the rater panel, also demonstrated higher confidence (P = 0.009), demonstrated skill during instrument manipulation (P = 0.011), and made fewer technical mistakes during the injection task (P = 0.048) compared with the control group. The raters' post hoc internal consistency was deemed adequate (r > 0.5 between serial measurements). CONCLUSION: The validity of the ES3 as an effective surgical trainer was verified in multiple instances, including those not depending on subjective rater evaluations. The ES3 is one of the few virtual reality simulators with a comprehensive validation record. Advanced simulation technologies need more rapid implementation in otolaryngology training, as they present noteworthy potential for high-quality surgical education while meeting the necessity of patient safety.