Objective structured assessment of technical skill in temporal bone dissection: validation of a novel tool.

OBJECTIVE: This study developed an assessment tool that was based on the objective structured assessment for technical skills principles, to be used for evaluation of surgical skills in cortical mastoidectomy. The objective structured assessment of technical skill is a well-established tool for evaluation of surgical ability. This study also aimed to identify the best material and printing method to make a three-dimensional printed temporal bone model. METHODS: Twenty-four otolaryngologists in training were asked to perform a cortical mastoidectomy on a three-dimensional printed temporal bone (selective laser sintering resin). They were scored according to the objective structured assessment of technical skill in temporal bone dissection tool developed in this study and an already validated global rating scale. RESULTS: Two external assessors scored the candidates, and it was concluded that the objective structured assessment of technical skill in temporal bone dissection tool demonstrated some main aspects of validity and reliability that can be used in training and performance evaluation of technical skills in mastoid surgery. CONCLUSION: Apart from validating the new tool for temporal bone dissection training, the study showed that evolving three-dimensional printing technologies is of high value in simulation training with several advantages over traditional teaching methods.

Patients with Lemierre syndrome have a high risk of new thromboembolic complications, clinical sequelae and death: an analysis of 712 cases.

BACKGROUND: Lemierre syndrome is characterized by head/neck vein thrombosis and septic embolism usually complicating an acute oropharyngeal bacterial infection in adolescents and young adults. We described the course of Lemierre syndrome in the contemporary era. METHODS: In our individual-level analysis of 712 patients (2000-2017), we included cases described as Lemierre syndrome if these criteria were met: (i) primary site of bacterial infection in the head/neck; (ii) objectively confirmed local thrombotic complications or septic embolism. The study outcomes were new or recurrent venous thromboembolism or peripheral septic lesions, major bleeding, all-cause death and clinical sequelae. RESULTS: The median age was 21 (Q1-Q3: 17-33) years, and 295 (41%) were female. At diagnosis, acute thrombosis of head/neck veins was detected in 597 (84%) patients, septic embolism in 582 (82%) and both in 468 (80%). After diagnosis and during in-hospital follow-up, new venous thromboembolism occurred in 34 (5.2%, 95% CI 3.8-7.2%) patients, new peripheral septic lesions became evident in 76 (11.7%; 9.4-14.3%). The rate of either was lower in patients who received anticoagulation (OR: 0.59; 0.36-0.94), higher in those with initial intracranial involvement (OR: 2.35; 1.45-3.80). Major bleeding occurred in 19 patients (2.9%; 1.9-4.5%), and 26 died (4.0%; 2.7-5.8%). Clinical sequelae were reported in 65 (10.4%, 8.2-13.0%) individuals, often consisting of cranial nerve palsy (n = 24) and orthopaedic limitations (n = 19). CONCLUSIONS: Patients with Lemierre syndrome were characterized by a substantial risk of new thromboembolic complications and death. This risk was higher in the presence of initial intracranial involvement. One-tenth of survivors suffered major clinical sequelae.

Endoscopic management of paediatric meningoencephaloceles: a case series.

INTRODUCTION: Congenital meningoencephaloceles represent a rare clinical entity, with its frequency being around 1 out of 4000-5000 live births. They usually present as a midline mass and the differential diagnosis includes dermoids, encephaloceles, and gliomas. Although the standard coronal approach with frontal craniotomy and pericranial flap has been considered the preferred method for several years, it is associated with risks and prolonged hospitalization. The endoscopic procedure is gaining ground and we are aiming to present our experience from five cases that were treated endoscopically. MATERIALS AND METHODS: Five cases of paediatric meningoencephaloceles (age ranging from 2.5 to 10 years) were treated in our department between the years 2007-2017. Four children had a congenital and one child a post-traumatic meningoencephalocele. The presenting symptoms included nasal obstruction, meningitis and CSF leak. All patients had pre-operative imaging with CT and MRI scans and the preferred method of repair was multi-layered closure. RESULTS: All our patients had uneventful recovery, without any post-operative complications. The follow-up period ranges from 39 to 98 months. All five patients remain asymptomatic and recurrence-free. CONCLUSION: Endoscopic management of paediatric meningoencephaloceles is a reliable and safe approach and it is known to have no adverse effects on facial growth. It carries a satisfactory success rate, reduces the in-hospital stay with lower cost of treatment, better cosmesis and lower morbidity than external procedures. It requires multidisciplinary team setting in a tertiary centre with experienced endoscopic anterior skull base surgeons. Pre-operative assessment and post-operative care are of paramount importance and larger series need to be studied to reach safe conclusions and establish management guidelines.

Reconstruction of frontal defects with calvarial grafts.

BACKGROUND: There are many options for the reconstruction of frontal sinus wall defect resulting from injury, neoplastic lesions and aesthetic deformities. These mainly include autogenous grafts, allogenous grafts, and alloplastic materials. The aim of the present study is to report the advantages of using autogenous calvarial bone grafts over other reconstruction techniques, in the reconstruction of frontal defects. METHODS: We describe 16 consecutive cases of anterior frontal sinus defects between 2004 and 2015, in which calvarial bone grafts were used. Medical records were retrospectively analysed to evaluate graft survival. RESULTS: Bone defects were caused by injury (3), aesthetic deformities (2), external frontal sinus surgeries (2), tumours (6: three osteomas, two fibrous dysplasias, one squamous cell carcinoma), and osteomyelitis (3). There were no significant complications during harvesting, and morbidity was minimal. Furthermore, at one and five-year follow-up, no graft resorption or rejection was noted, and cosmetic results were satisfactory. CONCLUSIONS: Our results indicate that calvarial bone graft is an appropriate material to use in anterior frontal sinus reconstruction.

Platelet-rich plasma in otolaryngology.

BACKGROUND: Platelet-rich plasma is a novel material that is being used more frequently in many surgical specialties. METHODS: A literature review on the current and potential uses of platelet-rich plasma in otolaryngology was performed. RESULTS: There is limited evidence on the use of platelet-rich plasma in otolaryngology compared with other specialties: only 11 studies on various subspecialties (otology, rhinology and laryngology) were included in the final review. CONCLUSION: Based on the limited number of studies, we cannot draw safe conclusions about the value of platelet-rich plasma in otolaryngology. Nevertheless, the available literature suggests that platelet-rich plasma holds promise for future research and may have a number of clinical applications.

Double primary malignant fibrous histiocytoma and squamous cell carcinoma of the larynx treated with laser laryngeal conservation surgery.

ΒACKGROUND: Synchronous multiple malignancies of the larynx are rare. We present a case here of synchronous primary laryngeal squamous cell carcinoma (SCC) and malignant fibrous histiocytoma (MFH) in a patient with hoarseness though with no history of exposure to radiation. Clinical, intraoperative, and histopathological findings in this patient are discussed. METHODS: Wide laser excision of the left supraglottic lesion and laser cordectomy of the right true vocal cord were performed. RESULTS: The patient presented with a recurrence of the ΜFH alone (with no recurrence of the SCC) two months after the first operation and was managed with an extended second look laser cordectomy. The patient is under regular follow-up and remained disease-free nine months from diagnosis. CONCLUSIONS: Our results show that early-stage simultaneous tumours of the larynx and particularly MFH and SCC can be treated efficiently with endoscopic laryngeal surgery alone. Close follow-up is of paramount importance because of the aggressive nature of MFH.

Management of globus pharyngeus.

Globus pharyngeus is a common ENT condition. This paper reviews the current evidence on globus and gives a rational guide to the management of patients with globus. The aetiology of globus is still unclear though most ENT surgeons believe that reflux whether acidic or not plays a significant role. Though proton pump inhibitors are used extensively in practice, there is little evidence to support their efficacy. Most patients with globus can be discharged after simple office investigations. The role of pepsin-induced laryngeal injury is an exciting concept that needs further study. Given the benign nature of globus pharyngeus, in most cases, reassurance rather than treatment or extensive investigation with rigid oesophagoscopy or contrast swallows is all that is needed. We need more research into the aetiology of globus.

Review article: reflux and its consequences--the laryngeal, pulmonary and oesophageal manifestations. Conference held in conjunction with the 9th International Symposium on Human Pepsin (ISHP) Kingston-upon-Hull, UK, 21-23 April 2010.

BACKGROUND: Gastro-oesophageal reflux disease (GERD) is one of the commonest diseases of Western populations, affecting 20 to 30% of adults. GERD is multifaceted and the classical oesophageal symptoms such as heartburn and regurgitation often overlap with atypical symptoms that impact upon the respiratory system and airways. This is referred to as extra-oesophageal reflux disease (EERD), or laryngopharyngeal reflux (LPR), which manifests as chronic cough, laryngitis, hoarseness, voice disorders and asthma. AIM: The 'Reflux and its consequences' conference was held in Hull in 2010 and brought together a multidisciplinary group of experts all with a common interest in the many manifestations of reflux disease to present recent research and clinical progress in GERD and EERD. In particular new techniques for diagnosing reflux were showcased at the conference. METHODS: Both clinical and non-clinical key opinion leaders were invited to write a review on key areas presented at the `Reflux and its consequences' conference for inclusion in this supplement. RESULTS AND CONCLUSION: Eleven chapters contained in this supplement reflected the sessions of the conference and included discussion of the nature of the refluxate (acid, pepsin, bile acids and non-acid reflux); mechanisms of tissue damage and protection in the oesophagus, laryngopharynx and airways. Clinical conditions with a reflux aetiology including asthma, chronic cough, airway disease, LPR, and paediatric EERD were reviewed. In addition methods for diagnosis of reflux disease and treatment strategies, especially with reference to non-acid reflux, were considered.

Spirulina in clinical practice: evidence-based human applications.

Spirulina or Arthrospira is a blue-green alga that became famous after it was successfully used by NASA as a dietary supplement for astronauts on space missions. It has the ability to modulate immune functions and exhibits anti-inflammatory properties by inhibiting the release of histamine by mast cells. Multiple studies investigating the efficacy and the potential clinical applications of Spirulina in treating several diseases have been performed and a few randomized controlled trials and systematic reviews suggest that this alga may improve several symptoms and may even have an anticancer, antiviral and antiallergic effects. Current and potential clinical applications, issues of safety, indications, side-effects and levels of evidence are addressed in this review. Areas of ongoing and future research are also discussed.

Aspirin sensitivity and the nose.

There is a well-recognized association of aspirin sensitivity, aspirin-induced asthma, nasal polyposis or sinusitis, known as Samter's triad. This article outlines the pathogenesis and clinical features of this condition and reviews current management options.

Current evaluation of the dysphagic patient.

Dysphagia is a symptom so common and diverse that is often considered as a disease in its own right. Its severity can range from a trivial problem to a lethal condition. It can seriously compromise the quality of life of affected patients, therefore management should be prompt. The implications of dysphagia in healthcare costs are immense. Assessment of dysphagic patients is based on a comprehensive history and thorough examination. In the present review we discuss physiology, aetiology, diagnosis and management emphasizing the role of a multidisciplinary team approach. We also focus on the role of fibreoptic endoscopic evaluation of swallowing which revolutionized over recent years the assessment of the dysphagic patient.

A "hard" neck lump.

We discuss a case of an asymptomatic cervical rib presenting as a hard neck lump in a 56-year-old woman. Cervical rib is a common condition associated with thoracic outlet syndrome. The diagnosis, investigation and management of this condition is an important differential diagnosis that an ENT surgeon should know in a patient presenting with a neck mass.