Effectiveness of skull X-RAY to determine cochlear implant insertion depth.

BACKGROUND: Cochlear implant (CI) insertion depth can affect residual hearing preservation, tonotopic range coverage, and Mapping. Therefore, determining insertion depth has the potential to maximize CI performance. A post-op skull X-RAY is commonly used to assess insertion depth, however its effectiveness has not been well established. Our primary objective was to assess the accuracy of post-op skull X-RAYs to determine insertion depth, compared to CT as the gold standard. Secondary objectives were to compare experience level of raters and different skull X-RAY views. METHODS: Thirteen patients with Advanced Bionic HiRes 90 K implants, and post-operative temporal bone CT scans were selected from the CI database at Sunnybrook Health Sciences Centre. Medical students, otology fellows, and CI surgeons evaluated insertion depths on post-op skull X-RAYs, while neuroradiologists evaluated CT scans. Descriptive statistics, regression analysis, and paired t-tests were used to compare the two types of imaging. RESULTS: X-RAYs and CTs provided an equivalent mean insertion depth of 337 degrees (p = 0.93), a mean difference of - 0.9 degrees and a standard deviation of paired differences of 43 degrees. Although means were similar across rater groups, CI surgeons (45 degrees) had the lowest standard deviation of paired differences. Comparing X-RAY views, Caldwell (29 degrees) had less variation than Towne (59 degrees) for standard deviation of paired differences. CONCLUSIONS: Skull X-RAYs provide accurate and reliable measurements for CI insertion depth. The Caldwell view alone may be sufficient for evaluations of insertion depth, and experience has a minor impact on the variability of estimates.

Jaw Opening Decreases Window to the Deep Parotid Lobe.

To describe the relationship between jaw opening and access to the deep parotid window, we identified the following distances in 10 human skulls: symphysis to angle of mandible, mastoid tip to angle of mandible, angle of mandible to condylar process, and mastoid tip to condylar process. With the jaw closed and open, these distances were measured with 1 to 3 wooden blocks, each measuring 1 cm, between the upper and lower incisors. The triangular deep parotid area formed by the last 3 distances was calculated. A repeated measures analysis of variance showed a significant decrease in the deep parotid area with increasing interincisal distance ( P < .01). A generalized estimating equation model demonstrated a statistically significant decreasing area of the deep parotid window with increasing interincisal distance. These results suggest that nasal intubation may improve access to the parotid window.

Surgeon performed ultrasound-guided fine-needle aspirates of the thyroid: 1067 biopsies and learning curve in a teaching center.

BACKGROUND: Surgeon performed ultrasound-guided fine-needle aspirates (UG-FNAs) reduce delay in diagnosis and allow for surgeon surveillance. We present the first report on a learning curve and impact of head and neck surgical trainees on adequacy rates. METHODS: Thyroid UG-FNA biopsies from 2009 to 2013 were reviewed retrospectively. Specimen adequacy, cytologic diagnosis, and surgical pathology were used to calculate adequacy and accuracy. RESULTS: One thousand sixty-seven biopsies were examined in 723 individuals. The adequacy rate from adoption into practice improved from 71% to 78% to 85% over 300 cases. When UG-FNA was subsequently taught to trainees, adequacy rates varied among trainees (p < .037), and there were higher nondiagnostic rates earlier in training (p = .04). Adequacy was not related to size or palpability, but cystic lesions yielded more inadequate specimens (p < .001). CONCLUSION: Surgeon performed UG-FNA biopsy can be performed adequately in an outpatient setting. Adequacy rates reach acceptable levels after 300 cases, whereas trainee involvement impacts adequacy rates. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1281-E1284, 2016.

Surgeon-performed ultrasound guided fine-needle aspirate biopsy with report of learning curve; a consecutive case-series study.

BACKGROUND: Fine-needle aspiration biopsy has become the standard of care for the evaluation of thyroid nodules. More recently, the use of ultrasound guided fine-needle aspiration biopsy (UG-FNAB) has improved adequacy of sampling. Now there has been improved access to UG-FNAB as ultrasound technology has become more accessible. Here we review the adequacy rate and learning curve of a single surgeon starting at the adoption of UG-FNAB into surgical practice. METHODS: UG-FNABs performed at Sunnybrook Health Sciences Centre from 2010 to 2015 were reviewed retrospectively. Nodule characteristics were recorded along with cytopathology and final pathology reports. Chi-square analysis, followed by the reporting of odds ratios with confidence intervals, were used to assess the statistical significance and frequencies, respectively, of nodule characteristics amongst both diagnostic and non-diagnostic samples. A multiple regression analysis was conducted to determine if any nodule characteristic were predictive of adequacy of UG-FNABs. The learning curve was assessed by calculating the eventual adequacy rates across each year, and its statistical significance was measured using Fischer's Exact Test. RESULTS: In total 423 biopsies were reviewed in 289 patients. The average nodule size was 23.05 mm. When examining if each patient eventually received a diagnostic UG-FNAB, regardless of the number attempts, adequacy was seen to increase from 70.8% in 2010 to, 81.0% in 2011, 90.3% in 2012, 85.7% in 2013, 89.7% in 2014, and 94.3% in 2015 (Fischer's Exact Test, p = 0.049). Cystic (χ(2) = 19.70, p <0.001) nodules were found to yield higher rates of non-diagnostic samples, and their absence are predictive of obtaining an adequate biopsy as seen in a multiple regression analysis (p < 0.001) Adequacy of repeat biopsies following an initial non-diagnostic sample was 75.0%. CONCLUSIONS: Surgeons are capable of performing UG-FNAB with a learning curve noted to achieve standard adequacy rates. Cystic nodules are shown to yield more non-diagnostic samples in the surgeon's office.

Development of an ototoxicity model in the adult CBA/CaJ mouse and determination of a golden window of corticosteroid intervention for otoprotection.

OBJECTIVE: To investigate the effect of timing of dexamethasone administration on auditory hair cell survival following an ototoxic insult with kanamycin and furosemide. STUDY DESIGN: Controlled experimental study. SETTING: Translational science experimental laboratory. METHODS: 5-6 week old CBA/CaJ mice, divided into 6 groups, were injected with kanamycin (1 mg/g SC) followed by furosemide (0.5 mg/g IP). Dexamethasone (0.1 mg/g IP) was injected at either 1 hour prior to insult, +1 hr, +6 hr, +12 hr, or +72 hr post insult. Temporal bones harvested on day 7 underwent Organ of Corti dissection. Immunohistochemical staining was performed using antibodies to myosin 7a, phalloidin, and TO-PRO. RESULTS: Hair cell counts demonstrate a uniform ototoxicity model with total loss of outer hair cells (OHCs) and near-total loss of inner hair cells (IHCs). The group pre-treated with dexamethasone showed a statistically significant improvement in counts compared to controls (p = 0.004). Counts from the other experimental groups given dexamethasone after the insult were highly variable but demonstrated some apical and middle turn inner hair cell survival. CONCLUSION: Treatment of systemic dexamethasone prior to ototoxic insult attenuates hair cell loss in a reliable, novel, ototoxicity model using kanamycin and furosemide in CBA/CaJ mice. Dosing with dexamethasone following ototoxic insult shows promising yet variable response in hair cell survival.

Educational value of a preoperative CT sinus checklist: a resident's perspective.

OBJECTIVE: The objective of this study is to evaluate the educational value and effectiveness of a preoperative computed tomography (CT) sinus anatomy checklist as a teaching method from the perspective of otolaryngology residents. DESIGN: Between 2009 and 2011, 15 otolaryngology residents completed a CT sinus anatomy checklist prior to the start of sinus surgery cases. A cross-sectional brief Likert-type questionnaire assessed the resident experience with the checklist. Nine items explored its perceived utility, role in the preoperative setting, incorporation into practice, and recall. SETTING: St. Michael's Hospital, tertiary care hospital. PARTICIPANTS: Otolaryngology residents rotating through St. Michael's Hospital between 2009 and 2011 were enrolled into this study. A total of 15 residents entered and finished the study. RESULTS: Overall, all residents strongly agreed that the checklist was useful. It ensured that the CT imaging was properly reviewed and increased their comfort level with the relevant anatomy. Nearly all the residents continue to use this checklist even after completing the rotation with the senior author (JML). CONCLUSIONS: The CT sinus anatomy checklist was perceived as useful overall by otolaryngology residents. In the future, checklists should be applied to other areas of head and neck surgical training to further standardize preoperative planning.

Objective assessment of perceived age reversal and improvement in attractiveness after aging face surgery.

IMPORTANCE: Primary reasons why patients pursue aesthetic facial surgery are to look younger and more attractive; however, there is minimal literature about the effect of aesthetic facial surgery on perceived age and attractiveness. OBJECTIVES: To objectively and quantitatively evaluate the degree of perceived age change and improvement in attractiveness following aesthetic facial surgical procedures. DESIGN: Prospective evaluation by independent raters of preoperative and postoperative photographs of 49 consecutive patients who underwent aesthetic facial surgery between July 4, 2006, and July 22, 2010. The photographs of these patients were presented to 50 blinded raters, each of whom was randomly assigned to 4 rater groups. Raters were asked to estimate the age of each patient in the photographs presented and to rate the patient's attractiveness on a scale of 1 to 10. SETTING: Facial plastic surgery private practice in Toronto, Ontario, Canada. PARTICIPANTS: Patient inclusion criteria consisted of primary facial surgical procedures with a minimum 6-month follow-up period, use of standardized photographs, and no cosmetic procedures in the intervening period. Raters were chosen from the province of Ontario, randomly assigned to 1 of 4 rater groups, and blinded to the objectives of the study. MAIN OUTCOMES AND MEASURES: The mean "years saved" (true age minus guessed age) and change in attractiveness scores after facial aesthetic surgery. RESULTS: The mean overall years saved following aesthetic facial surgery was 3.1 years (range, -4.0 to 9.4 years). There was a small but insignificant increase in attractiveness scores in postprocedural photographs relative to preprocedural photographs (P > .54). CONCLUSIONS AND RELEVANCE: In this study, aesthetic facial surgery was effective in reducing the apparent age of patients but did not consistently improve their attractiveness. LEVEL OF EVIDENCE: 4.

Pilot study to determine barriers to accessing sinus surgery.

OBJECTIVE: Given that anecdotal evidence has suggested that certain groups of patients have difficulty accessing sinus surgery, this study aimed to discover the characteristics and access factors that deter patients from surgery. SETTING: Patients were recruited from a community, academic otolaryngology-head and neck surgery practice serving a diverse community. DESIGN: In this cross-sectional study, patients with chronic sinusitis completed a pilot-tested questionnaire. We compared patients who already had sinus surgery to those who had not. MAIN OUTCOME MEASURES: The measured outcomes were descriptive statistics regarding patient demographics and direct ability to obtain sinus surgery. RESULTS: Of those surveyed, 26 patients had undergone surgery, whereas 18 patients had not. There were no differences between groups in terms of ability to speak English; however, there was a smaller component of employed patients in the presurgery group compared to the postoperative group. Age and ethnicity differed between groups, with more North American-born, younger patients in the presurgery group. The ability to afford medications postoperatively or to take time off work for surgery did not differ between groups. Eighty percent of all patients said that they would not be able to take 2 weeks off work. CONCLUSIONS: We found that ethnicity and work status differed between patients offered surgery and those who have already undergone sinus surgery. Given that many patients reported difficulties in several access areas despite undergoing surgery, it seems that there are barriers to patients scheduling surgery that are being overcome by some.