The impact of surgical set-up of endoscopic two surgeon four hand anterior skull base surgeries on surgeons' ergonomics.

BACKGROUND: The impact of different surgical set-ups of endoscopic two surgeon four hand anterior skull base surgeries on surgeons' ergonomics remain unclear. This study aims to explore the effect of surgeon, patient and surgical screen positioning on surgeons' ergonomics using the Rapid Entire Body Assessment (REBA) tool. METHODS: A total of 20 different surgical positions of anterior skull base surgery were simulated and the ergonomic impact on surgeons' neck, truck, leg and wrist were measured using the validated Rapid Entire Body Assessment (REBA) tool. To investigate the ergonomic effect of different surgical setups, the operating surgeon, assisting surgeon, patient head, camera and screen positions were positioned differently in each surgical position. RESULTS: The lowest REBA Score recorded is 3 whereas the highest score is 8. The REBA scores for the majority of positions are 3 highlighting that these positions are ergonomically favorable. Position 12 is the least ergonomically favorable position with a total REBA score of 19. In this position, operating surgeon is positioned to the right of the patient, assisting surgeon to the left of patient, patient head in central position with camera held by operating surgeon and one screen is placed to the right of patient. Positions 13 and 17 are the most ergonomically favorable positions with a total REBA score of 12. In these positions, the patient's head is positioned to the center, two screens were utilized, and the surgeons were positioned on either side of the patient. The utilization of 2 screens with a central patient head position with the surgeons placed on either side of the patient contribute towards a more ergonomically state in these positions. CONCLUSIONS: Certain positional behaviors are better at reducing musculoskeletal injury risk when compared to other. Positions with two screens and central head positions are more favourable ergonomically and surgeons should consider this set-up to reduce musculoskeletal injuries during anterior skull base surgery.

Patient and physician positioning during anterior skull base surgery impacts physician ergonomics.

BACKGROUND: The effects of anterior skull base surgery on surgeon's ergonomics remain unclear and this study explores the impact of patient, surgeon and screen positioning on surgeon's ergonomics during anterior skull base surgery using the Rapid Upper Limb Assessment (RULA) tool. METHOD: A total of 20 different surgical positions involving the operating surgeon, assisting surgeon, patient head position, camera position and screen position/number were simulated. For each position, the ergonomic effects on the upper limb, neck, trunk and lower limb of surgeons were analysed using the Rapid Upper Limb Assessment (RULA) tool. RESULTS: The lowest RULA score is 2 and the maximum score is 6. The majority of scores ranged from 2 to 3 suggesting the majority of positions have acceptable postures. The average RULA score of the right side of operating surgeon was 2.8 versus 2.95 on the left-side (p = 0.297). For the assisting surgeon, the average RULA score of the right side was 3.65 versus 3.25 for the left side (p = 0.053). The average combined (left and right) RULA score for the operating surgeon was 5.76 versus 6.9 for the assisting surgeon (p < 0.001). Position 17 (operating surgeon to the right of patient, assisting surgeon to the left of patient, central patient head position and two screens) is the most ergonomically favourable position. Position 2 (operating and assisting surgeon to the right of patient, patient head position to the right and one screen position to the left of patient) is the least favourable position. CONCLUSION: This simulation raises awareness of risk of musculoskeletal injury in anterior skull base surgery and highlights that certain positional behaviours are better for reducing injury risk than others. Two screens should be considered when performing a two-surgeon, four-hand anterior skull base surgery and surgeons should consider applying this to their own ergonomic environment in theatre.

Cost-Effectiveness of Septorhinoplasty.

Importance: Septorhinoplasties are performed for functional, aesthetic, or a combination of these indications. As a nonvital intervention, cost-effectiveness may be questioned. Objective: To determine the cost-effectiveness of septorhinoplasty. Design and Setting: The literature was reviewed for revision rates (RRs) and health utility values (HUVs) for both septorhinoplasty and revision septorhinoplasty. Age-specific mortality rates and life expectancies were used. Costs were gathered from international settings and analyzed in an adapted Markov model. Intervention: Septorhinoplasty versus no intervention. Main Outcomes and Measures: Cost-efficiency was calculated for different willingness-to-pay thresholds in a probabilistic sensitivity analysis. The effect of different parameters (costs, RRs, HUVs, age, gender) were reviewed and addressed in a sensitivity analysis for an incremental cost-effectiveness ratio (ICER) willingness-to-pay threshold of $50,000/quality-adjusted life year (QALY). Results: The ICER for septorhinoplasty for a 40-year-old woman ranges from $1216 to $3509/QALY (depending on the country) in comparison with no intervention. Septorhinoplasty is cost-effective in 98.8% (for a $50,000/QALY threshold). The sensitivity analysis showed high robustness of the cost-effectiveness for various scenarios. Conclusions and Relevance: Septorhinoplasty is a highly cost-effective treatment.

The microscope drape method to reduce aerosolisation during endoscopic sinus and skull base surgery in the COVID era. How i do it.

BACKGROUND: Otolaryngologists are faced with concerning challenges since the onset of the coronavirus disease (COVID-19) pandemic due to significant risk of occupational infection. Transmission can happen during intraoperative exposure to viral particles carried by droplets or aerosols. Endoscopic sinus and skull base surgery are notable for causing aerosolisation, putting healthcare staff at substantial risk. METHOD: We describe the creation of a tight-seal tent from a microscope drape covering the operative field and the operator's hands with the aim to contain aerosols during transnasal endoscopic surgery. CONCLUSION: The microscope drape technique is a simple barrier measure that could potentially improve safety during endoscopic procedures.

Endoscopic endonasal resection of large skull base schwannoma.

Schwannomas of the skull base can pose a surgical challenge due to their anatomical location. To date extensive craniofacial approaches have had to be used to access these lesions. We present a patient where an expanded endoscopic endonasal approach was used to address a large skull base schwannoma with good results. The approach confers significantly less morbidity and a substantially shorter hospital stay.

Patient-reported nasal morbidity following endoscopic endonasal skull base surgery.

OBJECTIVE: To quantify the frequency and severity of nasal morbidity following endoscopic endonasal skull base surgery using patient-reported outcome measures. METHODS: Retrospective review and follow-up of all patients who underwent endoscopic endonasal skull base surgery at University Hospital Southampton between January 2007 and December 2011. Demographic data were collated from case notes and patients were asked a standardised questionnaire by telephone interview. Statistical sub-analysis of pituitary and other anterior skull base pathology groups was performed using SPSS 1.8. RESULTS: Out of 151 included patients, 85 had a pituitary pathology and the remaining had other anterior skull base pathologies. The mean age was 55.2 years, with 75 male and 76 female patients. Totally 124 patients were interviewed with a median follow-up of 15 months. Mild or no nasal crusting was reported by 77% of patients. In those experiencing crusting, more than 50% resolved within 4 weeks. The majority of patients reported no nasal blockage (52%), pain (83%) or nasal discharge (57%) post-operatively. Totally 71% reported no change in sense of smell post-operatively. The only statistically significant difference between the two pathology groups was that surgery on other anterior skull base pathology was associated with an increased rate of developing anosmia (p = 0.02). CONCLUSION: Endoscopic endonasal skull base surgery is associated with a low level of patient-reported post-operative nasal morbidity. There is no significant difference in frequency of crusting, blockage, pain or discharge between pituitary and other anterior skull base pathology groups. However, anterior skull base surgery would appear to be associated with an increased rate of anosmia post-operatively.

Update on management of frontal sinus osteomas.

PURPOSE OF REVIEW: Endoscopic approaches are used increasingly as an alternative to external approaches in removal of frontal sinus osteoma. The purpose of this article is to review and highlight the recent articles on the management of frontal sinus osteoma over the past 24 months. RECENT FINDINGS: The evolution in endoscopic sinus surgery has allowed rhinologists to expand its indications in managing a wide range of frontal sinus pathologies, including frontal sinus osteomas. The surgeons are attempting endoscopic removal of higher grades of osteomas from frontal sinus, previously thought to be amenable only to external approach on its own or combined with endoscopic approach. Although recent retrospective studies have reported such successful attempts, open approaches, particularly osteoplastic flap, remain an important surgical technique when endoscopic approaches are limited. SUMMARY: The endoscopic approach is effective in surgical management of low-grade osteomas. For higher-grade (grade III and IV) osteomas endoscopic removal is technically challenging and requires availability of advanced instrumentation, including surgical navigation systems, along with surgical expertise.Open approaches to frontal sinus, particularly osteoplastic flap approach, are still valuable as it is a simple and well tolerated method for complete removal of higher-grade osteomas.

A rare case of nasal Mantle cell lymphoma.

A 56-year-old Caucasian man was referred to our clinic with the complaint of right sided unilateral nasal blockage which had been present for one year. Anterior rhinoscopy and computed tomograpy scan revealed a mass, filling the right nostril completely and lying in the right inferior meatus inseparable from the inferior turbinate. Following the biopsy, histopathological examination and immunohistochemical analyses, the diagnosis of Mantle cell lymphoma was established. To our knowledge, there have been no previous reports of a Mantle cell lymphoma presenting as an intranasal mass in the literature. In this article the clinical, radiological and pathological features as well as recent advances in treatment are discussed in the light of current literature.