Ergonomic Analysis of Otologic Surgery: Comparison of Endoscope and Microscope.

OBJECTIVE: The comparative postural health of surgeons performing endoscopic and microscopic otologic surgeries has been a topic of active debate, with many nascent or anecdotal reports suggesting the latter encourages suboptimal ergonomics. Using inertial body sensors to measure joint angles, this study sought to objectively evaluate and compare the ergonomics of surgeons during endoscopic and microscopic otologic surgeries. STUDY DESIGN: Prospective pilot trial. SETTING: Large, multicenter, academic hospital system. Performed 21 otologic operations (10 endoscopic and 11 microscopic) in November 2020 and January 2021. All attendings were fellowship trained in otology/neurotology. SUBJECTS: Eight otolaryngologists (four attendings and four residents) performing 21 otologic surgeries (11 microscopic and 10 endoscopic). INTERVENTION: Approach to otologic surgery: endoscope or microscope. MAIN OUTCOME MEASURES: Surgeons' neck and back angles while wearing ergonomic sensors affixed to either side of each major joint, mental and physical burdens and pain after each surgery (via modified NASA Task Load Index). RESULTS: Residents' necks (9.54° microscopic vs. -4.79° endoscopic, p = 0.04) and backs (16.48° microscopic vs. 3.66° endoscopic, p = 0.01) were significantly more flexed when performing microscopic surgery than when performing endoscopic surgery, although attending neck and back flexion were comparable during microscopic and endoscopic surgeries. Attendings reported significantly higher pain levels after operating microscopically than after operating endoscopically (0.13 vs. 2.76, p = 0.01). CONCLUSIONS: Residents were found to operate with significantly higher risk back and neck postures (as defined by the validated ergonomic tool, Rapid Entire Body Assessment) when operating microscopically. Attendings reported significantly higher levels of pain after operating microscopically versus endoscopically, suggesting that the suboptimal microscopic postures adopted earlier in training may pose an indelible risk later in a surgeon's career.

Implementation of a 4-dimensional computed tomography protocol for parathyroid adenoma localization.

PURPOSE: To present the results of our implementation of a four-dimensional computed tomography- (4DCT) based parathyroid localization protocol for primary hyperparathyroidism at a safety net hospital. METHODS: We performed a retrospective review of all patients who underwent parathyroidectomy for primary hyperparathyroidism at Elmhurst Hospital Center from June 2016 - September 2019. Patients treated prior to the implementation of 4DCT during October 2018 served as historical controls for comparison. Imaging-related costs and hospital charges were obtained from the Radiology Department for each patient. RESULTS: Forty-two patients underwent parathyroid surgery during the study period. Twenty patients had undergone 4DCT while 22 had nuclear medicine studies with or without ultrasonography. The sensitivity and specificity of 4DCT was 90.4% and 100% respectively, compared to 63% and 93.7% for nuclear imaging studies and 41% and 95% for ultrasound. The mean number of glands explored was significantly less in the 4DCT group, 1.8 ± 1.19 versus 2.77 ± 1.26 (p = 0.01). There was no increase in infrastructure or personnel costs associated with 4DCT implementation. CONCLUSIONS: 4DCT represents an increasingly common imaging modality for pre-operative parathyroid localization. Here we demonstrate that 4DCT is associated with a reduction in the number of glands explored and enables minimally invasive parathyroid surgery. 4DCT is a cost-effective and clinically sound localization study for parathyroid localization in an urban safety-net hospital.

Surgery of the Palatomaxillary Structure.

The palatomaxillary structure plays critical roles in both form and function of the midface. Surgical defects of the palate and maxilla can be associated with significant morbidity and deformity. Various defect classification systems have been used to assist in reconstruction and rehabilitation. Reconstructive options include prosthetic rehabilitation, local flaps, and free tissue transfer. Here, we review the functional and surgical anatomy of the palatomaxillary complex, defect classification systems, and provide an overview of reconstructive options.

Regional Reconstruction of Orbital Exenteration Defects.

Aggressive disease such as invasive fungal infections or malignancies may necessitate orbital exenteration. The defects of orbital exenteration are often complex involving adjacent structures. Rehabilitation of the orbital exenteration defect poses unique challenges to the reconstructive surgeon. Various options have been described ranging from secondary intention to microvascular free tissue reconstruction. Here the authors review local/regional options for reconstruction of orbital exenteration defects.

Septic arthritis of the sternoclavicular joint: A unique late complication after tracheostomy.

BACKGROUND: Septic arthritis of the sternoclavicular joint is a rare infection associated with significant morbidity and mortality. Several risk factors for septic arthritis have been reported in the literature ranging from immunodeficiency to intravenous drug use. CASE PRESENTATION: A 63-year-old male previously treated for synchronous squamous cell carcinomas of the epiglottis and floor of mouth presented with tenderness and swelling of the sternoclavicular joint two months after tracheostomy decannulation. Computed tomography and bone scans confirmed the diagnosis of septic arthritis of the sternoclavicular joint. The patient's clinical course, surgical treatment, and management considerations are discussed here. CONCLUSION: Septic arthritis of the SCJ is a rare but serious infection. Once diagnosed, septic arthritis of the SCJ should be promptly treated to prevent further morbidity and mortality.

Total mandibulectomy defect in the setting of chronic bisphosphonate use.

Bisphosphonates are among several drugs known in modern medicine to have a potentially deleterious effect on the mandible with chronic use. While purportedly causing a necrotic reaction in the bone, the complete mechanism is not fully elucidated yet as cases are quite rare in the general public. Despite the esoteric nature of this entity, patients suffering from bisphosphonate induced necrosis have a complicated and prolonged course often involving varying degrees of mandibular debridement with severe cases requiring reconstruction. In this report, we present the unique case of a patient with a progressive mandibular osteonecrosis requiring complete mandibulectomy and fibula flap reconstruction.

Epidemiological Trends of Head and Neck Cancer in the United States: A SEER Population Study.

PURPOSE: This study represents the most recent epidemiologic trends of head and neck cancer (HNC) in the United States. It provides an important discussion on oropharyngeal cancer and cancers related to the human papillomavirus. The objective was to identify trends in HNC (2002 to 2012) within the United States. MATERIALS AND METHODS: This study is a retrospective analysis of the US National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) submission. Using the November 2014 submission of the SEER database and SEER-18 data files, data from 2002 to 2012 were analyzed to determine the most recent epidemiologic trends. HNCs of all subtypes were analyzed together. Laryngeal cancers were further analyzed separately. Oropharyngeal cancers of the base of tongue and tonsil were analyzed independently to attempt to trend HPV-related cancers. RESULTS: From 2002 to 2012, there were 149,301 cases of HNC recorded in the SEER database. The HNC rate decreased by 0.22% per year (P = .0549) and the rate of laryngeal cancer decreased by 1.9% per year (P < .0001). The rate of oropharyngeal (HPV-related) cancer increased by 2.5% per year (P < .0001). HNC rates increased significantly in Kentucky and Connecticut and decreased in California (P < .05). HPV-related cancers increased significantly in all states except Georgia, Hawaii, and Michigan (P < .05). Laryngeal cancer rates decreased in California, Georgia, New Jersey, and New Mexico (P < .05). CONCLUSIONS: The overall incidence of HNC is decreasing in the United States. There is an increasing incidence of HPV-related cancers of the oropharynx. Meaningful differences in cancer incidence and rate of change exist between men and women. Furthermore, younger groups have a greater decrease of overall HNC, with an overall increase in HPV-related cancer in patients older than 50 years.

Management of rhinosinusitis during pregnancy: systematic review and expert panel recommendations.

BACKGROUND: Management of rhinosinusitis during pregnancy requires special considerations. OBJECTIVES: 1. Conduct a systematic literature review for acute and chronic rhinosinusitis (CRS) management during pregnancy. 2. Make evidence-based recommendations. METHODS: The systematic review was conducted using MEDLINE and EMBASE databases and relevant search terms. Title, abstract and full manuscript review were conducted by two authors independently. A multispecialty panel with expertise in management of Rhinological disorders, Allergy-Immunology, and Obstetrics-Gynecology was invited to review the systematic review. Recommendations were sought on use of following for CRS management during pregnancy: oral corticosteroids; antibiotics; leukotrienes; topical corticosteroid spray/irrigations/drops; aspirin desensitization; elective surgery for CRS with polyps prior to planned pregnancy; vaginal birth versus planned Caesarian for skull base erosions/ prior CSF rhinorrhea. RESULTS: Eighty-eight manuscripts underwent full review after screening 3052 abstracts. No relevant level 1, 2, or 3 studies were found. Expert panel recommendations for rhinosinusitis management during pregnancy included continuing nasal corticosteroid sprays for CRS maintenance, using pregnancy-safe antibiotics for acute rhinosinusitis and CRS exacerbations, and discontinuing aspirin desensitization for aspirin exacerbated respiratory disease. The manuscript presents detailed recommendations. CONCLUSIONS: The lack of evidence pertinent to managing rhinosinusitis during pregnancy warrants future trials. Expert recommendations constitute the current best available evidence.