Endoscopic Integrated Multipoint Laser System to Perform Quantitative Measurements for Anterior Skull Base Defects.

INTRODUCTION: Measurements in endoscopic sinus surgery (ESS) are usually obtained with variable accuracy. We aimed to validate endoscopic multipoint integrated laser systems (EIMLS) for use in ESS, which can acquire measurements within one-hundredth of a millimetre. METHODS: A 4.4 mm flexible endoscopic EIMLS projecting 49 laser points into the view was used to assess simulated anterior skullbase defects. Antero-posterior and lateral measurements were obtained and repeated 20 times by two surgeons. These were compared to measurements with surgical callipers. Intra and inter-observer reliability was assessed. RESULTS: Eighty measurements were obtained of simulated skullbase defects by each otolaryngology surgeon and compared to manual measurements. The mean difference shown was 0.56 cm. Bland-Altman plot shows low bias (0.044) but wide 95% limits of agreement (-1.8-1.9). CONCLUSION: EIMLS allows reliable and easy to obtain measurements within a simulated ESS environment. Translation of this technology offers promise in a future clinical setting but will require further refinement to improve accuracy.

Patient Selection, Outcome, and Unhappy Patients in Rhinoplasty.

This article discusses the process of patient selection for rhinoplasties and the many different psychological aspects that come into play. It is important to identify the warning signs and apply a multidisciplinary approach to the surgeons practice, in collaboration with specialist rhinoplasty psychologists. Patients' motivations and surgeon factors are also discussed, as this can lead to unhappy and unsatisfactory postoperative outcomes. Potential reasons for adverse outcomes throughout the pre- and postoperative periods are also described. Finally, a brief guide is provided to reduce the risks of an unhappy patient.

Patient Selection, Outcome, and Unhappy Patients in Rhinoplasty.

This article discusses the process of patient selection for rhinoplasties and the many different psychological aspects that come into play. It is important to identify the warning signs and apply a multidisciplinary approach to the surgeons practice, in collaboration with specialist rhinoplasty psychologists. Patients' motivations and surgeon factors are also discussed, as this can lead to unhappy and unsatisfactory postoperative outcomes. Potential reasons for adverse outcomes throughout the pre- and postoperative periods are also described. Finally, a brief guide is provided to reduce the risks of an unhappy patient.

Structured Preoperative Phone Counseling by Junior Medical Staff for Improving the Consent Process for Tonsillectomy.

OBJECTIVE: To assess the effectiveness of preoperative phone counseling by junior medical staff for improving the standard of informed consent for tonsillectomy. STUDY DESIGN: Prospective randomized controlled trial. SETTING: District general hospital. SUBJECTS AND METHODS: A total of 43 patients undergoing tonsillectomy were randomly allocated to 2 groups. Group A (n = 25) underwent the conventional consent process by the consultant ear, nose, and throat surgeon at the time of assessment (which generally takes place 6 to 12 months prior to surgery due to wait-list times). Group B (n = 18) underwent this same consent process but received a structured preoperative phone call 2 to 3 weeks prior to the day of surgery. A preoperative questionnaire assessing the knowledge of tonsillectomy, perioperative course, and risks was completed on the day of surgery. RESULTS: Group B had a better recall of the risks of tonsillectomy, recalling 7.1 of the 10 most significant risks, as compared with 4.6 for group A (P = .017). Group B had a better awareness of tooth damage (78% vs 30% of patients, P ≤ .001), voice change (61 vs 19%, P = .005), and burns to lips and mouth (44% vs 8%, P = .005). Finally, 35% more patients from group B rated their understanding of tonsillectomy as good or very good (P = .017). CONCLUSION: Preoperative phone counseling by junior medical staff closer to the time of surgery reinforces and clarifies the information previously provided by senior consultants at the time of initial consent for tonsillectomy.

Endoscopic skull base reconstruction of large dural defects: a systematic review of published evidence.

OBJECTIVES/HYPOTHESIS: Systematically review the outcomes of endoscopic endonasal techniques to reconstruct large skull base defects (ESBR). Such surgical innovation is likely to be reported in case series, retrospective cohorts, or case-control studies rather than higher level evidence. STUDY DESIGN: Systematic review and meta-analysis. METHODS: Embase (1980-December 7, 2010) and MEDLINE (1950-November 14, 2010) were searched using a search strategy designed to include any publication on endoscopic endonasal reconstruction of the skull base. A title search selected those articles relevant to the clinical or basic science of an endoscopic approach. A subsequent abstract search selected articles of any defect other than simple cerebrospinal fluid (CSF) fistula, sella only, meningoceles, or simple case reports. The articles selected were subject to full-text review to extract data on perioperative outcomes for ESBR. Surgical technique was used for subgroup analysis. RESULTS: There were 4,770 articles selected initially, and full-text analysis produced 38 studies with extractable data regarding ESBR. Of these articles, 12 described a vascularized reconstruction, 17 described free graft, and nine were mixed reconstructions. Three had mixed data in clearly defined patient groups that could be used for meta-analysis. The overall CSF leak rate was 11.5% (70/609). This was represented as a 15.6% leak rate (51/326) for free grafts and a 6.7% leak rate (19/283) for the vascularized reconstructions (χ(2) = 11.88, P = .001). CONCLUSIONS: Current evidence suggests that ESBR with vascularized tissue is associated with a lower rate of CSF leaks compared to free tissue graft and is similar to reported closure rates in open surgical repair.

Endoscopic skull base surgery for sinonasal malignancy.

Management of malignant neoplasms of the sinonasal tract and skull base is hampered by the relative low incidence and pathologic diversity of patient presentations. Many studies have reported successful outcomes in the endoscopic management of malignancy since 1996, and these are summarized in this article. Nonsurgical adjuvant therapies are important for locoregional control because surgery occurs in a restricted anatomic space with close margins to critical structures, and distant disease is an ongoing concern in these disorders. There remains a need for collaborative consistent multicenter reporting, and international registries have been established to assist in such efforts.

Reconstructive options for endoscopic skull base surgery.

This review describes the sequential learning from initial free tissue grafting reconstructive techniques to the current use of vascularized flaps. Outcomes and limitations of current endoscopic reconstructive techniques are discussed, including a systematic review of the outcomes of endoscopic endonasal techniques to reconstruct large skull base defects (ESBR). The various endoscopic techniques for local and regional flaps in skull base reconstruction are described. Additionally, EMBASE (1980-December 7, 2010) and Medline (1950 - November 14, 2010) were searched using a search strategy designed to include any endoscopic endonasal reconstruction of the skull base. The manuscripts selected were subject to full text review to extract data on perioperative outcomes for ESBR. Surgical technique was used for sub-group analysis.