Low-Cost Ear Procedure Simulator With Syringe and Tuning Fork: Training Course and Results.

INTRODUCTION: Medical simulation is a continuously expanding field. In surgical specialties, in particular, simulation can provide an alternative avenue for learning. The objective of this process improvement project was to evaluate the effectiveness and practicality of adding simulation-based training to our educational curriculum regarding common otologic procedures. MATERIALS AND METHODS: A low-cost, novel ear procedure simulator was designed and constructed from readily available clinic supplies. Participants were asked to fill out a pre-simulator survey to assess their own comfort and skill level before undergoing the simulation course. A pre-simulation PowerPoint training course was then administered to participants. The participants then underwent the simulation training course and were again asked to fill out a post-simulator training exercise survey to reassess their own comfort and skill level. Institutional review board approval was not required by Tripler Army Medical Center. RESULTS: A total of 15 participants consisting of junior residents in otolaryngology, third- and fourth-year medical students rotating on an otolaryngology clinical clerkship, and one physician assistant in otolaryngology were included in the study. There was a significant improvement in both provider comfort with the procedure and clinical performance of the procedure among participants after training on the simulation-based model. CONCLUSIONS: Simulation-based training provides a safe, effective, and cost-friendly alternative to clinical medical education. Future studies are needed to address the wide-scale applicability of these results to other forms of surgical training.

Cerebrospinal Fluid Otorrhea After a Routine Tympanostomy Tube Placement: A Review of the Literature on Hyrtl Fissure.

OBJECTIVE: To review the literature on Hyrtl fissure (HF) and contribute our experience with a 2-year old who developed cerebrospinal fluid (CSF) otorrhea during routine tympanostomy tube placement. METHODS: Data Sources: Pubmed and Google Scholar searches were conducted of articles in the English language literature from all time periods using the words Hyrtl, Hyrtl's fissure, HF, and tympanomeningeal fissure. Study Selection: All relevant articles were reviewed to identify cases of HF. RESULTS: Data Extraction: Nineteen cases, including ours, are described. Patient characteristics, method(s) of diagnosis and repair, and outcomes are reported. Computed tomography and intraoperative endoscopic images from our case are included. Presentation is more common in children (66.7% of cases where age was stated, n = 10) than in adults (33.3%, n = 5), and is most commonly unilateral (89.5%, n = 17). Cerebrospinal fluid otorrhea was the most common presentation. Six were discovered after tympanostomy tube placements while 3 were identified during cochlear implant work-up or after device failure. Surgical approaches described include endaural, transcanal, retrosigmoid, postauricular, and posterior fossa endoscopic. Multiple materials including bone wax, bone pate, fascia, muscle, and tissue sealant have been used. Our case describes an endoscopic repair in a child, which was successful at a 2-year follow-up. Data Synthesis: The small number of cases limits the utility of statistical analysis (n = 19). CONCLUSIONS: Hyrtl fissure is a rare but important entity that may be discovered when routine procedures have unexpected results. Hyrtl fissure should be included in the differential diagnosis when there is persistent clear otorrhea after a tympanostomy tube, cochlear implant misinsertion, meningitis, or unexplained middle ear effusion in an adult.

Vestibular Neurectomy for Intractable Vertigo: Case Series and Evaluation of Role of Endoscopic Assistance in Retrolabyrinthine Craniotomy.

Objective This study evaluates the utility of endoscopy for retrolabyrinthine vestibular nerve section (RLVNS). Design/Setting This is a retrospective review for RLVNSs by the senior author. The endoscope's utility was assessed and assigned a grade based on operative findings. Participants/Main Outcome Measures Fifteen patients (eight males and seven females; 53 and 47%, respectively) were identified with mean age 56.7 years. Indications included Ménière's disease (MD) in 12 of 15 patients (80%), uncompensated vestibular neuritis in 2 patients (13%), and other vestibular neuropathy in 1 patient (7%). Vertigo resolved in 14 of 15 patients (93%). Complications included decreased hearing in two patients (13%) and deep venous thrombosis in one patient (7%). There were no facial nerve complications or mortalities. Results Sectioning vestibular division of the vestibular-cochlear nerve was achieved without perceived benefit of endoscopy in the 80% of cases (grade 0, n = 12). Endoscopy was helpful in patients with a small mastoid (grade 1, n = 2, 13.3%), and deemed necessary where the flocculus of the cerebellum was adherent to the eighth nerve arachnoid at the porus acusticus (grade 2, n = 1, 6.7%). Conclusion RLVNS is a safe and efficacious procedure for the treatment of vertigo; the surgical endoscope may be a useful adjunct in selected cases. Patients with MD may expect the greatest benefit from surgery.

Revision Surgery for Vestibular Schwannomas.

Objectives To describe clinical outcomes of patients undergoing revision surgery for vestibular schwannomas. Design Retrospective case series. Setting Tertiary private neurotologic practice. Participants Patients who underwent revision surgeries for recurrent/residual vestibular schwannomas between 1985 and 2015. Main Outcome Measures Degree of resection, facial nerve function, cerebrospinal fluid (CSF) leak. Results A total of 234 patients underwent 250 revision surgeries for recurrent/residual vestibular schwannomas. Of these, 86 carried a diagnosis of neurofibromatosis type 2 (NF2). The mean number of prior surgeries was 1.26, and 197 (85%) prior surgeries had been performed elsewhere. The average age at surgery was 43. The most common approach employed at the time of revision surgery was translabyrinthine (87%), followed by transcochlear (6%), middle fossa (5%), and retrosigmoid (2%). Gross total resection was achieved in 212 revision surgeries (85%). Preoperative House-Brackmann facial nerve function was similar in non-NF2 and NF2 groups (mean: 2.7). Mean postoperative facial nerve function at last follow-up was 3.8 in the non-NF2 group and 3.9 in the NF2 group. History of radiation and the extent of resection were not associated with differences in facial nerve function preoperatively or postoperatively. CSF leaks occurred after 21 surgeries (8%), and six (2%) patients required reoperation. Conclusions This is the largest series of revision surgery for vestibular schwannomas to date. Our preferred approach is the translabyrinthine craniotomy, which can be readily modified to include the transcochlear approach for improved access. CSF leak rate slightly exceeds that of primary surgery, and gross total resection is achievable in the vast majority of patients.

'Compassionate use' protocol for auditory brainstem implantation in neurofibromatosis type 2: Early House Ear Institute experience.

OBJECTIVE: To report the preliminary outcomes of auditory brainstem implantation (ABI) under a compassionate use protocol for two ABI devices that are not approved by the US Food and Drug Administration. METHODS: A retrospective review was performed of neurofibromatosis type 2 (NF2) patients who underwent microsurgery for vestibular schwannoma (VS) and placement of either the Cochlear ABI541 or Med-El Synchrony ABIs. Peri-operative and device- related complications were reviewed. Audiometric performance was also evaluated. RESULTS: Seven patients received either the Cochlear ABI541 (6) or the Med-El Synchrony ABI (1) after the resection of VS. No device or patient-related complications occurred to date. Surgical times and early audiological performance are similar to our previous experience with the Cochlear ABI24 device. CONCLUSIONS: Early experience with the Cochlear ABI541 and Med-El Synchrony ABI devices under a compassionate use protocol suggest that both devices are safe with comparable utility to the Cochlear ABI24 device.

Endoscopic-Assisted Middle Fossa Craniotomy for Resection of Vestibular Schwannoma.

Background Rates of hearing preservation following surgery via middle fossa craniotomy in patients harboring tumors with unfavorable characteristics are significantly lower than for those patients with "favorable" tumors. Objectives We will present two cases both with unfavorable conditions, which underwent endoscopic-assisted middle fossa craniotomy (MFC) resection of intracanalicular vestibular schwannomas with preserved postoperative hearing. Methods Chart reviews were conducted on both patients. Their presentation, intraoperative details, and techniques, pre- and postoperative audiograms, and facial nerve outcomes are presented. Results Patient A had 5.6 × 6.8 × 13.2 mm intracanalicular tumor with unserviceable hearing (pure tone audiometry [PTA], 41; speech determination score [SDS], 47%; class D) but was blind so hearing preservation was attempted. Postoperative hearing was preserved (PTA, 47; SDS, 60%; class B). Patient B had a 5 mm round intracanalicular tumor immediately adjacent to the vestibule and cochlea without any fundal fluid present. Preoperative audiogram showed serviceable hearing (PTA, 48; SDS, 88%; class B). Postoperatively, aidable hearing was preserved (PTA, 51; SDS, 76%; class C). Conclusion Hearing preservation surgery via MFC can be enhanced with endoscopic-assisted dissection, especially in the lateral internal auditory canal. The superior optical view allows for preservation of cochlear nerve function and removal of residual tumor not otherwise seen on microscopy.

The effect of tonsillectomy alone in adult obstructive sleep apnea.

OBJECTIVE: The purpose of this study was to determine the effect of tonsillectomy as a single procedure in the treatment of adult obstructive sleep apnea (OSA). STUDY DESIGN: Prospective multi-institutional study evaluating adults with tonsillar hypertrophy scheduled to undergo tonsillectomy as an isolated surgery. SETTING: Tertiary care medical centers within the US Department of Defense. SUBJECTS AND METHODS: Adult subjects with tonsillar hypertrophy who were already scheduled for tonsillectomy were enrolled from October 2010 to July 2013. Subjects underwent physical examination, Epworth Sleepiness Scale, Berlin Questionnaire, and polysomnogram before surgery and after. Collected data included demographics, questionnaire scores, apnea-hypopnea index (AHI), and lowest saturation of oxygen. RESULTS: A total of 202 consecutive subjects undergoing tonsillectomy were enrolled. The final analysis included 19 subjects testing positive for OSA. The mean age was 27.9 years; mean body mass index, 29.6; median tonsil size, 3; and most frequent Friedman stage, 1. The AHI before surgery ranged from 5.4 to 56.4 events per hour. The mean AHI decreased from 18.0 to 3.2 events per hour after surgery, a reduction of 82%. The responder rate--with subjects achieving at least a 50% reduction of AHI to a value <15--was 94.7%. Following tonsillectomy, there were statistically significant reductions in median lowest saturation of oxygen level and Epworth Sleepiness Scale and Berlin scores. CONCLUSIONS: Adult tonsillectomy alone has beneficial effect in OSA management, particularly in young overweight men with large tonsils, moderate OSA, and low Friedman stage.

The role of preoperative imaging for cochlear implantation in postlingually deafened adults.

BACKGROUND: Preoperative imaging is standard practice for cochlear implant candidacy. Postlingually deafened adults rarely have temporal bone abnormalities that alter management. OBJECTIVES/HYPOTHESIS: To determine the role of preoperative imaging for cochlear implantation in postlingually deafened adults. We hypothesize that imaging does not alter management in the absence of history or physical examination findings suggestive of an anatomic abnormality. STUDY DESIGN: Nested case-control study. METHODS: We identified postlingually deafened adults with preoperative imaging and cochlear implantation at our institution from 1995 to 2008. Controls had a negative history and normal exam. Cases had suggestive history or exam. Imaging studies and operative records were reviewed. RESULTS: Approximately 164 patients met inclusion criteria-59 cases and 109 controls. Mean age at onset of hearing loss was 30.4 years (range, 0-73 yr), mean age at onset of deafness was 54.1 years (range, 9-89 yr), and mean age at implantation was 61.5 years (range, 20.6-89.7 yr). Twenty cases (34%) and 17 controls (16%) had abnormal imaging (p = 0.001). Six cases (8.5%) and 2 controls (1.8%) had changes in their management as a result of the imaging findings (p = 0.023). Both control patients had incidentally detected acoustic neuromas, which altered the side of the cochlear implantation. There was a strong association between preoperative history and exam findings and abnormality on imaging (p = 0.007). Abnormalities were 3 times more likely in patients with a positive history or exam (OR = 2.98; 95% CI, 1.36-6.54). CONCLUSION: In patients with a negative history and examination, imaging rarely alters management. MRI may detect incidental vestibular schwannomas in patients with asymmetric hearing losses. LEVEL OF EVIDENCE: 3b, Individual case-control study.

Propranolol therapy for reducing the number of nasal infantile hemangioma invasive procedures.

IMPORTANCE: Propranolol therapy is changing the treatment paradigm for infantile hemangioma. This study addresses the effect of propranolol therapy on the treatment of nasal infantile hemangioma (NIH), an area that often does not respond to medical therapy. OBJECTIVE: To determine if propranolol treatment is associated with fewer invasive treatments for NIH. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study conducted within a single pediatric institution's multidisciplinary vascular anomaly program for patients with NIH treated between January 1, 2003, and December 31, 2011. Three NIH cohorts were compared: prepropranolol (20 in group 1; 2003-2009), propranolol (25 in group 2; 2009-2011), and nonpropranolol (13 in group 3; 2009-2011) treatment. INTERVENTIONS: Analysis of systemic medical, laser, or surgical therapies for NIH. MAIN OUTCOMES AND MEASURES: The study plan was created to detect a change in invasive therapy for NIH. Data collected included presenting age, sex, affected nasal subunits, infantile hemangioma morphologic characteristics, treatment type and number, and primary treating service. An NIH grading system, based on nasal subunit involvement, helped quantify treatment change. Descriptive statistics summarized data, and a Cox proportional hazards regression model evaluated propranolol use and the likelihood of invasive treatments (surgical excision or laser). RESULTS: Of the 95 patients identified, 58 met inclusion criteria: 20 in group 1 (mean age, 4.8 months), 25 in group 2 (mean age, 4.9 months), and 13 in group 3 (mean age, 4.9 months). Nasal infantile hemangiomas involved the nasal tip subunit in 33 of 58 patients (56.9%). Eight of 13 patients (61.5%) in group 3 frequently had small NIH (grade 1). Patients in group 2 were less likely to undergo any invasive treatments (relative risk, 0.44; 95% CI, 0.27-0.73), have surgical excision only (0.45; 0.15-1.38), or undergo laser treatment only (0.44; 0.27-0.78) compared with those in group 1. Patients with higher-grade NIH had more medical or invasive therapy, but invasive procedures were carried out in each subgroup defined by grade. CONCLUSIONS AND RELEVANCE: Patients with isolated propranolol-treated NIH were less likely to undergo invasive treatment, but despite its implementation, the need for invasive treatment was not totally supplanted by its use.

Primary surgery vs primary sclerotherapy for head and neck lymphatic malformations.

IMPORTANCE: The optimal treatment for head and neck lymphatic malformations (LMs) is unknown. To our knowledge, this is the first head-to-head comparison of primary surgery and sclerotherapy for this condition. OBJECTIVE: To compare surgery and sclerotherapy as initial treatment for head and neck LMs. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study including patients in 2 pediatric vascular anomaly programs receiving treatment for head and neck LMs. INTERVENTIONS: Primary surgery or primary sclerotherapy and any subsequent therapy within 1 year. MAIN OUTCOMES AND MEASURES: Treatment effectiveness was measured by (1) need for further therapy after first treatment and within 1 year and (2) change in Cologne Disease Score (CDS). Resource utilization was reflected by total intervention number, hospital and intensive care unit (ICU) days, and tracheostomy placement. RESULTS: A total of 174 patients were studied. Their mean (SD) age at presentation was 4.2 (4.7) years; 45.1% were female. The initial treatment was surgery in 55.8%, sclerotherapy in 35.1%, and other interventions in 9.1%. The LM stage ranged from 1 to 5, with similar distributions (P = .15) across initial treatment types; 31.2% of LMs were macrocystic, 34.8% were microcystic, and 33.9% were mixed, with similar distributions across treatment types. Patients receiving sclerotherapy had worse pretreatment CDS subscores for respiration, nutrition, and speech (all P ≤ .02). In univariate analysis, initial surgery and initial sclerotherapy had similar effectiveness after the first intervention (P = .21) and at 1 year (P = .30). In multivariate analysis controlling for lesion stage and type, initial surgery and sclerotherapy did not differ in effectiveness after the first intervention (P = .28) or at 1 year (P = .97). Total CDS and subscale changes were similar between treatment types except for the nutrition subscale. Treatment type did not predict total number of interventions (P = .64), total hospital days (P = .34), total ICU days (P = .59), or higher likelihood of subsequent tracheostomy (P = .36). Higher LM stage predicted more hospital and ICU days and higher likelihood of tracheostomy (all P ≤ .02). CONCLUSIONS AND RELEVANCE: In this multisite comparison, initial surgery and sclerotherapy for head and neck LMs were similar in effectiveness and resource utilization. Higher stage predicted greater resource utilization.

Aspirin sensitivity syndrome (Samter's Triad): an unrecognized disorder in children with nasal polyposis.

Aspirin sensitivity syndrome is an underdiagnosed entity in pediatric otolaryngology. The diagnosis must be considered in a pediatric non-cystic fibrosis patient with florid nasal polyposis. In this small case series, we will describe 2 patient's presentation, work up, allergic and surgical therapies and their postoperative course. In doing so, we hope to increase awareness and to illustrate the details that are involved in its diagnosis and treatment.

In vitro phosphinate methylation by PhpK from Kitasatospora phosalacinea.

Radical S-adenosyl-L-methionine, cobalamin-dependent methyltransferases have been proposed to catalyze the methylations of unreactive carbon or phosphorus atoms in antibiotic biosynthetic pathways. To date, none of these enzymes has been purified or shown to be active in vitro. Here we demonstrate the activity of the P-methyltransferase enzyme, PhpK, from the phosalacine producer Kitasatospora phosalacinea. PhpK catalyzes the transfer of a methyl group from methylcobalamin to 2-acetylamino-4-hydroxyphosphinylbutanoate (N-acetyldemethylphosphinothricin) to form 2-acetylamino-4-hydroxymethylphosphinylbutanoate (N-acetylphosphinothricin). This transformation gives rise to the only carbon-phosphorus-carbon linkage known to occur in nature.