Does the History of Tracheoesophageal Fistula Repair Alter Outcomes of Laryngeal Cleft Repair?

OBJECTIVE: Tracheoesophageal fistula and esophageal atresia (TEA) and laryngeal cleft (LC) can coexist in some patients. The surgery-specific success rate of LC repair in children with associated TEA has not been well described. The aim of the study is to determine if the history of TEA alters the LC repair outcomes. STUDY DESIGN: Case series with chart review. SETTING: Single-institution academic medical center. METHOD: A retrospective review was conducted of patients with LC with and without TEA repair between January 2001 and November 2020. Data collected and analyzed included demographics and clinical characteristics, LC type, and LC with TEA timing of repairs. RESULTS: An overall 282 patients met the inclusion criteria of LC repair: LC (n = 242, 85.8%) and LC + TEA (n = 40, 14.2%). Revision repair was required in 43 patients (15.2%) with 8 (2.8%) needing a second revision repair. The first LC revision rate in the LC group was 36/242 (14.9%) as compared with 7/40 (17.5%) in the LC + TEA group (P = .67). The second LC revision rate in the LC and LC + TEA groups was 7 (2.9%) and 1 (2.4%), respectively. The median time to revision was 5.1 months (interquartile range, 3.45-10.6) in the LC group as compared with 29.2 months (interquartile range, 4.8-44.2) in the LC + TEA group (P = .06). CONCLUSION: The incidence of TEA and LC was 14.2% in our study. Based on our findings, history of TEA repair is not associated with a higher revision rate vs LC alone. The history of TEA repair did not alter the outcomes of LC repair.

2D versus 3D Endoscopy: Head-to-Head Comparison in a Simulated Model of Endoscopic Endonasal Dural Suturing.

Objective Endonasal dural suturing (EDS) has been reported to decrease the incidence of cerebrospinal fluid fistula. This technique requires handling of single-shaft instrumentation in the narrow endonasal corridor. It has been proposed that three-dimensional (3D) endoscopes were associated with improved depth perception. In this study, we sought to perform a comparison of two-dimensional (2D) versus 3D endoscopy by assessing surgical proficiency in a simulated model of EDS. Materials and Methods Twenty-six participants subdivided into groups based on previous endoscopic experience were asked to pass barbed sutures through preset targets with either 2D (Storz Hopkins II) or 3D (Storz TIPCAM) endoscopes on 3D-printed simulation model. Surgical precision and procedural time were measured. All participants completed a Likert scale questionnaire. Results Novice, intermediate, and expert groups took 11.0, 8.7, and 5.7 minutes with 2D endoscopy and 10.9, 9.0, and 7.6 minutes with 3D endoscopy, respectively. The average deviation for novice, intermediate, and expert groups (mm) was 5.5, 4.4, and 4.3 with 2D and 6.6, 4.6, and 3.0 with 3D, respectively. No significant difference in procedural time or accuracy was found in 2D versus 3D endoscopy. 2D endoscopic visualization was preferred by the majority of expert/intermediate participants, while 3D endoscopic visualization by the novice group. Conclusion In this pilot study, there was no statistical difference in procedural time or accuracy when utilizing 2D versus 3D endoscopes. While it is possible that widespread familiarity with 2D endoscopic equipment has biased this study, preliminary analysis suggests that 3D endoscopy offers no definitive advantage over 2D endoscopy in this simulated model of EDS.

Primary Dural Repair via an Endoscopic Endonasal Corridor: Preliminary Development of a 3D-Printed Model for Training.

Objectives Endonasal suturing is an investigational method for dural repair that has been reported to decrease the incidence of cerebrospinal fluid fistula. This method requires handling of single-shaft instrumentation in the narrow endonasal corridor. In this study, we designed a low-cost, surgical model using three-dimensional (3D) printing technology to simulate dural repair through the endonasal corridor and subsequently assess the utility of the model for surgical training. Methods Using an Ultimaker 2+ printer, a 3D-printed replica of the cranial base and nasal cavity was fitted with tissue allograft to recapitulate the dural layer. Residents, fellows, and attending surgeons were asked to place two sutures using a 0-degree endoscope and single-shaft needle driver. Task completion time was recorded. Participants were asked to fill out a Likert scale questionnaire after the experiment. Results Twenty-six participants were separated into groups based on their prior endoscope experience: novice, intermediate, and expert. Twenty-one (95.5%) residents and fellows rated the model as "excellent" or "good" in enhancing their technical skills with endoscopic instrumentation. Three of four (75%) of attendings felt that the model was "excellent" or "good" in usefulness for training in dural suturing. Novice participants required an average of 11 minutes for task completion, as compared with 8.7 minutes for intermediates and 5.7 minutes for experts. Conclusion The proposed model appears to be highly effective in enhancing the endoscopic skills and recapitulating the task of dural repair. Such a low-cost model may be especially important in enhancing endoscopic facility in countries/regions with limited access to cadaveric specimens.

Roadmap to Ventral Craniocervical Junction Through the Endonasal Corridor: Anatomic Evaluation of Inverted U-Shaped Nasopharyngeal Flap Exposure in a Cadaveric Study.

BACKGROUND: There is a paucity of data in the literature describing quantitative exposure of the ventral craniocervical junction through the endonasal corridor in a safe manner mindful of locoregional anatomy. OBJECTIVE: To quantify ventromedial exposure of O-C1 and C1-2 articular structures after turning an inverted U-shaped nasopharyngeal flap (IUNF) and to obtain measurements assessing the distance of flap margins to adjacent neurovascular structures. METHODS: In 8 cadaveric specimens, an IUNF was fashioned using a superior incision below the level of the pharyngeal tubercule of the clivus and lateral incisions in the approximate region of Rosenmuller fossae bilaterally. Measurements with calipers and/or neuronavigation software included flap dimensions, exposure of O-C1 and C1-2 articular structures, inferior reach of IUNF, and proximity of the internal carotid artery (ICA) and hypoglossal nerve to IUNF margins. RESULTS: The IUNF facilitated exposure of an average of 9 mm of the medial surfaces of the right/left O-C1 joints without transgression of the carotid arteries or hypoglossal nerves. The C1-2 articulation could not be routinely accessed. The margins of the IUNF were not in close (<5 mm) proximity to the ICA in any of the 8 specimens. In 6 of 8 specimens, the dimensions of the IUNF were in close (<5 mm) horizontal or vertical proximity to the hypoglossal foramina. CONCLUSION: The IUNF provided safe and reliable access to the medial O-C1 articulation. Given the close proximity of the exocranial hypoglossal foramen, neuronavigation assistance and neuromonitoring with attention to the superolateral IUNF margin are recommended.

Peritonsillar Abscess Simulator: A Low-Cost, High-Fidelity Trainer.

Audience: Our reusable low-cost peritonsillar abscess simulator (PTA) simulator is designed to train emergency medicine (EM) residents, fellows, and medical students. Trainees who are interested in otolaryngology (OTL) or this specific disease may also benefit from this simulator. Introduction: Peritonsillar abscess is one of the most common deep infections 1 of the head and neck, accounting for 7589 consultations and 11069 hospital bed days in the UK between 2009-2010.1,2 Emergency medicine physicians commonly treat this pathology with surgical and medical modalities. Not only is this a common diagnosis, but there is a significant cost associated with the evaluation and management of primary PTA. 3Demands for high-volume patient care and good patient outcomes are increasing in a medical climate of limited financial resources and resident work hours. Given these complexities, medical education is viewing simulation training, with proven success in various surgical specialties, as a valuable addition to resident education and patient safety. 3-5The PTA is the collection of pus in the space between the palatine tonsil and its capsule. Successfully locating the abscess is crucial because it prevents the unwanted damage of nearby vascular structures, patient discomfort, and failure to treat the infection. Management of peritonsillar abscess is primarily surgical and includes incision and drainage (I & D), needle aspiration, or Quinsy tonsillectomy.The simulator provides a realistic characteristic of typical PTA presentations, such as uvula deviation, swelling, trismus, and purulence during aspiration. While learning to drain a PTA, trainees must locate the infection with a needle without injury to the surrounding structures of the oral cavity and deep structures of the neck. The discomfort caused during this procedure can be unsettling for both physician and patient. Simulation use and testing enable the trainee to develop familiarity with handling instruments, increase comfort with the sequence of a procedure, and improve confidence in the ability to perform a procedure safely.6,7,8 Simulators provide improved patient outcomes and increased EM residents' comfort level. Educational Objectives: By the end of this training session, learners will be able to: 1) locate the abscess, 2) perform needle aspiration, and 3) develop dexterity in maneuvering instruments in the small three-dimensional confines of the oral cavity without causing injury to local structures. Educational Methods: Our PTA simulator was fabricated with a low-cost, non-degradable material and is the first known PTA simulator that used a validated survey for fidelity assessment. The simulator was fabricated using a silicone mold to mimic the oral cavity and oropharynx. A simulated abscess pocket consisting of saline encased in balloon material was placed in the proper anatomic location, allowing for abscess simulation on either side of the oropharynx model. The time to fabricate the model averaged 20 hours. The simulator was manufactured with low-cost materials at an expense of 45 USD and could be easily reproduced by any EM residency program. Research Methods: Twenty-one participants were instructed to expose and drain the simulated abscess. The model was evaluated using The Michigan Standard Simulation Experience Scale (MiSSES).7 Participants scored the simulator in five categories: Self-efficacy, fidelity, educational value, teaching quality, and the overall rating on a 5-point Likert scale of simulator. Overall rating and global evaluation scores were compared by groups (Group 1, Group 2) between training level (residents and attendings), specialty (emergency and otolaryngology), and previous experience (<5 or ≥5 drainages).Convenience sampling was used to determinate the sample. Variables were summarized using the mean and standard deviation for continuous variables and percentages and frequencies for categorical variables. The MiSSES was scored as previously described in the literature.7 The Kolmogorov-Smirnov test was used to test for normal distribution of the variables. T-test for independent samples was performed to determinate if there exists a difference between groups in perception of a PTA simulator. The statistical analyses were performed using SPSS version 20.0 Armonk, NY: IBM. Results: Twenty-one participants were enrolled in the study: residents (n=15) and attending (n=6) from OTL and EM departments. The simulator's plasticity allowed multiple attempts of needle aspiration and drainage without degradation and received high ratings on teaching quality, fidelity, and educational value. This PTA simulator achieved high fidelity ratings in the standard simulator's assessment survey for realism of environment, simulation of trismus, uvular deviation, and realism of the mucosal surfaces. On the MiSSES, the model received positive ratings (range 3.6 to 4.9). The highest rating was on teaching quality (4.9), fidelity (4.6), and educational value (4.5) (Table 1). We found that self-efficacy and teaching quality sections were rated higher for those who had less experience (≥5 PTA drainage), while fidelity was rated higher for OTL. The overall rating average was 4 and was higher of attendings, OTL, and those with less experience. All comparisons between groups were not statically significant (Table 2). About 76% of participants found that the simulator can be used in training with slight improvement or no improvement needed. (Table 3). Discussion: With favorable participant ratings and comments, we believe that this tool can offer high-fidelity simulation at a low cost. Widespread use may be possible, allowing training of EM residents in performing instrumentation of PTA in a controlled simulation environment. We have created a reusable low-cost PTA simulator that achieved a high score fidelity in a standard simulator's assessment survey. Topics: Peritonsillar abscess, oropharynx, emergency medicine residency, otolaryngology residency training.

Establishing an Endoscopic Chronic Subglottic Stenosis Rabbit Model.

OBJECTIVES/HYPOTHESIS: To develop a reproducible and consistent chronic subglottic stenosis (SGS) in an endoscopic animal model. STUDY DESIGN: Prospective study. METHODS: We conducted a prospective study using New Zealand white rabbits. Chronic SGS was induced endoscopically by Bugbee electrocautery to 50% to 75% of the subglottic area's circumference, followed by 4-hour endotracheal intubation. The rabbit airways were endoscopically assessed and sized with uncuffed endotracheal tubes (ETTs) before the injury, during follow-up, and at the endpoints. There were four endpoints: 2, 4, 6, and 8 weeks post SGS induction. Animals were humanely euthanized for histopathological examination of the subglottic injury site and microscopic measurement of the cricoid lumen. RESULTS: Twenty-two rabbits reached the endpoints, and 18 rabbits developed chronic SGS. ETT size significantly decreased by 0.5 from preinjury to the endpoint in all groups, P < .001. Control median cricoid lumen measurements were 20.48 mm2 , the median cricoid lumen measurement for the 2 weeks endpoint was 14.3 mm2 , 4 weeks 11.69 mm2 , 6 weeks 16.03 mm2 , and 8 weeks endpoint median was 16.33 mm2 . Histopathological examination showed chronic scar tissue and new cartilage formation at the cricoid level, mainly at the posterior subglottic injury site starting from 4 weeks postinjury. Collagen staining revealed substantial amounts of organized collagen and different collagen orientation starting 4 weeks postinjury lasting until 8 weeks postinjury. CONCLUSION: We developed an animal model to study chronic SGS. This model will be utilized to compare different endoscopic treatment interventions in acute SGS versus chronic SGS and further define the molecular basis of SGS. LEVEL OF EVIDENCE: NA Laryngoscope, 132:1909-1915, 2022.

Electrospinning of cyanoacrylate tissue adhesives for human dural repair in endonasal surgery.

Cerebral spinal fluid (CSF) leakage is a major postoperative complication requiring surgical intervention, resulting in prolonged healing and higher costs. Biocompatible polymers, such as cyanoacrylates, are currently used as tissue adhesives for closing surgical defects and incisions. Coupling these polymers with nanofiber technology shows promising results for generating nanofibers used in wound care, tissue engineering, and drug delivery. Fiber membranes formed by electrospinning of n-octyl-2-cyanoacrylate (NOCA) are investigated for in situ dural closures after neurosurgery to improve the quality of the closure and prevent post-surgical CSF leaks. Electrospun NOCA fiber membranes showed significantly higher sealing capabilities of defects in human dura, with an average burst pressure of 149 mmHg, compared with that of an FDA-approved common dural sealant that had an average burst pressure of 37 mmHg. In this study, microfabrication of NOCA fibers demonstrates a promising technique for dural repairs.

Risk of Infection Associated with Transmucosal Placement of Instrumentation in Clean-Contaminated Field: Systematic Analysis.

Instability of the craniovertebral junction (CVJ) following odontoidectomy is relatively common. Traditionally, separate stage posterior atlantoaxial ± occipitocervical fusion is used for treatment. A transmucosal approach using a clean-contaminated route is associated with hypothetical risks of infectious complications. There is a paucity of information in the literature assessing the risk of surgical site infection (SSI) using the transmucosal approach for hardware placement. The authors conducted a literature search through PubMed identifying patients with pathology requiring transmucosal (i.e., transnasal or transoral) CVJ fixation. Studies that described 1) cases requiring a transmucosal approach and 2) associated infectious complications were included. Rates of SSIs, device removal, unplanned reoperation, and hardware failures were analyzed. Descriptive statistics and odds ratios (ORs) were used to compare complications. Nine studies with a total of 431 patients were identified. There were 4 (0.93%) superficial SSIs and 4 (0.93%) deep SSIs. In total, 1.86% of patients experienced SSI. There were 18 (4.18%) cases of unplanned reoperation, 4 (0.93%) related to SSI. Five (1.16%) patients required removal of their anterior fixation device, 4 (0.93%) related to SSI. ORs comparing our results with Medvedev et al's retrospective National Surgical Quality Improvement Program study assessing the risk associated with posterior cervical fixation showed no statistical difference between postoperative infection rates (OR = 0.72, P = 0.36). An extensive review of the literature found no evidence to suggest placement of spinal hardware via transmucosal corridor is associated with an increased risk of SSI.

Rhinogenic headache in pediatric and adolescent patients: an evidence-based review.

BACKGROUND: Although some causes of rhinogenic headache, such as acute sinusitis, have clear diagnostic criteria, others, such as "sinus headache" and mucosal contact points, are more nebulous. Misdiagnosis of these entities and primary headaches may result in unnecessary medical or surgical treatment. The purpose of this systematic review is to delineate current understanding of diagnosis and treatment of rhinogenic headaches, including sinus and mucosal contact point headaches, in children. METHODS: PubMed, SCOPUS, and the Cochrane databases were searched for studies on sinus headache and mucosal contact point headaches in children. Studies were assessed for level of evidence, and risk of bias was assessed by Methodological Index for Non-Randomized Studies (MINORS) scoring. Diagnostic criteria, management strategies, and other clinical data were analyzed. RESULTS: Eight studies met the inclusion criteria. Level of evidence was predominantly 4. Forty percent of pediatric patients with migraine had been previously misdiagnosed with sinus headache. Of 327 pediatric patients in two studies, between 55% and 73% had at least 1 cranial autonomic symptom associated with their migraine. For children with mucosal contact point headaches, surgical management in select patients improved headache intensity or severity in 17 (89%) cases. CONCLUSION: The majority of pediatric patients with sinus headache harbor a primary headache disorder, with migraine being most common. Physicians should suspect primary headache disorders in pediatric patients with chronic headaches and a normal exam. Although some case series are supportive of surgical management for mucosal contact point headaches in children, the level of evidence supporting these recommendations is insufficient. High-quality clinical trials are necessary for continuing to improve outcomes in patients with these clinical entities.