The evaluation of e-learning resources as an adjunct to otolaryngology teaching: a pilot study.

BACKGROUND: The concept of e-Learning has been rapidly accepted as an important component of medical education and is especially adept at teaching clinical skills. However, their impact on learning, particularly in Otolaryngology Head and Neck Surgery (OHNS) medical school curriculum, has yet to be adequately explored. The aim of this pilot study is to develop interactive e-Learning resources and evaluate their impact in enhancing OHNS teaching in medical school. METHODS: This pilot study is a randomized controlled trial assessing the effectiveness of e-Learning resources in enhancing the current traditional lecture and tutorial-based teaching of OHNS in medical school. Nineteen final-year medical students from the University of Sydney were recruited for this study, who were randomly allocated into intervention group with additional e-Learning resources (Group A) and control group (Group B). Student knowledge was assessed through objective structured clinical examinations (OSCE) with use of standardized forms for objective scoring. Assessors were blinded to student randomization status. A post-study questionnaire was distributed to assess student feedback on the e-Learning resources. RESULTS: Eight students were allocated to Group A and 11 students to Group B. Group A performed significantly better than Group B in the overall examination scores (78.50 ± 13.88 v. 55.82 ± 8.23; P = < 0.01). With the minimum pass mark of 65%, the majority of students in Group A was able to pass the OSCE assessments, while the majority of students in Group B failed (87.50% v. 9.10%; P = 0.01). The post-test questionnaire on the e-Learning resources showed very favorable feedback from the students' perspective. CONCLUSION: Results from our pilot study suggests that the use of interactive online e-Learning resources can be a valuable adjunct in supplementing OHNS teaching in medical school, as they are readily accessible and allow flexible on-demand learning. Future studies involving large numbers of medical students are needed to validate these results.

Survival outcome of tonsillar squamous cell carcinoma (TSCC) in the context of human papillomavirus (HPV): A systematic review and meta-analysis.

OBJECTIVE: The objective of our study was to assess whether HPV-positive TSCC had better survival and prognosis rates, when compared to HPV-negative TSCC. METHOD: A systematic review and meta-analysis was performed comparing HPV status in TSCC patients. TSCC was confirmed with histopathology and HPV status was confirmed with PCR, immunohistochemistry and/or in-situ-hybridisation. The primary endpoints were overall survival (OS) and disease free survival (DFS). RESULTS: Twenty-four studies were identified, involving 1921 TSCC cases, of which 56.2% (1079) were HPV positive. OS was significantly higher in patients with HPV-positive compared to HPV-negative TSCC in years 1-5 (OR 2.54, P < 0.01; OR 2.93 P < 0.01; OR 2.74 P < 0.01; OR 2.20 P < 0.01, and OR 2.14 P < 0.01 respectively). Similarly, DFS was also significantly higher in patients with HPV-positive compared to HPV-negative TSCC in years 1-3 (OR 2.86, P < 0.01; OR 2.60 P < 0.02; and OR 2.60 P < 0.01 respectively), which was attenuated in years 4 and 5 (OR 1.83, P = 0.10 and OR 1.50, P = 0.12). CONCLUSION: This is the largest meta-analysis with 1921 patients, comparing non-HPV induced TSCC and HPV induced TSCC, looking at outcome and survival. HPV-positive had better OS and DFS.

Functional swallowing outcomes in nasopharyngeal cancer treated with IMRT at 6 to 42 months post-radiotherapy.

We sought to evaluate the swallowing function of 18 patients surviving nasopharyngeal cancer, who had been treated using an intensity-modulated radiotherapy (IMRT) protocol designed to minimise functional impairment. We compared the outcomes of a patient-reported oral function score with fiberoptic endoscopic examination of swallow (FEES), Australian Therapy Outcome Measures (AusTOMs) and a measure of trismus. While all patients returned to a fully oral diet, there was ongoing swallow dysfunction characterised by bolus residue and delay, but no aspiration. Dysphagia was of mild or moderate severity on all measures, generally because of the need for texture modification, impaired bolus transit or dysgeusia. There was xerostomia on self-reported measurement combined with reports of behaviours adaptive to xerostomia on AusTOMs; however, salivary functioning was less impaired on FEES. There was no trismus in this cohort. Our cohort lacked the morbidity experienced by cohorts reported in earlier studies, potentially due to the use of IMRT.

Routine tonsillar bed oversew after diathermy tonsillectomy: does it reduce secondary tonsillar haemorrhage?

Tonsillectomy is a common otolaryngological procedure and is associated with a small risk of postoperative pharyngeal haemorrhage. This study compares secondary post tonsillectomy haemorrhage rates between two operative techniques: diathermy tonsillectomy and diathermy tonsillectomy with tonsillar bed oversew. A total of 424 patients underwent tonsillectomies with or without other procedures such as adenoidectomy and grommet insertion by two ears, nose and throat surgeons at three hospitals from May 2012 to July 2013. A diathermy tonsillectomy was performed in 266 patients, while a diathermy tonsillectomy with tonsillar bed oversew was performed in 158 patients. All patients were followed up within 2-4 weeks of surgery. Primary haemorrhage did not occur in either surgical technique groups. Secondary haemorrhage occurred in 20 patients (7.52 %) in the diathermy tonsillectomy group and in 9 patients (5.70 %) in the diathermy with tonsillar bed oversew group. This result was not significantly different (OR = 0.74, 95 % CI 0.33-1.67, p = 0.47). Sex, age, indication for surgery and whether or not a tonsillectomy was performed alone or with other procedures were not significant factors for secondary haemorrhage. In summary, routine tonsillar bed oversew after diathermy tonsillectomy does not reduce the risk of secondary tonsillar haemorrhage.

A novel approach to surviving an acute aorto-oesophageal fistula: A case report.

INTRODUCTION AND IMPORTANCE: Acute aorto-oesophageal fistula poses a significant mortality risk, requiring immediate and decisive medical intervention. This report highlights the critical need for innovation in emergency surgical responses. CASE PRESENTATION: A 57-year-old male, with a history of aortic repair, presented with chronic anaemia and dysphagia. He suffered a cardiac arrest from massive hematemesis during surgery for an infected thoracic hematoma. Lacking a Stengsten-Blackmore tube, a 26Fr Foley catheter was used to control the bleeding. This measure stabilized the patient enough for a definitive endovascular repair with aortic stents, which successfully managed the bleeding. CLINICAL DISCUSSION: The treatment objectives for this condition include initial control of oesophageal bleeding, followed by endovascular management to further control the bleeding, subsequently releasing the oesophageal control, and ultimately preventing infection through the administration of intravenous antibiotics. CONCLUSION: This case illustrates the importance of adaptability and the use of unconventional methods in emergency situations, demonstrating that innovative solutions can be lifesaving in critical surgical emergencies.

Malignant otitis externa: an Australian case series.

OBJECTIVES: To establish a clinicopathological profile of malignant otitis externa (MOE) in an Australian tertiary referral institution. STUDY DESIGN: Retrospective cohort outcomes study. METHODS: 24 patients were identified with MOE between January 1998 and July 2007. Patients were classified into Radiological Grades I-IV. Laboratory investigations Including C-reactive protein (CRP), white cell count (WCC), glycosylated haemoglobin (HBA1c) and average glucose level over admission were recorded. RESULTS: Radiological Grade was significantly associated with duration of therapy (rank correlation 0.57, p = 0.004). CRP was a useful indicator confirming disease resolution. Diabetics with MOE had elevated average blood sugar levels during their Hospital admission (p < 0.001) and had poor overall glycaemic control represented by Elevated HBA1c scores (p < 0.001). CONCLUSIONS: Malignant otitis externa is a rare disease, which is best managed in a multidisciplinary team setting. This practical grading system can be used to predict the duration of therapy at time of diagnosis, which enables the efficient utilisation of Hospital resources. Poorly controlled diabetics are more susceptible to developing. MOE than diabetics with satisfactory glycaemic control and may represent a subgroup of more brittle diabetics. CRP combined with appropriate clinical and radiological investigations is useful in assessing disease resolution.

Dysphagia after emergency intubation: case report and literature review.

The authors present the case of a 62-year-old male who presented with dysphagia for 1 month after emergency intubation after sustaining a myocardial infarction. Subsequent clinical evaluation discovered an impacted partial denture as the source of this dysphagia. This case highlights clinically relevant issues regarding the multidisciplinary management of emergency intubation with subsequent dysphagia, the nature of dentures and their relevance to developmentally delayed individuals and an aging population. The diagnosis and management of impacted dentures involves valuable input from surgeons, physicians, radiologists and speech pathologists.

Tracheobronchial stents in palliative care: a case series and literature review.

OBJECTIVE: To evaluate the outcomes of tracheobronchial stenting in patients with malignant central airway obstruction and assist practitioners in palliative settings in understanding the indications, contraindications and management of tracheobronchial stents. METHODS: This retrospective study involved a consecutive case series of palliative patients with central airway obstruction secondary to inoperable cancers who underwent tracheobronchial stenting at a single institution. The European Cooperative Oncology Group (ECOG) scale was used to evaluate patient functional status before and after tracheobronchial stenting. RESULTS: Twenty-three patients underwent tracheobronchial stenting for malignant central airway obstruction. The majority of patients presented with symptoms of worsening dyspnoea (21 of 23; 91%). Postoperatively, there was a significant improvement in mean ECOG performance status from 2.88±0.34 to 1.58±0.50 (p<0.01). There was no intraoperative mortality resulting from tracheobronchial stenting. Five patients (21.74%) re-presented to hospital due to worsening symptoms and required emergency bronchoscopy. Two patients had stent migration, requiring stent replacement. One patient restenosed from tumour granulation, requiring microdebrider to debulk the mass. Two patients had stent failure secondary to external tumour compression, leading to death. CONCLUSION: Tracheobronchial stenting is a safe and effective procedure that offers rapid palliation of symptoms and improvement in patient functional status.

Respiratory Epithelial Adenomatoid Hamartoma: An Important Differential of Sinonasal Masses.

Background Respiratory epithelial adenomatoid hamartomas (REAH) are rare, glandular proliferations of the aerodigestive tract lined by ciliated respiratory epithelium. We report nine cases of REAH and devised a histopathological guide to differentiate these lesions from its main differentials. Methods Patients with biopsy-proven REAH were included in the series. Lesions were removed endoscopically and sent for histopathological analysis. The macroscopic and microscopic features were reviewed. Results Nine patients (age 59 ± 15.5 years, 78% male) with REAH were analysed. Findings revealed glandular proliferations lined by ciliated respiratory epithelium without metaplastic changes and intervening oedematous stroma. This is in contrast to a typically thickened epithelial basement membrane with oedematous stroma seen in nasal polyps. Conclusion REAHs are benign entities that should be included in the differential diagnosis for sinonasal masses. Prompt detection by tissue biopsy is crucial to differentiate these lesions from nasal polyps and more aggressive pathologies and avoid unnecessary surgery.

Parathyroid Frozen Section Interpretation via Desktop Telepathology Systems: A Validation Study.

BACKGROUND: Telepathology can potentially be utilized as an alternative to having on-site pathology services for rural and regional hospitals. The goal of the study was to validate two small-footprint desktop telepathology systems for remote parathyroid frozen sections. SUBJECTS AND METHODS: Three pathologists retrospectively diagnosed 76 parathyroidectomy frozen sections of 52 patients from three pathology services in Australia using the "live-view mode" of MikroScan D2 and Aperio LV1 and in-house direct microscopy. The final paraffin section diagnosis served as the "gold standard" for accuracy evaluation. Concordance rates of the telepathology systems with direct microscopy, inter-pathologist and intra-pathologist agreement, and the time taken to report each slide were analyzed. RESULTS: Both telepathology systems showed high diagnostic accuracy (>99%) and high concordance (>99%) with direct microscopy. High inter-pathologist agreement for telepathology systems was demonstrated by overall kappa values of 0.92 for Aperio LV1 and 0.85 for MikroScan D2. High kappa values (from 0.85 to 1) for intra-pathologist agreement within the three systems were also observed. The time taken per slide by Aperio LV1 and MicroScan D2 within three pathologists was about 3.0 times (P < 0.001, 95% confidence interval [CI]: 2.8-3.2) and 7.7 times (P < 0.001, 95% CI: 7.1-8.3) as long as direct microscopy, respectively, while MikroScan D2 took about 2.6 times as long as Aperio LV1 (P < 0.001, 95% CI: 2.4-2.7). All pathologists evaluated Aperio LV1 as being more user-friendly. CONCLUSIONS: Telepathology diagnosis of parathyroidectomy frozen sections through small-footprint desktop systems is accurate, reliable, and comparable with in-house direct microscopy. Telepathology systems take longer than direct microscopy; however, the time taken is within clinically acceptable limits. Aperio LV1 takes shorter time than MikroScan D2 and is more user-friendly.

Laryngeal Squamous Cell Carcinoma Survival in the Context of Human Papillomavirus: A Systematic Review and Meta-analysis.

BACKGROUND: Head and neck (H&N) squamous cell carcinoma (SCC) is a significant contributor to worldwide mortality and morbidity. Human papillomavirus (HPV) has been linked with H&N cancer and HPV-positive H&N SCC have been shown to have better survival outcomes. OBJECTIVE: To evaluate the effect of human papillomavirus (HPV) on laryngeal carcinoma (LSCC) survival outcomes and prognosis. METHOD: A systematic review and meta-analysis were performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. LSCC was confirmed based on histopathology, and HPV status was confirmed by either polymerase chain reaction, immunohistochemistry, and/or in-situ hybridization. RESULTS: There were 1214 studies which were identified, of which 14 studies were eligible for our review. A total of 2,578 cases of LSCC were included in analysis with 413 (16.0%) HPV-positive. Overall survival (OS) was not significant for HPV-positive LSCC in first five years (year one: OR 1.44 p=0.13; year two: OR 1.24 p=0.30; year three: OR 1.01 p=0.97; year four: OR 1.13 p=0.63; year five: OR 1.01 p=0.98). Disease-free survival (DFS) was similarly not significant for HPV-positive LSCC (year one: OR 1.08 p=0.68; year two: OR 1.22, p=0.31; year three: OR 1.13, p=0.69; year four: OR 0.93, p=0.80 and year five: OR 1.42, p=0.30). When studies are sub-divided into global regions, Chinese studies had better HPV-positive survival compared to North American studies in year five (OR 1.84 vs OR 0.46, p=0.04). CONCLUSION: This is the first study of its kind to evaluate the survival impact of HPV-positive LSCC patients. Unlike oropharyngeal cancer, HPV status does not make a difference to OS or DFS in LSCC. This supports data that HPV is not a prognostic factor in squamous carcinoma of the larynx.

Detecting Residual/Recurrent Head Neck Squamous Cell Carcinomas Using PET or PET/CT: Systematic Review and Meta-analysis.

OBJECTIVE: To evaluate the diagnostic accuracy of positron emission tomography (PET) and PET/computed tomography (CT) for detecting residual and/or recurrent local and regional disease and distant metastases in patients with head and neck squamous cell carcinomas (HNSCCs) following radiotherapy with or without chemotherapy. DATA SOURCES: A systematic review with no language restrictions was conducted using PREMEDLINE, MEDLINE, EMBASE, and Google Scholar. REVIEW METHODS: Only prospective studies with histopathological and/or clinical follow-up that assessed the diagnostic accuracy of PET and PET/CT in detecting residual and/or recurrent disease following radiotherapy with or without chemotherapy in patients with HNSCCs were included. RESULTS: Twenty-seven studies were identified. The pooled sensitivity and specificity of PET and PET/CT for detecting residual or recurrent disease at the primary site was 86.2% and 82.3%, respectively. For residual and recurrent neck disease, the sensitivity and specificity were 72.3% and 88.3%, while for distant metastases, the values were 84.6% and 94.9%. CONCLUSIONS: PET and PET/CT are highly accurate in detecting residual and/or recurrent HNSCC. PET/CT is more specific than PET alone. Specificity is also greater for scans performed more than 12 weeks after radiotherapy with or without chemotherapy. The authors support the use of PET/CT after 12 weeks posttreatment for the assessment of residual or recurrent disease.

Outcomes of microvascular free flap reconstruction for mandibular osteoradionecrosis: A systematic review.

INTRODUCTION: Osteoradionecrosis of the mandible is a devastating complication of radiotherapy in patients with head and neck cancer. Many cases present at a late stage, from months to years following completion of radiation therapy. When medical treatment fails, surgery may be required with a variety of free flaps available for microvascular reconstructive techniques. OBJECTIVE: To conduct a systematic review of the literature investigating the outcomes of free flap reconstruction of the jaw in mandibular osteoradionecrosis and determine the failure rates of different flap tissue. METHODS: A systematic literature search was performed using Medline (Ovid) Pubmed and Embase databases and Google Scholar. Primary outcome measures were flap failures and complications, with donor site complications representing the secondary outcome measure. Analysis of pooled outcomes was undertaken for different flaps. RESULTS: 333 articles were identified and 15 articles met the final inclusion criteria, detailing 368 primary free tissue flap transfers. There was a flap failure rate of 9.8%. There were 146 post-operative complications (39.7%), the most common being fistula formation (8.4%), hardware plate exposure (7.1%) and flap wound infections (6.5%). CONCLUSION: The fibula is the workhorse free flap for reconstruction in mandibular osteoradionecrosis. Evidence to date is largely limited with the need for larger powered multi-institutional prospective studies to determine the ideal flap donor tissue and evaluate patient and treatment predictors of free flap outcomes in order to tailor the best patient-based surgical approach for mandibular osteoradionecrosis.

The semi-lunar meatoplasty.

Stenosis of the external auditory meatus is known to be problematic for the otolaryngologist. Establishment of an adequate meatoplasty is important to restore normal otologic physiologic function, whether the meatoplasty is performed as a primary operation or as an adjuvant procedure. Numerous techniques have been devised for performing a meatoplasty. A new technique to create a large and patent meatoplasty is described using a semi-lunar incision in the conchal bowl.

Fracture and aspiration of a tracheostomy tube.

A 70-year-old woman presented with a fracture and aspiration of her polyvinyl chloride tracheostomy tube. Her chest X-ray showed that a foreign body was lodged in the right main bronchus. She was otherwise asymptomatic. The foreign body was removed under general anaesthesia using a flexible bronchoscope. The patient developed pneumonia after the procedure and was admitted to the intensive care unit. She was discharged home 5 days after the event with no permanent complications.

Cutaneous carcinosarcoma with metastasis to the parotid gland.

Cutaneous carcinosarcoma is a rare malignancy that exhibits both mesenchymal and epithelial components. It is similar to nonmelanoma skin cancers in terms of risk and prognostic factors. However, these malignancies are known to have a propensity for local recurrence and metastasis, even with adequate resection margins. Here we report a case of metastatic cutaneous carcinosarcoma to the parotid gland and review the relevant literature.

Synovial cell sarcoma of the larynx.

Synovial cell sarcoma represents a rare group of cancers, particularly in the head and neck region, that typically affects young individuals and has a male preponderance. Prognosis varies with patient age, site and size of the malignancy, degree of necrosis, high level of mitotic activity, and neurovascular invasion. Complete surgical resection of the tumor via partial or total laryngectomy is the first-line treatment in locally invasive disease. CO(2) lasers have been shown to be useful in controlling localized disease. There is also a role for adjuvant radiotherapy. Ifosfamide-based chemotherapy is most useful for malignant disease.

Hippocampal novelty activations in schizophrenia: disease and medication effects.

We examined hippocampal activation in schizophrenia (SZ) with fMRI BOLD in response to the presentation of novel and familiar scenes. Voxel-wise analysis showed no group differences. However, anatomical region-of-interest analyses contrasting normal (NL), SZ-on-medication (SZ-ON), SZ-off-medication (SZ-OFF) showed substantial differences in MTL-based novelty responding, accounted for by the reduction in novelty responses in the SZ-OFF predominantly in the anterior hippocampus and parahippocampal cortex. These differences in novelty-based activation in the SZ-OFF group represent disease characteristics of schizophrenia without confounding effects of antipsychotic medication and illustrate the tendency of antipsychotic drug treatment to improve memory functions in schizophrenia.

Learning and generalization in schizophrenia: effects of disease and antipsychotic drug treatment.

BACKGROUND: Schizophrenia involves alterations in hippocampal function. The implications of these alterations for memory function in the illness remain poorly understood. Furthermore, it remains unknown how memory is impacted by drug treatments for schizophrenia. The goal of this study was to delineate specific memory processes that are disrupted in schizophrenia and explore how they are affected by medication. We specifically focus on memory generalization--the ability to flexibly generalize memories in novel situations. METHODS: Individuals with schizophrenia (n = 56) and healthy control subjects (n = 20) were tested on a computerized memory generalization paradigm. Participants first engaged in trial-by-error associative learning. They were then asked to generalize what they learned by responding to novel stimulus combinations. Individuals with schizophrenia were tested on or off antipsychotic medication, using a between-subject design in order to eliminate concerns about learning-set effects. RESULTS: Individuals with schizophrenia were selectively impaired in their ability to generalize knowledge, despite having intact learning and memory accuracy. This impairment was found only in individuals tested off medication. Individuals tested on medication generalized almost as well as healthy control subjects. This between-group difference was selective to memory generalization. CONCLUSIONS: These findings suggest that individuals with schizophrenia have a selective alteration in the ability to flexibly generalize past experience toward novel learning environments. This alteration is unaccompanied by global memory impairments. Additionally, the results indicate a robust generalization difference on the basis of medication status. These results suggest that hippocampal abnormalities in schizophrenia might be alleviated with antipsychotic medication, with important implications for understanding adaptive memory-guided behavior.