Preoperative concerns of patients undergoing endoscopic sinus surgery

BACKGROUND

Patient-centered care is recognized as being fundamental to successful medical practice. The effectiveness of patient-centered care has classically been measured by posttreatment outcomes, such as patient compliance and psychosocial responses. Systematic assessment of patient concerns prior to treatment has been limited, to date. Endoscopic sinus surgery (ESS) is an elective procedure for chronic rhinosinusitis that carries a clear, defined set of risks. The objective of this prospective observational study was to determine the concerns of patients undergoing ESS for chronic rhinosinusitis.

METHODS

A total of 180 patients undergoing ESS for chronic rhinosinusitis with or without polyposis were recruited at 2 Canadian tertiary care centers. They completed a validated survey assessing their concerns regarding the risks and outcomes of surgery. Data was analyzed using descriptive statistics and analysis of variance.

RESULTS

Patients had a low degree of concern prior to undergoing surgery (overall score 2.8/9), though individual variability existed. Subjects felt the greatest level of concern regarding potential need for revision surgery as well as the wait time for surgery. Patients were least concerned about psychological factors (mean = 1.8/9). No differences with respect to age or gender were identified. Mean scores for cerebrospinal fluid leak and orbital injury were 3 and 3.2, respectively.

CONCLUSION

Patients' level of concern prior to undergoing elective surgery is generally low. Patients' areas of greatest concern may not align with those perceived by the physician. This study provides insight into patient concerns prior to undergoing elective sinus surgery and emphasizes the importance of the patient-centered approach to care.

Informed consent when prescribing medication: a randomized controlled trial

OBJECTIVES/HYPOTHESIS

To determine patient recall of specific risks associated with medication prescription and whether or not handouts are an effective tool to augment the informed consent process.

STUDY DESIGN

Double-blinded, randomized, controlled trial.

METHODS

Informed consent for prednisone prescriptions was studied by comparing the effect of a verbal discussion (describing 10 specific adverse drug reactions) in conjunction with a handout going over same, to a verbal discussion alone. Blinded assessments occurred by telephone interview 2 to 4 weeks following the intervention. Outcomes assessed were the number of risks of prednisone that patients could list and the number of risks they recalled having discussed with their physician. Other demographic details were also collected.

RESULTS

Twenty-five participants were randomly allocated to each group. Without prompting, the median number of risks spontaneously recalled by the handout group was not significantly different than the control group, and both groups had very low recall (two vs. one, P = .24). When provided a list of potential side effects, it was observed that the handout group recalled a higher median number of risks having been discussed with their physician compared to patients in the control group (eight vs. five, P = .003). The groups' demographics were otherwise identical.

CONCLUSIONS

Patients in general did not remember discussing adverse prednisone risks with their physician even a short time after the discussion took place. Although the patient handout resulted in improved recall of risks following the prescription of prednisone, its importance in the informed medication consent process remains an open question.

LEVEL OF EVIDENCE

1b.

Postoperative nasal debridement after endoscopic sinus surgery: a randomized controlled trial

OBJECTIVES

Postoperative debridement is a controversial subject in the rhinology literature. The objective of this randomized controlled trial was to determine the effect of regular debridement versus no debridement on disease-specific outcomes and patient inconvenience.

METHODS

Patients with chronic rhinosinusitis with polyposis who were to undergo basic sinus surgery (antrostomy, ethmoidectomy, and polypectomy) were randomized to either debridement (at postoperative weeks 2 and 4) or no debridement, and their outcomes were assessed at 4 weeks and at 6 months with the Lund-Kennedy Endoscopic Score (LKES), the Sino-Nasal Outcome Test-21 (SNOT-21), a visual analog scale for postoperative pain, and a novel scoring system for postoperative inconvenience (Post-Operative Inconvenience Scale; POIS). All patients were instructed to use high-volume saline rinses twice daily.

RESULTS

At 4 weeks after operation, there was no difference between the groups in regard to LKESs (control group, 2.1 of 20; debridement group, 2.4 of 20; p = 0.59) or SNOT scores (control group, 9.1; debridement group, 8.3; p = 0.47). The visual analog scale pain scores showed significance (control group, 19 mm; debridement group, 38 mm; p = 0.019), as did the POIS scores (control group, 18.3; debridement group, 6.1; p = 0.002). At 6 months after surgery, again no difference was seen between the groups on either LKESs or SNOT scores.

CONCLUSIONS

In our patient population, debridement after surgery did not affect disease-specific outcomes.

Association of CPAP bacterial colonization with chronic rhinosinusitis

STUDY OBJECTIVE

The purpose of our study was to investigate whether bacterial colonization of the continuous positive air-way pressure (CPAP) machine reservoirs occurred, and if so, if it was related to the development of chronic rhinosinusitis (CRS).

DESIGN

Prospective cohort study.

SETTING

London Health Sciences Center (LHSC).

PATIENTS

Regular CPAP users with obstructive sleep apnea (OSA).

INTERVENTIONS

N/A.

MEASUREMENTS AND RESULTS

Patient demographics were recorded and they were asked to fill out the chronic sinusitis survey (CSS) form. Patients then had their CPAP machines swabbed. An ANOVA was used to determine if the presence of microbacterial colonization was related to CSS scores. In total, 72 patients were included in the study. There was no significant difference in any of the scores between the group with positive cultures and the group without positive cultures.

CONCLUSIONS

Having a positive culture in the cpap reservoir does not seem to lead to an increased symptomatology of crs: although the reservoirs often become colonized, there seems to be no clinical impact.

Aspirin desensitization for aspirin-exacerbated respiratory disease (Samter's Triad): a systematic review of the literature

OBJECTIVES

To critically review the current literature regarding aspirin desensitization treatment for nasal polyposis in patients with Aspirin-Exacerbated Respiratory Disease (AERD).

STUDY DESIGN

Systematic review of the literature.

METHODS

All English literature published between January 1995 and February 2013 reporting specifically nasal outcomes following aspirin desensitization in AERD patients were eligible for inclusion. Exclusion criteria were non-investigative, non-human, and ex-vivo studies. Studies were categorized by level of evidence and evaluated for quality using the Downs and Black scale.

RESULTS

A total of 614 citations were retrieved and eleven studies met the criteria for analysis. Outcome measurements included self-reported symptom scores, amount of corticosteroid use, rate of revision surgery, and quantitative measurements such as rhinomanometry. Overall, most studies reported a significant improvement in symptom scores, decrease in corticosteroid use, and decrease in revision surgery. A few studies showed promising results with quantitative outcomes. However, most studies were of Level 2 evidence with small samples sizes. Rates of adverse events ranged from 12.5% to 23%.

CONCLUSIONS

Unlike traditional treatments for nasal polyposis, aspirin desensitization targets AERD etiology rather than phenotype and can be an effective therapeutic option. While the current literature shows encouraging results, additional studies are needed to better define clinical benefits.

The incidence of early post-operative complications following uvulopalatopharyngoplasty: identification of predictive risk factors

OBJECTIVE

Characterize complications following uvulopalatopharyngoplasty (UPPP) for obstructive sleep apnea.

STUDY DESIGN

Retrospective chart review.

SUBJECTS AND METHODS

Charts of patients undergoing UPPP at an academic teaching hospital from 1999 to 2005 were reviewed.

RESULTS

345 consecutive patients (248 inpatients; 97 outpatients) were studied. The most common post-operative complication in the entire study was oxyhemoglobin desaturation (12.8%). Three patients suffered major complications (airway obstruction, pulmonary edema, arrhythmia). Regarding complications limited to the post-anaesthetic care unit alone, only 8.2% of patients had oxyhemoglobin desaturation after discontinuation of oxygen supplementation. Inpatients requiring supplemental oxygen on the ward had significantly higher mean AHI (37.4 vs. 31.4; p=0.05) and BMI (32.3 kg/m(2) vs. 28.9 kg/m(2); p=0.004) than those who did not. Those inpatients who were obese (BMI > 30 kg/m(2)) with an AHI≥22 were associated with an increased risk of requiring oxygen on the ward (odds ratio = 3.48, 95% CI = 1.56 - 7.78).

CONCLUSION

The incidence of post-UPPP complications is much lower than the literature has historically suggested. Selected patients should be able to safely undergo outpatient UPPP. Patients with higher AHI, higher BMI, or multiple comorbidities are at higher risk for postoperative complications and are most appropriate for overnight monitoring.

An endonasal approach to the resection of a papillary seromucinous adenocarcinoma of the eustacian tube

Objectives

Papillary seromucinous adenocarcinoma of the sinonasal tract is exceedingly rare. The objectives of this case report are to describe a case of papillary seromucinous adenocarcinoma presenting in the nasopharynx and to review the literature pertaining to other similar cases.

Methods

A review of the patient's chart and a review of the English literature were conducted.

Results

We describe the case of a 64 year-old woman who presented with a 3-year history of epistaxis and right-sided otitis media with effusion. The patient had been followed for a known nasopharyngeal mass that had twice been biopsied and in both cases was considered a benign mass pathologically. A third biopsy was diagnosed as a low-grade papillary seromucinous adenocarcinoma. The patient was otherwise asymptomatic. The patient was referred to a multidisciplinary cancer clinic at which endoscopic resection was determined to be the preferred treatment modality. A literature review and approach to patients with nasopharyngeal masses will be presented.

Conclusions

Papillary seromucinous adenocarcinoma is a rare tumor that can present in the nasopharynx. We describe the endoscopic surgical management of one such patient that presented to our care.

Intraoperative ice pack application for uvulopalatoplasty pain reduction: a randomized controlled trial

OBJECTIVES/HYPOTHESIS

Pain after uvulopalatoplasty continues to cause patients significant morbidity, especially from the tonsillectomy portion. The literature describes multiple techniques to reduce post-tonsillectomy pain, none being definitive. The purpose of this study was to evaluate the effect of intraoperative ice pack application on post-uvulopalatoplasty pain.

STUDY DESIGN

Single-blinded, randomized controlled trial.

METHODS

After inclusion and exclusion criteria were met, patients were enrolled and randomized, and subsequently underwent standard electrocautery uvulopalatoplasty. Packs were placed into the tonsillar fossae immediately following tonsil removal and into the palate after the palatoplasty. Patients then completed a questionnaire that evaluated their experience for 10 days following surgery. The primary outcome was pain rated on a visual analog scale. Return to work and return to normal diet were also assessed. T test and Mann-Whitney statistical analyses, as well as routine descriptive statistics, were conducted.

RESULTS

Eighteen subjects were recruited. Patients that received intraoperative cold packs experienced a statistically significant change in VAS average pain [3.4 ± 1.1 cm (p = 0.00001)] when compared with patients receiving room temperature packs. No difference in return to work (p = 0.16) and return to normal diet (p = 0.12) was identified.

CONCLUSIONS

Intraoperative ice pack administration results in significantly reduced pain following electrocautery uvulopalatoplasty.

Olfactory outcomes following endoscopic pituitary surgery with or without septal flap reconstruction: a randomized controlled trial

BACKGROUND

Postoperative hyposmia and anosmia is an often overlooked complication of endoscopic pituitary surgery. Septal flaps have been utilized as a strategy for repairing and preventing postoperative cerebrospinal fluid (CSF) leaks. The olfactory impact of raising this flap for sellar reconstruction and CSF repair needs qualitative assessment. This study aims to ascertain the effect of the Hadad-Bassagasteguy (HB) flap on olfaction in endoscopic pituitary surgery.

METHODS

In this randomized controlled trial, patients undergoing pituitary surgery underwent computerized randomization. Those in Group 1 all had HB flaps raised and placed for sellar floor defects. Those in Group 2 underwent reconstruction with synthetic or nonautologous materials. The University of Pennsylvania Smell Identification Test (UPSIT) was administered preoperatively and 6 months postoperatively. Results were analyzed using nonparametric tests.

RESULTS

Twenty subjects were enrolled, 10 in each group. Eight subjects in Group 1 vs 3 in Group 2 had intraoperative CSF leak. All were repaired intraoperatively and none required additional intervention. Preoperatively, UPSIT scores were not significantly different between groups (p = 0.62). Preoperative vs postoperative comparisons were significant for a decrease in scores in both groups postoperatively (Group 1, p < 0.001; Group 2, p < 0.001). Those undergoing HB flap reconstruction had significantly worse scores postoperatively (p = 0.001).

CONCLUSION

Endoscopic pituitary surgery results in decreased olfaction with or without deploying a septal flap. However, use of the HB flap for reconstruction can worsen hyposmia at least 6 months after surgery. Olfaction should be considered when use of the HB flap is planned.

Nasal spray adherence after sinus surgery: problems and predictors

OBJECTIVES

To assess patient adherence to nasal spray regimens after endoscopic sinus surgery (ESS) and to study factors that predict adherence.

METHODS

A three-arm, randomized, blinded, controlled trial was conducted at a tertiary care academic hospital, studied via a prospective longitudinal survey, of 60 consecutive chronic rhinosinusitis patients managed with ESS and started on one of three postoperative nasal spray regimens. Structured telephone interviews were conducted after surgery over a 12-month period using a validated questionnaire that assessed both spray adherence and barriers to adherence. Patient demographics, time post-ESS, preoperative Sino-Nasal Outcome Test (SNOT) scores, Lund-Mackay scores, adherence risk factors, and polyp grades were used as covariates with logistic regression.

RESULTS

Overall, 57.4% of patients were nonadherent. Logistic regression showed that preoperative SNOT scores (p = .018, 95% CI = 0.84-0.98), time post-ESS (p = .016, 95% CI = 1.02-1.22), and the presence of an adherence risk factor (p = .03, 95% CI = 1.18-26.99) significantly predicted whether a patient was adherent and correctly classified 70.4% of all patients. Age, gender, and nasal spray regimen did not predict adherence (p > .05).

CONCLUSION

The majority of patients were nonadherent to post-ESS nasal sprays, irrespective of which nasal spray regimen they were on. Preoperative SNOT scores, time post-ESS, and the presence of an adherence risk factor predicted adherence. With this knowledge, otolaryngologists can selectively employ strategies to improve adherence in high-risk patients and possibly improve ESS outcomes.

Four-year outcomes of palatal implants for primary snoring treatment: a prospective longitudinal study

OBJECTIVES/HYPOTHESIS

The objective of this study was to evaluate the long-term effectiveness of palatal implants as the treatment of primary snoring.

STUDY DESIGN

Prospective longitudinal cohort study.

METHODS

This study compared snoring outcomes before and after soft palate implantation for patients diagnosed with primary snoring (no sleep apnea). Snoring severity was obtained by the subjects' sleep partners on a 10-point Likert scale. A paired Student t test compared the mean scale values preoperatively at week 52 and at the current 4-year follow-up. Body mass index for each patient was also compared to evaluate for any significant confounders.

RESULTS

Data were obtained from 23 patients out of 26 who were followed for the full study term. The follow-up time was on average 4 years following palatal implantation. A statistically (P < .016) and clinically significant improvement in the snoring scale was noted when comparing snoring severity between the preoperative and 4-year period and between the 52-week and 4-year scores. Although statistically significant improvement was found between the preoperative period and 52 weeks, there was a clinical deterioration in snoring scale scores between 52 weeks and 4 years. The mean (standard deviation) preoperative score was 9.5 (0.5), mean week-52 score was 5.0 (1.6), and mean 4-year score was 7.0 (1.8). Body mass index did not change through the observation interval.

CONCLUSIONS

Soft palate implantation is a possible surgical technique with which to attempt to achieve subjective improvement of primary snoring severity. Subjective improvement, however, deteriorates significantly over time, and is only minimally sustained at 4 years postoperatively. This study provides new information on long-term palatal implant effectiveness.

Comparison of purified plant polysaccharide (HemoStase) versus gelatin-thrombin matrix (FloSeal) in controlling bleeding during sinus surgery: a randomized controlled trial

OBJECTIVES

Purified plant polysaccharide (HemoStase) is a plant-derived hemostatic agent that has not previously been used in sinus surgery. This study was conducted to evaluate the effectiveness of this novel agent in the control of nasal bleeding during endoscopic sinus surgery. The volume of bleeding during endoscopic sinus surgery was hypothesized to not be statistically significantly different between a control group (gelatin-thrombin matrix; FloSeal) and an experimental group (purified plant polysaccharide; HemoStase).

METHODS

Eighteen patients with a history of chronic rhinosinusitis in whom maximal medical therapy failed who underwent endoscopic sinus surgery were randomized into one of two groups (control FloSeal group or experimental HemoStase group). In the control group, sites in the nose that were actively bleeding during the operation were controlled with FloSeal. In the experimental group, sites in the nose that were actively bleeding during the operation were controlled with HemoStase. The main outcome measure was total operative blood loss. Blood loss was the sum of blood removed by suction during the surgery (recorded in milliliters) and blood on surgical sponges (weighed and converted to milliliters). Statistical analysis was performed with the t-test and the Mann-Whitney U test.

RESULTS

The amounts of blood loss (mean +/- SEM) were not significantly different between the FloSeal (262 +/- 15 mL) and HemoStase (265 +/- 33 mL) groups (p = 0.93).

CONCLUSIONS

The results of this study demonstrate the use of a novel product for the control of intraoperative bleeding during endoscopic sinus surgery.

Olfactory outcomes after endoscopic transsphenoidal pituitary surgery

BACKGROUND

Olfaction has been demonstrated to have a great impact on patients' lives. Transsphenoidal endoscopic pituitary surgery is associated with potentially significant damage to olfactory tissues, but to date this issue has been only poorly documented in the literature.

STUDY DESIGN

Prospective cohort study comparing olfactory outcomes pre- and postpituitary surgery.

METHOD

Patients were administered the University of Pennsylvania Smell Identification Test (UPSIT) preoperatively and again at 6 months postoperatively. The endoscopic transsphenoidal pituitary surgery was carried out using a full middle turbinate preservation protocol. A Hadad-Bassagasteguy (HB) vascularized septal flap was raised in each case. Secondary outcomes included Lund-Kennedy endoscopy scores (LKES) and patient self-report of olfactory disturbance. The results were analysed using a paired t-tests.

RESULTS

Seventeen patients met inclusion criteria for the study. Mean preoperative UPSIT value was 37.2 (normosmia), and mean postoperative UPSIT value was 30.8 (moderate hyposmia) (P < .001). All patients were fully healed with normal LKES scores by 6 months. All patients complained of their olfactory dysfunction.

CONCLUSIONS

This study is the first to describe postoperative olfactory perturbations suffered by patients undergoing endoscopic transsphenoidal pituitary surgery. We hypothesize that olfactory impairment results from use of the HB flap. We recommend that the possibility of permanent olfactory changes be added to routine patient counseling and consent for this procedure, and that HB flaps be raised judiciously during trannssphenoidal endoscopic procedures.

Revision rates after endoscopic sinus surgery: a recurrence analysis

OBJECTIVES

Chronic rhinosinusitis with nasal polyposis is often refractory to medical and surgical management, especially in patients with asthma and aspirin intolerance. We used a contemporary database to investigate recurrence and revision surgery rates following endoscopic sinus surgery.

METHODS

We performed a cohort study using a survival analysis technique. Records were reviewed of 549 patients with nasal polyposis who underwent endoscopic sinus surgery over a 10-year period. The main outcome measure was disease-free and surgery-free survival following endoscopic sinus surgery, investigated with Kaplan-Meier analyses.

RESULTS

Patients with Samter's triad were significantly more likely to have a recurrence and undergo a second surgery following recurrence (risk-odds ratio, 2.7; 95% confidence interval, 1.5 to 3.2; p < 0.01) than were patients without asthma or with only asthma from the triad. The presence of initial frontal sinus disease also increased the likelihood of revision surgery (risk-odds ratio, 1.6; 95% confidence interval, 1.2 to 1.8; p < 0.05).

CONCLUSIONS

This is the first study to use survival analysis to document revision surgery rates following endoscopic sinus surgery. Revision surgery occurs at a high rate, especially in patients with asthma, Samter's triad, or frontal sinus disease. Patients should routinely be informed during clinical consultations about the likelihood of recurrence. Early intervention for frontal sinus disease may be considered.

Open versus endoscopic septoplasty: a single-blinded, randomized, controlled trial

BACKGROUND

A deviated septum can be corrected by either a conventional "open" or endoscopic approach. Controversy exists regarding comparative outcomes between these two techniques. Our objective was to compare the two according to subjective and objective criteria.

STUDY DESIGN

Prospective, single-blinded, randomized, controlled trial.

METHODS

Over a 6-month period, all patients diagnosed with a septal deviation meeting strict inclusion/exclusion criteria were recruited. Patients were randomly assigned to either the conventional or the endoscopic group. Outcome measures included surgical time, intraoperative complications, and pre- and postoperative data from the Nasal Obstruction Symptom Evaluation (NOSE) questionnaire. Chi-square and t-tests were used for statistical analyses.

RESULTS

Sixty-three patients were enrolled in the study: 32 in the endoscopic group and 31 in the conventional group. There were subjective postoperative improvements in the NOSE scores across all participants and within both groups (endoscopic: preoperative mean score  =  14.7, postoperative mean score  =  7.4, p < .05; conventional: preoperative mean score  =  15.2, postoperative mean score  =  6.3, p < .05), with no differences found between groups (p  =  .61). However, objective outcomes such as operative time (p < .001) and intraoperative complications (p  =  .01) favoured the endoscopic group.

CONCLUSION

The endoscopic approach for septoplasty may be considered superior to the traditional approach for the correction of septal deviation.

Image-guided transnasal endoscopic techniques in the management of orbital disease

PURPOSE

To assess the utility of image-guided transnasal endoscopic surgery for a variety of orbital diseases requiring decompression of at least one orbital wall.

METHOD

A descriptive case series of consecutive orbital procedures requiring decompression of at least one wall. All procedures were performed using a transnasal endoscopic approach and an intraoperative image-guided LandmarX system for anatomical guidance.

RESULTS

A 3-year review yielded 17 cases, including 6 cases with compressive mucoceles, 4 neoplasms, 4 patients with proptosis secondary to Graves' Ophthalmopathy, 1 case of an intraorbital abscess, 1 fungal mycetoma, and 1 hemangioma. These cases all had improved postoperative clinical status without any serious complications. The LandmarX system was a valuable intraoperative tool in all 17 cases.

CONCLUSIONS

The endoscopic transnasal approach to orbital decompression surgery allows for good visualization and is minimally invasive. Using this approach in conjunction with the LandmarX image-guided system allows for improved anatomical localization and provided good results in all cases.

Use of complementary and alternative medical therapies for chronic rhinosinusitis: a canadian perspective

BACKGROUND

Many Canadians use complementary and alternative medicines (CAMs) to treat their chronic diseases. The objective of this study was to report patients' use of CAM for chronic rhinosinusitis (CRS) and to determine factors predictive of CAM use.

METHOD

A cross-sectional survey was conducted. Self-report questionnaires were administered to patients with CRS using strict inclusion and exclusion criteria. The questionnaire included demographic information, questions pertaining to disease severity, and CAM use for CRS treatment. Statistical analysis was used to compare gender, age range, symptom duration, pharmacotherapy use, and surgical frequency among CAM users and nonusers. A binomial logistic regression model was developed to predict CAM use. Secondary outcome measures included factors predictive of CAM use, type of CAM used, and reasons for using CAM.

RESULTS

Data were obtained from 288 patients. Forty-five respondents (15.6%) had used CAM as a treatment for their CRS. CAM users were more likely to be females and more likely to have used each class of pharmacotherapy. On logistic regression, female gender and use of nasal corticosteroids were predictive of CAM use.

CONCLUSION

The use of CAM as treatment of CRS is common. Females and those who have used the various classes of pharmacotherapy are more likely to use CAM. Both female gender and nasal corticosteroid use are predictive of CAM use. Physicians should routinely inquire about CAM use from their patients with CRS.

Use of duraseal in repair of cerebrospinal fluid leaks

OBJECTIVE

The purpose of our article is to review the use of the DuraSeal Sealant System (Confluent Surgical Inc., Waltham, MA) in the repair of complex cerebrospinal fluid (CSF) leaks in endoscopic skull-base surgery.

DESIGN

Retrospective chart review.

SETTING

London Health Sciences Centre.

METHODS

A database of endoscopic skull-base cases between 2007 and 2009 that involved CSF leakage repaired with DuraSeal was created. Demographic data and operative reports were collected and analyzed qualitatively.

MAIN OUTCOME MEASURES

Recurrence of CSF leak after repair.

RESULTS

Five cases were identified that met study criteria. In four of the five cases, the repair was successful. There were no complications related to DuraSeal use. Comparison to a subset of patients using Tisseel Fibrin Sealant (Baxter, Toronto, ON) for repair did not show a significant difference in failure rate (χ2 = 0.029, p = .858).

CONCLUSIONS

There are a variety of techniques described to repair CSF rhinorrhea, with various studies demonstrating the advantages of using tissue glues in CSF leak repairs. We used DuraSeal in five patients to enhance graft strength and form a watertight seal. The system was effective in the majority of patients. Our study is the first to report on endoscopic endonasal repair of CSF leaks using DuraSeal.

Patient outcomes after soft palate implant placement for treatment of snoring

BACKGROUND

Multiple options are available for the treatment of snoring. Our objective was to evaluate a palatal implant system in the treatment of snoring caused specifically by retrovelar collapse.

STUDY DESIGN

Prospective long-term study comparing snoring outcomes pre- and post-soft palate implantation.

METHOD

Snoring patients without significant sleep apnea were offered palatal implantation after assessment via strict inclusion/exclusion criteria. Snoring severity was rated by the bed partner, in a longitudinal fashion, using a Likert scale both in the preoperative and postoperative settings. Paired Student t-tests were used to compare the mean snoring severity preoperatively and at different points of time postoperatively up to 1 year and to compare patient's body mass indices over the study timeline.

RESULTS

Data were obtained from 25 patients over a follow-up time of 1 year, for a total of 75 implants. A statistically and clinically significant improvement in the snoring was noted over the 52-week time period of the study in our patient population (mean preoperative score = 9.5, mean 52-week postoperative score = 5.0; p < .001). Body mass index did not significantly change over the duration of the study.

CONCLUSION

In our patient population, soft palate implantation was a safe and effective technique for achieving a subjective improvement in the intrusiveness of snoring as noted by the bed partner.

Impact of cosmetic facial surgery on satisfaction with appearance and quality of life

OBJECTIVES

To assess perioperative quality-of-life (QOL) changes in a facial plastic surgery patient population and to ascertain factors determinative of QOL changes. A notable paucity of objective scientific measurements of QOL exists within the facial plastic surgery literature.

METHODS

A 3-year prospective cohort study. The patient population, which comprised a consecutive series of patients 16 years or older, undergoing cosmetic nasal or facial surgery, was obtained from the senior author's (P.A.A.) private surgical practice. All patients presenting for surgery were offered participation. The main outcome measure was the 59-item Derriford Appearance Scale (DAS59), a valid and reliable instrument assessing psychological distress associated with self-consciousness of facial appearance. Three patient score subgroupings were established: group 1, the DAS59 scores for all patients; group 2, the DAS59 score according to sex; and group 3, the DAS59 score according to the main surgical procedure. Surveys were administered to eligible patients at the final preoperative clinic visit and at 3 months after surgery. Data from the case-control groups were analyzed by a blinded statistician with appropriate t tests.

RESULTS

A total of 93 patients were enrolled with a 100% response rate (82 females [88%] and 11 males [12%]). The most common procedures were rhinoplasty (49%) and surgery for the aging face (51%). Marked differences in perioperative QOL were noted across all DAS59 domains for group 1 and for all females in group 2. Male patients in group 2 analysis experienced QOL improvement only from DAS59 domain 2 (General Self-consciousness of Facial Appearance). Rhinoplasty and surgery for the aging face improved patients' QOL but differed with respect to which DAS59 domains were affected.

CONCLUSIONS

Quality of life was enhanced by facial plastic surgery in this patient population. Male and female patients seem to have different needs to be met from facial cosmetic surgery and correspondingly different areas of improvement in QOL. Rhinoplasty and surgery for the aging face act on different domains of QOL.

Conversion disorder in a child presenting as sudden sensorineural hearing loss

Pseudohypoacacusis is a form of conversion disorder in which a hearing loss is found in the absence of organic disease. A case of an 11-year-old boy with auditory conversion disorder after mild head trauma is reported. The child presented with unilateral hearing loss, with no accompanying vestibular symptoms and no history of otologic disease. Auditory testing revealed severe right-sided sensorineural hearing loss, however, CT scan was normal. There was a family history of conversion disorder and the child was undergoing an emotionally stressful period. It was decided to treat the child conservatively with close monitoring and a repeat audiogram 2 weeks later. One week after presentation, the child's hearing suddenly returned to normal after a second very minor head injury. It is important to consider pseudohypoacusis or conversion disorder even in cases such as trauma, when the clinical history supports a diagnosis of hearing loss.

Myxomatous lesions of the maxilla in children: a case series and review of management

OBJECTIVE

A paucity of data exists in the literature regarding the pediatric bony myxoma. Controversy exists regarding both its histopathologic origins and surgical management. The purpose of this study was to report on our experience in managing these patients, including diagnostic work-up, histopathologic findings and an evaluation of surgical treatment outcomes.

METHODS

A retrospective review was undertaken of all consecutive cases of pediatric bony myxoma treated between 1988 and 2001. Tumors were analyzed in terms of clinical data, imaging studies, histopathology and surgical treatment. A selective review of the literature regarding management of the bony myxoma is also presented.

RESULTS

Five lesions were identified, all of which occurred in the maxillary bone. Histopathologically our cases did not show a strong association with odontogenic epithelium. All cases were treated by surgical resection with conservative margins. No recurrences were documented over a mean follow-up period of 8.5 years.

CONCLUSION

The bony myxoma is a rare lesion in the pediatric population, and initial clinical or radiological misdiagnoses are not uncommon. The presupposed odontogenic origin of these tumors may need reassessment. Conservative resection with narrow margins is a safe and effective therapy for myxomas of the pediatric maxilla.

Pediatric laryngeal paralysis: a new proposed surgical therapy

OBJECTIVES

The cricothyroid muscle (CTM) has a separate innervation from that of intrinsic laryngeal muscles; therefore, its action may contribute to airflow resistance in children with laryngeal paralysis (LP) secondary to recurrent laryngeal nerve (RLN) palsy. We proposed removal of the CTM as a means of indirectly widening the paralyzed neonatal glottis.

METHODS

A prospective study was conducted using a piglet animal model to simulate LP and evaluate the proposed treatment's outcome. LP was induced via bilateral RLN sectioning in seven piglets. The CTMs were then removed. Animals acted as their own controls. Outcome measures consisted of serial inspiratory and expiratory airflow resistance measurements taken (1) with no intervention, (2) after RLN sectioning, and (3) after CTM removal. Several animals were awakened to assess their clinical responses to the interventions. The paired Student's t-test was used for statistical analysis.

RESULTS

Inspiratory airflow resistance was significantly increased by RLN sectioning (p = .0062) and then significantly decreased after subsequent CTM removal (p = .0005). Clinical responses to the interventions mirrored the measured findings.

CONCLUSIONS

Removal of the CTM significantly decreases inspiratory airway resistance in piglets with induced LP. This proposed surgical therapy for pediatric bilateral LP warrants further investigation.

Establishment of a bone-anchored auricular prosthesis (BAAP) program

OBJECTIVE

Bone-anchored auricular prostheses (BAAPs) are indicated for treatment of congenital or acquired microtia in children. This paper reports on our experience in establishing a BAAP program, including treatment algorithms, protocols and a discussion of the methodology, complications and patient satisfaction.

METHODS

Eleven consecutive children using BAAPs were reviewed. Outcome measures include patient selection criteria, long-term stability of the BAAP, skin reactions around the site, and patient satisfaction.

RESULTS

A patient selection program was developed and implemented, followed by a management protocol for surgery and follow-up. All children (100%) achieved osseointegration, with only one site revision necessary. A variable degree of skin irritation was noted in just over one third (39%) of cases. All children were satisfied with their prosthesis.

CONCLUSIONS

The use of BAAPs in a pediatric population is a safe and viable method to correct disfiguring microtia. The final result is generally very acceptable to the child.

A comparison of two methods of infiltration in breast reduction surgery

The superwet technique has been shown in previous studies to dramatically reduce blood loss in breast reduction surgery, compared with standard infiltration. A retrospective chart review of 303 consecutive patients undergoing bilateral breast reduction surgery was undertaken to demonstrate additional differences in complication rate, operative time, or sponge use in the operating room. In this series, 132 consecutive patients received standard infiltration along incision lines (25 cc per breast of 1:100,000 epinephrine), and 171 patients received superwet infiltration with 240 cc per breast of 1:1,000,000 epinephrine. The average operative time was significantly reduced in the superwet group, from 78.5 minutes to 70.7 minutes (p < 0.01 level). The average number of sponges used intraoperatively was also decreased significantly (p < 0.01), from 26 to 20 sponges. Complication rates were equally low in both groups, demonstrating the safety of the superwet technique. In addition to limiting blood loss, the superwet infiltration effectively reduces operative time and sponge use without increasing complications in breast reduction surgery.

A needs assessment of surgical residents as teachers

OBJECTIVE

To determine the needs of surgical residents as teachers of clinical clerks.

DESIGN

A needs assessment survey.

SETTING

Department of Surgery, University of Toronto.

PARTICIPANTS

Clinical clerks and surgical residents and staff surgeons.

METHODS

Three stakeholder groups were defined: staff surgeons, surgical residents and clinical clerks. Focus-group sessions using the nominal group technique identified key issues from the perspectives of clerks and residents. Resulting information was used to develop needs assessment surveys, which were administered to 170 clinical clerks and 190 surgical residents. Faculty viewpoints were assessed with semi-structured interviews. Triangulation of these 3 data sources provided a balanced approach to identifying the needs of surgical residents as teachers.

RESULTS

Response rates were 64% for clinical clerks and 66% for surgical residents. Five staff surgeons were interviewed. Consensus was noted among the stakeholder groups regarding the importance of staff surgeon role modelling and feedback, resident attitude, time management, knowledge of clerks' formal learning objectives, and appropriate times and locations for teaching. Discrepancies included a significant difference in opinion regarding the residents' capacity to address clerks' individual learning needs and to foster good team relationships. Residents indicated that they did not receive regular feedback regarding their teaching and that staff did not place an emphasis on their teaching role.

CONCLUSIONS

This study has, from a multi-source perspective, assessed the needs of surgical residents as teachers. These needs include enhancing residents' education regarding how and what to teach medical students on a surgical rotation, and a need for staff surgeons to increase feedback to residents regarding their teaching.