Surgical Coaching: Patient Perspectives Regarding Surgeon Coaches in the Operating Room

BACKGROUND

Surgical coaching programs have been introduced as platforms for ongoing professional development amongst independently practicing surgeons. While there is a plethora of evidence regarding the effectiveness of surgical coaching for practicing staff surgeons, patients' opinions regarding surgical coaching are largely unknown.

OBJECTIVES

To determine patients' baseline attitudes and opinions about the hypothetical situation of their treating surgeon having a surgical coach present during their upcoming operation, and to determine patients' baseline knowledge and prior exposure to surgical coaching.

DESIGN AND SETTING

This study was conducted at a tertiary hospital in Vancouver, Canada. Patients on the surgical waitlist of 2 independently practicing Otolaryngologists within the subspeciality of Neurotology were invited to participate in the study. Participants engaged in a semi-structured interview to discuss their opinions and knowledge of physician coaches and to learn about surgical coaching. The interview was conducted based on a pre-set script.

RESULTS

Of the 100 patients approached, 70 consented to participate. Forty-three (61%) participants identified as female, and the mean age was 56±15 years. Initially, 84% of participants (n = 59) consented to the hypothetical presence of a surgical coach. Post-discussion, this number increased to 95.7% (n = 67, p = 0.04). Prior participant exposure to coaching related to employment, education, athletics, or music was high (90%, n = 63). Younger participants between 25 and 45 years of age were more amenable to the presence of a surgical coach compared to participants >66 years of age (p = 0.01). After the interview, 55 (79%) participants were interested in learning more about surgical coaching.

CONCLUSION

Many patients were unaware of the rationale and importance of surgical coaching programs for practicing staff surgeons. Most patients, especially younger patients, were amenable to the presence of a surgical coach during their surgery, and this number increased in all age categories with patient education about surgical coaching.

A closer look at subjective caloric sensations: Is there more to vertigo than spinning?

BACKGROUND

There is a prevailing opinion that spinning sensations signify a peripheral vestibular pathology while non-spinning sensations are not of vestibular origin.

OBJECTIVES

1) Characterize the subjective sensations reported by patients during caloric testing. 2) Assess if the sensation was correlated with the peak slow phase velocity (SPV).

METHODS

Retrospective chart review at a Canadian adult tertiary-quaternary care balance centre for patients undergoing diagnostic caloric testing between December 2014 and September 2015.

RESULTS

Of 163 patients included, 122 had normal calorics and 41 demonstrated unilateral weakness. Spinning/rotatory movements were the most commonly reported sensations (55-70%). No sensation was reported among 10-20% of patients. Other non-rotatory sensations were reported 20-25% of the time. Both lack of sensation and other sensations were more likely to be correlated with SPVs that were significantly lower than those associated with spinning/rotating sensations. However, 18% of patients with normal calorics and robust SPVs with warm irrigation still reported non-spinning sensations.

CONCLUSIONS

During caloric irrigation, subjective sensations other than spinning and rotating are reported 20-25% of the time and these tend to be associated with lower peak SPV. Non-spinning vertigo is not uncommon as a subjective description of vestibular sensation even in normal patients with strong SPVs.

Threat effects on human oculo-motor function

Neuro-anatomical evidence supports the potential for threat-related factors, such as fear, anxiety and vigilance, to influence brainstem motor nuclei controlling eye movements, as well as the vestibular nuclei. However, little is known about how threat influences human ocular responses, such as eye saccades (ES), smooth pursuit eye tracking (SP), and optokinetic nystagmus (OKN), and whether these responses can be facilitated above normal baseline levels with a natural source of threat. This study was designed to examine the effects of height-induced postural threat on the gain of ES, SP and OKN responses in humans. Twenty participants stood at two different surface heights while performing ES (ranging from 8° to 45° from center), SP (15, 20, 30°/s) and OKN (15, 30, 60°/s) responses in the horizontal plane. Height did not significantly increase the slope of the relationship between ES peak velocity and initial amplitude, or the gain of ES amplitude. In contrast height significantly increased SP and OKN gain. Significant correlations were found between changes in physiological arousal and OKN gain. Observations of changes with height in OKN and SP support neuro-anatomical evidence of threat-related mechanisms influencing both oculo-motor nuclei and vestibular reflex pathways. Although further study is warranted, the findings suggest that potential influences of fear, anxiety and arousal/alertness should be accounted for, or controlled, during clinical vestibular and oculo-motor testing.

Vestibulo-spinal and vestibulo-ocular reflexes are modulated when standing with increased postural threat

We investigated how vestibulo-spinal reflexes (VSRs) and vestibulo-ocular reflexes (VORs) measured through vestibular evoked myogenic potentials (VEMPs) and video head impulse test (vHIT) outcomes, respectively, are modulated during standing under conditions of increased postural threat. Twenty-five healthy young adults stood quietly at low (0.8 m from the ground) and high (3.2 m) surface height conditions in two experiments. For the first experiment (n = 25) VEMPs were recorded with surface EMG from inferior oblique (IO), sternocleidomastoid (SCM), trapezius (TRP), and soleus (SOL) muscles in response to 256 air-conducted short tone bursts (125 dB SPL, 500 Hz, 4 ms) delivered via headphones. A subset of subjects (n = 19) also received horizontal and vertical head thrusts (∼150°/s) at each height in a separate session, comparing eye and head velocities by using a vHIT system for calculating the functional VOR gains. VEMP amplitudes (IO, TRP, SOL) and horizontal and vertical vHIT gains all increased with high surface height conditions (P < 0.05). Changes in IO and SCM VEMP amplitudes as well as horizontal vHIT gains were correlated with changes in electrodermal activity (ρ = 0.44-0.59, P < 0.05). VEMP amplitude for the IO also positively correlated with fear (ρ = 0.43, P = 0.03). Threat-induced anxiety, fear, and arousal have significant effects on VSR and VOR gains that can be observed in both physiological and functional outcome measures. These findings provide support for a potential central modulation of the vestibular nucleus complex through excitatory inputs from neural centers involved in processing fear, anxiety, arousal, and vigilance.

The effects of posteroventral pallidotomy on balance function in patients with Parkinson's disease

Parkinson's disease is a chronic, progressive neurodegenerative disorder resulting from dopaminergic cell loss in the pars compacta of the substantia nigra. Conventional treatment of Parkinson's disease consists of pharmacological replacement of dopamine. A treatment alternative, posteroventral pallidotomy (PVP), has been used for medically intractable stages of the disease. The purpose of this study was to evaluate the effects of PVP on balance function, as measured by dynamic posturography, in patients with medically intractable Parkinson's disease. Five subjects were studied within 2 days prior to and within 6 months following PVP. Pretreatment abnormalities were found in vestibular, visual, and somatosensory processing in balance function. Posteroventral pallidotomy resulted in improvement in vestibular compensation of posture in some patients, which may be at least partially due to an improvement in latencies to respond to changes in stance. Dynamic posturography is an effective tool in the evaluation of balance and posture in patients with advanced Parkinson's disease.

Formaldehyde fasciaform tympanoplasty: a reliable technique for closing large tympanic membrane perforations

Formaldehyde fasciaform grafting tympanoplasty is a reliable method, in experienced hands, to close large tympanic membrane perforations. The technique involves using autogenous temporalis fascia shaped by formaldehyde cross-linking on a special fasciaform mold (Hear America, Palo Alto, CA). This study was undertaken with the objective of assessing if an otologist with less experience in using this technique could obtain comparable results. The results of the initial 23 patients treated in this manner by one surgeon between August 1996 and January 1998 are reviewed. Success was measured by the rate of closure of the tympanic membrane perforation and by functional closure of the air-bone gap. Favourable results were obtained, with complete closure of 86% of the perforations and closure of the air-bone gap to 20 dB or less in 90% of subjects when the ossicular chain was intact. The formaldehyde fasciaform tympanoplasty technique produces consistent, reliable, and reproducible results for large tympanic membrane perforations.

Auditory disorder in central nervous system miliary tuberculosis: case report

We evaluated a 28-year-old female with a unilateral hearing loss of unusual pathogenesis, that of central nervous system miliary tuberculosis. Audiologic and otologic findings were consistent with left retrocochlear disorder, characterized by a profound hearing sensitivity loss, absent acoustic reflexes, normal otoacoustic emissions, and the presence of only wave I of the auditory brainstem response. Imaging studies revealed the presence of multiple punctate lesions, one of which was extra-axial and located at the left cerebellopontine angle. The pattern of audiometric test results, particularly the combination of normal otoacoustic emissions and profound hearing sensitivity loss, contributed importantly to the investigative sequence leading to the final diagnosis.

A double-blind placebo-controlled trial of baclofen in the treatment of tinnitus

OBJECTIVE

To determine the effectiveness of baclofen in ameliorating tinnitus in adult patients.

STUDY DESIGN

Randomized double-blind placebo-controlled trial.

SETTING

California Ear Institute at Stanford, California, a tertiary otology/neurotology referral center.

PATIENTS

Restricted to adults receiving otologic evaluation at the California Ear Institute at Stanford. Some patients had a primary complaint of tinnitus, whereas others with tinnitus were recruited during treatment for another condition. The study population was felt to be representative of the general population with tinnitus.

INTERVENTIONS

Three weeks of baclofen (10 mg orally twice daily for 1 week, 20 mg orally twice daily for the second week, and 30 mg orally twice daily for the third week) or placebo designed to mimic baclofen capsules in route, schedule, appearance, and taste were given to patients.

MAIN OUTCOME MEASURES

Tinnitus handicap inventory, pitch and loudness matching, and maskability of tinnitus.

RESULTS

Subjective and objective evaluation failed to demonstrate any clinical or statistical advantage of baclofen over placebo. Reports of subjective improvement occurred in only 9.7% of the baclofen versus 3.4% of the placebo groups, a nonsignificant difference. Withdrawal from the baclofen arm of the study occurred in 26% due to side effects, which could be attributed to the medication.

CONCLUSIONS

Baclofen is no more effective than placebo in ameliorating tinnitus in adult patients.

Multiple oncocytic laryngeal cysts presenting as acute airway obstruction

Solitary oncocytic cyst of the larynx is a recognized clinical and pathologic entity. Multiple oncocytic cysts have only rarely been described. A 67-year-old female presented with rapidly progressive airway obstruction requiring emergency tracheotomy. The obstruction was caused by multiple cystic lesions throughout the supraglottic region. Microscopic examination of laryngeal biopsies showed cysts within the lamina propria, lined by oncocytic epithelium. The differential diagnosis and pathogenesis of oncocytic cysts is discussed with a review of other laryngeal cystic lesions.

Connections of the superior olive in the chicken

The avian superior olive (OS) is known to be a station in the auditory pathway, although its anatomic connections remain uncertain. The afferent and efferent connections of OS neurons in the chicken were identified with wheat germ agglutinin conjugated to horse radish peroxidase (WGA-HRP) injected into the OS nucleus. Projections to the OS originate bilaterally in the cochlear nuclei (nucleus angularis) and the nucleus laminaris. Anterogradely labelled axon terminals were found in the ipsilateral nucleus magnocellularis, the contralateral intermediate nucleus of the lateral lemniscus, and the shell portion of the central nucleus of the inferior colliculus. Retrograde transport of [3H]-glycine from the OS was also charted. Glycine-transporting cells were found ipsilaterally in the nucleus angularis and the nucleus laminaris. Neuronal soma in a newly identified nucleus of the trapezoid body (NTB) were found to actively concentrate glycine, although the neurons probably do not synapse within the OS. Anatomically, the avian OS would appear to be part of the interaural intensity difference pathway; however, our data and published information are insufficient to establish a homology to the human lateral superior olive.

Phrenic nerve reinnervation of the cat's larynx: a new technique with proven success

Reinnervation of the posterior cricoarytenoid muscle (PCA) should provide vocal cord abduction on inspiration, and passive adduction to enable phonation. Previous investigators have shown that reinnervation is possible, but results have not been clinically encouraging. When reinnervation was successful, the question remained whether it was provided by the transplanted nerve or by the ingrowth of adjacent nerves. In this study the phrenic nerve was transplanted directly into the PCA in a series of 12 cats. Fibrin glue was used to overcome nerve trauma and to prevent retraction of the nerve from the PCA. Laryngoscopy, electromyography, and retrograde labeling of the phrenic motoneurons provided evidence of functional reinnervation in 9 cats. Partial or complete failure in the remaining 3 was due to retraction of the nerve from the muscle. These results appear to justify trials of the procedure in humans.