[Views of assistant professors on digital transformation in otorhinolaryngology education : Current status and perspectives in undergraduate and advanced training]

BACKGROUND

Digital transformation in curricular teaching in medicine comprises the use of digital teaching and learning formats as well as the transfer of digital skills for medical staff. Concepts of knowledge transfer and competency profiles also have to be adapted and transferred in advanced training due to necessary changes.

OBJECTIVE

The aim of this study was an evaluation of the current state of digital transformation in otorhinolaryngology teaching in undergraduate and advanced training at otorhinolaryngology departments of university medical centers in Germany.

MATERIALS AND METHODS

A questionnaire with nine questions on digital transformation was sent to the assistant professors of 37 national university ENT departments. The anonymous survey was conducted online via the online platform SurveyMonkey®.

RESULTS

Of the contacted assistant professors, 86.5% participated in the survey. Teaching sessions on digital skills for medical students are part of the curriculum in only 25% of ENT departments. Digital teaching formats are used by half of the departments in undergraduate training. Only 56.25% of the assistant professors receive support to realize the changes required by digital transformation. In 40.62% of departments, the issue of digital transformation is broached during advanced training, but only 28.12% use digital teaching methods to train junior doctors.

CONCLUSION

Aspects of digital transformation are implemented mainly in undergraduate education, partly driven by the COVID 19 pandemic. Overall, there is still considerable backlog in undergraduate and advanced training in ENT.

[Is the use of virtual reality in otorhinolaryngology teaching automatically positively rated by students? : A questionnaire-based evaluation among students]

BACKGROUND

Analogous to the situation in other disciplines, digital ENT teaching made significant progress during the pandemic. Most ENT clinics nationwide were able to offer a complete virtual teaching program in time. Innovative teaching methods were also used early on. This was recognized in student teaching evaluations. Due to the expansion of virtual reality (VR) in medical teaching, even greater satisfaction should be expected through improved teaching quality.

MATERIALS AND METHODS

Surveys were performed with students (n = 180) of the ENT block internship in the summer semester of 2023. The aim of the evaluation was to determine the students' satisfaction with and subjective effectiveness of the newly implemented VR digital teaching method for teaching ear anatomy and coniotomy. A survey was also carried out among resident physicians.

RESULTS

The ENT teaching was perceived favorably by the students, with an average rating of 11.7 out of 15. The learning effectiveness and the value of VR in the ENT learning portfolio was evaluated varyingly by the students. The physicians' assessment was different, with a more positive perception.

CONCLUSION

Virtual reality represents an innovative component in the teaching portfolio of otolaryngology. This new teaching method is viewed and accepted as a future-oriented tool. Remarkably, the physicians involved voted consistently positively, while the students gave more critical assessments and pointed out limitations in the individual and subjective areas. These findings are in contrast to the further development of innovative teaching methods demanded by student interest groups.

[Feasibility of clinical examination scenarios under pandemic conditions]

BACKGROUND

Due to the COVID-19 pandemic, contact restrictions occurred worldwide, which affected medical schools as well. It was not possible to hold classroom lectures. Teaching contents had to be converted to a digital curriculum within a very short time. Conditions for assessments posed an even greater challenge. For example, solutions had to be found for objective structured clinical examinations (OSCE), which were explicitly forbidden in some German states. The aim of this study was to evaluate the feasibility of an OSCE under pandemic conditions.

MATERIALS AND METHODS

At the end of the 2020 summer semester, 170 students completed a combined otolaryngology and ophthalmology OSCE. Examinations were held in small groups over the course of 5 days and complied with strict hygiene regulations. The ophthalmology exam was conducted face to face, and the ENT OSCE virtually. Students were asked to rate the OSCE afterwards.

RESULTS

Between 106 and 118 of the students answered the questions. Comparing the face-to-face OSCE with the virtual OSCE, about 49% preferred the face-to-face OSCE and 17% preferred the virtual OSCE; 34% found both variants equally good. Overall, the combination of an ENT and ophthalmology OSCE was rated as positive.

CONCLUSION

It is possible to hold an OSCE even under pandemic conditions. For optimal preparation of the students, among other things, it is necessary to transform teaching contents to a digital curriculum. The combination of an ENT and ophthalmology OSCE was positively evaluated by the students, although the face-to-face OSCE was preferred. The overall high satisfaction of the students confirms the feasibility of a virtual examination with detailed and well-planned preparation.

Evaluation of insertion quality of a slim perimodiolar electrode array

OBJECTIVES

The influence of cochlear morphology and electrode array design on scalar position and dislocation rates is of great interest in CI surgery. The aim of this study is to evaluate scalar position and specific points of dislocation in relation to cochlear morphology in patients implanted with a new slim perimodiolar electrode array.

MATERIALS AND METHODS

Patients were implanted using the slim modiolar electrode array (= SMA) (= 532/632 electrode array of Cochlear™). Postoperative imaging was performed via cone beam computed tomography (CBCT) and the scans were analyzed regarding cochlear morphology (distances A and B and cochlear height), scalar location of the electrode array, basal insertion depth and apical insertion angle. Furthermore, electrode array design and surgical protocols were evaluated.

RESULTS

81 ears implanted with the SMA were retrospectively included. We evaluated 3 electrode array tip fold over intraoperatively via X-ray imaging and performed revision during the same surgery. The CBCT scans showed 76 initial scala tympani (ST) insertions without dislocation. Two ears showed a dislocated array, one at 77° and the other at 163°. Three arrays were inserted into scala vestibuli (SV) via cochleostomy. These patients showed no signs of obliteration. Cochlear morphology showed no influence on angular insertion depth and scalar position.

CONCLUSIONS

The SMA showed a very low rate of scalar dislocations due to its slim electrode array design (2.7%). We could find a learning curve regarding the handling and the risk of dislocation and tip fold over with this electrode array. The rate of intraoperative tip fold over detection via X-ray imaging was 3.7%. Therefore, we highly recommend X-ray imaging and transimpedance matrix measurements within the surgery protocol. Scala vestibuli insertions happened in patients with cochleostomy only. We could identify two specific points of dislocation depending on electrode array design.

Positionspapier: ICD-Codierung der chronischen Rhinosinusitis mit Nasenpolypen (CRSwNP) im ICD-10-GM als Grundlage für eine Therapie mit Biologika – Empfehlungen des Ärzteverbandes Deutscher Allergologen (AeDA), der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Halschirurgie (DGHNOKHC) und des Deutschen CRS-Registers

Hintergrund Die chronische Rhinosinusitis mit Nasenpolypen (CRSwNP) ist eine multifaktorielle entzündliche Erkrankung der Schleimhäute von Nase und Nasennebenhöhlen. In Deutschland sind 3 verschiedene monoklonale Antikörper für die Indikation „Zusatztherapie zu intranasalen Glukokortikosteroiden für die Behandlung Erwachsener mit schwerer chronischer Rhinosinusitis mit Nasenpolypen“ zugelassen. Um die Verordnung in der zugelassenen Indikation (In-Label) zu dokumentieren, ist neben einer Dokumentation zahlreicher medizinischer Parameter die korrekte Auswahl der ICD-10-GM-Codierung entscheidend. Hierfür existieren in Deutschland bislang keine konsentierten Empfehlungen.

Methoden Basierend auf der internationalen Literatur und bisherigen Erfahrungen werden von einem Expertengremium von AeDA, DGHNO-KHC und Deutschem CRS-Register Codierungsmöglichkeiten von CRS und CRSwNP analysiert und auf dieser Basis eine konsentierte Empfehlung für die ICD-10-GM-Codierung in Deutschland ausgesprochen.

Ergebnis Die Internationale statistische Klassifikation der Krankheiten und verwandter Gesundheitsprobleme ICD-10-GM (International Classification of Diseases, 10. Revision, German Modification) ist die amtliche Klassifikation zur Verschlüsselung von Diagnosen in der ambulanten und stationären Versorgung in Deutschland. Der ICD-10-GM unterscheidet nicht adäquat zwischen heute anerkannten klinischen und immunologischen Differenzierungen der CRSsNP und der CRSwNP. Dennoch wird insbesondere bei indiziertem Einsatz von Biologika in der Therapie der schweren CRSwNP eine möglichst exakte Verschlüsselung mit den Codes J33.8 (im Einzelfall J33.1 oder J33.9) empfohlen.

Schlussfolgerungen Das Verständnis über die immunologischen Grundlagen der CRSwNP eröffnet neue Behandlungsansätze mit monoklonalen Antikörpern für Patienten mit schwerer, unkontrollierter Erkrankung. Hier geben wir Empfehlungen für eine adäquate ICD-10-GM-Codierung in Deutschland.

Empfehlungen zur Überprüfung der Wirksamkeit und Verlaufsdokumentation von Mepolizumab bei chronischer Rhinosinusitis mit Nasenpolypen (CRSwNP) im deutschen Gesundheitssystem – Empfehlungen des Ärzteverbandes Deutscher Allergologen (AeDA) und der AGs Klinische Immunologie, Allergologie und Umweltmedizin und Rhinologie und Rhinochirurgie der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Halschirurgie (DGHNOKHC)

BACKGROUND

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a multifactorial inflammatory disease of the mucous membranes of the nose and sinuses. Eosinophilic inflammation is described as a common endotype. The anti-IL5 antibody mepolizumab was approved in November 2021 as an add-on therapy to intranasal glucocorticosteroids for the treatment of adults with severe chronic rhinosinusitis with nasal polyps when systemic glucocorticosteroids or surgery do not provide adequate disease control. While national and international recommendations exist for the use of mepolizumab in CRSwNP, it has not yet been adequately specified how this therapy is to be monitored, what follow-up documentation is necessary, and when it should be terminated if necessary.

METHODS

A literature search was performed to analyze previous data on the treatment of CRSwNP with mepolizumab and to determine the available evidence by searching Medline, Pubmed, the national and international trial and guideline registries and the Cochrane Library. Human studies published in the period up to and including 10/2022 were considered.

RESULTS

Based on the international literature and previous experience by an expert panel, recommendations for follow-up, adherence to therapy intervals and possible therapy breaks, as well as termination of therapy when using mepolizumab for the indication CRSwNP in the German health care system are given on the basis of a documentation sheet.

CONCLUSIONS

Understanding the immunological basis of CRSwNP opens up new non-surgical therapeutic approaches with biologics for patients with severe, uncontrolled courses. Here, we provide recommendations for follow-up, adherence to therapy intervals, possible therapy pauses, or discontinuation of therapy when mepolizumab is used as add-on therapy with intranasal glucocorticosteroids to treat adult patients with severe CRSwNP that cannot be adequately controlled with systemic glucocorticosteroids and/or surgical intervention.

Empfehlungen zur Überprüfung der Wirksamkeit und Verlaufsdokumentation von Dupilumab bei chronischer Rhinosinusitis mit Nasenpolypen (CRSwNP) im deutschen Gesundheitssystem – Empfehlungen des Ärzteverbandes Deutscher Allergologen (AeDA) und der AGs Klinische Immunologie, Allergologie und Umweltmedizin und Rhinologie und Rhinochirurgie der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Halschirurgie (DGHNOKHC)

BACKGROUND

 Chronic rhinosinusitis with nasal polyps (CRSwNP) is a multifactorial inflammatory disease of the nasal and paranasal mucosa. A Type-2 inflammation is described as the most common endotype. Since October 2019 the anti-IL-4/-IL-13 antibody dupilumab has been approved in Germany as an add-on therapy to intranasal corticosteroids for the treatment of adults with severe chronic rhinosinusitis with nasal polyps, when systemic corticosteroids alone or surgery do not provide adequate disease control. While recommendations for the use of dupilumab in CRSwNP exist at both national and international levels, until now it has not been adequately established, how therapy should be monitored and when it should be discontinued in the German Health Care System.

METHODS

 A literature search was performed analyzing previous data on the treatment of CRSwNP with dupilumab and to determine the available evidence by searching Medline, Pubmed, the national and international trial and guideline registries and the Cochrane Library. Human studies published in the period up to 05/2022 were included.

RESULTS

 Based on international literature and previous experience, recommendations are given by an expert panel for follow-up and possible therapy breaks, therapy intervals or termination of therapy when using dupilumab for the indication CRSwNP in the German health care system based on a documentation form.

CONCLUSIONS

 Understanding the immunological basis of CRSwNP opens new non-surgical therapy approaches with biologics for patients with severe courses. The authors give recommendations for follow-up, possible therapy breaks, therapy intervals and a termination for dupilumab treatment as add-on therapy with intranasal corticosteroids for the treatment of adult patients with severe CRSwNP that cannot be adequately controlled with systemic corticosteroids and/or surgical intervention.

[Objective and subjective assessment of a structured approach to computed tomography scans of the paranasal sinuses]

BACKGROUND

Sound knowledge of individual anatomy is essential in sinus surgery to prevent potentially serious complications. For the paranasal sinuses, computed tomography (CT) is the imaging technique of choice to preoperatively analyze individual anatomy and the extent of disease.

OBJECTIVE

The purpose of this study was to evaluate the usefulness of a CT checklist to identify relevant anatomic variants in CTs of the paranasal sinuses.

MATERIALS AND METHODS

Junior and senior otolaryngology residents were asked to assess sinus CT scans for anatomic variants before and after implementation of the CLOSE mnemonic (cribriform plate, lamina papyracea, Onodi cell, sphenoid sinus pneumatization, and [anterior] ethmoidal artery). The rate of correctly identified variants was calculated. A questionnaire was distributed for subjective evaluation of the usefulness of the checklist.

RESULTS

Six junior and six senior residents were included in the study. The rate of correctly identified anatomic variations significantly improved from 23.1 to 50.9% and 24 to 39.8%, respectively, after implementation of the CLOSE mnemonic. The subjective evaluation of the CLOSE criteria showed very positive results.

CONCLUSION

The structured approach to sinus CT scans using CT criteria can improve identification of critical anatomic variants in CT scans of the paranasal sinuses and is rated highly positively by residents in training.

High-Resolution Gadolinium-Enhanced MR Cisternography Using Compressed-Sensing T1 SPACE Technique for Detection of Intracranial CSF Leaks

In patients with CSF rhinorrhea, accurate identification of the CSF leakage site is crucial for surgical planning. We describe the application of a novel gadolinium-enhanced high-resolution 3D compressed-sensing T1 SPACE technique for MR cisternography and compare findings with CT cisternography and intraoperative results. In our pilot experience with 7 patients, precise detection of CSF leaks was feasible using compressed-sensing T1 SPACE, which appeared to be superior to CT cisternography.

[Rare diseases of the maxillary sinus]

BACKGROUND

Silent sinus syndrome (SSS), organized hematoma (OH), and pneumosinus dilatans (PD) are rare, usually unilateral diseases of the maxillary sinus. Due to misinterpretation, excessive diagnostics and unnecessarily aggressive surgery or a delay in diagnostics and treatment are common.

OBJECTIVE

The objective of this study was to develop reasonable and comprehensible diagnostic criteria to improve diagnosis and treatment of these rare diseases.

METHODS

In this retrospective study, all patients treated for SSS, OH, and PD from 2012 to 2019 were identified. Patient history, diagnostic tests and results, and postoperative course were analyzed and compared with the available literature.

RESULTS

During the study period, 7 patients with SSS, 3 patients with PD, and 2 patients with OH were treated and available for follow-up. Comparison of these patients with the literature allowed us to develop diagnostic criteria.

CONCLUSION

Medical history combined with endoscopic and radiologic criteria should improve preoperative diagnosis of these three rare diseases of the maxillary sinus and help to distinguish them from other differential diagnoses. This approach should minimize morbidity for the patients.

["Online from tomorrow on please": comparison of digital framework conditions of curricular teaching at national university ENT clinics in times of COVID-19 : Digital teaching at national university ENT clinics]

Hintergrund

Die Corona-Krise beeinflusst nicht nur das professionelle Handeln, sondern auch die Lehre an den Universitäten. Schlagworte wie „E-Learning“ und „Digitalisierung“ suggerieren die Möglichkeit innovativer, ad hoc verfügbarer Lösungsansätze für die Lehre in der aktuellen COVID-19-Situation. Die aktuelle Umstellung auf digitale Lehre ist aber nicht primär durch eine didaktische Sinnhaftigkeit oder institutionelle Strategie, sondern durch äußere Notwendigkeit geprägt.

Ziel der Arbeit

Ziel der Arbeit war die Erfassung der Lehrsituation an nationalen Universitäts-HNO-Kliniken und akademischen Lehrkrankenhäusern zu Beginn des virtuellen Corona-Sommersemesters 2020.

Material und Methode

Ein eigens erstellter Fragebogen zur jeweiligen lokalen Situation, den örtlichen Rahmenbedingungen sowie zu bundesweiten Szenarien wurde an alle 39 nationalen Universitäts-HNO-Kliniken und 20 akademischen Lehrkrankenhäuser mit HNO-Hauptabteilung versandt.

Ergebnisse

Die ausgefüllten Fragebögen von 31 Universitätskliniken (UK) und 10 akademische Lehrkrankenhäuser (ALK) gingen in die Auswertung ein. Es zeigten sich offensichtliche Diskrepanzen zwischen verfügbaren Ressourcen und tatsächlich verfügbaren digitalisierten Lehrinhalten. Weitere Kritikpunkte offenbarten sich in Bezug auf die Kommunikation mit der Medizinischen Fakultät, die digitale Infrastruktur und insbesondere in der oftmals mangelnden Kollaboration mit den zentralen Supportstrukturen, wie Medien‑, Didaktik- und Rechenzentren.

Schlussfolgerung

Es gibt durchaus positive Beispiele für eine gelungene Überführung der Präsenzlehre in das ausschließlich virtuelle Sommersemester 2020 innerhalb der Universitäts-HNO-Kliniken. Mehrheitlich aber überwiegen kritische Einschätzungen der Lehrbeauftragten bzw. Ärztlichen Direktoren gegenüber der aktuellen Lehrsituation. Eine zeitkritische strategische Weiterentwicklung ist dringend erforderlich.

[Incomplete partition type III revisited-long-term results following cochlear implant. German version]

BACKGROUND

Incomplete partition type III (IP III) is defined by a missing lamina cribrosa between the cochlea and the internal auditory canal (IAC). Cochlear implantation (CI) may result in an insertion of the electrode array into the IAC. The aim of this study is to evaluate CI surgery protocols, long-term audiological outcome, mapping and electrophysiological data after CI in IP III patients.

MATERIALS AND METHODS

Nine IP III patients were implanted with perimodiolar electrode arrays between 1999 and 2014; eight of them were included in this study. We evaluated mapping data, stapedius reflexes, electrode impedances and ECAP thresholds. We matched them with 3 CI patients each with normal cochlear morphology regarding sex, age, side, implant type and surgical date. Speech discrimination was evaluated with the Oldenburger sentence test for adults, Göttingen audiometric speech test for children and the Freiburger monosyllabic word test.

RESULTS

3 years after CI IP III patients showed a significant increase in pulse width, calculated electric load and electrode impedances in basal electrodes. Intraoperative electrically-evoked stapedius reflexes could be measured in all patients. Speech recognition scores were lower than average scores for matched patients, but without statistical significance.

CONCLUSIONS

The significant increase of pulse width, electric load and electrode impedances of basal electrodes over time seem to be characteristic for IP III patients probably occurring due to fibrosis and neurodegeneration of the cochlear nerve. The long term audiological results are stable. Intraoperative imaging and stapedius reflexes are highly recommended to control the right position of the electrode array.

[Septal surgery in septorhinoplasty]

In general septoplasty precedes all other procedures in rhinoplasty as a straight, stable septum dictates the aesthetic and functional outcome. The patient's history and expectations, correct preoperative analysis and the surgeon's skills determine the approach in septum correction. As a rule of thumb, slight deviations, e.g. single vomer spurs, maxillary crests, the septal tilt and simple C and S-shaped deformities can be managed endonasally using a hemitransfixion incision and procedures such as the swinging door technique, scoring, batten grafts or caudal septal replacement grafts. In contrast, for severe S-shaped and wave-like deviations, cleft nose deformities, the multiple fractured septum as well as for most revision cases, the open approach with complete septal reconstruction has been found to be the method of choice. After initial general remarks on the basic procedures, the present article focuses on current concepts of septum correction which have to be adapted to the individual pathology.

[Nasal douching in acute rhinosinusitis]

BACKGROUND

Nasal douching is recommended for the treatment of a variety of diseases of the nose and paranasal sinuses. Nasal douching with saline solution has proven to be effective in chronic rhinosinusitis and after sinus surgery and is recommended by different otolaryngologic societies.

MATERIAL AND METHODS

A systematic review of the literature was performed to determine whether nasal douching is effective in the treatment of acute rhinosinusitis and in preventing recurrent upper respiratory tract infections. We also reviewed whether nasal douching has adverse eff ects and can lead to recurrent upper respiratory tract infections if performed regularly over a longer period of time.

RESULTS

Nasal douching with saline solution has a limited effect in adults with acute rhinosinusitis (level of evidence Ia). It is effective in children with acute rhinosinusitis in addition to the standard medication (level of evidence Ib) and can prevent recurrent infections (level of evidence IIb). It is assumed that nasal douching improves the function of the mucous membranes. There is currently no evidence that daily nasal douching with isotonic saline solution over a longer period of time has an adverse effect on the individual health or leads to a higher rate of infections.

CONCLUSION

Nasal douching with saline solutions can be recommended for adults with acute rhinosinusitis (grade of recommendation A), in addition to the standard medication in children with acute rhinosinusitis (grade of recommendation A) and to prevent recurrent infections (grade of recommendation B).

Elevated expression of extracellular matrix metalloproteinase inducer (CD147) and membrane-type matrix metalloproteinases in venous leg ulcers

BACKGROUND

Matrix metalloproteinases (MMPs) contribute to matrix remodelling in venous leg ulcers. Extracellular MMP inducer (EMMPRIN; CD147) has been reported to increase MMP expression, and membrane type 1 MMP (MT1-MMP) has been implicated in the activation of MMPs.

OBJECTIVES

To examine whether and to what degree EMMPRIN, MMP-2, MT1-MMP and membrane type 2 MMP (MT2-MMP) are expressed in venous leg ulcers as well as the association with MMP activity.

METHODS

EMMPRIN, MMP-2, MT1-MMP and MT2-MMP were analysed by zymography and immunohistochemistry in biopsies from healthy skin and lesional tissue from venous leg ulcers.

RESULTS

Zymography provided direct evidence of increased proteolytic activity of MMP-2 in lesional skin in comparison with healthy controls. Immunostaining showed intense expression of EMMPRIN, MMP-2, MT1-MMP and MT2-MMP in dermal structures of venous leg ulcers, whereas only EMMPRIN and MMP-2 showed elevated expression in perivascular regions. Our findings indicate that venous leg ulcers are characterized by elevated expression of EMMPRIN, MMP-2, MT1-MMP and MT2-MMP. The immunohistological findings of skin alterations reflect the dynamic process of activation of soluble and membrane-bound MMPs, which may be highly induced by EMMPRIN.

CONCLUSIONS

These data suggest for the first time that membrane-bound MMPs may favour enhanced turnover of the extracellular matrix and support unrestrained MMP activity in venous leg ulcers.

Crystallization and preliminary X-ray data of chloromuconate cycloisomerase from Alcaligenes eutrophus JMP134 (pJP4)

The pJP4-encoded chloromuconate cycloisomerase, an enzyme of the 2,4-dichlorophenoxy-acetate degradation pathway, was purified from cell-free extracts of Alcaligenes eutrophus JMP134 with a revised procedure. Tetragonal bipyramidal crystals were grown and characterized with respect to their X-ray diffraction properties. They were assigned to the space group I4, with cell dimensions of a = b = 111.9 A, c = 148.5 A. The crystals scattered to approximately 3 A resolution.