Endoscopic resection of a mucocele of the crista galli

Mucoceles expand by the process of bone resorption and new bone formation, which leads to local destruction and displacement of adjacent structures. We present the case of a 47-year-old woman who presented with recurrent headaches, nausea, and vomiting, all of which were believed to have occurred secondary to a mucocele of the crista galli. To the best of our knowledge, only 1 similar case has been previously reported in the world literature; in that case, the crista galli was drained externally. In our patient, resolution of symptoms was achieved by endoscopic dacryocystorhinostomy, endoscopic frontal sinusotomy, and drainage of the mucocele under image guidance. We recommend that an endoscopic surgical approach be considered for the management of mucoceles of the crista galli.

Silastic injection for vocal fold medialization resulting in a false-positive finding on F18 FDG-PET/CT

A false-positive uptake of F18-fluorodeoxyglucose (FDG) on positron-emission tomography/computed tomography (PET/CT) can result in confusion and misinterpretation of scans. Such uptakes have been previously described after injection of polytetrafluoroethylene (Teflon) into the vocal folds. Similarly, vocal fold injection of silicone elastomer (Silastic) can result not only in a false-positive FDG uptake on PET/CT, but also in chronic inflammation. We report a case of increased FDG uptake in a vocal fold after Silastic injection that was misinterpreted as a malignancy in a 70-year-old woman who had metastatic carcinoma of the stomach.

Feasibility of a synthetic temporal bone for training in mastoidectomy: face, content, and concurrent validity

OBJECTIVE

To investigate the face, content, and concurrent validity of the synthetic Pettigrew temporal bone (PTB) for mastoidectomy training as compared with cadaveric temporal bone (CTB).

STUDY DESIGN

A prospective evaluation study.

METHODS

Participants were invited to perform a step-by-step modified radical mastoidectomy using both bones and complete a 22-item, 5-point Likert scale questionnaire. The questionnaire is divided into 4 domains: face validity (FV), global content (GC), task-specific content (TSC), and curriculum recommendation (CR).

RESULTS

Thirty-six experts and 89 trainees completed all tasks, 63 using CTB and 62 using PTB. The PTB median FV was 4 (IQR: 4-5), GC of 4 (IQR: 4-5), TSC of 4 (IQR: 3-4), and CR of 4 (IQR: 4-5). The CTB was rated significantly higher than PTB by both groups in all domains; CTB FV: 5 (IQR: 4-5), GC: 5 (IQR: 4-5), TSC: 5 (IQR: 4-5), and CR: 5 (IQR: 5-5), p < 0.001 for each. Trainees rated PTB significantly higher than experts in all domains. There was no statistically significant difference between experts and trainees in rating the CTB in all domains. PTB gives similar haptic feedback to CTB, allows the use of suction and irrigation, has the important landmarks painted for identification, and contains articulating ossicles. The facial nerve anatomy was found to be inaccurate around the region of the second genu.

CONCLUSION

Participants found PTB to be valid for teaching some, yet not all, aspects of mastoid surgery, and experts agreed that it could improve global transferrable otologic skills. It is essential that the facial nerve anatomy is addressed before recommending this model.

Binary versus 5-Point Likert Scale in Assessing Otolaryngology Trainees in Endoscopic Sinus Surgery

Objectives:

(1) Examine the discriminant validity of 2 validated assessment tools in endoscopic sinus surgery (ESS) training. (2) Compare the binary versus the 5-point Likert-scale tools in ESS assessment.

Methods:

A cross-sectional study was conducted from February-August 2013. All otolaryngology trainees in the North-London training program were assessed while performing ESS on sheep heads, which previously showed face and content validity. Performance was rated by 2 blinded assessors using 2 validated tools: The Inter-Collegiate-Surgical-Curriculum-Project tool, which utilizes a binary system and is used throughout the UK surgical training system, and the John Hopkins 5-Point Likert scale ESS tool. The tools’ construct validities were tested by comparing performance of experts and novices. The tools were also tested by correlating task-specific and global skills ratings with overall performance level.

Results:

The binary tool showed higher inter-rater reliability than the Likert scale, both in task-specific (Kappa: 0.89 versus 0.62) and global skills (Kappa: 0.79 versus 0.68) rating. Both tools discriminated between different levels of expertise in global and task-specific skills (Kruskal-Wallis: P < .001 for all). But pairwise comparison showed that Likert scale tool was a better discriminator between novices and trainees, globally ( P = .016 versus P < .271) and task-specifically ( P = .049 versus P = .449). Likert scale tool also correlated better with overall performance globally ( r = 0.903 versus 0.741) and task-specifically ( r = 0.833 versus 0.802).

Conclusions:

While the binary assessment tool may show higher inter-rater reliability and is easier to complete, the Likert scale, when each level is well defined, showed good agreement and better construct validity, which can be useful when monitoring progress in training.

Optimal Endoscopic Management of Sinonasal Inverted Papilloma: Recurrence-Free Experience with Twenty-one Patients

Objectives:

1) Explore developments in endoscopic techniques and their application in the management of Sinonasal Inverted Papilloma (SNIP). 2) Describe 0% recurrence rates with aggressive endoscopic resection of complex SNIP.

Methods:

Retrospective single-center patient cohort analysis of twenty-one cases of SNIP treated by endoscopic resection at Charing Cross Hospital from December 2002 to September 2012. Pre-operative assessment included tomography or magnetic resonance imaging and biopsies. The origin and extent of the tumor determined the surgical strategy, and a combination of antrostomy, ethmoidectomy, sphenoidotomy, and endoscopic medial maxillectomy (EMM) with the assistance of angled instrumentation were performed. Sub-periosteal dissection followed by diamond burr drilling of the underlying bone were performed in all cases. All patients were followed up by regular endoscopic surveillance.

Results:

The study group consisted of 12 (57%) male and 9 (43%) female patients with a mean age of 59 years. Eleven patients (52%) had undergone previous surgery. Association with malignancy was seen in 2 patients (excluded from this study). All patients were treated by pure endoscopic means without adjunctive procedures. Completion surgery was performed on 1 patient with residual disease and histological atypia identified early after the operation. No recurrences were observed after a mean follow-up of 25 months.

Conclusions:

Our experience is one of the largest single-center recurrence-free case series for SNIP treated by pure endoscopic resection. It further supports the efficacy and safety of this technique even in complex recurrent cases and advocates its use as the gold standard first line surgical strategy.

Using Cumulative Summation to Draw Otolaryngology Trainees’ Learning Curves in Tonsillectomy

Objectives:

Assess the applicability of cumulative summation (CUSUM) in 1) showing trainees progress, 2) achieving competency, and 3) highlighting concerns in tonsillectomy surgery.

Methods:

We followed 9 otolaryngology junior trainees in their first 6-12 months in the specialty between 2011-2013. Tonsillectomy is the most common operation that introduces trainees to operative otolaryngology. Two outcome measures were used: operative time and post-operative bleeding. These were then compared to experienced surgeons (>100 tonsillectomies). For time CUSUM, the mean and standard deviation of the experts’ performance was used as the factor to draw the curve applying the formula (Cn=0, Cn-1+Xn-k) on consecutive procedures. k=0.2 to allow for 20% incidence of overrunning. For bleeding CUSUM, any post-operative bleed was regarded a negative outcome and k=0.05 to allow for 5% incidence.

Results:

Trainees performed 14-35 tonsillectomies each (ongoing). The average time for experts over 150 procedures was 23min (SD:11). Trainees’ operative time was higher (38min, SD:16, P<0.01). Xn=0 if the time was within 1SD of the experts (34min) and 1 if higher. Trainees’ time CUSUM plateaued after a variable number of cases (20-30) while that of experts remained low. For bleeding CUSUM, Xn=1 if reported and 0 if not. Bleeding was rare and did not reflect the same pattern.

Conclusions:

CUSUM using time can be used to monitor performance and draw learning curves for tonsillectomy. Bleeding is a rare complication and hence needs larger numbers to show improvement. The flexibility of the CUSUM makes it adaptable to any outcome. It allows early detection of poor performance to instigate intervention.

Rare sarcoma presented as sinusitis

Myxofibrosarcoma (MFS) also known as myxoid variant of malignant fibrous histocytoma is one of the most common soft tissue sarcomas of the extremities in adult and elderly patients with rare occurrences in head and neck region. Low-grade MFS is unusual among low-grade sarcomas because it often recurs relentlessly and multiplies despite wide local resection with gross negative margins. We report a case of extreme rarity and a tumour of aggressive nature in the maxillary sinus, which presented with non-specific sinonasal symptoms and we present a review of the radiological and histopathological characteristics of this rare tumour and recent evidence of management.

Surgical management of bilateral parotid lipomatosis in a patient with HIV

BACKGROUND

The long-term use of highly active antiretroviral therapy (HAART) in patients with human immunodeficiency virus (HIV) has led to sequelae including lipodystrophy syndrome (LDS). We present the first published case of surgical management of bilateral parotid lipomatosis in a patient with HIV on long-term HAART.

METHODS

We undertook review of the case notes from the time of diagnosis with HIV and literature review of this topic.

RESULTS

A 45-year-old man with HIV on HAART presented with a 4-year history of increasing bilateral facial swelling. He was asymptomatic apart from the stigmatizing cosmetic deformity. MRI revealed the parotid glands had been replaced by fat. He elected for surgery and parotid lipomatosis was diagnosed on histopathological examination.

CONCLUSION

Lipohypertrophy in LDS is rare in the literature and this presentation of bilateral parotid lipomatosis secondary to HAART is only the third reported case, and the first to undergo surgical resection.

Balloon Sinuplasty: balloon-catheter dilation of paranasal sinus ostia for chronic rhinosinusitis

More than 100 million patients worldwide suffer from chronic rhinosinusitis, and a considerable amount of money has been spent on research and treatments by healthcare providers. In the northern hemisphere, damp, temperate climates, along with higher concentrations of pollen, are associated with a higher prevalence of chronic rhinosinusitis. Owing to its persistent nature, the disease can become a significant cause of morbidity. If untreated, it can reduce quality of life and productivity. When medical treatment is not effective, surgery may offer an excellent outcome. Although functional endoscopic surgery has proven to be effective, many cases could be managed medically. Recent research has suggested that optimal medical treatment is as effective as surgery in patients with chronic rhinosinusitis at the end of 1 year. Balloon Sinuplasty (Acclarent, Inc., CA, USA) is a new technique in the management of sinusitis and is a hotly debated topic. It is a delicate, minimally invasive tool, and early research demonstrates promising outcomes in terms of safety and effectiveness. This novel technique has been approved by the US FDA. Recently, NICE raised no concerns regarding its safety and efficacy but will continue to review this procedure.

Unusual case of accessory nose associated with unilateral complete congenital choanal atresia

We report here an extremely rare and unusual case of accessory nose associated with unilateral complete congenital choanal atresia. Although other types of nasal congenital nasal anomalies are not rare, however, extreme rarity of nose duplication is worth reporting, as it is an extremely rare type of nasal congenital deformity.