Improving Patient Education of Facial Fractures Using 3-Dimensional Computed Tomography

OBJECTIVE

Advances in 3-dimensional modeling have revolutionized presurgical planning for maxillofacial reconstruction, yet little is known about how this technology may affect patient education. This study was designed to evaluate the efficacy of 2-dimensional computed tomography versus 3-dimensional computed tomography for patient education in maxillofacial reconstruction.

STUDY DESIGN

Crossover study.

SETTING

General otolaryngology outpatients from a tertiary referral center were recruited.

METHODS

A single computed tomography data set of a zygomaticomaxillary complex fracture was used to generate 2 educational video tutorials: one in a 2-dimensional format and one in a 3-dimensional format. The tutorials were embedded into the Qualtrics^XM platform. Participants were randomly assigned into 2 groups. Group 1 viewed the 2-dimensional tutorial, took a self-assessment survey, took an information recall survey, viewed the 3-dimensional tutorial, and finally took a tutorial comparison survey. Group 2 followed the same sequence but viewed the 3-dimensional tutorial followed by the 2-dimensional tutorial.

RESULTS

Group 2 participants (viewing the 3-dimensional tutorial first) scored better on the self-assessment survey than their counterparts in group 1 did (P = .023). Group 2 also scored better on the recall survey (P = .042). Of all participants, 61% preferred the 3-dimensional tutorial, and 31% preferred the use of both tutorials together in the comparison survey.

CONCLUSIONS

Three-dimensional patient educational tutorial regarding a zygomaticomaxillary complex fracture resulted in better knowledge retention and was preferred over the 2-dimensional format.

Multicenter Interrater Reliability in the Endoscopic Assessment of Velopharyngeal Function Using a Video Instruction Tool

Objective

Assess interrater agreement of endoscopic assessment of velopharyngeal (VP) function before and after viewing the video instruction tool (VIT). We hypothesized improvement in interrater agreement using the Golding-Kushner scale (GKS) after viewing the VIT.

Study Design

Prospective study.

Setting

Multi-institutional.

Methods

Sixteen fellowship-trained pediatric otolaryngologists who treat velopharyngeal insufficiency (VPI) rated 50 video segments using the GKS before and after watching the VIT. Raters assessed gap size percentage and lateral pharyngeal wall (LPW), soft palate (SP), and posterior pharyngeal wall (PPW) movement. Intraclass correlation coefficient was estimated for these continuous measures. Raters also indicated the presence of a palatal notch, Passavant’s ridge, and aberrant pulsations (categorical variables). Fleiss κ coefficient was used for categorical variables. Wilcoxon signed-rank test was performed on the difference between the pre/post individual video ratings.

Results

Reliability improved for all continuous variables after watching the instructional video. The improvement was significant for PPW (0.22-0.30, P < .001), SP (left: 0.63-0.68, P < .001 and right: 0.64-0.68, P = .001), and LPW (left: 0.49-0.54, P = .01 and right: 0.49-0.54, P = .09) but not significant for gap size (0.65-0.69, P = .36). Among categorical variables, agreement on Passavant’s ridge significantly improved (0.30-0.36, P = .03).

Conclusion

Exposure to a video instruction tool improves interrater agreement of endoscopic assessment of VP function. Significant improvement was observed in our primary end points, specifically posterior pharyngeal wall movement, soft palate movement, and lateral pharyngeal wall movement. There was less impact of the VIT on the interrater agreement of the categorical variables, palatal notch, Passavant’s ridge, and aberrant pulsations.

Backward Planning a Craniomaxillofacial Trauma Curriculum for the Surgical Workforce in Low-Resource Settings

BACKGROUND

Trauma is a significant contributor to global disease, and low-income countries disproportionately shoulder this burden. Education and training are critical components in the effort to address the surgical workforce shortage. Educators can tailor training to a diverse background of health professionals in low-resource settings using competency-based curricula. We present a process for the development of a competency-based curriculum for low-resource settings in the context of craniomaxillofacial (CMF) trauma education.

METHODS

CMF trauma surgeons representing 7 low-, middle-, and high-income countries conducted a standardized educational curriculum development program. Patient problems related to facial injuries were identified and ranked from highest to lowest morbidity. Higher morbidity problems were categorized into 4 modules with agreed upon competencies. Methods of delivery (lectures, case discussions, and practical exercises) were selected to optimize learning of each competency.

RESULTS

A facial injuries educational curriculum (1.5 days event) was tailored to health professionals with diverse training backgrounds who care for CMF trauma patients in low-resource settings. A backward planned, competency-based curriculum was organized into four modules titled: acute (emergent), eye (periorbital injuries and sight preserving measures), mouth (dental injuries and fracture care), and soft tissue injury treatments. Four courses have been completed with pre- and post-course assessments completed.

CONCLUSIONS

Surgeons and educators from a diverse geographic background found the backward planning curriculum development method effective in creating a competency-based facial injuries (trauma) course for health professionals in low-resource settings, where contextual aspects of shortages of surgical capacity, equipment, and emergency transportation must be considered.

A hybrid technique to address exposure keratopathy secondary to facial nerve paresis: A combination of a lateral tarsorrhaphy and lateral wedge resection

PURPOSE

To present the results of treating combined lower eyelid laxity, retraction and midface descent secondary to facial nerve weakness with a hybrid surgical procedure.

MATERIALS AND METHODS

A retrospective analysis of patients from January 2015 to January 2017 who underwent a hybrid surgical technique for the treatment of corneal exposure secondary to facial nerve paresis with a single surgeon was performed. Age, gender, and presence of exposure symptoms were recorded pre-operatively. Outcomes assessed included improvement of lower eyelid laxity and position, operative complications, and post-operative symptomatic relief.

RESULTS

A total of 11 patients underwent unilateral eyelid surgery. All patients had symptomatic relief and good functional outcomes defined as improvement in eyelid laxity, lower eyelid position, and objective corneal exposure. No cases required reoperation during an average follow up of 174.5 days.

CONCLUSIONS

Combining portions of a tarsorrhaphy and lateral wedge resection technique is a simple and effective procedure to improve lower eyelid position and limit corneal exposure secondary to facial nerve paresis.

Efficacy of Crosseal fibrin sealant (human) in rhytidectomy

OBJECTIVE

To examine the potential efficacy of Crosseal (the human protein, bovine component-free fibrin sealant) (OMRIX Biopharmaceuticals, Ltd, Brussels, Belgium) to reduce ecchymoses and hematoma formation in patients undergoing rhytidectomy.

METHODS

Before initiation of the study, approval was obtained from the US Food and Drug Administration for an Investigational New Drug Application and off-label use of Crosseal and from the Institutional Review Board of the University of California, Davis. Patients undergoing rhytidectomy with or without concomitant procedures were voluntarily enrolled without compensation in the study (N = 9). Patients were randomized according to which side of the rhytidectomy the tissue sealant was placed. In all patients in the study, 1 side of the rhytidectomy was treated with Crosseal; the other, untreated side was used as a control. Before closure of the skin, 2 mL of Crosseal was sprayed through a pressure regulator under the skin flap of the dissected area of the rhytidectomy only on 1 side. The skin was pretrimmed before placement and closed in standard fashion. A pressure dressing was left in place for 3 days before removal. Nine patients were originally enrolled in the study. On postoperative days 3 and 7, photographs were taken of the patients. The photographs were judged by 5 independent reviewers who were blinded as to which side had been treated with Crosseal. The judges rated the degree of ecchymoses on a scale of 1 (minimal) to 10 (severe) and were asked their opinion as to which side of the facelift had been treated with Crosseal. These results were compared using statistical analysis. Also on days 3 and 7, patients were examined for seroma or hematoma formation on each side of the face.

RESULTS

Our study demonstrated efficacy of Crosseal in reducing ecchymoses and swelling in all patients. The mean score for ecchymosis on the Crosseal-treated side was 4.5 and on the untreated (control) side was 6.2 (P < .01, Wilcoxon rank sum test). The rate of hematoma or seroma formation was 22% (2 of 9 patients) for the untreated side vs 0% (0 of 9 patients) for the treated side. This did not reach statistical significance (P = .43, Fisher exact test). Small hematomas developed in 2 patients on the control side, which were needle aspirated. There were no known long-term complications from either the use of Crosseal or the rhytidectomy.

CONCLUSION

Crosseal is efficacious in reducing ecchymoses after rhytidectomy.

Multicenter interrater and intrarater reliability in the endoscopic evaluation of velopharyngeal insufficiency

OBJECTIVE

To explore interrater and intrarater reliability (R (inter) and R (intra), respectively) of a standardized scale applied to nasoendoscopic assessment of velopharyngeal (VP) function, across multiple centers.

DESIGN

Multicenter blinded R (inter) and R (intra) study.

SETTING

Eight academic tertiary care centers.

PARTICIPANTS

Sixteen otolaryngologists from 8 centers.

MAIN OUTCOME MEASURES

Raters estimated lateral pharyngeal and palatal movement on nasoendoscopic tapes from 50 different patients. Raters were asked to (1) estimate gap size during phonation and (2) note the presence of the Passavant ridge, a midline palatal notch on the nasal surface of the soft palate, and aberrant pulsations. Primary outcome measures were R (inter) and R (intra) coefficients for estimated gap size, lateral wall, and palatal movement; kappa coefficients for the Passavant ridge, a midline palatal notch on the nasal soft palate, and aberrant pulsations were also calculated.

RESULTS

The R (inter) coefficients were 0.63 for estimated gap size, 0.41 for lateral wall movement, and 0.43 for palate movement; corresponding R (intra) coefficients were 0.86, 0.79, and 0.83, respectively. Interrater kappa values for qualitative features were 0.10 for the Passavant ridge; 0.48 for a notch on the nasal surface of the soft palate, 0.56 for aberrant pulsations, and 0.39 for estimation of gap size.

CONCLUSIONS

In these data, there was good R (intra) and fair R (inter) when using the Golding-Kushner scale for rating VP function based on nasoendoscopy. Estimates of VP gap size demonstrate higher reliability coefficients than total lateral wall, mean palate estimates, and categorical estimate of gap size. The reliability of rating qualitative characteristics (ie, the presence of the Passavant ridge, aberrant pulsations, and notch on the nasal surface of the soft palate) is variable.

Cryptococcal parotitis presenting as a cystic parotid mass: Report of a case diagnosed by fine-needle aspiration cytology

We report the fine needle aspiration (FNA) cytology findings that allowed us to diagnose cryptococcal parotitis in a 31-year-old HIV positive patient. The patient presented with painful and enlarged right parotid gland and a CT scan showed a cystic lesion with rim enhancement. The FNA cytology revealed yeasts of variable size, some of which had bright eosinophilic capsules in Diff-Quik stained preparations. Mucicarmine and silver stain supported the diagnosis of cryptococcal parotitis, which was later confirmed by fungal culture of the aspirated material. We thus show that fungal infection can present as a cystic parotid mass in an immunosuppressed patient and that the diagnosis can be made by FNA cytology.

Comparison of actual pallidotomy lesion location with expected stereotactic location

Accuracy of pallidotomy lesion placement was assessed by comparing actual lesion locations with expected pallidotomy lesion locations based on stereotaxy. Actual and expected lesions were compared in anteroposterior, dorsoventral and lateral axes. In 22 pallidotomies, actual lesion locations were determined using axial MR images. Expected lesion locations were calculated using a starting point derived from preoperative computerized tomography, displacements from the starting point based on microelectrode-driven electrophysiological refinement, and the trajectory angle of the lesioning tract relative to the anterior-posterior commissural plane. On average, actual lesion locations were found 2.91 +/- 2.23 mm posterior, 3.22 +/- 2.49 mm ventral, and 0.05 +/- 1.80 mm lateral compared to the expected lesion location. Discrepancies between the actual lesion and expected lesion locations may be mostly accounted for by posterior and ventral lesion spread from the exposed electrode tip, in-plane and volume averaging effects associated with MR images, and possible brain shifting during surgery. However, despite the remaining small differences between actual and expected lesion location, good clinical outcome of reduced dyskinesias and 'off' time along with UPDRS-based improvement in mentation, motor and activity of daily living measures was observed.

Analysis of pallidotomy lesion positions using three-dimensional reconstruction of pallidal lesions, the basal ganglia, and the optic tract

OBJECTIVE

To assess the position of radiofrequency pallidotomy lesions placed using microelectrode stimulation and cellular recordings in relation to a stereotactically defined starting point. Radiofrequency lesion locations were also evaluated in relation to the putamen, posterior limb of the internal capsule, and optic tract.

METHODS

Magnetic resonance images obtained from 23 patients with Parkinson's disease who underwent pallidotomy at the University of Kansas Medical Center were analyzed. Using computerized techniques, lesion positions in relation to the midcommissural point and a hypothetical starting point were determined. Data segmentation and three-dimensional reconstruction of pallidal lesions, the internal capsule, and the optic tract allowed assessment of lesion position in relation to internal anatomy. Clinical outcome of pallidotomy was assessed using both the Unified Parkinson's Disease Rating Scale and the Dementia Rating Scale.

RESULTS

Pallidal lesions were usually placed anterior and dorsal to the stereotactically defined starting point. The position of pallidal lesions in the men were observed, in four trials, to be significantly more dorsal than the lesions in the women. The outer zone of the lesion was usually adjacent to the internal capsule and the putamen and relatively close to the optic tract. The inner zone of the lesion was usually several millimeters removed from anatomic boundaries of the putamen, internal capsule, and optic tract. Patients achieved favorable outcomes, with reduced dyskinesias and "off" time and improvement of their Parkinsonian symptoms, as evidenced by clinical assessment, the Unified Parkinson's Disease Rating Scale, and the Dementia Rating Scale.

CONCLUSION

Microelectrode stimulation and cellular recordings usually led to a final pallidotomy lesion position that deviated from the stereotactically defined starting point. The pallidotomy lesions in the men were observed to be more dorsal than the lesions in the women. Clinical outcomes were not correlated with either lesion location relative to the starting point or distances between the pallidal lesion and the putamen, internal capsule, or optic tract. Kinesthetically responsive cells may be localized generally more anterior and dorsal to the starting point (within the globus pallidus) and may be grouped variably from patient to patient in relation to other basal ganglia structures. Although the primary lesion site is most likely within the sensorimotor region of the globus pallidus internus, the more dorsal locations of responsive cell groups may indicate that some lesion sites may be localized within the globus pallidus externus.

Magnetic resonance image evaluation of pallidotomy lesions: a volumetric and shape analysis

Determination of acute pallidotomy-produced lesion volumes, pre- and postpallidotomy globus pallidus (GP) volumes, and assessment of lesion shape using magnetic resonance (MR) imaging-based computerized segmentation (contouring) and three-dimensional rendering was made in 19 patients. Magnetic resonance image slice thickness (1.5 mm or 6 mm) was not found to be a significant factor influencing contour-based pallidotomy lesion volume estimates. Previously reported lesion volumes produced by pallidotomy have often been estimated using the ellipsoid volume formula. Using 1.5-mm-thick MR sections, contour-based pallidotomy-produced lesion volumes were significantly different from those volumes estimated by the ellipsoid formula. Globus pallidus volumes, estimated by contouring T2-weighted MR images, were bilaterally similar (2.4 ± 0.37 ml [right]; 2.2 ± 0.45 ml [left]). Postoperative GP volumes were found on the contralateral, unlesioned side to be 2 ± 0.45 ml and on the lesioned side to be 1.25 ± 0.45 ml. Using the contralateral, unlesioned side as a reference volume, approximately 39 ± 14% of the GP was visibly affected on the lesioned side. Seventeen of 18 patients had a favorable outcome with reduced dyskinesias and "off" time with improvement in parkinsonian symptoms.

Analysis of computerized three-dimensional rendering of pallidotomy-produced lesions based on MR images showed no relationship between lesioning technique and resulting lesion shape. Important factors in the volumetric analysis of pallidotomy lesions are identified and allow reasonable assessment of the pallidotomy lesion volume and shape and the extent of the affected GP.