The radiological unknown primary of the head and neck: Recommendations for imaging strategies based on a systematic review

OBJECTIVES

To develop recommendations for the radiological investigation of clinically occult primary cancer in the head and neck.

DESIGN AND SETTING

In accordance with PRISMA guidelines, a search was performed on Medline, Embase and Cochrane library databases to investigate the efficacy of ultrasound guided Fine Needle Aspiration (US FNAC), contrast enhanced CT (CECT), magnetic resonance imaging (MRI) and 18F-fluorodeoxyglucose PET-CT (18F-FDG PET-CT) in the investigation of head and neck squamous cell carcinoma from an unknown primary (HNSCCUP) presenting with a metastatic cervical lymph node (s). The Quality Assessment of Diagnostic Accuracy Studies Version 2 tool and SIGN 50 guidelines were used to assess the risk of bias and quality of the included studies.

PARTICIPANTS

Adult patients presenting with metastatic cervical lymph nodes from a HNSCCUP.

MAIN OUTCOME MEASURES

Utility of different imaging modalities (PET-CT, MRI, CE CT and US FNAC in the management of HNSCCUP).

RESULTS

Twenty-eight studies met inclusion criteria; these were meta-analyses, systematic reviews, prospective and retrospective studies.

CONCLUSIONS

The optimal imaging strategy involves utilisation of various imaging modalities. US FNAC can provide the initial diagnosis and HPV status of the occult primary tumour. CECT and MRI detect up to 44% of occult tumours and guide management. FDG PET-CT is the most sensitive imaging modality for the detection of CUP and should be performed prior to panendoscopy.

UBVRI night sky brightness at Kottamia Astronomical Observatory

Photoelectric observations of night sky brightness (NSB) at different zenith distances and azimuths, covering all the sky, at the Egyptian Kottamia Astronomical observatory (KAO) site of coordinates ϕ = 29° 55.9' N and λ = 31° 49.5' E, were done using a fully automated photoelectric photometer (FAPP). The Bessel wide range system (UBVRI) is used for the first time to observe NSB for three consecutive nights (1-3 August, 2022) under good seeing conditions after the moon sets. The deduced results were taken in photons and converted into mag/arcsec2. The average zenith sky brightness for U, B, V, R and I filters are found to be 20.49, 20.38, 19.41, 18.60 and 17.94 mag/arcsec2 respectively. The average color indices (U-B), (B-V), (V-R) and (R-I), at the zenith are detected to be 0.11, 0.98, 0.81 and 0.66, respectively. We plotted the isophotes of the sky brightness at KAO in U, B, V, R and I colors (filters) and determined both the average atmospheric extinction and sky transparency through these UBVRI filters. The atmospheric and other meteorological conditions were taken into our consideration during the observational nights. The results of the current study illustrate the main impact of the new cities built around KAO on the sky glow over it, and which astronomical observations are affected.

Use of cidofovir in a patient with severe mpox and uncontrolled HIV infection

A 48-year-old man with poorly controlled HIV presented with severe human monkeypox virus (hMPXV) infection, having completed 2 weeks of tecovirimat at another hospital. He had painful, ulcerating skin lesions on most of his body and oropharyngeal cavity, with subsequent Ludwig's angina requiring repeated surgical interventions. Despite commencing a second, prolonged course of tecovirimat, he did not objectively improve, and new lesions were still noted at day 24. Discussion at the UK National Health Service England High Consequence Infectious Diseases Network recommended the use of 3% topical and then intravenous cidofovir, which was given at 5 mg/kg; the patient made a noticeable improvement after the first intravenous dose. He received further intravenous doses at 7 days and 21 days after the dose and was discharged at day 52. Cidofovir is not licensed for use in treatment of hMPXV infection. Data for cidofovir use in hMPXV are restricted to studies in animals. Four other documented cases of cidofovir use against hMPXV have been reported in the USA in 2022, but we present its first use in the UK. The scarcity of studies into the use of cidofovir in this condition clearly shows the need for robust studies to assess efficacy, optimum dosage, timing, and route of administration.

"No drain, no gain": Validation of novel quinsy simulation model

OBJECTIVES

To test a novel, low-cost, home-made model for needle aspiration of PTA.To ascertain whether simulation-based teaching using this model was superior to lecture-based teaching in increasing confidence and reducing anxiety relating to PTA aspiration.To assess whether there was an improvement in outcomes for PTA patients at one hospital following the delivery of a simulation-based training session using our model.

METHODS

We designed two teaching sessions for junior doctors starting work in ENT: a simulation-based teaching session using a low-cost home-made simulation model and a lecture-based teaching session covering the same content. We asked the participants to complete pre- and post-session surveys regarding confidence and anxiety levels and analyzed this data. We also retrospectively collected data over 3 months for patients referred to ENT with suspected PTA and assessed their outcomes. We assessed patient outcomes before and after the delivery of a simulation-based training course using our model.

RESULTS

Simulation-based teaching using our model was shown to be associated with a statistically significant increase in junior doctors' confidence levels. Reaccumulation and reattendance rates for PTA following aspiration were 16.67% and 22.7% respectively preintervention and 0% and 7.14% respectively postintervention.

CONCLUSION

A regular simulation-based teaching session should be introduced using a PTA aspiration model for junior doctors as it leads to increased confidence levels, and reduced reaccumulation and recurrence rates of PTA.

LEVEL OF EVIDENCE

Level 4.

Oligometastatic renal cell carcinoma in the palatine tonsil: successful resection using trans-oral robotic surgery

A man in his mid 70s was referred to head and neck outpatients with bulky tissue in the left tonsillar fossa. He had previously been treated for oligometastatic renal clear cell carcinoma (diagnosed over 15 years prior to disease recurrence) by tonsillectomy and adjuvant radiotherapy (years from primary treatment), followed by trans-oral laser surgery to his oropharyngeal recurrence 3 years later. Examination under anaesthetic and biopsy confirmed further recurrence of disease in the left tonsillar fossa, with parapharyngeal extension, which has not been previously reported in the literature. After discussion in the head and neck and urology multi-disciplinary teams meeting, the patient was offered trans-oral robotic-assisted surgery (TORS) for local control and prevention of progression of a fungating oropharyngeal mass. TORS partial pharyngectomy and left buccal artery myomucosal flap reconstruction were successfully carried out, with preservation of some swallow function.

Emergency airway training: "Who are you going to FONA?"

OBJECTIVES

To demonstrate face and content validity of a home-made simulation model as a training tool for front of neck access (FONA) procedures.

DESIGN

This was a prospective evaluation study, in which experienced otolaryngologists and trainees were recruited to complete 3 tasks using our FONA model.

SETTING

The study was completed during regular simulation training days and international conferences.

PARTICIPANTS

A total of 52 participants completed the questionnaire and were included in the study; 25 were experts and 27 were trainees.

MAIN OUTCOME MEASURES

All participants completed a validated 15-item questionnaire using a 5-point likert scale to assess the model across 4 domains: face validity (FV), global content (GC), task-specific content (TSC) and curriculum applicability (CTR).

RESULTS

There were no statistically significant differences between the groups ratings for FV, GC, TSC or CTR (P = .76, .13, .4 and .67, respectively). The model achieved a median FV of 4 (IQR 4-5) with the agreement of experienced and trainee groups (68.9% and 92%, respectively). The median GC validity score was 5 (IQR 4-5) with the agreement of 87.6% and 98.4% in respected groups. The model achieved a median TSC of 4.8 (IQR 4-5) with the agreement of 54.5% and 99% in respected groups. The median CTR score was 5 (IQR 4-5) with the agreement of 54.4% and 100% in respected groups.

CONCLUSION

Our home-made FONA model achieved face and content validity for training and is safe and affordable for teaching basic front of neck access skills to otolaryngology trainees.

Swallowing Outcomes in 7 Patients Following Endoscopic Cricopharyngeal Myotomy With Primary Closure

Cricopharyngeal spasm and pharyngeal pouch can result in severe dysphagia symptoms that can have a significant impact on a patient's quality of life. Several surgical interventions have been demonstrated including balloon dilatation, botox injection, and open and endoscopic cricopharyngeal myotomy. The aim of this case series is to describe our technique for endoscopic cricopharyngeal myotomy and compare pre- and postoperative swallowing outcomes using objective swallowing questionnaires in a small series of patients. Seven patients diagnosed with cricopharyngeal spasm or grade 1 pharyngeal pouch on barium swallow were prospectively observed. MD Anderson Dysphagia inventory (MDADI) and Dysphagia handicap index (DHI) were given to patients before and after their operation. All patients underwent the same surgical technique with the cricopharyngeal bar divided and the defect closed with dissolvable sutures. Mean inpatient stay was 7 days (range 1-8) and mean time to resumption of soft diet was 4 (range 1-7) days. All patients resumed oral diet before discharge. MDADI scores showed improvement across all domains, however only the emotional score achieved statistical significance (P = .04). Dysphagia handicap index scores showed a statistically significant improvement across functional, emotional, and total domains. Postoperative chest infection treated with oral antibiotics occurred in 3 patients (43%) and no other complications were documented. In conclusion, endoscopic cricopharyngeal myotomy with primary sutured endoscopic closure can result in a significant benefit to patient's swallowing symptoms, emotional well-being, and quality of life.

Feasibility of Free Flap Reconstruction Following Salvage Robotic-Assisted Resection of Recurrent and Residual Oropharyngeal Cancer in 3 Patients

INTRODUCTION

Human papilloma virus (HPV)-positive oropharyngeal cancer carries a good prognosis when managed with primary chemoradiotherapy. However, the dramatically increasing rate of this disease means more patients are now developing recurrence, with surgery remaining the mainstay of treatment. Despite this, there is no agreed technique for excision of recurrent oropharyngeal cancer.

OBJECTIVE

We describe the transoral robotic technique employed by our head and neck multidisciplinary team (MDT) in the management of patients with recurrent HPV positive oropharyngeal cancer and assess their symptom severity using quality of life and swallowing questionnaires.

METHOD

Three (2 males:1 female, mean age 60.7 years) patients with recurrent or residual p16 positive oropharyngeal cancer following radical chemoradiotherapy were identified. All patients underwent selective neck dissection, tracheostomy, and transoral robotic surgery (TORS)-assisted partial oropharyngeal resection with the resultant defect closed with a robotic assisted radial forearm free flap (RFFF). Patient quality of life, symptom severity, and swallowing were assessed pre- and postoperatively using the University of Washington Quality of Life score and MD Anderson Dysphagia Index (MDADI).

RESULTS

Histopathological examination revealed complete clearance of the primary lesion in all cases. Two patients made uneventful recoveries, while one patient developed a chest infection and tracheocutaneous fistula managed conservatively. Mean inpatient stay was 15 days (range 8-27). University of Washington Quality of Life and MDADI scores showed a mild improvement in symptoms following surgery.

CONCLUSION

Surgical management of recurrent oropharyngeal cancer remains a technical challenge; however, MDT discussion and judicious use of TORS oropharyngeal resection and RFFF can result in good oncological and quality of life outcomes with acceptable postoperative complications and symptoms.

Novel Energy Devices in Head and Neck Robotic Surgery - A Narrative Review

The advent of trans-oral robotic surgery (TORS) has facilitated removal of tumors previously deemed unresectable, by providing access to the deep structures of the head and neck. Despite this, the wider dissemination of TORS has been restricted due to issues with line of access, as the da Vinci robot was never designed with head and neck surgery in mind. Flexible instruments and novel energy delivery devices offer great potential in overcoming some of the existing challenges surrounding TORS. This review aimed to summarize the existing literature surrounding energy delivery in TORS and highlight areas of future innovation. MEDLINE was searched for studies relating to energy delivery in TORS in November 2019. The existing literature surrounding monopolar and bipolar electrocautery, LASER (CO₂, Tm:YAG and blue LASER), Ligasure and Harmonic was reviewed. Additionally, the latest iteration of the da Vinci; the SP, and the FLEX robot were evaluated as novel methods of energy delivery in TORS. Overall, these novel energy devices and robotic systems are predicted to further improve energy delivery to the head and neck. The use of flexible LASER in particular is well substantiated in the literature. This has the potential to achieve treatment de-escalation, based on the excellent outcomes demonstrated for disease-free margins and post-operative morbidity.

Creating a Validated Simulation Training Curriculum in Otolaryngology

Purpose of Review

Simulation-based training is an integral component of surgical training. It allows practice of technical skills within a safe environment without compromising patient safety. This article seeks to review current virtual and non-virtual reality simulation models within the literature and review their validation status.

Recent Findings

Many simulation models exist within otolaryngology and are currently being used for education. New models are also continuously being developed; however, validity should be proven for the models before incorporating their use for educational purposes. Validity should be determined by experts and trainees themselves.

Summary

A validated simulation curriculum should be incorporated within the otolaryngology training programme. A curriculum based on the current training programme at our institution serves as an exemplar for local adoption.

Intraparotid lymph node metastasis from a nasal septal carcinoma: an unusual source of the unknown primary

Metastatic disease to the parotid lymph nodes typically occurs secondary to head and neck and cutaneous squamous cell carcinomas (SCC). Nasal septal SCC is an exceedingly rare primary cancer that rarely spreads to regional lymph nodes. A 39-year-old man presented with left-sided cervical lymphadenopathy and nasal polyposis. Initial assessment suggested that he may have a head and neck SCC of unknown origin with nodal deposits in close proximity to the parotid gland. Cross-sectional imaging did not reveal the primary source. After further review of imaging and examination under anaesthetic, the primary SCC was found on the left nasal septum. The patient ultimately required a type 1 craniofacial resection and adjuvant chemoradiotherapy to treat the disease. Thorough investigation of the 'unknown primary' SCC including cross-sectional imaging and endoscopic examination is essential for the diagnosis of rare and unusual primary SCCs. Nasal septal SCC can be successfully managed with combined modality treatment in the form of surgical resection and chemoradiotherapy.

Survival outcomes for head and neck cancer patients with N3 cervical nodal metastases

BACKGROUND

Management of metastatic N3 nodal disease from primary head and neck squamous cell carcinoma (HNSCC) is controversial. Recently, there has been a move to observation of the neck for those who achieve complete response (CR) after chemoradiotherapy (CRT). We sought to determine survival outcomes for N3 nodal disease, particularly for patients with human papilloma virus (HPV)-positive HNSCC.

METHODS

We carried out a systematic search of MEDLINE and Embase for articles between 01/2008 and 12/2017. Articles on N3 nodal disease in HNSCC patients treated with CRT or surgery + adjuvant RT/CRT were included if they reported on oropharyngeal or HPV+ subgroups. Local control (LC), nodal control (NC), distant metastasis-free survival (DMFS), disease-free survival (DFS) or overall survival (OS) was assessed.

RESULTS

Nine studies met the inclusion criteria. Eight of these studies (N = 5304) allowed further comparison: 4 were on CRT, 2 on surgery + RT/CRT and 2 on both. Four of these eight studies and the remaining included study reported on residual nodal disease on histology after neck dissection (ND) following CRT. Patients treated with CRT achieved LC rates of 77%-94% at 2-3 years; those who had a CR had LC of >90%. Better NC was noted in patients who achieved a CR. Three-year OS was better for HPV+ HNSCC (range, 55.2%-81%). Patients with CR had better survival outcomes (DMFS 77% at 3 years vs 69.8% for HPV+; OS 68.9% at 3 years vs 55.2% for HPV+). Primary surgery demonstrated similar survival for HPV+ vs HPV- and better survival in oropharyngeal cancers. Five-year DFS rates varied from 30% to 87%, and OS from 26.6% to 84%. For patients with non-CR, positive histology rates varied from 27.3% to 100%, with average positive histology rates of 27.3% in HPV+ patients with non-CR vs 60% for HPV- patients with non-CR.

CONCLUSION

The current literature does not support the de-escalation of treatment with HPV- N3 disease. Observation of HPV+ patients who achieve a CR post-CRT is reasonable but further prospective studies are required given the heterogeneity and risk of bias within these current studies. Planned ND should remain standard of care for non-CR cohort.

Transoral Robotic Surgery for Oropharyngeal Squamous Cell Carcinoma: Improving Function While Maintaining Oncologic Outcome

The improved survival in patients with HPV-positive (human papilloma virus) oropharyngeal squamous cell carcinoma as compared with HPV-negative disease calls for treatment that preserves quality of life, particularly a functional swallow. There are several trials currently assessing treatment de-escalation in terms of less invasive transoral robotic surgery, reduced-dose radiotherapy, and omission of chemotherapy in this disease cohort. It is important for head and neck oncology surgeons to stay abreast of developments in this area to offer their patients the most up-to-date treatment and consider recruiting patients to trials at their institutions. For this purpose, we provide a summary of current trials and associated challenges in managing a disease with fast-evolving treatment algorithms.

Specialty Showcase Days: Can Specialist Careers Workshops Improve The Consideration Of ENT For Medical Students?

OBJECTIVE

We hypothesize that poor consideration of specialist surgery is due to a lack of exposure to information about careers and practice itself. Ear, Nose, and Throat (ENT) surgery is given little weight in medical school curricula, despite ENT problems being extremely common. Our objective is to assess whether a specialty showcase day was sufficient to boost informed consideration of this career.

DESIGN

We designed a half-day course involving an interactive careers workshop exploring ENT as a specialty choice, alongside simulation stations of commonly presenting ENT problems led by ENT doctors. We used pre- and post-course evaluation sheets to explore factors that encourage and discourage students from surgical careers and perceptions of ENT.

SETTING

A large proportion of UK medical schools do not offer ENT placements, and of those that do, nearly half are not compulsory. This leaves students unaware of ENT as a career option and unclear about what an ENT career comprises. Our half-day course took place in the simulation suite at St Mary's Hospital, London.

PARTICIPANTS

Medical students were mainly in their third year of study and had aspirations towards a variety of surgical and non-surgical careers, with a minority aspiring towards ENT before the course.

RESULTS

Our results demonstrate that all students found the session useful and had a much better understanding of ENT practice, with almost all students leaving more likely to consider a career in ENT.

CONCLUSION

We would like to repeat this session in different student year groups and compare their perceptions with our results. We find our results a good case for including informative careers workshops as part of medical school teaching. We pose that interactive workshops exploring specialist surgical careers are a valid way to enable students in making informed career decisions - particularly in specialties that are under-represented at medical school.

Ventilation tube insertion simulation: a literature review and validity assessment of five training models

OBJECTIVE

The objective of this study was to identify and investigate the face and content validity of ventilation tube insertion (VTI) training models described in the literature.

DESIGN

A review of literature was carried out to identify articles describing VTI simulators. Feasible models were replicated and assessed by a group of experts.

SETTING

Postgraduate simulation centre.

PARTICIPANTS

Experts were defined as surgeons who had performed at least 100 VTI on patients. Seventeen experts were participated ensuring sufficient statistical power for analysis.

MAIN OUTCOME MEASURES

A standardised 18-item Likert-scale questionnaire was used. This addressed face validity (realism), global and task-specific content (suitability of the model for teaching) and curriculum recommendation.

RESULTS

The search revealed eleven models, of which only five had associated validity data. Five models were found to be feasible to replicate. None of the tested models achieved face or global content validity. Only one model achieved task-specific validity, and hence, there was no agreement on curriculum recommendation.

CONCLUSIONS

The quality of simulation models is moderate and there is room for improvement. There is a need for new models to be developed or existing ones to be refined in order to construct a more realistic training platform for VTI simulation.

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.

Utilisation, Reliability and Validity of Clinical Evaluation Exercise in Otolaryngology Training

OBJECTIVES

To investigate the utilisation, reliability and validity of clinical evaluation exercise (CEX) in otolaryngology training.

DESIGN

Retrospective database analysis.

SETTING

Online assessment database.

PARTICIPANTS

We analysed all CEXs submitted by north London core (CT) and speciality trainees (ST) in otolaryngology from 2010 to 2013.

MAIN OUTCOME MEASURES

Internal consistency of the 7 CEX items rated as either O: outstanding, S: satisfactory or D: development required. Overall performance rating (pS) of 1-4 assessed against completion of training level. Receiver operating characteristic was used to describe CEX sensitivity and specificity. Overall score (cS), pS and the number of 'D'-rated items were used to investigate construct validity.

RESULTS

One thousand one hundred and sixty CEXs from 45 trainees were included. CEX showed good internal consistency (Cronbach's alpha= 0.85). CEX was highly sensitive (99%), yet not specific (6%). cS and pS for ST was higher than CT (99.1% ± 0.4 versus 96.6% ± 0.8 and 3.06 ± 0.05 versus 1.92 ± 0.04, respectively P < 0.001). pS showed a significant stepwise increase from CT1 to ST6 (P < 0.001). In contrast, cS only showed improvement up to ST4 (P = 0.025). The most frequently utilised item 'management and follow-up planning' was found to be the best predictor of cS and pS (rs  = +0.69 and +0.21, respectively).

CONCLUSION

CEX is reliable in assessing early years otolaryngology trainees in clinical examination, but not at higher level. It has the potential to be used in a summative capacity in selecting trainees for ST positions. This would also encourage trainees to master all domains of otolaryngology clinical examination by end of CT.

Utilisation and outcomes of case-based discussion in otolaryngology training

OBJECTIVES

To assess the reliability, validity and outcomes of Case-based Discussion (CBD) in otolaryngology training.

DESIGN

Retrospective database analysis.

SETTING

National electronic database.

PARTICIPANTS

North London otolaryngology trainees.

MAIN OUTCOME MEASURES

We tested the tool's reliability along with its capacity to denote trainee progress. A score was calculated (cS) and compared across core (CT) and specialty trainees (ST) at all levels. The number of items rated as "development required" (D) was also examined.

RESULTS

One thousand four hundred and fifty-six CBDs were submitted by 46 trainees from 2007 to 2013, averaging 13.6 per trainee per year. Items relating to knowledge, management and judgement were more popular (98% usage), and better predictors of cS compared to other parameters (rs: +0.74, +0.70 and +0.72, respectively). CBD was found to be reliable (Cronbach's α = 0.848) and highly sensitive (99%), yet not specific. cS was significantly higher in ST than CT (95.3% ± 0.6 versus 88.7% ± 1.3). pS showed a similar pattern (3.15 ± 0.4 versus 2.0 ± 0.05) (P < 0.001). cS and pS increased from CT1 to ST8 (rs: +0.60 and +0.34, respectively). The number of D-rated items decreased with increasing year of training.

CONCLUSION

Case-based discussion is a reliable and valid tool in otolaryngology training. It is highly sensitive but not specific. Trainees should be encouraged to use it at all levels.

Construct validity of the ovine model in endoscopic sinus surgery training

OBJECTIVES/HYPOTHESIS

To demonstrate construct validity of the ovine model as a tool for training in endoscopic sinus surgery (ESS).

STUDY DESIGN

Prospective, cross-sectional evaluation study.

METHODS

Over 18 consecutive months, trainees and experts were evaluated in their ability to perform a range of tasks (based on previous face validation and descriptive studies conducted by the same group) relating to ESS on the sheep-head model. Anonymized randomized video recordings of the above were assessed by two independent and blinded assessors. A validated assessment tool utilizing a five-point Likert scale was employed. Construct validity was calculated by comparing scores across training levels and experts using mean and interquartile range of global and task-specific scores. Subgroup analysis of the intermediate group ascertained previous experience. Nonparametric descriptive statistics were used, and analysis was carried out using SPSS version 21 (IBM, Armonk, NY).

RESULTS

Reliability of the assessment tool was confirmed. The model discriminated well between different levels of expertise in global and task-specific scores. A positive correlation was noted between year in training and both global and task-specific scores (P < .001). Experience of the intermediate group was variable, and the number of ESS procedures performed under supervision had the highest impact on performance.

CONCLUSIONS

This study describes an alternative model for ESS training and assessment. It is also the first to demonstrate construct validity of the sheep-head model for ESS training.

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.

Antivirals for Idiopathic Sudden Sensorineural Hearing Loss

Objectives:

Determine the effectiveness and side effect profile of antivirals in the treatment of idiopathic sudden sensorineural hearing loss (ISSHL).

Methods:

We systematically searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 5), PubMed, EMBASE, CINAHL, and other databases to June 12, 2012. Reference lists of identified studies for further trials were also scanned. Selection criteria: Randomized controlled trials (RCTs) comparing different antivirals versus placebo (both with or without other treatment). Two authors independently extracted data. Meta-analysis was considered inappropriate and ultimately not possible due to differing treatment protocols and differing inclusion criteria and outcome measures between studies.

Results:

Four RCTs (257 participants) were identified. Two trials compared the addition of intravenous acyclovir with a steroid (prednisolone). Neither demonstrated any hearing improvement with ISSHL. Another showed no benefit with the addition of valacyclovir to prednisolone on hearing outcome. Comparing intravenous acyclovir plus hydrocortisone with hydrocortisone alone, the final trial did not show any statistically significant difference between groups. Even though no meta-analysis was possible, evidence from 4 RCTs has demonstrated no statistically significant advantage in the use of antivirals in the treatment of ISSHL.

Conclusions:

There is no evidence to support the use of antiviral drugs in the treatment of ISSHL. Further randomized controlled trials are needed for adequate meta-analysis to be performed to reach definitive conclusions. A uniform definition of ISSHL should also be established, together with what constitutes adequate recovery.

Scar Cosmesis: Assessment, Perception, and Impact on Body Image and Quality of Life—A Systematic Review

Objectives:

(1) Review current validated scar assessment tools and (2) describe the impact of scar cosmesis perception on body image and quality of life.

Methods:

Three independent reviewers performed comprehensive searches and identified 680 English language studies published between 1950 and 2014 (data sources: Medline, EMBASE, Cochrane Library, and Web of Science). Literature including case series, cross sectional studies, meta-analyses, and reviews was then screened and selected according to strict inclusion/exclusion criteria.

Results:

Scar assessment: Review included Vancouver Scar Scale, Patient and Observer Scar Assessment Scale, Manchester Scar Scale, Wound Evaluation Scale, and Western Scar Index. Validated qualitative assessment tools were clinically more useful than their quantitative counterparts. Patient perception input increased validity. Subjective satisfaction rating had little correlation with objective assessment of scarring. Perceptions: The size of defect did not correlate with impact, however location and visibility did. Psychosocial distress correlated with subjective severity. The large impact on physical and psychosocial quality of life (ascertained by generic and symptom-specific validated assessment tools, as well as qualitative studies with interpretive phenomenologic analysis) is not to be overlooked.

Conclusions:

Careful selection of scar assessment tools is vital to gauge severity and plan further treatment. No consensus exists on the single most appropriate tool. A validated assessment tool is important in the assessment of scarring. There is a tendency to underestimate and thereby worsen the impact of scarring on patients’ quality of life. Further studies are required, particularly in the context of thyroid surgery.

Learning Curves of Syllabus Head and Neck Procedures; Monitoring Trainees Performance and Progress

Objectives:

Otolaryngology trainees undergo regular procedure-based assessments (PBAs) throughout training; however, these are rarely used to analyze performance and monitor progress. The aim of the study was to validate PBA in assessing otolaryngology trainees in head and neck surgery (HNS) and identify the pattern by which trainees progress in syllabus HNS procedures.

Methods:

We analyzed all PBAs from North-Thames otolaryngology trainees, during early years or core (CT) and more senior specialty training (ST) years from 2008 to 2013. We used mean scores and standard deviations to draw procedure-specific learning curves. The PBA tool is procedure-specific. It is produced by the Joint Committee of Surgical Training and is used in assessing UK surgical trainees performance in all specialties. The tool is composed of 6 main domains: consent, planning, preparation, exposure/closure, technique, and postoperative care.

Results:

A total of 3306 PBAs from 46 trainees were identified; 1806 were HNS. PBA reliability was shown by high internal consistency (Cronbach’s Alpha:0.921) and discriminated between grades (CT and ST, Mann-Whitney U: P < .001) and levels (CT1-2 and ST3-8, Kruskal Wallis: P < .001). All domains correlated with overall performance, but the best predictor was technical skills. A total of 7 HNS procedures achieved sufficient power to draw learning curves (n > 100, 90% confidence): tonsillectomy: 309, pan-endoscopy: 186, microlaryngoscopy: 174, thyroidectomy: 152, tracheostomy: 137, adenoidectomy: 129, and lymphadenectomy: 101.

Conclusions:

Procedure-specific learning curves can be drawn to set milestones and deliver targeted training. Curves of various HNS procedures plateau at different stages in training. This method is more robust and should replace arbitrary numbers as a measure of competence.

Learning Curves of Syllabus Otological Procedures: Monitoring Trainee Progress and Understanding Competence

Objectives:

Otolaryngology trainees in the United King-dom undergo regular procedure-based assessments (PBAs) throughout training, however, these are rarely used to monitor progress or measure competence. The assessment tool is procedure specific and produced by the Joint Committee of Surgical Training. It consists of 6 domains: consent, planning, preparation, exposure/closure, operative technique, and postoperative care. The aim of the study was to validate PBA in assessing otolaryngology trainees and to identify the level and pace at which trainees show competence in syllabus otological procedures.

Methods:

This is a longitudinal study from October 2008 to October 2013. We analyzed all PBAs submitted by North-Thames London otolaryngology trainees, including junior or core trainees (CT) and senior specialty trainees (ST). We calculated and used the overall score (oS) mean and standard deviations to draw procedure-specific learning curves for common otological operations.

Results:

A total of 3306 PBAs from 46 trainees were analyzed, 621 were otological. PBA was highly reliable showing internal consistency (Cronbach’s Alpha: 0.921) and discriminated between different grades (CT and ST, Mann-Whitney- U: P < .001) and levels within each grade (CT1-2 and ST3-8, Kruskal Wallis: P < .001). All domains contributed to the calculated score and the most predictive was operative technique. Three procedures achieved sufficient power (n > 100, 90% confidence) to draw learning curves. The procedures were: ventilation tubes, tympanoplasty, and mastoidectomy.

Conclusions:

PBA is valid for assessing ENT trainees. Procedure-specific competency curves can be drawn to set milestones and deliver targeted training. They can help understand the pace and level at which trainees master individual otological procedures replacing arbitrary numbers currently in use.

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.

Anatomical margins of uncinectomy in endoscopic sinus surgery

BACKGROUND

Endoscopic sinus surgery is a common and generally safe ENT procedure. Orbital injury is a rare but devastating complication. The distance between the uncinate process and the lamina papyracea is the safety margin to avoid entering the orbital cavity and has not been measured previously.

METHODS

The authors reviewed 330 consecutive coronal CT scans of the paranasal sinuses to measure this distance and identify variation.

RESULTS

The distance can be as narrow as 0.1 mm and varies between sides. An air cell lateral to the uncinate is not uncommon; it increases the distance considerably p < 0.001 but is frequently unilateral (22%). Gender does not have an effect on this distance p = 0.90.

CONCLUSION

It is essential to carefully examine the area on a CT scan especially when performing front-to-back uncinectomy during endoscopic sinus surgery. The variation between the right and left sides should be considered to avoid unsafe assumptions.

Safety trial of Floseal(®) haemostatic agent in head and neck surgery

INTRODUCTION

Floseal® (Baxter, Hayward, CA, US) can be of value in reducing blood loss and haematoma rates. The manufacturer’s warnings include allergic reaction, poor wound healing and intravascular thrombosis. We aimed to determine whether Floseal® is safe to use in various head and neck surgery (HNS) procedures.

METHODS

A prospective trial was conducted using Floseal® in 42 various consecutive head and neck surgery procedures. Adverse incidents were used as the main outcome measure, including allergic reaction, wound breakdown, wound infection and thrombosis. Secondary outcome measures included haematoma formation, hospital stay, drain times and output.

RESULTS

No adverse incidents were recorded in the trial period. Two patients developed haematomas and required surgical exploration where a bleeding vessel was identified and dealt with.

CONCLUSIONS

Floseal® is safe to be used in head and neck surgery with no adverse effects. A larger number and a control group are required to ascertain its value in reducing blood loss, haematoma formation, drain usage and hospital stay.

Robotic-Assisted Thyroidectomy: The First UK Experience

Objective: To review our initial experience of robotic thyroidectomy, describe modifications for a Western population, and establish a robust framework for implementation in the UK.

Method: Prospective feasibility study (n = 15) performed in a tertiary referral center over 18 months. Procedure-related measures included conversions to open, operative time and the learning curve. Patient-related measures included biometrics, trans-axillary dissection area, voice and swallow function, pain, scar cosmesis, and global quality of life using validated assessment tools.

Results: Thyroid lobectomy was performed in 15 patients with no conversions to open. The average BMI was 25.6 (range, 19-35). Mean operative time was 200 minutes. A larger trans-axillary dissection area increased the total operative time. The average size of the excised nodule was 2.5 cm (range, 1.5-6.5 cm). All patients were discharged within 24 hours. No permanent complications occurred. There was 1 temporary brachial plexus neuropraxia which resolved within 5 days. The mean follow-up time was 7 months. The mean scar cosmesis score significantly improved from 56% on day 1 postoperatively to 98% at 12 months ( P = .01).

Conclusion: Robotic thyroidectomy is feasible for selected patients in the UK. The primary advantage is avoidance of a neck scar. Optimal arm position which minimizes brachial plexus injury is crucial. Validated training methods are necessary for safe adoption. A randomized clinical study will establish the clinical efficacy compared with conventional surgery.

Validating the Sheep Model in Rhinology Skills Training

Objective: 1) Investigate face and content validity of the sheep model in operative rhinology skills training. 2) Investigate the applicability and transferability of skills acquired in otolaryngology training curriculum.

Method: An evaluation study conducted in February 2012. Fifteen otolaryngology trainees (level: 3-5) and 5 experts completed 9 operative rhinology tasks on a pre-prepared sheep model and assessed face and content validity using a Likert scale across 20-item questionnaire. Participants also evaluated the model in teaching individual tasks and globally as training tool.

Results: The model achieved face validity of 4.1 with no significant difference between expert and intermediate groups (4.0 and 4.3, Wilcoxon P = .14). Content validity score was 4.2, with experts scoring higher than the intermediate group (4.0 and 4.5, Wlicoxon P = .043). The highest scoring skills were improving hand-eye-coordination and operative skills (4.7 and 4.6), and the worst was anatomy teaching (3.4). The highest scoring tasks were foreign-body removal and cerebrospinal fluid leak repair (4.4 and 4.0), and the worst was middle-meatal-antrostomy and septoplasty (3.3 and 3.6). Two data points were missing (99.5% completion). All agreed on transferability, incorporation into curriculum, and recommending to colleagues (4.2, 4.5, and 4.4).

Conclusion: The sheep model achieved face and content validity and is recommended by experts and trainees for teaching rhinology skills. Advantages include availability, realism, and applicability of acquired skills in rhinology procedures. The model achieved >4/5 Likert scale in teaching endoscopic examination, foreign-body removal, cerebrospinal fluid leak repair, and sphenopalatine artery ligation.

Antivirals for idiopathic sudden sensorineural hearing loss

BACKGROUND

Idiopathic sudden sensorineural hearing loss (ISSHL) is characterised by sudden loss of hearing of cochlear or retro-cochlear origin without an identifiable cause. Antivirals are commonly prescribed, but there is no consensus on the treatment regimen or their effectiveness.

OBJECTIVES

To determine the effectiveness and side effect profile of antivirals in the treatment of ISSHL.

SEARCH METHODS

We systematically searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 5), PubMed, EMBASE, CINAHL and other databases to 12 June 2012. We also scanned the reference lists of identified studies for further trials.

SELECTION CRITERIA

Randomised controlled trials comparing different antivirals versus placebo (both with or without other treatment).

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data, met to resolve disagreements and contacted study authors for further information. We assessed study risk of bias independently. We considered meta-analysis inappropriate and ultimately not possible due to differing treatment protocols of varying dose and duration, together with differing inclusion criteria and outcome measures between studies. The results of each study are reported individually.

MAIN RESULTS

We included four randomised trials (257 participants). The overall risk of bias in the included studies was low. Two trials compared the addition of intravenous acyclovir to a steroid (prednisolone). One included 43 participants, the other 70 patients. Neither demonstrated any hearing improvement with ISSHL. Another (84 patients) did not show any statistically significant difference between groups with the addition of valacyclovir to prednisolone (compared to steroid plus placebo) with respect to change in pure-tone audiogram. Comparing the addition of intravenous acyclovir to hydrocortisone with hydrocortisone alone, the final trial did not show any statistically significant difference between groups (60 patients). No trial documented any serious adverse effects related to the use of antiviral treatment. One study reported slight to moderate nausea equally in the acyclovir and placebo groups (one patient in each). Another reported insomnia, nervousness and weight gain with valacyclovir (number not specified). Even though no meta-analysis was possible, evidence from the four RCTs has demonstrated no statistically significant advantage in the use of antivirals in the treatment of ISSHL.

AUTHORS' CONCLUSIONS

There is currently no evidence to support the use of antiviral drugs in the treatment of ISSHL. The four trials included in this review were, however, small and with a low risk of bias. Further randomised controlled trials with larger patient populations, using standardised inclusion criteria, antiviral regimes and outcome measures, are needed in order for adequate meta-analysis to be performed to reach definitive conclusions. A uniform definition of ISSHL should also be established, together with what constitutes adequate recovery.

Specific versus Generic Outcome Measure in Adeno-Tonsil Pathology

Objective: 1) Compare the disease specific T14 outcome measure score to the generic quality of life CHQPF28 score in children with adenotonsillar pathology. 2) Investigate the relation of number of episodes of tonsillitis and presence of sleep apnea to both scores.

Method: Cross-sectional study carried out in 2011. Parents of 146 children undergoing tonsillectomy or adenotonsillectomy at 3 London hospitals completed both T14 and CHQPF28 questionnaires. We also inquired about the number of episodes of acute tonsillitis a child suffers from each year and whether they have obstructive sleep apnea (OSA). Their scores were analyzed to measure the relation between the 2 tests and investigate the usefulness of the T14 as a measure of the impact of adenotonsillar pathology on children’s health.

Results: The T14 infective and total score correlated well with the number of episodes of tonsillitis children have (Spearman rs = 0.5 and rs = 0.64). The obstructive element differentiated between children with OSA and no OSA ( t test P < .001). However, the overall T14 score, its infective and obstructive components, did not correlate well with the children CHQPF28 scores (rs = −0.01, P = .95; rs = −0.08, P = .53; rs = −0.09, P = .47; respectively).

Conclusion: The T14 performs well in predicting patients with significant adenotonsillar pathology with its infective and obstructive component and is a good outcome measure for treatment. It is not a good indicator of the impact of adenotonsillar disorder on the child’s overall well-being as a static measure when compared to a generic quality of life test.

Robotic Parathyroidectomy: A Prospective Case Control Study

Objective: 1) To assess the clinical efficacy and cost-effectiveness of the robotic approach compared with conventional targeted minimally invasive parathyroidectomy. 2) To evaluate whether the absence of a neck scar associated with the robotic approach offers any advantage(s) over conventional targeted minimally invasive parathyroidectomy. 3) To compare patient satisfaction between the 2 techniques.

Method: Prospective case control study of 30 patients that underwent targeted parathyroidectomy over 4 years (May 2009-February 2012) in a tertiary referral endocrine center. Fifteen patients had a robotic and 15 an endoscopic approach. Outcomes assessed included operative time, blood loss, biochemistry, pain, scar cosmesis, voice, quality of life, and complications.

Results: In all cases the parathyroid adenoma was successfully removed. There was 1 robotic conversion. Mean robotic operative time was approximately double that of the conventional approach. There were no significant differences in mean blood loss. Initial normalization of PTH and adjusted serum calcium levels occurred in 29 cases. The mean visual analogue score (VAS) for scar cosmesis was superior in the robotic cohort from 2 weeks (84% vs 65%, P < .01) to 1 year (94% vs 62%, P < .01). Postoperative VAS pain scores were similar in both groups ( P < .05). All EQ5 HD quality of life parameters significantly improved in both cohorts ( P < .05).

Conclusion: The robotic approach is a feasible “scar-less in the neck” alternative to conventional targeted minimally invasive parathyroidectomy with a superior cosmetic outcome. However, this novel approach is not suitable for all patients and appropriate patient selection is vital. Finally, the high cost of robotic parathyroidectomy currently hinders its more widespread use.