To Pack a Nose: High-Fidelity Epistaxis Simulation Using 3D Printing Technology

BACKGROUND: Initial management and stabilization of epistaxis is managed by a diverse offset of clinical providers with variable levels of training. OBJECTIVE: To determine the anatomic and clinical fidelity and ease of use of a novel simulator for the training and assessment of epistaxis management skills. STUDY DESIGN: Qualitative Research Study using expert questionnaire\u27s for validation of a newly developed simulator. METHODS: We performed a quasi-experimental intervention with 22 otolaryngology faculty and 10 trainees who independently evaluated the simulator. Data were collected in three phases: phase 1 (preliminary evaluation), phase 2 (final expert evaluation), and phase 3 (trainee evaluation). We designed a three-dimensional (3D) printed model from a de-identified patient computed tomography scan. Artificial blood was circulated through catheters to simulate bleeding from three distinct sites (sphenopalatine, Kiesselbach\u27s plexus, and anterior ethmoid). Four domains were assessed: Physical and anatomic attributes, Realism of experience, Ability to perform tasks, and Value and clinical relevance. Internal structure and validity were measured with Cronbach\u27s alpha and item outfit mean-square statistics. RESULTS: Results from otolaryngology faculty showed very high median ratings for Value of the simulator as a training tool (4.0/4) and high ratings for Relevance to practice (4.0/4), and realism of experience (4.0/4). Responses from otolaryngology trainees demonstrated high value for clinical training (4.0/4) and high likelihood to recommend use for future trainees (4.0/4). Confidence in managing epistaxis before (1.0/4) and after (3.0/4) simulator use was statistically improved (P = .03). CONCLUSIONS: Using 3D printing technology, we created a novel simulator for epistaxis management. Preliminary evidence suggests the model is cost-effective, anatomically realistic, relevant to trainees\u27 educational needs, and valuable as a training tool. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:747-753, 2022

Expanding use of osseointegrated implantation using 3-dimensional surgical planning: a paradigm shift in dental reconstruction

Medical modeling and 3-dimensional (3D) virtual surgical planning represent a rapidly expanding, technological advancement especially useful in complex mandibular or maxillary defects in head and neck reconstruction. With utilization of 3D surgical planning, the reconstructive surgeon can initiate dental rehabilitation during the primary surgery with osseointegrated implants (OI), streamlining a typically lengthy process to full oral rehabilitation. Careful patient selection is important to optimize outcomes with immediate OI, and factors to consider during the evaluation process include pathology, prognosis, anticipated defect, dental status, donor site availability, and patient motivation and resources. Synthesizing this information and developing a reconstructive plan with a multidisciplinary team approach is critical to expedite dental rehabilitation for select patients. A review of relevant literature and our surgical planning algorithm for selecting candidates for immediate OI is provided, along with our experience using this decision algorithm in a uniquely complex clinical case

Delivery system can vary ventilatory parameters across multiple patients from a single source of mechanical ventilation.

BackgroundCurrent limitations in the supply of ventilators during the Covid19 pandemic have limited respiratory support for patients with respiratory failure. Split ventilation allows a single ventilator to be used for more than one patient but is not practicable due to requirements for matched patient settings, risks of cross-contamination, harmful interference between patients and the inability to individualize ventilator support parameters. We hypothesized that a system could be developed to circumvent these limitations.Methods and findingsA novel delivery system was developed to allow individualized peak inspiratory pressure settings and PEEP using a pressure regulatory valve, developed de novo, and an inline PEEP 'booster'. One-way valves, filters, monitoring ports and wye splitters were assembled in-line to complete the system and achieve the design targets. This system was then tested to see if previously described limitations could be addressed. The system was investigated in mechanical and animal trials (ultimately with a pig and sheep concurrently ventilated from the same ventilator). The system demonstrated the ability to provide ventilation across clinically relevant scenarios including circuit occlusion, unmatched physiology, and a surgical procedure, while allowing significantly different pressures to be safely delivered to each animal for individualized support.ConclusionsIn settings of limited ventilator availability, systems can be developed to allow increased delivery of ventilator support to patients. This enables more rapid deployment of ventilator capacity under constraints of time, space and financial cost. These systems can be smaller, lighter, more readily stored and more rapidly deployable than ventilators. However, optimizing ventilator support for patients with individualized ventilation parameters will still be dependent upon ease of use and the availability of medical personnel

Factors Associated with Total Laryngectomy Utilization in Patients with cT4a Laryngeal Cancer

Background: Despite recommendations for upfront total laryngectomy (TL), many patients with cT4a laryngeal cancer (LC) instead undergo definitive chemoradiation, which is associated with inferior survival. Sociodemographic and oncologic characteristics associated with TL utilization in this population are understudied. Methods: This retrospective cohort study utilized hospital registry data from the National Cancer Database to analyze patients diagnosed with cT4a LC from 2004 to 2017. Patients were stratified by receipt of TL, and patient and facility characteristics were compared between the two groups. Logistic regression analyses and Cox proportional hazards methodology were performed to determine variables associated with receipt of TL and with overall survival (OS), respectively. OS was estimated using the Kaplan–Meier method and compared between treatment groups using log-rank testing. TL usage over time was assessed. Results: There were 11,149 patients identified. TL utilization increased from 36% in 2004 to 55% in 2017. Treatment at an academic/research program (OR 3.06) or integrated network cancer program (OR 1.50), male sex (OR 1.19), and Medicaid insurance (OR 1.31) were associated with increased likelihood of undergoing TL on multivariate analysis (MVA), whereas age > 61 (OR 0.81), Charlson–Deyo comorbidity score ≥ 3 (OR 0.74), and clinically positive regional nodes (OR 0.78 [cN1], OR 0.67 [cN2], OR 0.21 [cN3]) were associated with decreased likelihood. Those undergoing TL with post-operative radiotherapy (+/− chemotherapy) had better survival than those receiving chemoradiation (median OS 121 vs. 97 months; p = 0.003), and TL + PORT was associated with lower risk of death compared to chemoradiation on MVA (HR 0.72; p = 0.024). Conclusions: Usage of TL for cT4a LC is increasing over time but remains below 60%. Patients seeking care at academic/research centers are significantly more likely to undergo TL, highlighting the importance of decreasing barriers to accessing these centers. Increased focus should be placed on understanding and addressing the additional patient-, physician-, and system-level factors that lead to decreased utilization of surgery

Multi-institutional Comparison of Temporal Bone Models: A Collaboration of the AAO-HNSF 3D-Printed Temporal Bone Working Group

© American Academy of Otolaryngology–Head and Neck Surgery Foundation 2020. Objective: The American Academy of Otolaryngology–Head and Neck Surgery Foundation’s (AAO-HNSF’s) 3D-Printed Temporal Bone Working Group was formed with the goal of sharing information and experience relating to the development of 3D-printed temporal bone models. The group conducted a multi-institutional study to directly compare several recently developed models. Study Design: Expert opinion survey. Setting: Temporal bone laboratory. Methods: The working group convened in 2018. The various methods in which 3D virtual models had been created and printed in physical form were then shared and recorded. This allowed for comparison of the advantages, disadvantages, and costs of each method. In addition, a drilling event was held during the October 2018 AAO-HNSF Annual Meeting. Each model was drilled and evaluated by attending-level working group members using an 15-question Likert scale questionnaire. The models were graded on anatomic accuracy as well as their suitability as a simulation of both cadaveric and operative temporal bone drilling. Results: The models produced for this study demonstrate significant anatomic detail and a likeness to human cadaver specimens for drilling and dissection. Models printed in standard resin material with a stereolithography printer scored highest in the evaluation, though the margin of difference was negligible in several categories. Conclusion: Simulated 3D temporal bones created through a number of printing methods have potential benefit in surgical training, preoperative simulation for challenging otologic cases, and the standardized testing of temporal bone surgical skills

Anterior skull base reconstruction: a contemporary review

Anterior skull base (ASB) defects present a significant challenge in head and neck reconstructive surgery. The main goal of skull base reconstruction is to create a watertight separation between the intracranial cavity and aerodigestive tract. Successful reconstruction aims to prevent cerebrospinal fluid (CSF) leak, pneumocephalus, and a range of infectious manifestations. Functional outcomes and cosmesis are also critical considerations when developing a reconstructive plan. Advancements with endoscopic endonasal approaches have revolutionized skull base surgery but also have created new reconstructive challenges due to the narrow operative corridor, especially for extensive defects or salvage cases where microvascular free tissue transfer is required. Though a variety of techniques including local, regional, and free flaps have been described, ASB reconstruction remains a difficult undertaking due to the complex anatomy and high risk for post-operative complications. This review provides a comprehensive discussion of available reconstructive techniques that can be used after both open and endoscopic ASB resections to help determine the optimal reconstruction for a variety of defects

International consensus statement on allergy and rhinology: Sinonasal tumors

BACKGROUND: Sinonasal neoplasms, whether benign and malignant, pose a significant challenge to clinicians and represents a model area for multidisciplinary collaboration in order to optimize patient care. The International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors (ICSNT) aims to summarize the best available evidence and presents 48 thematic and histopathology-based topics spanning the field. METHODS: In accordance with prior ICAR documents, ICSNT assigned each topic as an Evidence-Based Review with Recommendations, Evidence-Based Review, and Literature Review based on level of evidence. An international group of multidisciplinary author teams were assembled for the topic reviews using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses format, and completed sections underwent a thorough and iterative consensus-building process. The final document underwent rigorous synthesis and review prior to publication. RESULTS: The ICNST document consists of 4 major sections: general principles, benign neoplasms and lesions, malignant neoplasms, and quality of life and surveillance. It covers 48 conceptual and/or histopathology-based topics relevant to sinonasal neoplasms and masses. Topics with a high level of evidence provided specific recommendations, while other areas summarized the current state of evidence. A final section highlights research opportunities and future directions, contributing to advancing knowledge and community intervention. CONCLUSION: As an embodiment of the multidisciplinary and collaborative model of care in sinonasal neoplasms and masses, ICSNT was designed as a comprehensive, international, and multidisciplinary collaborative endeavor. Its primary objective is to summarize the existing evidence in the field of sinonasal neoplasms and masses