A Child Presenting with a Bullet in the Middle Ear: Case Report

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Effectiveness of nasal irrigation devices: a Thai multicentre survey

Background Nasal irrigation is widely used as an adjunctive treatment for nasal diseases. There is little evidence regarding the efficacy of the devices used in this procedure. The objective of this survey was to evaluate the effectiveness of nasal irrigation devices based on the experiences of patients and physicians. Methods We conducted a multicentre survey study between November 2017 and October 2018. Physician and patient questionnaires were developed based on the available literature and expert opinion. The physician questionnaire was submitted to the Otolaryngology residents and staff of each centre and their network. The physicians were also asked to distribute the patient questionnaire to their patients. Results Information regarding 331 devices used by the patients was collected. The mean age of the patients was 45.46 ± 17.19 years (from 5 to 81). Roughly half were male, and half were female (48.6%: 51.4%). Among the high-pressure devices, we found that the high-pressure large-volume nasal irrigation devices yielded significantly higher symptom scores in seven of 12 domains (p < 0.05). Among the large-volume devices, we found that the large-volume high-pressure nasal irrigation devices received significantly higher symptom scores in 4 of 12 domains (p < 0.05). However, a higher proportion of patients using the large-volume high-pressure devices had retained fluid in the sinuses compared to those using large-volume low-pressure devices (p < 0.001). Conclusions This survey supports the regular use of nasal irrigation, particularly with large-volume high-pressure devices, as an effective treatment for nasal disease. It may be effective at clearing nasal secretion, improve nasal congestion, decrease post-nasal drip, improve sinus pain or headache, improve taste and smell, and improve sleep quality. It could be used by patients with good compliance and minimal side effects

The sensitivity and specificity of methylene blue spray to identify the parathyroid gland during thyroidectomy

Background Hypocalcemia is a common complication of thyroidectomy resulting from an injury to the parathyroid gland. Methylene blue, which is a medication and dye that has been used for more than a century, is safe and readily available. The previous study has found that methylene blue spray on the surgical field is absorbed by the parathyroid gland faster than in the perithyroidal area. This study was aimed to evaluate the diagnostic value of methylene blue spray to identify the parathyroid gland during thyroid lobectomy. Methods Patients who underwent thyroid lobectomy were recruited. After the recurrent laryngeal nerve was identified, methylene blue was sprayed onto the thyroid bed. After 5 min, the thyroid bed was inspected for areas in which the blue color had been rapidly absorbed. Biopsies were conducted for histopathology at both the stained area and the area in which the color had faded. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. Results A total of 47 patients participated in this study. The sensitivity of methylene blue spray to identify the parathyroid gland during thyroid lobectomy was 92.31% (95% CI [63.97–99.81]) and specificity was 56.79% (95% CI [45.31–67.76]). The PPV was 25.53% (95% CI [20.34–31.53]) and NPV was 97.87% (95% CI [87.39–99.67]). There were no patients with post-operative hypocalcemia, allergic reactions to the methylene blue, or methylene blue toxicity. Conclusion The methylene blue spray could serve as a screening tool for identification of the parathyroid gland

Fractured metallic tracheostomy tube in a child: a case report and review of the literature

<p>Abstract</p> <p>Introduction</p> <p>Tracheostomy is a common airway procedure for life support. The fracture of the tracheostomy tube is a rare complication. We report a case of a 14-year-old boy whose fractured stainless steel tracheostomy tube dislodged into the tracheobronchial tree. We include a literature review and proposed recommendations for tracheostomy care.</p> <p>Case presentation</p> <p>A 14-year-old Thai boy who had a stainless steel tracheostomy tube presented with a complaint of intermittent cough for 2 months. During tracheostomy tube cleaning, his parents found that the inner tube was missing. A chest X-ray revealed a metallic density foreign body in his right main bronchus. He underwent bronchoscopic removal of the inner tracheostomy tube and was discharged without further complications.</p> <p>Conclusion</p> <p>A fractured tracheostomy tube is a rare complication. Appropriate cleaning and scheduled replacement of the tracheostomy tube may prevent this complication.</p

Virtual reality for the training of ear surgery

© 2016 Dr. Patorn PiromchaiIn current residency surgical training programs, residents learn by observing their mentor and practicing under his/her supervision. For patient safety, the mentor needs to ensure that residents have sufficient practice before they perform surgery on patients. Simulation, ranging from low fidelity (e.g. suture practice on rubber models) to high fidelity (e.g. cadaveric temporal bone dissection), is ideal for this purpose and cadaveric bone dissection is the gold standard of simulated training for temporal bone surgery. However, it has a few setbacks. For example, it is limited by the shortage of cadaveric temporal bones and the bones have to be discarded after drilling and cannot be reused. Also, it is difficult to ensure that residents are exposed to a wide range of temporal bones, specifically ones with rare anatomical anomalies. Another concern is that illnesses may be transmitted through contact with diseased tissues and fluids. Virtual reality surgical simulation is an alternative form of high fidelity simulation that offers risk-free, relatively low cost training environments that can be used repeatedly if necessary at the convenience of the user. Reviews have found that practicing surgical procedures on virtual reality simulators improves trainees' operative performance. One major factor contributing to the success of virtual reality surgical simulation systems is their ability to capture clinical variation. Current simulators in Ear Nose and Throat (ENT) surgery mostly use the core training methodology: starting from easier procedures and moving onto more difficult ones. However, this configuration has traditionally been based on the same anatomical model. To the author’s best knowledge, there do not exist virtual reality simulators in the field of ENT that capture anatomical variation as a basis for surgical education. The aim of this thesis was to determine whether exposure to anatomical variation in a virtual reality simulated environment leads to better surgical outcomes, to establish the foundations of a more efficient model for surgical education. To achieve this goal, several investigations were carried out. Firstly, a systematic review and meta-analyses were conducted to examine the role of virtual reality simulation based training in ENT surgery, and to investigate whether it can improve the acquisition of surgical skills. This has revealed that there is currently no literature available in this field to inform whether anatomical variation is important for improving outcomes in simulation based surgical training. Secondly, methods were developed to identify internal anatomical structure variation of temporal bones by examining the bony surface landmarks in an effort to guide the selection of specimens that exhibit differences in anatomy. To this end, correlations between internal and external landmarks were determined and mathematical models developed to predict internal structure variation given combinations of multiple external landmarks using a library of CT scans. It was observed that these correlations and mathematical models were able to predict some anatomical variations with a high level of accuracy. Thirdly, to standardize the evaluation of competence in cochleostomy, an objective assessment tool was developed and validated. Its construct validity and inter-rater reliability were established to be high through evaluations of resident and expert performances on a standardized virtual temporal bone conducted by expert assessors using the proposed tool. Lastly, a randomised controlled trial of ENT residents performing cochleostomy was conducted to determine whether anatomical variation in virtual reality simulation based training improved surgical performance. Participants were randomly allocated to two groups: the experimental group who were exposed to a six different temporal bone anatomies over a period of three weeks and the control group who were trained on one standardized temporal bone over the same period of time. At the end of the training period participants’ performance on two novel temporal bones was assessed. It was observed that ENT residents who were exposed to a range of anatomical variations performed significantly better than those trained on a single anatomical model

Ototoxicity of povidone-iodine – A case report

Objective: The ototoxicity of povidone-iodine has been documented in animal studies. However, there is limited evidence of these ototoxic effects in humans. This is the first report to show the ototoxic effects of povidone-iodine in a human subject. Patient: A 36-year-old woman came to our hospital complaining of left unilateral persistent hearing loss. One month before presentation, her child had accidentally struck her on her left ear. She applied approximately three drops of povidone-iodine (10% weight/volume) into her left auditory canal. Immediately after application, she felt severe pain and vertigo. An audiogram revealed severe left unilateral sensorineural hearing loss. Magnetic resonance imaging showed mild enhancement of the left vestibule and basal turn of the left cochlea. Conclusions: Even a single application of povidone-iodine could cause significant hearing loss and disequilibrium. It should, therefore, be used with caution. Keywords: Povidone-iodine, Ototoxicit

Acute versus Chronic Invasive Fungal Rhinosinusitis: A Case-Control Study

Introduction Invasive fungal rhinosinusitis is a challenging condition that can be found mostly in immunocompromised patients. Failure to diagnose and treat this entity promptly usually results in rapid progression and death. The purpose of this study was to determine clinical presentation, complication and morbidity in patients with acute versus chronic invasive fungal rhinosinusitis. Setting and design Case-control study at Srinagarind Hospital, Khon Kaen University between January 1998 and May 2008. Methods The patient's data with the diagnosis of invasive fungal rhinosinusitis was included. Demographic data, underlying diseases, presenting symptoms, histologic sinonasal tissue evaluations, sinonasal tissue cultures, CT scan findings, surgical interventions, morbidity, and mortality were collected. Results Sixty-five patients were diagnosed as invasive fungal rhinosinusitis between January 1998 and May 2008. The data of six patients were unable to obtain. Fifty-nine patients were included in this study. Patients with immunocompromised status have significant greater risk for acute than chronic IFS, OR = 6.5 ( P = 0.004). Patients with mucosal necrosis have the significant higher risk for acute IFS, OR = 5.5 ( P = 0.01). There was no significant difference in orbital complications proportion between acute and chronic invasive fungal rhinosinusitis, OR = 2.42 ( P = 0.15). Sinus wall erosion have found significantly in chronic IFS group, OR = 0.24 ( P = 0.02). The average hospital stayed was 30.58 ± 26.43 days with no difference between groups ( P = 0.50). Fourteen patients in acute IFS group were dead (31.11%) while all patients in chronic IFS group were survived. Conclusions Invasive fungal rhinosinusitis continues to present a challenge to the otolaryngologist. Acute IFS was found most commonly in immunocompromised patients. The most consistent finding of acute IFS was mucosal necrosis and black crust/debris. The CT finding of sinus wall erosion may help in diagnosis of chronic IFS