Tension Pneumocephalus Related to Spontaneous Skull Base Dehiscence in a Patient on BiPAP

Spontaneous pneumocephalus is an uncommon phenomenon that may develop in patients with occult skull base defects. There have been reports of pneumocephalus occurring spontaneously in the setting of continuous positive airway pressure (CPAP) use (1). Tension pneumocephalus represents a neurosurgical emergency where intracranial air is trapped with increasing pressures resulting in neurological deterioration (2). Previous literature has also documented the growing understanding of how obesity, elevated intracranial pressure (ICP), obstructive sleep apnea (OSA), and cortical skull thinning are associated with spontaneous tegmen dehiscence and cerebrospinal fluid (CSF) leakage (3). Other mechanisms for spontaneous CSF leak include aberrant arachnoid granulation, congenital skull base dehiscences, increased abdominal and thoracic pressure resulting in reduced cerebral venous drainage, and age-related cortical thinning. In this report, we present the case of a bilevel positive airway pressure (BiPAP) user with an undiagnosed spontaneous tegmen dehiscence who developed spontaneous tension pneumocephalus

Outpatient management of cholesteatoma with canal wall reconstruction tympanomastoidectomy

Objectives The postoperative wound infection rate for canal wall reconstruction (CWR) tympanomastoidectomy with mastoid obliteration in the treatment of chronic otitis media with cholesteatoma has been reported to be 3.6%. Postoperative administration of 24–48 hours of intravenous antibiotics has been recommended. We aim to determine the infection rate of CWR with postoperative outpatient oral antibiotics. Study Design Institutional review board—approved retrospective case review. Setting Tertiary referral center. Patients: Retrospective review of consecutive patients who underwent CWR tympanomastoidectomy with mastoid obliteration at a single institution from 2014 to 2016. Main Outcome Measure: Patient characteristics (age, sex) were calculated. Rate of postoperative complications and infections within 1 month of surgery were calculated. Comparison to previous published infection rates with postoperative intravenous antibiotics. Results 51 patients underwent CWR followed by outpatient oral antibiotics with a mean age of 25.9 years (16 patients were less than 10 years old). There were no postoperative wound infections. Outpatient antibiotics showed non-inferiority to IV antibiotic historic controls (0% vs. 3.6%; 95% confidence interval [CI], 0–6.09%; p = 0.03). One patient had small postoperative wound dehiscence with CSF leak that was managed conservatively. One patient developed Clostridium difficile colitis on postoperative day 2. Conclusions The infection rate after CWR tympanomastoidectomy with use of outpatient antibiotics is low and is non-inferior to a historic cohort treated with inpatient intravenous antibiotics. A larger randomized controlled trial is warranted. Level of Evidence 4

Vibratory Stimulus Reduces In Vitro Biofilm Formation On Tracheoesophageal Voice Prostheses

Objectives/Hypothesis Demonstrate that biofilm formation will be reduced on tracheoesophageal prostheses when vibratory stimulus is applied, compared to controls receiving no vibratory stimulus, in a dynamic in vitro model of biofilm accumulation simulating the interface across the tracheoesophageal puncture site. Study Design Prospective, randomized, controlled, crossover in university laboratory. Methods Ex vivo tracheoesophageal prostheses were obtained from university-affiliated speech language pathologists at Indiana University School of Medicine, Indianapolis. Prostheses demonstrating physical integrity and an absence of gross biofilm accumulation were utilized. Sixteen prostheses were cleansed and sterilized prior to random placement by length in two modified Robbins devices arranged in parallel. Each device was seeded with a polymicrobial oral flora on day 1 and received basal artificial salivary flow continuously with three growth medium meals daily. One device was randomly selected for vibratory stimulus, and 2 minutes of vibration was applied to each prosthesis before and after meals for 5 days. The prostheses were explanted and sonicated, and the biofilm cultured for enumeration. This process was repeated after study arm crossover. Results Tracheoesophageal prostheses in the dynamic model receiving vibratory stimulus demonstrated reduced gross biofilm accumulation and a significant biofilm colony forming unit per milliliter reduction of 5.56-fold compared to nonvibratory controls (P < 0.001). Significant reductions were observed within length subgroups. Conclusion Application of vibratory stimulus around meal times significantly reduces biofilm accumulation on tracheoesophageal prostheses in a dynamic in vitro model. Further research using this vibratory stimulus method in vivo will be required to determine if reduced biofilm accumulation correlates with longer device lifespan

Three-Dimensional Printing and Its Applications in Otorhinolaryngology–Head and Neck Surgery

Objective Three-dimensional (3D)-printing technology is being employed in a variety of medical and surgical specialties to improve patient care and advance resident physician training. As the costs of implementing 3D printing have declined, the use of this technology has expanded, especially within surgical specialties. This article explores the types of 3D printing available, highlights the benefits and drawbacks of each methodology, provides examples of how 3D printing has been applied within the field of otolaryngology–head and neck surgery, discusses future innovations, and explores the financial impact of these advances. Data Sources Articles were identified from PubMed and Ovid MEDLINE. Review Methods PubMed and Ovid Medline were queried for English articles published between 2011 and 2016, including a few articles prior to this time as relevant examples. Search terms included 3-dimensional printing, 3D printing, otolaryngology, additive manufacturing, craniofacial, reconstruction, temporal bone, airway, sinus, cost, and anatomic models. Conclusions Three-dimensional printing has been used in recent years in otolaryngology for preoperative planning, education, prostheses, grafting, and reconstruction. Emerging technologies include the printing of tissue scaffolds for the auricle and nose, more realistic training models, and personalized implantable medical devices. Implications for Practice After the up-front costs of 3D printing are accounted for, its utilization in surgical models, patient-specific implants, and custom instruments can reduce operating room time and thus decrease costs. Educational and training models provide an opportunity to better visualize anomalies, practice surgical technique, predict problems that might arise, and improve quality by reducing mistakes

Survey of endoscopic skull base surgery practice patterns among otolaryngologists

Background Endoscopic skull base surgery (ESBS) is a rapidly expanding field. Despite divergent reported preferences for reconstructive techniques and perioperative management, limited data exist regarding contemporary practice patterns among otolaryngologists performing ESBS. This study aims to elucidate current practice patterns, primarily the volumes of cases performed and secondarily a variety of other perioperative preferences. Methods An anonymous 32-item electronic survey examining perioperative ESBS preferences was distributed to the American Rhinologic Society membership. Statistical significance between variables was determined utilizing Student t, chi-square, and Fisher exact tests. Results Seventy otolaryngologists completed the survey. The effective response rate was approximately 22.5%. Sixty percent of respondents were in full-time academic practice and 70% had completed rhinology/skull base fellowships. Annually, 43.3 mean ESBS cases were performed (29.1 private practice vs. 52.9 academic practice, P = .009). Academic practice averaged 24.1 expanded cases versus only 11 in private practice (P = .01). Of respondents, 55.7% stood on the same side as the neurosurgeon and 72.9% remained present for the entire case. Current procedural terminology coding and antibiotic regimens were widely divergent; 31.4% never placed lumbar drains preoperatively, while 41.4% did so for anticipated high-flow cerebrospinal fluid leaks. While considerable variation in reconstructive techniques were noted, intradural defect repairs utilized vascularized flaps 86.3% of the time versus only 51.3% for extradural repairs (P < 0.001). Major complications were rare. Postoperative restrictions varied considerably, with most activity limitations between 2–8 weeks and positive airway pressure use for 2–6 weeks. Most respondents started saline irrigations 0–2 weeks postoperatively. Conclusions Based on responses from fellowship- and non-fellowship-trained otolaryngologists in various practice settings, there remains considerable variation in the perioperative management of patients undergoing ESBS. Level of Evidence

Impact of lean on surgical instrument reduction: Less is more

OBJECTIVES/HYPOTHESIS: To determine whether instrument sets that are frequently used by multiple surgeons can be substantially reduced in size with consensus. STUDY DESIGN: Prospective quality improvement study using Lean Six Sigma for purposeful and consensual reduction of non-value-added instruments in adenotonsillectomy instrument sets. METHODS: Value stream mapping was utilized to determine instrumentation usage and reprocessing workflow. Preintervention instrument utilization surveys allowed consensual and intelligent set reduction. Non-value-added instruments were targeted for waste elimination by placement in a supplemental set. Times for pre- and postintervention instrument assembly, Mayo setup, and surgery were collected for adenotonsillectomies. Postintervention satisfaction surveys of surgeons and staff were conducted. RESULTS: Adenotonsillectomy sets were reduced from 52 to 24 instruments. Median assembly times were significantly reduced from 8.4 to 4.7 minutes (P \u3c .0001) with a set assembly cost reduction of 44%. Following natural log transformations, mean Mayo setup times were significantly reduced from 97.6 to 76.1 seconds (P \u3c .0001), and mean operative times were not significantly affected (1,773 vs. 1,631 seconds, P \u3e .05). The supplemental set was opened in only 3.6% of cases. Satisfaction was \u3e90% regarding the intervention. Set build cost was reduced by $1,468.99 per set. CONCLUSIONS: Lean Six Sigma improves efficiency and reduces waste by empowering team members to improve their environment. Instrument set reduction is ideal for waste elimination because of tool accumulation over time and instrument obsolescence as newer technologies are adopted. Similar interventions could easily be applied to larger sinus, mastoidectomy, and spine sets. LEVEL OF EVIDENCE: NA Laryngoscope, 2015

Lean belt certification: pathway for student, resident, and faculty development and scholarship

Since July 2013, 20 trainee participants have completed the quality improvement curriculum within the Indiana University Department of Otolaryngology-Head & Neck Surgery, including 7 otolaryngology residents, 6 otolaryngology-bound medical students, and 7 psychiatry residents. Nine faculty and staff attended. Participants were highly satisfied with the quality and effectiveness of the program. Following program implementation, 2 otolaryngology residents and 2 medical students initiated their own quality improvement projects. Lean training directly resulted in oral and poster presentations at national conferences, journal publications, and institutional research and quality awards. Students completing the program established a local affiliate group of an international health care quality organization. Quality improvement training can be successfully incorporated into residency training with overwhelming program satisfaction and results in greater scholarly and professional development for motivated participants. The skillset acquired by participants leads to projects that improve patient care, increase value, and justify equipment and personnel retention and expansion