Resident training in head and neck flap reconstruction in U.S. academic otolaryngology programmes.

The main objective of this study was to assess resident training in head and neck flap reconstruction, and to determine the confidence of graduating residents in performing these flaps independently. Questionnaires were distributed to otolaryngology residents graduating in 1997. Respondents recorded the number of pedicled and free flap procedures they performed, or assisted with, and indicated flaps they felt confident about performing independently. Pectoralis major myocutaneous (PMMC) (n = 560, mean 6.59) and radial forearm (RF) (66, 0.78) were the most common pedicled and free flaps performed. There was a significant difference (p = 0.0002, Mann-Whitney U test) between median confidence for pedicled (44.5 per cent) and free flaps (two per cent). Ten of the 17 flaps showed a significant Pearson correlation (p < 0.05) between number of procedures performed and confidence in performing them independently. Of the pedicled flaps, latissimus dorsi (LD) showed good correlation (r = 0.67), PMMC showed low correlation (r = 0.19) and other pedicled flaps fair correlation. Of the free flaps, LD (r = 0.64) and fibula (r = 0.50) showed good correlation and rectus abdominis and RF fair correlation. There was a fair inverse correlation (r = -0.29) between numbers of pedicled and free flaps performed. Higher correlation in flaps uncommonly performed reflects greater operative training necessary to achieve the confidence for performing these flaps independently. As respondents performed greater numbers of free flaps, the number of pedicled flaps decreased. It might thus be important to train residents in all aspects of pedicled flaps. Most respondents were of the opinion that additional training in free flaps was necessary for those planning a career in head and neck reconstructive surgery.

Impact of tympanostomy tubes on child quality of life.

BACKGROUND: The objective benefits of tympanostomy tubes for otitis media are well established, but the subjective impact of surgery on child quality of life (QOL) has not been systematically studied. OBJECTIVES: To determine the subjective impact of tympanostomy tubes on child QOL, and to compare the variability in QOL before surgery with that observed after surgery. DESIGN: Prospective, observational, before-and-after trial. SETTING: Fourteen referral-based pediatric otolaryngology practices in the United States. PATIENTS: Consecutive (64%) and convenience (36%) sample of 248 children (median age, 1.4 years) with otitis media scheduled for bilateral tympanostomy tube placement as an isolated surgical procedure. INTERVENTION: Tympanostomy tubes were inserted as part of routine clinical care. Validated measures of QOL (OM-6 survey), satisfaction with health care decision (Satisfaction With Decision Scale), and satisfaction with office visit; surveys were completed at baseline (visit 1), at surgery (visit 2), and after surgery (visit 3). MAIN OUTCOME MEASURES: Short-term changes in QOL before surgery (visit 1 to visit 2) and after surgery (visit 2 to visit 3). RESULTS: Changes in QOL before surgery were mostly trivial, and were smaller than changes observed after surgery (P<.001). Large, moderate, and small improvements in QOL occurred after surgery in 56%, 15%, and 8% of children, respectively. Physical symptoms, caregiver concerns, emotional distress, and hearing loss were most improved, but significant changes were also seen for activity limitations and speech impairment. Trivial changes occurred in 17% of children, and 4% had poorer QOL. Predictors of poorer QOL were otorrhea 3 or more days (10% of variance) and decreased satisfaction with surgical decision (3% of variance). Hearing status, child age, type of otitis media (recurrent vs chronic), and office visit satisfaction were unrelated to outcome. CONCLUSIONS: Tympanostomy tubes produce large short-term improvements in QOL for most children. The best outcomes occur when postoperative otorrhea is absent or minimal, and when parents are satisfied with their initial decision to have surgery. Further research is needed to document the long-term impact of tubes on child QOL.

The precochlear approach to the anterior petrous apex: an anatomic study.

The petrous apex is the most inaccessible portion of the temporal bone and surgical exposure presents considerable challenge. The transmastoid precochlear approach offers a direct intra temporal route to this region, providing good visual exposure with cochlea preservation. An anatomic study of 20 human temporal bones was performed to delineate the landmarks for this approach. Measurements to the tegmen tympani, carotid artery, and the anterior-superior limit of the cochlea were made from the cochleariform process, a constant landmark in the middle ear. Distances to the tegmen averaged 5.4 mm (range: 3.5-9 mm), to the carotid artery 9.3 mm (8-11 mm), and the cochlea 3.1 mm (2-5 mm). The entry to the apex admitted an average burr size of 3.5 mm (2-7 mm). We anticipate this approach will prove useful in the treatment of benign petrous apex lesions.

Pathogenesis of tympanosclerosis.

In spite of the wealth of information on the clinical, histologic, and pathologic aspects of tympanosclerosis, the pathogenesis of tympanosclerosis is still unclear. In an attempt to understand the pathogenesis, 319 human temporal bones from 196 individuals with otitis media were studied. The extent and nature of tympanosclerosis and the characteristics of the otitis media associated with it were studied. Forty-five temporal bones from 35 individuals with otitis media were found to have tympanosclerosis, giving an incidence of 14.1%. It was seen most commonly in individuals over 40 years of age (86.7%). The male-to-female ratio was 1.6:1. The most common site of occurrence was the tympanic membrane (88.9%). Tympanosclerosis was seen more often in the anterior and posterior inferior quadrants of the tympanic membrane and that, too, in a central position. Tympanosclerosis was seen more commonly in temporal bones with irreversible inflammatory changes, and in this group, late plaques were more commonly seen than early or intermediate plaques. Audiometric charts failed to show any direct relationship between extent of tympanosclerosis and the severity of hearing loss. The only audiometric finding of any consequence was a mixed hearing loss in the presence of middle ear tympanosclerosis.

Potter's syndrome: a temporal bone histopathological study.

Histopathological findings in seven temporal bones from four infants diagnosed as Potter's syndrome are described. The infants were labelled as Potter's syndrome after autopsy confirmed bilateral renal agenesis. Extrarenal manifestations included pulmonary hypoplasia and facial anomalies. The middle ear volume in infants with Potter's syndrome remained unchanged with age resulting in a significantly higher percentage of residual middle ear mesenchyme in these infants as compared to normal infants. Dehiscence of the facial nerve was seen in all the temporal bones studied. One ear showed the presence of eosinophilic effusion in the endolymphatic sac, an underdeveloped malleus and a wide facial nerve canal. The inner ear structures showed no significant anomalies except for the absence of the organ of Corti in the basal turn of the cochlea in one of the ears.