Airway and Voice Outcomes After Thyroarytenoid Myomectomy for Bilateral Vocal Fold Immobility.

INTRODUCTION: Type 4 posterior glottic stenosis and bilateral vocal fold paralysis are clinically challenging causes of bilateral vocal fold immobility (BVFI) that result in glottic airway obstruction. Established procedures for BVFI typically worsen dysphonia. We hypothesize the use of thyroarytenoid myomectomy (TAM) in the setting of BVFI will improve dyspnea with decreased detriment to voice. METHODS: Eleven unilateral TAM procedures were performed between April 2021 and June 2023 at a single institution. Pre- and postoperative patient reported outcomes were compared. Representative images of maximal glottic opening were analyzed in ImageJ to calculate ipsilateral bowing index (BI), total BI, maximum glottic surface area (MGSA), and maximum opening angle (MOA). Statistical comparisons were performed with paired t-tests when normality was confirmed with Shapiro-Wilk test and otherwise with Wilcoxon signed-rank tests, with threshold for significance of α = 0.05. Interrater reliability for objective glottal measures was compared with intraclass correlation coefficient (ICC). RESULTS: Dyspnea Index improved from mean (standard error) of 24.1 (3.8) to 9.1 (3.3), p = 0.004. Voice Handicap Index-10 improved from 20.0 (4) to 10.3 (3.8), p = 0.011. Glottal Function Index improved from 9.6 (1.4) to 6.3 (1.3), p = 0.017. There was no significant difference in ipsilateral BI, total BI, MOA, and median MGSA. There was good to excellent ICCs for all comparisons (0.83-0.95). CONCLUSIONS: TAM demonstrated significant improvement in symptoms from BVFI while not significantly altering glottal structure. These data suggest TAM improves dyspnea in patients with BVFI without significantly impairing voice. LEVEL OF EVIDENCE: 4 Laryngoscope, 2024.

Recurrent Neck Mass: A Case Report.

Fourth branchial cleft anomalies are an exceptionally rare cause of recurrent neck mass in pediatric and adult patients. In this report, we present a case of an infected fourth branchial cleft cyst in a 20-year-old woman that presented with recurrent throat pain and deep neck abscesses. After undergoing repeated incision and drainage procedures, the patient underwent definitive management with direct laryngoscopy, ablation of the left pyriform sinus tract, left hemithyroidectomy, and excision of the branchial anomaly without evidence of recurrence. In addition to diagnosis and management, this case report highlights the unique anatomical relationship between fourth branchial anomalies and the pyriform fossa as well as the superior and recurrent laryngeal nerves.

Post-tonsillectomy hemorrhage control with nebulized tranexamic acid: A retrospective cohort study.

OBJECTIVE: Evaluate nebulized tranexamic acid (TXA) as a treatment to reduce the need for an operation to control a post-tonsillectomy hemorrhage (PTH). METHODS: Based on a successful case report of a child treated with nebulized TXA for PTH in 2018, our institution began to treat PTH patients with three doses of nebulized TXA. To evaluate the outcomes of this non-invasive management, we conducted a three-year retrospective cohort study of children presenting with PTH from 2016 to 2019. Demographics, insurance, and laboratory information were collected from all pediatric tonsillectomies with and without adenoidectomy performed during the study period. Tonsillar fossae observations of bleeding and clot were documented before and after receiving TXA. RESULTS: The incidence of pediatric PTH at our institution during the study period was 5.4%. Fourteen out of 58 PTH patients received nebulized TXA. Receiving nebulized TXA had no adverse events and over 60% showed resolution of bleeding on exam. Receiving nebulized TXA compared to routine care decreased the need for an operation to restore hemostasis by 44%, p < 0.005. There was no significant difference in age, gender, body mass index, hemoglobin, platelet count, trainee presence, or Medicaid status between the children that received TXA and those that did not. CONCLUSION: Treatment of PTH with nebulized TXA may be a safe first-line therapy to decrease the need for operative control of bleeding. This data suggests that a large clinical trial is needed to determine the efficacy of nebulized TXA to mitigate this common and potentially fatal post-operative complication. LEVEL OF EVIDENCE: 4.

Struggling Prior to a Teaching Event Results in Superior Short-Term Skills Acquisition in Novice Learners.

OBJECTIVE: The act of generating an answer/solution before a learning episode has been shown to enhance performance, even if the learner produces incorrect answers/solutions. This phenomenon has been termed the pretesting effect. In essence, allowing a learner to struggle prior to instruction may be beneficial. The benefits of the pretesting effect have been demonstrated with declarative knowledge (i.e., facts). The objective of this study was to investigate whether the benefits of the pretesting effect extend to acquisition of procedural skill. DESIGN: Prospective, randomized, pretest-posttest experiment. PARTICIPANTS AND SETTING: Forty-two first- and second-year medical students enrolled at the University of Texas Health Science Center at San Antonio completed this study. INTERVENTIONS: Participants were randomly assigned to 1 of 2 instructional conditions. Participants in the teach-first (TF) condition watched a detailed instructional video of laparoscopic intracorporeal suturing and knot-tying (ICSKT) with auditory and text step-by-step instructions prior to attempting the exercise. In contrast, participants in the struggle-first (SF) condition attempted the ICSKT exercise prior to watching the instructional video. All participants completed 4 trials of ICSKT. The first trial was scored as the pretest and the final trial was the post-test. RESULTS: Participants in the TF group had higher pretest scores than participants in the SF group, however these differences were not significant. Despite the pretest deficit, participants in the SF group had higher post-test scores compared to the TF group (p = 0.03). CONCLUSIONS: Allowing learners to struggle with a procedural skill prior to receiving instruction results in superior acquisition of psychomotor skills.

Resident training experience with robotic assisted transabdominal preperitoneal inguinal hernia repair.

BACKGROUND: General surgery is the fastest growing field in the adoption of robotic assisted laparoscopic surgery. Here, we present the results of one institution's experience in training surgical residents in robotic assisted transabdominal preperitoneal inguinal hernia repairs. METHODS: Data were prospectively collected on patients undergoing robotic assisted laparoscopic inguinal hernia repair with residents. Data points included patient age, gender, complications, hernia difficulty, resident technical competency as measured by GEARS, Zwisch scores, operative time, and the number of robotic console cases reported by residents as primary surgeon. RESULTS: Residents who performed >30 robotic cases had significantly higher mean modified GEARS scores (p ≤ .002). Residents who completed 10 or fewer robotic cases achieved significantly lower mean modified GEARS and Zwisch scores than those who completed 11 or more (p < .001). CONCLUSIONS: Resident competency and autonomy improve with increasing total robotic case load. Attending surgeons grant more autonomy to residents with higher competency scores.

Femoral Head Dislocation into the Rectum Following Blunt Trauma.

Traumatic hip dislocations require prompt diagnosis and treatment to prevent avascular necrosis of the femoral head. This injury is further complicated when there is an ipsilateral femur fracture. Here, we present what is likely the first reported case of a patient with traumatic hip dislocation and ipsilateral femur fracture with transrectal displacement of the femoral head. The patient presented to a level one trauma center in 2006 as a transfer from another facility after being thrown from a pickup truck. Upon initial evaluation, a foreign body was palpated in the rectum. Computed tomography (CT) imaging showed that the right femoral head was lodged within the pelvis. In the operating room, an exploratory laparotomy was performed, and anoscopy confirmed the placement of the femoral head within the rectal lumen. The femoral head was extracted from the rectum transanally. The operation was abbreviated, as the patient became hemodynamically unstable, and he was taken to the intensive care unit. He returned to the operating room the following day for a repeat washout and proximal diversion. Despite numerous orthopedic procedures and operative washouts, he ultimately underwent a right hip disarticulation. Physicians should be aware that intracorporeal femoral head displacement is possible in select patients who have experienced a high-energy trauma mechanism. This is a complicated, highly morbid injury that poses various management challenges to orthopedic and acute care surgeons.