Failure Pressures of Dural Repairs in a Porcine Ex Vivo Model: Novel Use of Titanium Clips Versus Tissue Glue.

OBJECTIVE: Endoscopic skull base surgery is advancing, and it is important to have reliable methods to repair the resulting defect. The objective of this study was to determine the failure pressures of 2 commonly used methods to repair large dural defects: collagen matrix underlay with fibrin glue and collagen matrix underlay with polyethylene glue, as well as a novel repair method: fascia lata with nonpenetrating titanium vascular clips. METHODS: The failure pressure of the 3 dural repairs was determined in a closed testing apparatus. Defects in porcine dura were created and collagen matrix grafts were used as an underlay followed by either fibrin glue (FG/CMG) or polyethylene glycol glue (PEG/CMG). A third condition using a segment of fascia lata was positioned flush with the edges of the dural defect and secured with titanium clips (TC/FL). Saline was infused to simulate increasing intracranial pressure (ICP) applied to the undersurface of the grafts until the repairs failed. RESULTS: The mean failure pressure of the PEG/CMG repair was 34.506 ± 14.822 cm H2O, FG/CMG was 12.413 ± 5.114 cm H2O, and TC/FL was 8.330 ± 3.483 cm H2O. There were statistically significant differences in mean failure pressures among the 3 repair methods. CONCLUSION: In this ex vivo model comparing skull base repairs' ability to withstand cerebrospinal fluid leak, the repairs that utilized PEG/CMG tolerated the greatest amount of pressure and was the only repair that exceeded normal physiologic ICP's. Repair methods utilizing glues generally tolerated higher pressures compared to the novel repair using clips alone.

Workforce Considerations, Training, and Diseases in the Middle East.

Evaluating and providing global health assistance, humanitarian aid, and medical missions to Middle Eastern countries can be rewarding and challenging. A broad spectrum of financial capabilities supports effective health care delivery and infrastructure. Middle East tension can make obtaining a visa difficult. Personal safety considerations may hinder efforts to develop and carry out clinical and educational programs. Several Middle East countries have sophisticated and modern health care systems. Medical education and specialty training compares with that of Western medicine. The Middle East has a proud heritage as the foundation of many fundamental and modern medical and surgical principles.

Failure pressures after repairs of 2-cm × 2.5-cm rhinologic dural defects in a porcine ex vivo model.

BACKGROUND: The objective of this study was to determine failure pressures of 6 rhinologic repair techniques of large skull base/dural defects in a controlled, ex vivo model. METHODS: Failure pressures of 6 dural repairs in a porcine model were studied using a closed testing apparatus; 24-mm × 19-mm dural defects were created; 40-mm × 34-mm grafts composed of porcine Duragen (Integra), fascia lata, and Biodesign (Cook) were used either with or without Tisseel (Baxter International Inc.) to create 6 repairs: Duragen/no glue (D/NG), Duragen/Tisseel (D/T), fascia lata/no glue (FL/NG), fascia lata/Tisseel (FL/T), Biodesign/no glue (B/NG), and Biodesign/Tisseel (B/T). Saline was infused at 30 mL/hour, applying even force to the underside of the graft until repair failure. Five trials were performed per repair type for a total of 30 repairs. RESULTS: Mean failure pressures were as follows: D/NG 1.361 ± 0.169 cmH2 O; D/T 9.127 ± 1.805 cmH2 O; FL/NG 0.200 ± 0.109 cmH2 O; FL/T 7.833 ± 2.657 cmH2 O; B/NG 0.299 ± 0.109 cmH2 O; and B/T 2.67 ± 0.619 cmH2 O. There were statistically significant differences between glued (Tisseel) and non-glued repairs for each repair category (p < 0.05). CONCLUSION: All glued repairs performed better than non-glued repairs. Both D/T and FL/T repairs performed better than B/T repairs. No repair tolerated pressures throughout the full range of adult supine intracranial pressure.

Perception of Shame in Otolaryngology-Head and Neck Surgery Training.

OBJECTIVE: This survey was developed to assess the prevalence and effects of the perception of shame in otolaryngology-head and neck surgery residency training in the United States. STUDY DESIGN: Survey. SETTING: US otolaryngology training programs. SUBJECTS: Faculty and trainees in US otolaryngology training programs. METHODS: A 14-item survey to assess the prevalence of the experience of shame and the attitudes toward use of shame in otolaryngology residency training was sent to all otolaryngology-head and neck surgery program directors for distribution among their respective faculty and resident cohorts. RESULTS: A total of 267 responses were received (women, 24.7%; men, 75.3%): 42.7% of respondents were trainees; 7.0% of trainees thought that shame was a necessary/effective tool, compared with 11.4% of faculty; 50% of respondents felt that they had been personally shamed during residency; and 69.9% of respondents had witnessed another trainee being shamed during residency training. Trainees were most commonly shamed in the operating room (78.4%). Otolaryngology faculty members did the shaming 95.1% of the time. Although shaming prompted internal reflection/self-improvement in 57.4% of trainees, it also caused loss of self-confidence in 52.5%. Trainees who had been shamed were more likely to view shame as an appropriate educational tool (P < .05). CONCLUSION: Half of respondents have felt shamed during their residency training, and a majority has witnessed a colleague being shamed. Understanding the negative impact that shaming behaviors have on the learning environment and on the performance of the individual within it is an important first step in creating an environment maximally conducive to learning, professional development, and patient safety.

Failure pressures of three rhinologic dural repairs in a porcine ex vivo model.

BACKGROUND: The objective of this work was to determine the failure pressures of 3 commonly performed repair techniques of 5-mm dural defects in a controlled setting. METHODS: This was a pig dura ex vivo study. A testing apparatus was fabricated to study failure pressures of 3 different repairs in a porcine model. Five-millimeter (5-mm) dural defects were created and plugged with autologous mucosa/Tisseel (MT) (Baxter International Inc.), fat graft (FG), and bath plug (BP) techniques. Saline solution was infused at 30 mL/hour to apply unidirectional pressure to the repair until failure occurred. Five dural repairs were performed for each arm of the trial, for a total of 15 trials. RESULTS: The mean failure pressure of the MT repair was 4.3 ± 1.9 cmH2 O, of the FG repair was 10.9 ± 4.2 cmH2 O, and of the BP repair was 20.7 ± 2.2 cmH2 O. Differences among mean failure pressures were statistically significant. CONCLUSION: The BP repair showed significantly higher tolerances for pressure than the other 2 repairs. The BP repair was the only technique that withstood adult physiologic supine cerebrospinal fluid (CSF) pressure.

Cadaveric comparison of canine fossa vs transnasal maxillary sinus access.

OBJECTIVE: Anatomic limitations complicate complete eradication of debris from the maxillary sinus using an exclusively transnasal (TN) endoscopic technique. Creation of a canine fossa trephination (CFT) permits a more direct approach than removal via the maxillary ostium. METHODS: Microdebrider eradication of debris completely filling the maxillary sinus was performed on 5 thawed fresh-frozen cadaver heads (10 sides) using a TN or CFT approach. Postdebridement computed tomography (CT) scanning assessed remaining debris. Additional outcome measures included time of debris removal, number of different angled blades utilized, and clogging. RESULTS: A significantly greater amount of debris was left after the TN approach compared with CFT (3.88 cm(3) vs 2.88 cm(3), p = 0.015). Median blade utilization was significantly higher with the TN approach vs CFT (4 vs 1, p < 0.002). Time for debris eradication with CFT was similar regardless of expertise (323.4 vs 272.4 seconds, p = 0.21), but the TN approach showed a statistical difference in time-to-completion (698.8 vs 438.51 seconds, p = 1.7 × 10(-5)). CONCLUSION: Controversy surrounds the appropriate application of CFT due to disease process and approach-related morbidity. Rhinologists should have numerous well-studied options at their disposal. This model suggests that maxillary debris removal is accomplished more thoroughly with fewer microdebrider blades when a CFT approach is employed.

Effect of head position and surgical dissection on sinus irrigant penetration in cadavers.

BACKGROUND: Effective treatment for recalcitrant rhinosinusitis requires unobstructed surgical marsupialization of sinus cavities and use of delivery systems that will topically penetrate the sinuses. AIMS: To determine the extent of sinus penetration achieved with nasal irrigation by varying the ostial size and head position. METHODS: Ten thawed fresh-frozen cadaver heads were dissected in a staged manner. After each stage of dissection, sinus squeeze-bottle irrigations were performed in three head positions, and endoscopes placed via external ports into the sinus cavities viewed the sinus ostia. An ordinal scale was developed to grade ostial penetration of irrigations. Three reviewers independently graded the outcomes. RESULTS: Irrigant entry into sinuses increased with ostial size (P < .001) and the greatest differential of improvement in sinus penetration is obtained at an ostial size of 4.7 mm. Stages 2 and 3 (larger sinus ostia) of maxillary and sphenoid dissections have statistically greater irrigant penetration relative to earlier stages. Frontal sinus irrigation is worse in vertex to ceiling head position. There does not appear to be any significant advantage to head position with maxillary and sphenoid sinuses. CONCLUSIONS: This study shows that the larger the sinus ostium, the better the penetration of irrigant into the sinus, with an ostium of at least 4.7 mm allowing maximal penetration in the maxillary and sphenoid sinuses. The same benefit was not noted in the frontal sinus. Head position was only relevant to the frontal sinus where less penetration was seen with the head neutral (vertex to ceiling) position when compared to forward angled positions.

Validating the use of report-derived Lund-MacKay scores.

BACKGROUND: The Lund-MacKay score (LMS) is the standard for communicating radiological extent of chronic rhinosinusitis in research. However, retrospective analyses are often hindered by a substantial lack of radiological data. Calculating LMS from radiologists' reports may overcome this but has not been formally validated. METHODS: Twenty South Australian and 20 Texan patients with varying degrees of sinus disease were randomly chosen to undergo analysis. CT-derived LMSs were calculated directly by two expert rhinologists at each institution and compared with scores derived solely from accompanying radiology reports by two blinded reviewers. RESULTS: The total LMS obtained via the expert rhinologists correlated very highly with that obtained from radiology reports (Spearman rank correlation, 0.75-0.88; p < 0.001). However, when individual sinuses were specifically analyzed, the correlation was highly variable. CONCLUSION: The results show that in both South Australian and Texan tertiary rhinology centers, radiologists' reports can be reliably used to calculate the total LMS.

Presentation and management of extensive fronto-orbital-ethmoid mucoceles.

OBJECTIVES: The aim of the study was to report the presentation and management of extensive fronto-orbital-ethmoid (FOE) mucoceles. METHODS: This study is a retrospective chart review of 13 consecutive patients requiring surgical intervention for extensive FOE mucoceles. Patients were treated over the period from 1999 to 2003. Variables examined include chief complaint, risk factors, location of erosion, management, and complications. Follow-up ranged from 12 to 36 months. RESULTS: Most common chief complaint was eye proptosis, followed by forehead swelling and orbital cellulitis. Four patients had previous functional endoscopic sinus surgery (FESS) and another 4 patients had history of prior trauma and frontal sinus obliteration. Eleven patients had skull base erosion and 12 had orbital wall erosion. Four patients were managed endoscopically. Of these, 1 had previously undergone FESS, whereas the other 3 had no risk factors. All patients with prior trauma/obliteration were treated with coronal flap and frontal sinus obliteration. One patient who had undergone 2 previous FESS was successfully treated with coronal flap without obliteration. One patient treated with an osteoplastic flap had cerebrospinal fluid leak that was identified and repaired intraoperatively with a pericranial flap. CONCLUSION: Extensive FOE mucoceles can be successfully and safely treated by endoscopic and non-endoscopic methods. The choice of surgical approach mainly depends on the anatomy of the frontal recess. Prior trauma and FESS are associated with requiring coronal flap and frontal sinus obliteration.