Objective To evaluate the effect of anatomy-specific virtual reality (VR) surgical rehearsal on surgeon confidence and temporal bone dissection performance. Study Design Prospective pre- and poststudy of a novel virtual surgical rehearsal platform. Setting Academic otolaryngology-head and neck surgery residency training programs. Subjects and Methods Sixteen otolaryngology-head and neck surgery residents from 2 North American training institutions were recruited. Surveys were administered to assess subjects' baseline confidence in performing 12 subtasks of cortical mastoidectomy with facial recess. A cadaver temporal bone was randomly assigned to each subject. Cadaver specimens were scanned with a clinical computed tomography protocol, allowing the creation of anatomy-specific models for use in a VR surgical rehearsal platform. Subjects then rehearsed a virtual mastoidectomy on data sets derived from their specimens. Surgical confidence surveys were administered again. Subjects then dissected assigned cadaver specimens, which were blindly graded with a modified Welling scale. A final survey assessed the perceived utility of rehearsal on dissection performance. Results Of 16 subjects, 14 (87.5%) reported a significant increase in overall confidence after conducting an anatomy-specific VR rehearsal. A significant correlation existed between perceived utility of rehearsal and confidence improvement. The effect of rehearsal on confidence was dependent on trainee experience and the inherent difficulty of the surgical subtask. Postrehearsal confidence correlated strongly with graded dissection performance. Subjects rated anatomy-specific rehearsal as having a moderate to high contribution to their dissection performance. Conclusion Anatomy-specific virtual rehearsal improves surgeon confidence in performing mastoid dissection, dependent on surgeon experience and task difficulty. The subjective confidence gained through rehearsal correlates positively with subsequent objective dissection performance.
Objective To survey patients following sinonasal surgery regarding postoperative pain and opioid use. Study Design Patients were surveyed for 4 days following sinus and/or nasal surgery regarding their pain level and use of prescribed opioids. Setting Four academic medical centers and 1 private practice institution. Subjects Consecutive adult patients undergoing sinonasal surgery. Results A total of 219 subjects met criteria and were included for analysis; 134 patients (61%) took 5 or fewer combination oxycodone (5-mg) and acetaminophen (325-mg) tablets in the first 3 postoperative days, and 196 patients (89.5%) took fewer than 15. Fifty-one patients (23%) consumed no opioid pain medication. Opioid consumption was positively correlated with postoperative pain (R2 = 0.2, P < .01) but was not correlated with the use of acetaminophen (R2 = 0.002, P = .48). No significant difference in postoperative pain or opioid consumption was seen with respect to age, sex, specific procedures performed, postoperative steroids, or smoking history. Current smokers reported higher average pain than nonsmokers (P < .001) and also required more postoperative opioids (P = .02). Conclusions An evidence-based approach to postoperative pain control following sinonasal surgery that reduces the number of unused and potentially diverted opioids is needed. The current study suggests that 15 combination oxycodone (5-mg) and acetaminophen (325-mg) tablets provide sufficient pain control for 90% of patients in the immediate postoperative period following sinonasal surgery, irrespective of the specific procedures performed, use of acetaminophen, or use of systemic steroids. Smoking status may help surgeons predict which patients will require larger opioid prescriptions.
Medical imaging techniques provide a wealth of information for surgical preparation, but it is still often the case that surgeons are examining three-dimensional pre-operative image data as a series of two-dimensional images. With recent advances in visual computing and interactive technologies, there is much opportunity to provide surgeons an ability to actively manipulate and interpret digital image data in a surgically meaningful way. This article describes the design and initial evaluation of a virtual surgical environment that supports patient-specific simulation of temporal bone surgery using pre-operative medical image data. Computational methods are presented that enable six degree-of-freedom haptic feedback during manipulation, and that simulate virtual dissection according to the mechanical principles of orthogonal cutting and abrasive wear. A highly efficient direct volume renderer simultaneously provides high-fidelity visual feedback during surgical manipulation of the virtual anatomy. The resulting virtual surgical environment was assessed by evaluating its ability to replicate findings in the operating room, using pre-operative imaging of the same patient. Correspondences between surgical exposure, anatomical features, and the locations of pathology were readily observed when comparing intra-operative video with the simulation, indicating the predictive ability of the virtual surgical environment.
The objective of the study is to present a large case series of parapharyngeal space tumors (PPST) and the most comprehensive literature review of tumor histopathologic distribution. The study was designed as internal case series and full Pubmed/MEDLINE electronic database review in a tertiary academic medical center. Tumor histopathology and patient demographics were obtained from a comprehensive Pubmed/MEDLINE database review, as well from an internal case series of 117 patients referred to our center between 1993 and 2013. Main outcome and measures of the study were to define the age, gender, and histopathology of PPST within a large internal case series and among the current body of published literature, and to propose a diagnostic and treatment algorithm for these tumors. Our cohort included 117 cases, 58 females and 59 males, with benign tumors comprising 85 % (n = 99) and malignant tumors 15 % (n = 18). A systematic review of published literature from 1963 to the present revealed 37 case series, and when combined with our present series, yielded a total of 2160 cases. Benign tumors are most common (78.8 %), with tumors of salivary gland (44.4 %), neural (34.4 %), and vascular (2.64 %) origin representing the largest subtypes. Pleomorphic adenomas (30.9 %), paragangliomas (13.1 %), and schwannomas (12.3 %) comprised the majority of all cases. Due to their rarity, data regarding the histopathologic distribution of PPST is scarce. We provide one of the largest case series and the most comprehensive review of these tumors in the literature to date, and offer our algorithm for evaluation and treatment.
The poor anatomical spatial resolution of DW-MRI makes precise localization of cholesteatoma within the middle ear and mastoid a diagnostic challenge. This study suggests that the bony anatomic detail obtained via CT coupled with the excellent sensitivity and specificity of PROPELLER DW-MRI for cholesteatoma can improve both preoperative identification and localization of disease over DW-MRI alone.
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