Laryngosternopexy is a suturing method between the thyroid lamina and sternal ligament in order to relieve tension from the anastomosis when performing segmental resection of the airway.  A thick absorbable monofilament suture is passed through thyroid lamina and the interclavicular ligament of the sternum in a figure of eight fashion as described by Castellanos.1,2 In laryngosternopexy, the suture support is ventral to the anastomotic site in the midline. However, this places the "pexy" sutures in the way, making a tracheotomy and second stage decannulation difficult. We describe a modified laryngosternopexy (laryngoclaviculopexy) that can be performed with the "pexy" sutures out of the way to allow access to the trachea, and our initial experience with three patients.

Human ; Male ; Adult (a Person 19-44 Years Of Age) ; Larynx

Objective: This study aims to investigate which, if any head and neck symptoms (trismus, dysphagia, alterations in speech or facial movements, and dyspnea) might be good predictors of outcomes (mortality, tracheostomy, discharged, decannulated) and prognosis of tetanus patients. Methods: Design: Retrospective Cohort Study Setting: Tertiary National University Hospital Patients: Seventy-three (73) pediatric and adult patients diagnosed with tetanus and admitted at the emergency room of the Philippine General Hospital between January 1, 2013 and December 31, 2017. Demographic characteristics, incubation periods, periods of onset, routes of entry, head and neck symptoms, stage, and outcomes were retrieved from medical records and analyzed. Results: Of the 73 patients included, 53 (73%) were adults, while the remaining 20 (27%) were pediatric. The three most common head and neck symptoms were trismus (48; 66%), neck pain/ rigidity (35; 48%), and dysphagia to solids (31; 42%). Results of multivariate logistic regression analysis showed that only trismus (OR = 3.742, p = .015) and neck pain/ rigidity (OR = 4.135, p = .015) were significant predictors of decannulation. No dependent variable/symptoms had a significant effect in predicting discharge and mortality. Conclusion: Clinically diagnosed tetanus can be easily recognized and immediately treated. Most of the early complaints are head and neck symptoms that can help in early diagnosis and treatment resulting in better prognosis. In particular, trismus and neck pain/rigidity may predict the outcome of decannulation after early tracheotomy, but not of discharge and mortality.
tracheotomy ; tetanus ; trismus ; Neck Pain ; Muscle Rigidity

OBJECTIVE: To determine if there is a difference in the duration of mechanical ventilation and hospitalization between patients who underwent early compared to late tracheostomy.

METHODS:

Design:                Causal-Comparative (ex post facto) Chart Review

Setting:                Tertiary National University Hospital

Participants:                   Records of 68 pediatric patients who underwent elective tracheostomy from January 1, 2013 to June 30, 2018 were considered for inclusion. Patients were excluded if invasive mechanical ventilation was not done prior to tracheostomy, if they underwent emergency tracheostomy or had incomplete records. Selected patients were categorized in the early tracheostomy group if the procedure was performed within 14 days of mechanical ventilation and late tracheostomy group if performed beyond 14 days. Early post-tracheostomy weaning from mechanical ventilation was defined as less than 7 days from time of tracheostomy.

RESULTS: A total of 21 patients were included, 6 in the early tracheostomy group and 15 in the late tracheostomy group. Although early tracheostomy did not show significant association with shortened post-tracheostomy duration of mechanical ventilation (O.R. 6; C.I. 0.276 to 130.322; p = .476), two-sample t-tests showed the early tracheostomy group had a significantly shorter mean duration of mechanical ventilation and hospitalization compared to the late tracheostomy group (13.17 vs. 54.13 days, p = .0012; 21.17 vs. 66.67 days, p = .0032).

CONCLUSION: Although early tracheostomy does not shorten post-tracheostomy mechanical ventilation support, there is a significant difference in the duration of mechanical ventilation and hospitalization between early and late tracheostomy groups and this may suggest potential benefits of performing tracheostomy earlier in children.

 

KEYWORDS: tracheotomy; pediatric; mechanical ventilation; hospitalization

Human ; Male ; Female ; Adolescent (a Person 13-18 Years Of Age) ; Child Preschool (a Child Between The Ages Of 2 And 5) ; Tracheotomy ; Ventilation ; Hospitalization

Background and Objective: The pandemic has forced medical education to adopt online and hybrid set-ups, and this has greatly changed the way human anatomy is taught. Course-required knowledge can be accessed using raw references like original publications, collected reviews such as those found in books, as well as in shorter versions like summaries, and in online or electronic applications or software. With readily accessible online physical materials and human resources in anatomy, the value of learning by seeking out verifiable information to answer a real time query may change the current method of teaching and assessment of outcome-based learning in a heavy-recall subject such as human anatomy. For the student, sources of information or instruction are termed the “peripheral brain”. The objective of this study is to describe the medical students’ method in accessing medical information during a hybrid small group discussion. Methods: In a modified hybrid laboratory set-up, a class of 200 students were divided into 18 groups, with two students in each group acting as laboratory dissector, who will broadcast their in-person classroom activities to the group members via zoom. The groups rotated in nine specimen stations consisting of soft-embalmed cadavers, plastinated specimen, models, bones, and VH dissector™ virtual dissector. Students were allowed to use any type of resources to accomplish the following tasks: 1) look for listed structures, 2) identify landmarks, and 3) describe functions. A Google sheet survey was administered a month after the activity on the following domains: search strategy, targeted references, and verifiability of information. Results: There were 110 students with age range of 19-27 years old, who participated in the study. Their most accessed reference is still personally prepared notes, followed by electronic books. When using ebooks, the first thing students reported exploring is the table of contents, followed by the search button. If doing online search, the key word used is the structure or function of interest. In group dynamics, students prefer to divide the work and assign tasks to each member, instead of collectively and simultaneously discussing a topic. For them, the most important characteristic of a reliable peripheral brain is that it is the recommended reference, followed by how current the reference is, i.e., published in the last 3 to 5 years. Interestingly, for most students, the information must be acquired in 5 minutes, which is contrary to the preferred mode of reference. Artificial intelligence may enhance SGDs according to most of the students. In accessing peripheral brain, Google is perceived as the quickest, books are most reliable, and Pubmed is the most up-to-date. Most of the students preferred pre-assigned questions or tasks during SGDs, with equal distribution of work. Giving and receiving remote instructions is not a problem. Dealing with a difficult group member is important, but is not a problem in hybrid discussion. Conclusion The survey results provide valuable insight on learning strategies used by the current generation of medical students, who have started medical school during the pandemic and are used to online teachinglearning modes of instruction. These findings can be exploited in designing course activities. The concept of peripheral brain in small group discussions can be formally introduced to students learning anatomy to utilize modern technology in enhancing knowledge.
Anatomy ; Education, Medical

OBJECTIVE: To describe the extended transpalatine approach (ETPA) with transection of the ipsilateral greater palatine artery and extension of the ipsilateral retromolar incision and its corresponding surgical outcomes and present it as an option in the excision of juvenile angiofibroma (JA).

METHODS:
Design: Descriptive case series

Setting: Tertiary Public University Hospital

Subjects: 13 JA cases undergoing ETPA

RESULTS: Records of JA in a tertiary hospital from 2007 - 2013 were reviewed. Out of 35 JA patients, 13 underwent excision via extended transpalatine approach. Preoperative work-up included CT scan with contrast with or without preoperative embolization. In all patients, the wide field allowed easy tumor excision and facilitated inspection and hemostasis. There was only one recurrence in our series compared to 1 each for 4 endoscopic and 18 transmaxillary approaches. Not one of the patients developed a fistula or hypernasal speech. All patients had minimal palatal scarring, symmetric alveolar growth and palatal function.

CONCLUSION: The ETPA is a robust technique. It provides good exposure of JA with minimal preoperative requirements and postoperative complications.

Human ; Male ; Adolescent ; Child ; Angiofibroma

Dear Editor, The tympanic membrane and the ossicular chain contribute roughly 28 dB in hearing gain. In chronic suppurative otitis media, loss of tympanic membrane and lysis of the ossicular chain are significant causes of hearing loss.1 Through the years, hearing impairment has been augmented using various devices such as ear trumpets, carbon hearing aids, vacuum tube and transistor hearing aids, bone anchored hearing aids, and cochlear implants.2 This case report describes how a cotton wick was used to amplify sound.
Human ; Male ; Hearing ; Hearing Loss

OBJECTIVE: To describe outcomes of two simulation teaching methods in developing intubation skills of year level six medical students (clinical clerks).
METHODS: Students were shown a 6-minute video on intubation. Students were exposed to video-assisted learning, video-assisted learning with instructor-guided simulation, and video-assisted learning with experiential learning. Each student was assessed by a non-graded 11 point objective structured clinical examination.
RESULTS AND DISCUSSION: The three learning strategies: 1. Video-assisted learning, 2. Video-assisted learning with instructor-guided simulation, 3. Video-assisted learning with experiential learning (self-discovery learning) simulation showed OSCE mean scores (standard deviations) of 5.76 (2.16), 7.21 (2.35) and 7.60 (1.72), respectively. Failure of intubation was 21% (8/38), 2% (1/40) and 0% (0/36), respectively. There is an absolute risk reduction of 27-30% in failure of intubation when either VGL or VEL is used. Students recognized the contribution of the simulation-based activities to the development of their intubation skills. They appreciated the opportunity to actually perform intubation in a rehearsal setting before doing the procedure on real patients.
CONCLUSION: Medical simulation enhanced student skills development. Experiential learning or self-discovery learning method may be as effective as instructor guided simulation.

Intubation ; Problem-Based Learning

Background. Simulators in laryngology are an essential part of training. They provide an avenue for medical students and resident trainees to practice valuable psychomotor skills outside the realm of an actual patient encounter - thereby decreasing the risk of possible patient morbidity. Herein we present three locally manufactured simulation devices that can be used to train residents in laryngology procedures.

Objective. To present three simulation platform devices (Laser Box, Flexible Endoscopy Simulation, Thiel Cadaver Chair) and their applications in simulation-based learning

Methods. The Laser Box, Flexible Endoscopy Simulation, and Thiel Cadaver Chair were manufactured by outside parties designated as 'Laser Machinists'.

Results. Ten (10) units of the Laser Box, two (2) units of the Thiel Cadaver Chair, and two (2) units of the Flexible Endoscopy Simulation were constructed. They were used in a laryngology postgraduate course in our institution to teach the participants on endoscopies and laser phonosurgery.

Conclusion. Simulation for otolaryngologic procedures should be an essential part of training. The learning curve for procedures such as laryngoscopy and laser phonosurgery can be addressed with the production of simulation platforms. Most institutions in the Philippines still adopt the "see one, do one, teach one" approach, which lacks standardization and puts patients at risk. Various task trainers for laser phonosurgery and flexible endoscopy have been reported in the literature, but there seems to be no published data on the use of a cadaver chair for simulation. In the COVID-19 era, aside from being excellent teaching tools, simulation platforms derive their importance in helping train residents, educate medical students, and review consultants - maximizing skill development - and thereby decreasing repeated attempts, and indirectly, exposure to the SARS-CoV-2. Future validation studies are required for the models, with the eventual long-term goals to further standardize training, increase patient safety and incorporate a simulation-based curriculum for the specialty locally.

Laryngoplasty ; Larynx

OBJECTIVE: To develop a ventilation tube insertion simulator for training and evaluation of otorhinolaryngology residents in myringotomy with ventilating tube insertion.

METHODS:

            DESIGN:            Cross - Sectional Study

            SETTING:           Tertiary National University Hospital

            PARTICIPANTS:   Otologists and otorhinolaryngology resident trainees

A simulation tool for myringotomy with ventilation tube insertion was fabricated using silicone sealant, aluminum tube, rubber ball, plaster of paris and plastic sheet, and pretested by our expert panel. Residents were then evaluated using an objective structured clinical examination (OSCE) checklist while performing the procedure using the same model. Three trials were given, and OSCE scores were obtained, for each resident.

RESULT: The pinna, ear canal, tympanic membrane, malleus handle were deemed realistic by the expert panel. Residents performed the procedure at an average of 87 seconds. Average OSCE score for all residents was 17.17, with senior residents having a higher average score (18.3) than junior residents (16.6). However, this was not statistically significant (2 tailed t-value, significance level 0.05 = -1.27, p = .227). The most common cause of trial failure was dropping of the tube in the middle ear, while the most common error made was using more than 2 attempts at performing the incision.

CONCLUSION:  This simulation platform may be a valuable tool to use in educating and developing skills and proper technique of myringotomy with ventilation tube insertion. It is reproducible, affordable, realistic, sturdy and versatile in its applications. Residents who show adequate dexterity and consistency during simulation may eventually be allowed to perform the procedure on patients and provide feedback regarding the usefulness of the simulation.

Human ; Male ; Female ; Middle Aged (a Person 45-64 Years Of Age) ; Adult (a Person 19-44 Years Of Age) ; Otitis Media With Effusion ; Middle Ear Ventilation ; Tympanic Membrane ; Simulation Training ; Patient Simulation

Background and Objective: The COVID 19 pandemic has changed the way the human anatomy is taught. A necessary shift towards online instruction, combined with a decrease in cadaver donation has resulted in the need for maximizing formalinized, soft-embalmed, computerized, and plastinated cadaver specimens. Task-oriented activities allow students to demonstrate acquired knowledge and skills. It is the aim of this study to get the perspective of students in the utilization of available laboratory materials. Methods: One hundred forty-three students participated in task-oriented activities. Students demonstrated anatomy of the facial nerve, recurrent laryngeal nerve, and phrenic nerve by parotidectomy, thyroidectomy, and posterior neck dissection using formalinized cadaver and VH dissector™. Deep neck and sagittal structures in the plastinated specimen were identified using laser pointers. Ossicular mobility of the middle ear, and endoscopy of the nose and larynx were demonstrated using the soft embalmed cadaver. Students were surveyed on their perceptions on the utility of each cadaver specimen. Results: Formalinized and soft-embalmed cadaver were observed to present the most accurate anatomy, while the virtual dissector and plastinated specimens were seen to be the most sustainable and reusable. Conclusion Task-oriented learning in head and neck anatomy may use different cadaveric materials with varied accuracy and utility.
Anatomy ; Cadaver ; Education, Medical