Clinical Otolaryngology 2020-12-21

Course of symptoms for loss of sense of smell and taste over time in one thousand forty‐one healthcare workers during the Covid‐19 pandemic: Our experience

Matt Lechner, Jacklyn Liu, Nicholas Counsell, Ngan Hong Ta, John Rocke, Rajesh Anmolsingh, Nicholas Eynon‐Lewis, Sandtdeep Paun, Claire Hopkins, Sadie Khwaja, B. Nirmal Kumar, Samuel Jayaraj, Valerie J. Lund, Carl Philpott

Publication date 21-12-2020


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Is tracheotomy necessary for Transoral robotic surgery Base of Tongue Reduction in Obstructive Sleep Apnea Syndrome? Our Experience in 20 Patients.

Younes Chekkoury Idrissi, Jerome R. Lechien, Gilles Besnainou, Stéphane Hans

Publication date 21-12-2020


Abstract‐TORS BOT reduction is a safe surgical approach for OSAS patients with BOT collapse and failure to medical treatments.‐Tracheotomy may be avoided in patients without midline glossectomy due to the low risk of postoperative major hemorrhage.‐Tracheotomy is associated with a higher risk of aspiration, use of feeding tube, and lengthening of both the operative time and the hospital stay.

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Introducing an ethanol ablation service for recurrent symptomatic thyroid cysts within the NHS – a prospective study of twenty‐six patients

Shi Ying Hey, Lydia Robb, Pauline Gammack, Derek AJ Smith, Mark A Rodrigues, David Summers, Helen Reid, Iain J Nixon

Publication date 21-12-2020


Abstract●The majority of thyroid cysts are benign and asymptomatic but some continue to enlarge, causing local compressive symptoms or cosmetic concerns.●Image‐guided ablation of recurrent and symptomatic thyroid cysts has gained popularity worldwide over surgical removal, however, limited UK experience is reported to date.●Our series, conducted prospectively in a tertiary UK centre, has demonstrated that image‐guided ethanol ablation (EA) is safe, effective, well tolerated and economical.●Assessment of patient reported outcomes had shown a correlation between pre‐EA volume and Glasgow Benefit Inventory (GBI) score.●With its excellent radiological and clinical outcomes, EA should be routinely offered to patients with recurrent and symptomatic thyroid cysts in the shared decision making process.

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Clinicopathological features of DTC presenting in the UK versus internationally: An observational cohort study

R. Sawant, SY. Hey, K. Hulse, A. Hay, F.W Gibb, R. Adamson, I.J. Nixon

Publication date 21-12-2020


Abstract Introduction Very little data is available regarding differentiated thyroid cancer (DTC) managed in the UK, and no UK patients are included in the evidence base upon which international guidelines are based. Therefore, the aim of this study was to compare the clinicopathological features of patients with DTC presenting in a UK population with international patient cohorts.
Patients and Methods Data was collected from a prospectively held multidisciplinary team records from January 2009 ‐ December 2016. The local cohort was compared with cohorts from across the world based on clinicopathological features. Ethical approval was obtained by Lothian Caldicott Guardian (Ref 16133).
Results444 cases were diagnosed locally with a median age of 48 years (range 16‐86 years). 78% of patients were female. 25% of our patients had follicular carcinoma with an overall N1 rate of 20%. Distant disease was recorded in 5% cases.
In comparison with international data, our local cohort had a higher rate of follicular thyroid carcinoma. Variation was seen in terms of age, gender distribution, primary tumour size, nodal and distant disease. In Korea, where thyroid cancer screening has been undertaken, smaller tumours, higher rates of nodal disease and lower rates of distant disease are described.
Conclusion In our centre a higher rate of males are treated with larger primary disease and a higher percentage of follicular carcinoma. The reasons for this geographic variation in clinicopathological features in the UK are unclear. As a result, caution should be applied in translating the international move towards a more conservative approach to DTC in the UK in comparison with other areas of the world.

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Stapler Closure versus Manual Closure in Total Laryngectomy for Laryngeal Cancer: A Systematic Review and Meta‐Analysis

Yi‐Chan Lee, Tuan‐Jen Fang, I‐Chun Kuo, Yao‐Te Tsai, Li‐Jen Hsin

Publication date 21-12-2020


Abstract Objective Total laryngectomy (TL) is a life‐saving procedure for individuals with advanced laryngeal cancer and those suffering from recurrence after initial treatment. The present study aimed to evaluate the differences between stapler closure (SC) and manual closure (MC) of the pharynx during TL for patients with laryngeal cancer.
Design/SettingA systematic literature search was performed using the Pub Med, EMBASE and Cochrane Library databases. The data were analyzed using Comprehensive Meta‐Analysis software (Version 3; Biostat, Englewood, NJ). Dichotomous data were calculated as odds ratios (ORs), and continuous data were calculated as mean differences (MD) with 95% confidence intervals (CI).
Main Outcome/ResultsA total of 7 studies (535 patients) were included in this meta‐analysis. Pooled analysis showed that the operative time of TL was significantly reduced in the SC group (MD, ‐63.2; 95% CI, ‐106.0 to ‐20.4). Moreover, the SC group had a lower incidence of pharyngocutaneous fistula (OR = 0.38; 95% CI, 0.18 to 0.83; P = 0.016) and hospital stay (MD, ‐2.9; 95% CI, ‐5.6 to ‐0.1). The incidence of postoperative surgical site infection (OR = 0.41; 95% CI, 0.02 to 8.73; P = 0.565) was comparable between the two groups.
Conclusion Based on these results, SC may be a useful option for patients who need TL.

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The influence of radiotherapy on outcomes for auricular osseointegrated implants

Adam Arshad, Jacquline Chan, Stefan Edmondson, Maarten Vijverberg, Myrthe K S Hol, Peter Monksfield

Publication date 20-12-2020


Abstract Following surgical removal of the pinna for malignancy or craniofacial trauma, reconstruction with an auricular prosthesis provides an acceptable cosmetic option. The development of osseointegrated implants for the mounting of such auricular prostheses has significantly improved functional outcomes and aesthetics for patients.

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Octreotide versus oral dietary modification for the treatment of chylous fistula following neck dissection: a systematic review and meta‐analysis

Emma Molena, Emma King, Cameron Davies‐Husband

Publication date 20-12-2020


Abstract Aims Chylous fistula following neck surgery is a rare, but significant complication. Currently, there is no standardised treatment, which may comprise pressure dressings, oral dietary modification (ODM), surgery, or a combination of such measures. Octreotide is a somatostatin analogue that has gained popularity in the management of cervical chyle leaks. The effectiveness of octreotide compared with ODM is unclear. We provide a comprehensive, systematic review of the literature pertaining to the management of chylous fistulae, comparing both treatment strategies.
Methods The bibliographic databases MEDLINE, Cochrane, Pubmed, EMBASE and Google Scholar were searched from inception to October 2019. Search terms included (chyle title/abstract) OR (chylous title/abstract) AND (fistula title/abstract) OR (fistulae title/abstract) OR (leak title/abstract) AND (neck title/abstract) OR (dissection title/abstract). The study was conducted following the Preferred Reporting Items for Systematic Reviews and Meta‐Analysis (PRISMA) guidelines. Risk of bias was assessed using guidelines from the Joanna Briggs Institute (appendix 2). Outcome measures included the proportion of chylous fistulae that spontaneously resolved without the need for surgery and time taken until resolution, for both DM and octreotide, respectively.
Results The primary search identified 20 articles for review, comprising 313 patients. Three studies were suitable for pooled analysis. There was no statistically significant difference in the time taken for chylous fistula to resolve between groups (octreotide 10.0 days; ODM 12.0 days; p = .38). The overall rate of resolution was 89.6% and 81.5% respectively (p = .25). Surgery was highly effective in cases failing to resolve following intervention with either method (96% 53/55 patients).
Conclusion The use of octreotide for chylous fistula following neck dissection surgery is associated with a high rate of spontaneous resolution. However, significant heterogeneity, bias and concurrent use of ODM/TPN for patients in studies investigating octreotide precludes universal recommendation at this time. Further research in the form of randomised controlled trials is required to establish an independent treatment effect.

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Transoral robotic free flap inset in oropharyngeal cancer

Georg Haymerle, Emma Kristen Charters, Catriona Froggatt, James Wykes, Carsten E Palme, Jonathan R Clark

Publication date 19-12-2020


Abstract1. Practice doing pharyngoplasty closures in standard TORS improves suturing skills.2. The v‐lock is useful in areas where it is difficult to tie knots.3. Performing the inset prior to microvascular anastomosis reduces swelling and bleeding which will obstruct vision.4. Only introducing part (50%) of the flap to the defect for the first half of the inset improves access.5. 3 stay sutures placed before the flap is introduced in the most difficult locations (placed robotically) is helpful in challenging insets.

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Comparative performance of prediction model, non‐expert and tele‐diagnosis of common external and middle ear disease using a patient cohort from Cambodia that included one hundred and thirty‐eight ears

James Schuster‐Bruce, Prajwal Shetty, James O’Donovan, Rishi Mandavia, Touch Sokdavy, Mahmood F Bhutta

Publication date 19-12-2020


Abstract Efforts to combat the large global burden of ear and hearing disorders are hampered by poor availability of expert diagnosis We report the first study to directly compare prediction model, non‐expert and tele‐diagnosis of middle and external ear disorders.
A prediction model based upon a novel automated otological symptom questionnaire performed poorly, but absence of otorrhoea was found to reliably exclude a diagnosis of chronic suppurative otitis media.
Both on‐site non‐expert and expert tele‐diagnosis had high diagnostic specificity, but low sensitivity.
Future work could explore how the validity of these diagnostic methods may be improved.

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Analysis of the effects and predictors of tailor‐made notched music therapy for chronic idiopathic tinnitus patients: our experience with 70 patients

Mingfang Diao, Ruru Tian, Fangjie Tian, Xi Lin, Jianjun Sun

Publication date 19-12-2020


Abstract1. TMNMT can improve the self‐assessment scores of patients with chronic idiopathic tinnitus after three months of treatment.2. The therapeutic effect of TMNMT was not affected by gender, the side of the ear affected by tinnitus, the hearing level of the ear affected by tinnitus, tinnitus frequency,tinnitus duration or tinnitus loudness.3. Age and initial THI/VAS scores can be used as predictive factors for the treatment outcome of TMNMT.4. The study is valuable for clinicians in identifying suitable patients with chronic idiopathic tinnitus as candidates to receive TMNMT.5. The study was conducted in only one hospital, and the treatment effect was monitored for only three months. A larger sample size, a multicentre study, and a long treatment time are required to investigate the efficacy of treatment and the factors that predict the therapeutic effects in future studies.

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Admission avoidance in tonsillitis and peritonsillar abscess: A prospective national audit during the initial peak of the COVID‐19 pandemic

Matthew E Smith, INTEGRATE, The UK ENT Trainee Research Collaborative, John C Hardman, Chloe Swords, John P J Rocke, Abigail Walker, James E Bryan, Kristijonas Milinis, Rajeev G Mathew, Gareth H Jones, Oliver McLaren, Matthew E Smith

Publication date 17-12-2020


Abstract Objectives To report changes in practice brought about by COVID‐19 and the implementation of new guidelines for the management of tonsillitis and peritonsillar abscess (PTA), and to explore factors relating to unscheduled re‐presentations for patients discharged from the emergency department (ED).
Design Prospective multicentre national audit over 12 weeks from 6 April 2020.
SettingUK secondary care ENT departments.
Participants Adult patients with acute tonsillitis or PTA.
Main outcome measures Re‐presentation within 10 days for patients discharged from the ED.
Results83 centres submitted 765 tonsillitis and 416 PTA cases. 54.4% (n = 410) of tonsillitis and 45.3% (187/413) of PTAs were discharged from ED. 9.6% (39/408) of tonsillitis and 10.3% (19/184) of PTA discharges re‐presented within 10 days, compared to 9.7% (33/341) and 10.6% (24/224) for those admitted from ED. The subsequent admission rate of those initially discharged from ED was 4.7% for tonsillitis and 3.3% for PTAs.
IV steroids and antibiotics increased the percentage of patients able to swallow from 35.8% to 72.5% for tonsillitis (n = 270/754 and 441/608) and from 22.3% to 71.0% for PTA (n = 92/413 and 265/373).77.2% of PTAs underwent drainage (n = 319/413), with no significant difference in re‐presentations in those drained vs not‐drained (10.6% vs 9.5%, n = 15/142 vs 4/42, P = .846).
Univariable logistic regression showed no significant predictors of re‐presentation within 10 days.
Conclusions Management of tonsillitis and PTA changed during the initial peak of the pandemic, shifting towards outpatient care. Some patients who may previously have been admitted to hospital may be safely discharged from the ED.

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Cerumenolytics with or without manual extraction for impacted earwax: A network meta‐analysis of randomized clinical trials

Kannan Sridharan, Gowri Sivaramakrishnan

Publication date 16-12-2020


Abstract Background Many different substances for cerumenolysis have been evaluated in clinical trials. We carried out a systematic review and network meta‐analysis to compare their effectiveness.
Methods Electronic databases were searched for randomized clinical trials conducted in patients with impacted cerumen evaluating cerumenolytics. The primary outcome was the proportion of patients with wax clearance using manual techniques. Rankogram plot was used to assess the ‘best’ cerumenolytic.
Odds ratio (OR) with 95% confidence intervals (95% CI) was the effect estimate.
Results Twenty‐six studies were included in the systematic review and 25 in the meta‐analysis. Sodium bicarbonate (OR: 2.68, 95% CI: 1.2, 6.1) and paradichlorobenzene (OR: 30.9, 95%CI: 5.9, 161.3) were associated with significantly greater proportions of patients with wax clearance following syringing compared to normal saline. Rankogram plot revealed paradichlorobenzene to have the highest probability of being the ‘best’ cerumenolytic. Chlorobutanol was observed to be significantly better than normal saline in adults as well as following single application. Following multiple applications, glycerol, docusate sodium, hydrogen peroxide, oil, paradichlorobenzene, hydrogen peroxide/glycerol and arachis oil/chlorobutanol/paradichlorobenzene were observed with significant cerumenolytic activities.
Urea/hydrogen peroxide/glycerol was observed with a significant cerumenolytic activity without the need for further interventions such as syringing/aspiration/suction.
Conclusion We observed several cerumenolytics to be effective in the treatment of impacted earwax when accompanied by additional manual techniques such as syringing/aspiration/suction.

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Is Elective Contralateral Neck Dissection Necessary in 53 Salvage Total Laryngectomy Patients?

Gemma.E. Hogg, Christopher S.G. Thompson, Panagiotis Asimakopoulos, Ashley Hay, Iain.J. Nixon

Publication date 16-12-2020


Abstract Contralateral neck dissection in the salvage laryngectomy setting is controversial and associated with significant morbidity.13% had pathologically proven disease (cN0Pn+) during salvage laryngectomy, despite no clinical or radiological evidence of neck disease.92% had lateralised disease and 74% had a prophylactic contralateral neck dissection.2% had occult pathological disease in the contralateral neck histology.
The rate of occult contralateral nodal disease is low in lateralised primary disease and contralateral neck dissection can be safely spared in selected patients.

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A Comparison between Mygind and Kaiteki positions in administration of drops to the olfactory cleft

Dafna Gershnabel Milk, Grace C Khong, Osman H Çam, Fernando Alfaro‐ Iraheta, Claire Tierney, Firas Kassem, Samuel C Leong

Publication date 16-12-2020


Abstract Objectives Systemic steroids are a well‐known, proven treatment for olfaction impairment. Topical nasal steroids are an attractive alternative that avoids systemic side effects and might provide an increased local drug activity. Nonetheless, the access of the medication to the olfactory cleft (OC) by using low‐ volume devices, such as nasal drops, is greatly dependent on the position of the head.
We aimed to examine the accessibility of nasal drops to the OC area in two different head positions: the Mygind (lying head back) position and the Kaiteki position.
Design and Setting This is a cadaver study; the specimens were firstly positioned in Mygind and thereafter in Kaiteki positions. Nasal drops mixed with blue food dye were administered into the nostril in each head position. Endoscopic videos were recorded, and two blinded observers scored the extent of olfactory cleft penetration (OCP) using a 4‐point scale (0 = none, 3 = heavy).
Participants Twelve fresh frozen cadaver specimens.
Main outcome measures The dyes penetration to the OC.
Results The mean score of nasal drops penetrance to the OC in the Mygind position was 1.34, as compared to 1.76 in the Kaiteki position. The difference in the OCP score between the two groups was not statistically significant (p>0.05)Conclusion Both Mygind and Kaiteki head positions are reasonable alternatives in treatment with nasal drops for olfaction impairment. The preference of one position over another should rely on the patients comfort.

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What determines quality of life in patients with vestibular schwannoma?

Ineke M.J. Pruijn, Wietske Kievit, Mayke A. Hentschel, Jef J.S. Mulder, Henricus P.M. Kunst

Publication date 16-12-2020


Abstract Objectives Patients with a vestibular schwannoma (VS) experience a reduced quality of life (QoL). The main objective of this study was to determine the strongest predictors reducing physical and mental QoL from the disease‐specific Penn Acoustic Neuroma Quality of Life (PANQOL) questionnaire in patients with VS.
Design Observational study.
Setting Radboudumc Skull Base Centre, Nijmegen.
Participants Patients newly diagnosed with VS between 2014 and 2017 managed with either observation, stereotactic radiosurgery or microsurgery.
Main outcome measures QoL was assessed using the disease‐specific PANQOL and general Short‐Form (36) Health Survey (SF‐36). Multiple linear regression models with PANQOL domains as predictors, were used to determine the strongest predictors for SF‐36 QoL physical and mental health scores. Standardized Beta coefficients (β) were used for ranking.
ResultsA total of 174 patients (50% females, mean age 58.9 yr) returned the questionnaires, providing a 69% response rate. Fifteen patients (9%) were treated with microsurgery, 29 (17%) with stereotactic radiosurgery and 130 patients (75%) were observed in a wait‐and‐scan strategy. A lack of energy (β= 0,28; p= <0.001), lower general health (β= 0.22; p= <0.001), headache (β= 0.16; p= <0.001) anxiety (β= 0.15; p= <0.001) and balance problems (β= 0.10; p= <0.001) are the strongest predictors affecting physical health, while mental health is most affected by anxiety (β= 0.37; p= <0.001), a lack of energy (β= 0.34; p= <0.001), facial nerve dysfunction (β= 0.07; p= <0.001), balance problems (β= 0.04; p= <0.001) and headaches (β= 0.04; p= <0.001).
ConclusionA lack of energy, anxiety, headache and balance problems are the strongest predictors of both SF‐36 physical and mental QoL in patients with VS. More awareness and supportive care regarding energy, anxiety, headache and balance in informing, evaluating and treating patients with VS could improve QoL

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Prognostic value of the neutrophil‐to‐lymphocyte ratio, platelet‐to‐lymphocyte ratio and systemic immune‐inflammation index in patients with laryngeal squamous cell carcinoma

Zhilin Li, Yi Qu, Yang Yang, Wei An, Shaoqing Li, Bin Wang, Ying He, Jing Li, Qi Shao, Lizheng Qin

Publication date 15-12-2020


Abstract Objectives We aimed to determine the prognostic value of the neutrophil‐to‐lymphocyte ratio (NLR), platelet‐to‐lymphocyte ratio (PLR) and systemic immune‐inflammation index (SII) in patients with laryngeal squamous cell carcinoma (LSCC).
Design and settingA retrospective analysis of patients with LSCC was conducted in our hospitals. Clinical information, including age, sex, TNM classification and other demographic and clinical data, was acquired and analyzed. Progression‐free survival (PFS) and overall survival (OS) were calculated and compared using the Kaplan‐Meier method and log‐rank test.
ParticipantsA total of 147 patients with LSCC were included.
Results According to the receiver operating characteristic (ROC) curve, the optimal cutoff points for NLR, PLR and SII were 1.88, 117.36, and 517.64. The analysis revealed NLR, PLR and SII to be independent predictors for OS and PFS (p<0.05).
Conclusions Preoperative NLR, PLR and SII are promising prognostic predictors for patients with LSCC.

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Evaluation of narrow band imaging for diagnosis of unilateral nasal lesions

Dachuan Fan, Jinxiao Hou, Tianhong Zhang, Yijing Ye

Publication date 15-12-2020


Abstract Objectives This study aimed to investigate the effect of narrow band imaging (NBI) examination on differentiating diagnosis between benign and malignant neoplasms involving nasal cavity.
Design, Setting, ParticipantsA retrospective study was conducted to analyse cases from January 2018 to December 2019 at a single center. A total of 188 consecutive patients who were newly diagnosed with lesions in unilateral nasal cavity underwent complete examination with white light endoscopy (WLE) and NBI endoscopy. Biopsy specimens were harvested from the target lesions and sent to the pathologist for definite diagnosis. Participants with a history of congenital malformation, trauma and surgery in nasal cavity were excluded from the study.
Main outcome measures Endoscopic diagnosis was assessed using sensitivity, specificity, accuracy, positive and negative predictive values (PPV and NPV, respectively).
Results In identifying benign and malignant lesions of nasal cavity, NBI had a significant higher sensitivity (92.7% vs 70.7%, P = 0.020) and NPV (98% vs 92.3%, P = 0.032) than WLE, but there were no significant differences between NBI and WLE in specificity (98.6% vs 97.3%, P = 0.684), accuracy (97.3% vs 91.5%, P = 0.416) and PPV (95% vs 87.9%, P = 0.400).
ConclusionNBI as an emerging technique can improve the diagnostic accuracy by distinguishing benign and malignant lesions in nasal cavity, and remains a promising and helpful adjunct to the endoscopy techniques.

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Factors influencing long‐term treatment response to botulinum toxin injection for spasmodic dysphonia

Min Seok Kang, Seung Jin Lee, Hong‐Shik Choi, Jae‐Yol Lim

Publication date 14-12-2020


Abstract Objective The purpose of this study was to evaluate the outcomes of long‐term botulinum toxin type A (BoNTA) treatment for adductor spasmodic dysphonia (AdSD) and to determine the factors predictive of treatment response by investigating dose stability and average intervals.
Design Retrospective cohort study.
Setting Academic tertiary medical centre.
ExposuresA total of 470 patients with adductor spasmodic dysphonia, who received electromyography‐guided BoNTA injections over 12 years, were retrospectively enrolled in this study.
Main Outcomes and Measures The patients’ demographic data, baseline voice dynamics and treatment profiles (dose, frequency and intervals) were evaluated. Factors correlating with the dose adjustment ratio (number of increasing dosing/total number of BoNTA toxin injections) and changes in intervals between injections were statistically analysed.
ResultsA total of 122 patients, who received ≥ 4 injections and whose average treatment interval was < 240 days, were finally evaluated. Of them, 115 (94.3%) were female and seven (5.7%) were male, and the mean age at initial treatment was 34.89 ± 13.07 and 41.14 ± 12.71 years, respectively. On average, patients received 18.00 ± 13.33 injections (1.67 ± 0.60 U/injection) to alternating unilateral vocal folds. The treatment period was 65.07 ± 43.28 months and the mean interval between injections was 4.16 ± 1.28 months. The mean dose adjustment ratio among patients who received ≥ 4 injections was 0.15 ± 0.13, and dose changes occurred 4.36 times/patient. The patients’ age and gender significantly affected the treatment response, where younger or female patients showed greater dosing variability and shorter intervals between injections. However, the baseline voice dynamics (voice handicap index, fundamental frequency, jitter, shimmer, noise‐to‐harmonic ratio, maximum phonation time and degree of voice breaks) did not predict the dose adjustment ratio or interval changes. In addition, patients with fluctuating doses showed lower age and higher VHI subscale scores, and patients with short‐treatment interval (< 100 days) showed higher SDF0.
Conclusions Almost all patients received stable low doses of BoNTA over time, irrespective of the baseline results. Patients’ age, gender and VHI scores were correlated with poor treatment responses, such as frequent dose changes and shorter intervals between injections.

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Laryngeal sarcoidosis at a tertiary airway centre: Our experience with 32 patients

Anthony Rotman, Elizabeth F. Maughan, Maral J. Rouhani, Andrew Holroyd, Margaret Ashcroft, Chadwan Al Yaghchi, Guri Sandhu

Publication date 13-12-2020


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The changing face of tonsillectomy

Mat Daniel, James Tysome

Publication date 13-12-2020


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Changes in healthcare utilisation for paediatric tonsillectomy and adenoidectomy in the Netherlands: a population‐based study

Juliëtte J. C. M. Munster, Amir H. Zamanipoor Najafabadi, Janneke Hooft, Teus A. Barneveld, Stefan Böhringer, Jorrit S. Visser, Rolf H. Bremmer, Wilco C. Peul, Wilbert B. den Hout, Peter Paul G. Benthem

Publication date 13-12-2020


Abstract Objectives Tonsillectomy and adenoidectomy in children are controversial subjects with large regional variation in surgical rates, partly explained by cultural differences and lack of high‐quality evidence on indications for surgery. A quality of care cycle was executed on this topic in the Netherlands. The objective of this study was to estimate changes in healthcare utilisation for paediatric tonsil surgery in the Netherlands.
Methods Population‐based data on tonsillectomies and adenoidectomies in children up to age 10 were retrieved retrospectively from Dutch administrative databases between 2005 and 2018. A change point analysis was performed to detect the most pivotal change point in surgical rates. We performed univariate analyses to compare surgical patients’ characteristics before and after the pivotalpoint . Impact on healthcare budget and societal costs were estimated using current prices and data from cost‐effectiveness analyses.
Results The annual number of adenotonsillectomies reduced by 10 952 procedures (−39%; from 129 per 10 000 children to 87 per 10 000 children) between 2005 and 2018, and the number of adenoidectomies by 14 757 procedures (−49%; from 138 per 10 000 children to 78 per 10 000 children). The most pivotal change point was observed around 2012, accompanied by small changes in patient selection for surgery before and after 2012. An estimated €5.3 million per year was saved on the healthcare budget and €10.4 million per year on societal costs.
Conclusion The quality of care cycle resulted in fewer operations, with a concomitant reduction of costs. We suggest that part of these savings be invested in new research to maintain the quality of care cycle.

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The implications of variations in nasal irrigation recipes in the United Kingdom

Joshua D. Whittaker, Timothy Reynolds, Patrick K. Lee

Publication date 08-12-2020


Abstract Objective This study aims to investigate the variations in publicly available nasal irrigation recipes published in the United Kingdom (UK).
Design Internet searches used to identify eligible nasal irrigation recipes. These were then examined for their physical and biochemical properties, through theoretical calculations and experimental measurement.
Setting Recipes produced by healthcare providers or official national bodies in the UK.
Participants No human participants.
Main outcome measures Solution osmolality (classified into hypo‐, iso‐ and hypertonic), acidity (pH) and specific gravity.
Results Thirteen unique recipes were identified from 17 sources. Osmolality ranged from 166.2 to 1492.2 mosmol/kg in volumes ranging from 142 to 1136 m Ls (isotonic range 275‐295 mosmol/kg). Specific gravity ranged from 1.006 to 1.034. pH ranged from 7.74 to 8.11. No recipe produced a solution with isotonic properties. The majority produced hypertonic irrigations.
Conclusions Most publicly available nasal irrigation recipes produce hypertonic solutions but there is great variability in the osmolality and volume. UK organisations should take action to review published recipes to bring these into alignment with latest guidelines (recommending against hypertonic saline use) and reduce variability in patient interpretations.

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Effects of endogenous and exogenous oestrogen exposure on hearing level in postmenopausal women: A cross‐sectional study

Michelle Jee Young Suh, Sun Kyung Oh, Soo Bin Lee, Sung Huhn Kim

Publication date 08-12-2020


Abstract Objective To investigate the effect of endogenous and exogenous oestrogen exposure on hearing levels in postmenopausal women.
Study Design Retrospective cross‐sectional study.
Setting Population‐based survey data collected by the Korean National Health and Nutrition Survey between 1 January 2010 and 31 December 2012.
Subjects and Methods Participants comprised 3,653 postmenopausal women. Detailed histories for reproductive factors and data on the use of hormone replacement therapy were obtained through health questionnaires and otologic examinations, including pure‐tone audiogram and otoscopic findings. Complex‐sample linear regression models controlling for confounding factors were generated to determine whether hormone‐related factors were associated with hearing loss.
Results Women who experienced a longer duration of oestrogen exposure had better hearing compared to those who do not in multivariate model adjusting for confounding factors with a lower adjusted beta coefficient of hearing threshold (β = ‐0.18, 95% confidence interval = ‐0.3 to ‐0.07, P = .002). The results also suggested that hormone replacement therapy may be beneficial for attenuating hearing loss (β = ‐1.22, 95% confidence interval = ‐2.19 to ‐0.25, P = .014), particularly in the high frequency range from 3 k Hz to 6 KHz.
ConclusionA longer duration of lifetime oestrogen exposure (LEE) and the use of hormone replacement therapy are likely to attenuate hearing loss. These epidemiologic data provide evidence that oestrogen may be beneficial for attenuating age‐related hearing decline.

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Thyroid Function Control among Pregnant Women Following a Therapeutic Thyroidectomy

Gilad Horowitz, Maya Ish‐Shalom, Anton Warshavsky, Naftali Stern, Dan M. Fliss, Doron Comaneshter, Shlomo Vinker

Publication date 08-12-2020


Abstract The total number of thyroidectomies performed for both benign and malignant disease has dramatically increased throughout the past few decades, with females far outnumbering males, and younger patients (<45 years old) comprising roughly one‐quarter of operated cases.1‐3 During pregnancy, a woman’s thyroid physiology undergoes well‐defined changes,4,5 resulting in a significant increase in the total thyroxine pool, primarily during the first trimester.6 Since the pregnant woman is the sole source for fetal supply of thyroid hormones from conception to approximately 13 weeks of gestation, the fetuses of women who had undergone therapeutic total thyroidectomy rely on exogenous thyroxine.

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Ambient Pressure Tympanometry in the Workup of Patulous Eustachian Tube and Neurotologic Disorders

Anthony Thai, Jennifer Y. Lee, Zahra N. Sayyid, Davood K. Hosseini, Austin Swanson, Matthew B. Fitzgerald, Yona Vaisbuch

Publication date 08-12-2020


Abstract In contrast to previous reports, respiration‐synchronous APT wave patterns display low sensitivity (53.3%) in our retrospective cohort of 15 PET ears, as diagnosed by characteristic symptoms and otoscopy.
In 327 non‐PET ears, the largest cohort of non‐PET ears evaluated to date, respiration‐synchronous APT wave patterns demonstrate high specificity for PET (93.9%), consistent with previous literature.
APT performed solely at rest and with ipsilateral nostril respiration displays similar sensitivity for PET as the full battery of respiratory maneuvers.
Pulse‐synchronous wave patterns at rest may suggest an alternative neurotologic diagnosis requiring further workup, such as superior semicircular canal dehiscence.
Ambient pressure tympanometry is a rapid, simple and widely available tool that can be integrated into general otolaryngology clinics and warrants further study in the evaluation of PET and neurotologic disorders.

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Singing voice range profile: New objective evaluation methods for voice change after thyroidectomy

Jungirl Seok, Youn Mi Ryu, Seong Ae Jo, Chang Yoon Lee, Yuh‐Seog Jung, Junsun Ryu, Chang Hwan Ryu

Publication date 08-12-2020


Abstract Background After surgery in the thyroid region, patients may present with phonation or singing difficulty, even within their vocal range. We designed a novel voice evaluation method that reflects subjective and objective voice complications of the surgery.
Methods This tool recorded patients voice ranges while singing, which was named the singing voice range profile (singing VRP). Patients were asked to sing “Happy Birthday,” which has a one‐octave scale, at a comfortable tone and intensity. The singing VRP, standard VRP and voice handicap index‐10 (VHI‐10) results were recorded before thyroidectomy and 1 and 3 months after thyroidectomy for 128 patients. For subgroup analysis, a group where the maximum F0 of standard VRP in 1 month postoperatively was lower than the highest singing F0 of the preoperative singing VRP was defined as “Collapsed group” and the other group was “Preserved group.”Results The changes in the highest, lowest and range of singing fundamental frequency (F0) had decreased at 1 month postoperatively. Subsequently, they had improved significantly at 3 months postoperatively but were lower than those preoperatively (all P < .05, except for the change in the lowest singing F0 between 1 and 3 months postoperatively, P = .274). In the subgroup analysis, the singing range of the collapsed group (n = 65) showed significantly lower VHI‐10 scores, range of vocal F0 and singing F0 than those of the preserved group (n = 63) at 1 and 3 months postoperatively (all P < .001). At 3 months postoperatively, the singing F0 range in the preserved group had recovered to the range before surgery (13.0 ± 1.3 vs. 13.1 ± 1.4, P = .746 for the preserved group, and 13.0 ± 1.3 vs 11.5 ± 2.4, P < .001 for the collapsed group).
Conclusions Parameters measured by singing VRP showed a trend similar to the change in VHI‐10 and the maximum F0 of standard VRP. In addition, singing VRP allowed a qualitative classification of the postoperative voice function when combined with standard VRP. Therefore, it can be used as a supplementary voice evaluation tool to reflect the physiologic and functional aspects of voice.

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Implications of vestibular telemetry for the management of Ménière’s Disease—Our experience with three adults

John S. Phillips, Jacob L. Newman, John E. FitzGerald, Stephen J. Cox

Publication date 08-12-2020


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Long‐term swallowing outcomes of radiotherapy and transoral laser microsurgery for T1 glottic cancer treatment

Kerem Ozturk, Goksel Turhal, Duygu Durusoy, Emre Sahin, Ozlem Akagunduz, Sibel Eyigor, Serdar Akyildiz, Mustafa Esassolak

Publication date 08-12-2020


Abstract Introduction Both CO2 transoral laser microsurgery (CO2 TOLMS) and radiotherapy (RT) are standard of care in early glottic carcinoma. However, previous studies focus on voice outcomes rather than swallowing outcomes. This study aimed to compare the late post‐treatment effects of CO2 TOLMS and RT treatment on swallowing function in T1 glottic carcinoma.
Methods Forty patients (20 CO2 TOLMS and 20 RT) with T1 glottic cancer between May 2015 and January 2019 were included. Certain types of foods triggering dysphagia, any difficulties in bolus control, need to clean the throat, the sensation of lumping in the throat, choking, cough and xerostomia were questioned. Also, functional oral intake scale (FOIS), functional outcome swallowing scale (FOSS), Eating Assessment Tool‐10 test (EAT‐10) and flexible fiberoptic endoscopic examination of swallowing (FEES) findings were assessed.
ResultsCO2 TOLMS patients performed significantly better than the RT group regarding penetration and aspiration with 10 and 20 mL water according to the Penetration and Aspiration Scale (P < .05). The mean EAT‐10 Score was found 0 in the CO2 TOLMS group, and 3.20 ± 3.24 in the RT group (P < .05) (lower score indicates a better outcome). According to the Yale Pharyngeal Residue Severity Scale for vallecula, there was no statistically significant difference in vallecular residue between the groups (P > .05). A significantly lesser residue in piriform sinus was detected in the CO2 TOLMS group compared to the RT group with 5 mL and 10 mL water, 5 mL and 20 mL honey consistency food and yogurt according to Yale Pharyngeal Residue Severity Scale (P < .05).
Conclusion It is suggested that in the long term, CO2 TOLMS is more advantageous regarding swallowing function in the treatment of T1 glottic cancer.

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"Facial and hearing outcomes in transmastoid nerve decompression for Bells palsy, with preservation of the ossicular chain"

Akira Inagaki, Mariko Takahashi, Shingo Murakami

Publication date 08-12-2020


Abstract Objectives Facial nerve decompression is a salvage treatment for Bells palsy patients for whom a poor prognosis is anticipated with standard medical treatment. The transmastoid approach is a frequently performed approach, but it remains unknown if this surgery is effective when the ossicular chain is preserved. This study aimed to determine the efficacy of facial nerve decompression using the transmastoid approach in Bells palsy.
Design, setting and participants This retrospective study included patients who had undergone transmastoid facial nerve decompression with ossicular chain preservation and patients who met the criteria for surgery, but received only medical treatment between January 2007 and May 2019, at a single centre.
Main outcome measures Attainment of House‐Brackmann grade I at 12 months after onset of facial palsy.
Results The recovery rate to House‐Brackmann grade I in the decompression group in the early phase (≤18 days after onset) was higher than that of the medical treatment group, although the difference was not significant (70% vs 47%, P = .160). However, within this early surgery group, a subgroup of cases with ≥95% facial nerve degeneration demonstrated a significant improvement in recovery rate (73% vs 30%, P = .018). Among surgeries performed in the late phase (≥19 days), only a subgroup with ≥95% facial nerve degeneration was available for analysis, and the difference in recovery rate was not significant compared with medical treatment alone (26% vs 30%, P = 1.00). Post‐surgical hearing evaluation demonstrated that average hearing deterioration was 1.3 dB which was non‐significant, suggesting this procedure does not cause hearing loss.
Conclusions Transmastoid facial nerve decompression with ossicular chain preservation in the early phase after symptom‐onset is an effective salvage treatment for severe Bells palsy with ≥95% facial nerve degeneration.

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SerenoCem™ granules: A retrospective analysis of 43 patients and identification of a subset with progressive erosion

Fabrizio Bandino, Bruno Kenway, Michail Chatzimichalis

Publication date 06-12-2020


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Timing and volume of information produced for the Otolaryngologist during the COVID‐19 pandemic in the UK: A review of the volume of online literature

Cristina Cernei, Manu K. Shrivastava, William Colquhoun‐Flannery, Stuart C. Winter

Publication date 06-12-2020


Abstract Background The SARS‐CoV‐2 was first reported in December 2019 in Wuhan, China and has been declared a pandemic in March 2020. COVID‐19 has caused unprecedented and lasting biopsychosocial effects worldwide. All healthcare professionals have faced life‐threatening risks by attending their daily jobs. The daily emergence of advice and guidelines was necessary to ensure the safety of patients and staff. To this effect, all elective services came to a halt to preserve hospitals’ capacity for dealing with the sickest. This retrospective, descriptive review aims to assess the volume and timing of the advice released specifically relevant to UK ENT specialists.
Methods Two separate searches were performed. One involved online advice published in English by international, national and ENT‐specific organisations between January 1 and May 31. The date, title, source, type of advice and link to the advice were recorded in Excel. The resources were analysed per week of publication. A second separate search for peer‐reviewed publications was conducted using Pub Med Central and Cochrane databases.
FindingsCOVID‐19‐related guidance was considered, of which 175 were identified. 52/175 (29.7%) articles were published by international organisations. 56/175 (32%) were produced by national organisations, and 67/175 (38.28%) were produced by ENT specific organisations. The peak guidance production took place in the third and fourth week of March (16/03/2020‐29/03/2020) with 72/175 publications. Of these, 27/70 came from the international category, 17/70 from national bodies and 26/70 from ENT‐specific organisations. 13 863 total publications relating to COVID‐19 were found using Pub Med and Cochrane search strategies; 76% were relevant to ENT.
Conclusion The challenges faced by ENT relate to the unprecedented, sudden and daily changes to clinical practice. Multiple bodies interpreted the guidance, giving an opportunity for confusion and delay in treatments for patients. Implementing a system with clear lines of communication and dissemination of information will improve our response to future pandemic events whilst maintaining a commercial awareness to better use the human and financial resources of an already financially restricted NHS.

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Dyspnea Index: An upper airway obstruction instrument; translation and validation in Swedish

Eleftherios Ntouniadakis, Ole Brus, Mathias von Beckerath

Publication date 05-12-2020


Abstract Objective Upper airway dyspnea is a challenging condition in which assessing the discomfort experienced by the patient is essential. There are three patient‐reported outcome (PRO) instruments developed particularly for this patient group, none of which is available in Swedish. The aim of this study was to translate the Dyspnea Index (DI) into Swedish and validate the instrument for use in the Swedish‐speaking population by investigating its basic psychometric properties.
DesignA prospective instrument validation study.
Setting Tertiary referral center.
Participants Fifty‐three (n=53) patients with upper airway dyspnea and 19 healthy controls.
Main outcome measures The questionnaire was translated into Swedish (swDI) with a forward‐backward method. Reliability, repeatability, responsiveness and construct validity were assessed by asking the subjects to complete the swDI, a visual analog scale (VAS) at exertion and at rest and the Voice Handicap Index (VHI).
Results The swDI showed excellent internal consistency (Cronbach’s α: 0.85) and repeatability (interclass correlation coefficient: 0.87 and Pearson’s r: 0.89) in the patient group. No ceiling effect was observed (maximum score achieved was 39; 85% of the patients scored ≤36). SwDI scores moderately correlated with VAS at exertion (r: 0.59) and at rest (r: 0.42), yet poorly with the VHI (r: 0.36). The effect size (ES) was 3.8.
Conclusions The swDI is a valid, robust and reliable questionnaire for self‐assessment in Swedish‐speaking patients with upper airway obstruction. A future anchor‐based longitudinal study is needed to assess the smallest detectable change (SDC) and minimum important change (MIC) that were not estimated in our study.

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How many patients will be eligible for cochlear implantation (CI) on audiological grounds, once the new 2019 NICE guidance takes effect?

Robert Grounds, Eleojo Miachi, Tina Beckham, Codruta Neumann, Joseph Wasson

Publication date 04-12-2020


Summary The 2019 revised NICE guidance (TA566) on cochlear implantation (CI) lowered the audiological threshold at which patients become eligible for CI. NICE estimates this will result in a 70% increase in CI by 2024/25.
We performed a retrospective audit of all audiograms performed at East Kent Hospitals University Foundation Trust (serving a population of 695,000 people) over the last 6 years. We identified how many patients were eligible for CI using both the 2009 guidelines and the revised 2019 guidelines.
When using the 2019 guidelines, 163% more patients were eligible on audiological grounds for CI (P=0.0009).
Increased demand for CI surgeons will require either higher throughput from existing centres, or the creation of new centres entirely, whilst training more surgeons may require a corresponding increase in CI fellowships.

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Epstein‐Barr virus may contribute to the pathogenesis of adult‐onset recurrent respiratory papillomatosis: A preliminary study.

Martin Formánek, Debora Formánková, Pavel Hurník, Adéla Vrtková, Pavel Komínek

Publication date 02-12-2020


Abstract Objective Human papillomavirus (HPV) causes adult onset recurrent respiratory papillomatosis (AORRP), but AORPP prevalence is much lower than HPV prevalence. Thus, HPV infection is necessary, but not sufficient, to cause AORRP and other factors likely contribute to its pathogenesis. The present study aimed to investigate whether co‐infection with herpetic viruses may contribute to the pathogenesis of AORRP.
Design Prospective case‐control study conducted from January 2018 to November 2019.
Settings Tertiary referral center.
Participants Eighteen consecutive patients with AORRP and 18 adults with healthy laryngeal mucosa (control group) undergoing surgery.
Main outcome measures Cytomegalovirus, Epstein‐Barr virus (EBV), herpes simplex viruses 1 and 2, human herpesvirus 6, varicella zoster virus, and HPV (including genotyping) were detected in biopsies of papilloma or healthy mucosa using real‐time polymerase chain reaction and reverse line blot. Dysplasia and Ki67 levels were determined in papilloma specimens.
ResultsEBV was present in 6 (33.3%) AORRP patients and no control patients (P=0.019). Presence was not dependent on tobacco exposure (P=0.413) or HPV genotype or concentration (P>0.999). EBV presence was strongly related to increased cell proliferation (P=0.005) and number of previous surgeries (P=0.039), but not dysplasia (P>0.999). Human herpesvirus 6 was found in 3 (16.7%) AORRP biopsies, with one false positive. No other herpetic virus was found.
Conclusions Unlike other herpetic viruses, EBV seems to interact with HPV, enhancing cell proliferation and contributing to the pathogenesis and progression of AORRP. Further research is required to elucidate specific interactions and their role in the pathogenesis of AORRP.

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Factors related to a non‐localising technetium 99m sestamibi scan result during parathyroid adenoma imaging in primary hyperparathyroidism

Richard Jackson, Dylan Chew, Simon McClean, James England

Publication date 01-12-2020


Abstract Objectives The aim of this study is to investigate factors that are associated with having a non‐localising 99m Tc‐sestamibi scan.
DesignA retrospective study was performed on patients that underwent parathyroid surgery performed within a single institution between 2001 and 2018.
Setting Single tertiary centre for parathyroid surgery.
Participants230 patients underwent surgery for primary hyperparathyroidism due to a solitary parathyroid adenoma and had pre‐operative 99m Tc‐sestamibi imaging.
Main outcome measures Variables including age, gender, intra‐operative location of parathyroid adenoma, adenoma weight and pre‐ & post‐operative calcium and parathyroid hormone levels were investigated through univariate and multivariate analysis to identify any association with having a non‐localising (negative) 99m Tc‐sestamibi scan result.
Results Multivariate analysis identified that right‐sided adenomas (p=0.038), superior adenomas (p=0.042) and a lower pre‐operative PTH level (p=0.034) were all individual factors associated with having a negative 99m Tc‐sestamibi scan result. Although the weight of the adenoma was significant on univariate analysis (p=0.029), this was not demonstrated on multivariate analysis (p=0.422).
Conclusion Factors that were associated with having non‐localising 99m Tc‐sestamibi scan were right‐sided adenomas, superior adenomas, and lower pre‐operative PTH level. Further large prospective multicentre studies are needed to further evaluate these initial findings.

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Survival and treatment outcome of head and neck cancer patients with pulmonary oligometastases

Ines Lardinois, Didier Dequanter, Jérôme R. Lechien, Cyril Bouland, Rokneddine Javadian, Alexandra Rodriguez, Isabelle Loeb, Fabrice Journe, Sven Saussez

Publication date 28-11-2020


Abstract Objectives The purpose of this study was to determine the outcome of head and neck squamous cell carcinoma (HNSCC) patients developing lung metastasis.
Design Retrospective study.
ParticipantsHNSCC patients with lung metastasis treated between 2001 and 2018 were included.
Mean outcomes measures Statistical analyses described the relationship between patient survival, treatment efficacy and pulmonary metastasis occurrence.
Results One hundred HNSCC patients were included in the study. The median overall survival (OS) was 21 months. The median recurrence‐free survival (RFS) was seven months. Patient survival with only lung metastases was significantly longer compared to patients with lung metastases and lymph nodes involvement or other metastases. Moreover, patients with a single metastasis had longer post‐RFS and OS than patients with multiple metastases. The local control of metastasis was better when patients presented only lung metastases, and it was more effective in single metastasis. The surgery allowed better metastases local control than supportive care or radio and/or chemotherapy. In case of specific therapy, pulmonary resection was associated with a longer post‐RFS and a longer OS compared to supportive care or radio and/or chemotherapy.
Conclusions We confirmed, in the current study, the significant survival benefit for HNSCC patients treated by surgery for their pulmonary metastasis. While treatment of multiple metastases required palliative chemotherapy or best supportive care in most of the cases, specific surgical treatment in selected HNSCC patients should be considered.

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Role of specific IgE on staphylococcal enterotoxin B in chronic rhinosinusitis severity

Suk Won Chang, Jeong Jin Park, Chi Sang Hwang, Jae Sung Nam, Jong‐Gyun Ha, Wasan F. Almarzouq, Chang‐Hoon Kim, Joo‐Heon Yoon, Hyung‐Ju Cho

Publication date 25-11-2020


Abstract Objective To investigate the clinical significance of specific IgE‐staphylococcal enterotoxin B (IgE‐SEB) in CRS (chronic rhinosinusitis).
Design Retrospective analysis of patients who were positive for specific IgE‐staphylococcal enterotoxin B.
Setting Tertiary rhinology clinic.
ParticipantsA total of 965 patients who were tested for specific IgE‐staphylococcal enterotoxin B from December 2016 to December 2017.
Main outcome measures We retrospectively reviewed the records of 965 patients who were tested for specific IgE‐staphylococcal enterotoxin B from December 2016 to December 2017. Patient demographics, titre‐specific IgE to staphylococcal enterotoxin B levels, MAST, serologic test and medical records were reviewed.
Results IgE‐SEB (KU/L) was higher in CRS patients than non‐CRS patients (0.13 ± 0.37 vs 0.08 ± 0.22, respectively; P‐value: .044), and the IgE‐SEB (+, ≥0.35) rate was also higher (10.06% vs 4.46%, respectively; P‐value: .030). IgE‐SEB (KU/L) was higher in the CRS group than in the fungal sinusitis group (0.13 ± 0.37 vs 0.03 ± 0.05, respectively; P‐value: <.001), and the IgE‐SEB (+, ≥0.35) rate was also higher (10.06% vs 0%, respectively; P‐value: .015). Between the CRSsNP (chronic rhinosinusitis without nasal polyps) and CRSwNP (chronic rhinosinusitis with nasal polyps) groups, there were no differences in IgE‐SEB (KU/L) or IgE‐SEB (+) rates. IgE‐SEB positivity was not associated with the presence of polyps, concomitant asthma or postoperative recurrence. As the values of IgE‐SEB (KU/L) and the IgE‐SEB (+, >0.1) rate increased, the CRS severity also increased.
Conclusions IgE‐SEB showed a positive correlation with Lund‐Mackay CT severity score, but not with postoperative recurrence or nasal polyps. Further studies are needed to obtain clear evidence that IgE‐SEB can be considered as an independent CRS endotype.

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Treatment choice in single‐sided deafness and asymmetric hearing loss. A prospective, multi‐center cohort study on 155 patients

Mathieu Marx, Isabelle Mosnier, Christophe Vincent, Nicolas‐Xavier Bonne, David Bakhos, Emmanuel Lescanne, Jonathan Flament, Daniele Bernardeschi, Olivier Sterkers, Bernard Fraysse, Benoit Lepage, Benoit Godey, Sébastien Schmerber, Alain Uziel, Michel Mondain, Frédéric Venail, Olivier Deguine

Publication date 24-11-2020


Abstract Objectives To describe the treatment choice in a cohort of subjects with single‐sided deafness (SSD) and asymmetric hearing loss (AHL). To assess the reliability of the treatment trials.
Design In this national, multi‐centre, prospective study, the choice of subjects was made after two consecutive trials of Contralateral Routing Of the Signal (CROS) hearing aids and a Bone Conduction Device (BCD) on a headband. Subjects could proceed with one of these two options, opt for cochlear implantation or decline all treatments.
Setting Seven tertiary university hospitals.
Participants155 subjects with SSD or AHL fulfilling the candidacy criteria for cochlear implantation, with or without associated tinnitus.
Main outcome measures After the two trials, the number of subjects choosing each option was described. Repeated assessments of both generic and auditory‐specific quality of life were conducted, as well as hearing assessments (speech recognition in noise and horizontal localization).
ResultsCROS was chosen by 75 subjects, followed by cochlear implantation (n=51), BCD (n=18) and abstention (n=11). Patients who opted for cochlear implantation had a poorer quality of life (p=0.03). The improvement of quality of life indices after each trial was significantly associated with the final treatment choice (p=0.008 for generic indices, p=0.002 for auditory specific indices). The follow‐up showed that this improvement had been overestimated in the CROS group, with a long‐term retention rate of 52.5%.
Conclusions More than one third of SSD/AHL subjects are unsatisfied after CROS and BCD trials. Repeated quality of life assessments help counselling the patient for his/her treatment choice.

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The use of ultrasound‐guided preoperative colloidal charcoal injection in the surgical management of recurrent differentiated thyroid cancer—A pilot study in 3 patients

Ali Eker Moustafa, Frederick Robert Green, Sheila Fraser, Sriram Vaidyanathan, James W Moor

Publication date 21-11-2020


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The frequency of lymph node metastases by neck level in p16 positive oropharyngeal squamous cell carcinoma

Frederick R. Green, Ali E. Moustafa, Preetha Chengot, Amit Prasai, James W. Moor

Publication date 18-11-2020


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Longitudinal economic analysis of Bonebridge 601 versus percutaneous bone‐anchored hearing devices over a 5‐year follow‐up period

Nikul Amin, Andrew Jonathan Soulby, Daniele Borsetto, Irumee Pai

Publication date 12-11-2020


Abstract Objectives Percutaneous bone‐anchored hearing devices (pBAHDs) are the most commonly used bone conduction implants (BCI). Concerns surround the long‐term complications, notably skin‐related, in patients with percutaneous abutments. The active transcutaneous BCI Bonebridge system can help avoid some of these pitfalls but is often considered a second‐line option due to various factors including perceived increased overall costs.
Design Longitudinal economic analysis of Bonebridge BCI 601 versus pBAHD over a 5‐year follow‐up period.
SettingA specialist hearing implant centre.
Participants Adult patients (≥16 years) with conductive hearing loss, mixed hearing loss or single‐sided deafness, who received a Bonebridge or pBAHD implant between 1/7/2013 and 1/12/2018 with a minimum 12‐month follow‐up.
Main outcome measures We compared the mean costs per implanted patient for both implants at 1, 3 and 5 years postoperative time points. Clinical effectiveness was evaluated using objective and patient‐reported outcome measures.
Results The mean total cost per patient of Bonebridge was significantly higher than pBAHD at 1‐year post‐implantation (£8512 standard deviation SD £715 vs £5590 SD £1394, P < .001); however, by 5‐years post‐implantation this difference was no longer statistically significant (£12 453 SD £2159 vs £12 575 SD £3854, P > .05). The overall cost convergence was mainly accounted for by the increased long‐term complications, revision surgery rates and higher cost of the pBAHD external processor compared to Bonebridge.
Conclusions Long‐term costs of Bonebridge to healthcare providers are comparable to pBAHDs, whilst offering lower complication rates, comparable audiological benefit and patient satisfaction. Bonebridge should be considered as a first‐line BCI option in appropriate cases.

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Efficacy of toluidine blue in the diagnosis and screening of oral cancer and pre‐cancer: A systematic review and meta‐analysis

Do Hyun Kim, Eun A. Song, Sung Won Kim, Se Hwan Hwang

Publication date 12-11-2020


Abstract Aims The accuracy of toluidine blue (TB) and chemiluminescence for diagnosing oral cancer and pre‐cancer was evaluated.
Methods Two authors (working independently) comprehensively reviewed six databases (Pub Med, Cochrane database, Embase, Web of Science, SCOPUS and Google Scholar) from their dates of inception until March 2020. Oral mucosal disorder, as detected by TB, was compared with that detected by chemiluminescence. True‐positive, true‐negative, false‐positive and false‐negative data were extracted for each study. Methodological quality was evaluated using the Quality Assessment of Diagnostic Accuracy Studies tool (ver. 2). The extent of interrater agreement was also assessed.
Results Twenty‐nine prospective and retrospective studies were included. The diagnostic odds ratio (DOR) of TB was 7.017 (95% confidence interval CI, 4.544; 10.836). The area under the summary receiver operating characteristic curve was 0.766. The correlation between the sensitivity and the false‐positive rate was 0.196, indicating the absence of heterogeneity. TB exhibited moderate interrater reliability (0.6777; 95% CI, 0.43; 0.7455). Compared with chemiluminescence, as used in nine studies, TB had a lower sensitivity (0.659 vs 0.841), but a higher specificity (0.809 vs 0.345), negative predictive value (0.766 vs 0.690) and DOR (10.565 vs 5.203). Compared with clinical examination, as used in four studies, TB method had a higher sensitivity (0.891 vs 0.891), specificity (0.739 vs 0.634), negative predictive value (0.920 vs 0.714) and DOR (28.491 vs 8.526). Subgroup analysis showed that screening for severe dysplasia or more severe disease was significantly more sensitive, but less specific, than screening for all dysplasias.
Conclusions Although the diagnostic accuracy of TB in the diagnostic work‐up of oral cancer and pre‐cancer was higher than that of clinical examination, it was not high enough for TB to reliably be used alone. Instead, it should be combined with chemiluminescence or other diagnostic tools.

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Awake endoscopic assessment of the upper airway during tidal breathing: Definition of anatomical features and comparison with drug‐induced sleep endoscopy

Eli Van de Perck, Anneclaire V. Vroegop, Sara Op de Beeck, Marijke Dieltjens, Annelies E. Verbruggen, Paul H. Van de Heyning, Marc J. Braem, Olivier M. Vanderveken

Publication date 10-11-2020


Abstract Objectives Awake nasopharyngoscopy is routinely performed in the assessment of patients who require treatment for sleep‐disordered breathing (SDB). However, the applicability and accuracy of Müllers manoeuvre, the main evaluation method for this purpose, are disputable. The current study aimed to introduce an alternative method for awake nasopharyngoscopy in patients with SDB.
Design We defined qualitative anatomical features during tidal breathing at the levels of the soft palate, oropharynx, tongue base, epiglottis and hypopharynx, and compared these awake features to the sites and patterns of collapse as observed during drug‐induced sleep endoscopy (DISE).
Setting Tertiary care academic centre.
Participants Seventy‐three patients diagnosed with SDB.
Main outcome measures The primary outcome measure was the Kendalls tau correlation coefficient (τ) between observations during awake nasopharyngoscopy and DISE. Kappa‐statistics (κ) were calculated to assess the agreement on awake endoscopic features with a second observer.
Results In contrast to epiglottis shape, the modified Cormack‐Lehane scale was significantly associated with epiglottis collapse during DISE (P < .0001; τ = .45). Other upper airway features that were correlated with DISE collapse were the position of the soft palate (P = .007; τ = .29), crowding of the oropharynx (P = .026; τ = .32) and a posteriorly located tongue base (P = .046; τ = .32). Interobserver agreement of endoscopic features during tidal breathing was moderate (0.60 ≤ κ < 0.80).
Conclusion The current study introduces a comprehensive and reliable assessment method for awake nasopharyngoscopy based on anatomical features that are compatible with DISE collapse patterns.

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An enhanced recovery programme improves the comfort and outcomes in children with obstructive sleep apnoea undergoing adenotonsillectomy: A retrospective historical control study

Yu Zhang, Dawei Liu, Xiumei Chen, Jiahai Ma, Xicheng Song

Publication date 07-11-2020


Abstract Objective To explore the effects of an enhanced recovery after surgery (ERAS) programme on postoperative rehabilitation in children with obstructive sleep apnoea (OSA) during the perioperative period of adenotonsillectomy.
DesignA retrospective historical control study.
Setting Service improvement project.
Participants The study included 394 children with OSA (207 males, 187 females; age range, 2.5 years to 14 years) who underwent adenotonsillectomy.
Main outcome measures The children who had undergone adenoidal ablation and bilateral tonsillectomy were divided into an ERAS group (208 patients) treated with the combined optimisation measures and a control group (186 patients) treated with traditional measures during the perioperative period. The postoperative incidence of complications, pain scores, anxiety scores and postoperative diets in the two groups were assessed.
Results Patients in the ERAS group had significantly a lower overall complication rate and incidence of fever for 2 weeks of follow‐up when compared to patients in the control group through the application of perioperative optimisation measures. Furthermore, patients in the ERAS group had less post‐surgical pain, had better dietary intake at days 1, 3 and 7 after surgery and had lower preoperative anxiety scores after admission education and while waiting in the operation room.
Conclusion The ERAS programme consisting of combined optimisation measures can reduce physical and psychological trauma during the perioperative period of adenotonsillectomy performed for children with OSA.

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Development of a model to predict vestibular schwannoma growth: An opportunity to introduce new wait and scan strategies

Mayke A. Hentschel, Gerjon Hannink, Stefan C. A. Steens, Jef J. S. Mulder, Maroeska M. Rovers, Henricus P. M. Kunst

Publication date 06-11-2020


Abstract Objectives To develop a prediction model to predict vestibular schwannoma (VS) growth for patients in a wait and scan (W&S) strategy.
Design Retrospective cohort study.
Setting Tertiary hospital (Radboud university medical center, Nijmegen, the Netherlands).
Participants Patients with unilateral VS, entering a W&S strategy and at least one follow‐up MRI available. Data on demographics, symptoms, audiometry and MRI characteristics at time of diagnosis were collected from medical records.
Main outcome measures Following multiple imputation, a multivariable Cox regression model was used to select variables, using VS growth (≥2 mm) as outcome. Decision curve analyses (DCA) were performed to compare the model to the current strategy.
Results Of 1217 analysed VS patients, 653 (53.7%) showed growth during follow‐up. Balance complaints (HR 1.57 (95% CI: 1.31‐1.88)) and tinnitus complaints in the affected ear (HR 1.36 (95% CI: 1.15‐1.61)), Koos grade (Koos 1 is reference, Koos 2 HR 1.03 (95% CI: 0.80‐1.31), Koos 3 HR 1.55 (95% CI: 1.16‐2.06), Koos 4 HR 2.18 (95% CI: 1.60‐2.96)), time since onset of symptoms (IQR HR 0.83 (95% CI: 0.77‐0.88) and intrameatal diameter on MRI (IQR HR 1.67 (95% CI: 1.42‐1.96)) were selected as significant predictors. The models discrimination (Harrells C) was 0.69 (95% CI: 0.67‐0.71), and calibration was good. DCA showed that the model has a higher net benefit than the current strategy for probabilities of VS growth of >12%, 15% and 21% for the first consecutive 3 years, respectively.
Conclusions Patients with balance and tinnitus complaints, a higher Koos grade, short duration of symptoms and a larger intrameatal diameter at time of diagnosis have a higher probability of future VS growth. After external validation, this model may be used to inform patients about their prognosis, individualise the W&S strategy and improve (cost‐)effectiveness.

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In‐scalp incision technique for cochlear implantation

Hisashi Sugimoto, Miyako Hatano, Tomokazu Yoshizaki

Publication date 03-11-2020


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The role of nasal congestion as a defence against respiratory viruses

Ronald Eccles

Publication date 01-11-2020


Abstract Introduction This review discusses how nasal congestion may have benefits as a mechanism of defence against respiratory viruses.
MethodsA literature research was conducted on respiratory viruses and nasal congestion, following a recently published review on how temperature sensitivity is important for the success of common respiratory viruses.
Results The literature reported that common respiratory viruses are temperature sensitive and replicate well at the cooler temperatures of the upper airways (32°C), but replication is restricted at body temperature (37°C). The amplitude of the phases of congestion and decongestion associated with the nasal cycle was increased on infection with respiratory viruses and this caused unilateral nasal congestion and obstruction. Nasal congestion and obstruction increase nasal mucosal temperature towards 37°C and therefore restricted the replication of respiratory viruses.
Conclusion Nasal congestion associated with the nasal cycle may act as a mechanism of respiratory defence against infection with respiratory viruses.

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Predictors of OSA following adenotonsillectomy in children with trisomy 21

Diogo Raposo, Marco Menezes, João Rito, Mafalda Trindade‐Soares, Cristina Adónis, Helena Cristina Loureiro, Filipe Freire

Publication date 31-10-2020


Abstract Objectives Given that 30%‐50% of children with trisomy 21 have persistent obstructive sleep apnoea (OSA) after adenotonsillectomy, we evaluated whether demographic, clinical and polysomnographic factors predicted persistent OSA and OSA severity after adenotonsillectomy.
Design Retrospective study.
Setting Secondary care hospital.
Participants Retrospective review of 32 children with the diagnosis of trisomy 21 and OSA by polysomnography who underwent adenotonsillectomy, from January 2010 to December 2018.
Main outcome and measure Non‐parametric analysis was used to compare pre‐ and postoperative factors, and regression was used to model persistent OSA and OSA severity.
Results Thirty‐two children were included (17 males, median age 10.00 ± 8.00 years, median body mass index z‐score 0.89 ± 1.25). Overall, adenotonsillectomy resulted in a significant improvement in median obstructive apnoea‐hypopnoea index (oAHI) from 7.5 ± 8.95 to 4.40 ± 4.38 events per hour (P < .001) and in median OSA‐18 score from 85.00 ± 12.00 to 61.00 ± 37.75 (P < .001). Persistent OSA was found in 56.25% of the children. Univariate regression suggests that postoperative OSA‐18 score was associated with persistent OSA after adenotonsillectomy. Preoperative oAHI, preoperative oxygen desaturation index, pre‐ and postoperative OSA‐18 scores correlated with OSA severity after adenotonsillectomy. However, in a multivariate model only the postoperative OSA‐18 score correlated with OSA severity after adenotonsillectomy.
Conclusions Although adenotonsillectomy results in a significant improvement of OSA in children with trisomy 21, more than half of the children had persistent OSA. The postoperative OSA‐18 score was associated both with persistent OSA and OSA severity after adenotonsillectomy.

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Adults with inflammatory bowel disease are at a greater risk of developing chronic rhinosinusitis: A nationwide population‐based study

Yu‐Hsuan Lin, Cheng Li Lin, Chia‐Hung Kao

Publication date 21-10-2020


Abstract Background Both inflammatory bowel disease (IBD) and chronic rhinosinusitis (CRS) are characterised by dysregulated immune responses. Though previous studies have demonstrated the coexistence of IBD and CRS, investigations of their association using large sets of epidemiologic data are lacking.
Methods We examined IBD and the subsequent risk of CRS in a nationwide setting. For 1 January 2000 to 31 December 2010, we identified in the National Health Insurance Dataset of Taiwan a total of 8313 patients over the age of 20 years with IBD. We randomly extracted 33 252 cases without IBD to create a comparison group matching patients by age, sex and index year. Cumulative incidences were obtained using the Kaplan‐Meier method, and we calculated risk estimates for the development of CRS using the Cox proportional hazards model.
Results In 295 007 person‐years, we identified 521 (1.25%) cases of IBD. The IBD cohort had a 1.26‐fold (95% confidence interval CI, 1.17‐1.35) greater risk of developing CRS than the comparison group; for ulcerative colitis, it was 1.73‐fold (95% CI, 1.48‐2.05) and for Crohns disease it was 1.20‐fold (95% CI = 1.11‐1.29). Subsequent analysis stratified by age revealed that the risk was highest among the population with IBD aged 50 to 64 years (adjusted hazard ratio = 1.37; 95% CI, 1.18‐1.59). A follow‐up‐specific analysis demonstrated that the risk appeared to be highest with a follow‐up duration of less than 2 years.
Conclusion The present analysis indicates that personal history of IBD, especially the phenotype ulcerative colitis, is associated with increased risk of subsequent CRS.

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Rhinology in the COVID‐19 era: Our experience from a rhinology tertiary referral hospital and implications for future practice

Jennifer C. Magill, Samit Unadkat, Elizabeth Bullock, Mark S. Ferguson, Catherine Rennie, William E. Grant, Hesham A. Saleh

Publication date 21-10-2020


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A prospective multicentre external validation study of the Liverpool Peritonsillar abscess Score (LPS) with a no‐examination COVID‐19 modification

David Selwyn, Ding Yang, Elliot Heward, Ashwin Kerai, Elinor Thompson, Abulgasem Shommakhi, Scott Faulkner, Richard Siau, Hussein Walijee, Tom Hampton, Dorota Chudek, Supriya Singhera, Waqas Din, Andrew S. Lau

Publication date 20-10-2020


Abstract Objectives Our primary aim was to validate the Liverpool Peritonsillar abscess Score (LPS) externally in a new patient cohort. Our secondary aim was to modify the LPS in the light of the COVID‐19 pandemic to produce a no‐examination variant for use in this instance.
Design Prospective multicentre external validation study.
Setting Six different secondary care institutions across the United Kingdom.
Participants Patients over 16 years old who were referred to ENT with any uncomplicated sore throat such a tonsillitis or peritonsillar abscess (PTA).
Main outcome measures Sensitivity, specificity, positive predictive value and negative predictive value for both the original LPS model and the modified model for COVID‐19.
Results The LPS model had sensitivity and specificity calculated at 98% and 79%, respectively. The LPS has a high negative predictive value (NPV) of 99%. The positive predictive value (PPV) was slightly lower at 63%. Receiver operating characteristic (ROC) curve, including the area under the curve (AUROC), was 0.888 which indicates very good accuracy.
Conclusions External validation of the LPS against an independent geographically diverse population yields high NPV. This may support non‐specialist colleagues who may have concerns about mis‐diagnosing a PTA. The COVID‐19 modification of the LPS has a similar NPV, which may be of use where routine oral examination is to be avoided during the COVID‐19 pandemic.

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Identifying factors associated with spontaneous restoration of hearing in children with otitis media with effusion

Lowri Edwards, Rebecca Cannings‐John, Christopher Butler, Nick Francis

Publication date 20-10-2020


Abstract Objectives To identify predictors of acceptable hearing at 5 weeks, 6 and 12 months in children with bilateral otitis media with effusion (OME).
Design and setting Secondary analysis of OSTRICH data, conducted in hospital ear, nose and throat (ENT) and paediatric audiology and audiovestibular medicine departments across Wales and England.
Participants The OSTRICH study included 389 children aged 2‐8 years with bilateral hearing loss attributable toOME for at least 3 months.
Main outcome measures Baseline, 5‐week, 6‐ and 12‐month audiology measurements were collected and logistic regression models used to identify pre‐randomisation baseline variables that predicted return of acceptable hearing, which was defined as less than or equal to 20 dB hearing loss averaged within the frequencies of 0.5, 1, 2 and 4 k Hz in at least one ear in children assessed by pure tone audiometry, ear‐specific insert visual reinforcement audiometry or ear‐specific play audiometry less than or equal to 25 dB hearing loss averaged within the frequencies of 0.5, 1, 2 and 4 k Hz in children assessed by sound‐field visual reinforcement audiometry or sound‐field performance/play audiometry, based on national guidelines.
Results Less severe baseline hearing loss across both ears most consistently predicted acceptable hearing at 5 weeks (adjusted odds ratio aOR 0.91, 95% CI 0.87‐0.95), 6 months (0.94 0.90‐0.98) and 12 months (0.93 0.89‐0.97). Negative history of atopy (2.05 1.16‐3.61), never using hearing aids (aOR 2.16 1.04‐4.48), and being male (1.75 1.02‐2.99) were significant at 6 months, but not at 12 months. Symptom duration was a predictor at 5 weeks, but not at 6 or 12 months.
Conclusions Milder baseline hearing loss most consistently predicts acceptable hearing at 5 weeks, 6 and 12 months in children with chronic OME. Negative history of atopy, never using hearing aids, and male gender are associated with better prognosis. These predictors can be used to identify children that may not require treatment.

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Lithuanian version of nasolacrimal duct obstruction symptom scoring questionnaire. Cross‐cultural adaptation and validation. Short‐ and long‐term results

Tomas Jakštas, Tomas Balsevičius, Saulius Vaitkus, Evaldas Padervinskis

Publication date 19-10-2020


Abstract Objectives The objective of this study was to perform translation, cross‐cultural adaptation and validation of the Lithuanian version of specific nasolacrimal duct obstruction symptom scoring (NLDO‐SS) questionnaire and to evaluate short‐ and long‐term results of endoscopic endonasal dacryocystorhinostomy (EN‐DCRS) procedure.
Design, Setting, Participants Permission for questionnaire translation, cross‐cultural adaptation and validation was obtained from the authors of the original questionnaire. Translation, validation and cross‐cultural adaptation were carried out according to generally accepted methodology. Validation study of the Lithuanian version of NLDO‐SS (L‐NLDO‐SS) was performed, and short‐ and long‐term results of EN‐DCRS procedure were evaluated according to symptoms. In total, 44 patients were evaluated 2 weeks before the surgical intervention, a day before the surgery and 41 patients 2 months after the surgery, and again 10 months later.
Main outcome measures We analysed the internal consistency and test‐retest reliability of the L‐NLDO‐SS questionnaire. Cronbachs alpha was used to represent and evaluate internal consistency for ordinal responses. Validity was assessed by comparing scores between a control group of volunteers without NLDO and the NLDO group using Mann‐Whitney test. To test the limiting score on which the sensitivity and specificity curves cross in identifying patients with NLDO, receiver operating characteristic (ROC) curve analysis was used. The pre‐ and post‐operative scores were compared using the paired t‐test.
Results The results showed an acceptable internal consistency of L‐NLDO‐SS questionnaire, with Cronbachs alpha—.73 in the initial test group and .71 in the retest group. Pearsons correlation coefficient was .94 (P < .001), revealing good correlation between the initial scores and the retest scores. Our sample of healthy individuals had a mean L‐NLDO‐SS score of 11.42 (±12.69) points, and patients being scheduled for EN‐DCRS had a mean L‐NLDO‐SS score of 27.45 (±9.81) points. Post‐operatively mean L‐NLDO‐SS scores improved from 27.45 (±9.81) points to 4.45 (±6.29) points in the short term and to 5.83 (±4.17) in the long term, demonstrating the statistically significant responsiveness of the instrument over both timescales.
Conclusions Lithuanian version of NLDO‐SS questionnaire is a valid instrument for assessing patients with NLDO in the Lithuanian population. It demonstrated good internal consistency, reproducibility, validity and responsiveness.

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Defining appropriateness criteria for endoscopic sinus surgery in the management of adult dental implant patients with incidental maxillary sinus findings on conebeam computed tomography

Nikul Amin, Abigail Walker, Isam Alobid, Shahram Anari, Florian Bast, Rajiv K. Bhalla, Russell Cathcart, Philip G. Harries, Iain Hathorn, Carl M. Philpott, Yujay Ramakrishnan, Benjamin Stew, Pavol Surda, Fiona Ting, Claire Hopkins

Publication date 19-10-2020


Abstract Objectives Conebeam computed tomography (CBCT) imaging is commonly requested by dental implant surgeons, preoperatively, for patients being considered for dental implants. Incidental maxillary sinus findings often result in otolaryngology (ENT) referral for further assessment.
CBCT findings include transient and benign mucosal changes that may not require any intervention and therefore unnecessarily delay implant surgery.
We aim to define appropriateness criteria for ESS in the management of adult dental implant patients with incidental maxillary sinus findings on CBCT and provide guidance to both dental implant and ENT surgeons.
Design The RAND/UCLA appropriateness methodology was used to develop and define the appropriateness criteria.
SettingA virtual panel of 13 international experts in ESS.
Participants The expert panel completed two rounds of a modified Delphi ranking process for nine clinical scenarios, considering various factors affecting decision‐making processes.
Main outcome measures To define appropriateness criteria for ESS in adult dental implant patients who have incidental maxillary sinus findings on CBCT.
Results Patients with clinical symptoms and endoscopic findings of chronic rhinosinusitis together with an obstructed ostiomeatal complex (OMC) and concentric mucosal thickening of the ipsilateral maxillary sinus or pansinusitis were deemed appropriate candidates for ESS prior to their dental implant. ESS was not appropriate in asymptomatic patients with a patent OMC and mucosal thickening isolated to floor of the ipsilateral maxillary sinus.
For uncertain scenarios, further discussion between dental implant and ENT surgeon should be considered.
Conclusions This study has developed and reported a list of appropriateness criteria to offer ESS in adult dental implant patients with incidental maxillary sinus findings on CBCT.

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Emergency airway training: “Who are you going to FONA?”

Sanjana Bhalla, Issa Beegun, Chris Hogan, Zaid Awad, Neil Tolley

Publication date 19-10-2020


Abstract Objectives To demonstrate face and content validity of a home‐made simulation model as a training tool for front of neck access (FONA) procedures.
Design This was a prospective evaluation study, in which experienced otolaryngologists and trainees were recruited to complete 3 tasks using our FONA model.
Setting The study was completed during regular simulation training days and international conferences.
ParticipantsA total of 52 participants completed the questionnaire and were included in the study; 25 were experts and 27 were trainees.
Main outcome measures All participants completed a validated 15‐item questionnaire using a 5‐point likert scale to assess the model across 4 domains: face validity (FV), global content (GC), task‐specific content (TSC) and curriculum applicability (CTR).
Results There were no statistically significant differences between the groups ratings for FV, GC, TSC or CTR (P = .76, .13, .4 and .67, respectively). The model achieved a median FV of 4 (IQR 4‐5) with the agreement of experienced and trainee groups (68.9% and 92%, respectively). The median GC validity score was 5 (IQR 4‐5) with the agreement of 87.6% and 98.4% in respected groups. The model achieved a median TSC of 4.8 (IQR 4‐5) with the agreement of 54.5% and 99% in respected groups. The median CTR score was 5 (IQR 4‐5) with the agreement of 54.4% and 100% in respected groups.
Conclusion Our home‐made FONA model achieved face and content validity for training and is safe and affordable for teaching basic front of neck access skills to otolaryngology trainees.

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Preradiation tooth extraction and jaw osteoradionecrosis: Nationwide population‐based retrospective study in Taiwan

Pei‐Hsun Liao, Chi‐Hsiang Chu, Pei‐Ling Tang, Pei‐Chen Wu, Tsu‐Jen Kuo

Publication date 19-10-2020


Abstract Objective Radiotherapy (RT) for head and neck cancer (HNC) within 7 days of tooth extraction is contraindicated because it may increase the risk of osteoradionecrosis of the jaw (ORNJ). However, delayed RT could compromise survival in patients with HNC. By using a national healthcare database, we reviewed the contraindications and analysed other risk factors for ORNJ.
DesignA retrospective cohort study.
Setting By using Taiwans National Health Insurance Research Database, 5,062 HNC patients with at least one tooth extraction 1‐21 days before the first RT day (index day) and without any extractions during or after RT from 2000 to 2013 were included.
The patients were divided into two groups according to the time of tooth extraction before the index day: 1‐7 days and 8‐21 days.
Participants Taiwanese patients with head and neck cancer.
Main Outcomes Measure Univariate and multivariate Cox proportional hazard regression models were used to evaluate the risk factors of ORNJ.
Results The overall incidence of ORNJ in the included patients was 1.03% (mean follow‐up duration, 4.07 ± 3.01 years; range, 1.00‐13.99 years). Tooth extraction within 7 days before RT was not associated with increased ORNJ risk (hazard ratio HR =0.734; P = .312). Significant risk factors for ORNJ included oral cancer (adjusted HR = 3.961), tumour excision surgery within 3 months before RT (adjusted HR = 3.488) and mandibulectomy within 3 months before RT (adjusted HR = 5.985; all P < .001).
Conclusion In a mean follow‐up of 4 years, tooth extraction within 7 days before RT for HNC treatment did not increase the ORNJ risk compared with tooth extraction 7‐21 days before RT.

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Comparative cohort study of volumetric modulated arc therapy for squamous cell cancer of unknown primary in the head and neck—Involved neck only versus mucosal irradiation

Wai‐Yan Poon, Maureen Thomson, Philip McLoone, Christina Wilson, Robin Crosbie, Stefano Schipani, Derek Grose, Allan James, Carolynn Lamb, Mohammed Rizwanullah, Frances Campbell, Fiona Easton, Claire Paterson

Publication date 19-10-2020


Abstract Objectives Target volumes for irradiation remain ill‐defined for squamous cell cancer of unknown primary in the head and neck (SCCUP). The aim of this study was to compare involved neck only (INO) radiotherapy (RT) with irradiating involved neck plus potential mucosal primary sites and contralateral neck (MUC) in patients diagnosed and treated with modern diagnostics and techniques.
Design This is a retrospective cohort study. Patients with a diagnosis of SCCUP with unilateral neck disease were included.
Results Thirty patients were identified. All underwent FDG PET‐CT. 47% of patients had HPV‐positive SCC. 20 patients received RT to INO, 10 patients to MUC, all with volumetric modulated arc therapy (VMAT). A significantly lower dose for each organ at risk was delivered in INO‐treated patients, with mean dose to contralateral parotid gland 57% less. The proportion of patients with late grade 2 or worse xerostomia was higher in MUC patients. The incidence of grade 2‐3 mucositis (89% vs 45%) and grade 3 or worse dysphagia (50% vs 10%) was higher in MUC patients. Median follow‐up was 31 months. No mucosal primaries emerged. Progression‐free survival at 2 years was 74.7% for INO patients, 70% in the MUC group. Overall survival at 2 years was 79.7% in the INO group and 70% in the MUC patients.
ConclusionINO radiotherapy for patients with SCCUP of the head and neck is a safe treatment strategy resulting in clinically significant lower RT doses to OARS. Acute and late toxicities are reduced without detriment to patient survival.

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Prospective anatomical study to determine the site of insertion of recurrent laryngeal nerve into the larynx

James X. Wu, Martin Hanson, Shivangi Lohia, Hao Li, Laura Wang, Ashok R. Shaha, Ian Ganly

Publication date 19-10-2020


Abstract Objectives Determine whether the insertion site of the recurrent laryngeal nerve (RLN) occurs at a predictable distance from the midline trachea, to help guide safe dissection during thyroid surgery.
Design Prospective clinical trial. At the inferior edge of the cricoid cartilage, we measured the distance from mildline trachea to the RLN insertion site.
Setting Single institution.
Participants50 consecutive patients undergoing thyroid surgery.
Main outcome measures Distance from midline trachea to laryngeal insertion of RLN.
Results The study population included 36 women and 14 men, with 72 total nerves measured. The average distance‐to‐midline + standard deviation (range) of the RLN was 20.7 + 2.3 (17‐26) mm in women compared to 26.3 + 2.1 (22‐32) mm in men.
Conclusion The insertion point of the RLN into the larynx at the level of inferior border of the cricoid cartilage can be reliably predicted, to facilitate early identification of the RLN during thyroid surgery.

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Surgiflo® may have a potential impact on the healing process in cricotracheal resection anastomosis

Ahmed Musaad Abd El‐Fattah, Hisham Atef Ebada, Ali Tawfik

Publication date 19-10-2020


Abstract Objectives To evaluate the role of thrombin‐based haemostatic agent Surgiflo® (Ethicon) in improving the outcome of cricotracheal resection anastomosis.
Design Randomised controlled clinical trial.
Setting Otorhinolaryngology Department, Mansoura University Hospitals, Egypt.
Participants This study included 55 patients with grade III and IV subglottic and/or cervical tracheal stenosis, who underwent cricotracheal resection anastomosis.
Patients were randomly assigned into two groups: Surgiflo group (n = 20) and control group (n = 35). In Surgiflo patients, Surgiflo® was applied at the end of surgery over the whole operative field including the line of airway anastomosis with the purpose of adequate haemostasis and enhancing healing of the anastomosis.
Main outcome measures The success rate and the incidence of complications in both groups were compared.
Results At the end of treatment, decannulation rate was 95% (19/20) in the Surgiflo groups and 82.8% (29/35) in the control group. The overall incidence of complications was significantly lower in the Surgiflo group (P = .021). Need for further surgical airway interventions in the form of repeated dilatation, granulation tissue removal or performing a tracheotomy was reported in 22.9% (8/35) of control group patients, in comparison with 5% (1/20) in Surgiflo group.
Conclusion Direct Surgiflo® application in the operative field enhances the anastomotic healing, decreases the incidence of anastomotic complications and subsequently improves the outcome. It can be recommended as an adjuvant to surgery in patients undergoing cricotracheal resection anastomosis.

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Locoregional control, progression‐free survival and morbidity rates in N3 head and neck cancer patients with low primary tumour burden: A 301‐patient study

Florent Carsuzaa, Xavier Dufour, Philippe Gorphe, Christian Righini, Alain Cosmidis, Maximilien Rogé, Erwan De Mones, Stéphanie Servagi Vernat, Denis Tonnerre, Sylvain Morinière, Amaury Dugas, Olivier Malard, François Pasquier, Sébastien Vergez, Ulrike Schick, Michael Gérard, Julia Salleron, Juliette Thariat

Publication date 19-10-2020


Abstract Objectives In patients with N3 head and neck squamous cell carcinoma (HNSCC), N3 disease is associated with high regional relapse and metastatic risks. Patients with resectable N3 disease have better prognosis although their metastatic risk may be similar as in patients with unresectable disease. Neoadjuvant chemotherapy has been associated with lower metastatic rates, but N3 patients may die of rapid locoregional progression. We assessed outcomes with the three modalities in patients with low primary burden to better assess the specific prognosis of N3 disease.
Methods This retrospective multicentric study included T0‐2 N3 HNSCC patients. Outcomes and morbidity in upfront neck dissection (uND) vs non‐surgical groups were analysed and oncological outcomes and morbidity compared between patients undergoing chemoradiation or neoadjuvant chemotherapy in patients with initially unresectable N3 nodes.
Results Of 301 patients, 142 (47%) underwent uND, 68 (23%) neoadjuvant chemotherapy and 91 (30%) chemoradiation. The 24‐ and 60‐month incidence of locoregional relapse was 23.2% 18.3%; 28.4% and 27.4% 21.8%; 33.3%; it was lower in patients undergoing uND (P = .006). In patients with non‐surgical treatments, success rates were 57.8% 49.4%; 66.3% after chemoradiation and 38.1% 29.6%; 46.7% after neoadjuvant chemotherapy (P = .001). Overall morbidity was more frequent in patients undergoing uND (68.8%) (P < .001).
ConclusionuND improved locoregional control but increased morbidity and showed no survival benefit. Success rates were better after chemoradiation versus neoadjuvant chemotherapy. Neoadjuvant chemotherapy did not reduce metastatic rates but non‐responders to chemoradiation had poor PFS and survival rate, suggesting that predictive criteria are warranted.

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Polysomnography in children with obstructive sleep apnoea and neurocognitive disorders

Arvind Chandrakantan, Deep Patel, Mica Glaun, Deepak Mehta, Mary F. Musso, Amee Patel, Adam C. Adler

Publication date 19-10-2020


Abstract Objective The neurocognitive associations in paediatric obstructive sleep apnoea (OSA) are well known; however, whether polysomnographic features can predict these associations is unknown. Therefore, the primary objective of this study was to compare common polysomnographic parameters in children with OSA in the presence and absence of neurocognitive dysfunction.
Methods Polysomnography data for children ages 3‐6 years with mild‐moderate OSA who as defined by AHI between 5 and 10 were analysed from a single sleep centre at a tertiary paediatric hospital from January 2016 to December 2018.
The following parameters were identified: arousals per hour, percentage of time asleep, apnoea‐hypopnoea index (AHI), oxygen desaturation nadir during sleeps, baseline oxygen saturation during sleep, time spent with SpO2 less than 90%, maximum transcutaneous CO2, per cent of the total sleep time spent with TcCO2 greater than 50 mm Hg, age, body mass index (BMI), gender and type of disability in the neurocognitive dysfunction group. Neurocognitive diagnoses were recorded. Those with syndromic comorbidities were excluded. The study cohort was then compared to a cohort of 200 subjects with OSA and no neurocognitive disorders matched for age, gender and BMI. A paired column analysis by chi‐squared analysis was then undertaken between the two groups.
ResultsA total of 200 children were identified (126 males and 74 females) in the neurocognitive dysfunction group (OSA with neurocognitive dysfunction) and compared with 200 children in the control group (OSA without neurocognitive dysfunction) (113 males and 87 females). There were no statistical differences between groups.
Conclusion Commonly used polysomnographic indices are not predictive of neurocognitive dysfunction in paediatric OSA.

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Outcomes of a multidisciplinary Ear, Nose and Throat Allied Health Primary Contact outpatient assessment service

Christopher L. Payten, Jennifer Eakin, Tamsin Smith, Vicky Stewart, Catherine J. Madill, Kelly A. Weir

Publication date 19-10-2020


Abstract Background Traditionally, patients are seen by an ear, nose and throat (ENT) surgeon prior to allied health referral for treatment of swallowing, voice, hearing and dizziness. Wait‐times for ENT consultations often exceed those clinically recommended. We evaluated the service impact of five allied health primary contact clinics (AHPC‐ENT) on wait‐times and access to treatment.
SettingA metropolitan Australian University Hospital Outpatient ENT Department.
Participants We created five AHPC‐ENT pathways (dysphonia, dysphagia, vestibular, adult and paediatric audiology) for low‐acuity patients referred to ENT with symptoms of dysphonia, dysphagia, dizziness and hearing loss.
Main outcome measures Using multiple regression analysis, we compared waiting times in the 24‐month pre‐ and 12‐month post‐implementation of the AHPC‐ENT service. In addition, we measured the number of patients requiring specialist ENT intervention after assessment in the AHPC‐ENT, adverse events and evaluation of service delivery costs.
Results Seven hundred and thirty‐eight patients were seen in the AHPC‐ENT over the first 12 months of implementation (dysphagia, 66; dysphonia, 153; vestibular, 151; retro‐cochlear, 60; and paediatric glue ear, 308). All pathways significantly reduced the waiting times for patients by an average of 277 days, compared with usual care. The majority of patients were able to be discharged without ongoing ENT intervention (72% dysphagia; 81% dysphonia; 74% vestibular; 53% retro‐cochlear; and 32% paediatric glue ear). No adverse events were recorded.
Conclusions The AHPC‐ENT improved waiting times for assessment and access to treatment. Future research on cost‐effectiveness and diagnostic agreement between AHPs and ENT clinicians would provide further confidence in the model.

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Acknowledging personal biases in otolaryngology manuscript selection

William James Moss

Publication date 19-10-2020


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Letter to the Editor in reference to: Interspecialty referral of oesophagogastric and pharyngolaryngeal cancers delays diagnosis and reduces patient survival: A matched case‐control study

John E. Fenton

Publication date 19-10-2020


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Floseal: A novel application technique for the treatment of challenging epistaxis

Quentin Bonduelle, Timothy C Biggs, Fabian Sipaul

Publication date 19-10-2020


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Endopharyngeal Ultrasound: description of a novel technique to overcome a common diagnostic dilemma in a patient with a deep neck space mass

Taha Mur, Osamu Sakai, Lauren Tracy, Kei Suzuki, Daniel Faden

Publication date 19-10-2020


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Our experience of the increased rates of post‐tonsillectomy haemorrhage in 1538 children with pre‐operative infective symptoms or signs

James Johnston, Aaron Vergeer, Natasha Donaldson, Subhaschandra Shetty, Murali Mahadevan

Publication date 19-10-2020


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Letter to editor: A systematic review of the incidence of thyroid carcinoma in patients undergoing thyroidectomy for thyrotoxicosis

Ovie Edafe, Sabapathy P. Balasubramanian

Publication date 19-10-2020


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Management of cN0 low‐grade mucoepidermoid carcinomas of salivary glands: Prospective multicentre study of 152 cases of the French Network of Rare Head and Neck Tumors (REFCOR)

Laurie Saloner Dahan, Roch Giorgi, Renaud Garrel, Ludovic Le Taillandier de Gabory, Valérie Costes‐Martineau, Philippe Herman, Gilles Poissonnet, Olivier Mauvais, Olivier Malard, Sébastien Vergez, Emmanuelle Uro‐Coste, Béatrix Barry, Christine Bach, Dominique Chevalier, Francois Mouawad, Jean‐Claude Merol, Vianney Bastit, Juliette Thariat, Laurent Gilain, Xavier Dufour, Christian‐Adrien Righini, Patrick Dessi, Justin Michel, Thomas Radulesco, Caroline Even, Bertrand Baujat, Nicolas Fakhry

Publication date 19-10-2020


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How many patients will be eligible for cochlear implantation (CI) on audiological grounds, once the new 2019 NICE guidance takes effect? Evaluation of audiological data for the population of East Kent to estimate cochlear implantation eligibility based on NICE 2019 guidance (TA566) and NICE 2009 guidance (TA166)

Robert Grounds, Eleojo Miachi, Tina Beckham, Codruta Neumann, Joseph Wasson

Publication date 19-10-2020


Pubmed PDF Web

Clinical outcome of exclusive endoscopic tympanoplasty with porcine small intestine submucosa in 72 patients

Chin‐Kuo Chen, Li‐Chun Hsieh

Publication date 19-10-2020


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Concurrent chemoradiotherapy with low‐dose weekly platinum agent for head and neck carcinoma

Masayuki Kitano, Tsuyoshi Kojima, Yusuke Okanoue, Shintaro Fujimura, Seiji Oyagi, Kazuhiko Shoji, Ryusuke Hori

Publication date 19-10-2020


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Drainless head and neck surgery: A retrospective review of 156 procedures (thyroidectomy, parotidectomy and neck dissections in a tertiary setting)

Eleanor J. Crossley, Timothy C. Biggs, Mandar Jog, Konstantinos Marinakis, Fabian Sipaul, Phillip Brown, Tahwinder Singh

Publication date 19-10-2020


Pubmed PDF Web

Issue Information

Publication date 19-10-2020


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Retraction: Increased maternal serum placental growth hormone variant in pregnancies complicated by otosclerosis

Publication date 19-10-2020


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Is loss of sense of smell a diagnostic marker in COVID‐19: A systematic review and meta‐analysis

John Rocke, Claire Hopkins, Carl Philpott, Nirmal Kumar

Publication date 19-10-2020


Abstract Aims To systematically review the currently available evidence investigating the association between olfactory dysfunction (OD) and the novel coronavirus (COVID‐19). To analyse the prevalence of OD in patients who have tested positive on polymerase chain reaction (PCR) for COVID‐19. To perform a meta‐analysis of patients presenting with olfactory dysfunction, during the pandemic, and to investigate the positive predictive value for a COVID‐19‐positive result in this population. To assess whether olfactory dysfunction could be used as a diagnostic marker for COVID‐19 positivity and aid public health approaches in tackling the current outbreak.
Methods We systematically searched Med Line (Pub Med), Embase, Health Management Information Consortium (HMIC), Medrxiv, the Cochrane Library, the Cochrane COVID‐19 Study Register, NIHR Dissemination centre, Clinical Evidence, National Health Service Evidence and the National Institute of Clinical Excellence to identify the current published evidence which associates coronaviridae or similar RNA viruses with anosmia. The initial search identified 157 articles. A total of 145 papers were excluded following application of our exclusion criteria. The 12 remaining articles that presented evidence on the association between COVID‐19 and olfactory dysfunction were critically analysed.
Results Olfactory dysfunction has been shown to be the strongest predictor of COVID‐19 positivity when compared to other symptoms in logistic regression analysis. In patients who had tested positive for COVID‐19, there was a prevalence of 62% of OD. In populations of patients who are currently reporting OD, there is a positive predictive value of 61% for a positive COVID‐19 result.
Conclusion Our review has shown that there is already significant evidence which demonstrates an association between OD and the novel coronavirus—COVID‐19. It is unclear if this finding is unique to this coronavirus as individual viral phenotypes rarely present in such concentrated large numbers. We have demonstrated that OD is comparatively more predictive for COVID‐19 positivity compared to other associated symptoms. We recommend that people who develop OD during the pandemic should be self‐isolate and this guidance should be adopted internationally to prevent transmission.

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Post‐Treatment Head and Neck Cancer Care: National Audit and Analysis of Current Practice in the United Kingdom

INTEGRATE (UK ENT Trainee Research Network), Matthew Ellis, George Garas, John Hardman, Maha Khan, Hisham Mehanna, Matthew E. Smith, Theofano Tikka, Kishan Ubayasiri, Richard Williams, G. Garas, J. Hardman, M. Khan, H. Mehanna, M.E. Smith, T. Tikka, K. Ubayasiri, R. Williams, C. Swords, G. Wilson, R. Hone, R. Siau, T. Hampton, O. Mclaren, J. Fleming, T. Biggs, J. Fussey, M. Farr, R. Steven, D. Yiannakis, J. Adams, B. Wright, K. Davies, D. Dick, M. Adams, H Jones, T. Myuran, S. Goh, M. Dowling, J. Sinnott, A. Hardy, E. Halliday, J. Virk, F. Ahmed, J. Walton, B. van Beugen, N. Hope, M. Edmond, K. Lau, T. Ahmed, D. Nair, K. Varadharajan, D. Lin, L. Ferguson, S. Mahalingam, Y. Kamhieh, M. Afiq Slim, T. Tornari, A. Abdel‐Rahim, K. Hutson, A. Millington, T. Moorhouse, E. Farrar, S. Doumas, U. Kamel, P. Coyle, D. McAnerney, O. Mirza, D. Leopard, T. Saunders, L. McMurran, L. Johnstone, T. Oremule, J. Bates, A. Iacovidou, N. Upile, R. Chessman, R. Mcleod, T. Milner, R. Cheong, A. Gaunt, K. To, A. Tse, D Yap, E Noon, M Cresswell, A.S. Mallick, W. Crookes, C. Corner, N. Walker, R. Ricks, S. Healy, W. Kendall, G Fragkiadakis, K. Conroy, A. Pervez, N. Caton, R. Balakumar, C. Smith, A. Waters, R Advani, M. Shaker, E. Schecter, ZW Liu, K. Karamali, S. Alvi, B. Cosway, D. Thorley, M. Williams, P. Bijoor, B. Anwar, N. Hamilton, G. Moghul, S. Ansari, N. Mahon, S. Hey, H. Lancer, R. Ghedia, S. Dewhurst, M. Cherko, A. Carter, D. Pennell

Publication date 18-10-2020


Abstract Objectives We aimed to audit current United Kingdom (UK) practice of Head and Neck Cancer (HNC) post‐treatment surveillance against national guidelines and determine the outcomes of these practices in detecting recurrence.
Design National cross‐sectional study of current HNC surveillance practice.
SettingUK HNC outpatient departments.
ParticipantsHNC patients reviewed for post‐treatment surveillance.
Main outcome measures Compliance with UK multidisciplinary guidelines and rates of cancer recurrence detection by time, clinic type and symptoms.
Results Data were analysed from 5,123 consultations across 89 UK centres. 30% of consultations were in dedicated multidisciplinary clinics, with input from allied health professionals (AHPs) available on the day in 23% of all consultations. Recurrence was suspected in 344 consultations and investigated with MRI in 29.6% (n = 102) and PET‐CT in 14.2% (n = 49). Patient education regarding recurrence symptoms, and smoking and alcohol advice, was provided in 20.4%, 6.2% and 5.3% of cases, respectively. Rates of recurrence detected were 35% in expedited appointments and 5.2% in planned follow‐ups (P = .0001). Of the expedited appointments, 63% were initiated by patients and 37% by clinicians. Recurrence was higher in those with new symptoms (7.1% versus 2.2%). The strongest predictors of recurrence were dyspnoea (positive predictive value (PPV)=16.2%), neck pain (PPV = 10.4%) and mouth/throat pain (PPV = 9.2%).
Conclusions Dedicated multidisciplinary clinics comprise a minority of consultations for HNC surveillance in the UK, with low availability of AHPs. PET‐CT and MRI were underutilised for the investigation of suspected recurrence. There may be scope for greater emphasis on patient education and consequent patient‐initiated symptom‐driven follow‐up.

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Efficacy of argon‐helium cryoablation and its effects on immune function of patients with neck malignant tumours

Zheng Zheng, Yingchun Zhao, Yonghui An, Na Li, Changwen Bo, Wenhua Ma, Ying Guo, Changpeng Zou, Bo Tian, Sujing Zhang

Publication date 15-10-2020


Abstract Objectives Our study aimed to investigate the clinical efficacy of argon‐helium cryoablation and its effects on the immune function of patients with neck malignant tumours.
Design Retrospective study.
Setting Single‐institution academic tertiary care centre.
Methods Totally, 180 patients harbouring head and neck malignant tumours were divided into the argon‐helium cryoablation group (n = 150) and the radiotherapy group (n = 50). The efficacy of the two groups was compared, and the immune function was observed.
Results The short‐term clinical effect of the argon‐helium cryoablation group was significantly higher than that of the radiotherapy group (P < .05). After treatment, the CD3+, CD4+, CD8+ and CD4+/CD8+ of the argon‐helium cryoablation group were significantly better than those of the radiotherapy group (P < .001). The results of TNF‐α, IL‐1 β and CRP in the argon‐helium cryoablation group were significantly better than that in the radiotherapy group (P < .001).
Conclusion Argon‐helium cryoablation could effectively improve the immune function, 5‐year survival rate and local remission rate.

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A low fidelity Peritonsillar Abscess Drainage Simulator—Our experience of feedback from 117 trainees

Dorota Alicja Chudek, Imogen Wilson, Emma Hogg, Hannah Emerson, Elliot Heward, Ding Yang, David Selwyn, Andrew S. Lau

Publication date 09-10-2020


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Sublingual immunotherapy vs placebo in the management of grass pollen‐induced allergic rhinitis in adults: A systematic review and meta‐analysis

Dominika Boldovjáková, Sara Cordoni, Craig John Fraser, Aimee Beth Love, Lorna Patrick, Gary James Ramsay, Aaron Stephen James Ferguson, Anas Gomati, Bhaskar Ram

Publication date 09-10-2020


Abstract Introduction Allergic rhinitis (AR) is a common inflammatory condition of the nasal mucosa affecting approximately 20% of the population worldwide. Current therapies include intranasal antihistamines, corticosteroids, subcutaneous and sublingual immunotherapy (SLIT). This review and meta‐analysis assess the efficacy of SLIT in the management of grass pollen‐induced AR in adults.
Methods Ovid EMBASE, Ovid EBM Reviews, Cochrane Central Register of Controlled Trials, Ovid Med Line and Pub Med were searched using the following terms: ‘sublingual immunotherapy’, ‘SLIT’, ‘rhinitis’, ‘allergic rhinitis’, ‘rhinosinusitis’ and ‘rhino‐conjunctivitis’. All included studies were double‐blind, placebo‐controlled and randomised trials. Primary outcome was symptom score and secondary outcome included quality of life and safety profile. Meta‐analysis of symptom improvement was carried out.
Results Six studies were identified with 979 subjects randomly allocated to SLIT and 992 to a placebo control. All studies reported an improvement in symptoms with SLIT, with five reaching statistical significance (P < .05). Four studies reported statistically significant improvement in quality of life (P < .05). Oral pruritus was the most common adverse event reported. The overall risk of bias was high in 50% of the studies.
Conclusions Sublingual immunotherapy was a safe and effective treatment for grass pollen‐induced AR in adults, and therefore, consideration should be given to its use for moderate‐to‐severe disease in the UK‐wide population.

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Quantitative comparison of endoscopically assisted endonasal, sublabial and transorbital transmaxillary approaches to the anterolateral skull base

Bon‐Jour Lin, Da‐Tong Ju, Tzu‐Hsien Hsu, Yi‐An Chen, Tzu‐Tsao Chung, Wei‐Hsiu Liu, Dueng‐Yuan Hueng, Yuan‐Hao Chen, Chung‐Ching Hsia, Hsin‐I Ma, Ming‐Ying Liu, Chi‐Tun Tang

Publication date 08-10-2020


Abstract Objectives The aim of this anatomical study is to make quantitative comparison among three endoscopic approaches, encompassing contralateral endonasal transseptal transmaxillary transpterygoid approach (contralateral EEA), endoscopic sublabial transmaxillary transalisphenoid (Caldwell‐Luc) approach and endoscopic transorbital transmaxillary approach through inferior orbital fissure (ETOA), to the anterolateral skull base for assisting preoperative planning.
Design & Participants Anatomical dissections were performed in four adult cadaveric heads bilaterally using three endoscopic transmaxillary approaches described above.
Setting Skull Base Laboratory at the National Defense Medical Center.
Main outcome measures The area of exposure, angles of attack and depth of surgical corridor of each approach were measured and obtained for statistical comparison.
Results The ETOA had significantly larger exposure over middle cranial fossa (731.40 ± 80.08 mm2) than contralateral EEA (266.60 ± 46.74 mm2) and Caldwell‐Luc approach (468.40 ± 59.67 mm2). In comparison with contralateral EEA and Caldwell‐Luc approach, the ETOA offered significantly greater angles of attack and shorter depth of surgical corridor (P < .05 for all comparisons).
Conclusions The ETOA is the superior choice for target lesion occupying multiple compartments with its epicentre located in the middle cranial fossa or superior portion of infratemporal fossa.

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Subtotal functional sialoadenectomy vs four‐duct ligation for the treatment of drooling in neurologically impaired children: Long‐term follow‐up

Francesco De Peppo, Romina Caccamo, Maria Carmen Garganese, Emanuela Ceriati, Paola Marchetti, Ottavio Domenico Adorisio, Antonella Cerchiari, Sonia Battaglia

Publication date 08-10-2020


Abstract Objectives The best surgical option to treat drooling in neurodisabilities is still under debate. The aim of this study was to describe the technique of subtotal functional sialoadenectomy (SFS) (ie four‐duct ligation (4‐DL) together with bilateral sublingual gland excision) and its long‐term outcomes, in comparison with 4‐DL.
Design Retrospective observational cohort study.
Setting Unit of Pediatric Surgery of Bambino Gesù Childrens Hospital (Rome).
Participants Seventy‐five patients surgically treated for drooling between 2002 and 2012, with at least five years of follow‐up, divided into two groups: 4‐DL group (19 patients) underwent four‐duct ligation, and SFS group (56 patients) underwent subtotal functional sialoadenectomy.
Main outcome measures Primary end points were the evaluation of drooling improvement after surgery (parameters: Drooling Severity and Frequency Scale, DSFS; no of bibs/day; no of shirts/day; no of pneumonia/year; use of antidrooling drugs) and the comparison between two different surgical techniques.
Results Median age at surgery was 10 years (1‐35). Long‐term outcomes showed significant improvement in DSFS and in no of shirts/day in both groups. Significantly better results were found in the SFS group than in the 4‐DL group as far as DSFS (P value .045), no of bibs/day (P value .041), no of shirts/day (P value .032) are concerned. Reoperation rate for recurrence was 42% in the 4‐DL group and 0% in the SFS group (P value < .0001). Six patients (8%; 2 in the 4‐DL group and 4 in the SFS group) experienced perioperative complications, while 4 patients (5%; 2 in the 4‐DL group and 2 in the SFS group) recorded long‐term complications, with no difference between groups neither need for surgical treatment. No surgery‐related mortality was recorded.
Conclusions In our experience, subtotal functional sialoadenectomy ensured significantly greater long‐term effects than four‐duct ligation for drooling treatment in neurologically impaired child, with equal complication rate.

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Quality‐of‐life changes following three‐dimensional printing of prosthesis for large nasal septal perforations—Our experience of 13 patients

Gaurav S. Medikeri, Grace C. Khong, Sarah Fleming, Taran Malhotra, Samuel C. Leong

Publication date 04-10-2020


Abstract Nasal septal perforations can be caused by a number of aetiology including intra‐nasal drug abuse, trauma and iatrogenic causes.

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Otorhinolaryngology litigation in England: 727 clinical negligence cases against the National Health Service

Annakan Victor Navaratnam, Ahmad Hariri, Cherrie Ho, John T Machin, Tim WR Briggs, Andrew Marshall

Publication date 02-10-2020


Abstract Introduction Litigation against the National Health Service (NHS) in England is rising. The aim of this study was to determine the incidence and characteristics of otorhinolaryngology clinical negligence claims in England.
MethodsA retrospective review was undertaken of all clinical negligence claims in England held by NHS Resolution relating to otorhinolaryngology between April 2013 and April 2018. Analysis was performed using information for cause, patient injury and claim cost. Where claim information was adequately detailed, the authors categorised claims by subspecialty, diagnosis and surgery.
ResultsA total number of 727 claims were identified with an estimated potential cost of £108 million. Out of these, 463 were closed claims. Including open claim reserves, the mean cost of a claim was £148 923. Head and neck surgery was the subspecialty with the highest number of claims (n = 313, 43%) and highest cost (£51.5 million) followed by otology (n = 171, £24.5 million) and rhinology (n = 171, £13.6 million). Over half of claims were associated with an operation (n = 429, 59%) where mastoid surgery (n = 46) and endoscopic sinus surgery (n = 46) were equally associated with the greatest number of claims. The most frequent causes for clinical negligence claims included failure or delay to diagnose (n = 178, 25%), failure or delay to treat (n = 136, 19%), intra‐operative complications (n = 130, 18%) and failure of the consent process (n = 107, 15%).
Discussion Clinical negligence claims in otorhinolaryngology are related to several different components of patient management and are not limited to postoperative complications. This study highlights the importance of robust pathways in out‐patient diagnostics and the consenting process in order to deliver better patient care and reduce the impact of litigation.
Keywordsinformed consent, malpractice, clinical negligence claims, litigation, otolaryngology

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Manuka honey versus saline sinus irrigation in the treatment of cystic fibrosis‐associated chronic rhinosinusitis: A randomised pilot trial

Victoria S. Lee, Ian M. Humphreys, Patricia L. Purcell, Greg E. Davis

Publication date 02-10-2020


Abstract Objectives Manuka honey attacks biofilms, which contribute to bacterial persistence in cystic fibrosis sinusitis. The primary objective was to determine feasibility of investigating manuka honey as an irrigation treatment for cystic fibrosis sinusitis and secondarily to assess the treatments preliminary effectiveness.
Design Prospective, single‐blinded (clinician only), randomised, parallel two‐arm pilot trial.
Setting Tertiary rhinology clinic.
Participants Subjects had recalcitrant cystic fibrosis sinusitis and previous sinus surgery. They received manuka honey or saline sinus irrigations twice daily for 30 days.
Main Outcome Measures Main outcomes were recruitment/retention rates and tolerability. Preliminary effectiveness was assessed based on quality‐of‐life Sinonasal Outcome Test‐22 and Lund‐Kennedy endoscopic change scores and post‐treatment culture negativity.
Results Over 10 months, 13 subjects were enrolled, and 77% (10/13) were included in the analysis. Manuka honey irrigations were well‐tolerated. The quality‐of‐life change score was clinically significant for manuka honey (−9 −14,−6) but not saline (−5 −9,−1), although the difference was not statistically significant (P = .29). Lund‐Kennedy endoscopic change score was significantly better for manuka honey (−3 −5,−3) versus saline (0 0,0) (P = .006). There was no difference in post‐treatment culture negativity between manuka honey (1/5, 20%) and saline (0/5, 0%) (P = 1.00).
Conclusions Manuka honey irrigations were well tolerated, and retention rates were high. Preliminary data showed that manuka honey achieved a clinically important difference in quality‐of‐life score and a significantly better endoscopic outcome. Microbiological control was difficult to achieve. A future definitive trial would require multi‐institutional recruitment.

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Revised 15‐item Glasgow Benefit Inventory with five factors based on analysis of a large population study of medical and surgical otorhinolaryngological interventions

George G. Browning, Haytham Kubba, William M. Whitmer

Publication date 29-09-2020


Abstract Objectives To review, using confirmatory factor analysis, the widely used 18‐question Glasgow Benefit Inventory GBI that has three factors. Thereafter to develop, using exploratory factor analysis, a more coherent, revised version of the GBI.
Design Confirmatory and exploratory factor analysis of a large national GBI data set of ORL interventions.
Setting Adult otorhinolaryngology outpatient clinics in six University Hospital departments.
Participants One thousand nine hundred eighty adult patients who had complete GBI data and who underwent an active (medical or surgical) intervention, out of the total data set of 9005 patients from the original Scottish ENT Outcome Study SENTOS.
Results One of the 18 questions was discarded from the data base because it was not answered by 8% of respondents. Two of the original factors remained (Physical Health, renamed General Health, and Social Support, renamed Support). The General factor was split into three new factors (Quality of Life, Self‐Confidence and Social Involvement). The three new factors were found to give additional information regarding the area of benefit.
This reduced number of questions does not make any material difference to the results of the >196 existing GBI papers in the literature.
ConclusionA 15‐question GBI with five factors is provided that is more explanatory of the areas of benefit.

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Three‐dimensional printing to compare endoscopic endonasal surgical approaches: A technical note

Valentin Favier, Yaser Najaf, Arnaud Damecourt, Gérard Subsol, Guillaume Captier, Julien Boetto, Louis Crampette

Publication date 27-09-2020


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Regenerative efficacy of fibroblast growth factor for the treatment of aged vocal fold: From animal model to clinical application

Myung Jin Ban, Seung Chul Lee, Jae Hong Park, Ki Nam Park, Hee Kyung Kim, Seung Won Lee

Publication date 24-09-2020


Abstract Objectives We assessed fibroblast growth factor (FGF) regenerative efficacy in an aged vocal fold rat model and confirmed it in a prospective clinical trial.
Design, setting, and participants For animal experiments, 48 Sprague‐Dawley rats were divided into two groups: 24 six‐month‐olds (young group) and 24 twenty‐four‐month‐olds (old group). FGF was injected once a week thrice into the left vocal fold of the old group, dividing them into two sub‐groups (injected left and uninjected right). Additionally, we conducted a prospective clinical trial for 38 patients with aged atrophic vocal fold.
Main outcome measuresA month post‐injection, excised larynx from the three groups was subjected to comparative histopathological (ratio of relative lamina propria to total vocal fold) and mRNA expression analysis (of procollagen I, hyaluronic acid synthase (HAS)‐2 and matrix metalloproteinase (MMP)‐2) by real‐time PCR. We performed perceptual, stroboscopic, acoustic aerodynamic test and Voice Handicap Index survey prior to and 1, 6 and 12 months after FGF injection.
Results In rats, the relative lamina propria ratio increased after FGF injection. Procollagen I mRNA level decreased, whereas that of HAS‐2 and MMP‐2 increased significantly in the injected compared to the uninjected old group. Enrolled patients showed improved subjective and objective voice parameters after FGF injection, and these were maintained for a year. Potential side effects were not observed.
Conclusions Animal experiments and prospective clinical trial suggest that FGF injection to vocal fold can significantly improve voice quality until one year, without complications, and is effective for aged atrophic vocal fold treatment.

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Management of new onset loss of sense of smell during the COVID‐19 pandemic ‐ BRS Consensus Guidelines

Claire Hopkins, Mikkel Alanin, Carl Philpott, Phil Harries, Katherine Whitcroft, Ali Qureishi, Shahram Anari, Yujay Ramakrishnan, Anshul Sama, Elgan Davies, Ben Stew, Simon Gane, Sean Carrie, Iain Hathorn, Raj Bhalla, Chrissi Kelly, Nina Hill, Duncan Boak, B. Nirmal Kumar

Publication date 24-09-2020


Abstract Objectives The primary aim of the study is to provide recommendations for the investigation and management of patients with new onset loss of sense of smell during the COVID‐19 pandemic.
Design After undertaking a literature review, we used the RAND/UCLA methodology with a multi‐step process to reach consensus about treatment options, onward referral, and imaging.
Setting and participants An expert panel consisting of 15 members was assembled. A literature review was undertaken prior to the study and evidence was summarised for the panellists.
Main outcome measures The panel undertook a process of ranking and classifying appropriateness of different investigations and treatment options for new onset loss of sense of smell during the COVID‐19 pandemic. Using a 9‐point Likert scale, panellists scored whether a treatment was: Not recommended, optional, or recommended. Consensus was achieved when more than 70% of responses fell into the category defined by the mean.
Results Consensus was reached on the majority of statements after 2 rounds of ranking. Disagreement meant no recommendation was made regarding one treatment, using Vitamin A drops. Alpha‐lipoic acid was not recommended, olfactory training was recommended for all patients with persistent loss of sense of smell of more than 2 weeks duration, and oral steroids, steroid rinses, and omega 3 supplements may be considered on an individual basis. Recommendations regarding the need for referral and investigation have been made.
Conclusion This study identified the appropriateness of olfactory training, different medical treatment options, referral guidelines and imaging for patients with COVID‐19‐related loss of sense of smell. The guideline may evolve as our experience of COVID‐19 develops.

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Analysis of reflux as the aetiology of laryngeal dysplasia progression through a matched case‐control study

Wei Gu, Yan‐Yan Niu, Wen‐Ze Wang, Zhi‐Yong Liang, Xiao‐Feng Jin, Hong Huo, Jian Wang

Publication date 24-09-2020


Abstract Objectives Laryngeal dysplasia (LD) is a precancerous lesion of the larynx. In this study, the laryngeal tissue of patients with laryngeal dysplasia was taken as the research object, and the aetiology of reflux was analysed.
Method Patients with laryngeal dysplasia after surgery were selected as our subjects. The levels of pepsin, enterokinase and bilirubin in laryngeal tissue samples of the two groups were detected by immunohistochemical method.
Results The OR values (95% CI) of pepsin, enterokinase and bilirubin were 0.67 (0.19‐2.36), 0.80 (0.22‐2.98) and 1.33 (0.30‐5.96), respectively, in the univariate analysis. Besides, in the multivariate analysis, the OR values (95% CI) of pepsin, enterokinase and bilirubin were 0.57 (0.14‐2.30), 0.73 (0.18‐2.92) and 1.40 (0.30‐6.53), respectively.
Conclusion Larger sample size should be applied to prospective studies on whether reflux is a risk factor for laryngeal cancer.

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Olfactory changes after endoscopic sinus surgery for chronic rhinosinusitis: A meta‐analysis

Rui Zhao, Kai Chen, Yuedi Tang

Publication date 23-09-2020


Abstract Background Endoscopic sinus surgery (ESS) is an important treatment modality for chronic rhinosinusitis (CRS). However, its effect on olfaction remains controversial.
Objective of review To assess the olfactory impact of ESS in patients with CRS.
Type of reviewA meta‐analysis.
Search strategyA systematic literature search in the Pub Med, EMBASE and Cochrane Library databases was conducted to identify studies that assessed change in olfaction after ESS in patients with CRS. Search terms were related to paranasal sinus diseases, smell and endoscopy.
Evaluation method The extracted data included authors, publication year, study type, age, sex, diagnostic criteria, surgical mode, sample size, follow‐up time, olfaction measurement tool and outcome. We analysed the olfactory changes as continuous variables.
Results Thirty‐five studies including 3164 patients with CRS were eligible for the meta‐analysis. Among patients having CRS with nasal polyps, olfactory dysfunction improved, as assessed by the Sniffin Sticks total score (P = .000), Sniffin Sticks discrimination score (P = .023), Sniffin Sticks identification score (P = .005), University of Pennsylvania Smell Identification Test (P = .046) and Visual Analogue Scale (P = .000). However, the threshold score of the Sniffin Sticks test did not improve significantly (P = .361). Olfactory dysfunction did not improve in patients having CRS without nasal polyps according to the University of Pennsylvania Smell Identification Test (P = .404). In non‐classified CRS patients, improvement in olfactory dysfunction was observed according to the University of Pennsylvania Smell Identification Test (P = .000), Visual Analogue Scale (P = .001) and Questionnaire of Olfactory Disorders‐Negative Statements (P = .001). However, there were no significant improvements according to the Brief Smell Identification Test (P = .325), Sniffin Sticks threshold score (P = .160) and Sniffin Sticks identification score (P = .079).
Conclusion Endoscopic sinus surgery may be beneficial for improvement in olfactory conditions in patients with CRS. Further thorough and comprehensive studies need to be conducted.

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HPV genotype is a prognosticator for recurrence of respiratory papillomatosis in children

Rodrigo L. Nogueira, Daniel S. Küpper, Caroline M. Bonfim, Davi C. Aragon, Thiago A. Damico, Carolina S. Miura, Ivna M. Passos, Maurício L. Nogueira, Paula Rahal, Fabiana C. P. Valera

Publication date 22-09-2020


Abstract Objectives This study aimed to compare the prognosis according to age, genotype or human papillomavirus (HPV) variant in patients with recurrent respiratory papillomatosis (RRP).
Design Non‐concurrent cohort.
Participants Forty one patients with RRP.
Setting Tertiary referral hospital.
Main Outcome Measures Disease severity was defined by the number of surgeries performed, and Derkay score at surgeries, obtained from medical records. HPV was detected and genotyped, and HPV‐6 variants were also assessed.
Results Fifteen (36.58%) individuals belonged to the juvenile RRP group (JoRRP, less than 18 years), while 26 patients (63.41%) were allocated at the adult group (AoRRP, equal or more than 18 years). JoRRP patients needed, in average, a higher number of surgeries to control the disease than AoRRP patients (mean difference: 3.36). Also, JoRRP patients showed a higher Derkay score at each surgery (mean difference: 3.76). There was no significant difference in the number of surgeries when we compared patients infected with HPV‐6 or HPV‐11, neither in accordance to HPV‐6 variants. Patients with HPV‐11 presented a higher mean Derkay score at surgery than those with HPV‐6 (mean difference: 4.39); when co‐variated by age, we observed that this difference occurred only among JoRRP patients (mean difference: 6.15).
Conclusions Age of onset of RRP has an important impact on number of surgeries to control disease. Patients with JoRRP and HPV‐11 tend to present worse Derkay score at each surgery. HPV genotype among adults and HPV‐6 variants had no impact on the outcome of the disease.

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Using post‐operative trend in C‐reactive protein to predict fistula in neopharyngeal repairs following laryngectomy and pharyngectomy surgery in fifty‐five patients

Edwin Halliday, Ajith George

Publication date 22-09-2020


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Audiological Performance in Children with Inner Ear Malformations Before and After Cochlear Implantation: A Cohort Study of 274 Patients

Hilal Burcu Ozkan, Betul Cicek Cinar, Esra Yucel, Gonca Sennaroglu, Levent Sennaroglu

Publication date 22-09-2020


Abstract Background and Objective Inner ear malformations (IEMs) are common in children with hearing loss. The different types of IEMs form a unique subgroup of cochlear implant (CI) candidates. We aimed to evaluate the auditory perception outcomes of CI in children with different types of IEMs and compare them with CI users without IEMs.
Methods The study included 274 CI users with and without IEMs as two groups (n = 137, each). Both groups’ chronological age at implantation and duration of CI usage was matched (± 8 months). All subjects were evaluated pre‐operatively and post‐operatively by the Lings sound test and the auditory perception test battery, which includes the Meaningful Auditory Integration Scale (MAIS), closed‐set Pattern Perception Test (PPT) and open‐set Sentence Recognition Test (SRT). Besides, children with IEMs were assessed for language development.
Results Progress in the IEMs’ group differed according to the type of ear anomaly. CI users with enlarged vestibular aqueduct had the highest scores, while users with common cavity had the lowest. Children with IEMs performed well on the closed‐set test while having difficulty with the open‐set test.
Conclusion Cochlear implantation outcomes are favourable in IEMs’ patients with a cochlear nerve visible on magnetic resonance imaging. Our results indicate that it is critical to take the anatomical differences into account during follow‐up and rehabilitation programmes. Each CI user should be evaluated according to his or her individual needs.

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Impact of bile acids on the severity of laryngo‐pharyngeal reflux

Eugenio De Corso, Silvia Baroni, Giampiero Salonna, Michele Marchese, Marilena Graziadio, GIovanni Di Cintio, Gaetano Paludetti, Guido Costamagna, Jacopo Galli

Publication date 17-09-2020


Abstract Objectives The primary end point of this study was to evaluate the impact of bile acids on severity of laryngo‐pharyngeal reflux (LPR) and the possible correlation with esophagitis and upper airway malignancies. The second end point was to evaluate if salivary bile acids and molecules other than pepsin might serve as diagnostic biomarkers of LPR.
Design Observational prospective comparative study.
Setting Otorhinolaryngology unit of a tertiary hospital.
Participants Sixty‐two consecutive adult outpatients suspected of LPR.
Main outcome measures Bile acids, bilirubin and pepsinogen I‐II were measured in saliva. Patients underwent pH metry and based on the results of bile acids were subdivided as acid, mixed and alkaline LPR.
Results Significantly higher Reflux Findings Score (RFS) and Reflux Symptoms Index (RSI) were seen in patients with alkaline and mixed LPR compared to acid LPR. Salivary bile acids >1 µmol/L seem to be a reliable indicator of the severity of LPR. Compared to those without, patients with esophagitis or a history of upper airway malignancy have high concentrations of bile acids in saliva. Among the molecules studied, bile acids were the most suitable for diagnosis of LPR, with a sensitivity of 86% and a positive predictive value of 80.7%.
Conclusions Our data suggest that high concentrations of bile acids are associated with higher values of RSI and RFS in LPR as well as a higher risk of esophagitis and history of upper airway malignancies. We finally observed that bile acids provided the best biometric parameters for diagnosis of LPR among the molecules tested.

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Video laryngoscope‐guided (GlideScope®) injection of botulinum toxin in laryngectomy patients with limited neck extension

Yadsan Devabalan, Akshat Malik, Margaret Coffey, Peter Clarke

Publication date 17-09-2020


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Long‐term outcomes of juvenile‐onset recurrent respiratory papillomatosis

Yang Xiao, Xianxiang Zhang, Lijing Ma, Jun Wang

Publication date 17-09-2020


Abstract Objective To investigate the adult outcomes of children with juvenile‐onset recurrent respiratory papillomatosis via long‐term follow‐up.
Study Design Retrospective study.
Setting Beijing Tongren Hospital.
Participants The study includes 121 patients with recurrent respiratory papillomatosis.
Main outcome and measure We followed up respiratory papillomatosis patients aged least 14 years and analysed their clinical features based on recurrence‐free time.
Results In total, 112 (92.6%) patients underwent three or more operations. The age at initial operation was 4.3 ± 2.9 years; 47.9% (58/121) experienced recurrence and underwent surgical treatment after age 14. At follow‐up, 5% (6/121) had died, 41.3% (50/121) had been recurrence‐free for 5 years or more (cured group), and 53.7% (65/121) had recurrence in the past 5 years (recurrent group). The age at the last operation was 9.2 ± 4.6 years in the cured group. The overall operation frequency was higher in the recurrence group than in the cured group (17.8 ± 11.9 vs 8.7 ± 6.5). Additionally, the human papillomavirus (HPV) infection and tracheal dissemination rates were higher in the recurrence group than in the cured group (90.8% 59/65 vs 54.0% 27/50 and 26.2% 17/65 vs 10% 5/50, respectively).
Conclusion The mortality rate for juvenile‐onset recurrent respiratory papillomatosis is 5%. Approximately 50% of children experience recurrence and require repeated operations in adulthood. No significant difference in sex, age at initial operation or adjuvant therapy between the cured and recurrent groups was observed; however, significant between‐group differences were found in overall operation frequency, aggressive disease, tracheal dissemination of papilloma, and HPV infection.

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Treating twenty‐five cases of chronic resistant otitis externa with fluticasone propionate (Flixonase®): A case series

Shayan Shahidi, Abdul Nassimizadeh, Chris Coulson

Publication date 17-09-2020


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Targeted skull base biopsies in the management of central skull base osteomyelitis

Regi Thomas

Publication date 17-09-2020


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The validity of the Acoustic Breathiness Index in the evaluation of breathy voice quality: A Meta‐Analysis

Ben Barsties v. Latoszek, Geun‐Hyo Kim, Jonathan Delgado Hernández, Kiyohito Hosokawa, Marina Englert, Katrin Neumann, Svetlana Hetjens

Publication date 17-09-2020


Abstract Background The evaluation of voice quality with acoustic measurements is useful to objectify the diagnostic process. Particularly, breathiness was highly evaluated and the Acoustic Breathiness Index (ABI) might have promising features.
Objective of review The goal of the present meta‐analysis is to quantify, from existing cross‐validation studies, the evidence for the diagnostic accuracy of ABI, including its sensitivity and specificity.
Type of review Meta‐analysis.
Search strategy We searched in MEDLINE, Google Scholar and Science Citation Index, and as manual search for the term Acoustic Breathiness Index from inception to February 2020.
Studies were included that used equal proportion of continuous speech and sustained vowel segments, a recording hardware with a sufficient standard for voice signal analyses, the software Praat for signal processing and the customised Praat script, and two groups of subjects (vocally healthy and voice‐disordered). Furthermore, the diagnostic accuracy of ABI was measured.
Evaluation method The primary outcome variable was ABI. The score ranged from 0 to 10 with varying thresholds according to different languages to determine the absence or presence of breathiness.
A meta‐analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta‐analyses of diagnostic test accuracy study guidelines. Data were extracted, and the risk of bias was assessed using the QUADAS‐2 tool. The pooled sensitivity and specificity of ABI were determined using a summary receiver operating characteristic (SROC) approach to calculate also a weighted threshold value of ABI with its sensitivity and specificity.
ResultsA total of 34 unique citations were screened, and 10 full‐text articles were reviewed, including six studies. In total, 3603 voice samples were considered for further analysis separating into 467 vocally healthy and 3136 voice‐disordered voice samples. The pooled sensitivity was 0.84 (95% CI, 0.83‐0.85), and the pooled specificity was 0.92 (95% CI, 0.89‐0.94). The area under the curve of the SROC curve of this analysis showed an excellent value of 0.94. The weighted ABI threshold was determined at 3.40 (sensitivity: 0.86, 95% CI, 0.84‐0.87.; specificity: 0.90, 95% CI 0.88‐0.92).
Conclusions The results confirm the ABI as robust and valid objective measure for evaluating breathiness.

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Pan‐Scotland tonsillectomy outcomes: A national cross‐sectional study

Thomas D. Milner, Omar Hilmi, John Marshall, Kenneth MacKenzie

Publication date 16-09-2020


Abstract Objectives The aim of this study was to assess the current post‐tonsillectomy haemorrhage and return to theatre rates in Scotland.
Design National cross‐sectional study.
Participants and setting Tonsillectomy outcomes data were collated for all NHS patients undergoing tonsillectomy in Scotland between 1998‐2002 and 2013‐2017.
Main outcome measures Using Information Services Division (ISD) Scotland retrospective data, 30‐day re‐admission and 30‐day return to theatre rates allowed an assessment of post‐tonsillectomy haemorrhage rates. Data were validated through comparison with an audit conducted in NHS Greater Glasgow & Clyde between 2015 and 2016.
Results Tonsillectomy was performed in 27 819 patients between 1998 and 2002, and 23 184 patients between 2013 and 2017. 30‐day re‐admission rates increased considerably between the 1998‐2002 and 2013‐2017 cohorts, from 4.7% to 12.1% in paediatric patients, and 9.8%‐19.9% in adult patients. Similarly, 30‐day “return to theatre rates” increased between the two cohorts, from 1.2% to 1.7% in paediatric patients, and 3.6%‐4.9% in adult patients. Re‐admission and return to theatre rates were similar across Health Boards for both adult and paediatric tonsillectomies in each cohort.
Conclusions Current 30‐day re‐admission and return to theatre rates are significantly higher than the majority of reported series to date. The rising rate of tonsillectomy haemorrhage between cohorts is likely to be multifactorial, possibly reflecting an underestimation of previous rates and the changing profile of the tonsillectomy patient. A detailed audit of current practice is needed to investigate these tonsillectomy outcomes, which are similar across all Health Boards in Scotland. Of most significance are the implications for accurate patient consent and non‐elective ENT service provision.

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Trends in tonsillectomy surgery in children in Scotland 2000‐2018

Haytham Kubba, Laura S. Downie

Publication date 16-09-2020


Abstract Background Tonsillectomy is one of the most common surgical procedures in children but indications and surgical practice change over time.
Objectives We aimed to identify trends in tonsillectomy procedures in children, in particular the number of procedures performed, the age of child undergoing tonsillectomy and the type of hospital in which the surgery was performed.
Design Review of Scottish Morbidity Records data (SMR01) which are routinely collected after everyday case procedure or overnight stay in all Scottish NHS hospitals.
Setting All NHS hospitals in all 14 Scottish health boards.
Participants All children (0‐16 years) undergoing tonsillectomy, 2000‐2018.
Main outcome measures Number of tonsillectomy procedures; rate of tonsillectomy per 1000 children in the population; number of children aged 0‐2 years and 3‐4 years undergoing tonsillectomy; health board in which the surgery occurred; diagnostic coding for these episodes; length of stay and readmission within 30 days of surgery.
Results During 2000‐2018, there were 50,208 tonsillectomies performed in children in Scotland (mean 2642/year). The number of tonsillectomies per year remained constant (R = 0.322, P = .178) but tonsillectomies performed in children 0‐2 years rose from 0.41 to 1.56 per 1000 (R = 0.912, P < .001), and 3‐4 years from 3.06 to 6.93 per 1000 (R = 0.864, P < .001). The proportion of all childrens tonsillectomies performed up to age 4 rose from 20.6% to 35.9% and up to age 2 from 2.4% to 8.1%. All specialist childrens hospitals showed a significant increase in surgery in very young children.
Conclusions Tonsillectomy rates remained static between 2000 and 2018, despite a falling population. More tonsillectomies are now performed for obstructive sleep apnoea, at a young age and in regional childrens hospitals. This has important implications for the workload of these specialist hospitals.

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Pathognomonic ultrasonic images of congenital pyriform sinus fistula in Children

Che‐Yi Lin, Tzu‐Yu Hsiao, Wei‐Chung Hsu

Publication date 14-09-2020


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The role of upper GI flexible endoscopy in management of large pharyngeal pouches

Samyukta Ravisankar, Somayyeh Shahsavari, Jaiganesh Manickavasagam, Samit Majumdar, Pradeep Patil

Publication date 13-09-2020


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Identification of putative laryngeal and pharyngeal lichen planus lesions: An endoscopic preliminary evaluation in 16 patients

"Antonio M. Bulfamante, Umberto DAgostino Fiorenza, Paolo Castellarin, Carlotta Pipolo, Giancarlo Cacioppo, Giovanni Felisati, Alberto M. Saibene"

Publication date 09-09-2020


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New findings in a retrospective study on the efficacy of precision sound therapy of 156 tinnitus: “Drift” of tinnitus sites

Piao Xu, Qiongping Lin, Dafei Li, Jingya Yang, Haiyan Zhao, Shanshan Zhang, Guangyong Tian

Publication date 25-08-2020


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