Journal of Laryngology and Otology 2021-03-23

Anti-biofilm topical therapy in rhinosinusitis, coronavirus in India, anosmia prognosis, fish bones and flexible laryngoscopy

Fisher, Edward W,Fishman, Jonathan

Publication date 23-03-2021


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"Ambulatory management of common ENT emergencies – whats the evidence?"

Heining, C J,Amlani, A,Doshi, J

Publication date 17-02-2021


Objectives The global pandemic of coronavirus disease 2019 has necessitated changes to ‘usual’ ways of practice in otolaryngology, with a view towards out-patient or ambulatory management of appropriate conditions. This paper reviews the available evidence for out-patient management of three of the most common causes for emergency referral to the otolaryngology team: tonsillitis, peri-tonsillar abscess and epistaxis.
MethodsA literature review was performed, searching all available online databases and resources. The Medical Subject Headings ‘tonsillitis’, ‘pharyngotonsillitis’, ‘quinsy’, ‘peritonsillar abscess’ and ‘epistaxis’ were used. Papers discussing out-patient management were reviewed by the authors.
Results Out-patient and ambulatory pathways for tonsillitis and peritonsillar abscess are well described for patients meeting appropriate criteria. Safe discharge of select patients is safe and should be encouraged in the current clinical climate. Safe discharge of patients with epistaxis who have bleeding controlled is also well described.
Conclusion In select cases, tonsillitis, quinsy and epistaxis patients can be safely managed out of hospital, with low re-admission rates.

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Non-steroid, non-antibiotic anti-biofilm therapy for the treatment of chronic rhinosinusitis: a systematic review

Taylor, A,Fuzi, J,Sideris, A,Banks, C,Havas, T E

Publication date 05-03-2021


Objective Chronic rhinosinusitis patients with biofilms cultured from their sinonasal cavity have greater symptom burden and risk of recalcitrant disease. A number of non-antibiotic, ‘anti-biofilm’ treatments exist which show anti-biofilm properties in preclinical studies. There is little evidence evaluating their impact on clinical symptom scores in chronic rhinosinusitis.
MethodA systematic review was performed to assess the literature regarding the efficacy of non-steroid, non-antibiotic, anti-biofilm specific topical therapies in the treatment of chronic rhinosinusitis. The primary outcome assessed was change in validated patient reported outcome measures before and after anti-biofilm treatment.
Results Thirteen studies assessing the effect of anti-biofilm therapies in chronic rhinosinusitis through validated patient-reported outcome measures were included. Seven different anti-biofilm specific therapies for chronic rhinosinusitis were identified. None of the seven anti-biofilm therapies was identified as being confidently efficacious beyond placebo. Only one therapy (intranasal xylitol) showed a statistically significant reduction in symptom scores compared with placebo in more than one trial.
Conclusion Robust evidence supporting the use of various anti-biofilm therapies in chronic rhinosinusitis is lacking. Further high quality, human, in vivo trials studying the effect of anti-biofilm therapies in chronic rhinosinusitis are needed to address the deficiencies of the current evidence base.

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Otorhinolaryngological manifestations of coronavirus disease 2019: a prospective review of 600 patients

Bhatta, S,Gandhi, S,Saindani, S J,Ganesuni, D,Ghanpur, A D

Publication date 18-01-2021


Objectives To evaluate otorhinolaryngological manifestations of coronavirus disease 2019 infection and the time required for their resolution.
MethodsA prospective analysis was conducted of coronavirus disease 2019 patients presenting from 1 April 2020 to 30 July 2020. The otorhinolaryngological manifestations were evaluated based on patient history. The time required for symptom resolution was evaluated separately for intensive care unit and non-intensive care unit patients.
ResultsA total of 600 patients were included in the study; 13.3 per cent required the intensive care unit and 2.2 per cent expired.
The otorhinolaryngological manifestations were: sore throat (88 per cent), fever (78.8 per cent), anosmia or hyposmia (63.6 per cent), ageusia or hypogeusia (63.5 per cent), rhinorrhoea (51.3 per cent), nasal obstruction (33.5 per cent), sneezing (30.3 per cent), and breathing difficulty (18.6 per cent). The time required for symptom resolution was longest for breathing difficulty (23.6 days for intensive care unit and 8.2 days for non-intensive care unit patients).
Conclusion Otorhinolaryngological symptoms are one of the main presentations of coronavirus disease 2019 infection. The increased prevalence of medical co-morbidities in patients requiring intensive care unit and in deceased patients is also highlighted.

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Cervicofacial surgery and implantable hearing device extrusion: management of challenging cases

Carnevale, C,Til-Pérez, G,Arancibia-Tagle, D,Tomás-Barberán, M,Sarría-Echegaray, P

Publication date 01-03-2021


Objective To describe our management of implantable hearing device extrusion in cases of previous cervicofacial surgery.
MethodsA review was conducted of a retrospectively acquired database of surgical procedures for implantable hearing devices performed at our department between January 2011 and December 2019. Cases of device extrusion and previous cervicofacial surgery are included. Medical and surgical management is discussed.
Results Four cases of implant extrusion following cervicofacial surgery were identified: one involving a Bonebridge system and three involving cochlear implants. In all cases, antibiotic treatment was administered and surgical debridement performed. The same Bonebridge system was implanted in the middle fossa. The three cochlear implants were removed, and new devices were implanted in a more posterior region.
Conclusion Previous cervicofacial surgery is a risk factor for hearing implant extrusion. The middle fossa approach is the best option for the Bonebridge system. Regarding the cochlear implant, it is always suitable to place it in a more posterior area. An inferiorly based fascio-muscular flap may be a good option to reduce the risk of extrusion.

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Unusual complications of bone wax at the skull base

Panicker, R,Moorthy, R K,Rupa, V

Publication date 17-02-2021


Objective This study aimed to describe the clinical presentation, microbiological profile and management of complications of bone wax usage for surgical procedures at the skull base.
Method The case records of a series of five patients who developed post-operative surgical site complications because of bone wax usage during skull base surgery were reviewed.
Results In all five patients, persistent site-specific clinical features were noted along with intra-operative presence of excessive bone wax. Three unique cases of presentation, one with a fungal brain abscess because of Aspergillus flavus infection, another with fungal osteomyelitis because of Trichosporon beigelii infection and a third with intradural migration of bone wax into the cerebellopontine angle cistern are highlighted.
Conclusion The presentation of surgical site infection at the skull base because of excessive use of bone wax can be manifold. The need for testing appropriate cultures including fungal culture is highlighted.

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Anosmia in the first coronavirus disease 2019 outbreak in Europe: functional recovery after eight months

Capelli, M,Gatti, P

Publication date 26-02-2021


Background Severe acute respiratory syndrome coronavirus-2 is a formidable virus, responsible for coronavirus disease 2019 and endowed with marked neurotropism. The damage it causes to the nervous system is manifold. The main neurological manifestation is anosmia. Olfactory damage is often transient, but there are no data reflecting an observational period of several months.
Objective This study evaluated the trend of anosmia in patients affected by coronavirus disease 2019 in the eight months following diagnosis.
Methods Fifty-five subjects who presented with symptoms suggestive of coronavirus disease 2019 and who developed anosmia, between the end of February and the beginning of March 2020, were investigated. The patients were interviewed after eight months to determine functional recovery and assess the degree of recovery.
Results Ninety-one per cent of the population reported olfactory recovery and, of these, 53 per cent had total recovery after eight months. Females and younger age groups seem slightly advantaged in functional recovery. The elderly population appears to have excellent prospects for full functional recovery.
Conclusion Anosmia represents a frequent neurological manifestation during coronavirus disease 2019. Fortunately, it is transient in most cases, and only a small percentage of patients affected by it report long-term functional deficits.

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Radiological evaluation of lacrimal apparatus injury after functional endoscopic sinus surgery

Singh, G B,Rana, N,Tomar, S,Malhotra, S,Kumar, S

Publication date 01-03-2021


Objective To determine the incidence of nasolacrimal duct injury after functional endoscopic sinus surgery radiologically, using computed tomography.
Methods Fifty patients of either sex who underwent functional endoscopic sinus surgery were evaluated for nasolacrimal duct injury by computed tomography. Computed tomography was conducted pre-operatively, and post-operatively at the end of four weeks, and nasolacrimal duct injury was analysed.
Results The prevalence of nasolacrimal duct injury dehiscence was 1.16 per cent, with a similar incidence of 1.16 per cent for nasolacrimal duct injury post-operatively. However, no cases of symptomatic nasolacrimal duct injury were recorded.
Conclusion Computed tomography scan is an effective, non-invasive method to evaluate nasolacrimal duct injury following functional endoscopic sinus surgery, in accordance with evidence-based medicine.

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Effect of surgery, delivery device and head position on sinus irrigant penetration in a cadaver model

Mozzanica, F,Preti, A,Bandi, F,Fazio, E,Cardella, A,Gallo, S,Bulgheroni, C,Yakirevitch, A,Gera, R,Castelnuovo, P

Publication date 08-03-2021


Objective The extent of surgery, the type of device used and head position may influence nasal irrigation. The aim of this study was to determine the effectiveness of topical irrigant delivery to the paranasal sinuses according to these factors.
Method Four cadaveric heads underwent four stepwise endoscopic dissections. Irrigations were evaluated after every stage using different delivery devices (squeeze-bottle, gravity-dependent device and syringe) in two head positions (nose-to-sink and vertex down). Irrigant penetration into each sinus was estimated using a four-point scale.
ResultsA significant positive effect of surgery was demonstrated for each sinus as well as for the delivery device. High-volume irrigant devices are more effective, and the head position plays a significant role in irrigant distribution to the frontal sinus.
Conclusion This study further confirms the efficacy of high-volume irrigant devices. A vertex down position during the irrigation could improve delivery to the frontal sinus, and the widening of the ostia increases irrigant access to the sinuses.

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Telephone triage of suspected head and neck cancer patients during the coronavirus disease 2019 pandemic using the Head and Neck Cancer Risk Calculator version 2

Banerjee, S,Voliotidis, D,Parvin, L,Rama, S P K

Publication date 02-03-2021


Objective Utilisation of the Head and Neck Cancer Risk Calculator version 2 has been recommended during the coronavirus disease 2019 pandemic for the assessment of head and neck cancer referrals. As limited data were available, this study was conducted to analyse the use of the Head and Neck Cancer Risk Calculator version 2 in clinical practice.
Method Patients undergoing telephone triage in a two-week wait referral clinic were included. Data were collected and analysed using appropriate methods.
Results Sixty-four patients in the study were risk-stratified into low-risk (51.6 per cent, 33 of 64), moderate-risk (14.1 per cent, 9 of 64) and high-risk (34.4 per cent, 22 of 64) groups. Of the patients, 53.1 per cent (34 of 64) avoided an urgent hospital visit, and 96.9 per cent (62 of 64) were cancer free, while 3.1 per cent (2 of 64) were found to have a head and neck malignancy. The sensitivity, specificity, negative predictive value and accuracy were 50.00 per cent, 66.13 per cent, 99.92 per cent and 66.11 per cent, respectively.
Conclusion It is reasonable to use the calculator for triaging purposes, but it must always be accompanied by a meticulous clinical thought process.

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Risk of disease transmission from flexible nasoendoscopy during the coronavirus disease 2019 pandemic

Kavanagh, F G,Connolly, C,Farrell, E,Callanan, D,Brinkman, D,Affendi, A,Lang, E,Sheahan, P

Publication date 24-02-2021


Background Concerns have emerged regarding infection transmission during flexible nasoendoscopy.
Methods Information was gathered prospectively on flexible nasoendoscopy procedures performed between March and June 2020. Patients and healthcare workers were followed up to assess for coronavirus disease 2019 development. One-sided 97.5 per cent Poisson confidence intervals were calculated for upper limits of risk where zero events were observed.
ResultsA total of 286 patients were recruited. The most common indication for flexible nasoendoscopy was investigation of ‘red flag’ symptoms (67 per cent). Forty-seven patients (16 per cent, 95 per cent confidence interval = 13–21 per cent) had suspicious findings on flexible nasoendoscopy requiring further investigation. Twenty patients (7.1 per cent, 95 per cent confidence interval = 4.4–11 per cent) had new cancer diagnoses. Zero coronavirus disease 2019 infections were recorded in the 273 patients. No. 27 endoscopists (the doctors and nurses who carried out the procedures) were followed up.
The risk of developing coronavirus disease 2019 after flexible nasoendoscopy was determined to be 0–1.3 per cent.
Conclusion The risk of coronavirus disease 2019 transmission associated with performing flexible nasoendoscopy in asymptomatic patients, while using appropriate personal protective equipment, is very low. Additional data are required to confirm these findings in the setting of further disease surges.

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Investigative strategies for fish bone foreign bodies during the coronavirus disease 2019 pandemic: an analysis of ENT UK guidelines

Michaels, J,Orji, C,Green, F,Nogueira, C

Publication date 26-02-2021


Background By nature of their specialty, otolaryngologists are disproportionately exposed to coronavirus disease 2019 through aerosol-generating procedures and close proximity to the oropharynx during examination.
Methods Our single-centre, retrospective study analysed the pertinence of guidelines produced by ENT UK to improve the investigation and management of suspected upper aerodigestive fish bone foreign bodies during the coronavirus disease 2019 pandemic.
Results Our results demonstrated 43.3 per cent (n = 13) low-risk cases and 56.7 per cent (n = 17) moderate-risk cases. Nine fish bones (two low risk, seven moderate risk) were found; none of these were confirmed with X-ray and three (moderate risk) required nasoendoscopy for diagnosis. One patient required rigid pharyngoscopy.
Conclusion This study confirms that soft tissue neck X-ray and flexible nasoendoscopy are unnecessary in low-risk cases; however, early nasoendoscopy in higher suspicion cases is appropriate. Recommendations are made about the long-term sustainability of these guidelines, and additional measures are encouraged that relate to repeat attendances and varying prevalence of coronavirus disease 2019 in the hospital catchment area.

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Diagnostic yield of computed tomography in the evaluation of unilateral vocal fold palsy

Chew, H S,Goh, J C G,Tham, D Y A

Publication date 02-03-2021


Background There is a paucity of Asian-based data regarding the diagnostic yield of computed tomography imaging in the initial assessment of idiopathic unilateral vocal fold palsy.
Objectives To investigate the diagnostic yield of computed tomography in idiopathic unilateral vocal fold palsy cases in an Asian tertiary hospital, and to determine the causative pathologies and positive predictive factors.
MethodA retrospective chart review was conducted of patients (between 2010 and 2018) with a clinical diagnosis of idiopathic unilateral vocal fold palsy who underwent contrast-enhanced computed tomography of the neck and chest at Tan Tock Seng Hospital, Singapore.
Results The overall computed tomography diagnostic yield was 21 per cent, with malignancy accounting for 63.6 per cent of diagnoses. Degree of vocal fold weakness was the only significant predictor of positive computed tomography findings (11.5 per cent in vocal fold paresis vs 29.1 per cent in vocal fold paralysis, p = 0.025). None of the patients with negative computed tomography findings went on to develop disease after a mean follow up of 14.3 months.
Conclusion Computed tomography is a useful initial investigation for idiopathic unilateral vocal fold palsy, particularly in cases with vocal fold paralysis.

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Survival and function following pharyngo-laryngo-oesophagectomy in Wales: a twelve-year case series

Edwards, D R,Pope, L,Berry, S

Publication date 29-01-2021


Objective Treatment of locally advanced hypopharyngeal cancer can cause significant morbidity and late toxicity. Pharyngo-laryngo-oesophagectomy can achieve adequate surgical margins, but data on survival and functional outcome are limited, especially in Wales. This study aimed to describe mortality, morbidity and functional outcome following pharyngo-laryngo-oesophagectomy in a Welsh population.
Method This study was a retrospective case note review of pharyngo-laryngo-oesophagectomy cases in Wales over 12 years.
Results Fifteen patients underwent pharyngo-laryngo-oesophagectomy; all but one underwent gastric pull-up. Median survival and disease-free survival were 17 months (range, 2–53 months) and 14 months. Censored 3-month, 1-year and 3-year survival was 93, 71 and 50 per cent, respectively. Common Terminology Criteria for Adverse Events grading of long-term dysphagia was 1 in 58 per cent, 2 in 33 per cent and 3 in 8 per cent, and 87.5 per cent achieved a ‘moderate’ or ‘good’ voice rehabilitation.
Conclusion These results demonstrate favourable survival and reasonable functional outcome following pharyngo-laryngo-oesophagectomy, suggesting pharyngo-laryngo-oesophagectomy should be considered in all appropriate surgical candidates.

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Endoscopic laryngeal findings in patients undergoing thyroid and parathyroid surgery

Burckardt, E S,Baird, B J,Van Stan, J H,Burns, J A

Publication date 26-02-2021


Objectives This study aimed to report the pre- and post-operative laryngeal endoscopic findings in patients referred by non-otolaryngologists who are undergoing thyroid and/or parathyroid surgery, and to determine the number and nature of referrals before and after the release of the clinical practice guideline for improving voice outcomes after thyroid surgery.
Methods This retrospective cohort study, conducted at a tertiary care academic hospital, comprised adult patients referred by the endocrine surgery service for laryngoscopy from 2007 to 2018 (n = 166). Data regarding patient demographics, reason for referral and endoscopic findings were recorded.
Results The number of referrals increased significantly after the release of the practice guideline. The most common indication for referral pre- and post-operatively was voice change. The most common finding during laryngoscopy was normal examination findings (pre-operatively) and unilateral vocal fold immobility (post-operatively).
Conclusion Peri-operative thyroid and/or parathyroid patients have laryngoscopic findings other than vocal fold immobility. Laryngoscopy to detect structural and functional pathology is warranted.

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Relevance of level IIb neck dissection in patients with papillary thyroid carcinoma

Hosokawa, S,Takahashi, G,Okamura, J,Imai, A,Mochizuki, D,Ishikawa, R,Takizawa, Y,Misawa, K,Shinmura, K,Mineta, H

Publication date 23-02-2021


Background Cervical nodal metastasis is a key prognostic factor in patients with papillary thyroid carcinoma. The role of lymph nodes in papillary thyroid carcinoma management and prognosis remains controversial.
Methods Level IIb lymph nodes obtained from 44 patients with papillary thyroid carcinoma were histopathologically examined retrospectively. Specimens were classified as ipsilateral or contralateral. The number of dissected nodes and prevalence of level IIb metastasis were compared according to pre-operative clinical nodal stage.
Results In the node-negative neck, the prevalence of contralateral and ipsilateral IIb nodes was 0 out of 20 and 0 out of 3, respectively. In the node-positive neck, the prevalence of contralateral and ipsilateral IIb nodes was 1 out of 13 (7.70 per cent) and 3 out of 41 (7.32 per cent), respectively. Clinically determined and pathologically confirmed level IIb node negativity were significantly associated. Thirty-four patients (77.3 per cent) developed accessory nerve complications from level IIb dissection.
Conclusion Level IIb neck dissection for papillary thyroid carcinoma may be required if pre-operative examination reveals multilevel, level IIa or suspicious level IIb metastasis.

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Using a 4K three-dimensional exoscope system (Vitom 3D) for mastoid surgery during the coronavirus disease 2019 pandemic

Ally, M,Kullar, P,Mochloulis, G,Vijendren, A

Publication date 01-02-2021


Objective Microscopic surgery is currently considered the ‘gold standard’ for middle-ear, mastoid and lateral skull base surgery. The coronavirus disease 2019 pandemic has made microscopic surgery more challenging to perform. This work aimed to demonstrate the feasibility of the Vitom 3D system, which integrates a high-definition (4K) view and three-dimensional technology for ear surgery, within the context of the pandemic.
Method Combined approach tympanoplasty and ossiculoplasty were performed for cholesteatoma using the Vitom 3D system exclusively.
Results Surgery was performed successfully. The patient made a good recovery, with no evidence of residual disease at follow up. The compact system has excellent depth of field, magnification and colour. It enables ergonomic work, improved work flow, and is ideal for teaching and training.
Conclusion The Vitom 3D system is considered a revolutionary alternative to microscope-assisted surgery, particularly in light of coronavirus disease 2019. It allows delivery of safe otological surgery, which may aid in continuing elective surgery.

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An unusual case of ear mould impression material as a foreign body in the middle ear: case report

Manjunath, D,Vadlamani, S,Gaur, S K,Dutt, S N

Publication date 26-02-2021


Background The occurrence of retained ear mould impression material is rare and can lead to complications. The current case report describes one such complication, where the silicone impression material used to take the impression of the ear canal flowed into the middle ear through the pre-existing tympanic membrane perforation. Five days later, the patient presented with worsened hearing and blood-tinged discharge from the ear. Ear microscopy revealed a greenish foreign body in the middle ear.
Case report The foreign body was removed by tympanotomy and the perforation repaired using a temporalis fascia graft. A hearing aid was prescribed after ensuring that the perforation had healed.
Conclusion It is essential that the audiologist perform a basic otological examination before prescribing a hearing aid and preparing an ear mould. A clinical approach algorithm for audiologists, for prior to taking an impression, is suggested.

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Letter to the Editors regarding ‘A multi-centre analysis of a decade of endoscopic pharyngeal pouch surgery in Cheshire and Merseyside’

Heng, Z,Nieto, H R,Ishaq, S

Publication date 01-03-2021


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"Authors reply"

Hampton, T,Allan, J,Pearson, D,Emerson, H,Jones, G H,Junaid, M,Kanzara, T,Lau, A S,Siau, R,Williams, S P,Wilkie, M D

Publication date 01-03-2021


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JLO volume 135 issue 3 Cover and Front matter

Publication date 23-03-2021


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JLO volume 135 issue 3 Cover and Back matter

Publication date 23-03-2021


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