Journal of Laryngology and Otology 2022-07-05

Improving outcomes in necrotising otitis externa, telephone clinics, and topical pimecrolimus for chronic eczematous external otitis

Fishman, Jonathan,Fisher, Edward

Publication date 05-07-2022


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Emerging themes in necrotising otitis externa: a scoping review of the literature from 2011 to 2020 and recommendations for future research

Stapleton, E,Watson, G

Publication date 20-10-2021


Objective Necrotising otitis externa is an invasive, infective condition, with minimal evidence underpinning its diagnosis and management. This work aimed to analyse literature from the past decade, to identify emerging themes and important topics for future research.
MethodsA robust literature search and review were conducted by two researchers. Sixty studies were filtered into the final review. A grounded theory approach was used to identify core themes. Data within these themes formed the basis of the review.
Results There is no consensus regarding a clinical definition or outcome measures of necrotising otitis externa, and there exists no level 1, 2 or 3 evidence to diagnose, investigate, monitor or treat necrotising otitis externa. Emerging themes in the literature direct researchers to important topics for future clinical trials, including risk factors, microbiological culture, management strategies and radiology.
Conclusion In order to optimise understanding and management of necrotising otitis externa, future research requires robust clinical trials and consistently reported outcome measures.

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Management of retraction pockets: historic and novel approaches

Spinos, D,Mallick, S,Judd, O

Publication date 07-01-2022


Background Retraction pockets are collapsed segments of the tympanic membrane. Their formation is associated with a disruption in middle-ear ventilation pathways, leading to the loss of organised collagen of the tympanic membrane. There are several approaches in treating retraction pockets, which aim either to improve ventilation or repair the retraction pockets themselves.
MethodsA review of the literature regarding the classification and associated management of retraction pockets was conducted, using Medline and Cochrane Library databases, with the addition of our institutions experience in undertaking novel techniques.
Results All the current classification systems fail to guide treatment or prognosticate the disease. Commonly, an initial conservative approach is suggested for early stages, with no clear indication regarding when a surgical solution should be offered. There are conflicting data concerning the effectiveness of these treatments in terms of disease prevention, recurrence and hearing outcomes.
Conclusion Minimally invasive approaches utilising novel techniques may be key to reducing peri-operative morbidity and improving the overall patient experience.

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A systematic review and meta-analysis of otorhinolaryngological manifestations of coronavirus disease 2019 in paediatric patients

Yadav, M,Singh, A,Meena, J,Sankar, J M

Publication date 17-02-2022


Background This meta-analysis provides a quantitative measure of the otorhinolaryngological manifestations of coronavirus disease 2019 in children.
MethodsA structured literature review was carried out using Pub Med, Embase and Cochrane Central, employing pertinent search terms. The statistical analysis was performed using Stata version 14.2 software, and the analysed data were expressed as the pooled prevalence of the symptoms with 95 per cent confidence intervals.
Results The commonest symptoms noted were cough (38 per cent (95 per cent confidence interval = 33–42; I2 = 97.5 per cent)), sore throat (12 per cent (95 per cent confidence interval =10–14; I2 = 93.7 per cent)), and nasal discharge (15 per cent (95 per cent confidence interval = 12–19; I2 = 96.9 per cent)). Anosmia and taste disturbances showed a pooled prevalence of 8 per cent each. Hearing loss, vertigo and hoarseness were rarely reported.
Conclusion Cough, sore throat and nasal discharge were the commonest otorhinolaryngological symptoms in paediatric patients with coronavirus disease 2019. Compared with adults, anosmia and taste disturbances were infrequently reported in children.

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Characteristics, management and outcome of a large necrotising otitis externa case series: need for standardised case definition

Hodgson, S H,Sinclair, V J,Arwyn-Jones, J,Oh, K,Nucken, K,Perenyei, M,Sivapathasingam, V,Martinez-Devesa, P,Pendlebury, S T,Ramsden, J D,Matthews, P C,Pretorius, P,Andersson, M I

Publication date 19-01-2022


Background Necrotising otitis externa is a severe ear infection for which there are no established diagnostic or treatment guidelines.
Method This study described clinical characteristics, management and outcomes for patients managed as necrotising otitis externa cases at a UK tertiary referral centre.
ResultsA total of 58 (63 per cent) patients were classified as definite necrotising otitis externa cases, 31 (34 per cent) as probable cases and 3 (3 per cent) as possible cases. Median duration of intravenous and oral antimicrobial therapy was 6.0 weeks (0.49–44.9 weeks). Six per cent of patients relapsed a median of 16.4 weeks (interquartile range, 23–121) after stopping antimicrobials. Twenty-eight per cent of cases had complex disease. These patients were older (p = 0.042), had a longer duration of symptoms prior to imaging (p < 0.0001) and higher C-reactive protein at diagnosis (p = 0.005). Despite longer courses of intravenous antimicrobials (23 vs 14 days; p = 0.032), complex cases were more likely to relapse (p = 0.016).
ConclusionA standardised case-definition of necrotising otitis externa is needed to optimise diagnosis, management and research.

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Telephone clinic outcomes during the coronavirus disease 2019 pandemic: results from an ENT department

Mallick, S,Balakumar, R,Drysdale, A

Publication date 16-09-2021


Objective To study the impact of telemedicine on patient outcomes during a nationwide lockdown to halt the spread of coronavirus disease 2019.
MethodsA retrospective study was conducted to examine telemedicine consultations of newly referred patients over 7 days during a national lockdown. Overall outcomes of telephone clinics were recorded, measured as either patient discharged, imaging requested, patient referred to another specialty, further telephone follow up required, patient initiated follow up or face-to-face appointment required.
Results Data were collected from 104 patients. Outcomes showed that 17 patients were discharged, 15 had imaging requested, 11 were referred to another specialty, 11 had further telemedicine appointments, 31 had patient-initiated follow up and 19 received face-to-face appointments. Overall, 57 per cent of patients avoided hospital visits and 17 per cent required face-to-face appointments. Of higher risk patients, 49 per cent were managed remotely. After eight months, no significant morbidity or mortality was reported.
Conclusion Almost half of the higher risk patients avoided a hospital visit. The majority of patients were managed remotely, and thus the risk and spread of infection were reduced. Telemedicine has an important role in ENT out-patients.

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Telephone consultation for two-week-wait ENT and head and neck cancer referrals: initial evaluation including patient satisfaction

Rovira, A,Brar, S,Munroe-Gray, T,Ofo, E,Rodriguez, C,Kim, D

Publication date 26-10-2021


Objective To analyse the outcomes of telephone consultation, including patient satisfaction, for two-week-wait head and neck cancer referrals.
Methods Analysis of the data of this prospective study was centred on outcomes of the consultation, patient satisfaction and preference for telephone consultation.
Results Patient satisfaction and preference for telephone consultation were influenced by patient awareness of cancer referral. When comparing the three most common presenting symptoms, patients with sore throat were more satisfied than those with neck mass. Regarding telephone consultation outcomes, patients with neck mass were less likely to be discharged and more likely to require investigations than those with sore throat or hoarseness. Patients with hoarseness more often required a face-to-face appointment.
Conclusion Telephone consultation might be a valid initial encounter for the majority of two-week-wait head and neck cancer referrals, especially when the referral symptoms are considered. This work shows the validity and safety of telephone consultation for two-week-wait head and neck cancer referrals.

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A systematic review of interventions to prevent work-related musculoskeletal disorders in ENT surgeons

Storey, B,Verkerk, M,Hashtroudi, A,Golding-Wood, D

Publication date 29-09-2021


Objective Work-related musculoskeletal disorders in ENT surgeons are common and detrimental, yet few are aware of preventative measures. We evaluate the evidence for interventions to prevent work-related musculoskeletal disorders in ENT surgeons.
MethodA systematic search of databases up to 8 June 2021 was performed using Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines and predetermined inclusion criteria.
Results Seven prospective cohort studies and 2 case series were identified (51 participants). Interventions included novel equipment (n = 3), patient positioning (n = 2), clinician positioning (n = 3) and operative technique (n = 1). Five studies reported Rapid Upper Limb Assessment scores as outcome measures of strain. Strain decreased when adopting a favourable operating posture, using a supportive chair and keeping patients supine for clinic procedures.
ConclusionA small number of low-quality studies were identified. Modifiable risk factors exist, and ergonomic education may help prevent work-related musculoskeletal disorders. Further studies with longer term follow up are required.

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Vaccination rates in cochlear implant patients: a review of paediatric recipients

Rose, O,Moriarty, R,Brown, C,Teagle, H,Neeff, M

Publication date 26-10-2021


Objective This study aimed to investigate whether children with cochlear implants received the recommended vaccinations according to New Zealand national immunisation guidelines and to report the incidence of meningitis in this population after intervention.
MethodA retrospective review of the vaccination coverage of paediatric patients receiving cochlear implants between 2005 and 2019 was performed.
Results Data were collected on 203 children. Evidence of immunisation against Haemophilus influenza B was documented in 94.1 per cent of this cohort and 21.2 per cent received the seasonal influenza vaccine. The pneumococcal conjugate vaccine was fully administered in 81.8 per cent of children; however, only 16.9 per cent of eligible children had received the pneumococcal polysaccharide vaccine. There was marked improvement in compliance to the pneumococcal conjugate vaccine once it became fully funded for cochlear implant patients.
Conclusion Despite established guidelines, the paediatric vaccination rates were less than expected. Work is in progress to address this.

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Submersion with grommets: contamination is possible at minimal depth, as demonstrated with a novel middle-ear model

Farrell, E,Gendre, A,Viani, L,Glynn, F,Walshe, P

Publication date 07-01-2022


Objective Advice to patients following grommet insertion and waterproofing can vary from clinician to clinician. A laboratory based experiment was performed to determine at what depth water contamination would occur through various grommet tubes.
MethodsA novel experimental ear model was developed using an artificial tympanic membrane and ventilation tubes. Water contamination was identified using an effervescent solid that reacts when in contact with water. Measures of dispersion were used to describe the results.
Results The average depth of water contamination was: 19.64 mm (range = 11–33 mm, standard deviation = 5.55 mm) using a Shepard grommet; 20.84 mm (range = 18–26 mm, standard deviation = 1.97 mm) with a titanium grommet; and 21.36 mm (range = 18–33 mm, standard deviation = 3.03 mm) using a T-tube. Water contamination was possible at depths of 11–33 mm. The average pressure at water effervescent activation was 0.20 k Pa.
Conclusion Submersion underwater at any depth with grommets is likely to lead to middle-ear contamination. These findings are concordant with clinical studies.

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Topical treatment of eczematous external otitis involving the ear canal: long-term results of a trial comparing pimecrolimus 1 per cent versus clobetasone butyrate 0.05 per cent

Nemeth, Z,Verga, E,Verdolini, R

Publication date 07-01-2022


Background Eczematous external otitis is a common chronic condition that can have a significant impact on the life of sufferers, causing constant discomfort and pruritus, and leading to sleep deprivation. Treatment is based on the use of topical steroids, moisturisers and occasionally antibiotics. Results, however, can be disappointing, especially over the long term.
Methods This study compared the long-term response to pimecrolimus, administered to a group of 11 patients, against clobetasone butyrate, administered to an equivalent number of patients. Response to the treatment was assessed and statistically analysed at 3 and 12 months.
Conclusion Whereas the degree of improvement following the use of pimecrolimus and clobetasone butyrate was similar for the two groups at month 3, a highly statistically significant difference was documented at month 12, with a much greater and sustained improvement in the pimecrolimus group.

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Midnasal stenosis in adults with normative values

Ozturan, O,Senturk, E,Dogan, R,Ozdem, A,Aksoy, F

Publication date 07-01-2022


Background Congenital midnasal stenosis has previously been described as a cause of nasal obstruction in infants, and conservative and interventional treatments have been suggested. However, midnasal stenosis in adults has not been reported and related normative measurements have not been studied.
Methods Three adult patients presented with nasal obstruction and, based on examination and radiological findings, were diagnosed with midnasal stenosis. Anatomical measurements were studied in axial and coronal computed tomography scans, and compared with findings for 161 healthy individuals.
Results Anatomical measurements showed that the endonasal cavity was larger in males than females. The midnasal region was found to be constricted in patients compared to healthy controls.
Conclusion This is the first study to report on midnasal stenosis in adults and to define normative anatomical measurements in adults. In patients presenting with nasal obstruction, midnasal stenosis should be suspected during endoscopic visualisation of medially located middle turbinates and uncinate processes in nasal cavities. A definitive diagnosis of midnasal stenosis can be made by examining paranasal sinus computed tomography scans. Endoscopic middle turbinectomy, complete uncinectomy, mega maxillary antrostomy and partial anterior ethmoidectomy have been suggested to relieve midnasal stenosis.

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ENT symptoms of mask-wearing in the coronavirus disease 2019 era

Koseoglu, S,Cakıcı, K,Demirtaş, M,Gokdogan, O,Ucuncu, H

Publication date 17-03-2022


Objective Analysis of the otorhinolaryngological problems caused by mask-wearing in the coronavirus disease 2019 era.
MethodsA survey with 26 questions was sent by e-mail to 576 individuals.
Results The most frequently worn masks were three-layer surgical ear loop masks (n = 434, 80.1 per cent), followed by N95 or filtering facepiece code 2 masks (n = 58, 10.7 per cent), and cloth masks (n = 50, 9.2 per cent). The most bothersome symptoms caused by mask-wearing were difficulty in nasal breathing (n = 227, 41.8 per cent), nasal itching and pain (n = 93, 17.2 per cent), earache (n = 88, 16.2 per cent), difficulty in expressing oneself (n = 73, 13.5 per cent), difficulty in understanding speech (n = 56, 10.3 per cent), and ear itching (n = 5, 0.9 per cent).
Conclusion The problems associated with mask-wearing may result in avoidance of wearing them. Thus, there is a need for new methods that will reduce the problems related to mask-wearing, to increase their use in the community.

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Prevalence and evaluation of oropharyngeal dysphagia in patients with severe acute respiratory syndrome coronavirus 2 infection in the intensive care unit

Mallart, R,Rossignol, C,Poppe, J B,Prum, G,Tamion, F,Veber, B,Verin, E

Publication date 10-01-2022


Objective The main objective was to assess the prevalence of dysphagia in the intensive care unit in patients with coronavirus disease 2019.
Methods. A cohort, observational, retrospective study was conducted of patients admitted to the intensive care unit for severe acute respiratory syndrome coronavirus 2 pneumonia at the University Hospital of Rouen in France.
Results Over 4 months, 58 patients were intubated and ventilated, 43 of whom were evaluated. Screening revealed post-extubation dysphagia in 62.7 per cent of patients. In univariate analysis, a significant association was found between the presence of dysphagia and: the severity of the initial pathology, the duration of intubation, the duration of curare use, the degree of muscle weakness and the severity indicated on the initial scan. At the end of intensive care unit treatment, 22 per cent of the dysphagic patients had a normal diet, 56 per cent had an adapted diet and 22 per cent still received exclusive tube feeding.
Conclusion Post-extubation dysphagia is frequent and needs to be investigated.

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Paediatric day-case tonsillectomy – parent satisfaction questionnaire

Garry, S,"ORiordan, I",Wauchope, J,Lehane, H,Phelan, E,Heffernan, C

Publication date 28-01-2022


Objective To assess parent or guardian satisfaction with a newly instituted day-case tonsillectomy programme at a tertiary paediatric institution.
Methods After receiving ethical approval, an anonymous questionnaire was sent to the parent or guardian of every patient who underwent day-case tonsillectomy between July 2018 and December 2020.
ResultsA total of 135 patients were included. The parent or guardian of each patient was sent a questionnaire to be filled in and returned. Ninety-two completed surveys were returned. There were high satisfaction levels, with 91.3 per cent of parents or guardians feeling comfortable bringing their child home, and 92.4 per cent of parents or guardians would recommend day-case tonsillectomy to another parent or guardian. Of the parents or guardians, 10.9 per cent needed to contact healthcare services in the 24 hours following surgery.
Conclusion Day-case tonsillectomy has proven to be a safe, efficient service at our institution, with high satisfaction levels from patients and parents or guardians. Areas for improvement focused on communication at the time of discharge regarding follow up and analgesia.

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An awareness and prevalence study of Irish cold-water athletes and external auditory canal exostoses

Boyle, S,Keane, R,Jinih, M,McCarthy Deering, E,Patil, N,Choo, M

Publication date 07-01-2022


Objective This study aimed to determine the awareness, otological symptoms and prevalence of external auditory canal exostoses in Irish cold-water athletes.
Method An online and in person cross-sectional survey was undertaken with Irish cold-water athletes to explore athletes awareness, known prevalence of external auditory canal exostoses and attitudes towards preventive measures.
Results Of the 926 participants surveyed, 67.5 per cent were aware of external auditory canal exostoses. Triathletes reported the lowest awareness (39.9 per cent) among water athletes. A total of 9.7 per cent (n = 90) had previously been diagnosed with external auditory canal exostoses and 46.7 per cent (n = 42) were non-surfers. Ear symptoms were reported in 76 per cent of athletes. Otoscopic examinations showed that 23.7 per cent had external auditory canal exostoses, 3.6 per cent of whom were aware of their diagnosis.
Conclusion The majority of Irish surfing athletes are aware of external auditory canal exostoses. There is less awareness with regard to Irelands newly emerging sports such as open water swimming and triathlons. Over 90 per cent of athletes surveyed had no idea they had external auditory canal exostoses, which highlights the need to increase public awareness.

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Necrotising otitis externa and how to reduce length of hospital stay: a complete audit cycle of 77 hospital admissions

Mohammed, H,Chean Khun Ng, J,Qureshi, M H,Yates, P

Publication date 22-10-2021


Background Necrotising otitis externa is a serious condition that requires hospital admission. Longer hospital stays are associated with increased complications.
Method This was a closed audit cycle in a tertiary ENT centre of patients presenting with necrotising otitis externa to the ENT department between 2015 and 2019. The aim was to audit the length of hospital stay in comparison to national figures as well as the time needed for investigations.
Results The number of patients with necrotising otitis externa is increasing in England. Length of stay, however, appears to be more stable. A total of 66 admissions occurred over the study period for 48 patients in total, and mean length of stay was 12.4 days. After implementation of a new protocol, length of stay was reduced to 7.1 days.
Conclusion Patients with necrotising otitis externa require prompt diagnosis and management in order to shorten length of stay in hospital and avoid serious complications. Multi-disciplinary protocol development and implementation could help in reducing length of stay of necrotising otitis externa patients.

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Head & Neck Endocrine Surgery: A Comprehensive Textbook, Surgical, and Video Atlas D Goldenberg Thieme, 2021 ISBN 978 1 68420 146 4 pp 497 Price £205.00 €(D)229.99

Flood, L M

Publication date 19-05-2022


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JLO volume 136 issue 7 Cover and Front matter

Publication date 05-07-2022


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JLO volume 136 issue 7 Cover and Back matter

Publication date 05-07-2022


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