Journal of Laryngology and Otology 2022-05-20

Otitis externa management, septal surgery outcomes, laryngeal dysplasia and paediatric sleep-disordered breathing

Fisher, Edward W,Fishman, Jonathan

Publication date 20-05-2022


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Diagnostic and treatment challenges in neurofibroma concerning the external nose

Shakrawal, N,Chouhan, M,Solanki, B

Publication date 15-12-2021


Background This paper discusses clinical features and management aspects of an extremely rare entity, neurofibroma of the external nose.
Methods Database searches were performed using Pub Med, Embase and Google Scholar to identify previously published articles.
Results Twelve articles comprising 13 patients with neurofibroma of the external nose were included. The mean age of presentation was 31 years. Sixty-nine per cent of patients were diagnosed at final histopathology. External approach rhinoplasty was performed in 76.9 per cent of patients, while the intranasal approach was used in 15.3 per cent of patients. There was a 15.3 per cent association with neurofibromatosis type 1. Recurrence was noted in 23 per cent of patients.
Conclusion It may be challenging to diagnose this entity clinically because of its rarity and striking features on histopathology. Neurofibroma of the external nose should be kept in mind as a differential diagnosis for any soft progressive swelling over the nose. Management requires complete excision, with cosmesis and restoration of functions.

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A high-resolution computed tomography based scoring system to predict ease of electrode insertion in cochlear implantation

Das, A,Janweja, M,Dubey, A,Mitra, S,Sengupta, A

Publication date 30-09-2021


Objective This study aimed to formulate a scoring system based on high-resolution computed tomography scans to predict ease of electrode insertion during cochlear implantation via posterior tympanotomy in paediatric patients.
MethodA scoring system Cochlear Implantation Radiological Assessment Score (CIRAS) was formulated based on six parameters. This score was correlated with intra-operative findings, and receiver operating characteristic analysis was performed to determine the optimal cut-off score to predict difficulty of surgery and to establish the inherent validity of the scoring system by area under curve.
Results Receiver operating characteristic analysis showed that optimal cut-off score was 8 (93.1 per cent specificity and 56.52 per cent sensitivity), and area under the curve was 0.828. Patients with CIRAS of more than 8 had significantly higher time for surgery (p < 0.05).
ConclusionCIRAS is an easy to administer tool by utilising classical axial and coronal sections, without any numerical measures. Pre-operative assessment by this score gives a good idea of intra-operative challenges.

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Otitis externa: what is the problem with getting it right? A mixed-methods study in primary and secondary care

Mohammed, H,Mather, M W,Lumb, J,Butler, C C,Wilson, J A

Publication date 25-11-2021


Objective Otitis externa accounts for 1.1–1.3 per cent of patient presentations in primary care and 25 per cent of urgent referrals to ENT. This study aimed to explore otitis externa clinical decision-making at the primary-secondary care interface, otitis externa prevalence and recent trends in antimicrobial resistance in otitis externa related bacterial isolates and ototopical prescribing.
Method This is a mixed-methods study drawing on data from primary and secondary care and open National Health Service sources.
ResultsA total of 101 general practitioner survey respondents reported frequently prescribing oral antibiotics for otitis externa. General practitioner consultations for otitis externa increased 25 per cent over 15 years. General practitioner ototopical preparations cost the National Health Service £7 410 440 in 2006 and £11 325 241 in 2016. A total of 162 consecutive hospital otitis externa-related bacterial isolates yielded 128 pseudomonas species, with 18 that were resistant to gentamicin and 7 that were resistant to ciprofloxacin. Ten guidelines reviewed showed systematic inconsistencies.
Conclusion General practitioners reported regularly prescribing oral antibiotics for otitis externa. Antimicrobial drug resistance is common in otitis externa. The available guidance is suboptimal.

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Knowledge, attitude and practices regarding cochlear implants among medical doctors other than otolaryngologists: a prospective cross-sectional study

Reddy, Y Mounika,Anjali, L,Augustine, A,Mary, J,Ajay, P

Publication date 10-01-2022


Objective Cochlear implant is the standard treatment of choice for children and adults with severe to profound sensorineural hearing loss. The main objective of this study was to assess the knowledge, attitude and practices regarding cochlear implant among doctors other than otolaryngologists in a tertiary care academic institution.
MethodA 24-item knowledge, attitude and practices questionnaire was developed based on an extensive literature review and expert opinion and was administered to 100 non-otolaryngologists in a tertiary care academic institution to be completed in about 15 minutes. The data obtained was analysed to assess knowledge, attitude and practices regarding cochlear implant in this group.
Results The results showed that awareness regarding the option of cochlear implants for elderly and unilateral deafness was deficient. Surgeons and doctors in higher specialties did better when it came to practice related to cochlear implant. The age and experience of doctors also improved knowledge and practice with regards to cochlear implant.
Conclusion Improving awareness about cochlear implants and their benefits among non-otolaryngology colleagues can ensure that more people who could potentially benefit from cochlear implants will receive appropriate counselling and referral.

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Effect of pre-operative mastoid pneumatisation on tympanoplasty success

ElBeltagy, Y M,Askoura, A M,Hangal, D E A,Teaima, A A

Publication date 09-02-2022


Objective This study aimed to compare the effect of pneumatised and non-pneumatised mastoid on the success of tympanoplasty in terms of rate of graft uptake and air–bone gap improvement.
MethodA comprehensive electronic search of Pub Med Medline, Scopus, Web of Science and Cochrane Library was conducted in August 2020 for articles from 1990 to 2020. Selected studies were published in the English language, were conducted on human patients, were concerned with evaluating pre-operative mastoid pneumatisation on tympanoplasty success, were not laboratory studies and were not opinion studies. Five studies were included with 178 patients in the pneumatised group and 97 patients were included in the non-pneumatised group. Comparison between both groups was performed in terms of graft uptake rate and air–bone gap improvement.
Results Although the pneumatised group showed better graft uptake rate than the non-pneumatised group, there was no statistically significant difference between the two groups in the success rate of tympanoplasty.
Conclusion Pneumatisation of the mastoid does not significantly affect the success rate of tympanoplasty.

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A contemporary overview on the enigma of managing recalcitrant or intractable post-operative otorrhoea following middle-ear surgery: perspectives, principles and practices

Pandey, A Kumar,Hernot, S,ul Haq, A,Bansal, C,Kaintura, M,Bhardwaj, A,Varma, A,Anjum, F,Kumawat, A

Publication date 24-03-2022


BackgroundA common problem in otological surgeries is the persistence of ear discharge in a patient who has undergone middle-ear reconstructive surgery, despite an intact graft. There is a dearth of knowledge in the literature on treatment strategies in such post-operative cases of recalcitrant otorrhoea.
Method This was a retrospective observational descriptive study conducted on 45 patients who fitted the criteria for recalcitrant post-operative otorrhoea. All 45 patients showed no response to conservative treatment for 14 days from onset of discharge. Therefore, these patients were then given antiseptic ear drops.
Results Thirty patients out of 45 showed a good response to antiseptic ear drops and achieved a dry ear at the end of the treatment.
Conclusion In patients with recalcitrant otorrhoea with or without granulations after middle-ear reconstruction surgery, this study found that topical antiseptic ear drops, particularly those using boric acid powder, are more effective than topical antibiotic drops.

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Septoplasty: early (first year) and late (fourth year) post-operative results in 604 patients

Haye, R,Døsen, L K,TarAngen, M,Gay, C,Egeland, M T,Shiryaeva, O

Publication date 26-11-2021


Objective As prospective outcomes of septoplasty with or without turbinoplasty beyond the first year are few and have diverging results, this study evaluated later septoplasty results three to four years post-operatively.
Methods Patients undergoing septoplasty completed the Nasal Surgical Questionnaire pre-operatively, and at 6–12 months (early post-operative assessment) and 36–48 months (late post-operative assessment) after surgery. Primary outcome was visual analogue scale ratings for nasal obstruction (with a scale ranging from 0 to 100).
Results In 604 patients with high response rates, the largest improvements in nasal obstruction were from pre-operative to early post-operative assessments (daytime score reduction = 33.9, night-time reduction 40.5). Nasal obstruction ratings worsened slightly between early and late post-operative assessments (daytime score increase = 5.3, night-time score increase = 9.7). Improvements were better in patients aged over 35 years and in those with pre-operative nasal obstruction scores of more than 62. There were no differences based on surgery type, septal deviation, allergy or smoking.
Conclusion Septoplasty improves nasal obstruction in both the first and the fourth year after surgery. Post-operative improvements decline slightly over time but remain significant.

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Perspectives on paediatric sleep-disordered breathing in the UK: a qualitative study

Haighton, C,Watson, R M,Wilson, J A,Powell, S

Publication date 10-01-2022


Objective There is limited understanding of treatment pathways for paediatric sleep-disordered breathing. This study explored current UK pathways and what is important to well-being for parents and children.
Method The study comprised in-depth qualitative interviews (n = 22) with parents of children (2–9 years) with symptoms of sleep-disordered breathing referred to a regional ENT clinic (n = 11), general practitioners who might refer these children to ENT (n = 5) and hospital doctors involved in treating these children (n = 6). Interviews were audio recorded, transcribed verbatim, anonymised and analysed thematically.
Results General practitioners rarely identify seeing children with sleep-disordered breathing; conversely hospital doctors identify unsuspected issues. Parents are worried their child will stop breathing, but routes to referral and diagnosis are not straightforward. Modern technology can aid investigation and diagnosis. Patient weight is an issue for general practitioners and hospital doctors. Adenotonsillectomy is the treatment of choice, and information on paediatric sleep-disordered breathing is needed.
Conclusion Guidelines for the management of paediatric sleep-disordered breathing are needed.

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Non-opioid analgesics and post-operative pain following transoral robotic surgery for oropharyngeal cancer

Van Abel, K M,Sauer, A B,Kruthiventi, S C,Weingarten, T N,Noel, D B,Price, D L,Kasperbauer, J L,Janus, J R,Olsen, K D,Moore, E J

Publication date 10-01-2022


Objective To investigate associations between multimodal analgesia and post-operative pain among patients undergoing transoral robotic surgery for oropharyngeal squamous cell carcinoma.
Methods Records of patients who underwent surgery from 5 September 2012 to 30 November 2016 were abstracted. Associations were assessed using multivariable analysis.
ResultsA total of 216 patients (mean age of 59.1 years, 89.4 per cent male) underwent transoral robotic surgery (92.6 per cent were human papilloma virus positive, 87.5 per cent had stage T1–T2 tumours, and 82.9 per cent had stage N0–N1 nodes). Gabapentin (n = 86) was not associated with a reduction in severe pain. Ibuprofen (n = 72) was administered less often in patients with severe pain. Gabapentin was not associated with increased post-operative sedation (p = 0.624) and ibuprofen was not associated with increased bleeding (p = 0.221). Post-operative opioid usage was not associated with surgical duration, pharyngotomy, bilateral neck dissections, tumour stage, tumour size, subsite or gabapentin.
Conclusion Scheduled low-dose gabapentin was not associated with improved pain control or increased respiratory depression. Ibuprofen was not associated with an increased risk of bleeding and may be under-utilised.

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The impact of coronavirus disease 2019 on the head and neck cancer pathway in the West of Scotland

Drake, I,Rogers, A,Stewart, M,Montgomery, J

Publication date 28-02-2022


Objective The coronavirus disease 2019 pandemic has greatly disrupted head and neck cancer services in the West of Scotland. This study aimed to assess the impact of the first wave of the pandemic on cancer waiting times.
MethodsA retrospective review of multidisciplinary team records was undertaken between March and May in 2019 and the same months in 2020. Time-to-diagnosis and time-to-treatment for new cancers treated with curative intent were compared between the study periods, and subclassified by referral pathway.
ResultsA total of 236 new cancer patients were included. During the pandemic, pathways benefitted from reduced diagnostic and treatment times resulting from the restructuring of service provisions. A 75 per cent reduction in secondary care referrals and a 33 per cent increase in urgent suspicion of cancer referrals were observed in 2020.
Conclusion Head and neck cancer pathway times did not suffer because of the coronavirus pandemic. Innovations introduced to mitigate issues brought about by coronavirus benefitted patients, led to a more streamlined service, and improved diagnostic and treatment target compliance.

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Impact of coronavirus disease 2019 on head and neck urgent suspected cancer referral pathways in rural Wales

Abelardo, E,Gravelle, R,Scannell, M,Shastri, P,Vandekar, M,Davies, G,Volpini, L,Prabhu, V

Publication date 31-03-2022


Objective To assess the impact of the coronavirus disease 2019 pandemic on head and neck urgent suspected cancer referral pathways in rural areas of Wales.
MethodA retrospective audit was conducted of 2234 head and neck urgent suspected cancer referrals received from January 2019 to November 2020.
Results The referrals dropped by 35 per cent in 2020 compared to the same period in 2019. The time from general practitioner referral to the first ENT appointment improved during the pandemic (8.0 vs 10.0 days; p < 0.001). Of referrals, 92.1 per cent were seen within a 14-day period in 2020, compared with 79.6 per cent in 2019 (p < 0.001).
There were no differences between 2020 and 2019 in terms of: the (confirmed cancer) conversion rate (10.6 per cent vs 9.7 per cent; p = 0.60), general practitioner referral to multidisciplinary team discussion time (35.5 vs 41.5 days; p = 0.40) or general practitioner referral to initiation of treatment time (68.0 vs 78.0 days; p = 0.16).
Conclusion Whilst coronavirus disease 2019 reduced the number of overall head and neck urgent suspected cancer referrals, the pathways were generally unchanged, if not slightly improved, in rural Wales.

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Laryngeal dysplasia: a 10-year review of rates of progression to invasive carcinoma and treatment-specific outcomes in a regional ENT department in Northern Ireland

Donaldson, G,McCadden, L,Napier, S,Tan, T J

Publication date 18-02-2022


Background Laryngeal dysplasia represents a complex pre-malignant condition characterised by a spectrum of mucosal changes, with a reported malignant transformation rate from dysplasia to invasive carcinoma of 14.0 per cent.
Objective To identify whether increasing glottic dysplasia severity is associated with higher local malignant transformation rates or adverse clinical outcomes.
Methods This retrospective cohort study identified 125 patients with any histopathological grade of glottic dysplasia over a 10-year period who were followed up for a standardised 10-year period.
Results The malignant transformation rate was 21.8 per cent over 10 years, demonstrating a statistically significant greater risk with increasing dysplasia severity. The mean time to transformation was 52 months, with time to transformation statistically associated with increasing dysplasia severity. Rapid progression to carcinoma within 12 months occurred in 40 per cent of cases, and 58 per cent of subsequently diagnosed laryngeal squamous cell carcinomas were tumour stage T1.
Conclusion Laryngeal dysplasia carries a significant malignant potential, appearing greatest within 12 months of diagnosis and with increasing severity of dysplasia.

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Idiopathic subglottic stenosis in Saskatchewan Hutterite population

Holmes, C,Aravinthan, K,Murphy, R A,Gore-Hickman, R,Nair, S P,Sharma, A R

Publication date 14-02-2022


Background By studying the odds of developing idiopathic subglottic stenosis in the isolated and genetically unique Hutterite population, this study sought to strengthen the hypothesis that an underlying genetic predisposition may exist for its development.
MethodsA retrospective chart review examined the medical records of all adult patients treated for idiopathic subglottic stenosis in Saskatchewan between 2008 and 2018. Cases were segregated into Hutterite and non-Hutterite.
Results Four out of 36 cases of idiopathic subglottic stenosis occurred among Hutterites. The odds of a Hutterite developing idiopathic subglottic stenosis are 21.89 times higher than for non-Hutterites. Positive family history was only observed in the Hutterite population.
Conclusion The study strengthens the hypothesis that genetics may play a role in the aetiology of idiopathic subglottic stenosis by demonstrating that the genetically and socially unique Hutterites are more likely to develop this rare disease. This study is the first to demonstrate that a specific subpopulation is at a higher risk for developing idiopathic subglottic stenosis.

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Superior semicircular canal dehiscence repair with small middle fossa craniotomy using an oto-microscopic and co-endoscopic assisted approach

Tugrul, S,Yenigun, A,Kulaksiz, Y,Dogan, R,Aksoy, F,Ozturan, O

Publication date 10-01-2022


Objective Superior semicircular canal dehiscence is an uncommon neurotological disorder in which the petrous temporal bone overlying the superior semicircular canal lacks bone. Its most common symptoms include amplification of internal sounds, autophony, tinnitus, sound- and pressure-induced vertigo, hyperacusis, oscillopsia, and hearing loss. This video presentation aimed to demonstrate endoscopic-assisted repair of superior semicircular canal dehiscence with middle fossa craniotomy.
Method Eleven patients with superior semicircular canal dehiscence, verified with temporal computed tomography, were enrolled in the study.
Result An endoscopy-assisted middle fossa approach was applied to all patients. Superior semicircular canal dehiscence was successfully repaired with an endoscope in 11 patients.
Conclusion Endoscopic-assisted repair of superior semicircular canal dehiscence may be a superior approach compared with binocular operative microscopy.

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A novel approach to myringotomy simulation

Kelly, Z,Cao, A,Ahmedli, N,Nassar, M

Publication date 02-03-2022


Objective In the wake of the 2019 coronavirus disease pandemic, elective cases and opportunities for clinical application have decreased, and the need for useful simulation models has become more apparent for developing surgical skills. A novel myringotomy with ventilatory tube insertion simulation model was created.
Methods Residents across all levels at our institution participated in the simulation.
Participants were evaluated in terms of: time of procedure, microscope positioning, cerumen removal, identification of middle ear effusion type, canal wall trauma, tympanic membrane damage and tube placement.
Results Eleven residents participated. Scores ranged from 14 to 34, out of a maximum of 40. The average score among junior and senior residents was 24 and 31, respectively. The simulation was felt to be representative of the operating theatre experience.
Conclusion This study demonstrates a low-cost simulation model that captures several important, nuanced aspects of myringotomy with tube insertion, often overlooked in previously reported simulations.

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The Art and Science of Extended Deep Plane Facelifting and Complementary Facial Rejuvenation Procedures A A Jacono Quality Medical Publishing, 2021 ISBN 978 1 57626 460 7 pp 500 Price US$395.00

Whitehead, D E J

Publication date 14-02-2022


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Head and Neck Oncology: A Concise Guide A Mohammad, A Wadhwania CRC Press, 2021 ISBN 978 0 36742 131 1 pp 180 Price £69.99

Flood, L M

Publication date 17-02-2022


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Electrophysiological effects of slim straight intracochlear electrode position – CORRIGENDUM

Ordonez, F,Sudhoff, H,Todt, I

Publication date 14-03-2022


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JLO volume 136 issue 6 Cover and Front matter

Publication date 20-05-2022


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JLO volume 136 issue 6 Cover and Back matter

Publication date 20-05-2022


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