Clinical Otolaryngology

Clinical Otolaryngology

Transoral Microscopic Cautery‐Assisted Laser Tonsillectomy/Tongue Base Resection (TOMCAT)

03-12-2019 – Kishan Ubayasiri, Ayham Al Afif, Jasmijn Herruer, S Mark Taylor

Abstract
This is the first description in the literature of transoral oropharyngectomy achieved using a combination of microscope mounted laser and handheld monopolar diathermy.
Monopolar diathermy use in areas where cutting through large quantities of tissue is required, away from margins, significantly reduces operative time compared to laser resection alone. However, we find the laser causes less char and is superior for margin assessment and control.
This technique uses equipment already present in the majority of Head & Neck Surgical Oncology departments.

Assessment of induction chemotherapy regimen TPF versus GP followed by concurrent chemoradiotherapy in locally advanced nasopharyngeal carcinoma: a retrospective cohort study of 160 patients

01-12-2019 – Hui Guan, Yan He, Zhigong Wei, Jingjing Wang, Ling He, Xiaoli Mu, Xingchen Peng

Abstract
Nasopharyngeal carcinoma (NPC) is a cancer that originates from the nasopharyngeal epithelial tissue. NPC has s a unique pattern of geographical distribution, which is more common in East Asia and Southeast Asia 1. In China, there were an estimated over 60,600 new cases and 34,100 deaths of NPC in 2015 2. Because of its particular anatomical structure and its sensitivity to radiation, radiotherapy is the main treatment method. Patients with early disease usually achieve long‐term survival by radiotherapy alone.

Trends in Incidence of Cancer of Oral cavity, Oropharynx, and Hypopharynx in Taiwan: Data from the Nationwide Cancer Registry, 1979 ‐ 2016

01-12-2019 – Yi‐Hsien Lin

Abstract
There is a trend of rising incidence of oral and pharyngeal cancer in the world.1, 2 Cancer has been the leading cause of death in Taiwan since 1982.3 Cancer of oral cavity, oropharynx, and hypopharynx is the sixth highest incidence of malignancy in Taiwan.

Developing an innovative office‐based UK rhinology service – experience and outcomes in 22 patients undergoing office‐based local anaesthetic nasal polypectomy

30-11-2019 – Matthew L Coates, Alasdair Mayer, Sean Carrie

Journal Article

Abstract
Here we report outcomes from an office‐based UK nasal polypectomy cohort of 22 patients, and give an account of our experience of setting‐up and running the service.
There was a statistically significant reduction in total patient reported outcomes using SNOT‐22 scores, which were maintained at three months (Mean 11.55, 95% CI: 4.94‐18.15, difference in means 26.09, n = 22) and one year (Mean 7.20, 95% CI: 1.99 – 12.42, difference in means 21.80, n = 15)Patients returned to their normal daily activities after a mean of 2.7 days (0‐7 days), and the 11 working patients returned to work after a mean of 3.5 days (0‐14 days).
There were no major complications in this cohort. All patients were treated on an entirely outpatient basis, and no patient required further post procedure interventions in this cohort for complications or side effects. Epistaxis ‐ the most commonly reported post‐operative side effect – was reported as “no problem” or a “mild problem” by 90.1% patients.
Comparison with published literature reveals SNOT‐22 outcomes from this cohort at three months are equivalent those of patients receiving nasal polypectomy under general anaesthesia.

An Audit of Fifty Patients Receiving ArtissTM Fibrin Sealant in Lateral Selective Neck Dissections

29-11-2019 – Charles H Earnshaw, Andrew J Kinshuck, Christopher Loh, Sankalap Tandon, Shaun R Jackson, Terry M Jones, Jeffrey Lancaster

Journal Article

Abstract
Artiss
TM is a fibrin sealant used in wound closure of lateral selective neck dissections
Fifty patients received Artiss
TM, and thirty‐six patients were included in the control cohort
We show Artiss
TM use reduces the drain retention time and total volume drained
We show Artiss
TM use also reduces the length of hospital stay
Artiss
TM use has the potential to reduce the total cost of patient stay

Intranasal trigeminal training in empty nose syndrome: a pilot study on 14 patients

28-11-2019 – Serge‐Daniel Le Bon, Mihaela Horoi, Olivier Le Bon, Sergio Hassid

Journal Article

Abstract1. Empty nose syndrome is a rare and debilitating complication of turbinate surgery, with varying symptoms of which paradoxical nasal obstruction is typical.2. Trigeminal training consisting of three‐times daily levomenthol and eucalyptol inhalations for at least 30 days were associated with improved subjective nasal patency and quality of life.3. Trigeminal training is an outpatient, low‐cost, easy‐to‐do, non‐invasive and non‐harmful treatment modality that can be proposed to ENS patients as a preliminary step before considering surgery.4. Trigeminal lateralization testing seems to be a more reliable diagnostic tool than rhinomanometry in ENS.

Subclinical vestibular deficit in six‐canal video head impulse testing (vHIT) in patients with vestibular schwannomas

27-11-2019 – Hiteshkumar Tailor, Margaret Gaggini, Lorna Hastings, Richard Locke, John A. Crowther, Georgios Kontorinis

Letter

Sarcopenia Results in Poor Survival Rates in Oral Cavity Cancer Patients

26-11-2019 – Sheng‐Chiao Lin, Yaoh‐Shiang Lin, Bor‐Hwang Kang, Chun‐Hao Yin, Kuo‐Ping Chang, Chao‐Chuan Chi, Ming‐Yee Lin, Hsing‐Hao Su, Ting‐Shou Chang, Yun‐Ying She, Yu‐Hsi Liu, Ching‐Chih Lee

Journal Article

Abstract
Objective
This study aimed to determine the impact or survival of low skeletal muscle mass (SMM) among patients with oral squamous cell carcinoma (OSCC) undergoing primary surgery.
Design
This study was a retrospective cohort study.
Setting
OSCC patients treated at our referral center from April 2005 to March 2014 were examined.
Participants
The cohort comprised 276 patients with OSCC undergoing primary surgery.
Main outcome measures
Estimated SMM was measured by calculating the cervical skeletal muscle mass from a CT scan of the head and neck. The 5‐year overall survival (OS) and disease‐specific survival (DSS) were analyzed using a multivariable Cox regression model.
Results
There were 276 patients with a male‐to‐female ratio of 12:1. A low SMM (< 47.5 cm2/m2) was associated with worse survival. After adjustment for other factors, the result remained robust for OS (hazard ratio HR 1.74, 95% confidence interval CI 1.14‐2.67) and disease‐specific survival (HR 1.67, 95% CI 1.04‐2.67). In the subgroup analysis, worse OS and DSS was particularly noted in male patients (HR = 1.90, 95% CI 1.22‐2.97; HR = 1.91, 95% CI 1.27‐3.19) and in those younger than 60 years of age (HR = 1.91, 95% CI 1.14‐3.22; HR = 2.12, 95% CI 1.23‐3.64) with low SMM.
Conclusions
Low SMM was a significant independent factor that was associated with lower survival in patients who have oral cavity cancers and are undergoing primary surgery. Preoperative CT scans of the head and neck could be utilized to evaluate SMM, predict treatment outcomes, and facilitate nutrition management.

The impact of conductive hearing loss on balance

22-11-2019 – Gilad Horowitz, Omer J. Ungar, Yael Levit, Mordechai Himmelfarb, Ophir Handzel

Journal Article

Abstract
Background
Balance is a complex process involving the coordinated activities of multiple sensory, motor and biomechanical components. Balance function may be disturbed in subjects suffering from hearing loss but the impairment has been attributed to the pathology underlying the hearing loss.
Aim
The purpose of the study was to investigate the possible interference of simulated conductive hearing loss with the ability to maintain postural balance.
Methods
Twenty normal‐hearing subjects, 20‐30 years old, underwent the computerised dynamic posturography test battery before and after plugging their external ear canals with earplugs, thus simulating a 40d
B conductive hearing loss.
Results
Eighteen females and two males were tested before and after plugging their ear canals. Average CHL was 40 ± 4.9d
B. The composite equilibrium score was significantly diminished after plugging the ears with an average sway score of 73.5% (P < .05, T = 2.27). The fourth test condition was specifically affected with an average sway score of 72.85% with earplugs (P < .05, T = 2.37).
Conclusions
Conductive hearing loss has a negative effect on balance. This can be theoretically explained by the association between hearing loss and saccular dysfunction.

The role of allied healthcare professionals in head and neck cancer surveillance: A systematic review

22-11-2019 – John Rocke, Oliver Mclaren, John Hardman, George Garas, Matthew E Smith, Hiro Ishii, James Constable, Theofano Tikka, Zi Wie Liu, Richard Williams, Integrate (UK ENT Trainee Research Network)

Journal Article

Abstract
Objectives
The roles of Allied Health Care Professionals (AHPs) in Head and Neck Cancer (HNC) are wide ranging but not clearly defined. Inter‐regional variability in practice results from a lack of standardisation in approaches to the Multidisciplinary Team (MDT) make‐up and structure. Traditionally, the follow‐up of HNC patients is clinician led with multiple scheduled follow‐up appointments. The increasing population of HNC patients provides logistical, monetary and efficiency challenges.
This systematic review presents the roles of the multiple AHP sub‐groups in HNC with the aim of presenting how their differing skill sets can be integrated to modernise our approach in follow‐up.
Design
We searched MEDLINE, Embase, the Cochrane Library, NIHR Dissemination Centre, The Kings Fund Library, Clinical Evidence, National Health Service Evidence and the National Institute of Clinical Excellence to identify multiple subgroups of AHPs (Dentists, Speech and Language Therapists, Dieticians, Physiotherapists, Psychologists, Clinical Nurse Specialists) and evidence of their role in HNC follow‐up. Evidence not directly relating to HNC follow‐up was excluded.
Setting and Participants
This Systematic Review was undertaken online by the Integrate (UK ENT Trainee National Collaborative) Head and Neck Subcommittee.
Main Outcome Measures Most evidence was of low‐quality, and the broad nature of the protocol provided a wide variety of study models. Two authors screened the articles for relevance to the topic before final analysis.
Results
The main role identified was improvement in Quality of Life and symptom control rather than detecting recurrence. We also demonstrate that it is possible to stratify HNC follow‐up patients using their received treatment modality and Distress Thermometers to identify groups who will require more intensive AHP input.
Conclusions
HNC follow‐up covers a broad group of patients with differing needs. As such, a blanket approach to this phase of treatment is likely to be less effective than a patient‐led model where the group of AHPs are employed on a needs basis rather than at set time points. This will likely lead to greater patient satisfaction, earlier detection of recurrence and efficiency savings.

Estimating vocal fold stiffness: Using the relationship between subglottic pressure and fundamental frequency of phonation as an analog

22-11-2019 – Wen‐Hsuan Tseng, Chi‐Chin Chang, Tsung‐Lin Yang, Tzu‐Yu Hsiao

Journal Article

Abstract
Objective
The stiffness of the vocal folds is an important factor in voice production, yet clinically applicable measurements are still lacking. It has been demonstrated in an in vivo canine model that fundamental frequency (F0) increased linearly as subglottic pressure (Ps) increased, but with a lesser slope for higher levels of vocal fold tension. In this study, the relationship between F0 and Ps was investigated using the airflow interruption method in awake patients non‐invasively.
Design
Healthy volunteers enrolled for evaluation.
Setting
Single‐centre.
Participants
Thirty‐three healthy volunteers aged 20 and older were recruited, with one excluded for a recent asthma attack.
Main outcome measures
The relationships between F0 and Ps, described as the slope (Hz/k
Pa), were investigated when the participants sustained voicing the vowel/o/at 3 incremental frequencies 4 semitones apart in the modal register (F1, F2 and F3).
Results
Thirty‐two healthy volunteers (20 females, 12 males) aged 20‐47 years were enrolled for final analyses. There was a statistically significant difference in the slopes of the linear regression lines of F0‐Ps, depending on the frequency with which the vowel/o/ was produced (P < .001). The slope differed significantly between F2 and F1 (P < .001; P = .015), F3 and F1 (P < .001; P = .002) and F3 and F2 (P < .001; P = .005) for both women and men, respectively.
Conclusions
It was demonstrated that the higher the vocal fold tension, the smaller the slope between F0 and Ps. Using the relationship between F0 and Ps as an analog of vocal fold stiffness is potentially practical for clinical application.

Our experience of a paediatrician‐led clinic for the medical management of children with obstructive sleep disordered breathing

22-11-2019 – Haytham Kubba, Katherine Rowe, Gideon Pinczower, Robert Sloan, Michelle Waterham, Emma Weiss, Rachel Harwood

Journal Article

Abstract
Background
Obstructive sleep disordered breathing (OSDB) is very common in children. Adenotonsillectomy is usually curative, but there is emerging evidence that topical nasal steroids can also be effective for some children, and may avoid the need for surgery. The number of children referred for assessment of OSDB is increasing and in some departments, waiting times are long. We established a paediatrician‐led clinic for assessment and initial medical management of OSDB and in this study we report the proportion of children who avoided the need for surgery.
Method
Referral letters to the otolaryngology department were screened and those with suspected OSDB and no significant co‐morbidities were diverted to the paediatrician‐led clinic. We recorded data for a consecutive series of children seen in this clinic with suspected OSDB over a 3‐month period. Parents completed a 5‐item subset of questions from the OSA‐11 questionnaire before and after treatment with 6 weeks of topical nasal steroids.
Results
In the 3‐month study period, 103 children were seen, with a mean age of 6 (range 1‐16). Six (5.8%) had improved spontaneously before clinic attendance. Of the 97 children who were still symptomatic, 17 (17.5%) were referred directly for surgery on the basis of the severity of their symptoms, or because of other coexisting conditions that required surgical treatment (such as recurrent tonsillitis or otitis media). 3 declined intranasal steroids. 77 had a trial of intranasal steroids, of whom 34 (35%) reported enough improvement to avoid surgery, and 29 (28%) failed to improve and were referred for surgery. 14 (14%) failed to attend after the trial of steroids: of these, 5 (5%) were contactable by phone and confirmed improvement after topical steroids. OSA‐5 scores were significantly improved following intranasal steroids.
Discussion
A paediatrician‐led clinic can be an effective way to ease the workload of an over‐stretched otolaryngology service, and judicious use of topical nasal steroids can help around 40% of children with OSDB avoid surgery.

The Outcome and Decision‐making of Extracapsular Dissection for Benign Superficial Lobe Parotid Tumors: Our Experience in 144 Patients

22-11-2019 – Ping‐Chia Cheng, Wu‐Chia Lo, Chih‐Ming Chang, Tsung‐Wei Huang, Po‐Wen Cheng, Li‐Jen Liao

Journal Article

Abstract•The outcomes and decision‐making between extracapsular dissection (ECD) and superficial parotidectomy (SP) for benign superficial lobe parotid tumors were compared.•The ECD group had less transient facial paralysis rate and shorter hospitalization days than the SP group.•The ECD and SP groups had similar permanent facial paralysis rate and tumor recurrence rate.•The tumor location was the only associated factor for the choice of surgical techniques after the multivariate analyses.•No matter what the tumor size, tumor depth, or the pathology is, ECD can be applied as the first line surgical technique in most benign parotid tail tumors.

Fusobacterium necrophorum, a major provider of sinus thrombosis in acute mastoiditis: a retrospective multicenter pediatric study

20-11-2019 – Aurélie Coudert, Julia Fanchette, Gaëlle Regnier, Justine Delmas, Eric Truy, Richard Nicollas, Mohamed Akkari, Vincent Couloignier, Sonia Ayari‐Khalfallah

Journal Article

Abstract
Objective
To evaluate in children the clinical severity and evolution of otogenic lateral sinus thrombosis (OLST) due to Fusobacterium necrophorum compared to other bacterial otogenic thrombosis and propose a specific management flowchart for Fusobacterium OLST.
Design
A retrospective multicenter cohort study.
Settings
Four French ENT pediatric departments.
Participants
A total of 260 under 18 years old admitted for acute mastoiditis were included. Initial imaging was reviewed to focus on complicated mastoiditis and 52 OLST were identified. Children were then divided into two groups according to bacteriological results: 28 in the “OLST Fusobacterium group” and 24 in the “OLST other bacteria group”.
Results
There was a significant association between F. necrophorum and OLST (p<0.001). When compared to the OLST other bacteria group, children in the OLST Fusobacterium group were significantly younger (61 months vs. 23 months, p<0.01) and had a more severe clinical presentation: higher CRP (113 mg/L vs. 175.7 mg/L, p=0.02) and larger subperiosteal abscess (14 mm vs. 21 mm, p<0.01). Medical management was also more intensive in the OLST Fusobacterium group than in the OLST other bacteria group: increased number of conservative surgeries (66.7% vs. 92.9%, p=0.03) and longer hospital stay (13.7 days vs.19.8 days, p=0.02). At the end of follow‐up, the clinical course was good in both groups without any neurological sequelae.
Conclusions
Thrombotic complications are very frequent in case of Fusobacterium mastoiditis and clinicians should be aware of the initial severity of the clinical presentation. Under appropriate management, the clinical course of Fusobacterium OLST is as good as that of other bacterial otogenic thrombosis.

Etiopathology of Pediatric Neck Masses in a Tertiary Hospital in Jazan Province‐ Saudi Arabia

20-11-2019 – Fahd Alharbi, Mohamed Rifaat Ahmed

Journal Article

Abstract
Pediatric neck masses are one of the common conditions presenting to the otorhinolaryngologist.
This is retrospective study done on 136 children under the age of ten years presenting with neck masses to a tertiary referral hospital.
A complete and adequate clinical assessment should be the basis for every diagnostic and therapeutic decision in children with neck masses
Inflammatory neck masses in children were the commonest; followed by congenital masses.

Differences in the diagnostic value between fiberoptic and high definition laryngoscopy for the characterization of pharyngeal and laryngeal lesions: A multi‐observer paired analysis of videos

20-11-2019 – Constanze Scholman, Jeroen M. Westra, Manon A. Zwakenberg, Frederik G. Dikkers, Gyorgy B. Halmos, Jan Wedman, Jan E. Wachters, Bernard F.A.M. van der Laan, Boudewijn E.C. Plaat

Journal Article

Abstract
Objectives
High definition laryngoscopy (HDL) could lead to better interpretation of the pharyngeal and laryngeal mucosa than regularly used fiberoptic laryngoscopy (FOL). The primary aim of this study is to quantify the diagnostic advantage of HDL over FOL in detecting mucosal anomalies in general, in differentiating malignant from benign lesions and in predicting specific histological entities. The secondary aim is to analyse image quality of both laryngoscopes.
Design
Retrospective paired analysis with multiple observers evaluating endoscopic videos simulating daily clinical practice.
Setting
A tertiary referral hospital.
Participants
In 36 patients both FOL and HDL videos were obtained. Six observers were provided with additional clinical information and 36 FOL and HDL videos were evaluated in a randomised order.
Main outcome measures
Sensitivity, specificity, positive and negative predictive value and diagnostic accuracy of observers using both flexible laryngoscopes were calculated for detection of mucosal lesions in general and uncovering malignant lesions. Sensitivities were calculated for prediction of specific histological entities. Image quality (scale 1‐10) was assessed for both flexible laryngoscopes.
Results
HDL reached higher sensitivity compared to FOL for detection of mucosal abnormalities in general (96.0% vs 90.4%; p=0.03), differentiating malignant from benign lesions (91.7% vs 79.8%; p=0.03) and prediction of specific histological entities (59.7% vs 47.2%; p<0.01). Image quality was judged better with HDL in comparison with FOL (mean: 8.4 vs 5.4, p<0.01).
Conclusions
HDL is superior to FOL in detecting mucosal anomalies in general, malignancies and specific histological entities. Image quality is considered as superior using HDL compared to FOL.

Prognosis of oral squamous cell carcinoma with perineural invasion: A comparative study of classification types

19-11-2019 – Jae Park, Anna Megow, Adam Swalling, John‐Charles Hodge, Andrew Foreman, Samuel Boase, Rowan Valentine, Suren Krishnan, Eng H. Ooi

Journal Article

Abstract
Objective
To investigate the histological location and extent of perineural invasion (PNI) as prognostic factors.
Design
Retrospective review of medical records and histological analysis of 116 patients with oral squamous cell carcinoma (OSCC).
Setting
Two major public tertiary hospitals treating head and neck cancer, Royal Adelaide Hospital and Flinders Medical Centre, in South Australia.
Participants
Patients diagnosed with OSCC who underwent primary surgical treatment with curative intent at these two centres from January 1, 2005 through December 31, 2015.
Main Outcome Measures
The primary end points were disease‐free survival (DFS) and disease‐specific survival (DSS).
Results
The presence of PNI as a binary factor alone did not significantly influence the clinical outcomes. Extratumoural (ET) PNI as measured from the tumour edge was associated with worse DFS on multivariate analyses. Multifocal PNI was associated with worse DFS and DSS. DFS in multifocal PNI was worse irrespective of whether adjuvant therapy was administered.
Conclusions
The presence of multifocal and ET PNI in OSCC is associated with poor clinical outcomes. Patients with multifocal PNI were associated with worse DFS even with adjuvant therapy.

Application of augmented reality to surgical practice: A pilot study using the ODG R7 Smartglasses

19-11-2019 – Michael Yong, Julie Pauwels, Frederick K. Kozak, Neil K. Chadha

Letter

Endoscopic pharyngeal pouch stapling: A retrospective study of 55 patients comparing intubation difficulty and body mass index as factors for success

19-11-2019 – Sumrit Bola, Alexander Ashman, Stuart Winter

Letter

Lymph node ratio as a prognostic marker in advanced laryngeal and hypopharyngeal carcinoma after primary total laryngopharyngectomy

15-11-2019 – Stefan Grasl, Stefan Janik, Thomas Parzefall, Michael Formanek, Matthaeus C. Grasl, Gregor Heiduschka, Boban M. Erovic

Journal Article

Abstract
Background
We evaluated the prognostic value of lymph node ratio (LNR) in patients with advanced laryngeal and hypopharyngeal squamous cell carcinoma.
Study Design
Retrospective chart review.
Methods
Between 1994 and 2018, 79 patients underwent total laryngopharyngectomy and adjuvant therapy. LNR was determined and statistically compared to patients’ overall survival (OS), disease‐specific survival (DSS), disease‐free survival (DFS), locoregional and distant failure.
Results
The 5‐year OS, DSS and DFS rates were 45.6%, 73.4% and 56.9%, respectively. 24.1% and 25.3% developed loco‐ regional failure or distant metastatic disease, respectively. Univariate analyses showed that high LNR (cut‐off >0.07) was significantly associated with distant and locoregional failure. On multivariate analysis, LNR remained an independent predictor for OS (P = .004), DSS (P = .009) and DFS (P = .044).
Conclusion
Increased LNR in patients with advanced laryngeal or hypopharyngeal carcinoma is significantly linked to shortened OS, DSS, DFS and higher locoregional and distant metastatic disease.

Increase in IL‐17‐positive cells in sinonasal inverted papilloma

15-11-2019 – Chen Cao, Si Fei Yu, Yu Tao Zhou, Xue Xue Guo, Jie Bo Guo, Chang You Wu, Chun Wei Li, He Xin Chen

Journal Article

Abstract
Objective
Neutrophil infiltration in patients with sinonasal inverted papilloma (SNIP) is significantly high. Whether IL‐17, which is a potent factor mediating neutrophilic inflammation, is involved in the neutrophilic phenotype of SNIP is investigated in the current study.
Study design
Laboratorial study.
Participants
Nasal papilloma and inferior turbinate were collected from patients with SNIP (n = 50) and control subjects with septal deviation (n = 15).
Methods
IL‐17 + cells were evaluated in tissues obtained from patients with SNIP and control subjects with septal deviation, by immunohistochemistry and flow cytometry.
Main outcome measures
The IL‐17 + cells were mainly localised in mononuclear cells and neutrophils, and were up‐regulated in the SNIP samples compared with those in the controls. The IL‐17 + T‐cell subsets mainly included CD4+ (Th17, 60.0%) and CD8+ (Tc17, 30.0%), and both subsets were enhanced in the SNIP samples than controls. The total level of IL‐17 + cells was significantly correlated with neutrophil infiltration in the SNIP tissues. Furthermore, the SNIP homogenates could significantly promote IL‐17 production in peripheral blood mononuclear cells.
Conclusions
An increase in IL‐17 + cells is evident in SNIP and may be involved in neutrophil infiltration in local tissues. IL‐17 could be a potential therapeutic target to relieve the neutrophilic pathological change in SNIP.

No Impact on the Incidence Rate of Adenoidectomy 1998‐2014 on a National level in Denmark by the Use of Nasal Steroid and the introduction of Pneumococcal Vaccines

14-11-2019 – Casper Grønlund, Michael Frantz Howitz, Bjarki Ditlev Djurhuus

Journal Article

Abstract
Objective
To describe trends in incidence rates of adenoidectomy in children in Denmark from 1998‐2014 and to look for possible explanatory factors such as intranasal steroids and pneumococcal vaccination.
Design
A nationwide, population‐based, retrospective, interrupted time‐series analysis, using data from Danish registries.
Setting
Hospitals and private Ear, Nose, and Throat‐clinics.
Participants
Children who underwent adenoidectomy from 1998‐2014 in Denmark.
Main outcome measure
Adenoidectomy.
Methods
The National Patient Register and the National Health‐insurance Service Register were used to identify all adenoidectomies performed in children. The National Prescription Register supplied data on intranasal steroids.
Results174,557 adenoidectomies were identified, distributed among 153,022 children.
The annual incidence rate was stable at around 11 per 1,000 person‐years from 1998‐2004. A decrease was seen from 2004 reaching 7.9 in 2009, followed by an increase to 9.1 in 2014.
The highest age‐specific incidence rates were seen at 2‐3 years of age. An estimated 14% of children born in 2014 will have had adenoidectomy performed before turning 16 years old.
The proportion of adenoidectomies performed in private clinics compared with hospitals was 90%.
Conclusion
From 1998‐2004 the incidence rate of adenoidectomy in children in Denmark was among the highest in the world with around 11 per 1,000 person‐years. A decrease to 7.9 was seen from 2004‐2009. We found no inverse correlation on a national level between the incidence rates of adenoidectomy and intranasal steroid, nor the introduction of the Pneumococcal vaccine. The amount of intranasal steroids used in children in Denmark was negligible compared with adenoidectomy.

Role of matrix metalloproteinases and their inhibitors in the development of cervical metastases in papillary thyroid cancer

13-11-2019 – Boris Bumber, Marcel Marjanovic Kavanagh, Antonia Jakovcevic, Nino Sincic, Ratko Prstacic, Drago Prgomet

Journal Article

Abstract
Objective
To investigate the role of matrix metalloproteinases (MMPs) and their inhibitors (TIMPs) in the development of cervical metastases in papillary thyroid cancer. Our hypothesis is that level of expression of MMPs and TIMPs is associated with the development of cervical metastases and the pattern of metastatic process in papillary thyroid cancer.
Design
This research retrospectively investigates the expression of MMP‐1, ‐2 and ‐9 as well as TIMP‐1 and ‐2 in papillary thyroid carcinoma tissue. Tissue specimens were immunohistochemically treated with primary monoclonal antibodies against MMP‐1, MMP‐2, MMP‐9, TIMP‐1 and TIMP‐2.
Setting
Single‐centre study.
Participants
In total, samples of 159 patients were analysed. In all patients, total thyroidectomy was performed, whereas 102 patients underwent selective neck dissection of either central (level VI) or lateral neck (level II‐V). Subjects were divided into four groups.
Main outcome measures
Matrix metalloproteinases and TIMPs expression values were analysed in each group, and groups were compared to each other.
Results
Total number of patients was 159, of which 125 were women and 34 men. Comparing expression levels of MMPs and TIMPs in metastatic (study groups) and non‐metastatic (control group), papillary thyroid carcinomas yielded significant differences in MMP‐1 and TIMP‐1 expression levels, where the highest expression values were found in the group with metastasis in lateral neck. Expression levels of MMP‐2, MMP‐9 and TIMP‐2 did not differ statistically significant among the groups.
Conclusion
Elevated expression of MMP‐1 and TIMP‐1 in tumour tissue can be considered a predictive factor for the development of metastases.

Impact of insurance on survival in patientsxa0<xa065 with head & neck cancer treated with radiotherapy

13-11-2019 – Mark P. Sittig, Michael Luu, Emi J. Yoshida, Kevin Scher, Alain Mita, Stephen L. Shiao, Diana J. Lu, Jon Mallen‐St. Clair, Allen S. Ho, Zachary S. Zumsteg

Journal Article

Abstract
Objectives
The United States has a heterogenous health insurance landscape for patients <65 years. We sought to characterise the impact of primary payer on overall survival (OS) in insured patients younger than 65 with head and neck squamous cell carcinoma (HNSCC) treated with definitive radiotherapy.
Design/Study/Participants
The National Cancer Database was queried for patients <65 years old diagnosed from 2004 to 2014 undergoing definitive radiotherapy ± chemotherapy for cancers of the nasopharynx, oropharynx, hypopharynx and larynx. Uninsured patients and oropharyngeal cancers without known HPV status were excluded.
Main outcome
Overall survival.
Results
Overall, 27 292 insured patients were identified, including 17 060 (62.5%) with private insurance. Median follow‐up was 52.1 months. In multivariable models, patients receiving Medicaid (HR = 1.66, 95% CI 1.57‐1.75, P < .001), Medicare (HR = 1.64, 95% CI 1.55‐1.73, P < .001) and other government insurance (HR = 1.44, 95% CI 1.29‐1., P < .001) had independently increased mortality in comparison to those with private insurance. In propensity score‐matched cohorts, 5‐year OS was 65.5% vs 50.6% for privately vs government‐insured patients, respectively (P < .001). In multivariable subgroup analysis, private insurance was associated with improved survival in all subgroups. However, the magnitude of this effect was most pronounced in patients with HPV‐positive oropharyngeal cancer vs non‐HPV‐related cancer (interaction P < .001), younger patients (interaction P = .001), and those without comorbidity (interaction P < .001).
Conclusions
Patients <65 with HNSCC undergoing definitive radiation with private health insurance have markedly longer survival relative to patients with government‐sponsored insurance. This illustrates that increasing access to care may be necessary, but is not sufficient, to mitigate the significant disparities in the US healthcare system.

Our experience: Quantifying changes in tracheostomy tube position and orientation with repositioning of 14 patients (the Lunar positioning study)

09-11-2019 – Amali N Chandrasena, Jay Goswamy, Nicholas Calder, Uzma Khalil, Brendan A McGrath

Journal Article

Abstract
The majority of tracheostomy complications occur post insertion, with tube malposition contributing to device misplacement.
Endoscopic examination can be undertaken via tracheoscopic (T‐view) or trans‐laryngeal (L‐view) approaches.
We found significant differences occurred in the position and orientation of the tracheostomy tube following repositioning of a patient from insertion to nursing positions, irrespective of the scoring system used.
Greater variation in scores were apparent in patients who subsequently had clinical complications related to malposition.
We recommend post‐procedural endoscopy in the nursing position.

Alternate method for designing laryngoplasty implant using actual size CT scan images on a touchscreen device with a stylus

05-11-2019 – Rohan Bidaye, Chadwan Al‐Yaghchi, Guri Sandhu

Letter

Standardised Ki‐67 proliferation index assessment in early‐stage laryngeal squamous cell carcinoma in relation to local control and survival after primary radiotherapy

05-11-2019 – Emiel Kop, Geertruida H. Bock, Maartje G. Noordhuis, Lorian Slagter‐Menkema, Bernard F. A. M. Laan, Johannes A. Langendijk, Ed Schuuring, Bert Vegt

Journal Article

Abstract
Objectives
Ambiguous results have been reported on the predictive value of the Ki‐67 proliferation index (Ki‐67 PI) regarding local control (LC) and survival after primary radiotherapy (RT) in early‐stage laryngeal squamous cell cancer (LSCC). Small study size, heterogenic inclusion, variations in immunostaining and cut‐off values are attributing factors. Our aim was to elucidate the predictive value of the Ki‐67 PI for LC and disease‐specific survival (DSS) using a well‐defined series of T1‐T2 LSCC, standardised automatic immunostaining and digital image analysis (DIA).
Methods
A consecutive and well‐defined cohort of 208 patients with T1‐T2 LSCC treated with primary RT was selected. The Ki‐67 PI was determined using DIA. Mann‐Whitney U‐tests, logistic and Cox regression analyses were performed to assess associations between Ki‐67 PI, clinicopathological variables, LC and DSS.
Results
In multivariate Cox regression analysis, poor tumour differentiation (HR 2.20; 95% CI 1.06‐4.59, P = .04) and alcohol use (HR 2.84, 95% CI 1.20‐6.71; P = .02) were independent predictors for LC. Lymph node positivity was an independent predictor for DSS (HR 3.16, 95% CI 1.16‐8.64; P = .03). Ki‐67 PI was not associated with LC (HR 1.59; 95% CI 0.89‐2.81; P = .11) or DSS (HR 0.98; 95% CI 0.57‐1.66; P = .97). In addition, continuous Ki‐67 PI was not associated with LC (HR 2.03; 95% CI 0.37‐11.14, P = .42) or DSS (HR 0.62; 95% CI 0.05‐8.28; P = .72).
Conclusion
The Ki‐67 PI was not found to be a predictor for LC or DSS and therefore should not be incorporated in treatment‐related decision‐making for LSCC.

Impact of hyperlipidemia as a coexisting factor on the prognosis of idiopathic sudden sensorineural hearing loss: A propensity score matching analysis

05-11-2019 – Chengfang Chen, Mingming Wang, Hongya Wang, Wenping Xiong, Qinglei Dai, Baowei Wang, Xuhui Liang, Haibo Wang

Journal Article

Abstract
Objective
To define the impact of hyperlipidemia as a coexisting factor on the prognosis of Idiopathic Sudden Sensorineural Hearing Loss (ISSHL), we prospectively analysed the Lipid‐lowering therapy Group (LLTG) data compared with Control Group (CG) data to determine the effects of Lipid intervention on the prognosis of sudden hearing loss.
Design
A prospective, non‐randomized study.
Setting
Shandong Provincial Hospital Affiliated to Shandong University, Shandong, China.
Participants
A total of 653 in‐patient SSHL patients were enrolled between January 2014 to August 2018.
Main outcome measures
From January 2014 to August 2018, 653 patients with ISSHL who also had hyperlipidemia as coexisting factor were identified. Patients enrolled in LLTG (n = 200) or CG (n = 453) were compared by a propensity score matching analysis (PSM, caliper = 0.01, n = 2) to balance pre‐existing clinical characteristics. After matching, the effective rate of different hyperlipidemia types and different types of audiogram in both groups were performed by Cochran‐Mantel‐Haenszel test (CMH).
Results
After PSM, 440 patients were studied (146 in LLTG, 294 in CG), and the influence of interference factors was balanced, meanwhile, the final hearing level was better in LLTG than CG (P = .043), and hearing gain was higher in LLTG than CG (P = .006). Cure rate (32.9%), significant improvement rate (22.6%) and the total effective rate (76.0%) in LLTG were better than that in CG group (26.5%, 15.6% and 63.6%) after the Pearson chi‐square test (P < .05). Analysis with the Cochran‐Mantel‐Haenszel test showed that the total effective rate was better in LLTG than CG respectively (P = .009) in each different hyperlipidemia types, and there were statistically significant differences in TG higher group (TG Group; P = .018). Moreover, the total effective rate was better in LLTG than CG (P = .006) for all patterns of audiogram, and there were statistically significant differences in flat audiogram (P = .043).
Conclusions
Lipid‐lowering therapy can improve the curative effect of sudden hearing loss patients combined with hyperlipidemia. There was a significant difference in the total effective rate of TG Group after lipid intervention, suggesting that there might be causal relationship between TG and sudden hearing loss. There was a significant difference in the total effective rate between flat audiogram, which may suggest flat hearing loss was more likely caused by vascular dysfunction.

Nerve‐tumour interaction enhances the aggressiveness of oral squamous cell carcinoma

04-11-2019 – Tsung‐Lun Lee, Po‐Hsien Chiu, Wing‐Yin Li, Muh‐Hwa Yang, Pei‐Yin Wei, Pen‐Yuan Chu, Yi‐Fen Wang, Shyh‐Kuan Tai

Journal Article

Abstract
Objectives
Perineural invasion (PNI) is a poor prognostic pathologic feature of oral squamous cell carcinoma (OSCC). The mechanisms of PNI remain poorly understood, and nerve‐tumour interactions have been implicated for its pathogenesis.
Design and setting
Systematic investigation of nerve‐tumour interactions was performed using fresh human peripheral nerve. In vitro and in vivo models were used to determine the ability of human peripheral nerves to enhance OSCC migration/invasion. Retrospective cohort study was also carried out in one medical centre from 2001 to 2009.
Participants314 T1‐2 OSCC patients.
Main outcome measures
In the transwell migration/invasion assay, the cells in five representative fields were counted. In the nerve implantation model, tumour size was estimated. PNI quantification by PNI focus number was carried out in the OSCC patients to correlate with cervical lymph node metastasis and oncologic outcomes.
Results
The transwell migration/invasion assay demonstrated that human peripheral nerves, compared with subcutaneous soft tissue, significantly enhanced the migration/invasion abilities of OSCC. Moreover, the enhanced migration was dose‐dependent with increased length or number of peripheral nerve segments. The nerve implantation model showed that human peripheral nerve also enhanced OSCC growth in vivo. Finally, increased PNI focus number was found dose‐dependently associated with increased cervical lymph node metastasis and decreased 5‐year disease‐specific survival rates.
Conclusions
These results clearly indicated the presence of nerve‐tumour interaction that involved paracrine influences leading to aggressiveness of OSCC. Further investigations are required to explore key cell types and molecules involved in nerve‐tumour interactions for future therapeutic targeting of PNI in OSCC.

The Long‐term Effectiveness of Tinnitus Multivariate Integrated Sound Therapy (T‐MIST) in 148 tinnitus patients with normal hearing thresholds: Our initial experience

03-11-2019 – Yuanxin Zhao, Fei Zhao, Amr El Refaie, Bochen Wang, Danping Chen, Kangsong Chen, Tianxiang Lan

Letter

An estimation of smoking history in patients who consume loose and smokeless tobacco products

03-11-2019 – S A R Nouraei

Letter

Letter to the editor in reference to: “A web‐based prediction score for head and neck cancer referrals”

31-10-2019 – Theofano Tikka, Vinidh Paleri

Letter

The efficacy of statins as otoprotective agents: A systematic review

31-10-2019 – Pattarawadee Prayuenyong, Anand V. Kasbekar, David M. Baguley

Journal Article

Abstract
Objective
This systematic review examined the current literature, summarised research findings and identified research gaps regarding the efficacy of statins on audiological outcomes.
Methods
Systematic search of electronic databases and grey literature was performed. Eligibility criteria were the study of a statin drug with report of audiological outcomes such as hearing, tinnitus or balance in either human or animal studies. Data extraction and quality assessment were performed by two independently researchers. The characteristics of the study and research findings were collated and summarised. A narrative synthesis was conducted. Meta‐analysis was not possible due to heterogeneity of the included studies.
Results
Analysis of searches yielded 17 studies meeting the criteria. Included studies had variable drug type and dosage, outcome measures and associated inner ear conditions. Most animal experiments showed promising audiological outcomes after statin treatment, demonstrated by the results of auditory brainstem response, distortion product otoacoustic emissions and inner ear histology. However, no clear effect can be discerned in human trials due to the mixed results, and heterogeneity in research methodology and quality. Audiological outcomes were not always correlated with cholesterol levels.
Conclusions
Statins remain a potential candidate as otoprotective agents which warrant further investigation.

Shared decision‐making in older children and parents considering elective adenotonsillectomy

29-10-2019 – Amanda I. MacDonald, Jill Chorney, Michael Bezuhly, Paul Hong

Journal Article

Abstract
Objectives
Shared decision‐making describes a collaborative process in which healthcare providers and patients/families make treatment decisions using the best available evidence, while taking into account the patients values and preferences. The objectives of this study were to assess the level of decisional conflict and shared decision‐making experienced by older children and their parents when considering elective adentonsillectomies.
Design
A prospective cohort study.
Setting
Paediatric otolaryngology clinic in a teaching hospital.
Participants
Participants included 53 children older than 9 years and their parents who underwent consultation for tonsillectomy with or without adenoidectomy.
Main outcomes measures
Children and parents completed the Decisional Conflict Scale (DCS) and Shared Decision‐Making Questionnaire‐Patient Version (SDM‐Q‐9). Surgeons completed the Shared Decision‐Making Questionnaire‐Physician Version (SDM‐Q‐Doc).
Results
Overall, 10 (19%) parents and 18 (34%) children reported clinically significant decisional conflict. Parents who opted not to proceed with surgery had significantly higher DCS scores than those who decided to proceed with surgery. Both parents and children SDM‐Q‐9 and total DCS scores were significantly negatively correlated. Physician SDM‐Q‐Doc and parent total DCS scores were negatively correlated, while parent and physician SDM scores were positively correlated.
Conclusions
Many older children and parents reported significant decisional conflict when considering elective paediatric otolaryngology surgery. Decisional conflict levels for both children and parents decreased with greater perceived levels of shared decision‐making. Older children did not appear to discern the same levels of shared decision‐making as parents and surgeons. Future research should assess methods to implement shared decision‐making into clinical practice for clinicians, parents and children when appropriate.

Treating nasal symptoms associated with rhinitis using the intranasal herbal ointment Biyeom‐go: A prospective observational study

29-10-2019 – Mi Ju Son, Jeeyoun Jung, Young‐Eun Kim, Chang‐Sub Yeum, So Min Lee, So Young Jung, Ojin Kwon, Sungha Kim, Jeong‐In Kang, Hye‐Lin Kim, Jung‐Eun Lee, Dong‐Hyo Lee

Journal Article

Abstract
Objectives
The aim of the current study was to investigate the effectiveness and clinical feasibility of Biyeom‐go for the treatment of nasal symptoms associated with rhinitis.
Design
Prospective observational study.
Setting
This study was conducted at the Woosuk Korean Medicine Medical Center in South Korea.
Participants
Fifty‐eight patients with rhinitis participated in this study. All patients received Biyeom‐go treatment >3 times daily for a total of 4 weeks.
Main outcome measures
The primary outcome was the total nasal symptom score. Mini‐rhinoconjunctivitis quality of life questionnaire, nasal endoscopy index, total serum immunoglobulin E levels and immunologic factors in nasal lavage fluid were also measured.
Results
Biyeom‐go administration was associated with significant improvements in total nasal symptoms scores (P < .0001) and mini‐rhinoconjunctivitis quality of life questionnaire scores (P < .0001) in a time‐dependent manner. The nasal endoscopy index also significantly improved at weeks 2 (P = .0049), 3 (P < .0001) and 4 (P = .0001) after Biyeom‐go treatment. Significantly, increased interleukin‐2 levels (P = .005) and decreased interleukin‐8, chemokine (C‐C motif) ligand (CCL) 5, chemokine (C‐X‐C motif) ligand (CXCL) 9, CCL2 and CXCL10 levels were observed in the nasal lavage fluid.
Conclusions
The present findings suggest that Biyeom‐go may be beneficial for the management of rhinitis symptoms and rhinitis‐associated quality of life. Further well‐designed randomised controlled trials are needed to evaluate the effectiveness of Biyeom‐go for rhinitis.

Validate the classification of fungal rhinosinusitis: A retrospective analysis of 162 patients at a single institution

27-10-2019 – Man‐Wei Hua, Chih‐Ying Wu, Rong‐San Jiang, Ching‐Yun Chang, Kai‐Li Liang

Letter

The use of Floseal® in middle ear bleeding (Correspondence: Technical notes)

27-10-2019 – Georgina Wellstead, Ananth Vijendren, Junaid Hanif, John Phillips

Journal Article

Does the oral steroid treatment of patients with nasal polyposis cause osteopenia or osteoporosis?

27-10-2019 – Pernilla Sahlstrand‐Johnson, Mats Holmström, Anders Ehnhage

Journal Article

Abstract
Objectives
We aimed to investigate the bone mineral density (BMD) in a group of Swedish patients with chronic rhinosinusitis with nasal polyposis (CRSw
NP) with or without asthma, as well as to evaluate whether the treatment of this patient group is in accordance with the EPOS recommendations.
Design, settings and participants
Adult patients with a diagnosis of CRSw
NP, and a history of at least two courses of oral corticosteroids (OCS) during the last year, were consecutively included in this study at five centres.
Main outcome measures
The BMD of the patients was measured by Dual‐energy X‐ray absorptiometry (DXA), which is the only technology for classifying BMD according to the criteria established by WHO.
Results
A total of 51 patients, with an average number of 7 years with OCS treatment, were enrolled. During the last 12 months, the mean number of OCS courses was 2.76, and the total mean intake was 891 mg of Prednisone equivalents. According to the T‐scores, 17 patients were measured to have ≤−1 SD T‐score lumbar spine, which is considered to be osteopenia, and five patients had <−2.5 SD T‐score, considered as osteoporosis. However, when taking age and gender into account and analysing the Z‐scores, only 2 patients had a reduced density of the spine and none in the hip, which is no difference compared to a matched Swedish population.
Conclusions
This prospective study shows that 2‐3 moderate courses of OCS annually may be used without high risk of causing osteopenia/osteoporosis in patients with CRSw
NP.

Endoscopic ear surgery: Does it have an impact on quality of life? Our experience of 152 cases

24-10-2019 – Virangna Taneja, Thomas D. Milner, Arunachalam Iyer

Journal Article

The use of Transnasal Humidified Rapid‐Insufflation Ventilatory Exchange (THRIVE) in one hundred and five upper airway endoscopies. A case series

24-10-2019 – Eleanor Waters, Maximiliane Kellner, Pamela Milligan, Richard M. Adamson, Iain J. Nixon, Alistair F. McNarry

Letter

The microbiology of ear cultures in a high‐burden setting in tropical Australia: Implications for clinicians

23-10-2019 – Lyndon Nofz, Jarrad Koppen, Nadine De Alwis, Simon Smith, Josh Hanson

Letter

Transnasal humidified rapid insufflation ventilatory exchange in elective laryngopharyngoscopy

23-10-2019 – Kirsten E. Stewart, Alistair F. McNarry, Iain J. Nixon

Journal Article

ZNF703 is an important player in head and neck cancer

23-10-2019 – Ceren Orhan, Burak Bakır, Nejat Dalay, Nur Buyru

Journal Article

Abstract
Objectives
Despite advances in treatment, head and neck squamous cell carcinoma (HNSCC) remains difficult to treat and the overall survival rate has only modestly improved over the past years. Therefore, there is a need to understand the molecular mechanism of HNSCC. Zinc finger protein 703 (ZNF703) is an oncogenic transcription factor, and ZNF703 gene expression is altered in many cancers as a result of chromosome 8p12 amplification. The purpose of this study was to investigate the expression pattern of ZNF703 in HNSCC in association with CCND1 expression and Akt phosphorylation.
Design
Prospective study.
Setting
University hospital.
Participants
One hundred and five patients with HNSCC.
Methods
Fifty HNSCC tumour and non‐cancerous tissue samples were investigated by q
RT‐PCR and Western blotting.
Results
ZNF703 gene expression was increased in 22.9% of tumour tissues compared with its normal counterparts. The results were correlated with clinicopathological features, copy number variation and survival data.
Conclusion
ZNF703 over‐expression is associated with copy number variation and this over‐expression may activate PI3K/Akt signalling pathway in HNSCC.

Use of individual anatomical variations to customise window location in montgomery implant thyroplasty: A case series study

22-10-2019 – Enrique Zapater, Jorge Basterra, Isabel López, Natsuki Oishi, Ainhoa García‐Lliberós

Journal Article

Understanding and clinical relevance of chronic rhinosinusitis endotypes

22-10-2019 – Qasim Husain, Ahmad R. Sedaghat

Editorial

Abstract
Background
Chronic rhinosinusitis (CRS) is the downstream manifestation of heterogeneous pathophysiologic mechanisms leading to chronic sinonasal inflammation. Traditional grouping of patients by symptoms or clinical findings/phenotypes is being replaced by classification of CRS patients based on the underlying pathophysiologic mechanisms: endotypes.
Objective of Review
To provide an up‐to‐date review on the current knowledge of CRS endotypes with a focus on how the pathophysiologic mechanisms defined by each endotype may be targeted therapeutically. Special emphasis is placed on the clinical relevance of the material and how it may inform the current practice of otolaryngologists.
Type of Review
A systematic review of contemporary literature review focusing on the latest studies examining the role of endotypes in the management and treatment of CRS.
Search Strategy
A MEDLINE and PubMed Central search were undertaken to perform this review using the keywords “Endotype” and “Sinusitis.”Evaluation Method
Articles containing the keywords, as well as the references of those articles, were then examined for relevance.
Results
The endotypes for CRS are often defined based on the balance of T‐helper cell patterns of inflammation and can be grouped into Th2 and non‐Th2 inflammation. These groups have shown a variable response to medical and surgical therapy, demonstrating that existing mainstream treatments can be tailored to patients with specific endotypes. The inflammatory mediators of Th2 inflammation, IL‐4, IL‐5 and IL‐13 as well as Ig
E, are targeted by available biologic drugs that can be used for treatment of refractory disease.
Conclusions
Increased understanding of CRS endotypes has led to the identification of biomarkers that define these endotypes and act as targets for potential therapeutics. Increasing knowledge about characteristics associated with these endotypes and their responses to treatments, including both established mainstream CRS treatments and novel biologic medications, has allowed incorporation of CRS endotypes into the current clinical decision‐making. Treatment of CRS patients based on consideration of their endotypes is therefore not only presently possible but may improve clinical outcomes of those patients as well.

“A tinnitus symphony in 100 patients with Menieres disease”

22-10-2019 – Patricia Perez‐Carpena, Marta Martinez‐Martinez, Ramón Antonio Martínez Carranza, Angel Batuecas‐Caletrio, Jose A. Lopez‐Escamez

Letter

Predictors for failure of supraglottic superimposed high‐frequency jet ventilation during upper airway surgery in adult patients; a retrospective cohort study of 224 cases

19-10-2019 – Gyorgy B. Halmos, Charlotte M.A. Plate, Grita Krenz, Bouwe Molenbuur, Frederik G. Dikkers, Boukje A.C. van Dijk, Jan E. Wachters

Journal Article

Abstract
Supraglottic Superimposed High Frequency Jet Ventilation (SSHFJV) maximizes surgical field during endoscopic upper airway surgery.
In our retrospective series of 224 cases, there was a low incidence (12%) of failure with the use of SSHFJV in upper airway surgery.
Positive history of pulmonary pathology (OR=4.91) and high BMI (OR=1.15) were found to be significant independent factors for failure of SSHFJV in adult patients undergoing upper airway surgery.
Converting ventilation techniques could be safely performed when SSHFJV failed.
SSHFJV is a safe ventilation technique during upper airway surgery, even in combination with the application of CO2 laser.

A systematic review on prevention and management of wound infections from cochlear implantation

15-10-2019 – Ananth Vijendren, Daniele Borsetto, Eleanor J. Barker, Joseph G. Manjaly, James R. Tysome, Patrick R. Axon, Neil P. Donnelly, Manohar L. Bance

Journal Article

Abstract
Objective of review
Surgical site infections are a recognised complication of cochlear implant (CI) surgery with significant morbidity. Our aim was to search for the optimum prevention and management strategy to deal with this issue.
Type of review
Systematic review.
Search strategy
A systematic literature search was undertaken from the databases of Embase, CINAHL, MEDLINE®, Web of Science, Scopus and Cochrane Library according to the predefined inclusion and exclusion criteria.
Evaluation method
All relevant titles, abstracts and full‐text articles were reviewed by two authors who resolved any differences by discussion and consultation with senior authors.
Results
Fourteen articles were included in our review. The overall quality of evidence was low with the vast majority of the studies being retrospective case series and expert opinions. No randomised controlled trials were noted. We found consistent reports that intraoperative prophylactic antibiotics should be given to all patients undergoing CI and that the vast majority of CI wound infections had grown Staphylococcal spp. or Pseudomonas spp.
Conclusion
Our review has not identified any reliable or reproducible strategies to prevent and deal with wound infections after CI. We strongly encourage further research within this field and would suggest that a consensus of opinions from a multidisciplinary panel of experts may be a pragmatic way forward as an effective guide.

Fine‐needle aspiration cytology and radiological imaging in parotid gland tumours: Our experience in 103 patients

11-10-2019 – Clare Perkins, Edward Toll, Philip Reece

Letter

Introducing the Ambu® aScope™ for speech valve retrieval: How I do it

11-10-2019 – “Omar Mulla, Sarah ODonnell”

Journal Article

Value of clinical data and positional testing in patients with positional vertigo

11-10-2019 – Yunjuan Lin, Junfang Xue, Su‐Jeong Lee, Xiaoqin Wu, Haijun Shan, Xin Ma, Lisheng Yu, Jen‐Tsung Lai

Letter

Preoperative plasma fibrinogen as a predictive factor for post‐tonsillectomy haemorrhage

09-10-2019 – Stefan Grasl, Stefan Janik, Erich Vyskocil, Lorenz Kadletz, Matthaeus C. Grasl, Boban M. Erovic

Journal Article

Abstract
Objectives
To assess whether preoperative plasma fibrinogen is able to predict severe post‐tonsillectomy haemorrhage.
Study design
Retrospective chart review.
Methods
We included 456 patients who underwent tonsillectomy between 2008 and 2013. Preoperative plasma fibrinogen levels (PFL) were assessed in patients who developed severe bleeding requiring surgical revision under general anesthesia compared to those with uneventful postoperative courses.
Results414 (90.8%) had no severe post‐tonsillectomy haemorrhage. In contrast, 42 (9.2%) patients needed surgical hemostasis. PFL were significantly higher (P = .023) in patients with a severe bleeding. Univariate Cox‐regression analysis revealed that elevated preoperative fibrinogen represents a significant worse (P = .003; HR 2.66; 95% CI 1.38‐5.10) prognostic factor for postoperative bleeding. Even at multivariable analysis, increased PFLs were a significantly worse prognostic factor for post‐tonsillectomy haemorrhage (P = .016; HR 15.4; 95% CI 0.01‐0.6). High preoperative PFL was associated with significantly higher risk for post‐tonsillectomy haemorrhage within the first 31 days after surgery (65% vs 90%; P = .002). Moreover, accurate negative predictive value (NPV) of 95.1% pointed out that PFL could be used as a reliable preoperative screening marker.
Conclusions
Elevated PFL represents an independent worse prognostic factor for severe bleeding after tonsillectomy and could be helpful to identify patients at higher risk for PTH.

Surgical management of spontaneous temporal bone cerebrospinal fluid leaks: Results of a strategy based on defect location. A bicentric retrospective study of 44 cases

09-10-2019 – Esteban Brenet, Xavier Dubernard, Jean‐Charles Kleiber, Arnaud Bazin, André Chays, Philippe Herman, Benjamin Verillaud

Letter

Continuous versus intermittent intraoperative neuromonitoring in complex benign thyroid surgery: A retrospective analysis and prospective follow‐up

08-10-2019 – Anke Sedlmaier, Thomas Steinmüller, Mechthild Hermanns, Tadeus Nawka, Sebastian Weikert, Benedikt Sedlmaier, Philipp P. Caffier

Journal Article

Abstract
Objectives
To compare continuous (C‐IONM) vs intermittent intraoperative neuromonitoring (I‐IONM) in complex benign thyroid surgery, and to follow up patients with loss of signal (LOS) or unilateral vocal fold paralysis (UVFP).
Design
Retrospective clinical study, prospective case series.
Setting
University hospital and academic teaching hospital of Charité—University Medicine Berlin, Germany.
Participants
C‐IONM‐ and I‐IONM‐assisted thyroid surgery was conducted in 357 patients diagnosed with recurrent goitre, Graves’ disease, complex hyperparathyroidism, cervical preoperation (anterior access) and LOS in primary operation (2‐stage thyroidectomy).
Main outcome measures
To evaluate the incidence of early postoperative and permanent UVFP, and to report the results of phonosurgical therapy in patients suffering from persisting dysphonia.
Results
In 346 patients enrolled (81.8% female, 18.2% male) with 613 nerves at risk (NAR) being monitored (409 I‐IONM vs 204 C‐IONM), early postoperative UVFP was observed in 10.5% of I‐IONM vs 4.9% of C‐IONM group (P < .05), permanent paralysis in 1.5% of I‐IONM vs 1.0% of C‐IONM group (P = .619). In total, 72 patients (21%) experienced pathological events (19 LOS < 100 μV, 53 transient or permanent UVFP). Three patients with permanent UVFP and persisting dysphonia received phonosurgery with stable improvements of all acoustic‐aerodynamic parameters.
Conclusion
Compared to I‐IONM, C‐IONM‐application in complex benign thyroid surgery shows a significant reduction of transient UVFP and a non‐significant trend in preventing permanent UVFP. In persistent UVFP with dysphonia, endolaryngeal phonomicrosurgery and transcervical laryngeal framework surgery are long‐term effective treatment approaches to improve vocal function.

An epidemiological study of paediatric adenotonsillectomy in Victoria, Australia, 2010‐2015: Changing indications and lack of effect of hospital volume on inter‐hospital transfers

08-10-2019 – Aimy H.L. Tran, Rosemary S.C. Horne, Danny Liew, Joanne Rimmer, Gillian M. Nixon

Journal Article

Abstract
Objective
To describe the contemporary epidemiology of paediatric adenotonsillectomy in an Australian setting, examine the incidence rate over 2010‐2015 and investigate factors associated with inter‐hospital transfer.
Design
Retrospective population‐based study.
Setting
Multicentre study in the state of Victoria, Australia.
Participants
From the Victorian Admitted Episodes Dataset, which included all patients aged 0‐19 years who underwent adenoidectomy and/or tonsillectomy in Victoria, Australia between 2010 and 2015.
Main Outcome Measures
Annual incidence rate, hospital volume, inter‐hospital transfer.
Results
Between 2010 and 2015, 59 008 patients underwent 61 281 procedures, with highest number performed in males (52.7%), children aged under 10 years (73.5%) and in the higher socioeconomic groups (24.6% in quintile 4 and 23.2% in quintile 5). Seventy‐five cases (0.12%) resulted in inter‐hospital transfer, which was significantly associated with young age (under 5 years). More than a third of hospitals (35.7%) performed an average rate of <1 procedure per week. Hospital volume was not associated with risk of inter‐hospital transfer. The incidence rate of adenotonsillectomy procedures significantly increased over the study period (P < .001), driven by a significant increase in the rate of surgery performed for obstructive symptoms (P < .001).
Conclusions
The rate of adenoidectomy/tonsillectomy procedures is rising, with a higher proportion being performed in socioeconomically advantaged patients. This raises concerns regarding healthcare access, given the literature supporting higher rates of obstructive sleep‐disordered breathing and sore throat in lower socioeconomic groups. A third of hospitals performed small numbers of procedures, but we found no association between hospital volume and inter‐hospital transfers.

Impact of adenotonsillectomy on the evolution of inflammatory markers

08-10-2019 – Martín E. Marcano‐Acuña, Marina Carrasco‐Llatas, Miguel Tortajada‐Girbés, José Dalmau‐Galofre, Pilar Codoñer‐Franch

Journal Article

Abstract
Background
Tonsils are first‐line host defence organs against pathogenic agents and participate in local and systemic immunity. Persistent increases in systemic inflammatory responses may contribute to associated morbidity. The aim of this study was to verify the short‐ and long‐term impact of adenotonsillectomy on the evolution of inflammatory markers in 3‐ to 9‐year‐old children.
Methods
A prospective and longitudinal study was conducted over 1 year in 29 children who underwent tonsillectomy due to either chronic tonsillitis or adenotonsillar hypertrophy. Measurements of high‐sensitivity C‐reactive protein (hs‐CRP) levels were taken. Levels of Th1‐type cytokines interleukin‐1, interferon‐γ, and tumor necrosis factor‐α (TNF‐α) and anti‐inflammatory Th2‐type cytokines interleukin‐4, ‐5, ‐6, ‐10 and ‐13 were measured. Levels of transforming growth factor‐beta (TGF‐β) and intercellular adhesion molecule‐1 (ICAM‐1) were also determined. The results were compared to those of 29 control children.
Results
At baseline, children with surgery indications presented with higher levels of hs‐CRP, interleukin‐1 and ‐10, interferon‐γ, TNF‐α and ICAM‐1, whereas values of interleukin‐4 were significantly lower than in control children. Children with severe tonsillar obstruction had higher values of interleukin‐1, ‐4, and ‐5 and lower values of interleukin‐10 compared with children with recurrent tonsillitis. One year after surgery, the levels except IL‐4 did not show a significant difference from those obtained in the control group. The levels of hs‐CRP and TNF‐α decreased significantly in the first month.
Conclusion
Children with chronic tonsillitis and/or adenotonsillar hypertrophy have significantly elevated levels of proinflammatory cytokines. Adenotonsillectomy restores the normal values of these parameters 1 year after surgery.

Effect of piezoelectric osteotomy on postoperative oedema and ecchymosis after rhinoplasty

08-10-2019 – Do Hyun Kim, Haram Kang, Ho Jun Jin, Se Hwan Hwang

Journal Article

Abstract
Objectives
This study evaluated the efficacy of piezoelectric osteotomy in reducing oedema and ecchymosis during rhinoplasty via a systematic review with meta‐analysis.
Design and setting
Two authors independently searched the referenced databases. PubMed, Embase, SCOPUS, the Web of Science, the Cochrane library and Google Scholar databases were systematically searched from inception to January 2019.
Participants
Sufficient data were retrieved for a meta‐analysis of six trials with a total of 327 patients.
Main outcome measures
They included studies that compared piezoelectric osteotomy (treatment groups) with conventional osteotomy (control group). The outcomes of interest were operative time, mucosal injury, oedema, ecchymosis and postoperative pain. Baseline study characteristics, quality of study, numbers of patients in the treatment and control groups and outcomes were extracted.
Results
Intraoperative mucosal injury was significantly lower in the treatment group vs the control group, but operative time was longer in the treatment group. Eyelid oedema and ecchymosis in the first seven days postoperatively were statistically decreased in the treatment group vs the control group. In addition, pain in the first three days postoperatively was statistically decreased in the treatment group vs the control group. However, in a subgroup analysis according to osteotomy visibility in the control group (blind osteotomy vs osteotomy under direct vision), there was no significant difference in oedema and ecchymosis between treatment and osteotomy under direct vision.
Conclusions
Piezoelectric osteotomy during rhinoplasty can reduce eyelid oedema and eyelid ecchymosis compared to conventional osteotomy. However, piezoelectric osteotomy had no significant advantages in terms of postoperative oedema and ecchymosis compared to osteotomy under direct vision.

Three‐dimensional computed tomography analysis of frontoethmoidal cells: A critical evaluation of the International Frontal Sinus Anatomy Classification (IFAC)

08-10-2019 – Tomasz Gotlib, Paulina Kołodziejczyk, Magdalena Kuźmińska, Konstancja Bobecka‐Wesołowska, Kazimierz Niemczyk

Journal Article

Abstract
Objectives
Two major classifications of frontoethmoidal cells, Lee and Kuhn and the IFAC (International Frontal Sinus Anatomy Classification), distinguish anterior, posterior and medial cells. The European anatomical position paper includes also lateral cells. According to the IFAC, anterior cells push the frontal sinus drainage pathway (FSDP) medially, posteriorly or posteromedially. Posterior cells push the FSDP anteriorly. The only medial cell, pushing the FSDP laterally is the frontal septal cell, which is attached to or located in the interfrontal sinus septum. The aim of this study was to verify the IFAC and characterise cells, which are inconsistent with this classification.
Design
A radioanatomic analysis.
Setting
Tertiary university hospital.
Participants
One hundred and three Caucasian adult patients with no inflammatory changes in paranasal sinuses CT.
Main outcomes measure
Results of assessment of multiplanar reconstruction of thin slice CT.
Results
Two types of cells that cannot be classified using the IFAC were found: (a) Lateral cells extending between the skull base and the anterior buttress, pushing the FSDP anteromedially or medially, present in 34 (16.5%) of the sides, (b) Paramedian cells: medially based, not adjacent to the interfrontal septum, pushing the FSDP laterally and posteriorly, present in 33 (16%) of sides. Suprabulla cells and suprabulla frontal cells were found to push the FSDP in directions other than anterior 28% and 31% of the time respectively.
Conclusions
Neglecting lateral and paramedian cells may lead to inconsistent results between radioanatomical studies and impede communication between surgeons. They should be included in existing classifications of frontoethmoidal cells.

Clinical feeding examination with cervical auscultation for detecting oropharyngeal aspiration: A systematic review of the evidence

08-10-2019 – Thuy T. Frakking, Anne B. Chang, Michael David, Jane Orbell‐Smith, Kelly A. Weir

Journal Article

Abstract
Background
Cervical auscultation (i.e. listening to swallowing sounds) is the most commonly used technique in adjuvant to the clinical feeding examination by speech‐language pathologists worldwide to assess for oropharyngeal aspiration risk in children. Despite its relative popularity in clinical practice, little is known on the clinical utility of cervical auscultation within a paediatric population.
Objective
To determine the diagnostic test accuracy of the clinical feeding examination with cervical auscultation in the detection of aspiration in children.
Type of review
Narrative review. Prospero Registration: CRD42017081467 Search strategy: Medline/Pub Med, Embase, CINAHL, Aust
Health, Cochrane and UQ (Scopus) were searched up until October 2017. Specifically, the search terms used were: (((oropharyngeal OR respiratory) aspiration) AND (child* OR pediatr* OR paediatr*) and (cervical auscultation OR swallow sounds OR swallowing sounds OR accelerometry OR swallowing acoustics)). The search strategy also included scanning reference lists and citations of retrieved studies.
Evaluation method
Extracted studies were reviewed by two independent reviewers. Methodological quality of studies was assessed using the QUADAS‐2 tool.
Results
Only one study met inclusion criteria for this review, which had a bias for flow and timing. Use of cervical auscultation in conjunction with the clinical feeding examination to predict aspiration had a positive predictor value (PPV) of only 0.49 (0.31‐0.66), indicating potential over‐prediction of aspiration when cervical auscultation is used. In contrast a high NPV of 0.92 (0.78‐0.98) was reported indicating that cervical auscultation is useful at ruling out aspiration in children.
Conclusion
This review highlights the paucity of research studies assessing the accuracy of cervical auscultation as an adjuvant to the clinical feeding examination in aspiration detection within the paediatric population.

Development of the Alberta facial clinical evaluation scale: A patient‐centred outcomes instrument for facial nerve paralysis

08-10-2019 – Amr F. Hamour, Adrian I. Mendez, Vincent L. Biron, Robert Seemann, Kal Ansari, Richard Liu, Hadi Seikaly, David W. J. Côté

Journal Article

Abstract
Objectives
Facial nerve paralysis has functional, psychological and social consequences for patients. Traditionally, outcome measurements for facial nerve injuries have been clinician derived. Recent literature has shown that patient perspective is valuable and necessary in outcomes research. This study aimed to identify patient domains of concern and subsequently, develop a point‐of‐care questionnaire for clinical use.
Design
This mixed‐methods prospective study was completed in three phases. In Phase I, 15 facial nerve injury patients were interviewed individually. Interviews were digitally recorded, transcribed and coded with NVivo software. Analysis led to a conceptual framework detailing the most important quality of life outcomes. During Phase II, a focus group was held with five new patients in order to prioritise the outcome themes to a top six list. A second focus group was held with Otolaryngology‐Head and Neck staff surgeons to create a 25‐item questionnaire based on these six themes. In Phase III, the questionnaire was administered to 10 new patients to test for comprehension.
Setting
University of Alberta Hospital, Edmonton, Alberta, Canada.
Participants
A total of 30 patients with facial nerve injury were included in the various phases in the study. In addition, 5 staff Otolaryngology‐Head and Neck surgeons participated as focus group contributors.
Main outcome measures
Domains of concern and quality of life outcomes as reported by facial nerve injury patients.
Results
Patients identified a total of 16 themes encompassing both functional and psychological deficits related to their facial nerve injury. From these findings, a 25‐item Likert‐type scale, the A‐Fa
CE scale, was developed for clinical use.
Conclusions
Patients with facial nerve paralysis experience functional and psychological deficits. This study led to the creation of the first patient‐reported instrument for this population that addresses functional impairment, social function, psychological well‐being and self‐perception of appearance.

Long‐term evaluation of sound localisation in single‐sided deaf adults fitted with a BAHA device

08-10-2019 – Nicolas‐Xavier Bonne, Jean‐Noël Hanson, Fanny Gauvrit, Michaël Risoud, Christophe Vincent

Journal Article

Abstract
Objective
To perform a long‐term evaluation of the localisation capabilities in the horizontal plane of single‐sided deaf patients fitted with a BAHA device.
Design
Single‐centre retrospective study.
Participants
Twenty‐one adults with single‐sided deafness (SSD) with normal hearing in the contralateral ear (pure tone average <20 d
B, SDS > 90%) rehabilitated with a Cochlear BAHA device from 2003 to 2012 on the deaf side over a median follow‐up of 8 years.
Outcome measures
The task used in this paper is a sound localisation identification task with a set‐up of seven loudspeakers on a semi‐circular array at 30‐degree intervals performed at three periods: before BAHA, initially and at last follow‐up. Our main criterion of judgement was the root‐mean‐square (RMS) localisation error. In addition, the Bern Benefit in Single‐Sided Deafness Questionnaire (BBSS) was administered.
Results
The mean RMS localisation error was initially estimated at 64° without any rehabilitation (for a chance level RMS estimated at 81°). Initially, with the BAHA device, the RMS localisation error dropped to 51°. At the last follow‐up evaluation, a significant decrease at 23° was noted. Concerning the Bern Questionnaire, 19% of the patients (n = 4) did not report any change (score of 0), 33% (n = 7) are satisfied (score of +1 or +2) and 48% (n = 10) are very satisfied with the BAHA device (score better than +3).
Conclusion
Improvement of sound localisation in the horizontal plane for some SSD patients is likely related to altered processing of monaural spectral cues. The time needed to learn to use the azimuth‐dependent spectral cues takes time. Long‐term follow‐up should be considered for studies investigating sound localisation performance.

The all muscles preserved method in arytenoid adduction

08-10-2019 – Koji Matsushima

Letter

Analysis of revision and reimplantation of cochlear implantations in 45 cases

08-10-2019 – Yi Jiang, Jianan Li, Yongyi Yuan, Lihua Wu, Bo Gao, Qingshan Jiao, Guojian Wang, Dongyi Han, Shiming Yang, Pu Dai

Letter

Endoscopic type I tympanoplasty is as effective as microscopic type I tympanoplasty but less invasive—A meta‐analysis

04-10-2019 – István Pap, István Tóth, Noémi Gede, Péter Hegyi, Zsolt Szakács, Alexandros Koukkoullis, Péter Révész, Kinga Harmat, Adrienne Németh, László Lujber, Imre Gerlinger, Tímea Bocskai, Gábor Varga, István Szanyi

Journal Article

Abstract
Background
Endoscopic type I tympanoplasty was originally introduced in the 1990s, and the extensive spread of this practice can be easily observed. The conventional technique performed involves the repair of a tympanic membrane perforation, and is defined as microscopic type I tympanoplasty.
Objective of Review
The aim of this study was the comparison of postoperative outcomes of both the endoscopic and the microscopic type I tympanoplasty.
Type of Review
We conducted a meta‐analysis in accordance with the Preferred Reporting Items for Systematic Reviews and Meta‐analysis (PRISMA) guidelines.
Search Strategy
A systematic literature search was performed in the databases of PubMed, Embase, Cochrane Library, Clarivate Analytics‐Web of Science, Clinical
Trials.gov, World Health Organization Library, and Scopus by inserting, ‘myringoplasty OR (tympanoplasty AND perforation)’ into the search query. We applied only a ‘human’ filter. We excluded non‐English studies. Additional records were identified by checking the references of relevant studies.
Evaluation Method
Comparative studies were included in our analysis. We calculated the pooled odds ratio (OR) with 95% confidence interval (CI) for dichotomous outcomes and weighted mean difference (WMD) with a 95% CI for continuous outcomes. Additionally, we assessed the risk of bias and estimated the quality of evidence for each outcome.
Results
Our systematic search yielded 16 studies (involving 1179 interventions), eligible for analysis. The pooled graft uptake rate (OR: 1.21, CI: 0.82‐1.77; I2 = 0.0%), the postoperative hearing results (WMD = −1.13; 95% CI: −2.72‐0.45; I2 = 78.1%) and the operation time (WMD = −21.11; 95% CI: −42.60‐0.38; I2 = 99.3%), were all comparable amongst the two techniques. In contrast, the endoscopic type I tympanoplasty outperforms when regarding the pooled canaloplasty rate (OR = 7.96; 95% CI: 4.30‐14.76; I2 = 0.0%, P = 1.000) and features an increase in desirable cosmetic results (OR = 19.29; 95% CI: 11.37‐32.73; I2 = 0.0%, P = 0.839), when compared with the microscopic approach.
Conclusions
Based on our meta‐analysis, the surgical outcomes of endoscopic type I tympanoplasty in terms of graft uptake rate, postoperative hearing results and operation time were comparable to the microscopic type I tympanoplasty. In regards to cosmetics, an increase in desirable results was achieved in the endoscopic group, particularly the incidence of canaloplasty which proved to be significantly lower.

Hidden hearing loss and tinnitus: Utility of the high‐definition audiograms in diagnosis

04-10-2019 – Jérôme Lefeuvre, Julie Chedeau, Marc Boulet, Gérald Fain, Jean‐François Papon, Yann Nguyen, Jérôme Nevoux

Letter

Voice burden in teachers and non‐teachers in a UK population: A questionnaire‐based survey

04-10-2019 – Chaitanya Gadepalli, Catherine Fullwood, Frances Ascott, Jarrod James Homer

Journal Article

Abstract
Objective
To characterise the burden of voice disorders in teachers in a UK population, compare it with non‐teachers and identify groups of teachers who may be particularly at risk of developing a voice problem.
Design
Questionnaire‐based survey of primary and secondary school teachers and non‐teachers. Questions consisted of general demographics, VHI‐10 and questions relating to voice problems.
Methods
Distribution of questionnaires to teachers and non‐teachers and statistical analysis of the responses.
Setting
University teaching hospital.
Participants
Teachers and non‐teachers in a region of North West England.
Main outcome measures
Identification of risk factors for voice problems in teachers, compared to non‐teachers.
Results
A total of 210 primary and 244 secondary school teachers and 304 non‐teachers participated in the questionnaire survey. Response rates were 67.9% from primary schools, 41.2% from secondary schools and 40.0% from the non‐teachers. 30.0% of teachers and 9.0% of non‐teachers had reported problems with their voice. 12.8% of teachers and 2.0% of non‐teachers had missed work due to voice problems. 14.1% of teachers and 5.3% non‐teachers had seen a general practitioner for voice‐related problems, whilst 7.1% of teachers and 6.3% of non‐teachers had been referred to an otolaryngologist or speech therapist for voice problems. Factors related to VHI‐10 (P < .05) were identified.
Conclusions
Voice disorders are an occupational health problem for teachers, with a significant burden of these disorders in this group of teachers in the UK. We have identified risk factors that could be exploited to identify groups of teachers who would benefit from early intervention.

Radioresistant laryngeal cancers upregulate type 1 IGF receptor and exhibit increased cellular dependence on IGF and EGF signalling

04-10-2019 – Ali Qureishi, Guillaume Rieunier, Ketan A. Shah, Tamara Aleksic, Stuart C. Winter, Henrik Møller, Valentine M. Macaulay

Journal Article

Abstract
Objectives
Patients failing radiotherapy for laryngeal squamous cell carcinoma (LSCC) often require salvage total laryngectomy which has major functional consequences, highlighting a need for biomarkers of radiotherapy resistance. In other tumour types, radioresistance has been linked to epidermal growth factor receptor (EGFR) and type 1 insulin‐like growth factor receptor (IGF‐1R). Here, we evaluated IGF‐1R and EGFR as predictors and mediators of LSCC radioresistance.
Design
We compared IGF‐1R and EGFR immunohistochemical scores in patients with LSCC achieving long‐term remission post‐radiotherapy (n = 23), patients treated with primary laryngectomy (n = 22) or salvage laryngectomy following radiotherapy recurrence (n = 18). To model radioresistance in vitro, two LSCC cell lines underwent clinically relevant irradiation to 55 Gy in 2.75 Gy fractions.
Results
Type 1 insulin‐like growth factor receptor expression was higher in pre‐treatment biopsies of radiotherapy failures compared with those in long‐term remission and was upregulated post‐radiotherapy. Patients undergoing primary laryngectomy had more advanced T/N stage and greater tumour IGF‐1R content than those achieving long‐term remission. Pre‐treatment EGFR did not associate with radiotherapy outcomes but showed a trend to upregulation post‐irradiation. In vitro, radiosensitivity was enhanced by inhibition of EGFR but not IGF. Repeated irradiation upregulated IGF‐1R in BICR18 and SQ20B cells and EGFR in SQ20B, and enhanced SQ20B radioresistance. Repeatedly irradiated SQ20B_55 cells were not radiosensitised by inhibition of IGF and/or EGFR, but IGF‐1R:EGFR co‐inhibition suppressed baseline cell survival more effectively than blockade of either pathway alone, and more effectively than in parental cells.
Conclusions
Radiation upregulates IGF‐1R and may enhance IGF/EGFR dependence, suggesting that IGF/EGFR blockade may have activity in LSCCs that recur post‐radiotherapy.

Healthcare utilization, follow‐up of guidelines and practice variation on rhinosinusitis in adults; a health care reimbursement claims study in the Netherlands

03-10-2019 – N.M. Kaper, M.C.J. Aarts, R.J. Stokroos, GJMG van der Heijden

Journal Article

Abstract
Objectives
To provide insight into healthcare utilization of rhinosinusitis, compare data with clinical practice guideline recommendations and assess practice variation.
Design
Anonymized data from claims reimbursement registries of healthcare insurers were analyzed, from January 1st, 2016 until December 31st, 2016.
Setting
Secondary and tertiary care in the Netherlands.
Participants
Patients ≥ 18 years with diagnostic code “sinusitis”.
Main outcome measures
Healthcare utilization (prevalence, co‐morbidity, diagnostic testing, surgery), costs, comparison with guideline recommendation, practice variation.
Results
We identified 56,825 patients, prevalence was 0.4%. Costs were € 45,979,554.‐ that is 0.2% of total hospital‐related care costs (€21,831.3 x 106). Most patients were <75 years, with a slight female preponderance. 29% had co‐morbidities (usually COPD/asthma). 9% underwent skin prick testing, 61% nasal endoscopy, 2% X‐ray and 51% CT. Surgery rate was 16%, mostly in daycare. Nearly all surgical procedures were performed endonasally and concerned the maxillary and/or ethmoid sinus. 7 recommendations (25%), could be (partially) compared to the distribution of claims data. Except for endoscopy, health care utilization patterns were in line with guideline recommendations. We compared results for three geographical regions and found generally corresponding rates of diagnostic testing and surgery.
Conclusion
Prevalence was lower than reported previously. Within the boundaries of guideline recommendations, we encountered acceptable variation in healthcare utilization in Dutch hospitals. Health reimbursement claims data can provide insight into healthcare utilization, but they do not allow evaluation of the quality and outcomes of care and therefore results should be interpreted with caution.

Effect of endoscope assistance in tympanomastoidectomy for lowering the rate of residual cholesteatoma: Results from 91 paediatric patients

02-10-2019 – Dan Yaniv, Sharon Tzelnick, David Ulanovski, Ohad Hilly, Eyal Raveh

Letter

The “Chopstick Drilling Technique”: A novel solution to drilling bone in endoscopic ear surgery

02-10-2019 – Casey Vaughan, Nicholas Jufas, Nirmal P. Patel, Alexander J. Saxby, Jonathan H. K. Kong

Journal Article

The prognostic value and pathophysiologic significance of three‐dimensional fluid‐attenuated inversion recovery (3D‐FLAIR) magnetic resonance imaging in idiopathic sudden sensorineural hearing loss: A systematic review and meta‐analysis

02-10-2019 – Marc J. W. Lammers, Emily Young, David Fenton, Jane Lea, Brian D. Westerberg

Journal Article

Abstract
Background
The underlying pathophysiology of idiopathic sudden sensorineural hearing loss (ISSNHL) is still unknown. However, an increasing number of observational studies report intralabyrinthine signal alterations in patients with ISSNHL using three‐dimensional fluid‐attenuated inversion recovery (3D‐FLAIR) magnetic resonance imaging (MRI). These findings warrant a meta‐analysis.
Objective of review
To conduct a meta‐analysis assessing the value of 3D‐FLAIR MRI in identifying possible underlying labyrinthine pathophysiologic mechanisms and prognostication in patients with ISSNHL.
Search strategy
Two reviewers independently searched the Pubmed, Embase and Cochrane Library from inception until October 10, 2018 and evaluated eligibility based on titles and abstracts of all retrieved studies. All studies reporting on 3D‐FLAIR imaging in ISSNHL were included. Subsequently, the full text of eligible studies were evaluated.
Evaluation method
Adhering to the MOOSE guideline, two independent reviewers extracted data, assessed risk of bias and evaluated the relevance and quality of evidence. Data on the number of patients and events were extracted and hearing levels were converted to standardised mean differences (SMD) for conducting meta‐analyses. Random effects models for meta‐analyses were applied.
Results
Eight observational studies met our inclusion criteria (n = 638 patients). In 29%, high signal intensity was found on 3D‐FLAIR imaging, suggesting labyrinthine pathology (labyrinthitis 79%, intralabyrinthine haemorrhage 21%). High signal intensity on 3D‐FLAIR was associated with poorer hearing (SMD: 14 d
B, 95% CI 5.67‐22.94) and vertigo (RR: 1.92, 95% CI 1.16‐3.17) at baseline. Multivariate analyses demonstrated that patients with high 3D‐FLAIR signal intensity had 21 d
B lower final hearing pure‐tone averages (SMD: 21 d
B, 95% CI 9.08‐33.24).
Conclusions
Three‐dimensional fluid‐attenuated inversion recovery MR imaging can identify an underlying labyrinthine condition in up to 29% of patients with sudden hearing loss in whom previously no cause could be identified. Their final pure‐tone averages are more than 20 d
B worse than 3D‐FLAIR–negative patients, suggesting more severe labyrinthine damage. Findings such as these may contribute to our understanding of pathophysiologic mechanisms of ISSNHL.

Cochlear implantation in the presence of superficial siderosis

02-10-2019 – Mohamed Alshehabi, Peter Walshe, Laura Viani

Letter

Feasibility of early activation after cochlear implantation

02-10-2019 – Chuan‐Hung Sun, Chan‐Jung Chang, Chuan‐Jen Hsu, Hung‐Pin Wu

Journal Article

Abstract
Objectives
The purpose of the study is to investigate feasibility of early activation after cochlear implantation by evaluating long‐term impedance change and speech perception.
Design
Case‐control study
Setting
Between July 2015 and December 2016, we prospectively enrolled 20 subjects for early activation (within 24 hours after cochlear implantation). On the other hand, from November 2013 to July 2015, 20 age‐ and sex‐matched control subjects from the database of cochlear implantees treated with conventional activation schedule (4 weeks after surgery) were retrospectively enrolled.
Participant
Forty patients who underwent cochlear implantation surgeries.
Main outcome measures
The series impedance and speech perception score of both groups were compared.
Results
No statistical difference in long‐term follow‐up between the two groups was found using GEEs and multivariate analysis. In the early activation group, impedance reached a steady level by the 2nd postoperative week, and the hearing perception ability significantly improved by the 4th postoperative week.
Conclusion
This comparative study illustrated sequential impedance data during early activation (24 hours) and conventional activation (4 weeks) after CI surgery. There were no major complications in either group, and the safety of early activation with respect to impedance changes, postoperative residual hearing preservation and speech perception scores were non‐inferior to that of the conventional group. Therefore, in this study, we established the feasibility of early activation 24 hours after cochlear implantation.

Comparison of soft tissue preservation techniques for BAHA insertion in 41 patients: ‘Bus‐stop’ (open approach) vs MIPS (minimally invasive approach)

02-10-2019 – Alex Bennett, Rupali Sawant

Letter

In‐office ossicular chain reconstruction using hydroxyapatite cement

02-10-2019 – Donald Tan, Mehdi Abouzari, Khodayar Goshtasbi, Brandyn Dunn, Hamid R. Djalilian

Journal Article

Prospective randomized comparison of tongue base resection techniques: Robotic vs coblation

02-10-2019 – Mehmet Ali Babademez, Fatih Gul, Mecit Sancak, Hayati Kale

Journal Article

Abstract
Objective
The objective of this study was to determine the effectiveness and morbidities of two different tongue base surgical approaches in patients with obstructive sleep apnoea (OSA).
Design and Setting
We carried out a prospective analysis in order to understand in detail the relative impact on apnoeas of the two different tongue base procedures. Seventy cases in 85 patients with OSA were divided into two operating groups and randomized. Altogether, 37 transoral robotic surgeries (TORS) and 33 coblations were performed. The patency of retrolingual passage was investigated by Mullers manoeuvere, polysomnography. Apnoea‐hypopnea index (AHI) was the primary outcome measure with the Epworth Sleepiness Score (ESS). The final follow‐up visit was at 6 months.
Results
The AHI index improved from 29.7 ± 9 to 10.7 ± 3.9 (P < .005) following TORS and from 27.2 ± 6.4 to 10.3 ± 4 in the coblation group. Selecting a threshold of a 50% reduction in AHI and AHI less than 20 events/h, the overall success rate was 75.6% in TORS compared with 78.7% in coblation (P = .785). Similar results were seen in AHI reduction rates (36%, 37.8%, respectively). ESS showed a significant improvement 6 months following surgery in both groups.
Conclusion
Transoral robotic surgery technique showed higher complication rates than coblation. TORS and coblation of the tongue base represent a promising treatment option with a similar AHI improvement. However, coblation promises lower complication rates unlike TORS.

“M” line: new anatomical landmark for the maxillary sinus natural ostium

01-10-2019 – Janaina Gonçalves da Silva Leite, Joao Flavio Nogueira, John Pallanch, Ticiana Cabral da Costa, Moisés Ximenes Feijão, Raquel de Sousa, Lobo, Ferreira Querido, Maria Luzete Costa Cavalcante

Journal Article

Abstract
Objective
Describe a reliable anatomical landmark that can be used to locate the maxillary sinus natural ostium (MSNO) during endoscopic surgery, even if the uncinate process is preserved.
Design
Descriptive anatomical.
Setting
An anatomical and radiological study was performed to evaluate the consistency of the landmark, denominated “M” line.
Subjects and Methods
Dissections were performed in 57 cadaver heads (114 sides). In addition, 73 computerized tomography (CT) scans (146 sides) of patients with chronic inflammatory sinonasal disease were analyzed using a three‐dimensional (3D) reconstruction computer program.
Results
The “M” line crossed the MSNO in 112 dissected sides (98.2%) and 140 sides at CT 3D reconstruction (95.9%).
Conclusion
The “M” line is a reliable anatomical landmark for predicting MSNO location. As such, it could improve and facilitate endoscopic sinus surgery, using traditional, minimally invasive or uncinate preserving techniques.

Prognostic role of pretreatment serum albumin in patients with nasopharyngeal carcinoma: a meta‐analysis and systematic review

01-10-2019 – Huifen Yang, Kai Wang, Zheng Liang, Sitong Guo, Peng Zhang, Yi Xu, Huifang Zhou

Journal Article

Abstract
Background
Pretreatment serum albumin (ALB) is a novel index that was identified in recent years and is considered to be closely related to the prognosis of nasopharyngeal carcinoma (NPC). However, the association between ALB and NPC remains controversial.
Objective of Review
To assess the prognostic significance of pretreatment serum ALB in patients with NPC.
Type of Review
A systematic review and meta‐analysis.
Search Strategy
We searched PubMed, the Cochrane Library, and the Web of Science for studies published up to August 2018. The keywords used were related to albumin, nasopharyngeal carcinoma and prognosis.
Evaluation Method
We extracted the following data from all included studies: author, publication year, country, cancer center, time points of randomization, sample size, mean or median age, gender, TNM stage of NPC, cut‐off value of pretreatment serum albumin, number of high‐grade cases, and duration of follow up. Then, we generated the pooled hazard ratios (HR) for overall survival (OS) and distant metastasis‐free survival (DMFS) to perform this meta‐analysis.
Results
Ten studies comprising 7,339 cases were included. Lower pretreatment serum ALB levels were significantly associated with worse OS (HR=1.32, 95% CI 1.17–1.48) and DMFS (HR=1.40, 95% CI 1.08–1.80). In general, our findings were further verified in the subgroup analyses based on three features, including cancer stage, cut‐off value and analysis type.
Conclusion
A decreased level of pretreatment serum albumin implies a poor prognosis and can be detected to define the risk stratification of NPC patients.

Long term swallowing outcomes following transoral surgery and adjuvant radiotherapy versus adjuvant chemoradiotherapy for oropharyngeal carcinoma; Our experience in 37 patients

22-08-2019 – “A Ivy, S Stephen, D Goff, J Patterson, L Warner, V Paleri, R Goranova, J Kovarik, G Shaikh, C Kelly, J OHara”

Journal Article

Abstract
Approximately 75% of patients are recommended adjuvant oncological treatment after transoral surgery (TOS) for oropharyngeal squamous cell carcinoma.
Radiotherapy and chemoradiotherapy can result in significant long‐term swallowing difficulties, which can negatively impact upon quality of life.
This prospective study utilised a comprehensive and complementary set of measures, including a patient reported, clinician‐rated and an objective measure, to assess the change in swallowing function at long‐term follow‐up in patients undergoing TOS and adjuvant therapy.
Our results suggest a trend towards greater long‐term swallowing impairment with adjuvant chemoradiotherpy compared to adjuvant radiotherapy alone.
This article is protected by copyright. All rights reserved.

Clinical utility and effectiveness of a training programme in the application of a new classification of narrow‐band imaging for vocal cord leukoplakia: A multicentre study

13-08-2019 – Xiao‐Guang Ni, Gui‐Qi Wang, Feng‐Ying Hu, Xin‐Mao Xu, Ling Xu, Xiao‐Qin Liu, Xue‐Song Chen, Lin Liu, Xue‐Lian Ren, Yong Yang, Li Guo, Ya‐Jun Gu, Jin Hou, Jun‐Wei Zhang, Yan Yang, Biao Xing, Jia Ren, Hong‐Qiang Guo

Journal Article

Abstract
Objective
To analyse the application of a new narrow‐band imaging (NBI) classification in the diagnosis of vocal cord leukoplakia by laryngologists with different levels of laryngoscopic experience and to explore the impact of NBI training programmes on laryngologists’ identification of benign and malignant leukoplakia.
Design
Prospective multicentre study.
Setting
Tertiary hospitals.
Participants
Sixteen laryngologists were divided into less‐experienced and experienced groups and received NBI training course. Thirty cases of vocal cord leukoplakia were investigated.
Main outcome measures
Diagnostic accuracy and interobserver agreement under white light imaging (WLI), before and after NBI training, were analysed among doctors with varying levels of experience.
Results
The accuracy in the less‐experienced group was significantly lower than that of experience group (0.59 vs 0.69) under WLI. There was no significant difference in the diagnostic accuracy between the less‐experienced group and the experienced group before NBI training (0.75 vs 0.74) and after NBI training (0.79 vs 0.83). NBI training could improve the interobserver agreement from fair or moderate to good agreement.
Conclusion
The new NBI diagnostic classification is helpful for identifying benign and malignant vocal cord leukoplakia. In addition, the NBI training programme can improve the diagnostic accuracy and interobserver agreement of less‐experienced doctors to the level of experienced laryngologists.

Long‐term quality of life and sensory impact of great auricular nerve preservation in parotid surgery as measured with the Parotidectomy Outcome Inventory‐8

13-08-2019 – Olcay Cem Bulut, Ralph Hohenberger, Dare Oladokun, Katharina Odenwald, Peter K. Plinkert, Philippe A. Federspil

Journal Article

Abstract
Objectives
This study aimed to evaluate sensory dysfunction resulting from great auricular nerve (GAN) sacrifice versus preservation in parotid surgery for benign lesions and its imact on long‐term health‐related quality of life (QOL).
Design
Retrospective.
Setting/main outcome measures
Participants were divided into two groups (GAN and non‐GAN), and both short‐term (two postoperative weeks) and long‐term (at least 5 years) QOL were assessed. The second item of the Parotidectomy Outcome Inventory‐8 (POI‐8) was used to analyse postoperative sensory loss. All items of the POI‐8 questionnaire were used to determine health‐related QOL.
We used t test for dependent samples and Mann‐Whitney U‐test to compare patient groups
Participants
A total of 137 patients (65 male and 72 female) enrolled in this study. Average age at the time of surgery was 53 years (±12.8).
Results
The GAN preservation group had significantly better sensation than the GAN sacrifice in short term (2.8 vs 2.1; P = 0.017). Both groups experienced improved sensation in the long term, and there was a trend towards better QOL in the GAN‐preservation group. However, the difference in sensation was not statistically significant (1.7 vs 1.3; P = 0.145). Health‐related QOL also increased in the long term (compared to short term) for both groups (7.6 ± 6.2 to 12 ± 7.6; P < 0.0001) postoperatively. GAN preservation did not significantly improve sensation in long term, nor did it increase health‐related QOL postoperatively.
Conclusion
Although GAN preservation was easily feasible, it only improved sensation in short term. We report a negative result: GAN preservation did not significantly improve sensation in long‐term, nor did it increase health‐related QOL postoperatively when compared to GAN sacrifice.

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

13-08-2019 – Shutan Liao, Shan Lu, Guangliang Li, Ruiying Chen

Journal Article

Abstract
Objective
To investigate the potential role of maternal serum concentrations of placental growth hormone variant (GH‐V), insulin‐like growth factor (IGF) 1 and 2, and IGF‐binding proteins (IGFBP) 1 and 3 in pregnancies complicated by otosclerosis.
Method
Otosclerosis cases (n = 22) and age, ethnicity‐matched controls (n = 22) were selected in a nested case‐control study. Maternal serum hormone concentrations at 26 and 34 weeks of gestation were determined by enzyme‐linked immunosorbent assay (ELISA).
Results
Concentrations of all measured hormones except IGFBP‐1 were increased as gestation progressed. Maternal serum GH‐V concentrations at 26 and 34 weeks of gestation were significantly increased in the otosclerosis group, when compared to the control group (2.53 ± 0.17 ng/ml vs. 1.78 ± 0.19 ng/ml, P = 0.036; 4.34 ± 0.31 ng/ml vs. 3.12 ± 0.18 ng/ml, P < 0.001, respectively). Maternal serum IGF‐1 concentrations at 34 weeks in otosclerotic patients were significantly higher than in the controls (589.1 ± 21.4 ng/ml vs. 499.7 ± 17.8 ng/ml, P < 0.001). The increase of IGF‐1 was not observed at 26 weeks of gestation. Serum IGF‐2, IGFBP‐1 and IGFBP‐3 at either 26 or 34 weeks were unaltered between the two groups.
Conclusion
Maternal serum concentrations of GH‐V and IGF‐1 were altered in pregnancy complicated by otosclerosis, suggesting that the GH‐IGF axis may contribute to the development of this condition during pregnancy.

The use of freeze‐dried retronasal stimuli to assess olfactory function

13-08-2019 – Pooja Pal, Daniel Shepherd, Nazimah Hamid, Michael J. Hautus

Journal Article

Abstract
Objectives
To evaluate a test of olfactory perception that uses freeze‐dried stimuli developed to rapidly release aromas capable of migrating to the olfactory mucosa retronasally.
Design
Validation study.
Setting
Psychology and Chemistry Departments.
Participants
First, 15 participants provided data for psychometric functions. Second, 70 participants made perceptual judgments of retronasal stimuli. Inclusion criterion included informed consent and a satisfactory Nasal Obstruction Symptom Evaluation result.
Main outcome measures
First, psychometric functions were generated for two types of freeze‐dried stimuli (coffee and orange) using the Single‐Interval Adjustment Matrix method. Second, participants provided ratings of pleasantness, intensity, and familiarity and performed a standardised identification test using seven retronasally presented aromas alongside the previously validated Sniffin’ Sticks orthonasal olfactory test.
Results
Psychometric functions indicated a dose‐response relationship between aroma concentration and probability of detection. Test‐retest reliability of the retronasal stimuli was acceptable (r70 = 0.72, P < 0.001), and identification scores were not dependent on testing method (ie, retronasal vs Sniffin’ Sticks). Stimuli delivered using the Sniffin’ Sticks test were rated more pleasant than their retronasal counterparts.
Conclusions
Freeze‐dried retronasal stimuli offer an easy‐to‐use and rapid means to test olfaction function and are arguably well suited for clinical practice, but require further development and trialing prior to the adoption in the clinical context.

Validation of the olfactory disorders questionnaire for English‐speaking patients with olfactory disorders

13-08-2019 – Lorna Langstaff, Nisha Pradhan, Allan Clark, Duncan Boak, Mahmoud Salam, Thomas Hummel, Carl M. Philpott

Journal Article

Abstract
Objectives
To adapt the existing German language olfactory disorders questionnaire for use with English‐speaking patients. To validate the adapted version for routine clinical use.
Design
The translated version of the original German questionnaire was revised with a patient and a clinician to reflect British language and culture. Patients attending an olfactory dysfunction clinic were recruited to perform the adapted questionnaire on two occasions at least 1 month apart. Additional online participants completed the questionnaire via the charity Fifth Sense.
Main outcome measures
Retest reliability of the English olfactory disorders questionnaire (e
ODQ) in affected patients including potential for redundancy in any of the included questions. Correlation of e
ODQ scores with Sniffin’ Sticks scores.
Results
Eighty‐seven patients reporting olfactory dysfunction were recruited and had a mean age of 48 with 35% of them being male; 50 datasets were available for analysis. A total of 957 members of the charity entered responses into the online questionnaire; 699 responses could be scored with participants mean age of 55 years and with 69% reporting as female. The e
ODQ score and Sniffin’ Sticks threshold, discrimination and identification score at timepoint 1 were correlated to assess for concurrent validity, (r = −0.15, P = 0.17) and showed no significant correlation. Female participants had a significantly higher mean total e
ODQ score than men, 55.75 compared to 52.28 (P = 0.001). The average score was 54.7 (SD 13.5) with a range from 26 to 87. The internal consistency of the questionnaire was good with a Cronbachs alpha of 0.90 (confidence intervals 0.89, 0.91).
Conclusions
The results of this study support the use of the e
ODQ in a native English‐speaking population and highlight the different distinctions between “objective” testing of olfaction with the Sniffin’ Sticks test, and the patient reported impact of olfactory dysfunction on daily life. These two types of assessment can be easily administered in an outpatient setting and used in the assessment and management of olfactory dysfunction.

Responsiveness of acoustic rhinometry to septorhinoplasty by comparison with rhinomanometry and subjective instruments

13-08-2019 – Edward Ansari, Florence Rogister, Philippe Lefebvre, Sophie Tombu, Anne‐Lise Poirrier

Journal Article

Abstract
Objectives
Nose patency measures and instruments assessing subjective health are increasingly being used in rhinology. However, there is very little evidence of comparing existing methods responsiveness to change. We evaluated the responsiveness of acoustic rhinometry to nasal valve surgery by comparison with rhinomanometry and patient‐reported outcome instruments.
Design
Prospective case‐control study.
Setting
Tertiary referral University Hospital.
Participants
Sixty consecutive patients with internal nasal valve dysfunction and 20 healthy volunteers as control group were enrolled. Prospectively collected data included acoustic rhinometry, rhinomanometry, NOSE scale, SNOT‐23 questionnaire, visual analogue scale and demographics.
Main outcome measures
Primary endpoint was the responsiveness of acoustic rhinometry to functional septorhinoplasty surgery at 3 months. Secondary endpoints were ability of acoustic rhinometry to reflect “known group” differences and correlation to subjective symptoms.
Results
Acoustic rhinometry was highly responsive to septorhinoplasty (P < 0.0001) while anterior rhinomanometry was not (P = 0.08). Based on the quartiles of the postoperative change in NOSE score, patients were classified as, respectively, non‐responders, mild, moderate and good responders to surgery. Logistic regression model showed that acoustic rhinometry was able to discriminate non‐responders to responders to surgery (P = 0.019), while anterior rhinomanometry failed (P = 0.611). Sensitivity and specificity of acoustic rhinometry were significantly higher (ROC area = 0.76) than rhinomanometry (ROC area = 0.48). Acoustic rhinometry was also superior than rhinomanometry to discriminate patients from control subjects and agreed better with patients‐based subjective questionnaires.
Conclusions
Our study confirms and quantifies the responsiveness of acoustic rhinometry to nasal valve surgery, with a higher sensitivity and specificity than rhinomanometry.

The management of suspected or confirmed laryngopharyngeal reflux patients with recalcitrant symptoms: A contemporary review

13-08-2019 – Jerome R. Lechien, Vinciane Muls, Giovanni Dapri, François Mouawad, Pierre Eisendrath, Antonio Schindler, Andrea Nacci, Maria R. Barillari, Camille Finck, Sven Saussez, Lee M. Akst, Robert T. Sataloff

Journal Article

Abstract
Objective
To summarise current knowledge about the prevalence, aetiology and management of recalcitrant laryngopharyngeal reflux (LPR) patients—those who do not respond to anti‐reflux medical treatment.
Methods
A literature search was conducted following the PRISMA guidelines to identify studies that reported success of anti‐reflux medical treatment with emphasis on studies that attempted to be rigorous in defining a population of LPR patients and which subsequently explored the characteristics of non‐responder patients (ie aetiology of resistance; differential diagnoses; management and treatment). Three investigators screened publications for eligibility from PubMED, Cochrane Library and Scopus and excluded studies based on predetermined criteria. Design, diagnostic method, exclusion criteria, treatment characteristics, follow‐up and quality of outcome assessment were evaluated.
Results
Of the 139 articles screened, 45 met the inclusion criteria. The definition of non‐responder patients varied substantially from one study to another and often did not include laryngopharyngeal signs. The reported success rate of conventional therapeutic trials ranged from 17% to 87% and depended on diagnostic criteria, treatment scheme, definition of treatment failure and treatment outcomes that varied substantially between studies. The management of non‐responders differed between studies with a few differential diagnoses reported. No study considered the profile of reflux (acidic, weakly acid, non‐acid or mixed) or addressed personalised treatment with the addition of alginate or magaldrate, low acid diet, or other interventions that have emerging evidence of efficacy.
Conclusion
To date, there is no standardised management of LPR patients who do not respond to traditional treatment approached. A diagnostic and therapeutic algorithm is proposed to improve the management of these patients. Future studies will be necessary to confirm the efficacy of this algorithm through large cohort studies of non‐responder LPR patients.
Level of evidence2a.

Does access to saltwater swimming pools reduce ear pathology and hearing loss in school children of remote arid zone aboriginal communities? A prospective 3‐year cohort study

13-08-2019 – Linnett Sanchez, Andrew Simon Carney, Adrian Esterman, Karen Sparrow, David Turner

Journal Article

Abstract
Objective
To assess whether access to saltwater chlorinated swimming pools in remote Aboriginal communities is beneficial in reducing levels of middle ear disease and hearing loss in school children.
Design
A prospective 3‐year cohort study of children in 10 remote Aboriginal communities in South Australia with (n = 4) or without (n = 6) swimming pools.
Setting
Outback Australia.
Participants
Eight hundred and thirteen school‐age children residing in remote South Australia.
Main outcome measures
Prevalence of open and closed middle ear disease and prevalence of hearing loss.
Results
About 2107 ear assessments were conducted during the study period. 70.7% of children in communities with pools failed a screening test of hearing compared with 68.6% of children in non‐pool communities (P = 0.637). 32.3% of children had chronic otitis media (COM). There was no difference between pool and non‐pool communities in the frequency of either inactive (19.4% pool vs 22.6% non‐pool; P = 0.232) or active (19.8% pool vs 17.8% non‐pool; P = 0.383) COM. In children with bilateral intact tympanic membranes, 21.2% had unilateral and 20.6 had bilateral type B tympanograms. There was no difference between pool and non‐pool communities in the frequency of type B tympanometry (P = 0.465).
Conclusions
Hearing loss associated with both open and closed middle ear disease remains highly prevalent in children living in remote Aboriginal communities in South Australia. Access to swimming pools in this population does not appear to significantly reduce these high levels of middle ear disease or associated hearing loss.

E‐cigarettes and head and neck cancers: A systematic review of the current literature

13-08-2019 – Susanne Flach, Pavithran Maniam, Jaiganesh Manickavasagam

Journal Article

Abstract
Background
Cigarette smoking is a well‐established risk factor for head and neck (HN) cancers. Use of electronic cigarettes (e‐cigarettes) is gaining popularity, being advertised as benign alternatives to tobacco. A wide variety of potentially harmful chemical components with variable quantity have been identified in e‐liquids and aerosols of e‐cigarettes. However, use of e‐cigarettes remains controversial due to conflicting evidence.
Objectives
We aimed to assess the association between e‐cigarettes and HN cancers. We conducted a systematic review to evaluate the literature for evidence on carcinogenic effects of e‐cigarettes in the pathogenesis of HN cancers.
Type of review
Qualitative systematic review.
Search strategy
A PubMed/MEDLINE, Cochrane, CINAHL Plus, Trip Medical Database and Web of Science search was done for studies on e‐cigarettes and HN cancer.
Evaluation method
Abstract review of all articles, full article revision of included studies, data extraction and quality assessment were performed by two independent assessors.
Results
The literature search resulted in the identification of 359 articles. Eighteen articles were selected for inclusion into the systematic review. The majority were laboratory‐based studies, followed by several cohort and case studies, representing low‐level evidence. A few reports suggested DNA damage following exposure to e‐cigarettes potentially due to increased oxidative stress. Flavoured e‐liquids appear to be more harmful. There is variable evidence from clinical studies.
Conclusions
Our review outlines potential dangers associated with the use of e‐cigarettes and their role in HN cancers. More longitudinal and controlled studies are needed to assess the possible link between e‐cigarettes and HN cancers.

Role of diffusion‐weighted imaging in the discrimination of purulent intrasinusal content: A retrospective study

13-08-2019 – Thomas Radulesco, Ugo Scemama, Julien Mancini, Guy Moulin, Patrick Dessi, Justin Michel, Arthur Varoquaux

Journal Article

Abstract
Objectives
The objective of this study was to analyse MRI with morphological (T1, T2) and diffusion sequences (DWI, b1000) in patients presenting non‐aggressive patterns of sinus opacity and operated on by functional endoscopic sinus surgery (FESS).
Design
A retrospective study.
Setting
Diffusion imaging in paranasal sinus pathology remains little known. To date, no imaging system is capable of determining the purulent content of a non‐enhanced sinus filling.
Participants
We included consecutive patients having undergone FESS in whom MRI of the paranasal sinuses was performed. Subjects were allocated to Case (pus) or Control (no pus) groups depending on sinus content found intraoperatively. FESS was performed for bacterial acute rhinosinusitis, acute exacerbations of chronic rhinosinusitis, non‐purulent sinusitis, naso‐sinusal polyposis, antrochoanal polyp, isolated polyp, angiomatous polyp and eosinophilic fungal sinusitis. Tumours, mucoceles and fungus balls were excluded.
Main outcome measures
We analysed T1, T2, b1000 and MRI sequences and ADC map.
Results
On univariate analysis, intermediate signal in T2 and high signal in b1000 were associated with Cases (P < 0.001) as were low ADC values (P < 0.001). The difference in mean ADC values between Cases and Controls was statistically significant (respectively, 0.518 vs 2.041 × 10−3 mm2/sec, P < 0.01). On multivariate analysis, MRI with ADC < 0.725 × 10−3 mm2/sec and b1000_SI > brain was significantly associated with the case group. MRI with b1000_SI < brain and ADC > 1.450 × 10−3 mm2/sec was significantly associated with the control group.
Conclusions
Diffusion MRI offers extremely promising results regarding content characterisation of infectious sinus diseases.

Functional relevance of computational fluid dynamics in the field of nasal obstruction: A literature review

13-08-2019 – Thomas Radulesco, Lionel Meister, Gilles Bouchet, Jérôme Giordano, Patrick Dessi, Pierre Perrier, Justin Michel

Journal Article

Abstract
Background
Nasal airway obstruction (nasal obstruction) is a common symptom affecting the quality of life of patients. It can be estimated by patient perception or physical measurements. Computational fluid dynamics (CFD) can be used to analyse nasal ventilation modalities. There is a lack of comparative studies investigating the correlations between CFD variables and patient perception or physical measurements.
Objective of the review
Our goal was to define correlations between CFD variables and patient perception and physical measurements. We also aimed to identify the most reliable CFD variable (heat flux, WSS, total pressure, temperature…) characterising nasal breathing perception.
Type of review
Systematic literature review using PRISMA guidelines.
Search strategy
The selected studies were obtained from the US National Library of Medicine (PubMed) online database, MEDLINE (Ovid), Google Scholar and the Cochrane Library using a combination of Me
SH terms (nose, paranasal sinus, fluid dynamics, rhinology) and non‐Me
SH terms (CFD, nasal airway, nasal airflow, numerical, nasal symptoms). Studies that did not incorporate objective or subjective clinical assessment were excluded.
Evaluation method
We compared all results obtained by authors regarding CFD variables and assessment of nasal airway obstruction (clinical or physical).
Results
To compare nasal obstruction with CFD variables, most authors use CFD‐calculated nasal resistances, airflow, heat flux, wall shear stress, total pressure, velocities and streamlines. We found that heat flux appears to be the CFD variable most closely correlated with patient perception. Total pressure, wall shear stress and velocities are also useful and show good correlations. Correlations between CFD‐calculated nasal resistances and patient perception are stronger after correction of the nasal cycle.
Conclusions
The growing number of CFD studies on the nose has led to a better understanding of nasal obstruction. The clinical interpretation of previously unknown data, such as WSS and heat flux, is opening up new horizons in the understanding of this symptom. Heat fluxes are among the best CFD values correlated with patient perception. More studies need to be performed including temperature and humidity exchanges.

“How clean are your injections?”

13-08-2019 – Hannah Lancer, Mark Simmons

Letter

Effects of a wireless frequency modulation system on learning ability and emotional and behaviour problem improvement in 11 children with cochlear implant

13-08-2019 – Young Sang Cho, Ji Hyeon Ahn, Hye Yoon Seol, Sung Hwa Hong, Il Joon Moon

Letter

Evolving management strategies in head and neck paragangliomas: A single‐centre experience with 147 patients over a 60‐year period

13-08-2019 – J.A. Rijken, B. de Vos, L.P. van Hest, K.M.A. Dreijerink, M. den Heijer, W. Wisselink, G.J. Blom, E.F. Hensen, C.R. Leemans

Letter

Does cartilage thickness affect hearing results in real life? Long‐term results of cartilage and fascia graft in type 1 tympanoplasty

13-08-2019 – Mahmut Tayyar Kalcioglu, Ozan Tuysuz, Muhammed Zeki Yalcin, Erkan Karatas

Letter

The use of ARTISS™ in performing parotidectomies as day case surgery: A single‐centre review of 31 cases

13-08-2019 – Yanish Poolovadoo, Rohini Aggarwal, Sean Loughran

Letter

Post‐laryngectomy adjuvant radiotherapy in patients with pharyngocutaneous fistulae: Treatment regimens, outcomes and complications in 67 patients

13-08-2019 – Thomas Parzefall, Axel Wolf, Stefan Grasl, Gabriela Altorjai, Shelly Czeiger, Matthaeus Ch. Grasl, Boban M. Erovic

Letter

“CT and clinical prognostic factors in Bells palsy: A study of 56 cases”

13-08-2019 – Rémi Hervochon, Vincent Madelain, Ian Seiller, Ghizlene Lahlou, Yann Nguyen, Frédéric Tankéré

Letter

Large parapharyngeal tumours: Operative technique and case series of 17 patients

13-08-2019 – Andrew Williamson, Liam Sutton, Jagdeep Virk, Peter Clarke

Letter

Transoral laser microsurgery using high‐flow nasal cannula oxygenation: Our experience of 21 cases

13-08-2019 – Susanne Flach, Azza Elhoweris, Samit Majumdar, Simon Crawley, Jaiganesh Manickavasagam

Letter

Usefulness of ENT clinical examinations in hospitalised patients chronically addicted to alcohol and tobacco to detect head and neck squamous cell carcinomas. A retrospective study of 159 patients

13-08-2019 – Maxime Baert, Caroline Pascual, Aurélie Biet‐Hornstein, Ritoungarte Nadjingar, Céline Haremza, Cyril Page

Letter

Abstract
Objective
To determine whether an ENT clinical screening examination done on all patients chronically addicted to alcohol or tobacco would allow the early diagnosis of cancer of the upper aerodigestive tract.
Study Design
Case series with chart review.
Setting
Non‐university general hospital.
Subjects and methods
A total of 159 patients presenting chronic addiction to alcohol or tobacco hospitalized in an addiction center or a comprehensive medical clinic were included in this study covering the period 2011‐2016. All patients systematically benefitted from an ENT clinical examination to detect mucous membrane lesions. The lesions were categorized as: cancerous, pre‐cancerous, or benign. The patients were divided into two groups for comparison: 1) patients with symptoms (dysphagia, dysphonia, dyspnea upon inhalation, cervico‐facial pain, secondary otalgia, pharyngeal discomfort unrelated to deglutition, presence of a cervical swelling, or weight loss), and 2) asymptomatic patients.
Results
The ENT exam was normal in 121 patients (76.1%). Fifty‐two patients (32.7%) had at least one symptom. The ENT exam allowed us to detect a benign lesion in 11 patients, a pre‐cancerous lesion in 11 patients, and a cancer in 16 (13.22%) patients. All patients with cancer had at least one symptom.
Conclusion
An ENT clinical screening examination done on patients chronically addicted to alcohol or tobacco can allow early diagnosis of cancer, particularly in patients with at least one symptom.

The genetics of cholesteatoma study. Loss‐of‐function variants in an affected family

13-08-2019 – Peter Prinsley, Barbara A. Jennings, Mahmood Bhutta, Daniel Swan, Gavin Willis, Carl Philpott

Letter

The intra‐operative use of biological products: A multi‐centre regional patient perspective of a potential consenting conundrum

13-08-2019 – Karan Jolly, Adnan Darr, Anastasia Aslanidou, Duncan Bowyer, Shahzada Ahmed

Letter

A population‐based time trend study in the incidence of malignant otitis externa

13-08-2019 – Yen‐Fu Cheng, Tzong‐Han Yang, Chuan‐Song Wu, Yi‐Wei Kao, Ben‐Chang Shia, Herng‐Ching Lin

Letter

Polydioxanone sheet as a rigid framework in skull‐base repair: Our experience in thirteen patients

13-08-2019 – Mohd Afiq Mohd Slim, Hussain Jasem, Louise Melia, Gerald McGarry

Letter

Preoperative electrophysiological analysis predicts preservation of hearing and facial nerve function following vestibular schwannoma surgery with continuous intraoperative neural monitoring: Clinical outcomes of 22 cases

13-08-2019 – Makoto Hosoya, Naoki Oishi, Takanori Nishiyama, Masaru Noguchi, Kento Kasuya, Noriomi Suzuki, Hidemi Miyazaki, Kaoru Ogawa

Letter

Issue Information

13-08-2019 –

Giving epistaxis two fingers

13-08-2019 – Ayeshah Abdul‐Hamid, Ali Qureishi, Pablo Martinez‐Devesa, Robert Almeyda

CO2 laser “Ablation Suction” technique for treatment of laryngeal recurrent respiratory papillomatosis

13-08-2019 – Philippe F. Bowles, Alison Liu, Meredydd L. Harries