Journal of Laryngology and Otology

The Eustachian tube: balloon dilatation and decongestants, and novel approaches in otolaryngology education

12-02-2020 – Fisher, Edward W,Fishman, Jonathan

Journal Article

Otogenic intracranial complications: a 10-year retrospective review in KwaZulu-Natal, South Africa

22-01-2020 – Khuzwayo, Z B,Enicker, B

Journal Article

Objectives
To analyse the data for patients with otogenic intracranial complications during the study period and draw a comparison with internationally published literature.
Method
A retrospective, observational study was conducted, covering a 10-year period between 1 January 2002 and 31 December 2012.
Results
The study comprised 108 patients (66 males (61.1 per cent) and 42 females (38.9 per cent)), of which 75 per cent were aged less than 20 years. Post-auricular swelling, otorrhoea and a decreased level of consciousness were the most frequently reported symptoms in patients with otogenic intracranial complications. Patients with human immunodeficiency virus did not show any different patterns in terms of presentation and outcome.
Conclusion
A triad of post-auricular swelling, otorrhoea and a decreased level of consciousness should make the clinician more heedful of otogenic intracranial complications. Patients with human immunodeficiency virus and human immunodeficiency virus negative patients were equally affected and had similar presentations. Early surgical management of patients was associated with shorter hospital stays and better outcomes.

The early history and development of functional endoscopic sinus surgery

13-12-2019 – Kane, K J

Journal Article

Background
The concept of endoscopic diagnosis and procedures on the nasal cavity had been investigated for several decades in Europe in the early part of the twentieth century. It was Prof Walter Messerklinger and his assistant, Heinz Stammberger, with US colleague, David Kennedy, who brought the science and technique of functional endoscopic sinus surgery to the wider world.
Methods
The author, an English-speaking surgeon, was present at this movement from the commencement of its propagation, and has recorded the remarkable ascendency of this technique throughout the world.
Conclusion
The technique revolutionised the diagnosis and management of intranasal, sinus and intracranial conditions.

Three-dimensional printing as a tool in otolaryngology training: a systematic review

23-12-2019 – Chen, G,Jiang, M,Coles-Black, J,Mansour, K,Chuen, J,Amott, D

Journal Article

Objective
Three-dimensional printing is a revolutionary technology that is disrupting the status quo in surgery. It has been rapidly adopted by otolaryngology as a tool in surgical simulation for high-risk, low-frequency procedures. This systematic review comprehensively evaluates the contemporary usage of three-dimensional printed otolaryngology simulators.
Method
A systematic review of the literature was performed with narrative synthesis.
Results
Twenty-two articles were identified for inclusion, describing models that span a range of surgical tasks (temporal bone dissection, airway procedures, functional endoscopic sinus surgery and endoscopic ear surgery). Thirty-six per cent of articles assessed construct validity (objective measures); the other 64 per cent only assessed face and content validity (subjective measures). Most studies demonstrated positive feedback and high confidence in the models’ value as additions to the curriculum.
Conclusion
Whilst further studies supported with objective metrics are merited, the role of three-dimensional printed otolaryngology simulators is poised to expand in surgical training given the enthusiastic reception from trainees and experts alike.

Knowledge of the audiological effects, symptoms and practices related to personal listening devices of health sciences students at a South African university

22-01-2020 – Seedat, R Y,Ehlers, R,Lee, Y,”Mungomba, C”,Plaatjies, K,Prins, M,Randeree, M,Zakhura, M,Joubert, G

Journal Article

Objective
This study aimed to determine the knowledge of first year health sciences students at a South African university regarding hearing loss and symptoms attributable to personal listening devices and their practices concerning the use of personal listening devices.
Method
This was a cross-sectional study carried out using an anonymous self-administered questionnaire.
Results
Of 336 students, 269 (80.1 per cent) completed the questionnaire. While most participants could identify symptoms that could be caused by extensive use of personal listening devices, almost 30 per cent did not know that it could cause permanent hearing loss. Personal listening devices were used by 90.7 per cent of participants, with 77.8 per cent having used them for more than five years. Use was at a high volume in 14.9 per cent of participants and for more than 2 hours per day in 52.7 per cent.
Conclusion
The findings indicate the need for an educational programme to inform students as to safe listening practices when using personal listening devices.

“Ménières disease clinical subtypes in a population from the USA”

20-12-2019 – Crossley, J,Hussaini, A S,Kim, H J,Hoa, M

Journal Article

Objective
To ascertain the distribution of Ménières disease phenotype subgroups in a US-based cohort, based on a recently introduced classification scheme utilising a Spanish and Portuguese cohort.
Methods
A retrospective, cross-sectional, single-institutional chart review was conducted. The electronic medical records of Ménières disease patients were identified using International Classification of Diseases codes at a tertiary referral centre and reviewed to extract subgroup-defining features. Patients with definite Ménières disease as per American Academy of Otolaryngology–Head and Neck Surgery criteria were categorised into one of five subgroups, for unilateral and bilateral Ménières disease.
Results
Eighty-one patients with definite Ménières disease were identified. Seventy-two cases of unilateral Ménières disease were observed: 52.8 per cent were type 1, 20.8 per cent were type 2, 4.2 per cent were type 3, 18.1 per cent were type 4, and 4.2 per cent were type 5. This cohort differed significantly in distribution to a comparison Mediterranean cohort (p < 0.01). Nine cases of bilateral Ménières disease were observed.
Conclusion
The distribution of unilateral Ménières disease subtypes in this US population was different from that observed in a European population.

The effect of topical xylometazoline on Eustachian tube function

22-01-2020 – Joshi, K S,Ho, V W Q,Smith, M E,Tysome, J R

Journal Article

Background
Topical nasal decongestants are frequently used as part of the medical management of symptoms related to Eustachian tube dysfunction.
Objective
This study aimed to assess the effect of topical xylometazoline hydrochloride sprayed in the anterior part of the nose on Eustachian tube active and passive opening in healthy ears.
Methods
Active and passive Eustachian tube function was assessed in healthy subjects before and after intranasal administration of xylometazoline spray, using tympanometry, video otoscopy, sonotubometry, tubo-tympano-aerodynamic-graphy and tubomanometry.
Results
Resting middle-ear pressures were not significantly different following decongestant application. Eustachian tube opening rate was not significantly different following the intervention, as measured by all function tests used. Sonotubometry data showed a significant increase in the duration of Eustachian tube opening following decongestant application.
Conclusion
There remains little or no evidence that topical nasal decongestants improve Eustachian tube function. Sonotubometry findings do suggest that further investigation with an obstructive Eustachian tube dysfunction patient cohort is warranted.

Balloon Eustachian tuboplasty for Eustachian tube dysfunction: report of long-term outcomes in a UK population

08-01-2020 – McMurran, A E L,Hogg, G E,Gordon, S,Spielmann, P M,Jones, S E

Journal Article

Background
Balloon Eustachian tuboplasty is a surgical management option for Eustachian tube dysfunction; it has shown promising results in studies worldwide, but has had limited uptake in the UK. This study reports long-term outcomes for patients offered balloon Eustachian tuboplasty for chronic dilatory and baro-challenge-induced Eustachian tube dysfunction, and describes practical experience gained from its implementation.
Methods
Balloon Eustachian tuboplasty was conducted in 25 patients (36 ears) with Eustachian tube dysfunction over three years. Information on presenting symptoms and signs, audiometric findings, tympanometry, and Eustachian Tube Dysfunction Questionnaire-7 scores were recorded pre- and post-operatively with a minimum follow up of one year.
Results
Sixteen (64 per cent) of the 25 patients demonstrated symptom resolution after balloon Eustachian tuboplasty according to the Eustachian Tube Dysfunction Questionnaire-7. Fourteen (64 per cent) of the 22 patients with a type B or C tympanogram pre-operatively, had a type A trace post-operatively. Fifteen (75 per cent) of 20 patients with pre-operative conductive hearing loss showed improvement post-operatively, and 11 (50 per cent) of 22 patients with pre-operative middle-ear effusion or tympanic membrane retraction showed resolution.
Conclusion
Balloon Eustachian tuboplasty can improve subjective and objective measures of Eustachian tube dysfunction, and provide longer-term resolution.

Eustachian tube balloon dilatation: a cross-sectional, survey-based study of 137 UK consultants

23-12-2019 – Koumpa, F S,Moraitis, I,Bowles, P,Saunders, N

Journal Article

Objective
To explore the opinions of the UK consultant body on endoscopic Eustachian tube balloon dilatation in the context of Eustachian tube dysfunction.
Method
A 10-question online survey was distributed to ENT consultants currently practising in the UK (July–September 2018).
Results
A total of 137 ENT consultants responded. Twenty-three per cent reported experience of Eustachian tube balloon dilatation, with a further 10 per cent planning to start performing the procedure. Of those performing the procedure, 16 per cent had more than two years’ experience. Thirty-two per cent were performing zero to five procedures a year. Eustachian tube balloon dilatation was primarily conducted to treat Eustachian tube dysfunction symptoms, as well as retraction pockets, baro-challenge-induced Eustachian tube dysfunction and otitis media with effusion. The most common reason for not undertaking Eustachian tube balloon dilatation was insufficient evidence of efficacy (65 per cent). Seventy-two per cent of consultants thought that creating a national database for audit and monitoring purposes would benefit the specialty.
Conclusion
The majority of UK ENT consultants do not practise Eustachian tube balloon dilatation, citing a lack of high-level evidence to support its use. A national database for auditing and research could facilitate the creation of guidelines.

Ecchordosis physaliphora: a cautionary tale

20-12-2019 – Georgalas, C,Terzakis, D,Tsikna, M,Alatzidou, Z,de Santi, S,Seccia, V,Dallan, I

Journal Article

Background
Ecchordosis physaliphora is a congenital, benign lesion originating from notochordal remnants along the craniospinal axis, most frequently located at the level of the clivus and sacrum. Sometimes ecchordosis physaliphora is difficult to recognise and treat, with a total of twenty-six cases described in the literature.
Methods
This study reports on three cases of previously undiagnosed ecchordosis physaliphora presenting with cerebrospinal fluid rhinorrhoea and meningitis.
Conclusion
Endoscopic transclival or transsphenoid surgery including three-layer (fat, fascia and nasoseptal flap) reconstruction was used in all cases with complete resolution of the symptoms.

An artificial intelligence algorithm that differentiates anterior ethmoidal artery location on sinus computed tomography scans

23-12-2019 – Huang, J,Habib, A-R,Mendis, D,Chong, J,Smith, M,Duvnjak, M,Chiu, C,Singh, N,Wong, E

Journal Article

Objective
Deep learning using convolutional neural networks represents a form of artificial intelligence where computers recognise patterns and make predictions based upon provided datasets. This study aimed to determine if a convolutional neural network could be trained to differentiate the location of the anterior ethmoidal artery as either adhered to the skull base or within a bone ‘mesentery’ on sinus computed tomography scans.
Methods
Coronal sinus computed tomography scans were reviewed by two otolaryngology residents for anterior ethmoidal artery location and used as data for the Google Inception-V3 convolutional neural network base. The classification layer of Inception-V3 was retrained in Python (programming language software) using a transfer learning method to interpret the computed tomography images.
Results
A total of 675 images from 388 patients were used to train the convolutional neural network. A further 197 unique images were used to test the algorithm; this yielded a total accuracy of 82.7 per cent (95 per cent confidence interval = 77.7–87.8), kappa statistic of 0.62 and area under the curve of 0.86.
Conclusion
Convolutional neural networks demonstrate promise in identifying clinically important structures in functional endoscopic sinus surgery, such as anterior ethmoidal artery location on pre-operative sinus computed tomography.

“Incision of Hasners valve under endoscopic intranasal surgery for the treatment of nasolacrimal duct obstruction in children”

10-01-2020 – Keilani, C,Keller, P,Piaton, J-M

Journal Article

Objective
To evaluate the effectiveness and safety of a Hasners valve incision performed under endoscopic intranasal surgery for the management of congenital nasolacrimal duct obstruction.
Methods
This retrospective study comprised 484 patients with congenital nasolacrimal duct obstruction who underwent incision of Hasners valve under endoscopic intranasal surgery between April 2000 and October 2016. The primary endpoint was the procedures functional success rate. The secondary endpoints were Hasners valve and inferior turbinate anatomical findings, demographic data, complication rate and surgical duration.
Results
In patients with no medical history of nasolacrimal duct probing, 91 per cent had a successful result, 5 per cent had a partially successful result, 3.9 per cent showed no change and 0.1 per cent had a worse result following the procedure. Concerning the secondary endpoints, outcomes were more frequently successful in children younger than three years. Only one patient had a post-operative infection. All patients underwent general anaesthesia; no complications related to general anaesthesia were observed. Mean surgical duration was 13.1 ± 5.7 minutes.
Conclusion
Incising Hasners valve after medially displacing the inferior turbinate under nasal endoscopy seems to be an adequate primary surgical treatment for congenital nasolacrimal duct obstruction.

Determinants of successful tracheostomy decannulation in children: a multicentric cohort study

08-01-2020 – Schweiger, C,Manica, D,Lubianca Neto, J F,Sekine, L,Krumenauer, R,Caixeta, J A,Maunsell, R,Gomes Avelino, M

Journal Article

Background
Determining prognostic factors for the probability of tracheostomy decannulation is key to an adequate therapeutic plan.
Methods
A retrospective cohort study of 160 paediatric patients undergoing tracheostomy was conducted. Associations between different parameters and eventual tracheostomy decannulation were assessed.
Results
Mean follow-up duration was 27.8 months (interquartile range = 25.5–30.2 months). Median age at tracheostomy was 6.96 months (interquartile range = 3.37–29.42 months), with median tracheostomy maintenance of 14.5 months (interquartile range = 3.7–21.5 months). The overall tracheostomy decannulation rate was 22.5 per cent. Factors associated with a higher probability of tracheostomy decannulation included age at tracheostomy (hazard ratio = 1.11, 95 per cent confidence interval = 1.03–1.18) and post-intubation laryngitis as an indication for tracheostomy (hazard ratio = 2.25, 95 per cent confidence interval = 1.09–4.62). Neurological (hazard ratio = 0.30, 95 per cent confidence interval = 0.12–0.80) and pulmonary (hazard ratio = 0.41, 95 per cent confidence interval = 0.18–0.91) co-morbidities were negatively associated with tracheostomy decannulation. The probability of tracheostomy decannulation decreased significantly with increasing numbers of co-morbidities (p < 0.001).
Conclusion
Age, post-intubation laryngitis, and number and type of co-morbidities influence tracheostomy decannulation rate in the paediatric population.

Assessing the utility of non-surgical treatments in the management of vocal process granulomas

10-01-2020 – Rudman, J R,McGee, C S,Diaz, J,Rosow, D E

Journal Article

Objective
To determine whether patients would have equivalent or improved outcomes when receiving non-surgical management versus surgical removal for vocal process granulomas.
Methods
A chart review was performed for 53 adults with vocal process granulomas. All patients received baseline anti-reflux treatment consisting of twice-daily proton pump inhibitors and vocal hygiene education. Further treatment approaches were divided into non-surgical (i.e. inhaled corticosteroids, voice therapy, botulinum toxin injections) and surgical groups. Subjective parameters (Voice Handicap Index 10 and Reflux Symptom Index) and outcomes were tabulated and statistically compared. Cause of granuloma was also analysed to determine if this influenced outcomes.
Results
Of 53 patients, 47 (89 per cent) experienced reduction in granuloma size, while 37 (70 per cent) experienced complete resolution. The rate of complete granuloma resolution after initial treatment strategy alone was significantly higher in non-surgical compared to surgical patients (67 and 30 per cent, respectively; p = 0.039). No difference in outcome was seen between iatrogenic and idiopathic granulomas.
Conclusion
Non-surgical patients were more likely to experience initial treatment success than those who underwent surgical removal. Continued emphasis should be placed on conservative treatment options prior to surgery for patients with this condition.

Simulation-based ENT induction: validation of a novel mannequin training model

23-12-2019 – Bhalla, S,Beegun, I,Awad, Z,Tolley, N

Journal Article

Objective
To ascertain whether simulation-based teaching is superior to lecture-based teaching for an induction programme using a home-made induction model.
Methods
A simulation-based induction programme was designed and separate lecture-based teaching covering the same content was organised for junior doctors. The junior doctors were asked to complete pre- and post-induction surveys regarding confidence and anxiety levels. The skills taught included microsuction, flexible nasendoscopy, and anterior and posterior nasal packing. Structured interviews were conducted after the programme to gain qualitative data for analysis. The trainees’ knowledge retention was compared using a standardised written assessment one month after the session.
Results
Simulation-based teaching using the induction model was associated with a statistically significant increase in confidence levels and reduction in anxiety levels, and was associated with greater knowledge retention.
Conclusion
A regular simulation induction programme should be introduced using the induction model, as it leads to better knowledge retention and increased confidence levels.

Eustachian tube dysfunction in candidates for surgery for obstructive sleep apnoea syndrome

22-01-2020 – Ungar, O J,Rosenzweig, E,Betito, H Rotem,Cavel, O,Oron, Y,Handzel, O

Journal Article

Background
Defining the risk factors for Eustachian tube dysfunction can facilitate its prevention. It is hypothesised that Eustachian tube dysfunction as measured by the Eustachian Tube Dysfunction Questionnaire-7 is associated with obstructive sleep apnoea syndrome.
Methods
The questionnaire was systematically translated into Hebrew and validated in the accepted manner. This questionnaire was applied to obstructive sleep apnoea syndrome patients before and after expansion sphincter pharyngoplasty, in pre-set time intervals. The results were compared to those of controls from the general population.
Results
Thirty-one patients (males:females = 19:12) were enrolled in the obstructive sleep apnoea syndrome group. Mean age was 43 years (range, 31–55 years) and mean body mass index was 28 kg/m2 (range, 27–30 kg/m2). Median apnoea-hypopnea index (pre-operatively) was 34 events per hour. The questionnaire scores in expansion sphincter pharyngoplasty candidates were significantly worse than in controls (p < 0.001). Expansion sphincter pharyngoplasty did not change Eustachian tube function in the long term, but was associated with additional self-limiting Eustachian tube dysfunction in the first two post-operative months.
Conclusion
Eustachian tube dysfunction is significantly worse in patients with obstructive sleep apnoea syndrome compared to controls. Expansion sphincter pharyngoplasty is not associated with Eustachian tube function improvement.

Posterior semicircular canal paroxysmal positional vertigo triggers a new type of windmill nystagmus

17-12-2019 – Comacchio, F,Cutrì, N,Mion, M

Journal Article

Background
Periodic alternating nystagmus is a rare condition characterised by spontaneous horizontal nystagmus that periodically reverses direction, indicating an alteration of the velocity storage mechanism. Windmill nystagmus is a peculiar and rare variant of periodic alternating horizontal nystagmus with a superimposed periodic alternating vertical nystagmus. It is generally observed in blind patients.
Case report
This paper presents the unique case of a normally sighted patient with a windmill nystagmus triggered by an episode of benign paroxysmal positional vertigo due to bilateral posterior canalolithiasis. Videonystagmography revealed an anticlockwise up-beating nystagmus followed by a clockwise down-beating nystagmus with a cycle lasting 2 minutes, followed by a brief burst of horizontal left-beating nystagmus.
Conclusion
This case report represents the first observation of a new type of windmill nystagmus, probably provoked by a malfunction of the velocity storage mechanism, gaze-stabilisation and short-adaptation networks, with a loss of cerebellar inhibition.

Current Concepts of Sleep Apnea Surgery T Verse, N de Vries Thieme, 2019 ISBN 978 3 13240 119 8 pp 303 Price €129.99 US$144.99 £121.00

03-12-2019 – Flood, L M

Laryngology: A Case-Based Approach J Allen, S A Reza Nouraei, G S Sandhu Plural Publishing, 2019 ISBN 978 1 94488 359 1 pp 615 Price US$149.95

22-01-2020 – Flood, L M

The Waterside Ape: An Alternative Account of Human Evolution P Rhys-Evans CRC Press, Taylor and Francis Group, 2019ISBN 978 0 36714 548 4 pp 226 Price £21.99

11-11-2019 – Flood, L M

JLO volume 134 issue 1 Cover and Front matter

12-02-2020 –

JLO volume 134 issue 1 Cover and Back matter

12-02-2020 –