Transoral Laser Surgery for Adenosquamous Carcinoma of the Glottis: First Case Report and Review of the Literature.

Adenosquamous carcinoma of the head and neck is a rare cancer associated with poor prognosis. Histologically, it is identified through the presence of both adenocarcinoma and squamous cell carcinoma, although it may be difficult to diagnose from initial endoscopic biopsies. We report a case of adenosquamous carcinoma of the glottis in an 82-year-old female patient who presented with progressive hoarseness of voice and in whom initial biopsies had shown only moderate to severe dysplasia. This is the first case in the literature of a primary adenosquamous carcinoma of the glottis managed successfully with a CO2 laser left type Va cordectomy. The patient remained disease-free 28 months postoperatively.

Single-center Experience of Over a Hundred Implantations of a Transcutaneous Bone Conduction Device.

OBJECTIVE: To assess outcomes with a novel passive transcutaneous bone conduction device (t-BCD). STUDY DESIGN: Prospective data collection and patient review. SETTING: Tertiary referral center. PATIENTS: Patients who underwent implantation with the t-BCD between November 2013 and September 2016. INTERVENTION: Implantation of BAHA Attract. MAIN OUTCOME MEASURES: Surgical outcome, patient reported outcomes including the "Glasgow Benefit Inventory" and the "Client Oriented Scale of Improvement" for adults and the "Speech, Spatial and Qualities of Hearing scale" (SSQ-12) for children. RESULTS: One hundred five patients were implanted. Numbness superior to the incision was commonly noticed. Four patients (3.8%) developed skin tenderness and redness that settled with conservative measures. Among those patients who had a conversion from a percutaneous Bone Conduction Hearing Device (BCHD) to the t-BCD (n=15), 1 (0.9%) developed seroma and 2 (1.9%) developed skin dehiscence at the edge of the implant magnet. Significant improvement in Client Oriented Scale of Improvement and Glasgow Benefit Inventory scores with a global satisfaction of 84% and 77.4% was observed for those previously aided and unaided respectively, with use of the device. A 22% improvement in SSQ-12 mean score was observed in the pediatric population. CONCLUSION: This is the largest single-center series reported on this t-BCD. The complication rate is small but caution is required in patients of conversion from a percutaneous BCHD. The patients' satisfaction is high and the need for aftercare is minimal. Cost-effectiveness evaluation of these devices, development of core outcome sets and well-designed, prospective trials to compare the different BCHDs should be the focus of future research.

Nocebo Effect in Menière's Disease: A Meta-analysis of Placebo-controlled Randomized Controlled Trials.

OBJECTIVE: To estimate the frequency and strength of nocebo effects in trials for Menière disease (MD). DATA SOURCES: A literature search was conducted in PUBMED. The search terms we used were " Menière or Menière's," "treatment," and "placebo." Limitations included article type to be Clinical Trial or Randomized Controlled Trial, text availability to be Full text, Species to be Humans and Language to be English. STUDY SELECTION: We included placebo-controlled pharmaceutical RCTs that referred specifically to MD and recruited at least 10 adults in each arm. We excluded those studies with JADAD score ≤3. DATA EXTRACTION: Thirty-six articles were screened identifying 12 eligible studies. Studies were included after consensus of both authors. DATA SYNTHESIS: The meta-analysis was conducted using the RevMan programme as suggested by the Cochrane Collaboration Group. Data were analyzed using a random effects model. CONCLUSION: Nocebo is an important confounding factor of the reported AEs in RCTs for treatment of MD and subsequently in the clinical practice. The pooled estimate of the percentage of placebo-treated patients with at least one AE was 42.3% (95% CI 8.1% to 16.3%), in comparison to 53.8% (95% CI 48.0% to 59.5%) for active drug-treated patients. Reporting of RCTs in MD is suboptimal and we recommend authors to endorse the CONSORT checklist.

Addressing the Challenges in Tonsillectomy Research to Inform Health Care Policy: A Review.

Importance: Eighty-five percent of investment in medical research has been wasted, with lack of effect on clinical practice and policy. There is increasing effort to improve the likelihood of research being used to influence clinical practice and policy. Tonsillectomy is one of the most common otorhinolaryngologic surgical procedures, and its frequency, cost, and morbidity create a clear need for evidence-based guidelines and policy. The first systematic review on tonsillectomy was conducted 40 years ago and highlighted the lack of definitive evidence for the procedure. Since that study, the body of evidence has still not been able to sufficiently inform policy. This review provides an overview of the key challenges in research to inform tonsillectomy policy and recommendations to help bridge the evidence-policy gap. Observations: The challenges in using research to inform policy can be summarized as 4 main themes: (1) non-policy-focused evidence and lack of available evidence, (2) quality of evidence, (3) communication of research findings, and (4) coordinating time frames. Researchers and decision makers should be aware of the limitations of research designs and conflicts of interest that can undermine policy decisions. Researchers must work with decision makers and patients throughout the research process to identify areas of unmet need and political priority, align research and policy time frames, and disseminate research findings. Incentives for researchers should be reorganized to promote dissemination of findings. Conclusions and Relevance: It is important to consider why evidence gaps in tonsillectomy research have not been addressed during the past 40 years despite considerable investment in time and resources. These findings and recommendations will help produce research that is more responsive to policy gaps and more likely to result in policy changes.

UK bone conduction hearing device consensus workshop: Narrative summary.

OBJECTIVES: To identify United Kingdom (UK)-specific research priorities in the field of bone conduction hearing devices (BCHDs). METHOD: Narrative summary of the discussions and outcomes of a UK BCHD research workshop. The workshop was organized on 8 September 2016 under the auspices of the National Institute for Health Research (NIHR) Clinical Research Network (CRN) ENT Specialty group and Royal College of Surgeons (RCS) Clinical Research Initiative. Representatives from a wide range of patient and professional groups from the UK and abroad were invited to attend. Main outcome measures were research priorities and approaches in the field of BCHDs. RESULTS: Key research questions in the field of BCHDs are as follows: (1) What are the existing national BCHD practices? (2) What are the patient information and support needs on BCHDs? (3) Which outcomes should be measured across clinical studies in the field of BCHDs? The workshop suggested the following approaches to address these priorities: (1) a service evaluation of current UK BCHD practice; development of a national registry of BCHDs; (2) qualitative research to understand patient information and support needs; development of patient decision support tools; (3) development of core outcome sets for BCHDs. DISCUSSION: Building upon the framework of the recent UK Research Agenda for ENT, Hearing and Balance, patients and professionals defined key UK-specific research priorities and approaches in the field of BCHDs. This approach promotes engagement, buy-in, national collaboration and thereby value of future BCHD research.

Intermediate outcomes of a transcutaneous bone conduction hearing device in a paediatric population.

OBJECTIVE: The aim of this study was to review the outcomes of Bone Anchored Hearing Aid (BAHA®) Attract implantation in a cohort of paediatric patients. METHODS: Prospective data collection and case review were undertaken in a paediatric tertiary referral centre. We have included patients under the age of 16 years with unilateral or bilateral hearing loss that met the criteria for BAHA® Attract implantation. The main outcome measures were surgical complications and Patient Reported Outcomes including the 'Speech, Spatial and Qualities of Hearing scale' (SSQ-12) and 'Qualitative Feedback for BAHA® 5 Hearing Aids'. RESULTS: Twenty-five paediatric patients were implanted with the BAHA® Attract between June 2014 and July 2016. Nine of them had a conversion from a percutaneous Bone Conduction Hearing Device (BCHD). Four children had minor skin problems that settled with conservative measures. Two children with a previous percutaneous BCHD developed skin dehiscence over the magnet after conversion to the transcutaneous version. The SSQ-12 was completed by 6 children and an improvement of 22% was noted between the unaided and aided condition. The patients and their parents were generally satisfied with the BAHA® Attract. CONCLUSIONS: The BAHA® Attract offers a good solution for hearing rehabilitation in appropriately selected and counseled patients. The complication rate was low for primary surgery but higher in cases of conversion from a percutaneous device. Large, prospective data is needed to evaluate the relative risks and benefits of this BCHD.

Three year experience with the cochlear BAHA attract implant: a systematic review of the literature.

BACKGROUND: Bone conduction devices are widely used and indicated in cases of conductive, mixed or single sided deafness where conventional hearing aids are not indicated or tolerated. Percutaneous bone-conduction devices gave satisfactory hearing outcomes but were frequently complicated by soft tissue reactions. Transcutaneous bone conduction devices were developed in order to address some of the issues related to the skin-penetrating abutment. The aim of this article is to present a systematic review of the indications, surgical technique and audiological, clinical and functional outcomes of the BAHA Attract device reported so far. METHODS: A systematic computer-based literature search was performed on the PubMed database as well as Scopus, Cochrane and Google Scholar. Out of 497 articles, 10 studies and 89 reported cases were finally included in our review. RESULTS: The vast majority of implanted patients were satisfied with the aesthetics of the device scoring highly at the Abbreviated Profile of Hearing Aid Benefit, Glasgow Benefit Inventory and Client Oriented Scale of Improvement. Overall, hearing outcomes, tested by various means including speech in noise, free field hearing testing and word discrimination scores showed a significant improvement. Complications included seroma or haematoma formation, numbness around the area of the flap, swelling and detachment of the sound processor from the external magnet. CONCLUSIONS: The functional and audiological results presented so far in the literature have been satisfactory and the complication rate is low compared to the skin penetrating Bone Conduction Devices. Further robust trials will be needed to study the long-term outcomes and any adverse effects.

A randomized controlled trial of simulation-based training for ear, nose, and throat emergencies.

OBJECTIVES/HYPOTHESIS: Life-threatening ear, nose, and throat (ENT) emergencies are uncommon but require immediate skilled management. We investigated if traditional lecture-based teaching can be improved by a simulation and lecture hybrid approach. STUDY DESIGN: A single-blinded, prospective, randomized controlled trial. METHODS: Two groups of interns with no previous ENT experience were randomized to one of two training groups: a simulation/lecture hybrid group or a lecture-only control group. Both groups received 90 minutes of training covering the assessment of critically ill patients and four ENT emergency topics. Both groups received the same initial lecture slides. The control group received additional slides, and the simulation group received simulated emergency scenario training using basic mannequins. Following the training, candidates were asked to provide feedback on their perception of training, and they were formally assessed with a standardized one-to-one viva. RESULTS: Thirty-eight interns were recruited: 18 in the control group and 20 in the simulation group. The candidates in the simulation group performed significantly better in all viva situations (P < .05) and had better perception of learning (P < .05). Additionally, the simulation group was more likely to recommend the training to a colleague (P < .05). CONCLUSIONS: We have demonstrated that replacing traditional lecture-based training with a mixture of lectures and emergency scenario simulation is more effective at preparing junior doctors for ENT emergencies, and better met their learning needs. Implementing this kind of teaching is feasible with a minimum of additional resources or time. LEVEL OF EVIDENCE: 1b

Torticollis following tympanoplasty: an index case with lessons in encountering the unexpected.

The term torticollis is derived from the Latin words 'tortis' for twisted and 'collum' for neck. Typical features include sudden onset of severe unilateral pain, with restriction of movements and deviation of the neck to that side. Although torticollis is a well recognised abnormality, there is minimal literature identifying it as a sole long-standing complication in otological surgery. We present the case of a 15-year-old boy who developed permanent torticollis following a routine tympanoplasty. A CT of the neck revealed an atlantoaxial rotatory fixation with cross fusion between C1 and C2. This case highlights a rare cause of torticollis resulting from a routine otological procedure. It also differentiates between Grisel's syndrome, which is characterised by atlantoaxial subluxation as opposed to fusion. The role of the multidisciplinary team is imperative and in particular the need for urgent discussion with the neurosurgical team to ensure prompt assessment and management of the patient takes place.

Appendiceal endometriosis and carcinoid presented as acute appendicitis in pregnancy: a rare case report and review of the literature.

A 22-year-old pregnant woman presented at the twenty-seventh week of gestation in the Emergency Department with acute abdominal pain and right iliac fossa tenderness. Urgent MRI was done and was suggestive of acute appendicitis. A laparoscopy was performed that confirmed an inflamed and purulent appendix that was removed. The technique used is described in detail. The histopathologic findings were those of acute appendicitis, carcinoid, and endometriosis of the appendix. We report the first case of this extremely rare triad presented in pregnancy.

Appendiceal torsion associated with undescended caecum: a case report and review of the literature.

Torsion of the vermiform appendix is a rare disorder that causes symptoms similar to those of acute appendicitis. Primary and secondary causes of appendiceal torsion have been reported in the literature. Laparoscopy appears to be the most appropriate modality for diagnosis and treatment where the condition is suspected. To our knowledge this is the first case of appendiceal torsion in an adult causing right upper quadrant pain related to caecal malposition.

Hearing loss in Paget's disease: a temporal bone histopathology study.

BACKGROUND: Hearing loss in Paget's disease of bone (PDB) is typically mixed and bilateral. Although different mechanisms have been proposed, the pathophysiology of hearing impairment remains unclear. OBJECTIVE: The purpose of this study is to describe the histopathologic findings of temporal bones in patients with PDB and elucidate possible pathologic mechanisms related to hearing impairment. METHODS: This is an archival human temporal bone study of 8 subjects diagnosed with Paget's disease from the temporal bone collection of the UCL Ear Institute. RESULTS: A fractured stapes footplate was observed in 1 temporal bone and stapes footplate fixation in 2 other specimens. Obliteration of Cotugno's canal by extensive bone remodeling was observed in 78% of temporal bones. An intracochlear vestibular schwannoma was observed in 1 specimen (previously reported in the literature). Other findings include microfissures and microfractures of the otic capsule, bleeding in the scalae, strial atrophy, and cystic lesions in the spiral ligament. CONCLUSION: This study is the first to report a fractured stapes footplate, as a causative lesion of conductive hearing loss in PDB. Extensive bone remodeling around Cotugno canal also was a frequent finding, not reported before in the literature. We hypothesize that sensorineural hearing loss in patients with PDB of the temporal bone may, in some cases, be attributed to obliteration of Cotugno's canal by remodeling pagetoid bone, thus obstructing the venous drainage of the cochlea, with a subsequent effect on the function of stria vascularis and spiral ligament. This seems to be consistent with experimental studies in animals.