Cross-over septal flap technique for choanal atresia surgery in two centres: how I do it.

BACKGROUND: Choanal atresia is a congenital obstruction of the posterior nasal aperture. Endoscopic endonasal surgery has led to successful choanal atresia repair. This paper describes our surgical technique using septal mucosal flaps without the need for stenting. METHODS: This study comprised a multicentre retrospective review of patient notes. A cross-over septal technique is described, whereby bilateral vertical mucosal incisions are made at the posterior third of the septum, and the atretic plate and posterior vomer are removed. One flap is pedicled superiorly and rotated over the bare skull base and sphenoid bone; the contralateral flap is pedicled inferiorly to cover the exposed vomer remnant and hard palate. RESULTS: There were 12 patients from 2013 to 2020, aged 0.07-50 years, with a male to female ratio of 1:5. Ten patients had unilateral and two had bilateral choanal atresia. Nine patients had bony choanal atresia, with the remainder mixed. CONCLUSION: The cross-over technique for choanal atresia has low morbidity and 100 per cent success in our series. The use of mucoperiosteal flaps to cover exposed bone and minimal instrumentation to the lateral nasal wall reduce post-operative stenosis.

Laryngopharyngeal reflux: is laparoscopic fundoplication an effective treatment?

INTRODUCTION: Laryngopharyngeal reflux (LPR) is difficult to diagnose and treat owing to uncertainty relating to the underlying pathology. The initial management of LPR includes lifestyle modifications and oral medications. In patients who have failed to respond to proton pump inhibitor (PPI) therapy, anti-reflux surgery is considered; laparoscopic fundoplication is the surgery of choice. The primary aim of this review is to identify whether fundoplication is effective in improving signs and symptoms of LPR. The secondary aim is to identify whether patients who have had a poor response to PPIs are likely to have symptom improvement with surgery. The objective of the study is to establish the effect of laparoscopic fundoplication on the reflux symptom index score (RSI). METHODS: PubMed, Embase, Medline and Cochrane databases were used to search according to the PRISMA guidelines. Original articles assessing the efficacy of fundoplication in relieving symptoms of LPR were included. For each study, the efficacy endpoints and safety outcomes were recorded. FINDINGS: Nine studies from 844 initial records met the inclusion criteria: one prospective case control study, one retrospective case-control study, four prospective case series and three retrospective case series involving 287 fundoplications. All nine studies found fundoplication to be effective in improving symptoms of LPR (p < 0.05). CONCLUSION: Current evidence suggests laparoscopic fundoplication is an effective treatment for LPR and should be considered if medical management is unsuccessful.

Laryngopharyngeal reflux: is laparoscopic fundoplication an effective treatment?

INTRODUCTION: Laryngopharyngeal reflux (LPR) is difficult to diagnose and treat owing to uncertainty relating to the underlying pathology. The initial management of LPR includes lifestyle modifications and oral medications. In patients who have failed to respond to proton pump inhibitor (PPI) therapy, anti-reflux surgery is considered; laparoscopic fundoplication is the surgery of choice. The primary aim of this review is to identify whether fundoplication is effective in improving signs and symptoms of LPR. The secondary aim is to identify whether patients who have had a poor response to PPIs are likely to have symptom improvement with surgery. The objective of the study is to establish the effect of laparoscopic fundoplication on the reflux symptom index score (RSI). METHODS: PubMed, Embase, Medline and Cochrane databases were used to search according to the PRISMA guidelines. Original articles assessing the efficacy of fundoplication in relieving symptoms of LPR were included. For each study, the efficacy endpoints and safety outcomes were recorded. FINDINGS: Nine studies from 844 initial records met the inclusion criteria: one prospective case control study, one retrospective case-control study, four prospective case series and three retrospective case series involving 287 fundoplications. All nine studies found fundoplication to be effective in improving symptoms of LPR (p < 0.05). CONCLUSION: Current evidence suggests laparoscopic fundoplication is an effective treatment for LPR and should be considered if medical management is unsuccessful.

Disability from chronic ear disease in Nepal assessed using the World Health Organization Disability Assessment Schedule 2.0 instrument.

OBJECTIVE: Globally, South Asia has the highest proportion of disabling hearing loss. There is a paucity of data exploring the associated hearing loss and disability caused by chronic middle-ear disease in South Asia in the setting of surgical outreach. This study aimed to measure disability using the World Health Organization Disability Assessment Schedule 2.0 in patients undergoing ear surgery for chronic middle-ear disease in an ear hospital in Nepal. METHOD: The World Health Organization Disability Assessment Schedule 2.0 was translated into Nepali and administered by interview to patients before ear surgery, and results were correlated with pre-operative audiograms. RESULTS: Out of a total of 106 patients with a mean age of 23 years, the mean World Health Organization Disability Assessment Schedule 2.0 score was 17.7, and the highest domain scores were for domain 6 'participation in society' at a score of 34. There was a positive correlation of World Health Organization Disability Assessment Schedule 2 score with hearing level (r = 0.46). CONCLUSION: Patients with ear disease in Nepal have had their disability measured using the World Health Organization Disability Assessment Schedule 2.0. Our study demonstrated a correlation between impaired hearing and disability in a surgical outreach context, which was an expected but not previously reported finding.

The impact of noise in the operating theatre: a review of the evidence.

INTRODUCTION: Noise has been recognised to have a negative impact on performance and wellbeing in many settings. Average noise levels have been found to range between 51dB and 79dB in operating theatres. Despite these levels of noise, there is little research investigating their effect on surgical team functioning. METHODS: A literature review to look at the impact of noise in the operating theatre was performed on MEDLINE, which included the search terms 'noise' OR 'distraction' AND 'technical skill' OR 'Surgical skill' OR 'Operating Room'. Only 10 of 307 articles identified were deemed relevant. FINDINGS: Eight of ten studies found noise to be detrimental to communication and surgical performance, particularly regarding total errors and time to task completion. No studies found noise to be beneficial. Two studies found case-irrelevant verbal communication to be a frequent form of noise pollution in operating theatres; this is both perceived by surgeons to be distracting and delays patient care. CONCLUSION: Noise and irrelevant verbal communications were both found to be harmful to surgical performance, surgeon experience and team functioning.

Moffett's muted mules: the science of laryngology in the art of war.

BACKGROUND: Mules and other equine species have been used in warfare for thousands of years to transport goods and supplies. Mules are known for 'braying', which is disadvantageous in warfare operations. This article explores the fascinating development of surgical techniques to stop military mules from braying, with particular emphasis on the key role played by the otolaryngologist Arthur James Moffett in devoicing the mules of the second Chindit expedition of World War II. METHOD: The PubMed database (1900-2017) and Google search engine were used to identify articles related to devoicing mules in the medical and veterinary literature, along with information and images on the Chindit expedition. RESULTS: This paper reviews the surgical techniques aimed at treating braying in mules, ranging from ventriculectomy and arytenoidectomy to Moffett's approach of vocal cordectomy. CONCLUSION: Moffett's technique of vocal cordectomy provided a quick, reproducible and safe solution for devoicing mules. It proved to be advantageous on the battlefield and demonstrated his achievements outside the field of medicine.

Topical propranolol for infantile haemangiomas: a systematic review.

Infantile haemangiomas are the most common tumour of infancy. Whilst the majority are left untreated to involute spontaneously, residual skin changes commonly occur, particularly in superficial haemangiomas. The current first-line treatment for problematic lesions is oral propranolol; however due to the risk of systemic adverse effects, the use of off-label topical preparations has recently been investigated. Our systematic review was conducted in accordance with PRISMA guidelines. Four databases were searched to identify original articles evaluating the use of topical propranolol as the primary therapy for infantile haemangiomas. Twelve articles with a total of 597 patients and 632 haemangiomas were included. Three topical propranolol preparations were used, creams, ointments and gels and were all prepared by local pharmaceutical laboratories. The concentration of propranolol ranged from 0.5% to 5%. Treatment duration ranged from two weeks to 16.5 months. Overall, 90% of lesions improved following the initiation of topical propranolol. A good or excellent response, defined as a reduction in the size of at least 50%, was seen in 59% of lesions. Earlier initiation of treatment (less than 3 months of age) was associated with improved outcomes. No systemic adverse effects were reported. Minor local reactions were seen in 1.3% of patients. Topical propranolol is safer than oral propranolol, though may be less effective. Topical propranolol may be more suitable for patients with small, superficial haemangiomas at risk of cosmetic sequelae, where the cosmetic or symptomatic impact does not warrant oral propranolol treatment.

History of intranasal splints.

OBJECTIVE: Intranasal splints have long been utilised as a post-operative adjunct in septoplasty, intended to reduce the risk of adhesions and haematoma formation, and to maintain alignment during healing. METHODS: A Medline literature review of the history and evolution of intranasal splint materials and designs was performed. Advantages and disadvantages of various splints are discussed. RESULTS: Intranasal splints fashioned from X-ray film were first reported in 1955. Since then, a variety of materials have been utilised, including polyethylene coffee cup lids, samarium cobalt magnets and dental utility wax. Most contemporary splints are produced from silicon rubber or polytetrafluoroethylene (Teflon). Designs have varied in thickness, flexibility, shape, absorption and the inclusion of built-in airway tubes. Future directions in splint materials and designs are discussed. CONCLUSION: Intranasal splints have steadily evolved since 1955, with numerous novel innovations. Despite their simplicity, they play an important role in nasal surgery and will continue to evolve over time.

Why are ototopical aminoglycosides still first-line therapy for chronic suppurative otitis media? A systematic review and discussion of aminoglycosides versus quinolones.

OBJECTIVE: This systematic review aimed to establish that quinolones are as effective as aminoglycosides when used to treat chronic suppurative otitis media. METHOD: The review included good quality, randomised, controlled trials on human subjects, published in English, that compared topical aminoglycosides with topical quinolones for the treatment of chronic suppurative otitis media. RESULTS: Nine trials met the criteria. Two studies showed a higher clinical cure rate in the quinolone group (93 per cent vs 71 per cent, p = 0.04, and 76 per cent vs 52 per cent, p = 0.009). Four studies showed no statistically significant difference in clinical outcome. A significant difference in microbiological clearance in favour of quinolones was shown in two studies (88 per cent vs 30 per cent, p < 0.001, and 88 per cent vs 30 per cent, p < 0.001). CONCLUSION: Topical quinolones do not carry the same risk of ototoxicity as aminoglycosides. Furthermore, they are equal or more effective in treating chronic suppurative otitis media and when used as prophylaxis post-myringotomy. Topical quinolones should be considered a first-line treatment for these patients.

Balloon dilatation of the Eustachian tube: an evidence-based review of case series for those considering its use.

BACKGROUND: Eustachian tube dysfunction is common and implicated in persistent middle ear disease. Recent studies suggest the promise of balloon dilatation of the Eustachian tube to modify local anatomy and physiology, restoring normal function. OBJECTIVES: A literature review of the outcomes of balloon dilatation of the Eustachian tube was conducted, assessing four criteria (tympanometry, otoscopy findings, Valsalva and subjective symptoms). Outcomes were divided into short term (≤ 6 months) and long term (>6 months). Rates and severity of complications were documented. We also assessed cost, learning curve and requisite training. SEARCH STRATEGY: Medline via PubMed was consulted with the following search request: 'eustachian tube' OR 'auditory tube' AND 'balloon'. No restrictions were placed on study date, type or language. Non-clinical studies, published abstracts and very small studies (<10 procedures) were excluded. RESULTS: Our search yielded 24 results and six case series, five of which met the inclusion criteria. Balloon dilatation has been performed on 375 Eustachian tubes (235 patients) and demonstrates clear short-term (<6 month) benefits across all recorded outcome measures in a majority of cases. 69 of 89 (78%) tympanogram profiles recorded preoperatively as abnormal (Type B/C/open) resolved to type A profiles postoperatively. 40 of 46 (87%) otoscopy findings preoperatively reported as abnormal (tympanic membrane retraction, perforation or otitis media with effusion) normalised postoperatively. The ability to perform a consistently positive Valsalva manoeuvre improved from 15 of 139 (11%) to 89 of 139 (64%) cases following dilatation. The two largest studies reported on 210 and 100 procedures and described symptom improvement in 67% of cases at 2 months and 71% at 26.3 weeks, respectively. An overall complication rate of ≈ 3% was observed, and no major adverse events are reported (0%). Cost and learning curve of the procedure were both deemed to be acceptable. CONCLUSION: Balloon dilatation of the Eustachian tube appears to be safe, effective and affordable. Like many newly introduced techniques, the evidence remains limited to non-controlled case series, with heterogeneous data collection methods and lacking long-term outcomes. However, short-term data provides promising, consistent results based on objective measures, and when used selectively in patients refractive to maximal existing therapy, balloon dilatation presents a potentially significant advance.