Feasibility study of the Vitom 3D exoscope in ENT surgery using an animal model: relevance to coronavirus disease 2019.

OBJECTIVE: The application of a 4K display resolution three-dimensional exoscope system (Vitom 3D) was evaluated to determine the feasibility of adopting the system in ENT surgery in the coronavirus disease 2019 era and beyond. METHODS: Eighteen ENT surgeons performed structured otological tasks on fresh-frozen sheep heads using the Vitom 3D. Structured feedback of the participants' experience was analysed. RESULTS: Seventy-four per cent and 94 per cent of participants reported that the Vitom 3D was ergonomic and comfortable to use respectively. Whilst colour fidelity and image quality were very good, 50 per cent of participants reported image distortion and pixilation at the highest magnification. All participants agreed that there was an increased educational value to exoscope technology. Half the participants preferred the microscope over the Vitom 3D for fine otological work, which may reflect the learning curve. CONCLUSION: The Vitom 3D exoscope is a promising and viable alternative for performing otological surgery when using full personal protective equipment in the coronavirus disease 2019 era.

Aural fullness and transtympanic ventilation tubes in Ménière's disease: a scoping review.

BACKGROUND: Ménière's disease often presents with aural fullness, for reasons that are currently not well understood. Transtympanic ventilation tube insertion has been historically used for the management of this symptom, though the nature and mechanism of effectiveness is unclear. OBJECTIVE: To give an overview of the data available on the effects of ventilation tube insertion on aural fullness in Ménière's disease. METHODS: The databases PubMed, Embase, Medline, Scopus, Web of Science, Central and Google Scholar were searched to identify relevant records. Records were subsequently analysed and data extracted. RESULTS: Only two studies directly measured the effect of ventilation tube insertion on aural fullness, while three others measured it as a placebo to assess another treatment. Considerable heterogeneity was found amongst the studies, including conflicting conclusions. CONCLUSION: There is a paucity of evidence investigating the effect of grommet insertion on aural fullness in Ménière's disease. This work directs future research into this topic.

Sinonasal papilloma: what influences the decision to request a magnetic resonance imaging scan?

BACKGROUND: Computed tomography is the standard pre-operative imaging modality for sinonasal papilloma. The complementary use of magnetic resonance imaging as an additional investigation is debated. This study aimed to establish whether magnetic resonance imaging can accurately detect tumour extent and is a useful adjunct to computed tomography. METHODS: A retrospective review was conducted on 19 patients with sinonasal papilloma. The interpretation of computed tomography and magnetic resonance imaging scans, by three clinicians, was conducted by comparing prediction of tumour extent. The perceived necessity of magnetic resonance imaging was compared between clinicians. RESULTS: The addition of magnetic resonance imaging improved accuracy of pre-operative interpretation; specifically, this finding was significant in cases with frontal sinus involvement. Surgeons were more likely than a radiologist to request magnetic resonance imaging, particularly when computed tomography indicated frontal sinus disease. CONCLUSION: Pre-operative combined magnetic resonance imaging and computed tomography helped predict disease in the frontal sinus better than computed tomography alone. A close working relationship between the ENT and radiology departments is important for accurate tumour localisation.

Management of inverted papilloma: review.

BACKGROUND: Inverted papilloma is the most common benign tumour affecting the nose. There is a high rate of recurrence and a potential of malignant transformation. This review article aimed to identify the best available management of this pathology today. METHOD: A systematic review of the current English-language literature was performed. Only original articles with a minimum follow up of one year and an average follow up of two years were included. RESULTS: A total of 1385 patients from 16 case series were identified. The total recurrence rate for all patients was 11.5 per cent. Significantly lower recurrence rates were found for procedures using an attachment-oriented excision (recurrence of 6.9 per cent; p = 0.0001) and utilising frozen sections (recurrence of 7.0 per cent; p = 0.0001). CONCLUSION: There is a general trend towards endoscopic surgery. There may be some benefit to the use of attachment-oriented surgery and frozen sections. Multi-centred randomised controlled trials are required.

Independent prescriber physiotherapist led balance clinic: the Southport and Ormskirk pathway.

OBJECTIVE: To report the introduction and impact of non-medical prescribing, initiated to improve patient pathways for those presenting with dizziness and balance disorders. METHODS: The Southport and Ormskirk physiotherapy-led vestibular clinic sees and treats all patients with dizziness and balance disorders referred to the ENT department. Letters are triaged by an audiologist, who also performs an otological examination and hearing test; this is followed by an assessment with the independent prescriber physiotherapist. An ENT consultant is nearby if joint consultation is needed. Diagnoses, treatments and patient satisfaction were studied, with an analysis of the impact of medication management (stopping or starting medicines) on patients and service. RESULTS: In 12 months, 413 new patients with dizziness and balance disorders had appointments. The most common diagnoses were benign paroxysmal positional vertigo and vestibular migraine. Eighty-four per cent of patients required self-management strategies, 50 per cent exercise therapy, 48 per cent medication management and 24 per cent a particle repositioning manoeuvre. Patient satisfaction was high (99 per cent). CONCLUSION: Having an independent prescriber physiotherapist leading the balance clinic has reduced the number of hospital visits and onward referrals. Nearly half of all patients required medication management as part of their dizziness or balance treatment.

Does the working temperature affect the outcome following microwave endometrial ablation?

BACKGROUND: Menorrhagia is a common gynaecological complaint, with significant burden to both its sufferers and health service providers. The first line of treatment is usually medical/pharmaceutical although in some cases surgery is required. There are now a number of minimally invasive surgical techniques available that ablate the uterine lining and prevent the need for the removal of the uterus. Microwave endometrial ablation (MEA) is one of these techniques, and this paper investigates the effect of the working temperature on outcome. METHODS: A retrospective case note review of women who underwent MEA between June 2000 and August 2004. All women had a hysteroscopy followed by MEA. The duration of the procedure and mean working temperature of the MEA treatment was calculated. Women were followed up 6-8 months after surgery. FINDINGS: Two hundred and eleven women underwent the procedure, with an average duration of menorrhagia of 30 months prior to the procedure. Eighty-nine percent attended follow-up, 80 % were satisfied with the procedure and 40 % were amenorrhoeic. When the procedure was performed at higher working temperature within the manufacturers guidelines women were more likely to be amenorrhoeic (78.4 vs. 77.1 °C, p = 0.014). CONCLUSION: MEA is more effective in treating menorrhagia when used at a higher operating temperature.

Penetrating neck trauma and the need for surgical exploration: six-year experience within a regional trauma centre.

BACKGROUND: There has been a shift towards conservative management of penetrating neck trauma in selected patients. METHODS: A retrospective case note review of the management of penetrating neck trauma (2007-2013) was undertaken at our large teaching hospital and compared against best-evidenced practice. RESULTS: Sixty-three patients were admitted over six years. The incidence of penetrating neck trauma is reducing, contrary to our belief. Most cases were knife inflicted (33 out of 63), and of these most were attempted suicide. There was a high rate of negative findings for neck explorations under general anaesthesia (18 out of 22). Only nine cases had justification for general anaesthesia exploration according to best practice. CONCLUSION: The rate of neck explorations under general anaesthesia has dramatically fallen, in line with best practice. The need for operative intervention in patients with penetration of the aerodigestive tract or a major vascular injury should be based on clinical features, and these have been shown to be reliable indicators prior to open exploration.

The management of vacuum neck drains in head and neck surgery and the comparison of two different practice protocols for drain removal.

Introduction The management of vacuum neck drains in head and neck surgery is varied. We aimed to improve early drain removal and therefore patient discharge in a safe and effective manner. Methods The postoperative management of head and neck surgical patients with vacuum neck drains was reviewed retrospectively. A new policy was then implemented to measure drainage three times daily (midnight, 6am, midday). The decision for drain removal was based on the most recent drainage period (at <3ml per hour). A further patient cohort was subsequently assessed prospectively. The length of hospital stay was compared between the cohorts. Results The retrospective audit included 51 patients while the prospective audit included 47. The latter saw 16 patients (33%) discharged at least one day earlier than they would have been under the previous policy. No adverse effects were noted from earlier drain removal. Conclusions Measuring drainage volumes three times daily allows for more accurate assessment of wound drainage, and this can lead to earlier removal of neck drains and safe discharge.

Development of a physiotherapy-led balance clinic: the Aintree model.

OBJECTIVE: To create a 'one-stop' clinic in which assessment, diagnosis, treatment and therapies for most patients presenting with balance and dizziness disorders are delivered simultaneously. METHODS: Patients triaged via referral letters were selected to attend the balance clinic, which is led by specialist balance physiotherapists. Patients were seen by an audiologist, and a 'balance' ENT consultant was available for joint consultations when required. Further details of the clinic set up are discussed. RESULTS: Over an 18-month period, 200 new 'dizzy' patients attended the clinic. Benign paroxysmal positional vertigo and labyrinthitis were the commonest diagnoses. Fifty per cent of all patients were discharged after a single clinic visit. Questionnaires showed that patient satisfaction was high. CONCLUSION: The physiotherapy-led balance clinic has reduced patient waiting times to be seen, has a high level of patient satisfaction and is economically beneficial.

Activation of memory Th17 cells by domain 4 pneumolysin in human nasopharynx-associated lymphoid tissue and its association with pneumococcal carriage.

Pneumococcal carriage is common in children that may account for the high incidence of disease in this age group. Recent studies in animals suggest an important role for CD4+ T cells, T helper type 17 (Th17) cells in particular, in pneumococcal clearance. Whether this Th17-mediated mechanism operates in humans and what pneumococcal components activate Th17 are unknown. We investigated the ability of domain 4 pneumolysin (D4Ply) to activate CD4+ T cells including Th17 in human nasopharynx-associated lymphoid tissue (NALT) and peripheral blood. We show that D4Ply elicited a prominent CD4+ T-cell proliferative response. More importantly, D4Ply elicited a significant memory Th17 response in NALT, and a moderate response in peripheral blood mononuclear cells (PBMCs). This D4Ply-elicited memory Th17 response was more marked in carriage- than in carriage+ children in both NALT and PBMCs. In contrast, no difference was shown in D4Ply-induced Th1 response between the two groups. We also show D4Ply activated human monocytes and murine macrophages that was in part dependent on Toll-like receptor 4 (TLR-4). Our results support a protective role of Th17 against pneumococcal carriage in human nasopharynx, and identify a novel property of D4Ply to activate Th17 in NALT that may offer an attractive vaccine candidate in intranasal immunization against pneumococcal infection.

Non echo planar, diffusion-weighted magnetic resonance imaging (periodically rotated overlapping parallel lines with enhanced reconstruction sequence) compared with echo planar imaging for the detection of middle-ear cholesteatoma.

OBJECTIVES: We evaluated use of the periodically rotated overlapping parallel lines with enhanced reconstruction diffusion-weighted imaging sequence, compared with conventional echo planar magnetic resonance imaging, in the detection of middle-ear cholesteatoma. MATERIAL AND METHODS: Sixteen patients awaiting second-stage combined approach tympanoplasty and three patients awaiting first-stage combined approach tympanoplasty underwent magnetic resonance imaging with both (1) the periodically rotated overlapping parallel lines with enhanced reconstruction sequence (i.e. non echo planar imaging) and (2) the array spatial sensitivity encoding technique sequence (i.e. echo planar imaging). Two neuroradiologists independently evaluated the images produced by both sequences. Radiology findings were correlated with surgical findings. RESULTS AND ANALYSIS: Seven cholesteatomas were found at surgery. Neither of the assessed imaging sequences were able to detect cholesteatoma of less than 4 mm. Rates for sensitivity, specificity, and positive and negative predictive values are presented. CONCLUSION: Decisions on whether or not to operate for cholesteatoma cannot be made based on the two imaging sequences assessed, as evaluated in this study. Other contributing factors are discussed, such as the radiological learning curve and technical limitations of the magnetic resonance imaging equipment.

Facial nerve palsy secondary to middle-ear lipoma.

OBJECTIVE: We present the first reported case of a middle-ear lipoma presenting with facial nerve palsy. We review the available literature on middle-ear lipomas and alert the surgeon to the possibility of a lipoma occurring in this location. CASE REPORT: A 33-year-old man presented to our unit with a right-sided, House-Brackmann grade two, lower motor neurone facial palsy. A computed tomography scan revealed abnormal soft tissue in the epitympanic recess, extending to the region of the geniculate ganglion. At middle-ear exploration, a lump of fatty tissue was found filling the anterior middle-ear cleft, juxtaposed to the horizontal portion of the facial nerve. The patient's facial palsy resolved within a few weeks of surgery. CONCLUSION: Lipomas are a rare but real differential diagnosis of a mass in the middle ear. Early imaging is advised.