Safety of elective paediatric surgery during the coronavirus disease 2019 pandemic.

INTRODUCTION: Corona-virus Disease 2019 (COVID-19) has had a huge impact on the delivery of healthcare worldwide, particularly elective surgery. There is a lack of data regarding risk of postoperative COVID-19 infection in children undergoing elective surgery, and regarding the utility of pre-operative COVID-19 testing, and preoperative "cocooning" or restriction of movements. The purpose of this present study was to examine the safety of elective paediatric Otolaryngology surgery during the COVID-19 pandemic with respect to incidence of postoperative symptomatic COVID-19 infection or major respiratory complications. MATERIALS AND METHODS: Prospective cohort study of paediatric patients undergoing elective Otolaryngology surgery between September and December 2020. Primary outcome measure was incidence of symptomatic COVID-19 or major respiratory complications within the 14 days after surgery. Parents of prospectively enrolled patients were contacted 14 days after surgery and enquiry made regarding development of postoperative symptoms, COVID-19 testing, or diagnosis of COVID-19. RESULTS: 302 patients were recruited. 125 (41.4%) underwent preoperative COVID-19 RT-PCR testing. 66 (21.8%) restricted movements prior to surgery. The peak 14-day COVID-19 incidence during the study was 302.9 cases per 100,000 population. No COVID-19 infections or major respiratory complications were reported in the 14 day follow-up period. CONCLUSION: The results of our study support the safety of elective paediatric Otolaryngology surgery during the pandemic, in the setting of community incidence not exceeding that observed during the study period.

Risk of disease transmission from flexible nasoendoscopy during the coronavirus disease 2019 pandemic.

BACKGROUND: Concerns have emerged regarding infection transmission during flexible nasoendoscopy. METHODS: Information was gathered prospectively on flexible nasoendoscopy procedures performed between March and June 2020. Patients and healthcare workers were followed up to assess for coronavirus disease 2019 development. One-sided 97.5 per cent Poisson confidence intervals were calculated for upper limits of risk where zero events were observed. RESULTS: A total of 286 patients were recruited. The most common indication for flexible nasoendoscopy was investigation of 'red flag' symptoms (67 per cent). Forty-seven patients (16 per cent, 95 per cent confidence interval = 13-21 per cent) had suspicious findings on flexible nasoendoscopy requiring further investigation. Twenty patients (7.1 per cent, 95 per cent confidence interval = 4.4-11 per cent) had new cancer diagnoses. Zero coronavirus disease 2019 infections were recorded in the 273 patients. No. 27 endoscopists (the doctors and nurses who carried out the procedures) were followed up.The risk of developing coronavirus disease 2019 after flexible nasoendoscopy was determined to be 0-1.3 per cent. CONCLUSION: The risk of coronavirus disease 2019 transmission associated with performing flexible nasoendoscopy in asymptomatic patients, while using appropriate personal protective equipment, is very low. Additional data are required to confirm these findings in the setting of further disease surges.

Critical Airway Compromise due to a Massive Vagal Schwannoma.

We describe the case of a 37-year-old man with a slowly enlarging neck lump and compressive symptoms. He presented to a separate institution 10 years prior where an observational approach was advocated. Following preoperative investigations and embolization, an 11cm vagal schwannoma was excised and vagus nerve was sacrificed. Although conservative management is appropriate for a select patient population, surgical excision is treatment of choice for cervical neurogenic tumours and paraganglionomas and must be considered in young patients or rapidly expanding tumours to avoid compressive symptoms, as in this case.

Conceiving a national head and neck cancer screening programme.

BACKGROUND: This study was undertaken to determine the optimum approach to screening for head and neck cancer based on international experiences. OBJECTIVE: To determine whether or not head and neck cancer is suitable for screening, and, if so, what the ideal approach should be. METHODS: An electronic search of online databases up to and including May 2014 was conducted. Key search terms included 'head and neck', 'cancer', 'screening', 'larynx', 'oropharynx' and 'oral'. RESULTS: Subset analysis of high-risk cohorts showed statistically significant improvements in early detection of head and neck cancer via screening. CONCLUSION: Current levels of public awareness regarding head and neck cancers are suboptimal, despite increased incidence and mortality. Scheduled and opportunistic screening, coupled with efforts to enhance education and health behaviour modification, are highly recommended for pre-defined, high-risk, targeted populations. This can enable early detection and therefore improve morbidity and mortality.

Oncological and functional outcomes of transoral surgery for the treatment of oropharyngeal cancer.

BACKGROUND: Currently, most cases of oropharyngeal squamous cell carcinoma (OPSCC) are treated by chemoradiotherapy. However, serious concerns have arisen regarding toxicity and poor functional outcomes. Recently, transoral techniques for resection of selected OPSCC have been developed. AIMS: To review the outcomes of transoral surgery for OPSCC at our institution. METHODS: Retrospective review of 12 patients with OPSCC treated with transoral resection. Data on surgical complications, oncological outcomes, and functional outcomes were analysed. RESULTS: Primary sites were tonsil (9), soft palate (1), base of tongue (1), and posterior pharyngeal wall (1). There were no surgical complications. After the mean follow-up of 19 months, there were no local or regional recurrences. Two patients (one with synchronous lung cancer) died from distant metastases. No patient required gastrostomy tube or had long-term speech or swallowing impairments. CONCLUSION: Transoral resection is an excellent option for selected patients with OPSCC, offering excellent functional and oncological outcomes.

The effects of chronic alcoholism on cell proliferation in the human brain.

Neurogenesis continues in the human subventricular zone and to a lesser extent in the hippocampal subgranular zone throughout life. Subventricular zone-derived neuroblasts migrate to the olfactory bulb where survivors become integrated as interneurons and are postulated to contribute to odor discrimination. Adult neurogenesis is dysregulated in many neurological, neurovascular and neurodegenerative diseases. Alcohol abuse can result in a neurodegenerative condition called alcohol-related brain damage. Alcohol-related brain damage manifests clinically as cognitive dysfunction and the loss of smell sensation (hyposmia) and pathologically as generalized white matter atrophy and focal neuronal loss. The exact mechanism linking chronic alcohol intoxication with alcohol-related brain damage remains largely unknown but rodent models suggest that decreased neurogenesis is an important component. We investigated this idea by comparing proliferative events in the subventricular zone and olfactory bulb of a well-characterized cohort of 15 chronic alcoholics and 16 age-matched controls. In contrast to the findings in animal models there was no difference in the number of proliferative cell nuclear antigen-positive cells in the subventricular zone of alcoholics (mean±SD=28.7±20.0) and controls (27.6±18.9, p=1.0). There were also no differences in either the total (p=0.89) or proliferative cells (p=0.98) in the granular cell layer of the olfactory bulb. Our findings show that chronic alcohol consumption does not affect cell proliferation in the human SVZ or olfactory bulb. In fact only microglial proliferation could be demonstrated in the latter. Therefore neurogenic deficits are unlikely to contribute to hyposmia in chronic alcoholics.

Comparison of incidence of postoperative seroma between flapless and conventional techniques for thyroidectomy: a case-control study.

OBJECTIVES: The incidence of seroma after thyroidectomy has been reported between 1.3% and 7%. We hypothesised that a flapless thyroidectomy technique would reduce the incidence of seroma. DESIGN: Observational case-control study with comparison between retrospective cohort of patients undergoing thyroidectomy with raising of conventional skin flaps and prospective cohort undergoing flapless surgery. SETTING: Academic Teaching Hospital. PARTICIPANTS: Hundred and seventy-five consecutive patients undergoing thyroidectomy performed by a single surgeon. After the first 85 cases, a change in practice took place, from raising of conventional skin flaps to performing flapless surgery wherever feasible. MAIN OUTCOME MEASURES: Occurrence of postoperative seroma, defined as central neck swelling in postoperative period, confirmed by aspiration of serous fluid, and other complications. RESULTS: Eight patients who underwent concomitant lateral (jugular) neck dissection were excluded. Among the remaining 167 patients, there were eight seromas (5%). Following the change in practice to flapless surgery, there was a significant reduction in the incidence of seroma (P = 0.025). There was no significant difference in other complications (haematoma; recurrent laryngeal nerve injury; and hypocalcaemia). Among the entire group, the association between seroma and flapless surgery tended towards significance (P = 0.07). Other variables studied, including use of drain and concomitant central compartment neck dissection, had no effect on seroma. CONCLUSION: Flapless technique for thyroid surgery may reduce the incidence of postoperative seroma.

Diagnosis of submandibular gland tumors: a comparison of CT and ultrasound.

OBJECTIVES: This study aims at determining whether CT is superior to ultrasound in providing more accurate information in the investigation of submandibular gland tumours. MATERIALS AND METHODS: A retrospective study was carried out between 2005 and 2010. Thirty-five (35) patients, who presented with submandibular gland swelling and had diagnostic ultrasound or CT/MRI prior to surgery and histological examination of tissues removed at surgery were investigated to determine the correlation between radiologic diagnosis and histologic diagnosis. RESULTS: CT was used in the pre-op assessment of 22 patients, 12 of which had correct diagnosis when compared with the histology findings while ultrasound was used in pre-op assessment of 13 patients, 12 of which concurred with the histological diagnosis. With regards to ability to detect malignant lesion, ultrasound had much higher sensitivity than CT and comparable specificity. Therefore, in this study, ultrasound provided a better guide in the pre-op radiologic assessment of submandibular gland swelling. CONCLUSION: Our evaluation of pre-operative diagnosis of CT and ultrasound in the assessment of submandibular swellings reveal that ultrasound is better in determining the nature of the lesion.

Prospective double blind randomized clinical trial comparing 75% versus 95% silver nitrate cauterization in the management of idiopathic childhood epistaxis.

PRIMARY OUTCOME MEASURE: to evaluate which concentration of silver nitrate cauterization was more efficacious in the management of idiopathic childhood epistaxis. SECONDARY OUTCOME MEASURES: to evaluate side effects and pain scores of the differing concentrations. STUDY DESIGN: Prospective double blind randomized clinical trial. PARTICIPANTS AND SETTING: All children 16 years of age or younger referred by the accident and emergency department or general practitioner, with recurrent idiopathic epistaxis, who met the inclusion criteria entered the trial. Patients were randomized to receive either the 75% or 95% silver nitrate cauterization. Patients were reviewed at two weeks and eight weeks post cauterization. Pain scores, side effects and success of each treatments were recorded at the follow up clinic. RESULTS: 101 patients completed the trial. 52 patients were randomized to receive the 95% concentration, and 49 patients were randomized to receive the 75% cauterization. In the 75% concentration group, 98% of patients had total resolution of their symptoms at the eight-week follow up. Mean pain scores in this group was 1 out of 10. In the 95% group, 90% had total resolution of their symptoms at the eight-week follow up. Mean pain scores in this group was 5 out of 10. There was a statistical difference in efficacy and pain scores (0.01 and 0.001). CONCLUSION: We would recommend the use of 75% silver nitrate cauterization in the management of childhood epistaxis, it appears to be more efficacious, has fewer side effects and is better tolerated.

Cervical surgical emphysema following routine tonsillectomy.

Complications of tonsillectomy have been well documented. However spontaneous subcutaneous emphysema of the neck following tonsillectomy has rarely been described. We report a case of this complication in a young female patient.

A subcutaneous mandibulotomy approach for a salivary clear cell carcinoma of the retromolar trigone.

OBJECTIVE: We report a novel subcutaneous mandibulotomy approach for the excision of a rare clear cell carcinoma, not otherwise specified (NOS) of the retromolar trigone. METHOD: Case reports and a review of the medical literature concerning clear cell carcinoma and subcutaneous mandibulotomy are discussed. RESULTS: A subcutaneous mandibulotomy approach has recently been described for large tumours of the oropharyngeal and parapharyngeal spaces in two series of patients. Clear cell carcinoma, NOS is a rare condition, with few reports in the literature. CONCLUSION: This is the first occasion a subcutaneous mandibulotomy approach for an oral tumour has been described in Great Britain and Ireland, the second reported case of clear cell carcinoma originating in the retromolar trigone region and only the fourth case of associated lymph nodal metastases.

Hemithyroidectomy for benign thyroid disease: who needs follow-up for hypothyroidism?

OBJECTIVE: To identify the incidence and possible risk factors for the development of hypothyroidism following hemithyroidectomy and to determine a simple protocol for the post-op monitoring of thyroid function. DESIGN: Prospective study. SETTING: Tertiary Referral Centre. PATIENTS: Eighty-two consecutive patients who underwent hemi-thyroidectomy between May 2003 and May 2005 were included. The clinical and pathological factors were obtained and statistically analysed. RESULTS: Eighteen per cent of patients became hypothyroid post-operatively. Multivariate analysis demonstrated that risk factors for hypothyroidism following hemithyroidectomy included a pre-operative [TSH] >1.6 microIU/L [P = 0.008, hazard ratio (HR) 14, 95% confidence interval (CI) 2-54] and lymphocytic infiltration graded 3+ or more (P < 0.001, HR 42, 95% CI, 8-195%). There was no relationship between age, sex or weight of resected tissue and the risk of hypothyroidism. CONCLUSION: Patients with raised pre-operative [TSH] or with lymphocytic infiltration of their thyroid specimen should undergo regular testing of thyroid function within the first year of surgery. In all other patients, thyroid function at 12 months is sufficient.

The Allergic Rhinitis and its Impact on Asthma system: a new classification of allergic rhinitis and nasal responsiveness.

OBJECTIVES AND HYPOTHESIS: Allergic rhinitis has traditionally been classified into seasonal and perennial rhinitis. However, many subjects with dual sensitisation do not fit neatly into either category. Recently, the Allergic Rhinitis and its Impact on Asthma workshop has proposed a new allergic rhinitis classification, into intermittent and persistent forms. The purpose of the present study was to investigate whether the symptomatic and secretory responsiveness of allergic rhinitis sufferers correlated well with the Allergic Rhinitis and its Impact on Asthma classification, compared with the traditional classification. STUDY DESIGN: Experimental study. METHODS: Forty subjects with allergic rhinitis and 13 normal controls underwent a unilateral nasal bradykinin challenge protocol. Symptom scores were recorded and secretion weights measured bilaterally using filter paper disks. The symptomatic and secretory responses of allergic subjects were analysed according to both the traditional and the Allergic Rhinitis and its Impact on Asthma classifications, and the two systems were compared. RESULTS: For both classification systems, the two groups of allergic subjects were clearly demarcated by secretory responses. However, after classification according to the traditional system, there was a lack of clear demarcation between the groups as regards symptomatic response, whereas clear demarcation of symptomatic responses was seen after using the Allergic Rhinitis and its Impact on Asthma classification. CONCLUSIONS: In allergic rhinitis subjects, the degree of nasal responsiveness was closely related to their Allergic Rhinitis and its Impact on Asthma classification. Furthermore, this classification was not compromised by the inclusion of subjects with dual sensitisation. Thus, the Allergic Rhinitis and its Impact on Asthma classification may have advantages for future research studies on allergic rhinitis.

Cardiovascular hoarseness: an unusual presentation to otolaryngologists.

OBJECTIVE: We discuss the case of a 73-year-old woman with a six-month history of hoarseness secondary to an aortic arch pseudoaneurysm. METHOD: We present the findings of an extensive review of the literature relating to cardiovascular disorders involving the recurrent laryngeal nerve (i.e. Ortner's syndrome). RESULTS: Ortner's syndrome, also known as cardiovocal syndrome, is a rare condition, with few reports in the literature. CONCLUSION: This is only the second documented case of Ortner's syndrome in Great Britain and Ireland, and the first demonstrating an aortic pseudoaneurysm.

Penetrating air gun wound in the neck.

BACKGROUND: Injuries from air weapons can be serious and potentially fatal. It has been estimated that up to four million such weapons exist in UK households. CASE REPORT: We present the case of an 8-year-old boy who sustained a penetrating neck wound from an air gun. Use of the flexible laryngoscope in the resuscitation room allowed localization of the gun pellet in the airway. CONCLUSIONS: This approach, combined with careful clinical assessment led to immediate removal by direct laryngoscopy, thus avoiding the morbidity of unnecessary surgical exploration.

Should patients with benign positional vertigo be imaged?

Unexpected intra-cranial pathology is unusually encountered in patients with BPV in the presence of a classically positive Hallpike's response and in the absence of any other neurological signs or symptoms. We carried out a retrospective review to assess the incidence of unexpected intra-cranial pathology in patients with a clinical diagnosis of benign positional vertigo (BPV) and to review the role of radiological imaging in these patients. 145 consecutive patients seen by the senior author with a diagnosis of posterior semi-circular canal BPV over a five-year period were reviewed. In the series of 63 patients who underwent MRI, two cases (3.2%) had cerebral aneurysms, one patient had an epidermoid cyst (1.58%) and one patient had a large right parietal arterio-venous malformation. We would conclude that possible warning signs exist that may alert the clinician to the possibility of unexpected intracranial pathology including failed response to the initial Epley manoeuvre or any asymmetry in hearing. Thus, we would advocate imaging be performed on this sub-group of patients with BPV.

Silver nitrate cauterisation, does concentration matter?

Epistaxis from the anterior septum is frequently treated with a topical application of silver nitrate. There are two concentrations commercially available and in use by otolaryngologists, these are 75% and 95% silver nitrate. The purpose of the present study was to investigate the histological effect of the two different silver nitrate concentrations on mucosal tissue at a fixed contact time of 5 s. Twelve children undergoing routine tonsillectomy were included in this study. Prominent blood vessels on the mucosal surface of the tonsils were identified and a single vessel on each tonsil was selected for application of either 75% or 95% concentration of silver nitrate for 5 s. Depth of penetration across the tonsil tissue was measured following application of the two different silver nitrate concentrations. This study demonstrated a significant difference in depth of tissue penetration with the 95% averaging a twofold increase in penetration depth. It is likely that the increased depth of penetration with 95% silver nitrate may increase the risk of complication of nasal cautery such as septal perforation, particularly in patients undergoing repeated or bilateral nasal cautery.