Safety of Otological Operating During the COVID-19 Pandemic: A National Prospective Audit of 1130 Cases from 79 Centers.

BACKGROUND: To assess compliance with guidance produced by the UK body representing all ENT Surgeons (ENT UK) and the British Society of Otology (BSO) on restarting otological surgery after the first wave of the COVID-19 pandemic. Safety was assessed by recording surgical complica- tions and transmission of SARS-CoV-2 transmission during this period. METHODS: A prospective multicenter audit of otological surgery was conducted over a 12-week period, from June 15, 2020, to September 6, 2020. RESULTS: One thousand one hundred thirty cases from 79 hospital sites across Great Britain were involved in the study; 91.1% were tested for SARS-CoV-2 pre-operatively, none of whom tested positive; 70.4% were isolated for 7-14 days prior to surgery; 28.2% of surgeons wore full personal protective equipment, compared with 66.6% of anesthetists and 68.2% of scrub staff. The endoscope was used in 75 (6.7%) of all proce- dures, operations were changed to be performed under local rather than a general anesthetic in 3 cases (0.3%) and the "double drape" to protect against aerosol was used in 321 (27.4%) of cases. Trainees were present in 80.3% of cases. Complications occurred in 4% of cases. No patients or staff contracted SARS-CoV-2 during the audit. CONCLUSION: ENT UK and BSO guidance was variably followed, with the highest compliance for the use of an FFP3 mask, a negative SARS-CoV-2 swab, and trainee presence in theater. Surgeons did not use full personal protective equipment as frequently as their anesthetic and scrub team colleagues. There were only minimal changes in surgical and anesthetic techniques. Otological operation after the first wave of the SARS- CoV-2 pandemic was performed safely with no reported COVID transmission or increase in major complications despite changes in operating practice.

Primary Immunoglobulin G4-Related Laryngeal Disease: A Case Series and Review of Literature.

OBJECTIVE: Immunoglobulin G4-related disease (IgG4-RD) is an increasingly recognised cause of various systemic fibro-inflammatory conditions. However, laryngeal involvement as a primary feature is extremely rare. We aimed to report on a case series of such patients and examine the global literature relating to laryngeal involvement. METHODS: Having previously reported a case of IgG4-RD laryngeal pseudotumour, we describe a case series of further 4 patients with primary laryngeal IgG4-RD managed by our UK quaternary airway service and provide a brief overview of laryngeal IgG4-RD. RESULTS: Including our cases, 14 cases of primary laryngeal IgG4-RD have been reported. Vocal cord involvement is relatively uncommon. Repeat biopsies may be required to achieve histological diagnosis. Remission is achievable by commencement of immunomodulatory treatment, following which laryngeal reconstruction may be necessary. CONCLUSION: Laryngeal involvement is a rare presentation of IgG4-RD, itself a rare and difficult-to-diagnose condition. A high and prolonged index of suspicion is necessary from both surgical and pathological specialists for correct diagnosis and management.

Olfactory outcomes after transsphenoidal endonasal surgery.

Background: The endonasal approach is the gold standard for the resection of pituitary tumours, with either microscopic endonasal transsphenoidal (MET) or endoscopic endonasal transsphenoidal (EET) technique. Advantages and disadvantages of both techniques have been widely described in the literature, although limited attention has been paid to its impact on the sense of smell.Objective: The present study aims to quantify the effect of transnasal surgery on pituitary patients and examine olfactory outcomes.Methods: A prospective cohort study assessing the sense of smell of 20 patients (10 MET and 10 EET) pre-operatively. Olfactory function was re-assessed 6 months after surgery, using the University of Pennsylvania Smell Identification Test (Sensonics Inc., Haddon Heights, NJ).Results: The UPSIT (Sensonics Inc.) results showed a median pre-operative score of 33 (IQR 31-37.5) (normosmia). The median post-operative result was 25 (IQR 19.5-32), consistent with moderate microsmia. Twenty percent of the patients had normal olfactory function post-operatively, all of whom were from the EET group. Twenty percent had mild microsmia, equally divided in MET and EET subgroups. Seven patients had severe microsmia. Four patients were completely anosmic at 6 months follow-up.Conclusions: Patients undergoing a transsphenoidal procedure are at risk of olfactory disturbance post-operatively, which may include loss of the sense of smell. This information is relevant to the patients' perioperative experience, and should be incorporated into counselling with regards to outcomes and expectations. Although the study size is small, the study results suggest the ETS technique may be less traumatic for the olfactory function. A larger study powered to fully examine potential differences in olfactory outcomes following ETS and MTS is warranted.

Osteoradionecrosis--a review of current concepts in defining the extent of the disease and a new classification proposal.

Osteoradionecrosis (ORN) is potentially a debilitating and serious consequence of radiotherapy to the head and neck. Although it is often defined as an area of exposed bone that does not heal, it can also exist without breaching the mucosa or the skin. Currently, 3 classifications of ORN are in use, but they depend on the use of hyperbaric oxygen or are too complicated to be used as a simple aide-mémoire, and include features that do not necessarily influence its clinical management. We propose a new classification to cover these shortcomings and to take into account the increasingly widespread use of antifibrotic medical treatment. We classified a series of 85 patients with varying severities of ORN into 4 groups. An analysis of the outcomes of the series showed that the classification staged the severity of the condition simply and that the stage was relevant to both treatment and outcome. The new classification was therefore verified by the series presented.

Tonsillectomy discharge information - An improvement in both patient safety and satisfaction.

Approximately 20,000 adult and 25,000 paediatric tonsillectomies are performed each year in England. 0.9% of these patients return to theatre for post-tonsillectomy bleeding. The Royal College of Surgeons of England (RCSEng) have produced guidelines regarding emergency surgery, with standards for tonsillectomy discharge information. We audited our compliance with these guidelines and patient satisfaction regarding the information currently provided. Theatre records identified all tonsillectomies carried out between December 2012 and February 2013. 71 patients and their electronic discharge information were reviewed for post-operative bleeding information. Each patient was contacted, with a second call made to those who did not answer. 35 patients took part in our telephone questionnaire. Only 35% of patients had post-operative bleeding information on their discharge summary. 51% received no written information either in clinic or on the day of surgery, 66% recalled a verbal explanation. Only 54% knew to go to A&E if they experienced bleeding. 40% were not satisfied with their discharge information, stating that they wanted to know about bleeding, recovery expectations, and information regarding oral intake. A focus group was formed to discuss potential solutions to the audit outcomes and a tonsillectomy leaflet was produced inline with the trust patient information template. It contained specific instructions regarding bleeding and the nearest A&E contact details. It was reviewed by three tonsillectomy patients and their feedback regarding further information on post-operative diet, throat appearance and pain expectations was incorporated. A second cycle of the audit took place between August and September 2013. Results showed improvement, with 83% receiving an information leaflet and 100% a verbal explanation. 100% of patients were satisfied with their discharge information and 100% knew what to do if they bled. As a result we now meet the standards set out by the RCSEng and have increased our patient safety and satisfaction rates.