Self-reported alteration of sense of smell or taste in patients with COVID-19: a systematic review and meta-analysis on 3563 patients.

BACKGROUND: Emerging reports suggest that new onset of smell or taste loss are potential early clinical markers of SARS-CoV-2 infection, but it remains unclear as to what extent. Therefore, the purpose of this study is to systematically assess the prevalence of self-reported altered sense of smell or taste in patients with confirmed SARS-CoV-2 infection, overcoming the limitations of individual studies by meta-analysis of pooled data. METHODS: The databases Medline, Embase, Web of Science, Scopus and MedRxiv's set were searched from inception to the 4th May 2020. This study was conducted following the PRISMA checklist. RESULTS: 18 studies met the eligibility criteria out of the 171 initially screened citations. The overall prevalence of alteration of the sense of smell or taste was 47% , but estimates were 31% and 67% in severe and mild-to-moderate symptomatic patients, respec- tively. The loss of smell and taste preceded other symptoms in 20% of cases and it was concomitant in 28%. CONCLUSIONS: Based on this meta-analysis, we recommend self-isolation and testing, where possible, for patients complaining smell or taste impairment during COVID-19 pandemic in order to prevent spread of disease and propose the inclusion of loss of smell and taste as recognized symptoms of SARS-CoV-2 in the World Health Organization and other relevant regulatory body's lists.

A dural arteriovenous fistula associated with an encephalocele presenting as otitis media with effusion.

OBJECTIVE: This case report illustrates an unusual case of a dural arteriovenous fistula and an associated encephalocele presenting as otitis media with effusion.Case reportA 53-year-old man presented with right-sided hearing loss and aural fullness of 2 years' duration. Examination revealed ipsilateral post-auricular pulsatile tenderness. Computed tomography showed transcalvarial channels suggestive of dural arteriovenous fistula. Further magnetic resonance imaging demonstrated the presence of a temporal encephalocele herniating through the tegmen tympani defect, as well as the abnormal vascularity. Angiography confirmed a Cognard type I dural arteriovenous fistula, which is being managed conservatively. Surgical repair of the encephalocele was recommended but declined by the patient. CONCLUSION: Dural arteriovenous fistula is an uncommon intracranial vascular malformation rarely seen by otolaryngologists, with pulsatile tinnitus being the usual presentation. To our knowledge, this is the first reported case of dural arteriovenous fistula presenting with conductive hearing loss and otalgia.

A standardised pathway for the surveillance of stable vestibular schwannoma.

Introduction Conservative management of patients with a stable vestibular schwannoma (VS) places a significant burden on National Health Service (NHS) resources and yet patients' surveillance management is often inconsistent. Our unit has developed a standardised pathway to guide surveillance imaging of patients with stable VS. In this article, we provide the basis for our imaging protocol by reviewing the measurement, natural history and growth patterns of VS, and we present a cost analysis of implementing the pathway both regionally and nationally. Methods Patients with an extrameatal VS measuring ≤20mm in maximal diameter receive magnetic resonance imaging (MRI) six months after their index imaging, followed by three annual MRI scans, two two-year interval MRI scans, a single three-year interval MRI scan and then five-yearly MRI scans to be continued lifelong. Patients with purely intrameatal tumours follow the same protocol but the initial six-month imaging is omitted. A cost analysis of the new pathway was modelled on our unit's retrospective data for 2015 and extrapolated to reflect the cost of VS surveillance nationally. Results Based on an estimation that imaging surveillance would last approximately 25 years (+/- 10 years), the cost of implementing our regional surveillance programme would be £151,011 per year (for 99 new referrals per year) and it would cost the NHS £1,982,968 per year if implemented nationally. Conclusions A standardised surveillance pathway promotes safe practice in the conservative management of VS. The estimated cost of a national surveillance programme compares favourably with other tumour surveillance initiatives, and would enable the NHS to provide a safe and economical service to patients with VS.

Classification and management of cervical paragangliomas.

INTRODUCTION: Cervical paragangliomas are slow-growing tumours that eventually cause lower cranial nerve palsies and infiltrate the skull base. Surgical treatment may cause the same deficits and, in some, risks more serious neurological deficits. We describe a classification used to guide investigation, consent and management of cervical paragangliomas based on extensive experience. METHODS: The case notes of patients managed by the senior author at a tertiary referral skull base unit between 1987 and 2010 were reviewed retrospectively. A total of 87 cervical paragangliomas were identified in 70 patients (mean age: 46 years, range: 13-77 years). Of these, 35 patients had 36 vagal paragangliomas, 43 patients had 50 carotid body paragangliomas and 8 had both. One cervical paraganglioma arose from neither the carotid body nor the nodose ganglion. The main outcome measures were death, stroke, gastrostomy and tracheotomy. RESULTS: All tumours were classified pre-operatively based on their relationship to the carotid artery, skull base and lower cranial nerves. Type 1 tumours were excised with a transcervical approach, type 2 with a transcervical-parotid approach and type 3 with a combined transcervical-parotid and infratemporal fossa approach. Type 4 patients underwent careful assessment and genetic counselling before any treatment was undertaken. There were no peri-operative deaths; two patients had strokes, one required a long-term feeding gastrostomy and none required a tracheotomy. CONCLUSIONS: The use of a pre-operative classification system guides management and surgical approach, improves accuracy of consent, facilitates audit and clarifies which patients should be referred to specialised centres.

Cochlear function following implantation with a full electrode array.

OBJECTIVES: Clinicians traditionally advise patients that implantation with a conventional full cochlear implant array will lead to loss of any remaining hearing in the implanted ear. We sought to assess the extent to which 'standard' insertion of a full electrode array affects cochlear function. METHODS: Air conduction pure tone audiometry was performed as part of the routine 6-month postimplantation audiological assessment for 81 adult patients who preoperatively had identifiable pure tone thresholds. All patients were implanted with the nucleus CI24 device, with complete insertion of a straight array in 68 and a contour array in 13 patients. A separate cochleostomy was fashioned anterior to the round window using a 1 mm diamond burr, and the array inserted without lubrication. The operating surgeon was blinded to the inclusion of patients in this study at the time of surgery. RESULTS: Of 81 patients, 58 preserved some residual hearing at 6 months. The rate of preservation of hearing was higher in the low frequencies. At 500 Hz 77 patients had an identifiable preoperative pure tone threshold, still identifiable postoperatively in 48. At 4 kHz only 25 patients had an identifiable preoperative threshold, preserved in 9, and at 8 kHz 6 of 13 patients still had identifiable pure tone thresholds postoperatively. There was no correlation between the depth of insertion and hearing preservation, both groups having a mean of 5 stiffening rings inserted in addition to the 22 active electrodes. The mean deterioration in threshold in those who had residual hearing was 15 dB at 500 Hz, and in 29 patients the deterioration in the threshold was less than 15 dB. CONCLUSION: Insertion of a full conventional electrode array is not as damaging to cochlear function as often assumed. Residual low-frequency hearing may be preserved in approximately two-thirds of patients 6 months postoperatively. This study supports our counselling patients that despite the delicate nature of the inner ear there is a significant chance that their air conduction hearing will not be lost.

Hearing and ossicular chain preservation in cholesteatoma surgery.

OBJECTIVE: To assess the hearing changes associated with sacrificing an intact ossicular chain during cholesteatoma surgery. METHODS: We reviewed the operation notes of surgical procedures performed by the senior author between October 2000 and April 2006. Thirty-three cases were identified in which cholesteatoma surgery had been performed in the presence of a mobile, intact ossicular chain. One set of case notes was missing; therefore, 32 cases were included in the analysis. The ossicular chain was preserved in 17 cases (14 males and three females) and sacrificed in 15 (eight males and seven females). RESULTS: At the first post-operative assessment, a median air-bone gap deterioration of 3.3 dB was seen in patients in whom the ossicular chain had been sacrificed, while a median air-bone gap improvement of 3.3 dB was seen in those in whom the chain had been preserved. However, multivariable logistic regression analysis suggested that this difference in hearing outcomes was due to pre-operative hearing status, and that preservation of the ossicular chain did not lead to a better outcome. CONCLUSIONS: In cholesteatoma surgery, there is at most a marginal benefit in preserving the ossicular chain. In the current study, the better hearing outcomes associated with preservation of the ossicular chain were accounted for by patients' better pre-operative hearing status. This study did not demonstrate a difference in residual disease rate, but was underpowered to do so.

Late skin flap failure following cochlear implantation.

The objective of the study was to determine risk factors for late skin flap failure following cochlear implantation. The study design was a retrospective case series. Data were collated from 371 implanted patients over a ten-year period. Of these patients, 1.3 per cent (n = 5) developed late skin flap failure. It is concluded that skin flap failure is a significant, though relatively uncommon, complication of cochlear implant surgery. What causes flap failure and why it should occur in such a variable fashion are still largely unknown, though infection undoubtedly plays an important role. The aetiological factors associated with flap failure and possible prevention strategies are discussed.

An approach to the management of paroxysmal laryngospasm.

OBJECTIVE: To review the presentation, risk factors and management of paroxysmal laryngospasm. STUDY DESIGN: Retrospective review of cases. SETTING: A teaching hospital otolaryngology department with a subspecialty interest in airway disorders. PATIENTS: All patients diagnosed with laryngospasm over a two-year period were reviewed. Information was obtained about disease presentation, risk factors, management and symptom resolution. RESULTS: Laryngospasm was diagnosed in nine women and six men. The average age at presentation was 56+/-6.5 years, and there was an 80 per cent association with gastroesophageal reflux disease. Proton pump inhibitors led to complete symptom resolution in six patients and to partial symptomatic relief, requiring no further treatment, in a further four patients. Of the remaining five patients unresponsive to proton pump inhibitor therapy, two continued to experience syncopal episodes due to laryngospasm. Both these patients achieved complete remission after laryngeal botulinum toxin injection. Symptoms recurred after three to four months and were successfully treated with a repeat injection. CONCLUSIONS: The primary risk factor for spontaneous laryngospasm is laryngopharyngeal reflux. Symptoms are distressing and may be relieved in most cases by treatment aimed at suppressing gastric acid secretion. Laryngeal botulinum toxin injection appears to be a viable treatment modality in selected patients with refractory symptoms.

Results of endoscopic surgery and intralesional steroid therapy for airway compromise due to tracheobronchial Wegener's granulomatosis.

BACKGROUND: Upper airway compromise due to tracheobronchial stenosis commonly occurs in patients with Wegener's granulomatosis (WG). There is at present no consensus on the optimal management of this life threatening condition. OBJECTIVE: To assess the results of laryngo-tracheo-bronchoscopy, intralesional steroid therapy, laser surgery and dilatation in managing obstructive tracheobronchial WG. METHODS: Records of 18 previously untreated stridulous patients with obstructive tracheobronchial WG, treated between 2004 and 2006, were prospectively recorded on an airway database and retrospectively reviewed. Information about patient and lesion characteristics and treatment details were recorded. Treatment progress was illustrated using a timeline plot, and intervention-free intervals were calculated with actuarial analysis. RESULTS: There were nine males and the average age at presentation was 40 (16) years (range 13-74). There were 13 patients with tracheal and five with tracheal and bronchial lesions. The average tracheal lesion height was 8 (3) mm, located 23 (9) mm below the glottis. There were 1, 10 and 7 Myer-Cotton grade I, II and III lesions, respectively. Mean intervention-free interval following minimally invasive treatment was 26 (2.8) months. Following endobronchial therapy, the median intervention-free interval was 22 months (p>0.8 vs tracheal lesions). No patient required a tracheostomy or endoluminal stenting. CONCLUSIONS: Intralesional steroid therapy and conservative endoluminal surgery is an effective strategy for treating airway compromise due to active tracheal and bronchial WG, obviating the need for airway bypass or stenting. We recommend the combination of endotracheal dilatation, conservative laser surgery and steroid therapy as the standard of care for treating airway compromise due to obstructive tracheobronchial WG.

A prospective study to determine the incidence of atopy in children undergoing adenotonsillectomy for obstructive sleep apnea.

OBJECTIVES: To investigate the relationship between adenotonsillar hypertrophy seen in pediatric obstructive sleep apnea and upper airway allergy to airborne allergens. METHODS: A prospective study of Radioallergosorbent (RAST) tests to common airborne allergens in children (<16 years old) undergoing adenotonsillectomy for obstructive sleep apnea in a London Teaching Hospital. RESULTS: 20.9% of patients had a positive RAST result to house dust mite, 2.8% to cat hair, 0% to mixed feather, 7.8% to mixed grass pollen and 3.8% to dog hair. CONCLUSIONS: This study does not support the hypothesis that the adenotonsillar hypertrophy seen in pediatric patients with obstructive sleep apnea is contributed to by allergy to airborne allergens. It is possible that there is a localized allergic reaction in the upper respiratory tract mucosa which is not apparent on an assay of systemic IgE.

Haemodynamic instability during thyroid surgery: a baroreflex-mediated neurogenic phenomenon?

We present a case of marked intra-operative blood pressure instability in a euthyroid, fit 33-year-old female undergoing elective hemithyroidectomy. This led to significant haemodynamic compromise, cardiac failure and end-organ damage. There was no evidence of a vasoactive endocrine cause, and the nature and timing of the event strongly pointed towards baroreflex-mediated neurogenic sympathetic dysfunction. This can occur during carotid surgery and neck dissection. Although haemodynamic fluctuations may happen during thyroid surgery, their severity in this case was unusual. We believe this could have been a rebound phenomenon in response to acute decompression of the carotid artery which had been compressed by an enlarging cyst. We suggest that in similar cases blockade of the carotid sinus could attenuate such responses.

Magnetic resonance imaging screening for vestibular schwannoma: analysis of published protocols.

This study seeks to define the most appropriate guidelines for selection of patients for magnetic resonance imaging (MRI) to exclude a vestibular schwannoma. Improved selection may reduce patient anxiety and improve resource utilization. All MRIs of the internal auditory meatus, performed during the year 2000, were reviewed. Audiograms and symptoms were collated for all 'positive' scans and 100 negative scans. Information was analysed using seven published protocols and other defined frequency specific criteria. A diagnosis of vestibular schwannoma was made on 36 scans. Four criteria had a sensitivity of >95 per cent; of these the highest specificity (49 per cent) utilized an interaural difference at two adjacent frequencies of 15.dB in unilateral hearing loss and 20.dB in bilateral asymmetric loss. Applying our best protocol would have reduced the number of scans performed from 392 to 168. The one patient with a vestibular schwannoma who was excluded had trigeminal paraesthesia, an independent indication for investigation.

A novel retractor for use in cochlear implantation.

A new self-retaining scalp retractor is described, which elevates the scalp away from the skull to allow better access and vision in preparing the bony recess for a cochlear implant and protect the pericranium from surgical trauma. It is designed for use with the present generation of small vertical scalp incisions in cochlear implant surgery. In these incisions, the part of the skull drilled to create the implant bed is not directly under the wound; instead, it extends under a flap of scalp and pericranium for 5 cm or more. The retractor is simple to use, and the authors believe that it represents a new type of retractor, which may have other uses in the fields of orthopedic; ear, nose, and throat, cosmetic, and plastic surgery. Photographs demonstrate the instrument in use. A cochlear implant company has agreed to manufacture the instrument.

A novel retractor for use in cochlear implantation.

A new self-retaining scalp retractor is described, which elevates the scalp away from the skull to allow better access and vision in preparing the bony recess for a cochlear implant and protect the pericranium from surgical trauma. It is designed for use with the present generation of small vertical scalp incisions in cochlear implant surgery. In these incisions, the part of the skull drilled to create the implant bed is not directly under the wound; instead, it extends under a flap of scalp and pericranium for 5 cm or more. The retractor is simple to use, and the authors believe that it represents a new type of retractor, which may have other uses in the fields of orthopedic; ear, nose, and throat, cosmetic, and plastic surgery. Photographs demonstrate the instrument in use. A cochlear implant company has agreed to manufacture the instrument.

Intratympanic gentamicin for Ménière's disease; a survey of current UK practice.

Intratympanic gentamicin is increasingly used in the treatment of Ménière's disease. Many protocols have been published for its use, but there is little difference in outcome between them. The goal of the study was therefore to assess current UK practice in the use of intratympanic gentamicin. A postal and e-mail survey of consultant ENT surgeons in the UK was conducted. Of 34 consultants who regularly used intratympanic gentamicin, 21 used a protocol based upon a single intratympanic dose of gentamicin via a needle through the tympanic membrane and repeated after at least a week. The remaining 13 used either a regime of more frequent administration or attempted a more complicated route of delivery in an effort to improve reliability and selectivity of action. In the absence of evidence demonstrating benefit from regimens of increased complexity the majority of consultants are using the simplest possible protocol.