Background: Intra and post-operative blood loss is a major risk in head and neck (H&N) surgery. Recently the use of tranexamic acid (TXA) has been investigated by multiple studies for reducing intra and post-operative bleeding, however reported results are variable. Objectives: To determine the safety and efficacy of tranexamic acid use in Head and Neck surgery. Methods: Systematic review of MEDLINE, EMBASE, CINAHL, Cochrane Library, PubMed, ClinicalKey and Clinicaltrials.gov according to the PRISMA guidelines. Studies were included if they reported on intraoperative bleeding, volume or duration of post-operative drain or return to theatre rate for post-operative haemorrhage in adult populations following use of TXA. Risk of bias assessment with Cochrane Risk of Bias (RoB2) tool for RCTs and NOS tool for non-randomised studies. Results: 16 studies were identified (114, 407 patients). 8 studies evaluated TXA in major H&N surgery and 8 studies in tonsillectomy. Primary outcomes were reduction in intraoperative or post-operative bleeding. Secondary outcomes included the duration of post-operative drain placement and return to theatre rate. No adverse events were reported in any patients. TXA is effective in reducing intra-operative blood loss in tonsillectomy. However, the effect on post-tonsillectomy haemorrhage was unclear. Insufficient evidence exists of benefit of TXA on intra-operative bleeding in major H&N procedures. Post-operative bleeding rates were substantially reduced in most major H&N studies. The duration of drain placement and risk of blood transfusion was unchanged in most cases. Conclusion: TXA use is safe in H&N patients. Whilst sufficient evidence exists to support the use of TXA in tonsillectomy, insufficient evidence exists to recommend use in major H&N surgery. Key words: Tranexamic acid, Head and Neck surgery, thyroidectomy, tonsillectomy

Key PointsPrevious studies have linked recurrent or persistent BPPV to age, anxiety or/and depression and medical comorbidityFactors such as the socioeconomical status have not been assessed.In our retrospective powered cohort we showed that there is a positive correlation between recurrent or persistent BPPV and ageWe found no correlation with the presence of underlying anxiety/depression and recurrent or persistent BPPV and age.While one would have expected that the socioeconomical and educational status would have had an impact on recurrent/persistent BPPV, using the Scottish Index of Multiple Deprivation, we did not identify such link.

Objectives: To investigate the prevalence and risks factors associated with electrode migration in cochlear implant (CI) recipients. Design: Retrospective cohort study of all CIs performed between 1 January 2018-1 August 2021 in a single tertiary adult and paediatric cochlear implant centre in the UK. Main outcome measures: The primary aim is to determine the prevalence of electrode migration, based on comparing intraoperative surgeon report and results of a routine plain X-ray performed 2 weeks after surgery. Electrode migration is defined as the detection of movement of 2 or more electrodes out of the cochlea from time of surgery. Multivariate analysis was performed to investigate risk factors including preoperative factors and intraoperative factors that might predispose to migration. Results: 465 patients, having 516 distinct surgery sessions, with 628 implants were analyzed. Electrode migration occurred in 11.5% of all implants. Pre-existing cochlear abnormality was an independent associated risk factor for electrode migration (OR:3.40<1.20-9.62> p=0.021). Demographics, surgical technique, usage of a precurved electrode, CSF leak, surgeon seniority and intraoperative telemetry did not influence risk of migration. There were 5 implants which migrated later than 2 weeks, median: 263days, for which head injury was a common precipitating factor. There was some difference between different lateral wall electrodes Conclusion: Electrode migration in the early postoperative period is a common occurrence and is more likely in implant recipients with obstructed or malformed cochleae. Keywords : Cochlear implants, Electrode migration, Risk factors, Cochlear abnormalities, Postoperative X-ray

Objective: To investigate the association between laryngopharyngeal reflux (LPR), gastroesophageal reflux disease (GERD) and recalcitrant chronic rhinosinusitis (CRS). Data sources: PubMed, Cochrane Library, and Scopus. Review methods: Three investigators search database for studies investigating the relationship between LPR, GERD and recalcitrant CRS with or without polyposis. The following outcomes were investigated with PRISMA criteria: age; gender; reflux and CRS diagnosis; association outcomes and potential treatment outcomes. Authors performed a bias analysis of papers and provided recommendations for future studies. Results: A total of 17 studies investigated the association between reflux and recalcitrant CRS. According to pharyngeal pH monitoring, 54% of patients with recalcitrant CRS reported hypo or nasopharyngeal acid reflux events. The numbers of hypo- and nasopharyngeal acid reflux events were significantly higher in patients compared to healthy individuals in 4 and 2 studies, respectively. Only one report did not find group differences. The proportion of GERD was significantly higher in CRS patients compared to controls, with a prevalence ranging from 32% to 91% of cases. No author considered nonacid reflux events. There was an important heterogeneity in the inclusion criteria; definition of reflux and association outcomes, limiting the draw of clear conclusion. Pepsin was found in sinonasal secretions more frequently in CRS patients than controls. Conclusion: Laryngopharyngeal reflux and GERD may be a contributing factors of CRS therapeutic resistance, but future studies are still needed to confirm the association considering nonacid reflux event.

Objective: The causative virus of COVID-19 is SARS-CoV-2. The aim of the present study was to invastigate the in vivo virucidal activity of nasal irrigation with saline, nasal irrigation with Povidone-iodine (PVP-I) 1%, nasal irrigation with hypertonic alkaline and nasal irrigation with PVP-I 1% against SARS CoV- 2. Design: The present study was a prospective randomized clinical trial. Setting: A multicenter study involving tertiary care centers. Participants: The study included adult outpatients whose qualitative SARS-CoV-2 RT-PCR tests in nasopharyngeal swabs were positive. One hundred twenty patients divided into four equal groups. Standard COVID-19 treatment was given to group 1 (n=30), nasal irrigation containing isotonic solution was added to patients’ treatment in group 2 (n=30), nasal irrigation containing 1% PVP solution was added to patients’ treatment in group 3(n=30), and nasal irrigation containing 1% PVP solution and nasal irrigation containing hypertonic alkaline solution was added to patients’ treatment in group 4 (n=30). Main outcome measures: On the first day of diagnosis (day 0), nasopharyngeal swab samples were taken, on the 3rd and 5th days the nasopharyngeal viral load reduction in quantitative RT-PCR tests were calculated. Results: Between the 0-3rd Day and 0-5th days, the nasopharyngeal viral load reduction was significant in all groups (p< .05). In paired comparisons of groups, the nasopharyngeal viral load decrease in group 4 in first 3 days was significantly lower than all groups (p < .05). The nasopharyngeal viral load degrease in groups 3 and 4 in the first 5 days were significantly lower than group 1 (p < .05). Conclussion: This study was reveal that the use of hypertonic alkaline nasal irrigation together with 1% povidone-iodine was more effective in reducing viral load in the early period. The decreased nasopharyngeal viral load may reduce the carriage of infectious SARS-CoV-2 in patients. Our results suggest that 1% povidone-iodine and hypertonic alkaline nasal irrigation may be promising modality to prevent the COVID-19 epidemic.

Background: As elective surgical services recover from the COVID-19 pandemic a movement towards day-case surgery may reduce waiting lists. However, evidence is needed to show that day-case surgery is safe for many ENT operations including endoscopic sinus surgery (ESS). We aimed to investigate the safety of ESS in England. Methods: This was an observational, secondary analysis of administrative data. Participants were all patients in England undergoing elective ESS procedure aged ≥ 17 years during for the five years from 1st April 2014 to 31st March 2019. The exposure variable was day-case or overnight stay. The primary outcome was emergency readmission within 30 days post-discharge. Results: Data were available for 49,223 patients operated on across 129 NHS hospital trusts. In trusts operating on more than 50 patients in the study period, rates of day-case surgery varied from 100% to 20.6%. Rates of day-case surgery increased from 64.0% in 2014/15 to 78.7% in 2018/19. Day-case patients had lower rates of 30-day emergency readmission (odds ratio 0.71, 95% confidence interval 0.62 to 0.81). For secondary outcomes measures, there was no evidence of poorer outcomes for day-case patients. Outcomes for patients operated on in trusts with ≥80% day-case rates compared to patients operated on in trusts with <50% rates of day-case surgery were similar. Conclusions: ESS can safely be performed as day-case surgery at current rates. There is a potential to increase rates of day-case ESS in England, especially in departments that currently have low rates of day-case ESS.

Abstract Objective: To determine whether Betahistine dihydrochloride is effective in treating primary tinnitus in adults. Design: Intention-to-treat, randomized, triple-blinding, monocentric clinical trial Setting: Botucatu Medical School – State University of São Paulo (Unesp) in Brazil. Participants: 62 adults with primary tinnitus for at least six months (both sexes), and a Tinnitus Handicap Inventory score above 18 were randomized in two equal study groups: betahistine (24 mg of oral betahistine 12/12hs for 90 days), control group (a matched placebo). Main outcomes measures: Primary outcome measure - change in Tinnitus Handicap Inventory score; secondary outcome - Clinical Global Impression Improvement and participants’ perceived improvement after the intervention. Results: Participants had a median age (interquartile range) of 54 (48 to 60) years, with a balanced number of men and women. There was no significant difference in Tinnitus Handicap Inventory change before and after treatment between the study group and control (median difference of -2 points; 95% CI, -8 to 6 points); the Tinnitus Handicap Inventory after intervention was a median (interquartile range) of 4 (-4 to 14) lower in the betahistine group, and a median (interquartile range) of 2 (-6 to 10) lower in the placebo group. The secondary endpoint, covariate adjustment, and per-protocol analysis provided similar results, and side effects were without difference between both groups. Conclusion: Betahistine was ineffective when compared to the placebo in the treatment of the primary tinnitus .

Objectives To summarise current practices in the diagnosis and management of Deep Neck Space Infections (DNSIs) To inform future studies in developing a framework in the management of DNSIs Design This review was registered on PROSPERO (CRD42021226449) and reported in line with PRISMA guidelines. All studies from 2000 that reported the investigation or management of DNSI were included. The search was limited to English language only. Databases searched included AMED, Embase, Medline and HMIC. Quantitative analysis was undertaken with descriptive statistics and frequency synthesis with 2 independent reviewers. A qualitative narrative synthesis was conducted using a thematic analysis approach. Setting Secondary or Tertiary Care centres that undertook management of Deep Neck Space Infections. Participants All adult patients with a deep neck space infection. Main outcome measures The role of imaging, radiologically guided aspiration and surgical drainage in DNSIs. Results 60 studies were reviewed. 31 studies reported on imaging modality, 51 studies reported treatment modality. Aside from a single RCT all other studies were observational (n=25) or case series (n=36). CT was used to diagnose DNSI in 78% of patients, Mean percentage of management with open surgical drainage was 81% and 29.4% for radiologically guided aspiration. Qualitative analysis identified 7 major themes were identified on DNSI. Conclusion There are limited methodologically rigorous studies investigating DNSIs. CT imaging was the most used imaging modality. Surgical drainage was commonest treatment choice. Areas of further research on epidemiology, reporting guidelines and management are required.

Title: A prospective study comparing Itraconazole and systemic steroids as an adjunct to topical steroids in the post-operative management of Allergic fungal rhinosinusitis ABSTRACT Objectives The objective of this study was to compare the efficacy of Itraconazole and systemic steroids as an adjuvant to topical steroids in post-operative patients with Allergic Fungal Rhinosinusitis (AFRS) using both subjective and objective outcome measurements. Methods A prospective comparative study was conducted in a tertiary care center on 60 patients diagnosed with AFRS. Patients with chronic systemic illness and those undergoing revision surgery were excluded. Post-operative patients were divided into two groups of 30 each which received Itraconazole 400 mg OD or Methylprednisolone in tapering doses over six weeks. The outcomes were measured at the end of 6 weeks -Kupferberg endoscopic staging, Absolute Eosinophilic Count (AEC), Serum Immunoglobulin (IgE), and Sino Nasal Outcome Test - 20 scores. Results Our study showed no statistical significance in outcomes between the two groups treated with Itraconazole and Methylprednisolone regarding recurrence, AEC, IgE, and Quality of Life Assessment (p<0.01). Conclusion Itraconazole was comparable to Methylprednisolone in preventing disease recurrence in the post-operative management of AFRS. It may be a viable alternative to replacing systemic steroids where the latter may be contraindicated. Itraconazole given at a dose of 400 mg once daily for six weeks was a safe dose. Keywords: Allergic Fungal Rhinosinusitis, Itraconazole, endoscopy, Quality of Life, Methylprednisolone Key points: • Itraconazole was comparable to systemic steroid (Methylprednisolone) in preventing disease recurrence in the post-operative management of AFRS. • It may be a viable alternative to replacing systemic steroids where the latter may be contraindicated. • Itraconazole given at a dose of 400 mg once daily for six weeks was a safe dose. • Recurrence may be treated safely with Itraconazole than with steroids. • The course may be repeated in case of recurrence with close monitoring.

Abstract Background: Currently, the most common surgical modalities used for recurrent respiratory papillomatosis resection are microdebrider, CO2 laser, and KTP laser. However, complication rates vary among different surgical modalities and have been controversial in different studies. Objective of review: This study systematically reviews the available studies which reported intraoperative and postoperative complications, aiming to compare the safety of microdebrider, CO2 laser, and KTP laser. Type of review: Meta-analysis. Search strategy: Seven electronic databases (PubMed/MEDLINE, EMBASE[Ovid], Scopus, Cochrane Library, and Web of Science) were searched from inception through April 28th,2022. Randomized controlled, prospective or retrospective observational studies that recorded the complications of three different surgical modalities for recurrent respiratory papillomatosis resection were included in the meta-analysis. Evaluation method: Outcomes of interest were intraoperative and postoperative complications, and complication rate was calculated to evaluate the safety of surgical methods. Results: Twenty different studies was included in quantitative synthesis. Only one study compared outcomes of those three kinds of treatment modalities simultaneously, two studies compared microdebrider and CO2 laser, and the remaining studies focused on only one of three treatments. The weighted average complication rate for microdebrider was 0.03(95% confidence interval [CI] 0.00-0.21), n = 6, for CO2 laser treatment was 0.16 (95% confidence interval [CI] 0.09-0.25), n = 14，and for KTP laser treatment was 0.04 (95% CI 0.00-0.14), n =4. Conclusion：The limited evidence demonstrated that CO2 lasers in the surgical treatment of RRP may lead to more surgical complications, and microdebrider and KTP lasers may be safer. However, the heterogeneous data limits any strong comparison of outcomes of different treatment of laryngeal papillomas. Future randomised controlled trials that directly compare the safety of different surgical modalities are needed.

Background Olfactory dysfunction (OD) is a common but underreported problem that can significantly impact a patient’s quality of life. Dysfunction is prevalent in over 5% of the adult population and can be broadly categorised into conductive and sensorineural causes. Magnetic Resonance Imaging (MRI) can form part of the diagnostic work up, although its exact role is often debated. Objectives The aim of this study was to evaluate the value of MRI in managing patients with OD. Design/ Method A retrospective analysis of the records of patients presenting to national smell and taste clinic over a five-year period was performed. Variables included demographics, endoscopic findings, final diagnosis, psychophysical smell test and MRI results. Results A total of 409 patients underwent clinical assessment and smell testing for OD, of which 172 patients (42%) had MRI scans performed. The age range of patients was 10 to 93 years. Imaging in younger age-groups was associated with a higher rate of positive findings, however identifiable causes for OD were recorded across the range. MRI provided both diagnostic and prognostic information in those with idiopathic, traumatic, and congenital causes of OD. For example, MRI provided information on the extent or absence of traumatic gliosis in those with a head trauma history allowing further treatment and prognosis. Conclusion We recommend the adjunct use of MRI in patients with a clear history and examination findings of head injury, congenital cases and in apparent idiopathic cases. MRI should be requested to compliment clinical findings with a view to aiding decision-making on treatment and prognosis independent of patient’s age.

Objective: This study evaluates the benefits and limitations of selected modalities of digital image enhancement in detection of cholesteatoma remnants during endoscopic ear surgery (EES) and compares their usefulness in recognizing residual disease. Study Design: Cross-sectional study Setting: Tertiary referral hospital Methods: A total of 10 questionnaires of 18 intraoperative pictures with equal numbers of cholesteatoma and non-cholesteatoma images, each presented in three different image enhancing modalities (clara, spectra A, spectra B), were generated. Fifty-one experienced ear surgeons participated in the survey and were randomly assigned to a questionnaire and completed it at two time points. The experts were asked to rate for each picture whether cholesteatoma was present or not. Results Clara showed the highest accuracy in cholesteatoma detection, followed by spectra A and lastly spectra B. In contrast, spectra B showed the highest sensitivity and clara the highest specificity, while spectra A was placed in the middle for both values. Using the spectra B modality, most responses agreed across the two time points,. Ear surgeons assessed the usefulness, as well as preference among image modalities in the following order: clara, spectra B, spectra A. Conclusion The suitability of image enhancement techniques for application in EES could be shown. Clara can be considered the state-of-art technique throughout the procedure and has subjectively been evaluated best by surgeons. Due to its high sensitivity, spectra B is recommended regarding the final check after resection to prevent cholesteatoma residuals.

Background: A James Lind Alliance Priority Setting Partnership (JLAPSP) was established by Fifth Sense together with UEA to identify the top 10 research questions in the field of smell and taste disorders in the United Kingdom. Methods: After steering group was established, an electronic survey was disseminated to all stakeholders (patients, healthcare professionals, family, carers, researchers) to determine the list of questions. After removing out-of-scope responses, the remainder were consolidated to create summary questions. A literature search was conducted to remove already answered questions. A second survey was used to determine the top questions that formed the subject of final debate at a workshop attended by clinicians and patients to determine the top 10 priorities. Results: The 665 respondents to the initial survey provided 1698 research questions. Thirteen were out-of-scope and removed; remaining 1685 were then consolidated to form 147 summary questions. Following literature search and discussion with the steering group, 37 questions remained for the second survey, which 235 people responded. The top ten priorities agreed in the workshop covered themes of improved understanding of pathophysiologlogy, improving health services, and managing long-term effects of smell/taste disorders. The most important research question agreed was “How can we further our understanding of the mechanism of disease in the nerve pathways that affect smell and taste disorders, including where parosmia and phantosmia exist.” Conclusions: We report the top 10 research priorities in smell and taste disorders. These priorities will now empower researchers to secure research funding and provide the basis of the Fifth Sense research hub.

Objective: This study aimed to develop deep learning (DL) models for differentiating between eosinophilic chronic rhinosinusitis (ECRS) and non-eosinophilic chronic rhinosinusitis (NECRS) on preoperative computed tomography (CT). Methods: A total of 878 chronic rhinosinusitis (CRS) patients undergoing nasal endoscopic surgery were included. Axial spiral CT images were pre-processed and used to build the dataset. Two semantic segmentation models based on U-net and Deeplabv3 were trained to segment sinus area in CT images. All patient images were segmented using the better-performing segmentation model and used for training and validation of the transferred efficientnet_b0, resnet50, inception_resnet_v2, and Xception neural networks. Additionally, we evaluated the performances of the models trained using each image and each patient as a unit. The precision of each model was assessed based on the receiver operating characteristic curve. Further, we analyzed the confusion matrix, accuracy, and interpretability of each model. Results: The Dice coefficients of U-net and Deeplabv3 were 0.953 and 0.961, respectively. The average area under the curve and mean accuracy values of the four networks were 0.848 and 0.762 for models trained using a single image as a unit, while the corresponding values for models trained using each patient as a unit were 0.853 and 0.893, respectively. The generated Grad-Cams showed good interpretability. Conclusion: Combining semantic segmentation with classification networks could effectively distinguish between patients with ECRS and NECRS based on preoperative sinus CT images. Furthermore, labeling each patient to build a dataset for classification may be more reliable than labeling each medical image.

Objectives: To explore the effect of intranasal administration of rh-bFGF on postoperative chronic rhinosinusitis with nasal polyps(CRSwNP) patients. Design: A prospective, randomized, controlled, double-blinded trial. Setting and Participants: 75 hospitalized patients who met the criteria of primary bilateral CRSwNP were enrolled from March 2020 to January 2021. Main outcome measures: Visual analogue scale, 22 item Sino-Nasal Outcome Test ,Lund-Kennedy system, and Scanning electron microscopy and Quantitative real-time PCR. Results: 75 patients with CRSwNP were randomly divided into three groups, and 72 patients completed the 1-month medication regimen and 1 year follow-up. Rh-bFGF nasal spray and drop application reduced general nasal VAS scores within two weeks after ESS compared to the control group. In contrast, only rh-bFGF nasal drops reduced SNOT-22 scores at 2 weeks and 1 year compared to the control group. A significant reduction in the endoscopic L-K score was observed in the rh-bFGF nasal spray and drop group compared to the control group. This is primarily because rh-bFGF promotes cilia growth in the nasal mucosal epithelium after the operation, as illustrated by scanning electron microscopy and expression of CP110, Tap73 and Foxj1 mRNA. For eosinophilic CRSwNP, the general VAS score of rh-bFGF nasal drops was more obviously reduced compared to the control group after ESS. A similar trend was observed for L-K score. Conclusions: Rh-bFGF nasal-drops and sprays can quickly and effectively relieve postoperative symptoms and improve long-term prognosis of patients with CRSwNP. Moreover, rh-bFGF nasal-drops are also an effective method for postoperative patients with eosinophilic CRSwNP.

Key Points • CRP reduction at day five of more than 35% from the previous highest concentration post-laryngectomy or laryngopharyngectomy has been proposed to positively predict healing without pharyngocutaneous fistula • Retrospective cohort analysis of 163 patients has not been able to externally validate these findings. • ROC curves and subset analyses have not identified alternative parameters to reach significance • However, there is a non-significant association with decreasing postoperative CRP and healing without fistula. • Multicentre prospective studies to include post-operative procalcitonin could help refine this protocol further.

Introduction Recent guidelines suggest obstructive sleep apnoea (OSA) is not an absolute contraindication for same day discharge following surgery. The aim of this systematic review was to examine the feasibility and safety of day case nasal and/or palatopharyngeal surgery in patients with OSA. Methods We performed a systematic search of PubMed, EMBASE and the Cochrane library. Quality assessment of included studies was done. The protocol of this systematic review was registered with PROSPERO (CRD42021273451). Results A total of 1836 patients from ten observational studies were included. There were 268 (15.4%) nasal surgeries, 738 palatopharyngeal surgeries (42.4%) and 735 (42.2%) combined nasal and palatopharyngeal surgery. The majority of patients had moderate to severe OSA. A total of 860 patients (49.8%) were successfully discharged as day cases. There were no standard criteria for daycase surgery. Post-anaesthetic respiratory events were reported in 86/1750 (4.9%) patients. Oxygen desaturation was the most common respiratory event (83.7%, n = 72). There was no mortality reported. Conclusion Current data suggests day surgery is feasible in carefully selected patients with OSA undergoing nasal and/or palatopharyngeal surgery. Further well-designed prospective studies with an emphasis on the systematic assessment of complications are required to establish safety and daycase criteria.

Objective : This study aims to compare the potential sinus distribution between high-volume nasal irrigation and nasal spray in chronic rhinosinusitis patients who have not undergone sinus surgery. Design and Setting : A randomized clinical study was conducted at the Otolaryngology-Head & Neck Surgery Department, Ramathibodi Hospital, Faculty of Medicine, Mahidol University.Participants : 40 patients undergoing endoscopic sinus surgery for chronic rhinosinusitis. Thirty-eight patients met the inclusion criteria and were randomly assigned to receive nasal irrigation or nasal spray mixed with fluorescein sodium preoperatively. Main outcome measures : The primary outcome was the mean difference in the staining score of fluorescein in all sinuses between the two groups. Results : The total staining score of fluorescein in all sinuses via nasal irrigation was statistically more significant than the score via nasal spray, with a mean difference score of 2.90, 95%CI: 1.22-4.58, p-value 0.001. The most significantly affected sinuses were specific to the maxillary and anterior ethmoid sinuses, whereas the frontal and sphenoid sinuses had the slightest solution distribution from both techniques. Conclusion : Nasal irrigation is a potential route to deliver drugs into the sinus in unoperated CRS patients. However, it is not considered a superior method to nasal spray at the most challenging anatomical areas, i.e., the frontal and sphenoid sinuses. Keywords : Corticosteroid use, Endoscopic sinus surgery, Irrigations, Topical therapy for chronic rhinosinusitis, Medical therapy for chronic rhinosinusitis, Nasal polyp, Nasal spray, Chronic rhinosinusitis