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.
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
Key Points 1. This study reports clinical outcome data on 76 patients with platinum-resistant recurrent or metastatic head and neck squamous carcinoma treated with nivolumab, making it the largest published single centre case series of its kind. 2. Radiotherapy was administered alongside systemic therapy with nivolumab, defined as radiotherapy within 8 weeks of prior systemic therapy, in 16 of 76 patients (21%). 3. Nivolumab was continued following radiotherapy completion due to ongoing clinical benefit from the drug in 9 of 16 patients (56%). 4. Durable complete response following radio-immunotherapy was seen in 2 of the 9 patients (22%) who continued nivolumab subsequent to radiotherapy. 5. Indications for radiotherapy included symptom control (3 of 9), oligoprogression (5 of 9) and incomplete response (1 of 9).
Background The incidence of thyroid cancer is increasing globally due to the increase in detection of subclinical, low volume papillary thyroid microcarcinomas (PTMC) (<1cm). Several international groups have recommended an active surveillance approach for this low-risk disease. In contrast to many other countries, the UK’s approach to thyroid nodules is to avoid detection of incidental lesions where appropriate. Objective This study aims to establish the proportion of patients with thyroid cancer in the UK that would benefit from active surveillance. Design, participants, and outcome measures: Individuals with PTMC in NHS Lothian from 2009-2020 were reviewed from a local thyroid cancer database. The mode of detection of PTMC and proportion of patients who might benefit from active surveillance were established. Results From 651 individuals with differentiated thyroid cancer managed over 12-year period, 185 individuals with PTMC were identified (28.4%). The majority of PTMC 151/185 (81.6%) were either diagnosed post-operatively following thyroidectomy for benign disease or with nodal disease. Only 24 individuals with PTMC were identified following palpable thyroid nodule, incidental finding on imaging and surveillance screening. Therefore, when the indication for surgery was considered, only 24/651 (3.7%) patients were identified pre-operatively and would therefore be realistic candidates for active surveillance. Conclusion Less than 4% of patients with thyroid cancer in the UK would be appropriate for active surveillance. Rather than developing programs to deal with this minority of patients, focus should be maintained on minimizing detection of these low-risk cases.
Introduction: A large proportion of patients with infectious mononucleosis (IM) have abnormal liver function tests (LFT) at presentation. There is no guideline regarding the management and follow-up of these patients. Some patients also have abdominal ultrasound due to deranged LFT, the need for this practice is unclear. The aim of this systematic review was to evaluate the evidence base on LFT assessment in IM, time to resolution of derangement, and the role of abdominal ultrasound. Methods: A systematic search of PubMed, EMBASE and the Cochrane library was done. Two authors independently screened records for eligibility using pre-defined criteria. We included both adult and paediatric populations. Quality assessment of included studies was done. Results: A total of 3924 patients were included from 32 studies. A combination of typical clinical features, heterophile antibodies and EBV-specific antibodies were used to ascertain diagnosis. The following proportion of patients had abnormal LFTs: AST (57%); ALT (62%); ALP (65%); Bilirubin (16%); GGT (41%). Reported median (i.q.r.) time to resolution of LFT was 8 (6–12) weeks. Maximum time to resolution was >6 months. Clinical hepatomegaly and splenomegaly were found in 35% and 44% of patients respectively. Enlarged liver and spleen on ultrasound were seen in 16/29 (55%) and 38/38 (100%) of patients respectively. There were no reports of decompensated liver disease. Conclusion: Derangement in LFTs can persist over six months from initial presentation in IM. However, this is self-limiting. The evidence suggests serial liver function assessments and ultrasound abdomen are not required in immunocompetent patients with subclinical derangement in LFTs.
Introduction Silver nitrate is commonly used within otolaryngology to treat granulation tissue in severe otitis externa. It appears radio-opaque on CT (computed tomography) imaging and therefore can mimic bony fragments and foreign bodies. This is particularly cumbersome when the phenomena correlates to the clinical complaint. Discussion We report two cases of 73-year-old and 75-year-old males who presented with chronic otalgia and discharge. Granulation tissue in the external auditory canal was identified and chemically cauterised with silver nitrate. Subsequent CT petrous bones demonstrated an unidentified foreign body in the canal with extensive soft tissue swelling giving an impression of a wick in situ and “minor bony erosion in the left external acoustic canal” respectively. An additional CT of a 57-year-old female who had been treated with silver nitrate for granulomatous tissue reported “multiple highly radiopaque foci in the external auditory canal, suggestive of foreign body”. Though relatively unknown, this phenomenon has been reported in literature. However, there are few reports of silver nitrate artefacts in CT images of the head no cases in the context of otitis externa. Our patients avoided further imaging or surgery following clarification with the radiologists and symptomatic improvement with long-term intravenous antibiotics. Conclusion Given the prevalence of CT imaging and cauterization in otolaryngology, we recommend contemporaneously documenting the use of silver nitrate and highlighting this on request forms to avoid alarming erroneous reports, unnecessary investigation and surgical procedures. We also recommend, where clinically acceptable, to use silver nitrate prior to imaging.
Abstract Objectives: To assess the impact of risk factors on the disease control among CRS patients, following 1 year of functional endoscopic sinus surgery (FESS), and combining the risk factors to formulate a convenient, visualized prediction model. Design: A retrospective and nonconcurrent cohort study Setting and Participants: A total of 325 patients with Chronic rhinosinusitis (CRS) from June 2018 to July 2020 at the First Affiliated Hospital, the Third Affiliated Hospital, and the Seventh Affiliated Hospital of Sun Yat-sen University. Main Outcomes Measures: Outcomes were time to event measures: the disease control of CRS after surgery 1 year. The presence of nasal polyps, smoking habits, allergic rhinitis (AR), the ratio of tissue eosinophil (TER), and peripheral blood eosinophil count (PBEC)and asthma was assessed. The logistic regression models were used to conduct multivariate and univariate analyses. Asthma, TER, AR, PBEC were also included in the nomogram. The calibration curve and AUC (Area Under Curve) were used to evaluate the forecast performance of the model. Results: In univariate analyses, most of the covariates had significant associations with the endpoints, except for age, gender, and smoking. The nomogram showed the highest accuracy with an AUC of 0.760 (95% CI, 0.688-0.830) in the training cohort. Conclusions: In this cohort study that included the asthma, AR, TER, PBEC had significantly affected the disease control of CRS after surgery. The model provided relatively accurate prediction in the disease control of CRS after FESS and served as a visualized reference for daily diagnosis and treatment.
Introduction: Necrotising otitis externa (NOE) is a serious, progressive infection of the external ear canal. If untreated, it can invade into temporal bone, skull-base and surrounding tissue resulting in cranial nerve palsies, neurological infections and death. Patients present with unremitting, severe otalgia, otorrhoea and oedematous ear canals containing granulation. Surgery has a limited role; the mainstay of treatment involves a long course of intravenous antibiotics. Currently, there is no data on the complications of antibiotic treatment for NOE. This project aims to provide evidence on the nature/frequency of severe treatment-related complications requiring a change in antibiotic regime. Methods: A retrospective 5-year cohort analysis was performed on 64 patients who were treated for confirmed NOE with intravenous antibiotic therapy. Clinical notes, blood results and antibiotic prescriptions were documented and analysed. Results: Average duration of treatment was 11 weeks (range=38 weeks). There was an average of 2.1 antibiotic regimes per patient with 10 cases requiring inpatient admission due to treatment-related complications. 63% of treatment changes were directly related to adverse effects of intravenous antibiotics. Drug allergy/intolerance (n=18) and clinical deterioration i.e. Lack of symptomatic improvement and/or worsening inflammatory markers (n=18), were the most common reasons for antibiotic change. Neutropenia, deranged liver function tests and acute kidney injury were also recognised adverse effects of treatment. Conclusion: This study provides the first evidence on the notable frequency of antibiotic-related complications in NOE patients. Larger, multicentre studies are required in the future to validate our findings and will better inform both clinicians and patients of the risks of treatment.
- We retrospectively evaluated a large series of patients (n: 15) underwent a modified transmanubrial approach for wide mediastinal resection in case of malignance thyroid mass - In fourteen cases, also with thyroid tumor involving the middle line. A bilateral mTMA was necessary to perform a cava vein resection. - No major postoperative and cutaneous/sternum complications were detected. - mTMA allows an optimal exposure of the upper thoracic inlet achieving a complete radical oncological resection of the tumor/lymph-node and a safety vascular/tracheal control. - As a limitation, the modified mTMA is anatomically more demanding and not familiar for most surgeons in comparison to sternotomy
Objectives: We aimed to characterise the use of tracheostomy procedures for all COVID-19 critical care patients in England and to understand how patient factors and timing of tracheostomy affected outcomes. Design: A retrospective observational study using exploratory analysis of hospital administrative data. Setting: All 500 National Health Service hospitals in England. Participants: All hospitalised COVID-19 patients aged ≥ 18 years in England between March 1st and October 31st, 2020 were included. Main outcomes and measures: This was a retrospective exploratory analysis using the Hospital Episode Statistics administrative dataset. Multilevel modelling was used to explore the relationship between demographic factors, comorbidity and use of tracheostomy and the association between tracheostomy use, tracheostomy timing and the outcomes. Results: In total, 2,200 hospitalised COVID-19 patients had a tracheostomy. Tracheostomy utilisation varied substantially across the study period, peaking in April-June 2020. In multivariable modelling, for those admitted to critical care, tracheostomy was most common in those aged 40-79 years, in males and in people of Black and Asian ethnic groups and those with a history of cerebrovascular disease. In critical care patients, tracheostomy was associated with lower odds of mortality (OR: 0.514 (95% CI 0.443 to 0.596), but greater length of stay (OR: 41.143 (95% CI 30.979 to 54.642). In patients that survived, earlier timing of tracheostomy (≤ 14 days post admission to critical care) was significantly associated with shorter length of stay. Conclusions: Tracheostomy is safe and advantageous for critical care COVID-19 patients. Early tracheostomy may be associated with better outcomes, such as shorter length of stay, compared to late tracheostomy.
Objectives: Rhinitis affects up to 40% of the population worldwide and can significantly reduce quality of life. Some patients remain symptomatic despite maximal medical therapy. In refractory cases, posterior nasal neurectomy (PNN - the division of the intranasal nerve branches containing postganglionic parasympathetic fibres) is postulated to reduce symptom burden. The objectives of this paper were to review the literature to establish whether the procedure is effective and safe in the management of allergic and non-allergic rhinitis. Design: A systematic review of Pubmed, EMBASE and MEDLINE was undertaken. Studies were excluded if not available in English or undertaken in non-human subjects. Participants: Seventeen articles satisfied the inclusion criteria studying in total 2029 patients. Sample size ranged from 8-1056. Main Outcome Measures: Patient-reported objective and subjective outcomes and post-operative complications were reviewed Results: There were two randomised controlled trials, two case control studies, and the remaining thirteen were case series using both objective and subjective outcome measures. All but one study found improved patient reported outcomes following PNN. Complications were reported in 10 studies - haemorrhage was the most common complication and was observed in 28 patients (1.6% of subjects). Conclusions: Endoscopic posterior nasal neurectomy is safe and appears to be effective in the treatment of intractable rhinitis but the level of the available evidence was generally poor. Larger, well designed studies are needed to clarify its role in the management of difficult-to-treat rhinitis.
Objective: To summarize the accuracy of artificial intelligence (AI) computer vision algorithms to classify ear disease from otoscopy. Methods: Using the PRISMA guidelines, nine online databases were searched for articles that used AI methods (convolutional neural networks, artificial neural networks, support vector machines, decision trees, k-nearest neighbors) to classify otoscopic images. Diagnostic classes of interest: normal tympanic membrane, acute otitis media (AOM), otitis media with effusion (OME), chronic otitis media (COM) with or without perforation, cholesteatoma, and canal obstruction. Main Outcome Measures: Accuracy to correctly classify otoscopic images compared to otolaryngologists (ground-truth). The Quality Assessment of Diagnostic Accuracy Studies Version 2 tool was used to assess the quality of methodology and risk of bias. Results: Thirty-nine articles were included. Algorithms achieved 90.7% (95%CI: 90.1 – 91.3%) accuracy to difference between normal or abnormal otoscopy images in 14 studies. The most common multi-classification algorithm (3 or more diagnostic classes) achieved 97.6% (95%CI: 97.3.- 97.9%) accuracy to differentiate between normal, AOM and OME in 3 studies. Compared to manual classification, AI algorithms outperformed human assessors to classify otoscopy images achieving 93.4% (95%CI: 90.5 – 96.4%) versus 73.2% (95%CI: 67.9 – 78.5%) accuracy in 3 studies. Convolutional neural networks achieved the highest accuracy compared to other classification methods. Conclusion: AI can classify ear disease from otoscopy. A concerted effort is required to establish a comprehensive and reliable otoscopy database for algorithm training. An AI-supported otoscopy system may assist health care workers, trainees, and primary care practitioners with less otology experience identify ear disease.
It is important to give parents accurate information about complication rates as part of the process of informed consent for surgery. National, routinely-collected data give an opportunity to estimate the rates of rare adverse events such as bleeding, blood transfusion and death.We reviewed data for all Scottish NHS hospitals over the time period 2000-2018 to identify all children (aged 0-16 years) undergoing tonsillectomy, and to identify adverse events occurring within 30 days of the procedure.Readmission to hospital was required in 2%.Surgical arrest of haemorrhage was required in 1%.Blood transfusion occurred in 0.1% and death occurred in one child out of 50,194.