Objectives: Given that 30-50% of children with Down syndrome have persistent obstructive sleep apnea (OSA) after adenotonsillectomy, we evaluated whether demographic, clinical and polysomnographic factors predicted persistent OSA and OSA severity after adenotonsillectomy. Design: Retrospective study. Setting: Secondary care hospital. Participants: Retrospective review of 32 children with the diagnosis of DS and OSA by polysomnography type 1 who underwent adenotonsillectomy, from January 2010 to December 2018. Main outcome and measure: Non-parametric analysis was used to compare pre and postoperative factors, regression was used to model persistent OSA and OSA severity. Results: Thirty-two children were included (17 male, median age 10.00 ± 8.00 years, median body mass index z-score 0.89 ± 1.25). Overall, adenotonsillectomy resulted in a significant improvement in median obstructive apnea-hypopnea index (oAHI) from 7.5 ± 8.95 to 4.40 ± 4.38 events per hour (p<0.001) and in median OSA-18 score from 85.00 ± 12.00 to 61 ± 37.75 (p<0.001). Persistent OSA was found in 56.25% of the children. Univariate regression suggests that postoperative OSA-18 score predicted persistent OSA after adenotonsillectomy. Preoperative oAHI, preoperative oxygen desaturation rate, pre and postoperative OSA-18 scores correlated with OSA severity after adenotonsillectomy. However, in a multivariate model only the postoperative OSA-18 score was able to predict OSA severity after adenotonsillectomy. Conclusions: Although adenotonsillectomy results in a significant improvement of OSA in children with Down syndrome, more than half of the children had persistent OSA. The postoperative OSA-18 score predicted both persistent OSA and OSA severity after adenotonsillectomy.
Letter to the editorTry as we might to make the manuscript selection process as objective as possible, the crapshoot element is unquestionable. Prospective papers are being submitted more frequently than ever, which has broadened the number of reviewers. Medical students and senior faculty alike are being tasked with assessing manuscripts. Different levels of experience, knowledge and variable personal research interests introduce undeniable biases in how papers are ultimately critiqued. We’ve become keenly aware of the importance of evaluating research techniques and the studies themselves for risks of biases; PRISMA, MINORS, MOOSE and ROBINS tools lead a growing list of objective protocols and assessments.1,2,3,4 Have we ever thought of addressing potential biases in how we actually select articles for publication?Obviously, this would be no simple task, but that shouldn’t be a deterrent to making improvements in the process where possible; personal connections come to mind in this regard. Generally speaking, very little is being done to prevent reviewers from being aware of who the authors are and where they’re coming from. Additionally, many submission platforms allow for the selection of preferred reviewers as well as the ability to decline undesired reviewers. While these tendencies are understandable for multiple reasons, their potential to introduce personal biases is noteworthy. For the sake of argument, let’s assign a very simple “risk of personal bias reduction score” for a journal’s manuscript submission platform: One point is given for a) maintaining author confidentiality, b) maintaining institution/location confidentiality and c) avoiding the option to select or decline particular reviewers. As such, the scores range from 0 to 3, with 3 being the most favorable.So how are we doing? Table 1 shows a list of the top 20 otolaryngology journals to date as determined by the h -index, an increasingly popular measure of journal quality based on the number of publication citations.5 Ten of the 19 eligible journals did not take any measures to reduce the potential for personal biases, thus scoring 0. Eight journals earned one point for avoiding the opportunity to select or decline reviewers. Of note, several journals cite this feature as a means of reducing bias; encouraging the submitting author to target “unbiased” reviewers. The value of this is debatable as this feature can easily be used paradoxically. Lastly, one journal scored two points for blinding the reviewers to both the author names and locations.It may seem trivial at first glance, as we’ve grown so accustomed to these aspects of the submission process, but it really isn’t. The notion that editors reviewing manuscripts are immune to biases from prior personal connections and experiences would be extremely shortsighted. Do we really think a given reviewer can assess a submission from a beloved former trainee in a reliably unbiased fashion? How about a manuscript from an institution with which there was a falling out of some kind? These themes are getting increasingly acknowledged in academic publishing, with growing numbers of journals implementing safeguarding measures. At most, there appears to be a nascent interest in addressing these topics within otolaryngology field. With rejection rates at all-time highs, it behooves us to reflect upon what can be done to ensure that the best manuscript wins: Who the authors are, who they know, and where they’re from shouldn’t be significant factors. As it stands currently, our submission platforms leave open avenues for personal connections to have a considerable influence. Reforming these potential biases, or at the very least acknowledging them, is in order.
Introduction: Litigation against the National Health Service (NHS) in England is rising, costing £2.4 billion in 2018/19. The aim of this study was to determine the incidence and characteristics of otolaryngology clinical negligence claims in England. Methods: A retrospective review was undertaken of all clinical negligence claims in England held by NHS Resolution relating to otolaryngology between April 2013 and April 2018. Analysis was performed using information for cause, patient injury and claim cost. Where claim information was adequately detailed, the authors categorised claims by subspecialty, diagnosis and operation. Results: A total of 727 claims were identified with an estimated potential cost of £108 million. From these, 463 were closed claims. Including open claim reserves, the mean cost of a claim was £148,923. Head and neck surgery was the subspecialty with the highest number of claims (n=313, 43%) and highest cost (£51.5 million) followed by otology (n=171, £24.5 million) and rhinology (n=171, £13.6 million). Over half of claims were associated with an operation (n=429, 59%) where mastoid surgery (n=46) and endoscopic sinus surgery (n=46) were equally associated with the greatest number of claims. The most frequent reasons for litigation included failure or delay to diagnose (n=178, 25%) failure or delay to treat (n=136, 19%), intra-operative complications (n=130, 18%) and failure of the consent process (n=107, 15%). Discussion: Clinical negligence claims in otolaryngology are related to several different components of patient management and is not limited to post-operative complications. This study highlights the importance of robust pathways in outpatient diagnostics and the consenting process, especially in the high-risk speciality of head and neck surgery, in order to deliver better patient care and reduce the impact of litigation.
Functional rehabilitation of post-laryngectomy patients is a challenging task; this includes achieving optimal speech and swallowing outcomes. Botox injections are utilised to improve pharyngoesophageal segment tonicity to improve speech and swallowing outcomes. We propose a novel and efficacious technique using a portable video-laryngoscope, GlideScope®, to directly visualise the injection of botulinum toxin in total laryngectomy patients with severe radiation-induced changes.
Objectives The primary aim of the study is to provide recommendations for the investigation and management of patients with new onset anosmia during the COVID-19 pandemic Design After undertaking a literature review, we used the RAND/UCLA methodology with a multi-step process to reach consensus about treatment options, onward referral imaging. Setting and participants An expert panel consistent of 15 members was assembled. A literature review was undertaken prior to the study and evidence was summarised for the panellists. Main outcome measures The panel undertook a process of ranking and classifying appropriateness of different investigations and treatment options for new onset anosmia during the COVID-19 pandemic. Using a 9-point Likert scale, panellists scored whether a treatment was: Not recommended, optional, or recommended. Consensus was achieved when more than 70% of responses fell into the category defined by the mean. Results Consensus was reached on the majority of statements after 2 rounds of ranking. Disagreement meant no recommendation was made regarding one treatment, using Vitamin A Drops. Alpha lipoic acid was not recommended, olfactory training was recommended for all patients with persistent anosmia of more than 2 weeks duration, and oral steroids, steroid rinses and omega 3 supplements may be considered on an individual basis. Recommendations have been made regarding the need for referral and investigation have been made. Conclusion This study identified the appropriateness of olfactory training, different medical treatment options, referral guidelines and imaging for patients with COVID-19 related anosmia. The guideline may evolve as our experience of COVID-19 develops.
Key Points:We describe a novel procedure, Endopharyngeal Ultrasound (EPhUS) and EPhUS-guided FNAEPhUS requires an operator and an assistant, can be performed transnasal or transoral, and utilizes a Endoscopic Ultrasonography BronchoscopeEPhUS is a safe and effective method for biopsy of deep space neck masses inaccessible to transcutaneous FNAKey Words: Endoscopic, Ultrasound, Fine needle aspiration, Neck mass, Biopsy, minimally invasiveEthical Considerations: The patient presented below was informed that this procedure has not been reported in the past and agreed to proceed following standard informed consent. The patient consented to having their case published in the literature.
Treating twenty-five cases of chronic resistant otitis externa with fluticasone propionate (Flixonase®): a case series Utilising Flixonase® in treatment of chronic otitis externaKey points:Chronic cases of otitis externa, resistant to conventional treatments are notoriously difficult to treat, with resolution in these cases challenging.Guidelines suggest the use of corticosteroid in chronic otitis externa, however, there is no specific advice on which corticosteroid to utilise.Our case-series demonstrates the potential benefit of fluticasone propionate in patients who have previously failed a multitude of conventional management options.Despite the limitations of our study, our experience highlights a gap in the literature and suggest fluticasone propionate as an exciting and potentially important tool in the arsenal of the otolaryngologist.
Objective: To evaluate the auditory perception outcomes of cochlear implant (CI) in children with different types of inner ear malformations (IEMs) and to compare them with CI users with the normal cochlea. Design: Retrospective and prospective data collection. Settings: Tertiary referral hospital. Participants: There were 274 CI users with and without IEMs as two groups. Both groups’ chronological age at implantation and duration of cochlear implant usage was matched (±8 months). Main outcome measures: All subjects were evaluated preoperatively and postoperatively with Ling’s sound test and auditory perception test battery, which includes the Meaningful Auditory Integration Scale (MAIS), close-set Pattern Perception Test (PPT), and open-set Sentence Recognition Test (SRT). Also, children with IEMs were assessed for language development. Results: The incidence of IEMs were incomplete partition-II, 40 (29.19%), incomplete partition-I, 36 (26.2%), cochlear hypoplasia, 26 (18.9%), enlarged vestibular aqueduct, 14 (%10.2), incomplete partition-III, 10 (%7.2), common cavity, 8 (5.8%) and dilatation of vestibule, 3 (2.1%) patients. The significant difference was seen in Ling’s sound test and auditory perception test battery scores of children with incomplete partition-I, cochlear hypoplasia, and common cavity (p-value < .005). Conclusion: IEMs group showed different progress according to the type of ear anomaly. Although CI users with enlarged vestibular aqueduct (EVA) had the highest scores, users with common cavity had the lowest scores. Taking these results, caused by anatomical differences, in to account is very critical in follow-ups and rehabilitation programs. Each cochlear implant user should be evaluated according to his/her individual needs.
For centuries it has been humankind’s instinct to cover the mouth and nose when coughing or sneezing. Common sense would dictate this instinctively reduces the dispersion of aerosol and droplets and thus the spread of contact and airborne infections.Aerosol generating procedures (AGPs) have become a new byword for procedures that put clinicians at increased risk of contracting COVID-19. Whilst the title suggests the risk is simply in aerosols, the science is much more interesting. Droplets and aerosols are different, with the distinction between them based on size. Whilst experts disagree on the absolute size when an aerosol becomes a droplet, the general acceptance is that anything bigger than 50 microns (0.05mm) is a droplet and those smaller are aerosols.In most contagious respiratory infections, the principal transmission agents are droplets (1). This is due to the relatively high viral load in a droplet, purely due to its large size, and also the fact that large droplets have weight, and so gravity pulls them down onto surfaces that others can touch – so passing it on. This is why washing hands is so effective against droplet spread.Aerosol transmission is thought to be a much less frequent cause of transmission, mainly due to the very small viral load (given the aerosol itself is by definition very small). However, it is clearly more concerning as these very small, and therefore very light particles, can travel large distances on air currents and can be directly inhaled. That said, it is thought to only play a minor role in transmission compared to droplet spread.During the COVID-19 pandemic PHE (Public Health England) updated guidance on what it considers (AGPs) Aerosol Generating Procedures. Included within this list were examinations of the upper aerodigestive tract in ENT. Any procedure enacting air over a fluid mucosal surface therefore poses a risk of viral dispersion within both droplets and aerosol. Healthcare workers were recommended to reduce endoscopy of the nose and throat. Any essential examination had to be performed using high level PPE including an respirator (N95 or FFP3)(2).Anfinrud et al (3) graphically represented a visual reduction in aerosol production by creating light sheet from a 532-nm green LASER. Comparisons were made between a person talking with and without a cover for the mouth, in their instance, a slightly dampened wash cloth. Light flashes were recorded to evaluate the number of droplets ranging between 5-200 microns. They showed that by covering the mouth, virtually no light flashes were seen. This observation supports the well-known concept that covering the mouth does indeed reduce droplet production.On impact with smooth surfaces droplets disperse to smaller sizes and can aerosolise. Similarly impact onto soft surfaces absorbs droplets reducing their projection as well as the tendency to aerosolise (3).As the pandemic plateaus in countries across the world various strategies are to be considered to return to a new normal. This would facilitate the resumption of diagnostic services whilst maintaining the protection to healthcare workers. One suggestion is the use of facemasks to help reduce the risk of inadvertent droplet dispersion (2). Despite the ‘soft surface’ barrier masks create, in the ENT setting, facemasks obscure access to the nasal cavity thus preventing nasoendoscopy.The ‘SNAP’ (Safe Nasoendoscopic Airway Procedure) developed by endoscope-i Ltd (West Midlands, UK) is a single-use, valved endoscopic port, retrofitted to any surgical mask (Figure 1), permitting entry of a 4mm flexible and rigid endoscope to examine the naso and pharyngolarynx. The valve, a 10.9 mm cylindrical tube truncated by two opposing 45 degree inclined membranes 700 microns thick, approaches a point but terminates in a 700 micron thick and 500 micron wide plateau, creating a ‘duck bill’ formation The valves are formed using a FFF (fused filament fabrication) 3D printing technique with a Flashforge Creator Pro 3D printer. The plateau atop the valve serves to provide a reference for introducing a slit using a hardened steel razor blade that is 400 microns thin. The blade is mounted in a jig to ensure angle, penetration depth and position are controlled as it is driven through the membrane. These measures ensure that the valve opening is observably consistent and less than 50 microns. Once the SNAP is fitted to a surgical mask, any cough or sneeze generated during the procedure is caught within the mask. The valve is configured such that pressure from the patient side will serve to collapse the walls of the valve membrane thereby further sealing the slit in the valve. This seal has been in vitro tested with aerosolised fluorescein(figure 2). The 45-degree angle of the valve walls from the non-patient side similarly allows the blunt tip of the nasoendoscope to deform the valve walls with ease. The cylindrical form of the walls encourages the valve membranes to return to their original flat shape following withdrawal of the endoscope.During the COVID-19 pandemic our tertiary head and neck cancer referral centre managed 120 urgent 2ww cases. Using the Tikka et al calculator (4) 40% of referrals were redirected back to the GP. The remaining 60% either went direct for imaging or underwent endoscopy. In total 40 cases were endoscoped, 9 of which using the SNAP. All 9 cases scoped with the SNAP were completed without any adverse effect. No cough or sneeze was elicited during any of the examinations and observations between the two groups were identical. Subsequently one consultant lead FEES examination was performed under controlled conditions. Again, the procedure was completed without any complications. The patient self-remarked on the comfort of the endoscopy as a result of the stability provided by the SNAP device in the alar region the prevented inadvertent movement during the chin tuck and head turn exercises.Our observations demonstrate the SNAP device is a practical and safe tool to aid reduction in droplet dispersion whilst performing nasoendoscopy. We hope to see the inclusion of such a device in recovery guidelines by national bodies in order to facilitate the return of safe nasoendoscopy in the post COVID Pandemic era.
Aims 1. To systematically review the currently available evidence investigating the association between olfactory dysfunction (OD) and the novel coronavirus (COVID-19). 2. To analyse the prevalence of OD in patients who have tested positive on Polymerase Chain Reaction (PCR) for COVID-19. 2. To perform a meta-analysis of patients presenting with olfactory dysfunction, during the pandemic, and to investigate the Positive Predictive Value for a COOVID-19 positive result in this population. 3. To assess if olfactory dysfunction could be used as a diagnostic marker for COVID-19 positivity and aid public health approaches in tackling the current outbreak. Methods We systematically searched MedLine (PubMed), Embase, Health Management Information Consortium (HMIC), Medrxiv, the Cochrane Library, the Cochrane COVID-19 Study Register, NIHR Dissemination centre, Clinical Evidence, National Health Service Evidence and the National Institute of Clinical Excellence to identify the current published evidence which associates coronaviridae or similar RNA viruses with anosmia. The initial search identified 157 articles. 145 papers were excluded following application of our exclusion criteria. The 12 remaining articles, that presented evidence on the association between COVID-19 and olfactory dysfunction, were critically analysed. Results OD has been shown to be the strongest predictor of COVID-19 positivity when compared to other symptoms in logistic regression analysis. In patients who had tested positive for COVID-19 there was a prevalence of 62% of OD. In populations of patients who are currently reporting OD there is a positive predictive value of 61% for a positive COVID-19 result. Conclusion Our review has shown that there is already significant evidence which demonstrates an association between OD and the novel coronavirus – COVID-19. It is unclear if this finding is unique to this coronavirus as individual viral phenotypes rarely present in such concentrated large numbers. We have demonstrated that OD is comparatively more predictive for COVID-19 positivity compared to other associated symptoms. We recommend that people who develop OD during the pandemic should be self-isolate and this guidance should be adopted internationally to prevent transmission.