Objective: To evaluate whether prolonged operative time is negatively associated with post-operative complications and length of stay in patients undergoing microvascular free flap reconstruction for complex head and neck defects. Methods: 342 consecutive patients undergoing microvascular reconstruction for head and neck defects between 2017-2019 at a single institution were evaluated. Operative outcomes and operative time were compared whilst controlling for patient and treatment related factors. Results: Mean operative time was 551 minutes and length of stay was 16.2 days. An 11% increase in the risk of a post-operative complication was observed for every additional hour of operative time (OR 1.11, 95%CI 1.03 – 1.21, p=0.011) after adjusting for patient and treatment factors. A cut-off of 9 hours yielded a 92% increase in complications on either side of this (OR 1.92, 95%CI 1.18 – 3.13, p=0.009). Increased operative time was also associated with increased length of stay and return to theatres, but not medical complications. Conclusion: Prolonged operative time is significantly associated with increase surgical complications, length of stay and return to theatres when performing microvascular reconstructive surgery for head and neck defects. Keywords : free flap, microsurgery, operative time, length of hospital stay, complication rate, head and neck surgery Key points : 1. This study analyzed a contemporary cohort over a relatively short period where outcomes can reliably be recorded and verified 2. This is the first Australian study that demonstrated operative time as it relates to surgical technique, comparing pedicled and free flaps and also stratified by flap type, oncological resection, or comorbidity 3. Operations more than 9 hours duration were associated with an 89% increase in the odds of developing a surgical complication 4. Prolonged operative time was also significantly associated with length of stay and return to theatres 5. Future studies are needed to investigate associations with each component of operative time element separately in a multi institutional design

Introduction Otoscopy is a key clinical skill which following the introduction of the Medical Licensing Assessment all newly qualified doctors in the United Kingdom will be required to be able to perform independently. At present there is no consensus on a standardised method for objectively assessing otoscopy skills. Methods Prospective mixed methods study comparing face, content and construct validity of three different platforms for otoscopy skills assessment, using a traditional otoscope with manikin, digital otoscope (Tympahealth) with manikin, and traditional otoscope with a low-cost model ear (SimEar). Skills were assessed using a standardised mark scheme, and five expert assessors and twelve participants who rotated through three Objective Structured Clinical Examination (OSCE) stations representing each model. Assessors numerically ranked validity of each model, and participated in a semi-structured interview of opinion. Results Each platform differed in face, construct and content validity scores, with no one platform consistently outperforming others. Three main themes were identified during thematic analysis of expert assessor interviews: ability to assess what is seen, anatomical reality, and ease of use. The low-cost model showed greatest potential, where modification to include a silicone ear could lead to high validity with marginal increase in cost. Conclusion Several modalities for assessing otoscopy skills exist, each with advantages and disadvantages. Modifications to a low-cost model, for use with either a traditional or digital otoscope, could prove to be the best model.

Aim Approximately 5% 1 of all mucosal head and neck (H&N) squamous cell cancers (SCC) arise from the hypopharynx. 1 Patients with hypopharyngeal SCC (HPSCC) tend to have a poor prognosis compared with other subsites with reported 5-year survival of 27% in the UK.2 Most patients (80%) have stage III/IV disease at presentation.3 There are very few HPSCC-specific studies and this subsite is not well represented in more general H&N SCC trials. Thus, deciding the best treatment plan is difficult and relies on the expertise of an experienced multi-disciplinary team (MDT).4 Patient fitness for treatment complicates matters further. The incidence of H&N cancer increases with age and is closely correlated with deprivation.1 The aim of this series was to review outcomes of patients with HPSCC in our cancer network. Method This retrospective study included all patients with a histological or radiological diagnosis of HPSCC made from August 2016 to August 2018. They were identified from the cancer network MDT database. Subsites included pyriform fossa, post cricoid and posterior pharyngeal wall. Data including patient demographics, treatment details, toxicity and disease control were extracted from case records. Results 118 patients were evaluable. 8 (6.7%) patients had a radiological diagnosis, the remainder were biopsy proven HPSCC. The probability of survival at 24 months was higher in patients of good performance status (PS 0-1: 41.7%, 95% CI 29.7-53.2% Vs. PS ≥2: 27.5%, 95% CI 13.9-43.0%). Patients aged >70 years had a lower probability of survival at 24 months compared to those <70 (<70yrs 44.5%, 95% CI 27.1 – 55.9% Vs ≥70yrs 24.4%, 95% CI 12.6 – 38.3). 57 (48.3%) of the 118 patients were treated with radical intent, of which 19 (33%) died at time of follow-up. 14 of these deaths were cancer related. The median time from primary surgery to adjuvant RT was 17 weeks. Conclusion Most patients with HPSCC present with locally advanced disease and are unsuitable for active anti-cancer treatment. For those treated radically the pattern of treatment failure is loco-regional. A multimodality approach for locally advanced disease with surgery and radiotherapy appears to be advantageous in terms of survival.

Key Points  Transoral resection for oral cavity and oropharyngeal cancer has become popular.  Transoral conventional interrupt knot tying suturing for oral/oropharyngeal defect often requires time.  Transoral barbed knotless continuous suture could reduce operation time with a comparable complication rate.  Knotless barbed suture provides appropriate tension and secure closure with multiple anchors.  Transoral barbed knotless suture is particularly advantageous in deep and narrow areas.

Data Availability StatementThe data that support the findings of this study are available from the corresponding author upon reasonable request.

Introduction- Necrotising fasciitis is a rapidly progressive disease with high morbidity and mortality. Head and neck necrotising fasciitis is a rare clinical entity but may be admitted under an ENT specialist team. An understanding of the presenting features and the need for prompt management is imperative. Case Series-We present a series of patients admitted to hospitals across Greater Glasgow, United Kingdom under Otoloryngology and Maxillofacial surgical teams with head and neck necrotising fasciitis over an 8-year time period. Discussion-8 patients were identified in this case series. We highlight the clinical features, patient demographics and operative courses of this patient group. We highlight the need to recognise peri-ocular necrotising fasciitis, especially in the paediatric population which has not been discussed in the otolaryngology literature previously.

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.

Abstract Background This study aimed to evaluate whether changes in practice and patient behaviour due to the covid-19 pandemic impacted the presentation, management, and outcomes of patients with deep neck space infections (DNSI). Design Retrospective cohort study including all adults presenting to the otolaryngology department at a tertiary UK centre with a DNSI during the first 12 months of the covid-19 pandemic (n = 27), and those from the previous 12 month period (n = 26). Patients with peritonsillar abscess which did not involve deep neck spaces radiologically were excluded. Results The covid-19 pandemic cohort tended to present later after onset of symptoms (5.96 days vs 3.25 days, p = 0.0277), have abscess formation rather than inflammation only (77.8% vs 34.6%, p < 0.01), and develop complications (33.3% vs 7.7%, p = 0.0394). Not reaching statistical significance, the covid-19 pandemic cohort also had larger volume abscess (25.18cm3 vs 14.5cm3, p = 0.291), longer hospital stay (14.48 days vs 6.35 days, p = 0.114), and longer intensive care stay (7.88 days vs 1.78 days, p = 0.0992). Non-significant changes were noted in management, with the covid-19 pandemic cohort being seven times more likely to undergo tracheostomy (25.9% vs 3.8%, p = 0.0504), and more likely to undergo transcervical drainage (37% vs 19.2%, p = 0.224) and hot tonsillectomy (11.1% vs 0%, p = 0.236). Conclusion This study demonstrates the covid-19 pandemic led to delayed presentation and more severe infection, requiring more radical management in patients with DNSI.

Background and Objectives Granular myringitis is troublesome for otologist because uncertain etiology and often been overlooked due to vague clinical symptoms and signs. The ideal treatment is elusive. Our study was to investigate the clinical characteristics of granular myringitis and analyzing the effect of the two different strategies, including carbon dioxide laser (CO2 laser) and caustic agent cauterization to manage granular myringitis. Study Design: Retrospective review Subjects and Methods One hundred and thirty patients with granular myringitis receiving treatment at a single medical center from July 2009 to January 2018 were enrolled. We retrospectively reviewed the charts and surgical records. The main two different strategies to manage focal refractory granular myringitis were analyzed, including carbon dioxide laser and caustic solution. We also recorded the clinical course and determine which strategy is better. Results One hundred and thirty patients with granular myringitis were enrolled. 47/130 (36.1%) had previous otologic procedures. Frequent ototrrhea is the most common symptom (66.1%). Posterior-inferior quadrant is the most common site of involvement (58%). The successful rate of CO2 laser, caustic agent were 94.9% and 79.2%. The recurrence rate was comparable between CO2 laser and caustic agent. No major complication was found in either individual group. Conclusion: Otologic procedure may be a predisposing factor of focal chronic myringitis. Ear drops had poor efficacy compared to other treatments. It can be apply only on minor and fresh symptom cases. In this study, we suggest CO2 laser can be the first line treatment, especially for the troublesome or refractory GM cases, which had the higher successful rate and less complication comparing to caustic agent cauterization.

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.