5 Key Points: Prior studies demonstrated a failure to identify and localize head and neck cancers via near-infrared (NIR) imaging of indocyanine green (ICG) with a robot-integrated platform. However, our group demonstrated success in visualization of neoplasms using a commercially available dedicated NIR camera system and a technique called second window ICG (SWIG), in which ICG is injected 24 hours pre-operatively.We aimed to evaluate the SWIG technique in patients undergoing transoral robotic surgery (TORS) for oropharyngeal squamous cell carcinoma (OPSCC) and compare two NIR camera systems.System 1 showed poor tumor-margin delineation with no fluorescence in 4/6 cases (66.7%) and only minimal fluorescence in the remaining 2 cases (33.3%).System 2 showed marked fluorescence in 5/6 cases (83.3%), with good margin definition in 4 cases (66.7%). In 2 cases (33.3%), System 2 also identified tumor that was not visible under white light.In this preliminary case series, we found that System 2 outperforms System 1 in NIR imaging with SWIG during TORS for oropharyngeal tumor resection.

Objective: Epistaxis is the most common otolaryngological emergency and up to one third of patients in treated on an inpatient basis take oral anticoagulants (OAC). Direct oral anticoagulants (DOAC), an OAC subgroup, have been on the market since 2010 and are being increasingly prescribed due to the cardiologic and hematologic guidelines that favour them over vitamin K antagonists (VKA), the older of the OAC subgroups. The present study aims to investigate which subgroup of epistaxis patients taking OACs has a more favourable outcome. Design/Setting: A systematic review and meta-analysis were performed according to the PRISMA 2020 statement using the PubMed and Cochrane Library databases. Continuous data was analysed and standardized mean difference (SMD) was calculated according to Hedges’ g. Dichotomous data was analysed and the Mantel-Haenszel method was applied to establish the odds ratio (OR). Heterogeneity was assessed according to the I2 statistics. Main Outcome/Results: A total of 8 reports covering 1390 patients were included in the final synthesis. The pooled analysis demonstrated significantly shorter hospital stays in the DOAC group (SMD= -0.22, 95% CI -0.42 to -0.02, P= .03) and a significantly higher rate of posterior bleeding in the VKA group (OR= .39, 95% CI .23 to .68, P= .001). No statistically significant differences with regard to recurrence rates, admission rates, the need for transfusion, or surgical intervention (P= .57, .12, .57 and .38 respectively) were found. Conclusion: According to this meta-analysis, epistaxis patients taking DOACs have a more favourable outcome than patients taking VKAs.

Objective: Otitis media (OM) is a common disease in childhood, but much less prevalent in adults, where it, however, tends to have a less benign course. The incidence of OM in children has decreased in recent years, which might be partly explained by the introduction of watchful waiting strategies, and by the introduction of conjugate pneumococcal vaccination (PCV) in children. Adult OM has been sparsely studied, and it is not known whether a herd immunity effect has been achieved after the introduction of PCV. Watchful waiting is usually not considered in adult OM patients. The purpose of this study was to use a national database to investigate the incidence of adult OM in Sweden during the last 20 years. Design: The yearly number of patients aged 20 and over, admitted to hospital with OM was obtained through a national database from 2000 to 2019. The corresponding numbers for outpatients were obtained between 2005 and 2019. Main outcome measures: incidence of acute otitis media in adults in in- and outpatient care. Results: Incidence rates decreased steadily during the study period. Comparing data on hospitalised patients from 2016-2019 to 2005-2008 (PCV was introduced in 2009), the incidence rate ratio was 0.49 (95% CI 0.45-0.53); p<0.0001. The corresponding figures for outpatients were 0.62 (95% CI 0.61-0.63); p<0.0001. The decrease in hospital admissions was most pronounced among younger patients, whereas the opposite was true for outpatient visits. Conclusions: There has been a continuous decrease in incidence of adult patients admitted to hospital with OM in Sweden during the last twenty years. Outpatient visits for OM have declined since 2009.

Objectives To explore the impact of COVID-19 on the management and outcomes of acute paediatric mastoiditis across the UK. Design National retrospective and prospective audit Setting 48 UK secondary care ENT departments Participants Consecutive children aged 18 years or under, referred to ENT with a clinical diagnosis of mastoiditis. Main outcome measures Cases were divided into: Period 1 (01/11/19-15/03/20) before the UK population were instructed to reduce social contact, and Period 2 (16/03/20-30/04/21), following this. Periods 1&2 were compared for population variables, management and outcomes. Secondary analyses compared outcomes by primary treatment (medical/needle aspiration/surgical). Results 286 cases met criteria (median 4 per site, range 0-24). 9.4 cases were recorded per week in period 1 versus 2.0 in period 2, with no winter increase in cases in Dec 2020-Feb 2021. Patient age differed between period 1&2 (3.2 Vs 4.7 years respectively, p<0.001). 85% of children in period 2 were tested for COVID-19 with a single positive test. In period 2 cases associated with P. aeruginosa significantly increased. 48.6% of children were scanned in period 1 vs 41.1% in period 2. Surgical management was used more frequently in period 1 (43.0% Vs 24.3%, p=0.001). Treatment success was high, with failure of initial management in 6.3%, and 30-day re-admission for recurrence in 2.1%. The adverse event rate (15.7% overall) did not vary by treatment modality or between periods 1& 2. Conclusion The COVID-19 pandemic led to a significant change in the presentation and case-mix of acute paediatric mastoiditis in the UK.

Objective: The literature on the entity of the anterior larynx (AL) is restricted to little evidence on the difficulty encountered in exposing the larynx for intubation, perioperative morbidity and mortality, and scant reports on its prevalence in general adults and children. We here describe the prevalence of AL in a series of children presenting with aerodigestive symptoms and explore its association with functional abnormalities, congenital and structural anomalies or conditions. Setting: Tertiary pediatric center Methods: we conducted a retrospective case-control study. Using a prospectively collected surgical database we identified patients diagnosed with AL (grades IIb-III-IV Modified Cormack-Lehane scale) and sex and age-matched controls who had undergone full airway endoscopy for aerodigestive symptoms. We collected the demographics, presentations, associated diagnoses, and investigations. We compared the proportion of patients with large airway abnormalities and dysmorphism and estimated the prevalence of AL. Results: over a 5.5-year period, 58 children (28 females) were matched with 58 controls. Although both groups presented with permutations of stridor, respiratory failure, cyanotic spells, swallowing and feeding difficulties and SDB, AL presented much more with swallowing and feeding problems (33 vs 20, p<0.05). There were significantly more children with dysmorphism in the AL group (29 vs 9, P < 0.05). The prevalence of AL was 4.9%. Conclusions: This is the first study to report the prevalence of AL amongst a cohort of children with aerodigestive symptoms. Its significant association with dysmorphic features warrants genetic consultation. It is associated with swallowing abnormalities that justifies a systematic instrumental evaluation

Five Key Points • Subglottic stenosis (SGS) is the commonest tracheobronchial manifestation of granulomatosis with polyangiitis (GPA), with early recognition and treatment key to preventing its vasculitic progression and fibrosis. • Previous studies have shown SGS to be the first feature of GPA in 4% of cases. It is not uncommon to see negative biochemical (10% ANCA negative) and negative histological biopsies (77% of head and neck specimens are negative). • Our management strategy emphasized rapid SGS-GPA treatment with limited surgical manipulation of the airway and systemic immunosuppression (IS) to prevent evolution of SGS & concurrent systemic vasculitic relapse. • In our study early multi-disciplinary team involvement to deliver induction IS in the presence of active SGS-GPA led to a procedure free interval (PFI) of 31.3 months. This is a significant increase compared to other published studies. • Nineteen percent (4/21) of the cohort did not require any surgical input following induction IS.

Objective To determine the impact of the COVID-19 pandemic on acute admissions and inpatient activity at a tertiary referral centre. Design Retrospective review of coding-based inpatient electronic records. Setting An otolaryngology and head and neck surgery department at a UK major trauma and tertiary referral centre. Participants Otolaryngology patients admitted as an emergency over a period of 12 months pre-COVID19 (01/04/2019-31/03/2020) and 10 months post-COVID19 (01/04/2020-23/01/2021). Main outcome measures Baseline characteristics, admission rates, length of stay (LoS), overall mortality and 30-day mortality. Results 1844 records were reviewed; (1293 pre-COVID19, 551 post-COVID19). Admissions across all age groups were reduced, with an increase in mean age from 40.4 to 47.4 years (p=0.001). LoS remained unchanged (3.74 vs 3.82 days, p=0.251). Epistaxis remained the most common presentation, with an increased LoS compared to the pre-COVID19 cohort. GP referrals reduced from 18.0% to 4.2% (n=233 vs n=23, p<0.001) and ED referrals proportionally increased from 60.9% to 75.3%, n=787 vs n=417, p<0.001). Critical care admissions were higher in the post-COVID19 cohort (OR 1.82 (1.11-2.99) [95% CI], p=0.017). There was no significant difference in overall mortality between groups (n=74, 5.7% vs. n=33, 6.0%; p=0.844). Thirty-day mortality increased from 0.9% (n=12) pre-COVID19 to 2.3% (n=13) post-COVID19 (p=0.03). Conclusions This study demonstrates significant changes and a reduction in acute otolaryngology presentations. Our findings suggest that sicker, frailer patients were admitted during the pandemic. This study highlights important considerations for acute otolaryngology care moving forward after the pandemic.

Objectives The aim of this study was to compare patient reported pain scores and analgesia requirements between endoscopic and microscopic ear surgery. Design Prospective cohort study Setting Secondary care setting from June 2017 to December 2020. Participants Patients undergoing ear surgery performed by a single surgeon. Main outcome measures The primary outcome measure was patient reported pain as recorded by a visual analogue scale (VAS) at days 1,2,3 and 7 post-operatively. Secondary outcome measure was post-operative analgesia requirement. Results Overall, forty-nine patients encompassing 65.3 % (32/49) endoscopic and 34.7% (17/49) microscopic procedures were audited. Endoscopic procedures have statistically significant lower VAS pain threshold outcomes when compared against the microscopic procedures on post- operative day one (endoscopic group median VAS 1.5 [0.00;11.5] mm versus microscopic group median VAS 27.0 [15.0;65.0] mm); to day seven (endoscopic group median VAS 0.5 [0.00;2.75] mm versus microscopic group median VAS 9.00 [2.00;52.0] mm).  Requirement for analgesia was greater in the microscopic group at day one compared to the endoscopic group (64.5 %, 20/31 endoscopic group vs. 100 %, 17/17 microscopic; p= 0.004). Conclusion Endoscopic ear surgery is less painful and requires less analgesia in the initial post-operative period than microscopic surgery in this cohort. The overall results of this study are useful for pre-operative patient counselling and pain management in the clinical setting. Given the differing applications of microscopic and endoscopic ear surgery, further research is required to study the influence of bone removal, type of operation, and incision type on pain after ear surgery.

Abstract： Background: Baha Attract System was designed as non-skin penetrating bone conduction implant to minimize skin complication. However, there were insufficient studies on its long-time acoustic outcome and safety in microtia patients with auricle reconstruction surgeries, who have thinner retroauricular subcutaneous layer and theoretically vulnerable skin at the implant side. Objectives: To analysis the long-term hearing performance and soft tissue complications of Baha@ Attract System in microtia population. Study Design & setting: A prospective cohort study at single tertiary referral center. Patients: Twenty Mandarin-speaking patients with congenital bilateral microtia who were underwent Baha@ Attract implantation with or without auricle reconstruction surgeries simultaneously. Main Outcome Measure(s): Comparative analysis of audiological test results including hearing thresholds and speech recognition in quiet and in noise were pre- and post-operatively performed. subjective benefit as measured with the SSQ Scale. Soft tissue outcomes were monitored and documented. Results: The mean follow-up time was 36.11±3.30 months. Significant and stable improvements in hearing threshold and speech understanding in noise and quiet were demonstrated with aided condition. Subject evaluation revealed high level of patients’ satisfaction with the amplification in all the subscales. Adverse events including skin necrosis increased after one year post-operatively. Soft tissue evolution including sin thinning, erythema, epidermis atrophy, soft tissue atrophy, skin necrosis was seen or once developed in most of the participants. However, prevalence of severe soft tissue complication was not higher to non-microtia population. Conclusions: Baha@ Attract System provides favorable and stable hearing improvements for microtia patients. Combining plastic surgeries with implantation will not increase the prevalence of soft tissue complication. However, long-term soft tissue problems should be highly aware of even after one year post implantation. Key words: Baha Attract, microtia, hearing, soft tissue, skin necrosis

Objectives: To determine the effectiveness of ciprofloxacin 0.3% antibiotic eardrops in preventing clinically significant postoperative otorrhea and tube obstruction following grommet insertion in children. Design: 3-arm double-blinded randomized controlled trial. Randomisation in 1:1:1 ratio into two interventional and one control arm. The interventional groups received either 5 drops of topical ciprofloxacin 0.3% eardrops in each ear intraoperatively or intraoperatively and for 5 days postoperatively. The control group received no drops. Patients were assessed by blinded assessors at 6 weeks postoperatively. Setting: The study was conducted in a large tertiary health network in Melbourne, Australia. Participants: All children, 17 years and under, undergoing bilateral MEVT surgery with or without concurrent upper airway surgery for recurrent acute otitis media and chronic otitis media with effusion were approached. Main Outcome Measures: Presence of postoperative otorrhea and ventilation tube obstruction at 6 weeks postoperatively. Results: 256 pediatric patients completed the study with a median age of 4.02 years. 153 participants were male. Intraoperative antibiotics were more effective than control in preventing otorrhea (RR=0.341, 95%CI 0.158–0.738, NNT= 11.25, p=.006). Postoperative antibiotics were more effective than control in preventing ventilation tube obstruction (RR=0.424, 95%CI 0.193 to 0.930, NNT=14.7 p=.032). Conclusion: Intraoperative topical ciprofloxacin was effective at preventing early postoperative otorrhea and a prolonged course was effective at preventing ventilation tube obstruction. Future studies on this topic should seek to clarify whether particular subgroups of patients benefit more from prophylactic topical antibiotics and model for cost-effectiveness. Trial Registration: This trial was registered prospectively on the Australian New Zealand Clinical Trials Registry (ACTRN12618001082291) on the 28th of June 2018. Available at URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375306

Objectives: To assess the cohort of patients undergoing sialendoscopic intervention for improvement of symptoms and gland-related quality of life at long-term follow up. Design: retrospective review of medical records with a prospective follow-up by questionnaire. Methods: All patients undergoing sialendoscopy between March 2008 and June 2020 were analyzed in detail regarding indications, technical aspects and postoperative course. To maximize follow-up, patients also received a questionnaire by e-mail. Results: 272 sialendoscopies were performed in 221 patients. Median follow-up time was 37 months. The sialendoscopies were performed in 130 patients for lithiasis, in 66 for stenosis, in 14 for recurrent parotitis of childhood, in 8 for recurrent sialadenitis of unknown origin and in 3 for radio-iodine induced sialadenitis. Complications occurred in 11 of 272 sialendoscopies (4%). Those were iatrogenic perforations, temporary lingual nerve paresthesia and swelling of the floor of the mouth. 53% of patients returned the questionnaire, for a total of 146 evaluable sialendoscopies. The majority of the responders indicated that sialendoscopy had improved their symptoms (83.6%). Salivary glands could be preserved in 89% of the responder group. The highest percentage of patients reporting residual symptoms was found in the RPC group (81.3%) and the lowest in the lithiasis group (16.2%). Besides age, no statistical differences in demographic and pathological features between the responder and non-responder groups were found, supporting generalization of the responders’ results to the entire cohort. Conclusions: This study confirms the good long-term outcomes of sialendoscopic interventions in patients with chronic sialadenitis of different etiologies and a high rate of gland preservation.

Objectives: To determine the cost-effectiveness of auditory brainstem response prior to MRI (ABR-MRI) compared to standalone MRI to diagnose vestibular schwannoma. Design: A state transition decision-analytic model was developed to simulate costs and effects (quality-adjusted life years) for both treatment strategies for patients suspected of a vestibular schwannoma. Model input was derived from literature, hospital databases, and expert opinions. Scenario and sensitivity analyses addressed model uncertainty. Results: Over a lifetime horizon, ABR-MRI resulted in a limited cost-saving of \euro68 or \euro98 per patient (dependent on MRI sequence) and a health loss of 0.005 QALYs over standalone MRI. ABR-MRI, however, did miss patients with other important pathology (2% of the population) that would have been detected when using standalone MRI. Calculating the incremental cost-effectiveness ratio resulted in \euro14,203 or \euro19,550 saved per lost QALY if ABR-MRI was used instead of standalone MRI. The results were sensitive to the detection rate of vestibular schwannoma and health-related quality of life of missed patients. Conclusion: The cost-saving with ABR-MRI does not seem to outweigh the number of missed patients with VS and other important pathologies that would have been detected when using standalone MRI.

Abstract Objective: Although various guidelines have been established for the management of antithrombotic therapy during surgical treatments, surgical tracheostomy (ST) under continued antithrombotic therapy (CAT) remains a challenge. We investigated the risk factors for complications after ST by focusing on CAT use during ST. Method: Patients’ medical records from 2009 to 2020 were reviewed in this retrospective study. We selected patients who underwent ST at the Department of Otolaryngology of the University of Tokyo Hospital. Patient demographics, complications, and blood test values were recorded and statistically analyzed to identify the risk factors for postoperative complications. Results: We identified 288 patients (median age: 64 years; 184 men [64%]), among whom 40 (median age: 67 years; 29 men [73%]) underwent CAT. Although the patients undergoing CAT had significantly higher values of activated partial thromboplastin time (p = 0.002) and prothrombin time-international normalized ratio (p = 0.006) than those of antithrombotic naïve patients, no statistically significant intergroup differences were observed in the risks of bleeding, infection, or subcutaneous emphysema. Instead, ST under local anesthesia (p = 0.01) and ST for airway emergency (p = 0.02) significantly increased the risk of early postoperative complications. Conclusion: The results of the present study suggest that ST under CAT can be safely performed without any increased risk of postoperative complications. Nevertheless, surgeons should be extra cautious about early complications after ST under local anesthesia without intubation or ST for airway emergency. Key points: 1. We aimed to investigate the risk factors for complications after ST by focusing on CAT use during ST. 2. Patients undergoing CAT had significantly higher values of APTT and PT-INR than those of antithrombotic naïve patients. 3. ST under CAT can be safely performed without any increased risk of postoperative complications. 4. ST under local anesthesia and airway emergency was a risk factor for complications after ST. 5. Among the complications, subcutaneous emphysema was significantly more frequent in ST under local anesthesia and under airway emergency.

Objectives: The present meta-analysis sought to assess further evidence for the efficacy of steroids in vestibular neuritis (VN). Methods: The PubMed, EMBASE and Cochrane Library databases were searched through August 30, 2019. The main outcome measures were 1) complete caloric recovery, 2) improvement of canal paresis (CP) in caloric testing, and 3) dizziness handicap inventory. The follow-up times were divided into short, mid, and long-term. The main outcome measures were 1) complete caloric recovery, 2) improvement of canal paresis (CP) in caloric testing, and 3) dizziness handicap inventory. Results: Among 276 records identified, 5 studies (n = 253) were included in the analysis. The therapeutic effect of steroid on VN was confirmed (Hedges’g = 0.172, 95% CI 0.048 to 0.295, p = .006). This effect was statistically significant on long-term follow-up (Hedges’g = 0.496, 95% CI 0.285 to 0.708, p < .0001). The therapeutic effect of steroids on VN was better than that of non-steroid treatment (Hedges’g = 0.299, 95% CI 0.107 to 0.490, p = .002). However, this effect was obscured by combination of other treatments. The therapeutic effect of steroids on VN was statistically significant regarding complete caloric recovery and improvement in CP (Hedges’g = 0.364, 95% CI 0.181 to 0.547, p < 0.0001; Hedges’g = 0.592, 95% CI 0.315 to 0.5869, p < .0001) Conclusions: The results suggest that corticosteroids are effective at VN recovery, especially in long-term follow-up. More data are required before recommendations can be made regarding management in patients on corticosteroids.

1. We focused on 175 patients operated on for otosclerosis. There were 89 in group 1 (preoperative 4000 Hz BC threshold better than 2000 Hz) and 86 in group 2 (preoperative 2000 Hz BC threshold better than 4000 Hz). 2. Preoperatively, there was no significant difference in terms of average bone conduction (BC) thresholds, average air conduction (AC) thresholds and air-bone gap (ABG) between the two groups. 3. Three months and 1 year after surgery, group 1 had better audiometric outcomes than group 2 in terms of average AC and BC thresholds and ABG. 4. Postoperative BC gain was better in group 1 than group 2, particularly at 500 Hz, 1000 Hz and 2000 Hz. 5. When the 4000 Hz BC threshold was preoperatively impaired (group 2), it was not worsened after stapes surgery. This was not the case in group 1.

Key Points • Transnasal Oesophagoscopy (TNO) is an approach to inspect the upper aerodigestive tract, especially in the head and neck cancer (HNCA) population that present with dysphagia. • Twenty-five (25) office-based TNO procedures were performed, with a same-day discharge rate of 96% (24/25) and no reported complications. • This case series is the first to compare preoperative and postoperative outcomes (EAT-10) following stricture dilatation using TNO in the UK. Our results show a statistically significant improvement in symptom severity (EAT-10 scores) (n=11, P=0.001). In the majority of these patients, strictures were due to post-radiation complications. Biopsy in 4/5 cases was sufficient for diagnosis/ruling out disease. Of these patients, 80% had a previous HNCA. • This study identifies the remit for a new ‘one-stop’ TNO service for suspected cancer referrals, of which a large proportion are patients with a previous HNCA. Surveillance, therapeutics and diagnostics can be achieved in a single visit. • Earlier staging or treatment may be achieved due to a fast turnover in clinic

Key points 1. This is the first report of adult primary herpetic oropharyngitis in the view point of the differences between the two types of herpes simplex virus (HSV). 2. 41 (25 type 1 and 16 type 2) HSV specific antigen positive cases among 68 immunoserologically confirmed adult HSV primary infection cases were investigated. 3. Significantly low incidence of oral lesions and high incidence of nausea were seen in HSV type 2 oropharyngitis cases, that might mean particular correlation vagus nerve and HSV type 2. 4. Significantly increased white blood cell count and high C-reacative protein value were seen in oropharyngitis by HSV type 2. 5. HSV type 2 possibly cause more severe symptoms and higher inflammatory reactions than type 1, without oral lesions.

Objectives As we pass the anniversary of the declaration of a global pandemic by the World Health Organisation, it invites us to reflect upon the inescapable changes that coronavirus has wrought upon ENT and, in particular, rhinological practice. As it remains unclear when we will globally emerge from the shadow of COVID-19, a critical analysis of the evidence base on both the assessment and mitigation of risk is vital for ENT departments worldwide. This article presents a systematic review of the literature examining articles which consider either the quantification of risk or strategies to mitigate risk specifically in the setting of rhinological surgery. Design Systematic literature review. Results The literature search yielded a total of 3406 returns with 24 articles meeting eligibility criteria. A narrative synthesis stratified results into two broad themes: those which made an assessment as to the aerosolisation of droplets during sinus surgery, further subdivided into work which considered macroscopically visible droplets and that which considered smaller particles, and those studies which examined the mitigation of this risk. Conclusion Studies considering the aerosolisation of both droplets and smaller particles suggest endonasal surgery carries significant risk. Whilst results both highlight a range of innovative adjunctive strategies and support suction as an important variable to reduce aerosolisation, appropriate use of personal protective equipment (PPE) should be considered mandatory for all healthcare professionals involved in rhinological surgery given studies have demonstrated that close adherence to PPE use is effective at preventing COVID-19 infection.