Objectives: Salivary gland malignancies are an uncommon and heterogeneous group of cancers. We report our experience of clinicopathological variables that affect survival in patients treated by curative intent with surgery at a UK institution over a period of 15 years. Design: Retrospective cohort study Setting: Single centre study Participants We included 108 patients with malignant salivary gland tumours treated by curative intent with surgery from 2004 to 2019. Main outcome measures: The association between clinicopathological factors and their impact on overall survival (OS) and disease-free survival (DFS). Results: 77 (71.3%) presented with early pT classification and 81 (75%) of were node-negative. The parotid was the commonest site of malignancy (86, 79.6%). Perineural invasion (PNI) was present in 40 (37%) and lymphovascular invasion (LVI) was present in 20 (18.5%). 63 (58.3%) underwent adjuvant therapy. Median follow up was 36 months. Five-year OS and DFS were 81.7% and 71%. Age 50, pT classification 3-4, high tumour grade, PNI, and advanced TNM stage were all associated with worse OS and DFS, and LVI with worse DFS. There was no survival difference between a close (1-<5 mm) or negative (≥5 mm) resection margin. Conclusions: Age >50 years, advanced TNM stage, PNI and LVI are predictors of poor DFS. There was no difference in OS or DFS between patients with negative and close resection margins, indicating that close margins may be adequate for maintaining good oncologic outcomes in this group of patients.

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.

IntroductionVincristine is a vinca alkaloid chemotherapy agent used in the treatment haematological malignancies including acute lymphoblastic leukaemia (ALL) and some lymphomas. Common toxicity includes neuropathy which can be peripheral, autonomic or less commonly central1. Vincristine remains an essential chemotherapy agent in modern ALL protocols1,2,3. It’s mechanism of action is by inhibiting the M phase of mitosis by binding with the protein component of microtubules. Axonal degeneration takes place when axonal transport and secretory functions are impaired thus leading to apoptosis and toxicity in neural tissue. This is typically seen within the extra-ocular muscles and larynx in cranial neuropathy1.Recurrent laryngeal nerve palsy resulting in vocal cord paralysis (vcp) in children has been documented in the literature in multiple case reports and small number of case series4.We present the largest case series to date of seven children who sustained vcp secondary to vincristine chemotherapy for ALL and review 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.

Objectives: Chronic rhinosinusitis (CRS) is prevalent in the Cystic Fibrosis (CF) population. CRS exacerbations in CF are thought to contribute to pulmonary exacerbations. Literature regarding the impact of endoscopic sinus surgery (ESS) is inconclusive. This study examines rates of lung function decline and pulmonary exacerbation in CF patients who have undergone ESS. Design: Retrospective review of medical records. Setting: Academic Hospital. Participants: 40 adult CF patients. Main outcome measures: Rate of lung function decline (Forced Expiratory Volume1(FEV1) % predicted), number of pulmonary exacerbations (IV/oral antibiotic therapy +/- hospital admission) and total number days hospitalized 2 years post-operatively was collected. CRS patients undergoing ESS were matched to those without ESS by gender, age, and F508del genotype. Results: Forty patients (mean age 37.4, 60% male) were reviewed. No significant difference was found between the surgical group and controls in baseline FEV1(72.5% vs. 72.7%, p=0.98), 2-year pre-operative number of pulmonary exacerbations (3.05 vs. 1.65, p=0.10), or Lund-Mackay scores (12.25 vs. 11.55, p=0.71). No significant difference was found in 1-year (70.5% vs. 72.8%, p=0.84) or 2-year (70.4% vs. 72.6% p=0.80) post-operative FEV1 and 2-year post-operative pulmonary exacerbations (1.7 vs. 1.45, p=0.87). A significant increase was identified in total number days hospitalized post-operatively (4.85, p=0.02). In the surgical group, no significant difference was identified between preoperative and postoperative FEV1, 1 -year (-2.51%, p=0.32) and 2-years after ESS (-3.10%, p=0.51), postoperative rate of pulmonary exacerbations (-1.28, p=0.11), or in total number days hospitalized (3.74, p=0.14). Conclusions: In this study, ESS does not appear to significantly improve FEV1 or decrease the number of pulmonary exacerbations post-operatively.

Introduction There is currently a lack of available data clearly addressing whether the proportion of young patients diagnosed with head and neck cancer (HNC) within the U.S. has increased over the last several decades in comparison to other age cohorts. This study attempts to elucidate any trends in oral cavity, oropharynx, larynx and hypopharynx cancer age distribution in the United States population from 1975-2016. Unlike previous studies, this paper does not track incidence, but rather reports proportional changes of prevalence within age cohorts over time. Methods This is a retrospective chart review centered on data from the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute (NCI). Each decade interval from 1975-2016 displays the proportion of HNC patients, classified by primary tumor subsite, within each age cohort. Results Mean age at diagnosis increased for three of the four HNC evaluated. Oropharyngeal cancer was the only subsite to demonstrate an overall proportional increase, mainly in middle age (40-59 years) patients. Cancers of the oral cavity were the only subset to show a true increase in the proportion of young (0-39 years) patients. When stratifying by gender, the proportion of young patients in female HNC cases is higher than the proportion of young male HNC cases. Conclusion Overall, this study demonstrates an increased proportion of older HNC patients that is consistent with the aging population. Oral cavity is the only cancer to demonstrate a true increase in the proportion of young patients, likely from the increased incidence of young women diagnosed with this cancer. Case reports citing more young patients becoming diagnosed with other types of HNC are not currently supported by the data. Lastly, the increased proportion of middle-age patients with oropharyngeal cancer likely reflects the increase in HPV-related cancers.

Abstract Objective: Total laryngectomy (TL) is a life-saving procedure for individuals with advanced laryngeal cancer or those suffering from recurrence after initial treatment. The present study aims to evaluate the differences between stapler closure (SC) and manual closure (MC) of the pharynx during TL for patients with laryngeal cancer. Design/Setting: A systematic literature search was performed using the PubMed, Embase and Cochrane Library. The data were analyzed using Comprehensive Meta-Analysis software (Version 3; Biostat, Englewood, NJ). Dichotomous data were calculated by odds ratio (OR) and continuous data were calculated by mean difference (MD) with 95% confidence intervals (CI). Main outcome/Results: A total of 7 studies (535 patients) were included in this meta‐analysis. Pooled analysis showed that the operative time of TL was significantly reduced in the SC group (MD, -63.2; 95% CI, -106.0 to -20.4). Moreover, the SC group had a lower incidence of pharyngocutaneous fistula (OR = 0.38; 95% CI, 0.18-0.83; P = 0.016) and hospital stay (MD, -2.9; 95% CI, -5.6 to -0.1). The incidence of postoperative surgical site infection (OR = 0.41; 95% CI, 0.02-8.73; P = 0.565) was comparable between the two groups. Conclusion: Based on these results, SC may be a useful option for patients who need TL.

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.

Key Points- Congenital anosmia is usually associated with Kallmann syndrome, which is characterized by hormonal abnormalities such as hypogonadotropic hypogonadism.- On very rare occasions, an isolated congenital anosmia presents as olfactory bulb agenesis without this associated syndrome.- In previous studies of such cases, diagnosis is usually based on the absence of an olfactory bulb on structural MRI, rather than on objective functional measures.- Simultaneous functional MRI and olfactory event-related potential recordings can provide highly objective evidence of olfactory function.- We examined both structural and functional MRI and olfactory event-related potential data to diagnose isolated congenital olfactory bulb agenesis, gaining objective evidence of olfactory function.

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.

Background: The use of immunotherapy to treat recurrent/metastatic squamous cell carcinoma of the head and neck has become a popular research topic in recent years, and many clinical trials have been carried out. Objectives: To systematically evaluate the efficacy and safety of PD-1/PD-L1 inhibitors in the treatment of recurrent/metastatic head and neck squamous cell carcinoma. Methods: We searched PubMed, Embase, Cochrane Library and other databases up to 1 November 2019 for publications reporting the use of PD-1/PD-L1 inhibitors in the treatment of squamous cell carcinoma of the head and neck. Revman 5.0 was used for combination analysis, and the overall survival (OS), progression-free survival (PFS), overall response rate (ORR), and adverse events were determined. Results: Five articles were included. Compared with other treatment methods, this meta-analysis showed that treatment with PD-1/PD-L1 inhibitors can significantly improve OS (P < 0.0001), but there was no significant improvement in PFS or ORR. The risk of anaemia and nausea was significantly reduced by treatment with PD-1/PD-L1 inhibitors. Conclusions and Significance: Treatment with PD-1/PD-L1 inhibitors alone can improve the overall survival rate for recurrent/metastatic squamous cell carcinoma of the head and neck but there is no obvious advantage in other aspects and adverse events.

Background: The total number of thyroidectomies performed worldwide both for benign and malignant disease has increased dramatically during the past few decades. Gestational hypothyroidism has deleterious effects on the fetus. Objective: The aim of this study was to assess the extent of thyroid function control among pregnant women who had previously undergone a therapeutic thyroidectomy. Methods: This retrospective cohort study included all female patients insured in the largest health maintenance organization in Israel who were pregnant between May, 2001 and September, 2012 and had a medical history of thyroid surgery. The thyroid-stimulating hormone (TSH) levels throughout the pregnancy were compared to recommended trimestral values. A multivariate analysis was performed to determine risk factors for not attaining TSH recommended range. Results: A total of 477 females with a history of thyroid surgery had given 701 births during the study period. Forty-three percent (n= 203), had thyroidal malignancy. Nearly half of the women underwent total thyroidectomy (43.4% n=207). The women’s TSH values were within the recommended range in only 60% (n= 350) of the pregnancies during the first trimester (0.1-2.5 mIU/L), in 61% (n=335) during the second trimester (0.2–3 mIU/L), and in 70% (n=338) during the third trimester (0.3–3 mIU/L). In multivariate analysis, women that underwent a total thyroidectomy due to a benign thyroid disease, were at the highest risk for not attaining target TSH levels. Conclusions: This very large cohort of pregnant women with a past history of thyroid surgery demonstrated a significant percentage of pregnancies with TSH values above the recommended range. Women that underwent a total thyroidectomy due to benign thyroid disease were at the highest risk for gestational hypothyroidism.

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.

Objectives: The primary goal was to evaluate the effect of stimulus-duration on Electrogustometry (EGM) Thrasholds, to evaluate any gender-related influences and compare the above results to those after application of Taste-Strips. Design: Electrogustometry (EGM) thresholds of various stimulus duration (0.5, 1.0, 1.5, and 2.0 s) were measured in 212 non-smokers (age range: 10 – 80 years, divided into 8 age groups) without self-reported gustatory impairment. Furthermore, taste strips chemogustometry measurements in 132 participants were performed. Setting: Tertiary referral medical centre. Participants: 212 non-smokers, divided in 8 age-groups participated in the study. Main outcome measures: EGM-Thresholds and taste-strips, duration of stimuli Results: EGM-thresholds increased progressively with age and with increase in stimulus duration from 0.5 sec up to 2 sec. This pattern was consistent at all 6 anatomic areas, irrespective from gender. In contrast, in chemogustometry no differences related either to age or to gender were found. Conclusions: Age-related electrophysiological and functional gustatory decline can be better documented by EGM than using chemogustometry. This superiority of EGM was not influenced by stimulus duration; nonetheless, stimulus duration should be clearly documented in future quantitative EGM-threshold recordings, given that it may significantly influence EGM amplitude threshold measurements.