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.

Objective: To investigate the symptomatic relief and functional preservation of a novel surgical strategy combined with triple semicircular canal occlusion and endolymphatic sac decompression in patients with intractable Meniere’s disease. Design: Retrospective analysis. Setting: Patients with intractable Meniere’s disease in the Department of Otolaryngology Head & Neck in the Second Affiliated Hospital of Nanchang University between July 2015 and June 2019. Participants: Data from 46 patients diagnosed with Meniere’s disease, and underwent surgery Methods: Triple semicircular canal occlusion combined with endolymphatic sac decompression was performed in all patients with intractable Meniere’s disease. Pre- and postoperative vertigo attacks, hearing levels, tinnitus, aural fullness, and equilibrium function rehabilitation were analyzed at defined time points during follow-up. Results: A significant vertigo control rate was observed in all patients postoperatively. The overall control rate of vertigo postoperatively was 100% in the entire follow-up, with a complete control rate of 97.8% and a substantial control rate of 2.2%. The rate of hearing preservation was 54.35%, and all patients suffering from hearing deterioration were at stages III and IV. The rate of tinnitus and aural fullness alleviation was 65.8% and 100%, respectively. Four patients failed to regain the equilibrium function postoperatively. Conclusion: Combining triple semicircular canal occlusion with endolymphatic sac decompression is an efficient strategy for vertigo control in patients with intractable Meniere’s disease. Patients in advanced stages suffered more from hearing function deterioration. Hearing preservation and tinnitus alleviation warrant further investigation.

Key points - 3D exoscopy is an emerging visualisation technique designed to improve ergonomics and image quality during surgeries. - We present a novel application of the VITOM® 3D exoscope in cochlear implantation (IDEAL Stage 2a prospective case series). - The system enabled high-quality visualisation during both posterior tympanotomy and electrode insertion. - Both the chief surgeon and the staff members rated the ergonomics of the system highly. - 3D exoscopy is a useful alternative to conventional microscopy, but the two techniques remain to be directly compared in larger studies.

Key Points: 1. We have identified ambiguity in the current guidance on thyroid MDT’s, and have also found nationwide variation in compliance with this. 2. We recommend: a. All surgeons undertaking thyroid surgery should complete a minimum of 20 thyroid procedures per year, and this should also form part of surgeons’ annual appraisal. b. All surgeons should contribute data to UKRETS (unless prevented by local legal frameworks) and this should form part of surgeons’ annual appraisal and be audited by individual MDT’s and regional cancer networks. c. Thyroid MDT’s should be held weekly where possible, with a minimum frequency of fortnightly. d. The core membership of a thyroid MDT (stand alone and joint) should include thyroid surgeons, specialist radiology, endocrinology, nuclear medicine, nurse specialists, histopathology +/- cytology and clinical oncology.

A document by Mark Wilkie. Click on the document to view its contents.

Importance: Tumor encasement of the common carotid artery (CCA) and/or the internal carotid artery (ICA) in patients with advanced head and neck tumors represents a significant surgical challenge. At present, there are few reports on the treatment approach that can achieve the maximal oncological resection and reduce the difficulty of operation without affecting the carotid artery blood flow. Objective: To examine whether the combination of oncologic complete tumor resection and intravascular covered stent placement is more advantageous in the management of advanced head and neck cancer. Design, Setting, and Participants: Five patients with advanced head and neck squamous cell carcinoma (AHNSCC) invading one side of the carotid artery were retrospectively enrolled. The contrast-enhanced computed Tomography (CT) and angiography were performed to assess the severity of extrinsic tumor compression to the carotid artery. Covered stent was placed intra-arterially at least 1 cm proximal and distal beyond the area of tumor involvement. The tumor and the involved carotid artery were resected, and pectoralis major flap transfer was utilized for coverage of the great vessels supported with intra-arterial covered stent. Main Outcomes and Measures: Efficacy of oncologic complete tumor resection combined with endovascular stent placement. Results: The post-stenting demonstrated an improvement in the appearance and caliber of the affected carotid artery. Four patients experienced transient bradycardia and hypotension. All five patients underwent R0 resection. Postoperatively, the flap all had rich vascularity and healing. Three patients underwent adjuvant radiotherapy or chemoradiation. With median follow-up 6.5 months, one patient died of multiple organ failures at 6.5 months after surgery; one patient developed tracheal stoma recurrence and treated with salvaged surgery; the three other patients had no disease recurrence in their last follow-ups. Conclusions and Relevance: Surgical resection with intravascular covered stent placement could potentially achieve the maximal oncological resection without compromise carotid artery blood flow in patients with carotid artery encased head and neck cancer.

ABSTRACT Objectives Anecdotal evidence suggests that oropharyngeal squamous cell carcinoma (OPSCC) should be suspected in patients presenting with symptoms of peritonsillar abscess (PTA) or cellulitis (PTC). The aim of this study was to estimate the prevalence of OPSCC in patients presenting with symptoms of PTA/PTC. Method, Setting and Participants We retrospectively identified all adults with a coded diagnosis of PTA or PTC who presented between 2012-2016 inclusive, across six ENT units in ——–. Records were compared to that of the centralised regional head and neck cancer database. The clinical records of a subset of patients were reviewed for the purposes of data validation. Results A total of 1975 patients with PTA/PTC were identified. Three patients were subsequently diagnosed with OPSCC. None of the three actually had an objective underlying diagnosis of PTA/PTC on the same side. The prevalence of OPSCC in patients admitted with symptoms of PTA/PTC was 0.15%, or approximately 1:650 admissions. The records of 510 patients who presented over a one-year period (2016) were reviewed in even greater detail. There were 298 patients with PTA (59.4%), 151 with PTC (29.1%) and 61 had an alternative diagnosis (11.9%). High risk features (age ≥40, tonsillar asymmetry or tonsillar lesion) were present in 106 patients (24%). Urgent follow up was expedited for 77 patients (73%). Conclusion This study estimates the risk of OPSCC in patients with peritonsillar symptoms. The prevalence is low, even in a region with a relatively heavy disease burden. Clinicians should, however, retain a high level of suspicion in patients with persistent symptoms.

Objectives: Our study aimed to identify potential factors that influence rehabilitation outcomes in late-implanted adolescents and adults with prelingual deafness and attempted to develop a reliable nomogram. Design: This retrospective study included 120 subjects less than 30 years of age who had received cochlear implantation at a single medical center. The Categories of Auditory Performance (CAP) scale was used to evaluate the rehabilitation outcomes. A nomogram was constructed using the R and EmpowerStats software. Results: Univariate analysis indicated higher rates of auditory performance improvement in younger aged subjects. Residual hearing and regular and longer implant use were more common among subjects showing auditory performance improvement. Multivariate analysis identified residual hearing (Hazard Ratio, 6.11; 95% Confidence Interval, 1.83-20.41; P<0.01), age at implantation (Hazard Ratio, 0.31; 95% Confidence Interval, 0.14-0.83; P=0.02) and regular CI use (Hazard Ratio, 7.79; 95% Confidence Interval, 2.50-24.20; P<0.01) as independent predictors for auditory performance improvement. The nomogram’s predictive performance was satisfactory as verified by the calibration curve and Receiver operating characteristic (ROC) curve. Conclusions: We demonstrated that residual hearing, younger age, and regular CI use were associated with auditory performance improvement in this cochlear implant user population. Our nomogram model demonstrated satisfactory predictive performance for this population.

Unilateral vocal cord paralysis (UVCP) is a known complication of thyroid surgery, due to iatrogenic recurrent laryngeal nerve injury, with reported rates of 2-5% in children. The gold standard for assessing vocal cord function in flexible nasendoscopy (FNE) examination, which is considered high-risk for contraction of the COVID-19 virus. Intraoperative ultrasonographic assessment (IUA) of vocal cord function is a non-invasive and relatively simple procedure, performed in a supine position under general anesthesia. Objectives: To evaluate the validity of IUA modality in children undergoing thyroidectomy, and to compare it to the standard FNE. Design: A prospective double-blind study covering 24 months (March 2019-March 2021). Twenty thyroid lobectomies were performed, during 15 surgeries. Vocal cord function was assessed three times: Preoperatively by FNE, intraoperative (IUA) following extubation, and a second FNE on the first post-operative day. Settings: A tertiary pediatric hospital. Results: The overall accuracy of IUA results in our study was 92%. IUA sensitivity, specificity, positive and negative predictive values were 100%, 89%, 33%, and 100% respectively. Patient’s age demonstrated borderline significance (p= 0.08). The resident’s experience was associated with a better correlation between IUA and FNE results (p<0.05). Conclusions: IUA of vocal cord motion has a high accuracy rate for detection of iatrogenic vocal cord paralysis, similar to FNE. It is easily learned by residents, well tolerated by children, and it provides a safe and valid alternative modality while ensuring the safety of the medical staff in treating patients, especially in times of COVID-19 pandemic.

Objectives: The purpose of this study was the evaluation of any alterations in the microvascular network of the nasal mucosa in patients with pulmonary sarcoidosis and the investigation of potential correlations with olfactory acuity and serum levels of angiotensin-converting enzyme (sACE). Design: Patients’ nasal mucosa was examined with contact endoscopy (CE). A novel classification scheme for the microvascular pattern at the anterior septal mucosa (Little’s area) was introduced and implemented. Olfaction was tested using sniffin’sticks. Fifteen healthy subjects served as controls. Participants: 15 patients with pulmonary sarcoidosis and sinonasal symptoms. Main outcome measures: Microvascular pattern at the anterior septal mucosa (Little’s area). Olfaction tested using sniffin’sticks. Setting: Tertiary referral medical centre. Results: The nasal microvascular network was disrupted under CE in most (14/15) patients, while in one patient no microvascular net could be detected. Moreover, hyposmia was documented in four patients and complete anosmia in one patient. In healthy subjects, a very strong correlation between vascular pattern of the mucosa and olfactory test results was found (r=0.93). Conclusions: Contact endoscopy findings show promise and should be further tested, to evaluate their validity as a surrogate marker of mucosal nasal inflammation in sarcoidosis patients with sinonasal symptoms. Vascular patterns of nasal mucosa and olfaction seem to be strong correlated.

Remote communication in ENT has been expanding, spurred by the COVID-19 pandemic. Conferences and teaching have moved online, enabling easier participation, and reducing financial and environmental costs. Online multi-disciplinary meetings have recently been instigated in Africa to discuss management of cases in head and neck cancer, or cochlear implantation, expanding access and enhancing patient care. Remote patient consultation has also seen an explosion, but existing literature suggests some caution, particularly because many patients in ENT need an examination to enable definitive diagnosis. Ongoing experience and more research is needed to better understand how remote communication will fit into our future working lives, both during and after the pandemic.

5 succinct/key points 1. There is a considerable burden to outpatient head and neck cancer (HaNC) surveillance, and it is unclear to what extent the current recommendations facilitate the detection of HaNC. 2. Our 100 patient retrospective analysis demonstrated three asymptomatic recurrences (all within the first year of follow up) and 20 symptomatic recurrences (mean time to recurrence of 21.4 months). 3. Seventy-four percent of those patients who recurred did so within the first two years following primary treatment, increasing up to 83% by three years. 4. We believe the value of routine follow up is more apparent within the first two to three years following primary treatment as this is when the rate of recurrence is highest. 5. We anticipate larger trials investigating the efficacy of an initial two years of frequent follow up followed by longer-term patient-led follow up.

Objectives: This study aims to (i) investigate post-extubation dysphagia and dysphonia amongst adults intubated with SARS-COV-2 (COVID-19) and referred to speech and language therapy (SLT) in acute hospitals across the Republic of Ireland (ROI) between March and June 2020; (ii) identify variables predictive of post-extubation oral intake status and dysphonia and (iii) establish SLT rehabilitation needs and services provided to this cohort. Design: A multi-site prospective observational cohort study Participants: 100 adults with confirmed COVID-19 who were intubated across eleven acute hospital sites in ROI and who were referred to SLT services between March and June 2020 inclusive. Main Outcome Measures: Oral intake status, level of diet modification and perceptual voice quality. Results: Based on initial SLT assessment, 90% required altered oral intake and 59% required tube feeding with 36% unable for oral intake. Age (OR 1.064; 95% CI 1.018-1.112), proning (OR 3.671; 95% CI 1.128-11.943), and pre-existing respiratory disease (OR 5.863; 95% CI 1.521-11.599) were predictors of oral intake status post-extubation. Two-thirds (66%) presented with dysphonia post-extubation. Intubation injury (OR 10.471; 95% CI 1.060-103.466) and pre-existing respiratory disease (OR 24.196; 95% CI 1.609-363.78) were predictors of post-extubation voice quality. Thirty-seven percent required dysphagia rehabilitation post-extubation whereas 20% needed voice rehabilitation. Dysphagia and dysphonia persisted in 27% and 37% cases respectively at hospital discharge. Discussion: Post-extubation dysphagia and dysphonia were prevalent amongst adults with COVID-19 across the ROI. Predictors included iatrogenic factors and underlying respiratory disease. Prompt evaluation and intervention is needed to minimise complications and inform rehabilitation planning.

Background A dose of 5mg/kg lidocaine is considered appropriate for paediatric airway topicalisation. Existing literature suggests younger children are susceptible to toxic lidocaine plasma levels and achieve this at a faster rate. Aims The primary outcome of this study was to ascertain peak plasma lidocaine levels after topicalisation for airway endoscopy. Secondary endpoints included: time to peak lidocaine plasma levels, signs of lidocaine toxicity (restricted to ECG changes or seizures when under anaesthesia) and clinical adverse events of laryngospasm, coughing or desaturation during the procedure. Methods Data was collected prospectively over 18 months at Royal Manchester Children’s Hospital. Children aged 0-8 years undergoing elective diagnostic or therapeutic airway endoscopy were included within the study. Standardised 2% lidocaine was used for airway topicalisation. Dose varied depending upon practitioner usual practice. Venous blood sampling occurred at 5, 10, 15 and 20 minutes post administration and plasma lidocaine levels (ng/ml) analysed. Results A significant relationship exists between higher peak plasma levels and ages <18 months (p=0.00973). Strong linear correlation exists between weight and age for our cohort (r=0.88). Higher peak plasma lidocaine levels occur with total dose volumes between 2 and 3mls of 2% lidocaine local anaesthetic (p=0.03) compared with <2ml total dose volumes. Data suggests a potential relationship of lower weights achieving higher peak plasma levels (p=0.0516). Reduced IQR variation of peak plasma lidocaine levels exists when lidocaine dosing is <5mg/kg. Conclusions Age and total dose volume of topicalised lidocaine have a significant relationship with plasma lidocaine levels. A dose of 5mg/kg topicalised lidocaine for paediatric airway endoscopy is safe and provides good operating conditions. Lower patient weights trend toward higher peak lidocaine plasma concentrations and require further investigation.

Objectives: This study investigated the relationship between viral load and the incidence and recovery of olfactory and gustatory dysfunction (OD and GD), incidence of respiratory and gastrointestinal symptoms in COVID-19 patients. Design: A Retrospective Cohort Study. Setting and Participants: In total 599 outpatients’ cases polymerase chain reaction (PCR)–confirmed COVID-19-positive patients in Golestan province were included in the study. Main Outcome Measures: The incidence of OD, GD, their severity and the time of recovery was determined. The association of these variables with cycle threshold (CT) values of SARS-CoV-2 polymerase chain reaction was assessed. Results: The mean age of patients was 38.27 ± 13.62 years. The incidence of general symptoms included myalgia 70.1%, headache 51.8%, fever 47.7%, and dyspnea 21.4%. 41.9% of patients had gastrointestinal symptoms, including abdominal pain 26.5%, diarrhea 25.2%, nausea 20.5%, and vomiting 12.9%. 12.2% of patients had comorbidity. The trimester recovery rates of OD and GD were 93.94% and 94.74%, respectively. The mean recovery time of OD and GD was 14.56±13.37 and 13.8±3.77 days, respectively. The mean CT value in all patients was 27.45±4.55. There were significant associations between CT value with headache (P=0.04), GD (P=0.002) and OD (P=0.001). Conclusions: The intensity and the recovery of OD and GD in Covid-19 patients may be affected by initial viral load. Unlike to respiratory and gastrointestinal symptoms, the OD and GD were associated with lower viral load. Therefore, it may be recommended to use these clinical symptoms as an indicator in the initial screening of patients during pandemics.

Objective: The aim of this study was to ascertain the relationship between Bethesda category and molecular mutation of thyroid nodules in patients undergoing thyroidectomy. Design: A retrospective cohort of patients who underwent thyroidectomy following needle biopsy and molecular profile testing was performed. Setting: Two tertiary care academic hospitals. Participants: Consecutive patients with a dominant thyroid nodule who underwent both USFNA and molecular profile testing followed by thyroidectomy were included in the study. Main Outcome and Measures: The main outcome was postoperative diagnosis of thyroid cancer and aggressivity of disease based on histopathological variants, nodal metastasis or extra-thyroidal extension. Associations between Bethesda category, molecular mutation and postoperative pathology was assessed using descriptive analysis and Chi-square testing. Results: 451 patients were included. 95.9% (93/97) of patients with a BRAFV600E mutation had a Bethesda category V or VI (P<0.001), and all had confirmed thyroid cancer on postoperative pathology. Those with H, K or N RAS or EIF1AX mutations, gene expression profiling (GEP) or copy number alterations showed an association with Bethesda categories III and IV (P≤0.01). Those with no identified molecular mutation had a lower incidence of aggressive thyroid cancer compared to those with an identified mutation (12.6% vs 44.3%, P<0.01). Conclusion: BRAFV600E mutations were associated with thyroid cancer subtypes known to be more aggressive. These findings may help thyroid specialists better identify aggressive thyroid nodules associated with indeterminate Bethesda categories.