Abstract Objectives: In most cases, suspension laryngoscopy (SL) is efficient, bloodless and with minimal post-procedure discomfort. We aimed to identify predictive patient factors for acceptable surgical views at SL as well as quantify our tertiary airway unit’s complication rates. Design: Prospective cohort study of 150 consecutive microlaryngoscopy procedures involving SL over an 8-month period between November 2019 and July 2020. Patients were assessed pre-operatively for pre-existing oral, temporomandibular, dental, pharyngeal or laryngeal pathology, interincisor distance and qualitative gross limitations to neck extension and forward head posture. Intraoperatively, the laryngoscopic view was graded by anesthetic and surgical teams, and complications were recorded on patient interview in recovery. Setting: Tertiary adult airway service for predominantly benign pathology. Results: Adequate surgical views were obtained in 149/150 procedures. BMI and limitations to chin and neck movement had mild positive correlations with more difficult views in their own rights, but did not correlate with a statistically significant increase in complications. There was a negative correlation between age and interincisor gap (p=0.014), and wider mouth opening correlated with a lower incidence of sore throat (p=0.023). Macroglossia showed a statistically significant positive correlation with tongue symptoms (p=1.611x10-8). Conclusion: In the context of an experienced airway unit with a high caseload of predominantly benign pathology, SL is very effective and safe with low associated morbidity and no mortality. Patient-reported neck and chin movement were found to correlate well with the surgical view obtained. The most common complication of SL is temporary sore throat and there remain recognized risks of temporary tongue and dental symptoms.

• The UK National Institute for Health and Care Excellence has estimated a 70% increase in demand resulting from the 2019 modification to cochlear implant criteria • We modelled the projected increase using our large database of pure tone audiometry results, and adjusted for frailty as a marker of risk of general anaesthesia • Our results suggest an overall 79% increase in demand, with most of this for adult implantation, and in particular for those over the age of 65 • Our findings are important for those planning delivery of cochlear implant services

Key Points • Sepsis is associated with high morbidity and mortality and is a known complication of infections of the head and neck. Screening for sepsis should be conducted on admission in order to identify patients at risk and provide early intervention. • Our audit on an ENT ward in a district general hospital found that sepsis screening is poor, however this can be improved further by education and visual reminders such as poster or a clerking proforma. • The most common head and neck infections admitted to a district general hospital were tonsillitis, peritonsillar cellulitis and peritonsillar abscesses. • The incidence of sepsis as a complication of head and neck infections is very rare if diagnosed according to the updated qSOFA criteria. • Using SIRS criteria may result in falsely high rates of diagnosis of sepsis and may lead to excessive and inappropriate clinical management in patients who could otherwise be managed less aggressively.

A document by Mainak Dutta. Click on the document to view its contents.

Objectives: Epistaxis is the second most common referral to the Ear nose and throat (ENT) department. Frailty, a marker for biological vulnerability, has been shown to increase the risk of haemorrhage, but its impact in epistaxis patients is unknown. We aim to establish the impact of Clinical Frailty score, as well as other established risk factors for epistaxis, on the likelihood of admission in patients presenting to secondary care with epistaxis. Design: Retrospective cohort study Setting: University hospital Otolaryngology department Participants: Adult patients presenting to hospital with epistaxis between March 2019 and March 2020. Main outcome measures: We compare the clinical frailty score of patients admitted with epistaxis to those patients seen and treated same day. Results: 299 epistaxis presentations were identified, of which 122 (30.8%) required admission for further management. Clinical frailty score of ≥4 had an increased odds for admission (OR 3.15 (95% CI:1.94 – 5.16), p<0.001). In the majority of presentations (66.2%), patients were taking either an antiplatelet, anticoagulant or a combination of them. Of these presentations, the use of an anticoagulant (OR: 2.00 (95% CI: 1.20-1.92), p:0.10) and dual antiplatelet (OR: 2.82 (95% CI: 1.02-7.86), p:0.10, p:0.07) demonstrated increased odds of admission. Conclusions: We have shown that frailty increases the risk of admission in adult patients presenting with epistaxis. Frailty is becoming an increasingly apparent independent cause for haemorrhage in the elderly population. Careful consideration of bleeding risks, particularly in frail patients, needs addressing due to the morbidity associated with epistaxis.

Dear Editor,We reviewed the article entitled: “Analysis of reflux as the etiology of laryngeal dysplasia progression through a matched case-control study ”.1 The authors did not find differences in the level of pepsin, enterokinase and bilirubin in laryngeal dysplasia (LD) of patients with malignant transformationversus those without transformation. The involvement of reflux in the development of LD and laryngeal cancers is an important topic and the realization of such a study is important. However, we wish to draw attention to many points.First, it is difficult to know if the included patients with tissue pepsin really suffered from reflux. The detection of pepsin into the tissue means that patients had some pharyngeal reflux events the day before the surgery but cannot confirm the diagnosis. The sensitivity of pepsin detection in laryngeal tissue depends on the technique and the material (antibodies), reaching 75 to 85% depending on the type of reflux (acid versus nonacid).2 Moreover, we have no detailed information about the immunostaining technique, limiting the reproducibility of the protocol. The presence of pepsin into the tissue does not ensure the reflux diagnosis. Thus, for example, it has been showed that the back flow of gastric content and the deposit of pepsin into the tissue are influenced by the meals preceding the sample collection, making the pepsin tissue a poorly reliable marker of reflux.3 To improve the sensitivity, authors1 could have performed hypopharyngeal-esophageal pH-impedance monitoring, which is the only way to confirm the diagnosis.4Second, the LD malignant transformation involves many factors such as tobacco history, environmental factors, genetic, or immune response.5 The authors did not provide information about the tobacco history (pack-year data) of groups, which is an important data to consider the risk of malignant transformation. Even many years after the tobacco cessation, it is conceivable that patients with long/more severe history of tobacco consumption may have more cell mucosa DNA impairments and a higher risk to develop cancer.Third, the focus on pepsin as the only enzyme associated with malignant transformation limits the understanding of transformation mechanisms. More than 50% of patients had mixed or nonacid reflux,4 in which the activity of pepsin is decreased regarding the alkaline pH of refluxate. To reliably investigate the involvement of reflux in the malignant transformation, authors have to consider the entire content of refluxate, including bile salts and trypsin.4 Furthermore, bile salts may be involved in laryngopharyngeal malignant transformation.6In future studies, reflux has to be diagnosed at the LD diagnosis time and physicians have to follow the reflux clinical course over the time. More than 50% of reflux patients had chronic course,4which leads to a potential higher risk to develop cell DNA damage and lesions. Thus, cross-sectional study design is probably not adequate to study a disease association involving chronic and repeated exposure.Acknowledgments: No.

Abstract Background: Evidence showed that the sensation of nasal breathing is related to variations in nasal mucosa temperature produced by airflow. An appropriate nasal airflow is necessary for changing mucosal temperature. Therefore, the correlation between objective measurements of nasal airflow and patient-reported evaluation of nasal breathing should be dependent on the level of nasal airflow. Objectives: To find if the correlation between patient-reported assessment of nasal breathing and objective measurement of nasal airflow is dependent on the severity of symptoms of nasal obstruction or on the level of nasal airflow. Methods: The airway of 79 patients was evaluated using NOSE score and peak nasal inspiratory flow (PNIF). Three subgroups were created based on NOSE and three subgroups were created based on PNIF level to find if correlation was dependent on nasal symptoms or airflow. Results: The mean value of PNIF for the 79 patients was 92.6 l/min (SD 28.1 l/min). The mean NOSE score was 48.4 (SD 24.4). The correlation between PNIF and NOSE was statistically significant (p=0.03), but with a weak association between the two variables (r=-0.248). Evaluation of correlation based on symptoms demonstrated a weak or very weak association in each subgroup (r=-0.250, r=-0.007, r=-0.104). Evaluation of correlation based on nasal airflow demonstrated a very weak association for the subgroups with middle-level and high PNIF values (r=-0.190, r=-0.014), but a moderate association for the subgroup with low PNIF values (r=-0.404). Conclusions: This study demonstrated a weak correlation between NOSE scores and PNIF values in patients non-selected according to symptoms of nasal obstruction or to airflow. It demonstrated that patients with symptoms of nasal obstruction have different levels of nasal airflow and that low nasal airflow prevents the sensation of good nasal breathing. Therefore, patients with symptoms of nasal obstruction may require improving nasal airflow to improve nasal breathing sensation.

Objectives To report changes in practice brought about by COVID-19 and the implementation of new guidelines for the management of tonsillitis and peritonsillar abscess (PTA), and to explore factors relating to unscheduled re-presentations for patients discharged from the emergency department (ED). Design Prospective multicentre national audit over 12 weeks from 6th April 2020. Setting UK secondary care ENT departments Participants Adult patients with acute tonsillitis and PTA Main outcome measures Re-presentation within 10 days for patients discharged from the ED. Results 83 centres submitted 765 tonsillitis and 416 PTA cases. 54.4% (n=410) of tonsillitis cases and 45.3% (187/413) of PTA were discharged directly from the ED. 9.6% (39/408) of tonsillitis and 10.3% (19/184) of PTA discharges re-presented within 10 days, compared to 9.7% (33/341) and 10.6% (24/224) for those initially admitted from ED. The subsequent admission rate of those initially discharged from ED was 4.7% for tonsillitis and 3.3% for PTA. IV steroids were given to 67.0% of tonsillitis patients (n=505/754) and 73.6% of PTA (n=304/413). 77.2% of PTA patients underwent drainage during their initial presentation (n=319/413), but there was no significant difference in re-presentation rate in those drained Vs not-drained (10.6% vs 9.5%, n=15/142 vs 4/42, p=0.846). Univariable logistic regression showed no significant predictors of re-presentation within 10 days. Conclusions Management of tonsillitis and PTA was affected during the initial peak of the pandemic, with a shift towards outpatient care. Some patients who may previously have been admitted to hospital may be safely discharged from the ED.

Objectives: To report changes in practice brought about by COVID-19 and the implementation of new guidelines, and to explore factors relating to unscheduled re-presentations for patients discharged from the emergency department (ED). Design: Prospective multicentre national audit over 12 weeks from 6th April 2020. Setting: UK secondary care ENT departments. Participants: Adult patients with acute epistaxis Main outcome measures Re-presentation within 10 days for patients discharged from the ED. Results: 83 centres from all four UK nations submitted 2,631 valid cases. The majority of cases were ED referrals (89.7%, n=2,358/2,631). 54.6% were discharged from the ED following ENT review (n=1,267/2,322), of whom 19.5% re-presented within 10 days (n=245/1,259) and 6.8% were ultimately admitted (n=86/1,259). 46.7% of patients had a non-dissolvable pack inserted by ED prior to referral to ENT (n=1,099/2,355). The discharge rates for ED patients and their subsequent re-presentation rates were as follows: non-dissolvable packs, 29.5% discharged (n=332/1125), 18.2% re-presented (n=60/330); dissolvable products, 71.1% discharged (n=488/686), 21.8% re-presented (n=106/486); cautery only, 89.2% discharged (n=247/277), 20.0% re-presented (n=49/245); and no intranasal intervention, 85.5% discharged (n=200/234), 15.2% re-presented (n=30/198). Univariable logistic regression showed that not being packed by ED, antiplatelet medications, failed cautery and recent epistaxis treatment were significant predictors of re-presentation within 10 days. Conclusions: Management of acute epistaxis was notably affected during the initial peak of the pandemic, with a shift towards reduced admissions. This national audit highlights that many patients who may previously have been admitted to hospital may be safely discharged from the ED following acute epistaxis.

Introduction; This review discusses how nasal congestion may have benefits as a mechanism of defence against respiratory viruses. Methods; A literature research was conducted on respiratory viruses and nasal congestion, following a recently published review on how temperature sensitivity is important for the success of common respiratory viruses. Results; The literature reported that common respiratory viruses are temperature sensitive and replicate well at the cooler temperatures of the upper airways (32oC), but replication is restricted at body temperature (37oC). The amplitude of the phases of congestion and decongestion associated with the nasal cycle was increased on infection with respiratory viruses and this caused unilateral nasal congestion and obstruction. Nasal congestion and obstruction increase nasal mucosal temperature towards 37oC and therefore restricted the replication of respiratory viruses. Conclusion; Nasal congestion associated with the nasal cycle may act as a mechanism of respiratory defence against infection with respiratory viruses

Purposes: To evaluate the instant auditory benefit of an adhesive bone conduction hearing aid (ADHEAR) on children with bilateral congenital microtia, especially the sound localization ability under unilateral and bilateral fitting. Methods: Twelve patients with bilateral congenital microtia aged from 6 to 17 were included in this study. Pure tone threshold under sound field, speech recognition threshold in quiet and sound localization abilities were tested and compared before and after wearing the device. The pure tone threshold test was additionally repeated for two different wearing method – adhesive or fixed with softband; the sound localization test was repeated for both unilateral and bilateral fitting. Correlation analysis was then conducted to find the influencing factors of sound localization improvement. Results: Significant auditory improvement were found: the average pure tone threshold (PTA) reduced by 24.8 (adhesive) and 27.3 dB HL (softband), with no significant difference between the two wearing methods. The speech recognition threshold also improved by 29.0 dB. As for sound localization abilities, no significant improvement was found under unilateral fitting; but half (6 of 12) of the patients were notably benefited from bilateral fitting. The improvement was found to be strong correlated with the patients’ unaided sound localization ability – those with poorer localization abilities tends to benefit more. Moreover, it was found that the sound localization improvement was also negatively related with the malformation degrees of the patients’ head. Summary: ADHEAR affords significant auditory benefits for children with bilateral congenital microtia, in terms of sound and speech perception. The sound localization abilities could be partly improved instantly by bilateral fitting, and the improvement is related with factors such as adaption and skull malformations.

• Scapular and parascapular free tissue transfer (SFTT) is a well described reconstructive option for the head and neck. Majority of reported outcomes are of reconstruction of oromandibular and midface defects. The aim was to describe one institution’s experience with SFTT for reconstruction of PE defects. • This study was a retrospective review of patients undergoing SFTT for head and neck defects between 2009 and 2014 at a tertiary center. The cohort included patients undergoing reconstruction of PE defects with at least 6 months follow up. Seventeen patients (13 male and 4 female) met inclusion criteria. Surgical outcomes, speech, voice outcomes, swallowing outcomes, enteral feeding and tracheoesophageal puncture (TEP) usage were evaluated. • Two of 17 patients developed pharyngocutaneous fistulas (PCF) as inpatients. There was one major medical complication (pulmonary embolism) and 7 minor complications. Mean hospital length of stay was 15.7 days (SD 8.2). In post-operative setting, only one patient remained PEG-dependent, 11 patients supplemented oral intake with PEG feeds and 5 patients took nutrition solely by mouth. Four patients utilized written communication exclusively, 6 patients pursued TEP placement and 7 utilized electrolarynx. • The SFTT is a viable option for hypopharyngeal reconstruction. All scapula free tissue transfers remained viable for the duration of our review. Post-operative PCF rate were comparable to that reported after laryngectomy.

Objective: To investigate the clinical significance of specific IgE-staphylococcal enterotoxin in CRS. Design: Retrospective analysis of patients who were positive for specific IgE-staphylococcal enterotoxin B. Setting: Tertiary rhinology clinic. Participants: A total of 965 patients who were positive for specific IgE-staphylococcal enterotoxin B from December 2016 to December 2017 Main outcome measures: We retrospectively reviewed the records of 965 patients who were positive for specific IgE-staphylococcal enterotoxin B from December 2016 to December 2017. Patient demographics, titre specific IgE to staphylococcal enterotoxin B (IgE-SEB) levels, MAST, serologic test, and medical records were reviewed. Results: IgE-SEB (KU/L) was higher in CRS patients than Non-CRS patients (0.13±0.37 vs 0.08±0.22, respectively; p-value: 0.044), and the IgE-SEB (+, ≥0.35) rate was also higher (10.06% vs 4.46%, respectively; p-value: 0.030). IgE-SEB (KU/L) was higher in the CRS group than in the fungal sinusitis group (0.13±0.37 vs 0.03±0.05, respectively; p-value: <0.001), and the IgE-SEB (+, ≥0.35) rate was also higher (10.06% vs 0 %, respectively; p-value: 0.015). Between the CRSsNP (chronic rhinosinusitis without nasal polyps) and CRSwNP (chronic rhinosinusitis with nasal polyps) groups, there were no differences in IgE-SEB (KU/L) or IgE-SEB (+) rates. As the values of IgE-SEB(KU/L) and the IgE-SEB (+,>0.1) rate increased, the CRS severity also increased. Conclusions: IgE-SEB showed a positive correlation with CRS severity but not with postoperative recurrence or nasal polyps. Further studies are needed to obtain clear evidence that IgE-SEB can be considered as an independent CRS endotype.

Objectives: Given that 30-50% of children with Down syndrome have persistent obstructive sleep apnea (OSA) after adenotonsillectomy, we evaluated whether demographic, clinical and polysomnographic factors predicted persistent OSA and OSA severity after adenotonsillectomy. Design: Retrospective study. Setting: Secondary care hospital. Participants: Retrospective review of 32 children with the diagnosis of DS and OSA by polysomnography type 1 who underwent adenotonsillectomy, from January 2010 to December 2018. Main outcome and measure: Non-parametric analysis was used to compare pre and postoperative factors, regression was used to model persistent OSA and OSA severity. Results: Thirty-two children were included (17 male, median age 10.00 ± 8.00 years, median body mass index z-score 0.89 ± 1.25). Overall, adenotonsillectomy resulted in a significant improvement in median obstructive apnea-hypopnea index (oAHI) from 7.5 ± 8.95 to 4.40 ± 4.38 events per hour (p<0.001) and in median OSA-18 score from 85.00 ± 12.00 to 61 ± 37.75 (p<0.001). Persistent OSA was found in 56.25% of the children. Univariate regression suggests that postoperative OSA-18 score predicted persistent OSA after adenotonsillectomy. Preoperative oAHI, preoperative oxygen desaturation rate, pre and postoperative OSA-18 scores correlated with OSA severity after adenotonsillectomy. However, in a multivariate model only the postoperative OSA-18 score was able to predict OSA severity after adenotonsillectomy. Conclusions: Although adenotonsillectomy results in a significant improvement of OSA in children with Down syndrome, more than half of the children had persistent OSA. The postoperative OSA-18 score predicted both persistent OSA and OSA severity after adenotonsillectomy.

Objectives: Systemic steroids are a well-known, proven treatment for olfaction impairment. Topical nasal steroids are an attractive alternative that avoids systemic side effects and might provide an increased local drug activity. Nonetheless, the access of the medication to the olfactory cleft (OC) by using low- volume devices, such as nasal drops, is greatly dependent on the position of the head. We aimed to examine the accessibility of nasal drops to the OC area in two different head positions: the Mygind (lying head back) position and the Kaiteki position. Design and Setting: This is a cadaver study; the specimens were firstly positioned in Mygind and thereafter in Kaiteki positions. Nasal drops mixed with blue food dye were administered into the nostril in each head position. Endoscopic videos were recorded, and two blinded observers scored the extent of olfactory cleft penetration (OCP) using a 4-point scale (0 = none, 3 = heavy). Participants: Twelve fresh-frozen cadaver specimens Main outcome measures: The dye’s penetration to the OC Results: The mean score of nasal drops penetrance to the OC in the Mygind position was 1.34, as compared to 1.76 in the Kaiteki position. The difference in the OCP score between the two groups was not statistically significant (p>0.05) Conclusion: Both Mygind and Kaiteki head positions are reasonable alternatives in treatment with nasal drops for olfaction impairment. The preference of one position over another should rely on the patient’s comfort.

TitleThe Use of Ultrasound Guided Pre-Operative Colloidal Charcoal Injection in the Surgical Management of Recurrent Differentiated Thyroid CancerKeywords: thyroid cancer, neck recurrence, charcoal injection, ultrasound guidance, pre-operative localisation, reoperation

Background: The SARS-CoV-2 was first reported in December 2019 in Wuhan, China and has been declared a pandemic in March 2020. COVID-19 has caused unprecedented and lasting biopsychosocial effects worldwide. All healthcare professionals have faced life threatening risks by attending their daily jobs. The daily emergence of advice and guidelines was necessary to ensure the safety of patients and staff. To this effect, all elective services came to a halt to preserve hospitals’ capacity for dealing with the sickest. This retrospective, descriptive review aims to assess the volume and timing of the advice released specifically relevant to the UK Otolaryngologist. Methods: The search included online advice published in English by international, national and ENT-specific organisations between the 1st of January to the 31st of May. The date, title, source, type of advice and link to the advice was recorded in Excel. The resources were analysed per week of publication. A separate search for peer-reviewed publications was conducted using PubMed Central and Cochrane databases. Findings: 175 covid-19 related guidance’s were identified. 52/175 (29.7%) articles were published by international organisations. 56/175 (32%) were produced by national organisations and 67/175 (38.28%) were produced by ENT specific organisations. The peak guidance production took place in the third and fourth week of March (16/03/2020- 29/03/2020) with 72/175 publications. Of these, 27/72 came from the international category, 17/72 from national bodies and 28/72 from ENT-specific organisations. 13,863 total publications relating to COVID-19 were found using PubMed and Cochrane search strategies; 76% were relevant to ENT surgeons. Conclusion: The challenges faced by the Otolaryngologist relate to the unprecedented, sudden and daily changes to clinical practice. Multiple bodies interpreted the guidance giving an opportunity for confusion and delays in treatments for patients. Implementing a system with clear lines of communication and dissemination of information will improve our response in future pandemic events whilst maintaining a commercial awareness to better use the human and financial resources of an already financially-restricted NHS.

Objectives: To evaluate the safety of intratympanic and intravenous dexamethasone administration for the treatment of sudden sensorineural hearing loss(SSNHL) and hearing improvement at low, mid and high frequencies. Methods: SSNHL patients were randomly divided into two groups within 72 hours after onset and received 24 days of dexamethasone therapy.The group A patients only received intravenous dexamethasone once every other day.Patients in group B received 12 days intravenous dexamethasome and six injection of intratympanic dexamethasome from the 13th day to 24th day like in Group A.Side effects and hearing recovery were compared. Results: The discomfort of intratympanic injection were mild and transient, no tympanic membrane perforation and otitis media, whereas the systemic adverse effects increased cumulatively over the course of intratympanic dexamethasone treatment in group A.The systemic side effects were more serious in group B than in group A. On day 7 (D7),the average 3-frequency PTA (250, 500, and 1000 Hz) was 34.10±9.14 dBHL in group A and 25.70±6.88 dBHL in group B(P<0.05). Hearing recovery was better in group A than group B,but there are the same long-term efficacy at the 90-day follow-up.Group A had slightly better high-frequency hearing recovery than group B, but this difference was not statistically significant. There were no significant differences in the total effective rate of hearing improvement. Conclusions: Early intratympanic dexamethasone intervention led to the rapid recovery of hearing loss, with a good remedial effect on hearing at low-mid frequencies. Intratympanic dexamethasone was safer than intravenous dexamethasone for SSNHL, and high-frequency hearing recovery may have been better with intratympanic dexamethasone, but the difference was not statistically significant. Therefore, it is necessary to make individualized treatment decisions according to the patient’s condition.