Impact of COVID-19 pandemic: increase in complicated upper respiratory tract infections requiring ENT surgery?

PURPOSE: This study investigates the impact of the COVID-19 pandemic on complicated upper respiratory tract infections requiring surgical intervention in a tertiary referral center. The aim is to understand the consequences of pandemic-related measures and their subsequent relaxation on the incidence and characteristics of upper respiratory tract infection-related complications. METHODS: Patients who underwent surgery as a complication of upper respiratory tract infections between December 2014 to February 2023 were included. Demographic information, surgical procedures, microbiological findings, and clinical outcomes were assessed and analyzed comparing pre-pandemic, pandemic and post-pandemic groups. RESULTS: 321 patients were enrolled, including 105 patients (32.7%) in the pediatric population. Comparison of pre-pandemic (n = 210), pandemic (n = 46) and post-pandemic periods (n = 65) revealed a statistically significant increase in complicated otologic infections requiring surgical intervention in the post-pandemic period compared to the pandemic period (p value = 0.03). No statistically significant differences in other surgical procedures or demographic parameters were observed. A statistically significant increase in urgent ear surgery in the pediatric population between the pandemic and the post-pandemic period (p value = 0.02) was observed. Beta-hemolytic group A streptococcal infections showed a statistically significant increase in the post-pandemic period compared with the pandemic period (p value = 0.02). CONCLUSIONS: Relaxation of COVID-19-related restrictions was associated with an increase of upper respiratory tract infection-related otologic infections requiring surgical intervention with an increasing rate of beta-hemolytic group A streptococcal infections. These findings highlight the importance of considering the impact of the pandemic on upper respiratory tract infection complications and adapting management strategies accordingly.

To detach or not to detach the umbo in type I tympanoplasty: functional results.

PURPOSE: To compare the audiological outcomes, tympanic membrane (TM) healing rates and complication rates in patients undergoing endoscopic underlay and over-under tympanoplasty type I (TTI). METHODS: The study includes 95 patients who underwent endoscopic TTI in the period between 2018 and 2023: 56% of the patients had the underlay technique and 41% had the over-under technique. Data regarding pre- and postoperative hearing, perforation characteristics, surgical procedures, graft types and complications were retrospectively analyzed. Audiometrical assessment included air conduction (AC) and bone conduction (BC) pure tone averages (PTA) and air-bone gap (ABG), pre- and postoperatively. RESULTS: Both underlay and over-under techniques significant improved AC PTA, with a mean ABG improvements of 5.9 dB and 7.2 dB, respectively. There was no significant difference in BC PTA between pre- and post-operative, indicating no inner ear damage in both techniques. The over-under technique showed a significantly higher TM closure rate (94.4%) compared to the underlay technique (80.6%). Complications were rare, with only one case of TM lateralization requiring revision surgery. CONCLUSIONS: Endoscopic TTI is an effective treatment in improving auditory function in chronic middle ear diseases. In our cohort, the detachment of the umbo does not negatively influence the postoperative hearing results and does not increase rate of complications. Moreover, the over-under technique demonstrates superior TM closure rates, making it a valuable option for specific cases. However, future prospective studies with larger sample sizes and longer term follow-up are needed to validate these findings and provide more comprehensive insights.

Variability of the retrotympanum and its association with mastoid pneumatization in cholesteatoma patients.

PURPOSE: This study aimed to investigate the variability of the retrotympanum in patients undergoing surgical treatment for cholesteatoma. METHODS: We included 59 ears of patients undergoing middle ear surgery for cholesteatoma who had preoperative computed tomography scans. A retrospective analysis of the medical records was conducted. The sinus tympani (ST), subtympanic sinus (STS) and facial recess (FR) were classified into types A-C based on the relationship of their extension to the facial nerve. The mastoid and petrous apex were assessed and categorized as normal pneumatized or sclerotic. RESULTS: Type A extension was the most frequently found in all sinuses (ST 64%, FR 77%, STS 69%), Type B extension was found more often in ST (34%) and STS (24%) than in FR (15%). A very deep extension was found only rarely (ST 2%, FR 8%, STS 7%). A sclerotic mastoid was found in 67% of cases. Those cases showed a statistically significant difference regarding retrotympanum pneumatization when compared with normal mastoid. CONCLUSION: The most frequent variant of retrotympanic pneumatization in relation to the facial nerve was type A in all subsites in cholesteatoma patients. The variability among patients with cholesteatoma is different to previously published results in healthy subjects. Moreover, the pneumatization of the retrotympanum is associated with mastoid pneumatization.

Digital image enhancement may improve sensitivity of cholesteatoma detection during endoscopic ear surgery.

OBJECTIVES: This study investigates the possible benefits and limitations of the digital image enhancement systems provided by Storz Professional Image Enhancement System (SPIES) during endoscopic ear surgery (EES) for cholesteatoma. An increased detection of cholesteatoma residuals during the final steps of endoscopic surgery using DIE technology was hypothesized. DESIGN: Cross-sectional study. SETTING: Tertiary referral hospital. METHODS: A total of 10 questionnaires of 18 intraoperative pictures with equal numbers of cholesteatoma and non-cholesteatoma images, each presented in three different image-enhancing modalities (Clara, Spectra A, Spectra B), were generated. Fifty-one experienced ear surgeons participated to the survey and were randomly assigned to a questionnaire and completed it at two time points. The experts were asked to rate for each picture whether cholesteatoma was present or not. The answers were compared with the histopathological reports. RESULTS: Clara showed the highest accuracy in cholesteatoma detection, followed by Spectra A and lastly Spectra B. In contrast, Spectra B showed the highest sensitivity and Clara the highest specificity, while Spectra A was placed in the middle for both values. Using the Spectra B modality, most responses agreed across the two time points. Ear surgeons assessed the usefulness, as well as preference among image modalities for cholesteatoma surgery, in the following order: Clara, Spectra B, Spectra A. CONCLUSION: Digital enhancement technologies are applicable to EES. After complete cholesteatoma removal, Spectra B showed the highest sensitivity in the detection of cholesteatoma residuals as compared with Clara and Spectra A. Thus, Spectra B may be recommended to avoid missing any cholesteatoma residuals during EES.

Assessment of jugular bulb variability based on 3D surface models: quantitative measurements and surgical implications.

PURPOSE: High-riding jugular bulbs (JBs) among other anatomical variations can limit surgical access during lateral skull base surgery or middle ear surgery and must be carefully assessed preoperatively. We reconstruct 3D surface models to evaluate recent JB classification systems and assess the variability in the JB and surrounding structures. METHODS: 3D surface models were reconstructed from 46 temporal bones from computed tomography scans. Two independent raters visually assessed the height of the JB in the 3D models. Distances between the round window and the JB dome were measured to evaluate the spacing of this area. Additional distances between landmarks on surrounding structures were measured and statistically analyzed to describe the anatomical variability between and within subjects. RESULTS: The visual classification revealed that 30% of the specimens had no JB, 63% a low JB, and 7% a high-riding JB. The measured mean distance from the round window to the jugular bulb ranges between 3.22 ± 0.97 mm and 10.34 ± 1.41 mm. The distance measurement (error rate 5%) was more accurate than the visual classification (error rate 15%). The variability of the JB was higher than for the surrounding structures. No systematic laterality was found for any structure. CONCLUSION: Qualitative analysis in 3D models can contribute to a better spatial orientation in the lateral skull base and, thereby, have important implications during planning of middle ear and lateral skull base surgery.

Signal Alteration of the Inner Ear on High-Resolution Three-Dimensional Constructive Interference in Steady State Sequence in Patients with Ménière's Disease and Labyrinthitis.

INTRODUCTION: The aim of this study is to evaluate signal alteration in the inner ear using three-dimensional (3D)-constructive interference in steady state (CISS) sequence in patients with Ménière's disease and labyrinthitis and its correlation with clinical and audiological parameters. METHODS: The medical records of the department of otorhinolaryngology were searched for patients with Ménière's disease or labyrinthitis who underwent MRI with 3D-CISS sequence. Blinded analysis of these patients and of MRI from control subjects without middle or inner ear symptoms was performed to detect any signal asymmetry of the inner ear structures. The results were correlated with clinical symptoms and results of audiological and vestibular tests. RESULTS: Fifty-eight patients with definite Ménière's disease and 5 patients with labyrinthitis as well as 41 control exams were included. A separate analysis was performed for patients with probable Ménière's disease (n = 68). A total of 172 3D-CISS sequences were analyzed by 2 blinded independent neuroradiologists. A CISS-hypointense signal of the inner ear structures was found in 3 patients with definite Ménière's disease (5.2%), in 4 patients with probable Ménière's disease (5.9%), and 2 patients with labyrinthitis (40%). No CISS hypointensity was found in the control group. Although no significant difference in symptoms or audiological test results was found between patients with and without this signal change, the side of hypointensity was frequently correlated with the symptomatic side and with hearing impairment. DISCUSSION/CONCLUSION: CISS hypointensity of the inner ear structures was evident in patients with clinical conditions other than vestibular schwannoma - more frequently in labyrinthitis than in Ménière's disease. This signal alteration was frequently encountered on the same symptomatic side as that of the pathological audiology tests, but it is not a predictor for hearing or vestibular impairment.

Pediatric obstructive sleep-disordered breathing is associated with arterial stiffness.

The association between obstructive sleep-disordered breathing (oSDB) and arterial stiffness, an independent predictor of cardiovascular outcomes, is not well established in children. This study compared cardiovascular parameters between healthy and oSDB children and aimed to identify predictors of arterial stiffness indices in children with oSDB. Cross-sectional study realized in a tertiary hospital from June 2018 to January 2020. Forty-eight children (3 to 10 years old) with clinical diagnosis of oSDB and indication for adenotonsillectomy and 24 controls were evaluated. Cardiovascular parameters were measured non-invasively by brachial artery oscillometry with a portable device. The main arterial stiffness indices assessed were augmentation index and pulse wave velocity, both derived from the aortic pulse wave. In the oSDB group, the questionnaires Obstructive Sleep Apnea-18 (OSA-18) and Pediatric Quality of Life Inventory version 4.0 (PedsQL 4.0) were applied. The oSDB group had higher values of reflection coefficient (p = 0.044) and augmentation index (p = 0.003) than the control group. Stepwise multiple regression analysis revealed that age, female sex, reflection coefficient, and systolic volume were independent predictors of augmentation index. Higher pulse wave velocity values were associated with worse quality of life assessed by PedsQL 4.0 questionnaire. There was no association with OSA-18. The vascular and hemodynamic parameters were similar in both groups.Conclusion: Children with oSDB have increased augmentation index, an independent predictor of cardiovascular outcomes. The early identification of subclinical cardiovascular changes reinforces the importance of treating the disease, as well as changing lifestyle habits, to prevent complications in adulthood. What is Known: • The association between oSDB and cardiovascular risk in adults is well described in the literature. • Children with oSDB, regardless of their weight or sex, have higher PWV values when compared to non-snoring children. What is New: • Children with oSDB have augmented arterial stiffness, evidenced by the increase in AIx@75, measured non-invasively by brachial artery oscillometry with a portable device. • Low quality of life and therefore a high disease burden in children with oSDB may be a risk factor for arterial stiffness.

Revision canal-wall down surgery: comparison of surgical outcomes with three different techniques.

OBJECTIVE: This study aimed to analyze the role of the endoscope in revision canal-wall down (CWD) tympanomastoid surgery and compare its use to the more traditional microscopic approach. Moreover, we aim to investigate functional outcomes of revision surgeries in a cohort of two tertiary reference centers. METHODS: A total of 103 patients undergoing revision surgery after previous CWD tympanomastoidectomy were included in the present study and divided in three groups according to the surgical technique used: endoscope exclusive (n = 22), combined (n = 35) and microscope exclusive (n = 46). Data regarding surgical indications, pre-operative clinical and audiological assessments, intraoperative findings and surgical considerations were extracted. During follow-up, data regarding anatomic and audiologic outcomes were collected and persistence or recurrence of the disease assessed. RESULTS: The most frequent sites of cholesteatoma recurrence or persistence was the anterior epitympanum. There was a statistically significant ABG improvement of - 6.02 dB HL (95% CI - 8.87 to - 3.16, p < 0.001) between pre-operative and postoperative ABG, without significant effect of surgical technique. During follow-up, no significant differences regarding disease or otorrhea control were observed. Duration of surgery and hospitalization was shorter in the endoscopic cohort without statistical significance. Intra- and postoperative complications were lower in the endoscopic group. CONCLUSION: Revision CWD surgery can take advantage of the endoscope as a minimally invasive exclusive or adjunct tool to traditional microscopic procedures. Outcome measures of endoscopic revision CWD surgery showed anatomic and functional results comparable to those of the microscopic group. The complication rate, the duration of surgery and hospitalization were favorable in the endoscopic group.

Taste impairment after endoscopic stapes surgery: Do anatomic variability of chorda tympani and surgical technique matter? : Post-operative dysgeusia after EStS.

PURPOSE: To investigate how the anatomical configuration of the oval window region (OWR) influences the management of the chorda tympani (ChT) and the curetting of adjacent bony structures, in a setting of patients undergoing endoscopic stapes surgery (EStS); to assess the incidence of early and late post-operative dysgeusia and to identify anatomical and surgical factors influencing taste function after EStS. METHODS: Surgical video recordings of 48 patients undergoing EStS for otosclerosis between January 2019 and July 2020 were retrospectively revised, to classify the anatomical variability of selected middle ear structures and the management strategies for the ChT. Clinical records of included patients were reviewed for subjective early and late post-operative taste impairment using a 5-point Likert-scale. RESULTS: The most common configuration of the OWR was type III. The extension of the bony curettage resulted inversely proportional to the exposure of the OWR. The long-term rate of preserved post-operative taste function was 85%. Displacement of the ChT was necessary in 43/48 cases (90%), mostly medially (36/48, 75%). CONCLUSION: Bone curetting during EStS does not correlate with post-operative taste impairment. Despite 100% ChT preservation rate, dysgeusia may occur in a minority of patients, with no apparent relationship to anatomical variability or intraoperative management of the ChT. The use of CO2 laser could have a role in increasing the risk of post-operative dysgeusia after EStS.

Influence of head orientation and implantation site of a novel transcutaneous bone conduction implant on MRI metal artifact reduction sequence.

PURPOSE: The use of magnetic resonance imaging (MRI) is often limited in patients with auditory implants because of the presence of metallic components and magnets. The aim of this study was to evaluate the clinical usefulness of a customized MRI sequence for metal artifact suppression in patients with BONEBRIDGETM BCI 602 implants (MED-EL, Innsbruck, Austria), the successor of the BCI 601 model. METHODS: Using our in-house developed and customized metal artifact reduction sequence (SEMAC-VAT WARP), MRI artifacts were evaluated qualitatively and quantitatively. MRI sequences were performed with and without artifact reduction on two whole head specimens with and without the BCI 602 implant. In addition, the influence of two different implantation sites (mastoid versus retrosigmoid) and head orientation on artifact presence was investigated. RESULTS: Artifact volume was reduced by more than the 50%. Results were comparable with those obtained with the BCI 601, showing no significant differences in the dimensions of artifacts caused by the implant. CONCLUSION: SEMAC-VAT WARP was once more proved to be efficient at reducing metal artifacts on MR images. The dimensions of artifacts associated with the BCI 602 are not smaller than those caused by the BCI 601.

Awake Rhinology Surgery in Response to the COVID-19 Pandemic in Europe.

BACKGROUND: European health-care systems are faced with a backlog of surgical procedures following the suspension of routine surgery during the COVID-19 crisis. Routine rhinology surgery under general anaesthetic (GA) is now faced with significant challenges which include limited theatre capacity, the negative ramifications of surgical prioritization, reduced patient throughput in secondary care, and additional personal protective equipment requirements. Delayed surgery in rhinology, particularly with regards to chronic rhinosinusitis, has previously been shown to have poorer surgical outcomes, a detrimental effect on quality of life and long-term negative health socio-economic effects. Awake rhinology surgery under local anaesthetic (LA) provides an ideal alternative to GA. It provides a means of operating on patients in a setting alternative to currently oversubscribed main theatres, by utilizing satellite facilities, while ensuring identical surgical outcomes for patients who may otherwise have been forced to wait a long time for their procedure. It also confers additional benefits in terms of shorter recovery time and hospital stay for patients. OBJECTIVES: We have developed a set of recommendations that are intended to help support clinicians and managers to better adopt LA rhinology protocols and minimize the risk to the patient and health-care professionals involved. METHODOLOGY: International roundtable forums were conducted and supplemented by individual interviews. The international board consisted of 12 rhinologists experienced in awake rhinology surgery. Feedback was analysed and shared to develop a consensus of best practice. RECOMMENDATIONS: Local and national guidelines need to be adhered to with specific focus on patient and clinician safety. When performing awake rhinology procedures in the COVID-19 recovery process, consider implementing specific safety measures and workflow practices to safeguard patients and staff and minimize the risk of infection. CONCLUSION: Awake surgery potentially provides quicker access to routine rhinology surgery in the post-COVID-19 recovery phase, ensuring patients are treated in a timely matter, thereby avoiding higher downstream costs, and improving outcomes.

Learning curve for endoscopic tympanoplasty type I: comparison of endoscopic-native and microscopically-trained surgeons.

PURPOSE: Type I tympanoplasty is one of the first operations to be performed by ear surgeons in training and is increasingly performed using the endoscopic technique. The aim of the present study is to assess and compare the learning curve for type I tympanoplasties between a microscopically trained and endoscopic native ear surgeon. We hypothesize comparable learning curves between the two surgeons regardless of previous microscopic experience. METHODS: Retrospective analysis and comparison of the 25 first consecutive cases of type I tympanoplasty performed by a microscopically trained ear surgeon (MTES) and a native endoscopic ear surgeon (NEES). RESULTS: Mean duration of surgery in MTES and NEES groups was 54 ± 12.3 min and 55.6 ± 17.5 min, respectively. Both surgeons achieved a reduction of the surgery duration over time with statistically significant reduction from the first five cases to the last five cases in both groups. Graft intake rate was 92% after 3 months. Preoperative and postoperative PTA revealed a mean improvement of air bone gap (ABG) of 11.5 ± 7.1 dB HL in MTES group versus 9.3 ± 8.5 dB HL in NEES group, whereby the difference between the two groups was not statistically significant. CONCLUSION: Endoscopic type I tympanoplasty shows comparable results and learning curves in two beginning endoscopic ear surgeons independent of the previous microscopic experience. We recommend if available the parallel learning of both techniques.

Training model for salvage procedures in endoscopic stapes surgery.

PURPOSE: The learning curve in endoscopic stapes surgery, is flat and long. There is limited space during training for advanced and salvage procedures, which could be necessary in unexpected intraoperative scenarios. The aim of the present study is to develop an ex-vivo animal model for training in salvage and advanced procedures in endoscopic stapes surgery METHODS: After defining the difficult intraoperative scenarios requiring a salvage procedure during stapes surgery, we used the ovine model to create those intraoperative situations. After assessing the suitability of the model for that purpose, it was validated by subjective feedback rating (scale from 1 to 10) and by comparing the relevant anatomical structures for stapes surgery with the human. Finally, an optimal sequence of surgical steps was defined. RESULTS: 8 Fresh frozen lamb heads (16 ears) were studied. The selected intraoperative scenarios were: floating footplate, footplate fracture, luxation of the incus or necrosis of the long process, overhanging facial nerve, obliterative otosclerosis. The simulation resulted feasible and close to real. The mean overall rating for surgical scenarios ranged from 7.5 to 8.8 for residents and was consistent with the rating of senior surgeons, ranging from 7.67 and 9.0. Anatomical measures of the oval window area resulted similar between the ovine and the human. CONCLUSION: The ex-vivo ovine model is a suitable model for training in salvage and advanced procedures in exclusively endoscopic stapes surgery. The model can be used both for the training and maintenance of the acquired advanced skills in endoscopic stapes surgery.

Surgical implications of 3D vs 2D endoscopic ear surgery: a case-control study.

PURPOSE: To compare 3D to 2D technology in endoscopic ear surgery (EES); to report surgeons' feedback on the use of 3D in EES; to describe the operative setting for 3D EES. METHODS: A case-control study on EES was performed at a tertiary university center. All consecutive cases of 3D EES (case group) were matched to a control group operated with the standard 2D technique. Data on surgical approach, type of surgery, operative time, outcomes, and complications were compared between the two groups. After each surgery, the operating surgeons were asked to give a feedback on the use of 3D endoscopy, filling in a questionnaire based on 5-point Likert scales. RESULTS: None of the 3D procedures was switched to 2D. Nor intraoperative or long-term complications were recorded. The operative time was similar in both groups. Postoperative hearing function did not show any statistically significant difference between 3 and 2D patients. Ninety-six percent of participants agreed or strongly agreed on better views of anatomy and pathology with the 3D technique. Discomfort induced by 3D vision was rarely reported. CONCLUSION: Surgical and functional results from EES respectively performed with 3D and 2D systems are overall similar, suggesting that both techniques are safe and effective. According to the surgeons' feedback, 3D provides better depth perception and improved view of anatomy and pathology. Several surgeons are willing to use the 3D system for future EES. To guarantee the best 3D EES experience, the setting in the operating room plays a crucial role.

Epinephrine Use in Endoscopic Ear Surgery: Quantitative Safety Assessment.

INTRODUCTION: The management of bleeding in exclusive endoscopic ear surgery (EES) is largely dependent on epinephrine use. However, to date its suitability and safety have not been assessed. The aim of the present study would be to assess the safety profile of topical application and/or local infiltrationof diluted epinephrine during EES regarding the intra- and postoperative periods. We hypothesize that epinephrine may be safely used during EES. METHODS: Retrospective analysis of 90 EES cases performed at the University Hospital of Modena, Italy. Patient's charts and video recordings of the operations were assessed. RESULTS: Epinephrine was used in all cases for hemostatic purposes as following: (1) diluted epinephrine (1:200,000) injection: mean 1.2 mL (range: 0-3.5) corresponding to 0.006 mg (range 0-0.018), and (2) topical application (1:1,000) directly in the surgical field: mean 7 cottonoids (range: 0-18) corresponding to mean 0.56 mg (range: 0-1.44). No major cardiovascular adverse effects were assessed. Only 2 intraoperative hypertensive events were recorded. One sensorineural hearing loss was observed in a case of cholesteatoma involving the stapes; no facial palsy occurred during the study period. CONCLUSION: The combined use of local injection and topical epinephrine is a safe and effective strategy to control bleeding in exclusive EES, when used within the dilutions and quantities reported in this study.

Pleomorphic Adenoma of External Auditory Canal: Case Report of First Endoscopic Resection and Literature Review.

Ceruminous pleomorphic adenoma is a very rare, mostly benign tumor originating from the ceruminal glands in the external auditory canal. Histologically, it is a mixed tumor with epithelial and stromal parts of different proportions, and is recognized today by the World Health Organization (WHO) as a ceruminous adenoma. Similar to the pleomorphic adenoma of salivary glands, recurrence or malignant degeneration with cellular atypia and metastasis can occur on rare occasions. Here, we describe an 87-year old female patient with a growing spherical mass in the right external auditory canal. After exclusive endoscopic tumor resection, a ceruminous pleomorphic adenoma was histologically diagnosed. Due to the absence of nuclear pleomorphism, no increased mitotic rate, no perineural invasion and no fusion transcripts of the MYB or MYBL1 gene loci, an adenoid cystic carcinoma could be excluded. The postoperative course was without any evidence of complications. A literature review identified 44 articles with 49 patients that were considered. Hearing loss and ear sensations were the most commonly reported symptoms. Most cases underwent an excision via an endaural or retroauricular approach. Recurrences were described in four patients, three of which had a malignant transformation.

MRI Metal Artifact Reduction Sequence for Auditory Implants: First Results with a Transcutaneous Bone Conduction Implant.

OBJECTIVE: Magnetic resonance imaging (MRI) is often limited in patients with auditory implants because of the presence of metallic components and magnets. The aim of this study was to evaluate the clinical usefulness of a customized MRI sequence for metal artifact suppression for patients with implants in the temporal bone region, specifically patients with a transcutaneous bone conduction implant. METHODS: Two whole head specimens were unilaterally implanted with a transcutaneous bone conduction implant. MRI examinations with and without a primarily self-build sequence (SEMAC-VAT WARP) for metal artifact suppression were performed. The diagnostic usefulness of the acquired MRI scans was rated independently by two neuroradiologists. The sequence was also used to acquire postimplantation follow-up MRI in a patient with a transcutaneous bone conduction implant. RESULTS: The customized SEMAC-VAT WARP sequence significantly improved the diagnostic usefulness of the postimplantation MRIs. The image acquisition time was 12 min and 20 s for the T1-weighted and 12 min and 12 s for the T2-weighted MRI. There was good agreement between the two blinded raters (Cohen's κ = 0.61, p < 0.001). CONCLUSION: The sequence for metal artifact reduction optimized in Bern enables MRI at 1.5 T in patients with active transcutaneous bone conduction implants without sacrificing diagnostic imaging quality. Particularly on the implanted side, imaging of intracranial and supra- and infratentorial brain pathologies is clinically more valuable than standard diagnostic MRI without any artifact reduction sequences.

Blunt nasal trauma in children: a frequent diagnostic challenge.

OBJECTIVE: The clinical challenge in blunt nasal trauma in children, is to identify cases requiring specialized care among frequently encountered banalities, whilst trying to minimize the exposure to diagnostic procedures. We aim to evaluate the related diagnostic and therapeutic pathways and its outcome during follow-up. METHODS: This retrospective cohort study includes children up to 16 years presenting at the emergency department with blunt nasal trauma of our tertiary reference center. RESULTS: The incidence of blunt nasal injuries was estimated 1750 cases in 7 years. A total of 459 consecutive cases with suspected complications were enrolled. Univariate comparison between age groups revealed a statistically significant diminution of downfall related injuries with growing up, whereas blows (including violence) significantly increased with age (p < 0.001 each). The logistic regression model identified male sex as an independent risk factor for soft tissue lesions (OR 1.699, p = 0.017) and for frontobasal fractures (OR 2.415, p = 0.050). Age was not identified to play a significant role regarding localization of injuries. Delayed septorhinoplasties became necessary in 2 cases only (0.4%). The logistic regression model identified nasal bone fracture (OR 17.038, p < 0.001) and mandibular fracture (OR 4.753, p = 0.004) as independent risk factor for a surgical intervention. CONCLUSIONS: Blunt trauma to the nose is frequent in children. Trauma mechanisms differ significantly between age groups, whereas localization and concomitant injuries do not. Male sex was identified as an independent risk factor for soft tissue lesions and frontobasal fractures. In our experience, initial triage by the pediatric department with consecutive involvement of the ENT specialists in case of suspected complications is safe and effective and may help to reduce unnecessary diagnostic procedures/irradiation to the young patients.

Rating surgical field quality in endoscopic ear surgery: proposal and validation of the "Modena Bleeding Score".

PURPOSE: To develop and validate a bleeding score that could be applied in endoscopic ear surgery (EEarS). METHODS: A prospective validation study was performed. A new bleeding score, called "Modena Bleeding Score" (MBS), was created by the authors. It provides five grades for rating the surgical field during EEarS procedures (from grade 1-no bleeding to grade 5-bleeding that prevents every surgical procedure except those dedicated to bleeding control). A preliminary "face validity" was performed by 18 ENT specialists to assess possible misunderstandings in interpreting the scale. Then, 15 videos of endoscopic ear surgery procedures, each divided into three parts (t0, t1, and t2), were subsequently evaluated by 15 specialists, using MBS. The videos were randomly selected and assigned. Intra-rater reliability and inter-rater reliability were calculated. The clinical validity of the instrument was calculated using a referent standard (i.e., four ENT experts whose ratings were compared to those obtained by the former sample). RESULTS: The face validity showed a good consensus about the clarity and comprehension of the scale; both intra and inter-rater reliability demonstrated good performance (intra-rater reliability ranged from 0.741 to 0.991 and inter-rater reliability was 0.790); clinical validity also showed positive values, ranging from 0.75 to 0.93. CONCLUSIONS: MBS has proved to be an effective method to rate surgical field during EEarS, with good-to-excellent performances. Its use would possibly help comparisons of groups in clinical trials or comparisons between studies.