The learning curve for endoscopic tympanoplasties: a single-institution experience, in Birmingham, UK.

OBJECTIVE: This study aimed to assess whether increasing operative experience results in better surgical outcomes in endoscopic middle-ear surgery. METHODS: A retrospective single-institution cohort study was performed. Patients underwent endoscopic tympanoplasty between May 2013 and April 2019 performed by the senior surgeon or a trainee surgeon under direct supervision from the senior surgeon. Following data collection, statistical analysis compared success rates between early (learning curve) surgical procedures and later (experienced) tympanoplasties. RESULTS: In total, 157 patients (86 male, 71 female), with a mean age of 41.6 years, were included. The patients were followed up for an average of 43.2 weeks. The overall primary closure rate was 90.0 per cent. CONCLUSION: This study demonstrates an early learning curve for endoscopic ear surgery that improves with surgical experience. Adoption of the endoscopic technique did not impair the success rates of tympanoplasty.

Blunt neck trauma at a level I trauma centre: six-year retrospective case note review.

BACKGROUND: Blunt neck trauma can cause serious morbidity and mortality rates of up to 40 per cent, but there is a paucity of literature on the topic. METHOD: A retrospective case note review was performed for all blunt neck trauma cases managed at the Queen Elizabeth Hospital Birmingham between 1st January 2011 and 31st December 2017. RESULTS: Seventeen cases were managed, with no mortality and limited morbidity. Most patients were male (70.6 per cent) and road traffic accidents were the most common cause of injury (41.2 per cent). The median age of patients was 40.6 years (range, 21.5-70.3 years). Multidetector computed tomography angiography of the neck was performed in 9 patients (52.9 per cent) with 'hot' reports made by on-duty radiology staff matching consultant reports in all but 1 case. Six patients underwent operative exploration yielding a negative exploration rate of 33.3 per cent. Imaging reports matched operative findings in 3 cases (60 per cent). CONCLUSION: Blunt neck trauma is uncommon but usually presents in polytrauma. Imaging has inaccuracies when compared with operative findings, regardless of radiological experience.

endoscope-i: an innovation in mobile endoscopic technology transforming the delivery of patient care in otolaryngology.

INTRODUCTION: Digital and mobile device technology in healthcare is a growing market. The introduction of the endoscope-i, the world's first endoscopic mobile imaging system, allows the acquisition of high definition images of the ear, nose and throat (ENT). The system combines the e-i Pro camera app with a bespoke engineered endoscope-i adaptor which fits securely onto the iPhone or iPod touch. Endoscopic examination forms a salient aspect of the ENT work-up. The endoscope-i therefore provides a mobile and compact alternative to the existing bulky endoscopic systems currently in use which often restrict the clinician to the clinic setting. Areas covered: This article gives a detailed overview of the endoscope-i system together with its applications. A review and comparison of alternative devices on the market offering smartphone adapted endoscopic viewing systems is also presented. Expert commentary: The endoscope-i fulfils unmet needs by providing a compact, highly portable, simple to use endoscopic viewing system which is cost-effective and which makes use of smartphone technology most clinicians have in their pocket. The system allows real-time feedback to the patient and has the potential to transform the way that healthcare is delivered in ENT as well as having applications further afield.

Audiological outcome of stapes surgery for far advanced cochlear otosclerosis.

BACKGROUND: Patients with advanced otosclerosis can present with hearing thresholds eligible for cochlear implantation. This study sought to address whether stapes surgery in this patient group provides a clinically significant audiological benefit. OBJECTIVES: To assess pre- and post-operative hearing outcomes of patients with advanced otosclerosis, and to determine what proportion of these patients required further surgery including cochlear implantation. METHODS: Between 2002 and 2015, 252 patients underwent primary stapes surgery at our institution. Twenty-eight ears in 25 patients were deemed to have advanced otosclerosis, as defined by pure audiometry thresholds over 80 dB. The patients' records were analysed to determine audiological improvement following stapes surgery, and assess whether any further surgery was required. RESULTS: The audiological outcome for most patients who underwent primary stapes surgery was good. A minority of patients (7 per cent) required revision surgery. Patients who underwent cochlear implantation after stapes surgery (10 per cent) also demonstrated a good audiological outcome. CONCLUSION: Stapes surgery is a suitable treatment option for patients with advanced otosclerosis, and should be considered mandatory, before offering cochlear implantation, for those with a demonstrable conductive component to their hearing loss. A small group of patients get little benefit from surgery and subsequently a cochlear implant should be considered.

Endoscopic ear surgery: a hot topic?

OBJECTIVES: To summarise published research investigating maximal temperatures associated with endoscopes used in otology. Possible thermal issues surrounding the use of endoscopes in middle-ear surgery are discussed, and recommendations regarding the safest ways to use endoscopes in endoscopic ear surgery are made. METHODS: A non-systematic review of the relevant literature was conducted, with descriptive analysis and presentation of the results. RESULTS: There are currently no reports of any temperature-related deleterious effects in patients having undergone endoscopic ear surgery. There is debate regarding heat issues in endoscopic ear surgery, with a limited body of work documenting potential negative impacts of middle-ear heat exposure from endoscopes. The diameter of endoscope, type of light source used, distance from endoscope tip and duration of exposure are highlighted potential factors for high temperatures in endoscopic ear surgery. CONCLUSION: There is a trend towards endoscopes being used routinely in ear surgery. Simple practice points are recommended to minimise potential thermal risks.

Diffusion-weighted magnetic resonance imaging for residual and recurrent cholesteatoma: a systematic review and meta-analysis.

BACKGROUND: Diagnosis and management of recurrent or residual cholesteatoma can be problematic. Diffusion-weighted imaging magnetic resonance imaging (MRI) sequences have been used for follow-up of such lesions. More recent non-echoplanar imaging (non-EPI) sequences are thought to be superior to older echoplanar imaging (EPI) sequences. OBJECTIVE OF REVIEW: Evaluate whether diffusion-weighted magnetic resonance imaging is useful in the diagnosis of recurrent or residual cholesteatoma. TYPE OF REVIEW: Systematic review and meta-analysis. SEARCH STRATEGY: MEDLINE, EMBASE, CINAHL, Web of Science and the Cochrane Database were searched, with no limits on date or language. STUDY SELECTION: Adults or children who had previously undergone tympanomastoid surgery by any method with confirmation of recurrence/residual disease by second-look/revision surgery. EVALUATION METHODS: Two reviewers independently reviewed studies. Data extracted on 11 domains and rechecked. DATA SYNTHESIS: Statistical analysis with SPSS. RESULTS: A total of 575 studies were identified of which 27 met the inclusion criteria. These covered 727 patient episodes. For EPI studies: sensitivity (sd) 71.82 (24.5), specificity (sd) 89.36 (13.4), PPV (sd) 93.36 (8.1) and NPV (sd) 73.36 (15.8). For non-EPI studies: sensitivity 89.79 (12.1), specificity (sd) 94.57 (5.8), PPV (sd) 96.50 (4.2) and NPV 80.46 (20.2). Improved sensitivity of non-EPI sequences reached significance (P = 0.02). CONCLUSIONS: Diffusion-weighted MRI is both sensitive and specific for the detection of recurrent or residual cholesteatoma following ear surgery. Non-EPI techniques are superior to EPI techniques.

Litigation trends and costs in otorhinolaryngology.

BACKGROUND: Litigation in surgery is increasing and liabilities are becoming unsustainable. This study aimed to analyse trends in claims, and identify areas for potential risk reduction, improved patient safety and a reduction in the number, and cost, of future claims. METHODS: Ten years of retrospective data on claims in otorhinolaryngology (2003-2013) were obtained from the National Health Service Litigation Authority via a Freedom of Information request. Data were re-entered into a spreadsheet and coded for analysis. RESULTS: A total of 1031 claims were identified; of these, 604 were successful and 427 were unsuccessful. Successful claims cost a total of £41 000 000 (mean, £68 000). The most common areas for successful claims were: failure or delay in diagnosis (137 cases), intra-operative problems (116 cases), failure or delay in treatment (66 cases), failure to warn - informed consent issue (54 cases), and inappropriate treatment (47 cases). CONCLUSION: Over half of the claims in ENT relate to the five most common areas of liability. Recent policy changes by the National Health Service Litigation Authority, over the level of information divulged, limits our learning from claims.

Initial experience of a rapid-insertion bone-anchored hearing system: series of 20 consecutive implants.

Objective: The loading of bone-anchored hearing system sound processors usually occurs two to three months after surgical implant. This study examined a new bone-anchored hearing system coupling mechanism that permits loading at two weeks post-implantation without compromising osseointegration. Methods: Twenty implants were implanted into 15 patients. The interval between operation and time of processor loading was recorded, along with the cause of any delay and any late complications. Results: Two patients were fitted with implants at seven and nine weeks. The delay was a result of administrative errors; the patients reported no skin problems. Of the remaining 17 implants, 8 processors were fitted at 2 weeks, 1 at 3 weeks, 4 at 4 weeks, 3 at 7 weeks and 1 at 8 weeks. For those nine implants fitted later than two weeks, the delay was because of incomplete skin healing. Conclusion: The Oticon Medical Xpress system allowed processor loading at two weeks post-operatively, providing skin healing was adequate. Early loading occurred in approximately half of the patients. All patients were fitted within the two to three months traditionally allowed. Prolonged skin healing time was the main reason for the delayed fitting of sound processors.

Lifestyle management of unipolar depression.

OBJECTIVE: To be used in conjunction with 'Pharmacological management of unipolar depression' [Malhi et al. Acta Psychiatr Scand 2013;127(Suppl. 443):6-23] and 'Psychological management of unipolar depression' [Lampe et al. Acta Psychiatr Scand 2013;127(Suppl. 443):24-37]. To provide clinically relevant recommendations for lifestyle modifications in depression, derived from a literature review. METHOD: A search of pertinent literature was conducted up to August 2012 in the area of lifestyle factors and depression. A narrative review was then conducted. RESULTS: There is evidence that level of physical activity plays a role in the risk of depression, and there is a large and validated evidence base for exercise as a therapeutic modality. Smoking and alcohol and substance misuse appear to be independent risk factors for depression, while the new epidemiological evidence supports the contention that diet is a risk factor for depression; good quality diets appear protective and poor diets increase risk. CONCLUSION: Lifestyle modification, with a focus on exercise, diet, smoking and alcohol, may be of substantial value in reducing the burden of depression in individuals and the community.

A smart micro-drill for cochleostomy formation: a comparison of cochlear disturbances with manual drilling and a human trial.

BACKGROUND: Cochleostomy formation is a key stage of the cochlear implantation procedure. Minimizing the trauma sustained by the cochlea during this step is thought to be a critical feature in hearing preservation cochlear implantation. The aim of this paper is firstly, to assess the cochlea disturbances during manual and robotic cochleostomy formation. Secondly, to determine whether the use of a smart micro-drill is feasible during human cochlear implantation. MATERIALS AND METHODS: The disturbances within the cochlea during cochleostomy formation were analysed in a porcine specimen by creating a third window cochleostomy, preserving the underlying endosteal membrane, on the anterior aspect of the basal turn of the cochlea. A laser vibrometer was aimed at this third window, to assess its movement while a traditional cochleostomy was performed. Six cochleostomies were performed in total, three manually and three with a smart micro-drill. The mean and peak membrane movement was calculated for both manual and smart micro-drill arms, to represent the disturbances sustained within cochlea during cochleostomy formation. The smart micro-drill was further used to perform live human robotic cochleostomies on three adult patients who met the National Institute of Health and Clinical Excellence criteria for undergoing cochlear implantation. RESULTS: In the porcine trial, the smart micro-drill preserved the endosteal membrane in all three cases. The velocity of movement of the endosteal membrane during manual cochleostomy is approximately 20 times higher on average and 100 times greater in peak velocity, than for robotic cochleostomy. The robot was safely utilized in theatre in all three cases and successfully created a bony cochleostomy while preserving the underlying endosteal membrane. CONCLUSIONS: Our experiments have revealed that controlling the force of drilling during cochleostomy formation and opening the endosteal membrane with a pick will minimize the trauma sustained by the cochlea by a factor of 20. Additionally, the smart micro-drill can safely perform a bony cochleostomy in humans under operative conditions and preserve the integrity of the underlying endosteal membrane.

Bismuth iodoform paraffin paste hypersensitivity reactions in mastoid cavities following isolation of mucosal lining: a series of 587 patients.

AIM: (1) To assess hypersensitivity to bismuth iodoform paraffin paste impregnated ribbon gauze following its use in packing canal wall down mastoidectomy cavities; (2) to determine if isolation of the skin and mucosa from the pack, using thin Silastic sheeting and Cortisporin ointment, reduces hypersensitivity reactions, compared with a previous series; and (3) to review the literature and to determine if bismuth iodoform paraffin paste hypersensitivity precludes the consumption of seafood (due to its high iodine content). MATERIALS AND METHODS: All patients undergoing canal wall down mastoidectomy with intra-operative bismuth iodoform paraffin paste packing between 1985 and 2009 were identified and reviewed. RESULTS: Of 587 patients identified, the overall bismuth iodoform paraffin paste reaction rate was 1 per cent. All reactions were in patients undergoing revision mastoidectomy procedures, giving a reaction rate for revision procedures of 2.4 per cent. CONCLUSION: Reactions are an uncommon event following post-operative mastoid cavity packing using bismuth iodoform paraffin paste. Reaction rates may be lowered by preparing the cavity with Silastic sheeting and Cortisporin ointment prior to packing, thus isolating the skin and mucosal surfaces. Development of such a reaction does not preclude the consumption of seafood.

Robotics can lead to a reproducibly high-quality operative result for ear, nose, and throat patients.

The success rates and morbidity of operations on the ear, nose, and throat (ENT) have improved markedly in the last 20-25 years. This has been largely due to improved vision, by microscopes and endoscopes, and has led to a greatly reduced hospital stay. During this time there has been minimal improvement in surgical tools. This paper discusses the need for robotic tools, detailing the clinical constraints that proposed solutions need to adhere to, and presenting a recently trialled micro drilling robot for creating a cochleostomy in the cochlear implant procedure.

How good is a chest CT scan at predicting the risk of pulmonary metastatic disease in patients with head and neck cancer? A retrospective observational study.

OBJECTIVES: Our objectives were to assess whether a CT chest, when performed as part of initial staging investigations, is a robust method to identify lung metastases or synchronous primary lung cancers in patients with head and neck squamous cell and whether small nodules are likely to represent metastases in this group of patients. DESIGN: Retrospective observational study performed between 1994 and 2005. SETTING: Head and neck cancer department, Queen Elizabeth Hospital, Birmingham. PARTICIPANTS: All patients that were included had a new head and neck squamous cell carcinoma and underwent a CT chest as part of their staging investigation. MAIN OUTCOME MEASURES: The presence of lung masses on the initial screening CT of the chest as determined by the radiologist's report. The development of lung metastases or primary bronchogenic carcinoma in any patient. RESULTS: Two hundred and thirty-nine patients met the inclusion criteria. 38 (16%) patients had a CT chest report for a lung malignancy (either metastatic or primary bronchogenic), 33 of these 38 (87%) patients actually had a lung malignancy. 32 (13%) patients had a CT chest report for a small nodule, three of these 32 (9%) patients were later diagnosed with a lung malignancy, all at a different site to the nodule. 169 (71%) patients had normal CT chest reports, of these 3 (2%) patients were later diagnosed with a lung malignancy. CONCLUSIONS: The CT chest is a useful screening tool but is not infallible. Small nodules should be taken seriously and monitored, but should not alter the initial decision as to the management of the patient.

The effect of operating time on surgeons' muscular fatigue.

INTRODUCTION: A study was completed to determine if operating has an effect on a surgeon's muscular fatigue. SUBJECTS AND METHODS: Six head and neck surgery consultants, two ENT registrars, 20 normal controls from two tertiary referral centres in the West Midlands participated in the study. Electromyography (EMG) measurements were taken throughout a day of operating and fatigue indices were compared to controls performing desk work. RESULTS: The percentage changes in mean frequency of muscular contractions were examined; there was no significant difference in fatigue levels between consultants and registrars. Operating led to an increase in fatigue in all subjects, compared to no increase in controls performing desk work. It was also found that the brachioradialis muscle is used more than the mid-deltoid muscle and, hence, fatigues at a faster rate. CONCLUSIONS: Surgeons should be aware that their muscular fatigue levels will increase as an operation progresses; therefore, if possible, more complex parts of the operation should be performed as early as possible, or, in the case of a very long operation, a change in surgeon may be necessary.

An autonomous surgical robot for drilling a cochleostomy: preliminary porcine trial.

OBJECTIVE: To produce an autonomous drilling robot capable of performing a bony cochleostomy whilst minimising the damage to the underlying cochlear endosteum. DESIGN: In this laboratory based study, a robotic drill was designed to measure the changes in force and torque experienced by the tool point during the drilling process. This information is used to predict the point of breakthrough and stop the drill prior to damaging the underlying endosteal membrane. SETTING: Aston University. PARTICIPANTS: Five porcine cochleas. MAIN OUTCOMES MEASURES: An assessment was made of whether a successful bony cochleostomy was performed, the integrity of endosteal membrane was then assessed. RESULTS: The autonomous surgical robotic drill successfully performed a bony cochleostomy and stopped without damaging the endosteal membrane in all five cases. CONCLUSIONS: The autonomous surgical robotic drill can perform a cochleostomy whilst minimising the trauma to the endosteal membrane. The system allows information about the state of the drilling process to be derived using force and torque data from the tool point. This information can be used to effectively predict drill breakthrough and implement a control strategy to minimise drill penetration beyond the far surface.

A case of hyperkalaemia associated with hypocalcaemia.

An 84-year-old woman presented with lethargy and anorexia. Although routine biochemistry demonstrated mild hyponatraemia, moderate hyperkalaemia and severe hypocalcaemia, the patient did not demonstrate the usual symptoms of hypocalcaemia. An electrocardiogram did not demonstrate evidence of hyperkalaemia or hypocalcaemia. Repeated biochemistry confirmed hyponatraemia but that was associated with hypokalaemia and normocalcaemia. Initial management involved correction of the hyponatraemia and hypokalaemia with appropriate intravenous fluids. If serum biochemistry demonstrates hyperkalaemia in association with hypocalcaemia, pseudohyperkalaemia and pseudohypocalcaemia caused by contamination with potassium ethylenediaminetetraacetic acid should always be considered. This can be confirmed by repeating biochemistry, but ensuring the serum gel tube is drawn first when taking multiple blood samples to avoid this contamination.

Empty sella syndrome associated with a hyperfunctioning microadenoma invading the clivus.

The empty sella syndrome is usually associated with normal pituitary function. If dysfunction is present, this is commonly hypofunction. Hyperfunctioning microadenomas have been described in the presence of the empty sella syndrome. We present the first reported cases of a microadenoma invading the clivus associated with an empty sella.