Blood tests as biomarkers for the diagnosis and prognosis of sudden sensorineural hearing loss in adults: a systematic review.

OBJECTIVE: Sudden sensorineural hearing loss is considered idiopathic in up to 90 per cent of cases. This study explored the role of blood tests as biomarkers for the diagnosis and prognosis of sudden sensorineural hearing loss. METHOD: Two researchers filtered 34 papers into the final review. This review was pre-registered on the Prospero database and conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines. RESULTS: Raised inflammatory markers are almost universal in sudden sensorineural hearing loss, suggesting an inflammatory or autoimmune process. The most useful biomarkers are neutrophil-lymphocyte ratio, platelet-lymphocyte ratio and fibrinogen level. Focused investigations should be deployed on a case-by-case basis to identify underlying metabolic, infective and autoimmune conditions. CONCLUSION: A full blood count and coagulation screen (fibrinogen) is recommended in all cases of sudden sensorineural hearing loss. These are inexpensive, accessible and offer as much diagnostic and prognostic information as any other biomarker. There is emerging evidence regarding specific biomarkers for sudden sensorineural hearing loss prognosis, with heat shock protein-70, anti-endothelial cell antibody and prestin demonstrating potential; investigation of their validity through prospective, controlled research is recommended.

Common challenges in cochlear implant surgery performed under local anaesthesia and how to overcome them: the experience of UK surgeons.

BACKGROUND: Cochlear implantation performed under local anaesthesia is an increasingly accepted technique worldwide, though the literature to date includes only single-surgeon and single-centre experiences. This study explored the national experience of UK surgeons using this challenging surgical technique, with the goal of providing consensus recommendations. METHODS: A qualitative analysis was conducted of semi-structured interviews with 10 UK-based cochlear implantation surgeons, focusing on common challenges, how to overcome them and candidate selection. RESULTS: Cochlear implantation under local anaesthesia can potentially be offered to all eligible adult patients with favourable anatomy. A posterior tympanotomy and round window approach is recommended. Common challenges and recommendations are explored thematically: managing patient, surgeon and staff expectations; optimising communication; patient comfort and position; minimising pain and vertigo; and safe use of sedation. CONCLUSION: This is the first study of national experience of cochlear implantation performed under local anaesthesia. Key themes, including refinements to surgical technique and optimising patient comfort and communication, have been explored in depth.

Immunosuppression, infection, and epidermal compromise: an aetiological triad for necrotising otitis externa that highlights potential modifiable risk factors.

OBJECTIVE: A key clinical feature of necrotising otitis externa is granulation tissue arising from the ear canal, representing epidermal compromise. The aim of this work was to explore the role of epidermal compromise in the aetiology of necrotising otitis externa. METHOD: A structured risk factor history was taken from 54 patients diagnosed with necrotising otitis externa between 2017 and 2022. Primary care records were also reviewed. RESULTS: A total of 94 per cent of patients reported incidents of potential epidermal compromise preceding severe pain onset, including a 35 per cent incidence of ear syringing. A total of 94 per cent of patients were immunosuppressed, including 78 per cent with diabetes. All patients had medical co-morbidities. CONCLUSION: This study proposed an aetiological triad for necrotising otitis externa: immunosuppression, infection and epidermal compromise. Epidermal compromise is a potentially modifiable risk factor for necrotising otitis externa. Meticulous primary ear care for older adult, diabetic and immunosuppressed patients is recommended. These populations should never undergo ear syringing and should avoid ear canal trauma and prolonged exposure to moisture.

Participant expectations in a national otolaryngology mentorship programme.

OBJECTIVE: Mentoring within surgery is increasingly recognised as a powerful development tool, but participant expectations have not previously been explored. This study aimed to explore and analyse participant expectations from the UK's first national otolaryngology mentorship programme. METHOD: Participants completed open-ended questionnaires. Responses were qualitatively analysed using a grounded theory approach. Iterative cycles were used to develop codes using a constant comparison technique. Emerging categories were refined to identify core themes. RESULTS: Key mentee expectations were career, and clinical and academic guidance. Enhancing networking opportunities was highlighted by medical students and junior trainees. Psychosocial and lifestyle support were predominant themes for all trainees. Receiving impartial advice and guidance from outside their training region was expressed only by senior trainees. Mentor expectations aligned with those of mentees. CONCLUSION: This study identified key areas of the 'hidden curriculum' for students and trainees in otolaryngology, showing the evolving expectations and priorities as they progress through training.

Skills and competencies that a new ENT specialty trainee year 3 should possess: a live Delphi study.

OBJECTIVE: The aim of this study was to develop a novel live Delphi method to obtain a consensus on the skills and competencies that a new ENT registrar (specialty trainee level 3) should possess. Developing a clear outcome set for core surgical trainees is important so that this phase of training can be directed at specific aims. METHOD: Attendees at the North of England meeting participated in this Delphi exercise. Participants comprised a range of ENT professionals from medical student to consultant surgeons. The main outcome measure of consensus was defined prior to the study as the median response value: strongly agree or more for positive consensus and strongly disagree or less for negative consensus. RESULTS: This study identified multiple areas that reached consensus relating to elective and operative skills and demonstrated agreement in areas relating to ENT specific and allied specialty experience. CONCLUSION: This study has highlighted a novel method for shaping surgical curricula.

Patients' experience of necrotising otitis externa: a qualitative study.

BACKGROUND: Necrotising otitis externa is a serious infective condition. Patients are typically frail, diagnostic delay is common and severe pain is a key feature. This study aimed to qualitatively analyse patient-centred data to identify key themes in the patient's experience. METHODS: Open-ended questionnaires were sent to 28 patients. Responses were qualitatively analysed using a grounded theory approach. Iterative cycles were used to develop codes using a constant comparison technique. Emerging categories were refined to identify core themes. RESULTS: Four main themes emerged: severe pain, mental health, quality of life and diagnostic delays. CONCLUSION: This is the first study to explore patients' perspectives in necrotising otitis externa. It indicates a need to raise awareness of necrotising otitis externa, and to improve symptom management, pain control and quality of life. This valuable information can be used to identify research priorities, guide service improvements, improve clinical care and feed into the development of a Core Outcome Set for necrotising otitis externa.

The interface of paediatric ENT and autism spectrum disorder: a complex conundrum for otolaryngologists.

OBJECTIVE: Autism spectrum disorder is a lifelong neurodevelopmental condition encompassing complex physical and neurological symptoms, including complex sensory symptoms. This review explores the interface between autism spectrum disorder and paediatric ENT. METHODS: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses ('PRISMA') guideline, a robust literature search and review was conducted by two researchers. Thirty-four papers were filtered into the final review. RESULTS: Published literature clearly demonstrates potential for autism spectrum disorder to present in the form of auditory and other sensory symptoms to ENT surgeons and audiologists who may not fully appreciate this complex condition. Despite this well-documented link, auditory symptoms, auditory processing disorders and hearing loss within autism spectrum disorder remain poorly understood. CONCLUSION: Improved recognition and understanding of autism spectrum disorder by otolaryngologists could enable more effective diagnostic and management strategies for autistic children who present with auditory and other sensory symptoms. In light of the current 'autism epidemic,' there is an urgent need for further research on this theme.

Exploring theories for the exponential 16-year rise in incidence of necrotising otitis externa in England.

BACKGROUND: Necrotising otitis externa is a severe, life-threatening infection. Epidemiological data demonstrate a dramatic rise in reported cases in England from 2002 to 2017. The reasons for this remain elusive. METHODS: A quantitative descriptive study was undertaken using epidemiological data from the Hospital Episode Statistics database. Cases from 2002 to 2017 were compiled and analysed. Four potential theories were explored to explain the rise in incidence. RESULTS: Within the 16-year period, 7327 necrotising otitis externa cases were reported. Annual necrotising otitis externa incidence increased 1142 per cent within the 16-year period, from 123 recorded cases in 2002 to 1405 cases in 2017. This correlates with an increasing prevalence of diabetes, an ageing population and likely increased physician awareness of necrotising otitis externa. There is insufficient evidence to support antibiotic resistance as a significant associated factor. CONCLUSION: Correlation does not imply causation. It is likely that a combination of factors is contributing to the rise in necrotising otitis externa incidence, including increased physician recognition, diagnosis and accurate clinical coding.

Emerging themes in necrotising otitis externa: a scoping review of the literature from 2011 to 2020 and recommendations for future research.

OBJECTIVE: Necrotising otitis externa is an invasive, infective condition, with minimal evidence underpinning its diagnosis and management. This work aimed to analyse literature from the past decade, to identify emerging themes and important topics for future research. METHODS: A robust literature search and review were conducted by two researchers. Sixty studies were filtered into the final review. A grounded theory approach was used to identify core themes. Data within these themes formed the basis of the review. RESULTS: There is no consensus regarding a clinical definition or outcome measures of necrotising otitis externa, and there exists no level 1, 2 or 3 evidence to diagnose, investigate, monitor or treat necrotising otitis externa. Emerging themes in the literature direct researchers to important topics for future clinical trials, including risk factors, microbiological culture, management strategies and radiology. CONCLUSION: In order to optimise understanding and management of necrotising otitis externa, future research requires robust clinical trials and consistently reported outcome measures.

Patterns of medication use and imaging following initial diagnosis of sarcoidosis.

INTRODUCTION: Sarcoidosis is a rare inflammatory disease with unclear natural history. Using a large, retrospective, longitudinal, population-based cohort, we sought to define its natural history in order to guide future clinical studies. METHODS: We identified 722 newly diagnosed cases of sarcoidosis within Kaiser Permanente Northwest health care records between 1995 and 2015. We investigated immunosuppressive medication use in the two years following diagnosis, analyzed demographic and clinical characteristics, and quantified chest imaging and pulmonary function testing (PFTs) across the clinical course. RESULTS: Over two years of follow-up, 41% of patients were treated with prednisone. Of those, 75% tapered off their first course within 100 days, although half of those patients required recurrent therapy. Five percent of the entire cohort remained on prednisone for longer than one year, with an average daily dose of 10-20 mg. Chest imaging was associated with early prednisone use, and chest CT was associated with changes in prednisone dose. PFTs or demographics were not associated with prednisone use. Cumulative prednisone doses were significantly higher in African Americans (1,845 mg additional) and those who had a chest CT (2,015 mg additional). Overall, PFTs were less frequently obtained than chest imaging and had no significant change over disease course. DISCUSSION: The natural history of sarcoidosis varies greatly. For those requiring therapy, corticosteroid burden is high. Chest imaging drives medication dose changes as compared to PFTs, but neither outcome fully captures the entire history of disease. Prospective cohorts are needed with purposefully collected, repeated measures that include objective clinical assessments and symptoms.

Impact on patients of the coronovirus disease 2019 pandemic and postponement of cochlear implant surgery: a qualitative study.

OBJECTIVE: This study aimed to explore the impact of the coronavirus disease 2019 pandemic and postponement of elective surgical procedures for profoundly deaf patients awaiting cochlear implantation. METHOD: Open-ended questionnaires were sent to all adult patients awaiting cochlear implantation surgery. Qualitative analysis was performed using a grounded theory approach. RESULTS: Participants described a primarily negative impact on wellbeing from the surgery delay, expressing feelings of isolation or loneliness. Low mood, depression or hopelessness were commonly expressed by elderly participants; frustration and anxiety were described by young adults. Participants described a negative impact on their general daily life, describing difficulties communicating with facemasks and struggles with reliance on telephone communication because of social distancing. Despite these significant psychosocial challenges, only a minority described adaptive coping strategies. DISCUSSION: Profoundly deaf patients may be at greater psychosocial risk because of unique challenges from their hearing disability. Our findings can be used to develop evidence-driven strategies to improve communication, wellbeing and quality of life.

Undergraduate experience of ENT teaching during the coronavirus disease 2019 pandemic: a qualitative study.

BACKGROUND: Coronavirus disease 2019 has transformed medical education worldwide. Innovations in ENT teaching for medical students have focused on virtual learning, often replacing history-taking, patient examination and practical procedure observation. This qualitative study aimed to evaluate student experience and the impact of the altered learning environment. METHODS: Open-ended questionnaires were sent to students following ENT placements from March 2020 to March 2021. Responses were qualitatively analysed and coded using a grounded theory approach. Iterative cycles were used to develop codes via a constant comparison technique. Emerging categories from codes were refined to identify core themes. RESULTS: Core themes were explored, including: reduced clinical experience and patient contact compared with student expectations; challenges to learning opportunities in ENT; and the experience of different teaching methods, or preference for face-to-face teaching. CONCLUSION: Medical students on ENT placement have expectations of patient contact for learning opportunities. ENT departments should ensure that patient contact and face-to-face learning opportunities are facilitated, while maintaining safety, including appropriate personal protective equipment provision.

Role of open-ended questionnaires in patients with balance symptoms.

INTRODUCTION: A clear and detailed clinical history is essential in the assessment of patients with balance symptoms. The aim of this study was to assess the usefulness of open-ended questionnaires in the specialist balance clinic. METHODS: Fifty-four consecutive new patients completed an open-ended questionnaire, prior to a consultation in which the clinical history was taken using a standardised proforma. The results of the two were compared. RESULTS: The open-ended questionnaires provided patient-centred data, and did not provide clinicians with sufficient data for diagnosis. Patients were more likely to respond in the affirmative when asked about symptoms directly, than to report the same symptoms spontaneously on an open-ended questionnaire. When questions had a number of possible answers, patients were more likely to report them in full in an open-ended questionnaire than to provide a response during direct questioning.

Clinical diagnosis of Ménière's disease: how useful are the American Academy of Otolaryngology Head and Neck Surgery Committee on Hearing and Equilibrium guidelines?

INTRODUCTION: Ménière's disease is a diagnosis requiring expert clinical judgment. There are several differences between the American Academy of Otolaryngology Head and Neck Surgery diagnostic guidelines and Prosper Ménière's original description of the disease. METHODS: Six hundred and fifty patients attending a specialist balance clinic had their clinical profiles fully analysed according to each set of diagnostic criteria. RESULTS: Application of the American Academy of Otolaryngology Head and Neck Surgery guidelines resulted in the diagnosis of three times more patients than did use of Ménière's diagnostic criteria. Treatment options for patients in both groups were similar. It is unlikely that the application of different diagnostic criteria would have an effect on the treatment of individual patients. DISCUSSION: The American Academy of Otolaryngology Head and Neck Surgery guidelines are more sensitive and less specific in diagnosing Ménière's disease than Prosper Ménière's original description. Standardised criteria should be applied across published series, in order to make results accurate, comparable and useful in the long term. We would recommend the introduction of a stricter diagnostic category for definite Ménière's disease.

Sacculo-collic response in otosclerosis and following successful stapes surgery.

INTRODUCTION: The sacculo-collic reflex is believed to be a short latency, otolith-mediated myogenic response to sound. With the application of air-conducted sound, one would expect an absent response in stapes fixation, as a fixed stapes footplate will not transmit a pressure wave to the saccule. METHODS: Fifty patients (70 stapes surgery ears, 26 otosclerotic ears and four normal ears) and 40 controls underwent repeated sacculo-collic tests. RESULTS: The results support the proposed mechanism for the sacculo-collic response. The study also suggests that, whilst stapedotomy piston prostheses are effective in the reversal of conductive hearing loss, they produce an insufficient pressure wave to elicit a myogenic response to sound. CONCLUSION: The sacculo-collic test could be a useful tool for screening otolith function and inferior vestibular nerve integrity, but further work is needed to determine the effect of stapes surgery on saccular function.

Use of automated external defibrillators in a Brazilian airline. A 1-year experience.

After the incorporation of automated external defibrillators by other airlines and the support of the Brazilian Society of Cardiology, Varig Airlines began the onboard defibrillation program with the initial purpose of equipping wide-body aircrafts frequently used in international flights and that airplanes use in the Rio - São Paulo route. With all flight attendants trained, the automated external defibrillation devices were incorporated to 34 airplanes of a total fleet of 80 aircrafts. The devices were installed in the baggage compartments secured with velcro straps and 2 pairs of electrodes, one or which pre-connected to the device to minimize application time. Later, a portable monitor was address to the resuscitation kit in the long flights. The expansion of the knowledge of the basic life support fundamentors and the corrected implantation of the survival chain and of the automated external defibrillators will increase the extense of recovery of cardiorespiratory arrest victims in aircrafts.