Primary Tumour Detection in Carcinoma of Unknown Primary with Transoral Robotic Surgery (TORS) Tongue Base Mucosectomy: A Meta-analysis.

BACKGROUND: Head and neck carcinoma of unknown primary (CUP) represents a challenging diagnostic process when standard work-up fails to identify the primary tumour site. The aim of this systematic review and meta-analysis was to evaluate the diagnostic utility and complication profile of transoral robotic surgery (TORS) tongue base mucosectomy (TBM) in the management of CUP. PATIENTS AND METHODS: An electronic database search was performed in the EMBASE, MEDLINE, PubMed and Cochrane databases. A meta-analysis of proportions was performed to obtain an estimate of the overall proportion for the detection and complication rates. RESULTS: Nine studies representing 235 patients with CUP who had TORS TBM were included in the final analysis. The overall pooled tumour detection rate was 66.2% [95% confidence interval (CI) 56.1-75.8]. The incidence of tumour detection in human papilloma virus (HPV)-positive cases (81.5%, 95% CI 60.8-96.4) was significantly higher than HPV-negative cases (2.3%, 95% CI 0.00-45.7). Weighted overall complication rate was 11.4% (95% CI 7.2-16.2). The majority were grade I or II (80%) according to the Clavien-Dindo classification. CONCLUSIONS: This meta-analysis suggests TORS to be safe and effective in localising the primary tumour site in patients with CUP. While the current data supports the use of TORS in patients who are HPV positive, larger numbers of HPV-negative cases are required to determine the true diagnostic effect with TORS before any valid conclusions can be inferred in this particular subgroup. Further research should focus on high quality prospective trials with stringent methodological work-up to minimise heterogeneity and allow for more accurate statistical analysis.

Correlation of maximal nasal septal deviation with deviation at the maxillary insertion.

PURPOSE: It is unclear if septal deviation at the insertion points to the nasal cavity is associated with the overall septal deviation. This study aimed to assess septal deviation at the cribriform plate (CP) and maxillary crest (MC) using CT scans and to see if there was any correlation with overall septal deviation. METHODS: All consecutive CT sinus scans between January 2020 and December 2021 were retrospectively reviewed. Patients were excluded if they had a history of head, nasal or facial trauma, or any previous nasal surgical procedure. Angles between the septum and MC and the septum and CP as well as maximal angle of septal deviation (MSD) were measured. RESULTS: A total of 70 scans were included in the final analysis. The mean MSD was 8.14°. The mean septal deviation was 0.89° at the CP and 2.02° at the MC. The correlation coefficient between the deviation at the CP and MSD was 0.025 and between the deviation at the MC and MSD was 0.321. CONCLUSION: Our data reveal a positive correlation between septal deviation at the floor of the nose and overall septal deviation; this was not observed at the septal deviation at the roof. This could be explained due to the inherent tilt in the cribriform plate or by earlier ossification and fixation of the septum during its development at its insertion to the roof, thereby allowing further growth and potential for deviation of the lower part of the septum and its insertion to the floor.

Writing clinic letters in head and neck outpatient services-Are we doing what patients want?

INTRODUCTION: The Academy of Medical Royal Colleges have recently recommended all outpatient letters to be written directly to patients. We aimed to evaluate clinician and patient preferences for their outpatient letters from a head and neck department at a single-centre secondary care hospital. METHODS: A multiple-choice questionnaire was designed and circulated to patients over a 2-week period. The primary outcome measure was the patient preference for the writing style. In order to evaluate existing writing styles, clinic letters were retrospectively sampled from all consultant and registrar grade otolaryngology (ENT) and oral maxillofacial (OMFS) surgeons in the department. These were analysed for readability via Flesch Reading Ease Score and audience. RESULTS: Of all 80 included patient responses, 42 expressed a preference for letters to be written directly to the patient (52.5%). Only 5.0% (n = 4) of respondents exhibited a preference for letters to be written to their GP, with 42.5% (n = 34) of patients having no preference. All 54 surgeon letters (100%) were addressed to GPs. The average FRE score was 58.5, representing a reading level of "high school education." DISCUSSION: When considered in the wider body of similar studies, there is convincing evidence that patients would prefer letters to be written to them rather than GPs. The authors believe that there should be a push towards patient-directed letters becoming the norm. This will improve patients' understanding of their own health and treatment decisions, allowing them to be more involved in their care and increase patient-centred consultations.

Personal protective equipment guidance during a global pandemic: A statistical analysis of National perceived confidence, knowledge and educational deficits amongst UK-based doctors.

INTRODUCTION: On the 11th of March 2020, the World Health Organisation (WHO) declared a global pandemic following the upsurge of the novel coronavirus disease 2019 (COVID-19). Unprecedented global demand for personal protective equipment (PPE) resulted in restricted availability, as well as evolving guidance on use, the latter of which was complicated by conflicting guidance provided by numerous healthcare bodies. AIM: To assess perceived confidence and knowledge of PPE guidance as published by Public Health England (PHE) amongst doctors of varying specialties and grades. METHOD: A nationwide 11-point survey comprising of multiple-choice questions (MCQs) and a 5-point Likert scale assessing perceived confidence was disseminated to UK-based doctors using multiple platforms. Statistical analysis using one-way analysis of variance (ANOVA), Tukey's honest significant difference (Tukey HSD) and Pearson's chi-squared test was undertaken to assess for statistical significance. RESULTS: Data collated from 697 respondents revealed that average perceived confidence was low across all specialties and grades. Notably, 59% (n = 411) felt they had received insufficient education regarding up-to-date guidance, with 81% (n = 565) advocating further training. Anaesthetics and ophthalmology were highest and lowest scoring specialties in knowledge-based MCQs, achieving scores of 59% and 31%, respectively. Statistical analysis revealed significant differences between specialty, but not grade. CONCLUSION: Ensuring uniformity in published guidance, coupled with education may aid knowledge and subsequent confidence regarding the appropriate use of PPE. The absence of a unified consensus and sustained training not only poses significant ramifications for patient and healthcare professional (HCP) safety, but also risks further depletion of already sparse resources. Because of the novelty of COVID-19, appropriate PPE is continually evolving leaving an absence in formal training and education. This paper reveals insight into confidence and knowledge of PPE amongst doctors of various specialities/grades during a global pandemic, highlighting key deficits in education and training.

Endoscopic transsphenoidal surgery reconstruction using the fibrin sealant patch Tachosil®.

INTRODUCTION: The incidence of CSF leak following endoscopic transsphenoidal surgery remains the most important measure in the success of any repair. The nasoseptal flap (NSF) has played a pivotal role in reconstructing defects. However, morbidity associated with the NSF includes bleeding, septal injury, altered smell and crusting. Tachosil® is an absorbable fibrin sealant patch that promotes haemostasis and wound healing. The purpose of this study was to evaluate the effectiveness of Tachosil® to repair intraoperative defects during an endoscopic transsphenoidal approach. MATERIALS AND METHODS: All patients who underwent an endoscopic transsphenoidal approach with the use of Tachosil® at the Queen Elizabeth Hospital Birmingham, between January 2013 and June 2020 were retrospectively analysed. Tachosil® was used as an overlay patch over of the bony defect, in a multi-layered repair depending on the defect and grade of CSF leak. The primary outcome measure was post-operative CSF leak. RESULTS: A total of 52 primary procedures where Tachosil® was used as the overlay were analysed. There were 23 (44.2%) intraoperative CSF leaks. The overall post-operative CSF leak rate was 7.8% (n = 4), with all cases having had a Tachosil® overlay reconstruction with no NSF. A formal NSF was harvested in only five cases alongside the Tachosil® patch, where a grade 2 or more leak was identified at the time of the primary procedure, none of which developed a post-operative leak. No patient had any post-operative adverse outcomes that were attributed to Tachosil®. CONCLUSIONS: We believe this to be the largest case series evaluating the endoscopic use of Tachosil® in skull base reconstruction. Our data show that in endoscopic transsphenoidal approach, Tachosil® may be used safely in a multi-layered approach as an effective alternative to the NSF in low flow CSF leak cases, or alongside a NSF in higher flow leaks.

Personal protective equipment: knowledge of the guidance.

BACKGROUND: On 11 March 2020, the World Health Organization (WHO) declared a global pandemic in the wake of the coronavirus disease 2019 (COVID-19) outbreak. The unpredictable nature of transmission of COVID-19 requires a meticulous understanding of guidance on personal protective equipment (PPE) as published by WHO and Public Health England (PHE). AIM: To assess perceived confidence and knowledge of PHE guidance relating to PPE by nursing staff. METHODS: A nationwide survey was disseminated between May and June 2020 through social media platforms as well as internal mail via regulatory bodies and individual hospital trusts. RESULTS: Data were collated from 339 nurses. Perceived confidence as measured on a Likert scale was a mode score of 3/5, with the average score for knowledge-based questions being 5/10. Of the respondents, 47% cited insufficient training on PPE guidance, and 84% advocated further training. Conclusions: Unifying published PPE guidance and ensuring consistency in training can improve awareness, confidence, and knowledge among nursing staff.

Ranking Hospitals Based on Preventable Hospital Death Rates: A Systematic Review With Implications for Both Direct Measurement and Indirect Measurement Through Standardized Mortality Rates.

Policy Points The use of standardized mortality rates (SMRs) to profile hospitals presumes differences in preventable deaths, and at least one health system has suggested measuring preventable death rates of hospitals for comparison across time or in league tables. The influence of reliability on the optimal review number per case note or hospital for such a program has not been explored. Estimates for preventable death rates using implicit case note reviews by clinicians are quite low, suggesting that SMRs will not work well to rank hospitals, and any misspecification of the risk-adjustment models will produce a high risk of mislabelling outliers. Most studies achieve only fair to moderate reliability of the direct assessment of whether a death is preventable, and thus it is likely that substantial numbers of reviews of deaths would be required to distinguish preventable from nonpreventable deaths as part of learning from individual cases, or for profiling hospitals. Furthermore, population- and hospital system-specific data on the variation in preventable deaths or adverse events across the hospitals and providers to be compared are required in order to design a measurement procedure and the number of reviews needed to distinguish between the patients or hospitals. CONTEXT: There is interest in monitoring avoidable or preventable deaths measured directly or indirectly through standardized mortality rates (SMRs). While there have been numerous studies in recent years on adverse events, including preventable deaths, using implicit case note reviews by clinicians, no systematic reviews have aimed to summarize the estimates or the variations in methodologies used to derive these estimates. We reviewed studies that use implicit case note reviews to estimate the range of preventable death rates observed, the measurement characteristics of those estimates, and the measurement procedures used to generate them. We comment on the implications for monitoring SMRs and illustrate a way to calculate the number of reviews needed to establish a reliable estimate of the preventability of one death or the hospital preventable death rate. METHODS: We conducted a systematic review of the literature supplemented by a reanalysis of authors' previously published and unpublished data and measurement design calculations. We conducted initial searches in PubMed, MEDLINE (OvidSP), and ISI Web of Knowledge in June 2010 and updated them in June 2012 and December 2017. Eligibility criteria included studies of hospital-wide admissions from general and acute medical wards where preventable death rates are provided or can be estimated and that can provide interobserver variations. FINDINGS: Twenty-three studies were included from 1985 to 2017. Recent larger studies suggest consistently low rates of preventable deaths (interquartile range of 3.0%-6.0% since 2008). Reliability of a single review for distinguishing between individual cases with regard to the preventability of death had a Kappa statistic of 0.10-0.50 for deaths and 0.21-0.76 for adverse events. A Kappa of 0.35 would require an average of 8 to 17 reviews of a single case to be precise enough to have confidence in high-stakes decisions to change care procedures or impose sanctions within a hospital as a result. No study estimated the variation in preventable deaths across hospitals, although we were able to reanalyze one study to obtain an estimate. Based on this estimate, 200 to 300 total case note reviews per hospital could be required to reliably distinguish between hospitals. The studies displayed considerable heterogeneity: 13/23 studies defined preventable death with a threshold of greater than or equal to four in a six-category Likert scale and 11/24 involved a two-stage screening process with nurses at the first stage and physicians at the second. Fifteen studies provided expert clinical review support for reviewer disagreements, advice, and quality control. A "generalist/internist" was the modal physician specialty for reviewers and they received one to three days of generic tools orientation and case note review practice. Methods did not consider the influence of human or environmental factors. CONCLUSIONS: The literature provides limited information about the measurement characteristics of preventable deaths, suggesting that substantial numbers of reviews may be needed to create reliable estimates of preventable deaths at the individual or hospital level. Any operational program would require population-specific estimates of reliability. Preventable death rates are low, which is likely to make it difficult to use SMRs based on all deaths to validly profile hospitals. The literature provides little information to guide improvements in the measurement procedures.

Ovarian cancer: screening and future directions.

Ovarian cancer carries a lifetime risk of approximately 2% for women and is the leading cause of death from any gynecologic malignancy. Currently, no screening program for ovarian cancer exists for the general population in the UK. This review focuses on the evidence surrounding the efficacy of current markers and discusses future improvements in screening for this disease. One-off cancer antigen 125 (CA125) measurements for detecting ovarian cancer have been well researched. However, studies have highlighted low positive predictive values (5%) and high false positive rates leading to patient anxiety and unnecessary invasive follow-up. Commonly, in the UK, CA125 is combined with transvaginal ultrasound, but there is little evidence that this approach can decrease mortality from ovarian cancer. Recently the Risk of Ovarian Cancer Algorithm, involving a combination of serial CA125 measurements and age, has been shown to detect more early stage cancers. Nevertheless, these measures are not robust in decreasing mortality from ovarian cancer and are costly to implement. Newer markers, such as human epididymis protein 4, have shown greater specificity. Its combination with CA125 and menopausal status in the Risk of Ovarian Malignancy Algorithm can predict the risk of malignancy but provides no additional benefit as a screening tool. Advanced techniques are emerging, including ultrasound molecular imaging techniques using microbubbles targeted to kinase domain receptors, and fallopian tube cytology. To reduce mortality from ovarian cancer, detection of pre-invasive lesions is imperative as ovarian cancer may develop in the fallopian tube and spread to the peritoneal cavity before being detected systemically. It seems that screening tools for ovarian cancer are currently not worthwhile for implementation into a national program. An emphasis on reducing false positives rates, associated anxiety and subsequent overdiagnosis is needed.

An Update on Fetal Alcohol Syndrome-Pathogenesis, Risks, and Treatment.

Alcohol is a well-established teratogen that can cause variable physical and behavioral effects on the fetus. The most severe condition in this spectrum of diseases is known as fetal alcohol syndrome (FAS). The differences in maternal and fetal enzymes, in terms of abundance and efficiency, in addition to reduced elimination, allow for alcohol to have a prolonged effect on the fetus. This can act as a teratogen through numerous methods including reactive oxygen species (generated as by products of CYP2E1), decreased endogenous antioxidant levels, mitochondrial damage, lipid peroxidation, disrupted neuronal cell-cell adhesion, placental vasoconstriction, and inhibition of cofactors required for fetal growth and development. More recently, alcohol has also been shown to have epigenetic effects. Increased fetal exposure to alcohol and sustained alcohol intake during any trimester of pregnancy is associated with an increased risk of FAS. Other risk factors include genetic influences, maternal characteristics, for example, lower socioeconomic statuses and smoking, and paternal chronic alcohol use. The treatment options for FAS have recently started to be explored although none are currently approved clinically. These include prenatal antioxidant administration food supplements, folic acid, choline, neuroactive peptides, and neurotrophic growth factors. Tackling the wider impacts of FAS, such as comorbidities, and the family system have been shown to improve the quality of life of FAS patients. This review aimed to focus on the pathogenesis, especially mechanisms of alcohol teratogenicity, and risks of developing FAS. Recent developments in potential management strategies, including prenatal interventions, are discussed.

Synthesis and biological evaluation of oxindole linked indolyl-pyrimidine derivatives as potential cytotoxic agents.

In our endeavor towards the development of effective cytotoxic agents, a series of oxindole linked indolyl-pyrimidine derivatives were synthesized and characterized by IR, (1)H NMR, (13)C NMR and Mass spectral analysis. All the newly synthesized target compounds were assessed against PA-1 (ovarian), U-87MG (glioblastoma), LnCaP (prostate), and MCF-7 (Breast) cancer cell lines for their cytotoxic potential, with majority of them showing inhibitory activity at low micro-molar concentrations. Significantly, compound 8e was found to be most potent amongst all the tested compounds with an IC50 value of (2.43±0.29µM) on PA-1 cells. The influence of the most active cytotoxic compound 8e on the cell cycle distribution was assessed on the PA-1 cell line, exhibiting a cell cycle arrest at the G2/M phase. Moreover, acridine orange/ethidium bromide staining and annexin V binding assay confirmed that compound 8e can induce cell apoptosis in PA-1 cells. These preliminary results persuade further investigation on the synthesized compounds aiming to the development of potential cytotoxic agents.

Effect of Mirtazapine Treatment on Serum Levels of Brain-Derived Neurotrophic Factor and Tumor Necrosis Factor-α in Patients of Major Depressive Disorder with Severe Depression.

BACKGROUND: This study evaluated the clinical efficacy of mirtazapine and its effect on serum brain-derived neurotrophic factor (BDNF) and tumor necrosis factor-α (TNF-α) levels in patients of major-depressive disorder (MDD) with severe depression. METHODS: Patients (aged 18-60) with MDD diagnosed by DSM-IV criteria, and Hamilton Rating Scale for Depression (HAM-D) score ≥25 were included (n = 30). Mirtazapine was given in the doses of 30 mg/day. All patients were followed up for 12 weeks for the evaluation of clinical efficacy, safety along with serum BDNF and TNF-α levels. RESULTS: HAM-D score at the start of treatment was 30.1 ± 1.92, which significantly (p < 0.05) reduced to 13.47 ± 1.77 at 12 weeks of treatment. In responders, mean serum BDNF levels at the start of treatment were 2.32 ± 0.3 ng/ml, which significantly (p < 0.05) increased to 2.79 ± 0.33 ng/ml at 12 weeks of treatment and mean serum TNF-α levels at the start were 5.18 ± 0.67 pg/ml, which significantly decreased to 4.36 ± 0.72 pg/ml (p < 0.05) at 12 weeks of treatment. CONCLUSION: Our results suggest that mirtazapine is effective and well tolerated in severely depressed patients and treatment response is associated with an increase in serum BDNF and a decrease in serum TNF-α levels.

Comparing the use of high dose to standard dose corticosteroids for the treatment of sudden sensorineural hearing loss in adults - A systematic review.

OBJECTIVE: Idiopathic sudden sensorineural hearing loss (SSNHL) is typically treated with systematic or intratympanic corticosteroids. Current ENT-UK guidelines suggest treatment with a dose of oral prednisolone 1mg/kg/day for 7 days then tapered over a further 5 days. However, there is no consensus on the effectiveness of corticosteroids for idiopathic SSNHL and no universally accepted optimal regime. The objective of this systematic review was to examine the effect of high dose versus standard dose corticosteroids in the management of idiopathic SSNHL. METHODS: A systematic review was performed of all published data related to patients with idiopathic SSNHL who were treated acutely with high dose corticosteroid therapy. Articles were included that reported data on high dose, or comparing standard dose to high dose, oral or intravenous corticosteroid therapy for the treatment of patients with idiopathic sudden sensorineural hearing loss. Articles where patients received only combination treatment with intra-tympanic steroid were excluded. Risk of bias was assessed using the ROBINS-I tool and the ROB-2 tool. RESULTS: Six studies were included in the analysis, representing 919 patients. Two prospective single-arm studies of patients with SSNHL treated with a high dose steroid regime found mean hearing level improved (79.5dB to 42.3dB) and 45.8% of idiopathic patients had complete recovery of hearing. Three retrospective case-series comparing high dose to standard dose regimes found a significantly greater improvement in hearing level (38.3dB vs. 48.8dB, P = 0.042), a greater mean absolute hearing gain (44.4dB vs. 15.1dB) and a significantly higher rate of functionally relevant recovery (35.7% vs. 7.4%, P = 0.035) in patients treated with high dose regimes. The single included prospective randomised trial found no statistically significant difference in mean hearing level or speech discrimination score between patients treated with high dose pulse steroids or a standard dose regime. CONCLUSIONS: Our systematic review found the reported outcomes in the literature in this area to be mixed, with some studies suggesting a greater degree of hearing recovery with a high dose regime but others suggesting no difference. The overall quality of the available evidence was deemed to be low, with the studies at moderate risk of bias.

Carolyn's window approach for spontaneous frontal sinus meningoencephalocele.

Spontaneous meningoencephaloceles (MECs) are sparsely documented in the literature. Those occurring in the frontal sinus are an exceedingly rare entity. MECs are commonly associated with cerebrospinal fluid (CSF) rhinorrhoea. CSF rhinorrhoea is frequently misdiagnosed, causing delays in diagnosis and management. The subsequently increased risk of bacterial meningitis can be life-threatening to patients. We report the case of a woman in her late 70s with a spontaneous frontal sinus MEC, presenting with a 6-month history of CSF rhinorrhoea. The patient was successfully treated using the novel Carolyn's window approach endoscopically; 9-month follow-up revealed no skull-base breach. Our case emphasises the importance of considering MEC as a differential diagnosis for clear rhinorrhoea and demonstrates successful repair through a novel surgical approach.

Quality of life outcomes comparing primary Transoral Robotic Surgery (TORS) with primary radiotherapy for early-stage oropharyngeal squamous cell carcinoma: A systematic review and meta-analysis.

BACKGROUND: Transoral Robotic Surgery (TORS) and radiotherapy are considered oncologically equivalent primary treatment options for early-stage HPV-positive oropharyngeal squamous cell carcinoma (OPSCC). Quality of Life (QoL) and Patient Reported Outcome Measures (PROMs) are therefore imperative in supporting clinical decision-making and optimising patient-centred care. The aim of this article is to evaluate how these primary treatment modalities compare in terms of QoL. MATERIALS AND METHODS: Systematic review and meta-analysis of studies comparing primary TORS and primary radiotherapy for OPSCC using validated QoL tools. Swallowing and global QoL were the primary endpoints with secondary endpoints including all other QoL domains. An inverse variance random-effects model was employed to calculate the weighted estimate of the treatment effects across trials. RESULTS: A total of six studies collectively reporting on 555 patients were included (n = 236 TORS and n = 319 radiotherapy). Meta-analysis showed no significant difference for swallowing (mean difference = -0.24, p = 0.89) and global QoL (mean difference = 4.55, p = 0.14). For the remaining QoL domains (neck/shoulder impairment, neurotoxicity, voice, xerostomia, speech, and distress), the scarcity of data did not permit meta-analysis. However, the existing data showed no significant difference for any except for xerostomia where TORS appears favourable in the sole study reporting on this. CONCLUSIONS: TORS and radiotherapy appear to be comparable primary treatment options for early stage OPSCC when it comes to QoL. However, a substantial proportion of patients in the TORS group received adjuvant (chemo)radiotherapy rendering it difficult to establish the 'true' QoL outcomes following surgery alone. There are also minimal studies reporting QoL outcomes beyond swallowing and global QoL. Further research is therefore needed, including more randomised trials adequately powered to detect differences in QoL outcomes.

Blood, Sweat, and Tonsils: Bleeding After Abscess Tonsillectomy for Quinsy-A Meta-Analysis.

OBJECTIVE: Abscess tonsillectomy is performed during an active episode of quinsy. Apprehensions regarding an elevated bleeding risk have hindered its widespread acceptance. This study aims to assess the prevalence of post-tonsillectomy bleeding (PTB) associated with abscess tonsillectomy. DATA SOURCES: A search was performed on August 27, 2023 in Medline, Embase, PubMed, Cochrane CENTRAL, and Web of Science databases. REVIEW METHODS: The systematic review was conducted in adherence to the PRISMA guidelines. Pooled PTB rate was determined using a meta-analysis of proportions. The JBI tool was used to assess the quality of the included studies. RESULTS: Of the 525 search records, 18 studies met the eligibility criteria for final analysis. These comprised of retrospective single-center analyses. The pooled prevalence of PTB was 6.65% (95% C.I. 4.01-9.81), and the return-to-theatre rate was 2.35% (95% C.I. 1.48-3.37). There was no difference in PTB rate between unilateral and bilateral tonsillectomy. However, the bipolar technique was associated with a higher PTB rate compared to cold steel dissection. The overall quality of the body of evidence was moderate. CONCLUSION: Our study highlights the complications associated with abscess tonsillectomy. These findings contribute valuable insights into this potential treatment option for quinsy. LEVEL OF EVIDENCE: N/A Laryngoscope, 2024.

The diagnostic conundrum in necrotizing otitis externa.

Necrotizing otitis externa (NOE) is an aggressive and fast-evolving infection of the external auditory canal. Late diagnoses and untreated cases can lead to severe, even fatal consequences and so early diagnosis and treatment are paramount. NOE is a notoriously challenging diagnosis to make. It is therefore important to understand what diagnostic modalities are available and how otolaryngologists can use them to accurately treat such an aggressive disease. This review aims to evaluate the different diagnostic options available in NOE and discuss their advantages and limitations, thus, providing an up-to-date picture of the multimodal approach required in the diagnosis of this disease.

Incidence of Vestibular Schwannoma in Patients with Unilateral Tinnitus: A Systematic Review and Meta-Analysis.

OBJECTIVES: Vestibular schwannoma (VS) is a tumor of the vestibulocochlear nerve. Current literature indicates that 1.6% of patients undergoing magnetic resonance imaging of the internal auditory meatus (MRI IAM) for audiovestibular symptoms are diagnosed with a VS. However, there is limited research reporting on patients who present with unilateral tinnitus without asymmetrical hearing loss. This study is a systematic review and meta-analysis evaluating how many of those patients had a VS diagnosed on MRI IAM. DATABASES USED: Online searches of PubMed, Medline, and Embase databases were performed up to October 2022. METHODS: This meta-analysis was undertaken aligning with PRISMA guidelines. Articles reporting on patients having MRI IAM for unilateral tinnitus without asymmetrical hearing loss were included. Outcomes measures were patient demographics, VS cases, incidental findings, size, and management of tumor. A meta-analysis of proportions was performed using a random-effects model with the restricted maximum likelihood method. Quality assessment was performed using the Joanna Briggs Institute critical appraisal checklist. RESULTS: Seven case series were included in the review: a total of 1,394 patients. Seven patients had a VS, with a median size of 4 mm. The pooled detection rate for VS was 0.08% (95% confidence interval = 0.00-0.45). Subsequent management was reported in six cases of which four were actively monitored and two surgically excised. The most common incidental finding was sinus disease (49 patients). CONCLUSION: Our findings indicate that MRI IAM has a low diagnostic yield for VS detection in patients presenting with unilateral tinnitus without asymmetrical hearing loss, with mostly small tumors that are conservatively managed.

Endonasal endoscopic management of spontaneous cerebrospinal fluid rhinorrhoea: The Birmingham UK experience.

BACKGROUND: Spontaneous cerebrospinal fluid (CSF) leaks (SCSFL) occur in the absence of trauma, surgery, or underlying intracranial pathology. They represent a significant healthcare burden on patients with complications such as meningitis. We present our experience of SCSFL repair via the endonasal endoscopic approach. METHODS: All patients who underwent CSF fistula repair at a tertiary UK hospital, between 1st January 2012 to 31st December 2019, were identified and had their case notes analyzed retrospectively. RESULTS: There were 33 patients included consisting of 27 (81.8%) females, with age range from 31 to 81 years (mean 55.2). Mean body mass index (BMI) was 35.2 kg/m2 , with 32 (97.0%) patients overweight (BMI >25). All patients presented with intermittent watery rhinorrhoea and had a positive biochemical analysis. Computed tomography (CT) and/or magnetic resonance imaging (MRI) identified leak sites in 29 patients (87.9%). The most common intraoperative defect site was the cribriform plate (42.4%). A variety of closing techniques were used including onlay grafts (72.7%), tissue glue (87.9%), nasoseptal flaps (63.6%), mucosal free grafts (21.2%), fat grafts (21.2%), and additional support materials (87.9%). Nasal packing was used in all patients. The average length of stay was 1.6 days. Postoperative complications occurred in two patients (6.1%) (meningitis, epistaxis). Overall, there was a successful primary repair in 32 (97.0%) patients with most cases employing a multilayered reconstruction method (78.8%). CONCLUSION: Our results demonstrate excellent success rates with the endoscopic endonasal approach to SCSFL. This adds to the literature by demonstrating a detailed analysis of the experience in SCSFL management in one of the largest UK centres.