Thinking Beyond Giant Cell Arteritis in COVID-19 Times.

BACKGROUND: The coronavirus disease 2019 has displayed multi-system manifestations since its first presentation. This article highlights an unusual presentation of COVID-19 that was reviewed by our instituition's otolaryngology and ophthalmology team. METHODS: We present 2 cases of COVID-19 which presented with unilateral otalgia and ipsilateral pulsatile headaches involving the temporal area. They were referred to the otolaryngology team for assessment of otalgia and subsequently referred to the ophthalmology team for possible giant cell arteritis (GCA). Both patients had no jaw claudication, scalp pain, or tenderness. RESULTS: Serology testing showed raised C-reactive protein (CRP) but normal platelets and erythrocyte sedimentation rate. Case 1 was tested for COVID-19 as part of a preoperative workup which returned positive. With a marked similarity in presentation, Case 2 was tested for COVID-19 which also returned positive. CONCLUSIONS: These 2 cases highlight another set of symptoms that COVID-19 patients may present with. In the context of a COVID-19 pandemic, if a patient presents symptoms similar to GCA but with isolated CRP, it should prompt consideration for COVID testing.

A new "practical" plane for Eustachian tube measurements and its application in predicting middle ear dysfunction in patient with acquired cholesteatomas.

SETTING: The Eustachian tube plays a vital role in middle ear physiology. There has been evidence that Eustachian tube (ET) and angle are correlated with middle ear function. The measurements of these Eustachian tube features are now made possible with computed tomography and multiplanar reconstruction techniques. However, there has not been a standardised protocol devised to these measurements in limited window cone-beam CT scans of temporal bones. OBJECTIVE: The primary object of the present study is to establish and validate a new landmark in closer proximity to the middle ear that is consistently captured, thereby allowing ET angle and length to be measured from the majority of cone-beam CT scans. Secondarily, the ET anatomies of patients with middle ear dysfunction manifesting as acquired cholesteatoma are analysed with this new method of measurement. METHODS: This study undertook a step-by-step method to first validate the methods of ET measurement with Reid's standard plane, then identifying an alternative landmark, thus a new plane visible on limited window cone-beam CT scans of temporal bones and lastly, validating the application of this new plane in the measurements of ET angle and length. This new method of measurement was coined the Ku-Copson plane and was applied to 30 cochlear implant patients and 30 patients with acquired cholesteatomas. Their ET anatomies were analysed and compared. RESULTS: It was found that the new Ku-Copson mandibular fossa plane was a reliable and accurate plane for the measurement of ET angle and length. Furthermore, it was found that patients with acquired cholesteatomas have statistically significant smaller ET angles and shorter ET lengths when compared with patients with cochlear implants, of normal middle ear function. CONCLUSION: The newly proposed method utilising the right mandibular fossa as an anatomical landmark for ET angles and lengths measurement appears to be viable. The close proximity of this landmark to the middle ear means that it is highly likely to be captured in most cone-beam CT scans of the petrous temporal bones. This enables the retrospective examination ET angles and lengths to be conducted on CB CT scans. This study reports statistically significant difference in ET anatomy in patients with middle ear dysfunction.

Alveolar Osteitis: A Review of Current Concepts.

PURPOSE: The purpose of the present review was to explore the pathogenesis and etiology of alveolar osteitis (AO) to obtain a more intuitive understanding of the clinical prevention and management of the condition. The different treatment modalities were discussed through both the mechanistic understanding of AO and the evidence regarding the different modes of prevention and management. MATERIALS AND METHODS: The Ovid Medline, PubMed, and Cochrane Central Register online databases were used to complete an advanced search using the MeSH term "dry socket," generating 756 results. RESULTS: A total of 8 studies on the prevention of AO were included, with 66 studies included for review of the reported data overall. The information was categorized into incidence, etiology and pathogenesis, prevention, and management. The relevant background information and evidence for each category were summarized. CONCLUSIONS: Understanding of the pathogenesis and etiology of AO has improved in recent years, which has been helpful for developing effective evidence-based treatment and prevention of the condition. Clinicians should be aware of the complexity and multifactorial nature of the etiology of AO and the current concepts regarding the prevention and treatment of AO.

Internet-Based Programs Incorporating Behavior Change Techniques Are Associated With Increased Smoking Cessation in the General Population: A Systematic Review and Meta-analysis.

Background and aims: This study aims to (i) examine the effectiveness of internet-based smoking cessation programs; (ii) describe the number and type of behavior change techniques (BCTs) employed; and (iii) explore whether BCTs included in internet-based smoking cessation programs are related to program effectiveness. Methods: MEDLINE, CINAHL, EMBASE, PsycINFO, and CENTRAL databases were searched. Randomized controlled trials were included if they described the study of a smoking cessation program delivered via the internet; included current adult tobacco smokers from the general population; and were written in English. Random effects meta-analyses and meta-regressions were used to examine program effectiveness (pooled odds ratios, by outcome measure, i.e., 7 day point prevalence abstinence [PPA], 30 day PPA, other abstinence measure) in short- and long-term outcomes, and examine the associations between BCT number and type (individual BCTs and BCT domain) and program effectiveness. Results: Results from 45 studies were included (n = 65,736). Intervention effectiveness was found in the short term for all outcome measures (OR = 1.29, 95% CI 1.12, 1.50, p = .001), for "prolonged abstinence" (OR = 1.43, 95% CI 1.09, 1.87, p = .009), and "30 day PPA" (OR = 1.75, 95% CI 1.13, 2.72, p = .013). Internet-based programs were effective in the long term for all outcome measures (OR = 1.19, 95% CI = 1.06, 1.35, p = .004) and for "prolonged abstinence" (OR = 1.40, 95% CI 1.19, 1.63, p < .001). On average, interventions used more BCTs than comparison groups (6.6 vs. 3.1, p = .0002). The impact of specific individual BCTs and BCT domains on effectiveness was examined and is reported. Conclusions: Internet-based smoking cessation interventions increased the odds of cessation by 29 per cent in the short term and by 19 per cent in the long term. Internet-based smoking cessation intervention development should incorporate BCTs to increase effectiveness. Registration: CRD42015014676.

Meta-analysis on continuous nerve monitoring in thyroidectomies.

In the last decade, the introduction of continuous intraoperative recurrent laryngeal nerve (RLN) monitoring (C-IONM) has enabled the operator to verify the functional integrity of the vagus nerve-recurrent laryngeal nerve (VN-RLN) axis in real-time. We aim to present the current evidence on C-IONM utility for thyroid surgery by conducting the first meta-analysis on this technique. A systematic review of literature was conducted by two independent reviewers via Ovid in the Medline, EMBASE, and Cochrane reviews databases. The search was limited to human subject research in peer-reviewed articles of all languages published between Jan 1946 and April 2020. Medical subject headings (MeSH) terms utilized were thyroid surgery, thyroidectomies, recurrent laryngeal nerve, vagal nerve, monitor, and stimulation. Thirty-eight papers were identified from Ovid, another six papers were identified by hand-search. A random effect meta-analysis was performed with assessment of heterogeneity using the I2 value. A total of 23 papers that investigated the use of continuous vagal nerve monitoring during thyroid surgery were identified. The proportion of nerves at risk (NAR) with temporary RLN paralysis postoperation was 2.26% (95% CI: 1.6-2.9, I2  = 37). The proportion of NAR with permanent RLN palsy postoperation was 0.05% (95% CI: 0.08-0.2, I2  = 0). In this meta-analysis, there is one case of temporary vagal nerve paralysis secondary to VN electrode dislodgement, and a case of hemodynamic instability manifested in bradycardia and hypotension in the initial phase of surgery shortly after calibration. C-IONM is a safe and effective means by which RLN paralyses in thyroid surgery can be reduced.

Trauma patients with prehospital Glasgow Coma Scale less than nine: not a homogenous group.

PURPOSE: Prehospital guidelines stratify and manage patients with Glasgow Coma Scale (GCS) less than nine and any sign of head injury as affected by severe traumatic brain injury (STBI). We hypothesized that this group of patients is so inhomogeneous that uniform treatment guidelines cannot be advocated. METHODS: Patients (2005-2012) with prehospital GCS below nine and abbreviated injury scale head and neck above two were identified from trauma registry. Patients with acute lethal injuries, isolated neck injuries, extubated within 24 h or transferred interhospitally were excluded. Patients were dichotomized based on the worst prehospital GCS (recorded before sedatives) into two groups: GCS 3-5 and GCS 6-8. These were statistically compared using univariate analysis. RESULTS: The GCS 3-5 group (99 patients) when compared with the GCS 6-8 group (49 patients) had shorter prehospital times (63 vs. 79 min; p < 0.05), more frequent episodes of both hypoxia (30.3% vs. 7.7%; p < 0.05) and hypotension (26.7% vs. 6.4%; p < 0.05), more often required craniectomy (15.1% vs. 4.0%; p = 0.05) and higher mortality (33.3% vs. 2%; p < 0.05). In the GCS 3-5 group, prehospital endotracheal intubation was attempted more often (57.5% vs. 28.6%, p < 0.05) and was more often successful (39.3% vs. 10.2%; p = 0.05). Length of stay in ICU did not differ. CONCLUSIONS: STBI patients are fundamentally different based on whether their initial GCS falls into 3-5 or 6-8 category. Recommendations from trials investigating trauma patients with GCS less than nine as one group should be translated with caution to clinical practice.

Survival outcomes of hepatic resections in Bismuth-Corlette type IV cholangiocarcinoma.

BACKGROUND: Surgical resection for Bismuth-Corlette type IV (BC-IV) hilar cholangiocarcinomas, also termed Klatskin tumours are technically challenging and were once considered unresectable tumours. Following advances in hepatobiliary imaging and surgical techniques, emerging evidence suggests that surgical resection is a viable avenue for long-term survival. We aimed to identify factors affecting survival outcomes of hepatic resections for BC-IV cholangiocarcinomas. METHOD: A systematic review was performed across multiple databases and several clinical trial registries. Two reviewers independently screened and selected papers that contained survival data on BC-IV cholangiocarcinoma after hepatic resections. RESULTS: Of 13 499 papers from our search result, 21 papers satisfied the inclusion criteria. The median post-operative survival was 30.8 months. The average 1- and 5-year post-operative survivals were 61.6 and 33.3%, respectively. Predictors of long-term survival included achievement of R0 margins, minimisation of operative time and reduction intra-operative blood loss. CONCLUSION: Our analysis demonstrates improving post-operative outcomes and survival in surgical resection of BC-IV cholangiocarcinoma and suggests that radical surgical resection is a valid treatment option for the disease.

Moffett's Solution Causes Significantly Greater Postoperative Throat Pain Compared to Cophenylcaine in Sinonasal Surgery.

AIM: Preoperative decongestion with Moffett's solution is routine practice in sinonasal procedures providing an ideal operative field. Anecdotally, it is related to postoperative throat pain, yet a quantitative relationship has not been established. We compare the incidence and severity of postoperative throat pain after application of Moffett's solution against Cophenylcaine decongestion. METHODOLOGY: A total of thirty patients from two consultants were recruited. The intervention arm (twenty) was decongested with Moffett's solution and the control arm (ten) with Cophenylcaine. The primary outcome was self-reported postoperative throat pain as measured by visual analogue scale (VAS) at 2 hours, 4 hours, 6 hours, and next morning. RESULTS: There was a significantly higher VAS for throat pain in patients decongested with Moffett's solution in the early postoperative period (2 hours p=0.03, 4 hours p=0.04). CONCLUSION: Moffett's solution is associated with a greater severity of transient postoperative throat pain compared to topical Cophenylcaine. We recommend further studies to identify means to minimise this side effect. CLINICAL TRIAL REGISTRATION: This paper has been registered with the Australian and New Zealand Clinical Trials Registry under the registration number: ACTRN12619000772145.

A tale of two cities: prehospital intubation with or without paralysing agents for traumatic brain injury.

BACKGROUND: The role of prehospital endotracheal intubation (PETI) for traumatic brain injury is unclear. In Victoria, paramedics use rapid sequence induction (RSI) drugs to facilitate PETI, while in New South Wales (NSW) they do not have access to paralysing agents. We hypothesized that RSI would both increase PETI rates and improve mortality. METHODS: Retrospective comparison of adult primary admissions (Glasgow Coma Scale <9 and abbreviated injury scale head and neck >2) to either Victorian or NSW trauma centre, which were compared with univariate and logistic regression analysis to estimate odds ratio for mortality and intensive care unit (ICU) length of stay. RESULTS: One hundred and ninety-two Victorian and 91 NSW patients did not differ in: demographics (males: 77% versus 79%; P = 0.7 and age: 34 (18-88) versus 33 (18-85); P = 0.7), Glasgow Coma Scale (3 (3-8) versus 5 (3-8); P = 0.07), and injury severity score (38 (26-75) versus 35 (18-75); P = 0.09), prehospital hypotension (15.4% versus 11.7%; P = 0.5) and desaturation (14.6% versus 17.5%; P = 0.5). Victorians had higher abbreviated injury scale head and neck (5 (4-5) versus 5 (3-6); P = 0.04) and more often successful PETI (85% versus 22%; P < 0.05). On logistic regression analysis, mortality did not differ among groups (31.7% versus 26.3%; P = 0.34; OR = 0.84; 95% CI: 0.38-1.86; P = 0.67). Among survivors, Victorians had longer stay in ICU (364 (231-486) versus 144 (60-336) h), a difference that persisted on gamma regression (effect = 1.58; 95% CI: 1.30-1.92; P < 0.05). CONCLUSION: Paramedics using RSI to obtain PETI in patients with traumatic brain injury had a higher success rate. This increase in successful PETI rate was not associated with an improvement in either mortality rate or ICU length of stay.

Pericardial effusion as a rare complication of a perforated appendicitis.

INTRODUCTION: Whilst pericardial effusion is a known complication of abdominal pathology, it is rarely reported following ruptured appendicitis and even more rarely requires drainage in that situation. This work has been reported in line with the SCARE criteria (Agha et al., 2016). PRESENTATION OF CASE: We report a 14-year-old male who developed extensive right hepatorenal and right paracolic abscesses, bilateral pleural effusions and a large pericardial effusion following laparoscopic appendicectomy. Due to the size of the effusion, thoracoscopic pericardotomy was required. DISCUSSION: Pericardial effusion is a very rare complication of advanced appendicitis despite a demonstrable connection between the retroperitoneum and the mediastinum. Only two cases were reported in our literature search. There is no consensus as to whether percutaneous drainage or pericardiotomy is the treatment of choice. CONCLUSION: The report is presented as a reminder of a rare complication of a common general surgical condition.