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

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

Defining appropriateness criteria for endoscopic sinus surgery in the management of adult dental implant patients with incidental maxillary sinus findings on conebeam computed tomography.

OBJECTIVES: Conebeam computed tomography (CBCT) imaging is commonly requested by dental implant surgeons, preoperatively, for patients being considered for dental implants. Incidental maxillary sinus findings often result in otolaryngology (ENT) referral for further assessment. CBCT findings include transient and benign mucosal changes that may not require any intervention and therefore unnecessarily delay implant surgery. We aim to define appropriateness criteria for ESS in the management of adult dental implant patients with incidental maxillary sinus findings on CBCT and provide guidance to both dental implant and ENT surgeons. DESIGN: The RAND/UCLA appropriateness methodology was used to develop and define the appropriateness criteria. SETTING: A virtual panel of 13 international experts in ESS. PARTICIPANTS: The expert panel completed two rounds of a modified Delphi ranking process for nine clinical scenarios, considering various factors affecting decision-making processes. MAIN OUTCOME MEASURES: To define appropriateness criteria for ESS in adult dental implant patients who have incidental maxillary sinus findings on CBCT. RESULTS: Patients with clinical symptoms and endoscopic findings of chronic rhinosinusitis together with an obstructed ostiomeatal complex (OMC) and concentric mucosal thickening of the ipsilateral maxillary sinus or pansinusitis were deemed appropriate candidates for ESS prior to their dental implant. ESS was not appropriate in asymptomatic patients with a patent OMC and mucosal thickening isolated to floor of the ipsilateral maxillary sinus. For uncertain scenarios, further discussion between dental implant and ENT surgeon should be considered. CONCLUSIONS: This study has developed and reported a list of appropriateness criteria to offer ESS in adult dental implant patients with incidental maxillary sinus findings on CBCT.

Partial mandibulectomy without bony reconstruction in patients with oropharyngeal or mouth cancer.

AIM OF THE STUDY: Resection of tumours of the oral cavity has significant consequences relating to function and aesthetic properties. Advancements in surgical techniques and microvascular surgery have enabled reconstructive outcomes to reach those of pre-surgery levels with good functional and aesthetic results. However, reconstructive options are not without complications. MATERIAL AND METHODS: We report the outcome of 23 patients with large tumours of the oral cavity or floor of the mouth, who underwent resection of the tumour and parts of the mandible without bony reconstruction. The patient population consisted of 19 oropharyngeal carcinomas and four floor of the mouth cancers, all of which had stage cT4 (six female and 17 male patients), and with an average patient age of 59.8 years. The pre- and postoperative ability to open the mouth, level of pain while masticating, mastication function pre and post-surgery, and the aesthetic outcome post-surgery were measured. RESULTS: The results obtained were deemed pleasantly acceptable by the patients, from aesthetic, functional, and analgesic points of view. DISCUSSION: A thorough preoperative work up is required and discussion with a multidisciplinary team is a necessity. This treatment option is more acceptable to the patient than would be expected and provides a satisfactory functional and aesthetic outcome. Therefore, we believe that partial mandibulectomy without bony reconstruction is an acceptable management option for a carefully selected group of patients who may not be suitable for the extensive surgery involved with bony reconstruction.

The relationship between preoperative tympanograms and intraoperative ear examination results in children.

The tympanogram is an objective audiological method in adults and children which is often used in the evaluation of middle ear pathology. This should be alongside a thorough patient history and clinical examination prior to the decision to carry out a paracentesis or tympanostomy tube insertion. The goal of the study was to evaluate the relationship between the preoperative tympanogram and intraoperative ear examination results or middle ear findings. The retrospective study included 654 ears in 333 patients who underwent paracentesis with or without tympanostomy tube insertion between January and December 2011. The study cohort consisted of 206 male and 127 female patients with an average age of 3.7 ± 2.5 years. The results of the preoperative tympanogram were compared to those of the intraoperative ear findings. In 18.4 % of ears with a flat tympanogram, an air-filled middle ear was found intraoperatively (p < 0.01). Thus, tympanometry results cannot serve as the only indication for surgical intervention. A decision to treat should always be based on the merits of the symptomatology of the patient in conjunction with tympanometry findings.

Etiology and treatment of osteonecrosis of the mandible.

AIM OF THE STUDY: Post-radiogenic osteonecrosis of the mandible is a serious complication in patients with combined treated head/neck tumors. Osteonecrosis of the mandible can also occur following administration of bisphosphonates. In the present article we would like to present our experiences over the last five years in treating both bisphosphonate-associated osteonecrosis and osteoradionecrosis. MATERIAL AND METHODS: Of the patients treated in our hospital for bone necrosis of the mandible between January 2005 and June 2010, 16 were diagnosed with infected osteoradionecrosis and 10 with bisphosphonate-associated osteonecrosis. The patients with osteoradionecrosis were administered the classic osteomyelitis treatment. The same procedure was carried out on 5 of the 10 patients with bisphosphonate-associated osteonecrosis; the remaining 5 were treated conservatively due to advanced bone infection. The bone biopsies and specimens of both entities yielded by the surgical interventions were examined histologically after decalcification. RESULTS: Of the 16 patients treated for infected osteoradionecrosis, 7 recovered after decortication and long-term antibiosis. In 7 cases consolidation did not occur until after osseous continuity resection. In 2 cases the progress of the intraosseous infection could not be stopped with treatment. A typical first symptom of bisphosphonate-associated osteonecrosis was an alveolus that would not heal after a tooth extraction. In 50% of patients with bisphosphonate-associated osteonecrosis recovery was successful with a combination of surgery and long-term antibiosis. In the other patients with advanced bisphosphonate-associated osteonecrosis no definitive cure for the infection of the necrotic bone was possible. CONCLUSION: In terms of treatment, osteoradionecrosis proves complex, yet easier to treat than bisphosphonate-associated osteonecrosis. The removal of the infected bone tissue is often necessary, but it does not always lead to recovery. Therefore it can be concluded that prevention of intraosseous infection by consistent pretherapeutic dental hygiene is especially important.

Surgical closure of nasoseptal defects: postoperative patient satisfaction.

BACKGROUND: Nasoseptal defects are rather rare. The current therapy of choice is surgical closure. Objective clinical factors prove the efficacy of surgical intervention; however, to establish the quality of the procedure patients' subjective quality of life assessments must also be considered. METHODS: 31 patients participated in the study. The operation was always carried out according to the superior and inferior bipedicle bridge flap technique according to Schultz-Coulon. The patient survey was performed retrospectively, and patient satisfaction was evaluated using two different questionnaires: the Sino-Nasal Outcome Test 20 German Adapted Version (SNOT-20 GAV SDT) expanded by Neumann [2010], and the Glasgow Benefit Inventory (GBI). RESULTS: Evaluation of the GBI revealed significant improvements in the total score and the subscore 'general health' and therefore an improved quality of life. Evaluation of the SNOT-20 GAV SDT showed a significant reduction in the total score and a significant reduction in the primary nasal symptoms as well as in the items typical of septum defects and therefore less discomfort caused by the nasoseptal defect. CONCLUSION: As the gold standard for treatment of septum perforation, successful surgical closure leads to an improvement in subjective quality of life.

Patient-performed pinnaplasty using industrial nail glue.

Malformations of the pinna occur in around 2-5% of all newborns. Prominent ears in childhood can be a source of psychological distress and lead to bullying and social exclusion. We present the case of a 14-year-old girl who inflicted chronic, non-healing wounds in the post auricular area bilaterally after attempting to glue back her ears with industrial strength glue. To our knowledge, this is the first case of its kind to be published.

Current Practice: The Bilobed Flap from the Classic Indication to Cover a Small Defect on Face to Covering a Large Defect on the Chest.

A variety of flaps are available to cover skin defects after surgery or trauma in the head and neck area. The bilobed flap is a double transposition flap commonly used in reconstruction of small-to-medium skin defects of the face where skin is less mobile. However, larger defects can also be effectively treated with a bilobed flap in certain cases. The classic indication to cover a small defect on the nose and covering a large skin-defect after tumour resection in the jugular notch. After sufficient mobilization, the defects could easily be closed with no wound complications and with very good aesthetic and functional outcome. The bilobed flap, as a local flap, is possible in suitable locations even for larger skin defects. In addition to the simplicity of the procedure, good aesthetic results can be expected.

Correlation of skin test results and specific immunoglobulin E blood levels with nasal provocation testing for house-dust mite allergies.

BACKGROUND: Allergen-specific immunotherapy for house-dust mite (HDM) allergies is associated with lower success rates when compared with similar treatments for other inhalant allergens, such as grass or birch. One reason might be the greater difficulty in diagnosing patients with assumed HDM allergies because symptoms occur perennially and may differ from those of a conventional allergic rhinitis. OBJECTIVE: The aim of the study was to compare the different methods of diagnosis in patients with assumed HDM allergy. METHODS: We performed a retrospective analysis of nasal provocation tests (NPT) from patients (n = 161) evaluated for Dermatophagoides pteronyssinus (n = 127) and Dermatophagoides farinae (n = 104) allergies, and compared the results with other allergen testing methods (skin-prick test [SPT], intracutaneous test, and allergen specific immunoglobulin E levels [sIgE] to detect sensitization). Receiver operating characteristic curves were used for the analyses and the areas under the curve were calculated. RESULTS: For D. pteronyssinus and D. farinae, 86 and 70 complete data files, respectively, were available. For both tested HDMs, the results of the receiver operating characteristic curves showed a significant correlation for SPT and sIgE, with the results of the NPT (area under the curve, 0.742 to 0.763) but not for the intracutaneous test. In patients with a positive SPT (≥3 mm), an allergy was confirmed by the NPT in 69% of cases for D. pteronyssinus and 71% for D. farinae. A positive sIgE result (ImmunoCAP class of ≥2) was verified by the NPT in 69% of cases (D. pteronyssinus) and 70% (D. farinae). CONCLUSION: The predictability value for a positive NPT result is best for SPT and sIgE. Nevertheless, even if the results of both test systems are combined, the positive predictive value that was achieved was only 0.77 for D. pteronyssinus and 0.69 for D. farinae. Therefore, in patients eligible for immunotherapy for HDM, an NPT should be performed before the start of the therapy to verify a clinically relevant allergy.

Recovery of Transplanted Eyebrow From Radiation-Induced Anagen Effluvium.

Ablative surgery for skin cancer of the face can often leave patients with significant deformities. These disfigurements can include loss of hair in conspicuous areas such as the eyebrows, leaving the patients with unsightly facial asymmetry. Eyebrow transplantation serves to address this issue; however, it has often been discouraged in patients who are destined to receive radiotherapy to the cutaneous area in question. This is due to the anagen effluvium effect of radiation therapy on hair follicles. We present a case in which the transplanted eyebrow hair follicles survived the deleterious effects of radiotherapy, leaving the patient with a symmetrical and aesthetically satisfactory eyebrow appearance.

Effect of stapedotomy on pre-operative tinnitus and its psychosomatic burden.

OBJECTIVE: According to the literature, between 40 and 90% of otosclerosis patients suffering from hearing loss also suffer from tinnitus on the affected side. For a lot of these patients tinnitus represents a handicap that is just as debilitating as the hearing loss itself. The main goal of the surgical treatment of otosclerosis is a significant improvement in hearing loss, but frequent reports of reduced tinnitus after surgery suggest that this can be a positive side effect. METHODS: All patients who underwent stapedotomy were initially included in the study. Retrospectively, the tinnitus questionnaire as compiled by Goebel and Hiller was sent to the patients, and 34 patients (37 ears) replied. The pre- and postoperative cases of tinnitus were divided into compensated and non-compensated tinnitus. In addition the following tinnitus-related factors were evaluated: emotional, cognitive and mental burden; intrusiveness of the tinnitus; hearing problems; somatic ailments; and sleep disturbances. RESULTS: Over 80% of the patients surveyed suffered from tinnitus pre-operation. The tinnitus disappeared or improved in over 60% of the cases after stapedotomy. In addition, the related factors surveyed also improved appreciably post surgery and reached a significant level in patients with compensated tinnitus. CONCLUSION: Besides a significant improvement in hearing loss the intensity and the psychosomatic burden of a pre-operative tinnitus can be reduced by stapedotomy.