Delivering a net zero National Health Service: where does otorhinolaryngology - head and neck surgery stand?

OBJECTIVE: The National Health Service (NHS) recognised the risk to public health brought by climate change by launching the Greener NHS National Programme in 2020. These organisational changes aim to attain net zero direct carbon emissions. This article reviews the literature on initiatives aimed at mitigating the environmental impact of ENT practice. METHOD: Systematic review of the literature using scientific, healthcare and general interest (public domain) databases. RESULTS: The initiatives reviewed can be broken down into strategies for mitigating the carbon footprint of long patient stay, use of operative theatres and healthcare travel. The carbon footprint of in-patient stay can be mitigated by a shift towards day-case surgery. The ENT community is currently focused on the reduction of theatre waste and the use of disposable instruments. Furthermore, supply chains and healthcare delivery models are being redesigned to reduce travel. CONCLUSION: Future areas of development include designing waterless theatre scrubs, waste-trapping technologies for anaesthetic gases and a continuing investment in virtual healthcare.

Comparing the Use of High-Dose to Standard-Dose Corticosteroids for the Treatment of Bell's Palsy in Adults-A Systematic Review and Meta-analysis.

OBJECTIVE: Bell's palsy is typically treated with oral corticosteroids (40-60 mg daily). Concomitant antivirals are currently not recommended. The objective of this systematic review and meta-analysis was to examine the effect of high-dose versus standard-dose corticosteroids, without antivirals, in the management of Bell's palsy. DATABASES REVIEWED: Embase, MEDLINE, PubMed, CINAHL, Cochrane Library. METHODS: A systematic review and meta-analysis was performed according to PRISMA guidelines. Studies comparing high-dose (≥80 mg) or standard-dose (40-60 mg) corticosteroid therapy for Bell's palsy were included. Exclusion criteria were coexisting antiviral treatment, nonoral drug delivery, and facial palsy due to other causes. Risk of bias was assessed using ROBINS-I. A weighted estimate of treatment effects across trials as odds ratios (OR) using a Mantel-Haenzel random-effects model was calculated. RESULTS: Three articles were included in the analysis, representing 485 patients. There was a significant decrease in nonrecovery with high-dose, compared with standard-dose, corticosteroids at 6 months follow-up (OR = 0.17, 95% confidence interval = 0.05-0.56, p = 0.004). Overall adverse events were 5.8% (n = 28), all reported in one study in the high-dose group (transient elevated liver enzymes and fecal occult blood). CONCLUSIONS: Our analysis shows a favorable effect of high-dose corticosteroid in the treatment of Bell's palsy. It is the first to evaluate this effect without the use of antivirals in keeping with current treatment recommendations. As all included studies had a serious risk of bias, future research should focus on larger trials with more robust methodology. This will allow for more up-to-date and large-scale analyses where more valid conclusions can be drawn that may potentially influence treatment protocols.

Acute otitis externa: Consensus definition, diagnostic criteria and core outcome set development.

OBJECTIVE: Evidence for the management of acute otitis externa (AOE) is limited, with unclear diagnostic criteria and variably reported outcome measures that may not reflect key stakeholder priorities. We aimed to develop 1) a definition, 2) diagnostic criteria and 3) a core outcome set (COS) for AOE. STUDY DESIGN: COS development according to Core Outcome Measures in Effectiveness Trials (COMET) methodology and parallel consensus selection of diagnostic criteria/definition. SETTING: Stakeholders from the United Kingdom. SUBJECTS AND METHODS: Comprehensive literature review identified candidate items for the COS, definition and diagnostic criteria. Nine individuals with past AOE generated further patient-centred candidate items. Candidate items were rated for importance by patient and professional (ENT doctors, general practitioners, microbiologists, nurses, audiologists) stakeholders in a three-round online Delphi exercise. Consensus items were grouped to form the COS, diagnostic criteria, and definition. RESULTS: Candidate COS items from patients (n = 28) and literature (n = 25) were deduplicated and amalgamated to a final candidate list (n = 46). Patients emphasised quality-of-life and the impact on daily activities/work. Via the Delphi process, stakeholders agreed on 31 candidate items. The final COS covered six outcomes: pain; disease severity; impact on quality-of-life and daily activities; patient satisfaction; treatment-related outcome; and microbiology. 14 candidate diagnostic criteria were identified, 8 reaching inclusion consensus. The final definition for AOE was 'diffuse inflammation of the ear canal skin of less than 6 weeks duration'. CONCLUSION: The development and adoption of a consensus definition, diagnostic criteria and a COS will help to standardise future research in AOE, facilitating meta-analysis. Consulting former patients throughout development highlighted deficiencies in the outcomes adopted previously, in particular concerning the impact of AOE on daily life.

Workshop on the characterization of fiber-based scaffolds: Challenges, progress, and future directions.

A critical component of many tissue-engineered medical products (TEMPs) is the scaffold or biomaterial. The industry's understanding of scaffold properties and their influence on cell behavior has advanced, but our technical capability to reliably characterize scaffolds requires improvement, especially to enable large-scale manufacturing. In response to the key findings from the 2013 ASTM International Workshop of Standards and Measurements for Tissue Engineering Scaffolds, the National Institute of Standards and Technology (NIST), ASTM International, BiofabUSA, and the Standards Coordinating Body (SCB) organized a workshop in 2018 titled, "Characterization of Fiber-Based Scaffolds". The goal was to convene a group of 40 key industry stakeholders to identify major roadblocks in measurements of fiber-based scaffold properties. This report provides an overview of the findings from this collaborative workshop. The four major consensus findings were that (a) there is need for a documentary standard guide that would aid developers in the selection of test methods for characterizing fiber-based scaffolds; (b) there is a need for a strategy to assess the quality of porosity and pore size measurements, which could potentially be ameliorated by the development of a reference material; (b) there are challenges with the lexicon used to describe and assess scaffolds; and (d) the vast array of product applications makes it challenging to identify consensus test methods. As a result of these findings, a working group was formed to develop an ASTM Standard Guide for Characterizing Fiber-Based Constructs that will provide developers guidance on selecting measurements for characterizing fiber-based scaffolds.

Clinical and radiological guidance in managing facial nerve schwannomas.

OBJECTIVE: To present a review of all patients diagnosed with a facial nerve schwannoma (FNS) managed in our center over almost two decades, and suggest guidelines for their classification and management. STUDY DESIGN: Retrospective case review SETTING: Tertiary referral center PATIENTS: Twenty-eight patients with a facial nerve schwannoma INTERVENTION: Conservative or surgical management depending on clinical and radiological features MAIN OUTCOME MEASURE: Patient demographics, site of tumor, and clinical symptoms, including facial nerve function (House-Brackmann score) at baseline and follow-up. In those managed surgically, operative approach and surgical outcomes were also recorded. RESULTS: Of 28 patients, 16 were male. Mean age at presentation was 46 years. The majority presented with either facial weakness or hearing loss. The internal auditory canal segment of the facial nerve was the most commonly affected (19/28, 68%). Multi-segmental lesions were found in almost half (46%) of patients. Facial weakness was most commonly associated with involvement of the labyrinthine segment (89%). Overall, 16 (57%) patients were managed surgically. CONCLUSION: FNS may be difficult to distinguish on both clinical and imaging grounds from other cerebellopontine pathologies on the basis of audiovestibular symptoms alone. The presence of facial weakness in combination with imaging findings suggestive of FNS is highly suggestive for FNS. In patients with brainstem compression, rapid tumor growth, or House-Brackmann greater than 4, we suggest a surgical approach based on preoperative audiovestibular status, helping optimize long-term facial function and minimize morbidity. Facial nerve reanimation at the time of primary surgery is preferred.

Bone anchored hearing aids in children.

Bone-anchored hearing devices have evolved over recent years. This article provides an overview of the device history, indications, evolution of surgical technique, evidence for benefit and focuses on the challenges that are faced in the pediatric population.

Straight versus modiolar hugging electrodes: does one perform better than the other?

OBJECTIVE: To determine differences in speech perception outcomes for patients who received a CI422 and a Contour cochlear implant. STUDY DESIGN: Retrospective case review. SETTING: Tertiary referral center. PATIENTS: Thirty-two adults who underwent cochlear implantation. INTERVENTION: Cochlear implantation using a CI422 or Contour device. MAIN OUTCOME MEASURE: Bamford-Kowal-Bench (BKB) speech perception scores at 3 and 9 months after activation. RESULTS: The mean BKB scores at 3 months for the CI422 device were 86.0% in quiet and 55.1% in noise. This compares with 86.0% in quiet and 62.3% in noise for the Contour device. At 9 months, the mean BKB scores were 85.9% in quiet and 67.1% in noise for the CI422 and 90.1% in quiet and 77.6% in noise for the Contour device. There was no statistically significant difference (p > 0.05) between speech perception outcomes at 3 or 9 months. CONCLUSION: This study suggests that CI422 and Contour electrode both improve speech perception outcomes postoperatively, and there does not appear to be any significant difference in outcome between the two types of devices.

How reliable is the "scratch test" versus the Weber test after tympanomastoid surgery?

OBJECTIVES: To identify whether the scratch test can be used as an alternative to the Weber's test after tympanomastoid surgery. METHODS: This twin-center prospective study assessed major tympanomastoid surgery patients over a 6-month period. Patients were assessed postoperatively on Day 0 or Day 1 of surgery using a standardized proforma. A Weber's test was performed using a 512-Hz tuning fork, placed midline on the forehead to assess the direction of sound localization. This was directly compared with a scratch test, by asking the patient the following while scratching the head bandage in the midline: "Can you hear this? And which side is loudest?" RESULTS: Fifty-six patients were assessed in total. Sixteen mastoid explorations, 14 tympanoplasties, 18 combined approach tympanoplasties, and 8 other procedures were included, all of which had standard external auditory canal packing and head bandage. Assessment with Weber's test found 41 patients to have sound lateralizing to the operated ear. In comparison, 50 patients lateralized sound to the operated ear with the scratch test. Overall, Weber's test had a sensitivity of 73.2% and specificity of 100% compared with a sensitivity of 89.3% and specificity of 100% for the "Scratch Test." No patients had a dead ear after surgery. CONCLUSION: The scratch test proved to be more accurate than traditional postoperative tuning fork assessment and provides a quick, accurate, and simple solution for when such equipment is unavailable.

Magnetic resonance imaging and bone anchored hearing implants: pediatric considerations.

OBJECTIVE: Recent developments in bone conduction hearing systems have seen the introduction of transcutaneous devices comprising of magnetic components. Our aim was to identify the number of children implanted with a traditional, non-magnetic percutaneous bone anchored hearing implant (BAHI) who would not have been eligible for a transcutaneous implant based on magnetic resonance imaging (MRI) need. METHODS: A retrospective case review of 206 children who had a percutaneous BAHI at the Birmingham Children's Hospital (January 2009-October 2012) for auditory rehabilitation. RESULTS: Twenty-eight percent (56/206) of children required at least one MRI scan after receiving a BAHI and 10 percent of patients (20/206) required two or more MRI scans. The main indication for MRI scanning was for neurological co-morbidities; a MRI brain was the most common scan performed. CONCLUSION: Although transcutaneous hearing devices/middle ear implants have their clear benefits, it may be argued that these relatively more invasive surgical procedures may not be the best option for the child who will require MRI scanning at some point in the future. Clinicians should be mindful of any need for MRI scanning when considering implant choices in the pediatric population.

Bone-anchored hearing devices in children with unilateral conductive hearing loss: a patient-carer perspective.

OBJECTIVES: We sought to determine the outcome of implantation of a bone-anchored hearing device in children with unilateral conductive hearing loss. METHODS: A retrospective case note analysis was used in a tertiary referral pediatric hospital to study 17 consecutive cases of pediatric patients with unilateral conductive hearing loss who were fitted with a bone-anchored hearing device between 2005 and 2010. RESULTS: The average age of the patients at the time of bone-anchored hearing device fitting was 10 years 6 months (range, 6 years 3 months to 16 years). Qualitative subjective outcome measures demonstrated benefit. The vast majority of patients reported improved social and physical functioning and improved quality of life. All 17 patients are currently using their bone-anchored hearing device on a daily basis after a follow-up of 6 months. CONCLUSIONS: This study has shown improved quality of life in children with unilateral hearing loss after implantation of their bone-anchored hearing device. There was a high degree of patient satisfaction and improvement in health status reported by children and/or carers. Bone-anchored hearing devices have an important role in the management of children with symptomatic unilateral hearing loss. Perhaps earlier consideration of a bone-anchored hearing device would be appropriate in selected cases.

Quality-of-life outcomes after bone-anchored hearing device surgery in children with single-sided sensorineural deafness.

OBJECTIVE: To report our experience in a series of children with single-sided sensorineural deafness where a bone-anchored hearing device (BAHD) was used for auditory rehabilitation. STUDY DESIGN: Retrospective case review. SETTING: Tertiary referral centre. PATIENTS: Eight children (4 boys and 4 girls) who had BAHD surgery for single-sided sensorineural deafness between 2007 and 2010. INTERVENTION(S): Bone-anchored hearing device was used for auditory rehabilitation. MAIN OUTCOME MEASURE(S): Glasgow Children's Benefit Inventory (GCBI), Single-sided Deafness (SSD) Questionnaire and change in health benefit scores (visual analogue scale). RESULTS: All but one of the children showed a positive GCBI score; the child that reported a negative score was because of low self confidence and self-esteem issues secondary to bullying at school. The results of the SSD questionnaire were generally positive with a mean satisfaction score of the BAHD as 9/10. All the children had an improvement in heath benefit. CONCLUSION: Our findings add further evidence to support patient perceived benefit of a BAHD in single sided sensorineural deafness in the paediatric population.

Bone anchored hearing aids in children: an update.

OBJECTIVE: Over recent years, there have been a significant number of publications reporting evolving bone anchored hearing device (BAHD) indications and modifications in surgical techniques. We aim to present a review of recent trends in paediatric BAHD surgery and also discuss alternative treatment options available. METHODS: All papers referring to paediatric BAHD surgery (English language) were identified from Medline, Pubmed, Cochrane library and Embase search in May 2011. Abstracts were read and relevant papers were obtained. RESULTS: BAHDs have evolved over recent years as technology has advanced. New bone conduction hearing devices have recently been launched such as the Ponto system [Oticon™], Alpha 1 (M) hearing system [Sophono], Soundbite system [Sonitus] and the Vibrant Soundbridge system [Medel]. Modifications to existing implant systems have significantly altered BAHD practice with earlier loading of the sound processor now a positive step forward. CONCLUSIONS: The latest generation of percutanous devices have been designed to reduce skin complications, promote better osseointegration and earlier loading of the sound processor. Alternative devices without a skin-penetrating abutment are now available and have shown promising results in the paediatric population.

The 8.5mm abutment in children: the Birmingham bone-anchored hearing aid program experience.

OBJECTIVE: To the best of our knowledge, the use of the 8.5-mm abutment and its long-term outcome in the pediatric population has not been reported in the medical literature. We describe our experience with the use of the 8.5-mm abutment in a series of 16 children who have required a long abutment. STUDY DESIGN: Retrospective case series review. SETTING: Tertiary hospital. PATIENTS: Patients younger than 16 years who had an 8.5-mm bone-anchored hearing aid abutment fitted. INTERVENTION: Use of an 8.5-mm bone-anchored hearing aid abutment. MAIN OUTCOME MEASURES: Indications and complications with using the 8.5-mm abutment. RESULTS: We have used the longer abutment on both 3- and 4-mm fixtures. We have found the need to use it particularly around the time of puberty when we observed soft tissue problems develop. Follow-up after insertion of the long abutment ranged from 6 months to 6 years. There was 1 fixture extrusion 2 years after a long abutment had been fitted. CONCLUSION: Overall, we have found the long abutment to be useful in a selected pediatric population.

The use of a bone-anchored hearing aid (Baha) in children with severe behavioural problems--the Birmingham Baha programme experience.

OBJECTIVE: A trial of a bone conductor is traditionally used to determine whether a bone-anchored hearing aid (Baha) will be beneficial to a child. However there is a subgroup of children where a Baha assessment is not possible due to severe behavioural/mental/sensory disorders. We describe our experience in a small series of such children. METHOD: Retrospective case series review of four children at the severe end of the spectrum of behavioural difficulties who underwent Baha implantation where no formal preoperative hearing aid assessment was possible. The Glasgow Children's Benefit Inventory and a visual analogue scale assessing health status were used to determine the benefit of Baha implantation in this group. RESULTS: There was no surgical morbidity in this group although a more intensive postoperative follow up was required. All four children wore their hearing aids at least 8h a day. Parents reported a positive impact of the Baha on the behaviour and mood of their children. The Baha showed a positive benefit when assessed using the Glasgow Children's Benefit Inventory and showed a positive change in health status. CONCLUSIONS: We feel that our early experience with Baha in children with severe behavioural difficulties has been positive to date. Multidisciplinary teams should not dismiss these children even if a trial of a bone conductor is not possible. We feel that the bone-anchored hearing aid has been successful in our cases because the children do not physically feel the presence of the hearing aid.

Diffusion-weighted magnetic resonance imaging in the management of cholesteatoma.

Diffusion-weighted (DW) MRI has recently increasingly gained popularity in the diagnosis of post-operative cholesteatoma. The aim of this study is to prospectively evaluate the usefulness of echo-planar imaging (EPI) for the diagnosis of residual cholesteatoma. Fifty patients underwent DW-EPI before surgery. Fifteen patients had a scan before their first surgery and 35 patients underwent neuroimaging prior to their second look surgery. In the first preoperative group of 15 patients, DW-EPI confirmed cholesteatoma in all the patients. In the post-operative group DW-EPI identified or excluded cholesteatoma correctly in 29 out of 35 patients. Our study has demonstrated a sensitivity of 83% and specificity of 82% of DW-EPI for the diagnosis of residual cholesteatoma. DW-EPI can be a value imaging modality and may help the surgeon in selecting patients for revision surgery.