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.

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.

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.

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.

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.

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.

Surgical Implications of Superior Thyroid Cornu Agenesis in Laryngeal Malignancy.

The most commonly reported superior thyroid cornu (STC) anatomical variation is in STC syndrome, where the cornu is enlarged or medially displaced. STC agenesis is a rare laryngeal variation that can be unilateral or bilateral. Previous studies have reported STC agenesis in cadaveric or forensic studies in patients with an otherwise normal larynx. We report a case of unilateral STC agenesis in the context of a stage III glottic laryngeal squamous cell carcinoma. The variation was discovered intra-operatively during a total laryngectomy and was clinically unknown beforehand. There were no clinical or histological signs of bony erosion by the tumor. To our knowledge, this is the first report of unilateral STC agenesis in a patient with laryngeal malignancy. This article draws attention to a rare anatomical variant of the larynx and highlights the surgical implications including potential diagnostic challenges and operative considerations.

Synchronous mucoepidermoid carcinoma and papillary microcarcinomas of the thyroid gland.

Thyroid mucoepidermoid carcinoma (MEC) is a rare thyroid malignancy first documented in 1977. The majority of thyroid MECs are indolent, low-grade tumours with excellent prognosis. A woman in her 60s presented with an ongoing sensation of a lump in the left neck. There were no swallowing, voice or airway concerns. Ultrasound of the neck showed an enlarged thyroid with U5 and U3 features on the right and left lobes, respectively. Right fine needle aspiration cytology (FNAC) demonstrated certain features of Hurthle cell or anaplastic carcinoma (Thy5). Left FNAC showed Hurthle cell changes with atypical cells and prominent nucleoli (Thy3a). Following total thyroidectomy, histopathology revealed synchronous right low-grade MEC and left papillary thyroid microcarcinomas (pT2(m) N0 M0) on a background of Hashimoto's thyroiditis. This case adds to the literature and details the key histopathological features for a rare but important differential in patients with thyroid carcinoma due to synchronous histological types.

The Effectiveness of a Specific Foundation Year 1 Induction Programme in Improving Confidence for Newly Qualified Doctors in the UK.

Background: Despite the completion of 5 or 6 years of undergraduate study, the transition to a newly qualified foundation year 1 doctor (FY1) in the UK has been recognised as challenging. We created a specific FY1 Induction Programme and aimed to evaluate its effectiveness on perceived confidence and preparedness for newly qualified doctors by assessing their responses to surveys before and after the delivery of the course. Methods: Pre- and post-course surveys were administered at the start and end of the course, respectively. All questions were subjective and used a 5-point Likert scale (1, not at all confident, to 5, definitely confident) to assess perceived confidence in a range of questions before and after the course. Results: A total of 35 participants completed the pre-course survey and 41 completed the post-course survey. For all questions, there was a statistically significant increase in confidence ratings. All 41 participants completing the post-course questionnaire responded 'yes' to feeling more confident to be an FY1 after completing the programme compared to before (100%). Conclusions: Our study, along with previously published work, has shown a repeatable positive effect with implementation of transition courses for newly qualified doctors. Future research in this area could focus on more large-scale standardised learning events incorporated by different trusts prior to commencement as an FY1, to see if the positive effects found in our study are translatable across other regions. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-022-01616-8.

Evaluating the role of the self-assembling topical haemostat PuraBond® in Transoral Robotic Surgery (TORS) for oropharyngeal cancer: A case series.

Background: Transoral Robotic Surgery (TORS) has been increasingly employed in head and neck surgery for the assessment and treatment of malignancies over the last two decades. PuraBond® is a self-assembling viscous solution that forms a transparent hydrogel 3-D matrix to promote local haemostasis. This study aimed to assess the utility of PuraBond® in patients undergoing TORS for Human Papilloma Virus (HPV) positive oropharyngeal squamous cell carcinoma (OPSCC). Methods: All patients who underwent TORS with PuraBond® between October 2021-May 2022 at a single tertiary university hospital in the United Kingdom were included. Primary outcome measures included post-operative haemorrhage rate (primary; within 24hrs of surgery, secondary; 1-30 days post-surgery). Secondary outcome measures included, Length Of hospital Stay (LOS), swallowing complications, hospital re-admission, and surgeon-reported ease of PuraBond® application. Results: Twelve patients were included (13 procedures due to one second look and re-resection case). No patients developed primary or secondary post-operative haemorrhage. There were no re-attendances within 30 days. Average LOS was 2.78 days (range: 1.54-4.31 days). No patient required feeding tube insertion or tracheostomy. In all procedures, the use of PuraBond® was reported as 'easy'. Conclusion: This is the first study to evaluate the role of PuraBond® in TORS. The wide range of favourable outcomes reported support its safety and efficacy. The current findings mandate the need for larger, prospective, controlled studies to better define whether the known haemostatic and regenerative properties of PuraBond® may translate into direct patient benefit in the expanding field of TORS for HPV-mediated OPSCC.

The Effect of COVID on Nasal Fracture Management in ENT Emergency Clinics.

Study design: Retrospective cohort study. Objective: Management of nasal fractures is usually in ENT emergency clinics, with our center aiming to assess patients within 10-days. During 2020, there have been numerous lockdowns and social distancing measures implemented in the UK as a result of the coronavirus pandemic (COVID). This study aimed to assess the effect of COVID on nasal fracture management in ENT emergency clinics in terms of number of patients seen, time to follow up and their management strategies. Methods: All patients with suspected or confirmed nasal bone fractures presenting to the emergency department (ED) between January 1, 2019 and December 31, 2020 at our major trauma center were analyzed in 2 groups depending on the year they were seen (2019 vs. 2020). Results: There was a total of 104 patients analyzed, with 51.4% decrease in the number of patients seen in 2020 versus 2019. The mean days to follow up in 2019 was 8.09 days and 7.65 days in 2020 (P = .37). There was no statistically significant difference in the number of patients seen within the 10-day target between years (2019 = 65.7% vs. 2020 = 76.5%, P = .35). The majority of patients were managed with manipulation under anesthesia (MUA) in 2019 (n = 32, 45.7%) vs. discharge from clinic in 2020 (n = 21, 61.8%). Conclusions: Our study shows a drastic reduction in the number of patients seen in ENT emergency clinic from 2019 to 2020. This is in-keeping with other studies that have shown a reduction in ED attendances, trauma admissions and admissions across other specialties all around the world.

The efficacy and safety of intrathecal fluorescein in endoscopic cerebrospinal fluid leak repair -a systematic review.

BACKGROUND: Effective management of cerebrospinal fluid (CSF) leaks can reduce significant associated morbidity. Intrathecal fluorescein (IF) may be a valuable intra-operative adjunct to localise leak sites. Recent reports have demonstrated low doses of IF to be safe, however, no internationally accepted dose of IF has been agreed. OBJECTIVE: To assess the efficacy and safety of IF used in the endoscopic management of anterior skull base CSF fistulae. METHODS: A systematic review and descriptive analysis were performed of all published data in accordance to PRISMA guidelines. RESULTS: There were 18 included articles giving a total of 335 procedures where IF was used. Doses of IF ranged from 10mg - 150mg. IF positively identified the site of CSF fistula in 88.7% of cases (n = 297). There was a total of 25 reported peri-operative complications in all included studies (7.5%) with 5.1% (n = 17) potentially related to IF use. Of these, the complication rate was 3.9% at low IF doses (<50mg) and 80.0% at higher doses (≥50mg). CONCLUSION: Our review demonstrates that IF is effective at localising CSF fistulae with most significant complications being related to doses ≥50mg. We therefore propose that there is a potential for the licensing of IF in this field. Doses <50mg have consistently been shown to be safe while still maintaining effective localisation rates. Based on the most common doses used in this group, we recommend utilisation of a dosing below 50mg, with the most frequent range being between 10-30mg.

Medical management of rhinitis in pregnancy.

Medical treatment options for patients with rhinitis during pregnancy need careful considerations. It is important to distinguish between the causes of rhinitis, as this can influence treatment. Conservative options are important for patients with pregnancy-induced rhinitis (PIR) and pre-existing allergic or non-allergic rhinitis. Education and knowledge that PIR symptoms will resolve after pregnancy can offer some relief. Other strategies such as exercise, positioning, saline nasal douching/lavage, and nasal valve dilators are safe in pregnancy and can have a benefit in these patients with rhinitis of any aetiology. The main medical therapies usually used in rhinitis cannot always be directly translated to pregnant patients due to potential teratogenic effects. Topical corticosteroids have generally shown to be safe with budesonide having the strongest recommendations. Oral corticosteroids are mostly used in moderate-severe disease and should be avoided in the first trimester. Oral decongestants have associations with cardiac, ear, gut and limb abnormalities and are not recommended in the first trimester. Loratadine and cetirizine have been the most well-studied second-generation antihistamines and are generally considered safe. There has been no reported increased risk of teratogenicity with anticholinergics or cromones, with the latter being one of the first line options in pregnant women with allergic rhinitis. The role of allergen immunotherapy needs further research, but current guidance states it can be continued if already initiated prior to pregnancy. The management of rhinitis in pregnancy can therefore be complex. This review aims to evaluate the current medical management options for rhinitis in pregnancy.

Reconstruction and Cerebrospinal Fluid Leaks in Endoscopic Endonasal Approach for the Management of Clival Chordomas-A Systematic Review.

The success of the endoscopic endonasal approach (EEA) to surgically manage clival chordomas (CC) relies on robust repair methods to reduce complications, such as cerebrospinal fluid (CSF) leaks. Our study aims to evaluate the existing literature to assess reconstructive techniques utilised and post-operative CSF leak rates in this cohort. A systematic review and analysis was performed of all published data related to CC patients managed with an EEA. A total of 24 articles were included, representing 363 patients and 396 procedures. A variety of reconstruction methods were used with 95.9% of studies using an intracranial repair graft, 70.8% using a nasoseptal flap (NSF), 62.5% using glue/haemostat, 58.3% using nasal packs and 75.0% employing multi-layered reconstruction. Post-operative CSF leak rate was 10.1%. The leak rate was less in subgroups where a NSF was used (9.4%) although this was not statistically significant (p = 0.273). There were no differences in leak rates when glue/haemostat (p = 0.139) or nasal packs (p = 0.550) were used. Our review is the most up-to-date synthesis of the existing literature surrounding the EEA to CCs assessing reconstruction and post-operative CSF leaks. It demonstrates most authors employ a multi-layered reconstruction method. The lack of statistical significance observed for CSF leaks in subgroups is likely due to a variety of cofounding surgeon and patient factors. Higher quality prospective randomised multi-centric studies, with reporting of specific repair techniques will enable future systematic reviews to provide a more accurate consensus regarding optimal methods of reconstruction in this field.

The evolution of sinus surgery in England in the last decade - An observational study.

BACKGROUND AND OBJECTIVE: Sinus surgery has seen significant changes over the years with advancements in instruments, endoscopes and imaging. This study aimed to use Hospital Episode Statistics (HES) data to review the total number of sinus related procedures performed in both adults and children across England and identify whether there were any trends across the study period. We predicted an increase in endoscopic sinus procedures with a decline in open approaches to the paranasal sinuses. METHODS: Data from HES was extracted for the years 2010-2019. The operative (OPCS-4) codes relevant to all sinus procedures between E12.1 and E17.9 were analysed. After examination of overall sinus related procedures, further subgroup analysis was performed with regards to open or endoscopic techniques. RESULTS: The total number of sinus procedures performed between 2010 and 2019 was 89,495. There was an increase in endoscopic surgeries by 21.1% and a decrease of open surgeries 35.3% during this time. There was an overall increase in maxillary, frontal and sphenoid sinus procedures, with a decrease in ethmoid sinus and lateral rhinotomy operations. There was an increase in the proportion of endoscopic cases overall by 5.7% and for all sinuses individually. CONCLUSION: Overall, we see an increase in sinus surgery over the last 9 years from 2010 to 2019. These findings are in keeping with our initial hypotheses. Although our data set is limited by coding, and lack of patient factors, it represents most, if not all, of the data in England over a large study period. It is therefore useful to add to previous studies when demonstrating the increasing popularity of endoscopic sinus surgery over open procedures.

A Basic Intervention to Improve Compliance With Thromboprophylaxis in Patients With Neck of Femur Fracture.

Background: Venous thromboembolism (VTE) is a significant complication following orthopedic intervention for neck of femur fracture. Our aim was to evaluate compliance with The National Institute for Health and Care Excellence guidance surrounding VTE prophylaxis before and after a brief intervention in an orthopedic department at a district general hospital. Methods: A 2-cycle quality improvement project was conducted. The primary outcome measure was whether adequate thromboprophylaxis was appropriately prescribed. For the intervention between the 2 cycles, posters were placed in key prescribing areas of all orthopedic wards. Results: In cycle 1, 63 (76.8%) patients were correctly prescribed enoxaparin, and 14 (17.1%) were prescribed other anticoagulants, leaving 5 patients (6.1%) who did not receive thromboprophylaxis for no apparent reason. In cycle 2, 56 (87.5%) patients were correctly prescribed enoxaparin, and the remaining patients were covered with alternative therapies. Conclusion: Small but basic interventions can lead to improvements in VTE prophylaxis prescribing. Future focus should be on implementing similar interventions across hospitals.

The Effectiveness and Safety of Intrathecal Fluorescein in the Management of Cerebrospinal Fluid Leaks.

BACKGROUND: Cerebrospinal fluid (CSF) leaks can be associated with significant morbidity such as meningitis. Surgical management has proven effective, with endoscopic approaches having become the gold standard due to success rates >90%. Inability to localise the leak site prior to surgery is associated with surgical failure. The use of intrathecal fluorescein (IF) to localise CSF fistulae sites was first demonstrated in 1960. Despite this, its use in this context is unlicensed. OBJECTIVE: Evaluate the safety and efficacy of IF use in the management of CSF leak repairs in our centre. METHODS: All patients who underwent endoscopic repair of CSF fistula by a single surgeon where IF was used between January 2010 - September 2019 at a single-centre (tertiary skull base referral unit in the United Kingdom) were retrospectively analysed. Primary outcome measures were localisation of CSF fistula with IF (efficacy) and peri-operative complications likely to be attributable to IF (safety). RESULTS: There were 55 patients included (60 procedures) with a positive localisation rate of 90.0% with IF. The overall peri-operative complication rate was 8.3% (n = 5). It is likely that none were related to IF use. However, three complications may be linked giving a complication rate potentially related to IF of 5.0%. There were no peri-operative mortalities. CONCLUSION: Many studies have demonstrated IF to be safe at low doses (<50mg) with a high sensitivity, specificity and positive predicative value. Our results demonstrate that the use of IF in our centre is safe and effective at identifying CSF fistulae. While we have reported some complications in our cohort, these were unlikely to be directly attributable IF use. We have described no serious complications such as seizures, limb weakness or death. We believe this study adds to the growing body of evidence that IF use in the management CSF fistula repairs is safe and effective.

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 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.