Should paediatric tonsillar asymmetry be an indication for tonsillectomy? A single centre experience.

BACKGROUND: Paediatric tonsillar lymphoma (TL) is a rare diagnosis. Historically, the presence of clinical features such as tonsillar asymmetry, grossly abnormal tonsil appearance and cervical lymphadenopathy raise concern for this diagnosis. Tonsillar asymmetry is considered to be the most concerning clinical feature; however, asymmetry is often apparent due to differences in depth or shape of tonsillar fossa and tonsillar pillars, rather than a true difference in volume. There is debate whether a tonsillectomy is required in all cases of tonsil asymmetry to exclude lymphoma, and what clinical features should raise concern. The aim of this study was to establish whether the presence of clinical asymmetry can be deemed a reliable marker for genuine tonsil size discrepancies. We also sought to evaluate the clinical and examination characteristics that are concerning for lymphoma. METHODS: Retrospective review of clinical records for paediatric tonsil specimens sent for histological evaluation between 1 January 2012 and 1 January 2023 driven by a clinical suspicion of lymphoma at Starship Children's Hospital, New Zealand. Patient demographics and clinical data were recorded. A comparison was made between tonsil size asymmetry on clinical examination (Brodsky criteria) and tonsil volume difference based on dimensions given in pathology reports. RESULTS: One hundred and forty-three patients had tonsillectomies between 2012 and 2022 at Starship Children's Hospital due to concern for lymphoma. Of these, three were positive for lymphoma. Presence of pain and abnormal tonsil appearance were predictors for lymphoma (p<0.02). Interrater reliability agreement between clinical size difference and tonsil volume was poor, Kappa= -0.13 p<0.05. CONCLUSION: Clinical size difference is a poor predictor for true tonsil volume difference. We advise that assessment of tonsil size should be performed in conjunction with the examination of gross visual abnormalities and lymphadenopathy to guide clinical decision making.

Successful use of sclerotherapy in giant supraglottic vascular malformation.

A young male patient presented with an incidental finding of a large supraglottic vascular lesion. The lesion was initially noted during intubation 4 years ago. Although originally listed for elective excision, there was a significant delay and at the time of surgery, the lesion proved too large to remove and a significant threat to the patient's airway. An emergency tracheostomy was performed, followed by two consecutive treatments with sclerotherapy agents to reduce the size of the lesion. It was then successfully excised using a Thunderbeat ultrasound and bipolar dissection and cautery device.

Adult nasal chondromesenchymal hamartoma: a rare and benign tumour with aggressive malignant transformation.

Nasal chondromesenchymal hamartoma (NCMH) is an extremely rare benign tumour of the nasal cavity predominantly described in infants. We report a case involving a 48-year-old woman who had been diagnosed with NCMH a year earlier and now re-presented with a short history of progressive nasal blockage, recurrent epistaxis and orbital apex syndrome. Histopathology was suggestive of malignant transformation into sinonasal sarcoma. However, following multidisciplinary team (MDT) discussions, including second and third opinions from external departments, the histological diagnosis was revised to 'NCMH with bizarre stromal cells'. Despite this, the lesion demonstrated malignant features of rapid, invasive growth and was treated with palliative radiotherapy. The patient later developed radiological evidence of lung and liver metastases with subsequent pulmonary emboli. Shortly after this, she passed away. This case is unique in its diagnostic challenge, with ambiguous histopathological findings, and highlights the importance of an MDT approach when managing complex sinonasal tumours.

The Significance of Audiometric Notching in Individuals With a History of Noise Exposure: A Systematic Review.

OBJECTIVES: The diagnosis of noise-induced hearing loss (NIHL) is reliant on the appraisal of audiometric data. A notch, dip or bulge, centered at the 4-kHz frequency is considered to be pathognomonic. However, guidelines applied to assist the diagnosis of NIHL often allow for a notch centered between the 3- and 6-kHz frequencies. The primary outcome of this review is to document the relationship between audiometric notching at particular frequencies and the populations in which they have been identified. DESIGN: We included all population-based studies, cohort, cross-sectional, case-control, case-series, and case reports of adults and children, with exposure to noise and with a notch, dip or bulge. The review has been registered with Prospero (Registration: CRD42017079901) and prepared in line with the PRISMA guidelines. RESULTS: We included 84 articles in the final systematic review. There were a total of 1,438,987 individuals, aged 7 to 80 years old. The studies were conducted in 26 different countries. Fourteen studies identified notching at 3 kHz, 63 studies identified notching at 4 kHz, and 47 studies identified notching at 6 kHz. The Newcastle-Ottawa risk assessment tool was performed on 82 of the studies emphasizing the high risk of bias in observational studies. CONCLUSIONS: The overwhelming outcome of this systematic review demonstrates that the relationship between noise exposure and a 3- to 6-kHz audiometric notch is not straight-forward. A handful of articles have displayed a clear association between an individual's noise exposure and an audiometric notch. Unilateral notches, notches observed at 3 kHz and notches in the absence of continued high-intensity noise exposure must be scrutinized thoroughly. The ambiguous nature of NIHL directs its continued interest.

Neurological Complications of Acute Rhinosinusitis: Meningitis.

Meningitis remains a rare but potentially life-threatening intracranial complication of acute rhinosinusitis. We describe a case of a 62-year-old man with a background of chronic rhinosinusitis who presented to hospital with confusion, fever and bilateral green purulent rhinorrhoea. After immediate sepsis management, urgent contrast-enhanced computed tomography head revealed opacification of all paranasal sinuses and bony erosion of the lateral walls of both ethmoid sinuses. He was treated with intravenous antibiotics, topical nasal steroids, decongestants and irrigation. Following a turbid lumbar puncture and multidisciplinary discussion, he was admitted to the critical care unit and later intubated due to further neurological deterioration. After 13 days admission and rehabilitation in the community he made a good recovery. This case highlights the importance of timely diagnosis and appropriate management of acute rhinosinusitis and awareness of the possible complications. Joint care with physicians and intensivists is crucial in the management of these sick patients.

A safe and comparable alternative to BIPP packing following tympanoplasty for tympanic membrane perforation.

PURPOSE: To compare two post-operative ear packing methods following tympanoplasty for tympanic membrane perforation. METHODS: A prospective study of patients undergoing tympanoplasty for tympanic membrane perforation over a 2-year period was undertaken across two district general hospitals. Data, including demographics, pre-operative ear state, and graft type used for repair were recorded. Ears were packed using one of two distinct methods. Pack A: gelatin sponge, chloramphenicol ointment and an antibiotic-soaked ear wick. Pack B: antibiotic-soaked gelatin sponge, bismuth iodoform paraffin paste (BIPP) impregnated gauze dressing. The primary outcome measure was post-operative complications associated with each packing method RESULTS: One hundred and fifty-three tympanoplasties were performed during this period: 68 underwent Pack A and 85 underwent Pack B. Chi squared test showed no significant association between pack type and complication rate (p = 0.572). Univariate analysis suggested that age (p = 0.047) and concurrent bony canaloplasty (p = 0.006) significantly increased complication rates. Pre-operative ear status, indication, graft type and gender did not affect complication rate. CONCLUSIONS: BIPP-impregnated ribbon gauze and chloramphenicol/wick are both comparable methods for packing an ear following tympanoplasty for tympanic membrane perforation. This is useful information both for surgeons who commonly use BIPP and have a patient with a known iodine allergy, or who is not known to be allergic to iodine but has been packed with BIPP previously, and for those who do not have access to BIPP and wish to use a pack with comparable success.

Paediatric periorbital cellulitis: A 10-year retrospective case series review.

AIM: To identify the predictors of poor outcome and need for surgical management in paediatric patients with periorbital cellulitis. To assess the adherence to local guidelines in the management of periorbital cellulitis. METHODS: Retrospective descriptive analysis of clinical, laboratory and radiological characteristics of 175 paediatric periorbital cellulitis presentations at a UK teaching hospital over a 10-year period. Regression investigated correlations for continuous and categorical variables. RESULTS: A total of 175 paediatric presentations were diagnosed as periorbital infections over the 10-year period. Of these, 139 had pre-septal cellulitis, 27 had a subperiosteal abscess, 6 had an orbital cellulitis, 1 had an orbital abscess, 1 a cavernous sinus thrombosis and 1 an extradural abscess. Median age at presentation was 5 years (range: 1 month-17 years). In total, 169 (97%) cases received systemic antimicrobial treatment. Cross-sectional imaging occurred in 30% of cases and 18% required surgical intervention. Increasing C-reactive protein was associated with greater risk of post-septal disease and requiring surgery. The best predictors of post-septal disease in the multivariate analysis (R2 = 0.49, P = ≤0.001) were ophthalmoplegia (P = 0.009), proptosis (P = 0.016) and pain on eye movement (P = 0.046). Proptosis was the single most significant predictor of surgical management (R2 = 0.53, P = <0.001). CONCLUSION: Multidisciplinary involvement and early medical management can improve outcomes for most patients. Those who deteriorate despite medical management should be considered for prompt imaging and surgical management to avoid serious life-threatening or sight-threatening complications.

Accuracy of clinical scoring tools for the diagnosis of pediatric obstructive sleep apnea.

OBJECTIVES: To assess the diagnostic test accuracy of questionnaire and clinical examination-based scoring tools in the diagnosis of pediatric obstructive sleep apnea (OSA). METHODS: A comprehensive literature search was performed to identify studies published from 1960 to 2018 that evaluated the accuracy of clinical scoring tools in the diagnosis of pediatric OSA. Studies that did not include attended polysomnography as a reference standard were excluded. The study populations were children under 18 years old without craniofacial abnormalities, congenital syndromes, or other complex medical conditions. Outcomes measures were diagnostic test accuracy (DTA) statistics including sensitivity, specificity, and area under the curve (AUC) from receiver operating characteristic curve analysis. RESULTS: Fifteen different scoring tools were identified. Authors chose different polysomnographic criteria to diagnose OSA. Four of the tools had undergone multiple DTA studies by different authors (OSA Score, Sleep-Related Breathing Disorder [SRBD] scale, Severity Score, and OSA-18). The Pediatric Sleep Questionnaire SRBD scale, which is widely used, has a sensitivity of 71% to 84% in included studies, but specificity as low as 13% and a low AUC of 0.57-0.69, indicating poor diagnostic accuracy. None of the 15 scoring tools performed well enough to be considered accurate diagnostic tests for pediatric OSA. CONCLUSIONS: A well-designed questionnaire can provide crucial information on the impact of sleep-disordered breathing on a child's physical and psychological health, which may not be adequately reflected in objective polysomnography outcomes measures. However, DTA results indicate that published clinical scoring tools do not accurately predict a diagnosis of pediatric OSA as defined by polysomnography outcome measures. Laryngoscope, 130:1034-1043, 2020.

Localized Sinonasal Amyloidosis.

Localized amyloidosis involving the nasal mucosa is rare, with only 38 published cases reported to date. We report a case of amyloidosis localized to the sinonasal tract. A 61-year-old man presented with a 1-year history of left-sided nasal obstruction. Endoscopic examination and computed tomography revealed the presence of a nasal mass originating from the left inferior turbinate. The patient subsequently underwent an examination under anesthesia and an excision biopsy of the nasal mass. Histology confirmed amyloidosis with no immunospecific stains. Systemic amyloidosis testing was negative, leading to a diagnosis of localized sinonasal amyloidosis of nonamyloid A (AA) subtype. To our knowledge, this is the second reported case of non-AA subtype of the sinonasal tract. The patient was managed conservatively and is currently under close follow-up.

An Assessment of the Change in Compliance of Observational Otology and Audiology Studies With the STROBE Statement Guidelines: A Systematic Review.

OBJECTIVES: Observational studies often represent the best available evidence for surgical practice. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) recommendations were generated in 2007 with the aim of improving the quality of reporting. This study was designed to assess whether publication of STROBE guidelines has improved the quality of reporting in observational otology and audiology studies. DATA SOURCES: EMBASE and MEDLINE were searched using a comprehensive keyword search developed in conjunction with a scientific librarian. STUDY SELECTION: English language papers from six Otorhinolaryngology journals during two 6-month periods (2005 and 2016) were evaluated. DATA EXTRACTION: Two reviewers independently analyzed papers according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. DATA SYNTHESIS: Percentage scores for the two periods were compared using Mann-Whitney U test. CONCLUSIONS: Forty and 42 studies were returned for the 2005 and 2016 periods, respectively. The mean percentage of STROBE items that were met improved between 2005 and 2016 (58, 76%, respectively; p < 0.0001). Analysis indicated that improvements were greater in journals that endorsed STROBE guidelines (p = 0.02). This data suggests that STROBE has increased the reporting quality of observational studies; however, there are still significant further improvements to be met.

The Seasonal Variation of Benign Paroxysmal Positional Vertigo.

OBJECTIVE: Benign paroxysmal positional vertigo (BPPV) is characterized by recurrent episodes of positional vertigo due to dislodged otoconia debris within the semicircular canals. Many studies have proposed a correlation between Vitamin-D deficiency and recurrent BPPV. In the UK, serum Vitamin-D falls during the winter, reaching its lowest level in May and it is highest level in September. We hypothesize that if there is a relationship between BPPV and Vitamin-D levels, one would expect to see a seasonal variation in the incidence of BPPV among UK residents. METHODS: A retrospective review of clinic letters and general practitioner referrals for patients presenting to a University Otolaryngology department over a 4-year period. Patients were divided into two groups: those presenting during the months associated with low serum Vitamin-D levels, and those presenting during the months associated with high serum Vitamin-D levels. RESULTS: Three hundred thirty-nine patients were identified with posterior canal BPPV as a consequence of having had a positive Dix-Hallpike maneuver recorded in the clinical notes between October 2012 and October 2016. A Wilcoxon rank-sum test demonstrated there to be a statistically significant difference between the low serum Vitamin-D group and the high serum Vitamin-D group (p = 0.0367). CONCLUSION: The results confirm that there is a seasonal variation in the incidence of BPPV. This study is important as it adds to the mounting literature suggesting an association between serum Vitamin-D levels and BPPV. Second, it suggests a therapeutic strategy to improve outcomes in affected patients. Third, it adds significance to the hypothesized role of calcium metabolism for the development of inner ear disease.

A review of the world's published face transplant cases: ethical perspectives.

The highly publicised case of the first ever partial facial transplant in 2005 sparked fierce ethical debates, moral arguments and strong opinions, both within the medical community as well as the general public and mass media. As more patients have undergone facial transplantation over the last decade, some of this initial scepticism has given way to a wider acceptance of this significant reconstructive development. However, despite an improved understanding of the perioperative technicalities and postoperative perils, the risks remain significant and the long-term outcomes are still largely unknown. This article examines the major ethical challenges that have accompanied facial allo-transplantation since its inception. We discuss these ethical dilemmas in the context of the patients, donor families, healthcare professionals and society as a whole, while evaluating some of the emerging evidence and outcomes associated with the physical and psycho-emotional risks linked to this procedure.

What is the optimal diagnostic pathway in tuberculous lymphadenitis in the face of increasing resistance: Cytology or histology?

BACKGROUND: The London Borough of Newham has the highest rates of tuberculosis (TB) within Europe (116 per 100,000). There is a lack of guidance in lymph node (LN) TB on how to best obtain a positive culture, which is the gold standard in the face of increasing mycobacterial resistance. METHODS: An individual cohort study was carried out via a prospective local TB database capturing 90 cases of cervical LN TB over 34 months. We compared the diagnostic efficacy of fine needle aspiration (FNA) and excision biopsy of LN. RESULTS: FNA cytology revealed granulomata in 49%, acid-fast bacilli (AFB) in 8.6% and a positive culture in 40%. LN excision showed granulomata in 97.6%, AFB in 17.1% and a positive culture in 70.1%. There was an 18% resistance to first-line antimicrobials. CONCLUSIONS: We describe our experience and suggest an algorithm for the culture of TB organisms to avoid a lengthy diagnostic process.