Clinical Evaluation of a Novel Laser-Ablated Titanium Implant System for Bone Anchored Hearing Systems in a Pediatric Population and the Relationship of Resonance Frequency Analysis With Implant Survival.

OBJECTIVE: To evaluate the clinical outcomes of pediatric patients implanted a novel 4.5 mm wide laser ablated titanium bone anchored implant system and to evaluate the implant stability over the first 12-month period. STUDY DESIGN: A prospective, single-subject, repeated measure, cohort study. Participants served as their own controls. SETTING: Community and tertiary referral hospital pediatric assessment center. PATIENTS: A total of 115 consecutive pediatric patients aged 4 to 15 years were implanted with 176 laser ablated titanium bone anchored implants from January 2016 to January 2019. MAIN OUTCOME MEASURE: Clinical outcomes, implant failure rates, and post implantation implant stability quotient (ISQ) scores were studied over the first 12-month period. Data were analyzed for statistical significance through mixed effect modeling, with the significance level p = 0.01. RESULTS: A median 12-month survival of 96.6% was observed. Six implants (3.5%) were lost in total, one of these (0.6%) was lost due to trauma. Adverse skin reactions (Holgers grade 2-4) were observed in 4.4% of all postoperative visits, occurring in 22 individuals (19.1%). Neither the ISQ high (ISQH) nor ISQ low (ISQL) values increased significantly between the stage 1 and 2 surgeries. In contrast, the ISQ results, irrespective of abutment size, demonstrated an increasing trend from 49.1 to 57 over the 12 months review period. A statistically significant change was only demonstrated from the 3 months follow up onwards. CONCLUSION: The use of 4.5 mm wide laser-ablated titanium bone anchored hearing implants resulted in superior survival rates and excellent clinical outcomes compared with previous implant systems.

Clinical evaluation and resonance frequency analysis of laser-ablated titanium bone-anchored hearing implant system in children with Down Syndrome.

OBJECTIVES: To evaluate complication rates and resonance frequency analysis (RFA) of the stability of a new laser-ablated titanium Bone Anchored hearing Implant system in children with Down syndrome. METHODS: A prospective, single-subject, repeat measure, cohort study in which each participant served as their own control. Consecutive paediatric patients 4yrs- 15 years old, with a primary diagnosis of Down syndrome (trisomy 21) were implanted between January 2015-January 2020 with BHX Oticon wide implants. Evaluation of soft tissue reactions, fixture failure rates and post implantation Implant stability Quotient (ISQ) at both fixtures and abutment levels were studied over a 12-month period. Data was analysed for statistical significance through mixed effect modelling with significance set at p = 0.01. RESULTS: 31 consecutive paediatric patients with a diagnosis of Down syndrome were implanted with 43 Ponto BHX Oticon™ implant system. Twelve children had bilateral implants and nineteen were unilateral. Over the 12 month follow up 2 fixtures (4.6%) were lost, and adverse skin reactions (Holgers >2) were recorded in 3.2% of all clinical reviews. Implant level stability quotient showed no statically significant change between first and second stage 71.1-71.7. Abutment level ISQ increased from 46.2 to 56.7 p = 0.0001 at the 12-month review point as compared to that recorded at loading. CONCLUSION: Implant survival and adverse skin reactions were found to be in keeping with those in published literature and much improved compared to previous implant systems placed at this centre. Although abutment level ISQ showed an increase over the review period no correlation between this and implant loss can be concluded.

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.

Writing clinic letters in head and neck outpatient services-Are we doing what patients want?

INTRODUCTION: The Academy of Medical Royal Colleges have recently recommended all outpatient letters to be written directly to patients. We aimed to evaluate clinician and patient preferences for their outpatient letters from a head and neck department at a single-centre secondary care hospital. METHODS: A multiple-choice questionnaire was designed and circulated to patients over a 2-week period. The primary outcome measure was the patient preference for the writing style. In order to evaluate existing writing styles, clinic letters were retrospectively sampled from all consultant and registrar grade otolaryngology (ENT) and oral maxillofacial (OMFS) surgeons in the department. These were analysed for readability via Flesch Reading Ease Score and audience. RESULTS: Of all 80 included patient responses, 42 expressed a preference for letters to be written directly to the patient (52.5%). Only 5.0% (n = 4) of respondents exhibited a preference for letters to be written to their GP, with 42.5% (n = 34) of patients having no preference. All 54 surgeon letters (100%) were addressed to GPs. The average FRE score was 58.5, representing a reading level of "high school education." DISCUSSION: When considered in the wider body of similar studies, there is convincing evidence that patients would prefer letters to be written to them rather than GPs. The authors believe that there should be a push towards patient-directed letters becoming the norm. This will improve patients' understanding of their own health and treatment decisions, allowing them to be more involved in their care and increase patient-centred consultations.

Five year clinical outcomes and evaluation following implantation of the Oticon™ wide bone anchored hearing system in 47 children.

OBJECTIVES: The Oticon™ wide implant system was launched in 2009 and used at Birmingham Children's Hospital from 2014. To evaluate clinical outcomes of the Oticon™ wide implant (Oticon Medical), with a focus on skin complication rates and fixture loss over a 5-year period in a tertiary paediatric hospital in the UK. METHODS: Retrospective 5-year longitudinal case record review of 47 children who were implanted with the Oticon™ wide implant system at Birmingham Children's Hospital (BCH) between January 2014 and January 2016. RESULTS: 47 children (27 M:20F) were implanted with 70 Oticon wide implants 23 bilateral, 27 unilateral. Mean age at the time of implantation was 9y 6 m. The follow up was for a mean of 5.4 years. Significant soft tissue complications requiring treatment was found in 11% (n = 8) of loaded fixtures, abutment tightening on two patients, abutment exchange 6% (n = 4) and a 10% (n = 7) fixture failure. CONCLUSION: The Oticon™ wide implant system produces favourable results with regards to peri-abutment skin complications, fixture stability and revision surgery rates when compared to similar cohorts of children studied at Birmingham Children's Hospital.

Longitudinal study of use of the pressure free, adhesive bone conducting hearing system in children at a tertiary centre.

OBJECTIVES: To assess the long-term compliance and usability of the non-implantable, adhesive bone conduction hearing aid system in children. Review of patient demographics, compliance and continued use. Identification of factors that impact on future patient selection. METHODS: Retrospective case series review of all children aged 5 and above fitted with the adhesive bone conduction hearing aid at a paediatric tertiary centre in the UK between 2015 and 2019. Data collected from medical and audiological records. Patient demographics, skin complications, patient feedback and changes in hearing aid provision were recorded. RESULTS: 82 children (40 female, 42 male) were provided with 89 adhesive hearing devices. To date 72 (87.8%) of the fitted patients, continue to use the device daily with minimal reported skin complications. Of the 10 patients that no longer use the adhesive aid, 5 no longer use any hearing device at all and the remaining 5 patients use an alternative hearing system. These include spectacle aids (n = 2) and bone anchored hearing implant (n = 3). CONCLUSION: Adhesive aid products are reported to provide comparable audiological results to the commercial softband hearing aids. They provide an excellent alternative in the treatment of conductive hearing loss without the costs and possible complications of a surgical intervention. A compliance rate of 87.8% of all patients fitted with the adhesive system demonstrates a high level of patient satisfaction. The device may also provide an appropriate stepping stone to implanted device once a child reaches the age in which an autonomous decision can be made. Limitations of the device have been the variability in the longevity of the adhesive adaptor and interference with headscarves, hats and glasses with a low frequency of transient minor skin reactions reported.

Improving the quality of assessment and management of nasal trauma in a major trauma centre (MTC): Queen Elizabeth Hospital, Birmingham.

Background: Nasal fractures present in 39% of patients with facial trauma. These patients are assessed in the emergency department followed by outpatient review in the senior house officer-led emergency ear, nose and throat (ENT) clinic. Inadequate treatment of nasal trauma can result in debilitating functional and aesthetic problems. Inexperienced junior doctors may be apprehensive in assessing nasal trauma resulting in time pressured clinics and suboptimal management. Measures: A retrospective review of clinical noting over 3 months was carried out to gauge the extent of the problem. Three baseline measurements for satisfactory quality of assessments included: (1) 3/5 key symptoms elicited by the clinician (epistaxis, rhinorrhoea, nasal airway obstruction, dental malocclusion and diplopia). (2) Presence/absence of 'septal haematoma' (SH) and 'deviated nasal septum' (DNS) documented. (3) Patient follow-up within 2 weeks after the initial injury. Three Plan-Do-Study-Act (PDSA) cycles were conducted with implementation of interventions (proforma, clinic poster, patient information leaflet and training) as visualised in our 'driver diagram'. Results: The quality of nasal trauma assessments improved following each intervention. There was an increase from 86% to 100% patients being seen within 2 weeks of the injury. There was an improvement in quality of assessments following the teaching as two-thirds (PDSA cycle 2) followed by 100% (PDSA cycle 3) of clinical documentation included 'rhinorrhoea' and 83% (PDSA cycle 2) to 100% (PDSA cycle 3) included 'nasal airway obstruction'. Similarly, two thirds (PDSA cycle 2) followed by 100% (PDSA cycle 3) examined and documented the presence/absence of SH and DNS. A 100% improvement in trainee confidence was reported. We are now conducting more comprehensive assessments of nasal trauma patients. Conclusion: The need to provide relevant training and support to ENT junior doctors is crucial in their development, as well as to ensure delivery of high-quality patient-centred care.

First Pediatric Experience With a Novel, Adhesive Adapter Retained, Bone Conduction Hearing Aid System.

OBJECTIVES: To assess the audiological outcomes, practicalities, and impact on quality of life of a new, nonimplantable, adhesive retained bone conduction hearing aid in children. STUDY DESIGN: A prospective, single-subject repeat measure, cohort study. SETTING: Community and in pediatric assessment center. PATIENTS: Twenty-one children aged between 5 and 15 years with a conductive hearing loss of >/=25 dB HL in the better hearing ear. INTERVENTION: Audiological comparisons were made using pure-tone thresholds; unaided, with a softband aid, and with the new adhesive retained bone conducting system. MAIN OUTCOME MEASURES: Comparison of hearing threshold levels. Data analysis via paired t-testing, significance set at p value <0.01. Quality of life was assessed via the Glasgow Children's Benefit Inventory and a 10 cm linear analogue scale. A hearing aid review questionnaire provided insight into practical use. RESULTS: Statistically significant improvement in thresholds of 7.3 dB HL (p=0.0001) was demonstrated with the adhesive system as compared with softband aids. After 4 weeks of usage, the mean hearing thresholds for the adhesive hearing system improved from 55 dB HL ±â€Š2.4 to 31 dB HL± 7.9 in unaided and aided conditions.Improvements in QOL were demonstrated with LAS and GCBI. Four children reported mild skin reactions. Eighty-six percent reported improved self-confidence. CONCLUSION: The adhesive aid produces comparable audiological results to the commercial softband hearing aids. It provides an excellent alternative in the treatment of conductive hearing loss without the possible complications and costs of a surgical intervention. Furthermore, it preserves skin envelope over the mastoid for those who wish to proceed with an autologous pinna reconstruction in the future.

Middle Ear Pressures in Wind Instrument Musicians.

OBJECTIVES: This study aimed to assess if playing wind instruments leads to a measurable increase in middle ear pressure during note generation and to provide evidence to clinicians to advise musicians undergoing middle ear surgery. STUDY DESIGN: An observational cohort study of 40 volunteers in 7 different wind instrument categories underwent tympanometry at rest and during note production. SETTING: Community. PATIENTS: Recreational musicians aged over 18 years recruited from the student body attending Birmingham University, UK. INTERVENTION: None. MAIN OUTCOME MEASURES: Tympanometry is used as a noninvasive measure of middle ear pressure. The pressure at which peak compliance occurred was taken as an indirect measure of middle ear pressure. The data produced at rest and during note production was statistically analysed with paired t testing and significance set at a p value less than 0.01. RESULTS: Overall a statistically significant increase in middle ear pressure change of 0.63 mm Hg (p = 0.0001) during note production was identified. Musicians playing the oboe and trumpet demonstrate the largest increase in middle ear pressure of 1.46 mm Hg (p = 0.0053) and 0.78 mm Hg (p = 0.0005) respectively. CONCLUSION: The data provided by this study gives evidence for the first time that playing wind instruments does increase middle ear pressure. Although the clinical significance of this is yet to be determined the authors would advise that musicians who undergo otological procedures should refrain from playing their instruments until full recovery has been achieved as advised by their clinician following direct microscopic review.

Head and Neck Anatomy: Effect of Focussed Near-Peer Teaching on Anatomical Confidence in Undergraduate Medical Students.

OBJECTIVES: To assess the effect of near-peer head and neck anatomy teaching on undergraduates and to quantify the benefit from a focussed teaching course. Near-peer teaching involves colleagues within close seniority and age proximity teaching one another on a specified topic. DESIGN: Small group teaching sessions were delivered to medical students on 3 key areas of ENT anatomy. Participants were given a precourse and postcourse questionnaire to determine the benefit attained from the course. SETTING: An undergraduate anatomy course taking place at the University of Birmingham Medical School. PARTICIPANTS: A total of 30 medical students: 15 preclinical (years 1-2) and 15 clinical (years 3-5) medical students participated from a single institution. RESULTS: A total of 71% of students expressed inadequate teaching of head and neck anatomy in undergraduate curriculum. All students (n = 30) expressed benefit from the course, however the patterns of learning differed: preclinical students showed a significant improvement in both their ability to name anatomical structures and their application (p < 0.05). CONCLUSIONS: Near-peer learning provides benefit to all medical undergraduates in the context of teaching anatomy which may make it a valuable teaching tool for the future of medical education.