Changes in the provision of undergraduate ENT clinical placements across the UK in response to the coronavirus disease 2019 pandemic.

OBJECTIVE: This study aimed to report the changes made to ENT placements across the UK in response to the pandemic and their impact on student experience. METHODS: A questionnaire eliciting how ENT placements were provided before and after coronavirus disease 2019 was disseminated amongst Student and Foundation Doctors in Otolaryngology representatives. RESULTS: Thirty-eight respondents from 27 medical schools across the UK completed the survey (response rate of 90 per cent). Twenty-nine of the 38 respondents (76 per cent) reported a change in ENT placements in response to the pandemic. Six of the 38 students (16 per cent) remained satisfied with their ENT placements, as compared to 12 students prior to the pandemic (32 per cent). CONCLUSION: There is considerable variability in how medical schools responded to the pandemic. Most medical schools placed students into smaller groups, with less direct contact in the hospital. These changes resulted in lower student satisfaction. The increased emphasis on e-learning underscores the need for high quality e-learning materials to promote learning throughout the pandemic and in the future.

Superior semi-circular canal dehiscence syndrome: quantifying the effectiveness of treatment from the patient's perspective.

BACKGROUND: Superior semi-circular canal dehiscence syndrome is a disorder characterised by auditory and vestibular symptoms that can significantly impact quality of life, and yet it has no disease-specific quality of life instrument. METHOD: Thirty-six patients who underwent transmastoid superior semicircular canal resurfacing and plugging were included from an initial cohort of 60 surgically managed patients. A sub-cohort of 19 consecutive patients completed validated symptom and quality of life questionnaires before and after surgery. Of the 36 patients, 31 participated in a telephone semi-structured interview post-operatively. RESULTS: Following surgery, there was a statistically significant improvement in autophony index score (p = 0.02), symptom severity score (p < 0.001) and sound hypersensitivity (p = 0.01). Thematic analysis of telephone interviews suggested three main symptom themes: auditory hypersensitivity, dysequilibrium, headache and concentration difficulties. Dysequilibrium was found to persist post-operatively. CONCLUSION: Surgery improves overall symptoms and quality of life. However, important symptom themes may be overlooked using the outcome measures that are currently available. A unified disease-specific outcome measure is urgently required to better understand the impact of symptoms and measure treatment effects.

The provision of ENT teaching in the undergraduate medical curriculum: a review and recommendations.

OBJECTIVE: The existing provision of ENT teaching in the undergraduate curriculum is deemed inadequate by medical students, general practitioners and ENT surgeons alike. This study aims to explore the perceptions of a variety of stakeholders on how undergraduate ENT provision can be optimised. METHODS: This study involved semi-structured interviews with seven participants (two medical students, two general practitioners, two ENT surgeons and a curriculum developer). Inductive thematic analysis was used to identify key themes that emerged from the interviews. RESULTS: The four emergent themes were evaluation of current ENT provision, barriers to learning and teaching, alternate means of delivery of ENT education, and professional identity development. A number of barriers to learning and teaching in the clinical environment were identified including student-related, teacher-related and environmental factors. CONCLUSION: The existing ENT provision should be re-considered to help students achieve a basic level of competence in managing common ENT conditions. This can be achieved by ENT teaching in additional contexts including general practice, e-learning and simulation workshops.

The provision of undergraduate clinical placements in ENT during the coronavirus disease 2019 pandemic - exploring patient perspectives on a variety of approaches.

BACKGROUND: The coronavirus disease 2019 pandemic has greatly disrupted routine ENT services. Subsequently, universities have chosen to either augment or suspend clinical placements. OBJECTIVE: This study aimed to elicit patients' perspectives toward various approaches to clinical placements in ENT during the coronavirus disease 2019 pandemic. METHODS: Cross-sectional questionnaires were given to patients attending the ENT department for routine out-patient care. Responses were measured using a five-point Likert scale. Seventy-nine patients completed the survey. RESULTS: Ninety-five per cent of respondents felt the coronavirus disease 2019 pandemic had not reduced their comfort in interacting with medical students. Most participants reported being comfortable with students participating directly or remotely in their care, and with students having access to their anonymised data. Twenty-five per cent of participants stated that they are uncomfortable with consultations being recorded and shared for medical education purposes. CONCLUSION: A number of approaches to clinical placements remain acceptable to patients. Educational leads should continue to offer placements in ENT that can incorporate direct or remote observation of consultations.

The role of preoperative CT scan in patients with chronic otitis media.

Chronic otitis media may be due to chronic mucosal disease or cholesteatoma. Differentiating the two is usually achieved by clinical examination. The computed tomography (CT) scan is the standard imaging technique for the temporal bone, but its exact role in the preoperative assessment of patients with chronic otitis media is controversial. In this retrospective study we compared preoperative CT results with operative findings in 50 patients who had scan between January 2003 and December 2007. We analyzed the clinical presentation and checked if CT scan confirmed or excluded the presence of cholesteatoma and if this was affected by previous surgery. We concluded that CT scan could not be relied on to differentiate cholesteatoma from chronic mucosal disease. It should be used selectively in the preoperative preparation only if complications of the disease suspected.

Physiology of cerebrospinal fluid circulation.

PURPOSE OF REVIEW: This article describes the physiology of cerebrospinal fluid (CSF). We review current evidence and new concepts relating to CSF physiology with respect to CSF secretion, circulation and resorption and we highlight key pathophysiological associations including the relationship between CSF and intracranial pressure. RECENT FINDINGS: CSF secretion occurs primarily via the choroid plexus. Various transport mechanisms facilitate CSF secretion but the role Aquaporins play in this process is a recent discovery and an area of ongoing research. CSF circulation is a dynamic process but the importance of the perivascular 'Glymphatic system' and extraarachnoidal pathways of resorption are relatively new concepts. SUMMARY: CSF physiology is dependent on various interacting factors and is critical for normal brain development and function.

Predictors of audiological outcome following cochlear implantation in adults.

The objective of this study was to examine variables that may predict open set speech discrimination following cochlear implantation. It consisted of a retrospective case review conducted in a tertiary referral centre with a cochlear implant programme. The patients were 117 postlingually deafened adult cochlear implant recipients. The main outcome measures were Bench, Kowal, Bamford (BKB) sentence scores recorded nine months following implant activation. The variables studied were age at the time of surgery, sex, duration of hearing loss, aetiology of hearing loss, residual hearing, implant type, speech processor strategy, number of active electrodes inserted. Variables found to have a significant effect on BKB following univariate analysis were entered into a multivariate analysis to determine independent predictors. Multivariate ordinal regression analysis gave an odds ration of 1.09 for each additional year of deafness prior to implantation (confidence interval 1.06-1.13; p < 0.001). Duration of deafness prior to implantation is an independent predictor of implant outcome. It accounted for 9% of the variability. Other factors must influence implant performance.

Post-stapedectomy granuloma: a devastating complication.

OBJECTIVES: This paper reports three cases of severe post-stapedectomy granuloma, emphasising the variable presentation of this devastating complication and the challenges of its management. METHODS: A retrospective review was conducted of three cases of post-stapedectomy granuloma requiring surgical debulking between 2010 and 2015. Clinical symptoms, serial imaging, histopathology and post-operative outcomes were considered. RESULTS: Intra-operatively, extensive granulation tissue with erosion of the otic capsule was found. There was spread along the VIIth and VIIIth cranial nerves to the cochlear nucleus in one patient. Post-operative clinical improvement was demonstrable, corroborated by diminution of contrast enhancement on serial magnetic resonance imaging. Facial nerve function recovered, tinnitus amelioration was variable and some otalgia persisted. Post-operative complications included grade IV facial weakness and late Pseudomonas aeruginosa meningitis, which all resolved. CONCLUSION: To the authors' knowledge, this paper reports the only case of post-stapedectomy granuloma tracking to the brainstem. Otalgia was present in all our cases, and may be deemed a red flag symptom of progressive bony destruction and otic capsule involvement. Although granuloma remains rare, it should be considered in any patient with worsening otological symptoms following stapes surgery.

Botulinum toxin is effective and safe for palatal tremor: a report of five cases and a review of the literature.

Palatal tremor (formerly palatal myoclonus) is an extremely rare, but potentially treatable cause, of objective tinnitus. The tinnitus is thought to be secondary to rhythmic involuntary movements of the soft palate. Its aetiology is variable and it remains difficult to treat. Many different medical and surgical remedies have been tried but none have demonstrated reproducible success. Botulinum toxin has been used in sporadic cases and seems to produce good results. Ten patients with palatal tremor have presented to this department over the last three years. After discussion with the patients with regard to the management of this condition and possible complications, five opted for botulinum toxin therapy and five declined further intervention. Clinical diagnosis was made on the confirmation of soft palate movements synchronous with an audible clicking noise. Five patients underwent botulinum toxin injection into the insertion of the levator and tensor veli palatini muscles. Of the five that were treated with toxin, four showed complete resolution of symptoms after a course of treatment. Only one patient reported transient side effects. This would suggest that botulinum toxin is a safe and effective first line treatment for palatal tremor.

Cerebrospinal fluid leak rate after the use of BioGlue in translabyrinthine vestibular schwannoma surgery: a prospective study.

OBJECTIVE: To determine the effectiveness of BioGlue surgical adhesive in dural and middle ear closure after translabyrinthine vestibular schwannoma surgery. STUDY DESIGN: A prospective study. SETTING: Tertiary neurotological referral center. PATIENTS: There were 24 patients in the BioGlue series. BioGlue was used in the same manner in all cases. All patients received similar postoperative care. INTERVENTIONS: We studied the use of BioGlue and its possible effect on further reducing our department's cerebrospinal fluid leak rate for translabyrinthine vestibular schwannoma surgery. MAIN OUTCOME MEASURES: Postoperative events were documented that enabled us to determine the overall cerebrospinal fluid leak rate (including incidence of various leak routes and morbidity). RESULTS: The overall cerebrospinal fluid leak rate was 62.5% (15 of 24). Rhinorrhoea was the commonest route (80%), followed by postaural wound leak (33.3%) and external auditory canal otorrhoea (33.3%). Forty percent of cases had more than one cerebrospinal fluid leak route; 73.3% of leak cases required lumbar drain insertion, 40% needed pressure bandaging, and 66.7% had to undergo formal surgical repair. Forty percent had recurrent leaks after the initial episode had completely ceased. The mean extra stay in hospital as a result of the cerebrospinal fluid leak was 13.3 days. CONCLUSION: Our preliminary prospective study of the use of BioGlue for dural and middle ear closure in translabyrinthine vestibular schwannoma surgery demonstrated poor results. The high cerebrospinal fluid leak rate associated with the unusual presentations and ensuing management difficulties in controlling these leaks lead us to recommend that BioGlue not be used in translabyrinthine vestibular schwannoma surgery. The manufacturers have noted our results and have considered adding our recommendation to the product data sheet.

Myringoplasty.

There is marked diversity in the reported success rates for achieving an intact tympanic membrane following myringoplasty. Controversy exists about the factors thought to influence surgical outcome. Both of these facts have important implications for obtaining informed consent prior to surgery. This study reviews the factors thought to determine the likelihood of achieving complete closure of the tympanic membrane following surgical closure.

Device nonuse among adult cochlear implant recipients.

OBJECTIVE: To examine the causes and prevalence of previous and current device nonuse among adults who have received cochlear implants. STUDY DESIGN: Retrospective case review. SETTING: Adult tertiary referral center for cochlear implantation. METHODS: Two hundred fourteen consecutively implanted adult patients. The length of implant use ranged from 1 month to 14 years. MAIN OUTCOME MEASURE: A period of 4 consecutive weeks of nonuse of cochlear implant, including both obligatory and elective nonuse. RESULTS: Twenty-nine adults (13.6% of implantees) were identified as having at some stage not used their device for a period of more than 4 consecutive weeks. The main reason was device failure (n = 11). Ten adults are current nonusers (4.7% of implantees). Reasons include surgical complication necessitating explantation (n = 3), comorbid illness (n = 3), elective nonuse (n = 2), audiologic complication (n = 1), and device failure (n = 1). CONCLUSION: The overall prevalence of device nonuse was noted to increase slowly with time. The role of psychologic factors in contributing to the decision of an individual to elect to opt out of device use remains unproven.

An easier way of inserting the Shah permavent grommet.

Ventilation tube insertion plays an important role in the management of otitis media with effusion. In selected cases, repeated grommet insertion due to persistent eustachian tube dysfunction necessitates the need for longer-term ventilation. Insertion of such tubes can however occasionally be more difficult than insertion of standard grommets. One such long-term ventilation tube is the Shah permavent grommet. This paper describes a simple modification of the technique that is less time-consuming and less traumatic.

The genetics of hearing loss.

Hearing impairment is the most common sensory deficit with half of the causes of hearing loss having a genetic basis. There is a range of treatment devices but these do not correct the underlying pathology. Advances in molecular biology have greatly enhanced our understanding of the pathophysiology of genetic hearing loss, including potential treatments.

Venous thromboembolism prophylaxis in ENT surgery: a survey of current practice.

BACKGROUND: Venous thromboembolism is uncommon in ENT practice. There are no specific venous thromboembolism prophylaxis guidelines for ENT surgery, despite the bleeding risks associated with ENT surgery and the low incidence of venous thromboembolism. METHODS: An online poll of the ENT UK expert panel was conducted on the use of venous thromboembolism prophylaxis. RESULTS: A total of 132 responses were received. Of the respondents, 84.5 per cent routinely assess all of their patients for venous thromboembolism risk. In addition, 75.4 per cent use local health trust guidelines, with the National Institute for Health and Care Excellence being the most common source of national guidelines. There was significant heterogeneity in the use of low molecular weight heparin. Only 53.7 per cent of respondents felt that the guidelines they currently used reflect their practice. CONCLUSION: There is significant heterogeneity in venous thromboembolism prophylaxis. There is therefore scope for revision of the ENT UK venous thromboembolism prophylaxis guidelines to reflect general ENT practice.

Insulin receptors on the endolymphatic sac: an autoradiographic study.

Light microscopic autoradiographs were prepared of isolated guinea pig endolymphatic sac (ES) tissue incubated with iodine (I)-125-labeled insulin (insulin I 125). These demonstrated specific binding of the insulin I 125 to receptors in the ES. Receptor-mediated endocytosis of the insulin-receptor complex is postulated to occur, and the relevance of insulin receptors in the ES is discussed, with particular emphasis on the previously observed synthesis of hyaluronan from glucose by the ES.

Lasers in surgery for chronic ear disease.

This article describes specific situations in which the laser has been found to be useful in surgery for chronic ear disease. In the opinion of the authors, the most important application is the atraumatic removal of cholesteatoma from a mobile stapes. Additional uses include precise and hemostatic removal of diseased tissue (polyps, granulations, adhesions) and manipulations upon an intact ossicular chain without induction of vibrational trauma. Potential complications such as facial nerve and inner ear injury are considered.

Cochlear reimplantation.

Since its inception in 1988, the Cochlear Implant Programme in Manchester has successfully implanted 61 adults and 15 children. Of these 76 patients, 3 have undergone revision surgery, and these cases are presented. One patient was a 43-year-old blind man who underwent routine implantation with a Nucleus device. Six weeks after implantation the patient experienced sudden device failure following an electric shock from a domestic appliance. The patient was reimplanted with a similar device 3 weeks later and is making good progress. Assessment of the original implant showed a failure of one of the capacitors in the receiver-stimulator circuit. The second patient was a 51-year-old woman who underwent routine implantation with a Nucleus 22-channel device. The patient's audiologic performance fluctuated, and 14 months after the original procedure the patient was reimplanted. Analysis by the manufacturer suggested that the original implant was unstable at higher temperatures. The third patient, a 55-year-old woman, was implanted with an Ineraid multichannel device into the right cochlea. A postoperative radiograph showed the implant to be incorrectly positioned, and the procedure was revised 4 weeks later. Here it was found that the electrode system was running across the promontory, toward the eustachian tube orifice. This was reimplanted with satisfactory results.