Diffusion-weighted magnetic resonance imaging for residual and recurrent cholesteatoma: a systematic review and meta-analysis.

BACKGROUND: Diagnosis and management of recurrent or residual cholesteatoma can be problematic. Diffusion-weighted imaging magnetic resonance imaging (MRI) sequences have been used for follow-up of such lesions. More recent non-echoplanar imaging (non-EPI) sequences are thought to be superior to older echoplanar imaging (EPI) sequences. OBJECTIVE OF REVIEW: Evaluate whether diffusion-weighted magnetic resonance imaging is useful in the diagnosis of recurrent or residual cholesteatoma. TYPE OF REVIEW: Systematic review and meta-analysis. SEARCH STRATEGY: MEDLINE, EMBASE, CINAHL, Web of Science and the Cochrane Database were searched, with no limits on date or language. STUDY SELECTION: Adults or children who had previously undergone tympanomastoid surgery by any method with confirmation of recurrence/residual disease by second-look/revision surgery. EVALUATION METHODS: Two reviewers independently reviewed studies. Data extracted on 11 domains and rechecked. DATA SYNTHESIS: Statistical analysis with SPSS. RESULTS: A total of 575 studies were identified of which 27 met the inclusion criteria. These covered 727 patient episodes. For EPI studies: sensitivity (sd) 71.82 (24.5), specificity (sd) 89.36 (13.4), PPV (sd) 93.36 (8.1) and NPV (sd) 73.36 (15.8). For non-EPI studies: sensitivity 89.79 (12.1), specificity (sd) 94.57 (5.8), PPV (sd) 96.50 (4.2) and NPV 80.46 (20.2). Improved sensitivity of non-EPI sequences reached significance (P = 0.02). CONCLUSIONS: Diffusion-weighted MRI is both sensitive and specific for the detection of recurrent or residual cholesteatoma following ear surgery. Non-EPI techniques are superior to EPI techniques.

Lifestyle management of unipolar depression.

OBJECTIVE: To be used in conjunction with 'Pharmacological management of unipolar depression' [Malhi et al. Acta Psychiatr Scand 2013;127(Suppl. 443):6-23] and 'Psychological management of unipolar depression' [Lampe et al. Acta Psychiatr Scand 2013;127(Suppl. 443):24-37]. To provide clinically relevant recommendations for lifestyle modifications in depression, derived from a literature review. METHOD: A search of pertinent literature was conducted up to August 2012 in the area of lifestyle factors and depression. A narrative review was then conducted. RESULTS: There is evidence that level of physical activity plays a role in the risk of depression, and there is a large and validated evidence base for exercise as a therapeutic modality. Smoking and alcohol and substance misuse appear to be independent risk factors for depression, while the new epidemiological evidence supports the contention that diet is a risk factor for depression; good quality diets appear protective and poor diets increase risk. CONCLUSION: Lifestyle modification, with a focus on exercise, diet, smoking and alcohol, may be of substantial value in reducing the burden of depression in individuals and the community.

Robotics can lead to a reproducibly high-quality operative result for ear, nose, and throat patients.

The success rates and morbidity of operations on the ear, nose, and throat (ENT) have improved markedly in the last 20-25 years. This has been largely due to improved vision, by microscopes and endoscopes, and has led to a greatly reduced hospital stay. During this time there has been minimal improvement in surgical tools. This paper discusses the need for robotic tools, detailing the clinical constraints that proposed solutions need to adhere to, and presenting a recently trialled micro drilling robot for creating a cochleostomy in the cochlear implant procedure.

How good is a chest CT scan at predicting the risk of pulmonary metastatic disease in patients with head and neck cancer? A retrospective observational study.

OBJECTIVES: Our objectives were to assess whether a CT chest, when performed as part of initial staging investigations, is a robust method to identify lung metastases or synchronous primary lung cancers in patients with head and neck squamous cell and whether small nodules are likely to represent metastases in this group of patients. DESIGN: Retrospective observational study performed between 1994 and 2005. SETTING: Head and neck cancer department, Queen Elizabeth Hospital, Birmingham. PARTICIPANTS: All patients that were included had a new head and neck squamous cell carcinoma and underwent a CT chest as part of their staging investigation. MAIN OUTCOME MEASURES: The presence of lung masses on the initial screening CT of the chest as determined by the radiologist's report. The development of lung metastases or primary bronchogenic carcinoma in any patient. RESULTS: Two hundred and thirty-nine patients met the inclusion criteria. 38 (16%) patients had a CT chest report for a lung malignancy (either metastatic or primary bronchogenic), 33 of these 38 (87%) patients actually had a lung malignancy. 32 (13%) patients had a CT chest report for a small nodule, three of these 32 (9%) patients were later diagnosed with a lung malignancy, all at a different site to the nodule. 169 (71%) patients had normal CT chest reports, of these 3 (2%) patients were later diagnosed with a lung malignancy. CONCLUSIONS: The CT chest is a useful screening tool but is not infallible. Small nodules should be taken seriously and monitored, but should not alter the initial decision as to the management of the patient.

The learning curve for endoscopic tympanoplasties: a single-institution experience, in Birmingham, UK.

OBJECTIVE: This study aimed to assess whether increasing operative experience results in better surgical outcomes in endoscopic middle-ear surgery. METHODS: A retrospective single-institution cohort study was performed. Patients underwent endoscopic tympanoplasty between May 2013 and April 2019 performed by the senior surgeon or a trainee surgeon under direct supervision from the senior surgeon. Following data collection, statistical analysis compared success rates between early (learning curve) surgical procedures and later (experienced) tympanoplasties. RESULTS: In total, 157 patients (86 male, 71 female), with a mean age of 41.6 years, were included. The patients were followed up for an average of 43.2 weeks. The overall primary closure rate was 90.0 per cent. CONCLUSION: This study demonstrates an early learning curve for endoscopic ear surgery that improves with surgical experience. Adoption of the endoscopic technique did not impair the success rates of tympanoplasty.

Blunt neck trauma at a level I trauma centre: six-year retrospective case note review.

BACKGROUND: Blunt neck trauma can cause serious morbidity and mortality rates of up to 40 per cent, but there is a paucity of literature on the topic. METHOD: A retrospective case note review was performed for all blunt neck trauma cases managed at the Queen Elizabeth Hospital Birmingham between 1st January 2011 and 31st December 2017. RESULTS: Seventeen cases were managed, with no mortality and limited morbidity. Most patients were male (70.6 per cent) and road traffic accidents were the most common cause of injury (41.2 per cent). The median age of patients was 40.6 years (range, 21.5-70.3 years). Multidetector computed tomography angiography of the neck was performed in 9 patients (52.9 per cent) with 'hot' reports made by on-duty radiology staff matching consultant reports in all but 1 case. Six patients underwent operative exploration yielding a negative exploration rate of 33.3 per cent. Imaging reports matched operative findings in 3 cases (60 per cent). CONCLUSION: Blunt neck trauma is uncommon but usually presents in polytrauma. Imaging has inaccuracies when compared with operative findings, regardless of radiological experience.

A case of hyperkalaemia associated with hypocalcaemia.

An 84-year-old woman presented with lethargy and anorexia. Although routine biochemistry demonstrated mild hyponatraemia, moderate hyperkalaemia and severe hypocalcaemia, the patient did not demonstrate the usual symptoms of hypocalcaemia. An electrocardiogram did not demonstrate evidence of hyperkalaemia or hypocalcaemia. Repeated biochemistry confirmed hyponatraemia but that was associated with hypokalaemia and normocalcaemia. Initial management involved correction of the hyponatraemia and hypokalaemia with appropriate intravenous fluids. If serum biochemistry demonstrates hyperkalaemia in association with hypocalcaemia, pseudohyperkalaemia and pseudohypocalcaemia caused by contamination with potassium ethylenediaminetetraacetic acid should always be considered. This can be confirmed by repeating biochemistry, but ensuring the serum gel tube is drawn first when taking multiple blood samples to avoid this contamination.

An autonomous surgical robot for drilling a cochleostomy: preliminary porcine trial.

OBJECTIVE: To produce an autonomous drilling robot capable of performing a bony cochleostomy whilst minimising the damage to the underlying cochlear endosteum. DESIGN: In this laboratory based study, a robotic drill was designed to measure the changes in force and torque experienced by the tool point during the drilling process. This information is used to predict the point of breakthrough and stop the drill prior to damaging the underlying endosteal membrane. SETTING: Aston University. PARTICIPANTS: Five porcine cochleas. MAIN OUTCOMES MEASURES: An assessment was made of whether a successful bony cochleostomy was performed, the integrity of endosteal membrane was then assessed. RESULTS: The autonomous surgical robotic drill successfully performed a bony cochleostomy and stopped without damaging the endosteal membrane in all five cases. CONCLUSIONS: The autonomous surgical robotic drill can perform a cochleostomy whilst minimising the trauma to the endosteal membrane. The system allows information about the state of the drilling process to be derived using force and torque data from the tool point. This information can be used to effectively predict drill breakthrough and implement a control strategy to minimise drill penetration beyond the far surface.

Endoscopic ear surgery: a hot topic?

OBJECTIVES: To summarise published research investigating maximal temperatures associated with endoscopes used in otology. Possible thermal issues surrounding the use of endoscopes in middle-ear surgery are discussed, and recommendations regarding the safest ways to use endoscopes in endoscopic ear surgery are made. METHODS: A non-systematic review of the relevant literature was conducted, with descriptive analysis and presentation of the results. RESULTS: There are currently no reports of any temperature-related deleterious effects in patients having undergone endoscopic ear surgery. There is debate regarding heat issues in endoscopic ear surgery, with a limited body of work documenting potential negative impacts of middle-ear heat exposure from endoscopes. The diameter of endoscope, type of light source used, distance from endoscope tip and duration of exposure are highlighted potential factors for high temperatures in endoscopic ear surgery. CONCLUSION: There is a trend towards endoscopes being used routinely in ear surgery. Simple practice points are recommended to minimise potential thermal risks.

endoscope-i: an innovation in mobile endoscopic technology transforming the delivery of patient care in otolaryngology.

INTRODUCTION: Digital and mobile device technology in healthcare is a growing market. The introduction of the endoscope-i, the world's first endoscopic mobile imaging system, allows the acquisition of high definition images of the ear, nose and throat (ENT). The system combines the e-i Pro camera app with a bespoke engineered endoscope-i adaptor which fits securely onto the iPhone or iPod touch. Endoscopic examination forms a salient aspect of the ENT work-up. The endoscope-i therefore provides a mobile and compact alternative to the existing bulky endoscopic systems currently in use which often restrict the clinician to the clinic setting. Areas covered: This article gives a detailed overview of the endoscope-i system together with its applications. A review and comparison of alternative devices on the market offering smartphone adapted endoscopic viewing systems is also presented. Expert commentary: The endoscope-i fulfils unmet needs by providing a compact, highly portable, simple to use endoscopic viewing system which is cost-effective and which makes use of smartphone technology most clinicians have in their pocket. The system allows real-time feedback to the patient and has the potential to transform the way that healthcare is delivered in ENT as well as having applications further afield.

Audiological outcome of stapes surgery for far advanced cochlear otosclerosis.

BACKGROUND: Patients with advanced otosclerosis can present with hearing thresholds eligible for cochlear implantation. This study sought to address whether stapes surgery in this patient group provides a clinically significant audiological benefit. OBJECTIVES: To assess pre- and post-operative hearing outcomes of patients with advanced otosclerosis, and to determine what proportion of these patients required further surgery including cochlear implantation. METHODS: Between 2002 and 2015, 252 patients underwent primary stapes surgery at our institution. Twenty-eight ears in 25 patients were deemed to have advanced otosclerosis, as defined by pure audiometry thresholds over 80 dB. The patients' records were analysed to determine audiological improvement following stapes surgery, and assess whether any further surgery was required. RESULTS: The audiological outcome for most patients who underwent primary stapes surgery was good. A minority of patients (7 per cent) required revision surgery. Patients who underwent cochlear implantation after stapes surgery (10 per cent) also demonstrated a good audiological outcome. CONCLUSION: Stapes surgery is a suitable treatment option for patients with advanced otosclerosis, and should be considered mandatory, before offering cochlear implantation, for those with a demonstrable conductive component to their hearing loss. A small group of patients get little benefit from surgery and subsequently a cochlear implant should be considered.

Management of nasal injuries by UK accident and emergency consultants: a questionnaire survey.

OBJECTIVES: To determine how nasal injuries are managed by accident and emergency (A&E) consultants and produce a management protocol if the survey indicated a need. METHOD: A postal survey of UK A&E consultants. RESULTS: The response rate was 59%. A great deal of variation was found between departments and clinicians regarding the training of junior A&E staff, the equipment available, the management strategies employed, and the reasons for referral to ENT or maxillofacial departments. CONCLUSIONS: This survey shows that many more nasal injuries could be managed within the A&E setting without referral to ENT or maxillofacial departments. A flow chart of the optimal management of nasal injuries in Accident and Emergency departments is presented.

Litigation trends and costs in otorhinolaryngology.

BACKGROUND: Litigation in surgery is increasing and liabilities are becoming unsustainable. This study aimed to analyse trends in claims, and identify areas for potential risk reduction, improved patient safety and a reduction in the number, and cost, of future claims. METHODS: Ten years of retrospective data on claims in otorhinolaryngology (2003-2013) were obtained from the National Health Service Litigation Authority via a Freedom of Information request. Data were re-entered into a spreadsheet and coded for analysis. RESULTS: A total of 1031 claims were identified; of these, 604 were successful and 427 were unsuccessful. Successful claims cost a total of £41 000 000 (mean, £68 000). The most common areas for successful claims were: failure or delay in diagnosis (137 cases), intra-operative problems (116 cases), failure or delay in treatment (66 cases), failure to warn - informed consent issue (54 cases), and inappropriate treatment (47 cases). CONCLUSION: Over half of the claims in ENT relate to the five most common areas of liability. Recent policy changes by the National Health Service Litigation Authority, over the level of information divulged, limits our learning from claims.

A comparison of the pharmacological and biochemical properties of substrate-selective monoamine oxidase inhibitors.

1. M&B 9302, E-250, NSD 2023, and Lilly 51641, substrate-selective inhibitors of monoamine oxidase (MAO), and two non-selective inhibitors of MAO (tranylcypromine and phenelzine) have been compared in the rat for activity in (i) inhibiting rat brain monoamine oxidase in vitro and in vivo using tyramine, 5-hydroxytryptamine (5-HT) and benzylamine as substrates; (ii) increasing brain levels of noradrenaline (NA) and 5-HT and (iii) antagonizing tetrabenazine-induced sedation.2. Concentrations of M&B 9302 and Lilly 51641 required to produce 50% inhibition of 5-HT oxidation by brain mitochondrial MAO were 1.4 x 10(-8)M and 2.5 x 10(-7)M respectively. Higher concentrations were required to inhibit tyramine oxidation whilst benzylamine oxidation was inhibited only at concentrations above 10(-5)M.3. E-250 showed the reverse substrate-selectivity in inhibiting the oxidation of benzylamine at concentrations below that required to inhibit the oxidation of 5-HT. NSD 2023 showed little substrate selectivity in vitro.4. Qualitatively similar results were obtained in vivo, except that NSD 2023 showed more marked substrate-selectivity.5. All the inhibitors except E-250 produced a dose-related rise in brain 5-HT levels. Only phenelzine and Lilly 51641 showed a linear relationship between NA levels and dose.6. All the drugs antagonized, in dose-related fashion, the effects of tetrabenazine in reducing locomotor activity. E-250 and NSD 2023 failed to restore locomotor activity to control levels whilst in high doses the other inhibitors, when given before tetrabenazine, produced a considerable increase in locomotor activity.7. Antagonism of tetrabenazine sedation appears to be correlated with (a) inhibition of the enzyme species that oxidize 5-HT and NA but not with inhibition of the enzyme species that oxidize benzylamine; (b) the rise in brain 5-HT levels rather than NA levels.

The mentor effect in student evaluation.

OBJECTIVE: To determine if faculty mentors rate their mentored students higher than do nonmentors, and to ascertain if gender is a factor. METHODS: All third-year students (n = 101) from academic years 1996-1998, who performed their obstetrics and gynecology clerkship at the Milton S. Hershey Medical Center in the Penn State Geisinger Health System and were evaluated by full-time faculty (n = 18), were included in the study (total observations = 545). Students were rated by faculty on an ordinal scale in five categories. Generalized estimating equation methodology was used to fit proportional odds models for ordinal data to assess whether there were statistically significant mentor or faculty/student gender effects. RESULTS: Student evaluations from mentors were more likely to have better scores than student evaluations from nonmentoring-faculty for all five categories (all P <.01). The odds ratios (OR) for the mentor effect ranged from 2.1 (95% confidence interval [CI] 1.4, 3.2) for fund of knowledge to 3.2 (95% CI [2.1, 4. 8]) for attitude. For problem-solving and technical skills, male faculty were more likely than female faculty to give male students better scores (problem-solving skills: odds ratio [OR] = 1.7, 95% CI [1.0, 2.7]; technical skills: OR = 2.2, 95% CI [1.1, 4.6]). Mentoring-faculty evaluations were not strongly correlated with the students' objective examination scores. CONCLUSION: Overall, mentors score their mentored students statistically higher than do nonmentors. Gender differences in evaluation, while present, are less consistent and smaller than the mentor effect.

Pelvic magnetic resonance imaging in the evaluation of uterine torsion.

BACKGROUND: Uterine torsion is defined as the rotation of more than 45 degrees around the long axis of the uterus. An uncommon but potentially fatal event, uterine torsion is rarely diagnosed until the time of surgery. With magnetic resonance imaging (MRI), however, an accurate diagnosis of uterine torsion may now be made preoperatively. CASE: We describe a patient with uterine torsion in whom the correct diagnosis was made prenatally with the use of MRI, by the demonstration of an X-shaped configuration of the upper vagina. CONCLUSION: Distinctive features suggestive of uterine torsion were demonstrated by MRI and enabled an accurate preoperative diagnosis. To our knowledge, this is the first reported case of uterine torsion diagnosed on MRI.

Central hemodynamic effects of recombinant human relaxin in the isolated, perfused rat heart model.

OBJECTIVE: To determine the cardiac effects of relaxin in the isolated, perfused rat heart model, and to see if pregnancy modifies the hormone's actions. METHODS: Hearts were excised from 18 female Sprague-Dawley rats (ten pregnant, eight nonpregnant) and attached to a Langendorff apparatus. Left ventricular systolic pressure, heart rate, and contractility were measured. Hearts were exposed serially to 0.5, 1.0, 2.0, 4.0, 8.0, and 16.0 ng/mL concentrations of recombinant human relaxin. RESULTS: Hearts from pregnant rats had lower heart rates than those from nonpregnant animals. Relaxin increased heart rate, left ventricular systolic pressure, and contractility in a dose-dependent fashion. Pregnancy did not modify this response. CONCLUSION: Recombinant human relaxin is a potent inotropic and chronotropic agent. The effects coupled with the physiologic increase of relaxin during human pregnancy indicate that relaxin may be involved in the cardiovascular changes of pregnancy.

Prenatal diagnosis and management of massive bilateral axillary cystic lymphangioma.

BACKGROUND: Fetal lymphangiomas can occur in many different anatomic locations, including the most commonly seen nuchal cystic hygroma. CASE: A fetus at 18 weeks' gestation was found to have a massive right axillary hygroma. The fetal karyotype was normal. Serial ultrasound examinations indicated progressive enlargement, but no hydrops. At 32 weeks' gestation, a left axillary hygroma was also diagnosed. The patient underwent cesarean delivery. CONCLUSION: Prenatal diagnosis of nuchal cystic hygromas has a high association with karyotypic abnormalities, hydrops, and fetal demise; however, this association may not apply to cystic lymphangiomas at other locations.