Aetiology and management options for secondary referred otalgia: a systematic review and meta-analyses.

OBJECTIVES OF REVIEW: To review the literature for the evidence base for the aetiology and management of referred otalgia, looking particularly at non-malignant, neuralgic, structural and functional issues. TYPE OF REVIEW: Systematic review. SEARCH STRATEGY: A systematic literature search was undertaken from the databases of EMBASE, CINAHL, MEDLINE®, BNI, and Cochrane Library according to predefined inclusion and exclusion criteria. EVALUATION METHOD: All relevant titles, abstracts and full text articles were reviewed by three authors who resolved any differences by discussion and consultation with senior author. RESULTS: 44 articles were included in our review. The overall quality of evidence was low, with the vast majority of the studies being case-series with three cohort and four randomised-controlled trials included. The prime causes and management strategies were focussed on temporomandibular joint dysfunction (TMJD), Eagle syndrome and neuralgia. Our meta-analyses found no difference on the management strategies for the interventions found. CONCLUSIONS: Referred otalgia is common and treatment should be aimed at the underlying pathology. Potential aetiologies are vast given the extensive sensory innervation of the ear. An understanding of this and a structured approach to patient assessment is important for optimal patient management.

A narrative review of the management of pars flaccida tympanic membrane retractions without cholesteatoma.

OBJECTIVE: Review the effectiveness of surgical and non-surgical management strategies for isolated pars flaccida and combined pars tensa and flaccida tympanic membrane retractions in preventing progression or recurrence, improving hearing and preventing development of cholesteatoma. DESIGN: Narrative review. SETTING: ENT and otology services worldwide. PARTICIPANTS: Patients with non-cholesteatoma tympanic membrane retractions. MAIN OUCTOME MEASURE: Changes in retraction (progression or resolution, or development of a known sequela such as perforation). RESULTS: Eight full text papers are included: three randomised controlled trials and five case series or cohort studies of more than five patients (a total of 238 ears). Data exists for the use of conservative management, ventilation tubes, laser tympanoplasty, cartilage and fascia tympanoplasty, lateral attic reconstruction as well as mastoid procedures. CONCLUSION: Few high-quality studies on the management of isolated and combined pars flaccida retractions exist. For isolated pars flaccida retractions deemed to require surgical intervention, this review suggests that lateral attic reconstruction and cartilage tympanoplasty carries least risk of recurrence.

How we do it: the intra-operative identification of a pharyngocele.

A pharyngocele is an uncommon condition, where pharyngeal mucosa herniates through the thyrohyoid membrane. It can be difficult to locate when the patient is at rest. To locate the pharyngocele intra-operatively, a bag valve mask was used to inflate the herniated mucosa. We describe a cost-effective and simple way to locate the pharyngocele intra-operatively.

Bilateral vocal fold paresis: the only presenting sign of anti-MUSK antibody myasthenia gravis.

A previously fit and well 53-year-old man was referred to the otolaryngology clinic with intermittent stridor and was found to have bilateral vocal fold paresis. Subsequent airway compromise necessitated emergency surgical tracheostomy. The man was discharged home with tracheostomy in situ and a diagnosis of idiopathic bilateral vocal cord palsy, as all primary investigations were negative. Neurological disease was suspected following readmission to hospital several weeks later with diplopia. Electromyography and serum antibody testing confirmed a diagnosis of anti-muscle-specific tyrosine kinase antibody positive myasthenia gravis (MuSK-MG); a subset of MG where autoantibodies are directed against MuSK. Resolution of bilateral vocal fold paresis was found 8 months after a short course of immunoglobulin (intravenous immunoglobulin (IVIg)) and daily mycophenolate therapy was commenced. Multidisciplinary teamwork between ear, nose and throat surgeons, neurologists and speech therapists enabled successful decannulation of tracheostomy. The patient has recovered well and remains minimally symptomatic.

VITOM 4K 3D Exoscope: A Preliminary Experience in Thyroid Surgery.

Since its introduction in 2008, the Karl Storz 4K 3D VITOM® exoscope (Karl Storz SE & Co. KG, Tuttlingen, Germany) has been successfully used in various surgical disciplines. This paper describes our department's experience using this technology and its use in the first total thyroidectomy case. The set up of the 3D VITOM exoscope in the operating theatre allows for a user-friendly approach to thyroid surgery with the exoscope placed out of the line of sight of the surgeon with a monitor placed directly ahead. The surgeon has a control panel within reach, which allows for adjustments to image magnification and focus. The use of the 3D VITOM exoscope has the potential to confer significant improvements in patient outcomes by promoting efficient and safer surgery through superior operative visualisation.

Elective ENT surgery during the COVID-19 pandemic: Experience from a single UK centre.

AIM: To analyse the outcomes of patients who underwent elective ENT surgery during the first peak of the COVID-19 pandemic in a COVID free site. METHODS: This is a retrospective single centre case series of all patients undergoing elective ENT surgery over a 16-week period between 1 April and 22 July 2020. RESULTS: No patients, out of our cohort of 85, developed postoperative COVID-19 symptoms or complications of COVID-19. There were no mortalities. CONCLUSION: The results suggests that hospitals can safely manage elective ENT operating services during the pandemic.

A limited thoracocervical approach for accessing the anterior mediastinum in retrosternal goiters: Surgical technique and implications for the management of head and neck emergencies.

In this article we describe the surgical management of retrosternal goiters via a limited thoracocervical approach, and we explore how the respective surgical know-how can be used in the management of the carotid blowout syndrome. Four cases involving patients who had undergone thyroidectomy via a limited thoracocervical approach are retrospectively reviewed. An acute blowout of the innominate artery managed with the same principal surgical technique is also reviewed. Three patients had a total thyroidectomy and one had a hemithyroidectomy. No malignancy was found. There was no mortality or unexpected morbidity from the limited thoracocervical approach. The median length of the inpatient stay was 3 days. The blowout survivor lived for 9 months, with no rebleeding and with an acceptable quality of life. We conclude that a limited thoracocervical approach can be safely performed by head and neck surgeons for accessing the anterior mediastinum in retrosternal goiters, and the respective surgical know-how can be used in the immediate management of an acute carotid blowout syndrome with satisfying long-term results and provision of quality end-of-life care.

Assessing day-case septorhinoplasty: prospective audit study using patient-based indices.

The objective of this study was to evaluate the safety, efficacy and acceptability to patients of day-case septorhinoplasty. Twenty-nine patients undergoing elective septorhinoplasty in a dedicated teaching hospital day-case unit were asked to complete day surgery questionnaires (DSQ) at six weeks post-operatively. Details of surgery performed, demographic data, readmission rates and complications were collected prospectively. No major complications were recorded. One patient had to be admitted for overnight observation following post-operative bleeding. The DSQ showed that the great majority of patients were satisfied from the day-case setting (satisfaction score 81). This preliminary study showed that day surgery septorhinoplasty was acceptable to the patient and was associated with a very low re-admission rate. We believe that in carefully selected young healthy patients it is an acceptable alternative to an in-patient procedure.

Extramedullary plasmacytoma of the true vocal fold.

We report a rare case of extramedullary plasmacytoma (EMP) of the true vocal fold. Our patient, a 62-year-old woman, presented with dysphonia. On workup, fiberoptic laryngoscopy detected a lesion arising from the anterior half of her left true vocal fold. No evidence of other pathology was noted. The patient underwent radical radiotherapy, and the lesion resolved. Follow-up revealed no sign of recurrence. A type of myeloma, EMP is rare, especially in the larynx. To the best of our knowledge, our patient represents the sixth case of glottic EMP to be reported in the literature.

Diagnostic challenges and safety considerations in cochlear implantation under the age of 12 months.

AIM: To review the current knowledge on cochlear implantation in infancy, regarding diagnostic, surgical and anesthetic challenges. STUDY-DESIGN: Meta-analysis. EBM level: II. MATERIALS/METHODS: Literature-review from Medline and database sources. Related books were also included. STUDY SELECTION: Meta-analyses, prospective controlled studies, prospective/retrospective cohort studies, guidelines, review articles. DATA SYNTHESIS: The diagnosis of profound hearing loss in infancy, although challenging, can be confirmed with acceptable certainty when objective measures (ABR, ASSR, OAEs) and behavioural assessments are combined in experienced centres. Reliable assessment of the prelexical domains of infant development is also important and feasible using appropriate evaluation techniques. Overall, 125 implanted infants were identified in the present meta-analysis; no major anesthetic complication was reported. The rate of surgical complications was found to be 8.8% (3.2% major complications) quite similar to the respective percentages in older implanted children (major complications ranging from 2.3% to 4.1%). CONCLUSION: Assessment of hearing in infancy is feasible with adequate reliability. If parental expectations are realistic and hearing aid trial unsuccessful, cochlear implantation can be performed in otherwise healthy infants, provided that the attending pediatric anesthesiologist is considerably experienced and appropriate facilities of pediatric perioperative care are readily available. A number of concerns, with regard to anatomic constraints, existing co-morbidities or additional disorders, tuning difficulties, and special phases of the developing child should be also taken into account. The present meta-analysis did not find an increased rate of anesthetic or surgical complications in infant implantees, although long-term follow-up and large numbers are lacking.

Cochlear implantation under the first year of age--the outcomes. A critical systematic review and meta-analysis.

OBJECTIVE: To review the current knowledge on cochlear implantation in infancy, regarding auditory perception/speech production outcomes. STUDY-DESIGN: Meta-analysis. EBM level: II. METHODS: Literature-review from Medline and database sources. Related books were also included. RESULTS: The number of cohort-studies comparing implanted infants with under 2-year-old children was five; three represented type-III and two type-II evidence. No study was supported by type I evidence. Overall, 125 implanted infants were identified. Precise follow-up period was reported in 82. Median follow-up duration ranged between 6 and 12 months; only 17 children had follow-up duration equal or longer than 2 years. Reliable outcome measures were reported for 42 infants; 15 had been assessed with open/closed-set testing, 14 with developmental rating scales, and 13 with prelexical speech discrimination tools. Ten implanted infants assessed with open/closed-set measures had been compared with under 2-year-old implanted children; 4 had shown better performance, despite the accelerated rate of improvement after the first postoperative year. CONCLUSION: Neuroplasticity/neurolinguistic issues have led cochlear implant centers to implant deaf children in infancy; however, widespread policies regarding the aforementioned issue are still not justified. Evidence of these children's outperformance regarding auditory perception/speech production outcomes is limited. Wide-range comparisons between infant implantees and under 2-year-old implanted children are lacking. Longer-term follow-up outcomes should be also made available. There is a need to develop and validate robust measures of monitoring implanted infants. Potential factors of suboptimal outcomes (e.g. misdiagnosis, additional disorders, device tuning, parental expectations) should also be weighted, when considering cochlear implantation in infancy.