Primary Tumour Detection in Carcinoma of Unknown Primary with Transoral Robotic Surgery (TORS) Tongue Base Mucosectomy: A Meta-analysis.

BACKGROUND: Head and neck carcinoma of unknown primary (CUP) represents a challenging diagnostic process when standard work-up fails to identify the primary tumour site. The aim of this systematic review and meta-analysis was to evaluate the diagnostic utility and complication profile of transoral robotic surgery (TORS) tongue base mucosectomy (TBM) in the management of CUP. PATIENTS AND METHODS: An electronic database search was performed in the EMBASE, MEDLINE, PubMed and Cochrane databases. A meta-analysis of proportions was performed to obtain an estimate of the overall proportion for the detection and complication rates. RESULTS: Nine studies representing 235 patients with CUP who had TORS TBM were included in the final analysis. The overall pooled tumour detection rate was 66.2% [95% confidence interval (CI) 56.1-75.8]. The incidence of tumour detection in human papilloma virus (HPV)-positive cases (81.5%, 95% CI 60.8-96.4) was significantly higher than HPV-negative cases (2.3%, 95% CI 0.00-45.7). Weighted overall complication rate was 11.4% (95% CI 7.2-16.2). The majority were grade I or II (80%) according to the Clavien-Dindo classification. CONCLUSIONS: This meta-analysis suggests TORS to be safe and effective in localising the primary tumour site in patients with CUP. While the current data supports the use of TORS in patients who are HPV positive, larger numbers of HPV-negative cases are required to determine the true diagnostic effect with TORS before any valid conclusions can be inferred in this particular subgroup. Further research should focus on high quality prospective trials with stringent methodological work-up to minimise heterogeneity and allow for more accurate statistical analysis.

Correlation of maximal nasal septal deviation with deviation at the maxillary insertion.

PURPOSE: It is unclear if septal deviation at the insertion points to the nasal cavity is associated with the overall septal deviation. This study aimed to assess septal deviation at the cribriform plate (CP) and maxillary crest (MC) using CT scans and to see if there was any correlation with overall septal deviation. METHODS: All consecutive CT sinus scans between January 2020 and December 2021 were retrospectively reviewed. Patients were excluded if they had a history of head, nasal or facial trauma, or any previous nasal surgical procedure. Angles between the septum and MC and the septum and CP as well as maximal angle of septal deviation (MSD) were measured. RESULTS: A total of 70 scans were included in the final analysis. The mean MSD was 8.14°. The mean septal deviation was 0.89° at the CP and 2.02° at the MC. The correlation coefficient between the deviation at the CP and MSD was 0.025 and between the deviation at the MC and MSD was 0.321. CONCLUSION: Our data reveal a positive correlation between septal deviation at the floor of the nose and overall septal deviation; this was not observed at the septal deviation at the roof. This could be explained due to the inherent tilt in the cribriform plate or by earlier ossification and fixation of the septum during its development at its insertion to the roof, thereby allowing further growth and potential for deviation of the lower part of the septum and its insertion to the floor.

Cross-sectional analysis of hospital tasks handed over to general practitioners: workload delegation or dumping?

PURPOSE OF THE STUDY: New requirements for hospital clinicians to follow up and act on hospital-initiated investigations were introduced in 2016 in the National Health Service standard contract. We aimed to evaluate the tasks handed over from hospital clinicians to general practitioners (GPs). STUDY DESIGN: A retrospective observation of all tasks in a random sample of electronic discharge summaries at a university teaching hospital over a 1 month period was conducted. A single-best-answer questionnaire was circulated among hospital clinicians over 3 months to gain an understanding of their follow-up and referral practices. RESULTS: The total number of tasks found on discharge summaries (n=178) were 227, of which 39% were directed at GPs and 61% at the hospital team. Of 89 tasks delegated to GPs, 33% were inappropriate. Some tasks on discharge summaries were delegated more frequently to GPs such as blood tests (73%) and endoscopy requests (67%). While others were undertaken more often by hospitals clinicians including imaging requests (88%), follow-up appointments (87%) and onward referrals (71%). Surveyed doctors (n=72) admitted to asking GPs to follow up blood tests (52%), imaging and endoscopy (16%) and make onward referrals for related conditions (14%) and unrelated conditions (70%). CONCLUSION: The majority of outstanding tasks in the hospital setting were followed up by hospital clinicians. A considerable volume of tasks were delegated to GPs, of which a significant proportion were inappropriate. An increase in awareness and understanding among hospital clinicians of their responsibility to follow up hospital-initiated investigations is needed.

Increasing Medical Students' Confidence in Procedural Skills Using a Junior Doctor-Delivered Bedside Supervision Program.

PROBLEM: Clinical procedural skills are formally taught to medical students in clinical skills centers using mannequins. Exposure to procedural skills involving patients and opportunities to practice under the supervision of doctors are limited. INTERVENTION: A bedside supervision program was piloted at a district general hospital in the United Kingdom. The supervision model was chosen as the method to increase medical students' practice in basic procedural skills because it allowed safe practice with patients. CONTEXT: The program was an optional component of the medical students' clinical clerkships. Off-duty junior doctors were recruited as voluntary trainers. The trainers obtained requests for procedural tasks from the on-call doctors and ward nurses, following which the trainers supervised medical students performing the basic procedures with patient consent. OUTCOME: The pilot program was successfully run for 4 weeks. Fourteen students took part, and 9 (64%) completed a postintervention feedback questionnaire. The students' confidence (rating scale = 1-5) in performing procedural skills improved from a mean of 3.0 (SD ± 0.9) to 4.7 (SD ± 0.5) following a supervision session. Although the range of skills was limited to opportunistic encounters, the students reported high satisfaction and felt supervision enabled them to identify areas for improvement. LESSONS LEARNED: It is feasible to implement a junior doctor-delivered bedside program to supplement procedural skills training provided by medical schools. The challenges include reconciling the tension between junior doctors' service work and their teaching commitment, logistical issues such as recruiting a sufficient number of trainers and ensuring adequate coverage of training tasks.

Development, evaluation, and delivery of an innovative national undergraduate surgical workshop: recognition and management of the acutely unwell surgical patient.

PROBLEM: Recognition and management of acutely unwell surgical patients is an important skill to which medical students have little exposure. INTERVENTION: We present the evaluation of a novel national surgical workshop that consisted of high-fidelity simulations, lectures, case demonstrations, case discussions, and a basic surgical skills tutorial. The high-fidelity simulations re-created genuine patient encounters and were used to facilitate the acquisition of knowledge and skill in the early recognition and management of acutely unwell surgical patients. CONTEXT: The optional workshop was designed for senior medical students and delivered by surgical trainees. Students were asked to complete a 12-item evaluation questionnaire and a 26-item multiple-choice question (MCQ) quiz, which assessed their confidence; self-perceived competence; and knowledge prior to, immediately following, and 8 weeks after the workshop. Pre- and postdata were compared using student's two-tailed t test. OUTCOME: A total of 66 medical students from 6 UK universities attended, the majority of whom enjoyed the workshop (98.3%, n = 59). Participants' confidence rating (scale = 1-5) in assessing an unwell surgical patient improved from a mean of 2.5 (n = 47) to 4.4 (n = 60). Confidence in commencing initial management improved from a mean of 2.7 (n = 47) to 4.1 (n = 59). Confidence and self-perceived competence across 12 domains improved significantly following the workshop, two-tailed unpaired t test, t(22) = 8.64, p <.0001, d = 3.68. MCQ scores immediately following the workshop were a statistically significant improvement on the preworkshop MCQ scores (n = 44), paired two-tailed t test, t(43) = 7.76, p <.0001, d = 2.37, and the improvement was sustained 8 weeks following the workshop (n = 18), paired two-tailed t test, t(17) = 3.34, p =.0039, d = 1.62. LESSONS LEARNED: Feedback from students was very positive and clearly demonstrated that a workshop taught by surgical trainees improved medical students' confidence, self-perceived competence, and knowledge in the assessment and management of acutely unwell surgical patients.

Blood, Sweat, and Tonsils: Bleeding After Abscess Tonsillectomy for Quinsy-A Meta-Analysis.

OBJECTIVE: Abscess tonsillectomy is performed during an active episode of quinsy. Apprehensions regarding an elevated bleeding risk have hindered its widespread acceptance. This study aims to assess the prevalence of post-tonsillectomy bleeding (PTB) associated with abscess tonsillectomy. DATA SOURCES: A search was performed on August 27, 2023 in Medline, Embase, PubMed, Cochrane CENTRAL, and Web of Science databases. REVIEW METHODS: The systematic review was conducted in adherence to the PRISMA guidelines. Pooled PTB rate was determined using a meta-analysis of proportions. The JBI tool was used to assess the quality of the included studies. RESULTS: Of the 525 search records, 18 studies met the eligibility criteria for final analysis. These comprised of retrospective single-center analyses. The pooled prevalence of PTB was 6.65% (95% C.I. 4.01-9.81), and the return-to-theatre rate was 2.35% (95% C.I. 1.48-3.37). There was no difference in PTB rate between unilateral and bilateral tonsillectomy. However, the bipolar technique was associated with a higher PTB rate compared to cold steel dissection. The overall quality of the body of evidence was moderate. CONCLUSION: Our study highlights the complications associated with abscess tonsillectomy. These findings contribute valuable insights into this potential treatment option for quinsy. LEVEL OF EVIDENCE: N/A Laryngoscope, 2024.

Incidence of Vestibular Schwannoma in Patients with Unilateral Tinnitus: A Systematic Review and Meta-Analysis.

OBJECTIVES: Vestibular schwannoma (VS) is a tumor of the vestibulocochlear nerve. Current literature indicates that 1.6% of patients undergoing magnetic resonance imaging of the internal auditory meatus (MRI IAM) for audiovestibular symptoms are diagnosed with a VS. However, there is limited research reporting on patients who present with unilateral tinnitus without asymmetrical hearing loss. This study is a systematic review and meta-analysis evaluating how many of those patients had a VS diagnosed on MRI IAM. DATABASES USED: Online searches of PubMed, Medline, and Embase databases were performed up to October 2022. METHODS: This meta-analysis was undertaken aligning with PRISMA guidelines. Articles reporting on patients having MRI IAM for unilateral tinnitus without asymmetrical hearing loss were included. Outcomes measures were patient demographics, VS cases, incidental findings, size, and management of tumor. A meta-analysis of proportions was performed using a random-effects model with the restricted maximum likelihood method. Quality assessment was performed using the Joanna Briggs Institute critical appraisal checklist. RESULTS: Seven case series were included in the review: a total of 1,394 patients. Seven patients had a VS, with a median size of 4 mm. The pooled detection rate for VS was 0.08% (95% confidence interval = 0.00-0.45). Subsequent management was reported in six cases of which four were actively monitored and two surgically excised. The most common incidental finding was sinus disease (49 patients). CONCLUSION: Our findings indicate that MRI IAM has a low diagnostic yield for VS detection in patients presenting with unilateral tinnitus without asymmetrical hearing loss, with mostly small tumors that are conservatively managed.

The Prevalence of Incidental Mastoid Opacification and the Need for Intervention: A Meta-Analysis.

OBJECTIVES/HYPOTHESIS: The increasing use of cross-sectional imaging has led to the predicament of incidental mastoid opacification (IMO). We investigated the prevalence of IMO and the clinical need for ENT assessment or intervention when identified. STUDY DESIGN: Systematic review and meta-analysis. METHODS: The PRISMA statement standards were used to search electronic databases including Medline, Embase, PubMed, and Web of Science. The selection criteria were mastoid opacification found on computed tomography (CT) or magnetic resonance imaging (MRI) as incidental findings. RESULTS: A total of 16 studies were identified for qualitative analysis and 15 for quantitative analysis, mainly retrospective. The pooled prevalence of IMO in 246,288 patients was 8.4% (95% CI 5.5-12.0). The prevalence of IMO was significantly higher in studies with children (17.2%, 95% CI 10.9-24.6) than those with adults (6.1%, 95% CI 3.3-9.6); smaller sample size studies (12.4%, 95% CI 8.1-17.3) compared to larger sample size studies (4.1%, 95% CI 1.5-7.8); and when IMO was detected by viewing images (14.5%, 95% CI 9.9-19.8) compared to reading reports (3.5%, 95% CI 1.3-6.6). Imaging modality was not a significant moderator due to similar IMO rate on CT (8.6%, 95% CI 1.8-19.7) and MRI (10.4%, 95% CI 4.9-17.6). Nine studies reported on clinical outcomes of patients with IMO, and none reliably reported any cases of clinical mastoiditis. CONCLUSIONS: The term "mastoiditis" on radiology reports based on IMO does not indicate a clinical diagnosis of mastoiditis, although the current body of evidence is limited. Otolaryngology review is suggested if clinical correlation detects otological signs or symptoms. LEVEL OF EVIDENCE: NA Laryngoscope, 132:422-432, 2022.

Telephone Consultation in Otorhinolaryngology During the Coronavirus Disease 2019 Pandemic: a Cross-sectional Analysis of Effectiveness and Satisfaction for Patients and Clinicians.

The COVID-19 pandemic has necessitated measures to minimise face-to-face interaction. We assessed the efficacy of teleconsultation and patient satisfaction in adult otorhinolaryngology clinic. A prospective review of telephone consultations over 6 months in a single district general hospital was conducted. Data was collected on the characteristics and outcomes of teleconsultations by clinicians, and a questionnaire was sent to patients. Of 304 telephone consultations, 115 were new and 189 were follow-up. Five percent of patients were listed for surgery. The discharge rate was 31%, largely comprising of patients with otorhinolaryngological symptoms. High clinician and patient satisfaction were reported by 90% and 96%, respectively. Telephone consultation was a good one-stop treat and discharge service for a number of otorhinolaryngological complaints such as hearing loss, tinnitus and recurrent tonsillitis. Patient and clinician satisfaction was high. Careful triaging of referrals for telephone consultation can potentially reduce the number of face-to-face clinic appointments.

Surgical Implications of Superior Thyroid Cornu Agenesis in Laryngeal Malignancy.

The most commonly reported superior thyroid cornu (STC) anatomical variation is in STC syndrome, where the cornu is enlarged or medially displaced. STC agenesis is a rare laryngeal variation that can be unilateral or bilateral. Previous studies have reported STC agenesis in cadaveric or forensic studies in patients with an otherwise normal larynx. We report a case of unilateral STC agenesis in the context of a stage III glottic laryngeal squamous cell carcinoma. The variation was discovered intra-operatively during a total laryngectomy and was clinically unknown beforehand. There were no clinical or histological signs of bony erosion by the tumor. To our knowledge, this is the first report of unilateral STC agenesis in a patient with laryngeal malignancy. This article draws attention to a rare anatomical variant of the larynx and highlights the surgical implications including potential diagnostic challenges and operative considerations.

Recognition and Management of Button Battery Ingestion Amongst Emergency Practitioners.

Introduction Button battery ingestion (BBI) carries a significant risk of morbidity and mortality. We conducted a regional analysis following an NHS England national patient safety alert to evaluate the knowledge base in the emergency management of BBI amongst emergency practitioners. Methods A ten-point questionnaire was distributed electronically and in hardcopy formats to emergency departments across 15 hospitals within the West Midlands, United Kingdom. The questionnaire assessed participants' knowledge of emergency management of BBI. The effect of clinician grade and previous otorhinolaryngology experience on knowledge scores was evaluated. Results A total of 176 responses were received from 11 hospitals. A small proportion (18%) were aware of a local department protocol. The majority of participants (70%) routinely screened for a button battery in their history taking. Our findings highlighted a lack of awareness of the timeframe for mucosal injury, potential complications, radiological signs, and the necessity for immediate retrieval. The median knowledge score was 18.8% (IQR=12.5-31.3%). Both registrars and consultants scored the highest (median 25%). Previous otorhinolaryngology experience was associated with a higher median score (P=0.002). Conclusion Our multi-center regional emergency medicine analysis demonstrated knowledge deficiency in the initial assessment and management of BBI. A high index of suspicion for button battery ingestion is needed. In view of the time-critical nature of button battery impaction in the esophagus, a "golden hour" concept should be integrated into acute management pathways with the early involvement of otorhinolaryngologists.

A Systematic Review of Antibiotic Prescription for Acute Otitis Externa.

BACKGROUND: There is a perception among ear, nose, and throat (ENT) surgeons that oral antibiotics are over-prescribed for acute otitis externa (AOE), and the potential for topical therapy as first-line treatment is not fully realized in primary care. We evaluated the prescription rate of topical and oral antibiotics for AOE in primary care and in patients referred to the ENT emergency clinic. METHODS:  A systematic review was performed by searching the MEDLINE, Embase, PubMed, and Google Scholar databases between January 1990 and October 2020. The quality of the evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) tool. The outcome measures were the rate of topical and oral antibiotic prescriptions for AOE by primary care practitioners and the rate of oral antibiotic prescriptions that were not indicated. RESULTS: Seven studies met the inclusion criteria. The overall quality of evidence was moderate. The rate of topical antibiotic prescriptions was between 77% and 95%, and oral antibiotics varied between 6% and 30% in patients that were managed only in primary care. Patients that were referred to an ENT emergency clinic had initially been treated by primary care practitioners with topical antibiotics in 14%-60% of cases and oral antibiotics in 16%-17%. The most commonly prescribed oral antibiotics were Amoxicillin and Co-amoxiclav (amoxicillin/clavulanic acid). No study had comprehensively reviewed the indication for oral antibiotics. CONCLUSION: The rate of topical antibiotic prescriptions for AOE was high in primary care; however, the rate was frequently suboptimal in patients attending the ENT emergency clinic. Although the rate of oral antibiotic prescriptions was relatively low, the choice of antibiotic for empirical treatment frequently did not cover the typical bacteria in AOE. There is a need for improvement in primary care prescribing of topical therapy prior to referral to the ENT emergency clinic.

Development of a proforma to improve quality of handover of surgical patients at the weekend.

RATIONALE, AIMS, AND OBJECTIVES: The introduction of shift pattern of working in the medical profession has led to an increase in reliance on effective handover of patient information. We evaluated the use of a weekend handover proforma in General Surgical patients at a University Teaching Hospital. METHODS: A standardized weekend handover proforma was implemented. A pre-post survey of medical staff and prospective observational study on the use of the proforma was carried out. The impact of three strategies to reinforce change in clinical practice was investigated at random time-points. These were (1) presentation at a clinical governance meeting; (2) email; and (3) induction training on handover combined with one-to-one interactive training. The two outcome measures were compliance with the proforma, and "handover score," which was the amount of data transferred per patient. RESULTS: The survey highlighted inadequate provision for handover at the weekend. National guidelines were used to design the weekend handover proforma. There was 70% compliance with the new standardized proforma with a median handover score of 83% (IQR = 0-100). The results were presented at a clinical governance meeting, and the proforma was refined. After this change, the proforma was used in 71% of patients, and the median score was 65% (IQR = 0-80, P = 0.0516). Compliance after an email reminder was 69%, and median handover score was 80% (IQR = 0-90, P = 0.1037). After induction training, there was a significant improvement in proforma compliance (94%) and median score (90%, IQR = 80-90, P = 0.013). CONCLUSION: Effective transfer of handover information can be achieved over the weekend with the use of a standardized proforma. Use of the proforma was greatest after providing junior doctors with didactic training on handover combined with interactive guidance on completing the proforma.

Impacted denture in the oesophagus: review of the literature and its management.

Foreign body impaction in the oesophagus is a common cause of acute dysphagia. Oesophageal impaction of sharp objects such as dentures can be life threatening due to the risk of oesophageal perforation. This condition requires urgent treatment, and therefore prompt diagnosis and management is vital to avoid complications. Diagnosing oesophageal foreign body can be challenging due to its poor localising symptoms. We describe a case of an impacted denture in which considerable delays to treatment were encountered, and discuss the pitfalls and lessons learnt. This case and review of the literature draw attention to clinical assessment, investigation and treatment options for oesophageal foreign body impaction.

Postoperative hemiparesis following tonsillectomy.

We report a rare complication following a routine elective tonsillectomy. A 32-year-old woman woke up from general anaesthesia with left sided hemiparesis. She underwent extensive investigations, which were normal. At follow-up neurology clinic she was given a new diagnosis of hemiplegic migraine and commenced on treatment. This case draws attention to a rare cause of postoperative hemiparesis. Hemiplegic migraine is a differential diagnosis for postoperative motor deficit after exclusion of an acute neurological or metabolic event.

A rare case of extensive cranial Langerhans cell histiocytosis, synchronously presenting as otitis externa and giant cell arteritis.

Langerhans cell histiocytosis (LCH) is a rare histiocytic disorder of unpredictable clinical course and varied modes of presentation. The spectrum of presentation is wide, ranging from isolated eosinophilic granulomas to multiple lesions and diffuse systemic involvement. We present the case of a 52-year-old man, who presented with an 8-week history of worsening otalgia and superficial temporal tenderness attributed to otitis externa within the community and subsequently giant cell arteritis. Computed tomography and magnetic resonance imaging were undertaken due to atypical features, which demonstrated bony destruction within the right greater wing of the sphenoid, squamous part of temporal and mastoid bone, with middle cranial fossa communication. Intra-orbital extension was noted with abutment of the lateral rectus muscle. Mastoid biopsies demonstrated a mixture of lymphocytes, eosinophils and monomorphic epithelial cells with pale cytoplasm and focal areas of granulation tissue/necrosis. The features were consistent with a diagnosis of LCH, and the patient was subsequently transferred to a tertiary centre for definitive treatment.

Clinical need-directed blood tests: a step in saving the NHS?

BACKGROUND: Unnecessary blood tests are estimated to contribute to 25% of wastage in the National Health Service. The aim of this study was to assess the financial implication of clinical need-focused blood tests guided by a senior clinician in a district general hospital. METHODS: We conducted an observational longitudinal study over six months with pre- and postanalysis of a vetting intervention. A colorectal firm (Team A) implemented a vetting system that required a registrar or consultant to discuss which blood tests needed to be requested for each in-patient with junior doctors. Another colorectal firm (Team B) with a similar caseload was blinded to the study and was used as a control. RESULTS: The vetting initiative demonstrated a reduction of 33% of blood test requests, translating to a cost-saving of £2406 over three months. Following the intervention, the median number of tests requested per patient per day by Team A for C-reactive protein reduced from 0.8 to 0.63 (P = 0.0074), full blood counts reduced from 0.8 to 0.67 (P = 0.0138), liver function tests decreased from 0.8 to 0.6 (P = 0.0021) and urea and electrolytes fell from 0.8 to 0.63 (P = 0.0083). The number of tests per patient per day after the intervention was significantly less than the control group (P < 0.001). The length of hospital stay and admission to critical care were not adversely affected in the group that had less blood tests, P = 0.808 and P = 0.58, respectively. CONCLUSION: The direction, by a senior clinician, of the requesting of blood tests by junior doctors to ensure that requests were based on clinical need, reduced the number of inappropriate blood tests and resulted in some reduction in laboratory costs.

Follow-up care after grommet insertion in children: Review article.

BACKGROUND: Grommet insertion is a common procedure in children. A lengthy otolaryngology follow-up can have an adverse impact on clinic waiting times, new patient appointment availability, and pecuniary disadvantage for the hospital. OBJECTIVE OF REVIEW: To consolidate research and opinion concerning follow-up care following grommet insertion in a pediatric population. SEARCH STRATEGY: The literature between January 1990 and September 2015 was searched on MEDLINE (Ovid), Google Scholar, PubMed and Web of Science databases. RESULTS: Guidelines and consensus of opinion from the United States advocate that an initial post-operative review should take place within 4 weeks, and subsequent appointments every 6 months until grommet extrusion. Recent audit reports from the United Kingdom have shown that some groups arrange their first post-operative review at 3 months, and subsequent appointments vary considerably from no further follow-up to up to 24 months. Up to 75% of follow-up appointments were scheduled despite normal audiometry and clinical findings after grommet insertion, suggesting a large cohort of patients may undergo unnecessary specialist clinic reviews. General practioners (GP), audiologists or specialist nurses are potential alternative providers of regular reviews to ensure normal hearing thresholds and an adequate tympanic membrane healing course. CONCLUSION: Follow-up schedules are largely driven by consensus of opinion. A significant number of follow-up appointments in otolaryngology clinic appear to be redundant. Recently attention has been drawn to earlier discharge from otolaryngology clinic with subsequent follow-up in less resource and cost intensive clinics coordinated by GPs, audiologist or nurses, which may help alleviate some outpatient workload on acute hospital trusts.