A large case series of temporal bone fractures at a UK major trauma centre with an evidence-based management protocol.

OBJECTIVE: To review the management of temporal bone fractures at a major trauma centre and introduce an evidence-based protocol. METHODS: A review of reports of head computed tomography performed for trauma from January 2012 to July 2018 was conducted. Recorded data fields included: mode of trauma, patient age, associated intracranial injury, mortality, temporal bone fracture pattern, symptoms and intervention. RESULTS: Of 815 temporal bone fracture cases, records for 165 patients met the inclusion criteria; detailed analysis was performed on the records of these patients. CONCLUSION: Temporal bone fractures represent high-energy trauma. Initial management focuses on stabilisation of the patient and treatment of associated intracranial injury. Acute ENT intervention is directed towards the management of facial palsy and cerebrospinal fluid leak, and often requires multidisciplinary team input. The role of nerve conduction assessment for immediate facial palsy is variable across the UK. The administration of high-dose steroids in patients with temporal bone fracture and intracranial injury is not advised. A robust evidence-based approach is introduced for the management of significant ENT complications associated with temporal bone fractures.

Computed tomography versus magnetic resonance imaging in paediatric cochlear implant assessment: a pilot study and our experience at Great Ormond Street Hospital.

BACKGROUND: To date, there is a lack of consensus regarding the use of both computed tomography and magnetic resonance imaging in the pre-operative assessment of cochlear implant candidates. METHODS: Twenty-five patients underwent high-resolution computed tomography and magnetic resonance imaging. 'Control scores' describing the expected visualisation of specific features by computed tomography and magnetic resonance imaging were established. An independent radiological review of all computed tomography and magnetic resonance imaging scan features was then compared to the control scores and the findings recorded. RESULTS: Agreement with control scores occurred in 83 per cent (20 out of 24) of computed tomography scans and 91 per cent (21 out of 23) of magnetic resonance imaging scans. Radiological abnormalities were demonstrated in 16 per cent of brain scans and 18 per cent of temporal bone investigations. CONCLUSION: Assessment in the paediatric setting constitutes a special situation given the likelihood of congenital temporal bone abnormalities and associated co-morbidities that may be relevant to surgery and prognosis following cochlear implantation. Both computed tomography and magnetic resonance imaging contribute valuable information and remain necessary in paediatric cochlear implant pre-operative assessment.

Impact of the method and success of pharyngeal reconstruction on the outcome of treating laryngeal and hypopharyngeal cancers with pharyngolaryngectomy: A national analysis.

BACKGROUND: Surgical treatment of cancers that arise from or invade the hypopharynx presents major reconstructive challenges. Reconstructive failure exposes the airway and neck vessels to digestive contents. METHODS: We performed a national N = near-all analysis of the administrative dataset to identify pharyngolaryngectomies in England between 2002 and 2012. Information about morbidity, pharyngeal closure method and post-operative complications was derived. RESULTS: There were 1589 predominantly male (78%) patients whose mean age at surgery was 62 years. The commonest morbidities were hypertension (24%) and ischemic heart disease (11%). For 232 (15%) patients, pharyngolaryngectomy was performed during an emergency admission. The pharynx was closed primarily in 551 patients, with skin or muscle free or pedicled flaps in 755 patients and with jejunum and gastric pull-up in 123 and 160 patients, respectively. In-hospital mortality rate was 6% and was significantly higher in the gastric pull-up group (11%). Reconstructive failure had an odds ratio of 6.2 [95% confidence interval (CI) 2.4-16.1] for in-hospital death. The five-year survival was 57% and age, morbidities, emergency surgery, gastric pull-up, major acute cardiovascular events, renal failure and reconstructive failure independently worsened prognosis. Patients who underwent pharyngeal reconstruction with radial forearm or anterolateral thigh flaps had lower mortality rates than patients who had jejunum flap reconstruction (hazard ratio = 1.50 [95% CI 1.03-2.19]) or gastric pull-up (hazard ratio = 1.92 [95% CI 1.32-2.80]). CONCLUSIONS: Pharyngolaryngectomy carries a high degree of risk of morbidity and mortality. Reconstructive failure worsens short- and long-term prognosis, and the use of cutaneous free flaps appears to improve survival.

Importance of a dedicated neuroradiologist in reporting high-resolution computed tomography for otosclerosis: a retrospective comparison study of 40 patients.

OBJECTIVES: This study aimed to compare the reporting of high-resolution computed tomography of temporal bones for otosclerosis by general radiologists and a neuroradiologist within a local National Health Service Trust. METHODS: A retrospective case review of 36 high-resolution temporal bone computed tomography images obtained between 2008 and 2015 from 40 otosclerosis patients (surgically confirmed) was performed in a district general hospital setting. The main outcome measures were correct identification of otosclerosis by high-resolution computed tomography and adherence to the petrous temporal bone imaging protocol. RESULTS: Correct diagnosis rates were significantly different when made by general radiologists vs a neuroradiologist (p < 0.0001; two-tailed Fisher's exact test). None of the high-resolution computed tomography scans adhered to the temporal bone imaging protocol. CONCLUSION: The use of high-resolution computed tomography for suspected otosclerosis is helpful for diagnosis, disease staging, obtaining informed consent, surgical planning and prognosis. This study suggests that radiological detection of otosclerotic changes by high-resolution computed tomography of the temporal bone is significantly better when performed by a dedicated neuroradiologist than by a general radiologist. Use of a standardised temporal bone computed tomography protocol is recommended to provide consistently high-quality images for maximising disease detection.

Latest trends in the assessment and management of paediatric snoring and sleep apnoea.

OBJECTIVE: To investigate the assessment and management of paediatric snoring and obstructive sleep apnoea in UK otolaryngology departments. METHOD: A telephone questionnaire survey of UK otolaryngology departments was conducted over a 16-week period. RESULTS: The response rate was 61 per cent (85 out of 139 trusts). Use of pre-operative pulse oximetry was reported by 84 per cent of respondents, mainly to diagnose obstructive sleep apnoea (73 per cent) or stratify post-operative risk (46 per cent). Thirty-one per cent of respondents reported using post-operative pulse oximetry. Twenty-five per cent of respondents have a dedicated management protocol for paediatric obstructive sleep apnoea and snoring. Thirty-four per cent require prior clinical commissioning group approval before performing surgery. Fifty-eight per cent of respondents reported following up their obstructive sleep apnoea patients after surgery. The mean follow-up period (±standard deviation) was 6.8 ± 1.2 weeks. CONCLUSION: There is variation in the assessment and management of paediatric snoring and obstructive sleep apnoea across the UK, particularly in the use of pre- and post-operative pulse oximetry monitoring, and further guidelines regarding this are necessary.

Non-invasive Assessment and Symptomatic Improvement of the Obstructed Nose (NASION): a physiology-based patient-centred approach to treatment selection and outcomes assessment in nasal obstruction.

OBJECTIVES: To evaluate the impact of selecting treatment for nasal obstruction on the basis of a structured physiology-based assessment protocol on patient outcomes. DESIGN: Prospective longitudinal study. SETTING: District general hospital. PARTICIPANTS: A population of 71 patients with a mean age of 33 years, containing 36 males, presented with nasal obstruction for consideration of nasal surgery. All patients underwent a structured clinical assessment, skin prick allergy testing and oral-nasal flow-volume loop examination. Fifty-one patients completed the follow-up, and mean follow-up was 11 months. MAIN OUTCOME MEASURES: NOSE, SNOT-22 and NASION scales. RESULTS: Of the 51 patients who completed follow-up, six had conservative treatment, 28 had septal/turbinate surgery, and 17 underwent nasal valve surgery. Mean NOSE score fell from 68 ± 18 to 39 ± 31 following the treatment. Mean SNOT-22 score fell from 47 ± 20 to 29 ± 26 following the treatment. The difference between pre-treatment and post-treatment NOSE and SNOT-22 scores were statistically significant. Success rate of septal/turbinate surgery in patients without nasal allergy was 88%, and this fell to 42% in patients undergoing septal/turbinate surgery who also had nasal allergy. Presence of nasal allergy was the only independent predictor of treatment failure. Patients with nasal valve surgery reported significantly greater symptomatic improvement following surgery. The newly formed NASION scale demonstrated internal consistency with a Cronbach α of 0.9 and excellent change-responsiveness and convergent validity with correlation coefficients of 0.64 and 0.77 against treatment-related changes in SNOT-22 and NOSE scales, respectively. CONCLUSIONS: Successful surgical outcomes can be achieved with the use of a structured history, clinical evaluation and physiological testing. Flow-volume loops can help elucidate the cause of nasal obstruction. The newly formed NASION scale is a validated retrospective single time-point patient outcome measure.

Endotracheal tube positioning during neck extension in thyroidectomy.

OBJECTIVE: To evaluate the effect of body mass index and neck length on endotracheal tube movement during neck extension in thyroidectomy. METHODS: A prospective study was conducted of 30 patients undergoing thyroidectomy during an 8-month period. Patient characteristics were recorded and endotracheal tube displacement was determined. RESULTS: Mean body mass index was 27.8 kg/m2 (range, 17.5-34.7 kg/m2) and mean neck circumference was 43.2 cm (range, 28-56 cm). The mean (± standard deviation) upward displacement of the endotracheal tube during neck extension was 7.17 ± 5.87 mm. Patients with a larger body mass index had a significantly greater amount of tube displacement (R2 = 0.67, p < 0.0001), as did patients with a smaller neck length (R2 = 0.48, p < 0.0001). CONCLUSION: Neck extension results in upward displacement of the endotracheal tube. The amount of displacement is significantly higher in patients with a larger body mass index or shorter neck length. This has particular relevance for nerve monitoring in thyroidectomy.

Pulse oximetry in paediatric obstructive sleep apnoea: is it used appropriately?

OBJECTIVES: This study assessed the use of pulse oximetry testing in children with suspected obstructive sleep apnoea in a hospital setting. METHODS: A retrospective review of patients who underwent pulse oximetry testing between April 2013 and October 2013 was performed. Primary outcome measures included positive pulse oximetry results, defined as a McGill oximetry score of 2-4. RESULTS: Thirty-seven test results were usable for analysis: from 21 pre- and 16 post-operative tests. Only four patients had positive test results. There was a significant difference between pre- and post-operative quality of life outcome scores in the surgical group (p < 0.0001). CONCLUSION: Pre-operative pulse oximetry should be used as a guide to help triage patients who require specialist paediatric services, such as a paediatric intensive care unit. The use of pulse oximetry, particularly in the post-operative setting, is unlikely to change patient management and can incur unnecessary financial costs to UK National Health Service Hospital Trusts.