Endonasal endoscopic management of spontaneous cerebrospinal fluid rhinorrhoea: The Birmingham UK experience.

BACKGROUND: Spontaneous cerebrospinal fluid (CSF) leaks (SCSFL) occur in the absence of trauma, surgery, or underlying intracranial pathology. They represent a significant healthcare burden on patients with complications such as meningitis. We present our experience of SCSFL repair via the endonasal endoscopic approach. METHODS: All patients who underwent CSF fistula repair at a tertiary UK hospital, between 1st January 2012 to 31st December 2019, were identified and had their case notes analyzed retrospectively. RESULTS: There were 33 patients included consisting of 27 (81.8%) females, with age range from 31 to 81 years (mean 55.2). Mean body mass index (BMI) was 35.2 kg/m2 , with 32 (97.0%) patients overweight (BMI >25). All patients presented with intermittent watery rhinorrhoea and had a positive biochemical analysis. Computed tomography (CT) and/or magnetic resonance imaging (MRI) identified leak sites in 29 patients (87.9%). The most common intraoperative defect site was the cribriform plate (42.4%). A variety of closing techniques were used including onlay grafts (72.7%), tissue glue (87.9%), nasoseptal flaps (63.6%), mucosal free grafts (21.2%), fat grafts (21.2%), and additional support materials (87.9%). Nasal packing was used in all patients. The average length of stay was 1.6 days. Postoperative complications occurred in two patients (6.1%) (meningitis, epistaxis). Overall, there was a successful primary repair in 32 (97.0%) patients with most cases employing a multilayered reconstruction method (78.8%). CONCLUSION: Our results demonstrate excellent success rates with the endoscopic endonasal approach to SCSFL. This adds to the literature by demonstrating a detailed analysis of the experience in SCSFL management in one of the largest UK centres.

The Effectiveness of a Specific Foundation Year 1 Induction Programme in Improving Confidence for Newly Qualified Doctors in the UK.

Background: Despite the completion of 5 or 6 years of undergraduate study, the transition to a newly qualified foundation year 1 doctor (FY1) in the UK has been recognised as challenging. We created a specific FY1 Induction Programme and aimed to evaluate its effectiveness on perceived confidence and preparedness for newly qualified doctors by assessing their responses to surveys before and after the delivery of the course. Methods: Pre- and post-course surveys were administered at the start and end of the course, respectively. All questions were subjective and used a 5-point Likert scale (1, not at all confident, to 5, definitely confident) to assess perceived confidence in a range of questions before and after the course. Results: A total of 35 participants completed the pre-course survey and 41 completed the post-course survey. For all questions, there was a statistically significant increase in confidence ratings. All 41 participants completing the post-course questionnaire responded 'yes' to feeling more confident to be an FY1 after completing the programme compared to before (100%). Conclusions: Our study, along with previously published work, has shown a repeatable positive effect with implementation of transition courses for newly qualified doctors. Future research in this area could focus on more large-scale standardised learning events incorporated by different trusts prior to commencement as an FY1, to see if the positive effects found in our study are translatable across other regions. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-022-01616-8.

The Use of Auricular Cartilage Grafts in Septorhinoplasty: A Dual-Centre Study of Donor Site Patient-Reported Outcome Measures.

Objectives The use of autologous grafts is a key aspect of contemporary septorhinoplasty. When septal cartilage is deficient, auricular cartilage serves as a biocompatible, readily accessible alternative. Our study aimed to assess donor site patient-reported outcome measures (PROMs) where auricular cartilage has been harvested for use in septorhinoplasty, adding to the limited existing literature on this topic. Design A dual-centre, single-surgeon retrospective analysis of patients undergoing septorhinoplasty surgery with augmentation using auricular cartilage grafts was conducted. Grafts were harvested using an anterior anti-helical approach. Patients were followed up at one week, three months and 12 months post-operatively. Donor site outcomes were assessed across several physical and psychological domains by adapting the EAR-Q questionnaire, which was administered via telephone consultation. Responses were quantified using a Likert scale. Results A total of 22 patients met our inclusion criteria. Four were lost to follow-up, five were non-responders and one case was excluded due to documentation of body dysmorphic disorder. A significant proportion of patients reported no reduction in quality of life (QOL) or confidence attributed to donor site cosmesis. High satisfaction was noted with anti-helical donor site scars. Although noticeable differences in shape and symmetry were reported, these had negligible effects across psychological domains. Conclusions Preliminary results suggest high levels of patient satisfaction, with minimal physical and psychological donor site sequelae following auricular cartilage harvest in septorhinoplasty. Subsequent studies should involve the use of validated questionnaires, coupled with larger patient cohorts in order to provide further data for statistical analysis.

The evolution of sinus surgery in England in the last decade - An observational study.

BACKGROUND AND OBJECTIVE: Sinus surgery has seen significant changes over the years with advancements in instruments, endoscopes and imaging. This study aimed to use Hospital Episode Statistics (HES) data to review the total number of sinus related procedures performed in both adults and children across England and identify whether there were any trends across the study period. We predicted an increase in endoscopic sinus procedures with a decline in open approaches to the paranasal sinuses. METHODS: Data from HES was extracted for the years 2010-2019. The operative (OPCS-4) codes relevant to all sinus procedures between E12.1 and E17.9 were analysed. After examination of overall sinus related procedures, further subgroup analysis was performed with regards to open or endoscopic techniques. RESULTS: The total number of sinus procedures performed between 2010 and 2019 was 89,495. There was an increase in endoscopic surgeries by 21.1% and a decrease of open surgeries 35.3% during this time. There was an overall increase in maxillary, frontal and sphenoid sinus procedures, with a decrease in ethmoid sinus and lateral rhinotomy operations. There was an increase in the proportion of endoscopic cases overall by 5.7% and for all sinuses individually. CONCLUSION: Overall, we see an increase in sinus surgery over the last 9 years from 2010 to 2019. These findings are in keeping with our initial hypotheses. Although our data set is limited by coding, and lack of patient factors, it represents most, if not all, of the data in England over a large study period. It is therefore useful to add to previous studies when demonstrating the increasing popularity of endoscopic sinus surgery over open procedures.

Intra-operative use of biological products-Are we aware of their derivatives?

INTRODUCTION: Global medical advances within healthcare have subsequently led to the widespread introduction of biological products such as grafts, haemostats, and sealants. Although these products have been used for many decades, this subject is frequently not discussed during the consent process and remains an area of contention. METHODS: A nationwide confidential online survey was distributed to UK-based junior registrars (ST3-5), senior registrars (ST6-8), post-CCT fellows, specialist associates/staff grade doctors and consultants working in general/vascular surgery, neurosurgery, otolaryngology, oral and maxillofacial surgery and plastic surgery. RESULTS: Data were collected from a total of 308 survey respondents. Biological derivatives were correctly identified in surgical products by only 25% of survey respondents, only 19% stated that they regularly consent for use of these products. Our results demonstrate that most participants in this study do not routinely consent (81%) to the intra-operative use of biological materials. An overwhelming 74% of participants agreed that further education on the intra-operative use of biological materials would be valuable. DISCUSSION: This study highlights deficiencies in knowledge that results in potential compromise of the consenting process for surgical procedures. A solution to this would be for clinicians to increase their awareness via educational platforms and to incorporate an additional statement on the consent form which addresses the potential intraoperative use of biological products and what their derivatives may be. CONCLUSION: Modernising the current consent process to reflect the development and use of surgical biological products will help to ensure improved patient satisfaction, fewer future legal implications as well as a better surgeon-patient relationship.

Prevalence of Patients Who Return to Theatre Post-Adenoidectomy: A Review of Hospital Episode Statistics Data (2012-2019).

Introduction Risk of surgical intervention for post-adenoidectomy haemorrhage can be assessed with the analysis of the Hospital Episode Statistics (HES) data. Materials and methods HES data for England from 2012 to 2019 were analysed comparing the coded number of adenoidectomy procedures to the number of surgical arrests of post-adenoidectomy haemorrhage in adolescents/adults and children. Results Between April 2012 and April 2019, of 47,597 procedures, 52 (0.11%) patients required surgical arrest of post-adenoidectomy haemorrhage. In adults (n = 5,379), 11 patients returned to theatre for control of post-operative bleeding, whereas 41 children (n = 42,218) required this intervention. The total number of adenoidectomies was 3.7 times higher in children; however, adults were statistically two times more likely to require further surgical intervention for arrest of post-adenoidectomy haemorrhage (two-tailed p-value = 0.0031). Conclusion Children are more likely to return to theatre for surgical arrest of post-adenoidectomy haemorrhage, with p-values indicating the difference between the incidence of adults and children returning to theatre to be very statistically significant.

Personal protective equipment guidance during a global pandemic: A statistical analysis of National perceived confidence, knowledge and educational deficits amongst UK-based doctors.

INTRODUCTION: On the 11th of March 2020, the World Health Organisation (WHO) declared a global pandemic following the upsurge of the novel coronavirus disease 2019 (COVID-19). Unprecedented global demand for personal protective equipment (PPE) resulted in restricted availability, as well as evolving guidance on use, the latter of which was complicated by conflicting guidance provided by numerous healthcare bodies. AIM: To assess perceived confidence and knowledge of PPE guidance as published by Public Health England (PHE) amongst doctors of varying specialties and grades. METHOD: A nationwide 11-point survey comprising of multiple-choice questions (MCQs) and a 5-point Likert scale assessing perceived confidence was disseminated to UK-based doctors using multiple platforms. Statistical analysis using one-way analysis of variance (ANOVA), Tukey's honest significant difference (Tukey HSD) and Pearson's chi-squared test was undertaken to assess for statistical significance. RESULTS: Data collated from 697 respondents revealed that average perceived confidence was low across all specialties and grades. Notably, 59% (n = 411) felt they had received insufficient education regarding up-to-date guidance, with 81% (n = 565) advocating further training. Anaesthetics and ophthalmology were highest and lowest scoring specialties in knowledge-based MCQs, achieving scores of 59% and 31%, respectively. Statistical analysis revealed significant differences between specialty, but not grade. CONCLUSION: Ensuring uniformity in published guidance, coupled with education may aid knowledge and subsequent confidence regarding the appropriate use of PPE. The absence of a unified consensus and sustained training not only poses significant ramifications for patient and healthcare professional (HCP) safety, but also risks further depletion of already sparse resources. Because of the novelty of COVID-19, appropriate PPE is continually evolving leaving an absence in formal training and education. This paper reveals insight into confidence and knowledge of PPE amongst doctors of various specialities/grades during a global pandemic, highlighting key deficits in education and training.

Personal protective equipment: knowledge of the guidance.

BACKGROUND: On 11 March 2020, the World Health Organization (WHO) declared a global pandemic in the wake of the coronavirus disease 2019 (COVID-19) outbreak. The unpredictable nature of transmission of COVID-19 requires a meticulous understanding of guidance on personal protective equipment (PPE) as published by WHO and Public Health England (PHE). AIM: To assess perceived confidence and knowledge of PHE guidance relating to PPE by nursing staff. METHODS: A nationwide survey was disseminated between May and June 2020 through social media platforms as well as internal mail via regulatory bodies and individual hospital trusts. RESULTS: Data were collated from 339 nurses. Perceived confidence as measured on a Likert scale was a mode score of 3/5, with the average score for knowledge-based questions being 5/10. Of the respondents, 47% cited insufficient training on PPE guidance, and 84% advocated further training. Conclusions: Unifying published PPE guidance and ensuring consistency in training can improve awareness, confidence, and knowledge among nursing staff.

A Case of Laryngeal Fracture Precipitated by Swallowing.

We report the case of a non-traumatic laryngeal fracture precipitated by swallowing where the symptoms were initially misinterpreted as representing a possible laryngeal malignancy. By the time of diagnosis, the injury was associated with an anterior neck abscess that required urgent surgical intervention. A 61-year-old male presented with dysphonia, odynophagia and neck swelling that had begun shortly after feeling a sudden crack in his neck upon swallowing. This was initially suspected to represent a laryngeal malignancy until, while awaiting outpatient investigation, the patient re-presented with rapid progression of his symptoms. Urgent CT scan revealed a vertical fracture of the thyroid cartilage, and a large anterior neck abscess causing posterior displacement. This required urgent surgical drainage. No underlying neoplasm was found, and the patient made a full recovery with complete resolution of symptoms. Non-traumatic laryngeal fractures are extremely rare. This case demonstrates the diagnostic challenge they can pose and is the first to describe the presentation and surgical management of a case with fracture displacement due to localised infection.

Simultaneous dysphagia and stridor: an unreported presentation of hypocalcaemia.

Hypocalcaemia is a well-recognized complication of total thyroidectomy surgery. Patients who develop post-operative hypocalcaemia often report symptoms of neuromuscular instability including peripheral numbness and/or tingling. In severe cases, larygospasm with stridor and bronchospasm can occur. We present the first reported case in the literature, to our knowledge, of a 58-year-old male presenting with intermittent exertional stridor, dysphonia and dysphagia following thyroid surgery 2 years previously. Clinical and radiological investigations were unremarkable. Pre-operative screening for a planned panendoscopy to investigate his symptoms highlighted a profound hypocalcaemia (adjusted calcium 1.42 mmol/l). Following calcium replacement therapy, his symptoms subsided. There is an absence of literature describing both dysphagia and stridor synchronously. We not only advocate regular routine follow-up and compliance assessments for such patients but also the consideration of hypocalcaemia as a differential in any patient presenting with such symptoms following any thyroid surgery.

A novel and cost-effective technique for securing the nasal septum to the anterior nasal spine in septoplasty and/or rhinoplasty surgery.

Septoplasties and septorhinoplasties are common procedures in otolaryngology, aimed at addressing septal and/or bony pyramidal deflections to improve functional and cosmetic outcomes. The nasal septum as well as regulating air flow provides structural support to the nasal tip. The attachment of the nasal septum to the anterior nasal spine must be structurally resilient to prevent saddling or tip ptosis. This can be achieved by direct attachment with absorbable suture material to the periosteum of the anterior nasal spine or a drill fitted with 0.6 mm diamond tip burr (Ultrabur, Invotec International), to create channel through which the nasal spine can be secured to the anterior nasal spine. We describe a novel, and cost-effective alternative utilising a blunt fill needle and simple absorbable suture. A blunt fill needle (Sol-Millenium®, cost £0.03 per unit) is passed through to form a securing channel. The neoseptum is then secured using a figure-of-eight suture. Our novel technique enables the nasal septum to be secured to the anterior nasal spine in a cost effective and efficient manner.