Training in Endoscopic Ear Surgery: A Scoping Review.

OBJECTIVE: Despite the increasing popularity of Endoscopic Ear Surgery (EES), there is a lack of evidence to guide trainees as they introduce EES into practice. This review aims to evaluate training in EES including the optimal introductory procedures, methods of training, the learning curve, and the determination of competency in EES. In addition, this review seeks to identify any areas falling within these themes requiring further clarification. DATA SOURCES: A database search of Pubmed, Embase and the Cochrane Library was conducted in June 2022. Original articles, systematic reviews, and meta-analyses reporting on training in EES, introduction into practice, learning curves, and competency assessment were included. REVIEW METHODS: A scoping review was carried out in accordance with the Joanna Briggs Institute guidelines and reported according to PRISMA guidelines for scoping reviews. A qualitative assessment of results grouped thematically was performed. RESULTS: Twenty-eight studies met the inclusion criteria, with 24 rating as "fair" or "good" on quality assessment. Surgical simulation was the most frequently described method of training as utilized in 11 studies. The most suggested introductory procedure was tympanoplasty which was advocated for in five studies. Heterogeneity existed in the outcomes and methodologies used to measure EES learning curves, with an overreliance on surgical times. No robust definition of competency in EES procedures exists at present. CONCLUSIONS: Surgical simulation appears to be a beneficial training methodology for EES. However, there is a marked lack of objective data to describe the optimal introductory procedures or assessment of competency in EES. Laryngoscope, 133:3269-3278, 2023.

Clinical decision making in paediatric otitis media: A pilot quality improvement study.

OBJECTIVES: This study aimed to improve local management of paediatric otitis media using the 2022 American-Academy of Otolaryngology Head and Neck Surgery (AAO-HNS) Clinical Practice Guideline for Tympanostomy Tubes in Children. METHODS: A SQUIRE 2.0 compliant quality improvement study was carried out within the outpatient department of our otolaryngology tertiary referral centre. Local outpatient management of paediatric otitis media was compared to the AAO-HNS guidelines, specifically focussing on the decision to offer tympanostomy tubes. Following initial audit of practice, an educational session was performed within the otolaryngology department and local practice was subsequently re-evaluated. RESULTS: Overall, 88 children were included (46 pre-intervention and 42 post-intervention) with a mean age of 7.6 years (range 1-12 years). Sixty-four (72.7%) children presented with suspected otitis media with effusion. The remainder presented with recurrent or persistent acute otitis media (24/88, 27.3%). Twenty-six children were offered tympanostomy tubes (29.5%). Initial evaluation of practice identified that the decision to offer tympanostomy tubes was guideline appropriate in 76.1% of children (35/46). This significantly improved following an educational session (40/42, 95.2%, p = 0.02). The reasons for non-guideline compliance included: otitis media with effusion <3 months, no evidence of middle ear fluid and patients meeting criteria for tympanostomy tube insertion not being offered. CONCLUSIONS: A focussed educational intervention may improve local adherence to guidelines in the management of paediatric otitis media. Continued re-evaluation of local practice is essential in order to ensure children are managed in accordance with the guidelines.

Trans-canal tragal cartilage myringoplasty; a comparative analysis of endoscopic and microscopic approaches.

BACKGROUND: The advent of Endoscopic Ear Surgery (EES) has allowed otologists an improved view of the surgical field compared with conventional Microscopic Ear Surgery (MES). EES presents different challenges for surgeons and a learning curve is necessary. AIMS: The purpose of this study was to compare the efficacy of EES and MES for trans-canal tragal cartilage myringoplasty, an entry level EES. METHODS: We retrospectively analysed patients who underwent push through trans-canal tragal cartilage myringoplasty in our institution over 5 years (2016-2020). Exclusion criteria were: patients with prior ear surgery, non-tragal cartilage tympanic membrane graft, additional procedure at time of surgery and patients with insufficient follow up. EES and MES groups were compared using outcomes such as graft success rate, changes in pure tone audiometry (PTA), operative time and complications. RESULTS: Seventy-four patients met inclusion criteria (MES = 38, EES = 36). Mean age of included patients was 29.3 years with no significant demographic differences between groups. Graft success rate at 12 months was higher among the EES group versus MES (94.4% v 86.8%, p = 0.43). Mean operative time was reduced in the EES group (47.3 min v 53.8 min, p = 0.04). Hearing outcomes did not differ significantly between groups. No major operative complications occurred in either group. CONCLUSIONS: Outcomes were marginally better in the cohort who underwent EES. This supports that EES offers an otologic choice to complement established practice for trans-canal myringoplasty and may be used to facilitate introduction to EES for trainees and otologists wishing to learn this technique.

Endoscopic Versus Microscopic Type-1 Tympanoplasty: A Meta-Analysis of Randomized Trials.

OBJECTIVES: Totally endoscopic ear surgery is becoming increasingly utilized in otologic practice. Although the well-established microscope-assisted tympanoplasty remains the most common technique to repair a tympanic membrane defect, the merits of endoscopic approaches have been well-documented. This systematic review and meta-analysis compares the outcomes of endoscopic to microscopic tympanoplasty incorporating only randomized trials. STUDY DESIGN: Systematic review and meta-analysis. METHODS: A comprehensive search of PubMed/MEDLINE, Scopus, Cochrane Library, and EMBASE was conducted. All randomized studies comparing endoscopic to microscopic tympanoplasty were collected according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Quality assessment was carried out utilizing the Risk of Bias 2. RESULTS: The initial search identified 1711 studies, of which 9 met the inclusion criteria comprising of 540 patients (microscopic tympanoplasty 51.5%; endoscopic tympanoplasty 49.5%). The mean age was 32.5 years with a similar number of males (50.1%) and females (49.9%). Both endoscopic and microscopic groups had comparable outcomes with regards to graft success rate (RD 0.00; 95% confidence interval [CI], -0.04 to. 0.05; p = 0.87) and hearing improvement (MD 0.57 dB; 95% CI, -1.23 to 2.36; p = 0.54). A significantly shorter operative time was noted in the endoscopic group (MD, -24.73 min; 95% CI, -38.56 to -10.89; p = 0.0005). CONCLUSION: Our results, assimilating level 1 evidence, demonstrates that endoscopic and microscopic-assisted type-1 tympanoplasty have similar outcomes in both graft success and hearing improvement, with endoscopic approaches yielding a shorter operative time. LEVEL OF EVIDENCE: 1 Laryngoscope, 133:1550-1557, 2023.

Measuring the Angular Accuracy of a Clinician-Performed Epley Maneuver Used to Treat Benign Paroxysmal Positional Vertigo.

INTRODUCTION: Particle repositioning maneuvers have become the criterion standard for managing benign paroxysmal positional vertigo. The Epley canalolith repositioning maneuver is used to treat posterior canal benign paroxysmal positional vertigo and is successful in up to 90% of cases. However, when performed, there are many clinician variabilities, and angles are approximate. It is not known how accurate each angle needs to be for the target canal to be adequately stimulated. The objective of this study was to measure the angular accuracy of clinician-guided Epley maneuvers using a three-axis accelerometer. METHODS: Ten healthy subjects were recruited; participants had no known audio vestibular pathology. Five right-hand-dominant clinicians performed Epley maneuvers on both ears of two different participants. Twenty maneuvers were carried out in total. Angular movements were recorded using a vestibular feedback electronic device, the SHIMMER accelerometer. Data were recorded and analyzed using the EYESWEB Open Platform. RESULTS: Results showed that there was angular error at every stage of the clinician-performed Epley maneuver. The most accurate movement was positioning the head to the left of 45 degrees for a left ear maneuver with an average error of 2.94 degrees. The least accurate was when positioning the patient to face the floor at 135 degrees from supine for a right ear maneuver with an average error of 17.6 degrees. CONCLUSION: Even when experienced ENT clinicians perform a standard Epley maneuver, there is a wide range of angular inaccuracy at each stage. Face to floor is particularly inaccurate. However, given that a majority of procedures (90%) work on the first attempt, there must be an acceptable but unknown range of angular inaccuracy. Novel technologies could improve the angular accuracy, potentially give better results, and allow a broad range of individuals to perform a more accurate Epley maneuver.

Radiomic Detection of Malignancy within Thyroid Nodules Using Ultrasonography-A Systematic Review and Meta-Analysis.

Background: Despite investigation, 95% of thyroid nodules are ultimately benign. Radiomics is a field that uses radiological features to inform individualized patient care. We aimed to evaluate the diagnostic utility of radiomics in classifying undetermined thyroid nodules into benign and malignant using ultrasonography (US). Methods: A diagnostic test accuracy systematic review and meta-analysis was performed in accordance with PRISMA guidelines. Sensitivity, specificity, and area under curve (AUC) delineating benign and malignant lesions were recorded. Results: Seventy-five studies including 26,373 patients and 46,175 thyroid nodules met inclusion criteria. Males accounted for 24.6% of patients, while 75.4% of patients were female. Radiomics provided a pooled sensitivity of 0.87 (95% CI: 0.86−0.87) and a pooled specificity of 0.84 (95% CI: 0.84−0.85) for characterizing benign and malignant lesions. Using convolutional neural network (CNN) methods, pooled sensitivity was 0.85 (95% CI: 0.84−0.86) and pooled specificity was 0.82 (95% CI: 0.82−0.83); significantly lower than studies using non-CNN: sensitivity 0.90 (95% CI: 0.89−0.90) and specificity 0.88 (95% CI: 0.87−0.89) (p < 0.05). The diagnostic ability of radiologists and radiomics were comparable for both sensitivity (OR 0.98) and specificity (OR 0.95). Conclusions: Radiomic analysis using US provides a reproducible, reliable evaluation of undetermined thyroid nodules when compared to current best practice.

The psychological impact of COVID-19 on ear, nose and throat (ENT) specialists.

INTRODUCTION: Ear, nose and throat (ENT) specialists are a high-risk group for COVID-19. Although the implications of SARS-CoV-2 infection on physical health are well-documented, the psychological impact is frequently overlooked. AIMS: The aim of this study was to gauge the psychological impact of COVID-19 on ENT specialists in Ireland. METHODS: A national, cross-sectional, web-based survey was distributed to ENT specialists during the peak of the COVID-19 pandemic (21st May 2020-21st June 2020). The questionnaire collected sociodemographic and COVID-19 related data. The GAD-7 was utilized to measure symptoms of clinically significant anxiety disorder. RESULTS: Thirty-eight ENT specialists (M/F:24/12, median age, 38.7 years (23-60 years)) completed the survey. About 34% (n = 13) of participants screened positive for an anxiety disorder, of which 2 (5%) had moderate symptoms. The majority of participants (n = 32, 84%) felt ENT specialists had increased exposure to SARS-CoV-2 compared with other medical specialties. Additionally, 32% (n = 12) felt incapable of protecting themselves from infection. An encouraging proportion of ENT specialists (n = 22, 58%) were aware of psychological support available from national and institutional organizations. CONCLUSIONS: The long-term psychological sequelae of COVID-19 will be felt as the physical burden eases. As we adjust to new normalities, ENT surgeons must be conscientious of the mental health issues that arise from the working environment. Sources of anxiety emanated from a lack of control over infection risk, increased vulnerability to COVID-19 relative to other specialties and the implications this has for ENT specialists and their families. Future interventions must focus on increasing awareness of the available psychological support services for our healthcare workers.

Incidental findings on MRI scans of patients presenting with audiovestibular symptoms.

BACKGROUND: The evaluation of patients presenting with audiovestibular symptoms usually includes MRI of the internal auditory meatus, the cerebellopontine angle and the brain. A significant percentage of these scans will present unexpected, incidental findings, which could have important clinical significance. OBJECTIVE: To determine the frequency and clinical significance of incidental findings on MRI scans of patients with audiovestibular symptoms. MATERIALS AND METHODS: A retrospective analysis of 200 serial MRI scans. RESULTS: Gender distribution: equal. Age range: 17-82 years. One-hundred and four scans (52%) were normal and 1 scan (0.5%) demonstrated a unilateral vestibular schwannoma. Ninety-five scans (47.5%) demonstrated incidental findings. Sixty-six of these (33%) were considered of ishaemic origin and did not require further action. Five (2.5%) scans demonstrated significant findings which warranted appropriate referral; Two Gliomas (1%), 2 cases of extensive White Matter Lesions (1%), 1 lipoma (0.5%). The remaining scans demonstrated various other findings. CONCLUSION: Investigation of patients with audiovestibular symptoms with MRI scans revealed incidental findings in a significant percentage (47.5%). The majority of these findings were benign warranting no further action and only 2.5% required further referral. It is the responsibility of the referring Otolaryngologist to be aware of these findings, to be able to assess their significance, to inform the patient and if needed to refer for further evaluation.

Isolated microtia as a marker for unsuspected hemifacial microsomia.

OBJECTIVE: To determine the proportion of hemifacial microsomia (HFM) in patients with unilateral or bilateral "isolated" microtia. DESIGN: Prospective cohort clinical study. SETTING: University-affiliated, tertiary referral clinic for patients with microtia. PATIENTS: One hundred consecutive patients with isolated microtia. INTERVENTIONS: All the patients underwent a clinical examination and audiologic evaluation. The OMENS classification system was used to grade the severity of craniofacial features: orbital deformity, mandibular hypoplasia, ear deformity, nerve (cranial nerve VII) involvement, and soft-tissue deficiency. Each anatomical abnormality was graded from 0 (normal) to 3 (most severe) (score range, 0-15). MAIN OUTCOME MEASURES: The OMENS scores, percentage of patients with isolated microtia and undiagnosed HFM, and isolated microtia as an early clinical marker for HFM. RESULTS: Forty patients (40%) with microtia were determined to have HFM (31 unilateral and 9 bilateral). Mean patient age was 9.2 years (range, 6 weeks to 41 years), with male predominance (27 males and 13 females). The OMENS scores were less than 5 in 24 patients and 6 to 10 in 16 patients. Thirty patients had cranial nerve deficits, and 37 had mandibular asymmetry. Thirty-seven patients demonstrated conductive hearing loss, and 1 had sensorineural hearing loss. CONCLUSIONS: Isolated microtia served as an early clinical marker for asymmetrical facial growth in 40% of the patients. Isolated microtia and HFM could represent a spectrum of expression of the same developmental phenomenon.

Pediatric cholesteatoma: canal wall window alternative to canal wall down mastoidectomy.

OBJECTIVE: A previous pilot series described a hybrid mastoidectomy technique, canal wall window (CWW), which substituted for the canal wall down (CWD) procedure and involved slitting the posterior canal wall. The current, larger series compares the results of the CWW procedure with conventional surgical techniques. STUDY DESIGN: Retrospective analysis of 78 pediatric ears. SETTING: Academic tertiary referral center. PATIENTS: The mean patient age was 13.5 years. MAIN OUTCOME MEASURE(S): The data analyzed included ears later requiring conversion from CWW to CWD, dry/moist ear results, recidivation determined by two separate methods, and audiometric data statistically analyzed using independent-samples analysis (unpaired, two-tailed Student's t test). RESULTS: First, of 42 CWW ear procedures, 6 (14%) later required conversion to CWD. Second, dry ear results were as follows: for CWW, 94%; for CWD, 92%; and for CWU (canal wall up), 90%. Third, recidivation determined at 1 year (standard rate) was, for CWW, 19.5%; for CWD, 0%; and for CWU, 7.7%; the at-risk calculation rate was, for CWW, 27%; for CWD, 0%; and for CWU, 8.3%. The 6-year recidivation rate for all three surgical techniques was 0%. 4). The mean preoperative-to-postoperative four-tone air-bone gap change was, for CWW, from 29.7 to 26.4 dB; for CWD, from 32.9 to 39.0 dB; and for CWU, from 21.0 to 25.2 dB (postoperative CWW to CWD, p < 0.005). A postoperative air-bone gap result of 0 to 20 dB was achieved as follows: with CWW, in 13 of 36 ears; with CWD, in 2 of 14 ears; and with CWU, in 9 of 22 ears. CONCLUSION: Frequently, a CWW procedure can be substituted for a traditional CWD procedure. In the extended series, the CWW technique continued to provide hearing results similar to CWU rather than to CWD procedures in a young population who will bear the surgical outcome for many decades.

Clinical and genetic linkage analysis of a large Venezuelan kindred with Usher syndrome.

OBJECTIVE: To undertake a comprehensive investigation into the very high incidence of congenital deafness on the Macano peninsula of Margarita Island, Venezuela. METHODS: Numerous visits were made to the isolated island community over a 4-year-period. During these visits, it became apparent that a significant number of individuals complained of problems with hearing and vision. Socioeconomic assessments, family pedigrees and clinical histories were recorded on standard questionnaires. All individuals underwent thorough otolaryngologic and ophthalmologic examinations. Twenty milliliters of peripheral venous blood was obtained from each participant. A genome-wide linkage analysis study was performed. Polymorphic microsatellite markers were amplified by polymerase chain reaction and separated on polyacrylamide gels. An ABI 377XL sequencer was used to separate fragments and LOD scores were calculated by using published software. RESULTS: Twenty-four families were identified, comprising 329 individuals, age range 1-80 years, including 184 children. All families were categorized in the lower two (least affluent) socioeconomic categories. A high incidence of consanguinity was detected. Fifteen individuals (11 adults, 4 children) had profound congenital sensorineural hearing loss, vestibular areflexia and retinitis pigmentosa. A maximum LOD score of 6.76 (Linkage >3.0), between markers D11s4186 and D11s911, confirmed linkage to chromosome 11q13.5. The gene myosin VIIA (MYO7A) was confirmed in the interval. Clinical and genetic findings are consistent with a diagnosis of Usher syndrome 1B for those with hearing and vision problems. CONCLUSIONS: We report 15 Usher syndrome 1B individuals from a newly detected Latin American socio-demographic origin, with a very high prevalence of 76 per 100,000 population.

Partial tetrasomy of chromosome 22: genetic and surgical implications for otolaryngologists.

Partial tetrasomy of chromosome 22 is a rare multiple congenital anomaly syndrome that is more commonly known as cat-eve syndrome (CES). It is caused by the duplication of a 2-million base region of chromosome 22 (22 pter --> q 11 x 2). The phenotype is extremely variable, and its clinical characteristics include a combination of craniofacial, cardiac, renal, gastrointestinal, and genito-urinary defects. We describe a rare occurrence of CES in a Brazilian family: Three siblings were affected--monozygotic twin boys and their younger brother. All 3 were born to healthy nonconsanguineous parents. On examination, all 3 were found to have strabismus, primary telecanthus, bilateral coloboma iridis, and low-set ears with posterior rotation of the pinnae. Partial tetrasomy of chromosome 22 was confirmed by fluorescent in situ hybridization. To our knowledge, this is the first report of such an occurrence in one family. We discuss the genotype and phenotype of CES, with particular reference to inheritance patterns and craniofacial defects.