The use of MRI in a tertiary smell and taste clinic: Lessons learned based on a retrospective analysis.

BACKGROUND: Olfactory dysfunction (OD) is a common but underreported problem that can significantly impact a patient's quality of life. OD is prevalent in over 5% of the adult population and can be broadly categorised into conductive and sensorineural causes. Magnetic Resonance Imaging (MRI) can form part of the diagnostic work up, although its exact role is often debated. OBJECTIVES: The aim of this study was to evaluate the value of MRI in managing patients with OD. DESIGN/METHOD: A retrospective analysis of the records of patients presenting to a national smell and taste clinic over a 5-year period was performed. Variables included demographics, endoscopic findings, final diagnosis, psychophysical smell test and imaging results. RESULTS: A total of 409 patients, with an age range of 10-93 years, underwent clinical assessment and smell testing, of which 172 patients (42%) had MRI scans. Imaging in younger age-groups was associated with a higher rate of positive findings, however identifiable causes for OD were recorded across the range. MRI provided both diagnostic and prognostic information in those with idiopathic, traumatic and congenital causes of OD. For example, MRI provided information on the extent or absence of gliosis in those with a head trauma history allowing further treatment and prognosis. CONCLUSION: We recommend the adjunct use of MRI in patients with a clear history and examination findings of head injury, congenital cases and in apparent idiopathic cases. MRI should be requested to compliment clinical findings with a view to aiding decision-making on treatment and prognosis independent of patient's age.

The Difficult Neck Patient-Practical Management: A Personal Approach.

With increasing global trends in aesthetic surgery, the facial plastic surgeon will undoubtedly encounter a variety of patient types including those with more unfavorable underlying anatomy. The "difficult" neck represents a cohort of individuals that exhibit both anatomical and patient-related factors that may limit overall surgical improvement. Anatomical issues that contribute to the difficult neck include excessive fat ("heavy" neck), ptosis of deep structures, obtuse cervicomental angle, and abnormalities of the underlying skeletal framework, such as a low set hyoid and inadequate chin projection. It is important that these factors are recognized and highlighted preoperatively, and that surgery is tailored appropriately to the individual. Although satisfactory results can be achieved, these may be ultimately limited, and it is important that patients understand this. We will present a review of current thinking alongside our own practice in the identification and management of these "difficult neck" patients.

Dissolvable intranasal haemostatic agents for acute epistaxis: A systematic review and meta-analysis.

INTRODUCTION: Nasal packing is the mainstay of epistaxis management; however, packs cause patient discomfort and can lead to hospital admission. Absorbable haemostats provide clotting factors or act as a substrate to stimulate clotting and represent a potential treatment alternative. A systematic review was performed to evaluate the efficacy of topical haemostats in the management of epistaxis. METHODS: A systematic literature search of 7 databases was performed. Only eligible randomised controlled trials (RCTs) and observational studies were included. The primary outcome was short-term haemostatic success (<7 days). Secondary outcomes included long-term haemostatic control (no rebleeding 7-30 days), patient discomfort and adverse effects. Meta-analysis was performed where possible. RESULTS: Of 2249 records identified, 12 were included in the qualitative synthesis and 4 RCTs were included in meta-analysis. The following haemostats were reported: gelatin-thrombin matrix (n = 8), aerosolised/gel tranexamic acid (n = 1), cellulose agents (n = 2) and fibrin sealants (n = 1). Studies involving tranexamic acid on removable delivery devices (eg, pledgets) were excluded. There was heterogeneity in outcome measures and inclusion criteria (coagulopathies/anticoagulants were excluded in 3 RCTs and 2 observational studies). The short-term haemostatic success varied between studies (13.9% to 100%). No significant post-procedural complications were reported. The meta-analysis favoured absorbable haemostatic agent versus packing (risk ratio 1.20; 95% confidence interval 1.05 to 1.37; P = .007). The risk of bias across all studies was moderate to high. CONCLUSIONS: The evidence suggests haemostatic agents are effective at managing acute epistaxis when compared with nasal packing. More data are required before recommendations can be made regarding management in patients on anticoagulants.

Evaluation of Smoking as a Modifying Factor in Chronic Rhinosinusitis.

Importance: The negative association of smoking with the respiratory tract is well known; however, the association between smoking and chronic rhinosinusitis (CRS) has not been well characterized. Objective: To analyze whether active smoking was a risk factor for CRS development, smoking was associated with disease-specific quality of life, and smokers experience an increased symptom burden than nonsmokers. Design, Setting, and Participants: This subanalysis of the Chronic Rhinosinusitis Epidemiology Study (CRES), a prospective, questionnaire-based case-control study conducted between October 2007 and September 2013 was conducted across 30 UK tertiary/secondary care sites. Participants were identified at ear, nose, and throat outpatient clinics and classified into CRS phenotypes as per European Position Paper on Rhinosinusitis and Nasal Polyps 2012 criteria. The overall response rate of those identified to take part in the study was 66%. A total of 1535 questionnaires were returned, with 1470 considered eligible for inclusion. Data analysis was conducted in January 2020. Main Outcomes and Measures: The CRES was designed to distinguish differences in socioeconomic status, geography, medical comorbidities, lifestyle, and quality of life between patients with CRS and healthy controls. Results: A total of 1450 patients completed the smoking question, comprising 219 controls (15.1%; mean [SD] age, 47.3 [14.9] years; 143 women [68%]), 546 participants with CRS (37.7%; mean [SD] age, 51.8 [15.3] years; 259 women [53%]) without nasal polyps (CRSsNPs), and 685 participants (47.2%; mean [SD] age, 56.0 [14.5] years; 204 women [33%]) with CRS and nasal polyps/allergic fungal rhinosinusitis (CRSwNPs+). The mean age was similar, with a greater female preponderance in the control group and male in the CRSwNP group. The greatest number of active smokers was found among control participants (33 [15%]), with a lower rate of smokers in the patients with CRSwNPs+ (9.9%) and CRSsNPs (13.9%), respectively. We found a clinically significant difference in the mean difference in Sino-nasal Outcome Test (SNOT-22) scores between active smokers and nonsmokers for both CRS phenotypes (4.49, 12.25). In both CRS subgroups active smokers had significantly worse SNOT-22 scores than nonsmokers by a mean (SD) magnitude of 10 (18.99, 24.14) points. Nonsmokers also demonstrated a higher percentage of surgical procedures (1 or more), although this was not clinically or statistically different (0.34, 1.10). Conclusions and Relevance: This questionnaire-based case-control study demonstrated a clinically significant symptom burden associated with active cigarette smoking, with worse SNOT-22 scores in the smoking cohort by a mean magnitude of 10 points. We could find no demonstrable evidence that smoking increases the likelihood of need for revision sinus surgery. Clinicians should encourage smoking cessation alongside general CRS medical management.

Nodular fasciitis of the parotid gland engulfing the facial nerve: a conservative approach.

Nodular fasciitis (NF) is a rapidly growing benign lesion rarely reported in the parotid gland. It shares cytological features with other benign and malignant parotid neoplasms and may be difficult to diagnose based on fine needle aspiration cytology alone. Given this diagnostic conundrum, surgical excision for histology is recommended to facilitate definitive diagnosis. A case with significant involvement of the facial nerve is described, which has not previously been reported in the literature. Despite features of potential malignancy, the decision was taken to biopsy the lesion and not proceed to complete excision in an attempt to reduce the risk of facial nerve injury. Expert opinion later diagnosed NF. Contrary to accepted practice, where diagnostic uncertainty remains around the malignant potential of a lesion, risks and benefits of complete excision versus a conservative approach should be carefully weighed especially when the facial nerve is involved and NF is a possible diagnosis.

The importance of early flap coverage in deep sternal wounds.

BACKGROUND: Chronic or persistent wound infection is one of the key outcome measures after flap reconstruction in deep sternal wound infection (DSWI). This study aimed to assess potentially modifiable factors associated with chronic infection in patients undergoing flap reconstruction. MATERIALS AND METHODS: An analysis of a prospective database of 5239 median sternotomies performed during a 5-year period was carried out. Seventy-seven cases of DSWI were recorded, of which 23 cases proceeded to flap reconstruction. The flap-reconstructed patients were placed into groups according to the primary outcome measure of those who experienced chronic infection and those who remained infection free. RESULTS: Of the flap-reconstructed patients, 22% experienced subsequent chronic infection, whereas 78% remained infection free. The only 2 variables that were associated with chronic infection were the timing of flap reconstruction; median time 29.5 days (vs 12 days in the infection-free group), P=0.011 and time taken from diagnosis of wound infection/dehiscence to referral to the plastic surgical team; median 21 days (vs median 8 days in the infection free group), P=0.02. Each day of delay from the diagnosis of clinical infection to flap cover equated to an increase in risk of chronic infection of 1.2 times per day (OR=1.205, P=0.039). CONCLUSIONS: This study suggests that chronic infection after flap reconstruction in DSWI is associated with late flap cover. We suggest the need for a consensus agreement on the combined care and early management of DSWI.

Fibrin glue instillation under skin flaps to prevent seroma-related morbidity following breast and axillary surgery.

BACKGROUND: Fibrin glue (FG) combines fibrinogen and thrombin, under the presence of factor XIII and calcium chloride, and produces a 'fibrin clot' as would occur through the natural clotting cascade. FG is thought to close over any small vessels including lymphatics that are too small for conventional surgical closure, thereby reducing seroma formation, seroma incidence and related comorbidities. OBJECTIVES: To assess the evidence on the effectiveness of FG in people undergoing breast and axillary surgery and to establish whether FG is an efficient modality to prevent postoperative seroma and seroma-related outcomes. SEARCH METHODS: We searched the Cochrane Breast Cancer Group's (CBCG) Specialised Register (9 December 2011), the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 1 2012), MEDLINE (9 December 2011), EMBASE (9 December 2011), LILACS (22 October 2012), SCI-E (22 October 2012), the World Health Organization's International Clinical Trial Registry (9 December 2011) and ClinicalTrials.gov (22 October 2012). SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing the effectiveness of FG in terms of reducing the postoperative seroma incidence and related comorbidities in people undergoing breast and axillary surgery. DATA COLLECTION AND ANALYSIS: At least two review authors independently scrutinised search results, selected eligible studies and extracted the data. The pooled analysis of the extracted data was achieved by the statistical analysis on Review Manager software. The quality of studies was assessed using The Cochrane Collaboration's 'Risk of bias' tool. MAIN RESULTS: The search of four standard electronic databases yielded 119 potentially relevant studies but only 18 RCTs involving 1252 people were found suitable for statistical analysis. There was significant heterogeneity among trials and the majority of trials were of poor quality. The use of FG under skin flaps following breast and axillary surgery failed to reduce the incidence of postoperative seroma (risk ratio (RR) 1.02; 95% Confidence Interval (CI) 0.90 to 1.16, P value = 0.73), mean volume of seroma (standardised mean difference (SMD) -0.25; 95% CI -0.92 to 0.42, P value = 0.46), wound infection (RR 1.05; 95% CI 0.63 to 1.77, P value = 0.84), postoperative complications (RR 1.13; 95% CI 0.63 to 2.04, P value = 0.68) and length of hospital stay (SMD -0.2; 95% CI -0.78 to 0.39, P value = 0.51). FG reduced the total volume of drained seroma (SMD -0.75, 95% CI -1.24 to -0.26, P value = 0.003) and duration of persistent seromas requiring frequent aspirations (SMD -0.59; CI 95% -0.95 to -0.23, P value = 0.001). AUTHORS' CONCLUSIONS: FG did not influence the incidence of postoperative seroma, the mean volume of seroma, wound infections, complications and the length of hospital stays in people undergoing breast cancer surgery. Due to significant methodological and clinical diversity among the included studies this conclusion may be considered weak and biased. Therefore, a major multicentre and high-quality RCT is required to validate these findings.

Single-incision laparoscopic cholecystectomy versus conventional laparoscopic cholecystectomy: meta-analysis and systematic review of randomized controlled trials.

BACKGROUND: The objective of this study was to analyze systematically the randomized, controlled trials that compared single-incision laparoscopic cholecystectomy (SILC) and conventional laparoscopic cholecystectomy (CLC). METHODS: The meta-analysis was conducted according to the Quality of Reporting of Meta-analysis (QUORUM) standards. The included studies were analyzed systematically using the statistical software package RevMan. The summated outcomes were expressed as the risk ratios (RR) for dichotomous variables and standardized mean differences (SMD) for continuous variables. RESULTS: Eleven randomized trials encompassing 858 patients were retrieved from the electronic databases. In the random effects model, postoperative pain, postoperative complications, length of hospital stay, cosmesis score, conversion rate, and time to return to normal activities were statistically comparable between the two cholecystectomy techniques. SILC was associated with a longer operating time [SMD 0.71; 95 % confidence interval (CI) 0.38, 1.05; z = 4.18; p < 0.0001) and an increased requirement for additional port insertion (RR 6.54; 95 % CI 2.19, 19.57; z = 3.36; p < 0008). However, there was significant heterogeneity among the trials. CONCLUSIONS: SILC does not offer any advantage over CLC for treating benign gallbladder disorders. CLC may be used assiduously for this purpose.

An updated meta-analysis on the effectiveness of preoperative prophylactic antibiotics in patients undergoing breast surgical procedures.

To systematically analyze published randomized trials on the effectiveness of preoperative prophylactic antibiotics in patients undergoing breast surgical procedures. Trials on the effectiveness of preoperative prophylactic antibiotics in patients undergoing breast surgery were selected and analyzed to generate summated data (expressed as risk ratio [RR]) by using RevMan 5.0. Nine randomized controlled trials encompassing 3720 patients undergoing breast surgery were retrieved from the electronic databases. The antibiotics group comprised a total of 1857 patients and non-antibiotics group, 1863 patients. There was no heterogeneity [χ(2) = 7.61, d.f. = 7, p < 0.37; I(2) = 8%] amongst trials. Therefore, in the fixed-effects model (RR, 0.64; 95% CI, 0.50-0.83; z = 3.48; p < 0.0005), the use of preoperative prophylactic antibiotics in patients undergoing breast surgical procedures was statistically significant in reducing the incidence of surgical site infection (SSI). Furthermore, in the fixed-effects model (RR, 1.30; 95% CI, 0.89-1.90; z = 1.37; p < 0.17), adverse reactions secondary to the use of prophylactic antibiotics was not statistically significant between the two groups. Preoperative prophylactic antibiotics significantly reduce the risk of SSI after breast surgical procedures. The risk of adverse reactions from prophylactic antibiotic administration is not significant in these patients. Therefore, preoperative prophylactic antibiotics in breast surgery patients may be routinely administered. Further research is required, however, on risk stratification for SSI, timing and duration of prophylaxis, and the need for prophylaxis in patients undergoing breast reconstruction versus no reconstruction.

The role of fibrin glue instillation under skin flaps in the prevention of seroma formation and related morbidities following breast and axillary surgery for breast cancer: a meta-analysis.

A systematic review of randomised, controlled trials investigating the effectiveness of fibrin glue (FG) in reducing the postoperative seroma and seroma related morbidities following breast and axillary surgery was conducted. FG failed to influence the incidence of postoperative seroma, average volume of seroma, wound infection, complications and length of hospital stay in patients undergoing breast cancer surgery. However, a major multicentre and high quality randomised, controlled trial is required to validate these findings.