Cochlear implant eligibility in an adult hearing aid population: a multi-perspective service evaluation of a patient referral pathway at a British district general hospital.

OBJECTIVES: To quantify patient eligibility for cochlear implantation following National Institute for Health and Care Excellence 2019 guidelines (TA566) over five years at our institution, and identify factors influencing patients' decisions surrounding cochlear implantation referral. METHODS: A multi-perspective service evaluation was conducted at a district general hospital, comprising cochlear implantation eligible patients. The main outcome measures were: eligibility numbers for 2014-2019, comparing application of TA566 versus 2009 (TA166) guidelines; and patient interview transcripts and questionnaires. RESULTS: There was a 259 per cent average increase in cochlear implantation eligibility from 2014 to 2019. Most patients' thresholds were 80 dB HL or more at 3 kHz and 4 kHz. There are several cochlear implantation barriers, including patient-centred issues (e.g. health-related anxieties, implantation misperceptions) and external barriers (difficulty getting to regional implant centres). Motivating factors for cochlear implantation include improved quality of life and access to local cochlear implantation services. CONCLUSION: The TA566 guidelines have increased cochlear implantation eligibility, putting pressure on cochlear implantation centres and referring hospitals. Current referral systems have external and patient-centred implantation barriers. British cochlear implantation delivery may need rethinking to meet increasing populational demands and improve accessibility for those most vulnerable to these barriers.

Incidental mastoiditis on magnetic resonance imaging scans: clinical relevance and cost implications.

OBJECTIVES: To determine: (1) the incidence of incidental 'mastoiditis' reported on magnetic resonance imaging scans performed in patients with asymmetrical sensorineural hearing loss and/or unilateral tinnitus; (2) how many of those patients have actual otological pathology and/or require treatment; and (3) the financial implications of such a reporting practice. METHOD: Retrospective case series. RESULTS: Between October 2015 and November 2016, 500 patients underwent magnetic resonance imaging of the internal auditory meatus to rule out cerebellopontine angle lesions. There was an incidental finding of increased mastoid signalling in 5.8 per cent (n = 29), of which 20.7 per cent (6 of 29) were reported as bilateral cases. The diagnosis of 'mastoiditis' was found in 39.7 per cent (29 of 73). None of these patients had any pathology identified clinically. Other significant pathology was identified in a further 8.8 per cent (n = 44). CONCLUSION: The diagnosis of mastoiditis is primarily clinical. An incidental finding of high signalling in the mastoid region on magnetic resonance imaging is highly unlikely to represent actual clinical disease. In patients who are scanned for other reasons and who do not complain of otological symptoms, such findings are unlikely to require otolaryngology input.

Audiologist-led screening of acoustic neuromas in patients with asymmetrical sensorineural hearing loss and/or unilateral tinnitus: our experience in 1126 patients.

OBJECTIVE: To determine whether patients within an otolaryngology department presenting with asymmetrical sensorineural hearing loss and/or unilateral tinnitus can be safely and cost-efficiently screened for acoustic neuroma by audiologists as a first or only point of contact. METHODS: A prospective case series and cost analysis were conducted at a tertiary referral centre. Between April 2013 and March 2017, 1126 adult patients presented to the audiology department with asymmetrical sensorineural hearing loss and/or unilateral tinnitus. All were screened for acoustic neuroma with magnetic resonance imaging, based on pre-determined criteria. The main outcome measure was the presence of acoustic neuroma or other pathology on magnetic resonance imaging. RESULTS: Twenty-five patients (2.22 per cent) were found to have an acoustic neuroma (size range: 3-20 mm) and were referred to the otolaryngologist for further assessment. The remaining patients were appropriately managed and discharged by the audiologists without ENT input. This resulted in an overall cost saving of £164 850. CONCLUSION: Patients with asymmetrical sensorineural hearing loss and/or unilateral tinnitus can be safely screened for acoustic neuroma and independently managed by audiologists as a first or only point of contact, resulting in considerable departmental cost savings.

Bilateral glossopharyngeal nerve palsy following tonsillectomy: a very rare and difficult complication of a common procedure.

OBJECTIVES: Tonsillectomy is one of the most commonly performed otolaryngological procedures. Bilateral palsy of the glossopharyngeal nerve is an exceedingly rare complication that can result in significant morbidity. This case report aimed to raise awareness of this complication and outline management strategies. CASE REPORT: A 31-year-old woman who underwent routine tonsillectomy presented with progressive numbness of the palate, dysgeusia, xerostomia, paraesthesia of the tongue and the feeling of something in her throat within 2 weeks of surgery. She reported the post-operative onset of snoring. Examination revealed a symmetrically low, 'dropped' soft palate. Over time, her symptoms have lessened, but dysgeusia and snoring remain. CONCLUSION: The position of the glossopharyngeal nerve in the tonsillar bed makes it prone to injury during tonsillectomy, especially if 'hot' methods are used. Bilateral injury can result in significant morbidity that can be difficult to treat. Patients should be warned about this risk and care should be taken to minimise it.

The intra-operative incidence of Fallopian canal dehiscence during surgery for cholesteatoma: a prospective case-control study and review of the literature.

OBJECTIVE: To investigate Fallopian canal dehiscence (FCD) during cholesteatoma surgery. STUDY DESIGN: Prospective case-control study. PATIENTS: Four hundred and one patients with cholesteatoma and 172 with otosclerosis. INTERVENTIONS: Therapeutic. SETTING: District general hospital. MAIN OUTCOME MEASURES: (i) Intra-operative incidence of FCD during (a) surgery for cholesteatoma versus a homogeneous control group (patients with otosclerosis); (b) revision surgery for cholesteatoma as compared to primary surgery. (ii) Intra-operative incidence of a fistula if FCD is present. RESULTS: Data were prospectively collected and analysed using chi-square tests. FCD was found in 19% of cases versus 5.2% of controls. Intra-operative incidence of (i) FCD during cholesteatoma surgery versus otosclerosis surgery was statistically very highly significant (P < 0.0001, OR = 5.43); (ii) FCD during revision versus primary cholesteatoma surgery was not statistically significant (P = 0.83); and (iii) encountering a fistula in the presence of FCD during cholesteatoma surgery was statistically very highly significant (P < 0.0001, OR = 6.71). CONCLUSIONS: A surgeon is more likely to encounter FCD during cholesteatoma surgery than in stapes surgery. If during cholesteatoma surgery FCD is found, then a fistula is also more likely to be present, mainly of the semicircular canal. The incidence of FCD is not increased in revision surgery. These findings are very relevant for any otologist undertaking cholesteatoma surgery.

Consultant-led, multidisciplinary balance clinic: process evaluation of a specialist model of care in a district general hospital.

OBJECTIVE: A specialist balance clinic to effectively deal with dizzy patients is recommended by ENT-UK. We audit the patient pathway before and following the introduction of a consultant-led dedicated balance clinic. DESIGN: Process evaluation and audit. SETTING: ENT outpatients department of a district general hospital. MAIN OUTCOME MEASURES: The journey of dizzy patients seen in the general ENT clinic was mapped from case notes and recorded retrospectively. A consultant-led, multidisciplinary balance clinic involving an otologist, a senior audiologist and a neurophysiotherapist was then set up, and the journey was prospectively recorded and compared with that before the change. RESULTS: Of the 44 dizzy patients seen in the general clinic, 41% had further follow-up consultations; 64% were given definitive or provisional diagnoses; 75% were discharged without a management plan. Oculomotor examination was not systematically performed. The mean interval between Visits 1 and 2 was 8.4 weeks and the mean number of visits was 3. In the consultant-led dedicated balance clinic, following Visit 1, only 8% of patients required follow-up; 97% received definitive diagnoses, which guided management; all patients left with definitive management plans in place. In all patients, oculomotor assessment was systematically performed and all patients received consultant and, where necessary, allied healthcare professional input. CONCLUSIONS: By standardising the management experience for dizzy patients, appropriate and timely treatment can be achieved, allowing for a more seamless and efficient patient journey from referral to treatment. A multidisciplinary balance clinic led by a consultant otologist is the ideal way to achieve this.

Salivary gland pathology in the paediatric population: implications for management and presentation of a rare case.

INTRODUCTION: Salivary gland pathology in the paediatric population is rare and can present management challenges regarding both investigation and treatment. METHOD: Case report and review of available literature. RESULTS: A seven-year-old, fit, well girl presented with a two-month history of a painless mass over the left parotid area. Ultrasonography confirmed the presence of a well-defined, 1.5 × 2 cm, predominantly solid lesion with minor internal cystic spaces arising from the superficial part of the gland. Magnetic resonance imaging showed no invasion of the deep lobe or skeletal erosion. Superficial parotidectomy was performed via a facelift incision. Histopathology confirmed a diagnosis of pleomorphic adenoma. Review of the literature emphasised important differences in managing this pathology in the paediatric population when compared with adults. CONCLUSION: We present the youngest reported case of a pleomorphic adenoma of the parotid gland, detail its management, and discuss the general approach to parotid pathology management in the paediatric population.

The case for mistletoe in the treatment of laryngeal cancer.

INTRODUCTION: Complementary and alternative medicine usage, though rising, remains largely devoid of a sound scientific basis; however, there is increasing evidence to support its use in cancer therapy. AIM: To present the case of a patient with laryngeal carcinoma who made a full recovery following mistletoe therapy, despite failing to respond to chemoradiotherapy and salvage laryngectomy. DESIGN: Case report with relevant literature review. RESULTS: The patient developed extensive, unresectable stomal recurrence, and it was deemed appropriate to supply palliative care only. Following treatment with mistletoe extract injections after palliative radiotherapy, he recovered fully and was eventually discharged from care. CONCLUSION: The benefit of mistletoe in laryngeal cancer treatment requires further investigation, and might be considered in selected patients, as an adjunct or when other conventional therapies have failed.

The role of caffeine in otorhinolaryngology: guilty as charged?

Caffeine is implicated as causing or aggravating numerous otorhinolaryngological conditions, including tinnitus, Ménière's disease, laryngopharyngeal reflux, globus pharyngeus and dysphonia. We address caffeine's effects in such conditions and to determine whether such implications are founded. The defined search limits of data sources included human trials and either randomised control trials, meta-analyses, editorials, letters, clinical trials, case reports, comments or journal articles over the last 40 years. MEDLINE, EMBASE and CINAHL databases were searched using 'otorhinolaryngological diseases' and 'caffeine' as a duplicate filter. PubMed databases were searched using 'caffeine' in combination with 'tinnitus', 'Ménière's', 'vertigo', 'motion sickness', 'imbalance', 'vestibular migraine', 'voice', 'vocal hygiene', 'reflux', 'ear', 'nose', 'throat' and 'head neck cancer', respectively. Searches were not limited to the English language. MEDLINE, EMBASE and CINAHL database searches identified 417 papers. Of these, 200 abstracts were chosen for further scrutiny, following which 30 full manuscripts were chosen for full review. The PubMed database search identified 275 abstracts of which 33 were reviewed. Of the total 692 studies searched, 63 studies were reviewed and 36 were finally used. At present, there is little evidence in the literature to support the notion that caffeine causes or aggravates otorhinolaryngological conditions. In tinnitus, its withdrawal may actually worsen symptoms whereas in motion sickness, there is some clinical evidence for its benefit. More research is needed into the role caffeine plays in otorhinolaryngological conditions to allow clinicians to give informed advice to their patients.

Is there a change in the epidemiology of nasal fractures in females in the UK?

OBJECTIVE: To determine whether there is a change in the epidemiology of nasal fractures in females in the UK, and the potential contribution of the 'ladette' culture. METHODS: This paper reports a multi-centre retrospective study. Operating theatre data for all females who underwent manipulation of nasal fractures under anaesthesia between 2002 and 2009 were analysed. In addition, the case notes of all females presenting with nasal fractures over a five-year period (2004-2009) were retrospectively reviewed and the cited cause of the fracture was noted. RESULTS: From 2002 to 2009, there was an 825 per cent increase in nasal fractures in women aged 13-20 years. Almost one-quarter of all nasal fractures in one centre was attributed to non-domestic violence. The highest incidence of nasal fractures (67 per cent) was amongst white British females. CONCLUSION: There is an increasing trend in the number of women sustaining nasal fractures in the UK. The cause may be multi-factorial, but could be partially attributed to a rise in ladette culture. Further research on the role of alcohol consumption in this phenomenon is needed.

'Wind turbine syndrome': fact or fiction?

OBJECTIVE: Symptoms, including tinnitus, ear pain and vertigo, have been reported following exposure to wind turbine noise. This review addresses the effects of infrasound and low frequency noise and questions the existence of 'wind turbine syndrome'. DESIGN: This review is based on a search for articles published within the last 10 years, conducted using the PubMed database and Google Scholar search engine, which included in their title or abstract the terms 'wind turbine', 'infrasound' or 'low frequency noise'. RESULTS: There is evidence that infrasound has a physiological effect on the ear. Until this effect is fully understood, it is impossible to conclude that wind turbine noise does not cause any of the symptoms described. However, many believe that these symptoms are related largely to the stress caused by unwanted noise exposure. CONCLUSION: There is some evidence of symptoms in patients exposed to wind turbine noise. The effects of infrasound require further investigation.

Success of cricopharyngeal myotomy for specific and non-specific cervical dysphagia.

OBJECTIVE: The present study aimed to compare outcomes of cricopharyngeal myotomy (CPM) in patients with documented cricopharyngeal dysfunction (CPD) and those in whom the diagnosis is complex or in doubt. MATERIALS AND METHODS: Retrospective comparative study of all patients undergoing CPM between 2001 and 2010 at a single UK centre. Patients were classified as having either CPD (n = 15) or non-specific cervical dysphagia (NSCD) (n = 12) based on contrast swallow results. They completed a 10-point visual analogue scale (VAS) questionnaire regarding their ability to swallow solids preoperatively and 6 months postoperatively. Scores were compared between groups, and symptom recurrence at 12 months postoperatively was also noted. RESULTS: The median VAS for all patients in both groups preoperatively was 5.5 and improved postoperatively to 8.0 (p < 0.001), and median preoperative ratings between groups were similar (CPD = 6.0 vs. NSCD = 5.5; p > 0.05). The CPD group scored better postoperatively compared to their NSCD counterparts (CPD = 9.0 vs. NSCD = 7.5; p < 0.001). Recurrence rate at 12 months was lower in CPD (12.5%) compared to NSCD (60%) patients. CONCLUSION: After CPM, patients with CPD showed significant improvement in swallowing solids, as did patients with NSCD, although to a lesser extent. CPD patients experienced better outcomes compared to their NSCD counterparts, including lower complication and recurrence rates. Larger studies are required before CPM can be advocated as the standard of care for NSCD patients.

Cerebrospinal fluid otorrhoea following grommet insertion: management using a multi-layered graft technique and an important lesson revisited.

BACKGROUND: A spontaneous cerebrospinal fluid leak can sometimes only become apparent following grommet insertion and usually represents dehiscence of the tegmen tympani, which is an uncommon condition. OBJECTIVES: This report aimed to reaffirm the importance of recognising this unusual presentation and outline management options. CASE REPORT: A 63-year-old man with conductive hearing loss and type B (flat) tympanometry underwent grommet insertion into his left ear, which resulted in cerebrospinal fluid otorrhoea. A defect of the tegmen tympani was found. This was successfully repaired via a transmastoid approach using a multi-layered grafting technique. CONCLUSION: Dehiscence of the tegmen tympani is uncommon and may only come to light following grommet insertion, which may be problematic for the uninformed otolaryngologist. Education is important to ensure early recognition and appropriate management.

Periorbital cellulitis, subgaleal abscess and superior sagittal sinus thrombosis: a rare combination of complications arising from unilateral frontal sinusitis.

BACKGROUND: Subclinical infection of the sinuses can result in delayed diagnosis and unusual presenting complications. CASE REPORT: This paper describes the case of a 14-year-old boy with a rare combination of periorbital cellulitis, subgaleal abscess and superior sagittal sinus thrombosis following a late presentation of unilateral frontal sinusitis. RESULTS: Following multiple surgical procedures, and antimicrobial and anticoagulation therapy, the patient made a full recovery. CONCLUSION: Serious sinusitis complications still occur, and can do so in unusual combinations with minimal clinical signs. Systemic anticoagulation therapy is considered safe practice in the management of cerebral venous sinus thrombosis and may reduce morbidity and mortality.

Plasmacytoma of the atlas presenting as hoarseness: a rare cause of unilateral vocal fold palsy.

INTRODUCTION: Solitary bone plasmacytoma is a rare haematological malignancy that can present in a variety of ways. This study aimed to present a case of plasmacytoma of the atlas, as a rare cause of unilateral vocal fold palsy. METHOD: Case report. RESULTS: Following diagnosis via imaging and direct biopsy through the posterior pharyngeal wall, the patient was referred to the haematologists for further treatment of his plasmacytoma. CONCLUSION: Solitary bony plasmacytoma of the cervical spine is a rare haematological malignancy. Its presentation with a unilateral vocal fold palsy has not been previously described.