Burnout in ENT France: Update and risk factors; a STROBE analysis

BACKGROUND

Burnout can significantly impact practitioners and their co-workers, and hence patients. There are no data for the prevalence of burnout in French ENT specialists, or for associated risk factors.

MATERIAL AND METHODS

A French national cross-sectional online survey was performed on the initiative of the ENT National Professional Council (CNPORL), contacting all ENT specialists whose e-mail address was known to the French Society of ENT, the National Professional Council or the National ENT Union. The 22-question Maslach Burnout Inventory (MBI) was sent out, along with 16 extra questions on possible risk factors.

OBJECTIVES

The study sought to assess the prevalence and severity of burnout, using the MBI, and to analyze risk factors.

RESULTS

Among the 1936 physicians, 406 contacted responded to the questionnaire (21%). Mean age was 47±14 years (range, 25-77 years); 53% male, 47% female. 196 (48%) reported burnout, including 20 (5%) severe burnout. Independent risk factors for burnout of whatever severity, comprised social interaction issues, history of identified burnout, and medicolegal pressures. Social interaction issues were independently associated with specifically severe burnout.

CONCLUSIONS

Burnout affected almost half of respondents. There are identifiable risk factors, for which improvements could be implemented.

French Society of ENT (SFORL) guidelines. Management of acute Bell's palsy

AQFThe authors present the guidelines of the French Society of ENT and Head and Neck Surgery (SFORL) regarding the management of Bell's palsy in adults. After a literature review by a multidisciplinary workgroup, guidelines were drawn up based on retrieved articles and group-members' experience, then read over by an independent group to edit the final version. Guidelines were graded A, B, C or "expert opinion" according to decreasing level of evidence. Thorough ENT and neurological clinical examination is recommended in all patients presenting with peripheral facial palsy to confirm diagnosis of Bell's palsy. MRI with gadolinium enhancement should explore the entire course of the facial nerve, if possible within the first month. ENMG should be performed to assess prognosis for recovery. In confirmed Bell's palsy, corticosteroid therapy should be implemented as early as possible (ideally within 72h) at a dose of 1mg/kg/day for 7-10 days. Antiviral therapy should be associated to steroids in patients with severe and early-onset disease and in Ramsay-Hunt syndrome. Isolated antiviral therapy is not recommended. To date, there is no evidence that surgical facial nerve decompression provides benefit.

Cochlear implantation in far-advanced otosclerosis: hearing results and complications

Severe forms of otosclerosis known as far-advanced otosclerosis (FAO) can lead to severe to profound sensorineural hearing loss and can justify cochlear implantation. Because of the pathophysiology of otosclerosis, patients implanted for FAO may experience an increased rate of complications, such as facial nerve stimulation or electrode dislocation, and may have poorer hearing outcomes than expected. This retrospective study aimed to compare cochlear implantation hearing outcomes, surgical difficulties and complications in FAO patients versus non-FAO patients. Moreover, we evaluated whether high resolution computed tomography (CT scan) findings were predictive of perioperative problems, complications and hearing outcomes. FAO patients were diagnosed based on medical history, examination and CT scan. Thirty-five ears from FAO patients were compared to 38 control ears. Audiometric results were assessed at least 12 months after implantation by pure tone average, speech reception threshold, monosyllabic and disyllabic word recognition score (WRS) and Central Institute for the Deaf (CID) sentences test. Complications and surgical difficulties were compiled. CT scan findings were categorised within 3 grades of otosclerotic extension. No significant difference was found between FAO and non-FAO hearing outcomes, except that monosyllabic WRS were lower for FAO patients, especially those who underwent previous stapedotomy. Facial nerve symptomatology occurred in 8.6% of FAO patients; among these, one required explantation-reimplantation surgery. 86% of FAO implanted patients had retrofenestral extension on CT. These were associated with poorer disyllabic WRS (51% vs 68%, p < 0.05) than those with only fenestral involvement. Although not significant, high grade of severity on CT tended to be associated with surgical difficulties and complications. Cochlear implantation in FAO patients is an effective treatment technique. Though the overall complication rate is low, it tends to be higher in cases of severe extension on CT. Patient counselling should be adjusted accordingly.

International consensus (ICON) on treatment of Ménière's disease

OBJECTIVE

To present the international consensus for recommendations for Ménière's disease (MD) treatment.

METHODS

Based on a literature review and report of 4 experts from 4 continents, the recommendations have been presented during the 21st IFOS congress in Paris, in June 2017 and are presented in this work.

RESULTS

The recommendation is to change the lifestyle, to use the vestibular rehabilitation in the intercritic period and to propose psychotherapy. As a conservative medical treatment of first line, the authors recommend to use diuretics and Betahistine or local pressure therapy. When medical treatment fails, the recommendation is to use a second line treatment, which consists in the intratympanic injection of steroids. Then as a third line treatment, depending on the hearing function, could be either the endolymphatic sac surgery (when hearing is worth being preserved) or the intratympanic injection of gentamicin (with higher risks of hearing loss). The very last option is the destructive surgical treatment labyrinthectomy, associated or not to cochlear implantation or vestibular nerve section (when hearing is worth being preserved), which is the most frequent option.

Iatrogenic facial nerve injuries during chronic otitis media surgery: a multicentre retrospective study

OBJECTIVES

To give an insight into why, when and where iatrogenic facial nerve (FN) injuries may occur and to explain how to deal with them in an emergency setting.

DESIGN AND SETTING

Multicentre retrospective study in eight tertiary referral hospitals over 17 years.

PARTICIPANTS

Twenty patients with partial or total FN injury during surgery for chronic otitis media (COM) were revised.

MAIN OUTCOME MEASURES

Indication and type of surgery, experience of the surgeon, intra- and postoperative findings, value of CT scanning, patient management and final FN outcome were recorded.

RESULTS

In 12 cases, the nerve was completely transected, but the surgeon was unaware in 11 cases. A minority of cases occurred in academic teaching hospitals. Tympanic segment, second genu and proximal mastoid segments were the sites involved during injury. The FN was not deliberately identified in 18 patients at the time of injury, and nerve monitoring was only applied in one patient. Before revision surgery, CT scanning correctly identified the lesion site in 11 of 12 cases and depicted additional lesions such as damage to the lateral semicircular canal. A greater auricular nerve graft was interposed in 10 cases of total transection and in one partially lesioned nerve: seven of them resulted in an HB III functional outcome. In two of the transected nerves, rerouting and direct end-to-end anastomosis was applied. A simple FN decompression was used in four cases of superficially traumatised nerves.

CONCLUSIONS

We suggest checklists for preoperative, intraoperative and postoperative management to prevent and treat iatrogenic FN injury during COM surgery.

Early and late surgical site infections in ear surgery

A retroauricular approach is routinely used for treating chronic otitis media. The incidence of surgical site infections after ear surgery is around 10% in contaminated or dirty procedures. This observational prospective study describes surgical site infections after chronic otitis media surgery with the retroauricular approach and investigated their potential predictive factors. This observational prospective study included patients suffering from chronic otitis media and eligible for therapeutic surgery with a retroauricular approach. During follow-up, surgical site infections were defined as "early" if occurring within 30 days after surgery or as "late" if occurring thereafter. The data of 102 patients were analysed. Concerning early surgical site infections, four cases were diagnosed (3.9%) and a significant association was found with preoperative antibiotic therapy, wet ear at pre-operative examination, class III (contaminated) in the surgical wound classification, NNIS (National Nosocomial Infection Surveillance) index > 1, and oral post-operative antibiotic use. Seven late surgical site infections were diagnosed (7.1%) between 90 and 160 days after surgery and were significantly correlated to otorrhoea during the 6 months before surgery, surgery duration ≤60 minutes, canal wall down technique and use of fibrin glue. Surgical site infections after chronic otitis media surgery seem to be associated with factors related to the inflammatory state of the middle ear at the time of surgery in early infections and with chronic inflammation in late infections.

[Using the superficial temporal fascia flap in orbital surgery]

The superficial temporal fascia flap gives a fine malleable well vascularized tissue and can be used as a pedicled or a free flap to cover large areas of loss of substance. Its dissection needs a period of training. Its use in orbital surgery is rare. However when it is about an anophthalmic socket following radiotherapy with orbital retraction syndrome, it provides tissue of good quality. This could allow later reconstruction by mucous grafts. When used on cavities of exenteration it allows fast re-epithelialisation even post-radiotherapy, while allowing the monitoring of the cavity and in particular the early detection of any tumor recurrence. Its use is advantageous in unfavorable conditions especially after radiotherapy.

Stage II vestibular schwannoma: predictive factors for postoperative hearing loss and facial palsy

OBJECTIVES

To assess predictive factors for deafness and facial palsy after vestibular schwannoma surgery on a translabyrinthine or retrolabyrinthine approach, and to compare sequela results to those for gamma knife radiosurgery.

PATIENTS AND METHODS

A retrospective study included 70 patients operated on for stage II vestibular schwannoma (Koos classification). Postoperative hearing was assessed on pure-tone average and speech discrimination score, and facial palsy on the House and Brackmann classification, preoperatively and at 1 year postoperatively. Various predictive factors were assessed for both. Statistical analysis used the Fischer exact test, with a significance threshold of P<0.05.

RESULTS

Hearing was conserved in 18.9% of patients operated on with a retrolabyrinthine approach, with 8.1% conserving useful hearing. Facial function was conserved in 91.4%. Predictive factors for hearing conservation did not achieve statistical significance, but showed trends for: preoperative pure-tone average threshold≤30dB and speech discrimination score≥ 70%, age less than 55 years, tinnitus, nearly normal auditory brainstem response (ABR) latency, and homogeneous tumor on MRI. Predictive factors for conserved facial function likewise did not achieve statistical significance, but showed trends for: age less than 55 years, deafness of progressive onset, absence of cardiovascular risk factors, nearly normal ABR latency and tumor size<13.5mm on MRI.

CONCLUSION

Facial nerve risk is largely the same with surgery or gamma knife radiosurgery. Concerning hearing, gamma knife radiosurgery seems to provide better hearing conservation, but only over the short term.