Management of recurrent pinna haematoma following rugby injury: a surgical approach

A young adult male developed a left-sided pinna haematoma after a rugby injury. The haematoma reaccumulated after multiple attempts at drainage under local anaesthetic in emergency rooms and required incision and drainage in the theatre under general anaesthetic. Intraoperatively, multiple venous bleeding points were identified and these were controlled with bipolar diathermy. The wound was closed and dressed with bolster and crepe bandage. On day 7 postoperatively, the sutures and dressings were removed and the haematoma had not recurred. He returned to playing rugby on day 21 postoperatively and sustained another blunt impact to his left ear. He noticed new swelling over the posterior aspect of the same ear. This was drained via needle aspiration and there was no further reaccumulation of the pinna haematoma.

Prophylactic vs. Reactive Gastrostomy Tube Placement in Patients Treated with Radiotherapy for Head and Neck Cancer

PURPOSE/OBJECTIVE(S)

Radiotherapy (RT) for head and neck cancer (HNC) can cause acute toxicities resulting in weight loss warranting alterative enteral access. Some institutions favor prophylactic gastrostomy tube (GT) placement to prevent malnutrition at the forefront, while others choose to reactively place tubes if nutritional deficits arise. Though prophylactic GT placement may limit on-treatment weight loss, this approach may result in unneeded GT placement and may potentially impact long-term swallowing function.

MATERIALS/METHODS

Patients with HNC treated with CRT from 2018-2021 were reviewed. GT placement prior to CRT (prophylactic [ppx] tube) was performed at the discretion of the treating radiation oncologist. The remainder of patients were treated with reactive (rx) GT placement in the event of on-treatment weight loss approaching 10-15%. Patient, disease and treatment factors were abstracted from the medical record. Primary endpoints were placement of GT in the rx group, weight change at the end of RT, and time to tube removal.

RESULTS

In total, 278 patients were identified; 35 GT-dependent patients and 22 patients with nasal cavity/paranasal sinus cancers were excluded, yielding 221 for analysis. Baseline factors associated with GT group included age, ECOG, baseline swallowing function, primary site, T and N stage, stage group, and treatment year. Treatment factors associated with GT group were: neck target (bilateral v. unilateral/none), concurrent chemotherapy, and total dose. Of the 118 patients in the rx group, 14 (12%) required rx GT placement during or within 30 days of CRT. RT completion rates were similar between groups (95-96%, p = 1). GT was removed at last follow-up in 57% of patients in both groups (p = 1). Percent on-treatment weight loss was -8.9% (SD 6.7) and -7.2% (SD 6.1) for the ppx and rx groups, respectively (p = 0.04). Median Kaplan-Meier estimate of time to GT removal was 7.7 months (95% CI 6.0-11.3) and did not differ between groups (log-rank p = 0.87). Factors associated with the placement of rx GT include: concurrent chemotherapy (yes 20% vs. No 0%, p.0007) and baseline FOIS (5 or less 40% vs. 6 or more 9%, p = 0.02). T stage, N stage, overall stage, postoperative RT, degree of neck irradiation were not associated.

CONCLUSION

Reactive gastrostomy tube placement in patients treated with chemoradiotherapy for head and neck cancer patients is feasible and results in low rates of gastrostomy tube placement. There are no observed differences in on-treatment weight loss between patients treated using a prophylactic versus reactive approach. No differences in time to gastrostomy tube removal were observed.

Operationalising targeted next-generation sequencing for routine diagnosis of drug-resistant TB

BACKGROUND

Phenotypic drug susceptibility testing (pDST) for Mycobacterium tuberculosis can take up to 8 weeks, while conventional molecular tests identify a limited set of resistance mutations. Targeted next-generation sequencing (tNGS) offers rapid results for predicting comprehensive drug resistance, and this study sought to explore its operational feasibility within a public health laboratory in Mumbai, India.

METHODS

Pulmonary samples from consenting patients testing Xpert MTB-positive were tested for drug resistance by conventional methods and using tNGS. Laboratory operational and logistical implementation experiences from study team members are shared below.

RESULTS

Of the total number of patients tested, 70% (113/161) had no history of previous TB or treatment; however, 88.2% (n = 142) had rifampicin-resistant/multidrug-resistant TB (RR/MDR-TB). There was a high concordance between resistance predictions of tNGS and pDST for most drugs, with tNGS more accurately identifying resistance overall. tNGS was integrated and adapted into the laboratory workflow; however, batching samples caused significantly longer result turnaround time, fastest at 24 days. Manual DNA extraction caused inefficiencies; thus protocol optimisations were performed. Technical expertise was required for analysis of uncharacterised mutations and interpretation of report templates. tNGS cost per sample was US$230, while for pDST this was US$119.

CONCLUSIONS

Implementation of tNGS is feasible in reference laboratories. It can rapidly identify drug resistance and should be considered as a potential alternative to pDST.

Temperature and luminosity outputs of endoscopes used in transcanal endoscopic ear surgery: an experimental study

OBJECTIVE

To establish the relationship between endoscope temperatures and luminosity with a variety of light source types, endoscope ages, endoscope sizes, angles and operative distance in transcanal endoscopic ear surgery.

METHODS

Transcanal endoscopic ear surgery was simulated in an operating theatre using 7 mm plastic suction tubing coated in insulating tape. An ATP ET-959 thermometer was used to record temperatures, and a Trotec BF06 lux meter was used to measure luminosity. Luminosity and temperature recordings were taken at 0 mm and 5 mm from the endoscope tip.

RESULTS

Thermal energy transfer from operating endoscopes is greatest when: the light intensity is high, there is a light-emitting diode light source and the endoscope is touching the surface. Additionally, larger-diameter endoscopes, angled endoscopes and new endoscopes generated greater heat.

CONCLUSION

It is recommended that operative light intensity is maintained at the lowest level possible, and that the surgeon avoids contact between patient tissues and the endoscope tip.

Clinical utility of target-based next-generation sequencing for drug-resistant TB

BACKGROUND: In high TB burden countries, access to drug susceptibility testing is a major bottleneck. Targeted next-generation sequencing (tNGS) is a promising technology for rapid resistance detection. This study assessed the role of tNGS for the diagnosis of drug-resistant TB (DR-TB).METHODS: A total of 161 samples from bacteriologically confirmed TB cases were subjected to tNGS using the Deeplex^® Myc-TB kit and sequenced using the MiSeq platform. These samples were also processed for conventional phenotypic DST (pDST) using 13 drugs on Mycobacteria Growth Indicator Tube and line-probe assays (MTBDRplus and MTBDRsl).RESULTS: There were 146 DR-TB and 15 drug-susceptible TB (DS-TB) samples. About 70% of patients with DR-TB had no previous TB treatment history. Overall, 88.2% had rifampicin-resistant/multidrug-resistant TB (RR/MDR-TB), 58.5% pre-extensively drug-resistant TB (pre-XDR-TB) and 9.2% had XDR-TB as defined by the WHO (2020). Around 8% (n = 13) of samples were non-culturable; however, identified 8 were resistant to first and second-line drugs using tNGS. Resistance frequency was similar across methods, with discordance in drugs less reliable using pDST or with limited mutational representation within databases. Sensitivities were aligned with literature reports for most drugs. We observed 10% heteroresistance, while 75% of strains were of Lineages 2 and 3.CONCLUSIONS: Programme data supported tNGS in the diagnosis of DR-TB for early treatment using individualised regimens.

Comparison of endoscopic vs microscopic ossiculoplasty: a study of 157 consecutive cases

PURPOSE

The relatively new technique of trans-canal endoscopic ear surgery (TEES) when compared to microsurgery for ossiculoplasty has advantages of better visualization and no external incision but also has the disadvantage of being a one-handed procedure. Our study aimed to compare audiometric outcomes following ossiculoplasty performed via TESS with results of microsurgery.

MATERIALS AND METHODS

Data from a prospective audit of 157 consecutive patients who underwent ossiculoplasty by a single otologist from 2009 to 2018 was analyzed. TEES was introduced in the department in 2014; therefore, all patients before this period underwent microsurgery. Patients were classified by surgical approach, TEES, or microsurgery. Audiological outcomes were recorded at 3 and 12 months postoperatively and compared to pre-operative levels. Other variables included were the condition of stapes and reconstruction material used.

RESULTS

Of the 157 cases, 50 were TEES and 107 were microsurgery (81 microscope only and 27 combined with endoscope). There was statistically significant improvement (p < 0.001) in AC (43.4 dB pre-operatively, 36.2 dB postoperatively), BC (20.3 dB pre-operatively, 17.6 dB postoperatively), and ABG (21.8 dB pre-operatively, 16.7 dB postoperatively) in the total cohort. Both groups achieved an ABG better than 20 dB; 72% in TEES, 73% in the microscopic group, and there was no significant difference. There was no change in hearing at 12 months when compared to 3 months. No statistically significant difference was noted based on stapes condition, type of material used for ossiculoplasty, or tympanic membrane graft.

CONCLUSION

TEES is safe and as effective as microsurgery in ossiculoplasty with possibly much less pain and morbidity.

LEVEL OF EVIDENCE: 3

Sinogenic polymicrobial anaerobic orbital cellulitis: the importance of source control and broad empirical antibiotics

A man in his twenties with a history of recurrent sinusitis was urgently referred to the emergency department (ED) by an out-of-hours general practitioner following a 2-day history of increasing right eye pain, redness and swelling after a week of coryzal symptoms. He denied visual impairment and any history of recent dental pain or procedures. Initial assessment in ED noted fever, tachycardia and hypotension. Video consultation with ophthalmologist in the ED identified proptosis, periorbital erythema and chemosis with full eye movement solely affecting the right eye. Visual acuity of 6/6 was confirmed in both eyes. After review by the ear, nose and throat (ENT) team, a diagnosis of sinogenic right orbital cellulitis was made, empirical antibiotics started and care transferred to the ENT team for immediate surgical intervention. 48 hours postoperatively, the patient acutely deteriorated, developing ophthalmoplegia and visual acuity of 6/95 in the right eye. Repeat imaging demonstrated a deteriorating picture and urgent surgery was organised at a neighbouring hospital's specialist ENT unit combined with a change to his antibiotics. On day 4, 1 day following transfer, an anaerobic bacterium, Eggerthia catenaformis, was isolated from blood cultures collected on admission. The patient improved clinically following the second surgery and targeted antimicrobial therapy, eventually being discharged 10 days after initial presentation. In addition to E. catenaformis, the Anaerobic Reference Unit (Cardiff) identified two further anaerobic bacteria, Parvimonas micra and Dialister pneumosintes This paper presents the first documented case of polymicrobial anaerobic orbital cellulitis secondary to acute bacterial sinusitis. Moreover, this case underpins the importance of broad empirical antibiotics coupled with surgical source control to effectively manage a rare but sight-threatening and life-threatening disease.

Validation of the novel Deep Reality Viewer (DRV) 3D digital stereo viewer in otology surgery

Purpose

Magnification with accurate optic reproduction of the surgical field is essential in otology surgery, but current technologies are subject to specific disadvantages. This study aims to evaluate a novel 3D digital stereo viewer, the Deep Reality Viewer (DRV), in otology surgery, in comparison to both a 2D monitor and the gold standard of microscopy.

Methods

In this prospective clinical research study, ENT consultants and trainees evaluated visual and practical applications of the DRV. In visual assessment, participants (n = 11) viewed pre-recorded in vivo mastoid exploration displayed on a 2D monitor and the DRV screen. In practical assessment, participants (n = 9) performed otology surgical tasks on a cadaveric human head using both the microscope and DRV. Face, task-specific (TSV) and global content (GCV) outcomes were assessed using 5-point Likert scale questionnaires. Construct validity was assessed separately.

Results

The DRV achieved the pre-determined validation threshold of 4 for all validation parameters in both visual and practical assessment. The DRV significantly outperformed the 2D monitor in fourteen of 16 parameters. In comparison to microscopy, there was no significant difference in 13 of 16 parameters, with the DRV significantly outperforming in the remaining 3: defining anatomy (GCV), assessing middle ear anatomy (TSV) and overall TSV. Construct validity was not demonstrated for either technology.

Conclusion

The DRV achieved the validation threshold for all parameters, and outperformed the 2D monitor and microscopy in several parameters. This validates the DRV for performing otological procedures, and suggests that it would be a useful alternative to the gold standard of microscopy in otology surgery.

Level of evidence

N/A.

An audit of post-operative pain scores after endoscopic and microscopic ear surgery

-Endoscopic ear surgery is often described as minimally invasive, which may reduce postoperative pain -VAS pain scores related to endoscopic ear surgery were lower than those related to microscopic ear surgery in our cohort within the first post-operative week -At day one, two and seven, analgesia requirements were lower in the endoscopic ear surgery group than the microscopic ear surgery group -Opioid analgesia requirement was lower in the endoscopic ear surgery group than the microscopic ear surgery group at days one and two post-operatively -Due to the differing applications of endoscopic and microscopic ear surgery, further research may be required to study the influence of type of surgery, degree of bone removal and approach on pain after ear surgery.

Transcriptomic Changes During Stage Progression of Mycosis Fungoides

BACKGROUND

Mycosis fungoides (MF) is the most common cutaneous T cell lymphoma, which in the early patch/plaque stages runs an indolent course. However, ~25% of MF patients develop skin tumors, a hallmark of progression to the advanced stage and is associated with high mortality. The mechanisms involved in stage progression are poorly elucidated.

METHODS

We performed whole-transcriptome and whole-exome sequencing of malignant MF cells from skin biopsies obtained by laser-capture microdissection. We compared three types of MF lesions: early-stage plaques (ESP, n=12) as well as plaques and tumors from patients in late-stage disease (late-stage plaques [LSP], n=10, and tumors [TMR], n=15). Gene Ontology (GO) and KEGG analysis were used to determine pathway changes specific for different lesions which were linked to the recurrent somatic mutations overrepresented in MF tumors.

RESULTS

The key upregulated pathways during stage progression were those related to cell proliferation and survival (MEK/ERK, Akt-mTOR), Th2/Th9 signaling (IL4, STAT3, STAT5, STAT6), meiomitosis (CT45A1, CT45A3, STAG3, GTSF1, REC8) and DNA repair (PARP1, MYCN, OGG1). Principal coordinate clustering of the transcriptome revealed extensive gene expression differences between early (ESP) and advanced-stage lesions (LSP and TMR). LSP and TMR showed remarkable similarities at the level of the transcriptome, which we interpreted as evidence of cell percolation between lesions via hematogenous self-seeding.

CONCLUSION

Stage progression in MF is associated with Th2/Th9 polarization of malignant cells, activation of proliferation, survival, as well as increased genomic instability. Global transcriptomic changes in multiple lesions may be caused by hematogenous cell percolation between discrete skin lesions.

Effect of Personal Protection Equipment (PPE) and the Distance From the Eye Piece of Surgical Microscope on the Field of Vision; An Experimental Study

BACKGROUND

During the Covid-19 pandemic, otolaryngologists are at risk due to aerosol-generating procedures such as mastoidectomy and need enhanced personal protective equipment (PPE). Eye protection can interfere with the use of a microscope due to a reduction in the field of vision. We aimed to study the effect of PPE on the microsurgical field.

METHODS

Five surgeons measured the visual field using digital calipers at different power settings. They were done with no PPE, a surgical mask, FFP3 mask (N99), and with the addition of small goggles, large vistamax goggles, vistamax plus a face shield, and only a face shield. The measurements were repeated with rings of 5 mm increments. We also measured the "eye relief" of the microscope which is the ideal distance for maximum field of view.

RESULTS

There was no major reduction of the field with the surgical or FFP3 mask. But even simple goggles reduced the field up to 31.6% and there were progressive reductions of up to 75.7% with large goggles, 76.8% when a face shield was added, and 61.9% when only face shield was used. The distance rings more than 5 mm also affected the field of view.The eye relief of our eyepiece was found to be 15 mm.

CONCLUSION

The current PPE eye protection is not compatible with the use of a microscope. There is scope for research into better eye protection. Mitigation strategies including barrier drapes and alternative techniques such as endoscopic surgery or use of exoscopes should also be considered.

Spontaneous pneumomediastinum: an uncommon clinical problem with a potential for missed or delayed diagnosis

A 15-year-old man presented with an acute history of facial swelling following a bout of forceful eructation after eating. Subcutaneous emphysema was noted on examination of his left face and neck. He was initially managed with intravenous antibiotics for suspected facial infection. A chest radiograph performed on day 3 of admission identified subcutaneous emphysema of the upper thorax and neck. CT with oral contrast confirmed extensive subcutaneous emphysema of neck, thorax and upper abdomen, with associated pneumomediastinum. The site of air leak was not identified. He subsequently underwent upper gastrointestinal endoscopy and this was normal. Despite the delay in diagnosis, he remained haemodynamically stable, and repeated radiography showed improvement reflecting the benign course of this condition as described in existing literature. There are no previous published reports of spontaneous pneumomediastinum following eructation; therefore, high clinical suspicion should be maintained in this presentation.

Mastoid Obliteration with Synthetic Materials: A Review of the Literature

Canal wall down mastoidectomy is a surgical technique used for the eradication of middle ear disease. The remaining large mastoid bowl is associated with a number of issues; one of the main techniques that have been developed in order to avoid such problems is the obliteration of the mastoid cavity. The materials used for this reason are either biological or synthetic. The purpose of this survey is to review the published literature related to the therapeutic value of mastoid obliteration with synthetic materials. We searched Web of Science, PubMed, and MEDLINE from 2008 to 2018 using the criteria mastoid obliteration, canal wall down mastoidectomy, chronic otitis media, and cholesteatoma. The search focused on papers concerning the mastoid obliteration with synthetic material, as we focused on looking for outcomes and reported complications. Out of a total of 244 citations, 15 articles were identified, where patients underwent mastoid obliteration with synthetic materials. Most authors used bioactive glass as a filler material. Mastoid obliteration resulted in a decrease in the complications associated with the open mastoid cavity. On the basis of the available limited literature, it seems that mastoid obliteration with synthetic materials is a valuable and safe surgical technique for patients who undergo canal wall down mastoidectomy. The bioactive glass appears to be the most reliable synthetic material.

Proposal of a timing strategy for cholesteatoma surgery during the COVID-19 pandemic

Purpose

The COVID-19 infection is an aggressive viral illness with high risk of transmission during otolaryngology examination and surgery. Cholesteatoma is known for its potential to cause complications and scheduling of surgery during the pandemic must be done carefully. The majority of otological surgeries may be classified as elective and postponed at this time (e.g., stapedotomy, tympanoplasty); whereas, others are emergencies (e.g., complicated acute otitis media, complicated cholesteatoma with cerebral or Bezold’s abscess, meningitis, sinus thrombosis) and require immediate intervention. What is the ideal time for the surgical management of Cholesteatoma during the COVID-19 pandemic?

Methods

Senior otologic surgeons from six teaching hospitals from various countries affected by the COVID-19 from around the world met remotely to make recommendations on reorganizing schedules for the treatment of cholesteatoma which has a risk of severe morbidity and mortality. The recommendations are based on their experiences and on available literature.

Results

Due to the high risk of infecting the surgical staff it is prudent to stop all elective ear surgeries and plan cholesteatoma surgery after careful selection of patients, based on the extent of the disease and available resources. Specific precautions including use of appropriate personal protection equipment should be followed when operating on all patients during the pandemic. To facilitate the decision-making in the management of cholesteatoma, timing for surgery can be divided into two categories with 3 and 2 sub-groups based on disease severity.

Conclusions

Evidence on the timing of surgery of patients with cholesteatoma during the COVID-19 pandemic is lacking. This manuscript contains practical tips on how cholesteatoma surgery can be reorganized during this pandemic.

Toward personalized dose-prescription in locally advanced non-small cell lung cancer: Validation of published normal tissue complication probability models

PURPOSE

To identify published normal tissue complication probability (NTCP) models suitable for patient-specific dose-prescription in locally advanced non-small cell lung cancer (LA-NSCLC) through in-house validation.

MATERIAL AND METHODS

From eight previously published candidate NTCP models (≥grade 2 acute esophagitis and radiation pneumonitis; AE2, RP2), patient-specific dose-responses were calculated using model variables and fractionation-corrected doses for 241 LA-NSCLC patients treated with chemo-IMRT to 50-80 Gy@1.8-2.0 Gy between 2004 and 2014 (AE2/RP2 rate: 50%/12%). A model was judged final if it significantly predicted AE2 or RP2 (p ≤ 0.05), was discriminative and well calibrated (AUC > 0.60; Hosmer-Lemeshow test p_HL > 0.05), which were assessed as the median over 1000 bootstrap samples.

RESULTS

Models for AE2 had superior discrimination to RP2 models (AUC = 0.63-0.65 vs. 0.51-0.65). The final AE2 model included mean esophageal dose and concurrent chemotherapy (AUC = 0.65; p < 0.0001). The final RP2 model was a slightly adjusted version of the RP2 model with the best discrimination, and included age, mean lung dose, and pulmonary comorbidity (AUC = 0.73; p < 0.0001).

CONCLUSION

Of the eight investigated and published NTCP models, one model successfully described AE2 and one slightly adjusted model successfully described RP2 in the independent cohort. Estimates from these two NTCP models will, therefore, be considered internally when prescribing patient-specific doses in LA-NSCLC patients.

TP1-10 Non tumour brain biopsies in alder hey paediatric neurosurgery

Objectives

To review the utility of non-tumour brain biopsies in Alder Hey Children’s NHS Foundation Trust Paediatric Neurosurgery Department.

Methods

Operative records were searched for ‘biopsy’. Case notes were reviewed for referral source, histology, surgical complication and outcome. Tumour, epilepsy and non-brain biopsy cases were excluded.

Results

83 ‘biopsy’ cases were identified between 2008 and 2017. 31 tumour, 5 epilepsy, 2 infections and 28 non brain/other biopsies were excluded. 17 brain biopsies for non-tumour causes were seen. 15 patients were referred by neurology, 2 by rheumatology. 14 underwent a craniotomy/mini-craniotomy, 3 had burrholes.4 biopsies were non diagnostic, 2 were abnormal but inconclusive for diagnosis. Diagnoses included: 3 demyelinating lesions, 2 normal brain tissue, 1 neurosarcoidosis, 1 autoimmune encephalitis, 1 definite Rasmussen’s Encephalitis, 1 possible Rasmussen’s Encephalitis, 1 systemic lupus erythematosus associated CNS vasculitis, 1 inflammatory infiltrate (secondary to hydrocephalus/ventriculitis), 1 patient developed a late wound infection. No other surgical morbidities/mortalities were recorded. 11 of these cases had a change in management or the treating team were reassured due to the result of the biopsy (i.e. were able to start immunomodulatory drugs in the absence of infection).

Conclusions

65% of brain biopsies were diagnostic. 71% of biopsies either changed management or reassured the treating team about a line of management. The procedure is low risk with 0.06% morbidity and 0% mortality.

The physiological phosphorylation of tau is critically changed in fetal brains of individuals with Down syndrome

AIMS

Down syndrome (DS) is a common cause of mental retardation accompanied by cognitive impairment. Comprehensive studies suggested a link between development and ageing, as nearly all individuals with DS develop Alzheimer disease (AD)-like pathology. However, there is still a paucity of data on tau in early DS to support this notion.

METHODS

Using morphometric immunohistochemistry we compared tau phosphorylation in normal brains and in brains of individuals with DS from early development until early postnatal life.

RESULTS

We observed in DS a critical loss of physiological phosphorylation of tau. Rhombencephalic structures showed prominent differences between controls and DS using antibodies AT8 (Ser-202/Thr-205) and AT180 (Thr-231). In contrast, in the subiculum only a small portion of controls deviated from DS using antibodies AT100 (Thr-212/Ser-214) and AT270 (Thr-181). With exception of the subiculum, phosphorylation-independent tau did not differ between groups, as confirmed by immunostaining for the HT-7 antibody (epitope between 159 and 163 of the human tau) as well.

DISCUSSION

Our observations suggest functional tau disturbance in DS brains during development, rather than axonal loss. This supports the role of tau as a further important player in the pathophysiology of cognitive impairment in DS and related AD.