The role of ANCA in the management of cocaine-induced midline destructive lesions or ENT pseudo-granulomatosis with polyangiitis: a London multicentre case series

OBJECTIVE

In this multicentric study involving three London hospitals, we compared ANCA-positive and ANCA-negative cocaine-induced midline destructive lesions (CIMDL) patients to assess how presence of antineutrophil cytoplasmic antibodies (ANCA) may correlate with disease severity. Our secondary aims are to better classify etiology centered around ANCA positivity and, consequently, better disease management.

METHODS

A retrospective review was performed to identify patients with CIMDL seen between January 2019 and December 2022. Population data including age, sex, presentation, endoscopic findings, duration of cocaine use and active use of cocaine, type of treatment, laboratory (including ANCA serology), radiological, and histological findings were collected.

RESULTS

Forty CIMDL patients (25 male, median age of 42 years) were identified. The majority of them (72.5%) presented with either a septal perforation, a saddle nose deformity (22.5%), and/or a palatal fistula (20.0%). ANCA was positive in 71.1% of cases (66.7% p-ANCA). No statistically significant differences in the general characteristics, type of treatment, laboratory results, radiological or histological findings were observed when comparing ANCA-positive and ANCA-negative CIMDL patients or when comparing p-ANCA and c-ANCA patients. Similarly, no statistically significant difference was obtained when comparing the pattern of distribution of lesions between the two groups.

CONCLUSIONS

A large percentage of CIMDL patients showed positive ANCA test (71.1%) and in the majority of the cases a p-ANCA pattern specifically targeting PR3 (p-ANCA, PR3 + MPO-). However, ANCA positivity or presence of a specific ANCA pattern was not associated with more severe presentation or more aggressive disease. Given its similarities to granulomatosis with polyangiitis (GPA), we recommend the use of the term "cocaine-induced ENT pseudo-GPA" instead of CIMDL.

LEVEL OF EVIDENCE

IV Laryngoscope, 134:2609-2616, 2024.

Clinical factors influencing olfactory performance in patients with persistent COVID-19 smell loss longer than 1 year

Objectives

Factors affecting persistence of COVID-19-related olfactory dysfunction (OD) remain partially unknown. We aim to evaluate the clinical factors which could influence olfactory performance in patients with persistent COVID-19-related smell loss.

Methods

A retrospective analysis of 100 patients with persistent COVID-19-related OD was performed between October 2020 and December 2022 at a single-center long-COVID smell clinic. All subjects underwent smell assessment using Sniffin' Sticks (S'S) extended test, nasal endoscopy, nasal airflow evaluation (peak nasal inspiratory flow [PNIF]), allergy test (skin prick test [SPT]) for common aeroallergens, MRI of the head and patient-reported outcome measures (PROMs-VAS, SF-36, Short QOD-NS, SNOT-22). Based on S'S score, subjects were divided into normosmics (TDI ≥ 30.75) and dysosmics (TDI < 30.75).

Results

The median age was 42 years and the median length of patient-reported OD was 1.4 years. 20 patients (20.0%) were normosmic at the time of S'S assessment. Dysosmic patients were found to have significantly lower scores at the SF-36 health domains for energy/fatigue (p = .0004) and emotional wellbeing (p = .04) when compared to normosmics. A moderate correlation (r = .45-.59) between S'S scores and some PROMs was also demonstrated. At the multivariate analysis higher PNIF scores positively influenced odor threshold (p = .001) while positivity to SPT negatively influenced odor identification (p = .04).

Conclusions

Impairment of nasal airflow and sensitivity to aeroallergens can negatively affect olfactory performance in COVID-19-related OD. Long-COVID smell loss deeply affects QoL although recovery of olfaction can bring it back to a normal range.

Level of Evidence

IV.

Functional septorhinoplasty alters brain structure and function: Neuroanatomical correlates of olfactory dysfunction

Introduction

We previously demonstrated functionally significant structural plasticity within the central olfactory networks, in association with improved olfaction after surgical treatment of chronic rhinosinusitis (CRS). In order to confirm and expand on these findings, the primary aim of this study was to determine whether these same regions undergo functionally significant structural plasticity following functional septorhinoplasty (fSRP), in patients with non-CRS olfactory dysfunction (OD) of mixed cause. fSRP has previously been shown to improve olfactory function, and the secondary aim of this study was to provide initial insights into the mechanism by which fSRP affects olfaction.

Methods

We performed a pilot prospective, multimodal neuroimaging study in 20 participants undergoing fSRP, including patients with non-CRS OD of mixed cause, as well as normosmic surgical controls. Participants underwent psychophysical olfactory testing, assessment of nasal airway, structural and functional neuroimaging. This was performed pre- and postoperatively in patients, and preoperatively in controls.

Results

There was a statistically and clinically significant improvement in mean psychophysical olfactory scores after surgery. This was associated with structural and functional plasticity within areas of the central olfactory network (anterior cingulate, orbitofrontal cortex, insula, temporal pole). Improved psychophysical scores were significantly correlated with change in bilateral measures of nasal airflow, not measures of airflow symmetry, suggesting that improved overall airflow was more important than correction of septal deviation.

Conclusion

This work highlights the importance of these neuroanatomical regions as potential structural correlates of olfactory function and dysfunction. Our results also provide initial insight into the mechanistic effects of fSRP on olfaction. Further work could investigate the utility of these regions as personalised biomarkers of OD, as well as the role of fSRP in treating OD.

Safety of day-case endoscopic sinus surgery in England: An observational study using an administrative dataset

INTRODUCTION

As elective surgical services recover from the COVID-19 pandemic a movement towards day-case surgery may reduce waiting lists. However, evidence is needed to show that day-case surgery is safe for endoscopic sinus surgery (ESS). The aim of this study was to investigate the safety of day-case ESS in England.

DESIGN

Secondary analysis of administrative data.

METHODS

We extracted data from the Hospital Episodes Statistics database for the 5 years from 1 April 2014 to 31 March 2019. Patients undergoing elective ESS procedures aged ≥17 years were included. Exclusion criteria included malignant neoplasm, complex systemic disease and trans-sphenoidal pituitary surgery. The primary outcome was readmission within 30 days post-discharge. Multilevel, multivariable logistic regression modelling was used to compare outcomes for those operated on as day-cases and those with an overnight stay after adjusting for demographic, frailty, comorbidity and procedural covariates.

RESULTS

Data were available for 49 223 patients operated on across 129 NHS hospital trusts. In trusts operating on more than 50 patients in the study period, rates of day-case surgery varied from 20.6% to 100%. Nationally, rates of day-case surgery increased from 64.0% in the financial year 2014/2015 to 78.7% in 2018/2019. Day-case patients had lower rates of 30-day emergency readmission (odds ratio 0.71, 95% confidence interval 0.62 to 0.81). Outcomes for patients operated on in trusts with ≥80% day-case rates compared with patients operated on in trusts with <50% rates of day-case surgery were similar.

CONCLUSIONS

Our data support the view that ESS can safely be performed as day-case surgery in most cases, although it will not be suitable for all patients. There appears to be scope to increase rates of day-case ESS in some hospital trusts in England.

A multicenter real-life study to determine the efficacy of corticosteroids and olfactory training in improving persistent COVID-19-related olfactory dysfunction

Background

No definitive treatment exists to effectively restore function in patients with persistent post-infectious olfactory dysfunction (OD). Corticosteroids have been considered as a therapeutic option in post-infectious OD but their benefit in COVID-19-related OD remains unexplored. We aim to determine the role of the combination of corticosteroids plus olfactory training (OT) in improving persistent COVID-19-related OD.

Methods

A multicenter real-life cohort study was conducted between December 2020 and April 2022 on patients with reported COVID-19-related OD. Only patients with confirmed OD at Sniffin' Sticks (S'S) and those who attended their 6-month follow-up were included. Patients were started on a combined treatment of corticosteroids and OT. Patients refusing corticosteroids or not doing any treatment formed the control groups. Visual analogue scale (VAS) for sense of smell and SNOT-22 were used to assess patients reported symptoms.

Results

Sixty-seven subjects with reported COVID-19-related OD were initially seen. Normosmic patients at S'S (n = 14) and those not attending their follow-up (n = 9) were excluded. Of the 44 patients included in the analysis, 19 patients had the combined treatment (group A), 16 patients refused to take corticosteroids and did the OT alone (group B) whereas 9 patients did not do any treatment (group C). An improvement of threshold + discrimination + identification (TDI) score (p = .01) and VAS for smell (p = .01) was found in group A whereas only the TDI score improved in group B (p = .04). Presence of comorbidities, age, sex (male), and length of OD negatively influenced olfactory recovery.

Conclusions

Our study confirms the importance of OT in long-term OD suggesting that the addition of corticosteroids may give a benefit in terms of patient's perceived olfaction.

Level of Evidence

2b.

International Multicenter Study of Clinical Outcomes of Sinonasal Melanoma Shows Survival Benefit for Patients Treated with Immune Checkpoint Inhibitors and Potential Improvements to the Current TNM Staging System

Objectives Sinonasal mucosal melanoma (SNMM) is an extremely rare and challenging sinonasal malignancy with a poor prognosis. Standard treatment involves complete surgical resection, but the role of adjuvant therapy remains unclear. Crucially, our understanding of its clinical presentation, course, and optimal treatment remains limited, and few advancements in improving its management have been made in the recent past.

Methods We conducted an international multicenter retrospective analysis of 505 SNMM cases from 11 institutions across the United States, United Kingdom, Ireland, and continental Europe. Data on clinical presentation, diagnosis, treatment, and clinical outcomes were assessed.

Results One-, three-, and five-year recurrence-free and overall survival were 61.4, 30.6, and 22.0%, and 77.6, 49.2, and 38.3%, respectively. Compared with disease confined to the nasal cavity, sinus involvement confers significantly worse survival; based on this, further stratifying the T3 stage was highly prognostic (p < 0.001) with implications for a potential modification to the current TNM staging system. There was a statistically significant survival benefit for patients who received adjuvant radiotherapy, compared with those who underwent surgery alone (hazard ratio [HR] = 0.74, 95% confidence interval [CI]: 0.57–0.96, p = 0.021). Immune checkpoint blockade for the management of recurrent or persistent disease, with or without distant metastasis, conferred longer survival (HR = 0.50, 95% CI: 0.25–1.00, p = 0.036).

Conclusions We present findings from the largest cohort of SNMM reported to date. We demonstrate the potential utility of further stratifying the T3 stage by sinus involvement and present promising data on the benefit of immune checkpoint inhibitors for recurrent, persistent, or metastatic disease with implications for future clinical trials in this field.

Clinical outcomes, Kadish-INSICA staging and therapeutic targeting of somatostatin receptor 2 in olfactory neuroblastoma

INTRODUCTION

Olfactory neuroblastoma (ONB) is a rare cancer of the sinonasal region. We provide a comprehensive analysis of this malignancy with molecular and clinical trial data on a subset of our cohort to report on the potential efficacy of somatostatin receptor 2 (SSTR2)-targeting imaging and therapy.

METHODS

We conducted a retrospective analysis of 404 primary, locally recurrent, and metastatic olfactory neuroblastoma (ONB) patients from 12 institutions in the United States of America, United Kingdom and Europe. Clinicopathological characteristics and treatment approach were evaluated. SSTR2 expression, SSTR2-targeted imaging and the efficacy of peptide receptor radionuclide therapy [PRRT](177Lu-DOTATATE) were reported in a subset of our cohort (LUTHREE trial; NCT03454763).

RESULTS

Dural infiltration at presentation was a significant predictor of overall survival (OS) and disease-free survival (DFS) in primary cases (n = 278). Kadish-Morita staging and Dulguerov T-stage both had limitations regarding their prognostic value. Multivariable survival analysis demonstrated improved outcomes with lower stage and receipt of adjuvant radiotherapy. Prophylactic neck irradiation significantly reduces the rate of nodal recurrence. 82.4% of the cohort were positive for SSTR2; treatment of three metastatic cases with SSTR2-targeted peptide-radionuclide receptor therapy (PRRT) in the LUTHREE trial was well-tolerated and resulted in stable disease (SD).

CONCLUSIONS

This study presents pertinent clinical data from the largest dataset, to date, on ONB. We identify key prognostic markers and integrate these into an updated staging system, highlight the importance of adjuvant radiotherapy across all disease stages, the utility of prophylactic neck irradiation and the potential efficacy of targeting SSTR2 to manage disease.

Prevalence of olfactory dysfunction and quality of life in hospitalised patients 1 year after SARS-CoV-2 infection: a cohort study

OBJECTIVES

To determine the long-term prevalence of olfactory and/or gustatory dysfunction (OD±GD), associated risk factors and impact on quality of life (QoL) in previously hospitalised patients with COVID-19 1 year after infection.

DESIGN

A single-centre cohort study.

SETTING

Patients admitted at a large central London hospital with COVID-19 infection between 10 February 2020 and 22 May 2020.

PARTICIPANTS

150 adult subjects with previously confirmed SARS-CoV-2 infection were recruited between 10 December 2020 and 29 January 2021. Participants were predominantly male (102/150, 68.0%); mean age 58.0±15.9 years and 41.2% (56/136) were of black, Asian and minority ethnic backgrounds.

MAIN OUTCOME MEASURES

EQ-5D-5L values and Sino-Nasal Outcome Test-22 (SNOT-22) scores.

RESULTS

Long-term prevalence of OD±GD was 12.8% (19/149) at median time of 264.5 days following SARS-CoV-2 infection onset. Patients with OD±GD had a significantly higher median total SNOT-22 score (46.1; Q1-Q3: 23.0-60.0; 95% CI 23.0 to 60.0) compared with those without (16.0; Q1-Q3: 5.0-30.5; 95% CI 12.0 to 18.0) (p=0.0002), reflecting poorer QoL, particularly psychological well-being (p=0.0004), which was not alleviated with time (p=0.4977). Median EQ-5D-5L value was not significantly different between patients with OD±GD (0.70; Q1-Q3: 0.38-0.83; 95% CI 0.38 to 0.83) and those without (0.83; Q1-Q3: 0.61-0.94; 95% CI 0.75 to 0.89) (p=0.0627). Age, sex, ethnicity, smoking status, highest C reactive protein value, intubation and ventilation, and oxygen supplementation were not found to influence OD±GD (p>0.05).

CONCLUSIONS

12.8% of previously hospitalised patients with COVID-19 in London still report persistent problems with smell or taste up to a year after infection, impacting their QoL. Increased holistic support including psychological therapy and olfactory rehabilitation for affected patients may help to reduce long-term morbidity.

A retrospective study on long-term efficacy of intranasal lysine-aspirin in controlling NSAID-exacerbated respiratory disease

Purpose

Aspirin treatment after desensitization (ATAD) represents an effective therapeutic option suitable for NSAID-exacerbated respiratory disease (N-ERD) patients with recalcitrant disease. Intranasal administration of lysine-aspirin (LAS) has been suggested as a safer and faster route than oral ATAD but evidence for its use is less strong. We investigated nasal LAS therapy long-term efficacy based on objective outcomes, smell function, polyp recurrence and need for surgery or rescue therapy. Clinical biomarkers predicting response to intranasal LAS, long-term side effects and consequences of discontinuing treatment have been evaluated.

Methods

A retrospective analysis of a database of 60 N-ERD patients seen between 2012 and 2020 was performed in March 2021. They were followed up at 3-months, 1-, 2- and 3-years with upper and lower airway functions assessed at each follow-up.

Results

Higher nasal airflow and smell scores were found at each follow-up in patients taking LAS (p < 0.001 and p = 0.048 respectively). No influence of LAS on pulmonary function measurements was observed. Patient on intranasal LAS showed a lower rate of revision sinus surgery when compared to those who discontinued the treatment (p < 0.001). None of the variables studied was found to influence LAS treatment response.

Conclusion

Our study demonstrates the clinical effectiveness of long-term intranasal LAS in the management of N-ERD in terms of improved nasal airflow and olfaction and a reduced need for revision sinus surgery. Intranasal LAS is safe, being associated with a lower rate of side effects when compared to oral ATAD. However, discontinuation of the treatment at any stage is associated with a loss of clinical benefit.

Olfactory and Gustatory Function before and after Laparoscopic Sleeve Gastrectomy

Background and Objectives: Bariatric surgery is the gold standard for the treatment of morbid obesity, and current evidence suggests that patients undergoing surgery can show changes in their sense of taste and smell. However, no definitive conclusions can be drawn given the heterogeneity of the studies and the contrasting results reported in the literature. Materials and Methods: We enrolled 18 obese patients undergoing laparoscopic sleeve gastrectomy (LSG) and 15 obese controls. At baseline (T0) and 6 months after enrollment/surgery (T1), both groups underwent Sniffin’ Sticks and whole mouth test. Post-operative qualitative taste variations were also analyzed and SNOT-22, VAS for taste and smell, and MMSE were administered. Results: An improvement in the olfactory threshold was observed in the treatment group (p = 0.03) at 6 months. At multivariate analysis, the olfactory threshold differences observed correlated with MMSE (p = 0.03) and T0 gustatory identification (p = 0.01). No changes in sense of taste were observed between the two groups at 6 months, even though nine subjects in the treatment group reported a worsening of taste. This negatively correlated with age (p < 0.001), but a positive marginal correlation was observed with the olfactory threshold difference between T0 and T1 (p = 0.06). Conclusions: Olfaction can improve after LSG, and this seems to be the consequence of an improved olfactory threshold. Although we did not observe any change in gustatory identification, food’s pleasantness worsened after bariatric surgery.

The Nasal Obstruction Balance Index: A Novel Approach to Improving Correlation Between Unilateral Nasal Airway Measurements and Evaluating Nasal Airway Asymmetry

OBJECTIVES/HYPOTHESIS

Demonstrate that the Nasal Obstruction Balance Index (NOBI) model fulfils the unmet need of improving unilateral correlation between subjective and objective nasal obstruction outcome measures and identifying the more obstructed side. Improve correlation between unilateral objective nasal airway measurements (nasal inspiratory peak flow [NIPF] and acoustic rhinometry [AR]) and subjective Visual Analogue Scale for nasal obstruction (VAS-NO) scores. Improve assessment of nasal airway asymmetry by evaluating unilateral measurements both before and after the application of nasal decongestant; which the patient could better understand. NOBI represents a ratio calculated by taking the difference between left and right nasal airway measurements and divided by the maximum unilateral measurement. It is based on Poiseuille's law and aims to reduce the confounding variables which challenge nasal airway measurement.

STUDY DESIGN

Prospective cohort study.

METHODS

Forty-three controls and 34 patients with nasal obstruction underwent both unilateral and bilateral NIPF, AR and VAS-NO measurements; these were repeated after the application of nasal decongestant. The NOBI values for unilateral NIPF, AR, and VAS-NO were calculated both before and after decongestant.

RESULTS

The correlation between unilateral NIPF and AR measurements was enhanced considerably (r = 0.57, P < .01) when NOBI was applied. The NOBI metric significantly increased the correlation between unilateral NIPF, AR, and VAS-NO scores. Postdecongestant NOBI for NIPF and AR measurements correctly identified the more obstructed side in 82.4% and 94.1% of the deviated nasal septum (DNS) cases, respectively.

CONCLUSION

The NOBI model provides a better correlation between unilateral subjective and objective measurements and identifies the more obstructed side.

LEVEL OF EVIDENCE

Prospective cohort study (level III) Laryngoscope, 2021.

Characteristics of taste dysfunction in COVID-19 subjects coming from two different countries

Taste dysfunction (TD) has been recognised, together with olfactory dysfunction, as a key presenting symptom of COVID-19. The capability to recognise flavours, flavour intensities and aroma characteristics can be highly variable within the same population, as well as potentially diverse between culturally different populations. The aims of this study are to evaluate whether a difference in the types of TD presentation amongst COVID-19 positive subjects can be demonstrated and whether a difference exists between populations of different cultures.

Olfactory dysfunction in antineutrophil cytoplasmic antibody-associated vasculitides: A review of the literature

Olfactory dysfunction (OD) has been described in patients with antineutrophil cytoplasmic antibody-associated vasculitides (AAV), but the underlying mechanisms are not completely understood. The causes of altered smell function can generally be divided into conductive, sensorineural or others. To date no specific treatment is available for AAV-related OD and the efficacy of currently available options has not been explored. The aim of this review is to provide an overview of the causes that may lead to OD in patients with AAV. Current available treatments for OD and possible options in patients with AAV presenting with smell impairment are also mentioned.

The Evidence Base for the Benefits of Functional Septorhinoplasty and its Future Post COVID-19

Ever since the introduction of the concept of Procedures of Limited Clinical Value (PoLCV), procedures such as functional septorhinoplasty have been subject to additional funding restrictions within the British National Health Service. Recent publications have suggested that 10% of Clinical Commissioning Groups in the United Kingdom no longer fund septorhinoplasty surgery irrespective of the indications, including congenital malformations or post-trauma, and despite the strong evidence available in the literature in treating a range of health conditions. Thus, inequity exists across the country. At present functional septorhinoplasty surgery is frequently but incorrectly grouped together with aesthetic rhinoplasty, both of which are deemed to be cosmetic interventions. Moreover, as we exit the peak of the current coronavirus disease 2019 (COVID-19) pandemic, procedures deemed to be of lower clinical priority will potentially be at risk throughout Europe. The purpose of this review is twofold; the first is to put forward the evidence to commissioners in favor of functional septorhinoplasty surgery on patient well-being and mental health; the second is to demonstrate why functional septorhinoplasty surgery is a distinct procedure from aesthetic rhinoplasty and why it ought not to be classified as a procedure of limited clinical value.

Olfactory and taste dysfunction among mild-to-moderate symptomatic COVID-19 positive health care workers: An international survey

OBJECTIVES

To determine the prevalence of olfactory and taste dysfunction (OD; TD) among COVID-19 positive health care workers (HCWs), their associated risk factors and prognosis.

METHODS

Between May and June 2020, a longitudinal multicenter study was conducted on symptomatic COVID-19 PCR confirmed HCWs (COVID-19 positive) in London and Padua.

RESULTS

Hundred and fourteen COVID-19 positive HCWs were surveyed with a response rate of 70.6% over a median follow-up period of 52 days. UK prevalence of OD and TD was 73.1% and 69.2%, respectively. There was a male to female ratio of 1:3 with 81.6% being white, 43.7% being nurses/health care assistants (HCAs), and 39.3% being doctors. In addition, 53.2% of them worked on COVID-19 wards. Complete recovery was reported in 31.8% for OD and 47.1% for TD with a 52 days follow-up. The job role of doctors and nurses negatively influenced smell (P = .04 and P = .02) and taste recovery (P = .02 and P = .01). Ethnicity (being white) showed to positively influence only taste recovery (P = .04). Sex (being female) negatively influenced OD and TD recovery only in Paduan HCWs (P = .02 and P = .011, respectively). Working on a COVID-19 ward did not influence prognosis.

CONCLUSIONS

The prevalence of OD and TD was considerably higher in HCWs. The prognosis for OD and TD recovery was worse for nurses/HCAs and doctors but working on a COVID-19 ward did not influence prognosis. Sixty-eight percent of surveyed HCWs at 52 days continued to experience OD or TD requiring additional future medical management capacity.

LEVEL OF EVIDENCE

4.

The role of surgery in antineutrophil cytoplasmic antibody-associated vasculitides affecting the nose and sinuses: A systematic review

Background:

The ear, nose and throat region has been reported to be one of the commonest sites involved in antineutrophil cytoplasmic antibody (ANCA)–associated vasculitis diseases and often precedes the diagnosis of ANCA–associated vasculitis by many months. Although treatment for ANCA–associated vasculitis primarily requires systemic immunosuppressive therapy, there are specific indications for sinonasal surgery during the course of the disease process. The three major roles for surgery in sinonasal vasculitis are to aid diagnosis through biopsy, enable symptom relief and nasal reconstructive surgery consideration when in remission.

Purpose:

The aim of this systematic review is to provide an overview of the surgical procedures which can be performed in patients with ANCA–associated vasculitis presenting with sinonasal involvement.

Materials and methods:

A systematic literature search was performed for scientific articles on MEDLINE (PubMed Advanced MEDLINE Search) and EMBASE. The search included all articles up to April 2020.

Conclusion:

Surgical intervention during the active phase of ANCA–associated vasculitis disease can improve the patient’s symptoms and enable histological diagnosis. The surgical decision to manage the nose requires a multidisciplinary approach involving the vasculitis specialist and the ear, nose and throat surgeon. Nasal reconstruction can be performed to restore form and function but only when the disease is in remission so as to maximise success and minimise complications.

A Unilateral Mucoperichondrial/Mucoperiosteal Flap Including Inferior Turbinate with Contralateral Underlay Xenograft for a Large Nasal Septal Perforation Repair

Findings: We describe a septal perforation repair technique aimed for moderate to large perforations, which involves a unilateral transpositional/rotational flap utilizing lateral nasal wall and inferior turbinate (IT) mucosa and a contralateral underlay porcine small intestinal submucosa mesh. Meaning: The addition of IT mucosa as part of the unilateral lateral nasal wall mucoperichondrium/periosteal flap combined with a contralateral acellular matrix underlay optimizes the repair of larger perforations. The underlay acellular matrix acts as a scaffold for the regeneration of healthy mucoperichondrium akin to a tympanoplasty repair and reduces donor site morbidity.

Recovery of Elective Facial Plastic Surgery in the Post-Coronavirus Disease 2019 Era: Recommendations from the European Academy of Facial Plastic Surgery Task Force

The impact of the COVID-19 pandemic has resulted in widespread disruption to routine surgical services across the globe. As the peak of the initial pandemic passes, surgeons will increasingly resume elective work to address the backlog. Whilst urgent cases such as cancer work will be prioritized, the safe resumption of facial plastic surgery will remain an ongoing challenge; particularly if there are secondary waves of infection. Rhinoplasty and nasal reconstructive surgery in particular poses a unique challenge to address due to the due to the potential for aerosolizing the virus. A task force of facial plastic surgeons from the European Academy of Facial Plastic Surgery has collaborated to create this document detailing recommendations for resuming a safe facial plastic surgery practice. These include the need to embrace telemedicine, advice on surgical prioritization, planning of clinical area flow plans, advice on pre-/peri- and postoperative care as well as recommendations on training for residents and well-being for surgeons. The recommendations have been made in line with the best available evidence in the literature and are applicable to facial plastic surgery colleagues from around the world in order to resume a safe practice.

Draf III frontal sinus surgery for the treatment of Pott's puffy tumour in adults: our case series and a review of frontal sinus anatomy risk factors

Purpose

We present our case series of four adult patients with Pott’s puffy tumour (PPT), successfully treated with Draf III over a mean period of 11 months. A critical review of the literature is also provided.

Methods

A retrospective review of patients undergoing Draf III for PPT from January 2018 to January 2019 was performed.

Results

Four consecutive male patients ranging from 26 to 62 years, with a mean age of 49.5 ± 16.3 years, undergoing Draf III for Pott’s puffy tumour were included. Two patients had a Kuhn type IV frontal cell narrowing the frontonasal pathway and presented without previous sinus surgery, whereas the other two had previous sinus surgery. The success rate of the operation was 100% with an average length of follow-up of 11 months (range 5–18).

Conclusion

In our experience, the Draf III procedure is a highly effective treatment of PPT. In particular, we have demonstrated it to be very effective in accessing highly positioned Kuhn type IV cells.

Nasal Function Changes at High Altitude

BACKGROUND

An ever-increasing number of people are involved in sport activities at high altitude.

OBJECTIVE

This study aimed to evaluate the pulmonary and nasal functions, including nasal cytology, in healthy volunteers moving for 1 week from an altitude of 2000 m to another of 3400 m.

METHODS

Peak nasal inspiratory flow (PNIF), pulmonary function, including peak expiratory flow (PEF), mucociliary transport time (MCTt), nasal cytology, and oxygen saturation (O₂ sat) were studied in 5 different occasions-T1: at base camp (2000 m); T2: at the mountain refuge (3400 m); T3: after 7 days at 3400 m; T4: after the return at the base camp (2000 m); and T5: at the base camp (2000 m) after 15 days.

RESULTS

With respect to T1, PEF values decreased at T2 (P = .004), T3 (P = .004), T4 (P = .000), and T5 (P = .001). Forced expiratory volume in the first second and forced vital capacity did not differ among the 5 different times of measurements. In regard to T1, PNIF values increased at T2 (P = .003) and T3 (P = .001). MCTt and O₂ sat showed similar but opposite changes with MCTt increased at T2 and T3 in respect to T1 (P = .000 for both), while O₂ sat decreased at T2 and T3 in respect to T1 (P = .000 for both). At nasal cytology, the number of neutrophils increased at T2 in respect to T1 (P = .008). At multivariate analysis, PNIF changed with altitude from T1 to T4 even accounting for the effect of all the other variables (T1 vs T2 PNIF, P = .009; T1 vs T3 PNIF, P = .007; T1 vs T4 PNIF, P = .021).

CONCLUSIONS

Although the study has some limitations, being conducted on a small cohort and at no controlled environmental conditions, data seem to support the utility of MCTt for studying nasal mucosa damage induced by high altitude. Nasal cytology seems to be able to identify the inflammation of the nasal mucosa exposed to hypoxia. Further investigations on larger series and possibly conducted in hypobaric chamber at controlled standardized conditions are necessary in order to confirm these results and, most importantly, the improvement of PNIF at high altitude.

Investigating the nasal cycle using unilateral peak nasal inspiratory flow and acoustic rhinometry minimal cross-sectional area measurements

OBJECTIVE

To plot the nasal cycle using unilateral peak nasal inspiratory flow (UPNIF) and unilateral minimal cross-sectional area (UMCA) readings demonstrating a linear relationship in normal nasal function. Additionally, to determine how this changes in abnormal nasal function.

DESIGN

A cross-sectional study measuring UPNIF and UMCA in controls demonstrating normal nasal function and in patients with nasal obstruction.

SETTING

Royal National Throat Nose and Ear Hospital, London.

PARTICIPANTS

A total of 39 participants, 26 controls and 13 patients, were recruited. Controls exhibited normal nasal function with SNOT-22 <5. Patients nasal obstruction symptoms secondary to inflammation or structural abnormality with SNOT-22 >9.

MAIN OUTCOME MEASURES AND RESULTS

Airflow rates and resistance values were derived from UPNIF and UMCA measurements respectively based on Poiseuille's laws. Ratios between right and left UPNIF and UMCA values were taken to adjust for confounding factors. The relationship of 1/Resistance Ratio and Airflow Rate Ratio demonstrated a linear of direct proportionality of strong correlation and statistical significance (correlation coefficient = 0.76, P « 0.01). This suggests that data points from controls with a normal nasal cycle lie closely along the regressed line, whilst those lying significantly away were shown to belong to patients with nasal dysfunction. Olfactory dysfunction appears to be a sensitive discriminator in predicting this.

CONCLUSION

This study demonstrates the directly proportional relationship of 1/Resistance Ratio and Airflow Rate Ratio in normal nasal function. Furthermore, nasal pathology can be predicted if data points lie significantly outside these normal limits. Further studies are needed to validate exact normal and abnormal thresholds.

The internal nasal valve: a validated grading system and operative guide

Purpose

Nasal obstruction is a highly subjective and commonly reported symptom. The internal nasal valve (INV) is the rate limiting step to nasal airflow. A static INV grading score was devised with regard to visibility of the middle turbinate.

Methods

A prospective study of all patients who underwent primary external functional septorhinoplasty in 2017 for nasal obstruction. All patients’ INV score was assessed pre- and postoperatively in a blinded and independent fashion by surgeons of varying seniority.

Results

Twenty-eight patients were studied, with mean age 30.9 years and follow-up 18.8 weeks. Inter-rater and test–retest reliability of INV grading were excellent, with Cronbach’s alpha 0.936 and 0.920, respectively. There was also statistically significant improvement in both subjective and objective postoperative outcome measures including nasal inspiratory peak flows.

Conclusions

We demonstrate a novel, easy to interpret, clinically valuable grading system of the static internal nasal valve that is reliable and reproducible.

Peak nasal inspiratory flow correlates with quality of life in functional endoscopic sinus surgery

OBJECTIVES

Whilst nasal function and airflow improve subjectively following functional endoscopic sinus surgery (FESS), a clinically useful and objective tool for quantifying such improvement is lacking. The peak nasal inspiratory flow (PNIF) metre offers convenient and objective measures of nasal patency. However, it has not yet been established whether changes in PNIF after surgery reflect changes in subjective disease burden. In this study we aimed to determine whether changes in PNIF correlate with commonly used subjective symptom and quality of life outcome measures following FESS for chronic rhinosinusitis (CRS).

DESIGN

Prospective cohort.

SETTING

Royal National Throat Nose and Ear Hospital.

PARTICIPANTS

Thirty-seven patients undergoing FESS for CRS, with or without polyps (21 male, mean age 48.8).

MAIN OUTCOME MEASURES

PNIF, "SNOT-22", "NOSE" and "VAS" questionnaires were performed before and after surgery.

RESULTS

In all patients, there was a strong negative correlation between change in PNIF and change in "SNOT-22" score following surgery (Pearson r=-.64, P<.0001). Strong negative correlations were also seen during subgroup analysis of patients with and without polyps (r=-.57, P=.006 and r=-.67, P=.005, respectively). Change in PNIF correlated significantly with change in "NOSE" score following surgery in all patients and those without polyps (r=-.54, P=.0005 and r=-.68, P=.003). There were no significant correlations between PNIF and VAS (nasal obstruction).

CONCLUSIONS

Changes in PNIF after FESS appear to best reflect improvements in quality of life in CRS as measured using the "SNOT-22" questionnaire.

The outcome of septorhinoplasty surgery on olfactory function

OBJECTIVES

To assess olfactory outcomes in patients undergoing septorhinoplasty surgery in our unit.

DESIGN

Prospective cohort study.

SETTING

The Royal National Throat Nose and Ear Hospital, London.

PARTICIPANTS

Forty-three patients undergoing functional septorhinoplasty (Males = 26; mean age = 34.1 ± 12.2) were recruited into the study.

MAIN OUTCOME MEASURES

The primary outcome of olfactory function was assessed using 'Sniffin sticks'. Our secondary outcomes were assessment of patient quality of life using the disease specific Sino-nasal Outcome Test-23 questionnaire (SNOT-23) and a visual analogue scale for sense of smell. These measures were repeated at 12 weeks post operatively.

RESULTS

There was a significant change in the Sniffin' sticks score post-operatively (8.3 versus 9.6; P < 0.001). The SNOT-23 score also showed a significant improvement post-operatively (53.5 versus 40.4; P < 0.001). A significant improvement was not found in the smell/taste question (question 21) of the SNOT-23 questionnaire as well as the visual analogue scale for sense of smell. A difference in olfactory outcome was not found between open versus closed approaches, primary versus revision surgery and traumatic versus non traumatic cases.

CONCLUSIONS

The results show a measured significant improvement in olfaction following functional Septorhinoplasty but not a subjective improvement in the patients perception of their sense of smell and hence not a clinically significant difference. The reasons for the measured improvement are not clear and are likely to be multifactorial.

The need for an objective measure in septorhinoplasty surgery: are we any closer to finding an answer?

OBJECTIVES

To assess the reliability of nasal inspiratory peak flow (NIPF) in providing a clinically accurate objective measure following functional septorhinoplasty by comparing it to the validated disease-specific quality-of-life questionnaire, SNOT-22. Studies so far have demonstrated poor correlation between bilateral NIPF and symptom-specific nasal questionnaires following septorhinoplasty.

DESIGN

To perform a prospective comparative analysis between NIPF and the validated disease-specific quality-of-life questionnaire SNOT-22 and to determine whether a correlation exists following septorhinoplasty surgery.

SETTING

The Royal National Throat Nose and Ear Hospital, London.

PARTICIPANTS

A total of 122 patients (78 males, 44 females; mean age 33.5 ± 12.2 years) were recruited from the senior authors rhinology clinic and underwent functional septorhinoplasty surgery.

MAIN OUTCOME MEASURES

Preoperative and postoperative nasal inspiratory peak flow (NIPF) measurements were performed in addition to the completion of three subjective quality-of-life and symptom assessment tool questionnaires; Sinonasal Outcome Test 22 (SNOT-22), Nasal Obstruction Symptom Evaluation (NOSE) and Visual Analogue Scale (VAS: 0-10).

RESULTS

The mean preoperative NIPF was 88.2 L/min, and the postoperative value was 101.6 L/min and showed a significant improvement following surgery (P = 0.0064). The mean total SNOT-22 score improved significantly from 48.6 to 26.6 (P < 0.0001); the NOSE score from 14.1 to 6.6 (P < 0.0001); and the Visual Analogue Scale (VAS) blockage score from 6.9 to 3.2 (P < 0.0001). All individual domains assessed showed improvements postoperatively, but no correlation was found between the NIPF and SNOT-22 score. Equally, we did not find a correlation between NIPF and the symptom-specific NOSE questionnaire and the nasal blockage domain on the Visual Analogue Scale (VAS) scale.

CONCLUSION

We have demonstrated that NIPF does not correlate with the SNOT-22 disease-specific questionnaire, although both outcomes significantly improve postoperatively. At present, we are still lacking a clinically accurate objective measure of nasal function for the evaluation of patients undergoing septorhinoplasty surgery.

Safety of human olfactory mucosal biopsy for the purpose of olfactory ensheathing cell harvest and nerve repair: a prospective controlled study in patients undergoing endoscopic sinus surgery

BACKGROUND

Nasal olfactory mucosa is an accessible source of olfactory ensheathing cells for spinal cord regeneration. However, safety of the biopsy technique and the effects on sense of smell and nasal function have not been robustly assessed in the form of a prospective controlled study.

METHODOLOGY

National Health Service ethical approval was granted for this study of 131 patients. The primary outcome measure was olfactory function and the secondary outcomes included postoperative complication rates as well as the SNOT 22, NOSE scale scores and surgeon reported (Lund-Kennedy score) nasal function outcomes.

RESULTS

65 patients underwent functional endoscopic sinus surgery (FESS) and superior turbinate biopsy, and 66 patients underwent FESS only as the control group. There was no significant difference in complication rates between the two groups. All Olfactory function outcomes were unaffected following olfactory biopsy. We demonstrated that the patients quality of life and nasal patency as well as surgeon reported outcome measurements remain unaffected following olfactory harvesting.

CONCLUSIONS

We have uniquely provided level 2a evidence for the safety of endoscopic biopsy of olfactory mucosa, which does not affect nasal function or the sense of smell compared to standard FESS without biopsy.

Outcomes in endoscopic sinus surgery: olfaction, nose scale and quality of life in a prospective cohort study

OBJECTIVES

To determine the efficacy of endoscopic sinus surgery (ESS) on olfactory function in chronic rhinosinusitis patients with nasal polyps (CRSwNP) and without nasal polyps (CRSsNP) and to compare the nasal obstruction and symptom evaluation (NOSE) scale before and after surgery.

DESIGN

A prospective cohort study SETTING: Royal National Throat and Nose and Ear Hospital, London UK.

PARTICIPANTS

One hundred and thirteen patients with CRS; 60 CRSwNP and 53 CRSsNP.

OUTCOME MEASUREMENTS

Olfaction was measured using both the University of Pennsylvania Smell Investigation Test (UPSIT) and the 'sense of smell' visual analogue scale (VAS). The NOSE scale, the sinonasal outcome test (SNOT 22) and the Lund-Kennedy (LK) surgeon reported scores were also measured pre- and postoperatively at 6 months.

RESULTS

The UPSIT psychophysical measurement significantly improved following ESS in the CRSwNP subgroup as did the patients perceived VAS sense of smell. However, in the CRSsNP subgroup, the improved VAS and UPSIT measurements were not significant. The NOSE, SNOT 22 and LK scores all improved significantly. The olfactory improvement as measured by the UPSIT correlated to the SNOT-22, but a correlation between the NOSE score and UPSIT was not found.

CONCLUSIONS

Endoscopic sinus surgery significantly improved the patient's perceived and measured sense of smell in the CRSwNP subgroup which is the most surgically responsive CRS subgroup. Additionally, improved olfaction in the CRSwNP subgroup is most likely to improve the patient's quality of life. Endoscopic sinus surgery significantly improved the NOSE scale in both CRS subgroups at 6 months following surgery.

Early Changes in Brain Oxygen Tension May Predict Outcome Following Severe Traumatic Brain Injury

We report on the change in brain oxygen tension (PbtO2) over the first 24 h of monitoring in a series of 25 patients with severe traumatic brain injury (TBI) and relate this to outcome. The trend in PbtO2 for the whole group was to increase with time (mean PbtO2 17.4 [1.75] vs 24.7 [1.60] mmHg, first- vs last-hour data, respectively; p = 0.002). However, a significant increase in PbtO2 occurred in only 17 patients (68 %), all surviving to intensive care unit discharge (p = 0.006). Similarly, a consistent increase in PbtO2 with time occurred in only 13 patients, the correlation coefficient for PbtO2 versus time being ≥0.5 for all survivors. There were eight survivors and four non-survivors, with low correlation coefficients (<0.5). Significantly more patients with a correlation coefficient ≥0.5 for PbtO2 versus time survived in intensive care (p = 0.039). The cumulative length of time that PbtO2 was <20 mmHg was not significantly different among these three groups. In conclusion, although for the cohort as a whole PbtO2 increased over the first 24 h, the individual trends of PbtO2 were related to outcome. There was a significant association between improving PbtO2 and survival, despite these patients having cumulative durations of hypoxia similar to those of non-survivors.

Is sodium chloride worth its salt?

The choice of fluid for resuscitation of the brain-injured patient remains controversial, and the 'ideal' resuscitation fluid has yet to be identified. Large volumes of hypotonic solutions must be avoided because of the risk of cerebral swelling and intracranial hypertension. Traditionally, 0.9% sodium chloride has been used in patients at risk of intracranial hypertension, but there is increasing recognition that 0.9% saline is not without its problems. Roquilly and colleagues show a reduction in the development of hyperchloremic acidosis in brain-injured patients given 'balanced' solutions for maintenance and resuscitation compared with 0.9% sodium chloride. In this commentary, we explore the idea that we should move away from 0.9% sodium chloride in favor of a more 'physiological' solution.

Clinical review: neuromonitoring - an update

Critically ill patients are frequently at risk of neurological dysfunction as a result of primary neurological conditions or secondary insults. Determining which aspects of brain function are affected and how best to manage the neurological dysfunction can often be difficult and is complicated by the limited information that can be gained from clinical examination in such patients and the effects of therapies, notably sedation, on neurological function. Methods to measure and monitor brain function have evolved considerably in recent years and now play an important role in the evaluation and management of patients with brain injury. Importantly, no single technique is ideal for all patients and different variables will need to be monitored in different patients; in many patients, a combination of monitoring techniques will be needed. Although clinical studies support the physiologic feasibility and biologic plausibility of management based on information from various monitors, data supporting this concept from randomized trials are still required.

Variations in paranasal sinus anatomy: implications for the pathophysiology of chronic rhinosinusitis and safety of endoscopic sinus surgery

OBJECTIVES

To study the radiologic anatomy of the paranasal sinuses in patients with and without chronic rhinosinusitis to assess whether anatomic variations are associated with disease pathology, and to identify those variants that may impact operative safety.

SETTING

Tertiary referral otolaryngology unit.

MAIN OUTCOME MEASURES

Incidence and nature of anatomic variants with potential impact on operative safety, and the presence or absence of sinus mucosal disease and its correlation with anatomic variants with a potential impact on mucociliary clearance.

METHODS

We reviewed 278 computed tomographic scans from patients with rhinosinusitis symptoms to investigate anatomic variations that may predispose to sinusitis or impact on operative safety. The incidence of variants with potential impact on sinus drainage was compared between patients with and without sinus mucosal disease with logistic regression.

RESULTS

A closed osteomeatal complex was identified in 148 patients (53%), followed by concha bullosa in 98 patients (35%). Closed osteomeatal complex and nasal polyposis were independent risk factors for sinus mucosal disease. Anatomic variants with a potential impact on operative safety included anterior clinoid process pneumatization (18%), infraorbital ethmoid cell (12%), sphenomaxillary plate (11%), and supraorbital recess (6%). In 92% of patients, the level difference between the roof of the ethmoid cavity and the cribriform plate was Keros I.

CONCLUSIONS

Bony anatomic variants do not increase the risk of sinus mucosal disease. However, anatomic variants with a potential impact on operative safety occur frequently and need to be specifically sought as part of preoperative evaluation.

The role of nasal feminization rhinoplasty in male-to-female gender reassignment

OBJECTIVE

To objectively assess the results of rhinoplasty in feminizing the facial profiles of male-to-female transsexual patients undergoing gender reassignment.

METHODS

Twelve patients underwent nasal feminization as part of male-to-female gender reassignment. Global assessments of facial profile were performed, and nasofrontal, nasolabial, and supratip angles and the Goode ratio were objectively measured. Postoperative and long-term patient satisfaction was assessed.

RESULTS

The surgical procedures created more feminine nasal profiles in all patients. The mean +/- SD nasofrontal angle changed from 141.6 degrees +/- 6.0 degrees to 150.5 degrees +/- 5.5 degrees (P < .001). The nasolabial angle changed from 107.4 degrees +/- 14.3 degrees to 115.2 degrees +/- 11.7 degrees (P < .001), and the supratip angle from 1.7 degrees +/- 4.9 degrees to 12.8 degrees +/- 5.8 degrees (P < .001). The Goode ratio did not change significantly, remaining on average around 1.64 +/- 0.15. In 4 cases, spreader grafts were used to reconstruct the nasal valve, and no cases of valve insufficiency occurred.

CONCLUSIONS

Rhinoplasty is effective in achieving feminine facial profiles in patients undergoing male-to-female gender reassignment. This requires reducing the overall nasal size and changing nasal angles to those more reminiscent of the female form. Because of the extensive resections often required to modify the nasal form, it is important to pay particular attention to preserving function, which may require concomitant nasal valve reconstruction.

Thromboprophylaxis in ENT patients: A national survey

The aim of this survey was to establish whether ENT departments in England follow British Medical Journal guidelines on thromboprophylaxis. A telephone survey of doctors in 80 ENT departments was used to present six clinical scenarios. The participants were asked what their local department routinely did. They were also asked whether they were aware of a local or national thromboprophylaxis policy. For patients undergoing procedures other than major head and neck procedures, compliance was poor and ranged between 7.5% and 37.5%. For laryngectomy, the rate was 82.6%. There was no statistical difference in answers given by doctors of different levels of seniority. Where local thromboprophylaxis guidelines exist, compliance is found to be statistically better. These results suggest that most ENT departments do not follow national or local guidelines on thromboprophylaxis. Greater awareness of existing guidelines is required.

A prospective randomized controlled trial evaluating alcohol on loudness perception in cochlear implant users

AIM

The aim of this study was to determine the effects of alcohol on the psychophysical responses in patients with cochlear implants. This has not been previously studied. It was also hoped to provide information that could suggest possible sites of action of the known effects of alcohol on the auditory pathway.

DESIGN

A prospective randomized placebo-controlled trial, with full ethical approval.

PARTICIPANTS

Eight successful cochlear implant users were selected, of whom two had bilateral implants which were tested separately. In total 10 cochlear implants were tested.

INTERVENTION

Alcohol was given in the form of vodka (50% alcohol, 1 mL/kg body weight) with 500 mL of orange and cranberry juice. The placebo control was given in the form of 500 mL of orange and cranberry juice alone.

OUTCOME MEASUREMENT

The 'comfort level' (C level) was recorded before, and 1 h after alcohol or placebo ingestion for each patient's cochlear implant. Blood alcohol concentration was determined prior to alcohol or placebo consumption and then repeated after 45, 60, 90 and 180 min.

RESULTS

The mean blood alcohol concentration 1 h after ingestion was 50 mg/dL. In the 'alcohol' arm the mean electrical unit increase in the C level was 19.9 with a standard deviation of 2.2. In the control arm the mean change in C level was 0.10 with a standard deviation of 0.3.

CONCLUSIONS

In this first prospective randomized control study of the effect of alcohol on sound perception in cochlear implant users, alcohol significantly increased the upper end of the dynamic range (C levels) in comparison with placebo (P = <0.0001 using paired t-test analysis). This effect is likely to be the result of change in the auditory pathways proximal to the cochlea.

Prophylactic vs Postoperative Antibiotic Use in Complex Septorhinoplasty Surgery

OBJECTIVE

To compare the efficacy of prophylactic vs postoperative antibiotic use in complex septorhinoplasty and strengthen the evidence base for antibiotic use in nasal surgery.

DESIGN

A randomized, prospective, single-blinded trial. One hundred sixty-four patients requiring complex septorhinoplasty surgery were recruited sequentially from the waiting lists of the 2 senior authors. Power was calculated at 80% at the 5% significance level. Patients randomized to the prophylactic arm of the study received three 1200-mg intravenous doses of amoxicillin-clavulanate, given at induction of anesthesia and at 6 and 12 hours postoperatively. Patients in the postoperative antibiotic arm received a 7-day course of 375 mg of amoxicillin-clavulanate 3 times a day. Patients allergic to penicillin were given erythromycin. Clinical and microbiological evidence of infection on the 10th postoperative day was categorized as either minor (vestibulitis) or major (nasal or septal cellulitis, septal abscess, secondary hemorrhage, or donor-site infection) infections.

RESULTS

At follow-up, 6 (7%) of 82 patients in the prophylactic arm and 9 (11%) of 82 of patients in the postoperative arm showed evidence of infection. Most (80%) of infections were minor. There was no significant difference in infection rates between the prophylactic and postoperative arms on chi2 analysis (P = .42). All 164 patients completed the study on an intention-to-treat basis.

CONCLUSION

We recommend the use of prophylactic antibiotics rather than empirical postoperative antibiotics for patients undergoing complex septorhinoplasty.

Gold weight implants in the management of lagophthalmos in facial palsy

The otolaryngologist plays an essential role in the diagnosis and management of a facial palsy. We present one of the largest cohort prospective studies in the UK of 22 patients with gold weight implants, including ancillary oculoplastic techniques, and their outcomes. Facial paralysis places the eye at risk and protection and lubrication of the eye is paramount in the management of these patients. If recovery of facial function is likely to be delayed or negligible, gold weight loading of the upper lid has been shown to be effective in providing a dynamic solution to lagophthalmos. Following surgery, complete eye closure was possible in the upright position in 18 patients (82%). Two patients had their weights removed secondary to infection (9%). At long-term follow up, four patients judged their vision to have deteriorated (29%). Two of these, after investigation by the ophthalmologists, were found to have pressure astigmatism and removal corrected the visual problems. Overall patient satisfaction with the procedure is high and all reported improvement in eye closure following the operation. An algorithm for the management of the eye in patients with facial palsy is outlined.

Evaluation of hearing thresholds in 3-month-old children with a cleft palate: the basis for a selective policy for ventilation tube insertion at time of palate repair

Hearing thresholds in children with a cleft palate prior to cleft palate repair are not widely documented, and audiological criteria for short-term ventilation tube insertion do not exist. The aims of this prospective study are to estimate hearing thresholds in 40 children with a cleft palate by 3-month developmental age with auditory brainstem responses (ABRs) under natural sleep and to estimate a hearing threshold guideline for short-term ventilation tube insertion. Our results show a wide range of air conduction hearing thresholds using click ABRs (2-4 Hz), which ranged from 25 to 102 dBnHL in the left ear and from 25 to 80 dBnHL in the right ear with means of 53 and 49 and standard deviations of 17 and 13 respectively. The bone conduction thresholds ranged from 0 to 55 dBnHL with a mean of 26 and a standard deviation of 13. Eighty-three per cent of children had flat, type B, on high-frequency tympanograms, indicative of middle ear effusion. Thirty per cent of the infants had a cleft palate associated with a known syndrome. Currently, it is the authors' practice to use short-term ventilation tubes on a selective basis at the time of cleft palate repair when there is a conductive hearing loss of more than 55 dBnHL in the better ear as determined by ABR with type B high-frequency tympanograms. This threshold level takes into account electrophysiological and auditory pathway maturation discrepancies. With this as the guideline, between 28% and 35% of the children in this study would be eligible for surgery. This criterion still requires further validation.

Outpatient laser tonsillar ablation under local anaesthetic

Outpatient laser ablation of the palatine tonsils under local anaesthetic is an alternative technique to capsular tonsillectomy for recurrent tonsillitis under general anaesthetic. Laser tonsillotomy ablates up to 70% of the tonsillar tissue and is performed when patients choose not to have a conventional tonsillectomy, or are unfit for a general anaesthetic. The technique described here is an adaptation of Krespis' laser-assisted serial tonsillectomy (LAST) whereby only one sitting is required. Krespis' technique effectively eliminates recurrent tonsillitis in 96% of the cases over a 4-year follow-up period and represents the only substantial study looking at treating recurrent tonsillitis with outpatient laser ablation. This study is a retrospective postal survey of 19 patients who underwent laser tonsillar ablation under local anaesthetic for recurrent chronic tonsillitis from 1997 to 2001 and was performed in liaison with the clinical audit department at Basildon Hospital. We had a response rate of 74% and an admission rate of 0%, which compares favourably with day case tonsillectomy surgery. Of the patients, 75% did not experience further episodes of tonsillitis 12 months after the procedure and 77% of the patients were glad they had the operation. Although this technique does not completely eliminate tonsillitis, it offers an alternative for those patients who prefer a procedure that is done quickly in an outpatient setting without the additional problems of general anaesthesia, overnight hospital admission and long waiting lists.

Management of lateral cystic swellings of the neck, in the over 40s' age group

We present a series of three case reports of patients over the age of 40 with cystic swellings in the lateral neck. Clinically they masqueraded as branchial cysts, but subsequently were diagnosed as being squamous cell carcinoma cystic lymph node metastasis arising from an occult tonsillar primary. Currently there is an absence of national guidelines for the treatment of lateral neck cysts in the over 40s' age group that subsequently prove to be cystic metastases from occult tonsillar primaries. This disease process is more common than thought, with up to 80 per cent of so-called branchial cysts in the over 40s' age group being malignant. We recommend that patients over the age of 40 presenting with lateral cystic swellings in the neck should have a high suspicion of malignancy and require a panendoscopy, ipsilateral tonsillectomy and blind biopsies of Waldeyer's ring. This avoids inadvertent excision of a possible cystic lymph node metastasis. If the panendoscopy histology proves to be benign, then proceed to excision of the cyst with frozen section analysis of it. If this confirms it to be benign then that is all that is necessary; if the frozen section is however positive for carcinoma then the surgeon can proceed at that time to a formal neck dissection and therefore avoid a further procedure. In the event of an occult tonsillar malignancy, excision of the cyst as part of a neck dissection with post-operative radiotherapy is recommended. It is our aim to treat a cystic lymph node metastasis as you would a solid lymph node metastasis.