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Background: The cause of Ménière's disease remains enigmatic after 156 years. Schuknecht's rupture and potassium intoxication theory of attacks was based on histological studies. Objectives: This paper aimed to: present the most contemporary evidence indicating that ruptures do not usually occur, and discuss the possibility that detached saccular otoconia are the main cause of Ménière's disease; and to establish an unequivocal definition of the age of Ménière's disease onset. Method: The paper reviews the electrophysiological basis of the Gibson–Arenberg drainage theory used to explain vertigo attacks. The current, limited knowledge of the likely fate of detached saccular otoconia is discussed. Results: Electrophysiological studies during attacks do not support endolymph ruptures, but rather endolymph flowing in one direction and then in the opposite direction. Age of onset for Ménière's disease parallels that for benign paroxysmal positional vertigo. Conclusion: The similarity of age of onset spectrum for Ménière's disease and benign paroxysmal positional vertigo raises the possibility that the two conditions have the same fundamental cause. [ABSTRACT FROM AUTHOR]

Background: Severe acute respiratory syndrome coronavirus 2 emerged in December 2019 in Wuhan, China, and was declared a global health emergency of international concern by the World Health Organization on 30th January 2020. It has resulted in almost 600 000 deaths to date worldwide. Sudden sensorineural hearing loss is a known complication of a number of viral infections, but there is little in the literature to date on its association with coronavirus disease 2019. Case report: This paper presents the case of a 30-year-old female staff nurse who contracted coronavirus disease 2019 and presented to our department with a significant unilateral sensorineural hearing loss confirmed on audiogram. She was treated with a course of oral steroids, but unfortunately there was no improvement in her hearing. Conclusion: This case report is important as it highlights the importance of having a low index of suspicion when patients present with a variety of symptoms not previously associated with coronavirus disease 2019. The paper also discusses the controversy surrounding the use of steroids in the management of this disease. [ABSTRACT FROM AUTHOR]

Objective: The coronavirus disease 2019 pandemic resulted in the cessation of elective surgery. The continued provision of complex head and neck cancer surgery was extremely variable, with some UK centres not performing any cancer surgery. During the pandemic, Guy's and St Thomas' NHS Foundation Trust received high numbers of coronavirus disease 2019 admissions. This paper presents our experience of elective complex major head and neck cancer surgery throughout the pandemic. Methods: A head and neck cancer surgery hub was set up that provided a co-ordinated managed care pathway for cancer patients during the pandemic; the Guy's Cancer Centre provided a separate, self-enclosed coronavirus-free environment within the hospital campus. Results: Sixty-nine head and neck cancer patients were operated on in two months, and 13 patients had a microvascular free tissue transfer. Nosocomial infection with coronavirus disease 2019 was detected in two cases (3 per cent), neither required critical care unit admission. Both patients made a complete recovery and were discharged home. There were no deaths. Conclusion: Performing major head and neck surgery, including free flap surgery, is possible during the pandemic; however, significant changes to conventional practice are required to achieve desirable patient outcomes. [ABSTRACT FROM AUTHOR]

Background: Nasal lavage is an ancient practice that still has a fundamental role in the management of sinonasal conditions. The history related to these devices is extensive and remarkable. By reviewing it, it is hoped that a broader view can be achieved on what is currently possible with nasal lavage and how advances may be made in the future. Methods: A careful review of different sources, such as ancient manuscripts, registered patents and scientific papers, was conducted to achieve a thorough examination of the history related to nasal rinsing devices. Conclusion: Nasal lavage has evolved significantly since first considered for medical use and has always played a central role in the treatment of patients with sinonasal conditions. Further innovation is still necessary to surmount the shortcomings of current nasal lavage systems. [ABSTRACT FROM AUTHOR]

Objective: This paper describes the construction of portals for electrode placement during cochlear implantation and emphasises the utility of pre-operative temporal bone three-dimensional computed tomography. Methods: Temporal bone three-dimensional computed tomography was used to plan portal creation for electrode insertion. Results: Pre-operative temporal bone three-dimensional computed tomography can be used to determine the orientation of temporal bone structures, which is important for mastoidectomy, posterior tympanotomy and cochleostomy, and when using the round window approach. Conclusion: It is essential to create appropriate portals (from the mastoid cortex to the cochlea) in a step-by-step manner, to ensure the safe insertion of electrodes into the scala tympani. Pre-operative three-dimensional temporal bone computed tomography is invaluable in this respect. [ABSTRACT FROM AUTHOR]

Objective: To highlight the importance of imaging in reducing an accidental injury to the anomalous brachiocephalic trunk and its branches during tracheal surgery. Case report: This paper reports two cases of accidental injury to the great vessels in the neck during tracheal surgery. The first incident occurred during a repeat tracheostomy, when the right common carotid artery was injured. On reviewing the computed tomography images, the bifurcation of the brachiocephalic artery was seen to the left of the midline, and the right common carotid artery was adherent just below the tracheostomy site. The second incident happened during surgery for tracheal stenosis, when there was an inadvertent injury to the main brachiocephalic trunk, which was adherent to the trachea in the lower neck region. Conclusion: For airway surgeons, radiological assessment of vascular structures in relation to the trachea prior to surgery is as important as the endoluminal airway assessment for the best outcome. [ABSTRACT FROM AUTHOR]

Background: Tracheostomy, being a high aerosol-generating procedure, poses a great challenge to surgeons, especially during the coronavirus disease 2019 pandemic. It is important to preserve staff numbers as this fight may go on for a long time. Personal protective equipment plays a key role in the protection of healthcare workers. Barrier enclosure has been attempted in procedures such as intubation and tracheostomy. The use of boxes became popularised for intubation and they have been utilised in many centres. Methods: This paper describes the box designed by our team and presents our surgical experience with the box. The box is made of transparent acrylic. It is sealed at all ends, with a negative-pressure environment. The hand ports were designed to allow maximum manoeuvrability for surgeons, without restricting hand movements. Conclusion: The proposed box will provide more protection to healthcare workers during tracheostomy. However, the box is yet to be validated. [ABSTRACT FROM AUTHOR]

The article presents several abstracts for papers presented at the Association of Otolaryngologists in Training Conference that held at Glasgow, Scotland from July 7-8, 2016 including neck lump clinic significance; impact of body image on thyroidectomy patients; and human papilloma virus prognosis.

Background: Tonsillectomy and adenoidectomy have been among the most commonly performed procedures in children for approximately 100 years. These procedures were the first for which unwarranted regional variation was discovered, in 1938. Indications for these procedures have become stricter over time, which might have reduced regional practice variation. Methods: This paper presents a historical review on practice variation in paediatric tonsillectomy and adenoidectomy rates. Data on publication year, region, level of variation, methodology and outcomes were collected. Results: Twenty-one articles on practice variation in paediatric tonsil surgery were included, with data from 12 different countries. Significant variation was found throughout the years, although a greater than 10-fold variation was observed only in the earliest publications. Conclusion: No evidence has yet been found that better indications for tonsillectomy and adenoidectomy have reduced practice variation. International efforts are needed to reconsider why we are still unable to tackle this variation. [ABSTRACT FROM AUTHOR]

Background: Coronavirus disease 2019 was declared a pandemic on 11th March 2020. All non-urgent surgical procedures have been postponed indefinitely. The British Association of Head and Neck Oncology state that only those with treatable head and neck cancer unsuitable for alternative treatment should undergo surgery. This paper details our management of a patient who tested positive for severe acute respiratory syndrome coronavirus-2 days before curative surgery for laryngeal cancer. Case report: By following British Association of Head and Neck Oncology guidance, a 49-year-old male scheduled for total laryngectomy and bilateral neck dissection for a T3 transglottic squamous cell cancer was pre-operatively identified as an asymptomatic carrier of severe acute respiratory syndrome coronavirus-2. Following 14-day isolation and laboratory proven viral clearance, he underwent successful major surgery. He was managed throughout the peri- and post-operative phases without complications or adverse effects on staff. Conclusion: With careful planning, previous coronavirus disease 2019 positive status should not prevent an individual from undergoing successful total laryngectomy and bilateral neck dissection in a safe and timely manner during the pandemic. [ABSTRACT FROM AUTHOR]

Background: The World Health Organization declared coronavirus disease 2019 a pandemic on 11th March 2020. There is concern regarding performing endonasal surgical procedures because of a high viral load in the nasopharynx. This paper describes our experience in conducting emergency and urgent endonasal operations during the peak of the coronavirus disease 2019 pandemic in the UK. Objectives: To show the outcome of endonasal surgery during the peak of the coronavirus disease 2019 pandemic and to assess the post-operative rate of nosocomial coronavirus disease 2019 infection. Methods: A retrospective cohort study was conducted of all patients who underwent high priority endoscopic nasal surgery or anterior skull base surgery between 23rd March and 15th June 2020 at University Hospitals Birmingham NHS Trust. Results: Twenty-four patients underwent endonasal surgery during the study period, 12 were males and 12 were females. There was no coronavirus-related morbidity in any patient. Conclusion: This observational study found that it is possible to safely undertake urgent endonasal surgery; the nosocomial risk of coronavirus disease 2019 can be mitigated with appropriate peri-operative precautions. [ABSTRACT FROM AUTHOR]

Objective: This paper highlights the importance of reporting air–bone gap closure in stapes surgery according to the American Academy of Otolaryngology – Head and Neck Surgery guidelines and reviews compliance in recent years. Methods: A retrospective case series was conducted and the outcomes were reviewed. Closure of the air–bone gap was calculated in 204 adult patients using the aforementioned guidelines. Results were recalculated ignoring the Carhart phenomenon to determine any significant difference. Adherence to guidelines was also reported as a secondary outcome. Results: Ignoring the Carhart phenomenon resulted in 75 per cent over-reporting of successful air–bone gap closure (p < 0.001). Over-reporting occurred in 5.9 per cent of papers, and in 11.8 per cent it was difficult to determine how the results were reached. Conclusion: Despite the existence of clear guidelines, stapes surgery outcomes are still being over-reported as successful. This can lead to incorrect information being provided to patients during the consent process and makes comparative studies difficult. [ABSTRACT FROM AUTHOR]

Objective: The use of lasers in cholesteatoma surgery is common and well accepted. The most commonly used laser fibres are straight and non-adjustable; these have several limitations. This paper describes the use of an alternative laser fibre. Method: This ‘How I Do It’ paper describes and illustrates the use of an alternative curved adjustable fibre-optic diode laser in microscopic cholesteatoma surgery. Results: The curved, adjustable laser fibre allows accurate and atraumatic disease removal when the use of a straight laser fibre may be less effective or accurate. It reduces potential damage to delicate structures without the need for extra drilling or bone removal. Conclusion: It is suggested that the curved adjustable laser fibre is superior to the traditional straight fibre for cholesteatoma surgery. [ABSTRACT FROM AUTHOR]

Background: Migrated ingested foreign bodies in the aerodigestive tract can lodge within vital organs and vessels, causing potentially devastating complications. It is often difficult to localise these foreign bodies, with extrication resulting in the requirement for open approaches which may cause significant morbidity. Case report: This paper presents the case of an ingested migrated stingray bone lodged adjacent to the vertebral artery in the upper cervical spine. This was managed via an endoscopic transoral approach, with the assistance of an image-guidance system. Results: Successful extraction of the foreign body was achieved, with minimal residual morbidity. Conclusion: Our study showed that image-guided endoscopic surgery is a safe, precise and feasible option for the localisation and removal of migrated foreign bodies in the aerodigestive tract involving critical neurovascular structures. [ABSTRACT FROM AUTHOR]

Background: This paper discusses the concept of acoustic shock based on a literature review and the results of our own research into cases seen in both clinical and medicolegal practice. With the demise of traditional 'metal bashing' and 'smoke stack' heavy industries, there has been a decline in the incidence of noise-induced hearing loss and tinnitus in this form of employment. However, with the increasing establishment of call centre work, the emergence of acoustic shock has been noted. Acoustic shock is recognised as a clinical entity distinct from noise-induced hearing loss and acoustic trauma. Objective: This article discusses clinical implications, medicolegal considerations in light of a recent high-profile court case and proposed criteria for diagnosis. [ABSTRACT FROM AUTHOR]

Objective: Recent scientific literature has widely described a possible major role of smell dysfunction as a specific symptom of coronavirus disease 2019. This systematic review may provide a more holistic approach to current knowledge of the disease. Methods: A systematic review was completed using Embase, PubMed and Web of Science databases that considered original articles focused on olfactory evaluation in coronavirus disease 2019 patients, published between March and May 2020, in English language. Results: From the 483 research papers initially identified, 32 original studies were selected, comprising a total of 17 306 subjects with a laboratory confirmed diagnosis of coronavirus disease 2019. Individual study sample sizes ranged from 6 to 6452 patients. This comprehensive analysis confirmed that olfactory disorders represent an important clinical feature in coronavirus disease 2019, with a prevalence of 11–100 per cent in included patients, although there was heterogeneity in terms of assessment tools and population selection criteria. Conclusion: The results indicate that an accurate clinical evaluation should be carried out using structured questionnaires and tests with olfactory substances. [ABSTRACT FROM AUTHOR]

Objective: This study investigated the risk of contamination of lidocaine hydrochloride 5 per cent w/v and phenylephrine hydrochloride 0.5 per cent w/v topical solution after modification of the application technique. Methods: This paper reports a prospective basic sciences study involving 22 study samples and 1 control sample of the lidocaine hydrochloride and phenylephrine hydrochloride topical anaesthetic spray. The samples were assessed for microbiological contamination after a single use on patients using a modified application technique. The modification involves keeping the nozzle (actuator) pressed down whilst withdrawing the spray to at least 30 cm (1 ft) from the patient, before releasing the nozzle (actuator) and subsequently reapplying the spray. Results: Three of the 23 samples confirmed bacterial growth in the bottle contents, but there was no growth in any of the samples from the pump. These bacteria are considered to be contaminants. Conclusion: There is a potential to use the lidocaine hydrochloride 5 per cent w/v and phenylephrine hydrochloride 0.5 per cent w/v topical solution as a multi-use spray by changing the actuator between patients. This would have significant beneficial cost implications without the attendant infection control risk. [ABSTRACT FROM AUTHOR]

Background: Coronavirus disease 2019 is an international pandemic. One of the cardinal features is acute respiratory distress syndrome, and proning has been identified as beneficial for a subset of patients. However, proning is associated with pressure-related side effects, including injury to the nose and face. Method: This paper describes a pressure-relieving technique using surgical scrub sponges. This technique was derived based on previous methods used in patients following rhinectomy. Conclusion: The increased use of prone ventilation has resulted in a number of referrals to the ENT team with concerns regarding nasal pressure damage. The described technique, which is straightforward and uses readily available materials, has proven effective in relieving pressure in a small number of patients. [ABSTRACT FROM AUTHOR]

Background: Ingested foreign bodies are a common presentation to paediatric ENT services. Depending on the site, these are usually managed with flexible or rigid oesophagoscopy and retrieval. This paper presents a novel technique for removing a hollow foreign body that could not be removed using conventional means. Method and results: After rigid and flexible approaches failed, a guidewire was passed through the foreign body under fluoroscopic guidance and a dilatation balloon passed through the lumen of the object. Inflating the balloon allowed dilatation of the inflamed mucosa above and below the object, facilitating straightforward removal under traction. Conclusion: This is a novel and reproducible technique that uses equipment readily available in tertiary referral centres. Employed in this context, the technique enabled removal of an impacted object surrounded by granulation tissue, and would be appropriate for other objects with a lumen. [ABSTRACT FROM AUTHOR]

Background: Ex utero intrapartum treatment ('EXIT' procedure) is a well described method for maintaining maternal–fetal circulation in the setting of airway obstruction from compressive neck masses. When ex utero intrapartum treatment to airway is not feasible, ex utero intrapartum treatment to extracorporeal membrane oxygenation ('ECMO') has been described in fetal cardiopulmonary abnormalities. Objective: This paper presents the case of a massively compressive midline neck teratoma managed with ex utero intrapartum treatment to extracorporeal membrane oxygenation, allowing for neonatal survival, with controlled airway management and subsequent resection. Case report: A 34-year-old-female presented with a fetal magnetic resonance imaging scan demonstrating a 15 cm compressive midline neck teratoma. Concern for failure of ex utero intrapartum treatment to airway was high. The addition of the ex utero intrapartum treatment to extracorporeal membrane oxygenation procedure provided time for the planned subsequent resection of the mass and tracheostomy. Conclusion: Ex utero intrapartum treatment procedures allow for securement of the difficult neonatal airway, while maintaining a supply of oxygenated blood to the newborn. Ex utero intrapartum treatment circulation lasts on average less than 30 minutes. The arrival of extracorporeal membrane oxygenation has enabled the survival of neonates with disease processes previously incompatible with life. [ABSTRACT FROM AUTHOR]

Objective: Safe cochlear implantation is challenging in patients with canal wall down mastoid cavities, and the presence of large meatoplasties increases the risk of external canal overclosure. This paper describes our results of obliteration of the mastoid cavity with conchal cartilage as an alternative procedure in cases of canal wall down mastoidectomy with very large meatoplasty. Methods: The cases of seven patients with a canal wall down mastoidectomy cavity who underwent cochlear implantation were retrospectively reviewed. Post-operative complications were analysed. The mean follow-up duration was 4.5 years. Results: There was no hint of cholesteatoma recurrence and all patients have been free of symptoms during follow up. Only one patient showed cable extrusion six months after surgery, and implantation of the contralateral ear was needed. Conclusion: Pseudo-obliteration of the mastoid cavity with a cartilage multi-layered palisade reconstruction covering the electrode may be a safe alternative in selected patients with a large meatoplasty. [ABSTRACT FROM AUTHOR]

Objective: Hypocalcaemia is the most common complication after total or completion thyroidectomy. This study assesses recent evidence on predictive factors for post-thyroidectomy hypocalcaemia in order to identify the patients affected and aid prevention. Method: Two authors independently assessed articles and extracted data to provide a narrative synthesis. This study was an updated systematic search and narrative review regarding predictors of post-thyroidectomy hypocalcaemia using the Ovid Medline, Embase, Cochrane and Cinahl databases. Results were limited to papers published from January 2012 to August 2019. Results: Sixty-three observational studies with a total of 210 401 patients met the inclusion criteria. The median incidence was 27.5 per cent for transient biochemical hypocalcaemia, 12.5 per cent for symptomatic hypocalcaemia and 2.2 per cent for permanent hypocalcaemia. The most frequent statistically significant predictor of hypocalcaemia was peri-operative parathyroid hormone level. Symptomatic hypocalcaemia and permanent hypocalcaemia were seen more frequently in patients undergoing concomitant neck dissection. Conclusion: Many factors have been studied for their link to post-thyroidectomy hypocalcaemia, and this study assesses the recent evidence presented in each case. [ABSTRACT FROM AUTHOR]

Objective: To present our data evaluating the feasibility of simultaneous cochlear implantation with resection of acoustic neuroma. Methods: This paper describes a case series of eight adult patients with a radiologically suspected acoustic neuroma, treated at a tertiary referral centre in Newcastle, Australia, between 2012 and 2015. Patients underwent cochlear implantation concurrently with removal of an acoustic neuroma. The approach was translabyrinthine, with facial nerve monitoring and electrically evoked auditory brainstem response testing. Standard post-implant rehabilitation was employed, with three and six months' follow-up data collected. The main outcome measures were: hearing, subjective benefit of implant, operative complications and tumour recurrence. Results: Eight patients underwent simultaneous cochlear implantation with resection of acoustic neuroma over a 3-year period, and had 25–63 months' follow up. There were no major complications. All patients except one gained usable hearing and were daily implant users. Conclusion: Simultaneous cochlear implantation with resection of acoustic neuroma has been shown to be a safe treatment option, which will be applicable in a wide range of clinical scenarios as the indications for cochlear implantation continue to expand. [ABSTRACT FROM AUTHOR]

Objectives: Treatment of inflammatory and neoplastic disease in the maxillary sinus, pterygopalatine and infratemporal fossae requires appropriate surgical exposure. As modern rhinology evolves, so do the techniques available. This paper reviews extended endoscopic approaches to the maxillary sinus and the evidence supporting each technique. Methods: A literature search of the Ovid Medline and PubMed databases was performed using appropriate key words relating to endoscopic approaches to the maxillary sinus. Results: Mega-antrostomy and medial maxillectomy have a role in the surgical treatment of refractory inflammatory disease and sinonasal neoplasms. The pre-lacrimal fossa approach provides excellent access but can be limited because of anatomical variations. Both the transseptal and endoscopic Denker's approaches were reviewed; these appear to be associated with morbidity, without any significant increase in exposure over the afore-described approaches. Conclusion: A range of extended endoscopic approaches to the maxillary sinus exist, each with its own anatomical limitations and potential complications. [ABSTRACT FROM AUTHOR]

Objectives: This paper aimed to: retrospectively analyse single-centre results in terms of surgical success, respiratory outcomes and adverse events after short-term follow up in obstructive sleep apnoea patients treated with upper airway stimulation; and evaluate the correlation between pre-operative drug-induced sleep endoscopy findings and surgical success. Methods: A retrospective descriptive cohort study was conducted, including a consecutive series of obstructive sleep apnoea patients undergoing implantation of an upper airway stimulation system. Results: Forty-four patients were included. The total median Apnoea–Hypopnea Index and oxygen desaturation index significantly decreased from 37.6 to 8.3 events per hour (p < 0.001) and from 37.1 to 15.9 events per hour (p < 0.001), respectively. The surgical success rate was 88.6 per cent, and did not significantly differ between patients with or without complete collapse at the retropalatal level (p = 0.784). The most common therapy-related adverse event reported was (temporary) stimulation-related discomfort. Conclusion: Upper airway stimulation is an effective and safe treatment in obstructive sleep apnoea patients with continuous positive airway pressure intolerance or failure. There was no significant difference in surgical outcome between patients with tongue base collapse with or without complete anteroposterior collapse at the level of the palate. [ABSTRACT FROM AUTHOR]

Background: Levamisole is an increasingly common cutting agent used with cocaine. Both cocaine and levamisole can have local and systemic effects on patients. Methods: A retrospective case series was conducted of patients with a cocaine-induced midline destructive lesion or levamisole-induced vasculitis, who presented to a Dundee hospital or the practice of a single surgeon in Paisley, from April 2016 to April 2019. A literature review on the topic was also carried out. Results: Nine patients from the two centres were identified. One patient appeared to have levamisole-induced vasculitis, with raised proteinase 3, perinuclear antineutrophil cytoplasmic antibodies positivity and arthralgia which improved on systemic steroids. The other eight patients had features of a cocaine-induced midline destructive lesion. Conclusion: As the use of cocaine increases, ENT surgeons will see more of the complications associated with it. This paper highlights some of the diagnostic issues and proposes a management strategy as a guide to this complex patient group. Often, multidisciplinary management is needed. [ABSTRACT FROM AUTHOR]

Background: Individuals on anticoagulation therapy are at increased risk of bleeding, including epistaxis. There is a lack of available reversal agents for novel oral anticoagulation therapy. Objective: This paper reviews the current literature on epistaxis in the context of novel oral anticoagulation use, in order to recommend guidelines on management. Method: A comprehensive search of published literature was conducted to identify all relevant articles published up to April 2019. Results: Patients on oral anticoagulation therapy are over-represented in individuals with epistaxis. Those on novel oral anticoagulation therapy were more likely to relapse compared to patients on classic oral anticoagulants or non-anticoagulated patients. Idarucizumab is an effective antidote for bleeding associated with dabigatran use. Recommendations for epistaxis management in patients on novel oral anticoagulation therapy are outlined. Conclusion: Clinicians need to be aware of the potential severity of epistaxis and the increased likelihood of recurrence. High-quality studies are required to determine the efficacy and safety of andexanet alfa and ciraparantag, as well as non-specific reversal agents. [ABSTRACT FROM AUTHOR]

Objectives: Pharyngocutaneous fistulae are dreaded complications following total laryngectomy. This paper presents our experience using 3–5 ml gastrografin to detect pharyngeal leaks following total laryngectomy, and compares post-operative videofluoroscopy with clinical follow-up findings in the detection of pharyngocutaneous fistulae. Methods: A retrospective case–control study was conducted of total laryngectomy patients. The control group (n = 85) was assessed clinically for development of pharyngocutaneous fistulae, while the study group (n = 52) underwent small-volume (3–5 ml) post-operative gastrografin videofluoroscopy. Results: In the control group, 24 of 85 patients (28 per cent) developed pharyngocutaneous fistulae, with 6 requiring surgical correction. In the study group, 24 of 52 patients (46 per cent) had videofluoroscopy-detected pharyngeal leaks; 4 patients (8 per cent) developed pharyngocutaneous fistulae, but all cases resolved following non-surgical management. Patients who underwent videofluoroscopy had a significantly lower risk of developing pharyngocutaneous fistulae; sensitivity and specificity in the detection of pharyngocutaneous fistulae were 58 per cent and 100 per cent respectively. Conclusion: Small-volume gastrografin videofluoroscopy reliably identified small pharyngeal leaks. Routine use in total laryngectomy combined with withholding feeds in cases of early leaks may prevent the development of pharyngocutaneous fistulae. [ABSTRACT FROM AUTHOR]

Objective: This paper reviews our experience of potassium titanyl phosphate (KTP) laser in transcanal totally endoscopic cholesteatoma surgery. Methods: A prospective cohort study was conducted in a tertiary referral centre, involving a consecutive series of children with cholesteatoma who underwent totally endoscopic cholesteatoma surgery with a KTP laser. Results: The patients' mean age was 10.5 years (range, 1.8–18 years). A KTP laser was used in 70 of the 83 cases (84 per cent). The laser was not used in 13 'clean' cases, in which disease was removed more easily. Residual disease was detected in five cases (6 per cent), of which the KTP laser had been used in four (5 per cent). No complications were associated with KTP laser use. Conclusion: The combination of KTP laser use with endoscopic visualisation is effective for minimising the risk of residual disease using a minimally invasive surgical approach. The thin, semi-flexible fibre carrier of the KTP laser is ideally suited to work alongside the endoscope within the narrow confines of the ear canal. [ABSTRACT FROM AUTHOR]

Objective: This paper aims to report our experience with a minimally invasive surgical procedure for the treatment of chronic rhinosinusitis with nasal polyps, performed in a day-surgery setting under local anaesthesia. Methods: A retrospective study of 30 patients with chronic rhinosinusitis with nasal polyps was conducted. Sino-Nasal Outcome Test 22 and modified Lund–Kennedy scores were collected. Intra- and post-operative pain was evaluated using a 10-point visual analogue scale. Results: The mean Sino-Nasal Outcome Test 22 score decreased from 41.8 ± 15.8 pre-operatively to 13.3 ± 9.5 post-operatively (p < 0.001). Accordingly, the mean endoscopic score decreased from 6.8 ± 1.8 to 0.2 ± 0.7 (p < 0.001). The mean intra-operative pain score was 2.9 ± 3.2, and 29 patients (96.7 per cent) reported no pain in the post-operative period (visual analogue scale score = 0). Conclusion: Our study confirms that minimally invasive surgery represents a safe, repeatable procedure that results in remarkable subjective and objective improvement, without intra- and post-operative pain or discomfort. [ABSTRACT FROM AUTHOR]

Objective: Accessory nerve palsy affects a proportion of patients following neck dissection, and results in shoulder dysfunction and regional pain. This project aimed to establish the evidence supporting post-operative physiotherapy for the shoulder following neck dissection. Method: A systematic review was conducted of prospective trials investigating the efficacy of rehabilitation for shoulder or upper limb dysfunction and pain following any type of neck dissection. Results: A total of 820 papers were identified; through a staged review process, 7 trials were found that fulfilled the inclusion criteria. These included three randomised, controlled trials and four non-randomised studies. Five out of the seven trials demonstrated a statistically significant benefit of physiotherapy. Conclusion: Current evidence shows a benefit from physiotherapy in patients with shoulder dysfunction following neck dissection. Some evidence suggests progressive resistance is superior to other types of physiotherapy. Long-term benefit and cost efficacy have not been studied. [ABSTRACT FROM AUTHOR]

Background: Periodic alternating nystagmus is a rare condition characterised by spontaneous horizontal nystagmus that periodically reverses direction, indicating an alteration of the velocity storage mechanism. Windmill nystagmus is a peculiar and rare variant of periodic alternating horizontal nystagmus with a superimposed periodic alternating vertical nystagmus. It is generally observed in blind patients. Case report: This paper presents the unique case of a normally sighted patient with a windmill nystagmus triggered by an episode of benign paroxysmal positional vertigo due to bilateral posterior canalolithiasis. Videonystagmography revealed an anticlockwise up-beating nystagmus followed by a clockwise down-beating nystagmus with a cycle lasting 2 minutes, followed by a brief burst of horizontal left-beating nystagmus. Conclusion: This case report represents the first observation of a new type of windmill nystagmus, probably provoked by a malfunction of the velocity storage mechanism, gaze-stabilisation and short-adaptation networks, with a loss of cerebellar inhibition. [ABSTRACT FROM AUTHOR]

Background: Transmastoid occlusion of the posterior or superior semicircular canal is an effective and safe management option in patients with refractory benign paroxysmal positional vertigo or symptomatic superior semicircular canal dehiscence. A method of quantifying successful canal occlusion surgery is described. Methods: This paper presents representative patients with intractable benign paroxysmal positional vertigo or symptomatic superior semicircular canal dehiscence, who underwent transmastoid occlusion of the posterior or superior semicircular canal respectively. Vestibular function was assessed pre- and post-operatively. The video head impulse test was included as a measure of semicircular canal and vestibulo-ocular reflex functions. Results: Post-operative video head impulse testing showed reduced vestibulo-ocular reflex gain in occluded canals. Gain remained normal in the non-operated canals. Post-operative audiometry demonstrated no change in hearing in the benign paroxysmal positional vertigo patient and slight hearing improvement in the superior semicircular canal dehiscence syndrome patient. Conclusion: Transmastoid occlusion of the posterior or superior semicircular canal is effective and safe for treating troublesome benign paroxysmal positional vertigo or symptomatic superior semicircular canal dehiscence. Post-operative video head impulse testing demonstrating a reduction in vestibulo-ocular reflex gain can reliably confirm successful occlusion of the canal and is a useful adjunct in post-operative evaluation. [ABSTRACT FROM AUTHOR]

Background: Mastoiditis is an otological emergency, and cross-sectional imaging has a role in the diagnosis of complications and surgical planning. Advances in imaging technology are becoming increasingly sophisticated and, by the same token, the ability to accurately interpret findings is essential. Methods: This paper reviews common and rare complications of mastoiditis using case-led examples. A radiologist-derived systematic checklist is proposed, to assist the ENT surgeon with interpreting cross-sectional imaging in emergency mastoiditis cases when the opinion of a head and neck radiologist may be difficult to obtain. Results: A 16-point checklist (the 'mastoid 16') was used on a case-led basis to review the radiological features of both common and rare complications of mastoiditis; this is complemented with imaging examples. Conclusion: Acute mastoiditis has a range of serious complications that may be amenable to treatment, once diagnosed using appropriate imaging. The proposed checklist provides a systematic approach to identifying complications of mastoiditis. [ABSTRACT FROM AUTHOR]

Objective: There has been little reported on the transoral reconstructive options following salvage transoral robotic surgery. This paper describes the facial artery musculomucosal flap as a method to introduce vascularised tissue to a previously irradiated resection bed. Methods: A facial artery musculomucosal flap was used to reconstruct the lateral pharyngeal wall in 13 patients undergoing salvage transoral robotic surgery for oropharyngeal squamous cell carcinoma. Outcomes recorded include flap and donor site complications, length of stay, and swallowing and speech outcomes. Results: There were no immediate or late flap complications, or cases of delayed wound healing in this series. There were two facial artery musculomucosal related complications requiring surgical management: one bleed from the facial artery musculomucosal donor site and one minor surgical revision. Healing of the flap onto the resection bed was successful in all cases. Conclusion: The facial artery musculomucosal flap provides a suitable transoral local flap option for selected patients undergoing salvage transoral robotic surgery for oropharyngeal malignancies. [ABSTRACT FROM AUTHOR]

Background: The field of otology is increasingly at the forefront of innovation in science and medicine. The inner ear, one of the most challenging systems to study, has been rendered much more open to inquiry by recent developments in research methodology. Promising advances of potential clinical impact have occurred in recent years in biological fields such as auditory genetics, ototoxic chemoprevention and organ of Corti regeneration. The interface of the ear with digital technology to remediate hearing loss, or as a consumer device within an intelligent ecosystem of connected devices, is receiving enormous creative energy. Automation and artificial intelligence can enhance otological medical and surgical practice. Otology is poised to enter a new renaissance period, in which many previously untreatable ear diseases will yield to newly introduced therapies. Objective: This paper speculates on the direction otology will take in the coming decades. Conclusion: Making predictions about the future of otology is a risky endeavour. If the predictions are found wanting, it will likely be because of unforeseen revolutionary methods. [ABSTRACT FROM AUTHOR]

Abstracts of papers presented during the Association of Otolaryngologists in Training Annual Meeting on June 20, 2014 in Exeter, England is presented on topics including the parotid tumor, quality improvement, and procedures of limited clinical value in ear, nose, and throat (ENT).

Objectives:This paper reports three cases of severe post-stapedectomy granuloma, emphasising the variable presentation of this devastating complication and the challenges of its management.Methods:A retrospective review was conducted of three cases of post-stapedectomy granuloma requiring surgical debulking between 2010 and 2015. Clinical symptoms, serial imaging, histopathology and post-operative outcomes were considered.Results:Intra-operatively, extensive granulation tissue with erosion of the otic capsule was found. There was spread along the VIIth and VIIIth cranial nerves to the cochlear nucleus in one patient. Post-operative clinical improvement was demonstrable, corroborated by diminution of contrast enhancement on serial magnetic resonance imaging. Facial nerve function recovered, tinnitus amelioration was variable and some otalgia persisted. Post-operative complications included grade IV facial weakness and late Pseudomonas aeruginosa meningitis, which all resolved.Conclusion:To the authors’ knowledge, this paper reports the only case of post-stapedectomy granuloma tracking to the brainstem. Otalgia was present in all our cases, and may be deemed a red flag symptom of progressive bony destruction and otic capsule involvement. Although granuloma remains rare, it should be considered in any patient with worsening otological symptoms following stapes surgery. [ABSTRACT FROM AUTHOR]

Background:Tonsillectomy is one of the most common surgical procedures performed worldwide. There are a handful of common complications, with bleeding being the most feared; however, rarer complications can present to a wide range of medical professionals.Methods:A 12-year-old girl presented with cervicofacial emphysema following tonsillectomy. This paper discusses the case and the management adopted, and presents the findings of a comprehensive literature review.Results:The patient made a full recovery, and was discharged after 3 days following conservative management with intravenous broad-spectrum antibiotics and supplemental low-flow oxygen.Conclusion:This paper presents the first reported case of cervicofacial emphysema following Harmonic scalpel tonsillectomy. Although this is an exceptionally rare complication, it is potentially serious and warrants further description to improve awareness. [ABSTRACT FROM AUTHOR]

Background: Coronavirus disease 2019 critical care patients endure prolonged periods of intubation. Late tracheostomy insertion, large endotracheal tubes and high cuff pressures increase their risk of subglottic and tracheal stenosis. This patient cohort also often appears to have co-morbidities associated with laryngotracheal stenosis, including high body mass index and laryngopharyngeal reflux. Methods: This paper presents three coronavirus disease 2019 patients who were intubated for a mean of 28 days before tracheostomy, leading to complex multi-level stenoses. Results: All patients underwent multiple endoscopic tracheoplasty procedures and two required tracheal resections. There was a mean of 33.9 days between interventions. Coronavirus disease 2019 patients do not appear to respond as well to steroid, laser and balloon dilatation as other adult stenosis patients. Conclusion: Intubated coronavirus disease 2019 patients have an increased risk of laryngotracheal stenosis, as a result of multiple factors. Otolaryngology teams should be vigilant in investigating for this complication. International guidelines on time to tracheostomy should be followed, despite a diagnosis of coronavirus disease 2019. [ABSTRACT FROM AUTHOR]

Background: This paper reports the dangers of an ingested metal wire bristle from a barbeque brush, which resulted in oesophageal perforation. Case report: A 49-year-old gentleman presented to the emergency department with foreign body sensation and odynophagia after having consumed barbequed lamb for lunch. Computed tomography of the neck demonstrated a thin linear opacity near the thoracic inlet. The object could not be visualised on emergent rigid oesophagoscopy. Subsequent neck exploration enabled localisation of a retropharyngeal abscess and a thin wire bristle from a barbeque brush. Conclusion: Always consider the utensils employed in food preparation as a differential in ingested foreign bodies. Thin wire objects have a high propensity to migrate and result in complications, hence urgent intervention is vital. [ABSTRACT FROM AUTHOR]

Several abstracts are presented from the ENT Scotland Winter Meeting on topics including effect of the consultant-led Ear Nose Throat (ENT) service; treatment for otitis externa; and Gardasil vaccine for recurrent respiratory papillomatosis of larynx.

Several abstracts are presented from the ENT Scotland Summer Meeting on topics including benefits of silicone stents in primary endonasal dacryocystorhinostomy; the use of image guidance for endoscopic orbital decompression in thyroid eye disease; and the intratympanic therapy for refractory tinnitus.

Several abstracts are presented from the Otology Section Meetings of the Royal Society of Medicine on topics including validity of the Visible Ear Simulator as a tool for temporal bone dissection; and comparison of cervical and ocular vestibular-evoked myogenic potentials in patients with Ménière's disease.

Several abstracts are presented from the ENT Scotland Summer Meeting related to Ear Nose Throat (ENT) on topics including validation of a patient-centred outcome questionnaire for pinnaplasty; a study on laryngeal dysplasia; and adenotonsillar surgery for obstructive symptoms in children.

Several abstracts are presented from the Otology Section Meetings of the Royal Society of Medicine on topics including stability of the bone-anchored hearing aid (BAHA) abutment; identification of genetic variants in otosclerosis; and characterization of eosinophilic granulomatosis with polyangiitis.

Abstracts of papers presented at the Summer Meeting of ENT Scotland on May 8-9, 2014 in Dunblane, Scotland are presented including "Standardisation of Ultrasound Scan Reporting of Thyroid Nodules: Would an "R" Status Be Useful?" by A McPhee, V. Visvanathan and L. Clark, "Are We Managing Paediatric Periorbital Cellulitis Effectively?" by L. Hughes, I.Khan and H. Kubba and "Eraly Glottic Carcinoma: 10-Year Single-Centre Outcome Analysis" by JCL Yeo, S. Ali and E. Junor.

Objective: This paper reports a rare case of a 61-year-old man with sialodochitis fibrinosa. Methods: Clinical case report and review of current literature. Results: Sialodochitis fibrinosa is a diagnosis of exclusion and in many cases can be managed conservatively. Conservative management failed for this patient and he was managed successfully with staged bilateral total parotidectomy. Conclusion: Sialodochitis fibrinosa should be considered as a differential diagnosis of painful bilateral facial swelling. While conservative management is successful for many patients, staged bilateral total parotidectomy may be necessary for full remission of symptoms; the timing of this is crucial to reduce the risk of facial nerve palsy. [ABSTRACT FROM AUTHOR]

Background: Frontal sinus surgery is challenging as the frontal recess is prone to re-stenosis and there is subsequent occlusion of the frontal sinus outflow tract. In an attempt to maintain the frontal recess calibre and reduce frontal sinus re-stenosis, frontal sinus stents have been used with different materials and varying results. Objective: This paper presents the technique of using a modified Montgomery T-tube as a frontal sinus stent. Results and conclusion: The use of a soft, self-retaining and non-absorbable stent that can be used for stenting of the frontal sinus is described. Our technique is safe, effective, inexpensive and well tolerated. [ABSTRACT FROM AUTHOR]