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3D-FLAIR 1.5-Tesla MRI sequences can detect abnormalities that show as signal hyperintensity in patients with unilateral SSHL. We propose a simple objective method to detect these abnormalities based on the quantitative calculation of affected versus healthy contralateral ear signal intensity ratios. This signal hyperintensity may involve the cochlea, vestibule or the entire inner ear of affected ears. Such abnormalities were found in 45% of patients with SSHL, and hyperintensity was associated with lower initial and final hearing levels, as well as a lower ≥ 10 dB hearing recovery and more vertigo. We put hyperintensity itself forward as a marker of poor prognosis for patients with SSHL.

DESIGN The objective of this study was to establish whether autoinflation was an effective intervention in a paediatric audiology service. This was a pragmatic retrospective study with historical controls using a paired availability design. SETTING The study took place at a single paediatric audiology service in England. PARTICIPANTS All children seen in the clinic over a two-year period who were aged between 3 and 11 years and who had a type B tympanogram in at least one ear were included. The Otovent autoinflation device was available as a treatment option over the second year (Cohort B) but not the first (Cohort A). There were 976 children included in the study: Cohort A comprised 513 children, Cohort B comprised 463 children. MAIN OUTCOME MEASURES The aims were to evaluate whether there was improvement in hearing thresholds following introduction of an autoinflation device, and whether there was a reduction in further audiology follow-ups, and in referrals to an ear, nose and throat specialist for consideration of ventilation tube insertion. RESULTS AND CONCLUSIONS There was a statistically significant improvement in hearing thresholds in Cohort B compared to Cohort A, however the improvements were clinically minimal with small effect sizes. There was no significant difference in improvement of tympanometry results between the two cohorts. Significantly more children in Cohort B (autoinflation group) were referred to an ear, nose and throat specialist after their second appointment compared to Cohort A. It was feasible to introduce autoinflation into the care pathway, however there was no evidence of clinically meaningful improved outcomes for patients.

OBJECTIVE Many studies have evaluated the effectiveness of topical intraoperative mitomycin (MCC) usage in a wide range of otolaryngologic procedures with variable conclusions on effectiveness. This systematic review aims to provide a qualitative estimation of mitomycin C's treatment effectiveness in maintaining or preventing stenosis after surgical interventions. DESIGN AND SETTING Following the PRISMA guideline, a comprehensive systematic search of MEDLINE, EMBASE and CINAHL databases was performed including hand-searching and cross-reference checking. PARTICIPANTS The search was limited to humans, sample size greater than two and study designs including a comparative arm. MAIN OUTCOME MEASURES Outcome measures varied but included rates of restenosis, number of procedures, and post-surgical patency. RESULTS A total of 571 unique abstracts and 109 full articles were reviewed. Seventy-seven studies were included in the final analysis. The available evidence ranged from case series to randomized control studies. Meta-analysis was deemed inappropriate due to heterogeneity of study design. Thirty-eight studies assessed the effective of MCC in dacryocystorhinostomy, which is reported in a separate meta-analysis. All other studies were categorized into otolaryngologic site and pathology including choanal atresia (n = 5), endoscopic sinus surgery (n = 12), airway procedures (n = 9), esophageal procedures (n = 8) and other (n = 2). CONCLUSIONS The published literature on the effectiveness of MMC was mixed, but suggested topical MMC improved surgical outcomes in many otolaryngologic procedures compared to controls. This was the first review to assemble literature on MMC usage for different surgical procedures. Comprehensive interpretation of the data was limited due to heterogeneity in primary outcome, procedure type and study quality. High-quality prospective and randomized controlled studies are required to further confirm the positive effect of MMC use on surgical outcomes.

OBJECTIVES To investigate the association between diabetes mellitus (DM) and the prevalence and severity of hearing loss in a population of community-dwelling older adults in Singapore. MATERIALS AND METHODS This is a retrospective, cross-sectional study of 1787 adults aged 60-100 who had undergone a comprehensive audiological assessment in a community-based audiology clinic. Data extracted included their age, hearing profile, medical history, and comorbidities collected through verbal interview at the point of audiologic assessment. Multivariate linear regression and multivariate logistic regression were performed to investigate the relationship between DM and hearing loss. RESULTS The prevalence of DM in our studied population is 17.9%. After controlling for age, gender, race, hypertension, and hyperlipidaemia status, DM was found to be independently associated with at least moderate hearing loss (adjusted OR 1.3 [95% CI 1.06-1.59], p = .012). This was especially so in the younger (

Objective To evaluate the correlation of neonatal parameters with late-onset sensorineural hearing loss (SNHL) and vestibular dysfunction in individuals with congenital cytomegalovirus (cCMV) infection using the National Health Insurance Research Database (NHIRD) in Taiwan. Design Retrospective cohort study. Setting The whole Taiwanese population. Participants Patients with related diagnostic codes and examinations in their records were regarded as having cCMV infection. Each subject in that group was matched to 10 control individuals with noncongenital CMV infection on the basis of several neonatal parameters, including low gestational age, low birth weight, low Apgar score, maternal history of CMV infection and prolonged cCMV infection. A total of 5893 and 58 930 participants were enrolled in the study and control groups, respectively. Main outcome measures The main outcomes were the development of SNHL and the development of vestibular dysfunction within one year after birth as reflected by diagnostic codes and specific examinations. Cox proportional hazard regression was used to calculate the adjusted hazard ratio (HR) and 95% confidence interval (CI) of each primary outcome between the two groups. Results Overall, 109 and 397 episodes of SNHL developed in the study group and the control group, respectively, and the study group demonstrated a significantly higher incidence of SNHL (adjusted HR: 2.56; 95% CI: 2.07-3.18). In addition, similar incidence rates of vestibular dysfunction were found in the study group and the control group, with 7 and 90 events, respectively (adjusted HR: 0.77; 95% CI: 0.36-1.67). In subgroup analyses, a higher incidence of SNHL was correlated with lower gestational age (GA) (adjusted HR: 2.09; 95% CI: 1.29-3.39), lower birth weight (BW) (adjusted HR: 2.05; 95% CI: 1.28-3.30) and prolonged cCMV infection (adjusted HR: 3.92; 95% CI: 1.95-7.88). Conclusions Low GA, low BW and a long disease course are significantly correlated with late-onset SNHL in cCMV infection.

Objectives Anecdotal evidence suggests that oropharyngeal squamous cell carcinoma (OPSCC) should be suspected in patients presenting with symptoms of peritonsillar abscess (PTA) or cellulitis (PTC). The aim of this study was to estimate the prevalence of OPSCC in patients presenting with symptoms of PTA/PTC. Method, Setting and Participants We retrospectively identified all adults with a coded diagnosis of PTA or PTC who presented between 2012-2016 inclusive, across six ENT units in ——–. Records were compared to that of the centralised regional head and neck cancer database. The clinical records of a subset of patients were reviewed for the purposes of data validation. Results A total of 1975 patients with PTA/PTC were identified. Three patients were subsequently diagnosed with OPSCC. None of the three actually had an objective underlying diagnosis of PTA/PTC on the same side. The prevalence of OPSCC in patients admitted with symptoms of PTA/PTC was 0.15%, or approximately 1:650 admissions. The records of 510 patients who presented over a one-year period (2016) were reviewed in even greater detail. There were 298 patients with PTA (59.4%), 151 with PTC (29.1%) and 61 had an alternative diagnosis (11.9%). High risk features (age ≥40, tonsillar asymmetry or tonsillar lesion) were present in 106 patients (24%). Urgent follow up was expedited for 77 patients (73%). Conclusion This study estimates the risk of OPSCC in patients with peritonsillar symptoms. The prevalence is low, even in a region with a relatively heavy disease burden. Clinicians should, however, retain a high level of suspicion in patients with persistent symptoms.

Cochlear implants are medical devices indispensable for the treatment of severe-to-profound bilateral sensorineural hearing loss - The most commonly used surgical procedure for cochlear implantation involves temporal bone drilling associating mastoidectomy with a facial recess approach - Improvements in robot-assisted surgery since 2010 have raised questions about the possibility of "simplifying" cochlear implant surgery - This study showed that the use of robotic assistance coupled to CT guidance for cochlear implantation is possible and apparently safe for the entire procedure using a Robot that is already available worldwide. - Several improvements are required to optimize this procedure.

● Our retrospective cohort study aimed to elucidate which factors (nasal surgery: septoplasty or functional endoscopic sinus surgery (FESS), palate surgery: uvulopalatal flap (UPF) or palatal muscle resection (PMR)), demography, polysomnography, Friedman stage, drug-induced sleep endoscopy (DISE) results) influence the success of surgery in patients who had been operated to treat obstructive sleep apnea (OSA). ● We used seven machine learning (ML) models (logistic regression-based models (lasso, elastic net (EN), ridge), tree-based models (bagging, random forest (RF), support vector machine (SVM), and neural networks (NN)). ● Among the seven models, their performances were first ranked by the area under the receiver operating characteristic curve (AUC): lasso (0.8317), EN (0.7500), SVM (0.7163), bagging (0.7115), random forest (0.7115), NN (0.6923) and ridge (0.6538), which shows that lasso had the best performance. ● Tonsil grade and Nasopharynx Oropharynx Hypopharynx and Larynx (NOHL) classification of the epiglottis in DISE were selected as the most important variables in all models including lasso. ● Through the novel ML technique, the surgical success rate of OSA is ultimately dependent on tonsil grade and NOHL classification of the epiglottis in DISE regardless of the type of nasal or palate surgery.

Sporadic vestibular schwannomas (VS) can be treated using radiation therapy, microsurgical resection or a wait‐and‐scan approach. In general, small VS are usually followed (wait‐and‐scan) until a significant amount of growth per year is seen. In a recent study, 212 cases of VS were observed over time; 66% showed growth, of which 30% were fast growing (doubling in size in a year). 1 Frischer et al examined cases of VS after radiosurgery (Gamma Knife), and found a tumour control rate of 92% after 5 years of follow‐up. 2 However, among patients with initial Gardner‐Robertson class 1 or 2 hearing, only 55% maintained serviceable hearing (class 1 or 2) after 2 years, and 34% after 10 years. Several other studies have reported similar results. 3 , 4 A recent meta‐analysis concluded that among patients who undergo microsurgical treatment with a hearing‐preserving technique, 35–49% still have serviceable hearing five years later. 5 The above‐mentioned findings support the conclusion that most VS will require treatment after some period of observation. However, the currently available treatment options carry a high risk of loss of serviceable hearing. Some authors believe that the possibility of cochlear implantation in the setting of VS should completely change the treatment strategy for this disease. 6 However, patient outcomes with cochlear implants (CI) show a wide variation—with some patients having no auditory perception, while others exhibit open‐set speech understanding. 7 The intraoperative testing of cochlear nerve function using electrically evoked brainstem response audiometry (eABR) provides a means of objectively assessing cochlear nerve conduction, and has been increasingly applied in this setting. 7 , 8 In the present study, we aimed to assess outcomes of patients undergoing VS resection and CI, and to develop a new scoring system to preoperatively identify suitable patients for this treatment course. Appropriate preoperative classification of patients can have important impacts on patient counseling and expectations.

Objectives. Sarcoidosis is a multisystemic inflammatory disease with extrathoracic manifestations, most commonly affecting the young and middle-aged, female and black populations. Diagnosis usually requires evidence of non-caseating granulomata and, when treated, prognosis is usually favourable. We aim to establish the incidence, clinical features and optimal treatment of ENT manifestations of this disease. Design. We performed a review of the literature to determine the evidence-base supporting this. Results. ENT manifestations are present in 10-15% of patients with sarcoidosis, often as a presenting feature, and require vigilance for swift recognition and coordinated additional treatment specific to the organ. Laryngeal sarcoidosis presents with difficulty in breathing, dysphonia and cough, and may be treated by Speech and Language Therapy (SLT) or intralesional injection, dilatation or tissue reduction. Nasal disease presents with crusting, rhinitis, nasal obstruction and anosmia, usually without sinus involvement. It is treated by topical nasal or intralesional treatments but may also require endoscopic sinus surgery, laser treatment or even nasal reconstruction. Otological disease is uncommon but includes audiovestibular symptoms, both sensorineural and conductive hearing loss, and skin lesions. Conclusions. The consequences of ENT manifestations of sarcoidosis can be uncomfortable, disabling and even life threatening. Effective management strategies require good diagnostic skills and use of specific therapies combined with established treatments such as corticosteroids. Comparisons of treatment outcomes are needed to establish best practice in this area.

The T-graft is a new tool in the armament of structural rhinoplasty. The graft makes it easy to create a well- balanced nasal framework both for beginners and more experienced rhinoplastic surgeons. Due to its multifunctional character the T-graft allows the surgeon to control nasal length as well as nasal tip projection and -rotation. The T-graft is indicated in many anatomical features like in patients with a short nose or heavy soft tissue envelope, but also in patients with under projection of the nasal tip, under- or over-rotation of the nasal tip and deviations of the caudal nasal septum.

Purposes: To evaluate the instant auditory benefit of an adhesive bone conduction hearing aid (ADHEAR) on children with bilateral congenital microtia, especially the sound localization ability under unilateral and bilateral fitting. Methods: Twelve patients with bilateral congenital microtia aged from 6 to 17 were included in this study. Pure tone threshold under sound field, speech recognition threshold in quiet and sound localization abilities were tested and compared before and after wearing the device. The pure tone threshold test was additionally repeated for two different wearing method – adhesive or fixed with softband; the sound localization test was repeated for both unilateral and bilateral fitting. Correlation analysis was then conducted to find the influencing factors of sound localization improvement. Results: Significant auditory improvement were found: the average pure tone threshold (PTA) reduced by 24.8 (adhesive) and 27.3 dB HL (softband), with no significant difference between the two wearing methods. The speech recognition threshold also improved by 29.0 dB. As for sound localization abilities, no significant improvement was found under unilateral fitting; but half (6 of 12) of the patients were notably benefited from bilateral fitting. The improvement was found to be strong correlated with the patients’ unaided sound localization ability – those with poorer localization abilities tends to benefit more. Moreover, it was found that the sound localization improvement was also negatively related with the malformation degrees of the patients’ head. Summary: ADHEAR affords significant auditory benefits for children with bilateral congenital microtia, in terms of sound and speech perception. The sound localization abilities could be partly improved instantly by bilateral fitting, and the improvement is related with factors such as adaption and skull malformations.

Objectives This study aimed to compare the effects of middle turbinate resection vs bolgerization on the incidence of middle meatus synechia and their prognostic value on the patency outcomes after frontal sinusotomy. Design A randomised controlled study. Setting Tertiary centre hospital. Main outcome measures Thirty-eight patients undergoing bilateral frontal sinusotomy for chronic frontal sinusitis were included. Partial middle turbinate resection was alternated with bolgerization in both nasal cavities of every patient. The Lund-Kennedy endoscopic scores (LKESs) for both sides were compared at the first, third and sixth months postoperatively. Middle meatus synechia was assessed using the visual analogue score (VAS). Sinus patency was assessed at the end of the sixth month using a 70° nasal endoscope. Results The sinus patency outcome was significantly higher in the resected group (34\38) than the bolgerized group (26\38), (P = .047*). The VAS scores suggested that the middle turbinate bolgerization group showed a significantly higher incidence of middle meatal synechia than the partial middle turbinate resection group (4.47 ± 2.617 vs 3.29 ± 2.301; P = .040*). Conclusion Middle turbinate resection showed more favourable results than bolgerization concerning the sinus patency outcome after frontal sinusotomy. It also showed a lower incidence of middle meatus synechia postoperatively.

AIMS: Remote or tele-consultation has become an emerging modality of consultation in many specialities, including ENT. Advantages include increasing accessibility, potential to reduce costs and, during the COVID-19 pandemic, reduced risk of infection transmission. Here, we systematically collate and synthesise the evidence base on outcomes from remote consultation in adult and paediatric ENT services. METHODS: We performed a review in accordance with PRISMA guidelines. We searched Medline and Embase for relevant articles. Outcomes include specific patient pathway efficiency measures (including number of healthcare visits, lead time, touch time and handoff), patient/clinician satisfaction, cost analysis and safety implications. RESULTS: From 6325 articles screened, 53 met inclusion criteria. Publications included studies on remote consultation for initial, preoperative and follow-up assessment (including postoperative). In most instances, remote consultation reduced costs and time from referral to assessment and was associated with high patient satisfaction. However, a face-to-face follow-up appointment was required in 13%-72% of initial consultations, suggesting that remote consultation is only appropriate in selected cases. CONCLUSION: Remote consultation is appropriate and preferable for ENT consultation in specific conditions and circumstances. Future research should look to better define those conditions and circumstances, and report using recognised quality standards and outcome measures.

Following surgical removal of the pinna for malignancy or craniofacial trauma, reconstruction with an auricular prosthesis provides an acceptable cosmetic option. The development of osseointegrated implants for the mounting of such auricular prostheses has significantly improved functional outcomes and aesthetics for patients.

In contrast to previous reports, respiration-synchronous APT wave patterns display low sensitivity (53.3%) in our retrospective cohort of 15 PET ears, as diagnosed by characteristic symptoms and otoscopy. In 327 non-PET ears, the largest cohort of non-PET ears evaluated to date, respiration-synchronous APT wave patterns demonstrate high specificity for PET (93.9%), consistent with previous literature. APT performed solely at rest and with ipsilateral nostril respiration displays similar sensitivity for PET as the full battery of respiratory maneuvers. Pulse-synchronous wave patterns at rest may suggest an alternative neurotologic diagnosis requiring further workup, such as superior semicircular canal dehiscence. Ambient pressure tympanometry is a rapid, simple and widely available tool that can be integrated into general otolaryngology clinics and warrants further study in the evaluation of PET and neurotologic disorders.

Objective To investigate the effect of endogenous and exogenous oestrogen exposure on hearing levels in postmenopausal women. Study design Retrospective cross-sectional study. Setting Population-based survey data collected by the Korean National Health and Nutrition Survey between 1 January 2010 and 31 December 2012. Subjects and methods Participants comprised 3,653 postmenopausal women. Detailed histories for reproductive factors and data on the use of hormone replacement therapy were obtained through health questionnaires and otologic examinations, including pure-tone audiogram and otoscopic findings. Complex-sample linear regression models controlling for confounding factors were generated to determine whether hormone-related factors were associated with hearing loss. Results Women who experienced a longer duration of oestrogen exposure had better hearing compared to those who do not in multivariate model adjusting for confounding factors with a lower adjusted beta coefficient of hearing threshold (β = -0.18, 95% confidence interval = -0.3 to -0.07, P = .002). The results also suggested that hormone replacement therapy may be beneficial for attenuating hearing loss (β = -1.22, 95% confidence interval = -2.19 to -0.25, P = .014), particularly in the high frequency range from 3 kHz to 6 KHz. Conclusion A longer duration of lifetime oestrogen exposure (LEE) and the use of hormone replacement therapy are likely to attenuate hearing loss. These epidemiologic data provide evidence that oestrogen may be beneficial for attenuating age-related hearing decline.

Objectives This study aimed to evaluate hearing improvement at different frequencies and the safety of intratympanic (IT) and intravenous (IV) administration of dexamethasone for sudden sensorineural hearing loss (SSNHL). Methods SSNHL patients were randomly divided into two groups within 72 hours after onset and received 24 days of dexamethasone therapy. Group A received IT dexamethasone once every other day for 24 days. Group B received IV dexamethasone for 12 days, followed by IT dexamethasone once every other day for the following 12 days. Hearing recovery and side effects were compared. Results Subgroup analysis was performed to look for variation in hearing improvement in high frequency, low frequency and overall hearing at different time points. There was no evidence of a difference in hearing outcomes between IT dexamethasone and sequential IV plus IT treatments. Side effects of steroids were observed within 90 days after treatment. The local adverse effects of IT injection were mild. The systemic side effects in group B were more serious than those in group A. Conclusions IT dexamethasone was safer than IV dexamethasone, and there was no evidence of a difference in hearing outcomes between IT dexamethasone and sequential IV plus IT treatments. It is necessary to make individualised treatment decisions according to the patient's condition.

Objectives: To identify predictors of acceptable hearing at 5 weeks, 6 and 12 months in children with bilateral otitis media with effusion (OME). Design and setting: Secondary analysis of OSTRICH data, conducted in hospital ear, nose and throat (ENT) and paediatric audiology and audiovestibular medicine departments across Wales and England. Participants: The OSTRICH study included 389 children aged 2-8 years with bilateral hearing loss attributable toOME for at least 3 months. Main outcome measures: Baseline, 5-week, 6- and 12-month audiology measurements were collected and logistic regression models used to identify pre-randomisation baseline variables that predicted return of acceptable hearing, which was defined as less than or equal to 20 dB hearing loss averaged within the frequencies of 0.5, 1, 2 and 4 kHz in at least one ear in children assessed by pure tone audiometry, ear-specific insert visual reinforcement audiometry or ear-specific play audiometry less than or equal to 25 dB hearing loss averaged within the frequencies of 0.5, 1, 2 and 4 kHz in children assessed by sound-field visual reinforcement audiometry or sound-field performance/play audiometry, based on national guidelines. Results: Less severe baseline hearing loss across both ears most consistently predicted acceptable hearing at 5 weeks (adjusted odds ratio [aOR] 0.91, 95% CI 0.87- 0.95), 6 months (0.94 [0.90-0.98]) and 12 months (0.93 [0.89-0.97]). Negative history of atopy (2.05 [1.16-3.61]), never using hearing aids (aOR 2.16 [1.04-4.48]), and being male (1.75 [1.02-2.99]) were significant at 6 months, but not at 12 months. Symptom duration was a predictor at 5 weeks, but not at 6 or 12 months. Conclusions: Milder baseline hearing loss most consistently predicts acceptable hearing at 5 weeks, 6 and 12 months in children with chronic OME. Negative history of atopy, never using hearing aids, and male gender are associated with better prognosis. These predictors can be used to identify children that may not require treatment

BACKGROUND Endoscopic sinus surgery (ESS) is an important treatment modality for chronic rhinosinusitis (CRS). However, its effect on olfaction remains controversial. OBJECTIVE OF REVIEW To assess the olfactory impact of ESS in patients with CRS. TYPE OF REVIEW A meta-analysis. SEARCH STRATEGY A systematic literature search in the PubMed, EMBASE and Cochrane Library databases was conducted to identify studies that assessed change in olfaction after ESS in patients with CRS. Search terms were related to paranasal sinus diseases, smell and endoscopy. EVALUATION METHOD The extracted data included authors, publication year, study type, age, sex, diagnostic criteria, surgical mode, sample size, follow-up time, olfaction measurement tool and outcome. We analysed the olfactory changes as continuous variables. RESULTS Thirty-five studies including 3164 patients with CRS were eligible for the meta-analysis. Among patients having CRS with nasal polyps, olfactory dysfunction improved, as assessed by the Sniffin' Sticks total score (P = .000), Sniffin' Sticks discrimination score (P = .023), Sniffin' Sticks identification score (P = .005), University of Pennsylvania Smell Identification Test (P = .046) and Visual Analogue Scale (P = .000). However, the threshold score of the Sniffin' Sticks test did not improve significantly (P = .361). Olfactory dysfunction did not improve in patients having CRS without nasal polyps according to the University of Pennsylvania Smell Identification Test (P = .404). In non-classified CRS patients, improvement in olfactory dysfunction was observed according to the University of Pennsylvania Smell Identification Test (P = .000), Visual Analogue Scale (P = .001) and Questionnaire of Olfactory Disorders-Negative Statements (P = .001). However, there were no significant improvements according to the Brief Smell Identification Test (P = .325), Sniffin' Sticks threshold score (P = .160) and Sniffin' Sticks identification score (P = .079). CONCLUSION Endoscopic sinus surgery may be beneficial for improvement in olfactory conditions in patients with CRS. Further thorough and comprehensive studies need to be conducted.

Treating twenty-five cases of chronic resistant otitis externa with fluticasone propionate (Flixonase®): a case series Utilising Flixonase® in treatment of chronic otitis externaKey points:Chronic cases of otitis externa, resistant to conventional treatments are notoriously difficult to treat, with resolution in these cases challenging.Guidelines suggest the use of corticosteroid in chronic otitis externa, however, there is no specific advice on which corticosteroid to utilise.Our case-series demonstrates the potential benefit of fluticasone propionate in patients who have previously failed a multitude of conventional management options.Despite the limitations of our study, our experience highlights a gap in the literature and suggest fluticasone propionate as an exciting and potentially important tool in the arsenal of the otolaryngologist.

Background: Traditionally, patients are seen by an ear, nose and throat (ENT) surgeon prior to allied health referral for treatment of swallowing, voice, hearing and dizziness. Wait-times for ENT consultations often exceed those clinically recommended. We evaluated the service impact of five allied health primary contact clinics (AHPC-ENT) on wait-times and access to treatment. Setting: A metropolitan Australian University Hospital Outpatient ENT Department. Participants: We created five AHPC-ENT pathways (dysphonia, dysphagia, vestibular, adult and paediatric audiology) for low-acuity patients referred to ENT with symptoms of dysphonia, dysphagia, dizziness and hearing loss. Main outcome measures: Using multiple regression analysis, we compared waiting times in the 24-month pre- and 12-month post-implementation of the AHPC-ENT service. In addition, we measured the number of patients requiring specialist ENT intervention after assessment in the AHPC-ENT, adverse events and evaluation of service delivery costs. Results: Seven hundred and thirty-eight patients were seen in the AHPC-ENT over the first 12 months of implementation (dysphagia, 66; dysphonia, 153; vestibular, 151; retro-cochlear, 60; and paediatric glue ear, 308). All pathways significantly reduced the waiting times for patients by an average of 277 days, compared with usual care. The majority of patients were able to be discharged without ongoing ENT intervention (72% dysphagia; 81% dysphonia; 74% vestibular; 53% retro-cochlear; and 32% paediatric glue ear). No adverse events were recorded. Conclusions: The AHPC-ENT improved waiting times for assessment and access to treatment. Future research on cost-effectiveness and diagnostic agreement between AHPs and ENT clinicians would provide further confidence in the model.

Objective: To examine the construct validity, reliability and responsiveness of the Otology Questionnaire Amsterdam (OQUA). Design: Multicentre, longitudinal study in 2 separate cohorts of patients visiting an ENT surgeon via an online survey programme. Setting: Tertiary ENT clinics. Participants: Cohort 1 consisted of patients at their first visit at an ENT outpatient clinic with an ear complaint. Cohort 2 consisted of patients who underwent surgery, with a 3-month follow-up post-surgery. Main outcome measures: Construct validity: Hypothesis testing, internal consistency and inter-item correlation. Reliability: Test-retest reliability. The construct approach was used for assessing responsiveness. Hypotheses were formulated based on the association between the OQUA and Glasgow Health Status Inventory (GHSI) or Global Rating Scale (GRS). Results: Construct validity: The correlation between the individual items in the impact domain ranged from 0.424 to 0.737. Confirmatory factor analysis showed a good fit. As expected, the OQUA impact showed strong relationships with GHSI total and general scale. Reliability: The test-retest reliability coefficient ranged from 0.541 to 0.838. Responsiveness: All hypotheses were conformed. As expected, the change score of the OQUA showed good correlation between OQUA impact and GHSI and moderate correlation between the GRS and OQUA complaints. Conclusion: The OQUA has 8 complaint domains (earache, pressure sensation, itching, tinnitus, hearing loss, ear discharge, loss of taste and dizziness) and 1 impact domain. Each domain results in one score of 0-100. The OQUA shows good results for construct validity, (test-retest) reliability and responsiveness, supporting the potential benefit for the patient with an ear complaint visiting the ENT surgeon. The extensive validation furthermore confirms a certified generic otology PROM with an impact and a complaints' part, to be used in different types of otologic interventions and patient groups.

ENT involvement is common in ANCA-associated vasculitis (AAV), particularly in GPA and EGPA. Early recognition and treatment is important for good outcomes, yet evidence suggests that UK ENT surgeons may not consistently recognise the early features of AAV, despite a similar incidence to vestibular schwannoma. AAV is a rapidly advancing field, with significant developments in the understanding of its pathogenesis, classification and treatment over the past decade. Relevant vasculitis mimics are also discussed with a particular focus on the increasing prevalence of vasculitis mimics driven by an increase in recreational cocaine use, as well as the emergence and reclassification of several other vasculitis mimics in the head and neck. This article reviews key recent updates in the vasculitis literature, with a particular focus on those relevant to recognition and diagnosis of AAV for the ENT surgeon. Strengths and limitations of relevant diagnostic testing are discussed, and a method of evaluation of patients with features of AAV presenting to ENT services is outlined.

BACKGROUND Balance is a complex process involving the coordinated activities of multiple sensory, motor and biomechanical components. Balance function may be disturbed in subjects suffering from hearing loss but the impairment has been attributed to the pathology underlying the hearing loss. AIM The purpose of the study was to investigate the possible interference of simulated conductive hearing loss with the ability to maintain postural balance. METHODS Twenty normal-hearing subjects, 20-30 years old, underwent the computerised dynamic posturography test battery before and after plugging their external ear canals with earplugs, thus simulating a 40dB conductive hearing loss. RESULTS Eighteen females and two males were tested before and after plugging their ear canals. Average CHL was 40 ± 4.9dB. The composite equilibrium score was significantly diminished after plugging the ears with an average sway score of 73.5% (P

Background Chronic rhinosinusitis (CRS) is the downstream manifestation of heterogeneous pathophysiologic mechanisms leading to chronic sinonasal inflammation. Traditional grouping of patients by symptoms or clinical findings/phenotypes is being replaced by classification of CRS patients based on the underlying pathophysiologic mechanisms: endotypes. Objective of review To provide an up-to-date review on the current knowledge of CRS endotypes with a focus on how the pathophysiologic mechanisms defined by each endotype may be targeted therapeutically. Special emphasis is placed on the clinical relevance of the material and how it may inform the current practice of otolaryngologists. Type of review A systematic review of contemporary literature review focusing on the latest studies examining the role of endotypes in the management and treatment of CRS. Search strategy A MEDLINE and PubMed Central search were undertaken to perform this review using the keywords "Endotype" and "Sinusitis." Evaluation method Articles containing the keywords, as well as the references of those articles, were then examined for relevance. Results The endotypes for CRS are often defined based on the balance of T-helper cell patterns of inflammation and can be grouped into Th2 and non-Th2 inflammation. These groups have shown a variable response to medical and surgical therapy, demonstrating that existing mainstream treatments can be tailored to patients with specific endotypes. The inflammatory mediators of Th2 inflammation, IL-4, IL-5 and IL-13 as well as IgE, are targeted by available biologic drugs that can be used for treatment of refractory disease. Conclusions Increased understanding of CRS endotypes has led to the identification of biomarkers that define these endotypes and act as targets for potential therapeutics. Increasing knowledge about characteristics associated with these endotypes and their responses to treatments, including both established mainstream CRS treatments and novel biologic medications, has allowed incorporation of CRS endotypes into the current clinical decision-making. Treatment of CRS patients based on consideration of their endotypes is therefore not only presently possible but may improve clinical outcomes of those patients as well.

The aetiology of cholesteatoma remains elusive. In a recent systematic review, we discussed reports of multiple cases of cholesteatoma within families, which suggests a genetic predisposition in some cases (1). We have established a U.K. database and DNA sample bank that can be used to identify genetic variants that co‐segregate with cholesteatoma in multiply‐affected families. Recruitment to this Genetics of Cholesteatoma (GOC) Study is via the U.K. National Institute of Health Research Clinical Research Network. This preliminary communication describes the results of whole exome sequencing (WES) of DNA extracted from participants in the first fully sequenced family recruited to the study. Rare variants were filtered for co‐segregation with the cholesteatoma phenotype, and for their putative functional impact. We have identified loss of function variants in the genes EGFL8 and BTNL9 as candidate variants of interest. These are preliminary observations and the variants are of unknown significance to the disease pathology without replication or further investigation.

Objective To determine whether an ENT clinical screening examination done on all patients chronically addicted to alcohol or tobacco would allow the early diagnosis of cancer of the upper aerodigestive tract. Study design Case series with chart review. Setting Non-university general hospital. Subjects and methods A total of 159 patients presenting chronic addiction to alcohol or tobacco hospitalized in an addiction center or a comprehensive medical clinic were included in this study covering the period 2011-2016. All patients systematically benefitted from an ENT clinical examination to detect mucous membrane lesions. The lesions were categorized as: cancerous, pre-cancerous, or benign. The patients were divided into two groups for comparison: 1) patients with symptoms (dysphagia, dysphonia, dyspnea upon inhalation, cervico-facial pain, secondary otalgia, pharyngeal discomfort unrelated to deglutition, presence of a cervical swelling, or weight loss), and 2) asymptomatic patients. Results The ENT exam was normal in 121 patients (76.1%). Fifty-two patients (32.7%) had at least one symptom. The ENT exam allowed us to detect a benign lesion in 11 patients, a pre-cancerous lesion in 11 patients, and a cancer in 16 (13.22%) patients. All patients with cancer had at least one symptom. Conclusion An ENT clinical screening examination done on patients chronically addicted to alcohol or tobacco can allow early diagnosis of cancer, particularly in patients with at least one symptom.

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.A cross-sectional study measuring UPNIF and UMCA in controls demonstrating normal nasal function and in patients with nasal obstruction.Royal National Throat Nose and Ear Hospital, London.A total of 39 participants, 26 controls and 13 patients, were recruited. Controls exhibited normal nasal function with SNOT-225. Patients nasal obstruction symptoms secondary to inflammation or structural abnormality with SNOT-229.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.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.

Objectives Nasal obstruction is the most common symptom in nasal diseases. It can be evaluated objectively, that is by means of peak nasal inspiratory flow (PNIF) measures and/or subjectively by means of validated questionnaires. However, it has been reported that there is a lack of reliable correlation between subjective and objective measurements of nasal obstruction. The aim of the present study was to evaluate the correlation between PNIF measurements and the subjective sensation of nasal obstruction measured by means of a visual analogue scale (VAS) in a large population of consecutive rhinologic patients. Design Prospective clinical study. Setting Tertiary rhinological referral centre. Participant main outcome measures A total of 641 consecutive subjects were enrolled. Visual analogue scale and PNIF were performed to assess nasal obstruction. Nasal septal deviation was classified according to Mladina classification, and its severity was assessed using three levels of severity. Results Although weak, there was a significant negative correlation (r = -0.13, P = 0.001) between PNIF and VAS. Dividing the population in those affected by nasal septal deviation (NSD) and those affected by chronic rhinosinusitis (CRS), a week negative correlation between PNIF and VAS was again confirmed in both groups (r = -0.208, P = 0.006 for NSD and r = -0.13, P = 0.04 for CRS). Peak nasal inspiratory flow and VAS were also evaluated according to the grade of polyps and the type and level of septal deviation. Conclusions Visual analogue scale and PNIF significantly correlated, although with a low degree, in a large population of rhinologic patients. Peak nasal inspiratory flow, being cheap and simple to use, could be a good candidate to assist clinicians dealing with "airway" diseases in their daily clinical practice in order to provide comprehensive information on nasal function. Peak nasal inspiratory flow can in fact give some important rough insights on VAS, but these measurements cannot be alternative to each other.

OBJECTIVE To determine the audiological and clinical results of cochlear implantation in children below the age of 12 years old with congenital and acquired single-sided deafness. DESIGN Observational, descriptive, transversal study. MAIN OUTCOME MEASURES Speech reception thresholds, Cortical responses, Auditory Lateralization Test and SSQ questionnaire. PARTICIPANTS Children < 12 implanted for congenital or acquired SSD. RESULTS All the children with congenital SSD showed positive cortical responses. Positive results were obtained in the Auditory Lateralization Test for the following modalities: 0o, 45o and 90o. With respect to the Speech Test, the children with acquired SSD showed the following results: 92% and 100% in recognition and 48% and 68% (Azimuth modalities), Signal CI side 52% and 68% and Signal normal hearing side 44% - 60% (p < 0.05). In both group the processor was used for 6-12 hours. With respect to the SSQ questionnaire results, the parents were more satisfied within the post-operative period than within the pre-operative period (P

Objective To describe the clinical features of benign paroxysmal positional vertigo (BPPV) in children. Design A retrospective study. Setting Six children diagnosed with BPPV between March 2014 and March 2015 were retrospectively evaluated. BPPV was diagnosed using the Dix-Hallpike and supine roll tests and treated with either the modified Epley particle repositioning procedure or Lempert or Gufoni manoeuvre. Follow-up was performed at 1-week intervals until vertigo and nystagmus disappeared during positional testing. Participants A total of six children were followed up for a period of 10-22 months. Main outcome measures Clinical features such as history, nystagmus and symptoms of vertigo, dizziness and nausea. Results Six children were diagnosed with BPPV using positional testing and treated with the modified Epley or Lempert/Gufoni particle repositioning procedures. Four children were diagnosed with posterior canal BPPV, while the remaining two were diagnosed with horizontal canal BPPV. One girl reported a history of head trauma, one girl had a family history of vertigo, and one boy reported hearing loss in the same ear as that affected by BPPV. Overall, 83.33% of children (5/6) were completely relieved of vertigo following one treatment session. The remaining child was asymptomatic after two sessions. No child reported relapse of vertigo during the follow-up period. Conclusions BPPV can be diagnosed accurately by taking a detailed medical history and by use of positional testing. BPPV in children can be successfully identified and treated.

Background The first edition of the European position paper (EPP) on drug-induced sleep endoscopy (DISE) was published in 2014 with the aim to standardise the procedure, to provide an in-depth insight into the main aspects of this technique and to have a basis for future research. Since 2014, new studies have been published concerning new sedative agents or new insights into the pattern/levels of the obstruction depending on the depth of sedation. Therefore, an enlarged group of European experts in the field of sleep breathing disorders (SBD), including the most of the first DISE EPP main authors, has decided to publish an update of the European position paper on DISE, in order to include new evidence and to find a common language useful for reporting the findings of this endoscopic evaluation in adult population affected by SBD. Methods The authors have evaluated all the available evidence reported in the literature and have compared experience among various departments in leading European centres in order to provide an update regarding the standardisation of the DISE procedure and an in-depth insight into the main aspects of this technique. Results After the first European Position Consensus Meeting on DISE and its update, consensus was confirmed for indications, required preliminary examinations, where to perform DISE, technical equipment required, staffing, local anaesthesia, nasal decongestion, other medications, patient positioning, basics and special diagnostic manoeuvres, drugs and observation windows. So far, no consensus could be reached on a scoring and classification system. However, regarding this aim, the idea of an essential classification, such as VOTE with the possibility of its graded implementation of information and descriptions, seems to be the best way to reach a universal consensus on DISE classification at this stage. A common DISE language is mandatory, and attempts to come to a generally accepted system should be pursued.

Objective To identify which preoperative patient characteristics influence sequential bilateral cochlear implantation performance and to create a statistical model that predicts benefit. Design Multicentre retrospective cohort study. Setting All patients were operated in four academic teaching hospitals in Perth, Australia, and followed up by audiologists of the Ear Science Institute Australia. Participants A total of 92 postlingually deafened adult patients who had undergone sequential cochlear implantations between 19 June 1990 and 14 March 2016 were included. Patients were excluded if the 12-month follow-up consonant-nucleus-consonant (CNC) phoneme score was missing. Main outcome measure The effect of 18 preoperative factors on the CNC phoneme score in quiet (at 65 dB SPL) with the second cochlear implant (CI2) one year after implantation. Results Two factors were positively correlated to speech understanding with CI2: Wearing a hearing aid (HA) before receiving CI2 (r = 0.46, P = 0.00) and the maximum CNC phoneme score with the first CI (CI1) (r = 0.21, P = 0.05). Two factors were negatively correlated: the length of hearing loss before CI2 in the second implanted ear (r = -0.25, P = 0.02) and preoperative pure tone average (PTA) (0.5, 1, 2 kHz) before CI2 in the second implanted ear (r = -0.27, P = 0.01). The following model could be created: predicted CNC phoneme score with CI2 (%) = 16 + (44 * HA use before CI2 (yes)) - (0.22 * length of hearing loss before CI2 (years)) + (0.23 * CNC phoneme score with CI1 (%)). Because the effect of HA use before implantation played such a major role, we also created a model after exclusion of the HA factor: Predicted CNC phoneme score with CI2 (%) = 82 - (0.17 * length of hearing loss before CI2 (years)) - (0.27 * PTA in second implanted ear before CI2 (0.5, 1, 2 kHz)) + (0.20 * CNC phoneme score with CI1 (%)). Conclusion Advanced age or a long interval between implantations does not necessarily lead to poor CI2 results. Patients who are successful HA users before CI2, who have a low PTA before CI2, a high CNC phoneme score with CI1 and a limited length of hearing loss before CI2, are likely to be successful CI2 recipients.

Background The number of potential options for rehabilitation of patients with conductive or mixed hearing loss is continually expanding. To be able to inform patients and other stakeholders, there is a need to identify and develop patient-centred outcomes for treatment of hearing loss. Objective of review To identify outcome measures in the physical core area used when reporting the outcome after treatment of conductive and mixed hearing loss in adult patients. Type of review Systematic review. Search strategy Systematic review of the literature related to reported physical outcome measures after treatment of mixed or conductive hearing loss without restrictions regarding type of intervention, treatment or device. Evaluation method Any measure reporting the physical outcome after treatment or intervention of mixed or conductive hearing loss was sought and categorised. The physical outcome measures that had been extracted were then grouped into domains. Results The literature search resulted in the identification of 1434 studies, of which 153 were selected for inclusion in the review. The majority (57%) of papers reported results from middle ear surgery, with the remainder reporting results from either bone conduction hearing devices or middle ear implants. Outcomes related to complications were categorised into 17 domains, whereas outcomes related to treatment success was categorised into 22 domains. Conclusions The importance of these domains to patients and other stakeholders needs to be further explored in order to establish which of these domains are most relevant to interventions for conductive or mixed hearing loss. This will allow us to then assess which outcome measures are most suitable for inclusion in the core set.

OBJECTIVE Hearing loss subsequent to a unilateral vestibular schwannoma (VS) has an impact on the social life of non-operated patients. We investigated the utility of auditory brainstem responses (ABRs) for predicting the results of auditory rehabilitation in such patients. DESIGN Prospective study. SETTING University tertiary medical centre. PARTICIPANTS We collected the demographic, audiometric, ABR and imaging data of non-operated patients with unilateral VS. A hearing aid trial was performed over 1 month. We assessed auditory performance following the auditory rehabilitation according to the ABR results. Patients with distinct waves (I, III and V) were included in the "distinct ABR" group and patients with no ABR were included in the "desynchronised ABR" group. MAIN OUTCOME MEASURES Following the trial, audiometric performance and quality of life were evaluated with the Glasgow Benefit Inventory (GBI). SUBJECTS AND METHOD We collected the demographic, audiometric, ABR and imaging data of non-operated patients with unilateral VS. A hearing aid trial was performed over 1 month. Following the trial, audiometric performance and quality of life were evaluated with the Glasgow Benefit Inventory (GBI). We assessed auditory performance following the auditory rehabilitation according to the ABR results. Patients with distinct waves (I, III and V) were included in the "distinct ABR" group and patients with no ABR were included in the "desynchronised ABR" group. RESULTS In total, 25 patients were included in this prospective study; 15 in the "distinct ABR" group and 10 in the "desynchronised ABR" group. The speech recognition threshold (SRT, P < .0001; W = -120) and speech discrimination score (P = .0005; W = 78) were significantly improved in the aided vs unaided conditions. These improvements were not observed in the "desynchronised ABR" group for the SRT (P = .48; W = -10) and word recognition score (P = .06; W = 15). Ninety-three per cent of the patients in the "distinct ABR" group kept significantly (P = .04) the hearing aids following the trial compared to 20% in the "desynchronised ABR" group. CONCLUSIONS Auditory brainstem responses can help to predict the auditory performance following auditory rehabilitation in unilateral non-operated VS patients.

Performance of an abutment-level superpower sound processor for bone-anchored hearing, the Ponto 3 SuperPower from Oticon Medical (BCD2), was compared to an earlier model from Oticon Medical (BCD1).A comparative study in which each patient serves as its own control.Tertiary clinic.Eighteen experienced BCD1 users with profound mixed hearing loss.Speech reception thresholds in noise; APHAB and SSQ questionnaires.In a group of 18 patients with severe mixed hearing loss, the performance of a recently introduced bone conduction device (BCD2) is evaluated relative to that of an earlier model (BCD1). Speech reception thresholds for the sentence-in-noise test in the speech and noise frontal condition are not significantly different (P .05) for BCD1 and BCD2. Speech reception thresholds for frontal speech and three identical noise sources are 1.7 dB lower for BCD2 than for BCD1 (P .05). With the APHAB questionnaire, the score for background noise is significantly lower (P .01), that is more favourable, for BCD2 than for BCD1 with an effect size of 0.91. The APHAB domain scores for ease-of-communication, reverberation and aversiveness of loud sounds are not significantly different for both devices (P .05). Scores for the speech, spatial and quality of hearing domains of the SSQ questionnaire are significantly higher (P .01), that is more favourable, for BCD2 than for BCD1 with effect sizes of 1.22, 0.71 and 1.05, respectively. Scores for the SSQ-factors "speech understanding," "spatial," "clarity, separation and identification" and "listening effort and concentration" were all significantly higher (P .05) for BCD2 than for BCD1, with effect sizes of 1.28, 0.64, 0.98 and 0.78, respectively. On a proprietary questionnaire, 16 patients indicate a preference for BCD2 over BCD1 for conversations in a small group and two patients have no preference for either device. In a large group, one patient prefers BCD1, six patients have no preference, and eleven patients prefer BCD2. When listening to music, all patients prefer BCD2 over BCD1, with a strong preference for BCD2 for seven patients. When asked for an overall preference, all patients prefer BCD2 over BCD1, with nine patients strongly preferring BCD2.The lower speech reception thresholds in noise with BCD2 relative to BCD1 can be attributed to the "speech omni" directionality mode of BCD2. The combination of an improved directionality for primarily low-level inputs and a higher maximum force output, relevant for mid- and high-level inputs, results in a clear preference for BCD2 over BCD1.

Objectives: This study aimed to examine the psychosocial health status of adult cochlear implant (CI) users, compared to that of hearing aid (HA) users, hearing-impaired adults without hearing aids and normally hearing adults. Design: Cross-sectional observational study, using both self-reported survey data and a speech-in-noise test. Setting: Data as collected within the Netherlands Longitudinal Study on Hearing (NL-SH) between September 2011 and June 2016 were used. Participants: Data from 1254 Dutch adults (aged 23-74), selected in a convenience sample design, were included for analyses. Mean outcome measures: Psychosocial health measures included emotional and social loneliness, anxiety, depression, distress and somatisation. Psychosocial health, hearing status, use of hearing technology and covariates were measured by self-report; hearing ability was assessed through an online digit triplet speech-in-noise test. Results: After adjusting for the degree of hearing impairment, HA users (N = 418) and hearing-impaired adults (N = 247) had significantly worse scores on emotional loneliness than CI users (N = 37). HA users had significantly higher anxiety scores than CI users in some analyses. Non-significant differences were found between normally hearing (N = 552) and CI users for all psychosocial outcomes. Conclusions: Psychosocial health of CI users is not worse than that of hearing-impaired adults with or without hearing aids. CI users’ level of emotional loneliness is even lower than that of their hearing-impaired peers using hearing aids. A possible explanation is that CI patients receive more professional and family support, and guidance along their patient journey than adults who are fitted with hearing aids.

Background The round window is an important portal for the application of active hearing aids and cochlear implants. The anatomical and topographical knowledge about the round window region is a prerequisite for successful insertion for a cochlear implant electrode. Objective of review To sum up current knowledge about the round window anatomy and to give advice to the cochlear implant surgeon for optimal placement of an electrode. Type of review Systematic Medline search. Search strategy Search term "round window[Title]" with no date restriction. Only publications in the English Language were included. All abstracts were screened for relevance, that is a focus on surgical anatomy of the round window. The search results were supplemented with hand searching of selected reviews and reference lists from included studies. Evaluation method Subjective assessment. Results There is substantial variability in size and shape of the round window. The round window is regarded as the most reliable surgical landmark to safely locate the scala tympani. Factors affecting the optimal trajectory line for atraumatic electrode insertion are anatomy of the round window, the anatomy of the intracochlear hook region and the variable orientation and size of the cochlea's basal turn. Conclusions The very close relation to the sensitive inner ear structures necessitates a thorough anatomic knowledge and careful insertion technique, especially when implanting patients with residual hearing. In order to avoid electrode migration between the scalae and to achieve protect the modiolus and the basilar membrane, it is recommended to aim for an electrode insertion vector from postero-superior to antero-inferior.

Objectives According to clinical and comissioning guidelines for chronic rhinosinusitis (CRS), patients being referred to secondary care should have failed primary medical treatment with nasal douching (ND) and intranasal corticosteroids (INCS). The study objectives were to identify the rate of specific medical therapy in CRS patients and establish any differences in medication use, for both CRS and associated medical conditions, between CRS phenotypes. Design and setting Case-control study in a secondary care setting. Methods Participant-reported study-specific questionnaire capturing free text data on current medication use at the time of study entry. Qualitative interviews with 21 participants also explored their experience of CRS and its management. Particpants Patients with both without (CRSsNPs) and with polyps (CRSwNPs). Main outcome measures Reported use of CRS-related and non-related medications. Results Within a total of 1243 CRS participants, current INCS usage was low (18% in CRSwNPs, 12% in CRSsNPs); ND was being performed by only 1% of all participants. Bronchodilators and inhaled corticosteroids use was significantly higher in CRSwNPs participants (p < 0.0001). Antidepressants use was significantly higher in CRSsNPs (14% versus 7%, p < 0.0002). There were no significant regional variations in rates of INCS use, nor any significant influence of social deprivation. Conclusions The current use of baseline medical therapy in CRS appears to be very low, representing a combination of poor patient compliance, possible ineffectiveness of treatment and a lack of familiarity with current guidelines amongst general practitioners and some ENT specialists. Work is needed to disseminate guidelines to all practitioners involved and reduce unnecessary burden on existing healthcare resources for this common condition by ensuring timely referral and definitive management. This article is protected by copyright. All rights reserved.

Objectives To assess the impact of nasal septal perforation on quality of life. Design Retrospective cohort study. Setting Rhinology clinics from two hospitals in Liverpool, United Kingdom. Participants Patients diagnosed with nasal septal perforation (NSP). Main outcome measures Patients (n=26) diagnosed with NSP completed the Sino-Nasal Outcome Test-22 (SNOT-22). The collated data was compared with SNOT-22 scores from a cohort of healthy volunteers (n=34) and a cohort of patients (n=30) diagnosed with chronic rhinosinusitis (CRS). Results The mean total SNOT-22 score of NSP and CRS cohorts were higher than that observed in healthy volunteers. The mean total SNOT-22 score in the CRS cohort (57.2, standard deviation SD 10.3) was the higher than NSP (50.2, SD 23.5), although this difference did not achieve statistical significance. The mean score for the rhinologic-specific domains (rhinologic symptoms, extra-nasal rhinologic symptoms), ear/facial symptoms and psychological dysfunction domain were higher in the CRS cohort compared to NSP, although statistical significance was only observed in the extranasal rhinologic symptoms domain (11.2, SD 2.4 vs. 6.4, SD 4.1). Conversely, the mean sleep dysfunction domain score for NSP (12.7, SD 7.5) was higher than CRS (10.0, SD 4.9 respectively) although this was not statistically significant. Conclusions The present study has assessed the clinimetric and psychometric properties of patients suffering with symptomatic NSP. Future reports should consider inclusion of SNOT-22 data but with the addition of perforation-specific symptoms (nasal crusting, epistaxis, whistling noise). This article is protected by copyright. All rights reserved.

Tinnitus and sleep are closely related. One of the most important aspects of tinnitus is its association with sleep disturbance. According to the literature, up to 71% of patients with tinnitus report sleep problems (1); furthermore, insomnia is also associated with more distressing tinnitus (2). Conversely, sleep disturbance was proposed as one of the causes of chronic tinnitus (3). The relationship of tinnitus with sleep-disordered breathing (SDB) and obstructive sleep apnea (OSAS) has rarely been mentioned (4). In a recent population-based case-control study, the risk of tinnitus was found to increase 1.36 times in patients with OSAS. However, no detailed grading or severity of SDB (or OSAS) and tinnitus was provided. The purpose of this study was to investigate the exact relationship between tinnitus and SDB and delineate the incidence and severity of SDB in patients with chronic tinnitus; moreover, our study reports the preliminary outcome of tinnitus after intervention with continuous positive airway pressure (CPAP) in selected patients with moderate to severe SDB. This article is protected by copyright. All rights reserved.

Objective: The aim of this study was to gain insights related to positive experiences reported by adults with tinnitus living in the United Kingdom. Design: A cross-sectional survey design was used in a sample of adults with tinnitus who were interested in undertaking an Internet-based intervention for tinnitus. Setting: The study was UK wide and data collection was online. Participants: Participants consisted of 240 adults (137 males, 103 females), with an average age of 48.16 years and average tinnitus duration of 11.52 years (SD: 11.88). Main outcome measures: Tinnitus severity was measured by means of the Tinnitus Functional Index. To evaluate the secondary effects of tinnitus, the Insomnia Severity Index, the Hearing Handicap Inventory for Adults-Screening Version and the Cognitive Failures Questionnaires were administered. Positive experiences related to tinnitus were explored using an open-ended question format. Results: Around a third of participants (32.5%) reported positive experiences associated with tinnitus. The number of positive responses ranged from one to eight responses per participant, although there were fewer participants with more than one positive response. The predominant themes concerned for (i) coping; (ii) personal development; (iii) support, and to a lesser extent (iv) outlook. Younger participants, those with a lower hearing disability and those with fewer cognitive failures were more likely to report positive experiences associated with having tinnitus. Conclusions: This study has identified that personal development and a positive outlook are possible despite experiencing tinnitus. Ways to facilitate positive experiences related to tinnitus should be promoted, as these may reduce the negative consequences associated with tinnitus. The most prevalent positive theme was the ability to cope with tinnitus. Positive experiences were also drawn from having clinical and other support networks. This highlights the importance of providing tinnitus interventions that can assist people in coping with tinnitus, particularly to those less likely to relate tinnitus to any positive experiences. Those most likely to be helped include those who are older with greater cognitive difficulties and a greater hearing disability.

Objective Ossiculoplasty is a surgical procedure that recreates sound transmission of the middle ear in conductive hearing loss. Various materials have been used for ossicular reconstruction, but the most ideal material for ossiculoplasty remains controversial. The purpose of this study is to introduce a novel method of autologous ossiculoplasty, bone-cartilage composite graft (BCCG), and to compare its surgical results with different types of ossiculoplastic prostheses. Study Design A retrospective study was performed in a tertiary referral center. Methods Data of 275 patients who received ossiculoplasty using the three different materials of BCCG, Polycel®, and titanium were analyzed according to type of ossiculoplasty: partial or total ossicular replacement prosthesis (PORP or TORP). Hearing results, complication rates, and clinical parameters including age, sex, past history, preoperative diagnosis, and surgery type were compared among different groups. Results Ossiculoplasty with BCCG showed satisfactory hearing outcomes and the lowest complication rate among the three different materials. In particular, its extrusion rate was 0%. Conclusion We propose that the BCCG technique is a useful alternative method for ossiculoplasty, with proper patient selection. This article is protected by copyright. All rights reserved.

Acute otitis media (AOM), common childhood infection that is one of leading cause of antibiotic prescriptions for children, is diagnosed at least once in approximately 80% of preschool children and 30-40% of them have recurrent episodes. Antibiotic treatment of AOM is usually empiric, without isolation of otopathogens from middle ear fluid and their antibiotic susceptibility testing. Due to the improper antibiotic use, the infection can persist in some cases, termed AOM treatment failure. This article is protected by copyright. All rights reserved.

Locating the round window membrane during cochlear implantation surgery is crucial to insert the electrode array correctly and to minimize intracochlear damage. However, it can be difficult to access the round window membrane in certain patients, especially in paediatric patients or patients with inner ear malformations. Recently, it has been demonstrated that endoscopy enables excellent visualization and exploration of the round window niche in ear surgery. This article is protected by copyright. All rights reserved.

Background Age-related hearing loss (ARHL) is highly prevalent in older adults and more than two-thirds above age 70 years suffer from ARHL. Recent studies have established a link between ARHL and cognitive impairment, however, most of the studies have used verbally loaded cognitive measures to investigate the association between ARHL and cognition. It is possible that due to hearing impairment, the elderly may experience difficulty in following verbal instructions or completing tasks that heavily rely on hearing during cognitive assessments. This may result in over-estimation of cognitive impairment in such individuals. This baseline cross-sectional study investigated the associations between untreated hearing loss and a number of cognitive functions using a battery of non-auditory cognitive tests. Further, association between hearing loss and psychological status of older adults was examined. Study design Prospective case-controlled study. Methods A total of 119 participants (54 males, M = 66.33 + 10.50 years; 65 females M = 61.51 + 11.46 years) were recruited. All participants completed a hearing assessment, a computerised test battery of non-auditory cognitive functions and the depression, anxiety and stress scale. Results Hierarchical multiple regression analysis results revealed that hearing thresholds significantly associated with the working memory (P

• Idiopathic non allergic rhinitis (i-NAR) is a frequent cause of non-allergic rhinitis and associates nonspecific symptoms. There is no simple direct procedure to establish i-NAR diagnosis. • Diagnosis of i-NAR is currently based on an absence of a definite causal factor and a lack of evidence for IgE-mediated allergy by skin prick tests and allergen-specific serum IgE • Measurement of nasal compliance with acoustic rhinometry evaluates the vasomotricity-related deformability of the nasal mucosa. It has been already suggested that nasal compliance could be abnormal in i-NAR. • In this prospective case-controlled study of 42 patients with chronic rhinitis and 21 control patients, after topical decongestion, compliances in i-NAR group were significantly increased compared to allergic rhinitis (AR) and Control group (n=21) (p

Percutaneous titanium implants for bone conduction devices (BCDs) have offered, since 1977, a solution for patients with hearing loss not treatable by conventional hearing aids, such as patients with chronic ear infections or microtia and/or ear canal atresia. Percutaneous implants imply a continuous breach in the mechanical defensive barrier of the skin. To compensate for this breach, immunological mechanisms in the subcutaneous tissue surrounding the implant become more active. This article is protected by copyright. All rights reserved.