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Background Topical nasal decongestant sprays are used commonly in routine otolaryngology practice to reduce the symptoms of nasal airway obstruction (NAO) through vasoconstriction, thereby reducing the bulk of vasoerectile tissue and increasing nasal airflow. Such tissue is found predominantly on the lateral wall of the nose within the inferior turbinates (ITs), but recent evidence suggests that it may also be found medially within the nasal septal swell body (SSB). Objective To determine whether isolated topical decongestion of the medial nasal wall, targeting the SSB, is as effective as isolated decongestion of the lateral nasal wall, targeting the IT, in maximizing nasal patency. Methods A double-blinded, randomized controlled, crossover study was performed investigating the effect of decongestion of the lateral nasal wall or septum in isolation on nasal airflow. Isolated decongestion was performed by placing a cottonoid, soaked in oxymetazoline and attached to a silastic sheet, into the nasal cavity randomly facing either the septum or lateral nasal wall, bilaterally. Anterior rhinomanometry, acoustic rhinometry, peak nasal inspiratory flow (PNIF), and subjective patient-reported outcomes (Sinonasal Outcome Test (SNOT-22) and Nasal Obstruction Symptom Evaluation (NOSE) scores) were recorded at baseline and postdecongestion. Decongestion of the alternate site was then performed at a later date. Results A total of 20 healthy volunteers (30% females, mean age 26.6 ± 3.8 years) were recruited. Improvements in nasal obstruction and SNOT-22 scores were found following decongestion of the septum compared with baseline (mean difference: 0.82, t = 2.32, P = .04; mean difference: 3.30, t = 2.50, P = .04, respectively). Improvements in mean inspiratory flow, minimal cross-sectional area, volume, and PNIF were also demonstrated. Conclusion This study suggests that the SSB contains erectile tissue that responds to topical decongestant therapy in a similar manner to IT tissue. The SSB may represent a novel target in surgery for NAO.

ObjectiveDeep learning using convolutional neural networks represents a form of artificial intelligence where computers recognise patterns and make predictions based upon provided datasets. This study aimed to determine if a convolutional neural network could be trained to differentiate the location of the anterior ethmoidal artery as either adhered to the skull base or within a bone ‘mesentery’ on sinus computed tomography scans.MethodsCoronal sinus computed tomography scans were reviewed by two otolaryngology residents for anterior ethmoidal artery location and used as data for the Google Inception-V3 convolutional neural network base. The classification layer of Inception-V3 was retrained in Python (programming language software) using a transfer learning method to interpret the computed tomography images.ResultsA total of 675 images from 388 patients were used to train the convolutional neural network. A further 197 unique images were used to test the algorithm; this yielded a total accuracy of 82.7 per cent (95 per cent confidence interval = 77.7–87.8), kappa statistic of 0.62 and area under the curve of 0.86.ConclusionConvolutional neural networks demonstrate promise in identifying clinically important structures in functional endoscopic sinus surgery, such as anterior ethmoidal artery location on pre-operative sinus computed tomography.

Here we describe MyGene2, Geno2MP, VariantMatcher, and Franklin; databases that have made variant-level information together with phenotype or phenotypic features available to researchers, clinicians, health care providers and patients. Following in the footsteps of the Matchmaker Exchange project that connects exome, genome, and phenotype databases at the gene level, these databases plan to connect to each other using Data Connect, a standard for discovery and search of biomedical data from the Global Alliance for Genomics and Health (GA4GH).

Several authors have reported advantages of the purely endoscopic (PE) approach over traditional purely microscopic (PM) techniques for many sinus and anterior skull base procedures. However, in pituitary surgery, the PE approach carries a number of limitations. Experienced microscopically-trained neurosurgeons are required to master the endoscopic technique which has a steep learning curve due to its one-handed nature and optically-distorted 2-dimensional view. We describe our novel technique, the sequential endoscopic and microscopic pituitary procedure (SEMPP) which does not require microscopically-trained neurosurgeons to alter their technique. We compare SEMPP with the PE approach in terms of outcome and safety. Retrospective chart review of consecutive SEMPP cases performed at our institution between January 2010 and December 2013 was conducted. Operative time, gross total resection rate, resolution of endocrine and visual dysfunction, hospital length of stay, cerebrospinal fluid (CSF) leak rate and revision rates were recorded. 32 patients were identified (50% female, mean age 53.0 years), and 33 SEMPP cases. Mean operating time was 132 min (range 90–200). 69% of patients experienced gross total resection. Most patients (81.3%) with preoperative visual deficit either experienced complete resolution or improved symptoms. The remainder experienced no change in vision. 12.5% (n = 4) of patients experienced intraoperative CSF leaks. All were repaired intraoperatively or with conservative management. Two patients (6.3%) experienced epistaxis managed with conservative measures. The SEMPP technique demonstrates comparable outcomes, complication rates and operative time to PE and PM techniques described in the literature.

Background: Acute food bolus impaction (AFBI) is an uncommon problem in children. In many cases, AFBI is associated with a pre-disposing condition, such as oesophageal stenosis, dysmotility or reflux disease. We review the management and underlying aetiology of children presenting with AFBI at a tertiary paediatric hospital. Methods: Records of all children who presented to a tertiary pediatric hospital with AFBI over a 10-year period from 1994–2004 were retrospectively examined. Information regarding demographics, presenting symptoms, investigations, management and underlying pathology were assessed from hospital records. Results: Forty-six children (mean age 6 years, 28.3% female) with suspected AFBI were identified. All 46 patients were symptomatic, most commonly with vomiting (54.3%, n=25), drooling (34.8%, n=16), dysphagia (32.6%, n=15), refusal to eat (23.9%, n=11) and foreign body sensation (17.4%, n=8). Most (73.9%) children had impacted food bolus at the time of intervention, usually at the lower oesophagus. All identified food boluses were retrieved or dislodged successfully using either direct laryngoscopy or oesophagoscopy. About 47.8% of children had previous oesophageal surgery for trachea-oesophageal fistula (43.4%, n=20) or oesophageal atresia (4.3%, n=2). A small proportion had a known history of eosinophilic oesophagitis (EoE) (4.3%, n=2). Oesophageal biopsy for EoE was not routinely performed during the study period analysed. Conclusions: AFBI is uncommon and often associated with underlying pathology. Endoscopy is a useful tool for diagnosis and treatment, as well as to identify any underlying pre-disposing pathology. In all children presenting with AFBI without clear cause, investigation for EoE with oesophageal biopsy should be considered.

Background Implantable cardioverter‐defibrillator ( ICD ) improves survival when used for primary or secondary prevention of sudden cardiac death. Whether the benefits of ICD in patients with atrial fibrillation ( AF) are similar to those with normal sinus rhythm ( NSR ) is not well established. The aim of this study is to investigate whether ICD patients with AF are at higher risk of mortality and appropriate shock therapy compared with patients with NSR . Methods and Results Literature was searched and 25 observational studies with 63 283 patients were included in this meta‐analysis. We compared the outcomes of (1) all‐cause mortality and appropriate shock therapy among AF and NSR patients who received ICD for either primary or secondary prevention and (2) all‐cause mortality among AF patients with ICD versus guideline directed medical therapy. All‐cause mortality (odds ratio, 2.11; 95% confidence interval, 1.73–2.56; P P ICD patients with AF as compared to NSR . There was no statistically significant mortality benefit from ICD compared with medical therapy in AF patients (odds ratio, 0.69; 95% confidence interval, 0.42–1.11; P =0.12) based on a separate meta‐analysis of 3 studies with 387 patients. Conclusions Overall mortality and appropriate shock therapy are higher in ICD patients with AF as compared with NSR . The impact of ICD on all‐cause mortality in AF patients when compared to goal‐directed medical therapy is unclear, and randomized controlled trials are needed comparing AF patients with ICD and those who have indications for ICD, but are only on medical therapy.

Objectives Coins are the commonest foreign body ingested in paediatric populations. Although most ingested coins are either spontaneously passed or retrieved with medical intervention without serious consequence, there is potential for serious morbidity and mortality related to paediatric coin ingestion. We performed a 10-year retrospective review of Australian denomination coin ingestion at a tertiary paediatric hospital in Sydney, Australia. We attempted to determine whether a relationship exists between coin size, patient age, coin ingestion and spontaneous passage. Methods Hospital records of all children presenting in a 10-year period to a paediatric tertiary care centre for coin ingestion were reviewed. Demographic information, coin denomination, previous history, symptoms, investigations, management, outcome and complications were recorded. Results 241 cases were identified. The majority (55%) of cases occurred in children ≤3 years of age (range 7 months–11 years, mean 3.39 years). The most common location where coins were identified was in the proximal third of the oesophagus or at the cricopharyngeus (65%). Spontaneous passage occurred in 84 cases (34.9%) while 167 cases (69.3%) required intervention. Children ≤3 years were more likely to ingest small coins ( 3 years were more likely to ingest larger coins (22–26 mm) (OR: 2.17; 1.39–4.35). Conclusions Coin size, coin weight and age of the child appear to be predictors for both likelihood of ingestion and spontaneous passage in paediatric coin ingestion cases. A child with minimal symptoms, witnessed ingestion and radiographic identification of the coin in the lower oesophagus or more distal can often be safety observed for up to 24 h in anticipation of spontaneous passage.

Schneiderian-type papilloma of the middle ear is a rare finding. We present a 46-year-old Aboriginal man with a large tympanic membrane perforation and a Schneiderian-type papilloma filling the middle ear. The aim of this study is to familiarize clinicians with this uncommon disease through discussion of its clinical presentation, diagnostic considerations and management. A search of English-language peer-reviewed literature was undertaken using the key words “Schneiderian-type papilloma,” “inverted papilloma,” and “middle ear.” A total of 29 cases (including the present case) of Schneiderian-type papilloma involving the middle ear were reviewed. Common presenting symptoms include hearing loss, otalgia, and otorrhea. Middle ear disease is associated with higher rates of recurrence and malignant transformation than its sinonasal counterpart. Radical surgical resection is the only curative treatment. Schneiderian-type papilloma is a benign, but locally aggressive, epithelial neoplasm most commonly arising in the sinonasal tract. Whilst involvement of the middle ear is extremely rare, knowledge of this condition is important due to its propensity to recur and the high rate of malignant transformation.

Exome sequencing (ES) is rapidly being deployed for use in clinical settings despite limited empirical data about the number and types of incidental results (with potential clinical utility) that could be offered for return to an individual. We analyzed deidentified ES data from 6,517 participants (2,204 African Americans and 4,313 European Americans) from the National Heart, Lung, and Blood Institute Exome Sequencing Project. We characterized the frequencies of pathogenic alleles in genes underlying Mendelian conditions commonly assessed by newborn-screening (NBS, n = 39) programs, genes associated with age-related macular degeneration (ARMD, n = 17), and genes known to influence drug response (PGx, n = 14). From these 70 genes, we identified 10,789 variants and curated them by manual review of OMIM, HGMD, locus-specific databases, or primary literature to a total of 399 validated pathogenic variants. The mean number of risk alleles per individual was 15.3. Every individual had at least five known PGx alleles, 99% of individuals had at least one ARMD risk allele, and 45% of individuals were carriers for at least one pathogenic NBS allele. The carrier burden for severe recessive childhood disorders was 0.57. Our results demonstrate that risk alleles of potential clinical utility for both Mendelian and complex traits are detectable in every individual. These findings highlight the necessity of developing guidelines and policies that consider the return of results to all individuals and underscore the need to develop innovative approaches and tools that enable individuals to exercise their choice about the return of incidental results.

Background: Foreign body ingestion is a common problem in paediatric populations, with the most common culprits being coins or small toys. Fish bone ingestion is much less common in children than in adults. Fish bone impaction may lead to serious complications if untreated and, in children, often represents a diagnostic challenge. We review the presentation, investigation and management of fish bone impaction at an Australian tertiary paediatric hospital. Methods: Hospital records of all children presenting to a single, tertiary paediatric centre over a 10-year period for suspected foreign body impaction were identified and retrospectively reviewed specifically for fish bone impaction. Demographic data, presenting history, observed location, investigations performed and outcomes were assessed. Results: Forty-two children (mean age 6.2±4.0 years, 40.5% female) were identified as presenting with fish bone ingestion, accounting for 8.0% of all foreign body impaction over the 10-year period. Mean time to presentation from time of impaction was 19 hours. Seventeen children had a demonstrable fish bone in situ at time of review: 15 required removal; 1 passed spontaneously; and 1 was regurgitated. Ten fish bones were identified in the oral cavity. Plain X-ray was useful in identifying a fish bone in only 3 of 28 cases where X-ray was performed. No complications were experienced. Conclusions: Fish bones are uncommon foreign bodies ingested by children. Most fish bones were identified within the oral cavity or oropharynx, reinforcing the importance of thorough oral examination. Plain X-rays have limited sensitivity in the diagnosis of an impacted fish bone in children.