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Maral J Rouhani,1 Eleanor J Burleigh,2 Chloe Hobbis,2 Charlotte Dunford,1 Nadir I Osman,3 Christine Gan,1 Norma B Gibbons,1 Hashim U Ahmed,1,4 Saiful Miah1,5 1Department of Urology, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK; 2Medical School, University of Sheffield, Sheffield, UK; 3Department of Urology, Royal Hallamshire Hospital, Sheffield, UK; 4Division of Surgery, Department of Surgery and Cancer, Imperial College London, London, UK; 5Division of Surgery and Interventional Science, University College London, London, UK Background: We aimed to determine UK medical students’ perceptions and attitudes and interest toward medical leadership and clinician managers. Methods: A cross-sectional study was conducted during the academic year 2015–2016. An online questionnaire was distributed to 2,349 final-year students from 10 UK medical schools. Participants were asked to complete a 5-point Likert scale on their current perceptions, attitudes, and interest toward medical leadership and clinician managers. They were also asked to self-rate their leadership competences set by the Medical Leadership Competency Framework and to rate the quality of management and leadership training they received from their medical school. Results: In total, we received 114 complete responses. Only 7.9% of respondents were in agreement (strongly agree or agree) when asked whether they felt they were well informed about what a managerial position in medicine entails. When asked whether clinicians should influence managerial decisions within a clinical setting, 94.7% of respondents were in agreement with the statement. About 85% of respondents were in agreement that it is important for clinicians to have managerial or leadership responsibilities, with 63.2% of students in agreement that they would have liked more management or leadership training during medical school. Over half the respondents rated their management and leadership training they received during medical school as “very poor” or “poor” (54.4%). Conclusion: Our study suggests that UK medical students have an appetite for management and leadership training and appreciate its importance but feel that the training they are receiving is poor. This suggests that there is a gap between the demand for management and leadership training and the quality of training supplied by UK medical schools. Keywords: medical leadership, clinician managers, medical student, training

The hallmark of epidermolysis bullosa (EB) is fragile attachment of epithelia due to genetic variants in cell adhesion genes. We describe 16 EB patients treated in the ear, nose, and throat department of a tertiary pediatric hospital linked to the United Kingdom's national EB unit between 1992 and 2023. Patients suffered a high degree of morbidity and mortality from laryngotracheal stenosis. Variants in laminin subunit alpha-3 (LAMA3) were found in 10/15 patients where genotype was available. LAMA3 encodes a subunit of the laminin-332 heterotrimeric extracellular matrix protein complex and is expressed by airway epithelial basal stem cells. We investigated the benefit of restoring wild-type LAMA3 expression in primary EB patient-derived basal cell cultures. EB basal cells demonstrated weak adhesion to cell culture substrates, but could otherwise be expanded similarly to non-EB basal cells. In vitro lentiviral overexpression of LAMA3A in EB basal cells enabled them to differentiate in air-liquid interface cultures, producing cilia with normal ciliary beat frequency. Moreover, transduction restored cell adhesion to levels comparable to a non-EB donor culture. These data provide proof of concept for a combined cell and gene therapy approach to treat airway disease in LAMA3-affected EB., Competing Interests: Declaration of interests The authors declare no competing interests. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. For the purpose of open access, the corresponding author has applied a CC BY public copyright license to any author accepted manuscript version arising from this submission., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

The upper airway acts as a conduit for the passage of air to the respiratory system and is implicated in several chronic diseases. Whilst the cell biology of the distal respiratory system has been described in great detail, less is known about the proximal upper airway. In this review, we describe the relevant anatomy of the upper airway and discuss the literature detailing the identification and roles of the progenitor cells of these regions., (Copyright © 2024. Published by Elsevier B.V.)

Objectives: The objective was to report and analyse the characteristics and results of open aortopexy and thoracoscopic aortopexy for the treatment of airway malacia in a paediatric population., Methods: We report a retrospective consecutive case series of paediatric patients undergoing aortopexy for the treatment of airway malacia at a quaternary referral centre between December 2006 and January 2021. Outcome measures included days to extubation, continued need for non-invasive ventilation, further intervention in the form of tracheostomy and death., Results: 169 patients underwent aortopexy: 147 had open procedures (135 via median/limited median sternotomy and 12 thoracotomy) and 22 thoracoscopic. Mean follow up was 8.46 yrs (range 1-20 yrs). Most common site of airway malacia was the trachea (n = 106, 62.7 %), and 48 (28.4 %) had additional involvement at the bronchi with tracheobronchomalacia (TBM). 15 (8.9 %) had bronchomalacia (BM) only. Incidence of bronchial disease was lower in the thoracoscopic than open group (13.6 % vs 40.82 %; p < 0.0001). Mean time to extubation was 1.45 days, 2.59 days, 5.23 days in tracheomalacia, TBM and BM groups, respectively (p = 0.0047). Mean time to extubation was 1.35 days, 2 days, 3.67 days, and 5 days in patients with external vascular compression, TOF/OA, primary airway malacia, and laryngeal reconstruction, respectively (p = 0.0002). There were 21 deaths across the cohort, and all were in the open group. 71.4 % (n = 15) had bronchial involvement of their airway malacia., Conclusions: Open and thoracoscopic aortopexy are effective treatments for airway malacia in children. We have identified that involvement of the bronchi is a risk factor for adverse outcomes, and the optimum treatment for this patient cohort is still debatable., Level of Evidence: IV., Type of Study: Retrospective Study., (Copyright © 2023. Published by Elsevier Inc.)

Background: Superior semi-circular canal dehiscence syndrome is a disorder characterised by auditory and vestibular symptoms that can significantly impact quality of life, and yet it has no disease-specific quality of life instrument., Method: Thirty-six patients who underwent transmastoid superior semicircular canal resurfacing and plugging were included from an initial cohort of 60 surgically managed patients. A sub-cohort of 19 consecutive patients completed validated symptom and quality of life questionnaires before and after surgery. Of the 36 patients, 31 participated in a telephone semi-structured interview post-operatively., Results: Following surgery, there was a statistically significant improvement in autophony index score ( p = 0.02), symptom severity score ( p < 0.001) and sound hypersensitivity ( p = 0.01). Thematic analysis of telephone interviews suggested three main symptom themes: auditory hypersensitivity, dysequilibrium, headache and concentration difficulties. Dysequilibrium was found to persist post-operatively., Conclusion: Surgery improves overall symptoms and quality of life. However, important symptom themes may be overlooked using the outcome measures that are currently available. A unified disease-specific outcome measure is urgently required to better understand the impact of symptoms and measure treatment effects.

Objectives: In most cases, suspension laryngoscopy (SL) is efficient, bloodless and with minimal post-procedure discomfort. We aimed to identify predictive patient factors for acceptable surgical views at SL as well as quantify our tertiary airway unit's complication rates., Design: Prospective cohort study of 150 consecutive microlaryngoscopy procedures involving SL over an 8-month period between November 2019 and July 2020. Patients were assessed preoperatively for pre-existing oral, temporomandibular, dental, pharyngeal or laryngeal pathology, interincisor distance and qualitative gross limitations to neck extension and forward head posture. Intraoperatively, the laryngoscopic view was graded by anaesthetic and surgical teams, and complications were recorded on patient interview in recovery., Setting: Tertiary adult airway service for predominantly benign pathology., Results: Adequate surgical views were obtained in 149/150 procedures. BMI had a weak positive correlation with a more difficult view (r = .22, p = .008) but did not correlate with a statistically significant increase in any complication. There was a weak negative correlation between age and interincisor gap (r = -.20, p = .014), and wider mouth opening correlated very weakly with a lower incidence of sore throat (r = -.19, p = .023). Gross macroglossia showed a significant moderate positive correlation with tongue symptoms (r = .45, p = 1.611 × 10 -8 )., Conclusion: In the context of an experienced airway unit with a high caseload of predominantly benign pathology, SL is very effective and safe with low associated morbidity and no mortality. The most common complication of SL is temporary sore throat and there remain recognised risks of temporary tongue and dental symptoms., (© 2021 John Wiley & Sons Ltd.)

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 PubMed literature review to determine the evidence base supporting this., Results: ENT manifestations are present in 5%-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., (© 2021 John Wiley & Sons Ltd.)

Objective: The COVID-19 pandemic has led to unprecedented demands on healthcare with many requiring intubation. Tracheostomy insertion has often been delayed and the enduring effects of this on voice, swallow, and airway outcomes in COVID-19 tracheostomy patients are unknown. The aim of this study was to prospectively assess these outcomes in this patient cohort following hospital discharge., Methods: All COVID-19 patients who had undergone tracheostomy insertion, and were subsequently decannulated, were identified at our institution and followed up 2 months post-discharge. Patient-reported (PROMS) and clinician-reported outcome measures, endoscopic examination, and spirometry were used to assess voice, swallow, and airway outcomes., Results: Forty-one patients were included in the study with a mean age of 56 years and male:female ratio of 28:13. Average duration of endotracheal intubation was 24 days and 63.4% of tracheostomies were performed at day 21 to 35 of intubation. 53.7% had an abnormal GRBAS score and 30% reported abnormal swallow on EAT-10 questionnaire. 81.1% had normal endoscopic examination of the larynx, however, positive endoscopic findings correlated with the patient self-reported VHI-10 (P = .036) and EAT-10 scores (P = .027). 22.5% had spirometric evidence of fixed upper airway obstruction using the Expiratory-Disproportion Index (EDI) and Spearman correlation analysis showed a positive trend between abnormal endoscopic findings and EDI scores over 50 (P < .0001)., Conclusion: The preliminary results of this study reveal a high incidence of laryngeal injury among patients who underwent intubation and tracheostomy insertion during the COVID-19 pandemic. As these patients continue to be followed up, the evolution of these complications will be studied., Level of Evidence: 3 Laryngoscope, 131:E1918-E1925, 2021., (© 2020 The American Laryngological, Rhinological and Otological Society, Inc.)

Purpose: The use of nasal decongestant and nasal anaesthesia is currently not recommended during drug-induced sleep endoscopy (DISE) according to the European position paper. The evaluation of the effects of nasal decongestant/anaesthesia on DISE has not been performed before and our aim is to perform a pilot study to determine whether nasal decongestants/anaesthesia affects DISE outcomes., Methods: 27 patients undergoing DISE for OSA or for simple snoring were included. On each patient, DISE was performed twice, before and approximately 10 min after the administration of two puffs of co-phenylcaine nasal spray (lidocaine hydrochloride 5%, phenylephrine 0.5%, and benzalkonium chloride 0.01%) into each nostril. A nasal peak inspiratory flow was used for the objective assessment of nasal airway obstruction. During the first and the second DISE the loudness of the snoring was also recorded., Results: Change in DISE total grading after nasal spray administration was not statistically significant. For the same grading, changes in percentage of contribution to collapse were not statistically significant. Sex, AHI, BMI, tonsils grade, presence of rhinitis, turbinate hypertrophy, nasal septal deviation, or nasal peak inspiratory flow limitation had no influence on the effect of nasal spray. Co-phenylcaine did not significantly influence the loudness of snoring., Conclusions: Our pilot study supports the use of co-phenylcaine nasal spray during DISE and the positive effects of the nasal spray do not influence the grading outcome. Importantly, the decongestant enhances the nasal assessment during DISE and potentially aids in the diagnosis of nasal obstruction while the nasal anaesthetic component may be beneficial by reducing nasal discomfort during DISE and thereby helping to reduce the total dose of intravenous anaesthetic administered. However, further studies on a larger population are needed to confirm our results.

Pyogenic granuloma gravidarum is a benign fibrovascular proliferative lesion usually involving the oral gingivae in pregnant patients. While it also occurs, although less frequently, on other oral sites such as lips, tongue and palate, it is relatively unusual to find it in the nasal cavity. Furthermore, lesions normally involute spontaneously after childbirth. For persistent lesions requiring surgical management, imaging has historically been limited to CT. This case is notable not only for its uncommon location but also for its recurrent nature, failure to regress post partum and the use of MRI in the preoperative planning., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Stapes surgery is performed to treat hearing loss in patients with otosclerosis. Erosion of the long process of incus can occur postoperatively and requires demanding revision surgery to further improve the hearing. The authors describe a novel method of performing revision stapes surgery where there is erosion of the long process of incus., Methods: A retrospective case series analysis of a database of revision stapes operations performed by one surgeon between July 2013 and December 2017 at a tertiary center was carried out. 26 cases were identified where there was significant erosion of long process of incus. The ossicular chain in these cases was reconstructed using a novel technique of using cement to fix the piston prosthesis to the incus remnant. The full technique is described herein. The pre- and postoperative audiometric data were analyzed., Results: Mean preoperative air bone gap (ABG) was 29.3 dB and mean postoperative ABG was 9.9 dB. Of the 22 patients with recorded postoperative masked bone conduction thresholds, 16 had ABG closure to < 10 dB (72.7%)., Conclusion: We have shown highly favorable outcomes using this novel technique in addressing erosion of the long process of incus in revision cases for patients with otosclerosis.

Objective: Adenotonsillectomy is frequently performed for obstructive sleep apnoea, but is associated with post-operative respiratory morbidity. This study assessed the effect of paediatric Otrivine (0.05 per cent xylometazoline hydrochloride) on post-operative respiratory compromise., Methods: Paediatric patients undergoing adenotonsillectomy for obstructive sleep apnoea were included. The control group (n = 24) received no intervention and the intervention group (n = 25) received intra-operative paediatric Otrivine during induction using a nasal patty. Post-operative outcomes included pain, respiratory distress signs and medical intervention level required (simple, intermediate and major)., Results: Post-operative respiratory distress signs were exhibited by 4 per cent of the Otrivine group and 21 per cent of the control group. Sixty-eight per cent of the Otrivine group required simple medical interventions post-operatively, compared to 42 per cent of the control group. In the Otrivine group, 4 per cent required intermediate interventions; none required major interventions. In the control group, 12.5 per cent required both intermediate and major interventions. Fifty per cent of the control group reported pain post-operatively, compared with 40 per cent in the Otrivine group., Conclusion: Intra-operative paediatric Otrivine may reduce post-operative respiratory compromise in paediatric patients undergoing adenotonsillectomy for obstructive sleep apnoea. A randomised controlled trial is required.

Objective: The aim of the study was to perform a systematic review of existing evidence on the role of local anaesthetic nerve block (LAB) in patients undergoing endoscopic sinus surgery (ESS)., Design: The databases searched were the Cochrane Register of Controlled Trials, MEDLINE and Embase using the Ovid portal (1946-2017)., Results: Seven randomised controlled trials were included. Due to considerable heterogeneity of data, only two studies were pooled into meta-analysis which demonstrated a statistically significantly better surgical field quality during ESS in the LAB group compared with the control group (MD -0.86; 95% CI -2.24, 0.51; P = .009). No adverse events related to LAB toxicity were reported., Conclusions: Sphenopalatine ganglion LAB with adrenaline carries relatively low risk of morbidity, but may improve the quality of the surgical field in terms of bleeding. However, there are limitations of the study due to heterogeneity of methods, quality and size of the studies. Well-conducted large RCTs are needed using standardised inclusion criteria, balanced baseline characteristics of cohorts, and validated subjective and objective outcome measures., (© 2018 John Wiley & Sons Ltd.)

Background: The field of ENT surgery is one of the most varied specialties, with numerous subspecialties and continuing divergence. With this evolution there comes, however, a risk that specialists become de-skilled in certain areas. In the case of ENT emergencies, this can be particularly dangerous., Methods: Current guidance from relevant UK professional membership bodies regarding emergency surgery provision was inspected and a literature search was performed to identify studies relating to management of ENT emergencies in the context of increasing subspecialisation., Results and Conclusion: The specialty currently has provisions in place to ensure timely, appropriate and safe management of emergencies, in the form of guidelines and emergency clinics; however, there is scope for improvement of the system.

Objective: To collate information available in the literature regarding perioperative outcomes following elective laparoscopic abdominal aortic aneurysm repair., Materials and Methods: Electronic databases were searched and a systematic review was performed. In total, 1256 abstracts were screened, from which 10 studies were included for analysis. Perioperative and technical outcomes were analysed., Results: In the totally laparoscopic repair of infra-renal aneurysms (n = 302), 30-day mortality ranged between 0% and 6% and in the laparoscopic-assisted cases (n = 547) ranged between 0% and 7%. Of the former group, 5-30% of cases were converted to open repair, with 6% reintervention rate, whereas there was a 5-10% conversion and 3% reintervention rate in the latter group., Conclusions: The outcomes from selected patients in selected centres demonstrate that elective laparoscopic repair of aortic aneurysms is feasible and comparable in safety to open repair; it remains unclear, however, whether there are substantial advantages of this method compared with open and endovascular repair., (© The Author(s) 2014.)

Voltage-gated K(+) channels composed of Kv7.2 and Kv7.3 are the predominant contributors to the M-current, which plays a key role in controlling neuronal activity. Various lines of evidence have indicated that Kv7.2 and Kv7.3 form a heteromeric channel. However, the subunit stoichiometry and arrangement within this putative heteromer are so far unknown. Here, we have addressed this question using atomic force microscopy imaging of complexes between isolated Kv7.2/Kv7.3 channels and antibodies to epitope tags on the two subunits, Myc on Kv7.2 and HA on Kv7.3. Initially, tsA 201 cells were transiently transfected with equal amounts of cDNA for the two subunits. The heteromer was isolated through binding of either tag to immunoaffinity beads and then decorated with antibodies to the other tag. In both cases, the distribution of angles between pairs of bound antibodies had two peaks, at around 90° and around 180°, and in both cases the 90° peak was about double the size of the 180° peak. These results indicate that the Kv7.2/Kv7.3 heteromer generated by cells expressing approximately equal amounts of the two subunits assembles as a tetramer with a predominantly 2:2 subunit stoichiometry and with a random subunit arrangement. When the DNA ratio for the two subunits was varied, copurification experiments indicated that the subunit stoichiometry was variable and not fixed at 2:2. Hence, there are no constraints on either the subunit stoichiometry or the subunit arrangement.