Recent Submissions

  • Morbidity and Mortality Following Transoral Robotic Surgery, a Prospective Single Centre Study.

    Kumar, Sachin; Mettias, B; Laugharne, David; Mortimore, Sean
    To review complications including mortality after transoral robotic surgery (TORS) for both benign and malignant pathologies. This is a prospective observational study. Postoperative haemorrhage (8.7%) was the most common complication and 2 (1.7%) mortality were seen in this study. Airway complications and tracheostomy (1.7%), aspiration pneumonia (1.7%), swallowing problems and nasogastric feeding (7%), intra-operative pharyngocutaneous fistula (0.9%) and transient nasal regurgitation (3.5%) were also seen. The more tissue is removed the more is the risk of complication. Complications were mainly seen in the first year of starting the service of TORS and it is a reflection of the learning curve. However, secondary haemorrhage did not follow any pattern in our series. The postoperative haemorrhage was more common in patients with T2 oropharyngeal carcinoma. The mortality was seen in 2 patients (1.7%) with T2 oropharyngeal carcinoma due to postoperative haemorrhage. Higher T stage of oropharyngeal squamous cell carcinoma (OPSCC) needs bigger resection with resultant increase in morbidity.
  • Management of Retraction Pockets: historic and novel approaches.

    Spinos, Dimitrios; Mallick, Sameer; Judd, Owen
  • Frey's syndrome: A review of the physiology and possible role of neurotrophic factors.

    Judd, Owen
    OBJECTIVES: Frey's syndrome (FS) describes the phenomenon of gustatory sweating and is a cause of significant social embarrassment for sufferers. It has been attributed to aberrant growth of parasympathetic salivatory fibers in the auriculotemporal nerve toward overlying sweat glands. However, the exact mechanism behind this growth is unknown. This review aims to expand and elucidate the theory of aberrant regeneration in FS. METHODS: A review of the recent literature on nerve regeneration was conducted in order develop further insights into the etiology of both adult onset and pediatric FS. RESULTS: Neurturin, a neurotrophic factor released by both salivary and sweat glands, was identified as a possible key player in the etiology of FS. CONCLUSION: Further research into the role of neurturin could help to elucidate the pathogenic mechanisms underlying the condition and might reveal neurturin to be a potential target for pharmacological intervention. LEVEL OF EVIDENCE: NA (Basic Science Review).
  • Retinal Imaging in Infants

    Fung, THM (2021-01)
    Digital retinal imaging is at the core of a revolution that is continually improving the screening, diagnosis, documentation, monitoring, and treatment of infant retinal diseases. Historically, imaging the retina of infants had been limited and difficult to obtain. Recent advances in photographic instrumentation have significantly improved the ability to obtain high-quality multimodal images of the infant retina. These include color fundus photography with different camera angles, ultrasonography, fundus fluorescein angiography, optical coherence tomography, and optical coherence tomography angiography. We provide a summary of the current literature on retinal imaging in infants and highlight areas where further research is required.
  • The Use of Interlocking Polyetheretherketone Patient-Specific Facial Implants in the Treatment of Facial Deformities. A Retrospective Review of Ten Patients

    Thomas, Mathew (2020-12)
    Purpose: Polyetheretherketone (PEEK) is a versatile biocompatible material with a wide variety of clinical applications. Multiple-piece 3-dimensionally milled interlocking PEEK patient-specific implants are used in cases with restricted access or around vital structures. The interlocking joints reduce the number of fixation screws required by converting the multiple segments into one single implant. Stability of such joints is of paramount importance to prevent complications such as infection and implant extrusion. This retrospective study evaluates the clinical outcomes in the use of multiple-piece 3-dimensionally milled interlocking PEEK patient-specific implants as a treatment for various congenital and acquired facial deformities. Methods: Patients' records and clinical interviews were retrospectively reviewed. Results: A total of 10 patients were included; 6 of them (60%) were men. A planning cone beam scan (90%) or computed tomography scan (10%) were obtained following a standard protocol. All treatments were performed by a single surgeon, following a standardized approach. The follow-up time ranged from 11 to 61 months (mean = 37.1 months), No implant exposure, extrusion or removal were reported. Three patients (30%) have experienced complications. Recurrent edema was observed in 1 patient (10%), another patient (10%) experienced bilateral mental nerve paresthesia, and the third patient (10%) had recurrent sinusitis, which was successfully treated with functional endoscopic sinus surgery without removing the implant. Conclusion: Within the limitation of this study, 3-dimensionally milled interlocking PEEK patient-specific implants are safe, predictable, potentially save operative time, and readily adjustable. Extra stability and antislippage mechanism can be achieved by using the interlocking joint. Further studies on a larger cohort of patients is needed to confirm these results.
  • What still presents urgently to ENT during a pandemic? Experience of an ENT rapid access clinic during the coronavirus disease 2019 pandemic

    Stubington, TJ; Morrison, B; Sevilla, C; Judd, Owen (2021-01)
    Objectives: This study sought to determine the conditions that still present to ENT despite government advice to avoid unnecessary travel. It also assessed the impact of social distancing on pathologies presenting to ENT and reviewed the usefulness of telephone consultations in semi-urgent presentations. Method: A retrospective review was conducted of 97 instances of patient care carried out in the rapid access ENT clinic at a large district general hospital. Results: Otitis externa and foreign bodies represented 25 per cent and 13 per cent of consultations respectively. Tonsillitis and peritonsillar abscess were uncommon, representing 6 per cent of total consultations. Telephone appointments represented only 28 per cent of total consultations; however, they appeared to reduce the number of physical appointments required. Conclusion: Otitis externa and foreign bodies continue to be common during the pandemic. Social distancing measures reduced the number of tonsillitis and quinsy presentations. Telephone consultations are effective for certain urgent presentations to ENT, most noticeably nasal trauma and follow up of non-serious pathologies.
  • Food bolus and oesophageal foreign body: a summary of the evidence and proposed management process

    Stubington, TJ (2021-01)
    Purpose: Food bolus and oesophageal foreign bodies are a common presentation that may be managed by otolaryngologists, gastroenterologists, acute medicine physicians and accident and emergency. The condition is highly variable with presentations ranging from well patients whose obstruction spontaneously passes to peri-arrest with severe aspiration or impending airway compromise. Management of this condition is heterogeneous and often depends on the specialty the patient is originally admitted under. There exist European and American guidelines from the perspective of gastroenterology, but there are no UK-based guidelines and limited consideration of the role of the otolaryngologists and rigid oesophagoscopy. Methods: An extensive literature search was carried out to generate conclusions on key management questions for food bolus and oesophageal foreign bodies. This was then summarised into both a written summary of the evidence and a graphical decision tree. Results: This paper is a review article and presents conclusions regarding management options for food bolus and oesophageal foreign bodies. Conclusion: This article considers the current evidence surrounding investigation and management of oesophageal food bolus and foreign body. It draws conclusions regarding presentation, investigation and subsequent operative treatment. As part of this process, we propose a graphical decision tree to assist in management decisions.
  • Quantification of aerosol production during phacoemulsification and pars plana vitrectomy

    Fung, THM; Kuet, Mong-Loon; Poostchi, Ali; Pegg, Kate; Patel, MK; Gandhewar, Ravikiran (2020-11)
  • A multicentre audit to assess the effectiveness of the British Orthodontic Society 'Hold that Smile' retainer videos

    Murray, Alison (2020-03)
    Introduction: Retention is a crucial part of orthodontic treatment; however, patients often do not wear their retainers as advised. The British Orthodontic Society developed the 'Hold that Smile' campaign in 2017, to improve patient knowledge about retention. Information is provided in two formats: a cartoon and a conventional film. Objective: To assess whether patients find the 'Hold that Smile' videos useful and whether they improved patients' intended retainer wear. The gold standard was that 90% of patients should intend to wear their retainers in the long term after watching the videos. Design: National multicentre audit. Setting: Nine units in the UK. Methods: Patients aged ⩾ 10 years, in fixed appliances or retention, watched the retainer videos and then completed a questionnaire that was designed specifically for this audit. Each unit collected data for approximately 30 patients. Results: Data were collected for 278 patients in total. The average age was 17.9 years; 64.4% of patients were female and 35.6% were male. Most patients (86.3%) watched both videos and, of these, 44.1% preferred the film, 31.3% preferred the cartoon and 24.6% had no preference. The majority of patients (81.3%) felt that the film provided them with new information, compared with a lower percentage (48.5%) for the cartoon. More patients said they would recommend the film (76.3%) compared with the cartoon (63.3%). Before watching the videos, 77.0% of patients felt they knew about long-term retainer wear and 74.3% of those intended to wear their retainers in the long term. After watching the videos, 96.4% of all patients thought they would now wear their retainers long term. Conclusion: After watching the videos, there was a notable increase in the number of patients planning to wear their retainers long term and the gold standard was met. Therefore, these videos may be beneficial in improving understanding and compliance with retention.
  • Current perspectives on the surgical management of mandibular third molars in the United Kingdom: the need for further research

    Chiu, Geoff (2020-04)
    This survey of expert opinion regarding the management of mandibular third molar (M3M) impaction and its clinical sequelae was circulated to all members of the British Association of Oral and Maxillofacial Surgeons (BAOMS). It was completed by 289 clinicians who reported treating 60003 patients annually. Respondents included 199 (69%) specialists and 58 (20%) primary care clinicians. Most (99%) of the clinicians treated at least one M3M with complete surgical removal (CSR) annually. Only 69% performed one or more coronectomies (COR). Advocates of coronectomy reported lower rates of inferior alveolar nerve (IAN) injury, but IAN, lingual nerve, and adjacent second molar damage were rare, occurring in less than 0.5% of cases, with small differences between the COR and CSR groups. Although these differences are not statistically significant, they are likely to be clinically important. Also, the COR group would have comprised mainly high-risk teeth, while the CSR group would include many teeth at low risk of complications. This might have skewed the results. Those clinicians performing no coronectomies cited three main reasons for being low adopters of COR: the lack of irrefutable evidence to support its benefit, the increased need for a second operation, and more non-IAN complications. Although COR may prevent permanent IAN damage in high-risk cases, this paper highlights clinicians' views that there is a gap in evidence and knowledge to support COR. As a result, 47% of the clinicians surveyed recommended, and were prepared to participate in, further studies to determine the effectiveness and safety of COR.
  • A simple computerised technique for estimating resting lip position and symmetry

    Klimach, Stefan (2020-10)
    The angle between the commisure-commisure and the endocantus-commisure lines (CCE angle) is approximately equal to the contralateral angle. A computerised technique for assessing the gross symmetry and position of the lips by comparing left- and right-sided CCE angles was developed. This study established (1) the repeatability of computerized CCE angle measurement; (2) mean CCE angle magnitudes in healthy controls and suggest a "normal" reference range. Two authors independently measured CCE angles on frontal repose facial photographs of 104 volunteers on three separate occasions using facial analysis software. Twenty right-sided hemifaces with the largest CCE differences were then mirrored in the sagittal plane to produce symmetrical photographs. Measurements were repeated by a single author. There was high agreement of angle measurements between authors (inter-rater ICC of 0.89) and within each authors' repeated measurements (intra-raters ICCs of 0.85 and 0.77). Differences in the mean right and left-sided CCE angles in controls were small but statistically significant (82.4° and 81.7°, respectively, mean absolute difference 2.2 ± 1.7°, p < 0.05). The mean absolute differences had a skewed distribution. The 2.5th and 97.5th centiles were therefore set as limits of the range of asymmetries which could be regarded as "normal" (95% reference range, or 95% reference interval): 0.2°-6.2°. Measurements of opposing CCE angles in symmetrical mirrored images were similar (82.4° versus 82.3°, mean absolute difference 0.6°, p > 0.05). In conclusion, computerised CCE angle measurement is highly repeatable and may be a useful tool with which to assess gross resting lip symmetry.
  • Covid-19: face masks can be devastating for people with hearing loss but alternatives are available.

    Poostchi, Ali; Kuet, Mong-Loon; Richardson, PS; Patel, MK (2020-08)
    Chodosh and colleagues and Grote and Izagaren highlight an important matter but overlook the use of face shields, hoods, and other clear barriers that decrease disease transmission, facilitate lip reading, and reduce muffling. Face shields are also easier to manufacture, clean, and reuse. They protect the user’s eyes and are more acceptable than masks in a paediatric setting. The suggestion to adopt masks with clear windows is premature given the lack of evidence that they are more effective than face shields. Using a laser particle counter, we found that face masks and Perspex barriers had similar efficacy in reducing airborne and droplet transmission across a slit lamp. When a higher level of protection is required, clear ventilated hoods can be used and these have been successfully trialled with a view to widespread adoption. The authors have identified a salient problem to which cost effective and viable solutions are available and can be readily applied.
  • Novel technique using surgical scrub sponges to protect the nose and face during prone ventilation for coronavirus disease 2019.

    Stubington, TJ; Mansuri, MS (2020-07)
    Background: Coronavirus disease 2019 is an international pandemic. One of the features is acute respiratory distress syndrome, and proning has been identified as beneficial for a subset of patients. However, proning is associated with pressure-related side effects, including injury to the nose and face. Method: This paper describes a pressure-relieving technique using surgical scrub sponges. This technique was derived based on previous methods used in patients following rhinectomy. Conclusion: The increased use of prone ventilation has resulted in a number of referrals to the ENT team with concerns regarding nasal pressure damage. The described technique, which is straightforward and uses readily available materials, has proven effective in relieving pressure in a small number of patients.
  • Efficacy of slit lamp breath shields

    Poostchi, Ali; Kuet, Mong-Loon; Pegg, Kate; Richardson, PS; Patel, MK (2020-05)
    The use of enlarged breath shields has been suggested as part of a wide range of infection control measures implemented during the COVID-19 pandemic. Breath shields have long been a standard feature of slit lamps and act as a physical barrier between the examiner and subject but there is an absence of evidence on their effectiveness in reducing droplet transmission and respiratory infections.
  • Tracheotomy in COVID-19 patients: Optimizing patient selection and identifying prognostic indicators.

    Stubington, TJ; Mallick, AS; Reddy, C; Mansuri, MS (2020-05)
    BACKGROUND: Tracheotomy, through its ability to wean patients off ventilation, can shorten ICU length of stay and in doing so increase ICU bed capacity, crucial for saving lives during the COVID-19 pandemic. To date, there is a paucity of patient selection criteria and prognosticators to facilitate decision making and enhance precious ICU capacity. METHODS: Prospective study of COVID-19 patients undergoing tracheotomy (n = 12) over a 4-week period (March-April 2020). Association between preoperative and postoperative ventilation requirements and outcomes (ICU stay, time to decannulation, and death) were examined. RESULTS: Patients who sustained FiO2  ≤ 50% and PEEP ≤ 8 cm H2 O in the 24 hours pretracheotomy exhibited a favorable outcome. Those whose requirements remained below these thresholds post-tracheotomy could be safely stepped down after 48 hours. CONCLUSION: Sustained FiO2  ≤ 50% and PEEP ≤ 8 cm H2 O in the 48 hours post-tracheotomy are strong predictive factors for a good outcome, raising the potential for these patients to be stepped down early, thus increasing ICU capacity.
  • Nationwide randomised trial evaluating elective neck dissection for early stage oral cancer (SEND study) with meta-analysis and concurrent real-world cohort.

    Jones, Keith (2019-11)
    BACKGROUND: Guidelines remain unclear over whether patients with early stage oral cancer without overt neck disease benefit from upfront elective neck dissection (END), particularly those with the smallest tumours. METHODS: We conducted a randomised trial of patients with stage T1/T2 N0 disease, who had their mouth tumour resected either with or without END. Data were also collected from a concurrent cohort of patients who had their preferred surgery. Endpoints included overall survival (OS) and disease-free survival (DFS). We conducted a meta-analysis of all six randomised trials. RESULTS: Two hundred fifty randomised and 346 observational cohort patients were studied (27 hospitals). Occult neck disease was found in 19.1% (T1) and 34.7% (T2) patients respectively. Five-year intention-to-treat hazard ratios (HR) were: OS HR = 0.71 (p = 0.18), and DFS HR = 0.66 (p = 0.04). Corresponding per-protocol results were: OS HR = 0.59 (p = 0.054), and DFS HR = 0.56 (p = 0.007). END was effective for small tumours. END patients experienced more facial/neck nerve damage; QoL was largely unaffected. The observational cohort supported the randomised findings. The meta-analysis produced HR OS 0.64 and DFS 0.54 (p < 0.001). CONCLUSION: SEND and the cumulative evidence show that within a generalizable setting oral cancer patients who have an upfront END have a lower risk of death/recurrence, even with small tumours. CLINICAL TRIAL REGISTRATION: NIHR UK Clinical Research Network database ID number: UKCRN 2069 (registered on 17/02/2006), ISCRTN number: 65018995, Identifier: NCT00571883.
  • Follow up imaging of oral, oropharyngeal and hypopharyngeal cancer patients: Comparison of PET-CT and MRI post treatment.

    Breik, Omar; Kumar, A; Birchall, James; Mortimore, Sean; Laugharne, David; Jones, Keith (2020-06)
    There is currently no consensus as to the ideal timing, frequency and modality of imaging for follow up of head and neck cancer patients. The aim of this study was to analyze the diagnostic accuracy of PET-CT versus MRI, and imaging at 3 versus 6 months for follow up of head and neck cancer patients treated with curative intent with no clinical signs of treatment failure.MATERIALS AND METHODS: A retrospective study was performed for all head and neck cancers treated with curative intent at the Royal Derby Hospital. Data collected included demographic information, site of primary cancer, staging, treatment provided, type of follow up imaging performed and results of follow up imaging. Inclusion in the study was for oral, oropharyngeal and hypopharyngeal cancers treated with curative intent, asymptomatic patients, those who have had follow up imaging within 6 months of treatment, and those followed up for at least 2.5 years since treatment. RESULTS: A total of 140 patients were included in the study. 25% of patients had evidence of recurrent/metastatic disease on imaging, 60% of which were identified within 6 months post treatment. The majority (60%) of failures were due to distant metastases. The sensitivity and specificity of both MRI and PET-CT was higher at 6 months post-treatment compared to 3 months post-treatment. Overall the sensitivity and specificity for PET-CT and MRI within 3-6 months post treatment were 94.7% and 83.5% and 60% and 85.7% respectively for identifying treatment failure. CONCLUSION: Follow up Imaging at 6 months post treatment is more likely to accurately identify treatment failures with fewer false positives than imaging at 3 months. PET-CT is preferable to MRI for identifying post treatment locoregional and distant treatment failure.
  • Chondroid tenosynovial giant cell tumour: a rarity in the temporomandibular joint.

    Thomas, Mathew (2019-04)
    Tenosynovial giant cell tumours of the temporomandibular joint (TMJ) are extremely rare, particularly the subset of chondroid tumours. They can be broadly divided into localised and diffuse types, of which we know of only 116 reported cases in the TMJ. Rarer still are the subset of chondroid tenosynovial giant cell tumours, of which we know of only 30 cases that have affected the TMJ. We present a case that involved the TMJ, and include a discussion of its management.

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