Objective Surgery is the standard treatment for most tumors in the prestyloid parapharyngeal space (PPS) but it can be a challenging procedure because of the anatomical complexity of the area. Prestyloid surgery can be performed with various lateral approaches or with a medial approach using transoral robotic surgery (TORS) – either alone or in combination with a transcervical incision. Here we report our experience in the surgical management of prestyloid PPS tumors. Design We have retrospectively compared results with lateral or medial approaches to surgical resection of prestyloid tumors. Participants Between 2015 and 2020, 28 patients with prestyloid PPS tumors underwent surgery at our center: 14 with lateral approaches, including transcervical, transcervical-parotid, and transcervical-mandibular, 12 with TORS, and two with TORS plus a transcervical incision. Main outcome measures Surgical time, post-surgical complications, length of hospital stay, need for feeding tube, and relapse-free survival in the two patient groups. Results Pleomorphic adenoma was the most frequent tumor and 60.7% of the tumors were benign. Tumor volume and maximum length were similar in patients undergoing surgery with a lateral approach and in those undergoing TORS. Intraoperative image guidance and ultrasound were used in 33% of TORS. TORS was associated with less surgical time, fewer complications, and shorter hospital stays. Survival rates were similar in the two groups. Conclusion The medial approach by TORS offers better surgical results in prestyloid tumors than the open lateral approach and can be refined by intraoperative guidance.

Introduction: The creation of the “open cavity” to clear cholesteatoma results in significant morbidity in over a third of patients. Various biological and non-biological materials have been used to reduce or obliterated these mastoid cavities. Materials and Methods: This study reports the technique and results of using hydroxyapatite granules with a pericranial flap to obliterate troublesome cavities. Results: 50 mastoid obliterations were performed in 48 patients. 94% no longer required water precautions 2 months post-operatively and may use conventional hearing aids. Discussion: This technique improves patients’ quality of life and can enable discharge of patients previously reliant on ENT services.

BACKGROUND AND PURPOSE Anaplastic thyroid carcinoma (ATC) is the least common but most lethal of thyroid cancers despite various therapeutic options with limited efficacy. Some prognostic factors were identified in patients with ATC and a few patients survive for a relatively long time after modern intensive treatment. In order to help therapeutic decision-making, the purpose of this study was to develop a new prognostic score providing survival estimates in patients with ATC. METHODS Based on a multivariate analysis of 149 retrospectively analyzed patients diagnosed with ATC from 1968 to 2017 at a referral center, a propensity score was developed. A model was generated providing survival probability at 6 months and median overall survival estimates. RESULTS The median survival was 96 days. The overall survival rate was 35% at 6 months, 20% at 1 year and 13% at 2 years. Most of the patients (86%) died within 17 month, 17% died within the first month, 35% lived for 1–6 months and 47 % of the patients lived longer than 6 months after the initial consultation. The stepwise Cox regression revealed that the most appropriate death prediction model included metastatic spread, tumor size and age class as explanatory variables. This model made it possible to define three categories of patients with survival profiles which seems different: patients with no pejorative prognostic factor which had a survival probability at 6 months = 0,84 (95% CI: 0,69-1), patients with one or two pejoratives prognostics factors which have a survival probability at 6 months = 0,32 (95% CI: 0,22-0,46), and those with three pejoratives prognostics factors which had a survival probability at 6 months = 0,11 (95% CI: 0,018 - 0,71). CONCLUSION Distant metastasis, age and primary tumor size are strong independent factors that affect prognosis in patients with ATC. Using these significant pretreatment factors, we developed a score to predict survival in these poor prognosis patients in order to provide easy-to-use tools for clinical practice. External validation in an additional dataset is needed for further outlooks.

Objective: To investigate temporal bone findings in COVID-19 Design: Retrospective study Settings: Using the database of our tertiary pandemic hospital, patients with COVID-19 infection with a positive PCR test and temporal bone tomography imaging were evaluated. Participants: 42 PCR positive COVID-19 patients with temporal bone imaging. Main outcome measures: A grading system was created to evaluate effusion in the middle ear and mastoid air cells. Also any specific sign in temporal bone imaging. Results: Patients were divided into two groups according to their chest CT findings. Group 1 had specific chest CT findings and included 26 patients, group 2 had no findings in chest CT and included 16 patients. No obvious temporal bone involvement was observed in any of the patients. Temporal bone imaging findings were compared according to a grading system and there was no difference between the groups (p=0,50). Conclusion: The SARS-CoV-2 does not affect the temporal bone. There was no sign of effusion in mastoid air cells or the middle ear or any specific sign in the temporal bone in our study group.

Objective The objective of this multicentre retrospective case review was to assess the natural clinical course, efficacy and safety of Mastoid Obliteration with S53P4 Bioactive Glass (bioactive glass). Study Design Retrospective case note review Setting Regional Tertiary Referral centre and District General Hospital Participants Patients undergoing mastoid cavity obliteration as part of primary or secondary procedure with bioactive Glass between 2012 – 2018. Outcome measures were assessed from a prospectively collated database and case note review. Main Outcome Measures Primary outcomes were the common morbidities of a mastoid cavity; dry or discharging ear (Merchant’s scale), vertigo in cold air and a water tight middle ear. Patients were also assessed for audiological outcomes and recidivism. Results 90 patients were included. During the follow up period, (mean = 22 months; range = 6 - 59 months) cholesteatoma recidivism was observed in 2% of ears, (2 patients). An acceptably dry (Merchant Grade 0 – 1) ear was achieved in 91% of all ears (95% Primary Cases, 80% Secondary Cases). Delayed healing of the graft in the external ear canal retaining the S53P4BAG Bioactive Glass (BonAlive,(BonAlive Biomaterials Ltd., Turku, Finland)) within the mastoid occurred in 13% (12 ears). However, in all cases conservative management resulted in complete healing. Conclusions Bioactive glass provides a safe and effective means of mastoid obliteration. Complications including overlay graft failure and slow epithelisation resulting in prolonged postoperative discharge (up to 2 months) and dehiscence into the external ear canal do not preclude full recovery and may be successfully managed conservatively.

Abstract: Unlike most head and neck cancers, the presence of distant metastasis (DM) does not preclude curative intent treatment and surgical interventions are common in metastatic disease. DM has an adverse impact on survival and lends considerable morbidity to the patient. This research attempts to study the demographics, patterns of metastasis, and surgical interventions in this rare subgroup of patients with differentiated thyroid cancer (DTC). Materials and methods: Thirty two patients of DTC with radiologically or histopathologically or cytopathologically confirmed DM who underwent surgery at a tertiary care centre from August 2011 to December 2018 formed the study cohort of this retrospective study. Results: The study population comprised 59% females and had a median age of 55 (19- 79) years. Thorax was the most common site of metastasis, documented in 56% of patients, while 53% patients had bone metastases. Multiple DM were noted in 8 patients. All patients underwent total thyroidectomy or completion thyroidectomy with or without neck dissection. Surgery for metastatic sites was possible in 14 patients (44%) with debulking and spine fixation being the commonest surgical intervention for metastasis. Thyroidectomy, with or without neck dissection followed by radioactive iodine (RAI) ablation was used as the primary modality to treat DM in patients who did not undergo specific surgical treatment for distant metastases. The median dose of RAI received by patients was 400 (25 – 749) mCi, in one to four sessions (median- 2 sessions). Three patients received conventional chemotherapy, while four received Sorafenib. Conclusion: Metastasectomy in differentiated thyroid cancer with distant metastases is feasible in selected patients and surgical interventions are most commonly performed on the spine to prevent neurological complications. RAI ablation is universally administered in this subset of patients and in very high doses, often distributed in multiple sessions. The role of chemotherapy and tyrosine kinase inhibitor is still restricted to palliative settings and cost constraints remain a detriment to more widespread use.

Abstract: Objectives: Sudden deafness, also known as sudden sensorineural hearing loss (SSNHL), has numbers hypotheses about its etiology. One of them believes that changes in sex hormone levels may increase the risk of thrombosis and block the cochlear microcirculation, leading to the occurrence of SSNHL. Design: Women in different periods of physiological cycles, the levels of sex hormones in their body will change significantly, which had correlated to SSNHL. Participants: This study collected 435 female subjects who were admitted to the otolaryngology clinic of our hospital from July 2017 to November 2019. Setting: The participants were grouped by the menstrual cycle. Main outcome measures: The pure tone audiometry test results of the subjects were recorded and the differences among the groups were be analyzed. Results: 1. There was a significant difference in the average hearing threshold of subjects in different periods (F(3, 774)=8.773, P<0.001), and the average hearing threshold in follicular period (35.44 dBHL) was significantly lower than that in menstrual period (51.09 dBHL, P<0.001), luteal period (42.69 dBHL, P=0.036) and menopause (47.39 dBHL, P<0.001); 2. There was a correlation between the subjects at different periods and the severity of SSNHL (2 = 38.587, P <0.001), and the SSNHL severity was the slightest in the follicular period according to the mean rank value. 3. The analysis of SSNHL typing of subjects at different periods were variously (2 = 38.568, P < 0.001). Conclusions: The results of this study can explain the effect of sex hormone on SSNHL to a certain extent, and we will further explore the relationship between sex hormone levels and SSNHL, in order to provide more support for the diagnosis and treatment of SSNHL.

Objective:Scapular and parascapular free tissue transfer (SFTT) is a well described reconstructive option for the head and neck. Majority of reported outcomes are of reconstruction of oromandibular and midface defects. The aim was to describe one institution’s experience with SFTT for reconstruction of PE defects. Design: Retrospective review of patients undergoing SFTT for head and neck defects between 2009 and 2014 at a tertiary medical center. The cohort included patients undergoing reconstruction of PE defects with at least 6 months follow up. Setting:Tertiary medical center Participants:Patients undergoing SFTT for PE defects. Seventeen patients (13 male and 4 female) met inclusion criteria. Main outcomes and Measures: Surgical outcomes, speech, voice outcomes, swallowing outcomes, enteral feeding and tracheoesophageal puncture usage. Results:Seventeen patients met criteria – 4 female, average age at time of surgery 64.5 (SD 9.1). Thirteen patients were Caucasian and remaining four African American. Two of 17 patients developed pharyngocutaneous fistulas (PCF) as inpatients. There was one major medical complication (pulmonary embolism) and 7 minor complications. Mean hospital length of stay was 15.7 days (SD 8.2). In post-operative setting, only one patient remained PEG-dependent, 11 patients supplemented oral intake with PEG feeds and 5 patients took nutrition solely by mouth. Four patients utilized written communication exclusively, 6 patients pursued TEP placement and 7 utilized electrolarynx. Conclusion:The SFTT is a viable option for hypopharyngeal reconstruction. All SFTT remained viable for the duration of our review. Post-operative PCF rate were comparable to that reported after laryngectomy.

Objectives To investigate the ability of a physical barrier to reduce aerosol particle spread during a simulated aerosol generating procedure. Design A simulated aerosol generating procedure. Setting Standard hospital ward, St George’s Hospital, London. Participant One volunteer participant - they were healthy, asymptomatic, and a non-smoker. Main Outcome Measures 1. To compare the effect of the shield on particle frequency (according to particle size) at different locations. 2. To evaluate the length of time that particles remained within the shield, both with and without an aspiration unit. Results Clinical investigations using the shield demonstrated a twelve-fold decrease in the number of particles detected at the position of the operating surgeon when the shield was used (particle size 0.3μm; with shield 8662 versus 103800 without shield). Over a 7-minute period, there was a reduction in the number of particles. At 7 minutes, the total number of particles (size 0.3μm) measured within the shield was comparable to the particle frequency at ambient levels (8752 within the shield compared with 8592 within the ambient environment). The aspiration unit reduced the number of particles detected within the shield over time. An average of 9649 particles (similar to ambient level) sized 0.3μm were measured under the shield after 2 minutes when the aspiration unit was used. Conclusion The clinical simulation illustrates a significant decrease in the number of particles detected at varying locations when the shield is used. The shield, used with appropriate PPE, could help to minimise exposure to aerosol-generated particles such as during tracheostomies on patients with COVID-19.

Objectives: Second primary esophageal squamous cell neoplasms (ESCNs) are common in hypopharyngeal squamous cell carcinoma (HPSCC) patients and are associated with poor prognoses. The effectiveness of image-enhanced endoscopy (IEE) has not been well established. Design: Retrospective study with patients proven HPSCC between April 2016 and April 2018 receiving ESCNs screening via white-light imaging, narrow-band imaging, and Lugol chromoendoscopy. Setting: Data were collected from an electronic medical record at a single medical center in Taiwan. Participants: The study population included a total number of 130 patients with HPSCC receiving ESCNs screening via white-light imaging, narrow-band imaging, and Lugol chromoendoscopy Main Outcome Measures: Clinical data, incidence, and stage of second primary malignancy in HPSCC patients were obtained for statistical comparison. Results: Of 99 eligible patients, second primary ESCNs prevalence was 31%. Of the 69 patients assigned to the follow-up group, 23 with positive findings showed significantly increased previous histories of second primary malignancies in the upper aerodigestive tract. Among them, patients without symptoms at the time of IEE screening showed less advanced T stages and higher percentages of receiving minimally invasive therapy. Conclusions: Routine IEE screening is strongly recommended for HPSCC patients and can improve the detection rate of ESCNs and facilitate early-stage identification.

Introduction: This prospective randomized case-control study was performed to compare the surgical outcomes of our swing-door overlay tympanoplasty with or without absorbable gelatine sponge (AGS, gelfoam) packing in the middle ear cavity, according to the surgical procedure. Subjects and Methods: Fifty-seven patients who underwent swing-door overlay tympanoplasty by a single surgeon were enrolled in the study. The data of 30 patients of the gelfoam-packing group (GPG) and 27 patients of the non-gelfoam-packing group (NGPG) were prospectively collected and compared. Results: Closure of the tympanic membrane was found to be successful in all patients at postoperative 3 months evaluation. NGPG showed a statistically better healing process compared to GPG; earlier epithelialization and less fascia edema in NGPG than in GPG (P<0.05). The air-bone gap (ABG) measured at postoperative 1 and 2 months was smaller in NGPG than GPG, although there were no statistical differences. Conclusion: Swing-door overlay tympanoplasty showed good surgical outcomes in terms of graft uptake rate regardless of AGS packing. However, this study revealed earlier healing process and faster recovery of ABG in NGPG, thereby indicating that the gelfoam in the middle ear may interfere with both hearing recovery and the healing process of neodrum. Non-gelfoam packing in the middle ear cavity appeared to be superior to gelfoam packing in swing-door overlay tympanoplasty.

Key Points: • We describe a novel procedure, Endopharyngeal Ultrasound (EPhUS) and EPhUS-guided FNA • EPhUS requires an operator and an assistant, can be performed transnasal or transoral, and utilizes a Endoscopic Ultrasonography Bronchoscope • EPhUS is a safe and effective method for biopsy of deep space neck masses inaccessible to transcutaneous FNA

Objectives: To investigate how surgeons interpret the ATA 2015 and BTA 2014 guidelines for low risk well differentiated thyroid cancers (LRDTCs) and how they impact patient experiences across the UK. Design: Three nationally disseminated anonymised questionnaires. Setting: A nationwide snapshot of LRDTC management. Participants: Thyroid surgeons and their respective thyroid cancer multidisciplinary teams (MDTs) and thyroid cancer patients. Main outcome measures: The outcomes of interest were how surgeons/MDTs are managing LRDTCs and patient perspectives on ‘shared-decision-making’ and their ideal surgical management for LRDTCs. Results: 74 surgeons responded. 88% utilised BTA guidelines to assess recurrence risk. Tumour size, histology, stage T3b and central nodal involvement were important for >85%, but age (>45 years) only for 50%. In T1 (2cm), Thy5 solitary nodule, 58% supported hemi-thyroidectomy (HT), with 33% for total thyroidectomy (TT). In T2 (3cm) PTC, 54% opted for TT, with 24% favouring HT. Over 90% recommended TT for any incidentally excised microscopically positive lymph nodes. In T1a(m) multifocal micro-PTC, 63% suggested HT, but with contralateral benign nodules, 66% supported TT. 40% of patients felt ‘pros and cons’ of different managements were not fully explained. 47% felt they didn’t have significant input in their management, with 53% feeling final management was clinician’s choice. 60% preferred TT, with 80% wanting to ensure there was no cancer left and avoid recurrence. 20% preferred HT, with 46% wishing to avoid lifelong thyroxine. Conclusions: There is variation in risk assessment and management of LRDTCs nationally, with contrasting views of optimum treatment between patients and clinicians. These variations in practice are affecting patient experiences nationally.

An Unusual Clustered Series of Foreign Body Reactions to Oxidised Regenerated Cellulose in Head and Neck surgery - A Case series of four post-operative patients