Introduction- Necrotising fasciitis is a rapidly progressive disease with high morbidity and mortality. Head and neck necrotising fasciitis is a rare clinical entity but may be admitted under an ENT specialist team. An understanding of the presenting features and the need for prompt management is imperative. Case Series-We present a series of patients admitted to hospitals across Greater Glasgow, United Kingdom under Otoloryngology and Maxillofacial surgical teams with head and neck necrotising fasciitis over an 8-year time period. Discussion-8 patients were identified in this case series. We highlight the clinical features, patient demographics and operative courses of this patient group. We highlight the need to recognise peri-ocular necrotising fasciitis, especially in the paediatric population which has not been discussed in the otolaryngology literature previously.

Key Points 1. This study reports clinical outcome data on 76 patients with platinum-resistant recurrent or metastatic head and neck squamous carcinoma treated with nivolumab, making it the largest published single centre case series of its kind. 2. Radiotherapy was administered alongside systemic therapy with nivolumab, defined as radiotherapy within 8 weeks of prior systemic therapy, in 16 of 76 patients (21%). 3. Nivolumab was continued following radiotherapy completion due to ongoing clinical benefit from the drug in 9 of 16 patients (56%). 4. Durable complete response following radio-immunotherapy was seen in 2 of the 9 patients (22%) who continued nivolumab subsequent to radiotherapy. 5. Indications for radiotherapy included symptom control (3 of 9), oligoprogression (5 of 9) and incomplete response (1 of 9).

Background The incidence of thyroid cancer is increasing globally due to the increase in detection of subclinical, low volume papillary thyroid microcarcinomas (PTMC) (<1cm). Several international groups have recommended an active surveillance approach for this low-risk disease. In contrast to many other countries, the UK’s approach to thyroid nodules is to avoid detection of incidental lesions where appropriate. Objective This study aims to establish the proportion of patients with thyroid cancer in the UK that would benefit from active surveillance. Design, participants, and outcome measures: Individuals with PTMC in NHS Lothian from 2009-2020 were reviewed from a local thyroid cancer database. The mode of detection of PTMC and proportion of patients who might benefit from active surveillance were established. Results From 651 individuals with differentiated thyroid cancer managed over 12-year period, 185 individuals with PTMC were identified (28.4%). The majority of PTMC 151/185 (81.6%) were either diagnosed post-operatively following thyroidectomy for benign disease or with nodal disease. Only 24 individuals with PTMC were identified following palpable thyroid nodule, incidental finding on imaging and surveillance screening. Therefore, when the indication for surgery was considered, only 24/651 (3.7%) patients were identified pre-operatively and would therefore be realistic candidates for active surveillance. Conclusion Less than 4% of patients with thyroid cancer in the UK would be appropriate for active surveillance. Rather than developing programs to deal with this minority of patients, focus should be maintained on minimizing detection of these low-risk cases.

Introduction: A large proportion of patients with infectious mononucleosis (IM) have abnormal liver function tests (LFT) at presentation. There is no guideline regarding the management and follow-up of these patients. Some patients also have abdominal ultrasound due to deranged LFT, the need for this practice is unclear. The aim of this systematic review was to evaluate the evidence base on LFT assessment in IM, time to resolution of derangement, and the role of abdominal ultrasound. Methods: A systematic search of PubMed, EMBASE and the Cochrane library was done. Two authors independently screened records for eligibility using pre-defined criteria. We included both adult and paediatric populations. Quality assessment of included studies was done. Results: A total of 3924 patients were included from 32 studies. A combination of typical clinical features, heterophile antibodies and EBV-specific antibodies were used to ascertain diagnosis. The following proportion of patients had abnormal LFTs: AST (57%); ALT (62%); ALP (65%); Bilirubin (16%); GGT (41%). Reported median (i.q.r.) time to resolution of LFT was 8 (6–12) weeks. Maximum time to resolution was >6 months. Clinical hepatomegaly and splenomegaly were found in 35% and 44% of patients respectively. Enlarged liver and spleen on ultrasound were seen in 16/29 (55%) and 38/38 (100%) of patients respectively. There were no reports of decompensated liver disease. Conclusion: Derangement in LFTs can persist over six months from initial presentation in IM. However, this is self-limiting. The evidence suggests serial liver function assessments and ultrasound abdomen are not required in immunocompetent patients with subclinical derangement in LFTs.

Abstract Background This study aimed to evaluate whether changes in practice and patient behaviour due to the covid-19 pandemic impacted the presentation, management, and outcomes of patients with deep neck space infections (DNSI). Design Retrospective cohort study including all adults presenting to the otolaryngology department at a tertiary UK centre with a DNSI during the first 12 months of the covid-19 pandemic (n = 27), and those from the previous 12 month period (n = 26). Patients with peritonsillar abscess which did not involve deep neck spaces radiologically were excluded. Results The covid-19 pandemic cohort tended to present later after onset of symptoms (5.96 days vs 3.25 days, p = 0.0277), have abscess formation rather than inflammation only (77.8% vs 34.6%, p < 0.01), and develop complications (33.3% vs 7.7%, p = 0.0394). Not reaching statistical significance, the covid-19 pandemic cohort also had larger volume abscess (25.18cm3 vs 14.5cm3, p = 0.291), longer hospital stay (14.48 days vs 6.35 days, p = 0.114), and longer intensive care stay (7.88 days vs 1.78 days, p = 0.0992). Non-significant changes were noted in management, with the covid-19 pandemic cohort being seven times more likely to undergo tracheostomy (25.9% vs 3.8%, p = 0.0504), and more likely to undergo transcervical drainage (37% vs 19.2%, p = 0.224) and hot tonsillectomy (11.1% vs 0%, p = 0.236). Conclusion This study demonstrates the covid-19 pandemic led to delayed presentation and more severe infection, requiring more radical management in patients with DNSI.

Background and Objectives Granular myringitis is troublesome for otologist because uncertain etiology and often been overlooked due to vague clinical symptoms and signs. The ideal treatment is elusive. Our study was to investigate the clinical characteristics of granular myringitis and analyzing the effect of the two different strategies, including carbon dioxide laser (CO2 laser) and caustic agent cauterization to manage granular myringitis. Study Design: Retrospective review Subjects and Methods One hundred and thirty patients with granular myringitis receiving treatment at a single medical center from July 2009 to January 2018 were enrolled. We retrospectively reviewed the charts and surgical records. The main two different strategies to manage focal refractory granular myringitis were analyzed, including carbon dioxide laser and caustic solution. We also recorded the clinical course and determine which strategy is better. Results One hundred and thirty patients with granular myringitis were enrolled. 47/130 (36.1%) had previous otologic procedures. Frequent ototrrhea is the most common symptom (66.1%). Posterior-inferior quadrant is the most common site of involvement (58%). The successful rate of CO2 laser, caustic agent were 94.9% and 79.2%. The recurrence rate was comparable between CO2 laser and caustic agent. No major complication was found in either individual group. Conclusion: Otologic procedure may be a predisposing factor of focal chronic myringitis. Ear drops had poor efficacy compared to other treatments. It can be apply only on minor and fresh symptom cases. In this study, we suggest CO2 laser can be the first line treatment, especially for the troublesome or refractory GM cases, which had the higher successful rate and less complication comparing to caustic agent cauterization.

Introduction Silver nitrate is commonly used within otolaryngology to treat granulation tissue in severe otitis externa. It appears radio-opaque on CT (computed tomography) imaging and therefore can mimic bony fragments and foreign bodies. This is particularly cumbersome when the phenomena correlates to the clinical complaint. Discussion We report two cases of 73-year-old and 75-year-old males who presented with chronic otalgia and discharge. Granulation tissue in the external auditory canal was identified and chemically cauterised with silver nitrate. Subsequent CT petrous bones demonstrated an unidentified foreign body in the canal with extensive soft tissue swelling giving an impression of a wick in situ and “minor bony erosion in the left external acoustic canal” respectively. An additional CT of a 57-year-old female who had been treated with silver nitrate for granulomatous tissue reported “multiple highly radiopaque foci in the external auditory canal, suggestive of foreign body”. Though relatively unknown, this phenomenon has been reported in literature. However, there are few reports of silver nitrate artefacts in CT images of the head no cases in the context of otitis externa. Our patients avoided further imaging or surgery following clarification with the radiologists and symptomatic improvement with long-term intravenous antibiotics. Conclusion Given the prevalence of CT imaging and cauterization in otolaryngology, we recommend contemporaneously documenting the use of silver nitrate and highlighting this on request forms to avoid alarming erroneous reports, unnecessary investigation and surgical procedures. We also recommend, where clinically acceptable, to use silver nitrate prior to imaging.

Abstract Objectives: To assess the impact of risk factors on the disease control among CRS patients, following 1 year of functional endoscopic sinus surgery (FESS), and combining the risk factors to formulate a convenient, visualized prediction model. Design: A retrospective and nonconcurrent cohort study Setting and Participants: A total of 325 patients with Chronic rhinosinusitis (CRS) from June 2018 to July 2020 at the First Affiliated Hospital, the Third Affiliated Hospital, and the Seventh Affiliated Hospital of Sun Yat-sen University. Main Outcomes Measures: Outcomes were time to event measures: the disease control of CRS after surgery 1 year. The presence of nasal polyps, smoking habits, allergic rhinitis (AR), the ratio of tissue eosinophil (TER), and peripheral blood eosinophil count (PBEC)and asthma was assessed. The logistic regression models were used to conduct multivariate and univariate analyses. Asthma, TER, AR, PBEC were also included in the nomogram. The calibration curve and AUC (Area Under Curve) were used to evaluate the forecast performance of the model. Results: In univariate analyses, most of the covariates had significant associations with the endpoints, except for age, gender, and smoking. The nomogram showed the highest accuracy with an AUC of 0.760 (95% CI, 0.688-0.830) in the training cohort. Conclusions: In this cohort study that included the asthma, AR, TER, PBEC had significantly affected the disease control of CRS after surgery. The model provided relatively accurate prediction in the disease control of CRS after FESS and served as a visualized reference for daily diagnosis and treatment.

Introduction: Necrotising otitis externa (NOE) is a serious, progressive infection of the external ear canal. If untreated, it can invade into temporal bone, skull-base and surrounding tissue resulting in cranial nerve palsies, neurological infections and death. Patients present with unremitting, severe otalgia, otorrhoea and oedematous ear canals containing granulation. Surgery has a limited role; the mainstay of treatment involves a long course of intravenous antibiotics. Currently, there is no data on the complications of antibiotic treatment for NOE. This project aims to provide evidence on the nature/frequency of severe treatment-related complications requiring a change in antibiotic regime. Methods: A retrospective 5-year cohort analysis was performed on 64 patients who were treated for confirmed NOE with intravenous antibiotic therapy. Clinical notes, blood results and antibiotic prescriptions were documented and analysed. Results: Average duration of treatment was 11 weeks (range=38 weeks). There was an average of 2.1 antibiotic regimes per patient with 10 cases requiring inpatient admission due to treatment-related complications. 63% of treatment changes were directly related to adverse effects of intravenous antibiotics. Drug allergy/intolerance (n=18) and clinical deterioration i.e. Lack of symptomatic improvement and/or worsening inflammatory markers (n=18), were the most common reasons for antibiotic change. Neutropenia, deranged liver function tests and acute kidney injury were also recognised adverse effects of treatment. Conclusion: This study provides the first evidence on the notable frequency of antibiotic-related complications in NOE patients. Larger, multicentre studies are required in the future to validate our findings and will better inform both clinicians and patients of the risks of treatment.

- We retrospectively evaluated a large series of patients (n: 15) underwent a modified transmanubrial approach for wide mediastinal resection in case of malignance thyroid mass - In fourteen cases, also with thyroid tumor involving the middle line. A bilateral mTMA was necessary to perform a cava vein resection. - No major postoperative and cutaneous/sternum complications were detected. - mTMA allows an optimal exposure of the upper thoracic inlet achieving a complete radical oncological resection of the tumor/lymph-node and a safety vascular/tracheal control. - As a limitation, the modified mTMA is anatomically more demanding and not familiar for most surgeons in comparison to sternotomy

Objectives: We aimed to characterise the use of tracheostomy procedures for all COVID-19 critical care patients in England and to understand how patient factors and timing of tracheostomy affected outcomes. Design: A retrospective observational study using exploratory analysis of hospital administrative data. Setting: All 500 National Health Service hospitals in England. Participants: All hospitalised COVID-19 patients aged ≥ 18 years in England between March 1st and October 31st, 2020 were included. Main outcomes and measures: This was a retrospective exploratory analysis using the Hospital Episode Statistics administrative dataset. Multilevel modelling was used to explore the relationship between demographic factors, comorbidity and use of tracheostomy and the association between tracheostomy use, tracheostomy timing and the outcomes. Results: In total, 2,200 hospitalised COVID-19 patients had a tracheostomy. Tracheostomy utilisation varied substantially across the study period, peaking in April-June 2020. In multivariable modelling, for those admitted to critical care, tracheostomy was most common in those aged 40-79 years, in males and in people of Black and Asian ethnic groups and those with a history of cerebrovascular disease. In critical care patients, tracheostomy was associated with lower odds of mortality (OR: 0.514 (95% CI 0.443 to 0.596), but greater length of stay (OR: 41.143 (95% CI 30.979 to 54.642). In patients that survived, earlier timing of tracheostomy (≤ 14 days post admission to critical care) was significantly associated with shorter length of stay. Conclusions: Tracheostomy is safe and advantageous for critical care COVID-19 patients. Early tracheostomy may be associated with better outcomes, such as shorter length of stay, compared to late tracheostomy.

Objectives: Rhinitis affects up to 40% of the population worldwide and can significantly reduce quality of life. Some patients remain symptomatic despite maximal medical therapy. In refractory cases, posterior nasal neurectomy (PNN - the division of the intranasal nerve branches containing postganglionic parasympathetic fibres) is postulated to reduce symptom burden. The objectives of this paper were to review the literature to establish whether the procedure is effective and safe in the management of allergic and non-allergic rhinitis. Design: A systematic review of Pubmed, EMBASE and MEDLINE was undertaken. Studies were excluded if not available in English or undertaken in non-human subjects. Participants: Seventeen articles satisfied the inclusion criteria studying in total 2029 patients. Sample size ranged from 8-1056. Main Outcome Measures: Patient-reported objective and subjective outcomes and post-operative complications were reviewed Results: There were two randomised controlled trials, two case control studies, and the remaining thirteen were case series using both objective and subjective outcome measures. All but one study found improved patient reported outcomes following PNN. Complications were reported in 10 studies - haemorrhage was the most common complication and was observed in 28 patients (1.6% of subjects). Conclusions: Endoscopic posterior nasal neurectomy is safe and appears to be effective in the treatment of intractable rhinitis but the level of the available evidence was generally poor. Larger, well designed studies are needed to clarify its role in the management of difficult-to-treat rhinitis.

Objective: To summarize the accuracy of artificial intelligence (AI) computer vision algorithms to classify ear disease from otoscopy. Methods: Using the PRISMA guidelines, nine online databases were searched for articles that used AI methods (convolutional neural networks, artificial neural networks, support vector machines, decision trees, k-nearest neighbors) to classify otoscopic images. Diagnostic classes of interest: normal tympanic membrane, acute otitis media (AOM), otitis media with effusion (OME), chronic otitis media (COM) with or without perforation, cholesteatoma, and canal obstruction. Main Outcome Measures: Accuracy to correctly classify otoscopic images compared to otolaryngologists (ground-truth). The Quality Assessment of Diagnostic Accuracy Studies Version 2 tool was used to assess the quality of methodology and risk of bias. Results: Thirty-nine articles were included. Algorithms achieved 90.7% (95%CI: 90.1 – 91.3%) accuracy to difference between normal or abnormal otoscopy images in 14 studies. The most common multi-classification algorithm (3 or more diagnostic classes) achieved 97.6% (95%CI: 97.3.- 97.9%) accuracy to differentiate between normal, AOM and OME in 3 studies. Compared to manual classification, AI algorithms outperformed human assessors to classify otoscopy images achieving 93.4% (95%CI: 90.5 – 96.4%) versus 73.2% (95%CI: 67.9 – 78.5%) accuracy in 3 studies. Convolutional neural networks achieved the highest accuracy compared to other classification methods. Conclusion: AI can classify ear disease from otoscopy. A concerted effort is required to establish a comprehensive and reliable otoscopy database for algorithm training. An AI-supported otoscopy system may assist health care workers, trainees, and primary care practitioners with less otology experience identify ear disease.

It is important to give parents accurate information about complication rates as part of the process of informed consent for surgery.  National, routinely-collected data give an opportunity to estimate the rates of rare adverse events such as bleeding, blood transfusion and death.We reviewed data for all Scottish NHS hospitals over the time period 2000-2018 to identify all children (aged 0-16 years) undergoing tonsillectomy, and to identify adverse events occurring within 30 days of the procedure.Readmission to hospital was required in 2%.Surgical arrest of haemorrhage was required in 1%.Blood transfusion occurred in 0.1% and death occurred in one child out of 50,194.

•A 28-month retrospective review from February 2019 to April 2021 of penetrating neck injuries (PNIs) at our trauma centre revealed a 48% (n=25 to n=37) increase in PNIs ‘post-lockdown’ (lockdown date = 23rd March 2020). •The aetiology of PNI changed over time, with an increase in the proportion of Deliberate Self Harm’ (DSH) cases from 1/3 to 2/3rds of case (n=9 to n=25), an overall 177.8% increase ‘post-lockdown’. An increase in mortality was also seen with no deaths ‘pre-lockdown’, and 3 deaths ‘post-lockdown’. •‘Accidental Injuries’ (AI) increased from 4% to 10% of cases (n=1 to n=4) post lockdown, with ‘grievous bodily harm (GBH) reducing from half to 1/5th of all cases (n=13 to n=8), and ‘domestic violence’ from 8% of cases to no cases post lockdown (DV) ‘post lockdown’. •‘Pre-lockdown’ 10% of DSH patients (n=1) were noted to have a prior mental health diagnosis or psychiatric care, ‘post-lockdown’ this increased to 61.5% (n=16) of DSH patients. •Data from our tertiary trauma centre in London has shown a change in aetiology, psychiatric co-morbidity and number of PNIs pre and post lockdown.

Objectives: To assess the efficacy of avoiding mastoid pressure dressing (MPD) on children as a means of preventing discomfort and postoperative pain. Design: A retrospective controlled study. Setting: All operations were carried out by experienced surgeons using standard techniques, whose custom, not the gravity of any individual case, dictated the use of MPD. Participants: children who underwent mastoidectomy for inflammatory middle ear diseases at a tertiary centre from 2010-2020. Main outcome measures: Wound-related complications and visual analog scale (VAS) pain scores at discharge were compared between children who had a MPD applied following surgery and those who did not. Results: 119 cases were included. The demographic characteristics of the patients and surgical techniques employed similar for both groups. There were 91 patients in the MPD group and 28 in the non-mastoid dressing (NMPD) group. In the MPD group, 5 patients developed minor wound dehiscence, 8 experienced surgical site infections (SSI), and one patient developed a keloid. In the NMPD group, one patient had a SSI, while another had a local hematoma. Therefore, there were no differences between the groups in relation to postoperative complications (p = 0.47). Despite these similitudes, the NMPD patients suffered less postoperative pain, as measured by the VAS (p =.02). Conclusions: This study shows that no significant benefit is derived from using a MPD after mastoidectomy in children. Surgeons should adhere to principles of appropriate haemostasis and wound closure to prevent postoperative wound complications. Our study supports the abandonment of routine MPD on children following mastoidectomy.

Objectives: We aim to analyze long-term voice outcomes and Quality of Life (QoL) in patients undergoing Open Partial Horizontal Laryngectomy Type II (OPHL Type II) and to compare them to those obtained by patients undergoing Total Laryngectomy (TL) with voice prosthesis (VP). Design: Cross-sectional cohort study Setting: patients undergoing surgery for advanced laryngeal cancer, assessed during the usual follow-up consultations at the Phoniatric Unit (February 2020-December 2020). Participants: Forty-five patients were enrolled and divided into two groups: OPHL Group and TL Group. Main outcomes measures: Maximum phonation time, INFV0 scale, I-SECEL, UWQoL-V4 and MDADI questionnaires were used to assess the long-term outcomes. Results: Voices of patients undergoing OPHL Type II were worse than those of laryngectomized patients with VP. Nevertheless, scores in voice and dysphagia-related QoL were comparable and scores in the Social domain of QoL were better in OPHL group. Conclusions. OPHL Type II allows an acceptable voice recovery and a satisfactory QoL.

OBJECTIVE Little is known about the efficacy of using artificial intelligence to identify laryngeal carcinoma from images of vocal lesions taken in different hospitals with multiple laryngoscope systems. This multicenter study was aimed to establish an artificial intelligence system and provide a reliable auxiliary tool to screen for laryngeal carcinoma. Study Design: Multicentre case-control study Setting: Six tertiary care centers Participants: The laryngoscopy images were collected from 2179 patients with vocal lesions. Outcome Measures: An automatic detection system of laryngeal carcinoma was established based on Faster R-CNN, which was used to distinguish vocal malignant and benign lesions in 2179 laryngoscopy images acquired from 6 hospitals with 5 types of laryngoscopy systems. Pathology was the gold standard to identify malignant and benign vocal lesions. Results: Among 89 cases of the malignant group, the classifier was able to evaluate the laryngeal carcinoma in 66 patients (74.16%, sensitivity), while the classifier was able to assess the benign laryngeal lesion in 503 cases among 640 cases of the benign group (78.59%, specificity). Furthermore, the CNN-based classifier achieved an overall accuracy of 78.05% with a 95.63% negative prediction for the testing dataset. Conclusion: This automatic diagnostic system has the potential to assist clinical laryngeal carcinoma diagnosis, which may improve and standardize the diagnostic capacity of endoscopists using different laryngoscopes.