Subtotal petrosectomy for chronic suppurative otitis media requires obliteration of the mastoid cavity and middle ear. Usually, abdominal fat is used for this purpose. However, infection is a risk of using fat, which might require revision surgery. The use of S53P4 bioactive glass with antibacterial properties seems an attractive alternative.

Two patients with a history of chronic suppurative otitis media, complicated by profound perceptive hearing loss, had already been surgically treated, and were thereafter extensively treated conservatively. Because of recurrent chronic otorrhoea and pain, subtotal petrosectomy with obliteration of the cavity with S53P4 bioactive glass was performed.

Follow-up duration was 84 months and 18 months, respectively. No complications occurred peri-operatively. A dry ear was obtained and no late adverse events were observed.

S53P4 bioactive glass is feasible to use for obliteration after subtotal petrosectomy. Elimination of chronic suppurative otitis media can be achieved with this technique. The bioactive glass granules might be an attractive alternative to abdominal fat, which has a risk of infection.

With a growing ageing population, there is a higher prevalence of dementia in patients with conditions that can be managed surgically. Patients with dementia undergoing surgery under general anaesthesia often have poorer outcomes than those without. Therefore, local anaesthesia can be an option.

Two patients with severe dementia and advanced cholesteatoma were identified for operative management. They were deemed too high risk to proceed with general anaesthesia. This article describes our experience of performing mastoid surgery under local anaesthesia in the presence of a primary carer in the operating theatre.

The complete extirpation of cholesteatoma was achieved in both cases. The carers reported that local anaesthesia helped to facilitate communication and aid patient co-operation.

Our experience, albeit limited to two cases, illustrates an alternative individualised peri-operative strategy in the surgical management of patients with dementia and concurrent advanced cholesteatoma.

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) is a validated, risk-adjusted database for improving the quality and security of surgical care. ACS NSQIP can help participating hospitals target areas that need improvement. The aim of this study was to systematically review the literature analyzing the economic impact of using NSQIP. This paper also provides an estimation of annual cost savings following the implementation of NSQIP and quality improvement (QI) activities in two hospitals in Quebec.

In June 2018, we searched in seven databases, including PubMed, Embase, and NHSEED for economic evaluations based on NSQIP data. Contextual NSQIP databases from two hospitals were collected and analyzed. A cost analysis was conducted from the hospital care perspective, comparing complication costs before and after 1 year of the implementation of NSQIP and QI activities. The number and the cost of complications are measured. Costs are presented in 2018 Canadian dollars.

Out of 1,612 studies, 11 were selected. The level of overall evidence was judged to be of moderate to high quality. In general, data showed that, following the implementation of NSQIP and QI activities, a significant decrease in complications and associated costs was observed, which improved with time. In the cost analysis of contextual data, the reduction in complication costs outweighed the cost of implementing NSQIP. However, this cost analysis did not take into account the costs of QI activities.

NSQIP improves complication rates and associated costs when QI activities are implemented.

There is variation regarding the use of surgery and interventional radiological techniques in the management of epistaxis. This review evaluates the effectiveness of surgical artery ligation compared to direct treatments (nasal packing, cautery), and that of embolisation compared to direct treatments and surgery.

A systematic review of the literature was performed using a standardised published methodology and custom database search strategy.

Thirty-seven studies were identified relating to surgery, and 34 articles relating to interventional radiology. For patients with refractory epistaxis, endoscopic sphenopalatine artery ligation had the most favourable adverse effect profile and success rate compared to other forms of surgical artery ligation. Endoscopic sphenopalatine artery ligation and embolisation had similar success rates (73–100 per cent and 75–92 per cent, respectively), although embolisation was associated with more serious adverse effects (risk of stroke, 1.1–1.5 per cent). No articles directly compared the two techniques.

Trials comparing endoscopic sphenopalatine artery ligation to embolisation are required to better evaluate the clinical and economic effects of intervention in epistaxis.

To investigate the inflammatory/anti-inflammatory cytokine balance – T helper 1/T helper 2 ratios – in obstructive sleep apnoea patients, before and after treatment.

Twenty-eight patients received continuous positive airway pressure treatment and 29 patients who could not tolerate continuous positive airway pressure were scheduled for surgery. Serum levels of interleukins 2, 4 and 10, tumour necrosis factor-alpha, and interferon gamma were analysed by enzyme-linked immunosorbent assays before and three months after treatment.

The success rate of surgical treatment was 65.5 per cent. Mean compliance for the continuous positive airway pressure group was 40.9 per cent. The apnoea/hypopnoea index significantly decreased in both groups after treatment (p < 0.001). The interferon gamma/interleukin-4 ratio decreased following surgical treatment (p = 0.014), and the interleukin-2/interleukin-4 ratio decreased after treatment in 57 patients in the overall cohort (p = 0.032).

After treatment for obstructive sleep apnoea, some ratios reflecting T helper 1/T helper 2 cytokine balance favoured the T helper 2 direction, suggesting a shift to an anti-inflammatory state. Successful surgery and better continuous positive airway pressure compliance can help ameliorate inflammation in obstructive sleep apnoea patients, which may reduce associated morbidities.

To search for studies on tongue–lip adhesion and tongue repositioning used as isolated treatments for obstructive sleep apnoea in children with Pierre Robin sequence.

A systematic literature search of PubMed/Medline and three additional databases, from inception through to 8 July 2016, was performed by two authors.

Seven studies with 90 patients (59 tongue–lip adhesion and 31 tongue repositioning patients) met the inclusion criteria. Tongue–lip adhesion reduced the mean (± standard deviation) apnoea/hypopnoea index from 30.8 ± 22.3 to 15.4 ± 18.9 events per hour (50 per cent reduction). The apnoea/hypopnoea index mean difference for tongue–lip adhesion was −15.28 events per hour (95 per cent confidence interval = −30.70 to 0.15; p = 0.05). Tongue–lip adhesion improved the lowest oxygen saturation from 75.8 ± 6.8 to 84.4 ± 7.3 per cent. Tongue repositioning reduced the apnoea/hypopnoea index from 46.5 to 17.4 events per hour (62.6 per cent reduction). Tongue repositioning improved the mean oxygen saturation from 90.8 ± 1.2 to 95.0 ± 0.5 per cent.

Tongue–lip adhesion and tongue repositioning can improve apnoea/hypopnoea index and oxygenation parameters in children with Pierre Robin sequence and obstructive sleep apnoea.

Endoscopic stapling has become the primary procedure for pharyngeal pouch surgery because it is quick, less invasive and safe, but less is known about long-term outcomes.

Medical records were reviewed to compare rates of morbidity, operative failure, symptom control and revision surgery between open and closed procedures.

A total of 120 pharyngeal pouch procedures, carried out on 97 patients from 2000 to 2014, were studied. These included 80 endoscopic stapling and 40 open procedures. Twelve patients had complications (15 per cent) and there was one mortality (1.2 per cent) in the endoscopic stapling group. Ten patients (25 per cent) developed complications in the open procedure group, with no mortalities. Symptom recurrence was significantly greater in the endoscopic stapling group (26 per cent) than in the open procedure group (7.5 per cent). Multiple surgical procedures were required for 22 endoscopically stapled patients (32 per cent); none were required in the open procedure group. Although the male-to-female ratio for pharyngeal pouch incidence was 2:1, the ratio for multiple surgical procedures was 10:1.

Endoscopic stapling outcomes are not as good as those following an open approach on long-term follow up, and the early advantages are eliminated if pouch excision is avoided.

To report previously unreported complications of bilateral sphenopalatine artery ligation.

We present the case of a 45-year-old man who underwent bilateral sphenopalatine artery ligation to control intractable posterior epistaxis. After four months, he re-presented with nasal obstruction and crusting.

Examination under general anaesthesia showed posterior septal perforation and bilateral necrosis of the lower parts of the middle turbinates. The necrotic parts were excised. The patient had no more complaints.

Following sphenopalatine artery occlusion, ischaemic necrosis is a potential risk in anatomical areas that receive their only arterial supply from this artery. The staging of bilateral sphenopalatine artery occlusion needs to be studied.

Previous literature reviews comparing transoral laser surgery versus radiotherapy for glottic carcinoma treatment have analysed ‘early stage’ disease as one group. The current review aimed to assess local control outcomes, comparing these two treatment modalities, specifically for either tumour stage 1a or stage 1b lesions.

The three authors conducted independent, structured literature searches. Simple weighted means were calculated.

Thirty-six publications were analysed. Three-year local control rates for tumour stage 1a tumours were 88.9 per cent for transoral laser surgery (n = 1308) and 89.3 per cent for radiotherapy (n = 2405). For tumour stage 1b tumours, the local control rates were 76.8 per cent for transoral laser surgery (n = 194) and 86.2 per cent for radiotherapy (n = 492).

From this analysis of level four evidence, there was no demonstrable difference in local control rates for tumour stage 1a glottic squamous cell carcinoma treated by transoral laser surgery or radiotherapy. There was a trend towards improved local control of tumour stage 1b tumours treated with radiotherapy, but this finding was based on a limited number of published outcomes (n = 194).

To determine the success rate of initial probing in children with congenital nasolacrimal duct obstruction at different ages, using nasal endoscopy.

Fifty eyes of 38 consecutive children with congenital nasolacrimal duct obstruction underwent endoscopic nasolacrimal duct probing under general anaesthesia. Patients were followed up for at least three months. Probing success was defined as complete remission of symptoms and a normal fluorescein dye disappearance test result.

The age range of patients was 17–109 months. The success rates of probing were: 100 per cent (29 out of 29) for cases of stenosis at the lower nasolacrimal duct, 100 per cent (7 out of 7) for functional epiphora cases and 92.86 per cent (13 out of 14) for nasolacrimal atresia cases. Overall, there was only one child for whom the probing treatment for nasolacrimal duct obstruction was not successful; this child had Down's syndrome and a more complex developmental abnormality of the nasolacrimal duct. Age and site of obstruction were not found to significantly affect the outcome of probing.

Probing of the nasolacrimal system using an endoscopic approach allows direct visualisation of the nasolacrimal duct. This can facilitate diagnosis of the anomaly and significantly increase the procedure success rate.

The management of frontal sinus disease in cystic fibrosis patients represents a challenge for many surgeons. Procedures can vary from the minimally invasive to those involving extensive open surgery.

This study describes the outcomes of the endoscopic modified Lothrop procedure, in terms of safety and morbidity, for cystic fibrosis patients with frontal sinus disease who did not improve following traditional functional endoscopic sinus surgery.

The study setting was a tertiary referral unit in a London teaching hospital, the largest national base for adult cystic fibrosis patients. Two patients diagnosed in childhood with cystic fibrosis presented with histories of recurrent, severe frontal sinusitis; both had previously undergone multiple endoscopic sinus surgical procedures. The modified Lothrop procedure was performed on both patients. The outcome measures were symptom resolution and post-operative complications.

The endoscopic modified Lothrop procedure was beneficial in the cystic fibrosis patients with frontal sinus disease who failed to respond to standard functional endoscopic sinus surgery procedures.

The World Health Organization ‘Surgical Safety Checklist’ has been adopted by UK surgical units following National Patient Safety Agency guidance. Our aim was to assess compliance with our local version of this Checklist.

Otolaryngology trainee doctors prospectively assessed compliance with the local Checklist over a six-week period. A staff educational intervention was implemented and the audit was repeated 12 months later.

A total of 72 cases were assessed. The initial audit found that: 44 per cent of procedures were undocumented at ‘Sign in’; ‘Time out’ was inappropriately interrupted in 39 per cent of cases; the procedure started before Checklist completion in 33 per cent of cases; and the ‘Sign out’ was not read out in 94 per cent of cases and was not fully documented in 42 per cent of cases. Following education, re-audit indicated that overall compliance had improved from 63.7 per cent (±8.9 per cent standard error of the mean) to 90.4 per cent (±2.7 per cent standard error of the mean).

Our completed audit cycle demonstrated a significant improvement in Checklist compliance following educational intervention. We discuss barriers to compliance, as well as strategies for quality improvement, and we call for other surgeons to similarly publish their Checklist experience and assess its impact on surgical outcomes.

Thyroid cancers infiltrating the upper aerodigestive tract are not uncommon. The management of these cases can be demanding, with a high level of surgical skill required to achieve adequate primary resection and reconstruction.

This study was a single institution series of seven patients, managed over two years, who underwent tracheal resection for advanced thyroid cancer. All patients were older than 45 years (range, 45–65 years) and were predominantly male (six of seven). All patients presented to us with a swelling in the neck. Fine needle aspiration cytology detected thyroid cancer in all patients. None of the patients required a tracheostomy prior to surgery; however, they all had varying levels of airway compromise. One patient had lung metastasis at presentation. In all patients, the airway was successfully secured with fibre-optic assisted intubation prior to surgery. All patients underwent a total thyroidectomy with tracheal resection and anastomosis. Montgomery's suprahyoid release was utilised to achieve adequate laryngeal drop. None of the patients required a tracheostomy in the post-operative period. All patients received adjuvant therapy with either radioiodine ablation and/or radiotherapy.

Tracheal resection and primary reconstruction is a feasible surgical procedure for patients with thyroid cancer infiltrating the upper aerodigestive tract, with good clinical outcomes. However, the morbidity of the procedure mandates careful case selection, airway management and meticulous surgical technique.

We report the use and benefits of the ultrasonic dissector in the resection of difficult skull base lesions.

Five case reports are presented, and the utilisation of ultrasonic dissectors in otorhinolaryngology is reviewed.

The ultrasonic dissector was found to be a useful tool during the endoscopic resection of poorly accessible skull base tumours. Safe dissection and complete removal of all five lesions were achieved without any vascular injury. To our knowledge, this is the first report of the use of the ultrasonic dissector for the resection of sinonasal and skull base tumours.

The ultrasonic dissector was found to be particularly useful during the endoscopic transnasal approach to the petrous apex. During minimally invasive endonasal surgery, benefits include the length of the instrument, speed and precision of dissection, and low risk of vascular injury.