Obstructive sleep apnoea is a common chronic sleep disorder characterised by collapse of the upper airway during sleep. The nasal airway forms a significant part of the upper airway and any obstruction is thought to have an impact on obstructive sleep apnoea. A systematic review was performed to determine the role of rhinological surgical interventions in the management of obstructive sleep apnoea.

A systematic review of current literature was undertaken; studies were included if they involved comparison of a non-surgical and/or non-rhinological surgical intervention with a rhinological surgical intervention for treatment of obstructive sleep apnoea.

Sixteen studies met the selection criteria. The pooled data suggest that there are reductions in the apnoea/hypopnea index and respiratory disturbance index following nasal surgery. However, the current body of studies is too heterogeneous for statistically significant meta-analysis to be conducted.

Nasal surgery may have limited benefit for a subset of patients based on current evidence.

It is recognised that a limited cohort of patients receive open partial laryngeal surgery in specific centres within the UK, so sharing information around key clinical issues and recommendations for practice is necessary to improve outcomes.

This position statement provides practice recommendations based on a synthesis of the available evidence presented at the 12th Evidence Based Management day on ‘Laryngeal Cancer’ and the ensuing discussions. Literature searches and critical analysis of available evidence were undertaken and triangulated with the clinical experience of the authors to develop these recommendations.

This paper presents a comprehensive overview of challenges that the multidisciplinary team may encounter. It provides recommendations for swallow and speech rehabilitation after open partial laryngectomy, and suggests practical ways that these issues may be addressed pre- and post-operatively.

To investigate the expression of basic fibroblast growth factor in the matrix of human acquired cholesteatoma compared to the deep meatal skin. This topic does not appear to have been fully investigated before.

An immunochemical study was conducted. Cholesteatoma tissues from adult patients were collected during surgery (n = 19). Control specimens were taken from the deep meatal skin (n = 8) and compared.

A highly significant difference in basic fibroblast growth factor expression was identified between cholesteatoma and skin (mean ± standard error = 58.53 ± 3.6 per cent in cholesteatoma vs 40.6 ± 3.5 per cent in skin; p = 0.005). Both basal and parabasal keratinocytes were stained positive with basic fibroblast growth factor. Additionally, there was specific staining in the basal columnar middle-ear epithelium and mast cell membrane.

Basic fibroblast growth factor plays an active role in proliferative activity of cholesteatoma through its overexpression in basal and parabasal layers of cholesteatoma matrix. Moreover, its expression in the mast cell membrane supports its role in bone resorption activity.

The anatomy of the membranous labyrinth within the vestibule has direct implications for surgical intervention. The anatomy of the otoliths has been studied, but there is limited information regarding their supporting connective tissue structures such as the membrana limitans in humans.

One guinea pig and 17 cadaveric human temporal bones were scanned using micro computed tomography, after staining with 2 per cent osmium tetroxide and preservation with Karnovsky's solution, with a resolution from 1 µm to 55 µm. The data were analysed using VGStudio Max software, rendered in three-dimensions and published in augmented reality.

In 50 per cent of ears, the membrana limitans attached directly to the postero-superior part of the stapes footplate. If attachments were present in one ear, they were present bilaterally in 100 per cent of cases.

Micro computed tomography imaging allowed three-dimensional assessment of the inner ear. Such assessments are important as they influence the surgical intervention and the evolution of future innovations.

To recount experience with cerebrospinal fluid otorrhoea and temporal bone meningoencephalocele repair in a tertiary care hospital.

A retrospective review was conducted of 16 cerebrospinal fluid otorrhoea and meningoencephalic herniation patients managed surgically from 1991 to 2016.

Aetiology was: congenital (n = 3), post-traumatic (n = 2), spontaneous (n = 1) or post-mastoidectomy (n = 10). Surgical repair was undertaken by combined middle cranial fossa and transmastoid approach in 3 patients, transmastoid approach in 2, oval window plugging in 1, and subtotal petrosectomy with middle-ear obliteration in 10. All patients had successful long-term outcomes, except one, who experienced recurrence after primary stage oval window plugging, but has been recurrence-free after second-stage subtotal petrosectomy with middle-ear obliteration.

Dural injury or exposure in mastoidectomy may lead to cerebrospinal fluid otorrhoea or meningoencephalic herniation years later. Congenital, spontaneous and traumatic temporal bone defects may present similarly. Middle cranial fossa dural repair, transmastoid multilayer closure and subtotal petrosectomy with middle-ear obliteration were successful procedures. Subtotal petrosectomy with middle-ear obliteration offers advantages over middle cranial fossa dural repair alone; soft tissue closure is more robust and is preferred in situations where hearing preservation is not a priority.

Patulous Eustachian tube is a benign but notoriously difficult condition to treat successfully. Symptoms include autophony of voice and breathing, and aural fullness.

This paper presents a series of 8 patients (12 ears) for whom a novel computed tomography guided injection of silicone elastomer suspension implant (Vox) was used to treat patulous Eustachian tube. This is the largest and only series in the current literature using this technique.

The combined complete and partial symptom resolution rate was 91 per cent. Complications related to the procedure are described. The pros and cons of this novel approach are also discussed in relation to traditional endoscopic transnasal techniques.

Computed tomography guided injection of Vox for the treatment of patulous Eustachian tube is suggested to be a feasible alternative to endoscopic transnasal approaches, particularly for refractory cases.

Ki-67 is a monoclonal antibody that provides a means of evaluating the growth fraction of normal and neoplastic human cell populations. A Ki-67 index of less than 3 per cent is expected for a typical schwannoma. Vestibular schwannomas with an index of greater than 3 per cent are presumed to be actively proliferating and pose a theoretically higher risk for regrowth or recurrence.

A retrospective chart review was conducted. Ki-67 staining was performed and specimens were divided into two groups according to Ki-67 activity: less than 3 per cent (low index), and 3 per cent or greater (elevated index).

Eight patients (53.3 per cent) with elevated Ki-67 had recurrence or regrowth, versus five (8.5 per cent) in the low Ki-67 group. Among the 13 patients with recurrence or regrowth, the average Ki-67 value was 4.3 per cent. Among the 61 patients without recurrence or regrowth, the average Ki-67 value was 1.0 per cent.

The Ki-67 labelling index reliably identifies vestibular schwannomas with an elevated potential for recurrence or regrowth in subtotal or total resection cases. In patients with a Ki-67 index greater than 3 per cent, more frequent clinical examination and radiological follow up are recommended.

This study evaluated the effect of mail non-response on the validity of the results of nasal septal surgery.

Six months post-operatively, questionnaires with both prospective and retrospective ratings were mailed to patients. Patients who did not respond (non-responders) were contacted by telephone. This study compared two cohorts of patients using different interviewers (a nurse and a surgeon). Cohort one consisted of 182 patients (with 67 per cent mail response), and cohort two consisted of 454 patients (with 64.8 per cent mail response).

In both cohorts, the improvement in obstruction scores was significantly better among mail responders than among non-responders (telephone interviewees) using prospective ratings, but worse using retrospective ratings.

Mail responders had better improvement in nasal obstruction after septoplasty than non-responders. Therefore, low response rates may cause an overestimation of the results. The retrospective ratings obtained through telephone interviews are less reliable because they are influenced by memory and the patients’ tendency to give socially acceptable answers.

Subcutaneous immunotherapy is an effective and safe treatment for allergic rhinitis and allergic asthma. Different symptom scores are used to evaluate the efficacy of subcutaneous immunotherapy in clinical trials.

A total of 58 allergic rhinitis patients sensitised to house dust mites, with or without mild asthma, were included. Symptom score, medication score, visual analogue scale score and quality of life were assessed before and after 6, 12 and 24 months of subcutaneous immunotherapy.

After two years of subcutaneous immunotherapy, asthma symptom scores nearly reached zero, whereas the scores remained higher for nasal symptoms. The changes in asthma symptom scores were markedly different (p < 0.05) and occurred faster than the changes in nasal symptom scores when compared between monosensitised and polysensitised groups. Significant reductions in visual analogue scale score and medication score were demonstrated after subcutaneous immunotherapy.

Two-year subcutaneous immunotherapy with house dust mite vaccine is an effective treatment for both monosensitised and polysensitised allergic patients. The changes in asthma symptom scores were markedly different and occurred quicker than the changes in nasal symptom scores in Chinese house dust mite allergic patients.

This study aimed to examine nasal mucociliary clearance time in patients with Helicobacter pylori infection.

Fifty patients who were newly diagnosed with H pylori infection using gastric biopsy in the gastroenterology out-patient clinic, and 50 age- and gender-matched healthy adults who were admitted to the otorhinolaryngology out-patient clinic, were included in this study. After an otorhinolaryngological examination (anterior rhinoscopy and nasal endoscopic examination), the nasal mucociliary clearance time of each subject was calculated using the saccharine test.

The mean mucociliary clearance time was 06:29 ± 3:31 minutes (range, 00:55–15:19 minutes) in the control group and 10:12 ± 06:09 minutes (range, 01:28–32:00 minutes) in the study group. Comparisons of the two groups revealed a statistically significant difference (p = 0.002).

Nasal mucociliary clearance time was significantly increased in patients with H pylori infection. The results suggest that H pylori infection may have an unfavourable effect on nasal mucociliary clearance.

This study aimed to determine the distance between the most anterior part of the anterior nasal spine and the posterior septal angle.

Sinus computed tomography images from February to April 2016 were retrospectively analysed. Scans from adult Caucasians were included. Those with evidence of previous surgery, large slices or poor quality were excluded. The distance between the posterior septal angle and the most anterior part of the anterior nasal spine was measured digitally by two independent raters.

Of 122 scans, 100 met the inclusion criteria (49 males and 51 females; mean age of 52.5 years). The mean distance measured was 5.13 mm (standard deviation = 1.24 mm, range = 1.85–8.00 mm). Measurements between male and female patients were not significantly different (t=0.450, p=0.654, 95 per cent confidence interval = -0.382 to 0.606).

There is variability in the distance between the anterior nasal spine and the posterior septal angle. Surgeons should observe this relationship intra-operatively to avoid instability and unintended aesthetic changes.

This study focused on parotid gland tumours diagnosed as benign by fine-needle aspiration cytology and investigated the necessity of frozen section biopsy.

There were 104 cases of parotid gland tumour where fine-needle aspiration cytology was benign and frozen section biopsy was subsequently performed, between April 2006 and June 2016. In this retrospective study, the results of frozen section biopsy were analysed and compared with the final histological diagnosis.

Among the 104 cases diagnosed as benign by fine-needle aspiration cytology, 102 cases and 2 cases were diagnosed as benign and malignant, respectively, by frozen section biopsy. The final histological diagnoses showed that 98 cases were benign and 6 cases were malignant. The sensitivity and specificity values of frozen section biopsy in detecting malignant tumours were 33 per cent and 100 per cent, respectively.

The necessity of frozen section biopsy in cases with benign fine-needle aspiration cytology may be low in parotid gland surgery.

Evaluation of post-operative donor site disability remains unaddressed in radial forearm free flap cases. This study aimed to assess donor site dysfunction following radial forearm free flap harvest using validated general, disease-specific and site-specific disability questionnaires.

In this retrospective case series of 24 patients at a tertiary academic medical centre, patients were assessed using the Short Form 36 Health Survey, Short Musculoskeletal Function Assessment questionnaire, and Disabilities of the Arm, Shoulder and Hand questionnaire. One-sample z-tests were performed, comparing means of the cohort to controls.

Compared to population controls, the cohort had higher mean scores for the Disabilities of the Arm, Shoulder and Hand questionnaire (18.22 vs 10.1, p < 0.01), and Short Musculoskeletal Function Assessment questionnaire bothersome index (21.44 vs 13.77, p = 0.04), and a lower mean score for the Short Form 36 Health Survey physical component (38.88 vs 50, p < 0.01), indicating a greater disability for the cohort compared to controls.

Radial forearm free flap harvest causes significant long-term donor site disability in head and neck tumour patients. The Disabilities of the Arm, Shoulder and Hand questionnaire is a concise tool for measuring this dysfunction.

The Assessing and Caring for Patients’ Expectations in Laryngology (‘ACaPELa’) questionnaire was developed to guide laryngology clinic consultations. This study aimed to audit its use, revise it depending on outcomes and validate it.

The questionnaire was completed by all new patients attending a laryngology clinic over one year. The questionnaire was refined and validated in a new cohort of patients over a six-month period.

Thirty-seven of 242 patients (15.3 per cent) incorrectly gave the same ranking to more than one question. Questions with similar content were collapsed to cover broader themes, and an outcome question was added, resulting in the five-item Assessing and Caring for Patients’ Expectations in Laryngology – Revised (‘ACaPELa-R’) questionnaire. Using this revised questionnaire, there was a significant reduction in the number of same-ranked questions (4.4 vs 15.3 per cent; p = 0.003) and high patient satisfaction post-consultation (95.7 per cent).

The Assessing and Caring for Patients' Expectations in Laryngology – Revised questionnaire makes patients’ rank ordering of questions easier. It can be used to inform how different topics should be approached during the consultation and utilised for clinician self-audit.

Radiotherapy is an option to treat high-grade laryngeal dysplasia. This study aimed to evaluate the use of intensity-modulated radiotherapy, 55 Gy in 20 daily fractions, in treating this disease.

Acute toxicity was evaluated in all 14 patients treated. In 10 patients, functional voice outcome was measured using the Voice Handicap Index, and the Grade, Roughness, Breath, Asthenia, Strain (‘GRBAS’) scale. These measurements were performed pre-treatment and three months after intensity-modulated radiotherapy.

All but one patient managed to complete radiotherapy. Acute toxicity was significant (one patient developed grade 4 and three patients developed grade 3 dysphagia). Four patients required hospital admission. In 9 out of 10 patients, radiotherapy improved voice quality.

This radiotherapy regimen using intensity-modulated radiotherapy for laryngeal dysplasia is feasible and provided excellent functional outcome, but acute toxicity was significant. Dose de-escalation can be considered in the framework of clinical trials.

All patients undergoing tympanomastoid surgery should be assessed post-operatively for a ‘dead ear’; however, tuning forks are frequently inaccessible.

To demonstrate that smartphone-based vibration applications provide equivalent accuracy to tuning forks when performing Weber's test.

Data were collected on lay participants with no underlying hearing loss. Earplugs were used to simulate conductive hearing loss. Both the right and left ears were tested with the iBrateMe vibration application on an iPhone and using a 512 Hz tuning fork.

Occluding the left ear, the tuning fork lateralised to the left in 18 out of 20 cases. In 20 out of 20 cases, sound lateralised to the left with the iPhone (chi-square test, p = 0.147). Occluding the right ear, the tuning fork lateralised to the right in 19 out of 20 cases. In 19 out of 20 cases, sound lateralised to the right with the iPhone (chi-square test, p > 0.999).

Smartphone-based vibration applications represent a viable, more accessible alternative to tuning forks when assessing for conductive hearing loss. They can therefore be utilised on the ward round, in patients following tympanomastoid surgery, for example.

In order to remove a cholesteatoma in the mastoid under transcanal endoscopic ear surgery, it is necessary to perform transcanal endoscopic mastoidectomy. Bone dust and blood, however, obscure the surgical field. A novel endoscopic hydro-mastoidectomy technique was developed, in which the operator performs the mastoidectomy ‘underwater’ using a lens cleaning system that provides saline perfusion in the surgical space.

A curved round coarse diamond bur is attached to an otological drill. A lens cleaning sheath is fitted to the endoscope. The surgeon controls the infusion of saline solution by stepping on a footswitch of the power console.

Endoscopic hydro-mastoidectomy washes out bone dust and blood from the surgical field, improving the surgical view during mastoidectomy. Additionally, the operator can easily control the flow of saline perfusion.

This technique provides a clear surgical view by washing out bone dust and blood from the surgical area. The setup for endoscopic hydro-mastoidectomy technique is easy and the operator needs only to buy sheaths if they already own the power console, as many otological and rhinological surgeons do.

Chronic maxillary atelectasis is a rare and underdiagnosed condition in which there is a persistent and progressive decrease in maxillary sinus volume secondary to inward bowing of the antral walls. Chronic maxillary atelectasis is typically unilateral. Simultaneous bilateral chronic maxillary atelectasis is extremely uncommon.

A retrospective review was performed of patient data collected by the senior clinician over a three-year period (2015–2018). A comprehensive literature search was conducted to locate all documented cases of chronic maxillary atelectasis in English-language literature. Abstracts and full-text articles were reviewed.

Three patients presented with sinonasal symptoms. Imaging findings were consistent with bilateral chronic maxillary atelectasis. The literature review revealed at least nine other cases of bilateral chronic maxillary atelectasis. Management is typically via endoscopic middle meatus antrostomy.

Chronic maxillary atelectasis was initially defined as a unilateral disorder, but this description has been challenged by reports of bilateral cases. Further investigation is required to determine the aetiology and pathophysiology of the disease.

Deep neck space abscesses are an uncommon but life-threatening emergency presentation to the ENT surgeon because of potential acute airway compromise.

This paper presents a novel case of a palatine tonsillar, low-flow, lymphovenous malformation pre-disposing to multifocal deep neck space collections and resultant acute airway compromise.