ROYAL ACADEMY OF MEDICINE IN IRELAND IRISH JOURNAL OF MEDICAL SCIENCE
Proceedings of the RAMI Section of OtoRhinoLaryngology Head and Neck Surgery (ORL HNS) Spring Meeting, Saturday 23rd April 2016
Sheraton Hotel, Athlone, Co. Westmeath
Irish Journal of Medical Science Volume 185 Supplement 11 DOI 10.1007/s11845-016-1500-0
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Ir J Med Sci (2016) 185 (Suppl 11):S519–S525
Disclosure Statement
This supplement has received no external funding or sponsorship
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Ir J Med Sci (2016) 185 (Suppl 11):S519–S525 DOI 10.1007/s11845-016-1500-0
Proceedings of the RAMI Section of OtoRhinoLaryngology Head and Neck Surgery (ORL HNS) Spring Meeting, Saturday 23rd April 2016, Sheraton Hotel, Athlone, Co. Westmeath Cartilage Tympanoplasty
Aims: To evaluate the symptomatic benefit reported by parents of children undergoing tonsillectomy. Methods: The T-14 Paediatric Throat Disorders Outcome Test was administered pre and post operatively to parents of children undergoing tonsillectomy and those on the waiting list. Result: Eighty six children were recruited. A paired sample t test revealed that at 6 months after surgical intervention, there was a statistically significant decrease in T-14 scores. Conclusion: This study provides clear evidence that tonsillectomy provides significant improvement in PROMs vs. watchful waiting.
O’Shea R, O’Connor A, McConn-Walsh R Department of Otorhinolaryngology, Beaumont Hospital, Dublin Background: Tympanoplasty is a diverse procedure which can vary based upon choice of surgical approach and choice of graft. Available literature indicates that success rates of this procedure are also variable. Aim: To compare temporal fascia and tragal cartilage as graft material in tympanoplasty. Methods: All cartilage tympanoplasties performed between 2000 and 2016, under the supervision of a single surgeon were reviewed. Success was measured as persistent closure at most recent follow-up. Results: Temporalis fascia was used between 2000 and 2016, 139 tympanoplasties were performed and a closure rate of around 90 % was achieved. From 2006 onwards, tragal cartilage was used and achieved a closure rate of 93 % for 258 procedures. Conclusion: No significant difference was found between temporalis fascis and tragal cartilage.
Functional Outcomes Post Surgical Treatment of Advanced Staged Oral SCC, Cork Experience
Investigating New Methods in Recruiting Tinnitus Suffers For Clinical Trials Subramaniam T1, D’Arcy S2, O’Neill R2, Conlon B1 1 Departments of Otolaryngology, Head and Neck Surgery, St. James Hospital Dublin, 2Neuromod Devices Limited
Introduction: Recruiting patients for a clinical trial for the management of tinnitus can be challenging, as patients often do not seek clinician advice for this specific condition. The aim of this study is to investigate a novel method of patient recruitment for a clinical trial. Methods: An online application and screening pro forma was designed to obtain relevant data such as demographics, symptom characteristics and tinnitus loudness scale scores. Results: Ethical approval was obtained. The number of patients recruited is reviewed and a representative cohort is obtained. The targeted sample size to invite for the clinical screening is 360 participants. Conclusion: Initial outcomes are encouraging however; further assessment is necessary prior validation this method as a reliable screening and recruitment tool.
Nae A, Sheahan P, O’Leary G ENT Department South Infirmary-Victoria University Hospital, Cork Background: Oral SCC is a worldwide problem. Aim: The study goal was to evaluate functional outcomes after surgical treatment and recurrence. Methods: The retrospective study was conducted on patients treated in our center over 14 years and finally included 72 patients. Results: Sixty patients needed reconstruction with flap (88.3 %) or skin graft (11.6 %). Complications associated were mainly dehiscence, sinus (10 cases), infection and fail. NG and PEG tubes were inserted for 35, respectively 37 patients. Almost half of the patients returned to normal diet (48.6 %). Conclusion: Advanced oral cancer treatment has a high impact on patient’s functional and nutritional status.
Significant Improvements in Quality of Life Following Paediatric Tonsillectomy. Final Outcome of a Prospective Cohort Study
Digital Learning in Peri-Operative Thyroidectomy: is this the Way Forward? Cassar M, Brophy C, Moran T, Rowley H ENT department, Mater Misericordia University Hospital Post-thyroidectomy haemorrhage is a life-threatening complication in 0.4–4 % of patients. First responders to this time-sensitive bleeding usually have limited surgical experience, however a simple bedside procedure may prove lifesaving. Endocrine surgery is a fraction of the vast undergraduate curriculum. Clinical attachments are of limited value given the procedure length, limited visualisation of the operative field and distractions pertaining to the theatre environment. Traditionally we rely on books to convey visuospatial concepts, however with availability of powerful, pocket-sized devices and data we should embrace use of digital learning modules. This video is an overview of peri-operative thyroidectomy care emphasising on post-operative haemorrhage.
Thong G, Davies K, Keogh I Department of Otolayngology, Head and Neck Surgery, University College Hospital Galway Background: The clinical efficacy of tonsillectomy is under debate. Data supporting the benefit of adenotonsillectomy in the Irish population are sorely lacking.
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Doctor Google: Beneficial or Cyberchondria
Ir J Med Sci (2016) 185 (Suppl 11):S519–S525
A Novel Solo Endoscopic Nasogastric Tube Insertion Technique
Ionescu AM, Keane E, Patil N ENT Department Sligo University Hospital
Wijaya C, Ramli R
Background: Whether the Internet is useful or dangerous to get health information isn’t a novel question. Aim: We want to establish if the Internet can be useful for both clinicians and patients in the OPD setting. Methods: We asked 100 adults and 100 parents who attended SUH to fill a simple questionnaire. A quality assessment of several websites was undertaken. Results: The age and occupation are major factors influencing in the use of Internet. 80 % of parents are using the Internet compared with 57 % of adults. Conclusion: We are currently initiating an audit in the outpatient.
Department of Otorhinolaryngology, Beaumont Hospital, Dublin Background: Nasogasric tube (NGT) insertion under direct vision with a flexible endoscope gives a unique advantage to address difficult anatomy after multiple unsuccessful attempts via blind technique. Using equipments commonly available in any ENT clinic, we describe a single operator technique. Aim: To describe and propose a novel solo endoscopic technique for difficult NGT insertion. Methods: Charts for 15 patients were retrospectively reviewed. The techniques are comprehensively described. Results: 11 successful insertions and 1 failed attempt recorded. Mean procedure time is 154 s wand mean number of attempts is 1.33. Conclusion: This technique is a safe, straightforward, and could be performed by a single operator effectively.
Management of Tegmen Plate Defects O’Connor A, Hasan W, McConn Walsh R Otolaryngology, Beaumont Hospital, Beaumont, Dublin 9 Aim: To review the management of tegmen plate defects including presentation, aetiology, interoperative findings and surgical technique of repair. Method: Retrospective chart and database review of 52 patients with tegmen plate defects managed by a single surgeon in a tertiary referral centre. Result: Presentation included cholesteatoma 38 % (20); CSF leak 21 % (11); CSOM 17.3 % (9); FN palsy 9.6 % (5); Mastoiditis 3.8 % (2); Meningitis 3.8 % (2); cholesterol granuloma 1.9 % (1). 42.3 % (22) of cases were iatrogenic, 38.4 % (20) caused by cholesteatoma. In addition to the tegmen defects, intraoperative findings included dehiscent facial nerve in 26.9 % cases; eroded ossicles in 21.1 %; CSF 15.3 % and eroded SCC in 9.6 %. Conclusion: Tegmen defects can be successfully managed with early identification and good surgical repair technique.
Role of HPV/p16-Status on Survival in Head-and-Neck Metastatic Squamous Carcinoma From Unknown Primary Kharytaniuk N1, Molony P2, Boyle S1, Geyer L1, O’Leary G1, Werner R2, Heffron C2, Feeley L2, Sheahan P1 1 Department of Otorhinolaryngology, Head and Neck Surgery, South Infirmary Victoria University Hospital, Cork; 2Department of Pathology, Cork University Hospital, Cork
Background: Cancers of unknown primary (CUP) represent up to 10 % of all head-and-neck cancers. Aim: To investigate the impact of HPV/p16-status on survival in CUP. Methods: A 16-year retrospective review of cases with metastatic cervical lymphadenopathy from CUP, and known p16-status. Results: Fifty-one patients presented with neck nodal disease and unknown primary lesion site; 31/51 were p16-positive. Recurrence-free survival and disease-specific survival were shown to be worse in p16negative patients (HR 4.9; 95 % CI 1.0, 23.1) and p = 0.004 respectively. There were no disease-related deaths in p16-positive patients. Conclusion: HPV/p16-status was shown to be a significant prognosticator in head-and-neck CUP.
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Evaluating the Advantages Of Endoscopic Ear Surgery? A 2-Year Review Fernando C, Khoo SG Department of Otolaryngology/Head and Neck Surgery, St. Vincent’s University Hospital, Dublin 4 Aim: To review the advantages of endoscopic ear surgery procedures over a 2-year period. Methods: Retrospective review of all endoscopic otology cases by a single surgeon over a 2-year period. Results: Forty-six otological procedures were carried out with endoscopy as the primary visualization modality. Endoscopic tympanoplasty made up the majority of cases. There was an 80 % closure success rate. Conclusion: Endoscopic ear surgery is a valuable and effective visualization tool in middle ear surgery. In some cases of marginal TM perforations, endoscopy allowed full visualization of the entire perforation allowing for successful tympanoplasty without the need for canalplasty.
Drain Usage in Head And Neck Surgery: A National Review Keane E, Fitzgerald C, Skinner L, Donnelly M University Hospital Waterford Background: Topical haemostatic agents may be providing alternatives to drains in head and neck surgery. Aim: To assess the routine use of drains at a national level and/or any alternatives. Methods: A simple questionnaire to assess the use of drains for a variety of procedures (n = 9) and to identify any alternatives routinely being used in modern practice in Ireland. Results: At the time of submission, 15 surgeons had responded. Drain usage was commonplace and varied by procedure type. Amongst those who use an alternative, Artiss thrombin spray was the most commonly cited. Conclusion: Drain insertion is still routine in Ireland.
Ir J Med Sci (2016) 185 (Suppl 11):S519–S525
Can the Use of Sugammadex During Ambulatory Microlaryngoscopy Procedures Decrease Theatre Operating Time and Unplanned Admission Rates Wentzell S1, Keane S2, Kaare MTM1,3, Dillon P2, Fenton JE1,3 1 Departments of Otorhinolaryngology; 2Anaesthesia, Limerick University Hospital (UHL); 3GEMS, Limerick
Microlaryngoscopy is a day procedure facilitated by neuromuscular blockade. Procedure duration varies and can lead to delay in theatre exit and unplanned admission. The aim of this audit is to assess whether sugammadex has altered theatre operating times and unplanned admissions following microlaryngoscopic procedures. Sugammadex was introduced at UHL in 2010 and patients were divided into two groups; pre-sugammadex era (n = 87), and postsugammadex era (n = 129). Information was collected from patient files under a single consultant regarding theatre times and unplanned admissions. This audit supports the use of sugammadex in microlaryngoscopic procedures. Operating times were shown to decrease by 27 % and unplanned admission by 37 %. The use of sugammadex in microlaryngoscopic procedures is relatively new at UHL, and appears to be showing promising results.
Assessment of Outcomes of Cochlear Implant (CI) in Patients With Additional Needs Ramli RR, Glynn F, Walshe P, Viani L National Cochlear Implant Program, Beaumont Hospital, Dublin, Ireland Background: The incidence of additional disabilities is as high as 40 % in the congenitally deaf population. While the number of CI performed in this cohort is increasing, availability of literature on this topic is limited. Aim: The aim of this study is to determine the long-term outcome of CI in children with additional needs. Methods: It is a retrospective cohort study. Results: Average CAP score for children without additional needs was 5 and 4 for children with additional needs. Similar trend is observed with SIR scores. Conclusions: Poorer outcome post CI in children with additional needs is observed, despite this, CI provides a significant improvement in quality of life for these children and their families.
Prevalence and Characteristics of Hearing Loss in Adults with Turner’s Syndrome Brophy C1, Katiri R2, McQuaid S3, Rowley H1 1 Department of Otolaryngology/ENT Surgery, Mater Misericordiae University Hospital, Eccles Street, Dublin 7; 2Audiology Department, Clinic 8, Mater Misericordiae University Hospital, Eccles Street, Dublin 7; 3Department of Endocrinology, Mater Misericordiae University Hospital, Eccles St, Dublin 7
S523 Aim: The aim of this study was to investigate the prevalence and characteristics of hearing loss in our cohort of patients with Turner syndrome. Methods: Retrospective review of audiometric data from 45 patients. These patients attended the dedicated Turners clinic at the Mater hospital. Results: Forty of 45 patients had an audiological assessment. 10 patients had a normal audiogram. 18 patients (45 %) had a sensorineural hearing loss. Mixed hearing loss was seen in 2 (5 %) patients and pure conductive hearing loss in only 1 patient. Conclusion: 75 % of patients tested had a hearing loss. Our review highlights the importance of early audiological assessment in patients with Turner syndrome.
A Case Series of Combined Parotidectomy and Mastoidectomy for Management of Parotid Tumours with Associated Temporal Bone Invasion ´ Catha´in E´, Jaber S, Timon C, Casserly P O Royal Victoria Eye and Ear Hospital, Adelaide Road, Dublin 2 Background: Lateral temporal bone resection is advocated for the management of invasion of temporal bone by squamous cell carcinoma of the skin. With this case series, however, we demonstrate that parotidectomy plus mastoidectomy is adequate surgical management of parotid tumours with temporal bone invasion. Methods: This is a retrospective review of seven cases of parotid tumour with temporal bone invasion proceeding to surgery. Operative notes, imaging and histological results were accessed and reviewed for each case identified by the senior author. Results: Tumour was successfully resected in each case with negative margins. Conclusion: In certain cases, a parotidectomy combined with a cortical mastoidectomy is suitable for control of associated temporal bone disease arising from a parotid tumour, thus avoiding the risks associated with lateral temporal bone resection.
An Audit of ‘‘Sinusitis’’ Referrals by Gps: is it Time to Rethink the Sinogenic Headache??? Gyan-Baffour A, Mehanna R, Brophy C, Colreavy M ENT Department, Mater University Hospital, Dublin Aim: To determine if GP referrals of patients with ‘‘sinogenic’’ headaches and facial pains are truly of sinus origin. Methods: A retrospective review of new referrals to our Rhinology clinic with headache and facial pains over a 2-year period. Results: After clinical assessment, 38 % of patients required a CT scan, the remainder were referred to other services, did not attend appointments or were discharged from ENT. Of patients requiring CT scans, 60 % were normal and 40 % showed minimal paranasal disease. None required surgical intervention. Conclusion: The majority of sinogenic headaches referred to otolaryngologist by GPs are not truly of sinus origin.
Background: There is a well documented association between Turner syndrome and hearing loss.
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Aural Polyps. Audit of Our Challenging Cases ´ Catha´in E´, Casserly P Jaber S, O
Ir J Med Sci (2016) 185 (Suppl 11):S519–S525 Conclusion: The significant rise in tonsillitis throughout the UK raises the question whether we should revisit the criteria for tonsillectomy.
Royal Victoria Eye and Ear Hospital, Adelaide Road, Dublin 2 Polyps in the external auditory meatus (EAM) can suggest inflammatory process or reflect a serious condition that warrants urgent investigation. Our retrospective review assessed presentation of ear polyps alongside any surprising findings in the ear. In our study most common cause of EAM polyp was inflammation, followed by cholesteatoma. One case demonstrated a diagnostic dilemma with carcinoma proving difficult to exclude despite multiple imaging modalities and biopsy providing a diagnostic challenge. Other cases revealed unusual anatomy with one polyp overlying a dehiscent bony canal, and another connected to a dehiscent facial nerve. We highlight possible challenges faced when dealing with seemingly innocuous EAM polyps. We advocate thorough evaluation by imaging modalities and biopsy. An open mind in relation to investigating and treating this condition is essential.
Mastoid Obliterative; a Definitive Therapy
Our Experience with the Lumenis Acupulse Fiberlase CO2 Laser: A Review of 12 Cases Using the Lumenis Laser for Resection of Head And Neck Pathology
The Effect of BMI on Hemithyroidectomies
McConn-Walsh R, O’Connor A, Deegan B Otolaryngology, Beaumont Hospital Aims: Mastoidectomy patients are at a high risk for secretion build up and recurrent ear infections. In a tertiary referral center, over 10 years period, a single surgeon proposes a method for eliminating this risk by obliterating the mastoid cavity. Methods: Eighty-nine patients were identified in prospectively collected database, where the primary mastoid cavity is obliterated using a variety of materials. Results: 100 % of patients reported a success, with the goals being a dry ear cavity and reduced infections. Conclusions: Mastoid cavity obliteration is a viable option for revision mastoidectomy patients.
O’Reilly E, McEntee P, Timon C Department of Head and Neck Surgery, St. James’ Hospital, Dublin
Collery C, Sheahan P, Geyer L ENT Department South Infirmary-Victoria University Hospital, Cork Background: The Lumenis Laser is the first of its kind in Ireland. This flexible fibreoptic C02 laser facilitates surgery by a transoral approach on otherwise difficult to access areas. It’s a handheld device allowing the surgeon to guide the power of the laser. Aim: To demonstrate the use of this handheld laser in the resection of head and neck pathology. Methods: We carried out a retrospective review of the first 12 cases. Results: 12 patients were operated on in total, 5 females and 7 males. Conclusion: The Lumenis laser allowed for successful resection of head and neck pathology without a transcervical or transmandibular approach.
Background: Obesity is a surgically challenging epidemic. Hemithyroidectomy is a commonly performed surgery with serious potential risks. Aim: We examined if high BMI was associated with increased scar size, bleeding, drain use, tracheal deviation and substernal extension. Methods: This is a prospective cohort study. We collected data in three institutions over 3 years. Results: 173 patients, 47 % overweight. Small but significant increase in scar length for overweight patients 16.8 % increased incidence of tracheal deviation, 17.78 % increase in substernal extension of diseased thyroid tissue. Conclusion: BMI seriously impacts on hemithyroidectomies. Weight loss should be promoted prior to elective cases.
A 15-Year Analysis of Serious Tonsil Infections Compared to Tonsillectomy Rates in Wales
An Assessment of Diffusion-Weighted Imaging and Contrast-Enhanced MRI in the Diagnosis of Cholesteatoma Recurrence
Yap D, Harris AS, Clarke J
Kavanagh RG1, Carroll AG1, Hone SW2, Malone DE1, Killeen RP1
Department of ENT, Royal Gwent Hospital, Aneurin Bevan University Health Board, Cardiff Road, Newport, NP20 2UB
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Introduction: Sore throat and tonsillitis represent a significant burden to the National Health Service. National guidelines have sought to restrict the number of tonsillectomies performed. Method: Longitudinal cross-sectional study of population of Wales. Results: Using a linear regression model, there was a positive correlation between incidence of tonsillitis and number of admissions for peritonsillar abscess and retropharyngeal abscess. There was a statistically significant negative correlation between the incidence of tonsillitis and the number of tonsillectomies performed.
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Department of Radiology, St. Vincent’s University Hospital, Dublin 4; 2Department of Otolaryngology, Royal Victoria Eye and Ear Hospital, Adelaide Rd, Dublin 2 Background: MRI is used to diagnose cholesteatoma recurrence and we currently perform diffusion-weighted imaging (DWI) and contrast-enhanced MRI (CE-MRI). Aims: The aim of this study was to compare DWI to DWI with CEMRI for diagnosing cholesteatoma recurrence. Methods: MRIs in consecutive patients from January 2012 to December 2015 were assessed. Cholesteatoma recurrence was assessed using ‘‘short-sequence’’ (DWI) and ‘‘long-sequence’’ (DWI and CE-MRI) MRIs separately.
Ir J Med Sci (2016) 185 (Suppl 11):S519–S525 Results: There was excellent agreement between the short- and longsequence MRIs for diagnosing cholesteatoma recurrence. Conclusion: MRIs in patients with suspected cholesteatoma recurrence can be performed using DWI without the need for contrastenhanced sequences.
ENT and Irish Independence—a View from Both Sides Woods R, Timon C St. James’s Hospital, Dublin, Ireland Introduction: The Easter Rising began on 24th April 1916, with the Irish Free State eventually seceding from the United Kingdom in December 1922. ENT was a relatively new specialty, but there had been significant contributions by its early pioneers in Ireland, such as Sir William Wilde. Two internationally respected and closely linked ENT surgeons had particular roles to play in the Easter Rising and in the formation of the Irish Free State from opposing sides. Methods: Personal correspondence between two prominent ENT surgeons was analysed alongside books, memoirs and historical
S525 accounts. MEDLINE was searched for contributions of these surgeons to ENT. Discussion: Sir Robert Woods, the first surgeon in Ireland to specialise solely in ENT, had an illustrious career that included presidency of the Royal College of Surgeons and a knighthood from King George V. He became politicised during the Great War, being elected a Unionist Member of Parliament, and was involved in AngloIrish negotiations during secession. Woods was a dedicated teacher, with his prote´ge´ and eventual eulogist Oliver St. John Gogarty becoming another famous ENT surgeon. Gogarty was a polymath who not only established a successful ENT practice, but became a renowned author and poet and was well known for flamboyant theatrics in the operating room. He was a staunch Republican and Sinn Fe´iner who became a Senator in the new Irish Free State. Conclusion: With the 100 year anniversary of the 1916 Easter Rising on April 24th 2016, it is poignant to discuss the role of distinguished ENT surgeons in Irish politics. Practice at the time was evolving rapidly and contributions of these surgeons to the specialty were considerable.
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