ABSTRACTIntroductionMeasurements in endoscopic sinus surgery (ESS) are usually obtained with variable accuracy. We aimed to validate endoscopic multipoint integrated laser systems (EIMLS) for use in ESS, which can acquire measurements within one‐hundredth of a millimetre.MethodsA 4.4 mm flexible endoscopic EIMLS projecting 49 laser points into the view was used to assess simulated anterior skullbase defects. Antero‐posterior and lateral measurements were obtained and repeated 20 times by two surgeons. These were compared to measurements with surgical callipers. Intra and inter‐observer reliability was assessed.ResultsEighty measurements were obtained of simulated skullbase defects by each otolaryngology surgeon and compared to manual measurements. The mean difference shown was 0.56 cm. Bland–Altman plot shows low bias (0.044) but wide 95% limits of agreement (−1.8–1.9).ConclusionEIMLS allows reliable and easy to obtain measurements within a simulated ESS environment. Translation of this technology offers promise in a future clinical setting but will require further refinement to improve accuracy.

Objective: Demonstrate the utility of 3D printed temporal bone models in individual patient preoperative planning and simulation. Methods: 3D models of the temporal bone were made from 5 pediatric and adult patients at a tertiary academic hospital with challenging surgical anatomy planned for cochlear implantation or exteriorization of cholesteatoma with complex labyrinthine fistula. The 3D models were created from CT scan used for preoperative planning, simulation and intraoperative reference. The utility of models was assessed for ease of segmentation and production and impact on surgery in regard to reducing intraoperative time and costs, improving safety and efficacy. Results: Three patients received cochlear implants, two exteriorization of advanced cholesteatoma with fistulas (1 internal auditory canal/cochlea, 1 all three semicircular canals). Surgical planning and intraoperative referencing to the simulations by the attending surgeon and trainees significantly altered original surgical plans. In a case of X -linked hereditary deafness, optimal angles and rotation maneuvers for cochlear implant insertion reduced operating time by 93 min compared to the previous contralateral side surgery. Two cochlear implant cases planned for subtotal petrosectomy approach due to aberrant anatomy were successfully approached through routine mastoidectomy. The cholesteatoma cases were successfully exteriorized without necessitating partial labyrinthectomy or labyrinthine injury. There were no complications. Conclusion: 3D printed models for simulation training, surgical planning and use intraoperatively in temporal bone surgery demonstrated significant benefits in designing approaches, development of patient -specific techniques, avoidance of potential or actual complications encountered in previous or current surgery, and reduced surgical time and costs.

Introduction: Measurements in endoscopic sinus surgery (ESS) are usually obtained with variable accuracy. We aimed to validate endoscopic multipoint integrated laser systems (EIMLS) for use in ESS, which can acquire measurements within one-hundredth of a millimetre. Methods: 4.4mm flexible endoscopic EIMLS projecting 49 laser points into the view was used to assess simulated anterior skullbase defects. Antero-posterior and lateral measurements were obtained and repeated twenty times by two surgeons. These were compared to measurements with surgical calipers. Intra and inter-observer reliability was assessed. Results: 80 measurements were obtained of simulated skullbase defects by each otolaryngology surgeon and compared to manual measurements. The mean difference shown was 0.56cm. Bland-Altman plot shows low bias (0.044) but wide 95% limits of agreement (-1.8 – 1.9). Conclusion: EIMLS allows reliable and easy to obtain measurements within a simulated ESS environment. Translation of this technology offers promise in a future clinical setting but will require further refinement to improve accuracy.

IntroductionRecent work has highlighted communication difficulties when wearing personal protective equipment (PPE) in the clinical setting, but currently, there are little objective data on its effects. We assessed the impact of PPE on verbal communication in a simulated operating room and evaluated use of an audio communication device.MethodologyFrontline health professionals across specialties including surgery, anesthetics, and nursing undertook speech discrimination testing with and without standardized levels of PPE in a simulated operating room environment. Background noise (30- and 70-a-weighted decibel multitalker babble) at 2 distances (2 and 4 m) were selected representative of operating room environments. Bamford-Kowal-Bench (BKB) scoring (192 sentences per participant) was performed. A Digital Multichannel Transceiver System (DMTS) was evaluated. We assessed the effects of PPE use, distance, and use of the DMTS with pairwise comparisons, using a Bonferroni correction, and assessed participant experience via Likert scales.ResultsThirty-one healthcare professionals were tested. Without PPE in 70-a-weighted decibel "babble," median BKB sentence scores were 90% and 76% at 2 and 4 m (adjusted P < 0.0005). The median BKB sentence scores dropped to 8% and 4% at 2 and 4 m in PPE (adjusted P < 0.0005). Improved speech discrimination was achieved with DMTS use to 70% and 76% at 2 and 4 m. Personal protective equipment led to a statistically significant reduction in BKB scores across all conditions compared with baseline. Overall participant confidence in PPE clinical communication was low.ConclusionsAddition of PPE dramatically impairs speech discrimination and communication in high levels of background noise characteristic of clinical environments, which can be significantly improved using DMTS. Measures should be taken by teams through both through reduction of background noise and consideration of assistive technologies maximizing patient safety. This may be further rehearsed in a simulation environment.

Paediatric voice disorders in the normal paediatric population ranges from 6% to 20%. We outline the important features in the initial evaluation of a persistent altered cry or voice in children and highlight the subsequent management currently used by ear, nose and throat (ENT) surgeons and speech and language therapists (SLTs). It is important to appreciate that there are stark differences between a child and adult larynx due to anatomical and physiological changes during development. The voice history elicited from both child and parent includes birth and developmental history, hearing, early feeding and respiratory function. Red flag symptoms or signs presenting with dysphonia include stridor, dysphagia, failure to thrive and recurrent chest infections. The most likely cause for dysphonia in children presenting to general paediatric practice and primary care will be secondary to laryngitis, hyperfunction and vocal cord nodules, and laryngopharyngeal reflux. Regarding treatment, in most cases a non-surgical option is preferred with voice therapy preferably delivered by a specialist paediatric voice SLT. The maximum effectiveness of behavioural or direct therapy is to children over 7 years, for in excess of 8 weeks with additional rigorous home rehearsal.

Simulation resources offer an opportunity to highlight aerosol dispersion within the operating room environment. We demonstrate our methodology with a supporting video that can offer operating room teams support in their practical understanding of aerosol exposure and the importance of personal protective equipment.

Objective This systematic review aims to provide an overview of the current evidence-base for paediatric surgical reinnervation in unilateral and bilateral vocal fold palsies in clinical practice. We aim to assess patient demographics, surgical technique and pre- and post-operative outcome measures. Methods A systematic literature review was performed and reported according to international PRISMA recommendations. A comprehensive search of PubMed, Embase, and Cochrane CENTRAL databases for relevant publications for all available dates with appropriate MESH search criteria was performed. Articles were categorised by four authors independently. A pooled summative analysis was carried out to allow review of demographic and outcome data. Results Our systematic PRISMA approach resulted in 19 papers being selected for inclusion and analysis with 179 patients undergoing reinnervation (153 unilateral, 26 bilateral). The youngest patient was 1.9 years. Iatrogenic injury to recurrent laryngeal nerve most common aetiology (65.4% and 19.2% of unilateral and bilateral vocal fold palsies, respectively). Patent ductus arteriosus ligation was the single most common procedure resulting in unilateral vocal fold palsies (43.1% of cases). Statistically significant improvements in subjective and objective outcomes for both voice and swallowing were seen. Meta-analysis was able to be performed on the particularly evident improvements in GRBAS score and Maximum Phonation Time (MPT). GRBAS scores improved by 3.64 ( p < 0.01, 95% CI 2.65 to 4.63). MPT showed a statistically significant improvement of 5.26 s ( p < 0.05, 95% CI 4.28 to 6.24). No major complications were reported. Conclusion The current published evidence on one-hundred and seventy-nine paediatric surgical reinnervation procedures demonstrates its role as a safe and effective treatment for both unilateral and bilateral vocal fold palsies. Anatomically it has been shown to improve vocal fold tone, bulk and position. Both post-operative voice and swallowing outcomes show improvement as well as associated quality of life measures.

IntroductionWithin the UK, the majority of paediatric tracheostomy care is delivered by parents and carers at home. To facilitate this, extensive in-hospital training is delivered by a variety of health care professionals. Our goal was to assess carer perceptions of this process and highlight areas in which we can further improve our service and the training for other hospital providers of paediatric tracheostomy care.MethodsA mixed method approach was adopted. In Phase I, qualitative data from five semi-structured interviews with carers of children with a tracheostomy were thematically analysed and subsequently used to develop a questionnaire. In Phase II, the piloted questionnaire was distributed via telephone, email or post to all eligible caregivers who had been tracheostomy trained at GOSH in the last three years (n = 92). Qualitative and quantitative data were analysed using thematic analysis and descriptive statistics respectively.ResultsThirty-five completed questionnaires were received (38% response rate). Overall participants were highly satisfied with the training provided (mean score 8.42 on a scale of 1 (lowest) to 10 (highest)). Carer identified areas requiring improvement were caregiver education pre-tracheostomy; emergency and complication training; supervision and training post hospital discharge; training schedule; emotional support; and support from community healthcare teams. These findings led to multiple subsequent interventions to further improve the carer training programme including training videos, psychology provision on request and increased community training.ConclusionAlthough the evaluation of the service revealed high participant satisfaction in home carer training overall, in-depth analysis of caregivers’ experiences indicated common themes in the tracheostomy training service where further support would be beneficial. A carer-centred rather than health professional focus on training needs will allow future attention to be directed to areas of need identified by carers themselves as important to improve the tracheostomy training programme.

OBJECTIVE(S):Medico-legal claims involving children place a substantial financial burden on health services and have a profound emotional and psychological impact on clinicians. Our objective was to analyze both the common causes and cost of litigation in pediatric otorhinolaryngology. METHODS:A retrospective review of all clinical negligence claims within pediatric otolaryngology (0-17 years inclusive) in NHS (National Health Service) England held by the clinical negligence service 'NHS Resolution between' 4/2013 and 4/2020. RESULTS:There were 100 claims in pediatric otorhinolaryngology accounting for an estimated potential total cost of just under £49 million with an average of 14 claims per year. Over half (52%) of claims were related to an operation with cause codes "Operator Error/Intra-Op Problem", "Diathermy Injury" and "Failure to Warn - Consent" most cited. The most common operation cited in a claim was tonsillectomy with an average cost per claim of £47,084. There were 21 claims coded as either "failure to diagnose" or "failure to treat" in relation to cholesteatoma, with an average cost per claim of £61,086. CONCLUSION:This is the largest study to date analyzing the reasons and potential cost of clinical negligence claims within pediatric otolaryngology. Many learning opportunities exist to reduce patient morbidity, mortality and improve the patient experience through litigation data analysis.

Objectives To assess paediatric patients referred to the cochlear implant team, who despite undergoing the assessment, did not receive cochlear implantation. To identify the underlying reasons for this. Methods A retrospective case-note review of patients was assessed from June 2014 to June 2019 at two separate London teaching hospitals with paediatric cochlear implantation programmes. Results A total of 921 paediatric patients were assessed during the study period across both institutions. And, 196 (21%) did not proceed with the surgery. The decision not to undergo surgery was primarily parental/patient-directed in 114 (61%) and cochlear implant team-directed in 74 (39%). In total, eight (4%) patients exited the programme without a documented reason. Discussion A myriad of factors influenced the decision-making process for clinicians, patients and parents. The most cited parental/patient rationale against implantation was the wish to continue current means of communication 40 (35%), followed by concern regarding the risks of surgery 18 (15.8%) and the wish to allow the patient to make future decisions independently in view of the future technology 7 (6.1%). Cochlear implant team-directed decisions were largely due to being outside of the NICE criteria 27 (36.5%) or the risks of general anaesthesia 19 (25.7%) in addition to communication concerns 11 (14.9%). Conclusion Decision-making in cochlear implantation should not be underestimated. Extensive discussion and exploration of options with the multi-disciplinary team can aid decision-making, but the timescale and appreciation of the consequences of the decision inevitably lead to pressure. Exploration of reasons for non-implantation emphasises the importance of a multi-professional approach to manage these patients.

Recent technological advances within aeronautical engineering have demonstrated the delivery of objective quantitative endoscopic measurements to within one-hundredth of a millimeter. We sought to validate this emerging laser technology in a simulation-based assessment of pediatric airway stenosis. A 4.4-mm flexible endoscope, incorporating a laser measurement system projecting 49 laser points into the endoscopic view, was used to assess a simulated model of subglottic stenosis. Multiple anteroposterior and lateral measurements were obtained for each stenosis and compared with standard airway assessment techniques. Intra- and interobserver reliability was assessed. A total of 240 multipoint laser measurements were obtained of simulated airway stenosis. The mean difference from manual measurement was 0.1886 mm. The Bland-Altman plot showed low bias (0.011) and narrow 95% limits of agreement (-0.46 to 0.48). This advanced endoscopic measurement technique shows great promise for clinical development to benefit ongoing assessment and treatment of evolving pediatric airway stenosis.

Sudden sensorineural hearing loss (SSNHL) is defined as hearing loss of ≥30 dB in one or both ears, developing within 3 days, affecting ≥3 contiguous frequencies. It is rare in children, but if untreated can cause significant morbidity. During the critical developmental period, it may cause lifelong social, behavioral, and mental sequelae. Currently, little guidance exists on prognosis and management within a pediatric population. A systematic literature review of pediatric SSNHL on PubMed, EMBASE, and the Cochrane CENTRAL database was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations. A total of 620 papers met the Medical Subject Headings criteria, of which 14 met analysis criteria-13 were level 4 and 1 was level 2b evidence. A population of 732 individuals was analyzed. Most reported cases of pediatric SSNHL were idiopathic. Other etiologies included viral infection, trauma, ototoxic drugs, and structural abnormalities. Recovery was defined as any improvement in hearing after the initial loss, from slight to complete. Recovery ranged from 20% to 100%, with a pooled rate of 56%. Systemic steroids were the mainstay of treatment, although salvage intratympanic steroid therapy had a role after the failure of systemic steroids. Children with bilateral SSNHL had poorer outcomes than those with unilateral loss, with 29% showing improvement. Two studies reported outcomes with no treatment, for which recovery rate was 7%. This analysis of SSNHL shows that 61% of children with unilateral and 29% of children with bilateral SSNHL demonstrate some recovery, a worse prognosis than adults. Multiple treatment regimens exist, although comparison is challenging owing to inconsistently reported improvement parameters.

Objective: Paediatric velopharyngeal insufficiency (VPI) is a known but rare complication following adenotonsillar surgery that can have significant adverse effects on the communication as well as psychological wellbeing of the patient and their family. We sought to assess risk factors, aetiology, assessment and management of these patients through a dedicated multidisciplinary clinic. Methods: Retrospective data collection was performed for patients seen in the Great Ormond Street Hospital for Children multidisciplinary VPI clinic from the 1st of January 2015 until 30th of April 2020. Paediatric patients with previous adenotonsillar surgery and no evidence of cleft palate or speech and language disorder were included in the study. Results: 29 patients met the inclusion criteria, with 16 having previous adenotonsillectomy and 13 isolated adenoidectomy. In our VPI clinic, patients were seen on average for 4.9 occasions over a 38.3-month period. Clinical assessment was conducted using GOS.SP.ASS '98 speech assessment tool, speech videofluoroscopy and nasoendoscopy, as per individual needs. The main cause of post-adenoidectomy VPI was identified in 72.5% of the cases. Speech videofluoroscopy was performed in 27 cases. Associated anatomic features identified included deep pharynx (37%), long palate (22.2%) and variable levator position. Severe hypernasality was noted in 3 patients, while in 20 cases moderate or mild hypernasality was found. There were no patients with normal speech. Ten patients were treated with speech therapy alone, whereas surgical intervention was required in seventeen cases. In the population who received treatment and had adequately recorded follow-up, improvement in speech was noted in 86.9%, with 30.4% having oral resonance on last review. Of the patients with severe hypernasality, all improved but had some persistent hyper nasality on last clinic review. Conclusions: We present our multidisciplinary management of post adenoidectomy VPI. Through the investigations in our dedicated specialist VPI clinic, the cause of VPI was found more frequently than in previous reports in the literature. Intense treatment is usually required with lengthy follow-up and multiple attendances in VPI clinic. Main modalities of management include SLT, surgery and speech prostheses. Most patients' speech will improve with intervention. We highlight the importance of early recognition, referral and a multidisciplinary approach in treating this condition. We advise ENT surgeons to ensure patients are adequately aware of this complication given its potential impact.

Introduction Stress may serve as an adjunct (challenge) or hindrance (threat) to the learning process. Determining the effect of an individual’s response to situational demands in either a real or simulated situation may enable optimisation of the learning environment. Studies of acoustic analysis suggest that mean fundamental frequency and formant frequencies of voice vary with an individual’s response during stressful events. This hypothesis is reviewed within the otolaryngology (ORL) simulation environment to assess whether acoustic analysis could be used as a tool to determine participants’ stress response and cognitive load in medical simulation. Such an assessment could lead to optimisation of the learning environment. Methodology ORL simulation scenarios were performed to teach the participants teamwork and refine clinical skills. Each was performed in an actual operating room (OR) environment (in situ) with a multidisciplinary team consisting of ORL surgeons, OR nurses and anaesthesiologists. Ten of the scenarios were led by an ORL attending and ten were led by an ORL fellow. The vocal communication of each of the 20 individual leaders was analysed using a long-term pitch analysis PRAAT software (autocorrelation method) to obtain mean fundamental frequency (F0) and first four formant frequencies (F1, F2, F3 and F4). In reviewing individual scenarios, each leader’s voice was analysed during a non-stressful environment (WHO sign-out procedure) and compared with their voice during a stressful portion of the scenario (responding to deteriorating oxygen saturations in the manikin). Results The mean unstressed F0 for the male voice was 161.4 Hz and for the female voice was 217.9 Hz. The mean fundamental frequency of speech in the ORL fellow (lead surgeon) group increased by 34.5 Hz between the scenario’s baseline and stressful portions. This was significantly different to the mean change of −0.5 Hz noted in the attending group (p=0.01). No changes were seen in F1, F2, F3 or F4. Conclusions This study demonstrates a method of acoustic analysis of the voices of participants taking part in medical simulations. It suggests acoustic analysis of participants may offer a simple, non-invasive, non-intrusive adjunct in evaluating and titrating the stress response during simulation.

Objectives: To determine the feasibility of micro-CT as a high-resolution 3D imaging tool for thyroglossal duct cysts and to evaluate its role augmenting traditional histopathological examination of resected specimens. Methods: A single centre, prospective case series of consecutive children undergoing excision of a thyroglossal duct cyst was performed at a quaternary paediatric referral hospital in the United Kingdom. Consecutive children listed for excision of a thyroglossal duct cyst whose parents agreed to participate were included and there were no exclusion criteria. Results: Surgically excised thyroglossal duct cyst or remnant specimens from five patients (two males, three females) were examined using micro-CT alongside traditional histopathological examination. In all cases, micro-CT imaging was able to demonstrate 3D imaging datasets of the specimens successfully and direct radio-pathological comparisons were made (Figures 1-5, Supplementary Video 1). Conclusions: The study has shown the feasibility and utility of post-operative micro-CT imaging of thyroglossal duct cysts specimens as a visual aid to traditional histopathological examination. It better informs the pathological specimen sectioning using multi-planar reconstruction and volume rendering tools without tissue destruction. In the complex, often arborised relationship between a thyroglossal duct cyst and the hyoid, micro-CT provides valuable image plane orientation and indicates proximity of the duct to the surgical margins. This is the first case series to explore the use of micro-CT imaging for pediatric thyroglossal duct specimens and it informs future work investigating the generalizability of micro-CT imaging methods for other lesions, particularly those from the head and neck region where precisely defining margins of excision may be challenging.

The COVID-19 pandemic worldwide has led to the establishment of a large number of field hospitals created to facilitate emergency intensive care facilities outside the routine hospital setting notably created in the USA, India and China. The Nightingale Hospital arose within a conference centre in London with an initial capacity of 500 ventilated beds and potentially 4000 patients in total based on initial forecasts. As part of the Nightingale Hospital, we faced the challenge of overseeing potential management of ventilated tracheostomy patients within this unique field hospital setting. Given the potential morbidity associated with tracheostomy care and specific care needs, a key …

Paediatric otolaryngology practice involves examining and operating in anatomical locations with high levels of aerosol generation and transmission of COVID-19 to treating clinicians, especially from the asymptomatic patient populations including children. During the COVID-19 pandemic all emergent otolaryngological conditions affecting the airway, oral, and nasal cavities should be managed medically where possible and any operating deferred. We present guidelines for operating on paediatric otolaryngological patients when necessary during the COVID-19 pandemic, and incorporate experience gathered during microlaryngobronchoscopy on a COVID-19 positive infant at our institution.

Objectives: Assess the clinical utility of an Endoscopic Integrated Multipoint Laser System (EMLS) to otology. This is an emerging technology from automotive engineering that may offer the ability to accurately measure anatomy and pathology using an endoscope while undertaking ear surgery. Patients: Simulated otology patients were used incorporating the Phacon Temporal Bone synthetic models and Kyoto Kagaku Ear Examination Simulator models to allow assessment of the EMLS technology in evaluating external ear and middle ear pathology, e.g., perforation or prosthesis sizing. Intervention: Eight otolaryngology resident and fellows at a tertiary university teaching hospital were given training in EMLS and reviewed simulated anatomy and pathology within the models including tympanic membrane perforation, ossicular discontinuity, and a cochleostomy. Main Outcome Measure: Variance in measurement was assessed in relation to those made manually by an independent surgeon using surgical calipers (0.1 mm). Results: The 8 participants produced 47 mean measurements. The mean difference from independently made manual measurement was 0.294 mm (standard error of the mean 0.033). Maximum variance was 0.98 mm and minimum 0.01 mm. Conclusion: Use of an integrated endoscopic laser measurement tool allows reliable, easy-to-obtain measurements to be obtained within a simulated otological surgical environment. Translation of the technology to a thinner delivery system through a rigid endoscope offers further promise for routine use in a clinical setting.

Objective This study evaluates the current evidence base for total endoscopic stapes surgery, specifically to establish current efficacy and safety of the technique within clinical practice. Data Sources A systematic review of the literature on endoscopic stapes surgery was performed according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analysis checklist. A comprehensive search of PubMed, Embase, and the Cochrane Central Register of Controlled Trials database for relevant publications for all available dates with appropriate Medical Subject Headings search criteria in January 2018. Study Selection Out of the 160 articles identified in the search, 14 met the inclusion criteria for further analysis. Four of these were level III and 10 level IV evidence. Data Extraction A pooled patient population of 314 individuals was analyzed. Data Synthesis Documented postoperative air bone gap closure to within 20 dB was found in 95.3% of individuals (285 patients). Facial nerve palsy (temporary) occurred in three patients (0.6%), with all recovering. No total sensorineural hearing losses were recorded, but two moderate sensorineural hearing losses occurred (0.6%). Perilymph fistula was noted on four occasions (1.3%). Chorda tympani trauma was documented in 3.5% of cases, with taste disturbance documented in 13 patients (5%). Conclusions Our pooled analysis uses the current published evidence to establish the complication rate and audiological outcome for the endoscopic approach to stapes surgery. These outcomes are comparable to those documented in traditional use of the microscope for stapedectomy. Laryngoscope , 130:1282–1286, 2020