This paper discusses the concept of acoustic shock based on a literature review and the results of our own research into cases seen in both clinical and medicolegal practice. With the demise of traditional ‘metal bashing’ and ‘smoke stack’ heavy industries, there has been a decline in the incidence of noise-induced hearing loss and tinnitus in this form of employment. However, with the increasing establishment of call centre work, the emergence of acoustic shock has been noted. Acoustic shock is recognised as a clinical entity distinct from noise-induced hearing loss and acoustic trauma.

This article discusses clinical implications, medicolegal considerations in light of a recent high-profile court case and proposed criteria for diagnosis.

Coronavirus disease 2019 has had a dramatic effect on society and healthcare. Preparations were based on predictive models of need, and with uncertainty regarding risk to patients and healthcare workers. Actions taken had both immediate and ongoing ethical impacts. The most obvious of these was the shift in duty of care from individual patients to public health centred ethics and decision making.

In ENT, many procedures are aerosol-generating and so our capacity to provide care will remain significantly reduced. This reduction in capacity may result in difficult choices for patients when optimal care may be replaced by acceptable care. ENT surgeons may also be faced with unaccustomed paternalism when capacity prevents them from acting within the patients’ wishes.

Despite these challenges, the novel uses of technology highlight the desire to preserve and enhance the autonomy of our patients.

Nodal metastasis in salivary gland malignancies has important clinical implications; a good understanding of their complex anatomy is paramount to the head and neck surgeon.

A contemporary and comprehensive literature review was conducted of the lymphatic drainage of the salivary glands, with special emphasis on its surgical applications.

The parotid gland has extraglandular and intraglandular nodes acting as a single functional drainage unit. Intraglandular parotid notes are unique to the parotid gland, and consist of a larger superficial group and a smaller deep group. The presence of intraglandular submandibular nodes, as described by early anatomists, is much debated nowadays. The sublingual glands drain to the lingual lymph nodes, which are divided into median, intermediate and lateral groups.

This review highlights the complex arrangements of lymph nodes draining the salivary glands. It may provide a valid anatomical explanation for the nodal metastasis patterns commonly seen in salivary gland malignancy.

The current coronavirus disease 2019 pandemic has caused unprecedented challenges to surgical training across the world. With the widespread cancellations of clinical and academic activities, educators are looking to technological advancements to help ‘bridge the gap’ and continue medical education.

Simulation-based training as the ‘gold standard’ for medical education has limitations that prevent widespread adoption outside suitably resourced centres. Virtual reality has the potential to surmount these barriers, whilst fulfilling the fundamental aim of simulation-based training to provide a safe, effective and realistic learning environment.

The main limitations of virtual reality technology include comfort and the restrictive power of mobile processors. There exists a clear developmental path to address these restrictions. Continued developments of the hardware and software set to deepen immersion and widen the possibilities within surgical education.

In the post coronavirus disease 2019 educational landscape, virtual, augmented and mixed reality technology may prove invaluable in the training of the next generation of surgeons.

Chronic suppurative otitis media is a major cause of disabling childhood hearing loss, especially in low-income countries. Estimates on its prevalence in sub-Saharan Africa range from the lowest to the highest in the world (less than one per cent to more than five per cent). However, the prevalence of chronic suppurative otitis media in Zimbabwe is largely unknown. This study aimed to determine the prevalence of paediatric chronic suppurative otitis media and other middle-ear pathology in rural Zimbabwe.

A cross-sectional study was performed in primary school children aged 4–13 years from the rural province of Mashonaland East. Participants underwent video otoscopy and tympanometry.

Out of 451 examined children, two (0.4 per cent) had chronic suppurative otitis media. Acute otitis media was present in one (0.2 per cent), otitis media with effusion was present in five (1.1 per cent) and scarring was present in 69 (15.3 per cent).

Chronic suppurative otitis media and otitis media sequelae were surprisingly uncommon in this sample of rural primary school children in Zimbabwe. More studies, preferably population-based, are needed to enable more precise estimates of chronic suppurative otitis media prevalence in Zimbabwe.

Peri-orbital surgical emphysema is a rare complication that can occur after lacrimal surgery. It has only been described in isolated cases, following external dacryocystorhinostomy (n = 2) and Lester Jones tube insertion (n = 1).

A retrospective, non-comparative case series was conducted of patients who developed surgical emphysema following endoscopic dacryocystorhinostomy.

A total of 356 endoscopic dacryocystorhinostomy cases (primary, n = 316; revision, n = 40) were performed over a six-year period. Seven cases of post-operative surgical emphysema were identified, all of which were preceded by uncontrolled sneezing, nose-blowing or coughing within the first week of surgery. The occurrence of surgical emphysema post-endoscopic dacryocystorhinostomy in our centre was 7 in 356, or 2 per cent, over six years.

This is the first study to report the occurrence of surgical emphysema post-endoscopic dacryocystorhinostomy. Clinicians may wish to suggest patients stifle the aforementioned triggers within the first week to reduce the potential for surgical emphysema.

This study aimed to describe the microscopic over-under cartilage tympanoplasty technique, provide hearing results and detail clinically significant complications.

This was a retrospective case series chart review study of over-under cartilage tympanoplasty procedures performed by the senior author between January 2015 and January 2019 at three tertiary care centres. Cases were excluded for previous or intra-operative cholesteatoma, if a mastoidectomy was performed during the procedure or if ossiculoplasty was performed. Hearing results and complications were obtained.

Sixty-eight tympanoplasty procedures met the inclusion criteria. The median age was 13 years (range, 3–71 years). The mean improvement in pure tone average was 6 dB (95 per cent confidence interval 4–9 dB; p < 0.0001). The overall perforation closure rate was 97 per cent (n = 66). Revision surgery was recommended for a total of 6 cases (9 per cent) including 2 post-operative perforations, 1 case of middle-ear cholesteatoma and 3 cases of external auditory canal scarring.

Over-under cartilage tympanoplasty is effective at improving clinically meaningful hearing with a low rate of post-operative complications.

Post-tonsillectomy bleeding is the most frequent complication of tonsillectomy. Inherited platelet function disorders have an estimated prevalence of 1 per cent. Any association between post-tonsillectomy bleeds and undiagnosed inherited platelet function disorders has not been investigated before.

To assess the prevalence of inherited platelet function disorders in a cohort of post-tonsillectomy bleed patients.

An observational cohort study was conducted using hospital digital records. Platelet function analyser 100 (‘PFA-100’) closure time was tested on post-tonsillectomy bleed patients who presented to hospital.

Between 2013 and 2017, 9 of 91 post-tonsillectomy bleed patients who underwent platelet function analyser 100 testing (9.89 per cent) had positive results. Five patients (5.49 per cent) had undiagnosed inherited platelet function disorders. Four patients had false positive results secondary to a non-steroidal anti-inflammatory drug effect (specificity of 95.3 per cent) proven by repeat testing six weeks later, off medication. The false negative rate was 0 per cent.

The prevalence of inherited platelet function disorders in our post-tonsillectomy bleed cohort is five-fold higher than in the general population. Platelet function analyser 100 testing when patients present with a post-tonsillectomy bleed allows management of their inherited platelet function disorder.

To determine the radiological prevalence of frontal cells according to the International Frontal Sinus Anatomy Classification in patients undergoing computed tomography of the paranasal sinuses for clinical symptoms of chronic rhinosinusitis, and to examine the association between cell classification and frontal sinusitis development.

A total of 180 (left and right) sides of 90 patients were analysed. The prevalence of each International Frontal Sinus Anatomy Classification cell was assessed. Logistic regression analysis was used to compare the distribution of various cells in patients with and without frontal sinusitis.

The agger nasi cell was the most commonly occurring cell, seen in 95.5 per cent of patients. The prevalence rates for supra agger cells, supra agger frontal cells, supra bullar frontal cells, supra bullar cells, supra-orbital ethmoid cells and frontal septal cells were 33.3 per cent, 22.2 per cent, 21.1 per cent, 36.1 per cent, 39.4 per cent and 21.1 per cent, respectively. There was no significant difference in the occurrence of any of the cell types in patients with frontal sinusitis compared to those without (p > 0.05).

The presence of any of the International Frontal Sinus Anatomy Classification cells was not significantly associated with frontal sinusitis.

The current circumstances of the coronavirus disease 2019 pandemic necessitate the use of personal protective equipment in hospitals. N95 masks and face shields are being used as personal protective equipment to protect from aerosol-related spread of infection. Personal protective equipment, however, hampers communication. This study aimed to assess the effect of using an N95 mask and face shield on speech perception among healthcare workers with normal hearing.

Twenty healthcare workers were recruited for the study. Pure tone audiometry was conducted to ensure normal hearing. Speech reception threshold and speech discrimination score were obtained, first without using personal protective equipment and then repeated with the audiologist wearing an N95 mask and face shield.

A statistically significant increase in speech reception threshold (mean of 12.4 dB) and decrease in speech discrimination score (mean of 7 per cent) was found while using the personal protective equipment.

Use of personal protective equipment significantly impairs speech perception. Alternate communication strategies should be developed for effective communication.

To investigate the value of narrow-band imaging training for differentiating between benign and malignant vocal fold leukoplakia.

Thirty cases of vocal fold leukoplakia were selected.

Narrow-band imaging endoscopy training had a significant positive effect on the specificity of the differential diagnosis of vocal fold leukoplakia. In addition, the consistency of diagnostic typing of vocal fold leukoplakia by narrow-band imaging improved to ‘moderate agreement’ following the combination of types I and II and the combination of types IV, V and VI in the typing of vocal fold leukoplakia.

The narrow-band imaging training course may improve the ability of laryngologists to diagnose vocal fold leukoplakia. The new endoscopic diagnostic classification by narrow-band imaging needs to be further simplified to facilitate clinical application.

An increase in spontaneous lower motor neuron facial nerve (VIIth cranial nerve) palsies was seen during the severe acute respiratory syndrome coronavirus 2 outbreak in our emergency clinic. This led us to perform a single-centre cohort review.

A retrospective review was conducted of VIIth cranial nerve palsies from January to June 2020 and the findings were compared to those cases reviewed in the previous year. The severe acute respiratory syndrome coronavirus 2 incidence of the cohort was compared with that of the Liverpool population.

Our VIIth cranial nerve palsy incidence in the 2020 period was 3.5 per cent (30 out of 852), 2.7 higher than last year's rate of 1.3 per cent (14 out of 1081), which was a statistically significant difference (p < 0.01). Two of the 17 patients in our cohort tested positive for severe acute respiratory syndrome coronavirus 2 (11.8 per cent), contrasting with Liverpool's severe acute respiratory syndrome coronavirus 2 incidence (0.5 per cent).

Severe acute respiratory syndrome coronavirus 2 may be responsible for an increased number of facial nerve palsies; it is important for clinicians to be aware that this may being an initial presentation of the disease.

To assess intubation management in difficult airway patients by performing a multidisciplinary pre-operative examination of the airway using a flexible fibre-optic laryngoscope.

Patients with a known but stable difficult airway were evaluated prior to surgery in the pre-operative holding suite by both an ENT surgeon and an anaesthesiologist via a fibre-optic laryngeal examination.

Performing a pre-operative fibre-optic examination of the difficult airway led to a change in intubation strategy in 6 out of 12 cases. Intubation ‘first-pass’ success occurred in 9 out of 12 (75 per cent) of our patients.

By performing a multidisciplinary airway examination immediately prior to surgery, a safe plan to intubate on the initial attempt was developed. This resulted in improved first-pass success at intubation compared to historical data.

Nasal obstruction when lying down is a common complaint in patients with chronic nasal obstruction, but rhinomanometry is typically performed in the sitting position. This study aimed to analyse whether adding rhinomanometry in a supine position is a useful examination.

A total of 41 patients with chronic nasal obstruction underwent rhinomanometry and acoustic rhinometry, sitting and supine, before and after decongestion, as well as an over-night polygraphy.

Total airway resistance was measurable in a supine position in 48 per cent (14 of 29) of the patients with total airway resistance of equal to or less than 0.3 Pa/cm3/second when sitting and in none (0 of 12) of the patients with total nasal airway resistance of more than 0.3 Pa/cm3/second when sitting. After decongestion, this increased to 83 per cent and 58 per cent, respectively.

Increased nasal resistance when sitting predicts nasal breathing problems when supine. Rhinomanometry in a supine position should be performed to diagnose upper airway collapse when supine.

There are sparse data on the outcomes of endoscopic stapling of pharyngeal pouches. The Mersey ENT Trainee Collaborative compared regional practice against published benchmarks.

A 10-year retrospective analysis of endoscopic pharyngeal pouch surgery was conducted and practice was assessed against eight standards. Comparisons were made between results from the tertiary centre and other sites.

A total of 225 procedures were performed (range of 1.2–9.2 cases per centre per year). All centres achieved 90 per cent resumption of oral intake within 2 days. All centres achieved less than 2-day hospital stays. Primary success (84 per cent (i.e. abandonment of endoscopic stapling in 16 per cent)), symptom resolution (83 per cent) and recurrence rates (13 per cent) failed to meet the standard across the non-tertiary centres.

Endoscopic pharyngeal pouch stapling is a procedure with a low mortality and brief in-patient stay. There was significant variance in outcomes across the region. This raises the question of whether this service should become centralised and the preserve of either tertiary centres or sub-specialist practitioners.

The aim of this study was to investigate the clinical effect of the removal of nasal vestibular cysts through a modified longitudinal incision via a transoral sublabial approach.

In 28 cases, a nasal vestibular cyst was removed through a modified longitudinal incision via a transoral sublabial approach. A visual analogue scale score was used to evaluate the numbness of the nasal alar and upper lip. Post-operative complications were recorded. Medical photographs were used for assessment.

For all patients, incisions reached clinical primary healing one week after surgery. All patients were free of post-operative haematoma, infection, oronasal fistula and malformation. In the first week and the first month after surgery, numbness of the nasal alar and upper lip was recorded in few cases. The patients were followed up for 2–57 months without recurrence.

Removal of nasal vestibular cysts via a transoral sublabial approach with a modified longitudinal incision is a minimally invasive and simple surgical method with few complications and a quick recovery.

Post-auricular mastoid fistula is a rare occurrence. It typically appears following repeated soft tissue injury, and is commonly caused by chronic suppurative otitis media and repeated surgical treatments. Management is challenging, with few reported successful surgical techniques, which often have limited applicability.

This paper presents the case of a 58-year-old male with a persistent right-sided post-auricular cutaneous mastoid fistula resulting from two previous mastoidectomies. Although the patient underwent two simple primary closures, the fistula recurred. This was successfully treated with a new technique utilising a sternocleidomastoid rotational and cervical-fascial advancement flap, which was completely healed at the one-year follow up without a recurrence of the fistula.

This novel technique provided definitive obliteration of a persistent cutaneous mastoid fistula. Utilising a double-layered flap and a facelift incision results in excellent functional and cosmetic outcomes.