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.

Cerebrospinal fluid rhinorrhoea takes place when there is a breakdown of the barriers separating the nasal cavity from the subarachnoid space. The aim of this study was to assess the surgical outcomes of endoscopic transnasal cerebrospinal fluid leak repair with and without fibrin glue.

There were 43 patients with cerebrospinal fluid rhinorrhoea who underwent surgery for cerebrospinal fluid leak repair between 2014 and 2018. Patients were divided into group A, where fibrin glue was used, and group B, where fibrin glue was not used.

It was found that 74.4 per cent of cases were due to spontaneous cerebrospinal fluid leak. The most common site of a leak was the cribriform plate (65 per cent). There was a success rate of 96.1 per cent (25 of 26) in group A and 83 per cent (15 of 17) in group B. There was no statistically significant difference between the results of the two groups (chi-square test: p = 0.31).

There was no statistically significant difference in the results of cerebrospinal fluid leak repair with and without fibrin glue.

This study aimed to determine the knowledge of first year health sciences students at a South African university regarding hearing loss and symptoms attributable to personal listening devices and their practices concerning the use of personal listening devices.

This was a cross-sectional study carried out using an anonymous self-administered questionnaire.

Of 336 students, 269 (80.1 per cent) completed the questionnaire. While most participants could identify symptoms that could be caused by extensive use of personal listening devices, almost 30 per cent did not know that it could cause permanent hearing loss. Personal listening devices were used by 90.7 per cent of participants, with 77.8 per cent having used them for more than five years. Use was at a high volume in 14.9 per cent of participants and for more than 2 hours per day in 52.7 per cent.

The findings indicate the need for an educational programme to inform students as to safe listening practices when using personal listening devices.

Understanding the pattern of middle-ear cholesteatoma becomes pertinent with the rise of endoscopic surgery as surgeons decide on the optimal approach to visualise and extirpate disease. With modifications to the Telmesani attic–tympanum–mastoid staging system, this study aimed to evaluate the commonest patterns of middle-ear cholesteatoma and their implications for surgical approach.

A retrospective study was conducted in a single tertiary institution in Singapore. All patients undergoing cholesteatoma surgery between January 2012 and June 2015 were included. Staging of cholesteatoma was based on clinical assessment corroborated by radiological findings.

Out of the 55 ears included, 98.2 per cent had cholesteatoma involving the attic. The disease extended into the mastoid antrum and beyond in 43 cases (78.2 per cent). The facial recess and/or sinus tympanum was affected in 26 cases (47.3 per cent).

The majority of cholesteatoma cases present with extensive attic disease and significant mastoid involvement. In these cases, endoscopes may be best suited to adjunctive rather than exclusive use in surgery.

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.

The World Health Organization declared coronavirus disease 2019 a pandemic on 11th March 2020. There is concern regarding performing endonasal surgical procedures because of a high viral load in the nasopharynx. This paper describes our experience in conducting emergency and urgent endonasal operations during the peak of the coronavirus disease 2019 pandemic in the UK.

To show the outcome of endonasal surgery during the peak of the coronavirus disease 2019 pandemic and to assess the post-operative rate of nosocomial coronavirus disease 2019 infection.

A retrospective cohort study was conducted of all patients who underwent high priority endoscopic nasal surgery or anterior skull base surgery between 23rd March and 15th June 2020 at University Hospitals Birmingham NHS Trust.

Twenty-four patients underwent endonasal surgery during the study period, 12 were males and 12 were females. There was no coronavirus-related morbidity in any patient.

This observational study found that it is possible to safely undertake urgent endonasal surgery; the nosocomial risk of coronavirus disease 2019 can be mitigated with appropriate peri-operative precautions.

To determine sociodemographic factors associated with occupational, recreational and firearm-related noise exposure.

This nationally representative, multistage, stratified, cluster cross-sectional study sampled eligible National Health and Nutrition Examination Survey participants aged 20–69 years (n = 4675) about exposure to occupational and recreational noise and recurrent firearm usage, using a weighted multivariate logistic regression analysis.

Thirty-four per cent of participants had exposure to occupational noise and 12 per cent to recreational noise, and 13 per cent repeatedly used firearms. Males were more likely than females to have exposure to all three noise types (adjusted odds ratio range = 2.63–14.09). Hispanics and Asians were less likely to have exposure to the three noise types than Whites. Blacks were less likely than Whites to have occupational and recurrent firearm noise exposure. Those with insurance were 26 per cent less likely to have exposure to occupational noise than those without insurance (adjusted odds ratio = 0.74, 95 per cent confidence interval = 0.60–0.93).

Whites, males and uninsured people are more likely to have exposure to potentially hazardous loud noise.

This study aimed to evaluate surgical and functional outcomes, in a tertiary referral centre, of two different types of semi-implantable transcutaneous bone conduction devices.

This study involved prospective data collection and review of patients implanted between November 2014 and December 2016. Glasgow Hearing Aid Inventory (Glasgow Hearing Aid Benefit Profile or Glasgow Hearing Aid Difference Profile) and Client Oriented Scale of Improvement were completed where appropriate. Surgical and audiological outcomes were recorded in the surgical notes.

Glasgow Hearing Aid Difference Profile and Glasgow Hearing Aid Benefit Profile showed similar mean score in the active and the passive transcutaneous bone conduction devices. Client Oriented Scale of Improvement showed improvements in listening situations. Post-operative speech reception threshold showed better mean threshold in the active transcutaneous bone conduction devices group when compared with the passive transcutaneous bone conduction devices group. No device failures or surgical complications existed in either group, with the surgical time being less in the passive transcutaneous bone conduction devices group.

Both devices are reliable semi-implantable transcutaneous bone conduction devices with excellent surgical and functional outcomes and patient satisfaction. Overall surgical time was much less in the passive transcutaneous bone conduction devices group with no necessity for pre-planning. This is much easier to remove with the possibility of conversion to other devices in the manufacturer’s portfolio and wide-ranging wireless accessories. Further studies are needed to assess the longer-term results in a bigger population.

To predict skull base osteomyelitis in patients with necrotising otitis externa using diffusion-weighted imaging.

A retrospective analysis was conducted of 25 necrotising otitis externa patients with skull base osteomyelitis (n = 10) or without skull base involvement (n = 14) who underwent a single-shot diffusion-weighted imaging of the skull base.

The respective mean apparent diffusion coefficient values of the skull base, as determined by two reviewers, were 0.851 ± 0.15 and 0.841 ± 0.14 ×10-3mm2/s for the skull base osteomyelitis patients, and 1.065 ± 0.19 and 1.045 ± 0.20 ×10-3mm2/s for the necrotising otitis externa patients without skull base involvement. The difference in apparent diffusion coefficients between the groups was significant, for both reviewers (p = 0.008 and 0.012). The optimal threshold apparent diffusion coefficient for predicting skull base osteomyelitis in necrotising otitis externa patients was 0.945 ×10-3mm2/s and 0.915 ×10-3mm2/s, with an area under the curve of 0.825 and 0.800, accuracy of 87.5 and 83.3 per cent, sensitivity of 85.7 and 90.0 per cent, and specificity of 90.0 and 78.6 per cent, for each reviewer respectively.

Apparent diffusion coefficient is a non-invasive imaging parameter useful for predicting skull base osteomyelitis in necrotising otitis externa patients.

The aim of this study was to compare the differences between the no tympanomeatal flap approach and the tympanomeatal flap approach in endoscopic myringoplasty.

A total of 132 patients with tympanic membrane perforation were randomly divided into two groups: the no tympanomeatal flap approach group (group A, 56 ears) and the tympanomeatal flap approach group (group B, 76 ears). A comparison between the two groups was made.

The average operation time of group A was 36.00 ± 5.24 minutes, which was significantly shorter than that of group B, which was 43.89 ± 4.57 minutes (p = 0.002). The blood loss of group A was 5.08 ± 1.83 ml, which was significantly less than that of group B (9.67 ± 2.29 ml; p < 0.001). There were no differences in the degree of hearing improvement, the rate of hearing improvement, the dry ear time (when the external auditory canal and the operating cavity were dry) after operation and the success rate of tympanic membrane repair when compared between the two groups.

Compared with group B, group A (no tympanomeatal flap approach) can achieve the same effect but has the advantages of a shorter operation time and less blood loss during the operation.

Given the lack of evidence on patients with medically refractory vestibular migraine, this study aimed to identify factors associated with pharmacotherapy failure and progression to botulinum toxin injection in vestibular migraine.

A retrospective cohort study was conducted on definite vestibular migraine patients from September 2015 to July 2019 who completed the Dizziness Handicap Inventory at least six weeks apart..

The study comprised 47 patients (mean age = 50.2 ± 15.8 years), with a mean follow-up time of 6.0 ± 6.0 months. The mean pre-treatment Dizziness Handicap Inventory score was 57.5 ± 23.5, with a mean reduction of 17.3 ± 25.2 (p < 0.001) at last follow up. Oscillopsia (r = 0.458, p = 0.007), failure of first medication (r = 0.518, p = 0.001) and pre-treatment Dizziness Handicap Inventory question 15 (an emotional domain question) score (r = 0.364, p = 0.019) were the only variables significantly correlated with progression to botulinum toxin injection.

Motion hypersensitivity, failure of first medication, and fear of social stigmatisation suggest a decreased treatment response. These symptoms may require more aggressive treatment at an earlier stage.

Rate of learning is often cited as a deterrent in the use of endoscopic ear surgery. This study investigated the learning curves of novice surgeons performing simulated ear surgery using either an endoscope or a microscope.

A prospective multi-site clinical research study was conducted. Seventy-two medical students were randomly allocated to the endoscope or microscope group, and performed 10 myringotomy and ventilation tube insertions. Trial times were used to produce learning curves. From these, slope (learning rate) and asymptote (optimal proficiency) were ascertained.

There was no significant difference between the learning curves (p = 0.41). The learning rate value was 68.62 for the microscope group and 78.71 for the endoscope group. The optimal proficiency (seconds) was 32.83 for the microscope group and 27.87 for the endoscope group.

The absence of a significant difference shows that the learning rates of each technique are statistically indistinguishable. This suggests that surgeons are not justified when citing ‘steep learning curve’ in arguments against the use of endoscopes in middle-ear surgery.

Endoscopes provide a magnified view of the middle ear and visualisation of hidden areas. Otoendoscopes facilitate excellent visualisation of the round window niche during cochlear implantation.

To compare microscopic and endoscopic visualisation of the round window membrane during cochlear implantation in 20 patients.

Twenty patients who underwent cochlear implantation were included in the study. After maximum exposure of the round window, the accessibility of the round window membrane was graded according to the St Thomas Hospital classification, first by microscope and then by endoscope.

With the use of the endoscope, visualisation of the round window membrane improved in all the patients as compared to the microscope. The electrode array was inserted via a round window or extended round window approach in all but two cases; the latter cases required bony cochleostomy because of unfavourable anatomy.

The main benefit of endoscope-assisted cochlear implantation is improved visibility of the round window region.

The coronavirus disease 2019 pandemic has necessitated almost exclusive National Health Service focus on emergency work and cancer care. There are concerns that increased hospital and community pressures will lead to decreased referrals and worse outcomes for head and neck cancer patients.

This is a retrospective review of all cases referred for suspected head and neck cancer to our institution in January and April 2020.

There was a 55 per cent decrease in referrals but diagnostic yield rose from 2.9 per cent in January to 8.06 per cent in April. In both months, 100 per cent of patients met the 31- and 62-day targets, with similar 14-day wait time success (97.83 per cent for January vs 98.33 per cent for April). Referrals for laryngopharyngeal reflux rose from 27.5 per cent to 41.9 per cent. Referrals for those aged over 60 years fell from 42 per cent to 26 per cent.

It is suggested that further research be conducted into the reasons why fewer patients were referred, particularly elderly patients, and why laryngopharyngeal reflux is so prevalent in fast-track referrals.

To ascertain the distribution of Ménière's disease phenotype subgroups in a US-based cohort, based on a recently introduced classification scheme utilising a Spanish and Portuguese cohort.

A retrospective, cross-sectional, single-institutional chart review was conducted. The electronic medical records of Ménière's disease patients were identified using International Classification of Diseases codes at a tertiary referral centre and reviewed to extract subgroup-defining features. Patients with definite Ménière's disease as per American Academy of Otolaryngology–Head and Neck Surgery criteria were categorised into one of five subgroups, for unilateral and bilateral Ménière's disease.

Eighty-one patients with definite Ménière's disease were identified. Seventy-two cases of unilateral Ménière's disease were observed: 52.8 per cent were type 1, 20.8 per cent were type 2, 4.2 per cent were type 3, 18.1 per cent were type 4, and 4.2 per cent were type 5. This cohort differed significantly in distribution to a comparison Mediterranean cohort (p < 0.01). Nine cases of bilateral Ménière's disease were observed.

The distribution of unilateral Ménière's disease subtypes in this US population was different from that observed in a European population.

Individuals on anticoagulation therapy are at increased risk of bleeding, including epistaxis. There is a lack of available reversal agents for novel oral anticoagulation therapy.

This paper reviews the current literature on epistaxis in the context of novel oral anticoagulation use, in order to recommend guidelines on management.

A comprehensive search of published literature was conducted to identify all relevant articles published up to April 2019.

Patients on oral anticoagulation therapy are over-represented in individuals with epistaxis. Those on novel oral anticoagulation therapy were more likely to relapse compared to patients on classic oral anticoagulants or non-anticoagulated patients. Idarucizumab is an effective antidote for bleeding associated with dabigatran use. Recommendations for epistaxis management in patients on novel oral anticoagulation therapy are outlined.

Clinicians need to be aware of the potential severity of epistaxis and the increased likelihood of recurrence. High-quality studies are required to determine the efficacy and safety of andexanet alfa and ciraparantag, as well as non-specific reversal agents.

The nasal septal swell body is a normal anatomical structure located in the superior nasal septum anterior to the middle turbinate. However, the impact of the septal swell body in nasal breathing during normal function and disease remains unclear. This study aimed to establish that the septal swell body varies in size over time and correlates this with the natural variation of the inferior turbinates.

Consecutive patients who underwent at least two computed tomography scans were identified. The width and height of the septal swell body and the inferior turbinates was recorded. A correlation between the difference in septal swell body and turbinates between the two scans was performed using a Pearson's coefficient.

A total of 34 patients (53 per cent female with a mean age of 58.3 ± 20.2 years) were included. The mean and mean difference in septal swell body width between scans for the same patient was 1.57 ± 1.00 mm. The mean difference in turbinate width between scans was 2.23 ± 2.52 mm. A statistically significant correlation was identified between the difference in septal swell body and total turbinate width (r = 0.35, p = 0.04).

The septal swell body is a dynamic structure that varies in width over time in close correlation to the inferior turbinates. Further research is required to quantify its relevance as a surgical area of interest.

The aim of the present study was to evaluate the surgical and functional results of endoscopic butterfly-inlay cartilage myringoplasty and endoscopic push-through myringoplasty in the treatment of anterior perforation of the tympanic membrane.

This open-label randomised clinical study was conducted on 71 patients with small- and medium-sized anterior perforations of the tympanic membrane. Graft success rate, hearing results, operative time and complications were analysed.

Graft success rates for endoscopic butterfly-inlay cartilage myringoplasty and endoscopic push-through myringoplasty were 94.1 and 91.8 per cent, respectively (p > 0.05). Post-operative air–bone gap values significantly improved in both the endoscopic butterfly-inlay cartilage myringoplasty and endoscopic push-through myringoplasty groups. The average operative time was significantly shorter in the endoscopic butterfly-inlay cartilage myringoplasty group (31.5 minutes) compared to the endoscopic push-through myringoplasty group (41.7 minutes; p < 0.05).

When compared with the endoscopic push-through myringoplasty, the endoscopic butterfly-inlay cartilage myringoplasty technique, which is technically easier to perform, does not require packing and has a shorter operating time. It is a reasonable approach for repair of anterior perforations of the tympanic membrane.

To report feasibility, early outcomes and challenges of implementing a 14-day threshold for undertaking surgical tracheostomy in the critically ill coronavirus disease 2019 patient.

Twenty-eight coronavirus disease 2019 patients underwent tracheostomy. Demographics, risk factors, ventilatory assistance, organ support and logistics were assessed.

The mean time from intubation to tracheostomy formation was 17.0 days (standard deviation = 4.4, range 8–26 days). Mean time to decannulation was 15.8 days (standard deviation = 9.4) and mean time to intensive care unit stepdown to a ward was 19.2 days (standard deviation = 6.8). The time from intubation to tracheostomy was strongly positively correlated with: duration of mechanical ventilation (r(23) = 0.66; p < 0.001), time from intubation to decannulation (r(23) = 0.66; p < 0.001) and time from intubation to intensive care unit discharge (r(23) = 0.71; p < 0.001).

Performing a tracheostomy in coronavirus disease 2019 positive patients at 8–14 days following intubation is compatible with favourable outcomes. Multidisciplinary team input is crucial to patient selection.

Fungal otitis externa is prevalent in tropical and sub-tropical climates; however, over the past two decades, there has been a reported increase in the prevalence of otomycosis in paediatric patients from more temperate climates. This study aimed to review the children diagnosed with otomycosis at the University Hospital Limerick with reference to frequency, causative organism, predisposing factors and management.

A retrospective review was conducted of paediatric patients from 2001 to 2015. Patients with positive fungal ear swabs and a diagnosis of otomycosis were identified.

Ninety-three patients were positive for candida (mean age, 5.8 years), 10 patients were positive for aspergillus (mean age, 9.1 years) and 1 patient had mixed fungal infection containing both fungi. There was a positive correlation between a diagnosis of otomycosis and prior treatment with topical fluoroquinolones (r = 0.8; p < 0.01).

The incidence of otomycosis has been increasing since 2001, which correlates with an increase in the use of topical fluoroquinolones. Previous studies identify aspergillus as the commonest causative fungi; however, this study found that candida was the commonest isolated fungi in the paediatric population.