• A specialist dietitian should be part of the multidisciplinary team for treating head and neck cancer patients throughout the continuum of care as frequent dietetic contact has been shown to have enhanced outcomes. (R)

• Patients with head and neck cancer should be nutritionally screened using a validated screening tool at diagnosis and then repeated at intervals through each stage of treatment. (R)

• Patients at high risk should be referred to the dietitian for early intervention. (R)

• Offer treatment for malnutrition and appropriate nutrition support without delay given the adverse impact on clinical, patient reported and financial outcomes. (R)

• Use a validated nutrition assessment tool (e.g. scored Patient Generated–Subjective Global Assessment or Subjective Global Assessment) to assess nutritional status. (R)

• Offer pre-treatment assessment prior to any treatment as intervention aims to improve, maintain or reduce decline in nutritional status of head and neck cancer patients who have malnutrition or are at risk of malnutrition. (G)

• Patients identified as well-nourished at baseline but whose treatment may impact on their future nutritional status should receive dietetic assessment and intervention at any stage of the pathway. (G)

• Aim for energy intakes of at least 30 kcal/kg/day. As energy requirements may be elevated post-operatively, monitor weight and adjust intake as required. (R)

• Aim for energy and protein intakes of at least 30 kcal/kg/day and 1.2 g protein/kg/day in patients receiving radiotherapy or chemoradiotherapy. Patients should have their weight and nutritional intake monitored regularly to determine whether their energy requirements are being met. (R)

• Perform nutritional assessment of cancer patients frequently. (G)

• Initiate nutritional intervention early when deficits are detected. (G)

• Integrate measures to modulate cancer cachexia changes into the nutritional management. (G)

• Start nutritional therapy if undernutrition already exists or if it is anticipated that the patient will be unable to eat for more than 7 days. Enteral nutrition should also be started if an inadequate food intake (60 per cent of estimated energy expenditure) is anticipated for more than 10 days. (R)

• Use standard polymeric feed. (G)

• Consider gastrostomy insertion if long-term tube feeding is necessary (greater than four weeks). (R)

• Monitor nutritional parameters regularly throughout the patient's cancer journey. (G)

• Pre-operative:

○ Patients with severe nutritional risk should receive nutrition support for 10–14 days prior to major surgery even if surgery has to be delayed. (R)

○ Consider carbohydrate loading in patients undergoing head and neck surgery. (R)

• Post-operative:

○ Initiate tube feeding within 24 hours of surgery. (R)

○ Consider early oral feeding after primary laryngectomy. (R)

• Chyle Leak:

○ Confirm chyle leak by analysis of drainage fluid for triglycerides and chylomicrons. (R)

○ Commence nutritional intervention with fat free or medium chain triglyceride nutritional supplements either orally or via a feeding tube. (R)

○ Consider parenteral nutrition in severe cases when drainage volume is consistently high. (G)

• Weekly dietetic intervention is offered for all patients undergoing radiotherapy treatment to prevent weight loss, increase intake and reduce treatments interruptions. (R)

• Offer prophylactic tube feeding as part of locally agreed guidelines, where oral nutrition is inadequate. (R)

• Offer nutritional intervention (dietary counselling and/or supplements) for up to three months after treatment. (R)

• Patients who have completed their rehabilitation and are disease free should be offered healthy eating advice as part of a health and wellbeing clinic. (G)

• Quality of life parameters including nutritional and swallowing, should be measured at diagnosis and at regular intervals post-treatment. (G)

The endoscopic modified Lothrop procedure is mainly used for refractory frontal sinusitis. However, we have used it as an access procedure to facilitate treatment for an extended range of additional frontal sinus pathologies.

A retrospective review of patients who underwent the endoscopic modified Lothrop procedure for ‘alternative’ frontal sinus pathologies was conducted. Patient data were reviewed. The main outcome parameter measured was signs of recurrence.

Twelve patients (6 males, 6 females) from a 7-year study period, with a mean age of 45.2 years (range, 16–78 years), were analysed. The surgical indications included frontoethmoidal mucoceles, cerebrospinal fluid leaks within the frontal sinus, cystic fibrosis, frontal sinus osteoma, frontal sinus ossifying fibroma and frontal silent sinus syndrome. The mean follow-up period was 33.3 months. There were no known recurrences.

We have used the endoscopic modified Lothrop procedure for a range of frontal sinus pathologies, safely and effectively, with no peri-operative complications.

Epistaxis is a common and potentially life-threatening emergency. This survey assesses understanding and confidence in epistaxis management amongst current junior doctors.

A cross-sectional study was conducted of foundation year one and two doctors based at three National Health Service trusts within a single region of the UK, assessing basic understanding and procedural confidence.

A total of 111 foundation doctors completed this survey. The average duration of undergraduate exposure to otolaryngology was 8.1 days. Forty-one per cent of respondents stated that they would apply pressure to the nasal bones to control epistaxis. Seventy-five per cent lacked confidence in their ability to manage epistaxis. Those with two weeks or more of undergraduate exposure to otolaryngology were more confident than those with one week or less of exposure (p < 0.0001).

Junior doctors lack understanding and confidence in epistaxis management, with patient safety implications. Confidence is associated with the duration of undergraduate exposure to otolaryngology. A minimum emergency safe competency should be a priority during foundation training if not achieved in UK medical schools.

To examine factors potentially contributing to acutely exacerbated chronic tinnitus initiation using the Tinnitus Handicap Inventory.

Sixty acutely exacerbated chronic tinnitus out-patients were divided into two groups depending on whether hearing loss was aggravated or stable during tinnitus exacerbation. Total Tinnitus Handicap Inventory scores and scores for the three subscales (assessing functional limitations, emotional attitudes and catastrophic thoughts) were analysed.

Total Tinnitus Handicap Inventory scores did not differ between groups. In patients with acutely exacerbated chronic tinnitus and aggravated hearing loss, functional subscale scores were significantly higher after acutely exacerbated chronic tinnitus than at baseline, but catastrophic and emotional subscale scores did not change. In patients with acutely exacerbated chronic tinnitus and stable hearing loss, emotional subscale scores were significantly higher after acutely exacerbated chronic tinnitus than at baseline, but catastrophic and functional subscale scores did not change.

Elevated Tinnitus Handicap Inventory functional subscale scores might indicate further hearing loss, whereas elevated emotional subscale scores might be associated with negative life or work events.

Serum thyroglobulin is used as a surrogate marker for well-differentiated thyroid carcinoma recurrence. This study investigates whether thyroglobulin measured at the time of ablative radioactive iodine therapy predicts disease-free survival.

A retrospective review was conducted of patients with well-differentiated thyroid carcinoma presenting from 1989 to 2010 at the Royal Prince Alfred Hospital, New South Wales, Australia. Disease-free survival of patients with a significantly elevated stimulated thyroglobulin level (27.5 µg/l or higher) at the time of ablative radioactive iodine therapy was compared to that of patients without a significantly elevated thyroglobulin level using univariate analysis.

Patients with a thyroglobulin level of 27.5 µg/l or higher had an increased relative risk of disease recurrence of 4.50 (95 per cent confidence interval = 1.35–15.04). If lateral neck dissection was required at the time of surgery, patients also had an increased relative risk of macroscopic disease recurrence of 4.94 (95 per cent confidence interval = 1.47–16.55).

An elevated thyroglobulin level of 27.5 µg/l or higher at the time of ablative radioactive iodine therapy is a prognostic indicator for macroscopic disease recurrence in well-differentiated thyroid carcinoma.

To investigate the effects of different suture materials in the nasal cavity on encrustation and micro-organism colonisation.

Four different suture materials were used to suture the nasal septum. The effects of suture materials on intranasal encrustation were evaluated with anterior rhinoscopy. The sutures were removed and evaluated in terms of micro-organism colonisation on the 7th and 21st post-operative days.

Monofilament sutures were found to cause less encrustation and micro-organism colonisation. There was increased late-stage encrustation if an absorbable monofilament suture remained in place for a long time. The removal of a non-absorbable monofilament suture in the early or late post-operative period made no difference in terms of micro-organism growth on the suture.

The material and physical characteristics of sutures placed inside the nose may indirectly affect the healing process. It may be more appropriate to use different materials depending on the length of time the suture is to remain in place.

To compare the skin-related complications of the traditional skin flap method with a linear incision method of implantation.

All cases of bone-anchored hearing aid surgery performed by a single surgeon (n = 117) were compared over two periods: 1999–2011, when the traditional method of skin flap and soft tissue removal was used (group 1; n = 86), and 2012–2013, when linear incision without soft tissue removal was used (group 2; n = 31). All patients were followed up for one year and complications were recorded for that period.

There were 21 (24.4 per cent) skin-related complications in group 1 (skin overgrowth = 12, wound infection = 8 and numbness = 1) and 3 (9.7 per cent) complications in group 2 (wound infection = 3). Analysis using independent t-tests showed the results to be significant (p < 0.05; 95 per cent confidence interval = 0.0800–0.4473).

The linear incision without soft tissue removal method for bone-anchored hearing aid implantation reduces skin complication rates.

Docetaxel, cisplatin plus 5-fluorouracil is an efficacious induction regimen but is more toxic than cisplatin plus 5-fluorouracil. This study aimed to determine whether docetaxel and cisplatin without 5-fluorouracil maintains efficacy while decreasing toxicity.

A multicenter non-comparative pilot study of locally advanced squamous cell carcinoma of the head and neck was performed. Patients received primary therapy comprising three cycles of 75 mg/m2 docetaxel and 75 mg/m2 cisplatin followed by concurrent chemoradiotherapy. The primary endpoint was the response rate to the docetaxel and cisplatin induction regimen.

A total of 26 patients were enrolled: of these, 23 (88.5 per cent) received all three docetaxel and cisplatin cycles. Common grade 3–4 adverse events were febrile neutropenia (19.2 per cent of patients), diarrhoea (19.2 per cent) and non-neutropenic infection (15.4 per cent). The overall response rate to docetaxel and cisplatin induction chemotherapy was 65.4 per cent. A total of 23 patients (88.5 per cent) subsequently received chemoradiotherapy with a median radiotherapy dose of 70 Gy. The response rate to chemoradiotherapy was 73 per cent. At a median follow up of 44 months, the 3-year progression-free survival and overall survival rates were 62 per cent and 69 per cent, respectively.

Docetaxel and cisplatin induction chemotherapy is a feasible induction regimen with comparable efficacy to docetaxel, cisplatin and 5-fluorouracil induction chemotherapy.

To assess cardiac functions in adenotonsillar or tonsillar hypertrophy.

A prospective, interventional, academic centre based study was conducted on 25 children with adenotonsillar or tonsillar hypertrophy. All patients underwent pulsed 2-dimensional Doppler echocardiography, pulse oximetry and 12-lead electrocardiography. These assessments were repeated three months later to determine the impact of adenotonsillectomy.

There were significant differences in mean arterial oxygen saturation, pulmonary flow acceleration time and mean pulmonary artery pressure post-operatively. Adenotonsillectomy led to significant improvements in pulmonary flow acceleration time and pulmonary flow velocity time index, while tonsillectomy resulted in right ventricular early and late diastolic velocity index improvement.

Upper airway obstruction in children affects cardiac functioning and this can subsequently lead to morbidity and delayed growth. Hence, revision of surgical indications is advocated in adenotonsillar hypertrophy to avoid irreversible damage to cardiopulmonary functions.

• Preventative oral care must be delivered to patients whose cancer treatment will affect the oral cavity, jaws, salivary glands and oral accessibility. (G)

• Close working and communication between the surgeons, oncologists and restorative dental specialists is important in ensuring optimal oral health outcomes. (G)

• Intensity-modulated radiotherapy has been shown to reduce long-term xerostomia and should be offered to all appropriate patients. (R)

• If patients are deemed at risk of trismus they should be warned and its progressive and potentially irreversible nature explained. (G)

• Where it is known that adjuvant radiotherapy will be given, extractions should take place at primary surgery to maximise the time for healing and minimise the number of surgical events for patients. (G)

• Osseointegrated implants should be considered for all patients having resection for head and neck cancer. (G)

Juvenile nasopharyngeal angiofibroma often presents with lateral extensions. In countries with limited resources, selection of a cost-effective and least morbid surgical approach for complete excision is challenging.

Sixty-three patients with juvenile nasopharyngeal angiofibroma, with lateral extensions, underwent transpalatal, transpalatal-circumaxillary (transpterygopalatine) or transpalatal-circumaxillary-sublabial approaches for resection. Clinico-radiological characteristics, tumour volume and intra-operative bleeding were recorded.

The transpalatal approach was suitable for extensions involving medial part of pterygopalatine fossa; transpalatal-circumaxillary for extensions involving complete pterygopalatine fossa, with or without partial infratemporal fossa; and transpalatal-circumaxillary-sublabial for extensions involving complete infratemporal fossa, even cheek or temporal fossa up to zygomatic arch. Haemorrhage was greatest with the transpalatal-circumaxillary-sublabial approach, followed by transpalatal approach and transpalatal-circumaxillary approach (1212, 950 and 777 ml respectively). Tumour size (volume) was greatest with the transpalatal-circumaxillary approach, followed by transpalatal-circumaxillary-sublabial approach and transpalatal approach (40, 34 and 29 mm3). There was recurrence in three cases and residual disease in two cases. Long-term morbidity included small palatal perforation (n = 1), trismus (n = 1) and atrophic rhinitis (n = 2).

These modified techniques, performed with endoscopic assistance under hypotensive anaesthesia, without embolisation, offer a superior option over other open procedures with regard to morbidity and recurrences.

This study investigated genetic polymorphisms affecting the inducible nitric oxide synthase, superoxide dismutase and catalase enzymes in chronic otitis media patients with and without tympanosclerosis, and the role of genetic susceptibility in the disease aetiology.

A total of 162 patients who underwent surgery for chronic otitis media were divided into two study groups: a tympanosclerosis group and a chronic otitis media group. A third, the control, group comprised 188 healthy volunteers. Venous blood samples were evaluated using reverse transcriptase polymerase chain reaction.

There was a significant difference in GG genotype distribution of the −277A>G polymorphism in the NOS2 gene between the tympanosclerosis and control groups (p < 0.05). However, there were no significant between-group differences in the CC genotype distribution of the p.Ala16Val (C>T) polymorphism in the SOD2 gene (p > 0.05). There were significant differences in the TT genotype distribution of the −21A>T polymorphism in the CAT gene between the tympanosclerosis and control groups, and between the chronic otitis media and control groups (p < 0.05).

These results suggest that genetic predisposition may play a role in the aetiopathogenesis of tympanosclerosis.

To calculate the financial burden of recurrent respiratory papilloma. This study is UK-based, where up until now no financial estimates have been calculated for this group of patients.

Recurrent respiratory papilloma is caused by the human papilloma virus (subtypes 6 and 11). The burden for the patient and the healthcare system is significant given the recurrent nature of the disease.

Data were collected, using a questionnaire completed during routine clinical follow up, from a single centre managing recurrent respiratory papilloma in Glasgow, Scotland. Cost information was sourced from the Scottish Government's Information Services Division.

Fourteen patients with active recurrent respiratory papilloma between 2013 and 2014 were identified. The direct measurable cost to NHS Greater Glasgow and Clyde amounted to £107 478.

Recurrent respiratory papilloma is a benign condition, but the financial implications of diagnosis are significant. Recurrent respiratory papilloma has a natural history of relapse and remission, and patients may require healthcare input over a period of several years.

To evaluate the incidence rates and risk of sudden sensorineural hearing loss among patients with depressive disorders.

Data for 27 547 patients with newly diagnosed depressive disorders and 27 547 subjects without depressive disorders between 2001 and 2008 were yielded from the Taiwan National Health Insurance Research Database. Sudden sensorineural hearing loss incidence at the end of 2011 was determined. Cumulative incidence and adjusted hazard ratio were computed.

Sudden sensorineural hearing loss incidence was 1.45 times higher in the depressive disorders group compared to the non-depressive disorders group (p = 0.0041), with an adjusted hazard ratio of 1.460. A significant increased risk of developing sudden sensorineural hearing loss was noted in patients with diabetes mellitus, chronic kidney disease and hyperlipidaemia (p < 0.05).

The results suggest an increased risk of developing sudden sensorineural hearing loss in patients with depressive disorders. Co-morbidities such as diabetes mellitus, chronic kidney disease and hyperlipidaemia significantly aggravated the risk. Depressive disorders might be considered a risk factor for sudden sensorineural hearing loss. It remains to be seen whether control of depressive disorders can decrease the incidence of sudden sensorineural hearing loss in patients with depressive disorders.

To study and review the short- and long-term effects of intranasal steroids on obstructive adenoids.

In this prospective cohort study, 19 children previously treated with mometasone furoate for 3 months were contacted at 3, 6 and 12 months after cessation of treatment. Main outcome measures included: change in severity of nasal obstruction, allergic rhinitis and obstructive symptoms. A systematic review of literature was also performed.

By one year, 25 per cent of patients required adenoidectomy; the remaining children had no significant change in clinical score (p = 0.464), obstruction severity (p = 0.191) or allergic symptoms (p = 0.284). Fourteen pertinent studies were identified; all but one study showed improvement in the patients’ symptoms and/or degree of obstruction. Two studies with follow up reaching 25 months showed positive effects.

The short-term positive effect of some intranasal steroids on obstructive adenoids seems to persist in a significant number of patients after the cessation of treatment.

This paper objectively evaluates current information available to the general public related to glue ear on the World Wide Web.

The term ‘glue ear’ was typed into the 3 most frequently used internet search engines – Google, Bing and Yahoo – and the first 20 links were analysed. The first 400 words of each page were used to calculate the Flesch–Kincaid readability score. Each website was subsequently graded using the Discern instrument, which gauges quality and content of literature.

The websites Webmd.boots.com, Bupa.co.uk and Patient.co.uk received the highest overall scores. These reflected top scores in either readability or Discern instrument assessment, but not both. Readability and Discern scores increased with the presence of a marketing or advertising incentive. The Patient.co.uk website had the highest Discern score and third highest readability score.

There is huge variation in the quality of information available to patients on the internet. Some websites may be accessible to a wide range of reading ages but have poor quality content, and vice versa. Clinicians should be aware of indicators of quality, and use validated instruments to assess and recommend literature.

To investigate the rate of occult neck disease in patients with metastatic squamous cell carcinoma to the parotid gland following parotidectomy and neck dissection.

A consecutive series of patients treated between 2000 and 2014 for metastatic squamous cell carcinoma to the parotid were analysed. Patients were included if they had no clinical or radiological evidence of neck disease. Pathology of parotidectomy and neck dissection specimens was reviewed. Other variables analysed included patient immune status, surgery type, complications, use of positron emission tomography scanning and treatment with radiotherapy.

Sixty-five patients had no clinical or radiological evidence of neck disease initially. Forty-six patients (70.8 per cent) underwent neck dissection. Occult neck disease was only found in 8 of the 46 patients (17.3 per cent). Occult neck disease was found more often in those with immunocompromise (5.7 vs 38.5 per cent, p = 0.003). Patients who were immunocompromised had a significantly worse disease-specific survival rate at five years (0 vs 92 per cent, p = 0.0001).

Occult neck disease was seen in 17.3 per cent of patients and immunosuppression was a significant predictor for this.

Video hosting websites are increasingly being used to disseminate health education messages. This study aimed to assess the quality of advice contained within YouTube videos on the conservative management of epistaxis.

YouTube.com was searched using the phrase ‘how to stop a nosebleed’. The first 50 videos were screened. Objective advice scores and subjective production quality scores were attributed by independent raters.

Forty-five videos were analysed. The mean advice score was 2.0 out of 8 and the mean production quality score was 1.6 out of 3. There were no correlations between a video's advice score and its search results rank (ρ = −0.28, p = 0.068), its view count (ρ = 0.20, p = 0.19) or its number of ‘likes’ (ρ = 0.21, p = 0.18).

The quality of information on conservative epistaxis management within YouTube videos is extremely variable. A high search rank is no indication of video quality. Many videos proffer inappropriate and dangerous ‘alternative’ advice. We do not recommend YouTube as a source for patient information.

Sudden sensorineural hearing loss in divers may be caused by either inner-ear barotrauma or inner-ear decompression sickness. There is no consensus on the best treatment option. This study aimed to evaluate the therapeutic value of hyperbaric oxygen therapy for sudden sensorineural hearing loss in divers.

A literature review and three cases of divers with sudden sensorineural hearing loss treated with hyperbaric oxygen therapy are presented.

Hyperbaric oxygen therapy resulted in hearing improvement in 80 per cent of patients: 39 per cent had hearing improvement and 41 per cent had full recovery.

Hyperbaric oxygen therapy improved hearing in divers with sudden sensorineural hearing loss.