Background: Primary ciliary dyskinesia (PCD) is a rare disorder of ciliary motility, characterised by chronic rhinosinusitis (CRS), chronic otitis media with effusion, and recurrent respiratory tract infections that eventually lead to bronchiectasis. Despite almost all PCD patients having ear, nose, and throat (ENT) complications, there are few published studies on the progression of these symptoms with treatment. The Sino-Nasal Outcome Test-22 (SNOT-22) measures CRS symptom severity and its impact on quality of life, it is routinely implemented at Concord Repatriation General Hospital (CRGH)’s PCD clinic. The minimal clinically important difference (MCID) for total SNOT-22 scores has been demonstrated in published metrics to be 9 for surgical management and 8 for medical therapy, while MCID values for rhinologic, extra-nasal rhinologic, ear/facial, psychological dysfunction, and sleep symptom domain scores have been reported as 3.8–3.9, 2.4–2.5, 3.2–3.3, 3.4–3.9, and 2.9 respectively. This study aimed to evaluate changes in SNOT-22 scores and audiometry in a cohort of Australian patients with PCD treated at CRGH from 2015 to 2022, to assess whether optimal multidisciplinary team (MDT) management lead to a discernible reduction in ENT symptom burden. Methods: This study was a single site, retrospective medical records audit using the CRGH PCD patient database to review the SNOT-22 scores and audiometry thresholds of 103 patients from 2015 to 2022. Included patients had a confirmed diagnosis of PCD, were aged 6+ years, and had recorded at least one SNOT-22. Each patient’s initial results formed their “Baseline”, and were compared to their average results throughout treatment. SNOT-22 scores were described using overall and symptom domains (rhinologic, extra-nasal rhinologic, ear/facial, psychological dysfunction, sleep dysfunction). Data were analysed using the Wilcoxon signed-rank test and paired T-tests. All analyses were performed using Statistical Package for the Social Sciences (SPSS) software. A P value <0.05 was considered statistically significant. Results: From January 2015 to January 2022, 103 patients were screened, of whom 42 met the inclusion criteria for this study. Twenty-four of these patients recorded 2 or more SNOT-22 questionnaires, with an average baseline of 41.9 [standard deviation (SD): 13.7]. Significant improvement in SNOT-22 totals (9.0±12.4, P<0.001) and domain scores (rhinologic: 2.5±4.7, P<0.05; extra-nasal: 1.2±2.7, P<0.05; ear/facial: 1.9±4.1, P<0.05; psychological: 3.4±5.7, P<0.05; sleep: 2.0±4.6, P<0.05) were reported. While this surpassed the MCID for overall SNOT-22 scores, none of the domain changes exceeded their respective MCIDs. Although a small improvement of 0.7 (SD: 3.1) dB was also noted in audiometry, this was not significant (P=0.52). Conclusions: These results confirmed the efficacy of the MDT approach to PCD, demonstrating that optimal management in a multidisciplinary clinic reduces CRS symptom burden and leads to a discernible improvement in quality of life. This may be mediated by a global improvement in ENT symptoms, without any particular symptom group experiencing a meaningful change.

Abstract: Functional endoscopic sinus surgery (FESS) is performed for the management of medically refractory chronic rhinosinusitis (CRS). Given the vascularity of the nasal cavity, controlled hypotension is often employed to improve the intra-operative surgical field. Diplopia is a rare complication following FESS, and the most feared aetiology is either orbital trauma and/or injury to extraocular muscles. However, non-traumatic causes of diplopia can also occur coincidentally following FESS. Herein, we present two rare cases of delayed onset diplopia after FESS (range of onset from 10 to 30 days). There was no history of intra-operative orbital injury and nil evidence of orbital trauma on post-operative imaging. Case 1 had a history of hypertension and atrial fibrillation, while Case 2 did not have any vascular risk factors. The intraoperative systolic blood pressure during sinus surgery ranged from 80–95 and 85–110 mmHg. Case 1 was diagnosed with a decompensating esotropia (underlying strabismus) which was treated with prism glasses. Case 2 had a microvascular abducens nerve palsy that resolved after 3 months. This case study illustrates that, in the absence of orbital or extraocular muscle trauma during surgery, alternative diagnoses such as an underlying strabismus or microvascular cranial nerve palsy can be included in the differential diagnosis.

Background: To mitigate the cosmetic defect associated with parotidectomy, dermofat grafts have been utilized to restore the contour of the face and reduce complications such as salivary leak and Frey’s syndrome. This study aimed to investigate post-operative cosmetic satisfaction and complications rates associated with this method in limited parotidectomies for benign tumours. Methods: A cross-sectional study involving adult patients with benign parotid tumours undergoing parotidectomies with dermofat graft reconstruction between 2013–2021 was conducted. Patients were sent a questionnaire on donor site complications, gustatory sweating, and cosmetic satisfaction. Information on demographics, surgical details, tumour pathology and post-operative complications were gathered from existing records. Results: In the study group of 79 patients, there was a low rate of local complications: parotid sialocoeles (10%, n=8), parotid wound infection (3%, n=2), and parotid haematomas (1%, n=1); and dermofat graft donor site complications of infection (5%, n=4), seromas (1%, n=1) and haematomas (0%, n=0). Some patients reported donor site pain (24%, n=19) or donor site numbness (33%, n=26). Most patients reported “good” or “very good” cosmetic satisfaction (85%, n=67). Only three patients reported gustatory sweating (4%, n=3). Conclusions: Dermofat grafts are a reliable reconstruction method that allows for high patient cosmetic satisfaction and low post-operative complication risk.

Background: Burnout is an increasingly important phenomenon amongst healthcare professionals and leads to poorer healthcare delivery and provider well-being. This research sought to assess the severity and risk factors for burnout within the community of specialist otolaryngologists in New Zealand. Methods: A cross-sectional observational study was conducted amongst all New Zealand Otolaryngologists over a 6-month period from March to September 2019 to determine degree and severity of burnout. All otolaryngology consultants practicing in New Zealand were included in the study. The Maslach Burnout Inventory (MBI-HSS) was used to assess burnout. Demographic and work-related factors were collected in a separate questionnaire developed by the authors and univariate statistical analysis was conducted on each potential risk factor. Chi-square and Kendall’s Tau-B statistical tests were utilised to ascertain correlation with burnout. Results: Questionnaires were sent to 109 participants and 75 complete responses were returned. The prevalence of burnout in this group was 37.3%, with 9.3% demonstrating severe burnout. Predictors of burnout included feeling dissatisfied with their careers [rt=0.423, 95% confidence interval (CI): 0.289–0.540, P<0.001], feeling burdened by on-call demands [χ2(1, n=75)=13.385, P<0.001], and feeling that work was interfering with their personal, social, and family commitments (rt=0.361, 95% CI: 0.221–0.487, P<0.001). Participants subjectively feeling burnt out were more likely to meet the criteria for burnout on the MBI-HSS scale [χ2(1, n=74)=18.594, P<0.001]. Conclusions: A high proportion of New Zealand otolaryngologists suffered burnout. This poses significant risks to safe and efficient healthcare delivery as well as provider well-being. Additionally, there are likely more surgeons suffering moderate burnout than previously thought.

Background: Recent studies have shown that mepolizumab is an effective treatment in the management of chronic rhinosinusitis with nasal polyposis (CRSwNP). Defining which patients will benefit from this treatment is essential in guiding its role in the multimodal approach to CRSwNP and eosinophilic chronic rhinosinusitis (eCRS). The aim of this study is to define the clinical and disease features of those patients who report benefit from therapy compared to non-responders. Methods: A prospective phase 2 clinical trial was undertaken with a single-arm of non-blinded patients with open label therapy with mepolizumab (trial registration ID ACTRN12618000113257) from May 2019 to November 2020. Patients underwent treatment with mepolizumab 100 mg 4-weekly for 6 months. Data was collected at baseline and at 4, 8, 12, 16, 20 and 24 weeks of treatment, as well as 4 months post their last mepolizumab dose. Data collected included patient demographics, blood eosinophil count (cells/L), tissue histopathology outcomes [inflammation severity, type, eosinophil density (cell/HPF)], functional outcomes [endoscopic findings, nasal nitric oxide (nNO), fractional exhaled nitric oxide (FeNO)] and patient reported outcome measures [including Sino-Nasal Outcome Test 22-item (SNOT-22), Asthma Control Questionnaire 5-item (ACQ-5), nasal obstruction visual analogue scores (VAS) and nasal function VAS]. Responders were defined as those patients having a ≥1 improvement in a 13-point ordinal overall nasal function score. Results: Twenty patients were assessed (age 47.7±14.5 years and 50% female). All patients had prior sinus surgery (4.1±3.5 years) and all had comorbid asthma. Fourteen patients (70%) were classed as responders to mepolizumab therapy. Responders were associated with higher baseline symptom burden: SNOT-22 (51.3±17.3 vs. 30.7±19.1, P=0.03), ACQ-5 (2.3±1.2 vs. 1.2±0.5, P=0.03) and lower baseline nNO (300.4±169.7 vs. 645.0±318.7 parts per billion, P=0.005). Within 3 months following cessation of mepolizumab, there was a deterioration of clinical outcomes including blood eosinophils, tissue eosinophils, SNOT-22 and ACQ-5. Conclusions: In eCRS, responders were likely to have more severe symptomatic disease at baseline and lower nNO. Cessation of mepolizumab is associated with deterioration of both objective and subjective markers.

Background: Current trends amongst otolaryngologists managing recurrent acute tonsillitis favour interval “cold” tonsillectomy over acute “hot” tonsillectomy. However, patients experience significant morbidity awaiting interval tonsillectomy, exacerbated by growing waitlist times in the context of COVID-19. The aim of this cross-sectional pilot study was to determine the feasibility of “hot” plasma-mediated ablation (PMA) tonsillectomy for acute recurrent tonsillitis. Methods: A single-centre cross-sectional study with ethics approval was undertaken where patients over 16 years of age presenting with recurrent acute tonsillitis were offered PMA tonsillectomy. Patients who did not satisfy the Paradise criteria, were pregnant, had suspected tonsillar malignancy, bleeding diathesis, or significant comorbidities were excluded. Institutional electronic medical records and telephone follow-up at 1 month informed the following outcomes: post-tonsillectomy haemorrhage (PTH), operating time, length of stay, re-admission rate at 30 days, and post-operative infection. Statistical analysis of differences in operating time and length of stay for patients with and without peritonsillar abscess at time of surgery was performed using independent samples t-tests. Results: Twenty patients were recruited, with an equal distribution of males and females. The mean age was 33.3±13.6 years, operating time was 37.5±15 minutes, and length of stay 3.4±1.3 days. There were no readmissions or cases of PTH requiring return to hospital. Statistically significant difference was not found in those with and without peritonsillar abscess with respect to operating time (40.25±17.3 vs. 32.71±8.81 minutes, P=0.305) and length of stay (3±1.08 vs. 4±1.53 days, P=0.104). Conclusions: This pilot study concluded “hot” PMA tonsillectomy may be a feasible alternative to interval “cold” tonsillectomy that could reduce recurrent hospital admissions and waitlist times for patients with acute recurrent tonsillitis.

Background: Epistaxis is a common condition that is classically thought to present more frequently during cold and dry periods of the year. This study aims to investigate the associations between climatic variables and spontaneous epistaxis rates in markedly differing Australian climates. Methods: A retrospective cohort study of patients presenting with spontaneous epistaxis at Cairns Hospital in Queensland and Austin Hospital in Melbourne Victoria between July 1st, 2014 and December 31st, 2018 was conducted. Average daily temperature, relative humidity and dew point values were recorded for the same period from the Australian Bureau of Meteorology. Statistical analysis with Pearson’s correlation coefficient and simple linear regression was performed. Results: A total of 1,622 patients (1,260 at Austin and 362 at Cairns) were identified. There was a higher average age of presenter. There was significant negative correlation between average monthly temperature and epistaxis incidence at the Austin [r=−0.6, P<0.001, 95% confidence interval (CI): −0.73, −0.36] compared to Cairns (r=−0.4, P=0.004, 95% CI: −0.59, −0.12) hospitals. Furthermore, there was significant negative correlation between average monthly dew point and epistaxis incidence for Austin (r=−0.6, P<0.001, 95% CI: −0.71, −0.33) and Cairns (r=−0.5, P<0.001, 95% CI: −0.65, −0.23) hospitals. Negative correlation was highest when adjusted for seasonality at both institutions. Conclusions: This study represents the first Australian study to investigate the effect of climatic variables on epistaxis presentation rates. Negative correlations with temperature are consistent with previous studies. Negative correlation with dew point supports the use of traditional preventative measures such as warm air humidification systems, particularly in at-risk patients.

Background: Thickening of sinus mucosa is commonly found on magnetic resonance imaging (MRI). Although often referred to as “sinusitis”, such thickening is not well correlated with sinonasal symptoms. This study aimed to determine the diagnostic significance of MRI mucosal thickening using endoscopic examination and patient reported outcomes.

Background: Grommet insertion is one of the most common procedures in otolaryngology, however, consensus regarding water precaution advice post grommet insertion have been difficult to achieve. This study aims to identify the current Australian trend of water precaution advice post grommet insertion, and to compare with the current guidelines and overseas counterpart surveys. Methods: Members of Australian Society of Otorhinolaryngology Head and Neck Surgery (ASOHNS) were invited via email to participate in a voluntary and confidential survey. The questions related to experience level and state of practice of participants, as well as their water precaution advice for four main groups of water exposure: bathing, pool swimming, ocean swimming, and diving. Results: Of 168 respondents, 46% advised some form of water restriction for bathing, 70% for pool swimming, and 55% for ocean swimming. There was no significant difference in water precaution advice given between different experience levels of clinicians for bathing (P=0.60), ocean swimming (P=0.30), pool swimming (P=0.51), and diving (P=0.93). However, there was significant difference in precaution advice between northern and southern states for pool swimming (P=0.01), 86.5% versus 64.9% respectively. No significant difference was found for bathing (P=0.70), ocean swimming (P=0.57), and diving (P=0.89) between northern and southern states. Conclusions: Despite current guidelines and literature, this study captures the wide variability in current Australian practice for water precaution advice post grommet insertion. This may be due to variable patient environment in different geographical area of practice. Establishment of a local guideline may help to standardise practice, improve patient compliance, and ensure patients receive current evidence-based advice.

Background: The objective of this study was to assess the management of post-tonsillectomy haemorrhage (PTH). Methods: An anonymous, online, cross-sectional survey of Australian Society of Otolaryngology Head and Neck Surgery (ASOHNS) Consultants and Registrars was conducted with re-distribution two weeks later. Treatment decisions regarding three clinical scenarios of post-tonsillectomy haemorrhage for patients aged less than and more than six years old were presented to respondents. For each scenario a list of treatment options was presented for selection. SPSS version 27 (IBM) was used for statistical analysis. Results: One hundred and sixty-three out of the 565 members responded to our survey (29% respondent rate). The commonly selected options were obtaining bloods (78%), intravenous access (86%), intravenous fluids (60%), tranexamic acid (TXA) (59%), antibiotics (49%) and hydrogen peroxide gargles (31%), all of which were more likely to be used with severe bleeding. Respondents from Queensland were less likely to obtain bloods (42%) for patients presenting with no clot or active bleeding. However, clinicians from Queensland and Western Australia were more likely to use TXA (81% and 73% respectively) compared to the rest of the nation (49%). Registrars were more likely than consultants to take bloods and obtain intravenous access for those not actively bleeding but were less likely to prescribe antibiotics and suction tonsillar fossa clots. Conclusions: The findings from this study have demonstrated the common management options used by ASOHNS Consultants and Registrars for three scenarios of adult and paediatric patients presenting with PTH. Some findings are potentially due to local protocols. Responses demonstrate that there is variability in the management of PTH around Australia. The results could be used for the future development of an Australian or statewide consensus guideline regarding management of PTH.