Exploring implicit bias among ENT surgeons: an analysis of the implicit association test

OBJECTIVE

This study aimed to investigate the presence of implicit bias among ENT surgeons and explore the impact of the results of the Implicit Association Test on the surgeons' behaviour towards patients.

METHOD

Seven ENT surgeons who were not black, Asian or minority ethnic were asked to complete the Race Implicit Association Test. The surgeons also completed a survey about their perceptions of their implicit biases and the impact of the Race Implicit Association Test results on their behaviour towards patients.

RESULTS

The mean Race Implicit Association Test score for the ENT surgeons suggested a slight bias that favoured white over black people. Furthermore, 42 per cent of the surgeons thought that they had hidden or unconscious racial bias, 42 per cent said they would change their behaviour towards patients after receiving these results and 85 per cent thought that the Race Implicit Association Test was helpful for appraisal purposes.

CONCLUSION

The results suggest that ENT surgeons who are not black, Asian or minority ethnic may have implicit biases towards black patients. These findings highlight the need for interventions to reduce implicit bias among ENT surgeons and improve healthcare outcomes for marginalised populations.

68 Exploring Subconscious Bias: How Implicit Biases Can Affect Accessibility to Healthcare

Aim

Implicit biases involve associations outside conscious awareness that lead to a negative evaluation of a person on the basis of irrelevant characteristics such as race or gender. This article reviews healthcare professional's display of implicit bias towards patients in a tertiary centre.

Method

We retrospectively analysed a database of 285 patients who missed surgical outpatient appointments at a London tertiary hospital. Judges were asked to categorise all 285 patients into predefined ethnic categories: White British vs Black, Asian and Minority Ethnic vs White Non-British after reading the patient’s names.

Results

In the group where ethnicity was defined based on assessed origin of names, we report significant difference in discharge rates between White British vs Non-White British groups (34 vs 48%). There was also significant difference between White British vs Black, Asian and Minority Ethnic group (34% vs 57%). Discharge rates between males and females did not differ.

Conclusions

Clinicians are more likely to provide patients with another opportunity to attend an outpatient clinic after missing a booked appointment based on the patient having a perceived ethnicity of White British, whether deliberate or not. This study shows a bias of accessibility in healthcare dependent on ethnicity with greater flexibility given to White British patients.

69 Hot Saline Irrigation for Haemostasis in Functional Endoscopic Sinus Surgery: A Systematic Review and Meta-Analysis

Aim

The aim of this study was to perform a systematic review and meta-analysis of existing evidence on the role of hot saline irrigation (HSI) in patients undergoing functional endoscopic sinus surgery (FESS) and its impact on the visibility of the surgical field (VSF).

Method

A search of PubMed, Cochrane, Ovid (including Embase, Medline and Allied and Complementary Medicine Database) databases as well as Google Scholar was performed.

Results

Three randomised control trials (RCT) were included. All three were pooled into meta-analysis which demonstrated a statistically significant better VSF (MD -0.51; 95% CI -0.84, -0.18; P = 0.003), a reduction in total blood loss (TBL) (MD -56.40ml; 95% CI -57.30. -55.51; P = <0.0001) and a reduction in operating time (OT) (MD -7.01mins; 95% CI 9.02mins; 95% CI -11.76, -6.28; P = <0.0001) during FESS in the HSI group compared with the room temperature irrigation control group. Further subgroup analysis of studies that did not use topical vasoconstrictors showed a significant reduction in TBL and OT. There were no reported adverse events related to HSI.

Conclusions

This is the first systematic review that addresses HSI for haemostasis in FESS. The results suggest that HSI in FESS for chronic rhinosinusitis may significantly improve VSF, reduce TBL by 20% and decrease OT by 9 minutes. HSI is cheap and a readily available intervention with a low risk of morbidity and adverse events. However, there are limitations of the study due to significant heterogeneity of methods, quality, and size of the studies.

Skull base low-grade non-intestinal adenocarcinoma in a paediatric patient

Background: Non-intestinal adenocarcinomas of the sinonasal tract are uncommon neoplasms in adults, and particularly rare in the paediatric population. Case presentation: A 10-year-old male presented to the Paediatric Otolaryngology clinic with symptoms of recurrent epistaxis, persistent clear nasal discharge, and a left-sided polypoidal swelling causing nasal obstruction. An endoscopic biopsy of the polyp under general anaesthesia found a mass arising from the anterior olfactory cleft, and the histology report described the mass as a low-grade non-intestinal adenocarcinoma. CT and MRI of the sinuses post-biopsy demonstrated no bony structure infiltration. The patient underwent a further endoscopic operation for definitive excision of the nasal mass, and the histology findings confirmed a complete resection of the tumour. Conclusion: This case demonstrates the first case of a primary low-grade non-intestinal adenocarcinoma originating from the olfactory cleft.

EPOS 4 Patients

EPOS2020 is the 4th and most recent version of the European Position Paper on Rhinosinusitis and Nasal Polyps which was first published in 2005. It aims to provide the most up to date scientifically robust information on the topic published in the literature which has been critically analysed by an international group of clinicians drawn from all disciplines dealing with these problems together with patients. The guidelines offer evidence-based recommendations and care pathways for acute and chronic rhinosinusitis in both adults and children. Management of these diseases from the patients' perspective is an important part of EPOS2020. Not only is this included in the main document but, for the first time, we have produced a separate supplement dedicated to and in collaboration with patients, EPOS4Patients, which aims to provide information in an accessible format, to answer frequently asked questions about these diseases and their treatment options as well as including useful patient resources and websites. It has never been more important for patients to be actively involved in their care. Being well informed helps you to make the best decisions together with your doctor.

679 Anxiety and Depression Impacts on The Correlation Between Symptom and Radiological Severity in Patients with Chronic Rhinosinusitis

Introduction

Previous studies have reported little correlation between sino-nasal outcome test (SNOT-22) in chronic rhinosinusitis (CRS) and objective radiological scoring. We investigated whether anxiety and depression, which are highly prevalent in patients with CRS may cause symptom amplification and account for the lack of correlation in previous studies.

Method

100 patients with CRS were evaluated using the General Anxiety Disorder-7 (GAD-7), Patient Health Questionnaire-9 (PHQ-9), SNOT-22 and Lund Mackay Score (LMS).

Results

Overall correlation analysis did not show a significant relationship between SNOT-22 and LMS. Subgroup analysis of patients without anxiety or depression showed a significant correlation between SNOT-22 and LMS. We also observed a significant difference in both median SNOT-22 and LMS between patients who suffered with both anxiety and depression and patients without either.

Conclusions

When CRS patients who do not have anxiety and depression are analysed in isolation, or when these conditions are controlled in a multivariable regression, there is a significant correlation between radiological findings and symptom score. This correlation is absent in patients with anxiety and depression. Anxiety and depression should be considered in patients in whom there is a mismatch in symptom and radiological disease severity as it is associated with symptom amplification.

Awake tracheal intubation with the ProVu™ video stylet: a case series

Management of the difficult airway is integral to peri-operative practice. The development of devices to simplify airway handling are changing our approach to tracheal intubation. We report a case series of three patients who underwent awake tracheal intubation with the ProVu™ video stylet (Flexicare Medical Ltd, Mountain Ash, UK). All three patients had predicted difficult airways, including: limited mouth opening secondary to radiotherapy; previous exenteration, hemi-maxillectomy and scapular free flap formation; and cervical fixation. Awake tracheal intubation was performed successfully in all three cases, with no complications reported. This is the first reported case series of the ProVu™ video stylet as an awake tracheal intubation device. The benefits and limitations of this video stylet are discussed.

Six month follow-up of self-reported loss of smell during the COVID-19 pandemic

INTRODUCTION

Loss of smell and taste is now recognised as amongst the most common symptoms of COVID-19 and the best predictor of COVID-19 positivity. Long term outcomes are unknown. This study aims to investigate recovery of loss of smell and the prevalence of parosmia.

METHODOLOGY

6-month follow-up of respondents to an online surgery who self-reported loss of smell at the onset of the CO- VID-19 pandemic in the UK. Information of additional symptoms, recovery of loss of smell and the development of parosmia was collected.

RESULTS

44% of respondents reported at least one other ongoing symptom at 6 months, of which fatigue (n=106) was the most prevalent. There was a significant improvement in self-rating of severity of olfactory loss where 177 patients stated they had a normal smell of smell while 12 patients reported complete loss of smell. The prevalence of parosmia is 43.1% with median interval of 2.5 months (range 0-6) from the onset of loss of smell.

CONCLUSIONS

While many patients recover quickly, some experience long-term deficits with no self-reported improvement at 6 months. Furthermore, there is a high prevalence of parosmia even in those who report at least some recovery of olfactory func- tion. Longer term evaluation of recovery is required.

Safety and outcomes of percutaneous tracheostomy in coronavirus disease 2019 pneumonitis patients requiring prolonged mechanical ventilation

OBJECTIVES

Tracheostomy for coronavirus disease 2019 pneumonitis patients requiring prolonged invasive mechanical ventilation remains a matter of debate. This study analysed the timing and outcomes of percutaneous tracheostomy, and reports our experience of a dedicated ENT-anaesthetics department led tracheostomy team.

METHOD

A prospective single-centre observational study was conducted of patients undergoing tracheostomy, who had been diagnosed with coronavirus disease 2019 pneumonitis, between 21st March and 20th May 2020.

RESULTS

Eighty-one patients underwent tracheostomy after a median (interquartile range) of 16 (13-20) days of invasive mechanical ventilation. Median follow-up duration was 32 (23-40) days. Of patients, 86.7 per cent were successfully liberated from invasive mechanical ventilation in a median (interquartile range) of 12 (7-16) days. Moreover, 68.7 per cent were subsequently discharged from hospital. On univariate analysis, there was no difference in outcomes between early (before day 14) and late (day 14 or later) tracheostomy. The mortality rate was 8.6 per cent and no deaths were tracheostomy related.

CONCLUSION

Outcomes appear favourable when patients are carefully selected. Percutaneous tracheostomy performed via a multidisciplinary approach, with appropriate training, was safe and optimised healthcare resource utilisation.

Presentation of new onset anosmia during the COVID-19 pandemic

INTRODUCTION

Anosmia has not been formally recognised as a symptom of COVID-19 infection. Growing anecdotal evidence suggests increasing incidence of cases of anosmia during the current pandemic, suggesting that COVID-19 may cause olfactory dysfunction. The objective was to characterise patients reporting new onset anosmia during the COVID-19 pandemic METHODOLOGY: Design: Survey of 2428 patients reporting new onset anosmia during the COVID-19 pandemic.

SETTING

Volunteer sample of patients seeking medical advice of recent onset self-diagnosed loss of sense of smell RESULTS: 2428 surveys were completed within 7 days; 64% respondents were under 40. The majority of respondents reported onset of their anosmia in the last week. Of the cohort, 17% did not report any other symptom thought to be associated with COVID-19. In patients who reported other symptoms, 51% reported either cough or fever and therefore met current guidelines for self-isolation.

CONCLUSIONS

Anosmia is reported in conjunction with well-reported symptoms of coronas virus, but 1 in 6 patients with recent onset anosmia report this as an isolated symptom. This might help identify otherwise asymptomatic carriers of disease and trigger targeted testing. Further study with COVID-19 testing is required to identify the proportion of patients in whom new onset anosmia can be attributed to COVID-19.

Awake tracheal intubation in a suspected COVID-19 patient with critical airway obstruction

We report the airway management of a patient with suspected COVID-19 with impending airway obstruction requiring urgent surgical tracheostomy. To our knowledge, this is the first reported case of an awake tracheal intubation in a suspected COVID-19-positive patient. Various modifications were put in place during the awake tracheal intubation and surgical tracheostomy procedures to minimise aerosol generation from the patient, such as avoiding high-flow nasal oxygen, establishing conscious sedation with remifentanil before commencing airway topicalisation and avoiding transtracheal local anaesthetic infiltration. A multidisciplinary team discussion before performing the case highlighted aspects of both the airway management and the surgical procedure where particular care and modifications are required. There is a lack of national and international guidance for awake tracheal intubation and tracheostomy in COVID-19 cases. This report nevertheless addresses the key procedural modifications required.

European position paper on diagnostic tools in rhinology

The accurate diagnosis of rhinologic disease depends on the clinical history, examination findings and, in many cases, further investigations. There are a wide variety of diagnostic tests available, the choice of which depends upon the condition being assessed. This position paper is intended to provide an up-to-date comprehensive description of the diagnostic tools available to rhinologists, allergists, general otolaryngologists and other physicians with an interest in sinonasal disease. The literature has been reviewed and evidence-based recommendations are included. The relevant history and examination techniques are described, including endoscopic assessment of the nose. General and disease-specific quality of life instruments are an important tool in assessing the impact of rhinologic disease and the response to treatment. Relevant blood tests are discussed, as well as the various methods of allergy testing. Techniques for collecting microbiological and tissue samples are described, as well as the use of more specialised tests such as nasal nitric oxide and those evaluating ciliary structure and function. Imaging techniques and their indications are included. Chemosensory (smell and taste) testing is explained, and the available techniques for objective measurement of nasal airflow and patency are reviewed. Prompt and accurate diagnosis allows appropriate management to be initiated; an understanding of the currently available diagnostic tools is a vital part of the assessment of rhinologic disease.

Prevention of chronic rhinosinusitis

Prevention of chronicity of disease and minimising its impact with individualized treatment is a fundamental tenet of precision medicine. A review of the literature has been undertaken to explore how this may apply to chronic rhinosinusitis (CRS). Prevention may be thought of across 3 main domains. Primary prevention of CRS focuses on the avoidance of exposure to environmental factors associated with increased incidence of disease. This includes avoidance of tobacco smoke and occupational toxins. Although allergic rhinitis, respiratory infections and gastro-oesophageal reflux have been shown to be risk factors, there is no evidence as yet that treatment of these conditions is associated with reduced incidence of CRS. Secondary prevention of CRS is concerned with detecting a disease in its earliest stages, intervening to achieve disease and symptom control and preventing future exacerbations. Evidence based guidelines facilitate early diagnosis and appropriate use of medical and surgical interventions. In the future the use of endotypes to direct optimal is like to allow more clinically and cost-effective use of current and emerging treatments, such as monoclonal antibodies. Tertiary prevention aims to minimise the impact of an ongoing illness or injury that has lasting effects. Anxiety and depression have been shown to be associated with symptom amplification and may require treatment. The role of disease-related factors such as the role of the microbiome and osteo-neogenesis in the development of chronicity, and the development of severe combined upper airway disease needs further research.

mySinusitisCoach: patient empowerment in chronic rhinosinusitis using mobile technology

Mobile health technology is emerging to take a prominent position in the management of chronic diseases. These technologies aim at enhancing patient empowerment via education and self-management. To date, of all the different apps available for patients with sinus disease, none were developed by medical experts dealing with chronic rhinosinusitis (CRS). The European Forum for Research and Education in Allergy and Airway diseases (EUFOREA) has undertaken a multi-stakeholder approach for designing, developing and implementing a tool to support CRS patients in monitoring their symptoms and to provide patients with a digital support platform containing reliable medical information about their disease and treatment options. mySinusitisCoach has been developed by medical experts dealing with CRS in close collaboration with patients, primary care physicians and community pharmacists, meeting the needs of both patients and health care providers. From a research perspective, the generation of real life data will help to validate clinical studies, patient stratification and improve understanding of the socio-economic impact of CRS, thereby paving the way for better treatment strategies.

Role of local anaesthetic nerve block in endoscopic sinus surgery: A systematic review and meta-analysis

OBJECTIVE

The aim of the study was to perform a systematic review of existing evidence on the role of local anaesthetic nerve block (LAB) in patients undergoing endoscopic sinus surgery (ESS).

DESIGN

The databases searched were the Cochrane Register of Controlled Trials, MEDLINE and Embase using the Ovid portal (1946-2017).

RESULTS

Seven randomised controlled trials were included. Due to considerable heterogeneity of data, only two studies were pooled into meta-analysis which demonstrated a statistically significantly better surgical field quality during ESS in the LAB group compared with the control group (MD -0.86; 95% CI -2.24, 0.51; P = .009). No adverse events related to LAB toxicity were reported.

CONCLUSIONS

Sphenopalatine ganglion LAB with adrenaline carries relatively low risk of morbidity, but may improve the quality of the surgical field in terms of bleeding. However, there are limitations of the study due to heterogeneity of methods, quality and size of the studies. Well-conducted large RCTs are needed using standardised inclusion criteria, balanced baseline characteristics of cohorts, and validated subjective and objective outcome measures.

Rhinitis and its impact on quality of life in swimmers

INTRODUCTION

Limited data suggest that swimmers might be affected by rhinitis significantly more often than the general population. This can have impact on quality of life but also on performance. The aim of this study was to determine the prevalence and impact of QOL of rhinitis in swimming compared to nonswimming athletes and controls.

MATERIALS AND METHODS

This was an observational case-control, questionnaire-based study involving elite (n = 101) and nonelite swimming athletes (n = 107), nonswimming athletes (n = 38) and sex- and age-matched controls (n = 50). The survey instrument consisted of a general and the miniRQLQ. Main question used to assess the prevalence of rhinitis was from the ISAAC study.

RESULTS

Rhinitis was reported significantly more often by the elite swimmers (45%) than nonelite swimmers (31%), nonswimming athletes (32%) and controls (24%). Allergic rhinitis prevalence was similar in all groups (12%-18%). The prevalence of nonallergic rhinitis (NAR) was significantly higher in elite swimmers (33%) and nonelite swimmers (22%) compared to nonswimming athletes and controls. Overall mean miniRQLQ score and all subdomains except the "eye" domain showed significantly reduced QOL in elite and nonelite swimmers compared to nonswimming athletes and controls. Regular nasal medication was used significantly less by elite swimmers (18%) compared to controls (67%) and nonswimming athletes (42%).

CONCLUSION

This study revealed a high prevalence of NAR in swimmers and related impact on QoL. These findings highlight the importance to increase the awareness towards upper airway disorders in the swimming athletes and to ensure adequate management.

Chronic rhinosinusitis: New understanding of specific and general Quality of life scores

Our goal in treating chronic rhinosinusitis (CRS) is to reduce sinonasal symptoms and improve quality of life (QoL). In patients with CRS, sinonasal symptoms have a significant impact on QoL. Various validated measures exist to quantify QoL such as the 22-item Sinonasal Outcomes Test (SNOT- 22) and MSNOT-20 Young Persons Questionnaire (MSYPQ) specific to CRS, while others measure general QoL, such as the EuroQol 5-Dimensional general health-related QoL survey (EQ5D).

Rhinitis in Elite and Non-Elite Field Hockey Players

Rhinitis has been demonstrated to impose a significant disease burden upon the general population. We sought to determine the prevalence of rhinitis in athletes; to investigate its relationship with co-existing allergic symptoms; and to quantify the impact of rhinitis on quality of life in the athlete.3 subgroups were studied: elite field hockey players (FHP); non-elite FHP; and a sedentary control group.Participants were asked to complete a rhinitis self-report questionnaire; the "Allergic Questionnaire for Athletes" (AQUA), and quality of life Sinonasal Outcome Test - 22 (SNOT-22).142 participants completed the study (52 elite FHP; 40 non-elite FHP; 50 controls). There was a significantly higher prevalence of rhinitis in the elite and non-elite FHP groups than the sedentary control group (52% and 43% vs. 22%, p<0.05). Mean AQUA score was significantly higher in athletes with rhinitis. Quality of life scores were significantly worse in athletes with rhinitis than those without rhinitis (p<0.05).This study suggests regular exercise is associated with a significant increase in the prevalence of rhinitis. Elite FHP were most likely to report rhinitis, but the least likely to be using regular treatment. Quality of life was negatively affected, confirming the importance of nasal health to athlete welfare.