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OBJECTIVES: The aim of this study is to identify the most common and important features within the presenting history, clinical examination and chest radiograph that are associated with foreign body (FB) aspiration in the paediatric population, to support rationalised decision making in regards to proceeding with diagnostic bronchoscopy. METHODS: A retrospective notes review was conducted of 70 patients over a 12-year period at our tertiary referral centre. Their presenting history, clinical and radiographic signs were documented and univariate logistic regression model used to calculate odds ratios. RESULTS: The main features identified within our cohort with a positive FB finding at bronchoscopy were history of a cough (OR 5.1, p = 0.008) and radiographic evidence of hyperinflation or air trapping (OR 7.1, p = 0.016). Zero patients with a FB presented with only a positive history in the absence of other clinical or radiological signs. History of a witnessed choking episode neither increased or decreased the likelihood of as aspirated FB (OR 1, p = 0.967). CONCLUSIONS: We have identified two principal features, as described above, which are associated with paediatric FB aspiration. Reliance on a positive clinical history alone, but specifically the history of a witnessed choking episode, did not support the presence of a FB and other associated signs need to be considered in deciding to proceed to bronchoscopy.

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OBJECTIVE: To determine the impact of the COVID-19 pandemic on acute admissions and inpatient activity at a tertiary referral centre. DESIGN: Retrospective review of coding-based inpatient electronic records. SETTING: An otolaryngology and head and neck surgery department at a major UK trauma and tertiary referral centre. PARTICIPANTS: Otolaryngology patients admitted as an emergency over a period of 10 months pre-COVID19 (01/04/2019-23/01/2020) and 10 months post-COVID19 (01/04/2020-23/01/2021). MAIN OUTCOME MEASURES: Baseline characteristics, admission rates, length of stay (LoS), overall mortality and 30-day mortality. RESULTS: A total of 1620 records were reviewed; (1066 pre-COVID19, 554 post-COVID19). Admissions across all age groups were reduced, with an increase in mean age from 39.88 to 47.4 years (p = .018). LoS remained unchanged (3.85 vs 3.82 days, p = .160). Infection remained the most common presentation, followed secondly by epistaxis which entailed an increased LoS compared to the pre-COVID19 cohort. GP referrals reduced from 18.3% to 4.2% (n = 195 vs n = 23, p < .001) and ED referrals proportionally increased from 71.9% to 85.9% (n = 766 vs n = 476, p < .001). Critical care admissions were higher in the post-COVID19 cohort (OR 1.78 (1.07-2.98) [95% CI], p = .027). There was no significant difference in overall mortality between groups (n = 60, 5.6% vs. n = 33, 6.0%; p = .844). Thirty-day mortality increased from 0.9% (n = 12) pre-COVID19 to 2.3% (n = 13) post-COVID19 (p = .039). CONCLUSIONS: This study demonstrates significant changes and a reduction in acute otolaryngology presentations. Our findings may suggest that sicker, frailer patients were admitted during the pandemic. This study reports the observational effect that the pandemic has had on acute otolaryngology admissions, which may be relevant in addressing unmet care needs in the post-pandemic period.

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OBJECTIVE: To describe a case of silent sinus syndrome secondary to malignancy and discuss the pertinent clinical findings. Silent Sinus Syndrome (SSS) refers to a rare, asymptomatic condition whereby occlusion of the maxillary sinus ostium results in gradual resorption of air, creation of negative pressure and collapse of the maxillary walls. METHODS: Review of medical records and literature review using NCBI/PubMed. RESULTS: We describe a case of a 54-year-old gentleman presenting solely with enophthalmos. He had been diagnosed with stage IVa small lymphocytic lymphoma (SLL) 1.5 years prior to this, which was being managed with active surveillance. CT demonstrated severe bowing of the anterior and posterolateral wall, inferior displacement of the floor of the orbit and right enophthalmos, thus supporting a diagnosis of silent sinus syndrome. Compared to previous staging CT at the time of the lymphoma diagnosis these findings were entirely new, and soft tissue in the pterygomaxillary fissure was found to be enlarged. The patient underwent endoscopic sinus surgery and a right maxillary mega-antrostomy was performed to ventilate the maxillary sinus and prevent progression of eye symptoms. A biopsy was taken from the pterygopalatine fossa, which was confirmed to be chronic lymphocytic leukemia (CLL). CONCLUSION: This case is unique both in being secondary to malignancy, as well as being rapidly progressive given the presence of radiologically normal appearances 1.5 years prior to presentation. Although a rare condition, prompt recognition of SSS is vital to prevent ophthalmological complications. This report highlights malignancy as a potential cause in cases with focal bony remodeling.

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BACKGROUND: Novel oral anticoagulants (NOACs) are being increasingly used in the secondary prevention of thromboembolic stroke in patients with atrial fibrillation. Patients taking NOACs are difficult to manage perioperatively, and several unexpected complications have been reported in these patients. CASE REPORT: We report a case of a rivaroxaban-induced retroperitoneal haematoma in a 72-year-old man who underwent an L5/S1 anterior lumbar interbody fusion (ALIF) for grade 1 spondylolytic spondylolisthesis. The patient suffered from atrial fibrillation and was taking rivaroxaban, a factor Xa inhibitor, for thromboembolic risk reduction. In accordance with perioperative Novel Oral Anticoagulant (NOAC) guidelines, rivaroxaban was stopped 2 days preoperatively and restarted on the third postoperative day. The patient presented on the ninth postoperative day, complaining of severe left iliac fossa pain, nausea, and vomiting, accompanied by swelling and bruising around the surgical site. A computed tomography (CT) scan showed a large expanding retroperitoneal haematoma. The patient was taken back to theatre for an evacuation of the haematoma and subsequently recovered without any further complications. CONCLUSION: This is the first case of a rivaroxaban-induced retroperitoneal haematoma reported in the literature, secondary to elective spinal surgery. This report adds to the body of evidence on the risk of postoperative bleeding in patients taking NOACs. If patients on NOACs present with abdominal symptoms following anterior approach to the lumbar spine, treating clinicians should have a high index of suspicion for retroperitoneal haematoma.

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