Objectives Admission of patients with necrotising otitis externa (NOE) has been rising steadily over the last five years and mortality and morbidity associated with the disease is high. Our objective is to assess the value of adjuvant hyperbaric oxygen therapy in patients with necrotising otitis externa. Design and setting A retrospective, observational, case-control study was conducted by examining patients’ records over a four-and-a-half-year period at two secondary care sites in the UK. The (Non-HBO) control group treated conventionally and the (HBO) group treated with additional adjuvant HBO in a multiple occupancy therapy chamber at the James Paget University Hospital. The primary outcome measure was death. Secondary outcomes measures were resolution of pain and recovery from otalgia, facial nerve palsy and other cranial nerve palsies. Results There were 10 patients in the HBO group and 20 in the non-HBO group; mean age was 82.3 years and 88.3 years respectively. The mortality rate was 30% in the HBO group compared to 55% in the non-HBO group. Patients tolerated HBO well, had greater resolution of pain (90% vs 64%) and resolution of facial nerve palsy (67% vs 31%) than the non-HBO group. Resolution of other cranial neuropathies was similar. Conclusion Our case series suggests that HBO is potentially a life-saving intervention. It also suggests that patients treated with HBO therapy for NOE appear to improve both in terms of pain and facial nerve palsies compared with conventional treatment and sets the precedent for a trial to formally compare the adjunctive intervention of HBO.

Key Points Inverted papillomata are benign sinonasal tumours with high recurrence rates. Inverted papillomata recurrence is increased if operated on by a non-fellowship trained rhinologist. Inverted papillomata recurrence can be detected earlier in cases managed by specialist rhinology services. Inverted papillomata should be managed through a clear treatment pathway for sinonasal tumours. Other risk factors associated with increased recurrence include Krouse stage 3 and involvement of the frontal or maxillary sinuses.

Following the European Forum for Research and Education in Allergy and Airway Diseases (EUFOREA) treatment algorithm for chronic rhinosinusitis (CRS) with nasal polyps (CRSwNP), patients suffering from severe uncontrolled CRSwNP are recommended to receive oral corticosteroids, (revision) sinus surgery, systemic biologicals, and/or aspirin treatment after desensitization (ATAD). Given the major differences in indications, outcomes, practical considerations, risks and costs of these key pillars of treatment, there is a growing need to define criteria for each treatment option and list the clinically relevant and major considerations for them. This EUFOREA document therefore provides an expert panel overview of the expected outcomes, specific considerations and (contra)indications of the five major treatment arms of severe uncontrolled CRSwNP: oral corticosteroids, primary and revision sinus surgery, biological treatment, and ATAD. This overview of treatment considerations is needed to allow physicians and patients to consider the different options in the context of providing optimal and personalized care for severe uncontrolled CRSwNP. In conclusion, the five major treatment options for severe uncontrolled CRSwNP have intrinsic advantages, specific indications, and considerations that are of importance to the patient, the physician, and the society. This EUFOREA statement supports the unmet need to define criteria for the indication of every treatment pillar of CRSwNP.

Abstract Objectives: Olfactory dysfunction can expose individuals to day-to-day safety hazards. We sought to investigate the perceptions of safety in individuals affected with olfactory dysfunction, quantify the incidence of hazardous events, and how safety scares/incidents manifest through patient stories. Methods: A survey that included questions to capture quantitative and qualitative data was created. Responses were collected from 25th February 2022 to 28th September 2022. The survey was distributed through Fifth Sense media channels and open to anyone who claimed to suffer from olfactory dysfunction. Results: Our survey collected responses from 432 individuals. The majority were female (79.6%), ages 41-70. Around a fifth (16.7%) were non-UK residents, encompassing 21 different countries. Covid-19 was the commonest cause of olfactory dysfunction (22%). Majority (85.9%) were worried about any form of safety due to their smell dysfunction. Gas, smoke and food were major concerns. Specifically, 32.2%, 14.8%, 34.5%, 18.5% of participants have experienced at least one food incident, gas incident, gas scare, and work scare, respectively. Affected individuals have taken preventative measures at home (60.2%). Conclusion: There is an unmet need in mitigating safety concerns/events for individuals with olfactory dysfunction. We suggest educating the public sector and high-risk sectors such as gas companies, and introduction of safety ‘scratch and sniff’ cards as a screening method. Regular assessment of an individual’s olfactory ability, similar to routine assessments for other sensory systems (sight, hearing) would allow proactive identification of at-risk people, and allow corrective measures to take place.

Background: A James Lind Alliance Priority Setting Partnership (JLAPSP) was established by Fifth Sense together with UEA to identify the top 10 research questions in the field of smell and taste disorders in the United Kingdom. Methods: After steering group was established, an electronic survey was disseminated to all stakeholders (patients, healthcare professionals, family, carers, researchers) to determine the list of questions. After removing out-of-scope responses, the remainder were consolidated to create summary questions. A literature search was conducted to remove already answered questions. A second survey was used to determine the top questions that formed the subject of final debate at a workshop attended by clinicians and patients to determine the top 10 priorities. Results: The 665 respondents to the initial survey provided 1698 research questions. Thirteen were out-of-scope and removed; remaining 1685 were then consolidated to form 147 summary questions. Following literature search and discussion with the steering group, 37 questions remained for the second survey, which 235 people responded. The top ten priorities agreed in the workshop covered themes of improved understanding of pathophysiologlogy, improving health services, and managing long-term effects of smell/taste disorders. The most important research question agreed was “How can we further our understanding of the mechanism of disease in the nerve pathways that affect smell and taste disorders, including where parosmia and phantosmia exist.” Conclusions: We report the top 10 research priorities in smell and taste disorders. These priorities will now empower researchers to secure research funding and provide the basis of the Fifth Sense research hub.

Background Olfactory dysfunction (OD) is a common but underreported problem that can significantly impact a patient’s quality of life. Dysfunction is prevalent in over 5% of the adult population and can be broadly categorised into conductive and sensorineural causes. Magnetic Resonance Imaging (MRI) can form part of the diagnostic work up, although its exact role is often debated. Objectives The aim of this study was to evaluate the value of MRI in managing patients with OD. Design/ Method A retrospective analysis of the records of patients presenting to national smell and taste clinic over a five-year period was performed. Variables included demographics, endoscopic findings, final diagnosis, psychophysical smell test and MRI results. Results A total of 409 patients underwent clinical assessment and smell testing for OD, of which 172 patients (42%) had MRI scans performed. The age range of patients was 10 to 93 years. Imaging in younger age-groups was associated with a higher rate of positive findings, however identifiable causes for OD were recorded across the range. MRI provided both diagnostic and prognostic information in those with idiopathic, traumatic, and congenital causes of OD. For example, MRI provided information on the extent or absence of traumatic gliosis in those with a head trauma history allowing further treatment and prognosis. Conclusion We recommend the adjunct use of MRI in patients with a clear history and examination findings of head injury, congenital cases and in apparent idiopathic cases. MRI should be requested to compliment clinical findings with a view to aiding decision-making on treatment and prognosis independent of patient’s age.

• Telephone interviews were conducted with 19 MACRO trial participants from 5 ENT sites across the UK. • Trial participants experienced mixed levels of communication during the COVID period and some felt uninformed about the trial status and their clinical situation. • Participants were most concerned about getting COVID through interactions with other patients in hospital settings. Conversely, there was a high level of trust in healthcare professionals. • Pre-visit COVID-safety information, minimising contact with other patients, and strict waiting room management can facilitate the restart of the MACRO trial from the patient perspective. • Patient confidence in trial participation is likely to continue improving with COVID vaccination roll out.

Objectives: Smell/taste disturbances are a common but underrated, under-researched and under treated sensory loss and an independent risk factor for reduced longevity. This study aimed to characterise the experience of patients these disorders in seeking help. Design: The study was designed by patients together with clinicians through a dedicated workshop and conducted as a cross-sectional survey to capture experiences in public and private healthcare settings internationally. Setting: Primary, secondary and tertiary care. Participants: Any members of the public self-reporting a smell/taste disorder were invited to participate. Main outcome measures: The survey captured information including experience of getting consultations and referrals to medical professionals, treatments offered, costs incurred and related problems with mental health. Results: Of 673 participants; 510 female, 160 male, self-reported aetiology included sinonasal disease (24%), idiopathic (24%) and post-viral olfactory dysfunction (22%); true gustatory disorders were typically rare. Failure of medical professionals to recognise the problem was a key concern - 64%, 76% and 47% of GPs, ENT specialists and Neurologists acknowledged respectively. Other issues included repeated ineffective treatments, difficulties getting referrals to secondary/tertiary care, mental health problems (60%) and a mean personal cost of £421 to seeking advice and treatment. Whilst the participants were self-selecting, however they do represent those who are seeking help and intervention for their disorders. Conclusion: There is an unmet need for these patients in accessing healthcare including a clear need to improve education of and engagement with the medical profession in Otorhinolaryngology, General Practice and other specialties, in order to remove the current barriers they face.

Objectives We set out to create Consensus Guidelines, based on current evidence and relative risks of adverse effects and the costs of different treatments, that reflect the views of the British Rhinological Society (BRS) Council on where the use of biologics should be positioned within treatment pathways for CRSwNP, specifically in the setting of the National Health Service (NHS). Methods An expert panel of 16 members was assembled. A review of the literature and evidence synthesis was undertaken and circulated to the panel We used the RAND/UCLA methodology with a multi-step process to make recommendations on the use of biologics. Setting and participants N/A Results Recommendations were made, based on underlying disease severity, prior treatments and co-morbidities. A group of patients for whom biologics were considered an appropriate treatment option for CRSwNP was defined. Conclusions Although biologics are not currently available for the treatment of CRSwNP, the BRS Council have defined a group of patients who have higher rates of ‘failure’ with current treatment pathways, higher resource use and are more likely to suffer with uncontrolled symptoms. We would urge NICE to consider approval of biologics for such indications without applying further restrictions on use.

1. The age range of patients responding to the survey was 28-85 with a mean of 58\(\pm\)12 years with the duration of their disorder less than 5 years in 63% of cases. 2. Patients experience variable treatment, if at all, for post-viral olfactory loss 3. If treatment is given oral and/or intranasal steroids are typically given. 4. Several patients reported receiving imaging despite this not being clinically useful when there is a clear history and normal examination. 5. Over two thirds of patients experience parosmia and up to 5 years of the onset of the problem were still actively seeking a solution.

Background: Chronic rhinosinusitis (CRS) is a heterogenous group of inflammatory sinonasal disorders with key defining symptoms, but traditionally separated into phenotypes by clinical/endoscopic findings. It is not known if the two phenotypes have differing socioeconomic, co-morbidity and lifestyle differences. Objective: This analysis of the Chronic Rhinosinusitis Epidemiology Study (CRES) database sought to analyse any key differences in the socioeconomic variables between those with CRS with nasal polyps (CRSwNPs) and those without nasal polyps (CRSsNP). We also sought to analyse differences in comorbidities, lifestyle and quality of life. Methods: Patients with a confirmed diagnosis of CRS in secondary and tertiary care outpatient settings were invited to participate in a questionnaire based case-control study. Variables included demographics, comorbidities, socioeconomic factors, lifestyle factors and health related quality of life. Results: A total of 1204 patients’ data were analysed; 553 CRSsNP and 651 CRSwNP participants. The key socioeconomic variables did not demonstrate any notable differences, nor did lifestyle variables other than alcohol consumption being higher in those with CRSwNP (p=0.032). Aside from confirmation of asthma being more common in CRSwNP, it was notable that this group complained less of URTIs and CRSsNP participants showed evidence of lower HRQoL scores in respect of body pain (p=0.001). Conclusions: Patients with CRSwNP experience higher rates of asthma and lower rates of URTIs but otherwise do not demonstrate significant socioeconomic, comorbidity, lifestyle or quality of life issues other than for body pain and alcohol consumption.

IntroductionLoss of smell is a common complaint in adults and yet has been underestimated. Anosmia, complete loss of smell, is thought to affect at least 1-5% of the population[1]. Based on European estimates, anosmia is more prevalent than profound hearing loss or blindness in the UK. Causes for olfactory loss are varied but the main diagnostic groups include sinonasal disease (62%) and post-infectious olfactory dysfunction (PIOD) (11%)[2]. Olfactory dysfunction has now emerged as a key symptom in the coronavirus pandemic and it is possible we may see a cohort of patients with lasting problems following the peak of the Covid-19 impact[3, 4]. Historically, there is wide variation in clinical practice reported by clinicians to patients on prognosis or treatment[5]. Guidelines for the overall management of olfactory disorders now exist in the Position Paper on Olfactory Dysfunction[6] and recently the British Rhinological Society has produced a consensus statement on managing Covid-related PIOD[7] but the impact of those guidelines have yet to penetrate routine clinical practice.Previously published data has shown the high impact on quality of life experienced by olfactory disorder patients, including depression, anxiety, impairment of eating experience, feelings of isolation and relationship difficulties[8, 9]. Most patients suffer a loss of flavour perception which can adversely affect their appetite, but this can be made even worse when parosmia is also present. Given the number of potential treatment options for PIOD that have been proposed but yet to undergo formal evaluation through a randomised clinical trial[10], there is a pressing need to deliver more RCTs in this area. A recent German study has highlighted Vitamin A as a potential therapeutic agent for further evaluation[11]. In anticipation of setting up a clinical trial to evaluate the role of vitamin A intranasally for PIOD we sought to generate evidence of need to funders through Public and Patient Involvement (PPI) in partnership with the charity Fifth Sense that represents patients affected by Smell & Taste disorders in the UK (www.fifthsense.org.uk).The aim of this study was to characterise the experience of patients with PIOD in terms of the treatment they received in order to demonstrate any unmet need.