Zahir Mughal

A woman in her 60s presented with an 8-month history of right-sided facial pain, with new reduced visual acuity, bilateral diplopia, restricted right extraocular movements and red desaturation. Her comorbidities included relapsing–remitting multiple sclerosis, breast cancer and type 2 diabetes mellitus. Imaging showed an aggressive sinonasal process with erosion into the right orbit, skull base and cavernous sinus. Biopsy confirmed invasive fungal sinusitis with septate hyphae and culture identified Aspergillus fumigatus. Initial treatment with amphotericin B was complicated by acute kidney injury, prompting a switch to posaconazole. Due to disease progression, therapy was escalated to isavuconazole, alongside right orbital exenteration and skull-base debridement. At 12 months, she was symptom-free and remains on lifelong isavuconazole; MRI at 16 months showed no recurrence. This case highlights diagnostic challenges, targeted antifungal therapy and multidisciplinary surgical management in advanced sino-orbital aspergillosis, alongside the ethical complexity of choosing radical surgery over palliation with intracranial extension.

Objective: Ear, nose and throat (ENT) is often underrepresented in undergraduate medical curricula. E‐learning has emerged as a promising strategy to address this gap. This mixed‐methods systematic review aimed to evaluate the effectiveness of e‐learning in undergraduate ENT education. Data Sources: MEDLINE, Embase, Education Research Complete, and Web of Science were searched. Review Methods: The PRISMA guidelines were followed. Quantitative data were synthesized with a meta‐analysis of normalized gain scores to assess knowledge improvement. Qualitative findings were analyzed using thematic synthesis. Due to substantial heterogeneity, a narrative synthesis was performed for skills and confidence. Results: Twenty‐nine studies fulfilled the inclusion criteria. Knowledge scores improved by 26.8% (95% CI 23.7%–30.0%, n = 13), which was considered low gain. Skill improvement was variable ( n = 6), while confidence consistently improved ( n = 5). Thematic synthesis identified four themes: (1) multimedia resources, (2) learner autonomy and self‐directed engagement, (3) technical barriers, and (4) blended learning models. Conclusion: Knowledge and learner confidence improved with e‐learning. However, its impact on practical skills was limited. These findings support the integration of e‐learning as a complementary adjunct to clinical teaching.

Background/Objectives: In this study, we aimed to evaluate probiotics’ clinical efficacy and safety in adults with chronic rhinosinusitis (CRS), and summarize mechanistic evidence related to mucosal immunity and microbiota modulation. Methods: We performed a systematic review and random-effects meta-analysis. MEDLINE, Embase, Scopus, Web of Science, and the Cochrane Library were searched until May 2025. Eligibility: Randomized controlled trials (RCTs) and mechanistic studies investigating probiotics (any strain, dose, or administration route) in adults with CRS were eligible. Primary outcomes included changes in Sino-Nasal Outcome Test (SNOT-20/22) scores and CRS relapse rates. Secondary outcomes were adverse events and mechanistic endpoints. Results: Six studies (four RCTs, n = 337; two mechanistic studies) met the inclusion criteria. Probiotics did not significantly improve SNOT scores compared with the placebo, but trended in that direction (pooled mean difference—2.70; 95% CI −7.12 to 1.72; I² = 0%). Furthermore, probiotic use was associated with a non-significant trend towards fewer CRS relapses (risk ratio 0.41; 95% CI 0.16–1.04; p = 0.06; I² = 48%). Adverse events were mild and comparable to the placebo (risk ratio 0.87; 95% CI 0.33–2.34). Mechanistic data indicated that intranasal Lactococcus lactis W136 might downregulate type 1 inflammatory pathways and modestly increase microbiome diversity. Subgroup analyses (by route, duration, and CRS subtype) revealed no statistically significant effect modifiers, though mechanistic insights suggest possible differences in efficacy based on the CRS endotype and delivery method. Conclusions: Probiotics appear safe and may provide a small, non-significant improvement in CRS symptoms; emerging evidence of reduced relapse rates warrants further investigation through larger, endotype-stratified trials utilizing targeted probiotic strains and optimized delivery methods.

Objective: Although endoscopic surgery has advanced the treatment of cerebrospinal fluid (CSF) rhinorrhea, spontaneous leaks remain challenging due to their higher recurrence rates compared to other etiologies. This systematic review aims to identify factors influencing surgical success. Data Sources: Medline, Embase, Cochrane, and Web of Science were searched on 26 October 2024, and updated on 9 June 2025. Review Method: A meta‐analysis was conducted to estimate the pooled success rates, and meta‐regression was used to explore the impact of demographic and surgical factors. Study quality was appraised using the JBI critical appraisal tool. Results: A total of 47 studies, encompassing 2586 patients, met the inclusion criteria. The pooled primary repair success rate was 93.7% (95% CI 91.5%–95.7%), and the overall success rate after revision surgery was 99.7% (95% CI 98.9%–100%). Multilayer reconstruction demonstrated higher success rates (94.6%, 95% CI 91.6%–97.1%) compared to single‐layer techniques (87.6%, 95% CI : 77.7%–95.1%), although the difference was not statistically significant ( p = 0.09). Perioperative lumbar drain use did not significantly affect outcomes ( p = 0.4). Skull base defects involving the sphenoid sinus were associated with lower success rates ( p = 0.0004). The overall quality of evidence was moderate. Conclusions: Endoscopic repair remains the gold standard for managing spontaneous CSF rhinorrhea. Reconstruction technique and lumbar drain use did not significantly influence surgical success. Randomized controlled trials are warranted to validate these findings. Level of Evidence: N/A.

Introduction: Concerns about the adequacy of ENT education are widespread, particularly in the UK. Limited exposure during undergraduate and postgraduate training are key factors. This review aims to synthesize the literature on ENT education, identify gaps, and explore strategies for improvement. Methods: A literature search was conducted on Ovid Medline, supplemented by bibliography and citation tracking. Studies focusing on ENT higher surgical training programs were excluded. A narrative synthesis was performed. Results: Medical students and postgraduate doctors frequently reported insufficient ENT education, leading to under-preparedness for ENT practice. Undergraduate ENT curricula varied widely, with limited placement durations and inconsistent content delivery. Innovative educational interventions were found to enhance knowledge and confidence. However, students consistently valued direct patient interaction over technology alone. Conclusion: ENT education at the undergraduate level remains inconsistent, necessitating further action in the development of standardized curricula, and integration of technology with clinical exposure.

Objective: To explore the clinical presentations of isolated sphenoid sinus disease (ISSD).Setting and Design: A literature search was conducted on 23 December 2023 across electronic databases including Medline, Embase, Web of Science, and Cochrane. We performed a meta‐analysis of proportions using a random‐effects model to determine the prevalence of clinical findings in patients who presented with symptoms and had ISSD on radiological imaging. Sensitivity and subgroup analyses were employed to investigate sources of heterogeneity. The PRISMA guideline was followed.Participants: This study included patients with clinically significant isolated sphenoid sinus opacification on cross‐sectional imaging.Main Outcome Measure: The pooled prevalence of clinical symptoms and signs.Results: A total of 18 studies met the eligibility criteria, encompassing over 1000 patients. The prevailing symptoms were headache in 67.9% (95% CI 62.9–72.7), nasal symptoms 29.7% (95% CI 25.2–34.4), and visual disturbance 14.0% (95% CI 9.3–19.3). Subgroup analysis revealed a significant difference between neoplastic and inflammatory diagnoses concerning the development of visual symptoms (38.3% versus 15.5%, p = 0.0005). A negative nasendoscopic examination was found in 52.0% (95% CI 41.0–62.8) of cases.Conclusions: Headache emerged as the primary symptom of ISSD, followed by nasal and visual symptoms. Nasendoscopy had a high false negative rate, highlighting its limitation in assessing this condition. Our study highlights the key clinical findings associated with ISSD, which may indicate the need for imaging.

Background/Objectives: Cerebrospinal fluid (CSF) rhinorrhoea carries a significant risk of life-threatening intracranial complications. This review provides a contemporary overview of current management strategies for CSF rhinorrhoea. Methods: We conducted a literature review, examining studies from Medline, Embase, and Google Scholar published within the last 20 years. This narrative synthesis summarises the current and future trends in the management of CSF rhinorrhoea. Results: The management of CSF leaks requires a multidisciplinary approach, encompassing a thorough clinical assessment, targeted diagnostic testing, and a spectrum of surgical and non-surgical interventions. Endoscopic techniques, particularly the use of vascularised flaps such as the nasoseptal flap, has become central to anterior skull base reconstruction. Numerous graft and flap choices provide tailored solutions based on defect size and CSF flow characteristics, with reported success rates exceeding 90%. Conclusions: Endoscopic repair of CSF rhinorrhoea continues to evolve, with modern techniques significantly enhancing success rates and reducing morbidity. Further understanding of underlying aetiologies, advances in technology, and refinement in surgical technique are areas for future innovation in CSF rhinorrhoea management.

Objective: This study aims to investigate the trends in otology, rhinology, and head and neck (H&N) operations over the past decade in England. These trends will allow for predictive modelling to forecast the demand over the coming years to aid workforce and resource planning in ENT. Methods: Hospital Episode Statistics data were extracted between April 2012 and April 2023. A total of 121 otology, 114 rhinology, and 122 H&N procedure codes were included. Correlation and linear regression analyses were conducted to examine trends and produce a forecast model for the volume of operations. Results: A gradual upward trend in the volume of operations was observed in rhinology, with a positive correlation coefficient (R = 0.74). In contrast, otology (R = −0.67) and H&N (R= −0.75) showed negative trends, indicating a moderate decline in operational volumes over time. The COVID-19 pandemic significantly disrupted operating activity in rhinology and otology. To address the backlog and reach the pre-pandemic forecasted levels within the next five years, surgical capacity must increase by an additional 33,807 rhinology 25,486 otology, and 10,300 head procedures per year in England. Conclusions: This analysis highlights a need for prioritization and expansion of the ENT workforce and resources to manage the current backlog and anticipated increase in demand over the next five years.