Evidence before this study: Acute appendicitis is the most common general surgical emergency in children. Its diagnosis remains challenging and children presenting with acute right iliac fossa (RIF) pain may be admitted for clinical observation or undergo normal appendicectomy (removal of a histologically normal appendix). A search for external validation studies of risk prediction models for acute appendicitis in children was performed on MEDLINE and Web of Science on 12 January 2017 using the search terms ["appendicitis" OR "appendectomy" OR "appendicectomy"] AND ["score" OR "model" OR "nomogram" OR "scoring"]. Studies validating prediction models aimed at differentiating acute appendicitis from all other causes of RIF pain were included. No date restrictions were applied. Validation studies were most commonly performed for the Alvarado, Appendicitis Inflammatory Response Score (AIRS), and Paediatric Appendicitis Score (PAS) models. Most validation studies were based on retrospective, single centre, or small cohorts, and findings regarding model performance were inconsistent. There was no high quality evidence to guide selection of the optimum model and threshold cutoff for identification of low-risk children in the UK and Ireland. Added value of this study: Most children admitted to hospital with RIF pain do not undergo surgery. When children do undergo appendicectomy, removal of a normal appendix (normal appendicectomy) is common, occurring in around 1 in 6 children. The Shera score is able to identify a large low-risk group of children who present with acute RIF pain but do not have acute appendicitis (specificity 44%). This low-risk group has an overall 1 in 30 risk of acute appendicitis and a 1 in 270 risk of perforated appendicitis. The Shera score is unable to achieve a sufficiently high positive predictive value to select a high-risk group who should proceed directly to surgery. Current diagnostic performance of ultrasound is also too poor to select children for surgery. Implications of all the available evidence: Routine pre-operative risk scoring could inform shared decision making by doctors, children, and parents by supporting safe selection of lowrisk patients for ambulatory management, reducing unnecessary admissions and normal appendicectomy. Hospitals should ensure seven-day-a-week availability of ultrasound for medium and high-risk patients. Ultrasound should be performed by operators trained to assess for acute appendicitis in children. For children in whom diagnostic uncertainty remains following ultrasound, magnetic resonance imaging (MRI) or low-dose computed tomography (CT) are second-line investigations.

ObjectivesTo determine how long after symptom onset that the average patient with an idiopathic sudden sensorineural hearing loss (ISSNHL) presents to the otolaryngology clinic. In late presentations, to determine the time to presentation cutoff after which intervention may not be effective. To evaluate the effectiveness of oral steroids versus a combination of oral and intratympanic steroid therapy in late presentations of ISSNHL. Methods and proceduresSixty-four patients met inclusion criteria after chart review of 2,037 patients seen at Metro Health Hospital from 2006 to 2016 for sensorineural hearing loss. All sixty-four patients were used to calculate the average time to presentation, but only 40 were included to evaluate treatment efficacy because 24 were lost to follow-up or declined treatment. Audiograms were analyzed for baseline status and response to treatment. Therapy was either oral steroids or intratympanic (IT) steroids. Thirty-nine of the 40 treated patients received oral steroid therapy. Eighteen of these 39 patients received both oral and IT steroids. One patient received IT steroids only. ResultsFor all 64 patients in the study, the average time to presentation was 55 days, ranging from one day to 240 days. Data for 32 of the 40 treated patients were analyzed. These patients were further divided into smaller groups: Group 1 (N = 11) - treatment within seven days of symptom onset, Group 2 (N = 17) - time to treatment greater than seven days but less than 90 days of symptom onset, and Group 3 (N = 4) - greater than 90 days of symptom onset. In Group 2, there was a significant improvement in pure tone average (P-value: 0.005). Forty-seven percent of patients in this group had objective treatment response utilizing Wilson’s criteria. Two patients had a complete recovery and six had a partial recovery. Hearing gains ranged from 10 dB (decibels) to 23 dB. Sixty-three percent of patients with objective improvement also had subjective improvement. In Group 3, none of the patients met Wilson’s criteria for recovery. There was no statistically significant difference in response between patients treated with oral steroids only versus a combination of oral and IT steroids.ConclusionPatients with ISSNHL present to an otolaryngologist on average 55 days after symptom onset. There is statistically and clinically significant response to treatment in late presenters. Improvement can be seen up to three months from symptom onset. Oral steroid therapy is effective. IT steroid therapy may have an added benefit.

Collision tumors are two independent, distinct tumors occupying the same anatomical space. This case presents a pituitary adenoma-craniopharyngioma collision tumor presenting with hemianopsia. A 60-year-old with a past history of a nonsecretory pituitary adenoma presented with progressive headaches, bitemporal hemianopsia, and nausea. Previously, in 2008, his adenoma was effectively treated with nasal septal flap and transsphenoidal pituitary resection. A magnetic resonance imaging (MRI) was ordered for concern of recurrence, given his history and neurologic complaints. The MRI revealed a suprasellar mass extending into the third ventricle with displacement of the hypothalamus and optic chiasm. Laboratory testing revealed no indicators of endocrinopathy. The neurosurgical and otolaryngologic teams were elected to perform tumor resection given the ongoing symptoms. An image-guided transsphenoidal tumor resection with abdominal fat graft harvest and septal mucosal flap CSF leak repair was performed. Histopathological examination revealed two tumor components within the resection including an adamantinomatous craniopharyngioma and recurrent pituitary adenoma.