Medicolegal and ethical aspects of ORL-HNS in the new millennium

Cholesteatoma in three dimensions: a teaching tool and an aid to improved pre-operative consent

Background:

Otological surgeons face two recurring challenges. Firstly, we must foster an appreciation of the complex, three-dimensional anatomy of the temporal bone in order to enable our trainees to operate safely and independently. Secondly, we must explain to our patients the necessity for surgery which carries the potential for serious complication.

Methods:

Amira® software was applied to pre-operative computed tomography images of temporal bones with cholesteatoma, to create three-dimensional computer images. Normal structures and cholesteatoma were displayed in a user-friendly, interactive format, allowing both trainee and patient to visualise disease and important structures within the temporal bone.

Results:

Three cases, and their three-dimensional computer models are presented. Zoom, rotation and transparency functions complemented the three-dimensional effect.

Conclusion:

These three-dimensional models provided a useful adjunct to cadaveric temporal bone dissection and surgical experience for our residents' teaching programme. Also, patients with cholesteatoma reported a better understanding of their pre-operative condition when the models were used during the consenting process.

Why should disorders of the ear, nose and throat be treated by the same specialty? Can this situation persist?

The surgical specialty of otorhinolaryngology has its origins in the nineteenth century. Subsequently, the specialty also incorporated allied disciplines such as plastics and head and neck surgery. Following World War II, the survival of the specialty was threatened by the advent of antibiotics and the rise of the general surgeon. Despite this, the specialty of ENT was strengthened by strong post-war leadership and robust training.Today, with ENT knowledge ever increasing, the subspecialties have again begun to subdivide. Specialisation brings improved efficiency and outcomes; however, there remains a great need for the ENT generalist. Not all cases require subspecialist attention, and the generalist remains the basis of competent emergency cover. The natural development of otorhinolaryngology has brought the invaluable synergistic knowledge required to comprehensively treat disorders of the ear, nose and throat, knowledge that must not be overlooked when shaping the future of the specialty.

Informed consent for middle ear operations: a United Kingdom survey

Otorhinolaryngologists throughout the UK routinely perform middle ear operations. Although the risk of serious complications in the hands of a well-trained surgeon is very low, some of the complications of middle ear surgery are devastating to the patient viz. facial nerve palsy and complete hearing loss. The subject of informed consent is highly topical because of clinical governance and medico-legal implications. We have audited the practice of the Consultant members of the British Association of Otorhinolaryngologists-Head and Neck Surgeons via a postal questionnaire with regards to their consenting process prior to middle ear operations. Our study looked at the practice of discussing different complications and the complication rates, the person consenting, time spent on consenting, and the documentation. We found that wide variations exist in the consenting process. The implications of the results are discussed. This study is particularly pertinent at the present time with the implementation of the new consenting standards document published by the Department of Health.