An Audit of Adherence to SIGN Guidelines for Tonsillectomies: Completion of Third Cycle

Objective: It is important to ensure that our listing practice for tonsillectomy is in keeping with the best evidence available, as stated by the Scottish Intercollegiate Guidelines Network (SIGN). We audited the accuracy of documentation of the SIGN guideline indications for tonsillectomies to ensure appropriate listing of such patients.

Method: Medical notes of patients with recurrent tonsillitis presenting to our department were reviewed retrospectively to check for documentation of the SIGN indication for tonsillectomy. Three audit cycles were carried out, each over a 3-month period.

Results: Prior to intervention, only 51% (25/51) patients undergoing tonsillectomy had documented evidence of adherence to SIGN guidelines for surgery. Interventions following the first audit cycle included presentation of audit findings, introduction of guideline templates for doctors to complete, and recruitment of medical secretaries to return the notes to doctors if documentation was incomplete. Postintervention, audit cycles 2 and 3 showed respectively 100% (30/30), and 92% (36/39) of patients had documented evidence of adherence.

Conclusion: The introduction of a simplistic model of intervention as above improved the local adherence to SIGN guidance for tonsillectomy and translated to safe and better care for patients. This model is easily replicable and can be used in other ENT departments to improve patient care.

Predicting the site of attachment of sinonasal inverted papilloma

STATEMENT OF PROBLEM

Sinonasal inverted papilloma is a benign, epithelial neoplasm, which has a propensity for malignant transformation and recurrence. The evolution of endoscopic trans-nasal surgery has facilitated less destructive and, more functionally and cosmetically acceptable approaches to this tumour. Recurrence rates have been shown to be more favourable than after traditional external approaches. Precise surgery is enhanced by pre-operative localisation of the site of tumour attachment. The aim of this study was to examine, in a prospective fashion, the predictive value of osteitis on the pre-operative CT scan of the paranasal sinuses at correctly identifying the site of attachment of sinonasal inverted papilloma.

METHOD OF STUDY

Pre-operative CT scans of the paranasal sinuses in 24 patients with histology-proven sinonasal inverted papilloma were examined for osteitis, allowing a prediction of the site of attachment. Coronal reformats of thin-cut (1mm) axial CT scans were evaluated. Intra-operatively, the actual site of tumour attachment was established. A correlation between the predicted and actual site of tumour attachment was calculated.

MAIN RESULT

The predictive value of the osteitis sign was 95%.

PRINCIPAL CONCLUSION

Pre-operative identification of osteitis can be used in 95% of cases to accurately predict the intra-operative site of attachment of sinonasal inverted papilloma.

The inflammation produced by corticosteroid inhalers in the pharynx in asthmatics

OBJECTIVES

To investigate inflammation of the pharyngeal mucosa caused by inhaled corticosteroids.

DESIGN

Prospective, cross-sectional, single-blinded study.

SETTING

University Hospital Aintree, Liverpool, UK.

PATIENTS

Fifty adults were recruited from two local general practices and from general ENT clinics at our University hospital. Patients were allocated to one of four groups according to use of inhaled corticosteroids and the presence of adverse local side effects.

MAIN OUTCOME MEASURES

Scores achieved on a respiratory symptom questionnaire. Histological markers of inflammation and their correlation with pharyngitis. Statistical modelling included univariate and multivariate analyses, which included multiple linear and logistic regression, and discriminant analysis.

RESULTS

The regular use of inhaled corticosteroids predisposed subjects to hoarseness, weakness of voice, sore throat and throat irritation (P < 0.0001). Pharyngitis was significantly different between the groups (P < 0.0001). Furthermore, those not using an inhaled corticosteroid regularly had little or no clinically apparent pharyngitis, whereas those using an inhaled corticosteroid regularly had significantly higher pharyngitis scores (P = 0.0204). Similarly, weakness of voice (P = 0.0234), hoarseness (P < 0.001) and sore throat (P < 0.001) were also more common in those patients that used an inhaled corticosteroid on a regular basis. To our surprise, however, cellular markers of inflammation did not corroborate the appearances of clinical examination. We found that the five most important discriminators, between those that were using inhaled corticosteroid therapy regularly and those that were not, to be intra-epithelial inflammatory cells (scdf -1.2939); age (scdf 0.8389); use of a spacer device (scdf 0.5456); sore throat (scdf 0.4230) and throat irritation (scdf 0.4015). The groups were significantly different (P < 0.0001). The statistical model used, classified 68% of the cases correctly into their respective groups.

CONCLUSIONS

Inhaled corticosteroids predispose to pharyngitis and an inflammatory infiltrate. However, the clinical diagnosis of pharyngitis does not correlate well with cellular inflammatory infiltrate and is therefore, not a reliable measure of underlying inflammation. We advocate caution in the use of pharyngeal erythema as a measure of underlying inflammation.

Safety of budesonide in saline sinonasal irrigations in the management of chronic rhinosinusitis with polyposis: lack of significant adrenal suppression

OBJECTIVE

To evaluate the potential for hypothalamic-pituitary-adrenal (HPA) axis suppression by budesonide nasal irrigations in the treatment of refractory chronic rhinosinusitis with polyposis (CRSwP).

STUDY DESIGN

Retrospective, descriptive review of patient charts.

SETTING

Tertiary care rhinology practice in an academic teaching hospital.

PATIENTS

Eighteen adult subjects with CRSwP refractory to conservative medical therapy.

METHODS

The charts of consecutive patients identified as being treated with topical budesonide in saline for nasal irrigation from January to October 2006 were reviewed. In all cases, pre- and posttreatment morning cortisol levels had been measured following at least 8 weeks of uninterrupted therapy. In addition, a subset of patients who continued therapy longer than 8 weeks had undergone the more sensitive adrenocorticotropic hormone (ACTH) stimulation test.

RESULTS

All pre- and posttreatment morning cortisol levels were within the normal range. For an 8-week treatment period, there was no evidence of HPA axis suppression (p=.4171). For patients who continued treatment beyond 8 weeks, ACTH stimulation did not detect HPA axis suppression. Furthermore, there were no issues with compliance or acceptability, nor were any adverse side effects reported.

CONCLUSION

Budesonide in saline sinonasal irrigation for the treatment of refractory CRSwP does not cause HPA axis suppression. The efficacy of this higher dose of steroid delivered locally would benefit from further study.

Prospective, randomized cross-over trial to assess the ability of a dry-powder inhaler to reverse the local side effects of pressurized metered-dose inhalers

OBJECTIVES

To determine whether a corticosteroid dry-powder inhaler could reverse the pharyngeal and laryngeal side effects produced by a corticosteroid pressurised metered-dose inhaler.

DESIGN

Prospective, randomized, controlled, cross-over, evaluator-blinded study.

SETTING

University Hospital Aintree, Liverpool, United Kingdom.

PATIENTS

Thirty-seven adults recruited over a 12-month period from Ear, Nose and Throat clinics at our University hospital. Patients were randomized into three groups using a computer-generated random number list and sealed opaque envelopes.

MAIN OUTCOME MEASURES

Scores were achieved on respiratory symptom and vocal performance questionnaires. Acoustic analysis was performed followed by a standardized biopsy of the posterior pharyngeal wall. Histological markers of inflammation were correlated with pharyngitis. The data were tested for normality using the Kalmogorov-Smirnov test. The Kruskal-Wallis analysis of variance was used to investigate differences between medians and ranges. The data were further investigated for correlations using the Spearman test. Discriminant analysis was used to examine the effect of the three groups on each variable.

RESULTS

Discomfort scores (median and range) were significantly lower after dry-powder inhaler use than with either a spacer or water gargle (p < 0.01). These worsened after restoring pressurized metered-dose inhaler therapy. The reduction in pharyngitis in each of the three groups was not significant. Vocal performance scores improved with dry-powder inhaler use. Jitter, shimmer, and closed-phase quotient scores improved with dry-powder inhaler use (p < 0.01). Shimmer scores deteriorated once the pressurized metered-dose inhaler was restored (p < 0.01). There was no significant difference between the groups in most observed parameters of inflammation (p > 0.01).

CONCLUSION

A dry-powder inhaler may alleviate the local side effects produced by a pressurized metered-dose inhaler. Laryngeal dysfunction appears to be particularly responsive to the absence of propellant. More observational and randomized controlled trials are necessary to examine existing inhalers and specifically, how and why they cause local side effects.

Acoustic analysis in asthmatics and the influence of inhaled corticosteroid therapy

The impact of sustained inhaled corticosteroid (ICS) therapy on the larynx and pharynx was assessed using a prospective, cross-sectional, and investigator-blinded study conducted at the University Hospital Aintree, Liverpool, UK. Forty-six adults recruited from two local general practices and from general ENT clinics at our University hospital were investigated for the study. Patients were allocated to three groups according to ICS use. Laryngeal effects were measured by correlating the results of a vocal performance questionnaire, a respiratory symptom questionnaire, and measurements obtained by computerized speech analysis. Sustained vowels and connected speech were analyzed in normal and asthmatic subjects. Acoustic analysis was correlated with cellular markers of inflammation after biopsy. Regular ICS users had significantly more pharyngeal inflammation and throat discomfort (P<0.0001). Vocal performance was also worse in this group (P<0.0001). They were more likely to have hoarseness, weakness of voice, aphonia, sore throat, throat irritation, and cough (P<0.0001). All these variables were directly related to one another (P<0.0001). Multiple linear regression analysis showed that jitter was a good objective measure of hoarseness (P<0.05). Regular ICS users were significantly more likely to have abnormal jitter, shimmer, and closed-phase quotient scores (P<0.0001). There was no difference between the groups in the observed parameters of inflammation (P>0.01). A higher pharyngitis score did not correlate with any of the histological markers of inflammation (P>0.01). Local side effects are more common in asthmatics that use ICS regularly. Measures of laryngeal function are significantly worse in regular ICS users. However, histological markers and oropharyngeal redness are not reliable measures of inflammation.

Acute disseminated encephalomyelitis after mastoid surgery in a child

We present a case of acute disseminated encephalomyelitis after mastoid surgery in an 11-year-old child. The aim of this paper is to increase awareness about a previously unreported and an unusual neurological complication of cholesteatoma and mastoid surgery.

How we do it: adjunctive intravenous midazolam: diagnosis and treatment of therapy-resistant muscle tension dysphonia

Dysphonic patients with muscle tension are common at voice clinics. The majority respond to intensive vocal therapy. A small number of cases remain resistant to intensive vocal therapy. We have used intravenous midazolam to enhance therapy-resistant dysphonic patients' self-monitoring, their self-awareness and to change fixed patterns. Six of seven patients were discharged with restoration of normal voice 1 month after treatment.

Reconstituting middle turbinate anatomy after pituitary surgery

Pituitary surgery is now increasingly performed as a joint procedure combining the expertise of a neurosurgeon and an otorhinolaryngologist. As endoscopic sinus surgery is currently one of the commonest surgical procedures performed by ear, nose and throat surgeons, familiarity of sphenoid sinus anatomy over several years of training becomes second nature to those with this interest. The endoscopic approach to the pituitary fossa via the sphenoid sinus allows a minimally invasive approach, thus reducing postsurgical morbidity and duration of hospital stay. The surgical approach involves lateralization of the middle turbinate followed by burring away of the face of the sphenoid air cell. Those without experience of sinus surgery may neglect to reconstitute the position of the middle turbinate at completion of surgery. Further mucosal contraction, scarring and synechiae formation will cause spontaneous lateralization of the middle turbinate during the healing period. This may predispose the patient to chronic sinusitis as a consequence of occlusion at the critical osteomeatal complex. The most satisfactory postoperative results are achieved by maintaining patency of the middle meatus. This will allow sinus aeration and drainage, and the delivery of topical medication should this be required. This paper describes a conchopexy suture placed at completion of pituitary fossa surgery. A carefully placed suture will maintain a widely patent middle meatus during the phase of postoperative healing, thus reducing the risk of chronic sinusitis.

Conchopexy suture to prevent middle turbinate lateralisation and septal haematoma after endoscopic sinus surgery

Endoscopic ethmoidectomy is now one of the commonest surgical procedures performed by ear, nose and throat surgeons. Access to the ethmoid air cells is via the middle meatus following medialisation of the middle turbinate and uncinectomy. The most satisfactory postoperative results are achieved by maintaining patency of the middle meatus. This allows delivery of topical medication and sinus aeration. Spontaneous lateralisation of the middle turbinate during the healing period, with or without synechiae, can compromise the surgical benefit. This paper describes a conchopexy suture placed at completion of ethmoidectomy. A carefully placed yet simple suture technique will maintain a widely patent middle meatus during the phase of post-operative healing. A slight modification allows quilting of mucoperichondrial flaps after septal surgery.

The chondroid syringoma: report of a case arising from the external auditory canal

Chondroid syringoma is an uncommon, benign skin adnexal tumour. It usually presents as a slowly growing intradermal or subcutaneous nodule on the face. Treatment involves local excision with a cuff of normal tissue to prevent recurrence. A rare case of chondroid syringoma arising from the external auditory canal is reported. The clinical features, histology, treatment and follow-up are discussed.

Malleus osteotomy: improving access to the anterior tympanum

Access to the anterior tympanic cavity is often restricted by the handle of the malleus. The aim of this paper is to describe a surgical malleus osteotomy that allows the malleus handle to swing superiorly. The authors have found few problems related to this technique, especially with regard to restoration of normal post-operative hearing.

The local side effects of inhaled corticosteroids: current understanding and review of the literature

The frequent use of inhaled corticosteroids (ICSs), especially at higher doses, has been accompanied by concern about both systemic and local side effects. The systemic complications of ICSs have been extensively studied and are well-documented in the literature. There are comparatively few studies reporting on the local complications of ICSs. Compared with systemic side effects, the local side effects of ICSs are considered to constitute infrequent and minor problems. However, while not usually serious, these local side effects are of clinical importance. They may hamper compliance with therapy and the symptoms produced may mimic more sinister pathology. This review considers the prevalence of local side effects, their clinical features, the potential causes, the role of inhaler devices, and current measures that have been suggested to avoid the problem.

Comparison of Two Face Masks used to Deliver Early Ventilation to Laryngectomized Patients

Emergency airway management of laryngectomized patients is inherently complicated by the altered contours of their necks, by the presence of awkwardly placed tracheostomas, and by stomal strictures. Effective ventilation can also be compromised by the presence of hypertrophic peristomal scar tissue and by tumor recurrence. One common method of airway management involves the use of a pediatric face mask attached to a standard ventilation bag. We conducted a study of 20 laryngectomized patients to determine if they could be adequately ventilated through two commonly used pediatric face masks—the Laerdal mask and the Ambu mask. Ten of these patients had had an end tracheostoma in place for at least 1 year, and the remaining 10 had undergone stoma placement only recently. We found that all 20 patients achieved an adequate peristomal seal when using the Laerdal mask, whereas only 11 adequate seals were achieved with the Ambu mask. Therefore, we recommend that the Laerdal pediatric mask be used for early ventilation in laryngectomized patients.

Comparison of two face masks used to deliver early ventilation to laryngectomized patients

Emergency airway management of laryngectomized patients is inherently complicated by the altered contours of their necks, by the presence of awkwardly placed tracheostomas, and by stomal strictures. Effective ventilation can also be compromised by the presence of hypertrophic peristomal scar tissue and by tumor recurrence. One common method of airway management involves the use of a pediatric face mask attached to a standard ventilation bag. We conducted a study of 20 laryngectomized patients to determine if they could be adequately ventilated through two commonly used pediatric face masks--the Laerdal mask and the Ambu mask. Ten of these patients had had an end tracheostoma in place for at least 1 year, and the remaining 10 had undergone stoma placement only recently. We found that all 20 patients achieved an adequate peristomal seal when using the Laerdal mask, whereas only 11 adequate seals were achieved with the Ambu mask. Therefore, we recommend that the Laerdal pediatric mask be used for early ventilation in laryngectomized patients.

Simple, painless, cosmetic closure of endaural incisions

Endaural incisions provide a cosmetic approach to the middle-ear cleft, tympanic membrane for myringoplasty, and attic and antrum for small cavity mastoidectomy. These wounds have traditionally been closed with sutures, but platelet or fibrin adhesives provide an alternative. However, discomfort at the time of suture removal, particularly in children, and the risk of transmission of blood-borne infections in gels are limitations to these wound closure techniques. This paper describes our experience with Histoacryl glue (butyl-2-cyanoacrylate) in closing endaural incisions.

Does clinical assistant experience in ENT influence general practitioner referral rates to hospital?

Referral rates from individual partners within two demographically matched general practices to the local ENT service were gathered prospectively over a six-year period. The study was designed to determine if extra training in one practice altered these rates. A single partner from one practice attended otolaryngology clinics for regular training over a three-year period. This was funded by the local Family Practitioners' Committee. The funding enabled a locum to cover this partner's clinical commitment whilst he attended the specialist clinics for continued ENT training. The aim of this study was to identify whether the provision of continued ENT training and education to general practitioners (GPs) influenced referral patterns to specialist clinics.

The radiological anatomy of the anterior skull base

Two complications dominate the thoughts of any surgeon undertaking functional endoscopic sinus surgery (FESS), namely damage to orbital structures and fractures of the fovea ethmoidalis. To avoid these complications, a detailed knowledge of the paranasal sinus anatomy of the patient is essential. This is usually assessed using preoperative computerized tomography (CT) scans of the paranasal sinuses. Analysis of 151 CT scans, measuring the height of cribriform plate below a supraorbital horizontal and above the hard palate was performed. Variation of shape and take-off angle of the fovea ethmoidalis was also measured. Comparison between left and right sides, and between scans showing radiological features of sinonasal disease and normal scans, was undertaken. Five patterns of fovea ethmoidalis were identified. No statistically significant difference between left and right sides was demonstrable for any parameter, irrespective of pathological status.

Foreign body reaction to calcium alginate fibre mimicking recurrent tumour of the submandibular salivary gland

A 50-year-old woman was referred after the discovery of adenoid cystic carcinoma in an excised left submandibular gland. Treatment involved clearance of the left submandibular fossa, and bilateral levels II and III selective neck dissections. A left-sided submandibular haematoma developed during the immediate postoperative period. After removal of the clot, there was a persistent, low volume capillary ooze from the left submandibular fossa and a calcium alginate fibre pack (Kaltostat) was left in place to control the bleeding. After an extended period of time the pack excited a foreign body reaction which, on a computed tomogram, mimicked a recurrence of the tumour. We review the role of Kaltostat in this setting and its potential for foreign body reaction, which may mimic serious disease.

Metastatic testicular seminoma--a case report

We present the case of a 42-year-old male who presented with a hot, tender swelling in the left supraclavicular fossa. He was pyrexial on presentation with a mildly elevated leucocyte count of 12.4x10(9)/l. Clinical examination, including full ear, nose and throat assessment, proved unremarkable. The medical history revealed that 2 years earlier the patient had been diagnosed with a testicular seminoma for which he underwent a right inguinal orchidectomy and abdominal radiotherapy. CT scan highlighted a 6 cm para-laryngeal mass, of mixed attenuation, with an adjacent region of inflammation. Overall appearance was suggestive of an infective mass. Ultrasound-guided fine needle aspiration cytology revealed a metastatic seminomatous deposit. Imaging of the chest and abdomen revealed this as the only site of metastasis. He is currently undergoing chemotherapy, and is responding well. We review the pathology of testicular seminoma. This case highlights the myriad of pathologies that may present as a lump in the neck.

Tuberculous otitis media -- a diagnostic dilemma

Tuberculous otitis media can provide a diagnostic challenge even to the most astute and experienced clinician. The rarity of the condition and its propensity to masquerade as commoner otological conditions further delays diagnosis and treatment. We present the case of a 22-year-old female who presented with chronic aural discharge, unilateral hearing loss and recurrent hemifacial paralysis. The paper highlights the difficulty in diagnosis and stresses the need for a high index of suspicion in cases resistant to the common methods of treatment.

Management of a lump in the neck

This article reviews the management of adults who present with a neck lump, and discusses the potential causes and relevant investigations. The review emphasizes the avoidance of open biopsy and need for early referral to the appropriate specialist.