Correlation of maximal nasal septal deviation with deviation at the maxillary insertion

PURPOSE

It is unclear if septal deviation at the insertion points to the nasal cavity is associated with the overall septal deviation. This study aimed to assess septal deviation at the cribriform plate (CP) and maxillary crest (MC) using CT scans and to see if there was any correlation with overall septal deviation.

METHODS

All consecutive CT sinus scans between January 2020 and December 2021 were retrospectively reviewed. Patients were excluded if they had a history of head, nasal or facial trauma, or any previous nasal surgical procedure. Angles between the septum and MC and the septum and CP as well as maximal angle of septal deviation (MSD) were measured.

RESULTS

A total of 70 scans were included in the final analysis. The mean MSD was 8.14°. The mean septal deviation was 0.89° at the CP and 2.02° at the MC. The correlation coefficient between the deviation at the CP and MSD was 0.025 and between the deviation at the MC and MSD was 0.321.

CONCLUSION

Our data reveal a positive correlation between septal deviation at the floor of the nose and overall septal deviation; this was not observed at the septal deviation at the roof. This could be explained due to the inherent tilt in the cribriform plate or by earlier ossification and fixation of the septum during its development at its insertion to the roof, thereby allowing further growth and potential for deviation of the lower part of the septum and its insertion to the floor.

A-T Flap for Reconstruction of Nasal Dorsum Skin Defects

BACKGROUND

 Reconstruction of nasal defects can be challenging, especially when encountering larger defects. We describe the use of a single-stage conversion of an 'A' shaped defect to a 'T' shaped scar of large nasal skin defects in the cosmetically sensitive supra-tip and supra-alar regions.

OBJECTIVE

 This study aimed to determine whether an A-T flap is a suitable option for nasal reconstruction and if so where and what size defects it can be used for.

METHODS

 Retrospective case series review over an 8-year period (2011-2019) in a tertiary referral center in the United Kingdom. Case analysis was undertaken in 2020 including all patients who underwent A-T reconstruction of nasal defects. A review of histology, case notes, and clinical photography was undertaken.

RESULTS

 A total of 27 patients were identified-13 (48%) female and 14 (52%) male. The median age was 73 years (range 31-90 years). Defect locations were supra-tip (48%) and supra-alar (52%). The largest defect closed was 895 mm2 (30 × 38 mm). Range 35 to 895 mm2 (median 264 mm2). No patient required revision or corrective procedures. No functional impairment was identified. Patient and clinician reported aesthetic outcomes as good in all cases. No reports of this technique could be identified in the literature.

CONCLUSION

 The A-T flap is a viable option for supra-tip and supra-alar skin defects (up to 895 mm2 in our series). It aligns well with the basic principles of nasal reconstruction. The flap can be performed under local anesthesia in one stage, resulting in good functional and aesthetic outcomes and so can be considered a valuable tool for the nasal reconstructive surgeon.

Our experience and modification of the Antia-Buch flap for pinna reconstruction

OBJECTIVE

The Antia-Buch flap technique is used for the reconstruction of pinna helical defects. We present our modification of this flap to reconstruct large defects (greater than 20 mm) with good outcomes.

METHODS

A retrospective review was conducted on all modified Antia-Buch flaps performed in a single unit from January 2011 to April 2019. All adult patients (greater than 16 years of age) who underwent this method of reconstruction after surgical excision of a pinna lesion were included. Measurements of the excision specimens from the final histological reports were used to determine the defect size. The helical lengths of the defect were used for analysis. Medical records were reviewed to identify postoperative complications from the reconstruction.

RESULTS

A total of 103 patients underwent the modified Antia-Buch flap reconstruction. All cases were performed by a single surgeon (senior author SA). Patients were 51-96 years of age (mean 76 years, SD±8.6), including 92 males and 11 females. The helical length of defects closed was between 12 and 42 mm (mean 26.7 mm, SD±6.46), and defect widths were 6-37 mm (average 14.5 mm, SD±5.28). There were 5 complications in our series (4.8% complication rate), with a revision rate of 2.9% (n = 3).

CONCLUSIONS

Our case series is the largest in the literature. Our modification demonstrates that large pinna defects can be reliably repaired with modification of the Antia-Buch flap that gives patients the option of a single-stage reconstruction without added morbidity and a good cosmetic outcomes.

The management of posterior epistaxis in the United Kingdom, a national survey

Background: Posterior bleeds account for 5% of epistaxis. The patient cohort is often elderly and has significant co-morbidities. Such cases have been managed historically with urinary catheters, held in place with umbilical clips. Recently bespoke, double balloon, posterior packs have been utilised. The treatments remain in clinical equipoise with no gold standard or clear national guideline. Methodology: A ten question survey was sent out through www.surveymonkey.com. Attempts were made to contact all Trusts in the United Kingdom via the ENT on call service. A comparison of treatment costs was made. Results: 112 responses have been received. 54% of respondents reported a preference for bespoke posterior pack insertion, only 12% preferred catheters. Twice as many respondents have seen complications from urinary catheters: 14% vs 29%. The availability of posterior packs is inconsistent: 30% of respondents were not aware of the packs or reported them unavailable in their hospital. Conclusions: This survey provides the first comparison of the techniques in the United Kingdom. Bespoke packs have a lower complication rate and are preferred by ENT clinicians on the front line of patient care. We recommend that all UK trusts should stock posterior packs which should be used as first line treatment for cases of posterior epistaxis.

Socioeconomic, comorbidity, lifestyle, and quality of life comparisons between chronic rhinosinusitis phenotypes

BACKGROUND

Chronic rhinosinusitis (CRS) is a heterogeneous group of inflammatory sinonasal disorders with key defining symptoms, but traditionally separated into phenotypes by clinical/endoscopic findings. It is not known whether the two phenotypes have differing socioeconomic, comorbidity, and lifestyle differences. This analysis of the Chronic Rhinosinusitis Epidemiology Study (CRES) database sought to analyze any key differences in the socioeconomic variables between those with CRS with nasal polyps (CRSwNPs) and those without nasal polyps (CRSsNPs). We also sought to analyze differences in comorbidities, lifestyle, and quality of life.

METHODS

Patients with a confirmed diagnosis of CRS in secondary and tertiary care outpatient settings in the UK were invited to participate in a questionnaire-based case-control study. Variables included demographics, socioeconomic factors, comorbidities, lifestyle factors, and health-related quality of life (HRQoL) (level 3 evidence).

RESULTS

A total of 1204 patients' data were analyzed: 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 = .032), but the latter was not significant after adjusting for age and sex. Aside from confirmation of asthma being more common in CRSwNP, it was notable that this group complained less of upper respiratory tract infections (URTIs), and CRSsNP participants showed evidence of worse HRQoL scores in respect of body pain (P = .001).

CONCLUSIONS

Patients with CRSwNP experience higher rates of asthma and lower rates of URTIs; patients with CRSsNP have worse body pain scores. Otherwise, there are no demonstrable significant socioeconomic, comorbidity, lifestyle, or quality of life differences between the two phenotypes.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

Management of new onset loss of sense of smell during the COVID-19 pandemic - BRS Consensus Guidelines

OBJECTIVES

The primary aim of the study is to provide recommendations for the investigation and management of patients with new onset loss of sense of smell during the COVID-19 pandemic.

DESIGN

After undertaking a literature review, we used the RAND/UCLA methodology with a multi-step process to reach consensus about treatment options, onward referral, and imaging.

SETTING AND PARTICIPANTS

An expert panel consisting of 15 members was assembled. A literature review was undertaken prior to the study and evidence was summarised for the panellists.

MAIN OUTCOME MEASURES

The panel undertook a process of ranking and classifying appropriateness of different investigations and treatment options for new onset loss of sense of smell during the COVID-19 pandemic. Using a 9-point Likert scale, panellists scored whether a treatment was: Not recommended, optional, or recommended. Consensus was achieved when more than 70% of responses fell into the category defined by the mean.

RESULTS

Consensus was reached on the majority of statements after 2 rounds of ranking. Disagreement meant no recommendation was made regarding one treatment, using Vitamin A drops. Alpha-lipoic acid was not recommended, olfactory training was recommended for all patients with persistent loss of sense of smell of more than 2 weeks duration, and oral steroids, steroid rinses, and omega 3 supplements may be considered on an individual basis. Recommendations regarding the need for referral and investigation have been made.

CONCLUSION

This study identified the appropriateness of olfactory training, different medical treatment options, referral guidelines and imaging for patients with COVID-19-related loss of sense of smell. The guideline may evolve as our experience of COVID-19 develops.

Exploring the association between ingestion of foods with higher potential salicylate content and symptom exacerbation in chronic rhinosinusitis. Data from the National Chronic Rhinosinusitis Epidemiology Study

INTRODUCTION

Pharmacological salicylates are known to trigger respiratory exacerbations in patients with Non-Steroidal Exacerbated Respiratory Disease (N-ERD), a specific phenotype of Chronic Rhinosinusitis (CRS) and asthma. The impact of dietary sources of salicylates across subgroups of CRS is not well understood. The hypothesis is that in patients with nasal polyps present, there is likely to be a higher incidence of symptom exacerbation due to dietary salicylates regardless of any known response to pharmacological salicylate.

METHODS

The Chronic Rhinosinusitis Epidemiology Study (CRES) was a questionnaire-based case-control study which sought to characterise the UK CRS population in terms of sociological, economic and medical factors. Using specific questions to examine participant responses relating to symptom exacerbation from food groups thought to be high in salicylate content, this analysis of the CRES database sought to compare an estimate of the prevalence of dietary sensitivity due to food with higher potential salicylate content across patients with CRS with (CRSwNPs) and without nasal polyposis (CRSsNPs) and with allergic fungal rhinosinusitis (AFRS).

RESULTS

The CRSwNPs group were significantly more likely than controls to report symptom exacerbation due to ingestion of food groups with higher potential dietary salicylate content. The same trend was observed amongst CRSsNPs participants to a lesser degree. Reported response to the individual specific food groups wine, nuts, spicy foods, fruit and vegetables demonstrated that a statistically significant proportion of CRSwNPs and AFRS participants reported sensitivity to wine.

CONCLUSIONS

This analysis suggests that there is an association between symptom exacerbation in response to food products with higher potential salicylate content, specifically wine, in CRS patients both with and without nasal polyposis when compared to controls, but especially in the CRSwNPs and AFRS phenotypes. Further studies are needed to detail if this relationship represents a causal relationship to dietary salicylate. The data present the possibility that a wider group of CRS patients may elicit salicylate sensitivity than those with known N-ERD.

Prevalence of asthma, aspirin sensitivity and allergy in chronic rhinosinusitis: data from the UK National Chronic Rhinosinusitis Epidemiology Study

BACKGROUND

Chronic rhinosinusitis (CRS) is a common disorder associated with other respiratory tract diseases such as asthma and inhalant allergy. However, the prevalence of these co-morbidities varies considerably in the existing medical literature and by phenotype of CRS studied. The study objective was to identify the prevalence of asthma, inhalant allergy and aspirin sensitivity in CRS patients referred to secondary care and establish any differences between CRS phenotypes.

METHODS

All participants were diagnosed in secondary care according to international guidelines and invited to complete a questionnaire including details of co-morbidities and allergies. Data were analysed for differences between controls and CRS participants and between phenotypes using chi-squared tests.

RESULTS

The final analysis included 1470 study participants: 221 controls, 553 CRS without nasal polyps (CRSsNPs), 651 CRS with nasal polyps (CRSwNPs) and 45 allergic fungal rhinosinusitis (AFRS). The prevalence of asthma was 9.95, 21.16, 46.9 and 73.3% respectively. The prevalence of self-reported confirmed inhalant allergy was 13.1, 20.3, 31.0 and 33.3% respectively; house dust mite allergy was significantly higher in CRSwNPs (16%) compared to CRSsNPs (9%, p < 0.001). The prevalence of self- reported aspirin sensitivity was 2.26, 3.25, 9.61 and 40% respectively. The odds ratio for aspirin sensitivity amongst those with AFRS was 28.8 (CIs 9.9, 83.8) p < 0.001.

CONCLUSIONS

The prevalence of asthma and allergy in CRS varies by phenoytype, with CRSwNPs and AFRS having a stronger association with both. Aspirin sensitivity has a highly significant association with AFRS. All of these comorbidities are significantly more prevalent than in non-CRS controls and strengthen the need for a more individualised approach to the combined airway.

The Caucasian Nasal Septum: An In Vivo Computed Tomography Study

BACKGROUND

The nasal septum is composed of cartilaginous and bony components and an understanding of each component volume is essential in both functional and cosmetic surgery.

OBJECTIVES

We sought to radiographically measure septal dimensions on cross sectional computer tomography (CT) images, establishing average parameters for normal anatomy among a single, Caucasian population group.

METHODS

One hundred and fifty consecutive sinus CT scan images were examined and 100 cases with appropriate sagittal views were included in the study. On each septum, the sagittal CT images were assessed and 14 points were identified and 23 lengths measured and tabulated. Trigonometric formulae were used to accurately calculate surface areas of 11 resulting triangles which constituted the components of the nasal septum.

RESULTS

Measurements from 100 patients were included, with a mean age of 50.2 years, constituting 47 males and 53 females. Our surface area mapping established the following areas for both males and females respectively (mm2): quadrangular cartilage 1148 and 981; vomer 894 and 741; perpendicular plate of ethmoid bone 1244 and 1006; and total surface area 3287 and 2728. Our only statistically significant comparison in the series was found in the female series when age and reducing quadrilateral cartilage size were compared, highlighting reducing size with age (P = 0.04).

CONCLUSIONS

The study presents the largest published data series representing nasal septal measurements on CT images in a living Caucasian population. Our data demonstrates that septal size remains constant after adolescence, throughout our age-varied series (18-79 years), except in the female population where the quadrilateral cartilage reduces in size with age.

LEVEL OF EVIDENCE 4

Peripheral histological clearance of cutaneous BCC and SCC excised using the wet blotting technique

Introduction

Accurate identification of the peripheral margin of cutaneous basal cell and squamous cell carcinomas plays a crucial role in ensuring complete excision of the skin cancer. The recommended margin of excision for cutaneous malignancies varies in the current guidelines. The aim of this study was to assess the success rate of peripheral margin clearance with a 4 mm peripheral margin of excision when the clinical margin of the lesion has been identified using the wet blotting technique.

Methods

The peripheral margin of each skin cancer was marked using the wet blotting technique and a 4-mm margin of excision rule was applied to all skin cancers regardless of their type and other clinical features. Data collection was performed from patients who were operated on over a period of 34 months (2011 to 2014). Information gathered included patient demographics, clinical details of the lesion and histopathological data.

Results

The total number of patients identified were 456. The case notes were reviewed and eventually 276 patients were included and 180 patients were excluded. The histology report showed 95–97% clearance of the peripheral margin in all BCCs and SCCs regardless of their clinical features and their location.

Conclusions

Our study has shown that a standard rule of maintaining a 4 mm margin around all head and neck skin BCCs and SCCs, measured after the visible margin of the lesion had been accurately identified by the wet-blotting technique, can successfully achieve 95–97% peripheral clearance of all lesions, irrespective of the subtype, size and location.

Chronic rhinosinusitis and mood disturbance

BACKGROUND

This study is part of the Chronic Rhinosinusitis Epidemiology Study (CRES). The overarching aim is to determine factors that influence the onset and severity of chronic rhinosinusitis (CRS). The aim of this analysis is to determine whether those with CRS are more likely to report psychiatric morbidity and in particular mood disturbance compared with healthy controls.

METHODS

CRES consists of a study-specific questionnaire regarding demographic and socioeconomic factors and past medical history as well as a nasal symptom score (SNOT-22) and SF-36 (QoL - quality of life tool). Both of these tools contain mental health or emotional well-being domains. Participants were specifically asked whether they had ever consulted with their General Practitioner for anxiety or depression. Questionnaires were distributed to patients with CRS attending ENT outpatient clinics at 30 centres across the United Kingdom from 2007-2013. Controls were also recruited at these sites. Patients were divided into subgroups of CRS according to the absence/presence of polyps (CRSsNPs/CRSwNPs) or allergic fungal rhinosinusitis (AFRS).

RESULTS

Consultations with a family physician for depression or anxiety were higher amongst those with CRS than controls, but this was only significant for those with CRSsNPs. Odds ratio (OR) for CRSsNPs vs controls: 1.89; OR for CRSwNPs: 1.40. Patients with CRS showed significantly higher mental health morbidity than controls across the mental health and emotional wellbeing domains of the SF-36 and SNOT-22. Mean difference in the mental health domain of SF-36 was 8.3 for CRSsNPs and 5.3 for CRSwNPs. For the emotional domain of SNOT-22, differences were 7.7 and 6.3 respectively.

CONCLUSIONS

Depression and anxiety are significantly more common in patients with CRS compared to healthy controls, especially in those with CRSsNPs. This added mental health morbidity needs consideration when managing these patients in primary and secondary care settings.

A cross sectional analysis of a case-control study about quality of life in CRS in the UK; a comparison between CRS subtypes

BACKGROUND

The Sinonasal Outcome Test (SNOT-22) has been used as a patient reported outcome measure to grade symptom severity before and after treatment for chronic rhinosinusitis (CRS).

METHODOLOGY

This analysis uses data from the CRS Epidemiology Study (CRES). The overarching aim of CRES was to determine factors that influence the onset and severity of CRS. A study-specific questionnaire including SNOT-22 was distributed to patients with CRS attending ENT clinics across 30 centres in the United Kingdom. The aim of this analysis was to compare SNOT-22 scores between those with different types of CRS to determine any differences present in the total score or the subdomains and to assess whether any differences varied according to gender.

RESULTS

There were a total of 1249 CRS participants in the following subgroups: CRS without nasal polyps (CRSsNPs) (n=553), CRS with nasal polyps (CRSwNPs) (n=651), allergic fungal rhinosinusitis (AFRS) (n=45). Since there were differing gender ratios in each subgroup, males and females were analysed separately. The mean and standard deviation for SNOT-22 was: males CRSsNP 41.1 (21.0), CRSwNP 41.7 (20.5); females CRSsNP 49.6 (19.7), CRSwNP 49.5 (22.9). In the nasal domain, those with CRSwNP scored more highly than those with CRSsNP; for males 18.1 (8.1) vs. 15.9 (7.9); for females 19.6 (8.0) vs 16.7 (7.5).

CONCLUSIONS

Patients with CRSwNPs report higher symptom scores in the nasal domain of SNOT-22 than those with CRSsNPs with women in both subgroups reporting higher total scores than men.

A case-control study of medical, psychological and socio-economic factors influencing the severity of chronic rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) is a common and debilitating disorder. Little is known about the epidemiology of this disease. The aims of the study were to identify differences in socio-economic variables and quality of life between patients with chronic rhinosinusitis and healthy controls, to identify any significant associations between CRS and other medical co-morbidities, psychiatric disease or environmental exposure and to explore the experience of CRS from the perspective of CRS sufferers.

METHODS

Participants were recruited from ENT clinics from 30 centres across the UK. They completed a study-specific questionnaire considering environmental, medical and socio-economic factors, and SF-36 and SNOT-22 scores. All participants with CRS were diagnosed by a clinician and categorised as having CRS (with polyposis, without polyposis or allergic fungal rhinosinusitis (AFRS)). Controls included family and friends of those attending ENT outpatient clinics and hospital staff who had no diagnosis of nose or sinus problems and had not been admitted to hospital in the previous 12 months.

RESULTS

A total of 1470 study participants (1249 patients and 221 controls) were included in the final analysis. Highly significant differences were seen in generic and disease-specific quality of life scores between CRS sufferers and controls; mean SNOT-22 score 45.0 for CRS compared with 12.1 amongst controls. There were no clear differences in socioeconomic variables including social class, index of multiple deprivation and educational attainment between cases and controls. Common comorbidities with a clear association included respiratory and psychiatric disorders, with a higher frequency of reported upper respiratory tract infections.

CONCLUSIONS

CRS is associated with significant impairment in quality of life and with certain medical co-morbidities. In contrast to other common ENT disorders, no socioeconomic differences were found between patients and controls in this study.

Branchial Cyst Side Predilection: Fact or Fiction?

Objectives:

It is a common teaching that two thirds of branchial cysts occur on the left side of the neck. We reviewed the evidence behind this statement and assessed whether they actually do present twice as often on the left side.

Methods:

Our study comprised two parts: 1) a historical review of branchial cysts and 2) a retrospective review of 91 histologically confirmed cases operated on at two British hospitals in the years 1999 to 2005. The side of the branchial cyst was recorded.

Results:

Early studies on branchial cysts did not always rely upon histologic diagnosis; the definition of a branchial cyst has varied throughout medical history. The statement “two thirds of branchial cysts occur on the left” is based upon these early studies in which the definition was variable. In our study, right-sided branchial cysts were actually more common than left-sided branchial cysts (53.8% versus 45%; χ2 test, p = .399). One percent were bilateral.

Conclusions:

Ours is the largest single study in the past 50 years to look at the side predilection of branchial cysts in terms of histologic proof. We propose that branchial cysts may not present more commonly on the left side of the neck, as is commonly taught in medical schools.

The burden of revision sinonasal surgery in the UK-data from the Chronic Rhinosinusitis Epidemiology Study (CRES): a cross-sectional study

OBJECTIVES

The aim of this study was to investigate the surgical revision rate in patients with chronic rhinosinusitis (CRS) in the UK CRS Epidemiology Study (CRES). Previous evidence from National Sinonasal Audit showed that 1459 patients with CRS demonstrated a surgical revision rate 19.1% at 5 years, with highest rates seen in those with polyps (20.6%).

SETTING

Thirty secondary care centres around the UK.

PARTICIPANTS

A total of 221 controls and 1249 patients with CRS were recruited to the study including those with polyps (CRSwNPs), without polyps (CRSsNPs) and with allergic fungal rhinosinusitis (AFRS).

INTERVENTIONS

Self-administered questionnaire.

PRIMARY OUTCOME MEASURE

The need for previous sinonasal surgery.

RESULTS

A total of 651 patients with CRSwNPs, 553 with CRSsNPs and 45 with AFRS were included. A total of 396 (57%) patients with CRSwNPs/AFRS reported having undergone previous endoscopic nasal polypectomy (ENP), of which 182 of the 396 (46%) reported having received more than one operation. The mean number of previous surgeries per patient in the revision group was 3.3 (range 2-30) and a mean duration of time of 10 years since the last procedure. The average length of time since their first operation up to inclusion in the study was 15.5 years (range 0-74). Only 27.9% of all patients reporting a prior ENP had received concurrent endoscopic sinus surgery (ESS; n=102). For comparison, surgical rates in patients with CRSsNPs were significantly lower; 13% of cases specifically reported ESS, and of those only 30% reported multiple procedures (χ(2) p<0.001).

CONCLUSIONS

This study demonstrated that there is a high burden of both primary and revision surgery in patients with CRS, worst in those with AFRS and least in those with CRSsNPs. The burden of revision surgery appears unchanged in the decade since the Sinonasal Audit.

Tonsillectomy for recurrent sore throats in children: indications, outcomes, and efficacy

OBJECTIVE

To perform a comprehensive narrative review of the literature to provide a better understanding of the indications, outcomes, and efficacy of tonsillectomy for recurrent sore throats in children. This article explores the reasons why there is a lack of robust clinical evidence for its efficacy despite good evidence of positive reported outcomes from parents of children who undergo the procedure.

DATA SOURCES

Articles published between 1960 and July 2013 were searched in PubMed and Cochrane databases.

REVIEW METHODS

A narrative review method was adopted to provide a comprehensive overview of articles. Only individual, interventional studies on children (0-16 years old) undergoing tonsillectomy or adenotonsillectomy for recurrent sore throats with greater than 1 month of follow-up were included.

CONCLUSIONS

The inclusion criteria and outcome measures in the studies were varied, but most investigated changes in symptoms related to sore throats or illness episodes. Quality-of-life tools validated for measuring pediatric outcomes were used in a number of more recent studies. None of the outcome measures were specific for recurrent sore throats in children. No qualitative method designed studies were identified.

IMPLICATIONS FOR PRACTICE

The disparity between parental satisfaction rates and published clinical efficacy can be explained by a lack of parent/child outcome measures specific to tonsillectomy for recurrent sore throats. A more parent/child-centered approach may establish what tonsillectomy could offer this group of children.

Accuracy of predissection assessment of the lower lateral cartilage configuration: a cadaveric study

BACKGROUND

Preoperative planning of nasal tip surgery requires an accurate assessment of the nasal tip cartilages configuration. The current literature lacks any evidence on the accuracy of preoperative assessment of the lower lateral cartilages (LLC) shape.

OBJECTIVE

This study was designed to determine the accuracy of the LLC shape and configuration assessment prior to dissection.

METHODS

The configuration of the lateral, middle, and medial crura was assessed on 42 LLC (21 cadavers) prior to dissection by way of observation and palpation. The findings were then compared with those observed after LLC exposure through an open-approach dissection.

RESULTS

The accuracy of predissection LLC shape assessment was 42 of 42 (100%), 32 of 42 (76%), and 12 of 42 (29%) for medial, middle, and lateral crus, respectively.

CONCLUSIONS

The configuration of the lateral crus of LLC cannot be accurately assessed prior to exposure of the cartilage. A rhinoplastic surgeon who embarks on nasal tip surgery should be familiar with a number of techniques to address any tip deformity encountered after exposure, as the preoperative clinical and photographic assessments cannot reliably demonstrate the type of LLC deformity.

Delayed absence seizure: A complication of intrathecal fluorescein injection

Intrathecal fluorescein injection has a long history of use by surgeons to determine the exact site of a cerebrospinal fluid (CSF) leak from the skull base. This method, however accurate, is not without complications. We present a case of grand mal and absence seizure after intrathecal fluorescein injection and discuss the possible aetiological factors. We also review the articles in the diagnostic methods for the CSF rhinorrhoea and the complications of the intrathecal fluorescein injection.

Nonpharmacologic Effects of Botulinum Toxin on the Life Quality of Patients with Spasmodic Dysphonia

OBJECTIVE

Botulinum toxin (BT) injection improves objective and subjective voice measurements in spasmodic dysphonia; however, it is not clear whether the results are entirely caused by the neuromuscular blocking effects of BT or whether other factors (e.g., psychological or emotional) play a part. The aim of this study is to investigate whether nonpharmacologic factors contribute to the changes observed in the quality of life (QoL) after BT treatment of spasmodic dysphonia.

STUDY DESIGN

Prospective cohort study.

METHODS

Thirty-eight consecutive spasmodic dysphonic patients attending for repeat BT injections were investigated by recording their Voice Handicap Index (VHI) scores at three time points: 1) immediately prior to injection (baseline), 2) 1 day postinjection (when least pharmacologic change is expected), and 3) 2 weeks postinjection (when most pharmacologic change is expected). The changes in the total and domain VHI scores were compared between the two postinjection scores and the baseline value using two-way analysis of variance and the post hoc Bonferroni test.

RESULTS

Most of the change in VHI score occurred between the baseline and first postinjection measurement. For two of the domains (total and emotional), the change was statistically significant. The change between the two postinjection assessments was minimal, and no domain showed statistically significant change.

CONCLUSIONS

Our data indicate that the early improvements in QoL after BT injection can only in small part be attributed to the neurotoxic effects of the agent. We cannot say whether the reported effects in our study are attributable to a strong placebo response or are a real consequence of the patient's changing emotional state.

Cost-efficiency of endoscopic and external dacryocystorhinostomy

Background:

In most centres in the United Kingdom, endoscopic dacryocystorhinostomy is currently undertaken as a joint operation between ophthalmologists and otolaryngologists. The addition of an extra surgeon, the use of endoscopic equipment and the relatively lower success rate of this procedure made us compare endoscopic dacryocystorhinostomy and external dacryocystorhinostomy with regards to costs and income for our hospital.

Methods:

All 38 primary endoscopic dacryocystorhinostomy cases performed in our centre in 2001–2003 were retrospectively compared with the 49 external dacryocystorhinostomy cases performed in 1993–2000. Cost–income calculations were made based on: rate of local anaesthesia, success rate, rate of day case admission, hospital reference cost for dacryocystorhinostomy, and the income per case extracted from national tariffs (based on the Health Resources Group). Also, the average number of cases per session was used to calculate the income gained per session for each method.

Results:

The following rates between the endoscopic and the external dacryocystorhinostomy were found: local anaesthesia, 29 vs 6 per cent, respectively; day-case operation, 95 vs 12 per cent, respectively; and success rate, 87 vs 94 per cent, respectively. The average number of endoscopic dacryocystorhinostomy cases conducted in a single theatre session was twice that of external dacryocystorhinostomy cases. Endoscopic dacryocystorhinostomy generated approximately twice the income of external dacryocystorhinostomy (£6585 vs £3292, respectively).

Conclusion:

Endoscopic dacryocystorhinostomy is more cost-effective than external dacryocystorhinostomy, despite having a lower success rate and greater usage of resources, as the endoscopic procedure generates more income. This is mainly due to the higher number of cases per session and the higher rates of local anaesthesia and day case operations possible.

Post-tonsillectomy morbidity statistics: are they underestimated?

Background:

Post-tonsillectomy morbidity statistics are obtained when patients present to hospital with complications. The two common morbidities are pain and haemorrhage. Hospital-recorded morbidity rates may be an underestimation, as some patients are treated by general practitioners and are therefore not included in hospital audits.

Methods:

Prospective, cohort, questionnaire study to assess: the post-tonsillectomy haemorrhage rate (i.e. actual rate versus hospital recorded rate); and the number of patients with post-operative pain and/or bleeding who were treated with antibiotics by their general practitioner.

Results:

The response rate was 76 per cent (70/92). The actual rate of secondary haemorrhage was three times that noted in the hospital records (15.7 vs 5.7 per cent, respectively). Fifteen patients (21 per cent) required extra analgesia after discharge. General practitioners prescribed antibiotics for pain alone in six patients (11 per cent).

Conclusion:

The actual post-tonsillectomy haemorrhage rate is much higher than that recorded in hospital statistics. General practitioners differ in their treatment of post-tonsillectomy patients presenting with pain alone; some prescribe antibiotics in addition to analgesia.

Grisel syndrome: a delayed presentation in an asymptomatic patient

Grisel syndrome is a rare condition characterised by atlanto-axial subluxation following an inflammatory process in the head and neck region. It occurs more commonly in children and usually presents with cervical pain and torticollis, in addition to symptoms of the primary infection. We present the case of an asymptomatic 78-year-old man who was incidentally found to have atlanto-axial subluxation on a routine follow-up computed tomography scan, three months following successful treatment of a skull base infection. This case emphasises the importance of appropriate follow-up imaging for patients with skull base infections, even if they respond clinically to medical treatment.

How we do it: cost-benefit analysis of implementing a telephone review system in an ENT outpatient setting

There is an increasing pressure on the National Health Service (NHS) hospital consultants to reduce the waiting times. We have used an optional telephone review for a certain number of our outpatients so as to reduce the need for their in-person attendance. The result of our study, which was conducted in two phases, showed that almost half of the telephone follow-up patients (48%) were discharged over the phone. There was a direct saving of approximately 30 pounds per patient having a telephone follow-up.

Does listening to the sound of yourself chewing increase your enjoyment of food?

BACKGROUND

Anecdotal evidence suggests that listening to oneself eating results in a more pleasurable eating experience. Maximising the sensory experience of eating can result in increased oral intake and is potentially valuable in improving nutritional status in at-risk patients.

OBJECTIVE

This pilot study investigates the association between listening to the sound of oneself eating and the consequences on enjoyment of eating.

DESIGN

Prospective, randomized, controlled, cross-over trial of 10 fit, adult volunteers. Participants were timed eating a standardised amount of bread, and were randomized to eat in silence or whilst listening to their own amplified chewing and swallowing. Measurements of pulse and blood pressure were recorded throughout the procedure. Subjective pleasure scores were documented and the procedure repeated in the alternate study arm.

RESULTS

There was no significant relationship demonstrated between listening to oneself chewing and the enjoyment of eating.

CONCLUSION

Although this small pilot study was unable to demonstrate a significant relationship between listening to oneself chewing and enjoyment of eating, other evidence suggests that distraction techniques have a beneficial effect on dietary intake. Such techniques can be applied in a clinical setting and further work in this area has valuable potential.

Objective pulsatile tinnitus: a video clip demonstration of the condition

Pulsatile tinnitus is an uncommon condition. We describe a case of pulsatile tinnitus and visually demonstrate a pulsating tympanic membrane caused by a postoperative cerebrospinal leak into the mastoid air cells following resection of a left temporal petrous meningioma. To our knowledge, this is the first case in the literature where an objective pulsatile tinnitus has been captured on video (see www.laryngoscope.com).

Silencing the snorers: no gain without pain?

Objective: To compare the estimated effects of conservative surgery to those of a mandibular advancement splint (MAS) in the treatment of habitual snoring.

Method: Prospective, observational, non-randomized cohort study.

Results: Adequate follow-up data were available for 88 participants (23 following coblation, 65 after provision of an MAS). The mean reduction in snoring symptoms inventory (SSI) score for the 23 subjects undergoing coblation was 9.83 (± standard deviation 11.43). Reported pain duration was greatest with uvula amputation, but uvula coblation did not always adequately reduce its bulk. Of the 65 MAS patients, 39 (60 per cent) used the device regularly, with a mean fall in SSI of 12 (±16.4, p = 0.001). Approximately one in four patients in both groups achieved a significant fall in SSI (>15 points), and the measured effect sizes were close to 0.75 for both treatments.

Conclusions: Mandibular advancement splints and coblation have similar efficacies. However, their efficacy does not match that of radical surgery.

Neonatal disseminated methicillin-resistant Staphylococcus aureus presenting as orbital cellulitis

Orbital cellulitis and abscess are known complications of ethmoiditis in children, but they are very rare in the newborn. The authors report a case of orbital abscess caused by methicillin-resistant Staphylococcus aureus (MRSA) in a four-week-old neonate born four weeks prematurely.

Conservative management of epistaxis: are we putting patients at risk of developing venous thromboembolic complications?

A retrospective study of 1585 patients, admitted with epistaxis to a busy District General Hospital in the United Kingdom between 1990 and 2000, was undertaken in order to identify the relationship between hospital admission for epistaxis and the development of a venous thromboembolic event. Only one person (0.06%) developed pulmonary embolus (PE) within 6 weeks of hospital admission. No one developed a deep vein thrombosis (DVT). This compares with the incidence of DVT and fatal PE in the general population. In our study population, the incidence of both PE and DVT was found to be no greater than that seen within the community and certainly less than the incidence seen within a group of high risk hospitalised patients. We conclude that hospital admission for epistaxis does not place the patient at increased risk of thromboembolic disease.

Cochlear implantation in patients with MELAS syndrome

MELAS syndrome (mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes) is a rare congenital disorder of mitochondrial DNA (mt-DNA). Patients with this syndrome may present to the otolaryngologist with sensorineural hearing loss (SNHL) that is genetic in origin. Mitochondrial cytopathies can present with a variety of symptoms, but they occasionally present with SNHL as their first manifestation. Two cases of MELAS patients who responded well to cochlear implantation are presented. A review of the literature is also carried out focusing mainly on diagnosis, anesthetic considerations and management of these patients.