Helix advancement meatoplasty.

We describe a new technique of helix advancement meatoplasty. This technique is useful in both mastoid surgery and some cases of otitis externa. The technique is designed to avoid the problems of (1) inferior positioning of the meatoplasty at the time of surgery, and (2) later inferior migration of the pinna (as can occur when the suspensory ligaments of the pinna have been cut or weakened). Such outcomes can result in a mastoid cavity which is difficult to clean as the approach to it is awkward; in such cases, it is common to have to look up into the cavity rather than directly into it. Helix advancement meatoplasty improves post-operative visualisation and aeration. It eases cleaning of the cavity by creating a more superiorly placed meatoplasty, which is supported by the tragus and is therefore less likely to drop.

Accuracy of magnetic resonance imaging in diagnosing thyroid cartilage and thyroid gland invasion by squamous cell carcinoma in laryngectomy patients.

OBJECTIVES: We examined the accuracy of magnetic resonance imaging in assessing thyroid cartilage and thyroid gland invasion in patients undergoing total laryngectomy for squamous cell carcinoma, by comparing histopathology results with imaging findings. STUDY DESIGN: A retrospective study reviewed histology and magnetic resonance scan results for all total laryngectomies performed between 1998-2008 at University Hospital Aintree, Liverpool. METHODS: Pre-operative magnetic resonance images were reviewed independently by two consultant head and neck radiologists masked to the histology; their opinions were then compared with histology findings. RESULTS: Eighty-one magnetic resonance scans were reviewed. There were 22 laryngectomy patients with histologically verified thyroid cartilage invasion and one patient with thyroid gland invasion. There were 31 patients with apparent radiological thyroid cartilage invasion pre-operatively (with 17 false positives), giving sensitivity, specificity, and positive and negative predictive values of 64, 71, 45 and 84 per cent, respectively. On assessing thyroid gland invasion, there were nine false positive scans and no false negative scans, giving sensitivity, specificity, and positive and negative predictive values of 100, 89, 10 and 100 per cent, respectively. CONCLUSION: Magnetic resonance scanning over-predicts thyroid cartilage and gland invasion in patients undergoing total laryngectomy. Magnetic resonance scans have limited effectiveness in predicting thyroid cartilage invasion by squamous cell carcinoma in laryngectomy patients.

Evaluation of surgeons' marking of excision margins for superficial facial skin cancer lesions.

INTRODUCTION: We established a series of exercises that evaluated surgeons' marking of excision margins, and we sought to identify factors influencing such marking. METHODS: Twenty-four participants were asked to draw preset margins (3, 4, 5, 8 or 10 mm) on a series of life-size images representing noncosmetically and cosmetically sensitive facial sites, and also to draw circles of set diameters (3, 5 and 8 mm) on white paper. Margins were measured with vernier callipers calibrated to 0.05 mm. RESULTS: In the small margin (3 mm) and noncosmetically sensitive exercises, the mean margins drawn were greater than required. When a 10 mm margin was required in cosmetically sensitive areas and nonsensitive areas, the margin was consistently underestimated in the former group by all participants (p < 0.05). CONCLUSION: Surgeons marking facial lesions for excision should use a measurement of scale, in order to eliminate the inherent tendency to underestimate the margin required for large excisions and for cosmetically sensitive areas.

How informed is consent in a modern ENT department.

The Department of Health issued a model consent form for use throughout the NHS from the 1st April 2002. Details of benefits and serious or frequent risks should be included on the form. We undertook a study to identify what proportion of complications from otolaryngology procedures were being recorded. Local morbidity and mortality records and case notes were examined from March to November 2004. Complications were identified and recorded. The consent forms for these operations were examined to identify if these complications had been recorded on the form prior to surgery. Complications were classified as "serious", causing significant morbidity or increasing length of hospital stay or "frequent", occurring in 1% or more of cases. A total of 2,978 operations were performed between March and November 2004. Seventy complications were identified in 60 patients (2% of operated patients). Twenty-three complications were not recorded on the consent forms in 20 (33%) patients. A total of 67% of all the complications were documented on the form as potential problems resulting from planned operations. Seven (74%) of complications that occurred but were not recorded on the consent forms were judged as "serious" or "frequent". A significant proportion of serious or frequent complications are not being documented on the national consent forms before otolaryngological procedures and may not have been discussed. This may reflect a lack of openness during the consent process. In the current medical climate, this has serious ethical and medico-legal ramifications. It may also reflect a problem with the form and a need for a re-think of its design.

Day-case endoscopic sinus surgery using dissolvable haemostatic nasal packs: a pilot study.

In a prospective pilot study, we assessed the efficacy and safety of dissolvable nasal packs (Sinu-knit) for control of post-operative bleeding in patients undergoing endoscopic sinus surgery (ESS), as well as potential complications of this novel packing material and patients' satisfaction with the dissolvable nasal packs. The patients included were considered suitable for a day-case procedure. We excluded subjects under 16-year-old, as well as patients on warfarin or with any coexisting medical or social reasons rendering them unsuitable for a day-case procedure. The main outcome measures were: readmission rate, postoperative bleeding rate, any other postoperative complications and patient satisfaction survey (including management as a day case and views about the packs). Fifteen patients fulfilled our criteria and were enrolled in this study (between March and August 2005). Fourteen patients were able to go home on the same day. One patient stayed overnight because of vomiting. All operations were performed by the same surgeon and the same anaesthetist. There were no readmissions due to postoperative bleeding. All patients were followed up with rigid video-nasendoscopy weekly for three weeks with further reviews at 6 weeks, 3 months and a final follow-up 6 months postoperatively. No postoperative adhesions were seen on nasendoscopy up to 6 months postoperatively. Dissolvable packs appear to be safe and effective and can be used for day case sinus surgery. There is no need for packing removal, thus greater patients' satisfaction.

Personal protection equipment for biological hazards: does it affect tracheal intubation performance?

PURPOSE: Personal protection equipment (PPE) is recommended for use during airway management of patients with highly contagious respiratory tract illness. While its use in chemical hazards and its effect on airway management has been assessed previously, there has been no research assessing whether this equipment affects the ability to perform tracheal intubation. It is the intention of this investigation to answer this question. METHODS: Eighteen workers at various level of training were asked to wear three different types of PPE while performing four different types of tracheal intubation. The PPE used included the eye shield, face shield and the "Dustmaster". The intubation techniques were direct laryngoscopy, intubation through the intubating laryngeal mask (Fastrach) and flexible bronchoscopy using the eyepiece and an eyepiece with camera attached. We assessed the time to intubate as well as the incidence of oesophageal intubation. A short questionnaire was used to examine participants' subjective experiences of wearing the various types of PPE. RESULTS: There was no significant effect on the time to intubation for any of the methods studied. However, all subjects found that the face shield was uncomfortably hot to wear. Fibreoptic bronchoscopic intubation using the eyepiece was particularly difficult with all of the PPE used due to the distance of the subjects' eye from the eyepiece. CONCLUSION: Although the use of PPE may not affect the length of time to intubate manikins, certain types of PPE may be uncomfortable to wear and noisy. Further research is needed to investigate whether this could be a problem in the clinical setting or in actual difficult intubations.

The Bradford bone-anchored hearing aid programme: impact of the multidisciplinary team.

OBJECTIVES: The aim of this study was to assess the impact on implant survival, abutment skin reaction and patient satisfaction in patients implanted with a bone-anchored hearing aid (BAHA), following the introduction of a multidisciplinary team (MDT) in 1997. DESIGN AND METHODS: Part prospective and retrospective analysis. Implant survival and cause of failures were recorded along with abutment skin reaction (graded as none, mild, moderate and severe, according to the amount of wound care required). Patient satisfaction and quality of life were assessed using a questionnaire enquiring about several aspects of the use and benefits of their BAHA. SETTING AND PARTICIPANTS: Eighty patients treated at the Bradford Royal Infirmary between 1991 and 2005. The unit is a recognized tertiary referral centre. RESULTS AND CONCLUSIONS: Twelve out of 80 implants failed, giving an overall failure rate of 15 per cent. Kaplan-Meier survival curves show a steady decrease in implant survival. The MDT had a positive effect on implant survival and adverse skin reactions, with a higher proportion of patients experiencing no reaction after its introduction. There was a 92.5 per cent response rate to the questionnaire. Overall patient satisfaction was high, both before and after the introduction of the MDT.

Periorbital swelling: the important distinction between allergy and infection.

Orbital cellulitis and abscess formation are rare complications of sinusitis, however acute orbital inflammation is secondary to sinusitis in about 70% of cases. Delay in diagnosis must not occur to avoid serious complications such as blindness and life threatening intracranial sepsis. A case is reported in which despite late referral, emergency surgical intervention was sight saving.

Intermittent self-nasal packing for intractable epistaxis in a patient with Ehlers-Danlos syndrome.

Intractable epistaxis is a difficult problem to manage, particularly in a case complicated by Ehlers-Danlos syndrome. This is the first report describing intermittent self-packing of the nasal cavities at home to reduce hospital admissions and control symptoms. Some of the potential problems and complications are highlighted.

Dentures may be radiolucent.

Diagnosing ingested dental prostheses can be difficult and delays in treatment may result in serious complications. Patients often present with a vague history and very few reliable clinical signs. In addition, the fact that dental plates are often radiolucent may lead to the diagnosis being overlooked with disastrous consequences. A case of successful diagnosis and treatment is presented, and the importance of a high index of clinical suspicion to avoid the morbidity and mortality associated with missed impacted dentures is discussed.

Outcome in prenatally diagnosed fetal agenesis of the corpus callosum.

This study of the outcome and prognostic factors in prenatally diagnosed agenesis of the corpus callosum (ACC) was undertaken to see if there are any differences between subgroups, what relationship they have to neurodevelopmental outcome and whether this information aids the counselling of parents of fetuses with the condition. The outcome of 14 prenatally diagnosed fetuses with ACC and 61 postnatally diagnosed patients was assessed in terms of clinical problems, developmental milestones and neurological signs; each patient was then given a score out of 10, 0 being a normal outcome and 10 being the worst outcome, i.e. death or termination of pregnancy. Comparing patients diagnosed pre- and postnatally, several similarities were found indicating that the postnatal group can provide useful information about the prenatal group. There was a higher incidence of ACC in males than females. In the prenatally diagnosed patients complete ACC was more common than partial ACC, although this might be because partial ACC was easily missed. Complete ACC has a worse prognosis than partial ACC (p = 0.001), and when associated with other anomalies, especially of the central nervous system, the outcome is very bad (p < 0.01). The only neurodevelopmentally normal patients were in the isolated partial ACC group. This study highlights the need to perform a detailed review of fetal anatomy and the desirability of determining the karyotype of the fetus in all newly diagnosed cases of ACC so that as much information as possible is available before parents are counselled about the likely outcome.

The anaesthetic management of a woman with a 31-week abdominal pregnancy.

An 18-year-old primigravida was admitted to hospital complaining of abdominal pain and vomiting. An ultrasound examination suggested the diagnosis of advanced abdominal pregnancy and this was confirmed using magnetic resonance imaging. Two days later she underwent operative delivery of a live fetus. The placenta was left in situ as it was attached to a large number of pelvic structures. Such surgery can result in maternal death due to massive haemorrhage as there is no mechanism to stem blood loss from the placental bed. Death can also occur in the post-partum period from septic complications if the placenta is left in situ. The management of such patients requires personnel and equipment to deal with massive and rapid haemorrhage; aortic cross clamping may be required to control bleeding. In this case, surgery and recovery were uneventful.