International Multicenter Study of Clinical Outcomes of Sinonasal Melanoma Shows Survival Benefit for Patients Treated with Immune Checkpoint Inhibitors and Potential Improvements to the Current TNM Staging System.

Objectives Sinonasal mucosal melanoma (SNMM) is an extremely rare and challenging sinonasal malignancy with a poor prognosis. Standard treatment involves complete surgical resection, but the role of adjuvant therapy remains unclear. Crucially, our understanding of its clinical presentation, course, and optimal treatment remains limited, and few advancements in improving its management have been made in the recent past. Methods We conducted an international multicenter retrospective analysis of 505 SNMM cases from 11 institutions across the United States, United Kingdom, Ireland, and continental Europe. Data on clinical presentation, diagnosis, treatment, and clinical outcomes were assessed. Results One-, three-, and five-year recurrence-free and overall survival were 61.4, 30.6, and 22.0%, and 77.6, 49.2, and 38.3%, respectively. Compared with disease confined to the nasal cavity, sinus involvement confers significantly worse survival; based on this, further stratifying the T3 stage was highly prognostic ( p < 0.001) with implications for a potential modification to the current TNM staging system. There was a statistically significant survival benefit for patients who received adjuvant radiotherapy, compared with those who underwent surgery alone (hazard ratio [HR] = 0.74, 95% confidence interval [CI]: 0.57-0.96, p = 0.021). Immune checkpoint blockade for the management of recurrent or persistent disease, with or without distant metastasis, conferred longer survival (HR = 0.50, 95% CI: 0.25-1.00, p = 0.036). Conclusions We present findings from the largest cohort of SNMM reported to date. We demonstrate the potential utility of further stratifying the T3 stage by sinus involvement and present promising data on the benefit of immune checkpoint inhibitors for recurrent, persistent, or metastatic disease with implications for future clinical trials in this field.

Clinical outcomes, Kadish-INSICA staging and therapeutic targeting of somatostatin receptor 2 in olfactory neuroblastoma.

INTRODUCTION: Olfactory neuroblastoma (ONB) is a rare cancer of the sinonasal region. We provide a comprehensive analysis of this malignancy with molecular and clinical trial data on a subset of our cohort to report on the potential efficacy of somatostatin receptor 2 (SSTR2)-targeting imaging and therapy. METHODS: We conducted a retrospective analysis of 404 primary, locally recurrent, and metastatic olfactory neuroblastoma (ONB) patients from 12 institutions in the United States of America, United Kingdom and Europe. Clinicopathological characteristics and treatment approach were evaluated. SSTR2 expression, SSTR2-targeted imaging and the efficacy of peptide receptor radionuclide therapy [PRRT](177Lu-DOTATATE) were reported in a subset of our cohort (LUTHREE trial; NCT03454763). RESULTS: Dural infiltration at presentation was a significant predictor of overall survival (OS) and disease-free survival (DFS) in primary cases (n = 278). Kadish-Morita staging and Dulguerov T-stage both had limitations regarding their prognostic value. Multivariable survival analysis demonstrated improved outcomes with lower stage and receipt of adjuvant radiotherapy. Prophylactic neck irradiation significantly reduces the rate of nodal recurrence. 82.4% of the cohort were positive for SSTR2; treatment of three metastatic cases with SSTR2-targeted peptide-radionuclide receptor therapy (PRRT) in the LUTHREE trial was well-tolerated and resulted in stable disease (SD). CONCLUSIONS: This study presents pertinent clinical data from the largest dataset, to date, on ONB. We identify key prognostic markers and integrate these into an updated staging system, highlight the importance of adjuvant radiotherapy across all disease stages, the utility of prophylactic neck irradiation and the potential efficacy of targeting SSTR2 to manage disease.

Changes in the provision of undergraduate ENT clinical placements across the UK in response to the coronavirus disease 2019 pandemic.

OBJECTIVE: This study aimed to report the changes made to ENT placements across the UK in response to the pandemic and their impact on student experience. METHODS: A questionnaire eliciting how ENT placements were provided before and after coronavirus disease 2019 was disseminated amongst Student and Foundation Doctors in Otolaryngology representatives. RESULTS: Thirty-eight respondents from 27 medical schools across the UK completed the survey (response rate of 90 per cent). Twenty-nine of the 38 respondents (76 per cent) reported a change in ENT placements in response to the pandemic. Six of the 38 students (16 per cent) remained satisfied with their ENT placements, as compared to 12 students prior to the pandemic (32 per cent). CONCLUSION: There is considerable variability in how medical schools responded to the pandemic. Most medical schools placed students into smaller groups, with less direct contact in the hospital. These changes resulted in lower student satisfaction. The increased emphasis on e-learning underscores the need for high quality e-learning materials to promote learning throughout the pandemic and in the future.

The provision of undergraduate clinical placements in ENT during the coronavirus disease 2019 pandemic - exploring patient perspectives on a variety of approaches.

BACKGROUND: The coronavirus disease 2019 pandemic has greatly disrupted routine ENT services. Subsequently, universities have chosen to either augment or suspend clinical placements. OBJECTIVE: This study aimed to elicit patients' perspectives toward various approaches to clinical placements in ENT during the coronavirus disease 2019 pandemic. METHODS: Cross-sectional questionnaires were given to patients attending the ENT department for routine out-patient care. Responses were measured using a five-point Likert scale. Seventy-nine patients completed the survey. RESULTS: Ninety-five per cent of respondents felt the coronavirus disease 2019 pandemic had not reduced their comfort in interacting with medical students. Most participants reported being comfortable with students participating directly or remotely in their care, and with students having access to their anonymised data. Twenty-five per cent of participants stated that they are uncomfortable with consultations being recorded and shared for medical education purposes. CONCLUSION: A number of approaches to clinical placements remain acceptable to patients. Educational leads should continue to offer placements in ENT that can incorporate direct or remote observation of consultations.

Acute otitis externa: Consensus definition, diagnostic criteria and core outcome set development.

OBJECTIVE: Evidence for the management of acute otitis externa (AOE) is limited, with unclear diagnostic criteria and variably reported outcome measures that may not reflect key stakeholder priorities. We aimed to develop 1) a definition, 2) diagnostic criteria and 3) a core outcome set (COS) for AOE. STUDY DESIGN: COS development according to Core Outcome Measures in Effectiveness Trials (COMET) methodology and parallel consensus selection of diagnostic criteria/definition. SETTING: Stakeholders from the United Kingdom. SUBJECTS AND METHODS: Comprehensive literature review identified candidate items for the COS, definition and diagnostic criteria. Nine individuals with past AOE generated further patient-centred candidate items. Candidate items were rated for importance by patient and professional (ENT doctors, general practitioners, microbiologists, nurses, audiologists) stakeholders in a three-round online Delphi exercise. Consensus items were grouped to form the COS, diagnostic criteria, and definition. RESULTS: Candidate COS items from patients (n = 28) and literature (n = 25) were deduplicated and amalgamated to a final candidate list (n = 46). Patients emphasised quality-of-life and the impact on daily activities/work. Via the Delphi process, stakeholders agreed on 31 candidate items. The final COS covered six outcomes: pain; disease severity; impact on quality-of-life and daily activities; patient satisfaction; treatment-related outcome; and microbiology. 14 candidate diagnostic criteria were identified, 8 reaching inclusion consensus. The final definition for AOE was 'diffuse inflammation of the ear canal skin of less than 6 weeks duration'. CONCLUSION: The development and adoption of a consensus definition, diagnostic criteria and a COS will help to standardise future research in AOE, facilitating meta-analysis. Consulting former patients throughout development highlighted deficiencies in the outcomes adopted previously, in particular concerning the impact of AOE on daily life.

Earfold Implantable Clip System for Correction of Prominent Ears: Analysis of Safety in 403 Patients.

BACKGROUND: The Earfold system, a new treatment for the correction of prominent ears, consists of 3 components: the Earfold implant, the Earfold introducer, and the Prefold positioner. METHODS: This is an interim report based on an ongoing analysis of safety in a series of patients treated for prominent ears with the Earfold implant between February 2013 and September 2014. Safety was assessed based on adverse event reports and the need for implant revision; follow-up is ongoing. RESULTS: Seven surgeons used 1,200 Earfold implants to treat 403 patients (ages, 7-70 years; 63% male); the time since the initial implant procedure now ranges from 30 to 48 months. To date, 145 patients (36%) have returned for a follow-up visit (mean, 7.7 months [range, 1-34 months]). Adverse events requiring intervention have affected 39 of 403 (9.7%) patients; these include implant revisions (n = 17 [4.2%], most often due to implant visibility), skin erosion over the implant (n = 15 [3.7%]), and infection (n = 7 [1.7%]). Bleeding, recurrence of prominence, hematoma, deformity, or adverse scarring did not occur. CONCLUSIONS: This interim analysis has shown that Earfold prominent ear correction system is associated with relatively few adverse events that require intervention; a small number of patients experienced infection, implant extrusion, or implant visibility that required revision. Most adverse events were related to either patient selection or technical errors at implantation. It is expected that with continued use of Earfold by surgeons experienced in otoplasty, the adverse event incidence will decrease.

Effects of transcranial direct current stimulation on pain, mood and serum endorphin level in the treatment of fibromyalgia: A double blinded, randomized clinical trial.

BACKGROUND: Recent studies have shown that novel neuro-modulating techniques can have pain-relieving effects in the treatment of chronic pain. The aim of this work is to evaluate the effects of transcranial direct current stimulation (tDCS) in relieving fibromyalgia pain and its relation with beta-endorphin changes. MATERIAL AND METHODS: Forty eligible patients with primary fibromyalgia were randomized to receive real anodal tDCS or sham tDCS of the left motor cortex (M1) daily for 10 days. Each patient was evaluated using widespread pain index (WPI), symptom severity of fibromyalgia (SS), visual analogue scale (VAS), and determination of pain threshold as a primary outcome. Hamilton depression and anxiety scales (HAM-D and HAM-A) and estimation of serum beta-endorphin level pre and post-sessions were used as secondary outcome. All rating scales were conducted at the baseline, after the 5th, 10th session, 15 days and 1 month after the end of the sessions. RESULTS: Eighteen patients from each group completed the follow-up schedule with no significant difference between them regarding the duration of illness or the baseline scales. A significant TIME × GROUP interaction for each rating scale (WPI, SS, VAS, pain threshold, HAM-A, HAM-D) indicated that the effect of treatment differed in the two groups with higher improvement in the experimental scores of the patients in the real tDCS group (P = 0.001 for WPI, SS, VAS, pain threshold, and 0.002, 0.03 for HAM-A, HAM-D respectively). Negative correlations between changes in serum beta-endorphin level and the changes in different rating scales were found (P = 0.003, 0.003, 0.05, 0.002, 0002 for WPI, SS, VAS, HAM-A, and HAM-D respectively). CONCLUSION: Ten sessions of real tDCS over M1 can induce pain relief and mood improvement in patients with fibromyalgia, which were found to be related to changes in serum endorphin levels. ClinicalTrials.gov Identifier: NCT02704611.

Noise-induced hearing loss: a modern epidemic?

Hearing loss is an increasingly common problem in the UK, and noise-induced hearing loss is the second most common acquired cause. There is a greater burden on the younger population, as recreational noise exposure is an important contributor. New damaging hearing behaviours have emerged including loud music exposure at concerts, nightclubs and via personal music players. The mechanism of damage is thought to involve many diverse pathways, which include oxidative damage, mechanical shearing forces and glutamate excitotoxicity. Although no current treatment exists to reverse the damage caused, these pathways can be targeted by agents that are being trialled for use in post-exposure treatment and prevention, with conflicting results. Other preventative strategies are important in addressing damaging hearing behaviours, including 'safe listening' promotion with advocacy materials for young adults, and promoting safe listening devices.

Body dysmorphic disorder in patients undergoing septorhinoplasty surgery: should we be performing routine screening?

OBJECTIVE: Body dysmorphic disorder (BDD) is defined as having a preoccupation with a perceived flaw in one's appearance, which appears slight to others and significantly interferes with a person's functioning. When undetected in septorhinoplasty patients, it will often lead to poor outcomes. DESIGN: We performed a prospective cohort study to determine the prevalence of BDD in our patients and whether surgical correction could be considered. SETTING AND PARTICIPANTS: We recruited 34 patients being considered for septorhinoplasty in a tertiary referral rhinology clinic and a control group of 50 from the otology clinic giving a total of 84. MAIN OUTCOME MEASURES: Participants completed the Body Dysmorphic Disorder Questionnaire (BDDQ), the sino-nasal outcome test-23 (SNOT-23) and underwent nasal inspiratory peak flow (NIPF). Those found to be at high risk for BDD were referred to a clinical psychologist. RESULTS: Of the septorhinoplasty patients, 11 (32%) were high risk for BDD. Following psychological assessment, 7 (63%) patients were felt to be unsuitable for surgery and were offered psychological therapy. SNOT-23 scores were significantly higher in the BDD group indicating a negative impact on quality of life. NIPF readings were not significantly different in the BDD group compared to the control group. CONCLUSIONS: The BDDQ is a valid tool for identifying patients at risk of BDD. A close working relationship with clinical psychology has been advantageous to help the selection process of candidates for surgery when there is a high risk of BDD.

Retinal angiomatous proliferation occurring after radiotherapy.

PURPOSE: To describe two cases of retinal angiomatous proliferation (RAP)-like lesion following radiation therapy for primary tumor. PATIENTS AND METHODS: Retrospective evaluation of two patients with previous irradiation treatment for a pleomorphic adenoma of the lacrimal gland and a vocal cord carcinoma, respectively. Visual acuity (VA), fluorescein angiography and optical coherence tomography were performed and demonstrated a RAP-like lesion in both cases. Treatment with intravitreal injections of Ranibizumab was performed with a follow-up of 19 and 10 months, respectively. RESULTS: Both the patients had a positive response to the treatment with improvement in VA and reduction of intraretinal fluid. CONCLUSION: RAP-like lesions can develop following radiation treatment for a primary tumor. In patients presenting with idiopathic RAP, a history of prior radiotherapy should be considered.

Are randomised controlled trials involving adenotonsillectomy well reported?

INTRODUCTION: Evidence-based medicine guides clinical practice. Currently, the evidence base on adenotonsillectomy is under scrutiny to establish clinical guidelines. It is therefore important that reports of clinical trials are of high quality. Guidance on reporting of randomised controlled trials (RCTs) are available in the Consolidated Standards for Reporting Trials (CONSORT) statement first published in 1996 and revised in 2001 and 2010. METHODS: A review of randomised controlled trials on adenotonsillectomy published after 2001 was undertaken. Each report was systematically assessed using the checklist of items from the CONSORT statement. RESULTS: Twenty-five trials were identified. All trials, except one, were identified as a randomised controlled trial by title or abstract. Twenty percent of trials reported a sample size calculation. A third of trials reported their method of generating a random allocation sequence. Similarly, a third stated the method of implementing the random allocation. A fifth of trials reported a clear flow of trial participants, with only a single trial reporting this with the aid of a diagram. CONCLUSION: This review shows the quality of reporting needs to be improved. Critical appraisal of poorly reported trials may result in erroneous conclusions, even though these trials may have been carried out with rigorous adherence to a protocol of high standard. Authors of clinical trial reports should be encouraged to consult the CONSORT statement.

Interleukin-8 promoter polymorphism -251A/T is a risk factor for age-related macular degeneration.

BACKGROUND/AIMS: To determine whether four expression-related cytokine polymorphisms are associated with age-related macular degeneration (AMD). METHODS: DNA from 478 cases with AMD and 555 normal controls was genotyped for the pro-inflammatory IL1beta -511C/T, IL6 -174C/G, IL8 -251A/T and anti-inflammatory IL10 -1082G/A cytokine polymorphisms using the 5' nuclease TaqMan(R) assay for allelic discrimination. Associations with AMD were analysed using allelic frequencies. RESULTS: The -251A allele of the IL8 promoter gene polymorphism was more prevalent in AMD patients than controls (p = 0.037, OR = 1.21, 95% CI = 1.01 to 1.44). Adjusting for age, sex, body mass index (BMI), current smoking and past smoking status did not alter the AMD association significantly (corrected p value = 0.043, OR = 1.23, 95% CI = 1.0 to 1.50). CONCLUSION: The pro-inflammatory homozygous IL8 -251AA genotype is an important risk factor for AMD. This may have implications for future therapy with biological agents that could target this cytokine.

Prospective cohort comparison of bioactive glass implants and conchal cartilage in reconstruction of the posterior canal wall during tympanomastoidectomy.

OBJECTIVE: To compare the effectiveness of bioactive glass implants and conchal cartilage in reconstructing the posterior canal wall during tympanomastoidectomy. STUDY DESIGN: Prospective cohort clinical study. SETTING: Teaching hospital. PATIENTS: Patients with clinically diagnosed chronic suppurative otitis media and cholesteatoma awaiting tympanomastoidectomy were recruited. INTERVENTION: All patients underwent tympanomastoidectomy by the same surgeon. A first cohort of 12 patients underwent posterior canal wall reconstruction with autogenous conchal cartilage. A second cohort of 12 patients underwent such reconstruction with prefabricated bioactive glass. MAIN OUTCOME MEASURES: Primary- All patients underwent out-patient review at 1, 3, 6 and 12 months postoperatively, after which a second-look procedure was performed. Reconstructions were inspected for evidence of epithelialization, granulation, infection, stenosis, depression and extrusion. Secondary- All patients had perioperative serial pure-tone audiometry to check for any change in hearing levels upto 1 year postoperatively. RESULTS: By 1 year postoperatively, both reconstructive graft materials showed good epithelialization, no granulation, no infection, no ear canal stenosis, no depression and no extrusion. At operative second-looks, bioactive glass particularly showed good tissue bonding, including both neovascularization and connective tissue integration. Overall clinical outcome was equivalent for both materials. Both graft materials showed no statistically significant difference in postoperative hearing levels. CONCLUSIONS: Bioactive glass and conchal cartilage showed equivalent clinical outcome in reconstructing the posterior canal wall without significantly affecting hearing levels. As bioactive glass does not require second site morbidity and thus also reduces operative time, we prefer it for reconstructing the posterior canal wall following tympanomastoidectomy.

An analysis of the CFH Y402H genotype in AMD patients and controls from the UK, and response to PDT treatment.

AIM: Mutation in the complement factor H (CFH) gene is an important risk factor for age-related macular degeneration (AMD). In this study, we identified the strength of the CFH Y402H gene variant association in a UK AMD cohort and tested the hypothesis that this variant may influence the biological response of choroidal neovascularisation (CNV) following photodynamic therapy (PDT) for CNV. METHODS: A total of 557 cases with AMD and 551 normal controls were genotyped for the CFH Y402H (1277 C/T) variant using the 5' nuclease TaqMan assay for allelic discrimination. The CFH gene association for AMD, for the different CNV subtypes and for patients needing PDT was estimated. Twenty-seven PDT-treated patients were followed up for 15 months with ETDRS-derived vision, clinical examination, and fundus angiography. Individuals with different CFH genotypes were then analysed for any association with visual change following PDT. RESULTS: The risk association for AMD with the CFH CC genotype (odd ratio (OR)=3.62, Pc<0.0001) was similar to that reported in other Caucasian cohorts. The magnitude and strength of this association was stronger in AREDS stages 2-4 (ORs=4.48, 2.69, and 5.17). ORs for the risk of predominantly classic CNV were significantly raised for both the CC (OR=17.87, P<0.0001) and CT (OR=9.06, P=0.0002) genotypes. The number of patients carrying the high-risk C allele was 70.4% in those requiring PDT as compared to 52.3% in the non-PDT group (OR=2.16, P=0.011), and presence of the CC genotype significantly increased the risk of PDT (OR=5.48, P=0.015). The degree of visual loss following PDT was significantly higher in the CFH CC genotype group (P=0.038); 50% of CC cases (n=13) and 45% of the CT cases (n=12) lost 15 or more ETDRS letters at final follow-up. CONCLUSION: In this UK cohort of AMD patients, the CFH Y402H variant was significantly enriched in patients with predominantly classic CNV. Patients homozygous for the CFH Y402H genotype seem to have worse visual acuity after PDT.

Nasal saline irrigations for the symptoms of chronic rhinosinusitis.

BACKGROUND: The use of nasal irrigation for the treatment of nose and sinus complaints has its foundations in yogic and homeopathic traditions. There has been increasing use of saline irrigation, douches, sprays and rinsing as an adjunct to the medical management of chronic rhinosinusitis. Treatment strategies often include the use of topical saline from once to more than four times a day. Considerable patient effort is often involved. Any additional benefit has been difficult to discern from other treatments. OBJECTIVES: To evaluate the effectiveness and safety of topical saline in the management of chronic rhinosinusitis. SEARCH STRATEGY: Our search included the Cochrane Ear, Nose and Throat Disorders Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 4 2006), MEDLINE (1950 to 2006) and EMBASE (1974 to 2006). The date of the last search was November 2006. SELECTION CRITERIA: Randomised controlled trials in which saline was evaluated in comparison with either no treatment, a placebo, as an adjunct to other treatments or against treatments. The comparison of hypertonic versus isotonic solutions was also compared. DATA COLLECTION AND ANALYSIS: Trials were graded for methodological quality using the Cochrane approach (modification of Chalmers 1990). Only symptom scores from saline versus no treatment and symptom and radiological scores from the hypertonic versus isotonic group could be pooled for statistical analysis. A narrative overview of the remaining results is presented. MAIN RESULTS: Eight trials were identified that satisfied the inclusion criteria. Three studies compared topical saline against no treatment, one against placebo, one as an adjunct to and one against an intranasal steroid spray. Two studies compared different hypertonic solutions against isotonic saline. There is evidence that saline is beneficial in the treatment of the symptoms of chronic rhinosinusitis when used as the sole modality of treatment. Evidence also exists in favour of saline as a treatment adjunct. No superiority was seen when saline was compared against a reflexology 'placebo'. Saline is not as effective as an intranasal steroid. Some evidence suggests that hypertonic solutions improve objective measures but the impact on symptoms is less clear. AUTHORS' CONCLUSIONS: Saline irrigations are well tolerated. Although minor side effects are common, the beneficial effect of saline appears to outweigh these drawbacks for the majority of patients. The use of topical saline could be included as a treatment adjunct for the symptoms of chronic rhinosinusitis.

A new valid and reliable windtrainer VO2max protocol.

AIM: Maximal oxygen uptake (VO(2max)) cycling protocols usually require expensive laboratory ergometers where the athlete is unaccustomed to the cycling position. Recently, we developed a VO(2max) speed-ramped protocol with an indoor cycling simulator (Cateye Windtrainer WT) allowing cyclists to use their own bicycles during the VO(2max) test. The aim of this study was to test the validity of the WT protocol by comparing it with a traditional (TD) resistance-ramped protocol using an electronically braked ergometer. In addition, the retest reliability of the WT protocol was also determined. METHODS: Twenty experienced cyclists randomly completed 6 VO(2max) protocols consisting of one familiarization trial and two tests on the WT and TD protocols. RESULTS: There were minimal differences in maximal oxygen uptake values between protocols (WT 64.1+/-7.1, TD 63.3+/-7.4 mL/kg/min). The variability in the difference of the means between the two protocols was 0.8 mL/kg/min (95% confidence interval CI: -0.26-2.02), the coefficient of variation (CV) was 2.8% (95%CI: 2.2-4.2%) and the interclass correlation was r=0.94 (P<0.01; 95%CI: 0.86-0.98). The intratest difference within the WT protocol was 1.5% (95%CI: -1.9-5%), CV=5.3% (95%CI: 4.1-8%) and the retest correlation was r=0.81 (P<0.01; 95%CI: 0.57-0.92). CONCLUSION: The WT speed-ramped protocol is a valid and reliable method to assess VO(2max).

Sleep nasendoscopy: a 10-year retrospective audit study.

Sleep nasendoscopy was conceived at the Royal National Throat, Nose and Ear Hospital, UK in 1991, and has remained fully implemented in patient selection for targeted treatment of the spectrum of sleep-disordered breathing. The senior authors (B.T.K. and P.B.) have been performing sleep nasendoscopy together for over 10 years, and we look back at their decade's experience. A retrospective audit study based on case notes was performed over a 10-year period (1995-2005) in a tertiary-referral practice setting. Case notes were retrieved on all patients who had undergone sleep nasendoscopy during the study period, and agreed data were extracted and analyzed. A total of 2,485 sleep nasendoscopies were performed in patients with a mean age of 44.1 years, a 4:1 male preponderance, and a mean body mass index of 27.3 kg m(-2). Sleep nasendoscopy grading correlated well with apnoea-hypopnoea index and mean oxygen desaturation. Such grading helped us define and discuss treatment options with patients. After a median follow-up period of 518 days, 72% of patients reported feeling better; 26% of patients reported no change; and only 2% of patients reported feeling worse after treatment. Sleep nasendoscopy has proved to be a useful adjunctive method to identify the anatomical site of snoring, not to mention upper airway collapse, and remains integral to our tertiary-referral practice. It has allowed us quality assessment of the dynamic anatomy of sleep-disordered breathing that most closely and cost-effectively simulates the natural situation of patients. And for targeted treatment, such assessment has been fundamental.

A randomised controlled trial of routine suction drainage after elective thyroid and parathyroid surgery with ultrasound evaluation of fluid collection.

OBJECTIVE: To determine the need for suction drainage after elective thyroid and parathyroid surgery. DESIGN: Randomised controlled trial. SETTING: University teaching hospital. PARTICIPANTS: Patients requiring elective thyroid or parathyroid surgery were recruited and informed consent was obtained (n = 100). Before wound closure, patients were randomised into either group A (to remain without suction drainage) or group B (to receive suction drainage). Excluded patients were those requiring associated neck dissection and those with bleeding diatheses, all of whom would necessarily require drainage in our unit. MAIN OUTCOME MEASURES: Primary - ultrasound evaluation of any collection in the thyroid bed, performed 1-day postoperatively. Secondary - postoperative complications; length of in-patient stay. RESULTS: One hundred patients completed the study, and groups A and B comprised 50 patients each. Patients in each group exhibited a mean age of 49 years, and a male to female ratio of 1 : 9. Both groups were also well-matched regarding type of operation, size of tumour and histopathological diagnosis. Modal and median postoperative neck collection volume on ultrasound examination was 0 and 0 cm(3) respectively (range 0-16 cm(3)) in group A and was 0 and 0 cm(3) (range 0-70 cm(3)) in group B. This difference was not statistically significant, but three patients with a haematoma were all in the suction drainage group. Difference in complication rates between groups was also not statistically significant. Modal and median length of in-patient stay was 2 and 2 days respectively (range 2-3 days) in group A and 3 and 3 days (range 2-4 days) in group B, and this difference was statistically significant (P = 0.0006). CONCLUSION: Routine suction drainage after uncomplicated elective thyroid and parathyroid surgery appears unnecessary, and prolongs in-patient stay.