A feasibility study of using a high-definition intra-operative exoscope in teaching septorhinoplasty.

OBJECTIVE: This pilot study aimed to assess the feasibility of using a high-definition intra-operative exoscope in teaching septorhinoplasty. METHODS: The exoscope was used in septorhinoplasty cases with different trainers and trainees. A high-definition screen displayed real-time, magnified images. Post-procedure, a questionnaire was completed by trainer and trainees, assessing the feasibility, safety and content validity of the exoscope as a septorhinoplasty training tool. RESULTS: Trainees and trainers assigned favourable ratings to all aspects of the exoscope as a training tool, particularly with regard to teaching anatomy and improving visualisation. CONCLUSION: The exoscope is a potentially effective training tool in septorhinoplasty, and is especially useful in improving visualisation, without restricting the operator. Annotatable intra-operative photographs and videos allow trainees to study cases outside of the operating theatre environment. The use of an exoscope for septorhinoplasty in the UK may facilitate increased hands-on involvement earlier in training than is currently typical.

Getting it right first time: national survey of surgical site infection 2019.

INTRODUCTION: Surgical site infections (SSIs) are associated with increased morbidity and mortality. Deep SSI, or prosthetic joint infection (PJI), is associated with revision surgery involving longer operative times with higher infection rates, longer length of stay (LoS) and high costs in addition to the catastrophic effect on the patient. The surveillance of SSI is important for patient decision making, identification of outliers for support and maximising focussed improvement. This paper reports the findings of the second Getting it Right First Time (GIRFT) national SSI survey for orthopaedic and spinal surgery. METHODS: Data were submitted prospectively by 67 orthopaedic units and 22 spinal units between 1 May 2019 and 31 October 2019. For a patient to be included, they had to present with SSI within the study period and within 1 year of the index procedure. RESULTS: A total of 309 SSIs were reported from primary and revision, total hip, knee, shoulder, elbow and ankle replacements, and 58 SSIs were reported from lumbar spine single level discectomy or decompression, lumbar spine single-level instrumented posterior fusion, posterior cervical spine decompression and instrumented fusion and posterior correction of adolescent idiopathic scoliosis. SSIs rates have remained low compared with the 2017 survey. There were variations in SSI rates by procedure, with primary shoulder replacement reporting the lowest (0.4%) and revision shoulder replacement the highest (2.5%) rates. CONCLUSIONS: The authors recommend that the elective surgical restart following the COVID-19 pandemic provides a unique opportunity for all units to implement a full SSI prevention bundle to minimise the risk of infection and improve patient outcomes.

Safety of day-case paediatric tonsillectomy in England: an analysis of administrative data for the Getting It Right First Time programme.

We used the Hospital Episodes Statistics database to investigate unwarranted variation in the rates Trusts discharged children the same day after scheduled tonsillectomy and associations with adverse postoperative outcomes. We included children aged 2-18 years who underwent tonsillectomy between 1 April 2014 and 31 March 2019. We stratified analyses by category of Trust, non-specialist or specialist, defined as without or with paediatric critical care facilities, respectively. We adjusted analyses for age, sex, year of surgery and aspects of presentation and procedure type. Of 101,180 children who underwent tonsillectomy at non-specialist Trusts, 62,926 (62%) were discharged the same day, compared with 24,138/48,755 (50%) at specialist Trusts. The adjusted proportion of children discharged the same day as tonsillectomy ranged from 5% to 100% at non-specialist Trusts and 9% to 88% at specialist Trusts. Same-day discharge was not independently associated with an increased rate of 30-day emergency re-admission at non-specialist Trusts but was associated with a modest rate increase at specialist Trusts; adjusted probability 8.0% vs 7.7%, odds ratio (95%CI) 1.14 (1.05-1.24). Rates of adverse postoperative outcomes were similar for Trusts that discharged >70% children the same day as tonsillectomy compared with Trusts that discharged <50% children the same day, for both non-specialist and specialist Trust categories. We found no consistent evidence that day-case tonsillectomy is associated with poorer outcomes. All Trusts, but particularly specialist centres, should explore reasons for low day-case rates and should aim for rates >70%.

Utilisation of a smartphone-enabled video otoscope to train novices in otological examination and procedural skills.

OBJECTIVE: The ai/m of this study was to compare the self-reported confidence of novices in using a smartphone-enabled video otoscope, a microscope and loupes for ear examination and external ear canal procedures. METHOD: Medical students (n = 29) undertook a pre-study questionnaire to ascertain their knowledge of techniques for otoscopy and aural microsuction. Participants underwent teaching on ear anatomy, examination and procedural techniques using a microscope, loupes and smartphone-enabled video otoscopes. Confidence and preference using each modality was rated using a Likert-like questionnaire. RESULTS: After teaching, all modalities demonstrated a significant increase in confidence in ear examination (p < 0.0001). Confidence in using the smartphone-enabled otoscope post-teaching was highest (p = 0.015). Overall, the smartphone-enabled video otoscope was the preferred method in all other parameters assessed including learning anatomy or pathology (51.72 per cent) and learning microsuction (65.51 per cent). CONCLUSION: Smartphone-enabled video otoscopes provide an alternative approach to ear examination and aural microsuction that can be undertaken outside of a traditional clinical setting and can be used by novices.

Lessons from rhinology and facial plastic surgery clinical negligence claims in England 2013-2018.

OBJECTIVE: This study reviewed all rhinology clinical negligence claims in the National Health Service in England between 2013 and 2018. METHOD: All clinical negligence claims held by National Health Service Resolution relating to rhinology in England between 1 April 2013 and 1 April 2018 were reviewed. RESULTS: There were 171 rhinology related claims with a total estimated potential cost of £13.6 million. There were 119 closed claims (70 per cent) with a total cost of £2.3 million, of which 55 claims resulted in payment of damages. Over three quarters of all rhinology claims were associated with surgery (n = 132). Claims associated with endoscopic sinus surgery had the highest mean cost per claim (£172 978). Unnecessary pain (33.9 per cent) and unnecessary operation (28.1 per cent) were the most commonly cited patient injuries. CONCLUSION: Patient education and consent have been highlighted as key areas for improvement from this review of rhinology related clinical negligence claims. A shift in clinical practice towards shared decision making could reduce litigation in rhinology.

What can be learned from litigation in otology? A review of clinical negligence claims in England 2013-2018.

BACKGROUND: Litigation in the National Health Service continues to rise with a 9.4 per cent increase in clinical negligence claims from the period 2018 and 2019 to the period 2019 and 2020. The cost of these claims now accounts for 1.8 per cent of the National Health Service 2019 to 2020 budget. This study aimed to identify the characteristics of clinical negligence claims in the subspecialty of otology. METHODS: This study was a retrospective review of all clinical negligence claims in otology in England held by National Health Service Resolution between April 2013 and April 2018. RESULTS: There were 171 claims in otology, 24 per cent of all otolaryngology claims, with a potential cost of £24.5 million. Over half of these were associated with hearing loss. Stapedectomy was the highest mean cost per claim operation at £769 438. The most common reasons for litigation were failure or delay in treatment (23 per cent), failure or delay in diagnosis (20 per cent), intra-operative complications (15 per cent) and inadequate consent (13 per cent). CONCLUSION: There is a risk of high-cost claims in otology, especially with objective injuries such as hearing loss and facial nerve injury.

ENT trainees' experience of redeployment during the coronavirus disease 2019 pandemic: a qualitative study.

BACKGROUND: As a response to the acute strain placed on the National Health Service during the first wave of coronavirus disease 2019 in the UK, a number of junior doctors including ENT trainees were redeployed to other clinical specialties. This presented these trainees with novel challenges and opportunities. METHODS: A qualitative study was performed to explore these experiences, undertaking semi-structured interviews with ENT trainees between 17th and 30th July. Participants were recruited through purposeful sampling. Interview transcripts underwent thematic analysis using Dedoose software. RESULTS: Seven ENT trainees were interviewed, ranging from specialty trainee years four to eight ('ST4' to 'ST8') in grade. Six core themes were identified: organisation of redeployment, utilisation of skill set, emotional impact of redeployment, redeployed team dynamics, concerns about safety and impact on training. CONCLUSION: The ENT trainees' experiences of redeployment described highlight some important lessons and considerations for future redeployments.

The use of throat packs in ear, nose and throat, oral and dental surgery: a systematic review.

BACKGROUND: Throat packs are placed around the airway in patients undergoing upper airway surgical procedures under general anaesthetic to prevent aspiration or ingestion of blood, and consequent chest infections or postoperative nausea and vomiting (PONV). There is no definitive evidence for this, and each time a pack is placed, it risks being retained and obstructing the upper airway. This study aimed to determine whether throat packs are of benefit to patients undergoing upper airway surgical procedures. METHODS: Medline, Embase and Central were searched from conception to 15th January 2018 using individualised search strategies. A systematic search of multiple databases was undertaken using custom strategies to identify all relevant randomised controlled trials. Screening, risk of bias assessment and data extraction were undertaken independently by two authors. Primary outcomes included throat pain and PONV. Secondary outcomes included any adverse event documented. RESULTS: Thirteen papers were eligible for inclusion. No studies reported any instances of retained throat packs. Ten studies assessed the effect of throat packs on post-operative throat pain, with four papers showing a significantly higher incidence of pain when throat packs were used. One study showed throat pain to be slightly, but significantly, worse 24 hours post-surgery when a pack was not used. No paper showed throat packs to be of benefit in preventing PONV. CONCLUSION: The study was limited by methodological flaws of included trials, overall relatively low numbers of patients and difficulty in contacting authors to clarify information and obtain raw data. However, this systematic review found no evidence to support the use of throat packs. This supports the proposal that there is no indication for the routine use of throat packs in ENT, maxillofacial and dental procedures.

Incisional hernia rate after laparoscopic colorectal resection is reduced with standardisation of specimen extraction.

INTRODUCTION: Incisional hernia is a common complication of laparoscopic colorectal surgery. Extraction site may influence the rate of incisional hernias. Major risk factors for the development of incisional hernias include age, diabetes, obesity and smoking status. In this study, we investigated the effect of specimen extraction site on incisional hernia rate. METHODS: Two cohorts of patients who underwent laparoscopic colorectal resections in a single centre in 2005 (n=85) and 2009 (n=139) were studied retrospectively. In 2005 all specimens were extracted through transverse muscle cutting incisions. In 2009 all specimens were extracted through midline incisions. Demographic variables, rate of incisional hernias and risk factors for hernia development were compared between the year groups. All patients had been followed up clinically for two years. RESULTS: A total of 224 patients (mean age: 67.5 years, standard deviation: 16.35 years) were included in this study. Of these, 85 patients were in the 2005 transverse group and 139 were in the 2009 midline group. The total incisional hernia rate for the series was 8.0% at the two-year follow-up visit. For the 2005 group, the incisional hernia rate was 15.3% (n=13) and for the 2009 group, it was 3.6% (n=5) (p<0.01). The body mass index was higher in patients who developed incisional hernias than in those who did not (p=0.02). CONCLUSIONS: The 2005 group had a significantly higher incisional hernia rate than the 2009 group. This is due to the differences in the incision technique and extraction site between the two groups.

Prophylactic decompression of extensor pollicis longus to prevent rupture.

We present a case of a patient with spontaneous rupture of right extensor pollicis longus (EPL) tendon, who had also developed left wrist pain and weakness in his left EPL that MRI studies confirmed to be caused by tendinosis. Subsequently, decompression of left EPL and reconstruction of right EPL with palmaris longus tendon graft was undertaken. In this case, decompression of the left EPL tendon led to resolution of the patient's symptoms as well as preventing tendon rupture. We advocate the use of ultrasound imaging to evaluate EPL in these cases and prophylactic decompression of EPL tendon to avoid rupture in those patients found to have tendinosis.