The Effect of Midface Advancement Surgery on Obstructive Sleep Apnoea in Syndromic Craniosynostosis.

BACKGROUND: Children with syndromic craniosynostosis frequently suffer from obstructive sleep apnoea (OSA). The aim of the authors' study was to investigate if midface advancement surgery for patients with SC improved the severity of OSA by examining the results of sleep studies before and after surgery. METHODS: A retrospective comparison of the pre and postoperative sleep study data of children undergoing midface advancement surgery at Great Ormond Street Hospital between 2007 and 2016. RESULTS: A total of 65 children underwent midface advancement surgery between 2007 and 2016 at Great Ormond Street Hospital and had recorded pre- and postoperative sleep studies. Thirteen patients were excluded from the analysis as their sleep study techniques before and after surgery were not comparable (e.g., different conditions with prong/continuous positive airway pressure use). Fifty-six percent of the patients were treated by monobloc surgery and the remainder with bipartition surgery. A greater proportion of patients had a normal OSA grading following midface advancement (42.3% postoperatively vs. 23.1% preoperatively, P = 0.059) although no statistically significant categorical changes in OSA grade were observed. Seventy-one percent of the patients had a decrease in Apnoea-Hypopnoea Index after surgery (21 patients 2011 onward). Similarly, there was no significant change in median oxygen desaturation index or in oxygen saturation nadir following surgery. CONCLUSION: The authors report one of the largest reviews of the effects of midface advancement surgery on sleep study parameters. Most patients showed improvements in Apnoea-Hypopnoea Index and OSA grading, although measures of oxygenation showed no consistent change.

How we do it: the intra-operative identification of a pharyngocele.

A pharyngocele is an uncommon condition, where pharyngeal mucosa herniates through the thyrohyoid membrane. It can be difficult to locate when the patient is at rest. To locate the pharyngocele intra-operatively, a bag valve mask was used to inflate the herniated mucosa. We describe a cost-effective and simple way to locate the pharyngocele intra-operatively.

Percutaneous bone-anchored hearing implant surgery without soft-tissue reduction: up to 42 months of follow-up.

OBJECTIVE: To report the results of bone-anchored hearing implant (BAHI) surgery without soft-tissue reduction (WoSR); in our case, a series of 30 patients with a follow-up period of up to 42 months. PATIENTS: The study group included 30 patients between ages 17 and 79 years, where BAHI was indicated, during a 42-month period, between February 2010 and July 2013. Initially, only patients with medical comorbidities that could compromise wound healing were offered the procedure but, subsequently, all our patients are now offered this technique. INTERVENTION: Unlike in traditional techniques where all dermal and subcutaneous tissue and muscle are removed to enable the thinned skin to sit directly on the periosteum, here, in our series, using the WoSR technique, the soft tissue was preserved and only longer abutments (8.5, 9, and 12 mm) were used. MAIN OUTCOME MEASURE: Good early postoperative wound healing, absence of flap necrosis, absence of numbness around the surgical site, and trouble-free follow-up period, with 25 patients encountering no complications. RESULTS: Of the 30 patients, 25 have had no postoperative problems and five had mild inflammation, of which three patients developed intractable pain and underwent soft-tissue reduction. CONCLUSION: The technique WoSR for BAHI surgery seems to be a safe technique with consistently good results, decreasing operating time and patient morbidity and avoiding some of the complications seen in traditional techniques using soft-tissue reduction.

Managing human factors in the assembly of the paediatric bronchoscope.

Foreign body aspiration in children is a life threatening event and prompt bronchoscopy and extraction is essential for their survival. During a recent paediatric airway emergency at Torbay hospital, Devon, the theatre staff were unable to assemble the paediatric bronchoscope. We therefore investigated methods to improve the efficiency and timeliness of the assembly of the paediatric bronchoscope. To assess the current problem we asked ten theatre staff at random to assemble the paediatric bronchoscope. 70% of the staff were not able to assemble the paediatric bronchoscope. A prompt poster was developed as a visual aid to help demonstrate how to assemble the paediatric bronchoscope. Another ten theatre staff were asked to assemble the paediatric bronchoscope. Now all of the staff were able to assemble the paediatric bronchoscope. The prompt poster enabled all the theatre staff tested to correctly assemble the paediatric bronchoscope and the average time taken was reduced. To further develop the service mandatory training sessions have been arranged to help theatre staff remain confident and continue to develop their skills and knowledge.

The Champions League - Improving the quality of in-patient antibiotic prescription in Trauma and Orthopaedics.

A Trust level audit demonstrated that the trauma and orthopaedic department did not reach its own standards in adhering to Trust antibiotic prescribing guidelines. Junior doctors are the main prescribers of antibiotics during inpatient stays. Local policy states that for all inpatients on antibiotics, the start date, duration, and indication for antibiotics must be documented on the drug card. Each patient drug card was reviewed by the department pharmacist and it was recorded whether the documentation was in line with Trust policy. A monthly league table, coined 'The Champions League', was created. It was published monthly and displayed in the doctors' office and other clinical areas to highlight which doctors had or had not adhered to the prescribing guidelines. In August 2012 the monthly audit for the trauma and orthopaedic department included 74 patients. The total number of antibiotic courses prescribed was 28; of these courses only 15 (53.5%) had an indication documented and 15 (53.5%) had a review/stop date documented. In December 2012, after two published league tables, 61 patients were reviewed. A total of 19 antibiotic courses were prescribed; 18 (94.7%) had the indication documented and 16 (84.2%) had the review/stop date documented. The standards of prescribing improved within the department and good prescribing practice became ingrained into each doctor's practice. The league table proved to be a novel tool that helped to raise the profile of antibiotic prescribing and change doctor prescribing habits. It created a competitive spirit within the department which improved morale. Doctors responded positively to feedback if they were not achieving the desirable standards, and enjoyed the challenge of improving the standard of prescribing.

Laryngeal synovial sarcoma: a rare clinical entity.

Introduction. Synovial sarcomas (SS) are aggressive malignant soft tissue tumours that are thought to arise from pluripotent mesenchymal cells. Clinical Report. A 20-year-old male presented with an acute onset of respiratory stridor. Computer tomography scanning confirmed a mass arising from the left supraglottic larynx and an emergency tracheostomy was performed. A diagnosis of biphasic synovial sarcoma was formed. A total laryngectomy and left hemithyroidectomy was performed in conjunction with a left modified radical neck dissection. The patient received adjuvant chemotherapy followed by a course of radiotherapy and remains alive and disease free at 18 months after treatment. Discussion. Prognosis for patients with SS is related to primary tumour extent, grade, and size. The presence of the diagnostic translocation, t(X;18), is being targeted and hopefully will lead to the development of new therapeutics (Guadagnolo et al., 2007). Conclusion. Laryngeal SS remains a rare and poorly understood entity. A multidisciplinary approach to treatment is essential and long-term followup is imperative.