Defining performance levels in undergraduate otolaryngology education.

OBJECTIVES: This study seeks the opinions of qualified doctors on what they feel medical students should learn about otolaryngology. It aims to identify both the content deemed relevant and the performance levels for medical students in otolaryngology. METHODS: A national survey developed from a content analysis of undergraduate otolaryngology curricula from the UK was undertaken, accompanied by a review of the literature and input from an expert group. Data were collected from a wide range of doctors. RESULTS: Participants felt that graduating students should be able to: recognise, assess and initiate management for common and life-threatening acute conditions; take an appropriate patient history; and perform an appropriate examination for the majority of otolaryngology clinical conditions but manage only a select few. CONCLUSION: This study reports performance levels for otolaryngology topics at an undergraduate level. Participating doctors felt that a higher level of performance should be expected of students treating life-threatening, acute and common otolaryngology conditions.

Balloon Eustachian tuboplasty for Eustachian tube dysfunction: report of long-term outcomes in a UK population.

BACKGROUND: Balloon Eustachian tuboplasty is a surgical management option for Eustachian tube dysfunction; it has shown promising results in studies worldwide, but has had limited uptake in the UK. This study reports long-term outcomes for patients offered balloon Eustachian tuboplasty for chronic dilatory and baro-challenge-induced Eustachian tube dysfunction, and describes practical experience gained from its implementation. METHODS: Balloon Eustachian tuboplasty was conducted in 25 patients (36 ears) with Eustachian tube dysfunction over three years. Information on presenting symptoms and signs, audiometric findings, tympanometry, and Eustachian Tube Dysfunction Questionnaire-7 scores were recorded pre- and post-operatively with a minimum follow up of one year. RESULTS: Sixteen (64 per cent) of the 25 patients demonstrated symptom resolution after balloon Eustachian tuboplasty according to the Eustachian Tube Dysfunction Questionnaire-7. Fourteen (64 per cent) of the 22 patients with a type B or C tympanogram pre-operatively, had a type A trace post-operatively. Fifteen (75 per cent) of 20 patients with pre-operative conductive hearing loss showed improvement post-operatively, and 11 (50 per cent) of 22 patients with pre-operative middle-ear effusion or tympanic membrane retraction showed resolution. CONCLUSION: Balloon Eustachian tuboplasty can improve subjective and objective measures of Eustachian tube dysfunction, and provide longer-term resolution.

Is the use of a bone conduction hearing device on a softband a useful tool in the pre-operative assessment of suitability for other hearing implants?

OBJECTIVE: To assess whether pre-operative assessment with a bone conduction hearing device on a softband is an accurate predictor of performance with one of two transcutaneous hearing implants.Study designCohort study comparing pre-and post-operative speech audiometry using correlation analysis. METHODS: Pre-operative pure tone audiometry and aided half optimum speech recognition thresholds were compared with post-operative aided results for each ear that had undergone implantation. Data were collected prospectively. RESULTS: Full data were available in 24 ears. In 19 out of 24 ears (79 per cent), the difference between pre- and post-operative speech scores was less than 10 dB, demonstrating a good clinical correlation. The Pearson correlation coefficient was calculated at 0.66 (95 per cent confidence interval = 0.357-0.842), indicating a strong statistical correlation. CONCLUSION: Pre-operative softband testing shows good clinical correlation and strong statistical correlation with hearing implant performance. The findings suggest there is value in using the test to predict performance and guide patients' expectations.

Direct measurement of the round window niche dimensions using a 3-dimensional moulding technique--a human cadaveric temporal bone study.

OBJECTIVES: To directly measure the various dimensions of the RWN focusing on the bony overhang and the vertical height between the free margin of the bony overhang and floor of the niche. DESIGN: Laboratory-based anatomical study using formalin-preserved human cadaveric temporal bones. SETTING: Temporal Bone laboratory, Department of Otolaryngology University of Dundee Medical School & Ninewells Hospital, Dundee, UK. PARTICIPANTS: NA. MAIN OUTCOME MEASURES: Three measurements were carried out (i) the depth of the round window niche extending from the free margin of the bony overhang to the fundus; (ii) vertical height from the free margin of the overhang to the floor of the niche (entrance) and (iii) the antero-posterior (AP) dimension of the niche. RESULTS: Based on mould technique, the three dimensions were calculated as follows: mean bony overhang = 2.1 mm (range 1.9-2.4 mm), height of RWN = 2.0 mm (1.8-2.15 mm) and AP length = 4.0 mm (3.3-4.95 mm). CONCLUSIONS: Our data demonstrate that the mean dimension of the bony overhang superior to the RWM is 2.1 mm.

Clinical efficacy of tinnitus retraining therapy and cognitive behavioural therapy in the treatment of subjective tinnitus: a systematic review.

OBJECTIVE: This study aimed to compare the outcomes of two frequently employed interventions for the management of tinnitus: tinnitus retraining therapy and cognitive behavioural therapy. METHOD: A systematic review of literature published up to and including February 2013 was performed. Only randomised control trials and studies involving only human participants were included. RESULTS: Nine high-quality studies evaluating the efficacy of tinnitus retraining therapy and cognitive behavioural therapy were identified. Of these, eight assessed cognitive behavioural therapy relative to a no-treatment control and one compared tinnitus retraining therapy to tinnitus masking therapy. Each study used a variety of standardised and validated questionnaires. Outcome measures were heterogeneous, but both therapies resulted in significant improvements in quality of life scores. Depression scores improved with cognitive behavioural therapy. CONCLUSION: Both cognitive behavioural therapy and tinnitus retraining therapy are effective for tinnitus, with neither therapy being demonstrably superior. Further research using standardised, validated questionnaires is needed so that objective comparisons can be made.

Surgical management of external auditory canal lesions.

BACKGROUND: Lesions arising in the external auditory canal that require surgical excision are uncommon. They are associated with a range of pathologies, including bony abnormalities, infections, benign and malignant neoplasms, and epithelial disorders. METHODS: This paper describes a 10-year personal case series of external auditory canal lesions with chart, imaging and histopathology review. RESULTS: In total, 48 lesions required surgical management, consisting of: 13 bony lesions; 14 infective lesions; 14 neoplasms with 11 histological types (including ceruminous adenoma and the extremely rare cavernous haemangioma); 3 epithelial abnormalities; and 4 other benign lesions. The surgical management is described. CONCLUSION: This study emphasises the diagnostic differences between exostoses and osteomas, and between external auditory canal cholesteatoma and keratosis obturans. It also discusses the management of aural polyps, and highlights the need to excise external auditory canal masses for histology in order to guide subsequent treatment.

Skull base osteomyelitis: current microbiology and management.

INTRODUCTION: Skull base osteomyelitis typically presents in an immunocompromised patient with severe otalgia and otorrhoea. Pseudomonas aeruginosa is the commonest pathogenic micro-organism, and reports of resistance to fluoroquinolones are now emerging, complicating management. We reviewed our experience of this condition, and of the local pathogenic organisms. METHODS: A retrospective review from 2004 to 2011 was performed. Patients were identified by their admission diagnostic code, and computerised records examined. RESULTS: Twenty patients were identified. A facial palsy was present in 12 patients (60 per cent). Blood cultures were uniformly negative, and culture of ear canal granulations was non-diagnostic in 71 per cent of cases. Pseudomonas aeruginosa was isolated in only 10 (50 per cent) cases; one strain was resistant to ciprofloxacin but all were sensitive to ceftazidime. Two cases of fungal skull base osteomyelitis were identified. The mortality rate was 15 per cent. The patients' treatment algorithm is presented. CONCLUSION: Our treatment algorithm reflects the need for multidisciplinary input, early microbial culture of specimens, appropriate imaging, and prolonged and systemic antimicrobial treatment. Resolution of infection must be confirmed by close follow up and imaging.

Epistaxis: a contemporary evidence based approach.

This article provides a contemporary management protocol for adult epistaxis admissions, evidence based where possible, and otherwise based on the authors' own experience.

Quality of life and functional outcomes in the management of early glottic carcinoma: a systematic review of studies comparing radiotherapy and transoral laser microsurgery.

BACKGROUND: Early glottic carcinoma can be managed by radiotherapy and transoral laser microsurgery with similar control and survival rates. The functional and quality of life outcomes of these interventions are therefore important to guide management. OBJECTIVE OF REVIEW: To compare the different treatment modalities for early glottic carcinoma with respect to quality of life, post-treatment voice character and swallowing outcomes. TYPE OF REVIEW: A systematic review of the literature with defined search strategy. SEARCH STRATEGY: Searches of EBM databases, and literature databases using key words: glotti*, laryn*, neoplasm, radiotherapy and laser surgery from 1970 to November 2009. Articles were screened for relevance using pre-determined inclusion and exclusion criteria. EVALUATION METHOD: Articles reviewed by authors and data compiled in tables for analysis. RESULTS: No randomised controlled trials were identified. There were 15 studies reporting vocal outcomes, and perception of voice disability was measured in eight studies; numbers were low in all the papers. Cumulatively, results for 880 patients were included, 448 had trans-oral laser microsurgery and 442 had radiotherapy. For vocal outcomes, 12 studies found no significant difference between radiotherapy and laser surgery, three reported superior outcomes for radiotherapy, whereas for the perception of voice disability, five reported no difference between treatment groups, while the remaining three reported conflicting results. Nine studies reported quality of life outcomes; seven of these reported no difference between the treatment groups in overall scores although some report differences in subsets of questions. CONCLUSIONS: The evidence base to date demonstrates comparable vocal and quality of life outcomes for radiotherapy and transoral laser surgery for early glottic carcinoma. There is a need for consensus on which measures of vocal quality and life satisfaction to be used in research trials to allow comparison between studies.

Hyoid bone fracture identified only with nasal Valsalva manoeuvre.

OBJECTIVE: We present two cases of a hyoid bone fracture identified through careful clinical examination with a Valsalva manoeuvre during nasendoscopy. METHOD: Case reports and review of the literature, with emphasis on technique during nasendoscopy. RESULTS: The first patient had sustained a blow to the neck with a stick, six months prior to presentation with a globus sensation. External examination and standard nasendoscopy were unremarkable. The second patient had been struck across the neck by a wire whilst riding a motorbike at low speed. Endoscopy revealed swelling of the supraglottis. He recovered and was asymptomatic at review one month later. Computed tomography scans on both patients were unremarkable. During nasendoscopy, both patients were asked to forcibly expire with their mouths closed (the so-called nasal Valsalva manoeuvre), and the hyoid bone was seen to swing into view on the side where the first patient complained of symptoms, and in the second case where swelling had been noticed previously. CONCLUSION: We would not ordinarily have reached a diagnosis in these patients, as radiography and examination were otherwise unremarkable. The use of the nasal Valsalva manoeuvre during routine nasendoscopic examination is recommended, as unusual pathology may be demonstrated and the need for direct laryngoscopy under general anaesthesia may, in some instances, be avoided.

The impact of endonasal dacryocystorhinostomy (DCR), on patient health status as assessed by the Glasgow benefit inventory.

OBJECTIVE: To measure the effect of Endonasal DCR on the health status of patients, using a validated outcomes measure, the Glasgow Benefit Inventory. METHOD: Postal questionnaire with telephone follow up of patients undergoing Endonasal DCR in two institutions in Scotland. The same surgical technique is used in both centres. Patients were identified from prospectively collected data on consecutive patients undergoing this procedure. All adult patients, a minimum of twelve months post-intervention, were included. RESULTS: Ninety two of 123 patients (75%) completed the questionnaire, the mean age was 59 years and the sex ratio m:f was 1:1.8. The mean overall GBI for this intervention was + 32.7 (95% confidence intervals 27.8 - 37.6). The patients were grouped according to the indication for intervention: Obstruction of lacrimal system GBI + 32.7 (26.3-37.1), mucoecele + 40.1 (28.7-51.4), dacryocystitis + 19.4 (10.0-28.9). CONCLUSION: The GBI provides a measure of the effect of an ORL intervention on the health of a patient. Endonasal DCR scores highly when compared with a number of other rhinological procedures including rhinoplasty (GBI + 20), endoscopic sinus surgery (GBI + 23), and septal surgery (mean ranges from + 6 to + 24). Endonasal DCR is a successful intervention with demonstrable health benefits to the patient.

Follow up after middle-ear ventilation tube insertion: what is needed and when?

INTRODUCTION: There is a paucity of evidence to guide the post-operative follow up of patients undergoing middle-ear ventilation tube insertion for the first time. This study was conceived to identify current practice at our institution (Ninewells Hospital, Dundee) and to inform subsequent change in our follow-up procedure. METHODS: Two cycles of data collection and analysis were performed. All paediatric patients undergoing ventilation tube insertion for the first time were identified. Patients who had previously undergone ventilation tube insertion or additional procedures such as adenoidectomy or tonsillectomy were excluded. The first data collection period comprised all of the year 2000, and the second 18 months over 2003-2004. A minimum of 20 months' follow up was allowed for. Data regarding clinical findings and audiometry were recorded at each follow-up appointment. RESULTS: We identified a total of 50 patients meeting our criteria for inclusion in the first cohort. There were a total of 156 appointments between surgery and data collection (a mean of 3.12 per child). A total of 113 (72 per cent) appointments lead to no medical intervention. The only statistically significant difference between patients requiring further ventilation tube insertion (n = 10) and those not requiring further treatment during the study period (n = 40) was the average hearing threshold (p < 0.01). These findings prompted a change in the post-operative regime; all patients undergoing ventilation tube insertion were subsequently seen at three months for a pure tone audiogram, and further review depended on clinical and audiometric findings. Records for 84 children were identified and collected for the second cohort, there were a total of 154 appointments (a mean of 1.83 per child). In only 18 appointments (12 per cent) were normal findings and hearing recorded and children given a further review appointment. Sixteen of 29 (55 per cent) children with abnormal clinical findings (otorrhoea, tube blockage or extrusion) required some form of intervention (p < 0.05). Twenty-six had a mean hearing threshold worse than 20 dB at first review. Nineteen (73 per cent) required further intervention of some sort (p < 0.01). CONCLUSIONS: Our study demonstrated that the vast majority of review appointments resulted in no clinical intervention. We therefore question the need for regular follow up in this patient group. Twenty per cent (10 of 50 and 18 of 84) of our patients required further ventilation tube insertion within the study periods. This is consistent with rates reported in the literature. Children with abnormal clinical findings or a mean hearing threshold greater than 20 dB were significantly more likely to require further intervention. We would recommend one post-operative review with audiometry, three months after surgery. At this initial appointment, further review should be offered to those children with poor hearing, early extrusion, blockage or infection, as they are more likely to require further ventilation tube insertion. This strategy is dependent on good links with community primary care providers and easy access to secondary care for further management, should this be required.

The carpal bones: a basic test of medical students' and junior doctors' knowledge of anatomy.

With the changing emphasis of the modern medical school curriculum, many senior doctors and authors are commenting on a decline in anatomical knowledge of trainees. This study was conceived to provide a snapshot of medical students' and junior doctors' knowledge of anatomy. The carpal bones were chosen as a benchmark for anatomical knowledge as they are easily objectively examined and have clinical relevance to junior doctors in a number of disciplines. Twenty five fourth and final year medical students, fifteen pre-registration house officers (PRHOs) and ten senior house officers (SHOs) were recruited and the questionnaires were completed in the presence of one author. Of all participants recruited only fifteen could correctly name all eight carpal bones. Seven of these were SHOs in Surgery or Accident and Emergency (A&E). Seventeen medical students (68%) and nine PRHOs (60%) correctly identified less than five carpal bones. Most SHOs (90%) could name five or more bones; the proportion of PRHOs and medical students correctly naming more than five bones was similar (40% vs 32%). The scaphoid was the most frequently identified bone, with an accuracy of 92%. Only 15 candidates (30%) managed to name the triquetrum. The overall recognition scores obtained by medical students was poor, however the SHO's results were more reassuring. Anatomy teaching should be encouraged in undergraduate and postgraduate training.