A novel ENT iBook: what do junior doctors think?

Exposure to the specialty of Otolaryngology is limited. It may be consolidated by the use of an iBook as a self-study tool. The purpose of this study was to ascertain the perceptions of junior doctors on the clinical relevance of this novel educational resource. Three focus groups were formed each consisting of five junior doctors (eight female: seven male, median age 27 years). The iBook was found to be clinically relevant to the work of junior doctors, have a clear layout, with adequate interactivity and a good range of integrated multimedia elements.

Exploring medical undergraduates' perceptions of the educational value of a novel ENT iBook: a qualitative study.

Undergraduate otolaryngology exposure is limited. It may be consolidated by the use of an iBook as a self-study tool. Following invitation to participate by email, five focus groups were formed, each consisting of six medical students (18 female, 12 male, median age 23 years). The focus group transcripts were imported to the qualitative data analysis software NVivo (QSR International, UK). The iBook was found to have a clear and consistent presentation, and a focused and user-friendly style, with reasonable interactivity and a good range of well-integrated media elements. It was, overall, perceived to be a valuable educational resource by the medical students.

Oral steroids for the resolution of otitis media with effusion (OME) in children (OSTRICH): study protocol for a randomised controlled trial.

BACKGROUND: Otitis media with effusion (OME) is an accumulation of fluid in the middle ear affecting about 80 % of children by the age of 4 years. While OME usually resolves spontaneously, it can affect speech, behaviour and development. Children with persistent hearing loss associated with OME are usually offered hearing aids or insertion of ventilation tubes through the tympanic membrane. Oral steroids may be a safe and effective treatment for OME, which could be delivered in primary care. Treatment with oral steroids has the potential to benefit large numbers of children and reduce the burden of care on them and on health services. However, previous trials have either been too small with too short a follow-up period, or of too poor quality to give a definite answer. The aim of the Oral Steroids for the Resolution of Otitis Media with Effusion in Children (OSTRICH) trial is to determine if a short course of oral steroids improves the hearing of children with OME in the short and longer term. METHODS/DESIGN: A total of 380 participants (children of 2 to 8 years of age) are recruited from Hospital Ear, Nose and Throat departments in Wales and England. A trained clinician seeks informed consent from parents of children with symptoms for at least 3 months that are attributable to OME and with confirmed bilateral hearing loss at study entry. Participants are randomised to a course of oral steroid or a matched placebo for 1 week. Outcomes include audiometry, tympanometry and otoscopy assessments; symptoms; adverse effects; functional health status; quality of life; resource use; and cost effectiveness. Participants are followed up at 5 weeks, and at 6 and 12 months after the day of randomisation. The primary outcome is audiometry-confirmed satisfactory hearing at 5 weeks. DISCUSSION: An important evidence gap exists regarding the clinical and cost effectiveness of short courses of oral steroid treatment for OME. Identifying an effective, safe, nonsurgical intervention for OME in children for use in primary care would be of great benefit to children, their families and the NHS. ISRCTN: ISRCTN49798431 (Registered 7 December 2012).

Multicentric human papillomavirus-associated head and neck squamous cell carcinoma.

BACKGROUND: The purpose of this study was to present the clinicopathological features of a series of patients with human papillomavirus (HPV)-associated head and neck second primary tumors. METHODS: Patients with HPV-associated head and neck second primary tumors from 3 centers were identified. HPV infection was evaluated using p16 by immunohistochemistry (IHC), high-risk HPV DNA by in situ hybridization (ISH), and HPV genotyping by DNA polymerase chain reaction (PCR) enzyme immunoassay (EIA). RESULTS: Eleven patients were identified: 5 with synchronous and 6 with metachronous HPV-positive second primary tumors, the latter demonstrating a mean time interval of 5 years. There were 13 second primary tumors: 11 oropharyngeal, 1 nasopharyngeal, and 1 floor of the mouth. Nine of 10 genotyped patients harbored HPV-16, and 1 patient had HPV-33 in 3 synchronous tumors. CONCLUSION: HPV-associated second primary tumors may present as synchronous and/or metachronous lesions and can arise outside the oropharynx after prolonged intervals. Further work is necessary to identify patients at risk and to elucidate the mechanisms of HPV-associated head and neck second primary tumors.

Does temperature effect tympanometric evaluation of ear canal volume? A scientific study using an Ear Canal Model.

Tympanometric evaluation is a routine part of the complete otological examination. Although tympanometry when performed in standard conditions is known to accurately and precisely assess ear canal volume, the effects of variation in temperature have not been reported upon. This study examines the effect of temperature on the capability of the tympanometer to accurately evaluate external auditory canal volume in both simple and partially obstructed Ear Canal Models. An Ear Canal Model was designed using simple laboratory equipment including a 5 ml calibrated clinical syringe. This was attached to the sensing probe of a Kamplex tympanometer. Two basic trials were undertaken: (a) evaluation of the effect of temperature on the tympanometer in simple canal volume measurement and (b) assessing canal volume with partial canal occlusion. These studies were conducted at 0, 10, 20 and 30 °C in a Thermotron climatic chamber. 1,400 individual test scenarios were completed over the two arms of the study. At volumes of 1.4 cm(3) or below, tympanometry had a very high level of correlation (Spearman's ρ = 1) with the actual volume present at all tested temperatures except 0 °C. There was no significant relationship between temperature and degree of error in ear canal volume measurement in both simple and partially occluded models. The ability of the Kamplex tympanometer to accurately and precisely assess ear canal volume in this scientific model in both simple and partially occluded scenarios up to a volume of 1.4 cm(3) is not effected by ambient temperature. These findings suggest the Kamplex tympanometer could be used as an effective objective tool in both laboratory and human models of the external auditory canal.

Health costs and consequences: have UK national guidelines had any effect on tonsillectomy rates and hospital admissions for tonsillitis?

Tonsillectomy is a common therapeutic option in the management of recurrent tonsillitis. In 1999, the Scottish Intercollegiate Guidelines Network (SIGN) introduced SIGN 34 outlining appropriate indications for tonsillectomy. Following concerns of increasing hospital admissions for tonsillitis, in 2009 ENT UK suggested that too few tonsillectomies were being undertaken. This study analyses the effect the SIGN guidelines have had on trends in population rates of tonsillectomy and hospital admissions for tonsillitis and peritonsillar abscess in England, Scotland and Wales. A retrospective study was undertaken using the health databases of England, Scotland and Wales between 1999 and 2010. Tonsillectomy, acute tonsillitis and peritonsillar abscess were identified using national classification codes. Changes in rate of tonsillectomy and hospital admissions for tonsillitis and peritonsillar abscess were assessed using a linear regression model. 699,898 tonsillectomies were undertaken in the three national cohorts over the study period. Linear regression analysis suggested that implementation of SIGN 34 significantly reduced the population rate of tonsillectomy in England (p = 0.005) and Wales (p = 0.003) but not in Scotland (p = 0.24), and indicated there had been an increase in hospital admissions for acute tonsillitis in all cohorts (England p = 0.000008, Scotland p = 0.03, Wales p = 0.000005) and peritonsillar abscess in England (p < 0.05) and Wales (p = 0.03). SIGN 34 has reduced tonsillectomy rates in England and Wales but not in Scotland. This finding is associated with increasing hospital admissions for acute tonsillitis in all national cohorts, which may suggest that the current stipulated guidelines miss patients who would benefit from surgical intervention.

The European positional paper on rhinosinusitis and nasal polyps: has the introduction of guidance on the management of sinus disease affected uptake of surgery and acute admissions for sinusitis?

Rhinosinusitis is a common condition with adults experiencing 2-5 episodes per year. The European Positional Paper on Rhinosinusitis and Nasal Polyps (EP3OS) published in 2005 and updated in 2007 provided evidence-based guidelines on the management of sinus disease promoting a conservative approach to treatment. This study examines the effect of EP3OS on sinus surgery uptake and acute admissions for sinusitis in England and Wales. A retrospective study using the national electronic health databases of England (Hospital Episodes Statistics, HES online) and Wales (Patient Episodes Database of Wales, PEDW) was undertaken from 2000 to 2010 using the OPCS-4 codes E12-E17 (sinus surgery) and ICD10 code J01 (acute admission for sinusitis). Data were analysed for effect following the introduction of the EP3OS in 2005 using linear regression and Chi squared analysis. 116,370 sinus procedures and 10,916 acute admissions for sinusitis were made during the study period. No significant decrease in sinus surgery procedures occurred following the introduction of the EP3OS as may have been expected (p > 0.05), although subgroup analysis suggested a significant increase in Wales (p < 0.05). In addition, significant increases in acute admissions for sinusitis were observed following the introduction of EP3OS (p < 0.05). However, subgroup analysis suggested this was not the case in Wales (p > 0.05). The EP3OS appears to have had little impact on the rates of sinus surgery but more conservative approaches to managing of sinus disease may have led to an increase in acute admissions. Further research is required to investigate whether changes in practice were adopted.

Postoperative hemorrhage following adenoidectomy.

OBJECTIVES/HYPOTHESIS: To examine postoperative hemorrhage following adenoidectomy. STUDY DESIGN: Prospective multicenter observational study. METHODS: The Surgical Instrument Surveillance Programme (SISP) was established in 2003 to monitor tonsil and adenoid surgery in all hospitals in Wales. Data were examined between April 1, 2003 and June 30, 2008, for risk factors that may contribute to primary (R1) or secondary (R2) postoperative hemorrhage from the adenoid bed, of a severity sufficient to require a return to the operating room. RESULTS: There were 5,588 procedures included, of which 4,225 included simultaneous tonsillectomy. The study included 2,903 (52%) males with a median age of 5.8 years (interquartile range [IQR], 4.5-7.7 years) and 2,685 (48%) females with a median age of 6.5 years (IQR, 5.0-9.1 years). There were 22 patients (0.4%; confidence interval [CI], 0.2-0.6) who returned to the operating room with a postoperative hemorrhage arising from the adenoid bed. These were exclusively R1 hemorrhage; there were no instances of R2 hemorrhage (0.0%; CI, 0.0-0.1). No specific risk factors for R1 hemorrhage could be identified. There were 38 patients in the adenotonsillectomy group who returned to operating room with a postoperative hemorrhage arising from the tonsil bed (0.5%; CI, 0.3-0.8). R1 was seen in 22 patients (0.5%; CI, 0.3-0.8) and R2 in 16 patients (0.4%; CI, 0.2-0.6). CONCLUSIONS: Adenoidectomy appears to be primarily a procedure performed in childhood. The rate of R1 hemorrhage following adenoidectomy is one in 200 (0.5%) and is similar to the R1 hemorrhage rate for tonsillectomy. R2 hemorrhage following an adenoidectomy appears to be extremely rare. In children, the risk of a serious primary hemorrhage following an adenotonsillectomy is double that of either procedure when performed alone.

Have two UK national guidelines had any effect on grommets day-case utilisation and rate over the last 10 years?

UNLABELLED: Grommets insertion is a common otolaryngological procedure for the treatment of persistent otitis media with effusion. In 2002, the Department of Health (DoH) Day Surgery guidelines stipulated that at least 75% of grommets insertions should be undertaken as day-cases. In 2008, after governmental perception of a higher than necessary grommet insertion rate, the National Institute for Health and Clinical Excellence (NICE) guidelines aimed at reducing inappropriate grommet insertions. This study analyses the effect these national interventions have had on grommets insertion in England and Wales. A retrospective study was undertaken. Data were extracted from the patient episode databases of England (Health Episode Statistics) and Wales (Patient Episode Database of Wales) from 2000 until 2010 using OPCS-4 code D151. Statistical change in practice following the introduction of the interventions was assessed using linear regression. RESULTS: 341,526 and 16,400 grommets insertions were performed in England and Wales, respectively. Linear regression analysis demonstrated that implementation of the Day Surgery guidelines significantly improved day-case rates in both national cohorts (England P < 0.0001, Wales P < 0.0001) and reduced mean waiting times for grommets insertion in both cohorts (England P < 0.05, Wales P < 0.01). Regression analysis also showed that implementation of the NICE guidelines had no effect on the number of grommet insertions in England (P > 0.5) and Wales (P > 0.5). In conclusion, the DoH guidelines have increased grommets day-case provision and reduced waiting times in both England and Wales, whereas the NICE guidelines have not affected overall levels of grommet insertion in either national cohort.

Risk factors for postoperative hemorrhage following tonsillectomy.

OBJECTIVES/HYPOTHESIS: To identify the main risk factors associated with postoperative hemorrhage following tonsillectomy. STUDY DESIGN: Prospective multicenter observational study. METHODS: The Surgical Instrument Surveillance Programme (SISP) was established in 2003 to monitor tonsil and adenoid surgery and the associated complications in all hospitals in Wales. Data were examined between April 1, 2003, and June 30, 2008, by using binary logistic regression, for risk factors that may contribute to primary (R1) or secondary (R2) postoperative hemorrhage of a severity sufficient to require a return to the operating theater. RESULTS: A total of 17,480 procedures were included. Patients aged ≥12 years were 1.5 (1.0-2.1; P < .05) and 3 times (2.2-4.9; P < .0001) more likely to experience R1 and R2 complications, respectively. There were 2.5 times as many females as males aged ≥12 years who underwent tonsillectomy, but males were almost twice as likely to experience R1 (1.4-2.8), P < .0001, or R2 (1.2-2.5), P < .001, postoperative hemorrhage. There was a 1.9-fold increased likelihood of R1 (1.1-3.3), P < .05, with the most junior surgeon, and no relationship with R2. All techniques that used heat had a significantly greater adjusted odds of R2 as compared with cold dissection, with odds ranging from 2.7 (1.5-4.7), P < .001, for dissection plus bipolar diathermy and ties, to 13.0 (5.8-29.1), P < .0001, with coblation when used with other techniques. No additional risk was associated with specified single-use instruments. CONCLUSIONS: Patient age and sex and operative technique were the most significant factors affecting the risk and timing of serious postoperative hemorrhage, with no additional risk associated with the use of specified single-use instruments.

Airflow efficacy of ballpoint pen tubes: a consideration for use in bystander cricothyrotomy.

OBJECTIVE: To examine the suitability of commonly available ballpoint pens as a substitute emergency tracheostomy tube. METHODS: Commonly available ballpoint pens were examined and compared against two standard cricothyroidotomy sets. The pens were evaluated for dimensions, speed of construction of a temporary tracheostomy tube and airway resistance with differing flow rates. RESULTS: Internal diameters of the pens varied considerably. Time taken to construct a temporary tube ranged from 3 to 170 s, and in the majority of pens the airway resistance increased dramatically as the airflow rate increased. CONCLUSION: Contrary to popular belief, the majority of ballpoint pens appear unsuitable for use as a substitute tracheostomy tube. In this study only two pens fulfilled the criteria for use: the Baron retractable ballpoint and the BIC soft feel Jumbo.

Mucin-secreting papillary adenocarcinoma of the hyoid bone: a unique case.

We present a unique case of a mucin-secreting papillary adenocarcinoma of intestinal type which has invaded and completely destroyed the hyoid bone and metastasized to the cervical lymph nodes bilaterally. The tumour is believed to have originated from a malignant thyroglossal duct remnant, and was managed with surgery and radiotherapy. We describe the case and discuss the literature regarding hyoid bone tumours.