Improving correspondence to general practitioners regarding patients attending the ENT emergency clinic: a regional general practitioner survey and audit.

INTRODUCTION: The ENT emergency clinic provides an important out-patient service; however, often, no correspondence is sent to the general practitioner. AIM: To conduct a general practitioner questionnaire audit in order to assess whether a standardised, computerised clinic letter template could improve communication between the ENT emergency clinic and patients' general practitioners. STANDARD: All ENT emergency clinic patients should have a summary letter sent to their general practitioner. METHODS: One hundred general practitioner questionnaires were enclosed with the first 100 ENT emergency clinic template letters sent to patients' general practitioners. RESULTS: Seventy-two general practitioners responded (72 per cent). Of these respondents, only 7 per cent had previously received regular correspondence from the ENT emergency clinic before the introduction of the computerised letter template. Following its implementation, such a letter was sent to 100 per cent of the clinic patients' general practitioners. Ninety-seven per cent of the general practitioners valued the template letter, with a mean satisfaction score of 8.4 on a 10-point scale. Eighty-six per cent of the general practitioners stated that they would not prefer a dictated letter. CONCLUSION: The introduction of a simple, computerised clinic letter template improves communication with ENT emergency clinic patients' general practitioners.

What causes acute otitis externa?

External otitis is an extremely common condition and can affect between five to twenty per cent of the patients attending ENT clinics (Hawke et al., 1984). Its precise pathogenesis remains unclear, despite several aetiological classifications in the literature. The aim of this study was to investigate the relationship between infection, water exposure and trauma and the development of acute otitis externa. The study comprised 100 patients with their first attack of otitis externa and 150 age and sex matched controls. In only 40 per cent of cases could a primary microbiological cause be found. There was no significant statistical difference found between the two groups regarding the use of agents capable of traumatizing the external canal. Regular swimming, showering and hair washing were significantly more common in patients with acute otitis externa. Allergic disorders were nearly three times more common in the external otitis group suggesting a possible immunological aetiology.

Anatomy of the temporalis fascia.

The anatomy of the different layers of the temporalis fascia is reviewed. The superficial and deep layers of the temporalis fascia have been studied by light microscopy to assess any histological difference between the two. We have also assessed the physical characteristics of the different layers by measuring their Young's modulus in the wet and dry states. Anatomically the superficial layer is part of the epicranial aponeurosis and thus covers nearly the entire lateral aspect of the skull. The deep temporal fascial layer covers exactly the temporalis muscle and measures 10 x 12 cm. The fascial layers have a separate arterial and venous supply enabling them to be used as a homograft, a rotation flap or free microvascular flap. Histologically there is no difference between the two layers. A study of the physical characteristics of the two fascial layers using Young's modulus revealed no significant difference in elasticity between the two. The most significant factor affecting the elasticity was the state of hydration of the fascia.

Blood transfusion and laryngeal cancer.

Evidence exists to suggest a detrimental effect of blood transfusion on survival after resection for malignant disease. Immune suppression due to transfusion has been implicated, though this remains unproven. We have conducted a retrospective study of 69 patients (38 transfused, 31 not transfused) with squamous carcinoma of the larynx to assess the effect of blood transfusion on survival after laryngectomy. Patients were compared for age, sex, smoking habit, tumour site and stage, grade of operating surgeon, preoperative haemoglobin, tumour nucleolar organizer region status, and operation time. The minimum follow-up was 5 years. In the transfused group 21/38 died as a result of their malignant disease and only 4/31 in the untransfused group. This difference was highly significant (P less than 0.001, chi-squared test) and using a multivariate analysis the only variable associated with a decreased survival time was whether a blood transfusion had been received. We conclude that peri-operative blood transfusion is associated with decreased survival after laryngectomy. However, whether this association is causal remains unproven.

Metastatic meningioma in the neck.

Although meningiomas represent 15 per cent of tumours of the central nervous system, they rarely metastasize. A case is presented in which metastasis to a cervical lymph node occurred, together with local recurrence, nine years after initial diagnosis and treatment. This case serves to illustrate that malignant meningioma is a rare cause of a neck mass.

The effectiveness of double-gloving in otolaryngology.

Thirty-four sets of consecutively used double gloves (68 pairs) used by otolaryngologists and their assistants in operations known to have a high risk of glove punctures were studied. The perforation rates for the outer and inner layers were 35.3 and 8.8% respectively, indicating that a second set of gloves substantially improves the likelihood of maintaining an intact barrier between medical staff and patient.

The relationship of peak inspiratory airflow to subjective airflow in the nose.

A prospective study of 145 patients presenting for nasal surgery was designed to examine the relationship of peak nasal inspiratory airflow (PNIF) to subjective nasal airway patency (SNA). Patients admitted for surgery filled in a self-assessment Questionnaire and PNIF measurements were taken. Six weeks post surgery the procedure was repeated. The patients were divided into four operative groups and the results analysed accordingly. Improvement in SNA was noted in 80-96% of patients and PNIF improved in 60-83%. However, PNIF decreased in 17-40% of patients who felt they were improved. Statistical analysis using Spearman's Rank Correlation test showed no correlation between SNA and PNIF. Despite the well recognized problems of assessing subjective sensation of nasal airflow, we feel this study casts doubt on the usefulness of PNIF in routine clinical practice.

Is routine histological examination of nasal polyps justified?

This study aims to assess the indications for histological examination of polypoid lesions removed from the nose. To achieve this we have performed a national survey of consultant ENT surgeons and reviewed 2866 nasal polypectomy operations. The operations were performed between 1982 and 1988 in the Radcliffe Infirmary, Oxford and the Freeman Hospital, Newcastle. One hundred and fifty questionnaires were sent to randomly selected ENT consultants in the United Kingdom. One hundred and seventeen were returned completed (return rate 78%). The questionnaire asked whether or not the surgeon sent all polyps for examination and, if not, what his indications were for so doing. A retrospective review of all nasal polypectomy operations at the two hospitals was performed. The questionnaire revealed that 38% of the surgeons who replied sent all nasal polyps for examination and 62% did not. The commonest indications for requesting histology were unilateral polyps, abnormal appearance and a history of bleeding. The review of polypectomies showed that 74% of cases in Oxford were examined histologically and 33% in Newcastle. Two per cent of polyps were tumours, of which half were malignant. There were no cases in this study in which unsuspected malignancy was found. All cases of nasal tumours, benign or malignant, were diagnosed clinically either in the Outpatient clinic or in the operating theatre. The results of this survey suggest that it is unnecessary to send all nasal polyps for histological examination.

The fellowship examination in otolaryngology.

A questionnaire was sent to 26 successful candidates at the Royal College of Surgeons of London final fellowship examination in Otolaryngology. Twenty were returned complete. An audit of the surgical training and exam preparation of the candidates is presented. All candidates worked in teaching hospitals at the time of passing the exam and most received tuition from senior registrars. All candidates worked in the Midlands or South of the country. Fourteen of the 20 possessed another surgical fellowship. The average time spent in ENT was 29 months and in training outside ENT was 21 months.

Surgical glove perforation rates in otolaryngology.

Nine-hundred and eleven pairs of surgical gloves used by Ear, Nose and Throat surgeons and their scrub nurses were tested for perforations over a 6-week period. We studied the perforation rate for different surgical procedures and found the average rate to be 4.8%. The rates varied from endoscopy with a perforation rate of zero to major head and neck resections with a rate of 28.5%.

Pharyngeal paralysis due to botulinum toxin injection.

Botulinum toxin injection is now recognized as an effective treatment for spasmodic torticollis. Complications of this increasingly popular method of treatment include mild and transient dysphagia, with or without dysphonia, lasting up to four weeks. Two cases of paralysis of vocal cord contralateral to the injected sternomastoid have also been reported. A case of severe dysphagia lasting six weeks associated with ipsilateral vocal cord palsy following botulinum toxin injection is presented. The probable mechanism for these complications is discussed.

Eyelid necrosis complicating acute maxillary sinusitis.

Orbital cellulitis is a well recognized complication of paranasal sinusitis. Fearon et al. (1979) reviewed 6,770 cases of sinusitis, of which only 159 had orbital cellulitis. We report a case in which orbital cellulitis progressed to necrosis of the eyelids. This was treated by desloughing and split skin grafting.

A case of jaw locking.

An unusual case of symptomatic enlargement of the hyoid bone is reported. The patient's main complaint was of pain on swallowing and opening of the jaw. Partial excision of the greater cornu of the hyoid on each side, resulted in a complete remission of the symptoms.