Injection medialisation laryngoplasty: an alternative approach for challenging cases.

OBJECTIVE: Conventional injection medialisation laryngoplasty techniques may be compromised by patient-specific factors such as marked kyphosis, an anteriorly positioned larynx or intolerance to nasendoscopy. This paper describes a technique for successful injection medialisation laryngoplasty where conventional methods are precluded, in an 88-year-old man with presbyphonia on a background of Parkinson's disease. METHODS: After induction of general anaesthesia, a transoral introducing needle, shaped by tactile manipulation to match the curvature of a 'C-MAC' intubating video-laryngoscope 'D-blade' attachment, was introduced until visible above the glottis. The implant material was then injected into the paraglottic space as normal until satisfactory medialisation of the vocal fold was achieved. RESULTS: When reviewed in the out-patient clinic four weeks later, the patient's post-operative Voice Handicap Index score fell to 6, from a pre-operative score of 21. CONCLUSION: By utilising commonly available equipment and anaesthetic support to recreate the views and access conventional nasendoscopy and laryngoscopy facilitate, this novel procedure provides a viable and proven alternative in uncommon but challenging cases.

Subglottic cysts: The Great Ormond Street experience in 105 patients.

PURPOSE: The aim of the study was to assess the contemporary presentation and management of subglottic cysts and make recommendations on the treatment of these patients. METHODS: Retrospective case series of 105 patients between October 1999 and November 2017 from a paediatric teaching hospital. RESULTS: Ninety-one percentage (n = 96) had a history of prematurity, with a mean gestation of 27.2 weeks (SD ± 4.1). A history of intubation was found in 99% (n = 104) of cases [median 18 days (range = 1-176)]. Presenting symptoms were: Stridor 57.1%, (n = 60), difficult intubation 14% (n = 15), recurrent croup 11.4% (n = 12), failed extubation 7.6%, (n = 8), hoarseness/weak cry 10.5% (n = 10). Ninety percentage (n = 94) underwent intervention for management of SGCs with 86% (n = 81) treated with cold steel marsupialisation and 14% (n = 13) with CO 2 laser. Recurrent cysts occurred in 56% (n = 53) of cases. Treatment modality did not affect recurrence (p = 0.594 Δ). Sixty-six percentage (n = 69/105) of patients had one or more concurrent airway pathology at MLB. Most frequent was subglottic stenosis 47% (n = 49), with 16% (n = 8) subsequently requiring open reconstructive airway surgery. Mean duration of follow-up was 47.6 months (SD ± 38.3). CONCLUSION: SGC are an uncommon, reversible cause of upper airway obstruction and should be considered in the list of differential diagnoses in patients with a history of prematurity and perinatal intubation, presenting with stridor. While concurrent SGS is common, adequate symptom improvement in such cases may be achieved with SGC removal alone. Management is by surgical marsupialisation. Recurrence and additional airway pathologies are common and may necessitate longer-term treatment in centres with paediatric airway expertise.

Management of pinna haematoma study (MaPHaeS): A multicentre retrospective observational study.

OBJECTIVES: To assess current variation in the management of pinna haematoma (PH) and its effect on outcomes. DESIGN: Multicentre retrospective observational record-based study. SETTING: Eleven hospitals around the UK. PARTICIPANTS: Eighty-three patients above the age of 16 with PH. OUTCOME MEASURES: The primary outcome measure was recurrence rate of PH over a 6-month period post-treatment, assessed by treatment type (scalpel incision vs needle aspiration). Secondary outcome measures assessed the impact of other factors on recurrence, infection and cosmetic complications of PH over a period of 6 months. RESULTS: After adjusting for confounding factors, involvement of the whole ear, and management within an operating theatre were associated with a lower rate of recurrence of pinna haematoma. The drainage technique, suspected aetiology, choice of post-drainage management, grade and specialty of practitioner performing drainage, the use of antibiotic cover and hospital admission did not affect the rate of haematoma recurrence, infection or cosmetic complications. CONCLUSIONS: Where possible PH should be drained in an operating theatre. Multicentre randomized controlled trials are required to further investigate the impact of drainage technique and post-drainage management on outcome.

An alternative approach to primary rhinoplasty using Walsham forceps.

BACKGROUND: The successful execution of lateral osteotomies in rhinoplasty is an important step that can influence the functional and aesthetic outcome of the procedure. OBJECTIVE: This paper describes an alternative method for achieving mobilisation of the nasal bones by careful application of Walsham forceps during primary rhinoplasty.

A validation study on the use of intra-operative video recording as an objective assessment tool for core ENT surgery.

OBJECTIVES: To investigate the reliability and validity of remote scoring a video assessment of a core ENT surgical procedure (myringotomy and grommet insertion) and its suitability as an objective tool for assessing the technical skills of ENT surgeons. DESIGN: Single-blinded (raters) video assessment. SETTING: Tertiary Care University Hospital. PARTICIPANTS: Consultant and trainee [Specialty Registrar (StR) and Core Trainee (CT)] ENT surgeons performing a total of 30 consecutive index procedures. MAIN OUTCOME MEASURES: To determine the construct validity and the reliability of video assessment scoring of myringotomy and grommet insertion by two raters at ENT Consultant level with a subspecialty interest in Otology. To measure the performance (by rating) of participants compared to operative time. RESULTS: A strong correlation between scores by the two blinded raters was demonstrated (ρ = 0.748; P < 0.001). Median scores (/45) for each group were as follows: CT 25.5 (IQR 21.13-31.25), StR 33 (IQR 24.88-35) and Consultant 40 (IQR 35.38-42.63). Kruskal-Wallis test analysis showed statistically significant mean rank scores between the three different levels of experience (H = 12.77, P = 0.002). Multiple group comparisons indicated a significant difference between CT and Consultant groups (P < 0.001) and StR and Consultant groups (P = 0.007). Analysis of the time taken between the experience groups demonstrated a difference (H = 8.689, P = 0.013) although individual intergroup comparisons indicated this was only significant between CT and Consultant groups (P = 0.004). There was a significant negative correlation (ρ = -0.842; P < 0.001) between time taken for procedure and score achieved. CONCLUSIONS: Video assessment of myringotomy and ventilation tube insertion may represent a valid, feasible tool for use in summative and formative assessments of trainee ENT surgeons. Remote scoring of assessment procedures minimises bias and enables blinding of raters. ENT is well positioned to benefit from video assessment due to the high number of surgical procedures within the specialty that are performed utilising digital technology.

Obesity does not accelerate the decline in glomerular filtration rate associated with advancing age.

Obesity has been suggested as a risk factor for chronic kidney disease. However, it has also been suggested that the association between obesity and impaired glomerular filtration rate (GFR) arises from the invalid use of body surface area (BSA) for scaling. This study assesses the effect of obesity on GFR by comparing the age-dependent decline in obese (body mass index (BMI) >30 kg/m(2); n=149) and non-obese patients (n=589), aged >30 years, referred for measurement of GFR (Cr-51-EDTA and three blood samples). GFR was scaled to a BSA of 1.73 m(2) (GFR/BSA) and extracellular fluid volume of 13 l (GFR/ECV), both corrected for the one-compartment assumption. When non-obese patients were categorized into 10-year age brackets (from 31 to >70), GFR/BSA and GFR/ECV declined from 92 ml per min per 1.73 m(2) and 95 ml per min per 13 l, respectively, at 31-40 years to 58 and 59 at >70. The declines in obese patients were similar with corresponding values of 88 ml per min per 1.73 m(2) and 97 ml per min per 13 l at 31-40 and 57 and 59 at >70 years. Linear regression analysis of non-categorized data from age 40 years showed rates of decline slightly slower in the obese (0.82 vs 0.95 ml per min per 1.73 m(2) per year and 0.87 vs 1.02 ml per min per 13 l per year). No effect of obesity on renal function was shown. Scaling to BSA did not distort the results.