Do rhinology care pathways in primary care influence the quality of referrals to secondary care?

BACKGROUND: Chronic sinusitis is the most common routine presentation for a general ENT surgeon. The 2007 'Primary Care Guidelines: European Position Paper on the Primary Care Diagnosis and Management of Rhinosinusitis and Nasal Polyps' aimed to deliver evidence-based guidelines for the diagnosis and management of rhinosinusitis in specialist and primary care. OBJECTIVE: The aim of this audit was to assess the information provided in the referral letters to the ENT department regarding patients with potential rhinosinusitis, and compare this to the information required for the rhinology care pathways. METHOD: We evaluated one month of referrals to the ENT department. RESULTS: The quality of information in the referral letters was poor. Only 22 per cent of patient referrals included basic information about symptoms, duration and treatment. CONCLUSION: We plan to investigate why general practitioners are not complying with the pathway. In addition, the pathways will be more widely disseminated via the 'Map of Medicine' (an online resource for general practitioners). This should facilitate the receipt of the best evidence-based treatment for patients prior to referral to secondary care.

Audit: patient reported outcomes of extracorporeal septorhinoplasty.

BACKGROUND: Extracorporeal septorhinoplasty (ECS) presents an important option in the surgical correction of the markedly deformed and twisted nose. However, there is a paucity of literature on the qualitative outcomes of ECS. METHODOLOGY: Retrospective telephone and postal questionnaire study of operations performed over 2 years (2008-2009) under the care of a senior rhinologist at two linked hospitals in the United Kingdom. Questionnaires were designed (i) relating to the procedure and (ii) patient perceptions of surgical success, improvements in physical health, psychosocial functioning and social interactions. For succinctness a shortened version of the Glasgow Benefit Inventory was used. RESULTS: Forty-six cases were analysed eight of which were revision cases. Two cases required revision surgery and two minor complications occurred, managed conservatively. The patients had a minimum of two to three follow-ups from seven days to one year. Questionnaire scores suggested high satisfaction in response to surgical success, with notable improvements in physical health (sleep disturbance) and in general health and well-being. Regarding psychosocial functions patients reported feeling either moderately less self-conscious or not self-conscious at all post-surgery. Improvements in social interactions were less well-defined. CONCLUSION: In this audit of cases with significant deformities, ECS appears to confer high levels of satisfaction.

Learning about leadership - A personal account.

PURPOSE: A personal account of learning about leadership. This article introduces the theory of power and influence, and aimed to report especially the personal reflection, emotional intelligence and learning about oneself that occurred on the way. APPROACH: Reading, group discussion and active reflection. Thoughts, reflections and learning were recorded regularly. PRACTICAL IMPLICATIONS: The concept of leadership, influence tactics and emotional intelligence all have implications in workplace relationship management and ultimately leadership qualities. The issues discussed serves as food for thought for others. ORIGINALITY: This is a genuine and very personal learning experience.

Incidence of meningitis secondary to suppurative otitis media in adults.

AIM: Meningitis is the commonest intracranial complication of suppurative otitis media, and carries the risk of death and life-changing morbidity. This study aimed to estimate the risk of an adult in the UK developing otogenic meningitis. METHODS: Adults hospitalised with meningitis in Bristol from 1997 to 2002 were identified retrospectively. Cases confirmed by positive blood culture or cerebrospinal fluid investigation were studied. A case was classified as otogenic if there was coexistent evidence of ear infection. RESULTS: Eighty-seven cases of meningitis were analysed. The overall mortality rate was 5.7 per cent. Acute and chronic suppurative otitis media accounted for 13 and three cases, respectively. The adult population of Bristol at the midpoint of the study was 635,976. CONCLUSION: In this study, the age-adjusted incidence of otogenic meningitis was 0.42 per 100,000 per year.

What is in a name--patients' view of the involvement of 'care practitioners' in their operations.

BACKGROUND: There has been a plethora of new job titles emerging in the NHS. While the term 'nurse practitioner' was fairly well received, and offers a pretty clear indication of the background of the person working, other new titles can be misleading. Since 2003, when the NHS Modernisation Agency proposed its 'Changing Workforce Programme', nurses and other allied health professionals were recruited and trained to perform 'simple operations'. The surgical care practitioner is being developed along with other practitioners. OBJECTIVE: To find out whether patients are able to identify healthcare professionals by their title and what do patients think about a non-medically qualified person carrying out their operations. METHODS: A cross-sectional survey of ENT patients using a questionnaire. MAIN FINDINGS: Titles similar to those of medically qualified professionals--anaesthetic practitioner, consultant nurse and surgical care practitioners--can lead patients to think that they are doctors. Fifty-three per cent of the respondents agreed that not all hospital visits need to be attended by a doctor, but if an operation is needed, 92% of respondents thought it should be carried out by someone who is medically trained. Ninety-four per cent stated that they should be informed if this is not the case. Seventy-nine per cent of the respondents stated that they would rather wait longer to be operated on by a doctor than being operated on earlier by someone who is not medically qualified but trained to perform the operation only. This result is significant, p<0.001). CONCLUSION: Patients do find the different titles confusing, with many preferring a more transparent approach in knowing who their surgeon is. The majority would prefer to wait longer for their operation if this means it is carried out by a doctor.

Myringostapediopexy and myringolenticulopexy in mastoid surgery.

OBJECTIVE: To compare hearing results in patients undergoing myringostapediopexy or myringolenticulopexy in canal wall down mastoidectomy. STUDY DESIGN: Case series of one surgeon. A retrospective review of 83 consecutive mastoid cavity operations for primary cholesteatoma. Only those patients who had undergone either myringostapediopexy or myringolenticulopexy were included. SETTING: District general hospital. PATIENTS: Forty-two procedures were performed in 40 patients. The mean age was 42 years old. The average follow up was 5.9 years. INTERVENTION: Seventeen patients underwent myringolenticulopexy (the incus head was excised, leaving the lenticular process attached to the stapes prior to graft placement) and 25 underwent myringostapediopexy (type III tympanoplasty). MAIN OUTCOME MEASURES: Audiometry three to six months after surgery, and status of mastoid cavity after a minimum follow up of one year. RESULTS: Comparison of post-operative hearing results for the two groups showed a statistically significant hearing advantage for myringolenticulopexy (p = 0.029). In the myringolenticulopexy group, 92 per cent achieved a post-operative air-bone gap of less than 30 dB, compared with 62 per cent in the myringostapediopexy group. The mean post-operative air-bone gaps in the two groups were 17.5 and 24.7 dB, respectively. CONCLUSION: When surgically feasible, the technique of myringolenticulopexy is a useful method of preserving serviceable hearing in single-stage mastoid cavity surgery.

Spontaneous bilateral internal jugular vein thrombosis: a sign of metastasis.

Head and neck swellings are common referrals to the otolaryngology department, with a wide range of aetiologies. Internal jugular vein thrombosis presenting as swelling in the neck is a rare occurrence. The authors report a case of bilateral internal jugular vein thrombosis secondary to malignant lymphadenopathy of unknown origin. The patient presented with a short history of a diffuse swelling in the neck with neck stiffness. Examination revealed palpable cervical and axillary lymphadenopathy. Causes of spontaneous internal jugular vein thrombosis were discussed.