Comparison of clinical estimations and radiological measurements in the context of paediatric cervical masses: How accurate are we?

OBJECTIVES: Cervical masses represent a common presentation to the paediatric ENT outpatient clinic. Despite their high prevalence, few represent an underlying malignant pathology. Currently, there is no universally accepted algorithm for management of such cases in the United Kingdom. Local guidance often centres around clinical interpretation of size when determining the need for investigation. With such emphasis placed on size, the authors sought to investigate the accuracy of physician palpation and in turn explore the validity of common referral pathways. METHODS: A retrospective methodology was used to address the research objective. All paediatric ultrasound scans conducted during a 24-month period were reviewed to compare the clinical and radiological assessments of diameter. A 2 tailed paired student's t-test was selected to evaluate the differences between the two measurements and ultimately assess clinician accuracy. RESULTS: 753 paediatric cervical ultrasound scans were conducted during the 2-year period. Initial analysis identified three discrete ultrasonographically diagnostic groups: lymph nodes (n = 532), non-lymph node masses (n = 162) and normal anatomy (n = 59). Further analysis of clinical estimation and radiological measurement demonstrated a statistically significant difference (p < 0.02) for the lymph-node group. A statistically significant difference was not demonstrated within the non-lymph node group (p = 0.66). When clinician assessment resulted in a value outside of what was considered accurate, lymph node sizes were predominantly overestimated (62/91, 68%). Conversely, non-lymph node masses where the clinical measurement was not within 5 mm of the ultrasound measurement were more commonly underestimated in size (11/45, 55%) but this was not statistically significant. CONCLUSIONS: Our study demonstrates a statistically significant tendency for clinicians to overestimate paediatric cervical lymphadenopathy. Calliper measurement may further improve accuracy of assessment.

Academic ability and teamworking in medical students.

BACKGROUND: Teamworking is an essential skill for a doctor to develop in order to work effectively, and is required in the UK as part of the General Medical Council (GMC) Good Medical Practice guidance. Assessment of teamwork may be difficult, however, with medical school assessments being more commonly focused on knowledge and individual skills. We aim to explore the link between academic ability as measured at final medical examinations and teamworking. METHODS: All final-year medical students were asked to attend a simulation session in an immersive 22-bed simulated ward, which used a combination of patient simulators and high-fidelity manikin simulators, with nursing and telephone support. Students were split into separate groups stratified by performance in final-year assessments or in groups with mixed performance. Students were observed in real time by faculty staff and assessed with the individual Teamwork Observation and Feedback Tool (iTOFT), around which the debriefing was centred. Assessment of teamwork may be difficult RESULTS: The performance of 119 students in simulation was assessed, and groups with a mix of academic performance showed significantly greater teamworking ability as measured with the iTOFT as compared with those stratified by performance (p = 0.045). Final assessment at medical school was shown to be a poor predictor of teamworking ability: those who performed best at assessment seemed to underperform in teamworking. DISCUSSION: The simulated-ward learning activity received positive feedback, although the mix of patient simulators and high-fidelity manikins proved a challenge to some students. Medical school assessments appear to be inadequate in the assessment of teamworking ability, with change needed in future to ensure that this and other non-technical skills are assessed.

A hairy situation.

A 2-day-old neonate was transferred to a specialist paediatric otolaryngology centre with stridor at rest, feeding difficulties and an apparent mass in the oropharynx. The newborn displayed evidence of respiratory distress, however, she remained self-ventilating. MRI highlighted a fat-containing lesion in the postnasal space with no intracranial extension. A CT scan under general anaesthesia showed no underlying bony abnormality, and hence an examination of the nasopharynx, oropharynx and microlaryngoscopy and bronchoscopy were performed. The macroscopically hairy lesion arising from the superior aspect of the soft palate was resected. Histology displayed a benign growth measuring 28×17×12 mm in keeping with a hairy polyp. This is one of very few cases, to the best of our knowledge, in which a hairy polyp (bigerminal choristomas) has resulted in stridor in the first few days of life. Nasal masses in neonates, although a rare phenomenon, remain clinically important as they are obligate nasal breathers.

An unusual cause of stridor in an adult: mediastinal foregut duplication cyst.

We present a case of unusual presentation of stridor in an adult man who was identified to have a sudden expansion of a foregut duplication cyst in the mediastinum. This resulted in superior vena caval obstruction and subsequent airway compromise. Following resuscitation, the cyst was surgically removed via a thoracotomy which confirmed the diagnosis and provided definitive management. Foregut duplication cysts are an unusual cause of stridor in adults, with only five cases ever documented worldwide in the literature, presenting in such a manner. This case is a reminder of the importance of thorough clinical examination, the benefits of radiology as an indispensible adjunct and essential role of the multidisciplinary team.

Laryngotracheal anomalies in children with syndromic craniosynostosis undergoing tracheostomy.

Children with syndromic craniosynostosis may present with airway anomalies. We reviewed a cohort of such individuals who underwent tracheostomy at the Great Ormond Street Hospital for Children (London, UK) between 1999 and 2012 from a prospectively collated database. A case note review was undertaken in 11 patients. We evaluated the indication for tracheostomy in these children and the presence of laryngotracheal anomalies. The most common indication for tracheostomy was upper airway obstruction refractory to medical and first-line surgical management. Laryngotracheal anomalies were detected both at diagnostic microlaryngoscopy and bronchoscopy and at the time of tracheostomy. The commonest anomaly was a tracheal cartilaginous sleeve, but we also describe the figure-of-eight trachea that, to the best of our knowledge, has not been described before in this group of patients. A mutation of a fibroblast growth factor gene was found in 71% of our patients with a laryngotracheal anomaly. We present the largest cohort of children with syndromic craniosynostosis and confirmed anatomical anomalies of the airway and uniquely describe the figure-of-eight appearance of the trachea. These findings highlight the importance of thorough airway evaluation and the special care needed in airway management for children with syndromic craniosynostosis.

Nasopharyngeal tuberculosis presenting with auditory symptoms.

We present an unusual case of a 54-year-old Chinese lady presenting to the ears, nose and throat clinic after family members noticed that her hearing had progressively deteriorated over the preceding weeks. She also complained of tinnitus. Examination of the ears, nose and throat was unremarkable. Flexible nasoendoscopy demonstrated swelling in the postnasal space, which, following biopsy, was shown to be pathognomonic of tuberculosis. This was successfully treated with multidisciplinary input and the patient made a complete recovery.

Foreign body inhalation: a case of mistaken identity?

Inhalation and ingestion of foreign bodies is most common in pre-school children. In recent years, children have been increasingly exposed to electronic technology containing button batteries. These may be potentially inhaled or ingested. We present the case of a 4-year-old girl who presented with a choking episode and presumed inhalation of a button battery. Her chest radiograph demonstrated a potential point of confusion, with the presumed tracheal foreign body actually representing a patent ductus arteriosus coil. The true foreign body is visible in the stomach. If there is suspicion that a child has ingested or inhaled a button battery, the key stages of assessment are an accurate history and radiological investigation. This allows a prompt diagnosis so that effective intervention can be planned to avoid serious potential complications.

A strategy to overcome the radiology lottery in the staging of head and neck cancer: an aid to attaining the 30-day rule.

INTRODUCTION: Rapid access to radiological services is essential, if the British Association of Otolaryngologists - Head and Neck Surgeons Minimum Temporal Standards are to be met in the management of head and neck cancer patients. This study assesses a new initiative whereby the multidisciplinary team prioritises allocated imaging appointments rather than using the traditional radiological triage system. PATIENTS AND METHODS: This study was a prospective audit of all patients referred over a 3-month period with suspected head and neck cancer. The main outcome measures were: (i) median interval in days from general practitioner (GP) referral to staging scan; and (ii) median interval in days from first clinic appointment to staging scan. RESULTS: The new multidisciplinary team booking system led to a statistically significant reduction in the 'request-to-scan time' (from 12 days to 5 days). The time from 'GP to scan' also improved. CONCLUSIONS: This new multidisciplinary team-led booking system, could, in the future, speed up access to radiology services for head and neck cancer patients, allowing earlier definitive treatment.

Refractory choanal atresia: what makes a child susceptible? The great Ormond Street Hospital experience.

OBJECTIVE: An outcome analysis of factors that predispose patients to require multiple surgical procedures for choanal atresia repair. DESIGN: Retrospective case note review of choanal atresia patients identified from a prospectively collected database at Great Ormond Street Hospital for Children, London, between 1992 and 2005. SETTING: Specialist centre in pediatric otolaryngology. METHODS: All patients underwent atresia correction by a transnasal approach under endoscopic guidance using a 120 degrees Hopkins rod telescope to visualize the posterior choanae from the nasopharynx. The atretic plate was first perforated using urethral sounds. The posterior choanal opening was subsequently enlarged using the microdebrider drill. Portex endotracheal tubes were used as stents in selected cases. RESULTS: Twenty children (9 male, 11 female) were identified who underwent multiple surgical procedures for restenosis following choanal atresia repair during the study period. The number of procedures per patient ranged from 6 to 42. Approximately half of the patients had other associated major anomalies. CONCLUSIONS: Following primary endoscopic transnasal repair, 9.8% of the patients were considered to have refractory choanal atresia, requiring six or more surgical procedures. Male gender, bilateral disease, associated congenital anomalies, low birth weight, and small stent size are potential risk factors for restenosis of choanal atresia. There was no obvious relationship between the duration of stent placement and restenosis.

Tracheal cartilaginous sleeve with cricoid cartilage involvement in Pfeiffer syndrome.

Pfeiffer syndrome is one of a group of craniosynostosis syndromes in which rare tracheal anomalies have been described. This group of patients have a poor prognosis, and mortality can be related to airway complications and respiratory distress. We report a case of type II Pfeiffer syndrome with tracheal cartilaginous sleeve and cricoid cartilage involvement. We discuss our strategy for the management of the airway of this patient.