Curved adjustable fibre-optic diode laser in microscopic cholesteatoma surgery: description of use and review of the relevant literature.

OBJECTIVE: The use of lasers in cholesteatoma surgery is common and well accepted. The most commonly used laser fibres are straight and non-adjustable; these have several limitations. This paper describes the use of an alternative laser fibre. METHOD: This 'How I Do It' paper describes and illustrates the use of an alternative curved adjustable fibre-optic diode laser in microscopic cholesteatoma surgery. RESULTS: The curved, adjustable laser fibre allows accurate and atraumatic disease removal when the use of a straight laser fibre may be less effective or accurate. It reduces potential damage to delicate structures without the need for extra drilling or bone removal. CONCLUSION: It is suggested that the curved adjustable laser fibre is superior to the traditional straight fibre for cholesteatoma surgery.

Paediatric obstructive sleep apnoea: is our operative management evidence-based?

BACKGROUND: Despite the plethora of publications on the subject of paediatric obstructive sleep apnoea, there seems to be wide variability in the literature and in practice, regarding recourse to surgery, the operation chosen, the benefits gained and post-operative management. This may reflect a lack of high-level evidence. METHODS: A systematic review of four significant controversies in paediatric ENT was conducted from the available literature: tonsillectomy versus tonsillotomy, focusing on the evidence base for each; anaesthetic considerations in paediatric obstructive sleep apnoea surgery; the objective evidence for the benefits of surgical treatment for obstructive sleep apnoea; and the medical treatment options for residual obstructive sleep apnoea after surgical treatment. RESULTS AND CONCLUSION: There are many gaps in the evidence base for the surgical correction of obstructive sleep apnoea. There is emerging evidence favouring subtotal tonsillectomy. There is continuing uncertainty around the prediction of the level of post-operative care that any individual child might require. The long-term benefit of surgical correction is a particularly fertile ground for further research.

Paediatric obstructive sleep apnoea: can our identification of surgical candidates be evidence-based?

BACKGROUND: Paediatric obstructive sleep apnoea is a common clinical condition managed by most ENT clinicians. However, despite the plethora of publications on the subject, there is wide variability, in the literature and in practice, on key aspects such as diagnostic criteria, the impact of co-morbidities and the indications for surgical correction. METHODS: A systematic review is presented, addressing four key questions from the available literature: (1) what is the evidence base for any definition of paediatric obstructive sleep apnoea?; (2) does it cause serious systemic illness?; (3) what co-morbidities influence the severity of paediatric obstructive sleep apnoea?; and (4) is there a medical answer? RESULTS AND CONCLUSION: There is a considerable lack of evidence regarding most of these fundamental questions. Notably, screening measures show low specificity and can be insensitive to mild obstructive sleep apnoea. There is a surprising lack of clarity in the definition (let alone estimate of severity) of sleep-disordered breathing, relying on what may be arbitrary test thresholds. Areas of potential research might include investigation of the mechanisms through which obstructive sleep apnoea causes co-morbidities, whether neurocognitive, behavioural, metabolic or cardiovascular, and the role of non-surgical management.

The National Institute for Health and Clinical Excellence, and otolaryngology: review of the evidence.

BACKGROUND: The adoption of evidence-based practice is fundamental to good medical care; it ensures that intervention is clinically effective and safe. In a world of limited healthcare resources, consideration of cost-effectiveness must, unfortunately, restrict clinicians' choice. The National Institute for Health and Clinical Excellence has, for over 10 years, developed guidance to achieve a national consensus on best practice. OBJECTIVES: This review describes the Institute's methodology, examines guidance relevant to otolaryngology and presents more recent research to update the evidence.

A re-audit of paediatric ENT services in England and Wales.

OBJECTIVES: ENT has a high paediatric workload. National recommendations for provision of paediatric surgical services are provided by three key documents produced by the Department of Health and Royal Colleges of Surgeons and Anaesthetists. This second cycle audit assesses the current state of paediatric services in ENT departments in England and Wales based on these recommendations and whether progress has been made since the first audit in 2003. METHODS: A hyperlinked web-based questionnaire was e-mailed to ENT consultants in 164 ENT departments. The questionnaire addressed key areas recommended in the guidelines - theatre and anaesthetic provisions, inpatient/outpatients facilities and staff training. The responses were categorised according to hospital type - teaching hospitals, large or small district general hospitals and specialist stand-alone hospitals. RESULTS: An overall response rate of 56% was achieved. Children's ward facilities remained high across all types of hospitals, with most having dedicated paediatric medical cover and specialised staff. There was an improvement in the number of staff qualified to provide paediatric life support. The level of anaesthetic supervision and expertise in theatres improved, as did the overall level of post-operative management. However, the provision of acute pain services remained relatively low. CONCLUSIONS: Overall there has been an improvement in the provision of paediatric surgical services in accordance with the guidelines but there remains variability in some aspects relating to the size of the hospital.

Lymphoma presenting as neck lumps: causes of waiting time target breaches and potential solutions.

OBJECTIVES: This study aimed to assess the speed of referral, diagnosis and treatment of patients with lymphoma presenting with a neck lump, and to identify where delays are occurring that prevent UK national targets from being met. METHOD: The study entailed a retrospective survey of patients presenting with a neck lump secondary to lymphoma between 2006 and 2008 in Gloucestershire, UK. RESULTS: Forty-seven of 54 patients (87 per cent) were seen within 2 weeks of referral. However, the 62-day rule, which covers the time from referral to the initiation of treatment, was met in only 32 of the 54 cases (59 per cent). There were no breaches of the 31-day target, which concerned the time from decision to treat to the initiation of treatment. Subsequent target breaches were due to longer waiting times for radiological and pathological investigations. CONCLUSION: Radiological examinations should be ordered at the first consultation and biopsies performed as soon as possible. Establishing one-stop, rapid access clinics should improve the achievement of a maximum 62-day wait for patients with lymphoma presenting with neck lumps.

The management of otitis externa in UK general practice.

Acute otitis externa is common and provides a heavy workload for general practitioners. We aim to determine the first-line treatment used by general practitioners in the management of otitis externa and subsequent second-line treatment in a hospital ENT clinic. In addition, this study aims to ascertain whether local and national guidelines are being followed appropriately. A prospective observational study on the management of otitis externa in consecutive patients referred to an ENT emergency clinic was undertaken. Data were collected and analysed on symptoms, initial management by general practitioners, findings and treatment in the ENT clinic. A total of 106 patients were studied. The mean duration of symptoms before presentation to clinic was 13 days; 42% of patients received no treatment by their GP prior to referral to the ENT emergency clinic. Only 14% of patients received topical antibiotics alone, whilst 44% received oral antibiotics, either alone or in conjunction with topical antibiotics by their GP. Of the 106 patients, 86% received topical antibiotics in the ENT emergency clinic and oral antibiotics were reserved for those presenting with complicated acute otitis externa. Topical antibiotics are associated with a decrease in disease persistence, whilst oral antibiotics are associated with an increase. However, general practitioners are prescribing oral antibiotics more often than required. There are few regional guidelines and no explicit national guidelines on the management of acute otitis externa for GPs to refer to. We suggest the implementation of national guidelines to aid clinical practice.

A study of blood loss from phlebotomy in renal medical inpatients.

The objective of the study was to assess phlebotomy loss in renal medical in-patients in order to minimise an iatrogenic cause of anaemia. Phlebotomy has been shown to be a significant cause of iatrogenic blood loss in critical care. However, there has been limited research in patients with renal disease, at risk from anaemia. A prospective observational study was conducted of 70 consecutive patients admitted to an acute renal medicine ward in a tertiary care hospital over a period of four months. Inclusion criteria included adult patients with acute or chronic renal failure. Patients actively bleeding were excluded. Blood loss due to phlebotomy was determined from the patient's computerised records. The mean patient age was 61.5 +/- 16.5 years; the mean length of hospital stay was 23.1 +/- 19.8 days. The mean admission Hb was 9.8 +/- 2.0 g dL(-1) and 9.5 +/- 1.5 g dL(-1) on discharge. The total mean blood loss from phlebotomy during hospitalisation was 215.8 +/- 166 mL with a mean weekly blood loss of 55.7 +/- 11.23 mL. Losses were highest in the first week (mean of 76.8 mL), declining in subsequent weeks. Samples were taken for biochemistry (38%), FBC (36%), transfusion (13%) and others (13%). 46% of patients were transfused (mean 4.8 +/- 3.6 units). Blood loss was lower than in previous studies conducted in intensive care and general medicine but clinical staff should be aware of the cumulative blood loss from phlebotomy. Losses should be managed by optimising the frequency and volume of blood drawn for diagnostic laboratory tests.