Improving the Management of Post-Operative Hypocalcaemia in Thyroid Surgery.

Hypocalcaemia is a frequent, and potentially dangerous complication of total thyroidectomy occurring secondary to devascularisation of the parathyroid glands. This quality improvement (QI) project was undertaken in a large Ear, Nose and Throat (ENT) department in the East of England over a one year period. The project aimed to improve postoperative guideline compliance by optimising the recognition and management of patients at risk of hypocalcaemia. This process focussed on improving parathyroid hormone (PTH) and calcium blood testing, prophylactic calcium prescribing and the subsequent monitoring and management of hypocalcaemia. A baseline audit was conducted to determine the initial guideline compliance. The QI process subsequently involved the introduction of a new intraoperative PTH pathway and the amendment of trust guidelines. In addition, there was a focus on improving clinician awareness of guidelines, junior doctor education, communication between operating surgeons and junior doctors and the optimisation of patient handover. The project saw a significant improvement in the monitoring of hypocalcaemia (from 22.2% to 83.3% for patients with an intermediate risk of hypocalcaemia) and in the prescribing of prophylactic calcium supplements from 7.5% to 43.5%. The measurement of PTH at four hours improved from 42.5% to 52.2%. By optimising postoperative care, this QI project improved patient safety as well as impacting on the duration, and overall cost, of inpatient stay.

Office-based transnasal esophagoscopy biopsies for histological diagnosis of head and neck patients.

OBJECTIVES/HYPOTHESIS: To present yield of transnasal esophagoscopy (TNE) biopsies of upper aerodigestive tract (UADT) lesions and define the role of TNE as a safe alternative to rigid endoscopy. STUDY DESIGN: Retrospective case series. METHODS: All patients who underwent TNE-guided biopsies attempted over a 2-year period were included. Patients were identified using coding records and outpatient diaries. Demographic data were recorded as well as the histological diagnosis and additional histological diagnostic procedures. RESULTS: During the observation period, 134 TNE-guided procedures were attempted. The procedure could not be completed in 19 patients. There were 102/115 (89%) patients who did not require further interventions for histological diagnosis of the tumor. The most common biopsied area was the larynx (53), followed by the tongue base (29). The most common malignancy was invasive squamous cell carcinoma in 42/115 (36.5%). CONCLUSIONS: The work presented in this article strongly suggests that TNE-guided biopsy is a valuable diagnostic tool for patients suspected of having carcinoma of the UADT. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:2721-2726, 2019.

Collet-Sicard syndrome as a result of unilateral carotid artery dissection.

A 52-year-old man presented with sudden onset symptoms of multiple cranial nerve palsies (IX, X and XII) following a 10-day history of coryzal illness. Follow-up examination established atrophy of the trapezius suggesting additional involvement of the spinal accessory nerve (XI). Further investigation including CT and MRI demonstrated dissection of the internal carotid artery. Given the involvement of cranial nerves IX to XII, and that the patient demonstrated no signs of Horner's syndrome, we suggested that this patient fits the description of Collet-Sicard syndrome. On vascular opinion the carotid dissection was expected to resolve without intervention but the patient was prescribed aspirin for thromboprophylaxis. Gradual resolution of neurological symptoms was observed at 8-week follow-up.

Acute unilateral facial nerve palsy.

Mrs PS, 78 years of age, presented with acute left-sided otalgia, ear swelling and subsequent unilateral facial paralysis (Figure 1). She denied any otorrhoea or hearing loss. Past medical history relevant to the presenting complaint included: * Bell palsy diagnosed 20 years ago with no residual effect * biopsy confirmed benign parotid lump (diagnosed 3 years previously). Histopathology revealed a pleomorphic adenoma. Mrs PS declined surgical intervention at the time * chicken pox as a child * normal fasting blood glucose 1 month previously and no known immune compromise. Examination revealed yellow crusts and small vesicles on the external acoustic meatus (Figure 2). A 10 mm well defined firm and nontender nodule was palpable at the ramus of the mandible.

Are trainees being adequately taught myringoplasty? A prospective study of Eastern Deanery otolaryngology trainees' surgical experience.

Reviewing surgical training is an important function of a modern ENT unit, even more so following recent reform of postgraduate medical training in the UK. We have developed a tool to review otology training of Eastern Deanery trainees by constructing a middle ear surgery data base and use a commonly performed procedure, myringoplasty, to illustrate its function. Three hundred and ninety-three myringoplasty operations were identified between March 2002 and March 2006, of which 307 were included in this study as having had a myringoplasty alone uncomplicated by another middle ear procedure. Perforation closure was successful in 83% of these cases with 90% of patients experiencing a beneficial outcome regardless of supervision level. Trainees at all stages of training are being exposed to myringoplasty with an adequate de-escalation of supervision. Myringoplasty outcomes are independent of seniority, if appropriately supervised, implying that otology training in the Eastern Deanery is appropriate.

Management of patients with epistaxis by general practitioners: impact of otolaryngology experience on their practice.

This study aims to assess the management of patients with epistaxis by general practitioners (GPs) and to show whether previous experience as a junior doctor in ear, nose and throat (ENT) surgery influences their practice. A questionnaire was sent together with self-addressed reply envelopes to a random sample of 1,000 GPs. Four hundred and twenty eight GPs replied (43% response rate). Ninety-eight percent GPs see less than five epistaxis per week. Eighty-six percent GPs seek a specialist opinion for approximately one in four patients seen. Fifty percent GPs would arrange investigations. There was a wide variation in these and the first aid advice given. Fifteen percent GPs had previous experience in ENT. The only significant difference in the management of epistaxis with these GPs is that they were 2x more likely to cauterize a nose with silver nitrate (P=0.002). There is no general consensus on the management of epistaxis by GPs and despite previous experiences in the specialty as a junior doctor, this fails to have a significant impact on the day to day management of epistaxis.

Maxillary frontal process fracture complicating acute dacryocystorhinostomy.

A case of maxillary frontal process fracture complicating an acute endonasal dacryocystorhinostomy is presented. The management of this previously unrecorded complication and the corrective procedure that resulted in both patient and clinician satisfaction is described.

Do otolaryngology out-patients use the internet prior to attending their appointment?

The Internet has become a very important source of health information. We wanted to determine otolaryngology patients' access to, and use of, the Internet as a medical information resource, to identify factors that make patients more likely to use it, and to determine how useful they find this information. A questionnaire survey was completed by patients while waiting for their consultation in the out-patient department of the Royal National Throat Nose and Ear Hospital in London. Five hundred and thirty-five questionnaires were completed. Sixty-four per cent (344/535) reported having access to the Web. Of the 344 with access, 62 (18 per cent) had searched the Web for medical information prior to their consultation. Higher education (p <0.001) and age between 18 and 40 years (p = 0.001) correlated significantly with higher Internet use. Ninety-five per cent planned to use the Internet again. Approximately one out of five otolaryngology out-patients with Internet access reported having obtained medical information from the Web before their consultation. The majority found it helpful to some degree and were planning to use it again. As clinicians we should be aware of this use and the onus should be on ourselves to review these sites in order to guide our patients to sources of reliable and helpful medical information on the Internet.