Audit of Laparoscopic Cholecystectomy: Impact of Procedure Recording on Clinical Practice.

Recorded videos of laparoscopic surgery can be used to audit surgical practice with a view to improve clinical practice and surgical outcomes. The objective was to audit our own practice by reviewing video recordings of laparoscopic cholecystectomies to improve our dissection in Calot's triangle and to prevent gall bladder perforation. We used recorded videos of laparoscopic cholecystectomy. In this study initially one hundred consecutive videos were reviewed for: a) establishment of critical view of safety, b) optimization of critical view of safety by division of cystic artery before cystic duct, c) perforation of gall bladder and d) use of diathermy for cystic artery. This prospective interventional audit was performed in a Civil Hospital, Karachi and Hamdard University Hospital, Karachi, Pakistan from January 2008 to March 2010. Recommendations were made according to published literature to change the practice in these steps of procedures. These recommendations were implemented in practice and the following 100 videos were reviewed for the same criteria to see the impact on clinical practice. In the first group, critical view of safety was established in 91 patients compared with 99 patients in 2nd group (p=0.009), optimization of view was done in 54 and 83 patients respectively (p<001), perforation occurred in 32 and 19 patients respectively (p=0.035) and use of diathermy for cystic artery, which was the routine, was stopped completely in the 2nd group. Audit of recorded videos of laparoscopic cholecystectomy can be used as an effective tool to improve surgical practice for safer and better outcome.

General practitioners' versus consultants' perspective on indications for paediatric tonsillectomy: current trends.

AIMS: We undertook a study to ascertain what factors general practitioners consider important when referring children for tonsillectomy, and to compare these views with those of consultant ENT surgeons. METHODS: Web-based questionnaire study. RESULTS: A total of 141 general practitioners and 146 consultants responded. Tonsillectomy in children was regarded as a useful operation by 65 per cent of general practitioners and 98 per cent of consultant ENT surgeons. This difference was statistically significant (p < 0.001, chi-square test). In 1994, Donnelly et al. found that 92 per cent of general practitioners considered tonsillectomy in children a useful operation; our results were significantly different (p < 0.001, chi-square test). CONCLUSIONS: There is a good level of awareness and agreement on the currently accepted indications for paediatric tonsillectomy in both groups. However, there were important areas of difference between the two groups with regard to 'glue ear', recurrent ear infections and snoring. Standardised indications for tonsillectomy should be effectively disseminated to general practitioners.

YouTube resources for the otolaryngology trainee.

Contemporary surgical training faces many challenges. However, modern technology, including internet-based resources, provides the trainee with a wealth of materials to complement their traditional teaching. YouTube is an online repository of video clips, and contains many instructional resources of value to the otolaryngology trainee.

A comparison of the incidence of facial palsy following parotidectomy performed by ENT and non-ENT surgeons.

OBJECTIVE: To compare the complication rates of parotidectomy operations on benign histology performed by ENT and non-ENT surgeons. STUDY DESIGN AND SETTING: A seven-year (1994-2000) retrospective case notes review of patients undergoing parotidectomy in a United Kingdom district general hospital was performed. Patients with malignant histology were excluded. PARTICIPANTS: Patients were identified from the hospital computer database. One hundred and fifty-nine patients underwent parotidectomy for both benign and malignant conditions over the seven-year period. One hundred and thirty-seven (86 per cent) patients had parotidectomy for benign conditions and were included in this study. MAIN OUTCOME MEASURES: The presence or absence of facial palsy and other associated complications following parotidectomy surgery in both groups. RESULTS: The temporary facial palsy rates for ENT and non-ENT surgeons were 56 per cent and 57 per cent, respectively. The permanent facial palsy rates for ENT and non-ENT surgeons were 2 per cent and 7 per cent, respectively. Differences in facial palsy were not statistically significant. The difference in other complication rates such as Frey's syndrome, haematoma, salivary fistula, and neuroma were also not statistically significant. CONCLUSION: Our complication rates were comparable with published results. There was no significant difference in the observed rate of post-operative facial nerve palsy and other known complications following parotid surgery performed by ENT and non-ENT surgeons.

Inferior turbinate angiofibroma: an atypical presentation [correction of preservation].

Angiofibromas are nasopharyngeal tumours mostly seen in adolescent males. They usually present with nasal obstruction and epistaxis. They account for less than 0.5% of all head and neck tumours. Extranasopharyngeal angiofibromas although rare, have been reported (Ali et al., 1982). The most common extranasopharyngeal site is the maxillary sinus. We report a case of extranasopharyngeal angiofibroma arising from the inferior turbinate which had an unusual clinical presentation.

Prevalence of hearing impairment in siblings of deaf children.

OBJECTIVE: To assess the prevalence of hearing impairment in siblings of children with profound to total hearing impairment. METHOD: Two hundred and twenty siblings of children at a deaf school in Karachi completed the screening program. This consisted of a questionnaire and pure tone audiometry. RESULTS: One out of three (73 siblings) had a threshold of 25 dB or greater in their better ear. In a population, already aware of hearing loss, we note that only fifteen siblings had a previous audiogram. Although a positive family history is associated with hearing impairment in the siblings, no increase due to consanguineous marriages was noted. CONCLUSION: This assessment has underlined the need to increase public awareness of hearing impairment. It has also exposed the lack of it in families exposed to the condition.

Aggressive sino-nasal non-Hodgkin's lymphoma diagnosed in Nottinghamshire, UK, between 1987 and 1996.

In the 10-year period 1987 to 1996, 24 patients were diagnosed with aggressive non-Hodgkin's lymphoma of the nasal cavities or paranasal sinuses. The disease occurred in a relatively elderly population of median age 72 years (range 42 to 96) with a male predominance (male 15; female nine). The histology on review was mostly of the large B-cell subtype (21 patients); peripheral T-cell subtype (one), anaplastic large cell of T-cell type (one) and T/natural killer cell nasal lymphoma (one). The disease was localized in 20 patients (Stage IEA). The overall survival at 5 years was 40% (95% confidence interval (CI) 19-61); at 10 years it was 33% (95% CI 12-54). The cause-specific survival (excluding deaths from causes other than lymphoma) at 5 years and 10 years was 62% (95% CI 39-86).

Video imaging to assess neuromuscular blockade at the larynx.

UNLABELLED: We describe video imaging as a technique for assessing neuromuscular blockade at the larynx. We sought to determine the stability and reproducibility of this technique and to compare the effect of succinylcholine at the adductor pollicis and the larynx. Ten patients were studied. Anesthesia was induced and maintained with propofol. The recurrent laryngeal nerve was stimulated superficially and movements of the vocal cords were recorded on videotape by using a fiberoptic bronchoscope passed via a laryngeal mask airway. Neuromuscular function was recorded at the adductor pollicis by using a mechanomyograph. Twenty images of the vocal cords were examined repeatedly by one investigator and by ten independent observers. The mean difference between the two sets of observations was 0.86 degrees with a correlation coefficient (r) of 0.997. For 3 min before the administration of relaxant the coefficient of variation in the cord movement during supramaximal stimulation ranged from 1%-4% (median 2.7%). After the administration of succinylcholine 1 mg. kg(-1) the times to loss of T1 at the larynx and hand were 63 +/- 15 s and 63 +/- 12 s respectively. Times to 25% recovery were 215 +/- 36 s at the larynx and 436 +/- 74 s at the hand and times to 75% recovery were 285 +/- 55 s and 525 +/- 85 s respectively. These results indicate that video imaging may be a useful research technique for estimating neuromuscular blockade at the larynx and that the time to onset of succinylcholine at the larynx is similar to that at the hand, whereas the duration of blockade is significantly shorter at the larynx. IMPLICATIONS: Assessment of neuromuscular blockade at the larynx is possible by using a video imaging technique. By using this technique, the time to onset of neuromuscular blockade at the larynx is similar to that at the hand after the administration of succinylcholine; this finding is different from previously published data obtained by using a cuff pressure measurement technique.

Non-Hodgkin's lymphoma of the sinonasal tract.

OBJECTIVES: A review of the presenting features, management, and outcome of extranodal non-Hodgkin's lymphoma (NHL) of the sinonasal tract during a 10-year period in Nottingham, UK. STUDY DESIGN: Twenty-four patients received a diagnosis of extranodal NHL of the nasal cavity, paranasal sinuses, or both, from 1987 to 1996. The patients' data were collected prospectively in the Nottinghamshire Lymphoma Registry. METHODS: All patients' records and their histology were reviewed along with data entered into the Nottinghamshire Lymphoma Registry, noting the patient's age, sex, presenting symptoms and signs, staging, computed tomography findings, histology, treatment, complications, and outcome. RESULTS: The 24 patients with extranodal NHL of the sinonasal tract represent 1.63% of the 1,457 patients with NHL seen in the 10-year period of this study in Nottinghamshire. The median age was 72 years (range, 42-96 y), with a male dominance (male-to-female ratio: 15:9). Most patients presented with nonspecific nasal symptoms such as nasal obstruction and epistaxis. Only one patient had a relapse involving the central nervous system after treatment. All the histology was reviewed and showed a predominance of large B-cell subtype (21 patients). The overall 5-year survival was 40% (95% CI, 19%-61%) and 33% for 10-year (95% CI, 12%-54%). The cause-specific survival at 5 years and 10 years was 62% (95% CI, 39%-86%). CONCLUSIONS: A high degree of suspicion and appropriate use of computed tomography scans and surgical biopsy are the keys to the management of NHL.

Pharyngeal pouch carcinoma: real or imaginary risks?

Pharyngeal pouch or Zenker's diverticulum presents to the otolaryngologist with symptoms of dysphagia. As supported by the published literature, the condition is more frequently seen in Northern Europe, especially the United Kingdom, than elsewhere in the world. The cause of the reported increased incidence in the United Kingdom is not known, but may be dietary. Surgical management is the treatment of choice and is directed at the cricopharyngeus muscle by either an external or an internal approach. There is a real risk of carcinoma or carcinoma in situ developing in a treated or untreated pharyngeal pouch. Excision of the pouch sac is recommended in younger patients, less than 65 years, and in patients who have a large pouch. If endoscopic diverticulotomy is performed, then long-term patient symptom follow-up is to be advocated.

Frey's syndrome following parotidectomy: prevention using a rotation sternocleidomastoid muscle flap.

The benefit of using a sternocleidomastoid flap following parotidectomy to reduce the incidence of symptomatic gustatory sweating (Frey's syndrome) was reviewed. A retrospective study was undertaken to review subjective and objective symptoms of Frey's syndrome in two groups of patients, one of whom had undergone superficial parotidectomy with a sternocleidomastoid flap rotated at the time of surgery and a second group of patients who had undergone a standard superficial parotidectomy. A total of 22 patients, randomly sampled and willing to attend, were evaluated postoperatively, at a median time from surgery of 42 months (range 23-82 months) in the non-flap group and 44 months (range 14-66 months) in the flap group, by Minor's starch iodine test. In the 11 patients who had a sternocleidomastoid flap rotated, two had evidence of gustatory sweating. Of the 11 that had not undergone sternocleidomastoid flap rotation, nine patients showed evidence of gustatory sweating (P < 0.05, chi 2 test). There were two patients in total who had clinical symptoms of Frey's syndrome and both of these had not undergone flap rotation at the time of parotidectomy.

Ultrasonography in the evaluation of neck abscesses in children.

A prospective study evaluating the benefits of preoperative ultrasonography of paediatric neck abscesses is presented. Twenty-three consecutive children who presented with suspected neck abscesses to the Accident and Emergency Department at the Temple Street Children's Hospital between 1990 and 1992 have been evaluated prospectively. On admission, ultrasonography showed a collection of pus in 11 children and these underwent incision and drainage. The other 12 had intravenous antibiotics. Six of these remained pyrexial and had a repeat ultrasound after 72 h revealing pus which was drained. The remaining were managed successfully with medical treatment. In this study there were no negative surgical interventions and we recommend ultrasonography for preoperative evaluation of children with suspected inflammatory neck abscesses.

A prospective study of the psychological effects of rhinoplasty.

Fifty-three consecutive patients referred for rhinoplasty within the National Health Service by their General Practitioner were evaluated prospectively to determine the psychological impact of this procedure. The patients were independently assessed before surgery, and then 1 week and 4 months after the surgery using the Derogatis Stress Profile, a Self-Esteem Inventory, an Introspectiveness Inventory and a range of questions relating to their expectations of the surgery. Photographs were taken at their initial visit and at 4 months after surgery. These were rated at random order by 28 independent lay people. Pre-operatively, the surgeon also documented his objectives and later assessed how well he had achieved them. Surgical intervention had strong effects in improving self-esteem ratings. These effects became more marked from the first post-operative assessment to those at four months making it likely that this is a real effect of surgery.

ENT and general practice: a study of paediatric ENT problems seen in general practice and recommendations for general practitioner training in ENT in Ireland.

A questionnaire survey of 225 general practitioners was carried out to establish the proportion of their workload formed by paediatric ENT problems. Approximately 50% of children seeking medical care from their general practitioners had problems in this area. Infections of the upper respiratory tract and associated organs were the most commonly dealt with complaints. The monthly referral rate by GPs of paediatric patients in their practice to an ENT outpatient clinic was 4.3%. As ENT problems are seen so commonly in general practice it is important that teaching of otolaryngology at undergraduate and postgraduate levels is emphasised. We examined the present teaching structure of ENT in Irish universities and established that the appointment of a professorial unit dramatically improved the extent of the undergraduate curriculum. Non-specialist postgraduate ENT exposure was found to be inadequate and a number of mechanisms to improve postgraduate ENT training for GPs are suggested.

Langerhans' cell histiocytosis: head and neck manifestations in children.

BACKGROUND: Langerhans' cell histiocytosis (LCH) is an uncommon, poorly understood granulomatous disease, characterized by the idiopathic proliferation of Langerhan's cells or their marrow precursors. In 1985, the Philadelphia Work-shop adopted the term "Langerhans' cell histiocytosis" (LCH) to differentiate it from reactive and neoplastic causes of histiocytosis. METHODS: This study includes 73 pediatric patients diagnosed with this condition in Dublin, Ireland, and Nottingham, England, during a 34-year period (1959 to 1993). These patients are reviewed with respect to clinical presentation, difficulty with making a histological diagnosis, their management, and outcome. RESULTS: A total of 49 patients (67%) had head and neck involvement. Bony involvement was the most frequent sign, most frequently located in the skull. There were 11 deaths (15%) in this series, all associated with multisystem disease, and nine of these deaths were in children younger than 2 years of age. CONCLUSIONS: The role of otolaryngologists is important in the early and accurate evaluation, staging, and diagnosis of LCH. It may mimic more common diseases, such as otitis externa, acute mastoiditis, skin rash, gingivitis, or cervical lymphadenopathy. Patients with multisystem disease may be so ill at presentation that the head and neck lesions may be overlooked. The current management of LCH has become increasingly conservative, and in the 1990s, fewer cases are given chemotherapy or radiotherapy. The prognosis is very good for single-system disease and poor for multisystem disseminated disease with early onset.

Day case myringoplasty using tragal perichondrium.

Day surgery has an ever-increasing role to play in otology. In this study of myringoplasty, tragal perichondrial grafts were placed permeatally as a day case procedure in 32 patients. These are compared with a control group, matched for age and for the size of their perforations, in whom temporalis fascia was grafted via an endaural or postaural incision. The success rate was 94% in the perichondrial group as compared with 84% in the control group (no significant difference P > 0.05). Day case myringoplasty produced less morbidity for the patients and a 40% reduction in theatre time as well as the more obvious savings resulting from a shorter hospital stay.