Audit on the Quality of Operation Notes in Otolaryngology: Based on Electronic Template.

The operative note is a vital document in the treatment and safety of patients. Detailed recording of operation notes can be quite helpful in research, audit and medico-legal problems. This quality improvement programme was conducted to assess the quality of documentation on an electronic template in comparison to the Royal College of Surgeons (RCS) guidelines. The electronic template used for recording operation notes was compared with RCS guidelines for completeness. A retrospective review of operation notes for all the operations performed by ENT over 1-month period was done. The deficiencies were shared with the department during monthly quality-improvement meetings. A second cycle was carried out in the month of September. The electronic template that is being used in our hospital matches completely with the RCS recommendation. A total of 90 operative records were analysed in the initial audit. The Compliance was 100% in all parameters except five. In the second cycle of audit, compliance was found to be 100% across all parameters, except one-showing considerable improvement. Electronic templates offer easy recording of operation notes without the help of aide memoire, despite which deficiencies do occur. Regular audits are needed to maintain good record-keeping.

INFERR-Iron infusion in haemodialysis study: INtravenous iron polymaltose for First Nations Australian patients with high FERRitin levels on haemodialysis-a protocol for a prospective open-label blinded endpoint randomised controlled trial.

BACKGROUND: The effectiveness of erythropoiesis-stimulating agents, which are the main stay of managing anaemia of chronic kidney disease (CKD), is largely dependent on adequate body iron stores. The iron stores are determined by the levels of serum ferritin concentration and transferrin saturation. These two surrogate markers of iron stores are used to guide iron replacement therapy. Most Aboriginal and/or Torres Islander Australians of the Northern Territory (herein respectfully referred to as First Nations Australians) with end-stage kidney disease have ferritin levels higher than current guideline recommendations for iron therapy. There is no clear evidence to guide safe and effective treatment with iron in these patients. We aim to assess the impact of intravenous iron treatment on all-cause death and hospitalisation with a principal diagnosis of all-cause infection in First Nations patients on haemodialysis with anaemia, high ferritin levels and low transferrin saturation METHODS: In a prospective open-label blinded endpoint randomised controlled trial, a total of 576 participants on maintenance haemodialysis with high ferritin (> 700 µg/L and ≤ 2000 µg/L) and low transferrin saturation (< 40%) from all the 7 renal units across the Northern Territory of Australia will be randomised 1:1 to receive intravenous iron polymaltose 400 mg once monthly (200 mg during 2 consecutive haemodialysis sessions) (Arm A) or no IV iron treatment (standard treatment) (Arm B). Rescue therapy will be administered when the ferritin levels fall below 700 µg/L or when clinically indicated. The primary outcome will be the differences between the two study arms in the risk of hospitalisation with all-cause infection or death. An economic analysis and several secondary and tertiary outcomes analyses will also be performed. DISCUSSION: The INFERR clinical trial will address significant uncertainty on the safety and efficacy of iron therapy in First Nations Australians with CKD with hyperferritinaemia and evidence of iron deficiency. This will hopefully lead to the development of evidence-based guidelines. It will also provide the opportunity to explore the causes of hyperferritinaemia in First Nations Australians from the Northern Territory. TRIAL REGISTRATION: This trial is registered with The Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12620000705987 . Registered 29 June 2020.

Laryngopharyngeal Reflux: Symptoms, Signs, and Presence of Pepsin in Saliva - A Reliable Diagnostic Triad.

Introduction Twenty-four-hour multichannel intraluminal impedance with double probe pH monitoring (MII-pH), though considered the most sensitive tool for the diagnosis of gastroesophageal reflux disease (GERD), is invasive, time consuming, not widely available, and unable to detect non-acid reflux. In contrast, the presence of pepsin in the saliva would act as a marker for reflux, considering that pepsin is only produced in the stomach. Objective To evaluate the predictive value of salivary pepsin in diagnosing laryngopharyngeal reflux (LPR) as suggested by the results of reflux symptom index (RSI > 13), reflux finding score (RFS > 7), and positive response to treatment with a 4-week course of proton-pump inhibitors. Methods This prospective study was done at a tertiary care hospital on 120 adult patients attending ENT OPD with clinical diagnosis of LPR. The presence of pepsin in their pharyngeal secretions and saliva using a lateral flow device, the Peptest, was compared with RSI, RFS, and with the response to medical treatment using the Chi-squared test. Results Salivary pepsin was found to be positive in 68% of the patients, with 87.5% of them showing positive response to treatment. Chi-squared analysis showed a significant association between positive salivary pepsin and RFS > 7, RSI >13, a combination of RFS > 7 and RSI > 13 as well as with response to treatment ( p < 0.0001). Conclusion When considered along with the clinical indicators of RFS and RSI of more than 7 and 13, respectively, and/or with a response to treatment, a positive salivary pepsin test indicates statistically significant chance of presence of LPR.

Laryngopharyngeal Reflux: Symptoms, Signs, and Presence of Pepsin in Saliva - A Reliable Diagnostic Triad

Abstract Introduction Twenty-four-hour multichannel intraluminal impedance with double probe pH monitoring (MII-pH), though considered the most sensitive tool for the diagnosis of gastroesophageal reflux disease (GERD), is invasive, time consuming, not widely available, and unable to detect non-acid reflux. In contrast, the presence of pepsin in the saliva would act as a marker for reflux, considering that pepsin is only produced in the stomach. Objective To evaluate the predictive value of salivary pepsin in diagnosing laryngopharyngeal reflux (LPR) as suggested by the results of reflux symptom index (RSI > 13), reflux finding score (RFS > 7), and positive response to treatment with a 4-week course of proton-pump inhibitors. Methods This prospective study was done at a tertiary care hospital on 120 adult patients attending ENT OPD with clinical diagnosis of LPR. The presence of pepsin in their pharyngeal secretions and saliva using a lateral flow device, the Peptest, was compared with RSI, RFS, and with the response to medical treatment using the Chi-squared test. Results Salivary pepsin was found to be positive in 68% of the patients, with 87.5% of them showing positive response to treatment. Chi-squared analysis showed a significant association between positive salivary pepsin and RFS > 7, RSI >13, a combination of RFS > 7 and RSI > 13 as well as with response to treatment (p < 0.0001). Conclusion When considered along with the clinical indicators of RFS and RSI of more than 7 and 13, respectively, and/or with a response to treatment, a positive salivary pepsin test indicates statistically significant chance of presence of LPR.

Dynamic Slow Motion Video Endoscopy as an Adjunct to Impedance Audiometry in the Assessment of Eustachian Tube Function

Abstract Introduction Eustachian tube (ET) dysfunction plays an important role not only in the pathophysiology of various middle ear disorders, but also in predicting the outcome of the treatment. As there is no single test that assesses both the anatomic and physiological functions of the ET, a combination of tympanometry and dynamic slow motion video endoscopy may improve the sensitivity of ET function assessment. Objective To find out if there is any correlation between dynamic slow motion nasal video endoscopy and impedance audiometry in assessing ET function in patients with middle ear diseases. Methods Ours was a descriptive study performed with 106 patients attending the Ear, Nose and Throat (ENT) Outpatient Department of a tertiary care center in South India with features suggestive ofmiddle ear disease. All patients underwent impedance audiometry and dynamic slow motion nasal video endoscopy, and were graded based on the severity of the ET pathology. Results A total of 47 out of 97 patients with abnormal endoscopy findings also had abnormal impedance audiometry. The correlation was greater among the patients with higher grades of ET dysfunction. The endoscopy findings of 106 cases, when correlated with middle ear manometry, revealed that 56 cases showed complete agreement, and 50 cases showed disagreement. The nasal endoscopy results, when correlated with middle ear manometry studies by using McNemar's chi-squared (χ2) test, showed a significant association between the 2 tests (p = 0.017). Conclusion There is a significant alteration in middle ear pressure as the severity of the ET tube dysfunction increases. Impedance audiometry and nasal endoscopy provide a better measure of ET function.

Dynamic Slow Motion Video Endoscopy as an Adjunct to Impedance Audiometry in the Assessment of Eustachian Tube Function.

Introduction Eustachian tube (ET) dysfunction plays an important role not only in the pathophysiology of various middle ear disorders, but also in predicting the outcome of the treatment. As there is no single test that assesses both the anatomic and physiological functions of the ET, a combination of tympanometry and dynamic slow motion video endoscopy may improve the sensitivity of ET function assessment. Objective To find out if there is any correlation between dynamic slow motion nasal video endoscopy and impedance audiometry in assessing ET function in patients with middle ear diseases. Methods Ours was a descriptive study performed with 106 patients attending the Ear, Nose and Throat (ENT) Outpatient Department of a tertiary care center in South India with features suggestive of middle ear disease. All patients underwent impedance audiometry and dynamic slow motion nasal video endoscopy, and were graded based on the severity of the ET pathology. Results A total of 47 out of 97 patients with abnormal endoscopy findings also had abnormal impedance audiometry. The correlation was greater among the patients with higher grades of ET dysfunction. The endoscopy findings of 106 cases, when correlated with middle ear manometry, revealed that 56 cases showed complete agreement, and 50 cases showed disagreement. The nasal endoscopy results, when correlated with middle ear manometry studies by using McNemar's chi-squared (χ 2 ) test, showed a significant association between the 2 tests ( p = 0.017). Conclusion There is a significant alteration in middle ear pressure as the severity of the ET tube dysfunction increases. Impedance audiometry and nasal endoscopy provide a better measure of ET function.

Review Article: Retropharyngeal Abscess-Mimickers and Masqueraders.

To discuss a case of suspected retropharyngeal abscess having important clinical and academic significance. This paper discusses an unusual presentation and evolution of a well known condition such as retropharyngeal abscess. Though the diagnosis in this case was initially a retropharyngeal abscess, several unusual findings were evident, which interfered with the optimal management of the patient. A literature review revealed rare causes and lesions mimicking a retropharyngeal abscess, such as retropharyngeal calcific tendinitis and Kawasaki disease, which are neither familiar to otolaryngologists nor other specialists such as orthopedicians. It is possible that this patient was both over treated and undertreated at the same time. Though the diagnosis in this case could not be established with certainty, several important pieces of information came up, especially unusual causes of retropharyngeal abscess and management of the same. Retropharyngeal abscess is a well-known condition with established modes of management. However, certain variations may occur and may pose challenges in diagnosis and management. These variations are little known and need to be highlighted so that optimal management is ensured.

Triamcinolone Impregnated Nasal Pack in Endoscopic Sinus Surgery: Our Experience.

The selection of an effective packing method to prevent postoperative complications and recurrence following Endoscopic Sinus Surgery remains ambiguous at present. This study was conducted to evaluate the efficacy of Triamcinolone impregnated nasal pack in Endoscopic Sinus Surgery, in the prevention of postoperative crusting, edema, infection and recurrence. This study was an interventional randomized placebo-controlled study, conducted at a tertiary care centre in South India between February 2015 and May 2016, after getting approval from Institute Ethical Committee. 75 patients with bilateral chronic rhinosinusitis undergoing Endoscopic Sinus Surgery were selected for the study. After surgery, each patient was randomized to receive Polyvinyl Acetal (Merocel) nasal pack soaked with Triamcinolone to one side, while the contralateral side was packed with Merocel soaked with saline. Incidence of postoperative crusting, edema, polypoidal change and mucosal discharge was evaluated using the Endoscopic Staging System at 1st and 2nd weeks and at 1st and 3rd months of surgery. A significant reduction in mucosal edema was observed in the test group at all stages of follow up (p values <0.05). Incidence of crusting was found to be significantly lower in the test group (p values <0.05) except at 3 months (p value >0.05). However, there was no significant difference in the occurrence of polypoidal change and mucosal discharge between the groups. Triamcinolone impregnated nasal pack is an effective method to reduce the incidence of early postoperative complications following Endoscopic Sinus Surgery.

Erratum to: Review Article: Retropharyngeal Abscess-Mimickers and Masqueraders.

[This corrects the article DOI: 10.1007/s12070-017-1105-6.].

Potassium titanyl phosphate laser turbinate reduction in the management of allergic inferior turbinate hypertrophy: Our experience.

BACKGROUND: Allergic inferior turbinate hypertrophy is one of the most common causes of nasal obstruction. Several surgical methods can be used for the reduction of allergic inferior turbinate hypertrophy refractory to medical management. Herein, we share our experience with a potassium titanyl phosphate (KTP) laser, which is a relatively novel technique for turbinate reduction. OBJECTIVES: To evaluate the efficacy of KTP laser turbinate reduction in terms of symptomatic improvement and its effect on nasal mucociliary clearance. METHODS: This study was conducted in the Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India, from November 2012 to July 2013. Thirty patients with inferior turbinate hypertrophy refractory to medical management were selected. A KTP laser was used at 6 W in continuous mode, with a spot size of 0.6-1 mm, and energy delivered through a 400-µm optical fiber. A follow-up was done at 1 week, 1 month, and 3 months. All the values (both by the Sino Nasal Outcome Test scoring system and saccharine transit time) were assessed before surgery and at each follow-up visit. RESULTS: The patients showed significant differences in the symptoms (p < 0.0001) at each follow-up. The mean saccharin transit time showed significant prolongation during the first week and first month after surgery, which indicated adverse effects on the mucociliary system (p < 0.0001). This, however, was a temporary effect, and the mean saccharin time returned to normal limits (17.96 minutes) at the third postoperative month. The mean operative time was 11.62 minutes. The procedure was not associated with any serious intra- or postoperative complications. CONCLUSION: KTP laser turbinate reduction is a safe, effective, and minimally invasive procedure in the treatment of allergic inferior turbinate hypertrophy, with a minimal effect on the nasal mucosa. It can be done as an office procedure, with minimal complications.

Voice Outcome Following Carbon Dioxide Laser Assisted Microlaryngeal Surgery.

Very few studies have been conducted in South Indian population to evaluate glottic function and voice outcome following carbon dioxide (CO2) laser assisted microsurgery for benign lesions of the larynx. This is a descriptive study which aims at assessing the voice outcome (perceptual and acoustic) and vocal fold function (stroboscopic) following CO2 laser excision in benign vocal fold lesions. 50 adult patients with benign laryngeal lesions were selected to undergo CO2 laser excision in super-pulse mode at power setting of 6 watts. Perceptual analysis was done using GRBAS score. Voice analysis was done using Praat software and fundamental frequency, jitter, shimmer and harmonics to noise ratio were assessed. Stroboscopy was done to evaluate vocal fold function using glottic closure and mucosal wave pattern as parameters. Evaluation of these parameters was done pre-operatively and at 2, 6 weeks and 3 months post-operatively. Perceptual analysis revealed a significant improvement in the GRBAS score after surgery (p < 0.001). Acoustic analysis showed that all the parameters improved significantly after surgery (p < 0.001). Stroboscopy showed that vocal fold function improved in 98 % of patients in terms of completeness of glottic closure and regular, periodic mucosal wave. Super-pulse micro-spot carbon dioxide laser is a safe and effective treatment option for benign lesions of vocal folds, with excellent voice outcome.