Improvement in symptoms of obstructive sleep apnoea in children following tonsillectomy versus tonsillotomy: a systematic review and meta-analysis.

BACKGROUND: Tonsillotomy (or intracapsular tonsillectomy) is a modern technique which is seen by some as potentially superior to traditional (extracapsular) tonsillectomy for the removal of tonsillar tissue to treat obstructive sleep apnoea in children. It has been suggested that peri-operative pain and haemorrhage and postoperative haemorrhage are reduced with the tonsillotomy technique. However, no systematic reviews have been carried out to assess its efficacy in treating obstructive sleep apnoea compared to tonsillectomy. OBJECTIVE OF REVIEW: To assess whether subjective improvement in symptoms of obstructive sleep apnoea following tonsillotomy is comparable to that following tonsillectomy, measured using a standardised questionnaire, the Obstructive sleep apnoea-18 (OSA-18) tool. TYPE OF REVIEW: Systematic review of the literature and meta-analysis. SEARCH STRATEGY: PubMed (MEDLINE), followed by Ovid (MEDLINE), Cochrane Database of Systematic Reviews, American College of Physicians Journal Club, and the British Medical Journal were searched for articles published in English between 1995 and 2015 inclusive. EVALUATION METHOD: Literature search, systematic review and meta-analysis. Studies examining improvement in mean OSA-18 score following tonsillotomy, improvement in mean OSA-18 score following tonsillectomy, and examining both were selected, examined and used for meta-analysis. Studies with and without concurrent adenoidectomy were included. RESULTS: Four studies examining tonsillotomy and 16 studies examining tonsillectomy were included in the analysis. Using a random effects model, the pooled improvement in OSA-18 score for tonsillotomy was 2.46 (95% CI 1.92-2.99), and for tonsillectomy, it was 2.10 (95% CI 1.91-2.30). There was no significant difference between the methods. CONCLUSION: That there is no significant difference in subjective outcome between tonsillotomy and tonsillectomy may support wider use of tonsillotomy over tonsillectomy for the treatment of obstructive sleep apnoea in children.

Has the use of the linear incision reduced skin complications in bone-anchored hearing aid implantation?

OBJECTIVE: To compare the skin-related complications of the traditional skin flap method with a linear incision method of implantation. METHOD: All cases of bone-anchored hearing aid surgery performed by a single surgeon (n = 117) were compared over two periods: 1999-2011, when the traditional method of skin flap and soft tissue removal was used (group 1; n = 86), and 2012-2013, when linear incision without soft tissue removal was used (group 2; n = 31). All patients were followed up for one year and complications were recorded for that period. RESULTS: There were 21 (24.4 per cent) skin-related complications in group 1 (skin overgrowth = 12, wound infection = 8 and numbness = 1) and 3 (9.7 per cent) complications in group 2 (wound infection = 3). Analysis using independent t-tests showed the results to be significant (p < 0.05; 95 per cent confidence interval = 0.0800-0.4473). CONCLUSION: The linear incision without soft tissue removal method for bone-anchored hearing aid implantation reduces skin complication rates.

Does the quality of life impact of tonsillitis correlate with SIGN guideline compliance? An assessment of range and normality.

OBJECTIVES: To assess the scores of those who are eligible to be listed for tonsillectomy through compliance with the SIGN guidelines for any trends or range. DESIGN: A prospective study of all patients (aged 16 or above) listed for elective tonsillectomy from a nurse led tonsil clinic. Patients were given a TOI-14 questionnaire to complete after they had been added to the waiting list for surgery, but before undergoing tonsillectomy. Scores were assessed using SPSS. SETTING: Outpatient clinic. PARTICIPANTS: Patients aged over 16 listed for Tonsillectomy via SIGN Guideline 117. MAIN OUTCOME MEASURE: Scores from TOI-14, completed pre-operatively. RESULTS: 155 patients were listed from the nurse led clinic from October 2012 to August 2014; 5 questionnaires were excluded for being incomplete. The score range was 55 (15-70), with a calculated mean score of 45.62 and standard deviation of 9.701. Over 95% of results were within 2 standard deviations of the mean. A calculated negative skew also confirms that most patients who have clinical indications for tonsillectomy compliant with the SIGN guidelines show a higher score on the TOI-14. CONCLUSION: This analysis indicates a trend of pre-intervention scores on the TOI-14 questionnaire for those patients who have a SIGN guideline compliant clinical indication for a tonsillectomy. We therefore propose that this suggests correlation between 'clinically strong' indication for tonsillitis and patient perceived Quality of Life impact.

Short-term weight gain after adenotonsillectomy in children with obstructive sleep apnoea: systematic review.

BACKGROUND: Children with obstructive sleep apnoea commonly undergo adenotonsillectomy as first-line surgical treatment. This paper aimed to investigate whether this intervention was associated with weight gain after surgery in the paediatric population with obstructive sleep apnoea. METHOD: Two independent researchers systematically reviewed the literature from 1995 to 2014 for studies on patients who underwent adenotonsillectomy with weight-based measurements before and after surgery. The databases used were Ovid Medline, Embase and PubMed. RESULTS: Six papers satisfied all inclusion criteria. Four of these papers showed a significant weight increase and the others did not. The only high quality, randomised, controlled trial showed a significant increase of weight gain at seven months follow up, even in patients who were already overweight before their surgery. CONCLUSION: The current evidence points towards an association between adenotonsillectomy and weight gain in patients with obstructive sleep apnoea in the short term.

On the minimum requirements for otolaryngology clinics in National Health Service hospitals.

OBJECTIVE: This paper, a report by the Clinical Governance and Audit Committee of the Scottish Otolaryngological Society, presents a consensus view of the minimal requirements for ENT clinics in National Health Service hospitals. RESULTS AND CONCLUSION: The provision of adequate equipment and staff has gained increasing importance as the vast majority of ENT procedures can be safely performed in the out-patient or office setting.

Direct measurement of the round window niche dimensions using a 3-dimensional moulding technique--a human cadaveric temporal bone study.

OBJECTIVES: To directly measure the various dimensions of the RWN focusing on the bony overhang and the vertical height between the free margin of the bony overhang and floor of the niche. DESIGN: Laboratory-based anatomical study using formalin-preserved human cadaveric temporal bones. SETTING: Temporal Bone laboratory, Department of Otolaryngology University of Dundee Medical School & Ninewells Hospital, Dundee, UK. PARTICIPANTS: NA. MAIN OUTCOME MEASURES: Three measurements were carried out (i) the depth of the round window niche extending from the free margin of the bony overhang to the fundus; (ii) vertical height from the free margin of the overhang to the floor of the niche (entrance) and (iii) the antero-posterior (AP) dimension of the niche. RESULTS: Based on mould technique, the three dimensions were calculated as follows: mean bony overhang = 2.1 mm (range 1.9-2.4 mm), height of RWN = 2.0 mm (1.8-2.15 mm) and AP length = 4.0 mm (3.3-4.95 mm). CONCLUSIONS: Our data demonstrate that the mean dimension of the bony overhang superior to the RWM is 2.1 mm.

Clinical efficacy of tinnitus retraining therapy and cognitive behavioural therapy in the treatment of subjective tinnitus: a systematic review.

OBJECTIVE: This study aimed to compare the outcomes of two frequently employed interventions for the management of tinnitus: tinnitus retraining therapy and cognitive behavioural therapy. METHOD: A systematic review of literature published up to and including February 2013 was performed. Only randomised control trials and studies involving only human participants were included. RESULTS: Nine high-quality studies evaluating the efficacy of tinnitus retraining therapy and cognitive behavioural therapy were identified. Of these, eight assessed cognitive behavioural therapy relative to a no-treatment control and one compared tinnitus retraining therapy to tinnitus masking therapy. Each study used a variety of standardised and validated questionnaires. Outcome measures were heterogeneous, but both therapies resulted in significant improvements in quality of life scores. Depression scores improved with cognitive behavioural therapy. CONCLUSION: Both cognitive behavioural therapy and tinnitus retraining therapy are effective for tinnitus, with neither therapy being demonstrably superior. Further research using standardised, validated questionnaires is needed so that objective comparisons can be made.

Sinonasal symptoms in adults with ear disease.

BACKGROUND: The association between eustachian tube dysfunction and middle-ear effusion is well established. Studies have also demonstrated pathological changes affecting the middle-ear mucosa associated with chronic sinonasal inflammation. No previous studies have evaluated symptoms related to sinonasal inflammatory disease in different ear diseases. OBJECTIVE: To assess the presence of sinonasal symptoms in ear diseases using the Dundee Rhinogram. METHODS: Data were collected prospectively in the period February-October 2011. Sinonasal symptoms were graded using the Dundee Rhinogram. Student's t-test analyses were performed to identify any statistically significant associations. RESULTS: In total, 164 patients were assessed. There was a statistically significant association between sinonasal symptoms and mucosal middle-ear diseases (p < 0.005). The mean sinonasal symptoms score for mucosal middle-ear disease patients was 5.94 (range, 0-32). CONCLUSION: Assessment of sinonasal symptoms is paramount in patients presenting with an ear symptom; inflammatory sinonasal disease treatment may become necessary in the management of middle-ear mucosal disease for better patient outcome.

Surgical management of external auditory canal lesions.

BACKGROUND: Lesions arising in the external auditory canal that require surgical excision are uncommon. They are associated with a range of pathologies, including bony abnormalities, infections, benign and malignant neoplasms, and epithelial disorders. METHODS: This paper describes a 10-year personal case series of external auditory canal lesions with chart, imaging and histopathology review. RESULTS: In total, 48 lesions required surgical management, consisting of: 13 bony lesions; 14 infective lesions; 14 neoplasms with 11 histological types (including ceruminous adenoma and the extremely rare cavernous haemangioma); 3 epithelial abnormalities; and 4 other benign lesions. The surgical management is described. CONCLUSION: This study emphasises the diagnostic differences between exostoses and osteomas, and between external auditory canal cholesteatoma and keratosis obturans. It also discusses the management of aural polyps, and highlights the need to excise external auditory canal masses for histology in order to guide subsequent treatment.

Management of recurrent acute otitis media in children: systematic review of the effect of different interventions on otitis media recurrence, recurrence frequency and total recurrence time.

OBJECTIVE: To conduct a systematic review comparing the effect of three interventions (prophylactic antibiotics, tympanostomy tube insertion and adenoidectomy) on otitis media recurrence, recurrence frequency and total recurrence time. METHODS: Literature on recurrent otitis media was identified using the PubMed and Scopus search engines for the period January 1990 to March 2011. A hand search of the reference lists of relevant articles and textbooks was conducted to identify additional studies. Randomised, controlled trials with a minimum of 40 children and follow up of at least 12 months were included. RESULTS: Eighteen publications were identified. Each was assessed using preset inclusion criteria; seven publications met these criteria. CONCLUSION: Prophylactic antibiotics are effective in reducing otitis media recurrence, recurrence frequency and total recurrence time. Tympanostomy tube insertion failed to reduce the prevalence of otitis media recurrence, but reduced the recurrence frequency and total recurrence time. Adenoidectomy reduced otitis media recurrence; results on otitis media recurrence frequency differed but on average there was a reduction; however, the two studies with relevant data on total recurrence time had contradictory results.

First branchial arch abnormality: diagnostic dilemma and excision with facial nerve preservation.

OBJECTIVE: To report a case of first branchial arch abnormality and the problems associated with misdiagnosis. A succinct literature review is included. SETTING: Teaching hospital in Scotland. METHODS: A 10-year-old girl presented with localised erythema and swelling in the left parotid region. This was treated with antibiotics and incision and drainage. She re-presented four years later with a history of recurrent discharge. A first branchial arch abnormality was suspected and a magnetic resonance imaging scan arranged. RESULTS: Imaging showed a fluid-filled sinus tract originating adjacent to the anterior wall of the cartilaginous left external auditory canal. The sinus tract was seen to extend anteriorly and inferiorly through the superficial lobe of the left parotid, and to open onto the left cheek lateral to the left masseter. The tract was explored and excised under general anaesthesia, via two separate incisions, with preservation of the facial nerve. CONCLUSION: The diagnosis of a first branchial arch abnormality is generally based on a high index of clinical suspicion, when a neck swelling is noted in a child. Magnetic resonance imaging is a useful modality for investigation, and helps to delineate the position of the tract and its relationship to the facial nerve.

Facial paralysis during air travel: case series and literature review.

OBJECTIVE: We report three cases of recurrent, unilateral facial palsy associated with air travel. METHOD: The three cases are presented, along with a brief literature review concerning barotrauma and its association with air travel and facial palsy. RESULTS: All three patients experienced unilateral facial paralysis during air travel, accompanied by additional symptoms which varied between cases. Symptoms resolved spontaneously in all cases. Two patients received ventilation tube insertion to prevent further recurrence. Computed tomography scanning revealed no bony defect in two patients, while the third exhibited dehiscence of the facial canal which may have contributed to the condition. CONCLUSION: Available evidence suggests that eustachian tube dysfunction can contribute to increased pressure within the middle ear, leading to neuropraxia of the facial nerve. Cases of facial paralysis associated with air travel are under-reported. Since there is no evidence-based management protocol for this condition, further investigation of its pathology is encouraged in order to improve our understanding.

Bilateral acute mastoiditis and subperiosteal abscesses in a child managed by simultaneous bilateral mastoid surgery.

OBJECTIVE: We report a case of bilateral acute mastoiditis and subperiosteal abscesses successfully managed with simultaneous surgery. METHOD: A case report and literature review are presented. RESULTS: A two-year-old boy presented with fever, otalgia, otorrhoea and bilateral protruding ears. He was treated for 72 hours with intravenous antibiotics but failed to improve. Computed tomography confirmed bilateral mastoid abscesses with destruction of the mastoid cortex. Bilateral drainage of the subperiosteal abscesses and bilateral cortical mastoidectomies were carried out. Post-operatively, he recovered well, and free field audiometry showed a normal hearing threshold of 20 dB across all test frequencies. CONCLUSION: This is only the second reported case of bilateral mastoiditis and subperiosteal abscesses. This case illustrates the use of bilateral cortical mastoidectomy in the successful management of this condition following failed antibiotic therapy, and highlights important management considerations.

Sudden hearing loss and pregnancy: a review.

BACKGROUND: Acute hearing loss is a distressing albeit rare occurrence in pregnancy. Due to its infrequent presentation, little is known of its cause, and the best management is unclear. OBJECTIVE: To present a summary of current knowledge regarding sudden hearing loss in pregnancy and its management, by reviewing the published literature. DATA SOURCES: The following electronic databases: PubMed (MEDLINE), Ovid (MEDLINE), all EBM Reviews (Cochrane DSR, ACP Journal Club, DARE and CCTR) and Embase; plus a hand search of reference lists of retrieved papers. STUDY SELECTION AND DATA EXTRACTION: All papers retrieved using key word searches for 'sudden hearing loss and pregnancy' and 'sudden deafness and pregnancy' were reviewed. Due to the scarcity of literature, all studies identified were included in this review. DATA SYNTHESIS AND CONCLUSIONS: All retrieved papers were reviewed. Sudden hearing loss is a rare occurrence during pregnancy, leading to a dearth of literature due to limited clinical experience. Audiological investigation findings for such patients remain equivocal. Recovery can be spontaneous during the postpartum period. In patients who require medical treatment, a dextran 40 infusion can be employed. There remains scope for further research, in the form of larger studies, to ascertain the best management option for this clinical problem.

Use of minimally invasive parathyroidectomy techniques in sporadic primary hyperparathyroidism: systematic review.

The past two decades have seen rapidly changing attitudes towards the surgical management of primary hyperparathyroidism. Advances in localisation techniques and confidence with endoscopy have led to the development of numerous minimally invasive parathyroidectomy approaches, including open minimal incision and endoscopic and video-assisted parathyroidectomy. This paper systematically reviews the evidence for these methods to determine: (1) whether these new, minimally invasive techniques are comparable to conventional bilateral neck exploration methods in terms of success and complication rate; and (2) if they are comparable, which technique is likely to be best for cosmesis, patient safety and patient satisfaction. A search of the Medline, Cochrane Reviews and Scopus databases was conducted, using a defined list of search parameters. Abstracts were compared against inclusion and exclusion criteria, before the full text was sought and analysed for data. The evidence from each study was then assessed, based on study quality, and a recommendation made based on the level of evidence available. There is level 1b evidence that minimally invasive surgery is comparable to bilateral neck exploration in terms of efficacy and complication rates. This paper recommends that the treatment of choice for solitary adenoma (in most healthcare centres) should be open minimal incision parathyroidectomy, due to advantages in operative duration, learning curve and cost-effectiveness.

Masses and disease entities of the external auditory canal: radiological and clinical correlation.

A wide spectrum of disease entities can affect the external auditory canal (EAC). This review describes the normal anatomy of the EAC. Congenital abnormalities, infections, neoplasms, and miscellaneous conditions, such as cholesteatoma and acquired stenosis, are shown with reference to clinical relevance and management. Cases have been histologically confirmed, where relevant. The EAC is frequently imaged - for example, on cross-sectional imaging of the brain - and this review should stimulate radiologists to include it as an important area for review.

Consultant-based otolaryngology emergency service: a five-year experience.

OBJECTIVE: To present our experience of running a consultant-based otolaryngology emergency care service for more than five years. MATERIALS AND METHODS: In 2003, we developed a system of consultant-based emergency service: consultants spent a week on-call providing a dedicated emergency service, with routine commitments cancelled. RESULTS: Our new system had advantages over traditional working practices in terms of consultant involvement, trainee education, continuity and efficiency. It also reduced disruption to elective commitments for both consultants and registrars. This system was fundamental to the successful review of all urgent (and in future elective) cases within target periods. Only 31 per cent of new referrals to the consultant emergency clinics required a further appointment. Good teamwork and flexibility in working arrangements have been essential to the success of this service. CONCLUSION: Given that health service changes have reduced junior trainee working hours and numbers, and that patients increasingly expect to be treated by trained doctors, our new consultant-based emergency service has merit. Although implementation in other units may differ, we recommend this new service, for the above reasons.

Molecular and epidemiological analysis of methicillin-resistant Staphylococcus aureus otorrhoea: hospital- or community-acquired?

OBJECTIVES: (1) To identify newly diagnosed cases of methicillin-resistant Staphylococcus aureus ear infection in our local population; (2) to determine the risk factors involved in these patients' clinical courses, and (3) to type the bacterial strains isolated and thus identify whether they were hospital- or community-acquired. DESIGN AND SETTING: Retrospective review of case notes, together with laboratory-based molecular studies in the departments of otolaryngology and medical microbiology in a university teaching hospital in Scotland, UK. SUBJECTS: Over a two-year period, 35 patients were identified with ear swabs positive for methicillin-resistant Staphylococcus aureus infection. These cases came from both hospital and community settings. MAIN OUTCOME MEASURES: (1) Identification of primary methicillin-resistant Staphylococcus aureus otorrhoea in patients with no previously documented colonisation; and (2) molecular typing of the strains isolated, using spa technology, to identify whether they were hospital- or community-acquired. RESULTS: Of the 35 positive patients, 27 were previously known carriers of methicillin-resistant Staphylococcus aureus. The eight patients with newly diagnosed methicillin-resistant Staphylococcus aureus otorrhoea presented initially in the community. All of these patients had had contact with hospital staff (as in-patients or out-patients) in the weeks preceding development of their ear infection. Using the spa technique for molecular typing, we identified hospital-acquired ('epidemic') methicillin-resistant Staphylococcus aureus type 15 in all eight patients' isolates. All were sensitive to topical gentamicin. CONCLUSIONS: In our cohort, hospital-acquired methicillin-resistant Staphylococcus aureus type 15 was the commonest cause of methicillin-resistant Staphylococcus aureus otorrhoea, despite the fact that these patients all first presented in the community. We believe that contact with hospital staff or health care workers is a risk factor for acquiring methicillin-resistant Staphylococcus aureus otorrhoea in the community.