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.

Laryngomalacia: is there an evidence base for management?

BACKGROUND: The advent of supraglottoplasty clearly has transformed the surgical management of severe laryngomalacia. The condition, however, generally runs a milder course, with spontaneous resolution the norm. OBJECTIVES: To identify gaps in the knowledge and identify topics for future study. METHOD: Systematic review of the literature. RESULTS: The literature suggests that there is a range of abnormalities leading to the typical collapsing upper airway, and that neurological disease, other airway abnormalities, syndromes and gastroesophageal reflux all contribute to disease severity and influence outcomes. The procedures involved in supraglottoplasty are rarely specified, the indications for surgery are vaguely defined and the role of medical therapy is unclear. CONCLUSION: Every review article or survey of opinion suggests that there is still a marked variation in individual practice and a lack of consensus.

Risk factors for failure of supraglottoplasty.

OBJECTIVES: To assess for identifiable risk factors for failed surgical intervention in children with laryngomalacia. METHODS: Retrospective case note review between September 2007 and March 2012. Case notes were reviewed for demographic data, symptoms, co-morbidities, operative technique, postoperative recovery, complications, length of hospital stay including intensive care unit (ICU) care, and resolution of symptoms. RESULTS: 148 children underwent supraglottoplasty. Case notes were available for 115 (78%) patients. 35% (41/115) of cases were females and 65% (74/115) were male. A bimodal age distribution was observed with peaks at 3 months and 3.5 years. Those over one year of age were more likely to have complications (p = 0.035). There was no significant difference in outcomes for age (p > 0.05). In patients less than one year, reflux symptoms were significantly associated with a higher likelihood of failure of the operation (p = 0.013). Patients under one year with pre-operatively identified comorbid conditions were less likely to have an improvement in breathing (p = 0.002). Cold steel was used in 55% (63/115) of cases, laser only in 17% (20/115) cases and a combination of the two techniques in 28%, (32/115). There was no association between the surgical technique used and complications (p = 0.558). There was no association between improvement in symptoms and surgical technique used (p = 0.560). There was a significant association between delayed post-operative neurological diagnosis and failure of the operation (p < 0.001). 21 (18%) patients required a second procedure. CONCLUSIONS: Pre-operative predictors of failure were patients with reflux symptoms (p = 0.013). Patients that required a second procedure were 37 times more likely to have a delayed diagnosis of an underlying neurological condition. Failure of symptoms to improve after supraglottoplasty should alert the clinician to the possibility of an underlying neurological disorder.

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.

Outcomes of surgery for laryngotracheal stenosis-the parents perspective.

UNLABELLED: Reconstructive laryngeal surgery has been very successful in the treatment of laryngotracheal stenosis. Traditionally authors have used survival and decannulation rates as markers of success. OBJECTIVE: To evaluate the outcome of paediatric laryngotracheal surgery from the parents perspective. METHOD: Retrospective audit of all children undergoing laryngotracheal reconstruction or cricotracheal resection for laryngotracheal stenosis in a three year period at the Royal Hospital for Sick Children, Glasgow. An open-ended questionnaire was used to assess parental concerns regarding their child's airway, post-operative results and the current status of their voice, breathing and swallowing. RESULTS: 30 patients were eligible for the inclusion of which there were 17 responses (56%). The most common concerns pre-operatively were difficulty breathing, tracheostomy and survival. Post-operatively parents felt that breathing, voice and a reduction in the number of lower respiratory tract infections were the main improvements. We also identified the high level of importance that the parents assigned to their child's independence and ability to lead a normal life. CONCLUSION: This study has given us a unique insight into the concerns of parents who have children with laryngotracheal stenosis. It has also allowed us to evaluate our post-operative results from a qualitative perspective through the eyes of the parents.

Epiphora: an evidence based approach to the 12 minute consultation.

BACKGROUND: Epiphora is the presence of a watering eye which may be due to reflex tearing or defective drainage of tears. Whilst most cases present to the ophthalmologist the otolaryngologist has a key role to play in both assessment and management of these patients. METHODS: This review was based on a literature search last performed on 21st October 2009. MEDLINE and Cochrane databases were searched using the subject headings 'epiphora' or 'functional epiphora' in combination with diagnosis, investigation, management, treatment, intervention and surgery. Results were limited to English language articles. The personal biographies of the senior authors were also used. CONCLUSION: An accurate assessment of the site and degree of obstruction is important to ensure the correct management is undertaken. Medical treatment with nasal steroid spray may be effective but the majority of obstructed cases will require surgical intervention in the form of dacryocystorhinostomy (DCR). There is increasing evidence that powered endoscopic DCR has outcomes comparable with the 'gold standard' procedure of external DCR.

Case of maxillary avascular necrosis due to oral bisphosphonates, presenting with signs of malignancy.

OBJECTIVE: We report a rare case of avascular necrosis of the maxilla secondary to oral bisphosphonates. METHODS: Case report and review of the world literature concerning avascular necrosis as a result of bisphosphonate therapy. CASE REPORT: A 62-year-old woman presented with unilateral nasal obstruction, swelling of the cheek and an ulcerating lesion of the upper alveolus. She had a past medical history of osteoporosis, for which she took oral bisphosphonates. Investigation revealed necrosis of the maxilla, and avascular necrosis secondary to oral bisphosphonates was diagnosed. CONCLUSION: There have been several documented cases of avascular necrosis of the mandible and maxilla following intravenous bisphosphonates or dental procedures. In our case, bisphosphonates were only taken orally and no dental work had been undertaken. This patient's clinical presentation was highly suggestive of malignancy, and we would like to communicate this unusual case to other otolaryngologists.

The effect of FloSeal on post-tonsillectomy pain: a randomised controlled pilot study.

OBJECTIVES: To determine whether FloSeal as a haemostatic agent in tonsillectomy is associated with less postoperative pain than conventional haemostasis with ligatures. DESIGN: Randomised, controlled, single-blinded pilot study. SETTING: James Cook University Hospital, Middlesbrough, Cleveland, UK. PARTICIPANTS: Thirty patients over 16 years of age undergoing tonsillectomy for recurrent tonsillitis were recruited for the study. At surgery both tonsils were removed by cold steel dissection. Following randomisation one tonsil fossa had FloSeal applied and the other ligatures for haemostasis. MAIN OUTCOME MEASURES: The primary outcome measure was postoperative pain following tonsillectomy measured on a visual analogue scale. Pain was recorded three times a day for the first 10 days following surgery. Haemorrhage rates were also recorded as a secondary outcome. RESULTS: Complete data was analysed for 26 patients (87%). The data was grouped into distinct time periods: 0-2, 3-6 and 7-10 days. The sum of the visual linear analogue scale over the time periods for each patient was calculated. Using Wilcoxon Signed Ranks Test, the data was analysed and it was found that there was no statistically significant difference in postoperative pain scores between the control and treatment side at any time. There was a postoperative reactionary haemorrhage rate of 6.7% on the FloSeal side. CONCLUSION: In our pilot study there was no reduction in pain on the FloSeal side in the first 10 days following tonsillectomy which contrasts with previous findings in the literature.

Assessing breast tissue density by transillumination breast spectroscopy (TIBS): an intermediate indicator of cancer risk.

Risk assessment by parenchymal density pattern, a strong physical indicator of future breast cancer risk, is available with the onset of mammographic screening programmes. However, due to the use of ionizing radiation, mammography is not recommended for use in younger women, thereby rendering risk assessment unattainable at an earlier age. Visible and near infrared light was used on 292 women with radiologically normal mammograms to determine whether transillumination breast spectroscopy (TIBS) can identify women with a high parenchymal density pattern as an intermediate indicator of breast cancer risk. Principal component analysis (PCA) was used to reduce the spectral data and generate density scores for each woman. To assess the accuracy of TIBS, logistic regression was used to calculate crude and adjusted odds ratios (OR) and 95% confidence intervals (CI) for each score. Receiver operator characteristic (ROC) curves and area under the curve (AUC) were also calculated for the crude and adjusted logistic models. Optical information relating to tissue chromophores, such as water, lipid and haemoglobin content, was sufficient to identify women with high parenchymal density. The resulting AUC for the final and most parsimonious multivariate logistic model was 0.922 (95% CI 0.878-0.967). TIBS provides information correlating to high parenchymal density and is a promising tool for risk assessment, particularly for younger women.

Bone-anchored hearing aid modified with directional microphone: do patients benefit?

BACKGROUND: Bone-anchored hearing aids are well established in the treatment of patients with a conductive or mixed hearing loss. However, one of the main problems is that of sound localisation. This can be improved with a directional microphone. This study compared the quality of life of bone-anchored hearing aid wearers before and after the use of a directional microphone. METHOD: Eleven patients were included. They were required to wear the directional microphone for 12 weeks. Quality of life was measured using the Glasgow benefit inventory questionnaire, before and after the study period. RESULTS: The response rate was 82 per cent. The total benefit from the directional microphone was +49.7. The three components of the Glasgow benefit inventory were analysed separately, as follows: general subscale +57.4; physical health +42.6; and social scale +25.9. CONCLUSION: This is the first study to demonstrate a significant improvement in quality of life from a directional microphone fitted to a bone-anchored hearing aid.

A national audit of paediatric service provision in otolaryngology in England and Wales.

INTRODUCTION: Otolaryngology is the surgical speciality with the highest paediatric workload, accounting for 29% of the total. Children are not miniature adults and require specially trained staff, equipment, facilities and an environment appropriate to their needs. Documents from the Department of Health and the Royal Colleges of Surgeons and Anaesthetists have been published outlining national standards and recommendations for paediatric surgical service provision. We undertook an audit to assess the current state of paediatric services in ENT in England and Wales and how they conform to these guidelines. METHOD: A database of ENT departments in England and Wales was constructed and a postal questionnaire sent to a named consultant in each unit. The questionnaire encompassed the areas of recommendation outlined in the aforementioned reports. Respondents were also asked to state the kind of hospital in which they worked so a further breakdown of the results could be made. RESULTS: One hundred and eighty-nine units were included in the audit with a response rate of 56%. Structurally the documents recommend that each unit has a dedicated named paediatric ENT consultant and a designated clinical lead for children's surgery. This is being met in 54.7% and 56.6%, respectively. Omitting the specialist stand alone group the paediatric facilities in theatre were of a lower standard and overall only 30% met the requirements set by the reports. This theme continues when analysing the data of the provision of anaesthetic services with only 50% of the small district general hospitals having the appropriate level of supervision and expertise. One of the worst met targets is that of acute pain service being provided in only 26% of the hospitals that responded. Overall there is a common theme with the specialist stand alone units scoring the highest and the small district general hospitals scoring the lowest. CONCLUSION: This audit reveals that we are not meeting the guidelines in nearly 50% of the targeted areas. Paediatric care should be "child centred" and if we are not able to provide this specialised care then paediatric surgical services could be forced into centralisation.

Magnetic resonance imaging: is a single scan ever enough for the diagnosis of acoustic neuroma?

A patient presented with unilateral, right-sided hearing loss and tinnitus and underwent gadolinium-enhanced magnetic resonance imaging (MRI). A pure tone audiogram showed a right-sided sensorineural hearing loss. The MRI scan was initially negative but when repeated seven years later, following a further deterioration of symptoms, it showed a 2 mm, right-sided acoustic neuroma. This case has great potential significance for the diagnosis of acoustic neuroma, and it may raise medico-legal issues regarding the exclusion of this diagnosis. The case illustrates that a single negative scan may not be adequate if pure tone audiograms show deterioration in hearing loss.

Efficacy of antiviral agents in feline herpetic keratitis: results of an in vitro study.

PURPOSE: To determine, by a plaque reduction assay, the in vitro efficacy of novel antiviral agents in the treatment of feline herpes virus 1 (FHV-1) keratitis in the domestic cat (Felis felis). MATERIALS AND METHODS: A standard plaque reduction assay was performed using a laboratory strain of FHV-1 and embryo-derived feline kidney cells to determine the in vitro efficacy of the antiviral drugs penciclovir (PCV), bromovinyldeoxyuridine (BVdU), and (S)-9-(3-hydroxy-2-phosphonylmethoxypropyl) adenine (HPMPA) and to compare these with the drugs acyclovir (ACV) and trifluorothymidine (TFT). Efficacy was assessed by determining the dose of drug at which 50% plaque reduction was noted (ED(50)). RESULTS: HPMPA was found to have greatest antiviral activity (ED(50) 0.07 microg/ml). ACV was least active (ED(50) 24 microg/ml), while TFT was active with an ED(50) of 5.7 microg/ml. PCV and BVdU had intermediate activity (ED(50) 1.6 and 1.7 microg/ml, respectively). CONCLUSIONS: This study suggests that the efficacy of HPMPA, BVdU, and penciclovir in cats with herpesviral keratitis should be determined in vivo as their efficacy in vitro was substantially greater than that of acyclovir, already shown to have demonstrable but limited clinical antiviral activity.

Long-term, but not short-term, treatment with somatotropin during pregnancy in underfed pigs increases the body size of progeny at birth.

Treatment of pigs with porcine ST (pST) in early to mid-pregnancy increases body weight and length of their fetuses by mid-pregnancy, but this increased weight may not persist to birth. We investigated the effects of short- (25 d) and long-term (75 d) treatment with pST, and interactions between long-term pST treatment and crude protein content of diet, in restricted-fed gilts. In both experiments, Large White x Landrace gilts were bred at first estrus to Large White x Duroc boars and allowed to farrow naturally. In the first experiment, gilts were fed 1.8 kg/d of a diet containing 13.5 MJ DE/kg of DM and 15.05% CP (as-fed basis) throughout pregnancy, and were injected daily with 0, 2, or 4 mg pST from d 25 to 50 of pregnancy. Maternal treatment with pST from d 25 to 50 of pregnancy did not affect the number of piglets born per litter or progeny size at birth. In the second experiment, gilts were injected daily with 0 or 2 mg of pST and fed 2.2 kg/d of a diet containing 14.5 MJ DE/kg and either (as-fed basis) 16.6% (0.81% lysine) or 22.2% CP (1.16% lysine) from d 25 to 100 of pregnancy. All gilts were then fed 3.0 kg/d of the lower protein diet from d 100 of pregnancy to farrowing. Treatment with 2 mg pST/d from d 25 to 100 of pregnancy increased live weight of all gilts during the treatment period (P = 0.016), but the change in maternal live weight from d 25 to 100 of pregnancy was only increased (P = 0.001) by pST in gilts fed the higher protein diet. Live weight of gilts 1 d after farrowing was increased by pST treatment (P = 0.007), but was not altered by protein content of diet during pregnancy. In gilts fed the lower protein diet, but not in those fed the higher protein diet, pST treatment decreased maternal backfat depth during treatment (P < 0.020) and 1 d after farrowing (P = 0.002). Treatment with pST during pregnancy did not affect the number of piglets born per litter but independently increased body weight by 11.6% (P < 0.001) and length by 3.4% (P = 0.005) of progeny at birth and decreased (P < 0.01) the negative effect of litter size on body weight at birth. We conclude that in feed-restricted gilts, fetal weight gains in response to 25 d of pST treatment before mid-pregnancy are not maintained to term but that treatment with pST during most of pregnancy increases progeny size at birth and reduces maternal constraint of fetal growth.

A prospective comparison of the costs of reusable and limited-reuse laparoscopic instruments.

OBJECTIVE: To compare the cost and performance of 2 types of laparoscopic instrumentation: reusable laparoscopic hook cautery instruments and curved scissors, or limited-reuse laparoscopic hook cautery instruments and curved scissors. DESIGN: A randomized trial. SETTING: The operating room of a tertiary care hospital. METHOD: All general surgeons performing laparoscopic procedures at the hospital were randomized to be supplied with either reusable or limited-reuse hook cautery and curved scissors. Instrument use was recorded, together with principal outcome measures. OUTCOME MEASURES: Life expectancy of the instruments, the number of cases for which they were used, the number, nature and cost of repairs, their purchase cost and surgeon satisfaction. RESULTS: Reusable hook cautery instruments were less expensive than their limited-reuse counterparts. Excellent surgeon satisfaction was reported with the use of this type of instrument. The limited-reuse curved scissors arm of the study was terminated early because of a breach in study protocol. CONCLUSIONS: Reusable hook cautery instruments were better than their limited-reuse counterparts. Rigorous attempts to compare the cost of laparoscopic instruments may be limited by their rapid evolution in design and the availability of many types of instruments on the market.