European consensus-based (S2k) Guideline on the Management of Herpes Zoster - guided by the European Dermatology Forum (EDF) in cooperation with the European Academy of Dermatology and Venereology (EADV), Part 2: Treatment.

Herpes zoster (HZ, shingles) is a frequent medical condition which may severely impact the quality of life of affected patients. Different therapeutic approaches to treat acute HZ are available. The aim of this European project was the elaboration of a consensus-based guideline on the management of patients who present with HZ, considering different patient populations and different localizations. This interdisciplinary guideline aims at an improvement of the outcomes of the acute HZ management concerning disease duration, acute pain and quality of life of the affected patients and at a reduction in the incidence of postherpetic neuralgia (PHN) and other complications. The guideline development followed a structured and pre-defined process, considering the quality criteria for guidelines development as suggested by the AGREE II instrument. The steering group was responsible for the planning and the organization of the guideline development process (Division of Evidence-Based Medicine, dEBM). The expert panel was nominated by virtue of clinical expertise and/or scientific experience and included experts from the fields of dermatology, virology/infectiology, ophthalmology, otolaryngology, neurology and anaesthesiology. Recommendations for clinical practice were formally consented during the consensus conference, explicitly considering different relevant aspects. The guideline was approved by the commissioning societies after an extensive internal and external review process. In this second part of the guideline, therapeutic interventions have been evaluated. The expert panel formally consented recommendations for the treatment of patients with HZ (antiviral medication, pain management, local therapy), considering various clinical situations. Users of the guideline must carefully check whether the recommendations are appropriate for the context of intended application. In the setting of an international guideline, it is generally important to consider different national approaches and legal circumstances with regard to the regulatory approval, availability and reimbursement of diagnostic and therapeutic interventions.

European consensus-based (S2k) Guideline on the Management of Herpes Zoster - guided by the European Dermatology Forum (EDF) in cooperation with the European Academy of Dermatology and Venereology (EADV), Part 1: Diagnosis.

Herpes zoster (HZ, shingles) is a frequent medical condition which may severely impact the quality of life of affected patients. Different therapeutic approaches to treat acute HZ are available. The aim of this European project was the elaboration of a consensus-based guideline on the management of patients who present with HZ, considering different patient populations and different localizations. This interdisciplinary guideline aims at an improvement of the outcomes of the acute HZ management concerning disease duration, acute pain and quality of life of the affected patients and at a reduction of the incidence of postherpetic neuralgia and other complications. The guideline development followed a structured and predefined process, considering the quality criteria for guidelines development as suggested by the AGREE II instrument. The steering group was responsible for the planning and the organization of the guideline development process (Division of Evidence based Medicine, dEBM). The expert panel was nominated by virtue of clinical expertise and/or scientific experience and included experts from the fields of dermatology, virology/infectiology, ophthalmology, otolaryngology, neurology and anaesthesiology. Recommendations for clinical practice were formally consented during the consensus conference, explicitly considering different relevant aspects. The guideline was approved by the commissioning societies after an extensive internal and external review process. In this first part of the guideline, diagnostic means have been evaluated. The expert panel formally consented recommendations for the management of patients with (suspected) HZ, referring to the assessment of HZ patients, considering various specific clinical situations. Users of the guideline must carefully check whether the recommendations are appropriate for the context of intended application. In the setting of an international guideline, it is generally important to consider different national approaches and legal circumstances with regard to the regulatory approval, availability and reimbursement of diagnostic and therapeutic interventions.

Independent prescriber physiotherapist led balance clinic: the Southport and Ormskirk pathway.

OBJECTIVE: To report the introduction and impact of non-medical prescribing, initiated to improve patient pathways for those presenting with dizziness and balance disorders. METHODS: The Southport and Ormskirk physiotherapy-led vestibular clinic sees and treats all patients with dizziness and balance disorders referred to the ENT department. Letters are triaged by an audiologist, who also performs an otological examination and hearing test; this is followed by an assessment with the independent prescriber physiotherapist. An ENT consultant is nearby if joint consultation is needed. Diagnoses, treatments and patient satisfaction were studied, with an analysis of the impact of medication management (stopping or starting medicines) on patients and service. RESULTS: In 12 months, 413 new patients with dizziness and balance disorders had appointments. The most common diagnoses were benign paroxysmal positional vertigo and vestibular migraine. Eighty-four per cent of patients required self-management strategies, 50 per cent exercise therapy, 48 per cent medication management and 24 per cent a particle repositioning manoeuvre. Patient satisfaction was high (99 per cent). CONCLUSION: Having an independent prescriber physiotherapist leading the balance clinic has reduced the number of hospital visits and onward referrals. Nearly half of all patients required medication management as part of their dizziness or balance treatment.

Pooled analysis of the evidence for open cavity, combined approach and reconstruction of the mastoid cavity in primary cholesteatoma surgery.

BACKGROUND: Cholesteatoma is keratinising epithelium within the middle-ear cleft or mastoid. This disease destroys the peripheral organs of balance and hearing, with possible intracranial sequelae. The management of cholesteatoma is surgical and the primary aim is to remove the disease and prevent recurrence. Secondary aims are to obtain a non-discharging, hearing ear. Cholesteatoma surgery falls into two broad categories: open cavity surgery and combined approach surgery. A third surgical category is reconstruction of an open mastoid cavity after open surgery. This study performed a pooled analysis of the worldwide literature to compare the rates of cholesteatoma not being cured (i.e. recidivism), ear discharge and hearing change among open cavity, combined approach and reconstruction mastoid surgery for primary cholesteatoma. METHODS: A literature search for all types of cholesteatoma surgery in the PubMed, Google Scholar and Medline databases and in published conference proceedings was undertaken. RESULTS: There was no level 1 evidence for the best method of primary cholesteatoma surgery. The highest evidence level found (level 2; 5366 patients) shows no difference in hearing change or discharge rate between open and combined approach surgery; however, these methods fail to cure the cholesteatomas in 16.0 per cent and 29.4 per cent of cases, respectively. In a total of 640 patients, reconstruction and/or repair mastoid surgery using a variety of non-comparable techniques had a failure rate of between 5.3 per cent and 20 per cent. CONCLUSION: The available evidence suggests that reconstruction of the posterior canal wall and/or obliteration of the mastoid may be the best surgical treatment alternative. This technique appears to provide the lowest recidivism rate combined with a low post-operative ear discharge rate.

Malleus osteotomy: improving access to the anterior tympanum.

Access to the anterior tympanic cavity is often restricted by the handle of the malleus. The aim of this paper is to describe a surgical malleus osteotomy that allows the malleus handle to swing superiorly. The authors have found few problems related to this technique, especially with regard to restoration of normal post-operative hearing.

Problems in alloplastic middle ear reconstruction.

Alloplastic materials have been used in middle ear reconstruction since 1952. Biologically, biomaterials and specifically ceramics can be defined as being bioinert, bioactive or biodegradable; these terms being descriptive of the biochemical response provoked by the material in the host tissue. Various ceramics, carbons and polymers and their reactions have been studied by the author and his colleagues over the past 5 years utilising animal implantation and fibroblast culture studies aligned with experience from clinical usage. The qualities of the ideal alloplastic implant namely: biocompatibility, stabilisation and incorporation, the consistency of the implant and bioactive bonding and the biofunctionality or mechanics, are applied to the materials currently available. No single alloplastic material fulfills all criteria, the problems encountered in relation to the biomaterials are reported. A better understanding of the microstresses, fatigue and microfractures is necessary, before the ideal alloplastic biomaterial becomes available.

Laryngeal trauma vs length of intubation.

The frequency histograms of six patients' laryngographs were studied pre- and post-endotracheal intubation. The changes were correlated with the length of intubation. The post-operative hoarse voice was seen as an increase in the spread of the lower frequencies, and an increase in the fundamental frequency. The latter change was thought to be a subconscious compensation for the hoarseness. The increased lower frequency spread as measured by standard deviation was directly proportional to the length of intubation.

The tympanic membrane in cross section: a finite element analysis.

This paper applies the technique of finite element analysis to the tympanic membrane. A two-dimensional cross-sectional model of the tympanic membrane and malleus is described. A variety of experiments have been performed on this model, and the displacements under a uniform load are analysed. The shape of the displaced membrane and the movement of the umbo were found to be sensitive to a number of factors. These include the elastic modulus of the membrane, the presence and position of the axis or rotation of the malleus, and the size of the pars flaccida. Some implications of these results are discussed.

The role of radiography in the management of nasal fractures.

The role of radiographs in the management of nasal fractures is assessed. The injury is common and the total cost of radiographs significant. A retrospective study concluded that radiographs were not definitive in the management of nasal fractures. This prompted a prospective study, in which 54 patients were assessed clinically, radiologically and under anaesthesia. At each stage they were grouped into treatment and pathological categories and the contribution of each type of assessment studied. Radiographs were not found to be useful in the routine management of nasal fractures.

Grommet insertion in children: a survey of parental perceptions.

Grommet insertion is a widely accepted method of treatment of glue ear in children. There have been questions raised over the last few years about the indications for grommets and whether assessing the hearing alone is an efficient outcome measure. Parental pressure accounts for one of the factors that is taken into consideration when the decision to insert grommets for glue ear is made. In this paper, a prospective questionnaire is used to investigate the parental perceptions of the effectiveness of grommet insertion in children, focusing on alternative outcome measures such as general health, language, and social skills. The results of this survey suggest that grommet insertion causes improvement in many factors other than hearing and this seems to account for the parental pressure for siblings to have grommet insertion.

Acoustic schwannoma of traumatic origin? A temporal bone study.

A tumour of the singular nerve was found on examination of the temporal bones of a child who died 13 months after meningitis. The tumour consisted of a main mass with the appearance of an acoustic neuroma but close by and not connected were some nests of tumour cells inside the vestibule. This very unusual finding raises questions of the aetiology of this tumour which may have a bearing on the aetiology of other tumours of the VIIIth. nerve.

Changing incidence of sinus infection in children.

This study presents the results of a 20 year review of maxillary sinus wash-outs performed on children. The results show a decreasing incidence of purulent sinusitis over the study period. Only 17 per cent of antral wash-outs undertaken yielded pus, indicating that surgical practice has failed to adequately take account of the changing disease incidence.

Day case surgery in otolaryngology: the setting up and first year of a freestanding unit.

A freestanding day case surgery unit for ENT cases is described and the first year's experience reviewed. Special attention is paid to the variety, and complications, of surgery as the freestanding unit is 17 miles from the main ENT centre. The difficulties of running the unit are reviewed. The problems encountered include arranging training for the staff and maintaining optimum throughput of cases. Consideration is also given to the setting up and running costs of the unit. Four hundred and seventy-seven patients were treated from 46 lists. This accounted for 64 per cent of the total number of patients having ENT surgery in 1992 from our area.

Simple, painless, cosmetic closure of endaural incisions.

Endaural incisions provide a cosmetic approach to the middle-ear cleft, tympanic membrane for myringoplasty, and attic and antrum for small cavity mastoidectomy. These wounds have traditionally been closed with sutures, but platelet or fibrin adhesives provide an alternative. However, discomfort at the time of suture removal, particularly in children, and the risk of transmission of blood-borne infections in gels are limitations to these wound closure techniques. This paper describes our experience with Histoacryl glue (butyl-2-cyanoacrylate) in closing endaural incisions.

Efficacy of medical treatment as an adjunct to surgery in the treatment of secretory otitis media.

In a pilot controlled randomised trial of 38 children who had bilateral secretory otitis media, with effusion demonstrated at operation, we compared the efficacy of a six-week course of an oral decongestant--antihistamine combination and a mucolytic preparation with a control group in preventing the presence of middle-ear effusion six weeks after myringotomy and adenoidectomy. The mucolytic preparation decreased the presence of middle-ear effusion when compared to the decongestant-antihistamine combination and the control group (p = 0.06).

Dyskeratosis congenita and nasopharyngeal atresia.

Dyskeratosis congenita is a multisystem disorder with an increased incidence of neoplasia and opportunistic infections. A case is reported as a cause of complete nasopharyngeal atresia.

Intubation trauma: a comparison of two different endotracheal tubes.

In recent years endotracheal tubes with low pressure cuffs have become available with the aim of reducing trauma to the trachea and larynx. This paper uses laryngographic methods to analyse intubation trauma in 20 short to medium term intubations. No difference in laryngeal trauma was found between low pressure, large diameter cuffs when compared to standard cuffs.

Ear, nose and throat manifestations of Lyme disease.

The manifestations of Lyme disease as they may present to the ENT surgeon are discussed. The most important ENT symptom is facial palsy. Particularly when combined with other cranial palsies, systemic illness or signs of meningeal irritation, the diagnosis must be considered. Three case reports are used to illustrate the presentation and diagnosis and treatment of Lyme disease. The characteristics of the disease are reviewed and the limitations of serological testing outlined. The literature has concentrated on bilateral or relapsing facial palsy. A review of palsies in Zurich that presented to the ENT clinic found only unilateral and partial palsies. The diagnosis should be considered in every case of facial palsy of unknown aetiology especially in children.