Unexpected overnight stay following ENT day-case surgery: a 5-year audit.

Unexpected overnight stay following ENT day-case surgery: a 5-year audit. PROBLEMS/OBJECTIVES: Recent decades have seen a steady reduction in the average duration of hospitalization for all surgical patients, including those undergoing ENT procedures. Correspondingly, the proportion of day surgeries relative to in-patient surgeries has progressively increased. In the present observational study, we aimed to evaluate the proportion of unplanned overnight stays following planned day surgeries in our ENT unit, and the major causes of these unexpected overnight admissions. METHODS: From databases, we collected data from all patients who underwent ENT day-case surgery in Ziekenhuis Oost- Limburg between January 2008 and December 2013. RESULTS: A total of 10,440 patients underwent ENT day-case surgery during this period. The overall rate of unexpected overnight admission was 1.86%, with these overnight admissions most commonly due to anaesthetic (46.91%), surgical (19.59%), and organizational (17.01%) reasons. The types of ENT surgery at the greatest risk for prolonged hospitalisation were hemithyroidectomy (12.50%), tympanoplasty (12.15%), and uvulopalatopharyngoplasty (UPPP) (7.81%). We further identified a clear difference in the rate of unexpected overnight stay between surgery scheduled in the morning (1.17%) versus in the afternoon (12.98%). CONCLUSIONS: Our present findings highlight the various reasons for unexpected overnight admission after day-case surgery. To reduce the rate of unexpected overnight stays, we need to better understand these different reasons to support the ongoing search for possible solutions.

Facial trauma.

Facial trauma. Patients with facial trauma must be assessed in a systematic way so as to avoid missing any injury. Severe and disfiguring facial injuries can be distracting. However, clinicians must first focus on the basics of trauma care, following the Advanced Trauma Life Support (ATLS) system of care. Maxillofacial trauma occurs in a significant number of severely injured patients. Life- and sight-threatening injuries must be excluded during the primary and secondary surveys. Special attention must be paid to sight-threatening injuries in stabilized patients through early referral to an appropriate specialist or the early initiation of emergency care treatment. The gold standard for the radiographic evaluation of facial injuries is computed tomography (CT) imaging. Nasal fractures are the most frequent isolated facial fractures. Isolated nasal fractures are principally diagnosed through history and clinical examination. Closed reduction is the most frequently performed treatment for isolated nasal fractures, with a fractured nasal septum as a predictor of failure. Ear, nose and throat surgeons, maxillofacial surgeons and ophthalmologists must all develop an adequate treatment plan for patients with complex maxillofacial trauma.

Mucocutaneous leishmaniasis of the nose: a case report.

Mucocutaneous leishmaniasis of the nose: a case report. Leishmaniasis is a parasitic infection that is rarely seen in Belgium. The majority of new diagnoses are seen in patients living in or visiting endemic regions, which are mostly developing countries. Here we describe the case of a 60-year-old male patient who was referred to an ENT specialist because of an erythematous swelling of the left side of the nose tip, which had persisted for 3 months. Biopsies showed the presence of leishmaniasis. This case report alerts ENT physicians that leishmaniasis is part of the differential diagnosis in patients who present with an uncommon persistent lesion in the head and neck region and who have travelled to endemic regions or are immunodeficient.

Epidemiology of ENT emergencies.

OBJECTIVE: To give an overview of ear, nose, and throat (ENT) pathologies encountered in the emergency room (ER). METHODS: Retrospective analysis of 1296 files of patients visiting the ER between January 2008 and December 2012. Diagnosis, treatment, hospitalisation, referral, and demographic parameters were evaluated. RESULTS: Epistaxis is the most frequent ENT condition seen in the ER. One third of epistaxis patients are on anticoagulant therapy. The second most frequent conditions observed were infections of the pharynx and tonsils. Nasal fractures and vertigo were also frequently observed. CONCLUSION: Epistaxis and its treatment were the most frequent ENT diagnosis and therapy seen in the ER. Infections are the main cause of hospitalisation. Referral to other disciplines and revisits seldom occurred.

Patient reported outcome measures (PROMs) in children with sleep-disordered breathing undergoing adenotonsillectomy.

OBJECTIVES: Patient reported outcome measures (PROMs) asses the health status or health related quality of life from the patient's perspective. The aims of this study were to assess the effect of adenotonsillectomy on symptoms and daily functioning in children with sleep-disordered breathing (SDB) using an electronic questionnaire, and to determine if this is a feasible method to evaluate treatment outcome in this patient population. METHODS: The electronic questionnaire was administered to the parents of children undergoing adenotonsillectomy for SDB on the day of surgery (T0), and two weeks (T1) and six months (T2) after surgery. The questionnaire scored symptoms in 5 different fields (snoring, sleepiness, behaviour, appetite, and apnoea). Higher scores indicated more pronounced symptoms. The score on T0 measured the preoperative symptoms. The main outcome measure (the change in scores between the postoperative measurements and the preoperative measurement) was analysed using the Wilcoxon signed-rank test. RESULTS: Eighty-eight percent of invited patients participated in the study. Six percent had no access to internet, and another 6% did not wish to participate. Language problems were not reported. Response rates for T1 and T2 were 82.6% and 79.7% respectively. The T1 and T2 scores were significantly lower than the scores on T0 for snoring, behaviour, apnoea, and sleepiness. The T2 appetite score was significantly higher than on T0, which indicates an improvement of appetite. CONCLUSION: A comparison of pre- and postoperative results from an electronic disease-specific questionnaire indicated significantly improved symptoms and daily functioning in children undergoing adenotonsillectomy for SDB. High participation and response rates indicated it was feasible to assess treatment outcome by means of an electronic questionnaire.

ENT one day surgery: critical analysis with the HFMEA method.

OBJECTIVES: Research shows that 51.4% of adverse events in hospitals occur in surgery and that 3-22% of surgical patients experience adverse events. The risk may be even higher when turnover is high and when patients are children, as is often the case in ear, nose and throat surgery. This quality project therefore started in response to requests from physicians in two hospitals in the Flemish part of Belgium. The aim of this study is to use the Healthcare Failure Mode & Effect Analysis method to evaluate the process flow for ear, nose and throat patients, and to redesign the process to enhance patient safety. METHODOLOGY: In two One Day Clinics, processes were prospectively analysed using the Healthcare Failure Mode & Effect Analysis method. RESULTS: Similar potential failures were reported in both hospitals. The major failure mode was linked to the absence of an active identity check throughout the process. The process was therefore redesigned by implementing a surgical safety checklist and an active identity check protocol. Although the Healthcare Failure Mode & Effect Analysis is a time-consuming method, this systematic approach by a multidisciplinary team has been found to be useful in detecting failure modes that need immediate safety responses. The involvement of all disciplines and an open safety culture during the procedure were the most important conditions. CONCLUSIONS: The Healthcare Failure Mode & Effect Analysis is a useful instrument for detecting the failure modes in this care process.

Tongue and cheek metastases as the first clinical sign of a primary cancer.

Metastases to the oral cavity are rare and are most frequently seen in the jawbones. Soft tissue metastases as the first clinical sign of a metastatic cancer are quite exceptional. In this case report, we describe the history of a 67-year old patient presenting with painless oral lesions for 4 weeks. Biopsies showed metastases of an adenocarcinoma that was not yet identified. This case report highlights that an ENT physician should consider metastases to the oral cavity as part of the differential diagnosis in every patient with an uncommon, persistent oral lesion with unclear origin.

Tonsillectomy compared to acute tonsillitis in children: a comparison study of societal costs.

INTRODUCTION AND AIM: Tonsillectomy is one of the most commonly performed surgical procedures in children; its main indications are recurrent episodes of acute tonsillitis and adenotonsillar hypertrophy. The effectiveness of tonsillectomy for severe recurrent tonsillitis is generally accepted; however its socio-economic cost is less well investigated. This study aims to determine and compare the societal cost of a tonsillectomy and a severe throat infection. MATERIALS AND METHODS: The costs for both tonsillectomy and severe throat infection were evaluated. Costs of the surgical procedure and hospital stay were calculated based on resource use and personnel input at the participating hospital. The cost of work-related disability for both treatments was measured based on a questionnaire filled in by 275 parents of children undergoing a tonsillectomy. Data from two Belgian institutions (NIS and FOD) were used to calculate the cost of parents' absenteeism. RESULTS: An episode of acute tonsillitis in the child results in a longer period of parents' work absenteeism (mean of 3.1 +/- 0.3 days) compared to tonsillectomy (2.2 +/- 0.2 days). The cost of economic productivity loss amounts to 613 Euros (NIS) or 759 Euros (FOD) for acute tonsillitis and 435 Euros (NIS) or 539 Euros (FOD) for a tonsillectomy. The medical costs linked to the surgical procedure at the local department correspond to 535 Euros and for an acute tonsillitis to 46 Euros. CONCLUSIONS: From societal perspective, a tonsillectomy costs the equivalent of 1.4 times the cost of a severe throat infection. This indicates that in children suffering from recurrent acute tonsillitis, watchful waiting results in a higher cost compared to tonsillectomy, given the cumulative costs of parents' absenteeism.

Thrombospondin-1 in early flow-related remodeling of mesenteric arteries from young normotensive and spontaneously hypertensive rats.

We tested the hypotheses that TSP-1 participates in the initiation of remodeling of small muscular arteries in response to altered blood flow and that the N-terminal domain of TSP-1 (hepI) can reverse the pathological inward remodeling of resistance arteries from SHR.We measured (1) changes in gene/protein expression in MA of 6 week old WKY and SHR exposed to either increased (+ 100 %) or reduced blood flow (- 90 %) for 24-40 hours and (2) structural changes in MA of 12 week old SHR exposed for 3 days to hepI in organ culture.In both HF and LF of WKY, mRNA expression of eNOS, sGCα1 and PKG1ß were significantly reduced (p < 0.05), whereas mRNA of TSP1 was markedly increased (p < 0.05). In MA of young SHR, similar results were obtained except that eNOS mRNA was not reduced in LF. Expression of TSP1 protein was significantly increased in LF of young WKY and SHR (p < 0.05). Exposure of MA of 12 week old SHR to hepI (1 µmol/L) resulted in a rapid lumen diameter increase (+ 12 ± 2% after 3 days) without alteration in vascular reactivity, distensibility, media surface area or cell number.These are the first observations of reduced gene expression of eNOS/sGC/PKG and increased expression of TSP1 at the initiation of arterial remodeling in young WKY and SHR, irrespective of its outward or inward outcome. Furthermore, a fragment of TSP-1 rapidly and directly reversed pathological inward arterial remodeling of SHR in vitro.

Effect of adenotonsillectomy on the use of respiratory medication.

OBJECTIVE: Recurrent tonsillitis and upper respiratory tract obstruction due to adenotonsillar hypertrophy are the most common indications for (adeno)tonsillectomy ((A)TE). Symptoms of upper respiratory tract infection and obstruction can, however, be attributed to lower airway pathology and thus treated with respiratory medication - this is non-antimicrobial medication used for lower respiratory diseases like bronchitis, bronchiolitis, asthma and episodic wheezing. The aim of this study is to investigate the effect of the current (A)TE practice in Belgium on the use of respiratory medication in subjects aged 0-15. METHODS: Retrospective data on 11.114 subjects aged 0-15 years old who underwent (A)TE from January 1st 2002 until Sept 30th 2003 were retrieved from the database of the Christelijke Mutualiteit, the largest mutual health insurance society in Belgium. We compared the use of respiratory medication 12 months before and 12 months after (A)TE. RESULTS: Out of 11.114 subjects, 4.654 received at least one prescription for respiratory medication in the year before and/or after (A)TE. In this subgroup, the median respiratory medication use reduced with 32% in the year after surgery. CONCLUSION: Compared with the year before surgery, the median use of respiratory medication in subjects aged 0-15 drastically reduces in the year after (A)TE. A possible reason for this reduction is that children with upper airway obstruction and infections are often wrongly diagnosed as having lower airway problems.

Pharmacokinetic and pharmacodynamic properties of SOL1: a novel dual inhibitor of neutral endopeptidase and endothelin converting enzyme.

AIMS: The pharmacological profile of the novel putative neutral endopeptidase (NEP) and endothelin converting enzyme (ECE) inhibitor SOL1 was examined. MAIN METHODS: The enzyme inhibitory profile of SOL1 was established in vitro. The pharmacokinetic and pharmacodynamic profile was determined in rodents in vivo. KEY FINDINGS: In vitro, at neutral pH, 10 µM SOL1 inhibited NEP-1, NEP-2, and ECE-1 by 99%, 94% and 75%, respectively. The IC(50)s were 25, 25 and 3200 nmol/L, respectively. In anesthetized rats, SOL1 inhibited blood pressure (BP) responses to big-ET-1 and ET-1(1-31) with ED(50)s of 1.9 and 0.03 mg/kg, corresponding to plasma EC(50)s of 4.6 and 0.1 µmol/L, respectively. Pharmacokinetics of SOL1 were examined after single injections in mice and rats. In these species, the estimated clearance of SOL1 varied between 5 and 9 ml/kg.min and T(1/2) between 20 and 60 min. Steady state kinetics of SOL1 were examined after continuous s.c. infusions of SOL1 for 3 weeks at 50mg/kg.day in DOCA-salt hypertensive rats. This treatment lowered BP by 22 mmHg. Steady state concentrations of SOL1 in plasma were 3.9 µmol/L. In heart, lung, and kidney the concentrations of SOL1 were 0.4, 1.8, and 20.5 µmol/kg, respectively. About 63% of the daily dose was retrieved unaltered in the urine. SIGNIFICANCE: These data indicate that SOL1 is primarily a NEP inhibitor in vitro as well as in vivo. Given the preferential renal accumulation and renal clearance of SOL1 additional ECE-1 inhibition in the kidney may have contributed to its chronic BP lowering effects in the DOCA-salt hypertensive rat model.

Physiology of the mouth and pharynx, Waldeyer's ring, taste and smell.

This paper reviews the contribution of the different parts of the oral cavity and the pharynx to the basic physiology of breathing, phonation, speech, swallowing, and of Waldeyer's ring to the functioning of the immune system. We discuss the development of taste and smell, as well as possibilities for chemosensory testing in children.

Clinical aspects of chronic ENT inflammation in children.

In children, all ENT cavities are particularly prone to the development of chronic inflammation. This is due to many predisposing factors, of which the most common are unfavourable anatomy, absence of nasal blowing, day care attendance, allergy, immature immunity, gastro-oesophageal reflux and tobacco smoke exposure. The aim of this paper is to outline the most specific paediatric clinical aspects of chronic pharyngo-tonsillitis, rhinosinusitis, otitis media, adenoiditis and laryngotracheitis and the important influence that some of these pathologies exert on the others.

Specific medical and surgical treatment for chronic inflammatory diseases in children.

Treatment for chronic inflammatory conditions in children should take into account the specific pathophysiological and clinical processes underlying these disorders. These guidelines provide a framework for both the medical and surgical treatment of chronic inflammatory diseases such as otitis media, allergic rhinitis and chronic rhinosinusitis, chronic inflammation of tonsils and adenoids, and laryngitis. In addition, the role of vaccinations and immunomodulatory therapies is discussed. Whenever possible, the evidence levels for specific treatments comply with the Oxford Levels of Evidence.

Outpatient hemithyroidectomy: safety and feasibility.

OBJECTIVE: In Belgium, thyroidectomy is currently an inpatient procedure because of potential life-threatening post-operative complications that include hypocalcemia, laryngeal nerve damage and haemorrhage. Thyroidectomy can only be performed on an outpatient basis if the complication rate is low. The purpose of this study was to determine the feasibility and safety of outpatient hemithyroidectomy. METHODOLOGY: Between March 2008 and September 2010 we selected 54 patients who met our inclusion criteria for outpatient hemithyroidectomy. The procedure was carried out through a standard cervicotomy under general anaesthesia. No drains were used. We analysed patient outcome based on complications, unplanned admissions and readmissions. RESULTS: The mean age of the 54 patients was 46 years, and most of them were women (81%). The mean duration of surgery was 64 minutes, and there were no intra-operative complications. After an observation period of at least 3 hours, 44 patients (81.5%) were discharged as planned. Ten patients (18.5%) required admission for urine retention (n = 1), social circumstances (n = 1), persistence of nausea (n = 3), delayed anaesthesia recovery (n = 4) and patient preference (n = 1). All 10 were discharged the next day, and none were readmitted. CONCLUSIONS: Our study shows that outpatient hemithyroidectomy performed by experienced surgeons in carefully selected patients can be safe and is associated with a low complication rate. However, this series is small and larger studies are needed to confirm the results.

G-protein ßγ subunits in vasorelaxing and anti-endothelinergic effects of calcitonin gene-related peptide.

BACKGROUND AND PURPOSE: Calcitonin gene-related peptide (CGRP) has been proposed to relax vascular smooth muscle cells (VSMC) via cAMP and can promote dissociation of endothelin-1 (ET-1) from ET(A) receptors. The latter is not mimicked by other stimuli of adenylate cyclases. Therefore, we evaluated the involvement of G-protein ßγ subunits (Gßγ) in the arterial effects of CGRP receptor stimulation. EXPERIMENTAL APPROACH: To test the hypothesis that instead of α subunits of G-proteins (Gαs), Gßγ mediates the effects of CGRP receptor activation, we used (i) rat isolated mesenteric resistance arteries (MRA), (ii) pharmacological modulators of cyclic nucleotides; and (iii) low molecular weight inhibitors of the functions of Gßγ, gallein and M119. To validate these tools with respect to CGRP receptor function, we performed organ bath studies with rat isolated MRA, radioligand binding on membranes from CHO cells expressing human CGRP receptors and cAMP production assays in rat cultured VSMC. KEY RESULTS: In isolated arteries contracted with K(+) or ET-1, IBMX (PDE inhibitor) increased sodium nitroprusside (SNP)- and isoprenaline (ISO)- but not CGRP-induced relaxations. While fluorescein (negative control) was without effects, gallein increased binding of [(125) I]-CGRP in the absence and presence of GTPγS. Gallein also increased CGRP-induced cAMP production in VSMC. Despite these stimulating effects, gallein and M119 selectively inhibited the relaxing and anti-endothelinergic effects of CGRP in isolated arteries while not altering contractile responses to K(+) or ET-1 or relaxing responses to ISO or SNP. CONCLUSION AND IMPLICATIONS: Activated CGRP receptors induce cyclic nucleotide-independent relaxation of VSMC and terminate arterial effects of ET-1 via Gßγ.

Alice in Wonderland syndrome and upper airway obstruction in infectious mononucleosis.

The Alice in Wonderland syndrome is a rare clinical feature characterised by perceptual disturbances including visual disturbances and distortion of the body image. This uncommon--but often easy to recognise--syndrome, to which children seem particularly susceptible, can be defined in patients with Epstein Barr Virus (EBV) infection. This report describes a 10-year-old child with a mild upper airway obstruction and manifestations of the Alice in Wonderland syndrome resulting from an acute EBV infection. Because meningo-encephalitis was considered in the differential diagnosis, an MRI examination was performed under midazolam sedation, leading to a severe life-threatening upper airway obstruction.

Current Belgian adenotonsillectomy practice: a survey among Belgian ENT specialists.

OBJECTIVES: Tonsillectomies and adenotonsillectomies (TE and ATE) are among the most frequently performed operations in the western world. Despite the lack of generally accepted clinical guidelines about indications, the beneficial role of the procedure has been established. The aim of this study was to identify current practice relating to indications for tonsillectomies and adenotonsillectomies among Belgian ENT specialists. METHODS: An anonymous questionnaire was sent to all Belgian ENT specialists. Part I of the questionnaire included questions about the ENT specialist himself/herself and his/her practice. Part II comprised questions about indications for TE/ATE in children up to 16 years of age. Part III included questions about indications in adults. RESULTS: 238 out of 528 questionnaires were completed and returned. The majority of physicians consider TE/ATE to be indicated if a child or an adult suffers 3 or 4 tonsillitis episodes per year. The decision to operate on children for upper airway obstruction is mainly based on clinical and anamnestic findings. A peritonsillar abscess is usually considered to be an indication for surgery. We compared the results between different groups of ENT specialists and could detect differences in decision-making only according to the number of years of ENT practice. The stringency of surgeons' indications decreases with increasing surgeon age. CONCLUSIONS: The majority of respondents consider tonsillectomies/adenotonsillectomies to be indicated after 3 to 4 episodes of tonsillitis per year. In the case of upper airway obstruction in children, surgical indications are mainly based on clinical and anamnestic findings. Surgical decision-making appears to be influenced by the number of years of ENT practice.

Antibiotic use and doctor visits are reduced after adenotonsillectomy.

OBJECTIVE: A tonsillectomy, with or without an adenotomy ((A)TE), is a common surgical procedure in children. The most important indications are recurrent tonsillitis and upper airway obstruction secondary to adenotonsillar hypertrophy. The aim of this study was to investigate whether the current (A)TE practice in Belgium reduced the need for medical care. STUDY DESIGN AND METHODS: The database of the Christelijke Mutualiteit, one of the most important health insurance organizations in Belgium, provided data on approximately 11,000 (A)TE's in children aged 0 to 15 years, performed by different ENT-specialists from Jan 1st 2002 to Sept 30th 2003. We compared the use of antibiotics during the 12 months before and the 12 months after (A)TE. We also compared the number of visits to pediatricians and general practitioners during the 12 months before and the 12 months after surgery. RESULTS: The median antibiotic use dropped from 4 boxes in the year before the operation to 1 box in the year after the operation. The median number of doctor visits also dropped from 7 visits in the year before to 4 visits in the year after (A)TE. CONCLUSION: Although there are no generally accepted guidelines on the indications for (A)TE in Belgium, the current practice effectively reduced the need for medical care.

Routine pathological evaluation after tonsillectomy: is it necessary?

OBJECTIVES: There is still no consensus regarding the necessity of sending every tonsil specimen for histological examination following tonsillectomy. To add to this discussion, we assessed the incidence of preoperatively unexpected malignancy in the postoperative tonsil specimens of adults and children in our ENT department. METHODS: We conducted a retrospective study of the histopathology results of all patients who underwent tonsillectomy between January 1999 and February 2006 in the ENT department of East Limburg Hospital in Genk. The charts of patients with postoperative histopathological malignancy were further analysed and reviewed for preoperative indications of the tonsillectomy and for preoperative suspicion of malignancy. RESULTS: A total of 2989 patients were included in the study: 2058 children (defined as 16 years or younger) and 931 adults. No malignancy was found among the children. In 20 adults, malignancy was diagnosed, but in all cases there was a preoperative suspicion of malignancy. No patient without preoperative risk factors was found to have malignancy on pathological evaluation of the tonsils. CONCLUSION: Our results indicate that routine histopathological examination of tonsils removed for benign disease in adults and children is clinically unnecessary. We propose that on an individual basis, the surgeon should decide the need for histological examination depending on preoperative risk factors and peroperative gross examination. Such a strategy will only be medicolegally possible where there are national and scientifically (evidence)based ENT consensus reports or guidelines on this issue.