The post-operative tonsillectomy (POPT) study: A multi-centre prospective paediatric cohort study.

OBJECTIVES: Tonsillectomy is the most common operation performed by otolaryngologists in the UK, despite this we have a poor understanding of the post-operative recovery. We aimed to investigate post-operative bleeding and pain following paediatric tonsillectomy using a patient diary. DESIGN: Prospective observational cohort study. SETTING: Multi-centre study involving 12 secondary and tertiary otolaryngology units across the North of England. Patients were recruited from 1st March 2020 to 30th June 2022. Multilevel ordered logistic regression model statistics were performed. PARTICIPANTS: Children (≥4 years, ≤16 years) undergoing tonsillectomy (with or without adenoidectomy) for benign pathology. MAIN OUTCOME MEASURES: Frequency and severity of post-operative bleeding. Intensity and pattern of post-operative pain. RESULTS: In total 297 children were recruited, with 91 (30.6%) diaries eligible for analysis. Post-operative bleeding occurred in 44% of children. Most frequently blood in the saliva was reported (82.9%). Increasing age significantly increased bleeding odds by 17% per year (p = .001). Bleeding frequency decreased with higher surgeon grade (p = .003) and when performing intracapsular coblation tonsillectomy (p = .02) compared with other techniques. Lower age and intracapsular coblation tonsillectomy, against other techniques, significantly reduced rates of pain post-operatively (p < .0001 and p = .0008). CONCLUSION: A high level of low-level post-operative bleeding was observed. Pain scores remained high for 5 days post-operatively then gradually reduce to normal by day 13. Intracapsular coblation tonsillectomy appears to be superior to all other techniques in terms of reducing post-operative bleeding and pain. These findings should be used to guide patients in the consent process to inform them of the expected nature of post-surgical recovery.

Performance Characteristics of Basophil Activation Tests for Diagnosing Penicillin Allergy: A Meta-Analysis.

BACKGROUND: Approximately 10% of the global population identify themselves as penicillin allergic, yet 90% are not truly allergic and could safely tolerate penicillin. There is no simple way to identify these people. Current in vitro diagnostics include specific immunoglobulin E (with a sensitivity of 19% and specificity of 97%) and a basophil activation test (BAT) with undefined sensitivity and specificity. OBJECTIVE: To define the sensitivity and specificity of BAT in the diagnosis of penicillin allergy METHODS: We searched PubMed and EMBASE from inception to April 2, 2023, for original studies evaluating the performance characteristics of BAT for penicillin allergy in adults. Study selection, data extraction, risk of bias, assessment with QUADAS-2 tool, certainty assessment with Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology were performed independently, in duplicate. Meta-analysis was performed using Reitsma methodology. RESULTS: Twenty-two studies fulfilled the inclusion criteria. Twelve used the same positive threshold giving a summary point sensitivity 51% (95% confidence interval [95% CI]46%-56%) and specificity 89% (95% CI 85%-93%). Significant risk of bias was identified owing to patient selection. GRADE certainty of evidence rated sensitivity very low due to imprecision and specificity as low. There was great heterogeneity in methods used. Use of 1,000 basophils per test did not improve performance above 500 basophils. CONCLUSIONS: BAT sensitivity is highly variable across studies and remains too low to be considered as a routine element of clinical practice. BAT specificity is not as good as specific immunoglobulin E in penicillin allergy diagnosis. Significant further work is required in this field before clinical application of BAT in routine practice.

Virtual reality in simulation-based emergency skills training: A systematic review with a narrative synthesis.

Objective: An important role is predicted for virtual reality (VR) in the future of medical education. We performed a systematic review of the literature with a narrative synthesis, to examine the current evidence for VR in simulation-based emergency skills training. We broadly define emergency skills as any clinical skill used in the emergency care of patients across all clinical settings. Methods: This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines. The data sources accessed during this study included: PubMed, CINAHL, EMBASE, AMED, EMCARE, HMIC, BNI, PsychINFO, Medline, CENTRAL, SCOPUS, Web of Science, BIOSIS Citation Index, ERIC, ACM Digital Library, IEEE Xplore, and ProQuest Dissertations and Thesis Global. Cochrane's Rob 2 and ROBVIS tools were used during study quality assessment. No ethical review was required for this work. Results: Thirty-four articles published between 14th March 1998 and 1st March 2022 were included in this review. Studies were predominantly conducted in the USA and Europe and focussed on a variety of healthcare disciplines including medical, nursing, and allied health. VR education was delivered using head-mounted displays, Cave Automatic Virtual Environment systems, and bespoke setups. These systems delivered education in a variety of areas (emergency medicine, equipment training, obstetrics, and basic/advanced life support). Subjective potential advantages of this technology included realism, replayability, and time-effectiveness. Reports of adverse events were low in frequency across the included studies. Whilst clear educational benefit was generally noted, this was not reflected in changes to patient-based outcomes. Conclusion: There may be educational benefit to using VR in the context of simulation-based emergency skills training including knowledge gain and retention, skill performance, acceptability, usability, and validity. Currently, there is insufficient evidence to demonstrate clear cost-effectiveness, or direct improvement of patient or institutional outcomes, at this stage.

Primary squamous cell carcinoma of the thyroid gland successfully treated with surgical resection and adjuvant chemoradiotherapy.

A 57-year-old woman presented with a 3-month history of an enlarging thyroid mass causing breathlessness and dysphagia. Cross-sectional imaging showed a thyroid tumour infiltrating the trachea and abutting the oesophagus. She underwent panendoscopy, total thyroidectomy and planned tracheal resection, but due to intraoperative findings, a staged procedure was planned instead. Histological analysis revealed a poorly differentiated squamous cell carcinoma (SCC) which was positive on paired box gene 8 (PAX8) immunostaining, suggesting a diagnosis of primary thyroid SCC. She subsequently underwent total laryngectomy and bilateral neck dissections followed by radiotherapy with concurrent cisplatin chemotherapy. The patient remains disease-free 22 months after treatment. Median overall survival is 10 months for macroscopically completely resected tumours. PAX8 immunostaining is a novel technique which helps with the diagnostic challenge of distinguishing between primary thyroid SCC and SCC metastatic to the thyroid from extrathyroidal sites. Complete surgical resection with adjuvant chemoradiotherapy may result in a favourable outcome despite conflicting reports in the literature.

Fatal laryngeal burn from ingestion of a hot fish cake: Case report and literature review.

INTRODUCTION: Laryngeal burn from hot food ingestion is a rare but potentially life-threatening presentation. It is essential that clinicians have a high index of suspicion of potential airway obstruction in such cases. To our knowledge, this is the only case of fatal laryngeal oedema caused by hot solid food ingestion reported in the literature. PRESENTATION OF CASE: A 51 year old male presented to the Emergency Department complaining of a burn to the throat following ingestion of a piping hot fish cake. On initial assessment he reported only mild pain and increased saliva production. There was no evidence of stridor, dysphagia, dyspnoea or aspiration and hence the patient was discharged and advised to return if he experienced any worsening of his symptoms. 2 h later the patient collapsed at home and died due to airway obstruction from delayed laryngeal oedema. DISCUSSION: 27 cases of laryngeal burn from ingestion of hot food or liquid were identified in the literature. Only one fatality following ingestion of hot liquid has been reported. This is the first documented fatal laryngeal burn due to ingestion of hot solid food. At present, there are no guidelines for the assessment and management of laryngeal contact burns. CONCLUSION: Patients may be relatively asymptomatic immediately after thermal injury to the larynx. Endoscopic examination of the larynx is required to identify laryngeal oedema. Any sign of thermal injury to the laryngeal mucosa warrants admission for observation and definitive management of the airway should be considered.