Interventions for acute otitis externa.

BACKGROUND: Acute otitis externa is an inflammatory condition of the ear canal, with or without infection. Symptoms include ear discomfort, itchiness, discharge and impaired hearing. It is also known as 'swimmer's ear' and can usually be treated successfully with a course of ear drops. OBJECTIVES: To assess the effectiveness of interventions for acute otitis externa. SEARCH STRATEGY: Our search for published and unpublished trials included the Cochrane Ear, Nose and Throat Disorders Group Trials Register; CENTRAL; PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; mRCT and additional sources. The date of the most recent search was 6 January 2009. SELECTION CRITERIA: Randomised controlled trials evaluating ear cleaning, topical medication or systemic therapy in the treatment of acute otitis externa were eligible.We excluded complicated acute otitis externa; otitis externa secondary to otitis media or chronic suppurative otitis media; chronic otitis externa; fungal otitis externa (otomycosis); eczematous otitis externa; viral otitis externa and furunculosis. DATA COLLECTION AND ANALYSIS: Two authors assessed eligibility and quality. MAIN RESULTS: Nineteen randomised controlled trials with a total of 3382 participants were included. Three meta-analyses were possible. The overall quality of studies was low.Topical antimicrobials containing steroids were significantly more effective than placebo drops: OR 11 (95% CI 2.00 to 60.57; one trial).In general, no clinically meaningful differences were noted in clinical cure rates between the various topical interventions reviewed. One notable exception involved a trial of high quality which showed that acetic acid was significantly less effective when compared with antibiotic/steroid drops in terms of cure rate at two and three weeks (OR 0.29 (95% CI 0.13 to 0.62) and OR 0.25 (95% CI 0.11 to 0.58) respectively).One trial of low quality comparing quinolone with non-quinolone antibiotics did not find any difference in clinical cure rate.No trials evaluated the effectiveness of ear cleaning.Only two trials evaluated steroid-only drops. One trial of low quality suggested no significant difference between steroid and antibiotic/steroid but did not report the magnitude or precision of the result. Another trial of moderate quality comparing an oral antihistamine with topical steroid against topical steroid alone found that cure rates in both groups were high and comparable (100% (15/15) and 94% (14/15) respectively at three weeks). AUTHORS' CONCLUSIONS: There is a paucity of high quality trials evaluating interventions for acute otitis externa. The results of this systematic review are largely based on odds ratios calculated from single trials, most of which have very broad 95% confidence intervals because of small to modest sample sizes. The findings may not be wholly generalisable to primary care for a variety of reasons; only two of the 19 trials included in the review were conducted in a primary care population setting, and in 11 of the 19 trials ear cleaning formed part of the treatment (an intervention unlikely to be available in primary care). Despite these reservations, some meaningful conclusions can be drawn from the evidence available:Topical treatments alone, as distinct from systemic ones, are effective for uncomplicated acute otitis externa. In most cases the choice of topical intervention does not appear to influence the therapeutic outcome significantly. Any observed differences in efficacy were usually minor and not consistently present at each follow-up visit. Acetic acid was effective and comparable to antibiotic/steroid at week 1. However, when treatment needed to be extended beyond this point it was less effective. In addition, patient symptoms lasted two days longer in the acetic acid group compared to antibiotic/steroid.The evidence for steroid-only drops is very limited and as yet not robust enough to allow us to reach a conclusion or provide recommendations. Further investigation is needed.Given that most topical treatments are equally effective, it would appear that in most cases the preferred choice of topical treatment may be determined by other factors, such as risk of ototoxicity, risk of contact sensitivity, risk of developing resistance, availability, cost and dosing schedule. Factors such as speed of healing and pain relief are yet to be determined for many topical treatments and may also influence this decision.Patients prescribed antibiotic/steroid drops can expect their symptoms to last for approximately six days after treatment has begun. Although patients are usually treated with topical medication for seven to 10 days it is apparent that this will undertreat some patients and overtreat others. It may be more useful when prescribing ear drops to instruct patients to use them for at least a week. If they have symptoms beyond the first week they should continue the drops until their symptoms resolve (and possibly for a few days after), for a maximum of a further seven days. Patients with persisting symptoms beyond two weeks should be considered treatment failures and alternative management initiated.

Dyspnea-Think outside of the box, a case of subglottic stenosis.

Dyspnea is a common presentation in upper and lower airway obstructive causes. However, biphasic stridor and hoarseness should prompt evaluation of the upper airway. Nasendoscopy carried out by the otolaryngology team is a quick and an effective way of evaluating the upper airway.

Surgical complications of tracheo-oesophageal puncture and speech valves.

PURPOSE OF REVIEW: Speech rehabilitation following total laryngectomy is central to future quality of life. Although other options exist, surgical voice restoration has emerged as the 'gold standard' management strategy in the majority of laryngectomees. Taking this into account, what are the complications of this technique and how should they be successfully managed? The purpose of this review is to provide a comprehensive review of the subject, with particular reference to technique, complications and outcome. RECENT FINDINGS: As with any surgical intervention, complications may occur in the early postoperative period or later. The article provides a detailed explanation of the varying problems detailed in individual reports, and in case series. Primary or secondary tracheo-oesophageal puncture is also discussed, along with complications resulting from the speech valve itself. SUMMARY: The positive impact of surgical voice restoration on quality of life in the alaryngeal patient considerably outweighs the complications commonly associated with the procedure. Greater knowledge of the potential problems should continue to reduce the complication rate. Primary puncture, in a patient selected and subsequently managed in a multidisciplinary environment, would appear to provide the best outcome for the patient.

Acquired paediatric subglottic cysts: a series from Manchester.

UNLABELLED: Subglottic cysts (SGC) have long been regarded as a rare cause of airway obstruction but through increased awareness an increase in the number of cases of SGC has been reported. OBJECTIVE: This paper describes the pathogenesis and management of SGC. DESIGN: Retrospective case series. Ethical approval not sought. SETTING: Royal Manchester Children's Hospital. PATIENTS: Two hundred and six new referrals for direct laryngotracheobronchoscopy (DLTB) were identified from records between September 2003 and September 2005. MAIN OUTCOMES MEASURED: Age at birth, sex, length of intubation, presenting symptoms, age at presentation, DLTB findings, interventional procedures, and follow-up DLTBs. RESULTS: Fourteen out of 206 (6.8%) infants were diagnosed as with subglottic cysts. This represented the fourth most common cause of upper airway pathology. Thirteen out of 14 (93%) infants were preterm (26.8 weeks S.D. 25.3-28.3 weeks). All infants had been intubated ranging from 1 to 180 days (median 42 days). The onset of symptoms ranged from 1 to 13 months (median 4.25 months). Initially, 8/14 (57.2%) infants had SGC cysts marsupialised with microforceps. A further six cysts (50%) were decapped between 2 and 4 months and one between 6 and 12 months. CONCLUSION: The number of cases of SGC has been increasing over the last three decades and represents the fourth most common causes of airway obstruction in our series. There is a delay in onset of symptoms and high rate of recurrence in the first 4 months. It is therefore prudent to reschedule further endoscopic evaluation between 2 and 4 months and after 6 months should the clinical need arise.

Does Meningitis Stop CSF Rhinorrhea following Lateral Skull Base Surgery?

In cases of cerebrospinal fluid (CSF) rhinorrhea following lateral skull base surgery, fibrosis and fibrin formation resulting from meningitis has been postulated as a mechanism of spontaneously resolving the CSF leak. This study was undertaken to explore any possible relationship between the cessation of CSF leak and meningitis. A retrospective study at a tertiary referral center of 232 consecutive patients was performed. Out of a total of 232 procedures, 29 patients developed CSF rhinorrhea, of whom 7 subsequently developed meningitis. Bacteria were isolated in CSF obtained at lumbar puncture in 5 cases, with the CSF analysis in the remaining 2 cases suggesting aseptic meningitis. Conservative treatment failed to stop the CSF rhinorrhea in 6 of 7 cases. In this study, the development of meningitis did not appear to aid in the resolution of the CSF rhinorrhea. We conclude that surgical intervention should not be delayed in the expectation that meningitis and conservative interventions may promote CSF leak resolution.

A comparison of surgical techniques used in dynamic reanimation of the paralyzed face.

OBJECTIVES: To compare the outcomes of three surgical techniques used in the rehabilitation of the paralyzed face. STUDY DESIGN: Retrospective study. SETTING: University-based tertiary referral center. PATIENTS: Between 1976 and 2000, rehabilitative facial nerve surgery was performed on 70 adult patients with varying underlying diseases. INTERVENTION: Three methods of facial nerve rehabilitative surgery were performed: end-to-end anastomosis, cable nerve graft interposition, and classic faciohypoglossal transposition. MAIN OUTCOME MEASURES: The House-Brackmann grade was scored at 6, 12, 24, and 36 months by the two senior authors. A favorable outcome was defined as House-Brackmann Grade

Endoscopic resection and topical 5-Fluorouracil as an alternative treatment to craniofacial resection for the management of primary intestinal-type sinonasal adenocarcinoma.

Introduction. Intestinal-type adenocarcinoma of the sinonasal tract is very rare and is responsible for less than 4% of tumours of the sinuses. Craniofacial resection has been the mainstay of treatment for many years; however, techniques for endoscopic resection are constantly being developed. Discussion. The use of transnasal endoscopic resection (TER) and topical chemotherapy applications as an alternative to cranio-facial resection (CFR) is discussed. TER offers advantages over CFR in terms of fewer intra-operative complications and an improved cosmetic outcome. Survival and metastatic rates are similar between both procedures. Patients with locally invasive tumours are better managed with CFR. Topical applications of 5-Fluorouracil has been shown to be effective in increasing survival in patients with sino-nasal malignancy. Conclusion. Trans-nasal endoscopic resection and topical 5-Fluorouracil could potentially offer an acceptable alternative treatment to the standard of cranio-facial resection. This should be investigated in trials with a longer followup period than this paper in order to directly compare the two treatment modalities.

An assessment of fine-needle sampling techniques.

INTRODUCTION: Fine-needle cytology sampling, when adequate, is highly sensitive and specific for tissue-type diagnosis, with figures of 94% and 88%, respectively. This study explores the technique of sampling to reduce interoperator variability and ensure maximal tissue yield. MATERIALS AND METHODS: Apple cortical tissue was sampled as a proxy of human lymph node. A total of 200 samples, by four methods, with 50 by each sampling method, were taken using blue venepuncture needles and weighed to assess tissue yield. RESULTS: Results were analysed using one-way analysis of variance and Tukey's HSD test. Comparable yields, by mass, were achieved by both straight lance and coring techniques (P > 0.05). Significantly greater yield was achieved with a multiplanar technique (P < 0.05). CONCLUSIONS: Multiplanar sampling increases mass yield of tissue in fine-needle sampling. Coring appears to have little bearing on yield.

Mucosal melanoma of the head and neck: radiotherapy or surgery?

INTRODUCTION: Head and neck mucosal melanoma (MuM) is rare, comprising < 1% of all melanomas in Western Europe. METHODS: A retrospective analysis of case records of patients treated between 1965 and 2001 was carried out. (Survival outcomes were obtained from the case notes and cancer registry.) The median age of the 68 patients was 63 years (range 29-86 years). Thirty-nine percent were male, and 61% were female. (The minimum follow-up time was 15 months.) The two most common primary sites were the sinonasal complex (65%) and oral cavity (19%). Twenty-one percent of patients presented with metastases (nodal or distant). Fifty-five patients were treated with curative intent: 30 patients with primary radiotherapy and 25 patients with surgery +/- postoperative radiotherapy. RESULTS: The overall survival was 22% at 5 years, and the cancer-specific survival was 32% at 5 years. CONCLUSION: MuM has a poor overall prognosis. Poor prognostic indicators are site at presentation and presentation with metastasis. This series is unique in that a significant proportion of patients were given primary radiotherapy as definitive treatment. Surgery may have advantages, particularly for oral cavity MuM. In contrast to previous reports, definitive radiotherapy is worthy of consideration as curative treatment.

Audit of clinical coding of major head and neck operations.

INTRODUCTION: Within the NHS, operations are coded using the Office of Population Censuses and Surveys (OPCS) classification system. These codes, together with diagnostic codes, are used to generate Healthcare Resource Group (HRG) codes, which correlate to a payment bracket. The aim of this study was to determine whether allocated procedure codes for major head and neck operations were correct and reflective of the work undertaken. HRG codes generated were assessed to determine accuracy of remuneration. PATIENTS AND METHODS: The coding of consecutive major head and neck operations undertaken in a tertiary referral centre over a retrospective 3-month period were assessed. Procedure codes were initially ascribed by professional hospital coders. Operations were then recoded by the surgical trainee in liaison with the head of clinical coding. The initial and revised procedure codes were compared and used to generate HRG codes, to determine whether the payment banding had altered. RESULTS: A total of 34 cases were reviewed. The number of procedure codes generated initially by the clinical coders was 99, whereas the revised codes generated 146. Of the original codes, 47 of 99 (47.4%) were incorrect. In 19 of the 34 cases reviewed (55.9%), the HRG code remained unchanged, thus resulting in the correct payment. Six cases were never coded, equating to pound15,300 loss of payment. CONCLUSIONS: These results highlight the inadequacy of this system to reward hospitals for the work carried out within the NHS in a fair and consistent manner. The current coding system was found to be complicated, ambiguous and inaccurate, resulting in loss of remuneration.