How I do it: intracapsular coblation tonsillectomy.

BACKGROUND: There has been increased interest in the adoption of an intracapsular tonsillectomy technique in the UK in recent years. The adoption of any newer surgical technique inevitably is accompanied by an educational need. OBJECTIVES: This paper aims to outline the equipment preparation and surgical steps for intracapsular coblation tonsillectomy, including recognition of the tonsillar capsule. The paper also discusses how to avoid and deal with common complications and technical difficulties.

Susceptibility of Rice to Oebalus pugnax (F.) (Hemiptera: Pentatomidae) Feeding at Different Levels of Grain Maturity and Impacts on Insecticide Termination.

The stages of rice, Oryza sativa L. (Poales: Poaceae), grain maturity that are most susceptible to rice stink bug, Oebalus pugnax (F.), damage have been identified; however, the stage at which they are no longer capable of causing appreciable damage during grain maturity is unclear. The objective of this study was to determine the susceptibility of rice to rice stink bug feeding at different levels of grain maturity and determine an insecticide termination timing. Rice stink bug damage was examined using five levels of grain maturity described as percent of kernels reaching mature straw coloration referred to as hard dough (20, 40, 60, 80, and 100%) across a range of infestation levels using single panicle sleeve cages and large cages. Hybrid and conventional cultivar rice panicles at 20, 40, and 60% hard dough were found to be susceptible to indirect yield loss, as two rice stink bugs per panicle resulted in over 7% peck. In large cage trials, 25 rice stink bugs caused 0.7-1% peck to hybrid and conventional rice plots at 20% hard dough. Much less damage was observed once rice reached 60% hard dough, where peck averages only reached 0.4%. Decreased damage at 60% hard dough was validated using uncaged trials where 0.4% additional peck was observed in unsprayed plots. These data indicate that rice in the early stages of hard dough is susceptible to large levels of indirect yield loss, but unless significant densities of rice stink bug are present at 60% hard dough, no more sampling or applications are necessary.

Multidisciplinary guidelines for the management of paediatric tracheostomy emergencies.

Temporary and permanent tracheostomies are required in children to manage actual or anticipated long-term ventilatory support, to aid secretion management or to manage fixed upper airway obstruction. Tracheostomies may be required from the first few moments of life, with the majority performed in children < 4 years of age. Although similarities with adult tracheostomies are apparent, there are key differences when managing the routine and emergency care of children with tracheostomies. The National Tracheostomy Safety Project identified the need for structured guidelines to aid multidisciplinary clinical decision making during paediatric tracheostomy emergencies. These guidelines describe the development of a bespoke emergency management algorithm and supporting resources. Our aim is to reduce the frequency, nature and severity of paediatric tracheostomy emergencies through preparation and education of staff, parents, carers and patients.

Controversies in the management of deep neck space infection in children: an evidence-based review.

BACKGROUND: Deep neck space infection (DNSI) is defined as infection in the potential spaces and fascial planes of the neck. Early recognition of DNSI can be challenging due to the complex head and neck anatomy; hence, a high index of suspicion is required to prevent a delay in diagnosis and appropriate management. OBJECTIVE OF REVIEW: There remains a lack of consensus on the management of paediatric DNSI with many advocating a more aggressive approach with immediate surgical drainage, while others favour a more conservative approach with medical management in the first instance. The current literature on the management of paediatric DNSI is reviewed. TYPE OF REVIEW AND SEARCH STRATEGY: A literature review performed in November 2015 searched PubMed using the terms 'deep neck space', 'infection', 'paediatric', 'pediatric', 'children', 'imaging', 'conservative', 'antibiotic' and 'surgery'. Articles not in the English language were excluded. RESULTS: (i) Clinical presentation: Management of a compromised airway is the priority. Clinical history and examination enables the identification of the primary source of infection and presence of complications. (ii) Investigations: Laboratory and microbiological investigations should be appropriately targeted, and CT imaging is the modality utilised in most cases. The presence of specific complications may warrant other imaging modalities. (iii) Antibiotics: An evidence-based antibiotic regime is proposed. (iv) Conservative treatment: In children lacking indications for surgical intervention, a trial 48 h of intravenous antibiotics (IV Abx) should be commenced. v) Surgical intervention: Indications include signs of airway compromise, presence of complications, no clinical improvement after 48 h of IV Abx, abscess >2.2 cm on CT imaging, age <4 years and ITU admission. CONCLUSIONS: An appreciation of head and neck anatomy is vital to understanding disease pathology and potential complications of DNSI, which may be life threatening. Both conservative and surgical approaches are viable treatment options and may compliment each other. Current evidence suggests that clinical management should be targeted towards the individual patient as factors such as age of the child may influence the balance of a conservative versus a surgical approach.

Congenital familial subglottic stenosis: a case series and review of literature.

Subglottic stenosis is a narrowing of the endolarynx and maybe classified as congenital (primary) or acquired (secondary). Congenital stenosis maybe caused by a small cricoid cartilage, thick submucosa or other laryngeal abnormalities and remains a well-known cause of stridor in infancy. It occurs sporadically and familial occurrence is rare. Our case series identifies three children with congenital subglottic stenosis born to consanguineous parents. Congenital subglottic stenosis in siblings of unrelated parents has been previously reported, but not in consanguineous parents indicating a strong genetic link. We recommend further genetic research to assess the mode of possible heritage in this disease.

Treatment of paediatric laryngeal papillomas: web survey of British Association of Paediatric Otolaryngologists.

BACKGROUND AND OBJECTIVE: Recurrent respiratory papillomatosis is the most common benign neoplasm of the larynx in children. Intralesional injection of cidofovir may have some potential as an adjunctive treatment. There is no standardised protocol in the UK for the management of recurrent respiratory papillomatosis. This study aimed to investigate the management practices of surgeons treating paediatric recurrent respiratory papillomatosis in the UK. METHOD: A web questionnaire survey was sent by e-mail to all members of the British Association of Paediatric Otorhinolaryngology. RESULTS: Out of 35 respondents, 23 were at that time treating children with recurrent respiratory papillomatosis. Nineteen respondents preferred to use a microdebrider, 12 preferred laser, and 5 preferred cold steel along with either laser or a microdebrider. Twelve surgeons used cidofovir for selected patients and 12 surgeons did not use cidofovir for any patients. Cidofovir was considered after 0­4 surgical procedures by seven respondents, after 4­6 surgical procedures by four respondents and after 6 surgical procedures by six respondents. Eleven respondents warned patients about the possible side effects of cidofovir and five gave no warning. CONCLUSION: There was no consensus as to when it would be appropriate to use cidofovir, indicating the need for cidofovir usage guidelines.

12 minute consultation: An evidence-based approach to the management of a child with speech and language delay.

BACKGROUND: Speech and language delay is a common developmental disorder. Persistent delay may lead to adverse effects on literacy, educational achievement and psychosocial development. Affected children are commonly referred to the otolaryngologist; hence, a structured management approach is required to facilitate diagnosis and allow for early intervention and improved outcomes. METHODS: A literature search was performed on 05 November 2012 using the MEDLINE, EMBASE and Cochrane databases with the search terms paediatric, children, speech, language, delay, disorder, investigation and management. Relevant references from selected articles were reviewed after reading the abstract. RESULTS: Speech and language delay may be primary, meaning there is no associated comorbidity to account for the delay, or secondary, where it can be attributed to another condition or syndrome. Secondary causes include hearing loss and syndromes such as Down syndrome amongst many others. Speech and language therapy has been shown to be effective for primary disorders. If the delay is found to be secondary in nature, onward referral to an appropriate healthcare professional is required. CONCLUSIONS: The outpatient consultation for a child with speech and language delay should consist of a structured history and examination with the aim of identifying whether the delay is primary or secondary in nature. Relevant targeted investigations should lead to a correct diagnosis of the delay and enable appropriate treatment. This often requires a multidisciplinary approach and always requires full cooperation from the child's parents.

The involvement of parents in healthcare decisions where adult children are at risk of lacking decision-making capacity: a qualitative study of treatment decisions in epilepsy.

BACKGROUND: Patients with intellectual disabilities (ID) receive health care by proxy. It is family members and/or paid support staff who must recognise health problems, communicate with clinicians, and report the benefits, if any, of a particular treatment. At the same time international and national statutes protect and promote the right of people with disabilities to access the highest attainable standards of health on the basis of free and informed consent. METHODS: To consider the role of parent-proxies in the management of epilepsy in adult children with ID who are at risk of lacking capacity to make decisions about their health care we interviewed 21 mothers. FINDINGS: These mothers are not pursuing changes in treatment that might improve their son or daughter's epilepsy, nor are they willing to countenance changes in treatment. Clinicians concerned to build and sustain therapeutic alliances with these mothers, our evidence suggests, may well avoid going against their wishes. DISCUSSION: Our research highlights the interactional contingencies of a hitherto neglected three-way clinical relationship comprising parent-proxy, an adult at risk of lacking decision-making capacity, and a treating clinician. This is a relationship, our findings suggest, where little importance is attached to either patient consent, or involvement in treatment decisions.

Review article: reflux and its consequences--the laryngeal, pulmonary and oesophageal manifestations. Conference held in conjunction with the 9th International Symposium on Human Pepsin (ISHP) Kingston-upon-Hull, UK, 21-23 April 2010.

BACKGROUND: Gastro-oesophageal reflux disease (GERD) is one of the commonest diseases of Western populations, affecting 20 to 30% of adults. GERD is multifaceted and the classical oesophageal symptoms such as heartburn and regurgitation often overlap with atypical symptoms that impact upon the respiratory system and airways. This is referred to as extra-oesophageal reflux disease (EERD), or laryngopharyngeal reflux (LPR), which manifests as chronic cough, laryngitis, hoarseness, voice disorders and asthma. AIM: The 'Reflux and its consequences' conference was held in Hull in 2010 and brought together a multidisciplinary group of experts all with a common interest in the many manifestations of reflux disease to present recent research and clinical progress in GERD and EERD. In particular new techniques for diagnosing reflux were showcased at the conference. METHODS: Both clinical and non-clinical key opinion leaders were invited to write a review on key areas presented at the `Reflux and its consequences' conference for inclusion in this supplement. RESULTS AND CONCLUSION: Eleven chapters contained in this supplement reflected the sessions of the conference and included discussion of the nature of the refluxate (acid, pepsin, bile acids and non-acid reflux); mechanisms of tissue damage and protection in the oesophagus, laryngopharynx and airways. Clinical conditions with a reflux aetiology including asthma, chronic cough, airway disease, LPR, and paediatric EERD were reviewed. In addition methods for diagnosis of reflux disease and treatment strategies, especially with reference to non-acid reflux, were considered.

Self-poisoning suicide deaths in England: could improved medical management contribute to suicide prevention?

BACKGROUND: Suicide by self-poisoning is a major cause of death worldwide. Few studies have investigated the medical management of fatal self-poisoning. AIM: To describe the characteristics and management of a national sample of individuals who died by intentional self-poisoning in hospital and assess the quality of care that they received. DESIGN: National population-based descriptive study and confidential inquiry. METHODS: Adults (aged ≥ 16 years) who had died by self-poisoning in English hospitals in 2005 and received a coroner's verdict of suicide or undetermined death at inquest were included. Socio-demographic and clinical data were collected through detailed questionnaires sent to clinicians at the treating hospitals. A panel of three expert assessors rated each case with respect to quality of care and likely contribution to the fatal outcome. RESULTS: We obtained information on 121 cases (response rate for questionnaires 77%). Expert assessors rated 41/104 cases [39% (95% CI 30-49%)] as having received inadequate care; in the majority (38/41-93%) of these, this poor care was felt to have potentially contributed to the patient's death. The most common reason for a rating of inadequate care was poor airway management (recorded in over half of inadequate care cases). In three cases, the receipt of inadequate care was associated with the presence of some form of advance directive. CONCLUSION: In as many as 39% of in-hospital self-poisoning fatalities, the care received may be in some way sub-optimal. The challenge for clinical services is to ensure that optimal management strategies are implemented in practice.

Radio opacity of various ENT foreign bodies in sheep's neck preparation.

We conducted an experimental study to evaluate the radio densities of different ENT foreign bodies. Various ENT foreign bodies were placed in the oesophagus of a sheep's neck preparation. An X-ray lateral view of the neck was taken, following the soft tissue neck protocol. Foreign bodies were grouped depending upon their radio densities and pixel value. The visibility of different materials on plain radiographs depends on their ability to absorb X-rays, and their inherent radio density and relation between it and the tissue in which they are embedded.

How is epilepsy treated in people with a learning disability? A retrospective observational study of 183 individuals.

Epilepsy in those with learning disability (LD) is currently managed by various health agencies with no obvious criteria for selecting particular care pathways and limited evidence-based descriptions of optimal treatment. The aim of this study was to examine relationships between management strategies and clinical outcomes in a community-based cohort of individuals with epilepsy and LD. The results may inform epilepsy management directly and contribute to an evidence base to support development of formal clinical trials. An attempt was made to recruit all individuals with epilepsy and LD known to community LD health services in one geographic area. However, those with profound LD were under-represented in the final sample. Information relating to the epilepsy, the severity of the LD, comorbidities and epilepsy management were obtained retrospectively both from the clinical notes and from interviews with carers and clinicians. We recruited 183 individuals of whom 33% had no reported seizures in the previous three months whilst 12% recorded more than 20 seizures per month. 73 individuals were receiving monotherapy, 66 were treated with two AEDs and 42 were prescribed three or more AEDs at the time of the study. In those taking monotherapy, there was no difference in the mean monthly seizure frequency between groups taking different AEDs. Similarly, for those prescribed two AEDS, no particular combination was associated with significantly lower seizure frequency. One third of the sample was receiving epilepsy management from hospital neurology services but no criteria determining choice of treatment pathway were identified. The findings suggest that more research needs to be carried out to identify both optimal care pathways and AED strategies.