Non-invasive Assessment and Symptomatic Improvement of the Obstructed Nose (NASION): a physiology-based patient-centred approach to treatment selection and outcomes assessment in nasal obstruction.

OBJECTIVES: To evaluate the impact of selecting treatment for nasal obstruction on the basis of a structured physiology-based assessment protocol on patient outcomes. DESIGN: Prospective longitudinal study. SETTING: District general hospital. PARTICIPANTS: A population of 71 patients with a mean age of 33 years, containing 36 males, presented with nasal obstruction for consideration of nasal surgery. All patients underwent a structured clinical assessment, skin prick allergy testing and oral-nasal flow-volume loop examination. Fifty-one patients completed the follow-up, and mean follow-up was 11 months. MAIN OUTCOME MEASURES: NOSE, SNOT-22 and NASION scales. RESULTS: Of the 51 patients who completed follow-up, six had conservative treatment, 28 had septal/turbinate surgery, and 17 underwent nasal valve surgery. Mean NOSE score fell from 68 ± 18 to 39 ± 31 following the treatment. Mean SNOT-22 score fell from 47 ± 20 to 29 ± 26 following the treatment. The difference between pre-treatment and post-treatment NOSE and SNOT-22 scores were statistically significant. Success rate of septal/turbinate surgery in patients without nasal allergy was 88%, and this fell to 42% in patients undergoing septal/turbinate surgery who also had nasal allergy. Presence of nasal allergy was the only independent predictor of treatment failure. Patients with nasal valve surgery reported significantly greater symptomatic improvement following surgery. The newly formed NASION scale demonstrated internal consistency with a Cronbach α of 0.9 and excellent change-responsiveness and convergent validity with correlation coefficients of 0.64 and 0.77 against treatment-related changes in SNOT-22 and NOSE scales, respectively. CONCLUSIONS: Successful surgical outcomes can be achieved with the use of a structured history, clinical evaluation and physiological testing. Flow-volume loops can help elucidate the cause of nasal obstruction. The newly formed NASION scale is a validated retrospective single time-point patient outcome measure.

Endoscopic-guided injection of botulinum toxin into the cricopharyngeus muscle: our experience.

OBJECTIVE: To assess the efficacy of endoscopic-guided botulinum toxin injection into the cricopharyngeus muscle and evaluate the duration of its effects. METHODS: A 3-year prospective study of 12 patients undergoing injection of botulinum toxin was conducted, with a telephone survey to assess dysphagia pre-operatively, and at 1, 3 and 6 months post-treatment, using the MD Anderson Dysphagia Inventory. RESULTS: Median age was 66.2 years. Causes of cricopharyngeal dysphagia included idiopathic cricopharyngeal hypertrophy (67 per cent), previous cerebrovascular accident (17 per cent), cranial nerve palsy (8 per cent) and previous chemoradiotherapy to the neck (8 per cent). There were no complications. Two patients had repeat injections after six months. There was significant improvement in MD Anderson Dysphagia Inventory scores at one and three months versus pre-operative scores (73.1 ± 14.9 vs 46.9 ± 7.6, p = 0.0001, and 65.1 ± 11.5 vs 46.9 ± 7.6, p = 0.0001), but not at six months (51.0 ± 11.0 vs 46.9 ± 7.6, p = 0.14). CONCLUSION: Endoscopic-guided injection of botulinum toxin into the cricopharyngeus muscle is a safe and effective method for treating cricopharyngeal muscle dysfunction, lasting up to six months.

A multi-centre audit of epistaxis management in England: is there a case for a national review of practice?

OBJECTIVE: The ENT-UK Clinical Audit and Practice Advisory Group initiated a pilot audit to investigate variance in epistaxis management between six units nationwide. METHOD: All patients with a diagnosis of epistaxis who were admitted for in-patient care at six ENT departments between November 2011 and February 2012 were prospectively enrolled. RESULTS: A total of 166 patients were included in the study. Variance was demonstrated between the six units in a number of the key outcome areas. Twenty-eight per cent of patients were identified as eligible for operative intervention for epistaxis in one unit, compared with only 12.5 per cent in another. CONCLUSION: There are measurable, patient-relevant outcomes to assess epistaxis management and these can highlight areas of potential improvement. This pilot audit gives a snapshot of modern practice, which shows variance between the six units assessed. A national audit may allow us to improve patient experience and maximise efficiency in delivering emergency care in our most common patient encounter.

Impact of unilateral vocal fold mobility impairment on laryngopulmonary physiology.

OBJECTIVE: To examine the impact of unilateral vocal fold mobility impairment (UVFMI) on airway physiology. STUDY DESIGN: Cross-sectional observational study. PARTICIPANTS: There were 21 patients with UVFMI and 53 controls. MAIN OUTCOME MEASURES: All patients and patient controls underwent a maximum-effort flow-volume loop examination. Forced expiratory flow in one second (FEV1 ), forced expiratory volume (FVC), peak inspiratory flow rate and peak expiratory flow rate (PIFR and PEFR, respectively) and area under the inspiratory and expiratory flow-volume loops (AUCI nspiratory and AUCE xpiratory, respectively) were measured. The ratio of PEFR to PIFR and AUCE xpiratory to AUCI nspiratory was derived. RESULTS: There were 48 males and 26 females. Mean age at measurement was 39 ± 11 years. Patients and controls were matched for age, sex, height and weight. None of the expiratory variables were significantly different between the groups. PIFR was significantly lower in UVFMI patients compared with controls (3.4 ± 1.2 versus 5.3 ± 1.8; P < 0.0001), as was AUCI nspiratory (11.5 ± 6.3 versus 17.5 ± 8.5; P = 0.0002). PEFR/PIFR provided the best differentiation between patients with UVFMI and controls with an area under the Receiver Operating Characteristic (ROC) curve of 0.96 and at a threshold of 1.9, and PEFR/PIFR had sensitivity and specificity of 95.2% and 90.6%, respectively. CONCLUSIONS: Flow-volume loops are a non-invasive method of studying vocal abduction and could compliment voice assessment and laryngoscopy in UVFMI. With further research, they could provide an outcome measure for laryngeal rehabilitative procedures, and a shared physiological language for screening and surgical quality assurance.

A prospective, single-blind, randomised, crossover study comparing three nasal hygiene systems and corresponding patient preference for such devices.

OBJECTIVE: To assess subjective preference using three nasal hygiene systems: Stérimar Original(®), Emcur(®) and Sinus Rinse™. DESIGN: We used a prospective, single-blind, randomised, crossover study to compare three nasal hygiene systems: Stérimar Original, Emcur and Sinus Rinse. SUBJECTS: Eighteen adult volunteers were recruited and were asked to rate their experience over three days using three well-established nasal hygiene systems. A standard visual analogue scale was used to assess five criteria: (1) simplicity of instructions; (2) ease of use; (3) comfort; (4) perceived nasal clearance (effectiveness) and (5) single best overall system. RESULTS: Stérimar Original was found to have the easiest instructions to understand compared to the other two systems. There was no significant difference between Stérimar Original and Sinus Rinse with regards to ease of use but they were both significantly easier to use than Emcur (p < 0.05). There was no statistically significant difference between the three systems when comparing the last three criteria. There was no alteration in preference when the cost of each treatment was disclosed to the subjects, and no significant side effects were reported. CONCLUSION: The instructions accompanying Stérimar Original appeared to be the easiest to understand, while Stérimar Original and Sinus Rinse were easier to use than Emcur.

An audit of the nature and impact of clinical coding subjectivity variability and error in otolaryngology.

OBJECTIVES: To audit the accuracy of clinical coding in otolaryngology, assess the effectiveness of previously implemented interventions, and determine ways in which it can be further improved. DESIGN: Prospective clinician-auditor multidisciplinary audit of clinical coding accuracy. PARTICIPANTS: Elective and emergency ENT admissions and day-case activity. MAIN OUTCOME MEASURES: Concordance between initial coding and the clinician-auditor multi-disciplinary teams (MDT) coding in respect of primary and secondary diagnoses and procedures, health resource groupings health resource groupings (HRGs) and tariffs. RESULTS: The audit of 3131 randomly selected otolaryngology patients between 2010 and 2012 resulted in 420 instances of change to the primary diagnosis (13%) and 417 changes to the primary procedure (13%). In 1420 cases (44%), there was at least one change to the initial coding and 514 (16%) health resource groupings changed. There was an income variance of £343,169 or £109.46 per patient. The highest rates of health resource groupings change were observed in head and neck surgery and in particular skull-based surgery, laryngology and within that tracheostomy, and emergency admissions, and specially, epistaxis management. A randomly selected sample of 235 patients from the audit were subjected to a second audit by a second clinician-auditor multi-disciplinary team. There were 12 further health resource groupings changes (5%) and at least one further coding change occurred in 57 patients (24%). These changes were significantly lower than those observed in the pre-audit sample, but were also significantly greater than zero. Asking surgeons to 'code in theatre' and applying these codes without further quality assurance to activity resulted in an health resource groupings error rate of 45%. The full audit sample was regrouped under health resource groupings 3.5 and was compared with a previous audit of 1250 patients performed between 2007 and 2008. This comparison showed a reduction in the baseline rate of health resource groupings change from 16% during the first audit cycle to 9% in the current audit cycle (P < 0.001). CONCLUSIONS: Otolaryngology coding is complex and susceptible to subjectivity, variability and error. Coding variability can be improved, but not eliminated through regular education supported by an audit programme.

Identification of predictors and development of a screening protocol for cerebello-pontine lesions in patients presenting with audio-vestibular dysfunction.

OBJECTIVES: Magnetic resonance imaging (MRI) scanning in the investigation of cerebellopontine angle lesions represents a finite resource, the use of which needs to be carefully rationalised. Our aim was to identify predictive factors that can distinguish between patients with and without cerebellopontine angle lesions, and develop a screening protocol which could be useful in the clinical setting as an aid to clinical judgment. DESIGN: Case-control study. SETTING: Secondary care. PARTICIPANTS: Audio-vestibular features were collated on 136 patients (M : F 1.39 : 1) and 288 controls (M : F 1 : 1.1). INTERVENTION: Diagnostic by analysis of symptoms and audiometric data using logistic regression, receiver-operator characteristic curves and backwards elimination. MAIN OUTCOME MEASURES: Development of a predictive algorithm comprising those factors which are most strongly predictive of the presence of a cerebellopontine angle lesion. RESULTS: Positive predictors of a cerebellopontine angle lesion include the interaural threshold difference at 1 (P = 0.044) and 4 kHz (P = 0.034). The threshold in the better hearing ear at 0.25 kHz exerts a negative predictive (i.e. protective) effect (P = 0.005). The presence of tinnitus does not appear to influence the outcome on logistic regression. Although vertigo does exert an influence on the overall model, its impact is highly equivocal. CONCLUSIONS: We have identified audiometric factors which exert a positive and negative predictive influence on the presence of a cerebellopontine angle lesion, and audiovestibular symptoms which appear to exert little effect on the model. Our predictive equation represents a user-friendly standardised method of risk-stratification of patients within a general otolaryngology clinic.

Tension pneumo-orbit treated by endoscopic, endonasal decompression: case report and literature review.

OBJECTIVE: We present a 38-year-old man with a tension pneumo-orbit following medial orbital wall fracture, managed with endoscopic decompression. METHOD: A case report and a review of the world literature concerning the aetiology, clinical features and management of medial orbital wall fractures are presented. RESULTS: Our patient presented with a post-traumatic tension pneumo-orbit exacerbated by air travel and nose-blowing. Computed tomography revealed a fracture of the ethmoid bone, and intra-orbital emphysema causing proptosis. Management with endoscopic, endonasal surgery produced excellent results, with decompression achieved and immediate and sustained improvement in visual acuity. CONCLUSION: A search of the world literature revealed no documented cases of tension pneumo-orbit as a complication of medial orbital wall fracture. Endoscopic sinus surgery is currently used in the management of nasal and sinus diseases and their orbital complications. We discuss this extended indication of endoscopic surgery, and its advantages over other surgical approaches.

Screening patients with sensorineural hearing loss for vestibular schwannoma using a Bayesian classifier.

OBJECTIVES: Selecting patients with asymmetrical sensorineural hearing loss for further investigation continues to pose clinical and medicolegal challenges, given the disparity between the number of symptomatic patients, and the low incidence of vestibular schwannoma as the underlying cause. We developed and validated a diagnostic model using a generalisation of neural networks, for detecting vestibular schwannomas from clinical and audiological data, and compared its performance with six previously published clinical and audiological decision-support screening protocols. DESIGN: Probabilistic complex data classification using a neural network generalization. SETTINGS: Tertiary referral lateral skull base and a computational neuroscience unit. PARTICIPANTS: Clinical and audiometric details of 129 patients with, and as many age and sex-matched patients without vestibular schwannomas, as determined with magnetic resonance imaging. MAIN OUTCOME MEASURES: The ability to diagnose a patient as having or not having vestibular schwannoma. RESULTS: A Gaussian Process Ordinal Regression Classifier was trained and cross-validated to classify cases as 'with' or 'without' vestibular schwannoma, and its diagnostic performance was assessed using receiver operator characteristic plots. It proved possible to pre-select sensitivity and specificity, with an area under the curve of 0.8025. At 95% sensitivity, the trained system had a specificity of 56%, 30% better than audiological protocols with closest sensitivities. The sensitivities of previously-published audiological protocols ranged between 82-97%, and their specificities ranged between 15-61%. DISCUSSION: The Gaussian Process ORdinal Regression Classifier increased the flexibility and specificity of the screening process for vestibular schwannoma when applied to a sample of matched patients with and without this condition. If applied prospectively, it could reduce the number of 'normal' magnetic resonance (MR) scans by as much as 30% without reducing detection sensitivity. Performance can be further improed through incorporating additional data domains. Current findings need to be reproduced using a larger dataset.

Endonasal endoscopic approach to the petrous apex: an image-guided quantitative anatomical study.

BACKGROUND: The petrous apex is a relatively inaccessible region, deeply situated within the skull base. Removal of lesions from this area, traditionally accomplished via lateral approaches, can cause significant morbidity. We undertook an anatomical study to investigate the surgical anatomy of the petrous apex through an endonasal endoscopic approach, which has been sporadically described in the literature, to investigate its feasibility and to characterise clear and consistent surgical landmarks for access. METHODS: Cadaveric dissections were performed on five heads. Pre-dissection computed tomography scans were used, with the BrainLab navigation system, to verify entry into the petrous apex. Surgical landmarks were characterised in relation to fixed sphenoid sinus structures, and surgical access before and after drilling the sphenoid sinus rostrum was quantitatively compared. RESULTS: The landmark for entry into the petrous apex was the intersection of a vertical line halfway between the medial surface of the internal carotid artery and the midline, with a horizontal line one-third of the way up from the postero-inferior floor of the sphenoid sinus. The dimensions of the postero-superior sphenoid sinus were characterised by the inter-carotid distance, pituitary-to-sphenoid-floor distance and the width of the sphenoid sinus floor, which were 15 +/- 3 mm, 16 +/- 3 mm and 26 +/- 1.6 mm respectively. The surface area of surgical access was 193 +/- 28 mm(2), increasing to 316 +/- 39 mm(2) after drilling of the sphenoid rostrum (P < 0.001; paired t-test). CONCLUSIONS: Endoscopic approach to the petrous apex is anatomically feasible, and, aided by image navigation, could extend the scope of endonasal surgery to access highly-selected lesions in the middle cranial fossa.

The Great Ormond Street Hospital paediatric cochlear implant programme 1992-2004. A review of surgical complications.

The authors present a review of surgical complications following cochlear implantation at Great Ormond Street Hospital, since inception of the programme in 1992 until June 2004. Complications are defined as major (resulting in re-operation, explantation, re-implantation or which resulted in permanent serious morbidity or mortality) or minor (where the implant was not threatened). A comparison of surgical complication rates is made both with an earlier study in the same institution and also with other cochlear implantation centres worldwide. The decrease in surgical complication rates is discussed along with the difficulties inherent in cochlear implantation in the paediatric population with coexisting medical complaints.

Immunohistochemical estimation of cell cycle phase in laryngeal neoplasia.

We previously developed an immunohistochemical method for estimating cell cycle state and phase in tissue samples, including biopsies that are too small for flow cytometry. We have used our technique to examine whether primary abnormalities of the cell cycle exist in laryngeal neoplasia. Antibodies against the markers of cell cycle entry, minichromosome maintenance protein-2 (Mcm-2) and Ki67, and putative markers of cell cycle phase, cyclin D1 (G1-phase), cyclin A (S-phase), cyclin B1 (G2-phase) and phosphohistone H3 (Mitosis) were applied to paraffin-embedded sections of normal larynx (n = 8), laryngeal dysplasia (n = 10) and laryngeal squamous cell carcinoma (n = 10). Cells expressing each marker were determined as a percentage of total cells, termed the labelling index (LI), and as a percentage of Mcm-2-positive cells, termed the labelling fraction (LF). The frequency of coexpression of each putative phase marker was investigated by confocal microscopy. There was a correlation between Mcm-2 and Ki67 LIs (rho = 0.93) but Mcm-2 LIs were consistently higher. All cells expressing a phase marker coexpressed Mcm-2, whereas Ki67 was not expressed in a proportion of these cells. The putative phase markers showed little coexpression. Labelling index values increased on progression from normal larynx through laryngeal dysplasia to squamous cell carcinoma for Mcm-2 (P = 0.001), Ki67 (P = 0.0002), cyclin D1 (P = 0.015), cyclin A (P = 0.0001) and cyclin B1 (P = 0.0004). There was no evidence of an increase in the LF for any phase marker. Immunohistochemistry can be used to estimate cell cycle state and phase in laryngeal biopsies. Our data argues against primary cell cycle phase abnormalities in laryngeal neoplasia.

A bifid intra-tympanic facial nerve in association with a normal stapes.

A rare facial nerve anomaly was incidentally discovered whilst performing a tympanoplasty and ossicular reconstruction on a patient with an acquired unilateral conductive hearing loss. The nerve was seen to bifurcate and straddle a normal stapes superstructure as it ran posteriorly through the middle ear, a unique and as yet unreported combination. This case highlights the importance of vigilance regarding facial nerve anatomical variations encountered during middle-ear surgery thus avoiding inadvertent damage. The purported embryological mechanism responsible for such anomalies of the intra-tympanic facial nerve is discussed.

Deafness in Vogt-Koyanagi-Harada syndrome.

Sudden onset sensorineural hearing loss is a well recognized entity frequently encountered in otolaryngological practice. However, the combination of such deafness as part of a wider systemic disorder is fortunately rare. Almost 100 years after the syndrome was classified, we describe a case of Vogt-Koyanagi-Harada syndrome occurring unusually in a Caucasian woman and characterized by sudden hearing loss. A brief review of this rare condition is presented.

Audit of doctors' knowledge of major incident policies.

INTRODUCTION: The aim of this study was to audit doctors' knowledge of their hospital's major incident policy. MATERIALS AND METHODS: Pre- and post-intervention interviews were conducted with doctors selected at random in a central London teaching hospital on where to report to in a major incident. Doctors working in hospitals with accident and emergency departments within the M25 motorway were asked if they had read or received training on their hospital's major incident policy. RESULTS: Pre-intervention, 4.4% of doctors knew where to report to in a major incident. A 1-sided information sheet on the major incident policy was distributed to doctors and posted in areas frequented by doctors. Following this intervention, 78% of doctors knew where to report to in a major incident. Doctors in only 2 out of 38 hospitals with accident and emergency departments within the M25 corridor had read or received training on their major incident policy. CONCLUSIONS: More needs to be done by hospitals to ensure that doctors have a better awareness of their hospital major incident policy.

A minimally invasive immunocytochemical approach to early detection of oral squamous cell carcinoma and dysplasia.

Squamous dysplasia of the oral cavity indicates increased risk of progression to squamous cell carcinoma (SCC). An important advance would be the development of a minimally invasive assay for identification of oral SCC and dysplasia. We have investigated the suitability in this context of immunostaining oral smears for minichromosome maintainance proteins (MCMs), sensitive and specific biomarkers of cell cycle entry. Immunohistochemical examination of 66 oral tissue samples showed a greater frequency of Mcm-2 expression in surface layers of moderate/severe dysplasia and SCC compared to benign keratosis/mild dysplasia. Immunocytochemistry for Mcm-2/Mcm-5 was performed on 101 oral smears. Conventional smears included 23 from normal mucosa, benign proliferative disease and mild dysplasia, all of which were MCM negative. Of 52 conventional smears of SCC tissue samples, 18 were inadequate. However, MCM-positive cells were present in 33/34 adequate samples. Of 26 liquid-based cytology smears, 19 out of 20 smears from SCC were adequate and all were MCM positive. Six smears from benign lesions were adequate and MCM negative. We conclude that MCMs are promising markers for early detection of oral SCC and dysplasia, particularly in a liquid-based cytology platform. Detection of MCMs would be amenable to automation and potentially applicable in the developing world. Further studies are now warranted.

The hands and feet of Archaeolemur: metrical affinities and their functional significance.

Recent expeditions to Madagascar have recovered abundant skeletal remains of Archaeolemur, one of the so-called "monkey lemurs" known from Holocene deposits scattered across the island. These new skeletons are sufficiently complete to permit reassembly of entire hands and feet--postcranial elements crucial to drawing inferences about substrate preferences and positional behavior. Univariate and multivariate analysis of intrinsic hand and foot proportions, phalangeal indices, relative pollex and hallux lengths, phalangeal curvature, and distal phalangeal shape reveal a highly derived and unique morphology for an extinct strepsirrhine that diverges dramatically from that of living lemurs and converges in some respects on that of Old World monkeys (e.g., mandrills, but not baboons or geladas). The hands and feet of Archaeolemur are relatively short (extremely so relative to body size); the carpus and tarsus are both "long" relative to total hand and foot lengths, respectively; phalangeal indices of both the hands and feet are low; both pollex and hallux are reduced; the apical tufts of the distal phalanges are very broad; and the proximal phalanges are slightly curved (but more so than in baboons). Overall grasping capabilities may have been compromised to some extent, and dexterous handling of small objects seems improbable. Deliberate and noncursorial quadrupedalism was most likely practiced on both the ground and in the trees. A flexible locomotor repertoire in conjunction with a eurytopic trophic adaptation allowed Archaeolemur to inhabit much of Madagascar and may explain why it was one of the latest surviving subfossil lemurs.

Malignant melanoma of the nose.

Malignant Melanoma of the nose is a rare neoplasm, with primary mucosal melanoma being more aggressive than its cutaneous counterpart (Land,1982). The presentation is often not as dramatic as compared to its progression. While cutaneous melanomas typically present with obvious and consistent features, melanomas of the mucosal form are often diagonised late due to their hidden location and relatively non-specific features. This tumour can metasiasise by lymphasies or bloodsream. Moreover the tumour is often quite resistent to complete cure especially due to reccurence and metastotis. We wish to empahsize that early diagonisis with a high index of suspicion is essential for the management of this condition, by means of two case reports of patients who attended the ENT clinic at Southend Hospital, UK, both of whom were being treated for nasal polyposis in whom the diagonisis susbsequently turned out to be malignant melanoma.

Aberrant expression of minichromosome maintenance protein-2 and Ki67 in laryngeal squamous epithelial lesions.

Histological classification of laryngeal epithelial lesions is highly subjective, and methods of cytological detection are not well developed. Improved determination of aberrant cell cycle entry may allow increased objectivity in histological assessment and enable the development of less invasive diagnostic cytology tests. Sections of normal larynx (n=10), laryngeal dysplasia (n=20) and laryngeal squamous cell carcinoma (SCC) (n=10) were classified according to the Ljubljana classification and stained for markers of cell cycle entry, minichromosome maintenance protein-2 (Mcm-2) and Ki67. Expression patterns were compared using double labelling confocal microscopy. There was a correlation between Mcm-2 and Ki67 labelling indices (rho=0.93; 95% CI [0.84, 0.97]) and both markers showed increased expression from normal epithelium to SCC (Mcm-2, P=0.001; Ki67, P=0.0002). Importantly, there was minimal expression of Mcm-2 or Ki67 in the most superficial layers of normal larynx and abnormal or atypical hyperplasia, in contrast to carcinoma in situ and SCC. Clusters of Mcm-2/5-positive cells were present in cytological preparations from SCC, but not from those showing atypical hyperplasia or inflammation in non-neoplastic tissue. Minichromosome maintenance protein-2 staining may increase the objectivity and reliability of histological grading of laryngeal epithelial lesions. Laryngeal brushings, combined with immuno-enhanced liquid-based cytology, could be useful, as a less invasive approach, to the detection of laryngeal malignant and premalignant lesions.