Cost-comparison study of reusable and disposable rhinolaryngoscopes in a large English teaching hospital.

OBJECTIVE: This study aimed to compare the cost per use of video-rhinolaryngoscopy using reusable and disposable devices in a tertiary referral centre. METHODS: A cost-comparison study was performed that utilised retrospective cost data and prospective utilisation data to compare the total costs of using reusable video-rhinolaryngoscopes versus a single-use alternative. RESULTS: It was estimated that 4776 and 1821 procedures were performed annually with reusable and disposable video-rhinolaryngoscopes, respectively. The cost per use was £66.61 for reusable devices versus £150.00 for disposable devices. The break-even point (i.e. when cost per use was equal, occurred at 1374 procedures per year). Thereafter, it was cheaper to use reusable devices. CONCLUSION: Disposable rhinolaryngoscopes may present a cheaper solution to services with low rates of rhinolaryngoscope utilisation. However, for larger services considering replacement of their reusable rhinolaryngoscopes with disposable units, it is likely that the recurring costs will be prohibitive in the medium to long term.

A rare cause of diplopia: Solitary extramedullary plasmacytoma of the skull base.

Diplopia is a common presenting complaint with a broad spectrum of differential diagnoses. Causative pathologies may affect the eye, extraocular muscles, neuromuscular junction, cranial nerves and central nervous system. Tumours, inflammatory and autoimmune conditions, vasculopathies and atypical infections are the most common underlying pathologies. Solitary extramedullary plasmacytoma is a rare cause of diplopia. This case emphasises the importance of submucosal biopsies for diagnosis and early involvement of the multidisciplinary team. Moreover, we advocate a low threshold for a second opinion and further immunohistochemistry, particularly when there is diagnostic uncertainty with histological discordance.

[Pott's puffy tumour: innovative technique in calvarial reconstruction].

BACKGROUND: Pott's puffy tumour is a rare complication of sinusitis. This osteomyelitis can affect the outer and inner tables of the frontal sinus. The treatment of Pott's puffy tumour combines medical and surgical approaches. Surgical approaches have traditionally been open, but endoscopic techniques have been adopted recently in select cases. The bony defect from debridement can be left alone, or closed with autografts or allografts. OBJECTIVE: To describe a technique for the reconstruction of a large skull vault after the debridement of extensive osteomyelitis of the anterior cranial vault. METHODS: Modified distraction osteogenesis is used in the cranial vault, to induce new bone formation. This is customarily used to lengthen long bones. The advantages of this technique include avoiding autologous grafts or alloplastic cranioplasty in the infected surgical bed, and allowing primary closure. RESULTS: Early post-operative imaging results have been encouraging, with no reported complications. CONCLUSION: Modified distraction osteogenesis is a novel technique in the primary reconstruction of calvarial bone.

Impact of recombinant PTH on management of hypoparathyroidism: a systematic review.

The treatment of post-surgical hypoparathyroidism (following thyroid or parathyroid surgery) is challenging. Presently, this condition is treated with calcium and vitamin D supplements rather than replacing the missing parathyroid hormone. Not only is it challenging to maintain normocalcaemia, but concerns of hypercalciuria and ectopic calcification have also been raised using these supplements. There is an ongoing debate whether recombinant parathyroid hormone (rPTH), which as yet is unlicensed for treating hypoPTH, may offer a more physiological solution. The objective of the study was to assess the effectiveness and safety of rPTH in maintaining normocalcaemia and normocalcuria in hypoparathyroidism. This was a systematic review performed using independently developed search strategies including Medline, Embase, CINAHL, Cochrane, Zetoc, conference proceedings and a manual search until 15 July 2014. Data extraction was undertaken by one reviewer (YR). Studies were synthesised through narrative review with tabulation of results. Of 2,141 studies identified, only eleven studies fitted the inclusion criteria. These studies suggest that rPTH is useful in normalising serum calcium levels. Excretion of urinary calcium levels is reduced with PTH 1-34 but remained unchanged in a number of studies using PTH 1-84. Recombinant PTH is well tolerated. The majority of studies included post-surgical hypoparathyroidism with marked heterogeneity. Further prospective, larger, long-term trials are necessary to evaluate the long-term efficacy and adverse profile of rPTH, including head to head comparisons between PTH 1-34 and PTH 1-84.

Biofilms in chronic rhinosinusitis: what is new and where next?

BACKGROUND: Chronic rhinosinusitis is a common, heterogeneous condition. An effective means of mitigating disease in chronic rhinosinusitis patients remains elusive. A variety of causes have been implicated, with the biofilm theory gaining increasing prominence. OBJECTIVE: This article reviews the literature on the role of biofilms in chronic rhinosinusitis, in terms of pathophysiology and with regard to avenues for future treatment. METHODS: A systematic review of case series was performed using databases with independently developed search strategies, including Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, Cochrane library, and Zetoc, in addition to conference proceedings and a manual search of literature, with the last search conducted on 18 January 2014. The search terms included the following, used in various combinations to maximise the yield of articles identified: 'biofilms', 'chronic rhinosinusitis', 'DNase', 'extracellular DNA' and 'biofilm dispersal'. RESULTS: The existing evidence lends further support for the role of biofilms (particularly the Staphylococcus aureus phenotype) in more severe, recalcitrant disease and poorer surgical outcomes. CONCLUSION: Multimodality treatment, with a shift in paradigm to incorporate anti-biofilm strategies, is likely to form the mainstay of future recalcitrant chronic rhinosinusitis management.

Co-phenylcaine Forte spray: innovative ways of minimising cost.

OBJECTIVE: To investigate whether multiple-use Co-phenylcaine Forte® spray was more cost-effective than single-use vials. METHODS: A literature review was conducted to determine the risk of cross-contamination associated with multiple-use topical nasal anaesthetic spray. The costs of multiple-use Co-phenylcaine Forte and single-use co-phenylcaine were compared, and potential savings were calculated. The cost of procuring these drugs from other sources was also examined. RESULTS: Switching to multiple-use Co-phenylcaine Forte spray would lead to at least 40 per cent savings if bought from our local retailer. Potential savings of more than 70 per cent could be made if the drugs were procured from sources other than our local distributor. CONCLUSION: Multiple-use Co-phenylcaine Forte spray is safe to use and more cost-effective than single-use vials. This paper illustrates how money can be saved within the National Health Service through changes in drug procurement. Similar cost savings to those calculated for our department could be made in other ENT departments nationally, depending on their annual consumption of co-phenylcaine.

Paranasal sinus computed tomography anatomy: a surgeon's perspective.

Computed tomography scans serve as a critical 'roadmap' for functional endoscopic sinus surgery. A systematic evaluation of such scans, and an awareness of any anatomical variants that may modify one's surgical approach, allow one to pre-empt complications. This article describes, from a novice's perspective, two methods of evaluating paranasal sinus computed tomography scans: a quick assessment technique; and a step-wise, operative approach covering radiological features relevant to pre- and peri-operative management.

Bone-anchored hearing aids in children and young adults: the Freeman Hospital experience.

OBJECTIVE: To investigate the utilisation of bone-anchored hearing aids and Softband, as well as the effects on quality of life, amongst the paediatric and young adult population of Freeman Hospital, Newcastle Upon Tyne, UK. METHOD: Retrospective, anonymised, cross-sectional survey using the Glasgow Benefit Inventory and Listening Situation Questionnaire (parent version), administered at least three months following the start of bone-anchored hearing aid or Softband use. RESULTS: One hundred and nine patients were included, of whom syndromic children made up a significant proportion (22 of 109). Patients using bone-anchored hearing aids obtained significant educational and social benefit from their aids. The mean Listening Situation Questionnaire difficulty score was 17 (15 patients), which is below the trigger score of 22+ at which further reassessment and rehabilitation is required. 87% (of 15 patients) did not require further intervention. The overall mean GBI score for the 22 patients (syndromic and non-syndromic) was +29. CONCLUSION: The use of bone-anchored hearing aids and Softband results in significant improvements in quality of life for children and young adults with hearing impairment. There is significant under-utilisation of bone-anchored hearing aids in children with skull and congenital abnormalities, and we would advocate bone-anchored hearing aid implantation for these patients.

Laryngeal schwannoma: case report and literature review.

Neurogenic tumours of the larynx, particularly schwannomas are rare. We report a case report of a schwannoma in a 30-year-old woman which was excised endoscopically. The aim of this paper is to highlight this rare condition and management options to the otolaryngological community.

Use of DBS sample collection to determine circulating drug concentrations in clinical trials: practicalities and considerations.

BACKGROUND: A clinical investigation was performed into the practicalities of the collection of blood samples for the determination of drug exposures on filter paper, known as dried blood spot (DBS) sampling using a two-period, single-dose, open-label trial conducted in 11 healthy volunteers who received a single oral dose of paracetamol. Questionnaires relating to the blood sampling and spotting process and tolerability were completed by staff and volunteers. Paracetamol concentrations in DBS samples obtained by venous cannula (DBS-Can) were compared against those from fingerprick (DBS-FP) and fresh whole blood obtained from a cannula (WB-Can). RESULTS: The questionnaires demonstrated that FP and blood spotting was easy to perform and well tolerated and compared favorably with cannula sampling. Paracetamol concentrations in DBS-Can were greater than those in WB-Can (positive bias) except below 8000 ng/ml when both were interchangeable. When comparing DBS-FP to DBS-Can, both the bias and variability differed significantly across the five sampling time points. CONCLUSION: The study has shown that the DBS technique is practical in the context of a clinical trial. Interchangeability of drug concentrations between blood sampling site and mode of blood collection has to be checked and taken into account when designing pharmacokinetic studies for other compounds.

Reanimation following facial palsy: present and future directions.

BACKGROUND: An understanding of the management of chronic facial palsy is vital for otolaryngologists, due to its common presentation to ENT surgeons. There is currently a lack of consensus on the optimum management of this condition. This article reviews the existing literature and offers a perspective on current management, as well as an insight into future treatments. METHODS: A literature search was performed, using the Medline, Embase and Cochrane databases from 1966 to the present, using the keywords listed below. Articles were reviewed. Selection was limited to English language articles on human subjects. RESULTS AND CONCLUSION: A tailored, multidisciplinary approach using combinatorial therapy should be used for reanimation of the face following facial palsy. Advances in surgical and non-surgical techniques, and the exchange of information from centres of excellence via global databases, will enable objective appraisal of results and the development of an evidence-based approach to facial reanimation.

Comorbidity in nasopharyngeal carcinoma: a preliminary communication on the prevalence, descriptive distribution and impact on outcome.

OBJECTIVES: Comorbidity has been shown to be a determinant in treatment selection and survival in squamous cell cancer of the head and neck at various subsites. The objective of this study is to analyse the effect of comorbidity burden on outcome of nasopharyngeal cancer using the Adult Comorbidity Evaluation-27 (ACE-27) instrument. DESIGN: Retrospective analysis. SETTING: Tertiary care centres. PARTICIPANTS: This study included 59 patients diagnosed with nasopharyngeal carcinoma between 1989-2003 in the North-East of England. Exclusion criteria included non-squamous neoplasms of the nasopharynx. Comorbidity was assessed retrospectively from the notes using standard validated techniques described earlier. Tumour, treatment and survival data were obtained from prospective databases. Data was analysed using SPSS for Windows. MAIN OUTCOME MEASURES: Comorbidity and outcome of treatment. RESULTS: Comorbid burden was evident in 44% of patients, with moderate or severe comorbidity in 19%. The cardiovascular system was the most commonly affected system (27%). Cox's proportional hazard model showed age and stage of tumour to have an impact on disease specific survival. Comorbidity was not seen to predict the outcome independent of other factors. The sample size of this study is powered to detect only medium to large effects. We estimate that 614 subjects will be needed to detect a correlation coefficient of 0.1 with 80% power, assuming a type 1 error rate of 5%. CONCLUSION: This study shows for the first time that the comorbidity burden seen in nasopharyngeal cancer does not affect prognosis independent of the TNM staging.

Diagnosis and management of olfactory disorders: survey of UK-based consultants and literature review.

BACKGROUND: The diagnosis and management of olfactory disorders is an often neglected topic in otolaryngology. This article evaluates current clinical practice within the United Kingdom, and provides a literature-based review of the diagnosis, management and prognosis of olfactory pathology. DESIGN: A questionnaire was sent to consultant and associate specialist members of the British Association of Otolaryngologists and Head and Neck Surgeons. The responses were documented to gain an impression of how olfactory disorders are managed in the United Kingdom. The literature relating to olfactory dysfunction was then evaluated and the findings summarised. CONCLUSIONS: Management of olfactory pathology varies across the United Kingdom. The literature suggests that chemosensory testing is optimal and that both forced-choice and threshold testing should be applied if objective evaluation is required. Imaging can be of value but the appropriate technique should be used. Olfactory function can recover following head injury, viral infection and chronic sinonasal disease, although varying degrees of dysfunction are likely to persist. There is a role for the use of corticosteroids, particularly when administered systemically. More research is needed to establish the appropriate dose and length of treatment.

A review of retraction pockets: past, present and future management.

Retraction pockets can lead to hearing loss and cholesteatoma. Distinguishing stable from progressive disease is challenging to any otologist. The management of retraction pockets is a contentious issue with present treatment options often plagued with recurrence. The purpose of this article is to summarize recent developments in the aetiology of retraction pockets of the pars tensa, its diagnostic and management problems and to define possible future therapeutic options.

Effect of awake Carotid Endarterectomy under local anaesthesia on peri-operative blood pressure: blood pressure is normalised when carotid stenosis is treated under local anaesthesia.

BACKGROUND: Carotid Endarterectomy can be performed under local, regional or general anaesthesia. One of the most important effects of the type of anaesthetic used is on the systemic blood pressure. Although variations in blood pressure during and following carotid endarterectomy have been studied previously, the effects of awake carotid endarterectomy under local anaesthesia on blood pressure and its comparison with similar procedures under similar types of anaesthesia have not. METHODS: Peri-operative blood pressure measurements were collected from the records of 25 consecutive patients for each of the following five procedures; Carotid Endarterectomy under general anaesthesia (CEAGA), Anterior Cervical Discectomy and Fusion under general anaesthesia (ACDF), Cerebral Angiography under local anaesthesia (ANG), Carotid Endarterectomy patients under local anaesthesia who were symptomatic (CEALAS) and Carotid Endarterectomy patients under local anaesthesia who were asymptomatic (CEALAA). The recordings were then analysed to find out if there were any clinically significant variations in peri-operative blood pressure. FINDINGS: There is a significant and consistent difference when the pre-operative value was compared with the 4 hour and 24 hour post-operative recordings between the local and general anaesthetic groups for carotid endarterectomy. Carotid endarterectomy reduces the systolic and diastolic blood pressures post-operatively when performed under local anaesthesia and only the diastolic pressure was reduced when performed under general anaesthesia. CONCLUSION: The study provides evidence about the effect of carotid endarterectomy on the systemic blood pressure and its variations when performed under different types of anaesthesia. There is significant post-operative reduction in both the systolic and diastolic blood pressure values and the intraoperative fluctuation is minimal when local anaesthesia is used. Further studies are required to find out how this affects the long-term blood pressure and clinical outcome of the patient.

Defective maintenance of intracellular Ca2+ homeostasis is linked to increased muscle fatigability in the MG29 null mice.

Mitsugumin 29 (MG29) is a transmembrane protein that is normally found in the triad junction of skeletal muscle. Our previous studies have shown that targeted deletion of mg29 from the skeletal muscle resulted in abnormality of the triad junction structure, and also increased susceptibility to muscle fatigue. To elucidate the basis of these effects, we investigated the properties of Ca2+-uptake and -release in toxin-skinned Extensor Digitorium Longus (EDL) muscle fibers from control and mg29 knockout mice. Compared with the control muscle, submaximal Ca2+-uptake into the sarcoplasmic reticulum (SR) was slower and the storage of Ca2+ inside the SR was less in the mutant muscle, due to increased leakage process of Ca2+ movement across the SR. The leakage pathway is associated with the increased sensitivity of Ca2+/caffeine -induced Ca2+ release to myoplasmic Ca2+. Therefore, the increased fatigability of mutant EDL muscles can result from a combination of a slowing of Ca2+ uptake, modification of Ca2+-induced Ca2+ release (CICR), and a reduction in total SR Ca2+ content.

Co-expression of MG29 and ryanodine receptor leads to apoptotic cell death: effect mediated by intracellular Ca2+ release.

Perturbation of intracellular Ca2+ homeostasis has been shown to regulate the process of cell proliferation and apoptosis. Our previous studies show that mitsugumin 29 (MG29), a synaptophysin-related protein localized in the triad junction of skeletal muscle, serves an essential role in muscle Ca2+ signaling by regulating the process of store-operated Ca2+ entry. Here we report a functional interaction between MG29 and the ryanodine receptor (RyR)/Ca2+ release channel. The purified MG29 protein enhances activity of the RyR/Ca2+ release channel incorporated into the lipid bilayer membrane. Co-expression of MG29 and RyR in Chinese hamster ovary cells leads to apoptotic cell death resulting from depletion of intracellular Ca2+ stores, despite neither protein expression alone exhibits any significant effect on cell viability. In transient expression studies, the presence of RyR in the endoplasmic reticulum leads to retention of MG29 from the plasma membrane into the intracellular organelles. This functional interaction between MG29 and RyR could have important implications in the Ca2+ signaling processes of muscle cells. Our data also show that perturbation of intracellular Ca2+ homeostasis can serve as a key signal in the initiation of apoptosis.

Dysfunction of store-operated calcium channel in muscle cells lacking mg29.

The store-operated calcium channel (SOC) located in the plasma membrane (PM) mediates capacitative entry of extracellular calcium after depletion of intracellular calcium stores in the endoplasmic or sarcoplasmic reticulum (ER/SR). An intimate interaction between the PM and the ER/SR is essential for the operation of this calcium signalling pathway. Mitsugumin 29 (MG29) is a synaptophysin-family-related protein located in the junction between the PM and SR of skeletal muscle. Here, we identify SOC in skeletal muscle and characterise its regulation by MG29 and the ryanodine receptor (RyR) located in the SR. Targeted deletion of mg29 alters the junctional membrane structure, causes severe dysfunction of SOC and SR calcium homeostasis and increases the susceptibility of muscle to fatigue stimulation. Severe dysfunction of SOC is also identified in muscle cells lacking both type 1 and type 3 RyRs, indicating that SOC activation requires an intact interaction between the PM and the SR, and is linked to conformational changes of RyRs. Whereas defective SOC seems to be inconsequential to short-term excitation-contraction coupling, the slow cumulative calcium entry through SOC is crucial for long-term calcium homeostasis, such that reduced SOC activity exaggerates muscle fatigue under conditions of intensive exercise.