Sinonasal cancer: an overview of the emerging subtypes.

BACKGROUND: Advances in immunohistochemistry have spearheaded major developments in our understanding and classification of sinonasal tumours. In the last decade, several new distinct histopathological entities of sinonasal cancer have been characterised. OBJECTIVES: This review aims to provide a clinical update of the major emerging subtypes for the ENT surgeon and an overview of the management strategies available for this heterogeneous group of pathologies. CONCLUSION: Although rare, knowledge of sinonasal neoplasm subtypes has implications for prognosis, treatment strategies and the development of novel therapeutic targets.

The internal nasal valve: a validated grading system and operative guide.

PURPOSE: Nasal obstruction is a highly subjective and commonly reported symptom. The internal nasal valve (INV) is the rate limiting step to nasal airflow. A static INV grading score was devised with regard to visibility of the middle turbinate. METHODS: A prospective study of all patients who underwent primary external functional septorhinoplasty in 2017 for nasal obstruction. All patients' INV score was assessed pre- and postoperatively in a blinded and independent fashion by surgeons of varying seniority. RESULTS: Twenty-eight patients were studied, with mean age 30.9 years and follow-up 18.8 weeks. Inter-rater and test-retest reliability of INV grading were excellent, with Cronbach's alpha 0.936 and 0.920, respectively. There was also statistically significant improvement in both subjective and objective postoperative outcome measures including nasal inspiratory peak flows. CONCLUSIONS: We demonstrate a novel, easy to interpret, clinically valuable grading system of the static internal nasal valve that is reliable and reproducible.

Impact of developing a multidisciplinary coded dataset standard on administrative data accuracy for septoplasty, septorhinoplasty and nasal trauma surgery.

OBJECTIVE: This study aimed to develop a multidisciplinary coded dataset standard for nasal surgery and to assess its impact on data accuracy. METHOD: An audit of 528 patients undergoing septal and/or inferior turbinate surgery, rhinoplasty and/or septorhinoplasty, and nasal fracture surgery was undertaken. RESULTS: A total of 200 septoplasties, 109 septorhinoplasties, 57 complex septorhinoplasties and 116 nasal fractures were analysed. There were 76 (14.4 per cent) changes to the primary diagnosis. Septorhinoplasties were the most commonly amended procedures. The overall audit-related income change for nasal surgery was £8.78 per patient. Use of a multidisciplinary coded dataset standard revealed that nasal diagnoses were under-coded; a significant proportion of patients received more precise diagnoses following the audit. There was also significant under-coding of both morbidities and revision surgery. CONCLUSION: The multidisciplinary coded dataset standard approach can improve the accuracy of both data capture and information flow, and, thus, ultimately create a more reliable dataset for use outcomes and health planning.

A national analysis of trends, outcomes and volume-outcome relationships in thyroid surgery.

OBJECTIVES: Thyroid conditions are common, and their incidence is increasing. Surgery is the mainstay treatment for many thyroid conditions, and understanding its utilisation trends and morbidity is central to improving patient care. DESIGN: An N = near-all analysis of the English administrative dataset to identify trends in thyroid surgery specialisation, volume-outcome relationships, and the incidence and risk factors for short- and long-term morbidity. MAIN OUTCOME MEASURES: Between 2004 and 2012, 72 594 patients underwent elective thyroidectomy in England. Information about age, sex, morbidities, nature of thyroid disease and surgery, adjuvant treatments and complications including hypocalcaemia and vocal palsy was recorded. RESULTS: Mean age at surgery was 49 ± 30, and a female predominance (82%) was observed. Most patients underwent hemithyroidectomy (51%) or total thyroidectomy (32%). Patients underwent surgery for benign (52.5%), benign inflammatory (21%) and malignant (17%) thyroid diseases. Thyroid surgery grew by 2.9% a year and increased in specialisation. Increased surgeon volume significantly reduced lengths of stay: the proportion of length of stay outliers fell from 11.8% for patients of occasional thyroidectomists (<5 per year) to 2.8% for patients of high-volume surgeons (>50 thyroidectomies a year). Post-discharge vocal palsy and hypocalcaemia occurred in 1.87% and 1.58% of cases, respectively. High-volume surgeons had a reduced incidence of vocal palsy, and volumes >30 were consistently protective. CONCLUSIONS: Thyroid surgery is increasingly specialised. High-volume surgeons, that is patients who perform 50 or more thyroidectomies per year, achieve lower complications and shorter lengths of stay.

Evaluation of Pseudomonas fluorescens for the management of tomato early blight disease and fruit borer.

Early blight disease and fruit damage by Helicoverpa armigera are serious problems of tomato causing heavy losses in the yield. An experiment was conducted to evaluate the efficacy of talc based formulation of antagonist Pseudomonas flourescens (Psf) delivered through two different forms of substrate, farmyard manure (FYM) and vermicompost, for the management of tomato early blight disease. Two treatments of Psf, were selected Solarization of nursery soil + seeds and seedlings root dip treatment with Psf formulation + Use of FYM colonized with Psf formulation; Solarization of nursery soil + seed and seedlings root dip treatment with Psf formulation + Use of vermicompost colonized with Psf formulation. These were compared with farmer's practice and untreated control. The impact of all these treatments on tomato fruit borer, H. armigera was also studied. There was not much variation in plant growth parameters (plant height and canopy width) between all the treatments. Both biocontrol treatments (17.69% and 141.3 q acre-1; 15.70% and 139.4 q acre-1, respectively), as well as farmer's practice (10.25% and 208.5 q acre-1) were found to be better than untreated control (29.21% and 94.6 q acre-1) in reducing the incidence of early blight disease in tomato and increasing the marketable yield of tomato fruits. However, the farmer's practice was found to be significantly better than both biocontrol treatments of Psf in controlling fruit damage due to disease, as well as fruit borer. The effect of both bioagents enriched formulations i.e. FYM+Psf and vermicompost+Psf with respect to disease was significantly at par with each other, whereas they had no impact on the fruit borer incidence. The results indicated that either of biocontrol treatments of P. flourescens using farmyard manure and vermicompost, as delivery substrates, can be considered as one of the component along with chemical control in developing IPM programme for the management of early blight disease in tomato.

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.

Optimising outcomes in the management of spontaneous cerebrospinal fluid rhinorrhoea.

BACKGROUND: To describe our experience of the management of spontaneous cerebrospinal fluid (CSF) rhinorrhoea in a large case series focusing on surgical approach, peri-operative management and outcomes; to evaluate the efficacy of endoscopic CSF leak repairs. METHODOLOGY: Retrospective chart review was performed for all patients with spontaneous CSF rhinorrhoea managed from 2003 to 2011 at a tertiary referral centre. Data regarding demographics, presentation, site of leak, peri-operative management, surgical approach, body mass index (BMI), follow up and success rates was collated. RESULTS: Thirty-six patients were identified: 9 male and 27 female with a mean age of 50.4 years. Eight patients had previous failed repairs in other units. Success rate after first surgery was 89 % and after second surgery was 100 %. Four patients had recurrences, 3 underwent successful revisions and the fourth had complete cessation of the leak after gastric bypass surgery and weight reduction. All failures were before 2004 prior to instigation of an anatomic three-layered repair with no further failures in the following 7 years. Mean follow up was 21.5 months. Mean body mass index was 34.0 kg/m2. Fifty percent of spontaneous leaks were from the cribriform plate, 22 % sphenoid, 14 % ethmoid and 14 % frontal sinus. CONCLUSION: Endoscopic CSF fistula closure has become the gold standard of care. In order to optimise the outcome, we recommend a multidisciplinary approach to manage the associated idiopathic intracranial hypertension and an anatomic three-layered closure technique for recalcitrant cases.

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.

Uncommon and rare causes of vocal fold paralysis detected via imaging.

BACKGROUND: Cross-sectional imaging can be used to trace the course of the vagus nerve and its laryngeal branches to detect many of the causes of vocal fold paralysis. The most frequent aetiologies are surgical injury and tumoural involvement of the recurrent laryngeal nerve anywhere along its course. METHOD: This review article focuses on the uncommon and rare causes of vocal fold paralysis that have been detected or diagnosed on cross-sectional imaging. RESULTS AND CONCLUSION: Uncommon causes included a tortuous oesophagus, tracheal diverticulum, cervical osteophytes and cardiovocal syndrome. These examples are presented with clinical case histories and radiological appearances, and are discussed in the context of the current literature.

Endovascular intervention in acute deep vein thrombosis.

The widespread prevalence of deep venous thrombosis (DVT) is well documented. Its acute and chronic manifestations, including the post-thrombotic syndrome (PTS), inflict a heavy personal and socioeconomic burden on society. Conventional anticoagulation treatment regimens have been widely used in the treatment of acute DVT, with many patients developing significant long-term morbidity. Numerous systemic, surgical, and endovascular therapies have been employed in an attempt to achieve immediate and effective clot lysis. In this paper, we discuss these various techniques, their efficacy as established in the current literature, and their risks and benefits. Pharmacomechanical thrombolysis (PMT) specifically has recently emerged as a low-risk, highly effective means of treating acute DVT, often being performed in the outpatient setting. Ongoing investigations will help further define the utility of this evolving transformative therapy.

Endolymphatic sac tumour: case report and literature review.

OBJECTIVE: To increase awareness of the presentation, diagnostic difficulties and management of endolymphatic sac tumours. CASE REPORTS: A 79-year-old man with a 6-month history of unilateral hearing loss, tinnitus and vertigo, who was suspected to have an endolymphatic sac tumour on imaging, underwent successful transmastoid-translabyrinthine resection. A 53-year-old man with unilateral hearing loss and pulsatile tinnitus underwent subtotal resection of a suspected paraganglioma, which was identified histologically. Due to interval growth, gamma knife radiosurgery was performed followed by subtotal petrosectomy, at which juncture an endolymphatic sac tumour was reported. METHODS: A review of the world literature was carried out using Medline, which identified less than 150 reported cases of endolymphatic sac tumour. CONCLUSION: Endolymphatic sac tumours are rare lesions of the petrous temporal bone. Although benign, they can be locally destructive. At present, there is no consensus regarding the management and long-term follow up of these tumours. Surgical resection is usually favoured, although treatment with radiotherapy and gamma knife surgery has also been reported.