Effect of intratympanic steroid administration on sensorineural hearing loss associated with acute otitis media.

OBJECTIVE: To evaluate a small cohort of patients who presented with symptoms and signs consistent with acute infective sensorineural hearing loss who were treated with intratympanic steroids. METHOD: Seven patients received a 7-day course of oral antibiotics and oral prednisolone followed by 3 intratympanic injections of methylprednisolone and 1 week of topical dexamethasone drops. RESULTS: Hearing improved in 57 per cent of patients (four out of seven). The mean improvement in this group was 24 dB (range, 10-52 dB). The magnitude of the sensorineural hearing loss at presentation was less in those who responded to intratympanic steroid therapy than in non-responders (mean pure tone average of 30 dB versus 65 dB pre-intratympanic steroids, and 14 dB versus 83 dB post-intratympanic steroids, respectively). CONCLUSION: The results of our study suggest that intratympanic steroids provide a valuable contribution to the treatment of acute infective sensorineural hearing loss and may provide additional benefit by virtue of a concentrated local steroid effect in patients who do not respond to antibiotics.

Long-term quality-of-life outcomes in children undergoing adenotonsillectomy for obstructive sleep apnoea: a longitudinal study.

OBJECTIVES: To assess a cohort of patients who underwent adenotonsillectomy for obstructive sleep apnoea, 4 years after surgery for evidence of continued and long-term improvement in quality of life. We also sought to compare our results to Child Health Questionnaire scores obtained from our previous study. We also compared our data with a healthy UK children population from normative data available. DESIGN: Longitudinal study. SETTINGS: University Hospital Tertiary Referral Centre. PARTICIPANTS: A 4-year follow-up study of 37 children who underwent adenotonsillectomy for obstructive sleep apnoea confirmed on polysomnography. There were 19 boys and 18 girls from our initial cohort. The primary caregiver completed the validated Child Health Questionnaire Parental Form version-28, 4 years after initial surgery. Our control group consist of 221 healthy children aged 6-18 that were included as 'normal' controls in a study looking at children with juvenile arthritis. The children were defined as healthy by a physician and/or after declaration by the parent. MAIN OUTCOME MEASURE: Child Health Questionnaire Parental Form version-28 scores. RESULTS: A total of 33 patients (89%) from our initial cohort were contacted. The mean age was 10.6 (median, 11; range, 5-16). When compared with results obtained 3 months postoperatively, the mean scores were higher in five domains and were statistically significant in three subscales (Role Limitations P < 0.00001; Bodily Pain P < 0.002; and Global Health P < 0.02). There was a significant deterioration in Behaviour subscale (P < 0.0007) in spite of surgery. Compared with controls, 4-year follow-up scores were higher in five domains with the Global Health domain (P < 0.0004) being statistically significant. When the 4-year follow-up scores were compared with preoperative values, these were higher in all 13 domains with statistically significant improvements in nine domains, indicating that improvements had persisted 4 years after surgery. At 4 years, however, the means scores in many domains remain lower when compared with controls. CONCLUSION: Quality-of-life data are an important measure when deciding on a specific clinical intervention. In the short term, quality-of-life measures have been shown to improve after adenotonsillectomy for obstructive sleep apnoea. Our study demonstrates that the benefits of surgery are still persistent and the children continue to improve in the long term.

Improving tracheostomy care: a prospective study of the multidisciplinary approach.

OBJECTIVES: Suboptimal standards in tracheostomy care have been highlighted as a growing concern in view of the increasing demands for intensive care services. Our objective is to assess the impact of our model for tracheostomy care on patients with short-term tracheostomies (<4 months in situ) following their discharge from the intensive care unit. The model has three components: The St Mary's tracheostomy care bundle checklist, a dedicated tracheostomy multidisciplinary team and an educational programme. DESIGN: A 38-month prospective cohort study. SETTING: A London Teaching Hospital. PARTICIPANTS: A total of 102 patients with tracheostomy within the 19-month pre-intervention cohort and 95 patients in the 19-month post-intervention cohort. MAIN OUTCOME MEASURES: The number of clinical incidents, mean time taken for decannulation, mean total tracheostomy time and total number of days spent in the intensive care unit were assessed before and after the intervention. RESULTS: Time to decannulation following intensive care unit discharge decreased from 21 to 11 days, as did the mean total tracheostomy time, from 34 to 25 days (both statistically significant with a P < 0.0001 Mann-Whitney U-test). The number of critical incidents, which included all patients prior to exclusion, substantially declined following the introduction of intervention from 58 to 7 in the second year after intervention. CONCLUSIONS: A multidisciplinary care model significantly expedited the decannulation process and reduced the overall time that a tracheostomy was in situ. The intervention was associated with a reduction in clinical incidents and shorter intensive care unit admissions, which can be associated with significant monetary savings.

Should we apply suction during fine needle cytology of thyroid lesions? A systematic review and meta-analysis.

INTRODUCTION: Fine needle aspiration cytology (FNAC) is a well-established investigation in thyroid disease. Fine needle sampling without aspiration (FNS) is less commonly used but often easier to perform. Both methods have advantages and disadvantages but, as yet, there is no agreement on which method produces better specimens for cytological diagnosis. MATERIALS AND METHODS: We undertook a review of the literature and performed a meta-analysis of the results of four cross-over trials. RESULTS: The resulting odds ratio favoured FNS (OR = 0.99; 95% CI 0.88-1.11) but was not statistically significant. A fifth paper not included in the meta-analysis reported results in favour of FNS (P = 0.003). CONCLUSIONS: There is no evidence from the meta-analysis that one method is superior to the other; however, taking into consideration all available evidence, it seems that FNS may be easier to perform and may produce better samples.

What is the impact of consultant supervision on outpatient follow-up rate?

This study investigated the impact of consultants on recycling rates of patients in the ENT outpatient clinic. A retrospective case review of 4205 consecutive patients who attended ENT outpatient clinics of an UK teaching hospital over a 3-month period was conducted. There was a significant association between grade of medical staff and recycling rate of new patients, and also for review patients. Junior doctors have lower recycling rates in consultant-led clinics compared with clinics in the absence of consultants for both new patients (consultant-led 41.0%, without consultant 60.1%; P < 0.01) and old patients (consultant-led 48.9%, without consultant 65.0%; P < 0.01). Individual consultant's practice was reflected upon the overall recycling rate of the clinic as a whole (r = 0.94, P = 0.001). In conclusion, individual consultant's practice dictated recycling rate in the ENT outpatient clinic. Junior doctors were less likely to make follow-up appointments when directly supervised by their consultants.

Survey of current undergraduate otolaryngology training in the United Kingdom.

The General Medical Council's core curriculum model for undergraduate medical training is leading to changes in the way specialist subjects are taught. A postal survey was undertaken to evaluate the current state of undergraduate clinical teaching in otolaryngology in the United Kingdom. Data were received from all 27 medical schools. Six medical schools (22 per cent) do not have a compulsory ENT attachment, although three of these offer an optional attachment. Fifty-eight per cent of all ENT attachments are combined with other specialties including dermatology, ophthalmology and neurology. The average length of time spent with the ENT department during medical school training is one and a half weeks. Forty-two per cent of students do not have a formal assessment of their clinical skills or knowledge at the end of such attachments.

Persistent otorrhoea after ventilation tube insertion: a treatment protocol.

Otorrhoea is the commonest complication of ventilation tube (grommet) insertion. In some cases it may be unresponsive to short courses of topical antibiotic/steroid drops and/or systemic antibiotics. This study investigated whether a five-day course of inpatient treatment with intravenous antibiotics, topical medication and daily microsuction was effective in treating persistent otorrhoea. Eleven subjects were included, of whom nine responded to the proposed treatment regimen. We recommend that patients with persistent otorrhoea after ventilation tube insertion should be managed according to these guidelines before considering an examination under anaesthetic or a ventilation tube removal.

Synchronous fat plug myringoplasty and tympanostomy tube removal in the management of refractory otorrhoea in younger patients.

OBJECTIVE: Tympanostomy tubes are associated with many complications, the most common being recurrent otorrhoea, in many cases resistant to medical treatment. With the associated vestibulo-cochlear toxicity of many topical antibiotics, their use is dose limited. Removal of the tympanostomy tube has been shown to cure the otorrhoea, however, it is associated with a high persistent perforation rate of 10-28%. A synchronous fat plug myringoplasty was performed with tube removal in an attempt to reduce the residual perforation rate. METHODS: A retrospective study of 13 consecutive children, nine male and four female, mean age 9.1 years (median=9, range 2-15), with a total of 15 ears (left=6, right=9) had either Shah Tubes (n=5), Shepard Tubes (n=1) or Shah Long Term Tubes (n=9) in-situ for middle ear effusions. The tubes were removed for recurrent otorrhoea. The tubes had been in-situ for a mean of 38.8 months (median=31, range 9-84 months). All ears had recurrent infections, with a variable response to topical antibiotics. All were under the care of one specialist, who performed all the procedures. At the time of tube removal, a standard fat graft myringoplasty was done. RESULTS: The procedure was successful in 15 of the 15 ears, and all perforations had closed by 3 weeks. Pure tone audiometry improved in 11 ears, remained the same in two and worsened in two (0-10 and 11-15 dBA, respectively). There were no complications arising from the procedure. Mean follow up was 13.7 months (median=9, range 3-31). None of the patients have re-perforated, but two have required re-ventilation of their middle ear for middle effusions, and one of these two has also undergone subsequent adeno-tonsillectomy. CONCLUSIONS: Our experience in this small series shows that the removal of a tympanostomy tube for recurrent otorrhoea can be successfully managed with a fat plug myringoplasty, with the benefit of a reduction in the persistent perforation rate following tympanostomy tube removal. It is a simple technique that requires little extra operating time with no significant morbidity.

Effect of anaesthetic agents on tympanometry and middle-ear effusions.

Following informed parental consent 93 children underwent bilateral grommet insertion. Tympanometry was performed pre-operatively, and immediately prior to myringotomy. A standardized anaesthetic was used. At myringotomy the presence or absence of fluid was recorded, as well as the time since induction of the general anaesthetic. A pre-operative type B tympanogram predicted a middle-ear effusion at myringotomy in 92 per cent of patients. A pre-operative type C2 tympanogram predicted a middle-ear effusion at myringotomy in 39 per cent of patients. Sixty tympanograms (30 per cent) changed following a general anaesthetic. Fourteen type B tympanograms changed to type A and eight of these had effusions. The duration of the general anaesthetic did not influence the probability of a middle-ear effusion being present at myringotomy. A pre-operative type B tympanogram is a good predictor of middle-ear fluid. The duration of the general anaesthetic is not significant in predicting the presence of a middle-ear effusion.

The effect of topical adrenaline on the development of myringosclerosis after tympanostomy tube insertion.

OBJECTIVE: To determine the effect of topical adrenaline application after myringotomy and before tympanostomy tube placement on the development of myringosclerosis. STUDY DESIGN: A prospective, randomized, double-blind study, with each patient acting as his or her own control. Ethical approval and full parental consent were obtained. SETTING: Department of Otorhinolaryngology-Head and Neck Surgery in a university teaching hospital. PATIENTS: Fifty children satisfying inclusion and exclusion criteria for first-time tympanostomy tube insertion. THERAPEUTIC INTERVENTION: Myringotomy followed by adrenaline application to incision before tympanostomy tube insertion. Control contralateral ear received saline application after myringotomy. Follow-up examination was done 14 to 21 days after surgery and again after 1 year by a single blinded surgeon. MAIN OUTCOME MEASURE: Comparison of myringosclerosis between adrenaline-treated ears and matched control ears. RESULTS: No difference was found in early morbidity between the two groups of ears. Myringosclerosis after 1 year was not found to have been significantly affected by adrenaline application (p = 0.2) CONCLUSION: The use of adrenaline on the myringotomy site before tympanostomy tube placement was not found to influence early postoperative morbidity or the later development of myringosclerosis.

Botulinum toxoid in the management of gustatory sweating (Frey's syndrome) after superficial parotidectomy.

Botulinum toxin has been successfully used to treat Frey's syndrome occurring in a 31-year-old patient following superficial parotidectomy for pleomorphic adenoma. An initial injection of 7.5 U (0.3 ml over 6 cm2 of cheek) resulted in 3 months' resolution of gustatory sweating and flushing and a second injection 12 months' symptomatic improvement. The symptoms recurred after further facial surgery.

Matrix metalloproteinase-2 and matrix metalloproteinase-9 in cholesteatoma and deep meatal skin.

A qualitative and quantitative study of the presence of Matrix metalloproteinase-2 (MMP-2) and Matrix metalloproteinase-9 (MMP-9) in cholesteatoma was performed. Ten cholesteatoma and four deep meatal skin specimens were analysed for gelatinase activity at molecular weights corresponding to MMP-2 and MMP-9 using Sodium Dodecyl Sulphate Polyacrylamide Gel Electrophoresis (SDS PAGE) Zymography. Gelatinase activity at 72 kDa and 92 kDa was investigated. Western blotting was employed using primary monoclonal antibodies to provide a qualitative assessment of MMP-2 and MMP-9. Non-parametric data analysis using the Mann-Whitney U test did not show a significant difference in expression of MMP-2 (P = 0.51) or MMP-9 (P = 0.14) between the two tissue types. Western blotting showed the presence of both MMP-2 and MMP-9 in the majority of specimens, both cholesteatoma and deep meatal skin.