Paediatric quality-of-life following adenotonsillectomy: an evaluation of T14 paediatric throat disorder quality-of-life outcomes according to operative indication.

INTRODUCTION: Adenotonsillectomy is the most common surgical intervention for obstructive sleep apnoea (OSA) or recurrent tonsillitis. The Paediatric Throat Disorder Quality of Life Outcome (T14) questionnaire is a validated tool completed by parents to compare the outcome of surgery by measuring the pre- and postoperative scores. This study was undertaken to evaluate the quality-of-life outcome in children undergoing surgical intervention for recurrent tonsillitis and/or OSA. METHODS: This was a prospective, uncontrolled study of 117 children who underwent adenotonsillectomy and tonsillectomy at a single tertiary ear, nose and throat department. An analysis of pre- and postoperative T14 paediatric throat disorder quality-of-life outcomes was undertaken at 12 months. RESULTS: Of the 117 children, 105 were included in the study sample; 75 with recurrent tonsillitis, 8 with OSA and 22 with both tonsillitis and OSA. All children had an improved T14 score postoperatively. The greatest change in pre- and postoperative T14 score was observed in the tonsillitis and OSA combined group (mean change -29.36, p<0.001). However, an improvement in T14 score was also noted in the tonsilitis (-24.453, p<0.001) and OSA groups (-14.25, p<0.001). CONCLUSIONS: This study found a statistically significant improvement in the T14 quality-of-life score at 12 months postoperatively in children undergoing adenotonsillectomy. This demonstrates improved parental perception of their child's symptoms for all operative indications of adenotonsillectomy.

Lingual tonsil: clinically applicable macroscopic anatomical classification system.

OBJECTIVE: To classify the adult lingual tonsil according to the macroscopic appearance. STUDY DESIGN: Prospective study. LEVEL OF EVIDENCE: Four. METHODS: Lingual tonsils were classified according to their appearance and relationship to surrounding structures. This was possible following serial views of lingual tonsils. The classification was named 'Swansea classification for lingual tonsil', representing the place of origin. The classification was then discussed with fellow clinicians. Independent professional observers graded lingual tonsil pictures. Intra-observer agreements were measured to validate the classification. RESULTS: A total of 22 professional observers went through a set of six pictures of three different grades of lingual tonsil. The pictures were then graded for validation. The intra-observer agreement was 0.81, confirming good agreement. CONCLUSION: Swansea classification for lingual tonsil is reliable and reproducible. This classification should be routinely used during ENT examination, enabling accurate documentation and providing opportunities for future research and audit of practice.

Active versus passive humidification for self-ventilating tracheostomy and laryngectomy patients: a systematic review of the literature.

OBJECTIVE: To determine whether active or passive humidification methods are more effective in preventing pulmonary complications in self-ventilating neck breather patients. DESIGN: Systematic Review adhering to PRISMA guidance (checklist sourced from www.equator-network.org/). SETTING: Review of current published relevant literature at a tertiary department of Otolaryngology and Head & Neck Surgery. PARTICIPANTS: We included all separate studies and comparison studies of active and passive humidification techniques in adult and paediatric neck breather patients. MAIN OUTCOME MEASURES: The primary outcome is the reduction in pulmonary complications. Secondary outcomes include patient compliance; carer and user satisfaction. RESULTS AND CONCLUSIONS: Seven studies were included in this review: two RCTs (133 patients), one randomised controlled cross-over trial (29 patients), three randomised prospective studies (171 patients), and one retrospective study (73 patients). Only one study was conducted on paediatric neck breathers. The overall quality of the studies was low. Five studies were at a high risk of bias. Of the remaining two studies, one study had a low risk of bias and the other had an unclear risk. Despite limited subject evidence, results show that passive methods of humidification (mainly HME) is the preferred choice of humidification in the spontaneously breathing neck breather patients group mainly due to the reduction in pulmonary complaints, and better patient compliance.

The relationship between serum urea levels and outcome in acute epistaxis.

OBJECTIVES: To establish whether, for the patient presenting with epistaxis, there is a relationship between clinical outcome and serum urea levels measured on initial attendance at the accident and emergency (A&E) department. METHODOLOGY: Records were reviewed from all patients attending a single teaching hospital A&E department between 1st January 2010 and 11st February 2011 with a diagnosis of epistaxis. Patients were analysed according to their admission serum urea and creatinine levels and then grouped according to clinical outcome. RESULTS: We identified 278 patients (145 males, 133 females), 82 of which required hospital admission. Eleven required blood transfusion, and five required surgical arrest of the haemorrhage. No patients died. Serum urea and creatinine levels were measured in 119/278 patients. The mean serum urea level was significantly higher in patients admitted for further management of epistaxis than in patients who were discharged from the A&E department (9.35 mmol/l vs. 6.74 mmol/l, respectively; p = 0.003). There was no significant difference in mean serum urea levels between patients who were transfused and patients who were not, or between patients who went to the operating theatre and patients who did not. CONCLUSIONS: Elevated serum urea levels on hospital admission are related to more severe clinical outcome in epistaxis.

Rigid endoscopy in the out-patient clinic.

OBJECTIVE: This paper presents an efficient and ergonomic system for performing rigid endoscopic examination in the out-patient clinic setting. The set-up encourages user comfort, and facilitates clear images of the nasal mucosa, nasal cavity and paranasal sinuses. EQUIPMENT: This consisted of anti-fog solution, a 5 ml syringe, a cardboard receiver and gauze. CONCLUSION: By using disposable equipment we encourage good infection control practices. We recommend that users of rigid endoscopes in the out-patient setting consider setting up for each patient in this manner.

'Valve-stabilised' rhinospirometry can predict the benefit of septal surgery: a pre- and post-operative correlation study.

Septoplasty is a procedure often associated with high levels of patient dissatisfaction post-operatively. This study examined whether rhinospirometry and a modified 'valve-stabilised' technique could pre-operatively predict the outcome of septal surgery and therefore have a role as an objective tool for selection of patients suffering from nasal obstruction due to septal deformity for the procedure of septoplasty. A prospective study was performed of patients attending Singleton Hospital, Swansea, for surgical treatment of nasal obstruction due to septal deformity. Participants were asked to undertake decongested visual analogue scoring (VAS) and rhinospirometric assessment of their nasal obstruction in both normal 'resting' and 'valve-stabilised' nasal positioning. These investigations were undertaken on the day of surgery and 6 weeks post-operatively. Results were converted into nasal partition ratio scores and were assessed statistically for difference, correlation and accuracy. A total of 29 individual participants were included in the study. Septal surgery produced a statistically significant improvement in nasal airflow symmetry in the normal 'resting' nasal position using rhinospirometry (Wilcoxon ranked p > 0.5). This difference was not seen between evaluations in 'valve-stabilised' position (Wilcoxon p < 0.001). No statistical difference was evident between pre-operative 'valve-stabilised' testing and post-operative 'resting position'. The finding was also apparent on VAS nasal assessment. Correlation studies showed a strong relationship between pre-operative 'valve-stabilised' and post-operative 'resting' rhinospirometry results (Spearman's rho = 0. 586, p < 0.002). The strength of this relationship between VAS assessments was less pronounced (Spearman's rho = 0.386 p = 0.07). 'Valve-stabilised' rhinospirometry and VAS appear to be useful pre-operatively to predict the outcome of septal surgery, in terms of airflow symmetry, for nasal obstruction due to septal deformity, with pre-operative 'valve-stabilised' results correlating well with the post-operative standard 'resting' outcomes. Valve-stabilised rhinospirometry may have a role in pre-operatively predicting of likely post-operative patient satisfaction, although further studies are required in this area.

The accuracy and reproducibility of rhinospirometry in detecting flow asymmetry in a nasal cavity model.

The objective of this study is to investigate the appropriateness of the NV1 rhinospirometer in the assessment of asymmetrical nasal airflow using a nasal cavity model. The Study is a laboratory-based basic-science study using an artificial model of nasal airflow. It is conducted in Medical Physics Department, Singleton Hospital, Swansea, Wales. A nasal cavity model was created with a series of parallel flow symmetry/asymmetries that were each assessed using standard flow volume measurements. The results were converted into Nasal Partition Ratios (NPRs) for each trial scenario and were examined against a mathematically calculated NPR derived using Pouseille's law. Experimental scenario results were assessed for correlation, accuracy and precision against the mathematically derived result. In this study 300 individual test scenarios were completed using 2 different flow volumes and 15 different symmetry/asymmetry combinations. Correlation of the attained results against the mathematically derived figure gave a very strong correlation, using Spearman's Rho = 0.975. Accuracy was excellent within one Standard deviation of the expected results. It was concluded that the NV1 rhinospirometer is an accurate and precise objective marker of airflow symmetry in the nasal cavity model giving strong correlation, accuracy, precision and reproducibility. The rhinospirometer, as a precision tool, has displayed potential to become an effective objective marker of nasal airflow in the assessment of nasal obstruction; however, clinical trials are required to examine whether the accurate results of this laboratory study are transferable to clinical practice.

Tonsillectomy à chaud for quinsy: revisited.

In a prospective study involving 16 patients over a 12 month period, we determined whether tonsillectomy à chaud is an acceptable alternative to interval tonsillectomy for patients with quinsy. Guidelines for the acute surgical management of quinsy (or peritonsillar abscess) were established following a departmental audit. Sixteen patients were admitted with a quinsy plus an indication for tonsillectomy; 12 were evaluated prospectively. Each was treated either by incision and drainage or needle aspiration, rehydration, analgesia and intravenous antibiotic therapy, followed by a tonsillectomy à chaud (immediate tonsillectomy) within 30 h of the acute admission. Despite initial drainage, a high incidence of pus was detected intra-operatively. A much larger group of patients had peritonsillitis rather than peritonsillar abscess. Of the 16 patients admitted with a quinsy and indication for tonsillectomy over a 12 month period, 12 consented to tonsillectomy à chaud. Aspiration was used to confirm the presence of a quinsy in seven patients (58%), and incision and drainage in the remaining five. There were no complications, and further hospitalisations were avoided thus reducing patient morbidity and costs. We propose that tonsillectomy à chaud remains a justifiable alternative to interval tonsillectomy for such patients when personnel and theatre facilities permit.

Snore site discrimination using statistical moments of free field snoring sounds recorded during sleep nasendoscopy.

The non-invasive measurement of free field snoring sounds to estimate the site of snoring is an important development in the diagnosis, treatment and management of sleep-related breathing disorders. We investigated characteristics of the probability density function by testing the sensitivity of the statistical moments to amplitude patterns in the snoring acoustic signal. Snoring sounds from 15 patients were recorded whilst performing sleep (under anaesthetic) nasendoscopy evaluation. We demonstrated, using a fuzzy 2-means clustering method, that a combination of the statistical dimensionless moment coefficients of skewness and kurtosis could discriminate between pure palatal and non-palatal snoring subject groups.

Eye observation and corneal protection during endonasal surgery.

Traumatic orbital complications of endonasal surgery, although rare, are a cause of significant morbidity. Although a variety of methods of monitoring eye function during surgery have been described, the best method remains direct perioperative observation of the eye. However, the eye must also be protected during surgery otherwise corneal drying will occur and corneal abrasion may result. This article describes and illustrates the use of Geliperm, a sterile, transparent, pliant hydrogel dressing, as a corneal protector allowing continuous observation of the eye during endonasal surgery.

Validity of sleep nasendoscopy in the investigation of sleep related breathing disorders.

OBJECTIVE: To validate the technique of sleep nasendoscopy using target controlled infusion in symptomatic patients and a control group of asymptomatic individuals. DESIGN: Prospective cohort study. SETTING: Department of otolaryngology-head and neck surgery and anesthesia in a teaching hospital. PARTICIPANTS: Two groups of patients were compared and matched for their body mass index. The first group consisted of 53 patients with a history suggestive of obstructive sleep apnea. The second group consisted of 54 patients with partner-confirmed history of no snoring. These patients were undergoing anesthesia for other reasons. Both groups of patients were free of associated otorhinolaryngologic symptoms. MAIN OUTCOME MEASURE: Assessment of production of snoring or obstruction in patients with no documented history of snoring when sedation was administered as part of general anesthesia using target controlled infusion with propofol. RESULTS AND CONCLUSIONS: None of the patients in the asymptomatic group snored or obstructed at any level of propofol, and this was clearly significant on comparison with the symptomatic group (P < .001). All of the symptomatic patients were induced to become symptomatic (snoring/obstruction).

The treatment of acute dacryocystitis using laser assisted endonasal dacryocystorhinostomy.

AIMS: To determine whether acute dacryocystitis complicated by abscess formation can be successfully treated using laser assisted endonasal dacryocystorhinostomy. METHODS: A protocol was adopted for the management of acute dacryocystitis presenting to an ophthalmology department. All patients were assessed jointly by an ophthalmologist and otolaryngologist for their suitability for primary internal drainage via a nasal endoscopic approach. All suitable patients during the study period August 1999 to November 2000 were managed by intravenous antibiotics and holmium:YAG laser dacryocystorhinostomy. RESULTS: Nine patients were studied (mean age 72 years (range 38-82 years), three men, six women). A history of chronic epiphora was found in 78% of patients, and recurrent nasolacrimal infections in the same 78%. Resolution of symptoms and signs of acute dacryocystitis occurred in all nine patients. No recurrence of acute dacryocystitis occurred during the median follow up period of 11 months (range 6-31 months). Ostium patency defined as the absence of epiphora and the observation of irrigated lacrimal fluorescein at the ostium was achieved in 67% of patients. Epiphora recurred in 33% of cases. CONCLUSION: Laser assisted endonasal dacryocystorhinostomy is an effective primary treatment in cases of acute dacryocystitis complicated by abscess formation. In addition, pre-existing symptoms of epiphora and recurrent nasolacrimal infections are relieved in the majority of patients.

A new and clinically symptomatic variant of thyroid cartilage anatomy.

We present a previously undescribed variation in the anatomy of the superior cornu of the thyroid cartilage. In the five cases described, the tip of the cornu turned medially and caused an indentation into the pharynx. These indentations were symptomatic and caused pain and globus sensation. Resection of them led to resolution of the symptoms. A survey of the incidence of this variation of the thyroid cartilage in a clinic population is presented.

Endosupralayngeal laser resection of a symptomatic anatomical laryngeal variant: a minimally-invasive technique for a newly-recognised condition.

A variant of thyroid cartilage anatomy has recently been described as a cause of significant pharyngeal and laryngeal symptoms. After clinical recognition, spiral CT imaging confirms the anatomical relationships and a minimally-invasive technique is offered to allow surgical removal of the variant. The authors describe the surgical technique that was developed to avoid the need for an alternative, more conventional, external approach, and the instruments found to be particularly suitable for providing appropriate access to the supralaryngeal region.

Failure of insertion of a laryngeal mask airway caused by a variation in the anatomy of the thyroid cartilage.

We report the failure of insertion of a laryngeal mask airway in a patient with a pre-operative diagnosis of an abnormality of the superior cornua of the thyroid cartilage. We believe that this is the first time that this reason for failure has been reported.

A new approach to improving illumination in the nose during endonasal surgery.

Despite improvements in light sources the problem of illumination during endonasal surgery persists. This is particularly so in the presence of blood which absorbs light and renders the operative field dark as a consequence. This paper describes a series of in vitro experiments that show how improved illumination is possible using readily available, inexpensive, sterilisable and flexible materials. The hypothesis tested was that white coloured materials, when placed into the nasal cavity during endonasal surgery, improve illumination of the operative field by reflecting light onto the area of surgical interest. This hypothesis was tested with the use of a light proof box into which were introduced blood coloured and reflective materials. The light reflected back from a fixed blood coloured surface within the box was measured. The introduction of white materials into the box provided greater illumination than blue or foil surfaces.