Have reducing tonsillectomy rates in England led to increasing incidence of invasive Group A Streptococcus infections in children?

OBJECTIVES: To determine whether there is a correlation between falling tonsillectomy numbers and increasing numbers of tonsillitis admissions and invasive Group A ß-haemolytic streptococcus (iGAS) infection in children aged 14 and under in England. DESIGN: An observational cross-sectional study was performed. SETTING: The data extracted covered the period from 1991 until 2014. PARTICIPANTS: Hospital admissions for tonsillectomies, tonsillitis/pharyngitis and all diagnoses of iGAS in children aged 14 and under who had a tonsillectomy. MAIN OUTCOME MEASURES: Correlation between trends in tonsillectomies, tonsillitis/pharyngitis and iGAS. RESULTS: Across all age groups, there was a dramatic reduction in the total number of tonsillectomies performed in England from 28 309 in 1990/1991, down to 6327 in 2013/2014 (77.7% reduction). The numbers of hospital admissions for management of acute tonsillitis and pharyngitis have risen dramatically. iGAS numbers have increased steadily over this time period and more than doubled in children aged 14 and under. There are significant negative correlations between the trend in iGAS infections and numbers of tonsillectomies in all ages. There are also strong positive correlations between the trend in numbers of tonsillitis episodes and the number of iGAS infections in all under 14-year groups; the strongest correlation was seen in the 1- to 4-year age group (+0.92 Pearson correlation coefficient). CONCLUSIONS: There appears to be a correlation between falling tonsillectomy numbers, increasing hospital admissions with tonsillitis and rising iGAS infection in England. Further studies are required to assess the aetiological role of tonsillitis in predisposing to iGAS infection and the potential societal benefit of tonsillectomies.

Primary versus secondary tracheoesophageal puncture: systematic review and meta-analysis.

BACKGROUND: Tracheoesophageal puncture represents the 'gold standard' for voice restoration following laryngectomy. Tracheoesophageal puncture can be undertaken primarily during laryngectomy or in a separate secondary procedure. There is no current consensus on which approach is superior. The current evidence comparing primary and secondary tracheoesophageal puncture was assessed. METHODS: A systematic review and meta-analysis of articles comparing outcomes for primary and secondary tracheoesophageal puncture after laryngectomy were conducted. Outcome measures were: voice success, overall complication rate and pharyngocutaneous fistula rate. RESULTS: Eleven case series met the inclusion criteria, two prospective and nine retrospective. Meta-analysis did not demonstrate statistically significant differences in overall complication rate or voice outcomes, though it suggested a significantly increased risk of pharyngocutaneous fistula in primary compared to secondary tracheoesophageal puncture. CONCLUSION: Primary tracheoesophageal puncture is a safe and efficient approach for voice rehabilitation. However, secondary tracheoesophageal puncture should be preferred where there is a higher risk of pharyngocutaneous fistula.

Does intranasal steroid spray technique affect side effects and compliance? Results of a patient survey.

BACKGROUND: Intranasal steroid sprays are fundamental in the medical management of inflammatory rhinological conditions. Side effects are common, but these may be related to the method of application rather than the medication itself. METHODS: A survey was distributed to patients using intranasal steroid sprays at the ENT out-patient clinic at Aberdeen Royal Infirmary over three months. This evaluated the spray technique used, side effects and compliance. RESULTS: Of 103 patients, 22 patients (21.4 per cent) reported side effects, including nasal irritation and epistaxis. Of the 20 patients with epistaxis, 80 per cent used an ipsilateral hand technique (p = 0.01). Thirty patients demonstrated poor compliance because of lack of symptom improvement or side effects. Seventy-seven per cent of this group used the ipsilateral hand technique. CONCLUSION: Patients who used their ipsilateral hand to apply the intranasal steroid spray were more likely to develop epistaxis and have poor compliance than those who used other techniques. Patients who struggle with compliance because of side effects should avoid this method of intranasal steroid application.

Does the EarPopper(®) device improve hearing outcomes in children with persistent otitis media with effusion? A randomised single-blinded controlled trial.

OBJECTIVE: To provide an independent evaluation of the efficacy and safety of the EarPopper(®) in improving hearing outcomes in children with otitis media with effusion (OME) and reducing the ventilation tube insertion rate. STUDY DESIGN: Randomised single-blinded controlled trial. SETTING: The Ear Nose and Throat Department of a district general hospital (Heatherwood and Wexham Park). PARTICIPANTS AND METHODS: Twenty-nine children aged between 4 and 11 years diagnosed with persistent OME lasting at least 3 months with an average hearing of 25 dBHL or worse in the better ear were randomised to a treatment or control group for 7 weeks using random computer-generated codes. Syndromic children, children with developmental delay, previous grommets and cleft palate were excluded. The audiologists were blinded at the final post-treatment audiogram. RESULTS: After the seven-week period, the mean improvement in air conduction across all frequencies was 10.9 dBHL in the treatment group (P < 0.001) and 3.6 dBHL in the control group (P = 0.201). At every frequency, the treatment group had larger improvements in air conduction, the largest being at 4 kHz where the mean air conduction in both ears improved by 14.8 dBHL. Compliance with the EarPopper(®) was over 90%, the only side-effect reported being discomfort in the ears immediately after use which resolved and did not affect compliance. The ventilation tube insertion rate was 53.3% in the treatment group and 78.6% in the control group. Median follow-up time for all patients is 47.7 months. CONCLUSION: Our study shows that the EarPopper(®) is a safe, effective treatment option for children with hearing loss from persistent OME, and it reduces the rate of ventilation tube insertion. More studies with larger sample sizes are required to support our findings.

Postoperative nasal debridement following functional endoscopic sinus surgery, a systematic review of the literature.

BACKGROUND: Chronic rhinosinusitis is a significant health problem, and the optimal postoperative treatment regime for patients post functional endoscopic sinus surgery has been a topic debated for years. OBJECTIVE OF REVIEW: To systematically review and critically evaluate the evidence relating to postoperative debridement of the nasal cavity following functional endoscopic sinus surgery to guide best practice. SEARCH STRATEGY: A search of the following databases was performed: Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effectiveness, and Cochrane Central Register of Control Trials. Ovid Medline, EMBASE, Pubmed. The following key words were used: Postoperative, functional endoscopic sinus surgery, sinus surgery, debridement, follow-up, from 1970 to 2013. EVALUATION METHOD: Two independent reviewers assessed the relevant articles using the consort guidance on systematic reviews Moher et al. BMJ 2010; 340: c869. RESULTS: The best evidence available was 1B, with six Randomsied control trial (RCTs) identified. Four studies compared debridement against no debridement, and two looked at the frequency of the debridement. Cumulatively, results for 337 patients were included. Visual analogue scores were used in all studies. None of the results at the long-term follow-up showed any difference in sino-nasal outcome test scores or objective endoscopic scores. Four of the six studies demonstrated some benefit in symptom scores but only one in the long term. Two papers demonstrated the debridement group suffered more pain in the postoperative period. CONCLUSIONS: Currently, there is no clear evidence for frequent postoperative debridement. Further well-designed RCTs are required to establish clear benefit, optimal frequency, extent and timing of debridement.

Sexual asphyxia causing blunt carotid artery injury and Horner's syndrome.

OBJECTIVE: To highlight a rare cause of Horner's syndrome, and to review the management of blunt carotid artery injury. METHOD: Literature search via PubMed for related articles. RESULTS: Horner's syndrome and blunt carotid artery injury are rare phenomena; sexual asphyxia as a cause has not previously been reported. This case is also the first of its kind to have radiological evidence of injury to the external carotid artery but not the internal carotid artery. In Horner's syndrome, additional symptoms of ipsilateral headache or neck pain, tinnitus, or any cerebral ischaemic symptoms should raise suspicion of blunt carotid injury. CONCLUSION: Blunt carotid artery injury is a potentially fatal condition and can present without radiological evidence. Early recognition and management with anticoagulants or antiplatelet drugs is crucial to prevent mortality and morbidity.