A summative, Objective, Structured, Clinical Examination in ENT used to assess postgraduate doctors after one year of ENT training, as part of the Diploma of Otorhinolaryngology, Head and Neck Surgery.

CONTEXT: 'High stakes' postgraduate medical examinations should conform to current educational standards. In the UK and Ireland, national assessments in surgery are devised and managed through the examination structure of the Royal Colleges of Surgeons. Their efforts are not reported in the medical education literature. In the current paper, we aim to clarify this process. OBJECTIVES: To replace the clinical section of the Diploma of Otorhinolaryngology with an Objective, Structured, Clinical Examination, and to set the level of the assessment at one year of postgraduate training in the specialty. METHODS: After 'blueprinting' against the whole curriculum, an Objective, Structured, Clinical Examination comprising 25 stations was divided into six clinical stations and 19 other stations exploring written case histories, instruments, test results, written communication skills and interpretation skills. The pass mark was set using a modified borderline method and other methods, and statistical analysis of the results was performed. RESULTS: The results of nine examinations between May 2004 and May 2008 are presented. The pass mark varied between 68 and 82 per cent. Internal consistency was good, with a Cronbach's alpha value of 0.99 for all examinations and split-half statistics varying from 0.96 to 0.99. Different standard settings gave similar pass marks. CONCLUSIONS: We have developed a summative, Objective, Structured, Clinical Examination for doctors training in otorhinolaryngology, reported herein. The objectives and standards of setting a high quality assessment were met.

BSACI guidelines for the management of rhinosinusitis and nasal polyposis.

This guidance for the management of patients with rhinosinusitis and nasal polyposis has been prepared by the Standards of Care Committee (SOCC) of the British Society for Allergy and Clinical Immunology (BSACI). The recommendations are based on evidence and expert opinion and are evidence graded. These guidelines are for the benefit of both adult physicians and paediatricians treating allergic conditions. Rhinosinusitis implies inflammation of the nose and sinuses which may or may not have an infective component and includes nasal polyposis. Acute rhinosinusitis lasts up to 12 weeks and resolves completely. Chronic rhinosinusitis persists over 12 weeks and may involve acute exacerbations. Rhinosinusitis is common, affecting around 15% of the population and causes significant reduction in quality of life. The diagnosis is based largely on symptoms with confirmation by nasendoscopy. Computerized tomography scans and magnetic resonance imaging are abnormal in approximately one third of the population so are not recommended for routine diagnosis but should be reserved for those with acute complications, diagnostic uncertainty or failed medical therapy. Underlying conditions such as immune deficiency, Wegener's granulomatosis, Churg-Strauss syndrome, aspirin hypersensitivity and allergic fungal sinusitis may present as rhinosinusitis. There are few good quality trials in this area but the available evidence suggests that treatment is primarily medical, involving douching, corticosteroids, antibiotics, anti-leukotrienes, and anti-histamines. Endoscopic sinus surgery should be considered for complications, anatomical variations causing local obstruction, allergic fungal disease or patients who remain very symptomatic despite medical treatment. Further well conducted trials in clearly defined patient groups are needed to improve management.

Dental otalgia.

BACKGROUND: Secondary or referred otalgia can represent a diagnostic challenge to the otolaryngologist. Collectively, dental disorders are the most common causes of secondary otalgia presenting to the ENT clinic, and may account for up to 50 per cent of referred otalgia. Temporomandibular joint dysfunction syndrome represents the most common dental cause of referred otalgia. Decay and pulpal inflammation of posterior teeth can also frequently present as otalgia. The common embryological developmental origin of both oral and dental structures and the ear is responsible for their overlapping sensory nerve supplies, and this explains referred otalgia secondary to dental and temporomandibular joint disorders. These disorders can be easily overlooked, resulting in unnecessary and costly investigations. AIMS: This review aims to give a succinct overview of common dental causes of otalgia, and to provide ENT clinicians with guidelines for performing a rapid and simple dental and temporomandibular joint examination, which will reliably diagnose or exclude dental otalgia.

Total serum IgE and IgE antibodies specific to house dust mite found in two aged-matched cohorts of children with and without otitis media with effusion.

OBJECTIVES: To determine whether otitis media with effusion (OME) is associated with elevated serum immunoglobulin E (IgE) and IgE specific for house dust mite. DESIGN: Forty-seven children who had evidence of bilateral OME, both otoscopically and on tympanometry, on two separate occasions, 3 months apart were admitted for ventilation tubes. Forty-eight children admitted for minor eye surgery who had otoscopically normal ears and no history of middle ear problems were used as controls. Bloods samples were taken under anaesthesia. Total IgE and IgE radioallergosorbent test (RAST) to house dust mite was measured by the Pharmacia Unicap 100 system. The results from the two groups were compared. SETTING: Birmingham Children's Hospital. PARTICIPANTS: Children between the ages of 3 and 10. Children with Down's syndrome, cleft lip and palate, ciliary abnormalities, known immunodeficiencies and cardiac abnormalities were excluded. MAIN OUTCOME MEASURES: Total IgE and RAST to house dust mite. A RAST of >0.35 was taken to be positive. RESULTS: There was no statistical difference between the control and study groups for the total IgE. Six children from both study and control groups had a raised house dust mite RAST. There was no difference in the levels between either group. CONCLUSIONS: Our findings indicate that there is no direct relationship between OME and biochemical evidence of allergy, specifically to house dust mite.

Wegener's granulomatosis and subglottic stenosis: management of the airway.

Wegener's granulomatosis is a multisystemic disease characterized by foci of necrotizing vasculitis and granuloma formation. Subglottic stenosis may occur either as a presenting feature or a late-stage manifestation of the disease, but will occur in approximately 10-20 per cent of cases. We present a series of seven cases of Wegener's granulomatosis with subglottic stenosis and discuss our management of this condition. Where there is active disease, tracheostomy is the first-line surgical treatment of respiratory obstruction, as an adjunct to full medical therapy. More aggressive or elaborate surgical treatments should be reserved for non-active cases in which patients have not required medical treatment for one year.

Nasal polyps.

Nasal polyps are as common as adult onset asthma and unilateral polyps require histological examination. Medical therapy with corticosteroids should be tried before surgery. The anatomy should be demonstrated with computed tomography before endoscopic surgery.

Serum IgA and IgG functional antibodies and their subclasses to Streptococcus pneumoniae capsular antigen found in two aged-matched cohorts of children with and without otitis media with effusion.

The relationship between acute otitis media and otitis media with effusion (OME) is uncertain and the aetiology of OME is multifactorial. Otitis media with effusion may be an inflammatory condition; both bacteria and viral infections could play a part in this inflammation. The four bacteria Streptococcus pneumoniae, Haemophilus influenza, Staphylococcus aureus and Branhamella catarrhalis cause 60% of the infections whereas S. pneumoniae accounts for up to 35%. IgA provides the dominant surface response to polysaccharide and lipopolysaccharide antigens, of which IgA2 is the main subclass. Once the mucosa has been breached, most protection is provided by IgG. IgG2 acts mainly against bacterial capsular antigens. This study looked at two groups of 50 children with and without OME who were aged between 3 and 10 years. The aims were to determine if, firstly, the levels of the serum immunoglobulins were different in the two groups, secondly whether these children made the appropriate antibody response to the capsular antigen to S. pneumoniae (PCP), and finally if there was a delay in the maturity of the IgA response. The total IgG, IgA and all subclass levels were measured using radial immunodiffusion. Levels of functional IgA and IgG were measured using ELISAs (25 patients in each group). The results were analysed with non-parametric tests. The immunoglobulin levels were within the normal levels for both groups. There were very good correlations between the IgG total anti-PCP and the IgG2 anti-PCP (R > 0.9, p = 0.001). There was a good correlation between the levels of both IgG total and IgG2 anti-PCP against IgA total anti-PCP in both groups (R > 0.85, p > 0.01). This confirms a normal antibody response between both groups of patients. The ages of the controls and patients (50 samples) were correlated with increasing titres of circulating functional antibodies (P = 0.001). This is highly suggestive of a normal age-related response. In conclusion, the findings were contradictory to our original hypothesis that there is a subtle difference in surface protection between children with and without OME. We believe that a previous history of recurrent acute otitis media is unrelated to the development of OME after 3 years of age.

Allergen immunotherapy in ENT: historical perspective.

The origins of immunology and allergy are founded upon the early 19th century microbiological studies of Jenner and Pasteur. It was discovered that the immune system could cause harm. The subspecialty of allergy began with the coining of the term by Von Pirquet in 1906 to describe disorders resulting from hyper-reaction to normally innocuous environmental agents. Understanding the scientific basis of the immune system and allergy allowed Noon and Freeman, and later Cooke, to develop allergen immunotherapy. Initially the technique was crude, but with the subsequent key discovery of IgE, more accurate methods of diagnosis (such as the radioallergosorbent test (RAST)) and treatment ensued. The efficacy of specific immunotherapy has been demonstrated by many double-blind trials culminating in the WHO position paper. DNA recombinant technology has provided detailed molecular understanding of allergic disorders, which has resulted in several novel methods of immunotherapy that are potentially safer and more effective. Use of recombinant allergens, T-cell peptides, DNA vaccination with CpG motifs or plasmid vectors and anti-IgE strategies with monoclonal antibodies are showing promise.

Infection, allergy and the hygiene hypothesis: historical perspective.

The 'hygiene hypothesis' was popularized in the late 1980s to explain the high prevalence of atopic disorders in the developed countries. It links atopic disorders and the lack of early life infections. An association between the two is not novel and dates back to the beginnings of allergy, immunology and microbiology. Allergy and infection have always been closely related and the study of one has often provided new insights into the pathobiology of the other. Early research into bacterial infections led to the discovery of the human immune system and the concept of allergy. An important relationship exists between parasite infections and the development of atopic disorders. This review traces the long and intimate historical relationship between infection and allergy.

Th2 dominance in nasal mucosa in patients with Wegener's granulomatosis.

Wegener's granulomatosis initially affects upper respiratory tract organs including the nasal mucosa in more than 90% of patients. The inflammation is typically granulomatous with associated vasculitis. T lymphocytes are usually a prominent component of the leucocyte infiltrate. Previous studies using peripheral blood T cells have implicated IFN-gamma rich Th1-type responses. This study addressed the cytokine milieu in nasal mucosa from 10 patients with active Wegener's granulomatosis using immunohistochemistry. Increased levels of CD3+ T cells and eosinophils were present compared with normal and disease controls. There was increased expression of IL-4, down-regulation of IL-2 and no detectable IFN-gamma. There was increased expression of the chemokine receptor CCR3 by infiltrating cells, consistent with an IL-4 dominant, Th2-biased response. In contrast, renal biopsy tissue from 10 patients with active Wegener's granulomatosis showed expression of IL-2 and IL-4. The Th2-type environment within nasal mucosa, often the initial site of disease activity in Wegener's, is consistent with a local allergic response in these patients.

Clinical and histopathological correlation of nasal polyps: are there any surprises?

Nasal polypectomy is a common operation. There is debate about whether all nasal polyps removed at operation should be sent for histopathological examination. To investigate this, a prospective study was performed to check the correlation of clinical and histopathological examination. Three hundred and forty-four nasal polypectomy specimens during the period from September 1997 to September 1999 were sent for histopathological diagnosis, with the clinical diagnosis documented on the pathology form. The clinical diagnosis was then correlated with the histological diagnosis. Three hundred and twenty-eight specimens were diagnosed as inflammatory polyps and 16 as tumours, of which seven were malignant. There was a good correlation between the clinical and histological findings in 340 cases. There was disagreement between the forms and reports in four cases. When the notes were consulted, three cases had forms that were incorrectly filled in. There was only one unsuspected case of inverted papilloma in a polyp specimen, which looked like a benign inflammatory polyp. This study indicates there is a 99.7% correlation between clinical and histopathological diagnosis.

Assessment of mucociliary transport in patients with chronic mucoid rhinitis.

Chronic rhinitis is the manifestation of a heterogeneous group of disease entities and often proves difficult to manage successfully. We present the investigations of the mucociliary system in 40 patients with mucoid rhinorrhoea as their principal symptom of whom 20 had pan respiratory disease. The saccharin clearance time (SCT) was measured and classified as normal if it was below 20 min. Objective measurement of clearance was made using 99mTechnetium-labelled human serum albumin (99mTc-HSA). We have standardized our method using a micrometer syringe driver to produce a droplet of consistent size (droplet size, 0.01 ml, SD 0.0002 ml) that reduces the dose of radiation. The movement of the droplet was measured over 20 min (RLT). The mean, maximum rate and percentage moved were calculated. Patients were divided into those who had chest disease (20) and those without and a chi 2-test was performed for the mean RLT time between the two groups. There was a strong correlation between mean and maximum rates (r = 0.91). One patient has a normal SCT and normal RLT. Patients with chest disease had a significantly lower mean RLT (P > 0.01). Assuming that RLT is the standard investigation, six patients were normal but had an abnormal SCT, this is a false positive error of 15%. The false negative error was 4/40 (10%). The association between sinus and chest disease with abnormal mucociliary clearance is stressed.

Nasal haemophilic pseudotumour.

Haemophilic pseudotumour or haemophilic cyst is a rare complication of haemophilia, occurring in one to two per cent of individuals with a severe factor VIII or IX deficiency. We report a case of a haemophilic pseudotumour in a hitherto unreported site, the bony nasal pyramid, and believe this case is also unique on account of it having occurred in a patient with mild haemophilia. The diagnosis and treatment of this rare condition is also reviewed.

Children who withdraw consent for elective surgery.

Parents and legal guardians have authority to consent to medical treatment on behalf of minors. Recently, the concept of emerging competence has been popularized, whereby a child may achieve sufficient understanding and maturity to enable him/her to make a wise choice in his/her own interests. Although there are undoubted merits in involving children in their medical treatment, the ultimate legal authority for consent rests with parents and guardians acting on the advice of doctors and in the child's best interests. We describe two cases in which children withdrew their consent to elective surgery, despite the help and encouragement of their parents and doctors. Surgery was cancelled rather than use force to induce anaesthesia. In practice, it seems that a child must demonstrate a greater maturity and understanding to refuse medical treatment than to agree to it. Some advice is given to clinicians facing similar situations.

Increase in epithelial mast cell numbers in the nasal mucosa of patients with perennial allergic rhinitis.

The aim of the study was to compare the numbers and distribution of mast cells in the nasal mucosa of perennial allergic rhinitis (PAR) patients and controls, as demonstrated by different staining methods for light microscopy. Biopsies of inferior turbinate mucosa were taken from 10 patients with PAR and 10 patients undergoing septoplasty or septorhinoplasty (control group). Sections for light microscopy were stained with azure A. chloroacetate esterase and an ABC immunohistochemical technique using antibody to tryptase. Three times more mast cells were found in the epithelium of PAR patients compared to controls using the immunohistochemical technique (p = 0.0074). This method demonstrated considerably more mast cells than the other stains. The increase in epithelial mast cells is consistent with the migration of mast cells seen in seasonal allergic rhinitis, and this may be important in the phenomenon of nasal priming seen after repeated antigen exposure.

Mucociliary function in patients with nasal polyps.

Patients with nasal polyposis complain of nasal blockage and rhinorrhoea, which may be due to impaired mucociliary clearance. The saccharine clearance time and ciliary beat frequency of samples of ciliated epithelium from patients with nasal polyps was measured. We also studied the effect of fluid from the oedematous stroma of nasal polyps and of histamine and prostaglandin (PG) D2, E2 and F2 alpha on the cilia from normal individuals. Polyp fluid was found to increase ciliary beat frequency. Histamine and PGD2 had no effect, but PGE2 and PGF2 alpha both increased ciliary beat frequency and so may cause the ciliostimulatory effect of polyp fluid. The saccharine clearance time was prolonged in three of nine patients, but ciliary beat frequency was only slightly reduced in one of these. Thus, where mucociliary clearance is reduced, it is likely to be due to abnormalities of mucus rather than impaired ciliary activity.

The effect of temperature on nasal ciliary beat frequency.

Using a photometric method of measuring ciliary beat frequency, the effect of temperature on ciliary activity was investigated. A linear increase in ciliary beat frequency between 19 degrees and 32 degrees C was found. Between 32 degrees and 40 degrees a plateau was reached in which temperature did not significantly affect frequency and above 40 degrees C the frequency began to decline. It is concluded that nasal cilia are not critically dependent upon temperature in the range 32 degrees and 40 degrees C, the temperature range in which this tissue normally operates.

Medical treatment of nasal polyps.

Polyps are a multifactorial disease that affect the nasal lining and sinus mucosa, and in about one-third of the patients are associated with asthma. Polyps may occur in other respiratory diseases such as cystic fibrosis, primary ciliary dyskinesia and immune deficiencies. Allergy does not predispose to polyp formation, although mast cell reactions appear to be important. This explains why corticosteroids are effective in controlling some cases and helping to prevent recurrence in some others. Polyp formation in the sinuses is due to three factors: (1) the balance between the inflammatory response and the local homoeostatic mechanisms; (2) the relatively poor blood supply of the sinuses; and (3) the complex anatomy of the ethmoids and middle meatus which aggravates the existing oedema. Half the cases resolve on inhaled corticosteroids. Surgery should be tailored to the patient's needs, but on principle the simplest, least invasive operation should be tried first. If the patients are still symptomatic or recurrence is a problem, surgery may be followed by corticosteroids. If inhaled corticosteroids do not control the symptoms, then oral therapy may be required.

Sinus computerized tomography in primary hypogammaglobulinaemia.

Thirteen patients suffering from primary hypogammaglobulinaemia receiving intravenous immunoglobulin replacement therapy underwent computerized tomography of the paranasal sinuses. The CT scans were evaluated and related to clinical data from the patients, who were selected for study on the basis of having symptoms of rhinosinusitis. The scans varied from normal to demonstrating widespread sinus abnormality. There was no relationship between the scan findings and duration of ENT symptoms, range of current symptoms, or the interval between the onset of ENT symptoms and the start of intravenous immunoglobulin replacement therapy. It is nevertheless possible that prompt institution of replacement therapy, after correct diagnosis early in the course of the disease, may prevent the development of sinus disease refractory to such treatment.