General anaesthetic vs local anaesthetic myringoplasties: a systematic review and meta-analysis.

AIMS: To assess all available data and determine the success rates and tolerability of local anaesthetic myringoplasty in comparison with those undertaken under general anaesthetic myringoplasty. MATERIALS AND METHODS: The study was designed following a PRISMA-P protocol and registered with the PROSPERO database. MEDLINE, Cochrane Library (CDSR/Central), EMBASE and CINHAL-were directly searched for studies, which met the inclusion criteria. OBJECTIVES: Primary objective was to compare perforation closure rates between patients undergoing myringoplasty under local anaesthetic and those under general anaesthetic from all available published data. Secondary outcomes include complications, such as 'any minor complications', infection rates in the first 6 month post-op, facial nerve weakness, dysgeusia and patient satisfaction. RESULTS: 27 studies were included in the final analysis and found that myringoplasty had an overall perforation closure rate of 89%. The pooled proportion of closures after myringoplasty under local anesthesia was 87% and for myringoplasties under general anesthesia was 91%. Analysis of myringoplasty under local anaesthesia focusing on 'in-office' performed procedures only, found a closure rate of 88%. CONCLUSIONS: There is no significant difference in the success rate of myringoplasty surgery when performed under local or general anaesthetic as measured by perforation closure rates. However, there are other factors, which can drive choosing local anaesthetic surgery, such as minimising anaesthetic risks, reducing costs and reducing environmental impact.

An interesting case report of delayed presentation of visual loss from an Ethmoid Mucocoele. Should we offer emergency decompression?

Paranasal sinus mucocoeles commonly involve the frontoethmoidal sinuses and can rarely present with vision changes due to expansion and invasion through the orbit. A 50-year-old female presented out of hours with an acute, 16-h history of complete left sided visual loss, on a background of 3 days of visual changes. A left ethmoid mucocoele extending into the left orbital apex causing compression of the optic nerve was diagnosed on imaging. Emergency endoscopic sinus surgery with decompression and marsupialization of the ethmoid mucocoele was performed, which resulted in improvement of vision. This case is unusual due to improvement in vision despite the length of visual loss prior to surgical intervention. This case demonstrates the importance of considering rhinological causes for vision loss, and how critical early identification and surgical intervention can be to prevent serious complications such as permanent vision loss.

Hands-on teaching, shadowing, and supported learning through acute clinics to help improve the confidence of and meet training needs for junior doctors working in ear, nose, and throat surgery.

BACKGROUND: Ear, nose, and throat (ENT) surgery is a niche and unique specialty that has been recognized as being poorly taught throughout medical school and postgraduate training. Junior doctors who rotate into this specialty often find it hard and struggle to manage patients. Aims: The aim of this study was to devise a junior doctor-focused induction program with specific emphasis on shadowing and partnered working to improve confidence and competence. METHODS: Feedback from previous trainees was used to identify valuable training opportunities within the 4-month rotation. Trainers identified clinical areas where supported learning could be delivered. Trainees were allocated to rotate between theater, ward, on-call shifts, and acute clinics. The degree of time spent in each area was analyzed in order to balance service provision vs learning needs. Furthermore, novel strategies were introduced in each session to maximize learning experiences. Junior doctors were aware of the opportunities that would be available to them at the start of the rotation. In order to assess whether the aims were met, a questionnaire survey was used to assess exposure to core ENT practical skills and junior doctors' confidence levels in carrying them out unsupervised. RESULTS: Junior doctors spent 40% of their time assessing new acute admissions. Twenty percent of time was spent in ENT clinic, but novel practical methods of induction were introduced such as 1 week of directly supervised shadowing, followed by a transition period with regular debrief. A three-stage model was used to offer training in practical procedures in the clinical setting. Over half of the trainees felt confident in undertaking 50% of the core ENT procedures unsupervised. CONCLUSION: Our study reveals that giving junior doctors a relevant, focused and appropriate induction helps orientate them, give them the opportunity to ask questions, and also find their grounding in order to begin working. Having dedicated time to shadow and be with a colleague to assess and treat patients initially, with ongoing telephone and in person support, ensured that their confidence and competence improved very quickly. It also improved workplace satisfaction and motivated doctors to undertake self-directed learning and improve and enhance their skills beyond the minimum.