Carl Philpott

Protocol biopsy of the stable renal transplant: a multicenter study of methods and complication rates.

Background. Clinical trials in renal transplantation must use surrogate markers of long-term graft survival if conclusions are to be drawn at acceptable speed and cost. Morphologic changes in transplant biopsies provide the earliest available evidence of damage, and “protocol” biopsies from stable grafts can be used to reduce the number of patients needed in clinical trials. This approach has been inhibited by concerns over safety, but the risk of biopsy of a stable kidney, with no active inflammation or acute functional impairment, has never been formally estimated. Methods. In accordance with a predefined set of questions, a retrospective audit of a sequential series of protocol biopsies was performed in four major transplant centers. Results. A total of 2,127 biopsy events were assessed for major complications, and 1,486 were assessed for minor ones. There were no deaths. One graft was lost, under circumstances indicating that the loss should have been prevented. Three episodes of hemorrhage required direct intervention. Three further patients required transfusion. There were two episodes of peritonitis, but one was arguably an unrelated event. All serious complications presented within 4 hr of biopsy. Conclusions. The incidence of clinically significant complications after protocol biopsy of a stable renal transplant is low. Direct benefits to the patients concerned (irrespective of the benefit that may accrue in clinical trials) were not formally assessed but seem likely to outweigh the risk of the procedure. We believe that it is ethically justifiable to ask renal transplant recipients to undergo protocol biopsies in clinical trials and routine care.

Paediatric retropharyngeal abscess

Retropharyngeal abscess (RPA) is an uncommon condition with the potential for significant morbidity and mortality if not detected early. The authors present a case report of a 19-month-old child who presented with the common clinical features of a retropharyngeal abscess and in whom the diagnosis was not established by examination and ultrasonography. This led to a delay in appropriate management until a computed tomography (CT) scan was performed under general anaesthesia. The scan demonstrated the diagnosis and surgical drainage was performed under the same anaesthetic. The child subsequently made a complete recovery. The investigation and treatment of RPAs is a matter of some debate and the authors review the recent literature to determine the best management strategy.

A double‐blinded randomized controlled trial of coblation versus conventional dissection tonsillectomy on post‐ operative symptoms

Objectives:  The aim of this study was to compare postoperative symptoms following coblation tonsillectomy with those experienced following a traditional cold dissection.

Comparison of Subjective Perception with Objective Measurement of Olfaction

OBJECTIVE: To see if nasal peak inspiratory flow rate and subjective sense of smell had any correlation with olfactory thresholds. STUDY DESIGN AND SETTING: A cohort study of 186 normal volunteers was recruited from among staff and visitors at a university hospital. Olfactory thresholds were detected for each subject (103 with eucalyptol and 83 with phenethyl alcohol), along with nasal peak inspiratory flow (PIFR). Subjective sense of smell, along with nasal symptoms, mood, and alertness, were recorded on visual analogue scores. RESULTS: Subjective perception of smell had no correlation with olfactory thresholds detected (P = 0.4057) and the other subjective measures also had no correlation. There was a significant relationship of PIFR to thresholds in the group tested with phenethyl alcohol (P = 0.002). CONCLUSION: As with the sensation of nasal patency, the self-assessment of a subjects sense of smell has poor correlation with their actual olfactory ability. SIGNIFICANCE: A patients history cannot be relied upon when determining their olfactory ability and formal testing should be performed. EBM rating: A-1b

The burden of revision sinonasal surgery in the UK-data from the Chronic Rhinosinusitis Epidemiology Study (CRES): a cross-sectional study.

Objectives The aim of this study was to investigate the surgical revision rate in patients with chronic rhinosinusitis (CRS) in the UK CRS Epidemiology Study (CRES). Previous evidence from National Sinonasal Audit showed that 1459 patients with CRS demonstrated a surgical revision rate 19.1% at 5 years, with highest rates seen in those with polyps (20.6%). Setting Thirty secondary care centres around the UK. Participants A total of 221 controls and 1249 patients with CRS were recruited to the study including those with polyps (CRSwNPs), without polyps (CRSsNPs) and with allergic fungal rhinosinusitis (AFRS). Interventions Self-administered questionnaire. Primary outcome measure The need for previous sinonasal surgery. Results A total of 651 patients with CRSwNPs, 553 with CRSsNPs and 45 with AFRS were included. A total of 396 (57%) patients with CRSwNPs/AFRS reported having undergone previous endoscopic nasal polypectomy (ENP), of which 182 of the 396 (46%) reported having received more than one operation. The mean number of previous surgeries per patient in the revision group was 3.3 (range 2–30) and a mean duration of time of 10 years since the last procedure. The average length of time since their first operation up to inclusion in the study was 15.5 years (range 0–74). Only 27.9% of all patients reporting a prior ENP had received concurrent endoscopic sinus surgery (ESS; n=102). For comparison, surgical rates in patients with CRSsNPs were significantly lower; 13% of cases specifically reported ESS, and of those only 30% reported multiple procedures (χ2 p<0.001). Conclusions This study demonstrated that there is a high burden of both primary and revision surgery in patients with CRS, worst in those with AFRS and least in those with CRSsNPs. The burden of revision surgery appears unchanged in the decade since the Sinonasal Audit.

The Impact of Olfactory Disorders in the United Kingdom

Olfactory disorders are believed to affect 5% of the general population and have been shown to bear significant psychosocial consequences to sufferers. Although more common than blindness and profound deafness in the United Kingdom, the impact of these disorders has not been assessed to date and the plight of British patients has yet to be quantified. In 2012, a patient support organization, Fifth Sense, was founded to provide information and support to sufferers of chemosensory disorders. Following a recent members conference, a survey of the membership was conducted anonymously using a series of questions based on an existing olfactory disorders questionnaire. From 496 respondents, this has demonstrated high rates of depression (43%) and anxiety (45%), impairment of eating experience (92%), isolation (57%), and relationship difficulties (54%). Women appear to have significantly more issues than men in terms of social and domestic dysfunction relating to olfactory loss (P = 0.01). Qualitative disorders also affected more than 1 in 5 members with parosmia reported in 19% and phantosmia in 24%. This paper discusses the details of the British story of anosmia and other related disorders as depicted by those most affected.

Validation study of the “Sniffin’ Sticks” olfactory test in a British population: a preliminary communication

Clin. Otolaryngol. 2012, 37, 23–27

Position Paper on Olfactory Dysfunction

Background Olfactory dysfunction is an increasingly recognised condition, associated with reduced quality of life and major health outcomes such as neurodegeneration and death. However, translational research in this field is limited by heterogeneity in methodological approach, including definitions of impairment, improvement and appropriate assessment techniques. Accordingly, effective treatments for smell loss are limited. In an effort to encourage high quality and comparable work in this field, among others, we propose the following ideas and recommendations. Whilst the full set of recommendations are outlined in the main document, points include the following: • Patients with suspected olfactory loss should undergo a full examination of the head and neck, including rigid nasal endoscopy with small diameter endoscopes. • Subjective olfactory assessment should not be undertaken in isolation, given its poor reliability. • Psychophysical assessment tools used in clinical and research settings should include reliable and validated tests of odour threshold, and/or one of odour identification or discrimination. • Comprehensive chemosensory assessment should include gustatory screening. • Smell training can be helpful in patients with olfactory loss of several aetiologies. Conclusions We hope the current manuscript will encourage clinicians and researchers to adopt a common language, and in so doing, increase the methodological quality, consistency and generalisability of work in this field.

Endoscopic management of inverted papillomas: long-term results--the St. Paul's Sinus Centre experience.

OBJECTIVES To demonstrate that computer-assisted endoscopic management of inverted papillomas yields excellent long-term results in terms of preventing recurrence and minimizing significant morbidity and mortality. METHODS A retrospective chart review of patients who are being followed up for tumour recurrence or have undergone tumour removal between 2000 and 2008. All cases were undertaken using the GE Instatrak 3500+ navigation system. RESULTS Inverted papillomas are the most common tumour managed endoscopically (57% of all sinonasal tumours) with 76 patients seen over the last 8 years. Approximately 50% of these cases had undergone previous surgery in another centre where the tumour was either not recognized or the resection was incomplete. Twentynine percent of these patients had a recurrence but only three required a revision procedure using an open approach; otherwise recurrences were successfully managed endoscopically. Endoscopic recurrence during the first half was 32% (versus 14% for open procedures), dropping to a recurrence rate of 11% in the latter period. CONCLUSIONS Endoscopic management of inverted papillomas allows good control of the disease and avoids unnecessary morbidity associated with open procedures. Although there is a higher initial recurrence rate, these recurrences can be successfully managed endoscopically, and computer navigation can be a useful adjunct in achieving this.

Does the use of the combined oral contraceptive pill cause changes in the nasal physiology in young women

Background Changes in nasal physiology have been observed during pregnancy and the menstrual cycle. The role of female hormones in these changes is unclear. The aim is to investigate the effect of the modern combined oral contraceptive pill (COCP). Methods Eleven women were recruited from a family planning clinic. Anterior rhinoscopy, peak inspiratory flow rate, acoustic rhinometry, anterior rhinomanometry, mucociliary clearance time, and rhinitis quality-of-life questionnaire (RQLQ) scores were recorded at days 1 and 14 pre- and post-COCP. Results Increased nasal obstruction midcycle pre-COCP, with significant differences for anterior rhinoscopy (p = 0.001) and peak inspiratory flow rate (p = 0.022), was found. No statistical difference was shown between pre- and post-COCP results apart from day 1 anterior rhinoscopy findings (p = 0.05). Conclusion The modern COCP has no significant effect on nasal physiology.