G.S. Sandhu

Estimating the population incidence of adult post-intubation laryngotracheal stenosis.

(33) and 9% (37) during spring, summer, autumn and winter respectively. Our audit did show a specific trend of non-attenders with respect to seasonal changes. The spring had least non-attenders compared with other seasons. Males accounted for more compared with females, except in winter. The paediatric age group and middle aged (35– 49 years) accounted for >50% of non-attenders. Children, following grommet insertion, were the most likely patients to default. Of 32 recurrent non-attenders, 16 (50%) were suffering from ear problems. The most frequent non-attenders during each season were those who had a prior appointment within 3 months. Our hospital policy is to send reminder letters only to those patients who are given appointments after 3 months. This could be a reason for high numbers of non-attenders among those who do not receive the reminder letter. The overall non-attendance rate was similar to the national average. Finding a satisfactory way to remind patients of their appointment would help in breaking the vicious cycle of non-attenders and the long waiting list. Patients who received reminder letters turned up promptly. Irrespective of the duration between the present and the next appointment, we recommend that all patients should be sent a reminder letter (or message in a different format) a week before the consultation is due. The overall effect would be efficient use of NHS resources and better patient care.

Botulinum toxin in the management of sialorrhoea: a systematic review

• Sialorrhoea can be a significant problem in both adults and children and can cause both physical and psychosocial problems.

A multidisciplinary audit of clinical coding accuracy in otolaryngology: financial, managerial and clinical governance considerations under payment‐by‐results

Objectives:  To audit the accuracy of otolaryngology clinical coding and identify ways of improving it.

Physiological comparison of spontaneous and positive-pressure ventilation in laryngotracheal stenosis

BACKGROUND We compared spontaneous and positive-pressure ventilation in patients undergoing general anaesthesia for the treatment of extrathoracic, intralumenal laryngotracheal stenosis to assess the best method of ventilation in this patient group. METHODS Records of 30 patients with laryngotracheal stenosis, but not with a tracheostomy, undergoing lumen-restoring surgery were prospectively reviewed. Awake spirometry and flow-volume loops were recorded before the procedure. Patients received i.v. anaesthesia induction, muscle paralysis, and positive-pressure ventilation through a laryngeal mask airway (LMA). Anaesthetized tidal volume (TV) and flow-volume loop measurements were obtained. RESULTS We studied 19 males and 11 females [mean age 47 (SD 19) yr], ASA Grade III or IV, with lesions at 31 (10) mm below the vocal cords. Peak inspiratory flow (PIF) and peak expiratory flow (PEF) rates were 2.0 (1.2) litre s(-1) and 3.2 (1.7) litre s(-1) when awake. Tidal volumes were 657 (193) ml [9.2 (3.6) ml kg(-1)] and 586 (158) ml [8.3 (3.1) ml kg(-1)], respectively, when anaesthetized. There was a significant reduction in the PEF/PIF ratio, from a mean of 2.4 (1.3) awake to 1.0 (0.1) when anaesthetized (P<0.0001). A significant correlation was noted between awake PEF and anaesthetized expiratory TV (r=0.57; P<0.001) but not between awake PIF and anaesthetized inspiratory TV. DISCUSSION Positive-pressure ventilation through an LMA is an effective method of ventilating patients with laryngotracheal stenosis. Spontaneous ventilation creates negative inspiratory intratracheal pressure that exacerbates an extrathoracic lesion, whereas positive-pressure ventilation generates positive intratracheal pressure that improves ventilation. This helps explain the apparent resolution of airway obstruction after positive-pressure ventilation.

A proposed system for documenting the functional outcome of adult laryngotracheal stenosis

patients with acute epistaxis requiring admission. The survey revealed that oral diazepam was routinely prescribed in patients with acute epistaxis in all but two of the hospitals (Leicester and Newcastle). The reasons given for its use were invariably patient anxiety [n 1⁄4 10 (100%)] and acute hypertension [n 1⁄4 8 (80%)] attributed to anxiety. The dose prescribed varied between 2 and 5 mg. The regimen of prescription also varied from stat doses to as required to regularly three times a day. The duration of prescription was either until cessation of epistaxis or until normalisation of blood pressure. Our institution subsequently published the results of a prospective study examining the effects of oral diazepam on blood pressure and anxiety levels in patients requiring hospital admission for acute epistaxis. Our study found that oral diazepam did not offer any additional benefit in terms of lowering blood pressure and anxiety levels in these patients. The main side-effects of diazepam are drowsiness and confusion. This is of particular relevance to patients with acute epistaxis because they tend to be of an older age group and hence, more prone to sideeffects of drugs. Sedation in these patients may lead to the risk of unnoticed posterior epistaxis and aspiration. We therefore advise the use of oral diazepam with caution. In conclusion, our survey showed that, despite the lack of evidence on the benefits of oral diazepam in patients with acute epistaxis, the use of oral diazepam is a common although non-standardised practice in UK.

Securing tracheal stents : a new and simple method

Indwelling silastic stents have been used in the subglottis and upper trachea to manage laryngotracheal abnormalities. A number of methods of fixation have been described. The authors describe a quick and simple method of fixing endoluminal tracheal stents using a single suture.

How we do it: Transnasal fibreoptic oesophagoscopy

• Transnasal fibreoptic oesophagoscopy (TFO) allows the upper aerodigestive tract, from the nasal vestibule to the gastric cardia to be examined in the outpatients department without sedation.

Intracranial polyps in patients with Samter's triad

Background We describe three patients with Samters triad (nasal polyps, aspirin intolerance, and asthma) with skull base dehiscence in whom the polyps extended into the extradural space and also resulted in hypertelorism and widening of the nasal bridge. Methods One patient died in a road traffic accident while awaiting surgery. The other two patients underwent endoscopic resection of the polyps with a combined osteoplastic flap. Results Histology confirmed benign eosinophilic polyps with edematous stroma and a markedly thickened basement membrane. There were no complications or revision procedures. Both are symptomatically well with improvement of the hypertelorism. Conclusion These cases indicate that polyps in Samters triad may be extremely aggressive, resulting in intracranial extension. A combined endoscopic and osteoplastic flap approach is a safe and effective surgical option.

IgG4-Sclerosing Pseudotumor of the Trachea: A Case Report and Review of the Literature

I mmunoglobulin G (IgG) molecules are a family of glycoproteins involved predominantly in the anamnestic or secondary immune response and comprise 4 subclasses (IgG1-4) that vary in their capacity to trigger effector functions and their serum prevalence, with IgG4 being the least abundant. During autoimmune disease processes, the normally protective antimicrobial function of these molecules is targeted to healthy tissues, often with deleterious consequences.

An approach to the management of paroxysmal laryngospasm.

OBJECTIVE To review the presentation, risk factors and management of paroxysmal laryngospasm. STUDY DESIGN Retrospective review of cases. SETTING A teaching hospital otolaryngology department with a subspecialty interest in airway disorders. PATIENTS All patients diagnosed with laryngospasm over a two-year period were reviewed. Information was obtained about disease presentation, risk factors, management and symptom resolution. RESULTS Laryngospasm was diagnosed in nine women and six men. The average age at presentation was 56+/-6.5 years, and there was an 80 per cent association with gastroesophageal reflux disease. Proton pump inhibitors led to complete symptom resolution in six patients and to partial symptomatic relief, requiring no further treatment, in a further four patients. Of the remaining five patients unresponsive to proton pump inhibitor therapy, two continued to experience syncopal episodes due to laryngospasm. Both these patients achieved complete remission after laryngeal botulinum toxin injection. Symptoms recurred after three to four months and were successfully treated with a repeat injection. CONCLUSIONS The primary risk factor for spontaneous laryngospasm is laryngopharyngeal reflux. Symptoms are distressing and may be relieved in most cases by treatment aimed at suppressing gastric acid secretion. Laryngeal botulinum toxin injection appears to be a viable treatment modality in selected patients with refractory symptoms.