Ivan Keogh

Serious complication of tongue piercing.

The case of an 18-year-old patient who developed critical upper airway compromise after central tongue piercing is presented. Otolaryngologists must be aware of the many potential complications of tongue piercing and their management.

Surgical checklists: the human factor.

BackgroundSurgical checklists has been shown to improve patient safety and teamwork in the operating theatre. However, despite the known benefits of the use of checklists in surgery, in some cases the practical implementation has been found to be less than universal. A questionnaire methodology was used to quantitatively evaluate the attitudes of theatre staff towards a modified version of the World Health Organisation (WHO) surgical checklist with relation to: beliefs about levels of compliance and support, impact on patient safety and teamwork, and barriers to the use of the checklist.MethodsUsing the theory of planned behaviour as a framework, 14 semi-structured interviews were conducted with theatre personnel regarding their attitudes towards, and levels of compliance with, a checklist. Based upon the interviews, a 27-item questionnaire was developed and distribute to all theatre personnel in an Irish hospital.ResultsResponses were obtained from 107 theatre staff (42.6% response rate). Particularly for nurses, the overall attitudes towards the effect of the checklist on safety and teamworking were positive. However, there was a lack of rigour with which the checklist was being applied. Nurses were significantly more sensitive to the barriers to the use of the checklist than anaesthetists or surgeons. Moreover, anaesthetists were not as positively disposed to the surgical checklist as surgeons and nurse. This finding was attributed to the tendency for the checklist to be completed during a period of high workload for the anaesthetists, resulting in a lack of engagement with the process.ConclusionIn order to improve the rigour with which the surgical checklist is applied, there is a need for: the involvement of all members of the theatre team in the checklist process, demonstrated support for the checklist from senior personnel, on-going education and training, and barriers to the implementation of the checklist to be addressed.

Acute epiglottitis in adults: a recent experience with 10 cases

OBJECTIVES Our objective was to examine the presentation, clinical course and management of acute epiglottitis in a recent series of adult patients. METHOD All consecutive adults with acute epiglottitis or supraglottitis admitted to a tertiary referral centre over a recent six-month period were included in this retrospective study. The diagnosis of epiglottitis or supraglottitis was established by flexible nasolaryngoscopy. RESULTS Ten patients were included. Two patients had concurrent acute tonsillitis and one had a peritonsillar abscess. Blood cultures were negative in all cases. Pathogens were isolated by throat swabs only in the two patients with acute tonsillitis. Two patients underwent intubation for management of airway obstruction. A combination of cefotaxime and metronidazole was the most common antibiotic regimen used. CONCLUSION The rising incidence of acute epiglottitis in the adult population mandates vigilance on the part of the otolaryngologist. Selective airway intervention is recommended for patients with airway obstruction of more than 50 per cent.

Safe surgery, the human factors approach

Studies estimate that a degree of error occurs in 5-15% of all hospital admissions, with 45% of errors occurring in the operating theatre. Staffing limitations, high turnover rates, site and side-specific surgical procedures, make operating theatres a high-risk environment. Valuable lessons may be learned from the aviation experience with error management. With over 70% of air-crashes occurring due to human rather than technical error, the Human Factors Approach to error recognises the potential for errors occurring due to human limitations, such as stress and fatigue. It encourages error reporting in a non-punitive environment, where it is seen as a valuable source of information, facilitating education and future error prevention. Errors in healthcare and surgery however, have been traditionally associated with secrecy and embarrassment, often reaching an unsatisfactory endpoint with no resultant education. Application of the Human Factors Approach to error management in healthcare, can only serve to improve safety standards in our hospitals and satisfy ever-increasing public expectations.

Perda auditiva genética

The progress in the research of genetic hearing loss has advanced our understanding of the molecular mechanisms that govern inner ear development, function and response to injury and aging. In the developed world, over 50% of childhood deafness is attributable to genetic causes and even age-related hearing loss has been associated with genetic mechanisms. AIM: The objective of this review is to summarize recent knowledge in genetic hearing loss. STUDY DESIGN: Sistematic review. MATERIAL AND METHODS: The literature review included articles indexed at MEDLINE (The National Library of Medicine, The National Institute of Health - USA) focusing on publications from the past 3 years plus the information available at the Hereditary Hearing Loss Home Page. CONCLUSION: Advances in the genetics of hearing loss have enhanced our comprehension of auditory function and have enabled more accurate diagnosis. Hopefully, as we further understand the molecular elements of the auditory system, this knowledge will help in the development of new therapies for the treatment of the underlying genetic defects.

A meta-analysis of the effectiveness of crew resource management training in acute care domains

The healthcare industry has seen an increase in the adoption of team training, such as crew resource management (CRM), to improve teamwork and coordination within acute care medical teams. A meta-analysis was carried out in order to quantify the effects of CRM training on reactions, learning, behaviour and clinical care outcomes. Biases in the research evidence are identified and recommendations for training development and evaluation are presented. PUBMED, EMBASE and PsychInfo were systematically searched for all relevant papers. Peer reviewed papers published in English between January 1985 and September 2013, which present empirically based studies focusing on interventions to improve team effectiveness in acute health care domains, were included. A total of 20 CRM-type team training evaluation studies were found to fulfil the a priori criteria for inclusion in the meta-analysis. Overall, CRM trained participants responded positively to CRM (mean score 4.25 out of a maximum of 5), the training had large effects on participants’ knowledge (d=1.05), a small effect on attitudes (d=0.22) and a large effect on behaviours (d=1.25). There was insufficient evidence to support an effect on clinical care outcomes or long term impacts. The findings support the premise that CRM training can positively impact teamwork in healthcare and provide estimates of the expected effects of training. However, there is a need for greater precision in outcome assessment, improved standardisation of methods and measures, and more robust research design. Stronger evidence of effectiveness will require multi-level, multicentre, multispecialty and longitudinal studies.

Advances in bio-optical imaging for the diagnosis of early oral cancer.

Oral cancer is among the most common malignancies worldwide, therefore early detection and treatment is imperative. The 5-year survival rate has remained at a dismal 50% for the past several decades. The main reason for the poor survival rate is the fact that most of the oral cancers, despite the general accessibility of the oral cavity, are not diagnosed until the advanced stage. Early detection of the oral tumors and its precursor lesions may be the most effective means to improve clinical outcome and cure most patients. One of the emerging technologies is the use of non-invasive in vivo tissue imaging to capture the molecular changes at high-resolution to improve the detection capability of early stage disease. This review will discuss the use of optical probes and highlight the role of optical imaging such as autofluorescence, fluorescence diagnosis (FD), laser confocal endomicroscopy (LCE), surface enhanced Raman spectroscopy (SERS), optical coherence tomography (OCT) and confocal reflectance microscopy (CRM) in early oral cancer detection. FD is a promising method to differentiate cancerous lesions from benign, thus helping in the determination of adequate resolution of surgical resection margin. LCE offers in vivo cellular imaging of tissue structures from surface to subsurface layers and has demonstrated the potential to be used as a minimally invasive optical biopsy technique for early diagnosis of oral cancer lesions. SERS was able to differentiate between normal and oral cancer patients based on the spectra acquired from saliva of patients. OCT has been used to visualize the detailed histological features of the oral lesions with an imaging depth down to 2–3 mm. CRM is an optical tool to noninvasively image tissue with near histological resolution. These comprehensive diagnostic modalities can also be used to define surgical margin and to provide a direct assessment of the therapeutic effectiveness.

Pediatric Cholesteatoma: Canal Wall Window Alternative to Canal Wall Down Mastoidectomy

Objective: A previous pilot series described a hybrid mastoidectomy technique, canal wall window (CWW), which substituted for the canal wall down (CWD) procedure and involved slitting the posterior canal wall. The current, larger series compares the results of the CWW procedure with conventional surgical techniques. Study Design: Retrospective analysis of 78 pediatric ears. Setting: Academic tertiary referral center. Patients: The mean patient age was 13.5 years. Main Outcome Measure(s): The data analyzed included ears later requiring conversion from CWW to CWD, dry/moist ear results, recidivation determined by two separate methods, and audiometric data statistically analyzed using independent-samples analysis (unpaired, two-tailed Students t test). Results: First, of 42 CWW ear procedures, 6 (14%) later required conversion to CWD. Second, dry ear results were as follows: for CWW, 94%; for CWD, 92%; and for CWU (canal wall up), 90%. Third, recidivation determined at 1 year (standard rate) was, for CWW, 19.5%; for CWD, 0%; and for CWU, 7.7%; the at-risk calculation rate was, for CWW, 27%; for CWD, 0%; and for CWU, 8.3%. The 6-year recidivation rate for all three surgical techniques was 0%. 4). The mean preoperative-to-postoperative four-tone air-bone gap change was, for CWW, from 29.7 to 26.4 dB; for CWD, from 32.9 to 39.0 dB; and for CWU, from 21.0 to 25.2 dB (postoperative CWW to CWD, p < 0.005). A postoperative air-bone gap result of 0 to 20 dB was achieved as follows: with CWW, in 13 of 36 ears; with CWD, in 2 of 14 ears; and with CWU, in 9 of 22 ears. Conclusion: Frequently, a CWW procedure can be substituted for a traditional CWD procedure. In the extended series, the CWW technique continued to provide hearing results similar to CWU rather than to CWD procedures in a young population who will bear the surgical outcome for many decades.

Blood splash and tonsillectomy: an underestimated hazard to the otolaryngologist

Mucocutaneous exposure is an important route of transmission of hepatitis viruses and HIV in healthcare workers. Few data exist in the literature on the risk of transconjunctival exposure during many surgical procedures. We investigated the use of eye protection during tonsillectomy and measured the incidence of potential eye splash. No otolaryngologist surveyed routinely used eye protection during tonsillectomy. Splash events occurred in 23 out of 103 tonsillectomies. In all cases the surgeon was unaware of the splash. Splash events were significantly more likely to occur during adult tonsillectomy (p < 0.05). We strongly advise the routine use of eye protection during tonsillectomy.

Routine nasopharyngeal biopsy in adults presenting with isolated serous otitis media: is it justified?

Nasopharyngeal malignancy accounts for less than 2 per cent of all head and neck cancers. Serous otitis media (SOM) causing deafness is a recognized indicator of nasopharyngeal obstruction and the possibility of a nasopharyngeal malignancy must be considered in all adults. Examination under anaesthesia (EUA) and biopsy of the nasopharynx is routinely undertaken in many centres to rule out nasopharyngeal malignancy in adults with SOM. The purpose of this 10-year retrospective study was to evaluate the case records of all adult cases of SOM, including their presentation, clinical findings, management and nasopharyngeal biopsy results. Eighty-five patients were included in the study. Fifty-nine presented with unilateral SOM and 26 with bilateral SOM. The primary presenting complaint in all cases was hearing loss. A nasopharyngeal mass was documented in 55 patients (69 per cent). Four nasopharyngeal masses were noted to have irregular or exophytic mucosa on flexible nasendoscopy. All patients underwent a EUA of the ears and a nasopharyngeal biopsy. The four patients with suspicious-looking masses were all found to have malignancies (two squamous cell carcinomas, one B-cell non-Hodgkin lymphoma and one adenocarcinoma). Three of these patients presented with unilateral SOM and one with bilateral SOM. All other patients with masses were found to have benign lymphoid hyperplasia. In total, 4.7 per cent of the adults with conductive hearing loss secondary to SOM were found to have a malignancy on nasopharyngeal biopsy. We would advocate a high index of suspicion of a nasopharyngeal tumour in adults presenting with SOM. If a mass is found in the nasopharynx then it should be biopsied. If no mass is found then it is not necessary to biopsy; however, close follow up, with repeat fibre-optic nasendoscopy, is advised.