Jonathan Fishman

Optimising care in an age of austerity: patient-reported outcome measures in paediatric ENT, journal bias, tonsillectomy and endoscopic ear surgery

When resources are in short supply, it is particularly important to focus care on areas of greatest need, monitor outcomes in a reliable fashion and, where possible, apply the principles of evidence-based medicine. Data on interventions (particularly those which are for publication) should beunbiased.Unfortunately,monitoring outcomes is expensive in terms of resources and staff time, as is auditing, and much of our practice is therefore experience-based rather than evidence-based. When did you last see a routine post-tonsillectomy case as a follow-up patient in your publicly funded clinic? How do our trainees learn what is ‘normal’ after surgery if they never see their patients unless complications occur? This issue of The Journal of Laryngology & Otology has a review fromNewcastle and Carlisle, which surveys patient-reported outcome measures. It highlights the variety of measures available, the lack of universal adoption, the problems with validity and reliability, and the need for both general and disease-specific questionnaires, as well as the need for paediatric style rather than adult questionnaires. Many readers will be familiar with the ‘T-14’ Paediatric Throat Disorders Outcome Test questionnaire, used in paediatric tonsillectomy cases; fewer will be aware of one for adult mastoid cavity care. There is a long way to go before patientreported outcome measures can be relied upon in the way that we hope for. When evidence on treatment outcomes gets as far as an otolaryngology journal, how reliable is that? If the paper by Kaper et al. is taken at face value, then the answer is disappointing. ENT journals cannot compete with general medical journals for impact factor, but can strive harder to ensure that reporting of treatment outcomes reaches acceptable standards. A paper from Geelong, Australia, in this issue of The Journal, studied 2863 patients over 16 years after tonsillectomy, all of whom stayed in hospital at least 1 night, and evaluated risk factors for the requirement of in-patient stay. The results agreed closely with current UK guidelines, and confirm that, for the great majority of cases, day surgery is acceptable. The mention of tranexamic acid use routinely after tonsillectomy echoes recent publications. On a brighter note, the Britain–Nepal Otology Service ‘BRINOS’ team have raised the possibility that even in very resource-poor environments, like Nepal, innovative techniques such as endoscopic ear surgery may have great value, as long as care is taken over technique.

The future of British otorhinolaryngology is in safe hands

One of the most exciting developments in British otorhinolaryngology is the setting up of trainee networks to enhance research and audit. Mehta and colleagues have asked themselves whether they can design and deliver a national audit of how epistaxis is managed, given the perceived wide variations and lack of data. They confirm that they can and that there is variation in the management of epistaxis. Regional trainee collectives have been mobilised towards national projects, and high-quality data have been recorded through webbased interfaces. This work, along with a previous collaboration on peritonsillar abscess management, across the UK, confirms the viability of the endeavour. The future of British otorhinolaryngology is in safe hands. Mindfulness is all the rage in today’s world. An excellent randomised controlled study of mindfulness meditation versus relaxation therapy in the management of tinnitus, by Arif and colleagues from the Welsh Hearing Institute and University Hospital of Wales, shows an improvement in outcomes for both these modalities, and reveals that mindfulness mediation performed better as compared to relaxation therapy. This is likely to lead to a change in therapy for patients who are appropriate for this modality and it adds to the armamentarium of therapies for tinnitus. The long-held notion that the fascia graft used for tympanoplasty ought to be dry and parchment-like is brought into question by Jiang and Lou. These authors report that using dry or wet temporalis fascia graft does not affect the outcome of a type I underlay graft, and suggest that a wet graft may shorten the duration of surgery for tympanoplasty. This adds to the earlier report from Shanker et al., which reported that the success rate for type I tympanoplasty is the same in wet and dry mucosal otitis media. The question of race as a factor in thyroid cancer has been considered by Keane and colleagues, in a retrospective analysis of 8 studies involving over 600 000 adult patients. They show that variations exist in racial groups, which are also dependent on gender. Black and white people have a higher proportion of follicular cancer. This is in contrast to papillary thyroid cancer; Megwalu and Saini previously reported that black patients had significantly worse overall survival after adjusting for sex, marital status, age, year of diagnosis, multifocal disease and type of surgery.

Topical aural antibiotic use in the UK - time for a change of policy?

Practitioners in the UK can be excused for being confused when it comes to the appropriate use of topical antibiotics for discharging ears. The two groups of antibiotics used topically in the ear are aminoglycosides and quinolones. Confusion over their use arises from two points of contention. Firstly, is the fact that because of potential ototoxicity the data sheets for topical aminoglycosides advise against their use in the presence of a non-intact tympanic membrane. Secondly, quinolones are not licensed for aural topical use in the UK. These issues are discussed in detail in a review article by Harris and colleagues. The authors review the effectiveness of topical quinolones in chronic suppurative otitis media, and conclude that they are equal or more effective in treating chronic suppurative otitis media than aminoglycosides. The potential development of antibiotic resistance to quinolones is cited as a theoretical disadvantage in their use, although in practice there does not appear to be any evidence for this. It seems that, possibly as a result of the licensing anomaly, the ENT-UK guidelines concerning the use of topical antibiotics are out of step with those currently in place in the USA, Canada, Australia and New Zealand. Otolaryngologists the world over will be familiar with their patients having a high level of psychiatric morbidity. Otological complaints are particularly likely to be associated with depression and anxiety, with tinnitus being perhaps the most frequently associated symptom. Two articles in this issue address this association. Yilmaz and colleagues examined patients with isolated itching of the external auditory canal and found a very high level of type D personality, characterised by depression, negative affect and social inhibition. The occurrence of depressive disorders in patients with sudden sensorineural hearing loss is perhaps more of a surprise. Lin and colleagues, however, in a large population-based study, found a 1.45 times higher level of sudden sensorineural hearing loss in patients with depression compared to those without. Co-morbidities such as diabetes mellitus, chronic renal disease and hyperlipidaemia also significantly increased the risk of sudden hearing loss. Early diagnosis of head and neck cancer is accepted to be the principle behind good patient outcomes and survival in these conditions. In the UK, the process of referral for suspected cancer is acknowledged to have scope for improvement. Gogarty and colleagues investigate the possibility of designing a national head and neck cancer screening programme. They recommend tailored screening programmes for specific populations known to be at risk of developing head and neck cancer, rather than mass population screening. Finally, the Editors and staff of The Journal of Laryngology & Otology welcome readers to this new 2016 volume. To the Senior Editorial staff, we welcome Musheer Hussain and Jonathan Fishman. It is also with sadness that we mention the passing away of Sue Perkins. Sue was our main journal production contact at Cambridge University Press; she worked closely with The Journal staff to ensure the timely and effective publication of The Journal. Shewill be very muchmissed by all who had the privilege of working with her.

Understanding long-term outcomes requires prospective data collection

The rise of ‘big data’ in medical research, including genetics, should help us understand more fully the natural history and prevalence of disorders and what can be expected from our interventions, and so help us counsel our patients. Obtaining data for accreditation and revalidation purposes is a bonus, but of secondary importance. Agreement on what data need to be collected prospectively for audit, research, billing and outcomes is not easy, and is compounded by communication difficulties between clinicians and administrative coding staff. This Journal of Laryngology & Otology issue contains an article that looks at septal surgery and nasal trauma patients, and the experience of a team who liaised closely with their coding team to identify and correct problems in communication and resulting errors. The problems identified are likely to be widely applicable, not just to this patient group or this institution. This study complements articles in recent issues on the efficacy of common ENT procedures and wide data collection on quinsy management. Myringoplasty outcomes nationally and in local centres has been a prominent topic in recent Journal editions. This month’s issue contains an article investigating revision myringoplasty outcomes. It showed that revision surgery and primary surgery had similar outcomes in that particular centre, which was helpful in that hospital when counselling patients preoperatively. Voice and swallowing problems in patients with Parkinson’s disease crop up in the clinic occasionally, but the literature contains few sizeable series. This issue reports on a series of 13 patients from a tertiary voice clinic in Lewisham, which provides the basis for a strategy to help these often-neglected patients. Epistaxis is a major reason for acute admission to ENT wards, and the rise of anti-coagulation use in the management of cardiac disorders has exacerbated the problem. The article by Flood and colleagues in this issue examines every aspect of the evidence in relation to the use of endoscopic sphenopalatine artery ligation, which has become a mainstay of treatment, albeit with some variation in indications and in treatment algorithms. This analysis complements views from other recent Journal contributions on the topic. A forthcoming Journal ‘virtual issue’ will focus on epistaxis.

The nasal cycle 122 years on – are we any wiser?

The nasal cycle was first described by Kayser as far back as 1895. In the latest of a recent series of articles on nasal airflow in The Journal of Laryngology & Otology, Price et al. challenge a previously held view concerning a relationship between hand dominance and nasal airflow laterality. In this most recent study, no correlation between nasal airflow dominance and handedness was identified. Their results argue against the existence of a dominant nasal passage. In a prospective randomised controlled trial involving 290 children, aged 2–11 years, with bilateral otitis media with effusion (OME), Hussein et al. conclude that the use of oral steroids leads to higher rates of early complete resolution of OME at 6 weeks. However, no long-term benefit of using oral steroids, or intranasal steroids, was demonstrated. A randomised controlled trial assessing the use of oral steroids in OME (the Oral Steroids for the Resolution of Otitis Media with Effusion in Children (‘OSTRICH’) study) is ongoing and the results are eagerly awaited. Also in relation to OME, another study in this month’s issue investigated the relationship between OME and childhood obesity. The authors found a higher prevalence of obesity in the chronic OME group, highlighting a possible association that warrants further investigation. Recent guidelines recommend a ‘watch and wait’ policy for neck management in patients with early lip carcinoma in the absence of clinically suspicious cervical lymph nodes. A study by Eskiizmir et al. in this month’s issue concludes that tumour stage is an important determining factor affecting prognosis in surgically treated patients with early-stage lip cancer for whom a ‘watch and wait’ policy for neck status has been implemented. Finally, two articles in this month’s issue report on the successes and complications of paediatric cochlear implantation. Mulwafu et al. report on the first four cases of cochlear implantation in Malawi. The challenges of establishing a cochlear implant service in the developing world are discussed, and in particular the need for collaboration, support and exchange of expertise are deservedly emphasised. Schwartz et al. report on inadvertent intra-operative hyperthermic events in paediatric patients undergoing cochlear implantation, and explore possible mechanisms and predisposing factors.

Hearing and vestibular rehabilitation, with a focus on the elderly

The increasing proportion of our patients in the ‘elderly’ age group in the developed world has effects on ENT as well as every other branch of medicine. In The Journal of Laryngology & Otology in the recent past, we have looked at a variety of topics of particular interest to the otolaryngologist and geriatrician, including pharyngeal pouch, vestibular dysfunction and presbyacusis, and cochlear implantation. In this issue, an auditory brainstem response study focuses on the mechanism of hearing difficulty in the elderly, especially in noisy surroundings, comparing the elderly and young adults. This revealed significantly lower amplitudes and increased latencies in brainstem responses in the elderly, indicating that subcortical mechanisms are involved in this deficiency. With regard to the frequent need for vestibular rehabilitation therapies in the elderly, it is disappointing but perhaps not surprising that elderly males are apparently more likely to fail to complete vestibular rehabilitation programmes than their younger counterparts. Vestibular rehabilitation programmes may not be inexpensive, but bone-anchored hearing aids are an established and necessarily expensive aid to hearing impairment rehabilitation. The review paper from Manchester helps us to understand why the take-up of this technology is not always as high as might be hoped for. The authors call for much more evidence to help providers focus their efforts appropriately and to help patients take advantage of what could help them a great deal. This issue of The Journal has papers on both adult and paediatric subglottic stenosis. Sharma and colleagues describe a decade of experience in balloon dilatation at Great Ormond Street Hospital, which has considerable advantages over open surgery in these challenging cases. These authors provide practical guidance on the technique based on 166 cases. Nicolli and colleagues, from Pennsylvania, describe a retrospective case–control study in adults, in which they identify obesity and diabetes mellitus as risk factors for the development of subglottic stenosis. These papers complement a paper from New Delhi published in 2014, which investigated the aetiology and management of subglottic stenosis. Ear trauma is a topic that is often neglected. Song et al. help redress this with a detailed study of patients with temporal bone fractures that spare the otic capsule. Happy reading!

Adenoids in paediatric chronic rhinosinusitis, deep neck space infections and optimising otowicks in otitis externa

The exact role of the adenoid in paediatric chronic rhinosinusitis is still under debate. In this month’s issue of The Journal of Laryngology & Otology, a study by Bettadahalli and Chakravarti demonstrates an improvement in quality of life following adenoidectomy for paediatric chronic rhinosinusitis.Whether the improvement seen following adenoidectomy is related to adenoiditis, or is due to the elimination of the contribution of the adenoids to sinus disease, is unclear. Nonetheless, there is increasing evidence that within the setting of paediatric chronic rhinosinusitis, the adenoid acts as a reservoir of pathogenic bacteria through the formation of biofilms, rather than a source of obstruction per se. The 2012 European position paper on rhinosinusitis endorses adenoidectomy for the management of paediatric chronic rhinosinusitis in cases where maximal medical therapy has failed. A largemulticentre, retrospective studybyMejzliket al. in this month’s issue, involving 586 patients, analyses the factors that contribute to life-threatening complications in patients with deep neck infections. In their study, the proportion of patients demonstrating life-threatening complications (defined as mediastinitis, sepsis, dyspnoea, pneumonia, internal jugular vein thrombosis, pleural effusion and death) was found to be as high as 10.2 per cent. Infections involving the retropharyngeal and major blood vessels spaces, and the presence of Candida albicans in cultures, were found to be the highest risk factors for the development of such complications. This is a reminder of how devastating deep neck space infections can be; such infections require prompt treatment. Their investigation complements a study published earlier this year, which demonstrated the effectiveness and safety of ultrasound-guided drainage as an alternative to conventional incision and drainage, and the recently published national prospective multicentre audit of quinsy management and outcomes. An elegant in vitro study by Bola et al. demonstrates how otowicks require priming with six drops so that the initial dose is fully absorbed, before starting treatment. Bacteria were also shown to penetrate otowicks, although this was prevented by continuous application of antibacterial ear drops. The study also questions the usual recommendation of replacing otowicks every 2–3 days to prevent bacterial colonisation, as the findings showed that otowicks still transmit antibacterial drops at 5 days. This may be useful if encountering a delay in patient review. Newer, less-invasive techniques are being applied within the field of head and neck surgery. In this issue, Moreno et al. report on the use of 3 Tesla magnetic resonance imaging (MRI) in the pre-operative evaluation of tongue squamous cell carcinoma. The authors conclude that the3TeslaMRI imagingmeasureof tumour thickness correlated highly with histological tumour thickness, and is an effective method of detecting both nodal metastasis and extracapsular spread. This technique may be useful in predicting pre-operativelywhich patients require neck dissection. Also in this issue, Golding et al. describe the use of ultrasound-guided wire localisation, a technique already well established in breast surgery, to facilitate removal of pathological cervical lymph nodes.

The two-hit hypothesis and paraganglioma of the head and neck

The article on management of head and neck paraganglioma in this month’s Journal of Laryngology & Otology is being published on the first anniversary (10 July 2017) of the passing away of Alfred G Knudson, the architect of the two-hit theory, fundamental to our understanding of tumour genetic mutation. This theory explained, for the first time, among other matters, why some develop a tumour early in life and others late. As tumours are the result of accumulated mutations to a cell’s DNA, it follows that one born with a single mutation needs a second ‘hit’ for a tumour to occur, and another born without mutation requires two hits, reflecting a play betwixt germ line and somatic mutation. We honour Alfred G Knudson (born 1923), who worked at the Fox Chase Cancer Centre Philadelphia, for his work that led to the concept of tumour suppressor genes. As our understanding of head and neck paraganglioma increases, we realise that surgery, which has long been the mainstay of treatment, is no longer so. This is not to say that surgery is out, but management is tempered by advances in genetics, improvements in diagnostic imaging and the longitudinal behaviour of these tumours. A quarter of patients with head and neck paragangliomas harbour predisposing genetic mutations. SDHD mutations were found in all patients with familial head and neck paraganglioma in a paper from Belgium. In sporadic cases, the prevalence of SDHB mutations was twice that of SDHD mutations. Patients harbouring SDHB mutations had unilateral late-onset head and neck tumours, without evidence of recurrence or malignancy. The work by Harrison and Corbridge, on active surveillance of head and neck paragangliomas over a fiveyear period, demonstrates the favourable outcome of avoiding surgery. Although the numbers are small, the paper is a useful addition to existing literature and relevant to our circumstances. Chan and colleague’s paper, on the association of pre-operative oxygen saturation as a predictor of future need for paediatric intensive care in children who undergo supraglottoplasty for laryngomalacia, is a first such study from the UK. This has implications for a number of other procedures undertaken in children with potential airway issues. Lou and Lou reviewed the application of moist agents to the edge of traumatic tympanic membrane perforations; they show that it shortens closure times and improves closure rates. This is not in keeping with traditional teaching to leave traumatic perforations of the eardrum alone. Jellinge et al. had previously shown a 97 per cent closure rate through a policy of simple watchful waiting.

Getting the message across. An August bank holiday long ago

Public heath and awareness campaigns have a luminous history. Much still needs to be done. The association between ill health and deprivation now has an acceptance that was not too long ago carefully suppressed in the UK. We remember ‘The Black Report’, which showed that the health of the nation has improved, but the improvement has not been equal across all social classes, and that gap in inequalities of health between lower and higher social classes is widening. Published by the Department of Health and Human Services in 1980, the then UK government made the report public on the August bank holiday weekend and printed only 260 copies. Nevertheless, its impact has been huge, and not just in the UK. Otolaryngologist head and neck surgeons have long been aware of this association and the effects that deprivation can have. The case for public awareness seems strong. The paper from Humber and Yorkshire Coast Cancer Network investigates their public health campaign on croaky voice and the impact it had on the stage of presentation of laryngeal cancer. They show that the impact was limited and that the most deprived wards in their region have the highest incidence of laryngeal cancer. They accept that public health campaigns are complex processes, and a more effective campaign may improve outcomes, but the message is stark. Jahn’s article highlights the association between benign positional vertigo and endolymphatic hydrops in the management of patients with vertigo. He uses statistical data on epidemiology to make the point and a hypothesis to explain the association. This association is known; whether the hypothesis offered will stand the test of time remains to be seen. It is nevertheless plausible and makes sense. Andrews and colleagues’ paper on the assessment of nasal patency shows that the overwhelming majority of surveyed UK ENT surgeons use the clinical misting pattern test rather than the objective peak nasal inspiratory flow measure. They emphasise the need for a simple, non-invasive device that would objectively measure airflow during physiological resting. The problems in obtaining standard reference values in the assessment of nasal patency are known. Crosbie and colleagues’ investigated the association between sinonasal anatomical variants and the risk of developing orbital cellulitis and associated complications in children with acute rhinosinusitis. Their results show that anatomical variants do not predispose these children to orbital cellulitis or other complications.

National audit of epistaxis management

It is sometimes tempting to malign the current tranche of junior doctors; punishing shift patterns lead to frequent absences from operating theatres, and, when present, some seem so demoralised one wonders if they will last the distance. It is a tough time to be a trainee in any specialty, but it seems the impact of contract changes has been felt most acutely in the surgical specialties. At a time, therefore, when most should be running for the hills, our ENT trainees instead have come together to deliver a carefully planned, well executed and meticulously presented National Audit of Epistaxis Management. The ENT-UK Audit Group had toyed with the idea of an epistaxis audit for some time, having developed a local audit into a small pilot. However, a lack of funding, and, being honest, a lack of enthusiasm from the consultant members, who are often removed from the daily management of patients with epistaxis, meant the project faltered. Then along came Integrate, the National ENT Trainee Research Collaborative, and my greatest contribution to the project was to realise they would do a much better job. Although Sean Carrie and I have subsequently sat on the Executive Steering Group, our input has been supportive, but limited. Junior doctors are very much on the frontline with the management of epistaxis, and, with a promise of fair recognition for their contribution, are ideally placed to capture the data. What is perhaps surprising is how well they have managed the process and then critically evaluated the results. Dissatisfied with the lack of clear ‘gold standards’ against which to audit care, the team first decided they would develop the standards de novo, based on a suite of comprehensive literature reviews published alongside the main audit. In order to assimilate the often poor-quality evidence and produce guidelines, a consensus meeting was convened, where all the evidence was considered and debated. Then followed a Delphi-type process, where the consensus panel were asked to express levels of agreement with the recommendations until consensus was reached. The guidelines presented are the result of an enormous amount of work by dozens of junior doctors. After piloting a data collection tool, the full National Audit of Epistaxis Management was launched late last year. The group managed to achieve ascertainment levels of 94 per cent of epistaxis admissions across 113 National Health Service (NHS) hospitals across the UK, on a shoestring budget provided by ENT-UK. In contrast, the National Audit of Surgery for Chronic Rhinosinusitis, with the support of the Royal College of Surgeons of England, and considerable financial input, captured 77 per cent of eligible cases in 87 NHS hospitals. So, what of the findings? Will this revolutionise the care of epistaxis patients? Probably not – what they find is that actually, by and large, we are pretty good at managing patients with epistaxis. I was particularly pleased that there is no evidence that consultant input is beneficial for the majority of these patients, so I can sleep soundly at night when on call. There are things we can do better – early consideration of cautery may reduce length of stay, for example; don’t always just reach for the nasal packs. We should also perhaps be a little concerned; over 51 per cent of patients were on anticoagulation, so this is not a problem that is likely to fall in prevalence anytime soon. What this does show, more than anything, is that the future lies in the hands of our junior doctors, but we have no reason to be fearful. We have a hardworking, intelligent, inspirational group of junior doctors; many will have had their first taste of collaborative research, but several, I am sure, will go on to become our academic leaders in the future. Before the ink has dried on the last paper, there are already mutterings of their next project; perhaps a trial, or two, or more... As our Editors at The Journal of Laryngology & Otology have commented previously, the future of ENT is in very safe hands. Congratulations to all involved in the National Audit of Epistaxis Management – you have done a fantastic job and should be extremely proud of your achievements. To the Steering Group, you have all been outstanding, and I could not have put the project in better hands. Thank you also to The Journal for permitting the articles to be published together. Finally, The Journal Senior Editors would like to take this opportunity to thank all those who have contributed to the success of this year’s journal, including all the authors, Assistant Editors, reviewers, advisers, production staff, our publishing partners The Journal of Laryngology & Otology (2017), 131, 1033–1034. EDITORIAL ©JLO (1984) Limited, 2017 doi:10.1017/S0022215117002419