Mamun Rashid

An Unusual Case of a Tonsillolith

Tonsilloliths are rare calcified concretions that develop in tonsillar crypts within the substance of the tonsil or around it. Large tonsilloliths can mimic many conditions including abscesses or neoplasms. Given the wide range of differentials, it is difficult to diagnose tonsilloliths unless there is a considered emphasis on thorough history taking, careful inspection and a detailed characterisation of the lesion through digital palpation. This may be further supplemented with investigations such as plain radiography and computer tomography. Here, we illustrate a case with risk factors of oropharyngeal cancer and a history of fish bone impaction in the throat that was initially diagnosed as a “tonsillar foreign body” which turned out eventually to be a large tonsillolith.

Unplanned Re-admissions in ENT: How Much Do They Cost?:

Objective: Unplanned hospital re-admissions are a significant source of morbidity and mortality and are a major fiscal burden to the National Health Service. The cost of re-admissions to ENT services has not previously been described. We present an audit, evaluating the cost per patient for ENT re-admissions in our department. Method: A prospective audit of all ENT patients who were re-admitted within 28 days of initial discharge over a 3-month period was observed. Cost was calculated using the Department of Health reference books. Results: n = 24 (17 emergencies, 7 elective) Emergencies: 53% otitis externa (7/17) and tonsillitis (2/17); all returned due to pain. Elective: 86% posttonsillectomy, including hemorrhage (3/7) and pain (3/7). Cost: Total: £25’237.50 (£1051.56 per patient) Otitis externa: £8983.61 (£1122.95 per patient) Post-tonsillectomy bleed/pain: £4670.21 (£778.37 per patient) Otitis externa/post tonsillar combo: £9761 (39% of total cost). Conclusion: Unplanned re-admissions to ENT cost £25,237.50 over three months. Nearly 40% of this was due to otitis externa, tonsillitis, or as a postoperative complication of tonsillectomy due to suboptimal analgesia. We would recommend greater awareness of departmental caseloads as a means to develop targeted strategies in reducing re-admissions.

ENT Service Compliance to United Kingdom Targets for Suspected Cancers

Objective: The NHS Cancer Plan sets out a 2-week maximum wait for out-patient appointments for suspected cancers. The NHS Improvement Plan sets an 18-week limit from referral to treatment for noncancer cases. Research on evaluation of adherence to these targets is lacking, and we therefore present data to address this issue. Method: An audit was performed at a local GP practice over a 4-month period. EMIS database was used to retrieve correspondence with commissioned ENT services. Date of referral, clinic attendance, type of investigations, and date of first definitive treatment were observed. Standards for the 2-week and 18-week target are both 100%. Results: n = 31.97% (30/31) were compliant with the “2-week rule.” Only 42% (13/31) were compliant with the 18-week pathway. Of the cases that breached the 18-week pathway, 56% (10/18) were pending clinic, 33% (6/18) investigations and 11% (2/18) treatment. Conclusion: Despite extensive frameworks formulated by the Department of Health for tackling waiting times, our data suggest that the local ENT services are not in compliance with the 2-week or 18-week standards. There is need for wider debate and national review.

An Audit of Adherence to SIGN Guidelines for Tonsillectomies: Completion of Third Cycle

Objective: It is important to ensure that our listing practice for tonsillectomy is in keeping with the best evidence available, as stated by the Scottish Intercollegiate Guidelines Network (SIGN). We audited the accuracy of documentation of the SIGN guideline indications for tonsillectomies to ensure appropriate listing of such patients. Method: Medical notes of patients with recurrent tonsillitis presenting to our department were reviewed retrospectively to check for documentation of the SIGN indication for tonsillectomy. Three audit cycles were carried out, each over a 3-month period. Results: Prior to intervention, only 51% (25/51) patients undergoing tonsillectomy had documented evidence of adherence to SIGN guidelines for surgery. Interventions following the first audit cycle included presentation of audit findings, introduction of guideline templates for doctors to complete, and recruitment of medical secretaries to return the notes to doctors if documentation was incomplete. Postintervention, audit cycles 2 and 3 showed respectively 100% (30/30), and 92% (36/39) of patients had documented evidence of adherence. Conclusion: The introduction of a simplistic model of intervention as above improved the local adherence to SIGN guidance for tonsillectomy and translated to safe and better care for patients. This model is easily replicable and can be used in other ENT departments to improve patient care.