Robin Youngs

Sphenopalatine artery ligation: technical note.

Epistaxis is a common problem. Most patients presenting to hospital will stop bleeding with simple first-aid measures or with nasal packing. Those who do not stop will usually require surgical management. For persistent posterior epistaxis, the sphenopalatine artery may be ligated as the artery leaves the sphenopalatine foramen to enter the nasal mucosa of the lateral wall of the nose. This may be performed endoscopically. We describe the anatomy of the area and the surgical technique. We also present a brief review of the literature on this technique.

The spatial organisation of keratinocytes in acquired middle ear cholesteatoma resembles that of external auditory canal skin and pars flaccida

A scanning electron microscopic study of acquired middle ear cholesteatoma was undertaken in order to compare morphological findings with those of keratinising squamous epithelium of the tympanic membrane and external auditory meatus. Analysis of results confirms a highly ordered vertical architecture, with cell stacking, in the stratum corneum of cholesteatoma, similar to that found in the skin of the deep external auditory meatus and the pars flaccida of the tympanic membrane. These findings support the notion that acquired cholesteatoma originates by immigration of epithelium from the pars flaccida and external meatus rather than by metaplasia of middle ear mucosa.

Epithelial migration in open mastoidectomy cavities

Twenty patients who had undergone open cavity mastoidectomy for chronic middle ear disease were selected for study. Following initial microscopic aural toilet, each cavity was painted in its medial aspect with a marker solution of Bonneys Blue dye. Each patient was assessed at weekly intervals for a minimum of three months following application of dye, and a photographic record made of the cavity. Information was also sought regarding the clinical behaviour of the mastoid cavities, with particular regard to degree of otorrhoea, and accumulation of debris. Migration of epithelium inferred by visible movement of dye occurred in 17 of the 20 mastoid cavities. In all these cases migration occurred in a medial to lateral direction, towards the exterior. In two cases there was no visible migration throughout the period of observation, and inspection after six months revealed the dye to be still present in the original position. Both these cases were of dry trouble-free cavities in which accumulation of debris did not appear to be a problem. This finding calls into question the assumption that clean trouble-free cavities are maintained by a satisfactorily functioning epithelial migration. In the four cavities which suffered from intermittent otorrhoea, epithelial migration occurred at a similar rate to that in dry cavities.

Temporal bone histopathology of open mastoidectomy cavities

Open cavity mastoidectomy remains the principle surgical treatment of middle ear cholesteatoma in the United Kingdom. A significant proportion of mastoid cavities are prone to intermittent or continuous discharge. In this study the temporal bone histopathology of four patients who had undergone open cavity mastoidectomy is presented. Cavities were predominantly lined with stratified keratinizing squamous epithelium. Residual air cells were obliterated by fibrous tissue, with no evidence of persistent respiratory epithelium. Where inflammatory changes were found, these consisted of areas of granulation tissue in association with epithelial ulceration. Residual cholesteatoma pearls (epidermoids) were not associated with significant inflammatory changes.

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.

Focus on tracheostomy.

Tracheostomy has long been a vital standard of the otolaryngologist’s repertoire. An important review article in this issue by the National Confidential Enquiry into Patient Outcome and Death (‘NCEPOD’) in the UK examines current practice in tracheostomy. The emergence of percutaneous tracheostomy techniques used by critical care doctors has changed the scope of this operation, with the majority (69.6 per cent) of procedures being undertaken in this way in the UK during the survey period. Surgical tracheostomy continues to be undertaken on those patients unsuitable for percutaneous techniques. Patients undergoing surgical tracheostomy tend to have unfavourable anatomy, which has implications for training. With the procedure becoming more commonplace, there could be a tendency to underplay the potential complications. The review found that complications were common, both in the critical care and ward environment, occurring in just over 20 per cent of cases. Accidental decannulation and hypoxia were the most frequent serious complications. Another issue is the increasing number of patients that cannot be successfully decannulated, with discharge to a community setting becoming difficult. A previous Editorial in The Journal of Laryngology & Otology demonstrated the utility of The Journal Archives in documenting the history of Ménière’s disease. An article in the current issue adds to archive material in reporting the effects of intratympanic methylprednisolone perfusion in patients with intractable Ménière’s disease. She and colleagues report effective control of vertigo and improved functional activity in this difficult group of patients. This method of treatment appears also to offer the advantage of hearing preservation compared with the potentially ototoxic effects of intratympanic aminoglycoside treatment. The increasing awareness of the use of intratympanic medication has been one of the most exciting developments in otology in recent years. Finally, perhaps the most striking image in this issue of The Journal is of a green temporal bone in a patient who had undergone long-term treatment with tetracycline antibiotics. Antibiotics are now used for long periods in the treatment of many conditions, including rhinosinusitis. This article serves as a reminder of the potential hazards of this type of treatment.

Antiviral treatment for Bell's palsy?

The treatment of Bell’s palsy or idiopathic facial paralysis is highly controversial. Much of this contention surrounds the use of specific antiviral medication in this condition. The widely quoted Scottish Bell’s Palsy Study confirmed the efficacy of prednisolone in the recovery of facial function, but suggested that the antiviral acyclovir provided no benefit, whether administered alone or in combination with prednisolone. An article in this issue by de Ru and colleagues critically reviews the evidence on this topic by both examining the literature and considering new evidence. They suggest that antiviral medication can be crucial when given in the most severe cases, which include those with severe deficit and the elderly. They also review the evidence for facial nerve surgical decompression; they propose that in cases of complete paralysis with no sign of recovery, where electrophysiological tests show a poor prognosis, decompression might be indicated and should be discussed with the patient. Another article in this issue also examines treatment options for the most severe cases of Bell’s palsy. Watson and colleagues, using a retrospective analysis, found that tailored facial physiotherapy improved outcomes in patients with prolonged paralysis. The Editors appreciate that treatment of Bell’s palsy remains an issue of debate and welcome comment on the pages of The Journal of Laryngology & Otology. A number of articles in this issue address head and neck cancer. Hughes and colleagues review the potential for viral gene therapy in head and neck cancer. They describe viral gene products currently licensed for use in head and neck cancer, and consider the many challenges that would facilitate the use of gene therapy in combination with conventional therapy. This review adds to the articles already published in The Journal on the genetics of head and neck cancer. Positive outcomes for head and neck cancer patients are strongly correlated with early diagnosis, and many initiatives have been proposed to achieve this goal. Two articles in this issue look at factors in cancer diagnosis. Nash and colleagues found that initial referral to a non-head and neck cancer centre was significantly associated with a delay in diagnosis. Iqbal and colleagues examined the role of clinical suspicion or ‘gut instinct’ in head and neck cancer diagnosis. They concluded that although clinical suspicion could not be quantified, it should be regarded as an integral part of patient assessment.

Predators and moustaches

As predicted, the advent of electronic communication has profoundly affected scientific publication. The milieu in which scholarly publication now occurs is very murky indeed. One of the ways in which transparency has been lost from scientific publication is in the rise of ‘predatory journals’. These journals have arisen on the back of ‘open-access’ publication wherein articles become freely available to the scientific community a short time after publication and without a paid subscription. In this model of publication, the cost of production and dissemination of material is borne by the author. Predatory journals have jumped on this bandwagon solely as a means of generating financial gain. The extent of this problem has been highlighted by a recent article in the British Medical Journal. There are hundreds of predatory journals aggressively seeking material for publication in exchange for cash. These journals, which include otolaryngology titles, are not backed up by the rigorous process of peer review that underpins respected journals, and production standards are poor. Unfortunately, with the pressure to publish for career advancement, articles do find their way to predatory journals, with the work published often being lost forever in an electronic swamp. We would encourage authors of otolaryngology articles to spurn these predatory journals and submit their work to mainstream titles that are well known within the specialty. Most respected otolaryngology journals continue to operate a production model based on subscriptions, and will not charge authors for publication. An important measure in minimising post-operative complications in surgery as a whole is adequate prophylaxis against venous thromboembolism. Venous thromboembolism complicating ENT surgery is very uncommon, at around 0.2 per cent. In the current issue of The Journal of Laryngology & Otology, Nash and colleagues report a survey of current UK practice. They found that current venous thromboembolism guidelines are not specific for ENT surgery and as a result adherence to these guidelines is not complete. Finally, ENT surgeons will be aware of the importance of minimising the risk of hospital-acquired infections. Resistant organisms, particularly Staphylococcus aureus, have been implicated in life-threatening ENT infections. An article in the current issue examines the possibility of moustaches being a breeding ground for micro-organisms. Fortunately for those with moustaches, the state of the owners’ facial hair had no relationship to the possibility of nasal colonisation with S aureus.