S.A.R. Nouraei

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.

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.

How we do it: a method of neck dissection for histopathological analysis

BackgroundDissection of the lymphatic structures in the neck is an integral part of the management of many head and neck cancers.We describe a technique of surgical dissection, preparing the tissue for more precise histological analysis while also reducing operative time and complexity.MethodsWhen dissected, each level is excised between lymph nodes groups and put into a separate pot of formalin taking care to avoid rupture of any obvious pathological nodes.ResultsThis makes for a simpler dissection as the surgeon progresses, as a larger more cumbersome specimen is avoided and manipulation of involved nodes is actually reduced with a reduced risk of tumour spillage.ConclusionWe feel that our technique provides several advantages for the histopathologist as well as the surgeon. As the dissection of the specimen into the relevant levels has already been performed, time is saved in orientating and then dissecting the specimen. Accuracy of dissection is also improved and each piece of tissue is a more manageable size for processing and analysis.This technique may also have several surgical advantages when compared with the commonly practiced techniques e.g. with reducing in-vivo specimen manipulation, hence reducing the risk of inadvertent injury to important structures and tumour spillage.

The role of surgical audit in improving patient management; nasal haemorrhage: an audit study.

BackgroundNasal bleeding remains one of the most common Head & Neck Surgical (Ear Nose and Throat [ENT]/Oral & Maxillofacial Surgery [OMFS]) emergencies resulting in hospital admission. In the majority of cases, no other intervention is required other than nasal packing, and it was felt many cases could ideally be managed at home, without further medical interference. A limited but national telephone survey of accident and emergency departments revealed that early discharge practice was identified in some rural areas and urban departments (where adverse socio-demographic factors resulted in poor patient compliance to admission or follow up), with little adverse patient sequelae. A simple nasal packing protocol was also identified.The aim of this audit was to determine if routine nasal haemorrhage (epistaxis) can be managed at home with simple nasal packing; a retrospective and prospective audit.Ethical committee approval was obtained. Similar practice was identified in other UK accident and emergency centres. Literature was reviewed and best practice identified. Regional consultation and feedback with regard to prospective changes and local applicability of areas of improved practice mutually agreed upon with involved providers of care.MethodsRetrospective: The Epistaxis admissions for the previous four years during the same seven months (September to March).Prospective: 60consecutive patients referred with a diagnosis of Nasal bleeding over a seven month time course (September to March). All patients were over 16, not pregnant and gave fully informed counselled consent.New Guidelines for the management of nosebleeds, nasal packing protocols (with Netcel®) and discharge policy were developed at the Hospital. Training of accident and emergency and emergency ENT staff was provided together with access to adequate examination and treatment resources. Detailed patient information leaflets were piloted and developed for use.ResultsPreviously all patients requiring nasal packing were admitted. The type of nasal packing included Gauge impregnated Bismuth Iodoform Paraffin Paste, Nasal Tampon, and Vaseline gauge. Over the previous four year period (September to March) a mean of 28 patients were admitted per month, with a mean duration of in patient stay of 2.67 days.In the prospective audit the total number of admissions was significantly reduced, by over 70%, (χ2 = 25.05, df = 6, P < 0.0001), despite no significant change in the number of monthly epistaxis referrals (χ2 = 4.99, df = 6, P < 0.0001). There was also a significant increase in the mean age of admitted patients with epistaxis (χ2 = 22.71, df = 5, P < 0.0001), the admitted patients had a mean length of stay of 2.53 days. This policy results is an estimated saved 201.39 bed days per annum resulting in an estimated annual speciality saving of over £50,000, allowing resource re-allocation to other areas of need. Furthermore, bed usage could be optimised for other emergency or elective work.ConclusionExclusion criteria have now been expanded to exclude traumatic nasal haemorrhage. New adjunctive therapies now include direct endoscopic bipolar diathermy of bleeding points, and the judicious use of topical pro-coagulant agents applied via the nasal tampon. Expansion of the audit protocols for use in general practice.This original audit informed clinical practice and had potential benefits for patients, clinicians, and provision of service. Systematic replication of this project, possibly on a regional and general practice basis, could result in further financial savings, which would allow development of improved patient services and delivery of care.

An audit of the nature and impact of clinical coding subjectivity variability and error in otolaryngology.

To audit the accuracy of clinical coding in otolaryngology, assess the effectiveness of previously implemented interventions, and determine ways in which it can be further improved.

Development and validation of a health informatics algorithm for identifying major head and neck cancer surgery amidst Hospital Episode Statistics data

1 MullaceM., Gorini E., SbroccaM. et al. (2006)Management of nasal septal perforations using silicone nasal septal button. Acta Otorhinolaryngol. Ital. 26, 216–218 2 Blind A., Hulterstr€ om A. & Berggren D. (2009) Treatment of nasal septal perforations with a custom-made prosthesis. Eur. Arch. Otorhinolaryngol. 266, 65–69 3 Døsen L.K. & Haye R. (2008) Silicone button in nasal septal perforation. Long term observations. Rhinology 46, 324–327

Impact of unilateral vocal fold mobility impairment on laryngopulmonary physiology

To examine the impact of unilateral vocal fold mobility impairment (UVFMI) on airway physiology.

Reducing treatment delay by improving information flow within the multidisciplinary team: a muticycle audit spiral in head and neck cancer

It is suggested that disease-free survival would have been a better outcome to evaluate. However, only 10% of patients in the series had malignant disease. So the disease-free survival would be inappropriate for the purposes of the study. This was to investigate the effect of surgical experience on all forms of thyroid surgery. There are many other blunderbuss comments that are used to denigrate the Duclos et al.’s paper such as ‘the exclusion of a large centre’, which are not supported on closer reading. Guidera et al. could also have evaluated papers 4 and 5 they referenced better to identify their considerable limitations. [see ‘Volume of cases’].