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 be unbiased. 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 from Newcastle and Carlisle, which surveys patient-reported outcome measures. 1 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; 2 fewer will be aware of one for adult mastoid cavity care. 3 There is a long way to go before patient-reported 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. 4 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. 5 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. 6
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, 7 as long as care is taken over technique. 8