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Otitis externa management, septal surgery outcomes, laryngeal dysplasia and paediatric sleep-disordered breathing

Published online by Cambridge University Press:  20 May 2022

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Abstract

Type
Editorial
Copyright
Copyright © The Author(s), 2022. Published by Cambridge University Press on behalf of J.L.O. (1984) LIMITED

A common otological problem in primary and secondary care is otitis externa, and it is remarkable that there are so many problems in management associated with this condition. There appears to be a confusing mismatch between guidelines, routine specialist advice and what actually happens day to day in primary care. This issue's ‘paper of the month’ is a study from Newcastle upon Tyne,Reference Mohammed, Mather, Lumb, Butler and Wilson1 which spells out the nature of these difficulties in no uncertain terms and should be widely read. The ‘price’ paid for the misuse of oral antibiotic therapy in the wider population administered for this condition could be considerable, and not just in terms of (wasted) money paid out; it also includes difficulties with the antimicrobial management of infections affecting other parts of the body, as well as the most lethal form of otitis externa, necrotising (‘malignant’) otitis externa, which has been the topic of many recent articles in The Journal of Laryngology & Otology, including guidelines from 2020.Reference Hopkins, Bennett, Henderson, MacSween, Baring and Sutherland2

Surgery of the nasal septum has historically been over-used. In addition, outcome discussions during conversations with patients for pre-operative consent can often leave something to be desired, and have a tinge of optimism. The Journal has previously published articles on this topic.Reference Marshall, Johnston and Jones3,Reference Winterton, Alaani, Loke and Bem4 The current issue includes a study from Norway, in which a large cohort of septoplasty patients were reviewed using a questionnaire completed at 6–12 months and at 3–4 years.Reference Haye, Døsen, TarAngen, Gay, Egeland and Shiryaeva5 The validity of such questionnaires has previously been established.Reference Haye, Døsen, Tarangen and Shiryaeva6 The results showed a significant, although not radical, fall-off in positive outcomes between the two assessments, somewhat less than other studies have shown, and may reflect careful pre-operative patient selection by the clinicians involved. One interesting finding was that the change in outcomes over time was not significantly affected by whether or not turbinate surgery was included with septoplasty.Reference Seden, Araz Server, Yigit and Misir7 The conclusion that outcomes are better in patients whose noses are more blocked before surgery chimes with previous studies.

Laryngeal dysplasia is a condition with a considerable propensity to transform to invasive squamous carcinoma, and the monitoring and treatment of this condition occupies much of a laryngologist's time.Reference Sadri, McMahon and Parker8 A study from Belfast, Northern Ireland,Reference Donaldson, McCadden, Napier and Tan9 examined a large cohort of affected patients, and found a malignant transformation rate of 21.8 per cent, slightly higher than some estimates.Reference Weller, Nankivell, McConkey, Paleri and Mehanna10 One important point in the authors’ conclusions is that each of the severity types (mild, moderate and severe) behave as distinct entities in relation to prognosis and malignant transformation, with moderate dysplasia having a higher rate of malignant transformation in this series than had been expected.

Sleep-disordered breathing in children has a considerable effect on the quality of life of the child and family.Reference Mitchell and Kelly11 Furthermore, it creates much anxiety in parents, and is increasing in prevalence along with increasing childhood obesity, but it is readily amenable to surgery – usually adenotonsillectomy.Reference Marcus, Moore, Rosen, Giordani, Garetz and Taylor12 The Journal has documented the increasing interest in using tonsillotomy in place of tonsillectomy.Reference Sakki, Roine, Mäkinen, Sintonen and Nokso-Koivisto13 This issue has another thought-provoking paper on the topic from Newcastle upon Tyne, which examines treatment pathways for children with suspected sleep-disordered breathing.Reference Haighton, Watson, Wilson and Powell14 This qualitative study involved interviewing parents and professionals from primary and secondary care; the accounts will strike a chord with anyone who has been involved with these patients and families. The messages are not at all comfortable to read and there seems every reason to suppose that they are widely applicable to other geographical areas. Parents are worried that their child will stop breathing and do not always feel listened to; even when they are listened to, the professional may not be well enough aware of the condition to deal with it effectively. The central message from the study is that there is a clear need for guidelines to help parents and professionals navigate their way through system, which at present seems very unsatisfactory, to benefit this vulnerable group of patients.

References

Mohammed, H, Mather, MW, Lumb, J, Butler, CC, Wilson, JA. Otitis externa: what is the problem with getting it right? A mixed-methods study in primary and secondary care. J Laryngol Otol 2022;136:486–9110.1017/S0022215121003649CrossRefGoogle ScholarPubMed
Hopkins, ME, Bennett, A, Henderson, N, MacSween, KF, Baring, D, Sutherland, R. A retrospective review and multi-specialty, evidence-based guideline for the management of necrotising otitis externa. J Laryngol Otol 2020;134:487–9210.1017/S0022215120001061CrossRefGoogle ScholarPubMed
Marshall, AH, Johnston, MN, Jones, NS. Principles of septal correction. J Laryngol Otol 2004;118:129–3410.1258/002221504772784586CrossRefGoogle ScholarPubMed
Winterton, RIS, Alaani, A, Loke, D, Bem, C. Role of information leaflets in improving the practice of informed consent for patients undergoing septoplasty. J Laryngol Otol 2007;121:134–710.1017/S002221510600257XCrossRefGoogle ScholarPubMed
Haye, R, Døsen, LK, TarAngen, M, Gay, C, Egeland, MT, Shiryaeva, O. Septoplasty: early (first year) and late (fourth year) post-operative results in 604 patients. J Laryngol Otol 2022;136:514–9CrossRefGoogle ScholarPubMed
Haye, R, Døsen, LK, Tarangen, M, Shiryaeva, O. Good correlation between visual analogue scale and numerical rating scale in the assessment of nasal obstruction. J Laryngol Otol 2018;132:327–810.1017/S0022215118000257CrossRefGoogle ScholarPubMed
Seden, N, Araz Server, E, Yigit, O, Misir, E. Does turbinate reduction combined with septoplasty have better outcomes than septoplasty alone? A randomised, controlled study. J Laryngol Otol 2022;136:55–910.1017/S0022215121003340CrossRefGoogle Scholar
Sadri, M, McMahon, J, Parker, A. Laryngeal dysplasia: aetiology and molecular biology. J Laryngol Otol 2006;120:170–710.1017/S0022215105005360CrossRefGoogle ScholarPubMed
Donaldson, G, McCadden, L, Napier, S, Tan, TJ. Laryngeal dysplasia: a 10-year review of rates of progression to invasive carcinoma and treatment-specific outcomes in a regional ENT department in Northern Ireland. J Laryngol Otol 2022;136:547–53CrossRefGoogle Scholar
Weller, MD, Nankivell, PC, McConkey, C, Paleri, V, Mehanna, HM. The risk and interval to malignancy of patients with laryngeal dysplasia; a systematic review of case series and meta-analysis. Clin Otolaryngol 2010;35:364–7210.1111/j.1749-4486.2010.02181.xCrossRefGoogle ScholarPubMed
Mitchell, RB, Kelly, J. Behavior, neurocognition and quality-of-life in children with sleep-disordered breathing. Int J Pediatr Otorhinolaryngol 2006;70:39540610.1016/j.ijporl.2005.10.020CrossRefGoogle ScholarPubMed
Marcus, CL, Moore, RH, Rosen, CL, Giordani, B, Garetz, SL, Taylor, G et al. A randomized trial of adenotonsillectomy for childhood sleep apnea. N Engl J Med 2013;368:2366–7610.1056/NEJMoa1215881CrossRefGoogle ScholarPubMed
Sakki, AJ, Roine, RP, Mäkinen, LK, Sintonen, H, Nokso-Koivisto, J. Impact of tonsillotomy versus tonsillectomy on health-related quality of life and healthcare costs in children with sleep-disordered breathing. J Laryngol Otol 2022;136:(May issue, not yet published)CrossRefGoogle Scholar
Haighton, C, Watson, RM, Wilson, JA, Powell, S. Perspectives on paediatric sleep-disordered breathing in the UK: a qualitative study. J Laryngol Otol 2022;136:520–610.1017/S0022215121004242CrossRefGoogle ScholarPubMed
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