Objectives: To determine the levels of intra- and inter-grade variability of the vetting of general practice (GP) letters as well as the intra-rater reliability of letterprioritization.

Design: Prospective assessment of letter vetting and questionnaire survey.

Setting: Three otolaryngology secondary referral centres in Bristol and Bath, UK.

Participants: Twelve consultants, nine registrars, four staff and associate specialists (SAS) and 16 senior house officers (SHOs) in otolaryngology.

Methods: Fifty GP letters (not including ’fast-track’ referrals) addressed to one of the ENT departments were chosen sequentially. These were anonymized, photocopied and included in the questionnaire to all participating staff. Participants were asked to vet the letters as ’urgent’, ’soon’ or ’routine’ according to supplied waiting time criteria. The same letters were sent out again six weeks later.

Results: There was no significant difference between grades for the mean number of letters vetted into each category. Intra-grade variability was high; the number of letters vetted urgentvaried from one out of 50 to 15 out of 50 for the consultants.The intra-rater reliability was high.

Conclusion: The grade of trainee seems to make little difference with regard to ability to prioritize referrals, but within grades there is little agreement on what constitutes an urgent referral. We suggest further research, looking at the final outcome of patients, needs to be done to try to establish evidence-based guidelines to assist with letter vetting.

Objective: To audit sore throat management in adults, introduce proforma-based guidelines and to reaudit clinical practice.

Setting: Adult emergency department of an inner city teaching hospital.

Methods: A literature search was carried out to identify relevant guidelines. In stage one, patients presenting to the emergency department with sore throat were identified retrospectively from the emergency department attendance register. Proformas were completed retrospectively. In stage two, new guidelines were introduced and staff educated about the guidelines. In stage three, patients presenting with sore throat were identified at triage and proformas were completed at time of consultation.

Outcome Measures: (1) appropriate clinical assessment of the likelihood of bacterial infection using the clinical scoring system, (2) appropriateness of antibiotic prescription, (3) recommendation of supportive treatments to patients.

Results: Introduction of a clinical scoring system reduced the inappropriate prescribing of antibiotics from 44 per cent to 11 per cent. Correct antibiotic prescription rose from 60 per cent to 100 per cent. Although the variety of advice given about supportive treatment increased, the actual number of patients receiving documented supportive advice fell from 67.8 per cent in stage one to 58 per cent in stage three.

Conclusion: The introduction of clinically based guidelines for the diagnosis and management of sore throat in adults can reduce inappropriate antibiotic prescribing.

Choanal atresia is a significant congenital anomaly, which may be associated with other congenital anomalies. Recommendations have been previously proposed for neonatal screening of all newborns to detect this condition. A previously unreported, simple method using the automatic tympanometer to screen newborns for congenital choanal atresia is proposed. A prospective study was performed over a one-month period on all newborns at El-Sahel Teaching Hospital, Cairo, to evaluate the efficacy of this manoeuvre.

The nostrils of 143 newborn infants were evaluated during the study period. The sensitivity of the technique in diagnosing a patent nostril was 100 per cent. The specificity of the technique for detecting distal obstruction was 100 per cent. There were no complications of the described procedures. The study revealed that the novel method of screening for choanal atresia in newborns using the automatic tympanometer is simple, minimally invasive and highly reproducible.

The aim of this study was to determine whether certain weather variables influence the secondary post-tonsillectomy haemorrhage rate and to examine the influence of a change in these variables on secondary haemorrhage. This was a prospective study carried out in a tertiary referral institution. All patients undergoing bilateral tonsillectomy over a one-year period were included. Local weather data, including daily temperature (max/min), relative humidity and water vapour pressure, were acquired. All patients readmitted to our department with secondary post-tonsillectomy haemorrhage were recorded. Of 346 patients undergoing tonsillectomy, 32 developed secondary haemorrhage (9.2 per cent). A significant negative correlation was found between secondary haemorrhage rate and the average monthly temperature (max/min) and water vapour pressure (Pearson’s correlation = −0.8) (p ≤ 0.002). These results suggest that performing tonsillectomy in warmer weather when the water vapour pressure is higher may reduce the secondary haemorrhage rate.

Waardenburg syndrome is an autosomal-dominant trait resulting from mutations occurring in different genes. It is often characterized by varying degrees of: congenital hearing loss; dystopia canthorum; synophrys; broad nasal root; depigmentation of hair (white forelock), skin or both; and heterochromic or hypochromic irides.

A retrospective case study was done to assess speech perception, speech production, general intelligence and educational setting in six profoundly hearing-impaired children with Waardenburg syndrome (four with type I, one with type II and one with type III) ranging in age from two years to 14 years, seven months (mean = six years, six months). None of the patients had malformation of the cochlea and were implanted using Nucleus 22/24 and Med-el combi40+. Five out of the six cases were of average intelligence and one had a borderline intelligence quotient. The follow-up period ranged from one year, 10 months to six years, six months (mean = three years, six months) after implantation. The evaluation of auditory perception in patients was accomplished using the Persian Auditory Perception Test for the Hearing-Impaired, a Persian Spondee wordstest and the Categories of Auditory Performance Index. The Speech Intelligibility Rating test was used to evaluate speech production ability. All the patients’ speech perception and speech intelligibility capabilities improved considerably after receiving the implants, and they were able to be placed in regular educational settings. Patients used their cochlear-implant devices whenever awake, implying that they benefitted from the devices. We suggest that any further expansion of cochlear-implantation criteria in children include those with Waardenburg syndrome.

A difficult Groningen valve change is one of the problems frequently encountered in the post-laryngectomy patient. A safe and simple technique for this procedure is described.

The value of theatre attendance by undergraduates is uncertain. This study aimed to evaluate the perceived benefits of attending operating theatre sessions during undergraduate otolaryngology attachments. The study comprised a questionnaire survey carried out in a university medical school. Fourth-year medical students were asked to complete a questionnaire at the end of their two-week attachment in otolaryngology. Completed questionnaires were returned by 152 students. The three most common student expectations were to see and learn common ENT operations, to see the anatomy involved and to learn about the disease being operated upon. Sixty per cent of students reported that their expectations had been met. On a Likert scale from 1 (strongly disagree) to 7 (strongly agree), the importance of theatre attendance as part of the curriculum was rated to be 4.7 (95 per cent confidence interval (CI) = 3.7 to 4.2) and the satisfaction of educational needs in operating theatre teaching was rated to be 3.9 (95 per cent CI = 3.7 to 4.2). Students perceived attending otolaryngology theatre sessions to be beneficial. This information is important in the planning of the otolaryngology undergraduate curriculum.

Adenoidectomy Is A Surgical Procedure Frequently Carried Out In Otolaryngological Practice, Traditionally Undertaken Blindly With Curettage Using An Adenotome Following Palpation Of The Adenoid Bed. While A Number Of Alternative Methods Have Been Described For Surgical Removal Of The Adenoid Pad (Power-Assisted/Microdebrider, Transnasal Adenoid Ablation, Suction Coagulation And Liquefaction/Aspiration) None Has Become The Definitive Procedure. Suction Diathermy Adenoidectomy Has Been Known And Used For Some Time; It Has Gained In Popularity Over Recent Years And Is Established As An Alternative To Conventional Curettage, Particularly In Children.

We Describe Several Techniques Which Improve The View Of The Surgical Field While Performing Suction Diathermy Adenoid Ablation.

We report here a very rare case of bilateral congenital choanal atresia untreated for the 27 years after birth. A 27-year-old Japanese man complaining of long-term nasal obstruction, snoring and daytime sleepiness visited our hospital. He exhibited the characteristic appearances of long face and bilateral hypoplastic cheeks. Examination by flexible fiberscopy and computed tomography led us to diagnose him with bilateral choanal atresia. Subsequent polysomnography revealed the number of apnoea or hypopnoea episodes per hour (apnoea—hypopnoea index, or AHI) to be over 10. On the basis of these observations, we modified the diagnosis to obstructive sleep apnoea syndrome (OSAS) secondary to congenital choanal atresia.

In this experimental study, we attempted to perform selective deafferentation of the posterior semicircular canal ampulla of guinea pigs using carbon dioxide laser beam. The results of this study document the efficacy of this procedure in achieving deafferentation of the posterior semicircular canal safely with regards to the other semicircular canals, the otolithic organ and the organ of hearing. Moreover, the procedure is performed with relative ease compared with other procedures previously described for selective deafferentation of the posterior semicircular canal. The clinical application of such a procedure for the treatment of intractable benign paroxysmal positional vertigo in humans is suggested.

To elucidate the influence of radiation therapy on the larynx in patients who receive radiotherapy to the neck, we observed the changes in the distribution of the laryngeal glands. Human adult larynges from patients with either laryngeal or hypopharyngeal cancer were histopathologically examined, and the changes in the glandular distribution as well as in the ratio of serous or mucous type cells were surveyed using an image analysis system. The mean ratio of the area occupied by glandular acini in the subglottic larynx was 0.182 in the non-radiation group and 0.098 in the radiation group (p < 0.001). Although no statistical difference was observed, the average density of the glands decreased and the average ratio of serous-type/mucous-type glandular cells decreased in the irradiated larynx. The glandular acini are often replaced with fibrous connective tissue and the ratio of serous-type glandular cells decreases. These results indicate that not only the voice function but also the local defence function of the larynx might be impaired after radiotherapy.

Background: Branchiogenic carcinoma occurs only rarely. A pathologic description and post-operative adjuvant therapy with carboplatin (CBDCA) and daily oral 5-fluorouracil (UFT) are analysed.

Case report: We present the case of a 52-year-old man with a lateral neck mass lesion. A fine-needle aspiration was performed and cytological examination showed class IV disease. The patient underwent excision of the mass and an intra-operative rapid pathological diagnosis of squamous cell carcinoma was made; we then went on to perform neck dissection. The patient received post-operative radiation therapy (total 64 Gy) and chemotherapy (CBDCA 100 mg/week and UFT 300 mg/day). He was followed up for 62 months after surgery without any evidence of recurrence of cancer.

Conclusion: This case satisfies the histological criteria established by Martin and Khafif for a primary branchiogenic carcinoma. The management would be wide surgical excision of the tumour, including neck dissection, followed by adjuvant therapy, such as chemoradiation. As post-operative adjuvant therapy for primary branchiogenic carcinoma, chemoradiotherapy with carboplatin and UFT was a safe and well tolerated regimen.

Traumatic orbital complications of endonasal surgery, although rare, are a cause of significant morbidity. Although a variety of methods of monitoring eye function during surgery have been described, the best method remains direct perioperative observation of the eye. However, the eye must also be protected during surgery otherwise corneal drying will occur and corneal abrasion may result. This article describes and illustrates the use of Geliperm®, a sterile, transparent, pliant hydrogel dressing, as a corneal protector allowing continuous observation of the eye during endonasal surgery.

Objective: To investigate the previously documented inverse association between ambient temperature and presentation rates for patients with epistaxis and seasonal variation of emergency presentation rates for patients with epistaxis.

Study design: A retrospective analysis of all consecutive emergency patients with epistaxis presenting to hospital from the community over a five-year period, 1997–2002 (1830 days), including those who required admission to hospital with epistaxis over the same period. Patients in whom there was a clear aetiology for the epistaxis (traumatic, recurrent, iatrogenic, coagulopathic and hypertensive) were excluded.

Setting: A tertiary referral centre in south-west London serving a population in excess of 2.8 million.

Method: A retrospective analysis of all patients presenting or admitted to St George’s Hospital with epistaxis over a five-year period. Daily ambient temperature readings from London Heathrow airport were recorded for the same period. Presentations were correlated with monthly temperature variations and the month itself. Statistical analysis with Pearson’s correlation coefficient was performed.

Results: 1373 patients with epistaxis presented to our department, of whom 386 (28.1 per cent) were admitted to hospital. No correlation is seen between ambient temperature and presentation rate for patients with epistaxis. No seasonal preponderance is noted for presentation rate (Pearson r = 0.160, p = 0.221) in this series.

Conclusion: To our knowledge, this is the largest study to date examining ambient temperature association and epistaxis, and the first to investigate presentation rate in place of admission rate. We feel that the exclusion of all patients with epistaxis not admitted to hospital introduces a bias. In this series, there is no correlation between ambient temperature, seasonal preponderance, presentation rate or admission rate for patients with epistaxis. This is contrary to previously reported findings. We do not support the view that there is a relationship between epistaxis and temperature or seasonal variation. This contradicts the current belief that incidence of epistaxis displays seasonality, and has implications for the allocation of resources for healthcare provision within ENT departments.

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.

Ventilation tube insertion plays an important role in the management of otitis media with effusion. In selected cases, repeated grommet insertion due to persistent eustachian tube dysfunction necessitates the need for longer-term ventilation. Insertion of such tubes can however occasionally be more difficult than insertion of standard grommets. One such long-term ventilation tube is the Shah permavent grommet. This paper describes a simple modification of the technique that is less time-consuming and less traumatic.

Objectives: Lesions in the anterior segment of the vocal fold are sometimes difficult to access by means of conventional suspension microlaryngoscopy under general anaesthesia because of anatomical factors such as short, stout and inflexible necks, reduced jaw protrusion, and long incisors. Various techniques have recently been proposed for the management of inaccessible glottic lesions, most of which are performed under general anaesthesia. The use of flexible videoendoscopic surgery under topical anaesthesia in two cases of anterior glottic lesions that could not be treated by means of conventional suspension laryngoscopy is described.

Study design: Case report.

Methods: A flexible videobronchoscope with an instrument channel was inserted transnasally on an out-patient basis. While the examiner carried out the endoscopy, an assistant manoeuvred the biopsy forceps through the instrument channel, and removed the lesion.

Results: Both patients underwent successful removal of an anterior glottic polyp, and the one-year follow-up evaluation revealed normal anatomy of the vocal folds and normal vocal function.

Conclusions: Flexible videoendoscopic surgery under topical anaesthesia is a safe, simple and minimally invasive procedure that can be considered as an alternative to traditional endoscopic surgery for inaccessible anterior glottic lesions.

Hearing loss associated with high-voltage electric shock is a rare entity and minimal information is available in the current literature about this condition. To our knowledge, this article represents the first case report in the literature of improvement in sensorineural hearing loss sustained due to a high-voltage electric shock.

A case report of a patient who incurred various otologic problems, including hearing loss and tinnitus, is presented. An improvement in hearing loss and tinnitus was observed in the subsequent follow up after one month. Audiological findings and possible pathophysiology of hearing loss are discussed.

We recommend that further studies be done to investigate the incidence, severity and pathophysiology of hearing loss in such cases.