Volume 5 Issue 1 - 2012

Currently the national news is full of articles and reports about doctors and the planned strike (the first strike since 1975) over the pension reforms. It would appear that the press has little sympathy with the apparently ‘highly paid’ medical profession. No doubt the recent articles in the press pertaining to the relationship of the media tycoons and the politicians running our country would explain why there seems to be a much better representation to the public of why doctors should take the ‘hit’ on pensions rather than explaining the relatively sparse ‘perks’ that are available for highly trained individuals doing important jobs, with the pension probably being the most important one. Recent year-end financial reports of most NHS Trusts and the need to ‘sweat assets’ makes more gloomy reading for the average hospital doctor.

The recent controversy concerning the PIP breast implants has highlighted the problem of inconsistent outcome data. In spite of more than 30,000 PIP women being fitted with the breast implants over a 10-year period, the manufacturers, healthcare providers and surgeons have no reliable data on its rupture rate. This is not unique to cosmetic surgery; surgical outcome data are not always available for non-cosmetic procedures too. For ENT procedures, certain surgical outcomes are more accessible because they are short term observations (post-tonsillectomy bleeding) or collected as part of the service provision requirements (cochlear implant, head and neck cancer surgery).


Pulsatile tinnitus is a rare form of tinnitus characterized by pulsatile sound that is synchronous with the heartbeat. Unlike idiopathic non-pulsatile tinnitus, an underlying vascular cause may be identified. Common causes include carotid artery atherosclerosis, Arteriovenous malformation or fistulae or vascular tumours. It should be thoroughly investigated using magnetic resonance angiography, computer tomography venography or traditional angiography. Many aetiologies are amenable to either angiographic or surgical intervention.


Defects of the pinna may be congenital or acquired. The vast majority of patients with congenital defects requiring reconstruction are children with microtia and almost all acquired defects presenting in adult patients are due to trauma or tumour resection. A comprehensive review of ear reconstruction is of course beyond the scope of this article. Here the principles of reconstruction of the pinna will be described, and the management of the more common clinical scenarios will be addressed.


Squamous cell carcinoma of the larynx is the most common malignancy of the upper aerodigestive tract seen in the United Kingdom. The glottis is the most frequently involved sub-site and three-quarters of these patients will present with early disease. Historically, the treatment of choice for all patients with early laryngeal cancer was external beam radiotherapy (RT). This has been challenged over the last decade with the popularisation of transoral laser micro surgery (TLM) as an alternative technique that offers similar locoregional control rates as well as comparable functional outcomes.1 This article aims to give a thorough overview of the presentation, diagnosis, investigation and management of early laryngeal cancer including the evidence behind the changing attitudes regarding definitive treatment.


Despite recent advancements in both medical and surgical treatment for chronic rhinosinusitis (CRS), this condition still causes very significant morbidity and reduction of quality of life in those patients who suffer from it. If medical therapy fails to improve symptoms sufficiently then surgery is offered. However some patients experience persisting or recurrent symptoms after surgical intervention so there is scope to improve the efficacy of current perioperative care. There is however surprisingly limited scientific evidence on which to base a rational regimen of perioperative care. This article will review the currently available evidence, and highlight where deficiencies in our knowledge lie.


Stability of Bone Integrated implants is influenced by the bond between bone and implant. This can be evaluated using Resonance Frequency Analysis (RFA). Disagreement exists amongst experts concerning time to activate or ‘load’ the implant. Current practice is 6 to 12 weeks. Particular caution is exercised in revision surgery. Here we present a case of a 62 year-old gentleman implanted with a Bone Anchored Hearing Aid (BAHA). RFA measurements identified instability in the first implant, loading was postponed and the implant lost. RFA identified higher stability following revision BAHA. These values facilitated successful loading at two weeks. This is the first report of the clinical usefulness of RFA to expedite loading time well below standard protocol in revision surgery.


Objective: To present an alternate Venous Thromboembolism (VTE) prophylaxis risk stratification tool, based on NICE guidance. To evaluate the efficacy, ease of use and benefit of our tool, through cyclical audit.
Methods: Initial standards based audit of departmental VTE prophylaxis against NICE guidelines. Intervention: Design and introduction of a compulsory, nurse led, VTE risk stratification tool accompanied by staff training sessions and instructional posters. Re-audit of implementation and effectiveness 3 and 9 months later.
Results: of the 24 patients reviewed in the standards based pilot audit, none were assessed for their risk of VTE and 44% received sub-optimal treatment. Re-audit of 22 patients, 9 months after implementation of the risk stratification tool, showed 100% compliance with VTE risk stratification and 100% of patients were provided with optimal prophylaxis during their hospital stay.
Conclusion: The incidence of VTE in Otolaryngology patients is low and many of them fully mobile after short operations. The VTE risk stratification tool presented here is ideal for this cohort of patients as it treats patients based on their cumulative risk rather than for a single risk factor as suggested by the NICE flowchart.
A Compulsory, nurse-led policy, accompanied by staff training and educational posters proved successful in improving compliance with published guidance in our department. We would urge other ENT units to adopt a similar policy.


A questionnaire was distributed to all patients undergoing an elective otolaryngology procedure during a two-week period. The “sign in” was performed as per the instructional video on the National Patient Safety Agency website.
Certain questions e.g. anticipated blood loss and risk of aspiration, increased anxiety levels of some patients prior to anaesthesia induction. Consequently, the “sign in” was modified so that the anxiety-provoking questions were discussed prior to the arrival of the patient. The questionnaire was distributed for another two-week period – the “sign in” did not increase anxiety levels in any of these patients.
A simple modification of the timing of asking certain questions removed this anxiety and improved the patient journey experience through our operating department.

In section A, what is the structure indicated by the arrows?

Reissner’s membrane, which is also known as the vestibular membrane. It separates the perilymph containing scala vestibuli from the endolymph filled scala media.


Background: Over recent years ENT surgery has been subject to many internal and external pressures. These have been particularly evident in emergency service provision, leading to questions being raised over the adequacy of this service.
Objectives: A literature review was performed with the aims of 1) assessing current UK ENT emergency service provision and 2) identifying relevant areas of concern.
Results: Nationally there is a distinct lack of published research and audit into ENT emergency service provision; this needs to be addressed. According to the research which is available there is a lack of adequate ENT training and experience among the junior doctor grades. The situation is worsened by them being expected to work in a cross covering scheme with, at times, unrelated specialities. These problems appear to be compounded by issues surrounding senior level cover, importantly a lack of confidence in paediatric airway management and the impact of sub specialisation on consultant emergency skills. Finally, simple methods of providing a safety net and standardising ENT emergency care, such as inductions and guidelines are not widely implemented.
Conclusions: Major issues with current UK ENT emergency service provision have been highlighted; these problems could potentially lead to inadequate ENT emergency care and patient harm. To not act on such information could be deemed to be negligent.


Pulse oximetry is used to screen, aid diagnosis and measure severity of Obstructive sleep apnoea (OSA). Traditionally, pulse oximetry required an overnight stay at our centre. In-patient tests are potentially non-representative of a typical night’s sleep due to unfamiliar surroundings and noisy environment. The purpose of this audit was to compare inpatient and home pulse oximetry.


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