Objectives: The incidence of seroma after thyroidectomy has been reported between 1.3-7%. We hypothesized that a flapless thyroidectomy technique would reduce the incidence of seroma.

Design: Observational case-control study with comparison between retrospective cohort of patients undergoing thyroidectomy with raising of conventional skin flaps, and prospective cohort undergoing flapless surgery.

Setting: Academic Teaching Hospital.

Participants: 175 consecutive patients undergoing thyroidectomy performed by a single surgeon. After the first 85 cases, a change in practice took place, from raising of conventional skin flaps to performing flapless surgery wherever feasible.

Main Outcome Measures: Occurrence of postoperative seroma, defined as central neck swelling in postoperative period, confirmed by aspiration of serous fluid, and other complications.

Results: 8 patients who underwent concomitant lateral (jugular) neck dissection were excluded. Among the remaining 167 patients, there were 8 seromas (5%). Following the change in practice to flapless surgery, there was a significant reduction in the incidence of seroma (p=0.025). There was no significant difference in other complications (haematoma; recurrent laryngeal nerve injury; hypocalcaemia). Among the entire group, the association between seroma and flapless surgery tended towards significance (p=0.07). Other variables studied, including use of drain, and concomitant central compartment neck dissection, had no effect on seroma.

Conclusion: Flapless technique for thyroid surgery may reduce the incidence of postoperative seroma.

© 2012 Blackwell Publishing Ltd

Objective:  To determine if intranasal triamcinolone acetonide prevents the regrowth of nasal polyps after polyp surgery.

Study design:  Randomised, double-blind, placebo-controlled, prospective study.

Setting:  Helsinki University Central Hospital

Participants:  Sixty patients with nasal polyps entered the study. Patients were included upon arrival for elective polyp operations determined according to our standard clinical criteria. The recurrence of nasal polyposis was followed up for nine months after surgical treatment at three-month intervals.

Main outcome measures:  Anterior rhinoscopy, nasal endoscopy, olfactory threshold measurement, active anterior rhinomanometry (RMM) and acoustic rhinometry (ARM) were performed at every follow-up visit.

Results:  On the whole, there was a significant inter-group difference in the change in polyp size of ASA tolerant patients during the follow-up. In patients with ASA intolerance there was no inter-group difference (p=0.28). No significant differences were noted for nasal resistance, nasal cavity volume, sense of smell and nasal symptoms.

Conclusion:  Triamcinolone acetonide prevents regrowth of nasal polyps after polyp surgery in ASA-tolerant patients, but not in ASA-intolerant patients.

© 2012 Blackwell Publishing Ltd

Objective of review:  We present the current literature surrounding peritonsillar abscess management highlighting areas of controversy.

Type of review and search strategy:  Literature review using Medline and Embase databases (search terms ‘peritonsillar abscess’, ‘peritonsillar infection’ and ‘quinsy’) limited to articles published 1991-2011 (English language).

Results:  1) Investigations: Intraoral ultrasound has a sensitivity and specificity of between 89%-95% and 79%-100% respectively for correctly diagnosing peritonsillar abscess and is underutilised currently. 2) Medical management: Steroids can effectively aid recovery, reducing hospitalisation time and improving symptom relief, however further study is needed, especially related to risk and cost benefit. Penicillin and metronidazole are an effective combination in 98-99% of cases of peritonsillar abscess. 3) Surgical management: Overall there is no convincing evidence in favor of either aspiration or incision & drainage. Quinsy tonsillectomy is subject to great geographic variation, however is a safe procedure and reduces overall recovery time when compared with interval tonsillectomy. 4) Admission: Peritonsillar abscess can be effectively managed as an outpatient in many cases. 5) Further management: Overall the recurrence rate of peritonsillar abscess is poorly defined but estimated as 9-22% based on current evidence. Interval tonsillectomy may be indicated in selected groups of patients at high risk of recurrence.

Conclusions:  Peritonsillar abscess is a common condition with increasing incidence. We demonstrate the potential for evidence-based modifications in clinical management. However, lack of national consensus may mean that this evidence base is not being adequately exploited in current practice. A national audit of peritonsillar abscess management, in particular looking at recurrence rates and patient experience with different management strategies, appears indicated.

© 2012 Blackwell Publishing Ltd

Objectives:  To determine minimum airflow rate required for olfactory stimulation in successfully rehabilitated laryngectomised patients after learning the polite yawning technique (PYT) and to confirm the hypothesis that sense of smell is rehabilitated once the nasal airflow is re-established.

Study design:  Prospective open interventional trial.

Setting:  Tertiary academic hospital.

Participants:  The study population comprised 100 laryngectomised patients. The control group consisted of 100 nonlaryngectomised patients of similar age and sex. Rhinomanometry was used to measure air flow in the right and left nostrils, respectively, while the Smell Diskettes Olfaction test (SDOT) was used to test each individual’s sense of smell.

Main outcome measures:  The primary endpoint was increasing the airflow while the secondary endpoint was improvement in the Smell Diskettes Olfaction test score after learning the polite yawning technique.

Results:  The difference in the Smell Diskettes Olfaction test results before and after introducing the polite yawning technique was statistically significant (F = 53.077; P < 0.001). The number of accurately identified odours increased with each measurement. There was a significant difference among rhinomanometric measurements of airflow through the right (F = 65.002; P < 0.001) and left nostrils (F = 75.465; P < 0.001). Nasal airflow improved with each measurement. The minimum airflow required for olfactory stimulation in successfully rehabilitated patients was approximately 60 cm³/s. The control group had considerably better airflow in both nostrils than the laryngectomised group. The difference between the total number of rehabilitated (normosmic) patients (48%) in the laringectomised group and normosmic participants (56%) in the control group (z = 1.132; P = 0.129) was not statistically significant.

Conclusion:  The number of odours identified by laryngectomised patients increased with the volume of nasal airflow. The number of patients with rehabilitated olfactory function approximated the percentage of normosmic individuals in the non-laryngectomised population. These findings confirm the hypothesis that sense of smell is rehabilitated once the nasal airflow is re-established.

© 2012 Blackwell Publishing Ltd

Aim:  An assessment of the effect of otolaryngological management on the health-related quality of life of patients.

Setting:  Six otolaryngological departments around Scotland.

Method:  Application of the Health Utilities Index mark 3 (HUI-3) before and after treatment and the application of the Glasgow Benefit Inventory after treatment.

Subjects:  9005 adult patients referred to outpatient clinics. Complete GUI-3 data was collected from 4422 patients; complete GBI data from 4235; complete HUI-3 and GBI data from 3884.

Results:  The overall change in health related quality of life (HUI-3) from before to after management was just +0.02. In the majority of subgroups of data (classified by type of management) there was essentially no change in HUI-3 score. The major exceptions were those patients provided with a hearing aid (mean change 0.08) and those whose problem was managed surgically (mean change 0.04). The mean GBI score was only 5.3. Those managed surgically reported a higher GBI score of 13.0 while those provided with a hearing aid reported a score of 7.0.

Conclusion:  We found that patients treated surgically or given a hearing aid reported a significant improvement in their health related quality of life after treatment in otolaryngology departments. In general, patients treated in other ways reported no significant improvement. We argue that future research should look carefully at patient groups where there is unexpectedly little benefit from current treatment methods and consider more effective methods of management.

© 2011 Blackwell Publishing Ltd

Objectives:  The correlation between subjective and objective outcomes of nasal obstruction is still a matter of controversy. The aim of this study was to determine the minimal level of side difference in Nasal Airway Resistance (Nasal Airway Resistance measured by Broms’ v₂) between the two nasal cavities, that could be discerned subjectively by the patient on a Visual Analogue Scale (VAS). Nasal Airway Resistance was calculated from rhinomanometric measurements of nasal airflow and transnasal pressure after decongestion of the nasal mucosa.

Design:  A retrospective study.

Setting:  ENT-department, Vaxjo Central Hospital, Sweden.

Participants:  We studied 1,000 active anterior rhinomanometries from patients with nasal obstruction and compared the side difference of Nasal Airway Resistance with the side difference of VAS estimated immediately prior to the rhinomanometry. Each measurement was done after nasal decongestion.

Results:  When the difference in Nasal Airway Resistance between the two nasal cavities was larger than 20˚ (Broms’ v₂) or R₂ > 0.36 Pa/cm³/sec, we found a significant correlation between side differences of the objective measurement and the subjective assessment (VAS). With a Nasal Airway Resistance side difference over 20˚, an additional 20˚ difference corresponded to a 0.9 centimetre average VAS change. The more obstructed side of the nose could be determined by VAS in 823 (82.3%) of 1,000 patients. Yet 177 (17.7%) patients had a paradoxical sensation of nasal obstruction with the low resistance side of the nose experienced as the most congested side.

Conclusion:  A significant correlation between the side differences of Nasal Airway Resistance and VAS can serve as a supplement to rhinoscopy in decisions about nasal surgery. This study also showed that in 17.7% of patients there was a negative correlation between subjective and objective evaluations of Nasal Airway Resistance. But in this group the Nasal Airway Resistance side difference was mostly over 20˚.

Objectives;  The aim of this study was to compare the surgical outcomes of endoscopic sinus surgery in two patient groups: adults younger than 65 years of age and adults aged 65 years or older.

Design;  A retrospective study.

Setting;  This study was conducted at an academic tertiary referral center.

Participants;  One hundred and eighty consecutive older patients (≥65 years), and 180 adult patients (>15, <65 years) with chronic rhinosinusitis who underwent endoscopic sinus surgery under local anesthesia between 1997 and 2007 were enrolled in this study.

Main outcome measures;  Recurrence and complication rates were analyzed. Data were analyzed using the Mann-Whitney test, Fisher’s Exact test, the Pearson Chi-Square test, and univariate and multivariate logistic regression. P < 0.05 was considered statistically significant.

Results;  When looked at without control for other factors the surgical complication rates were higher in the older group patients (31%) compared with the younger patients (11%). However, multivariate logistic regression analysis showed that preoperative duration of symptoms, length of follow-up, and diabetes mellitus were positively correlated with complications. In this analysis, the older patients, once controlled for these factors, were less likely to have complications. Regarding recurrence, in multivariate analysis there was no difference between the older and the younger group with preoperative duration and length of postoperative follow-up having a small effect.

Conclusions;  Comorbidity especially diabetes mellitus and duration of the condition should be the factors considered preoperatively to predict the likely hood of complications rather than whether the patient is younger or older that 65 years of age.

Background:  Tonsillectomy is one of the most common surgical procedures, but there is debate whether systemic steroids should be used to reduce pain and post-operative complications.

Objective of review:  To determine whether peri-operative steroids reduce post-tonsillectomy pain and complications in adults.

Type of review:  Systematic review and meta-analysis of randomised controlled trials.

Search strategy:  We searched MEDLINE (1950–2010), EMBASE (1980–2010), CINAHL (1981–2010), Web of Science, ProQuest, metaRegister, Conference Proceedings Citation Index, the Cochrane Library and reference lists of relevant studies.

Evaluation method:  Two reviewers independently selected trials and extracted data on their quality, characteristics and results. Trials included adults (age >16 years) undergoing elective tonsillectomy where peri-operative steroids were used, and the results were compared with control or placebo.

Results:  There were seven randomised controlled trials (580 patients) reporting post-operative pain. Meta-analysis demonstrates that dexamethasone in adults reduces the pain level experienced in the first post-tonsillectomy day [standard mean difference (SMD): −0.63, 95% CI: −1.13 to −0.12] with significant heterogeneity (I² = 84%, P < 0.00001). Sub-group analysis to explore heterogeneity demonstrated this reduction in pain was mostly with high total dose steroids (total >10 mg over first 24 h post-operatively; SMD: −1.48, 95% CI: −2.17 to −0.79, P < 0.00001), especially when given both intra-operatively and post-operatively. There was no significant effect with low doses (SMD: −0.12, 95% CI: −0.36 to 0.13, P = 0.35). There were three trials (231 patients) that reported post-operative nausea and vomiting, three other trials (270 patients) reporting on bleeding and three trials (401 patients) reporting other complications (infections and odynophagia). There was a significant reduction in post-operative nausea and vomiting (RR: 0.53, 95% CI: 0.36 to 0.80, P = 0.002, I² = 26%) and bleeding (RR: 0.45, 95% CI: 0.25 to 0.80, P = 0.007, I² = 0%), but the reduction in the other complications did not reach statistical significance (RR: 0.69, 95% CI: 0.48 to 1.01, P = 0.06, I² = 0%). Pooling of these complications (post-operative nausea and vomiting, bleeding, infections and odynophagia) shows that in six trials (501 patients), the use of dexamethasone significantly reduced post-operative complications following tonsillectomy in adults (RR: 0.59, 95% CI: 0.49 to 0.71, P < 0.00001, I² = 0%), when compared with placebo or control.

Conclusions:  Dexamethasone reduces pain, post-operative nausea and vomiting, bleeding and overall post-operative complications in adults undergoing tonsillectomy. However, the effect of the dose of dexamethasone on post-operative pain and whether dexamethasone reduces bleeding require further research.

Objectives:  To compare two titanium total ossicular replacement prosthesis (TORP) stabilisation techniques in canal wall down mastoidectomy presenting with footplate only and absent malleus handle.

Design:  Prospective, controlled, randomised study.

Setting:  Tertiary Otology Department.

Participants:  Patients operated on with canal wall down mastoidectomy between 1999 and 2009 were randomised into two groups. Two techniques enhancing the TORP stability were compared: Hüttenbrink’s method (63 patients, Group 1) and author’s (GB) procedure (62 patients, Group 2). Hüttenbrink’s technique consists in placing a cartilage shave with a hole in the middle over the footplate. Through this hole, the end of the TORP is accommodated. The author’s method involves using a cartilage split in the middle, to lodge the TORP’s shaft at one end and to lay the opposite end over the fallopian canal.

Main outcome measures:  Mean postoperative air–bone gap, hearing gain and air–bone gap closure within 20 dB. Auditory outcomes were evaluated at 1 year postoperatively.

Results:  Postoperative air–bone gap closure within 20 dB (successful outcome) at 1 year was achieved in 59% of patients in Group 1 and 72% in Group 2 (P = 0.03). Mean postoperative air–bone gap was 24.4 ± 10.8 dB for Group 1 and 20.17 ± 9.8 dB for Group 2. The difference is 4.23 dB (95% confidence interval, 0.65–07.81), statistically significant: P = 0.02. Hearing gain was 20.3 ± 9.5 in Group 1 and 25.1 ± 10.2 in Group 2, significantly superior: P = 0.007.

Conclusion:  Better hearing outcomes for author’s method could be demonstrated, but our sample size cannot exclude small and possible trivial, group differences.

Objective:  To test the hypothesis that using lidocaine nasal spray will result in improved pain and comfort outcomes during an extended flexible endoscopic nasal examination.

Design:  A split-body, double-blind, placebo-controlled randomised trial. After receiving a rinse of oral mouthwash (Listerine^®), patients were randomised to receive placebo in one nasal cavity and 30 mg of topical lidocaine in the other.

Setting:  A tertiary care centre outpatient Otolaryngology clinic.

Participants:  Twenty-two patients who required an extended bilateral flexible endoscopic nasal examination. An extended nasal examination consisted of an examination of a minimum of two osteomeatal regions on each side of the nasal cavity.

Main outcome measures:  Discomfort and pain were assessed using a 100-mm Visual Analogue Scale (VAS). Our study utilised the definition of pain based on International Association for the Study of Pain. Pain was defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Discomfort was defined as the overall unpleasant experience of the procedure. This included all aspects of the examination such as the pain or other negative sensations associated with the examination, any side effects associated with the application of the nasal sprays as well as any anxiety associated with the examination. A Wilcoxon sign-rank test was used for the primary outcome measures.

Results:  There was a significant reduction in discomfort scores on the treatment side of the nasal cavity compared with the control side (median VAS score of 18.6 mm versus 44.6 mm; P = 0.01). The change in pain between the treatment side compared with the control side did not reach our definition of statistical significance (5.1 mm versus 9.2 mm; P = 0.05). Patients with an active or uncontrolled inflammatory disorder of the nasal cavity experienced a significantly greater reduction in pain compared to those without an inflammatory condition (median change of the VAS score, −15.6 versus +1.0; P = 0.01).

Conclusions:  After a rinse with oral mouthwash, the use of lidocaine results in a significant reduction in the discomfort associated with an extended bilateral flexible endoscopic nasal examination. Patients undergoing such an examination would benefit from the application of lidocaine after masking the negative flavour using oral mouthwash.

Objectives:  The relationship between physician case volume and patient outcome in patients with head and neck cancers such as nasopharyngeal carcinoma treated by radiotherapy is unknown. This study was designed to investigate the association between the case volume of radiation oncologists and the survival of patients with nasopharyngeal carcinoma.

Design:  Retrospective cohort study.

Setting:  Based on nationwide claims data (National Health Research Insurance Database) in the years 2002–2008.

Participants:  Newly diagnosed patients with nasopharyngeal carcinoma receiving curative radiotherapy in the year 2003.

Main outcome measures:  Overall survival until 2008. We used the running log-rank test to decide the optimal threshold for categorising the case volume of radiation oncologists. The characteristics of patients, their treatments and contact with health service providers were considered as co-explanatory variables. The log-rank test and Cox regression were performed. Sensitivity analyses were carried out regarding major study assumptions.

Results:  Five hundred and sixty-two patients with nasopharyngeal carcinoma newly diagnosed in 2003 were identified as the study cohort. The 5-year overall survival was better among patients treated by high-volume (≥6 patients in year 2002) radiation oncologists than by low-volume (<6 patients in year 2002) radiation oncologists (77%versus 64%, P = 0.0007). The adjusted hazard ratio of death was 0.65 (95% confidence interval, 0.48–0.91) upon multivariate analysis. Patients aged at least 65 years also had a lower survival rate than those younger than 65 years old (adjusted hazard ratio of death: 2.81, 95% confidence interval: 1.94–4.08).The physician case volume and patient outcome effect remained the same after sensitivity analyses.

Conclusions:  Patients with nasopharyngeal carcinoma treated by high-volume radiation oncologists have better survival compared with those treated by low-volume radiation oncologists. Further studies are needed to verify our findings with similar cancer cohorts treated by modern radiotherapy techniques or other types of radiotherapy.

Objectives:  To assess whether the use of ice-lollies after tonsillectomy with or without adenoidectomy in children aged 2–12 reduces pain in the immediate postoperative period.

Design:  A prospective, randomised, single-blinded study design consisting of two groups with an intention to treat analysis.

Setting:  Tertiary referral centre.

Participants:  Children aged 2–12 undergoing tonsillectomy with or without adenoidectomy.

Main outcome measures:  Pain assessment by nursing staff in the form of the validated modified Children’s Hospital of Eastern Ontario Pain Scale at 15, 30 and 60 min and 4 h.

Results:  Ninety-two patients were recruited into the study with 46 allocated to receive an ice-lolly and 41 not to receive an ice-lolly after exclusion of those with incomplete data. The two groups were comparable for number, age, sex and diagnosis. The pain score at every time interval was lower in the group that had received the ice-lolly compared with the group that had not. This was statistically significant at 30 (P = 0.008) and 60 min (P = 0.049).

Conclusion:  Our data suggest that ice-lollies are a cheap, effective and safe method of reducing postoperative pain up to one hour following paediatric tonsillectomy.