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The article discusses the role of diagnostic rigid oesophagoscopy in panendoscopy procedures for confirming and staging pharyngolaryngeal cancers. It highlights the limitations and risks associated with rigid oesophagoscopy, such as low diagnostic yield and potential complications. The author suggests considering alternatives like transnasal panendoscopy to improve patient outcomes and reduce risks. The importance of informed consent and adherence to guidelines for safer and more effective diagnostic procedures is emphasized. [Extracted from the article]

Introduction: Gastric inlet patches are often incidental, but can also be a treatable cause of laryngo‐esophageal symptoms. Methods: We retrospectively reviewed all patients whose gastric inlet patches were diagnosed following assessment for laryngopharyngeal and swallowing symptoms. Improvement following Argon Plasma Coagulation (APC) was assessed using Minimum Clinically‐Important Difference methodology combining voice, throat, and swallowing domains. Correlations between APC response and measures of reflux and mucosal barrier integrity, measured during 24‐h pH‐impedance manometry, were obtained. Proximal and Distal Mean Nocturnal Baseline Impedance (MNBI) values were separately calculated and the novel variable of Mucosal Impedance Gradient was derived as [((Distal MNBI‐Proximal MNBI)/((Distal MNBI + Proximal MMBI)/2)) x 100]. Key Results: Inlet patches were detected in 57 of 651 patients who had Transnasal Panendoscopy (8.7 ± 2.2%). There were 34 males. Mean age was 58 years. Mean duration of symptoms was 2 years. The commonest symptoms were hoarseness (n = 33), throat symptoms (n = 24), and dysphagia (n = 21), respectively. APC was used to ablate patches in 34 patients. Treatment response was 71% at a mean followup of 5.5 months. MIG > − 25% predicted response to APC, with area under the receiver operating characteristic curve of 0.875 (Sensitivity = 81%; Specificity = 100%; p < 0.0001). Conclusions: Gastric inlet patches are common and under‐recognized. They can cause protracted pharyngo‐esophageal symptoms. Patch ablation is an effective treatment for carefully selected patients. Optimal patient selection requires multidisciplinary teamwork. Mucosal Impedance Gradient could further refine patient selection. [ABSTRACT FROM AUTHOR]

Objectives: Dysphagia is a presenting symptom of both pharyngeal and oesophageal cancers. The referral pathway choice is determined by whether it is thought to be oropharyngeal or oesophageal, and this is in turn influenced by whether dysphagia is perceived to be above or below the suprasternal notch. We studied the concordance between the presence of pharynx‐localised dysphagia (PLD) and the location of the underlying disease processes. Design: A subset analysis of the Dysphagia Hotline Cohort, collected between 2004 and 2015, of patients with PLD and a structural diagnosis. Main outcome measures: Information about patient demography and presenting symptoms were recorded. The incisor‐to‐pathology distance, and the nature of the pathology, were recorded. Logistic regression analysis was used to identify independent predictors of malignancy. Results: The study included 177 patients. There were 92 males, and mean age at presentation was 74 years. The commonest benign pathologies were cricopharyngeal dysfunction with or without pharyngeal pouch (n = 67), peptic stricture (n = 44) and Schatzki's ring (n = 11). There were 49 cases of cancer, including one hypopharyngeal cancer, one cervical oesophageal cancer, 28 cancers of the upper/mid‐thoracic oesophagus, 15 cancers of the lower thoracic oesophagus and 4 cardio‐oesophageal cancers. In 105 (59%) patients, PLD was caused by oesophageal disease. Independent predictors of malignancy were weight‐change (loss >2.7 kg), a short history (<12 weeks) and presence of odynophagia. Nineteen (39%) of oesophageal cancers that presented with dysphagia that was localised only to the pharynx would have been beyond the reach of rigid oesophagoscopy. Conclusions: Pharynx‐localised dysphagia is more likely to be a referred symptom of structural oesophageal disease, including cancer, than a primary symptom of structural pharyngeal disease. Absence of additional alarm symptoms such as a short history, weight‐loss, and odynophagia, do not adequately exclude the possibility of oesophageal cancer. When the differential diagnosis of PLD includes malignancy, cancer should be presumed to be arising from the oesophagus or the cardio‐oesophageal region until proven otherwise. This requires direct visualisation of the mucosal surfaces of the oesophagus and the cardio‐oesophageal region, using either transoral or transnasal flexible endoscopy, irrespective of whether the initial assessment occurs within head and neck or upper gastrointestinal suspected cancer pathways. [ABSTRACT FROM AUTHOR]

Pre-oxygenation is an essential part of rapid sequence induction of general anaesthesia for emergency surgery, in order to increase the oxygen reservoir in the lungs. We performed a randomised controlled trial of transnasal humidified rapid insufflation ventilatory exchange (THRIVE) pre-oxygenation or facemask pre-oxygenation in patients undergoing emergency surgery. Twenty patients were allocated to each group. No patient developed arterial oxygen saturation < 90% during attempted tracheal intubation. Arterial blood gases were sampled from an arterial catheter immediately after intubation. The mean (SD) PaO2 was 43.7 (15.2) kPa in the THRIVE group vs. 41.9 (16.2) kPa in the facemask group (p = 0.722); PaCO2 was 5.8 (1.1) kPa in the THRIVE group vs. 5.6 (1.0) kPa in the facemask group (p = 0.631); arterial pH was 7.36 (0.05) in the THRIVE group vs. 7.34 (0.06) in the facemask group (p = 0.447). No airway rescue manoeuvres were needed, and there were no differences in the number of laryngoscopy attempts between the groups. In spite of this, patients in the THRIVE group had a significantly longer apnoea time of 248 (71) s compared with 123 (55) s in the facemask group (p < 0.001). Transnasal humidified rapid insufflation ventilatory exchange is a practicable method for pre-oxygenating patients during rapid sequence induction of general anaesthesia for emergency surgery; we found that it maintained an equivalent blood gas profile to facemask pre-oxygenation, in spite of a significantly longer apnoea time. [ABSTRACT FROM AUTHOR]

Objectives: To validate the Clinical Chronic Obstructive Pulmonary Disease Questionnaire (CCQ), a patient-administered instrument developed for bronchopulmonary disease as a disease-specific psychophysical outcome measure for adult laryngotracheal stenosis. Design: Prospective observational study. Settings: Tertiary/National referral airway reconstruction centre. Participants: Thirty-three tracheostomy-free patients undergoing endoscopic laryngotracheoplasty. Main outcome measures: CCQ and the Medical Research Council (MRC) Dyspnoea scale, a previously validated but more limited scale, were administered to patients 2 weeks before surgery, preoperatively, and 2 weeks after endoscopic laryngotracheoplasty. Pulmonary function was assessed preoperatively. Internal consistency was assessed with Cronbach α statistics and test–retest reliability was determined using intraclass correlation. Correlations between CCQ and MRC scale, and pulmonary function were used to assess convergent and divergent validity respectively. Instrument responsiveness was assessed by correlating total and domain-specific CCQ scores with anatomical disease severity and post-treatment effect size. Results: There were 12 males and 21 females. Mean age was 44 ± 15 years. Cronbach α coefficient and intraclass correlation coefficient were 0.88 and 0.95 respectively. Total and domain-specific CCQ scores significantly correlated with the MRC scores ( P < 0.001) and significant correlations between CCQ and peak expiratory flow rate and FEV1 were identified ( P < 0.03). There were statistically significant changes in total and domain-specific CCQ scores when different stenosis severities were compared. Clinical COPD Questionnaire scores also changed significantly and congruently following surgery ( P < 0.05 in both cases). Discussion: Clinical COPD Questionnaire is a valid and sensitive instrument for assessing symptom severity and levels of function and well-being in adult patients with laryngotracheal stenosis and can be used as a patient-centred disease-specific outcome measure for this condition. [ABSTRACT FROM AUTHOR]

Objectives: To audit the accuracy of otolaryngology clinical coding and identify ways of improving it. Design: Prospective multidisciplinary audit, using the ‘national standard clinical coding audit’ methodology supplemented by ‘double-reading and arbitration’. Settings: Teaching-hospital otolaryngology and clinical coding departments. Participants: Otolaryngology inpatient and day-surgery cases. Main outcome measures: Concordance between initial coding performed by a coder (first cycle) and final coding by a clinician-coder multidisciplinary team (MDT; second cycle) for primary and secondary diagnoses and procedures, and Health Resource Groupings (HRG) assignment. Results: 1250 randomly-selected cases were studied. Coding errors occurred in 24.1% of cases (301/1250). The clinician-coder MDT reassigned 48 primary diagnoses and 186 primary procedures and identified a further 209 initially-missed secondary diagnoses and procedures. In 203 cases, patient’s initial HRG changed. Incorrect coding caused an average revenue loss of £174.90 per patient (14.7%) of which 60% of the total income variance was due to miscoding of a eight highly-complex head and neck cancer cases. The ‘HRG drift’ created the appearance of disproportionate resource utilisation when treating ‘simple’ cases. At our institution the total cost of maintaining a clinician-coder MDT was 4.8 times lower than the income regained through the double-reading process. Conclusions: This large audit of otolaryngology practice identifies a large degree of error in coding on discharge. This leads to significant loss of departmental revenue, and given that the same data is used for benchmarking and for making decisions about resource allocation, it distorts the picture of clinical practice. These can be rectified through implementing a cost-effective clinician-coder double-reading multidisciplinary team as part of a data-assurance clinical governance framework which we recommend should be established in hospitals. [ABSTRACT FROM AUTHOR]

Objectives: To study the radiologic anatomy of the paranasal sinuses in patients with and without chronic rhinosinusitis to assess whether anatomic variations are associated with disease pathology, and to identify those variants that may impact operative safety. Setting: Tertiary referral otolaryngology unit. Main Outcome Measures: incidence and nature of anatomic variants with potential impact on operative safety, and the presence or absence of sinus mucosal disease and its correlation with anatomic variants with a potential impact on mucociliary clearance. Methods: We reviewed 276 computed tomographic scans from patients with rhinosinusitis symptoms to investigate anatomic variations that may predispose to sinusitis or impact on operative safety. The incidence of variants with potential impact on sinus drainage was compared between patients with and without sinus mucosal disease with logistic regression. Results: A closed osteomeatal complex was identified in 148 patients (53%), followed by concha bullosa in 98 patients (35%). Closed osteomeatal complex and nasal polyposis were independent risk factors for sinus mucosal disease. Anatomic variants with a potential impact on operative safety included anterior clinoid process pneumatization (18%), infraorbital ethmoid cell (12%), sphenomaxillary plate {11%), and supraorbital recess (6%). In 92% of patients, the level difference between the roof of the ethmoid cavity and the cribriform plate was Keros I. Conclusions: Bony anatomic variants do not increase the risk of sinus mucosal disease. However, anatomic variants with a potential impact on operative safety occur frequently and need to be specifically sought as part of preoperative evaluation. [ABSTRACT FROM AUTHOR]

Objectives: To assess the sensitivity and responsiveness of the Medical Research Council (MRC) scale, a psychophysical dyspnoea assessment instrument to the presence and treatment of adult laryngotracheal stenosis. Design: Prospective observational study. Settings: Tertiary/National referral airway reconstruction centre. Participants: Fourty tracheostomy-free patients undergoing endoscopic airway examination/laryngotracheoplasty. Main outcome measures: Demographic and clinical information, obtained from patient records, lesion severity, which was recorded intraoperatively, standard spirometry, which was measured preoperatively, and the MRC dyspnoea scale, which was administered preoperatively and at the first outpatient visit 4–6 weeks later. Results: There were 16 males and 24 females. Mean age at presentation was 44 ± 14 years (± SD). Postintubation stenosis was the commonest aetiology (73%) followed by idiopathic subglottic stenosis and Wegener’s Granulomatosis. Six patients were examined post-treatment and had minimal residual stenosis and the remaining patients had glottic stenosis ( n = 11) or Myer–Cotton Grade I ( n = 8), II ( n = 7) or III ( n = 8) tracheal stenoses. Pre-treatment MRC dyspnoea scores and the degree of change in the MRC score following treatment strongly correlated with pre-treatment stenosis severity ( r = 0.75 and r = −0.71 respectively; P < .001). Moreover statistically significant correlations existed between preoperative peak expiratory flow and forced expiratory volume in 1 s and preoperative MRC dyspnoea scores ( r = −0.34 and r = −0.35 respectively; P < 0.05). Discussion: Exertional dyspnoea is the hallmark symptom of laryngotracheal stenosis and for many patients it is the primary cause of disability. These findings confirm that the MRC dyspnoea scale is an appropriate outcome instrument for assessing dyspnoea associated with this condition. [ABSTRACT FROM AUTHOR]

Keypoints • Post-tracheostomy ‘lambdoid’ deformity of the trachea is a specific and uncommon variant of adult post-intubation laryngotracheal stenosis, in which airway obstruction is caused by inward collapse of over-resected tracheal cartilage as a result of post-decannulation stomal contracture. • We evaluated the results of endoscopic tracheoplasty as an alternative to open tracheal resection in 11 patients treated for this condition between 2004 and 2006. • Patients were treated with endoscopic CO2 laser resection, dilatation and endotracheal mitomycin C application. Suspension micro-laryngo-tracheoscopy and high-frequency supraglottic jet ventilation were used. Eleven patients with an average age of 56 years and lesion height and distance from glottis respectively of 11 ± 5 mm and 35 ± 12 mm were treated. • The median number of treatments fell from four at the start of the series to two at the end ( P = 0.08). The average follow-up was 17 ± 8 months and all patients were cured with no cases of dysphagia or dysphonia. Almost all patients achieved and maintained a Medical Research Council Dyspnoea Scale of I or II. • Endoscopic tracheoplasty is an effective treatment for this condition. It achieves a successful outcome while avoiding the operative risks, prolonged hospitalisation, and morbidity that is associated with tracheal resection. We recommend it as the standard of care for treating patients with this injury. [ABSTRACT FROM AUTHOR]

Objectives: To investigate the relationship between clinical variables and biochemical markers of calcium homeostasis and parathyroid adenoma size, in patients undergoing surgery for primary hyperparathyroidism. To determine the potential clinical utility of the findings in preoperative planning and prediction of postoperative hypocalcaemia. Design: Retrospective data analysis. Participants: Ninety-two patients treated surgically for primary hyperparathyroidism caused by a solitary parathyroid adenoma between 1996 and 2006. Main outcome measures: Complete data was obtained for 77 participants including patient demographics, perioperative calcium, parathyroid hormone and phosphate levels, adenoma weight and histological dimensions. Multiple and binary logistic regression analyses were used to investigate the relationship between clinical and biochemical variables and adenoma weight and volume. Similar analysis was used to identify predictors of postoperative hypocalcaemia. Setting: University Teaching Hospital Otolaryngology Department. Results: The mean age at presentation was 59 years. The mean preoperative calcium and PTH levels were 2.86 ± 0.2 mmol/L and 17.2 ± 12.3 ng/L, respectively, falling to 2.3 ± 0.01 and 4.1 ± 2.7 postoperatively. The mean adenoma weight was 1.71 ± 1.41 g. No correlation existed between clinical variables and preoperative biochemical markers of calcium homeostasis and adenoma weight or volume. There was a weak correlation between the preoperative to postoperative change in calcium and PTH levels {[ δCa2+] vs. [ δPTH]} ( r = 0.24; P < 0.05) but no predictors of postoperative hypocalcaemia could be identified. Conclusions: Biochemical parameters will not accurately predict the size of a parathyroid adenoma. The size of a parathyroid adenoma does not correlate with postoperative calcium levels and is therefore not useful as a predictor of postoperative hypocalcaemia. [ABSTRACT FROM AUTHOR]

Keypoints • Transnasal fibreoptic oesophagoscopy (TFO) allows the upper aerodigestive tract, from the nasal vestibule to the gastric cardia to be examined in the outpatients department without sedation. • This permits patients with symptoms of upper aerodigestive pathology to be investigated at the initial consultation without the need for inpatient endoscopy or swallow studies. • The technique is easily learned, and is statistically comparable with standard flexible nasoendoscopy in respect of procedural pain and discomfort. • It is highly cost-efficient, paying for itself within 1 year, and thereafter leading to cost savings of over 80%. • Its role can be expanded to encompass investigating patients with potentially malignant disease processes, as well as outpatients ‘panendoscopy’ and biopsy, and a number of therapeutic interventions. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented about the adult laryngotracheal stenosis.

A response by D. Baring and O. Hilmi to the comments by G. Weiner regarding their article on otorhinolaryngology (ORL) is presented.

A letter to the editor which discusses the risks and benefits of surgical treatment is presented.

A response by S. A. R. Nouraeito a letter to the editor about the article concerning the clinical coding accuracy in otolaryngology in the previous issue is presented.

A letter to the editor is presented in response to the article related to the development of a software used for objective assessment of facial symmetry.

A letter to the editor related to the development of a planimetry software for digitising printed graphs and historical clinical investigations is presented.

A letter to the editor is presented in response to the article on the effectiveness of a four-point suture fixation technique on securing surgical tracheostomies.

A letter to the editor is presented about the incidence of adult post-intubation laryngotracheal stenosis.

Background: To undertake a national analysis of clinical activity pattern and outcome of thyroid and parathyroid surgery using bespoke Hospital Episode Statistics data linkage. Methods: Records of patients undergoing thyroid or parathyroid surgery between 2004 and 2012 were obtained. Morbidity was quantified using the Charlson index. Index procedures were linked to the presence of diagnoses and procedures indicative of laryngeal paralysis, regardless of which provider treated the patient. The rate of utilisation of speech and language therapy services in the 18 months before and after thyroid/parathyroid surgery was also calculated. Results: There were 18,931 males and 77,715 females. Mean age at treatment was 52±28 years. Mean length of stay was 2.5 days. There were 75,039 thyroidectomies and 24,234 parathyroidectomies. There were 45,753 benign thyroid conditions, 8519 benign thyroid neoplasms, 17,234 benign inflammatory thyroid conditions, and 9982 thyroid cancers. There were 14,303 benign parathyroid cases, 11,268 benign parathyroid neoplasms, and 199 parathyroid cancers. There were 439 immediate vocal palsies identified. There were 264 cases of immediate airway compromise and 272 tracheostomies were placed. In-hospital mortality occurred in 103 (0.11%) and there were 763 acute cardiac and 533 respiratory events. There were 885 (0.9%) late vocal palsies and mean surgery to diagnosis delay was 577 days. There were 180 vocal medialisations and 555 patients had speech and language therapy. Surgical volume below 25 cases per year and presence of malignant or benign inflammatory thyroid disease increased the risk of laryngeal palsy. Conclusions: Use of Hospital Episode Statistics data for clinical outcomes management is a complex proposition, but through creating and validating data linkages it is possible to obtain a more comprehensive picture of clinical activity, treatment outcomes, and complications. The utility of this data can be further improved through developing a Minimum Coded Dataset Standard (MCDS) to compliment the current national audit. [ABSTRACT FROM AUTHOR]