Royal National Throat Research Articles

Going electronic: an Epic move.

Medicine and dentistry have historically existed as separate entities, resulting in the creation of separate patient health records, which may limit patient care and safety. The General Dental Council emphasise the need to 'make and keep contemporaneous, complete and accurate patient records' as part of the expected standards of the dental team, with no suggested preference on paper or electronic notes. Despite offering clear advantages in primary care dental practice for efficiency, patient accessibility and financial benefit, the comparatively limited uptake of electronic records in dentistry in the secondary care setting has created barriers for patients and clinicians in delivery of evidence-based oral care. In this paper, we report on the challenges and benefits presented by the national drive to integrate technology into the NHS, including the enhancement this can provide to patient care. In primary care dentistry, electronic record keeping is well established in the UK. There is sparse literature or reported outcomes on the use of electronic record keeping in dental departments in secondary care. The Royal National Ear, Nose and Throat and Eastman Dental Hospitals is now a fully digitised hospital through the introduction of Epic, a fully integrated electronic health record. We explore the role of electronic record keeping in primary and secondary care dental practice, the benefits to patient care and the challenges presented when implementing an electronic health record. We consider the benefits and challenges in digitising a centrally-based specialist teaching dental hospital, including specific features of Epic, which provide enhanced user accessibility and applications for general use and specialised services, including research and public health surveillance.

Accepting the COVID-19 vaccine: supporting informed decision making

Introduction The COVID-19 vaccination programme is intended to protect public health (particularly those at increased risk of developing severe disease with COVID-19) and to relieve the pressures on the National Health Service. This paper discusses the uptake and attitudes of staff working in a London teaching hospital towards receiving the COVID-19 vaccine while considering measures to support informed decision making. Methods An online survey was used to collect demographic information and opinions of staff across all divisions of the Royal National Ear, Nose and Throat and Eastman Dental Hospitals. Results Vaccine safety, long-term effects and information on social media were frequently reported concerns from staff choosing to decline a COVID-19 vaccine at this time. Addressing misinformation, conspiracy theories and inequality surrounding the pandemic should be central in supporting population groups in receiving the benefits of vaccination. Focus groups and tailored clinics to discuss vaccine concerns have provided a safe environment for staff at the trust to address these concerns. Conclusions Success of a vaccine programme depends on public confidence and willingness to participate. There is a need to ensure that population groups are adequately educated about the safety of approved vaccines in order to support informed decision making.

Investigating the nasal cycle using unilateral peak nasal inspiratory flow and acoustic rhinometry minimal cross-sectional area measurements.

To plot the nasal cycle using unilateral peak nasal inspiratory flow (UPNIF) and unilateral minimal cross-sectional area (UMCA) readings demonstrating a linear relationship in normal nasal function. Additionally, to determine how this changes in abnormal nasal function. A cross-sectional study measuring UPNIF and UMCA in controls demonstrating normal nasal function and in patients with nasal obstruction. Royal National Throat Nose and Ear Hospital, London. A total of 39 participants, 26 controls and 13 patients, were recruited. Controls exhibited normal nasal function with SNOT-22 <5. Patients nasal obstruction symptoms secondary to inflammation or structural abnormality with SNOT-22 >9. Airflow rates and resistance values were derived from UPNIF and UMCA measurements respectively based on Poiseuille's laws. Ratios between right and left UPNIF and UMCA values were taken to adjust for confounding factors. The relationship of 1/Resistance Ratio and Airflow Rate Ratio demonstrated a linear of direct proportionality of strong correlation and statistical significance (correlation coefficient=0.76, P«0.01). This suggests that data points from controls with a normal nasal cycle lie closely along the regressed line, whilst those lying significantly away were shown to belong to patients with nasal dysfunction. Olfactory dysfunction appears to be a sensitive discriminator in predicting this. This study demonstrates the directly proportional relationship of 1/Resistance Ratio and Airflow Rate Ratio in normal nasal function. Furthermore, nasal pathology can be predicted if data points lie significantly outside these normal limits. Further studies are needed to validate exact normal and abnormal thresholds.

Evaluation of balance function in patients with radiologically (CT scan) confirmed otosclerosis

Objective: To assess balance function in patients with radiologically confirmed otosclerosis. Methods: Sixteen patients (14 females and 2 males), who attended the Neuro-Otology clinic/ ENT clinics at the Royal National Throat Nose and Ear Hospital, participated in this study. After general medical, audiological and Neuro-Otological examination, patients underwent the caloric and rotational testing.&#x0D; Results: Thirteen of the 16 patients had radiologically confirmed otosclerosis (12 females and 1 male). A total of 3 patients (2 females and 1 male) did not have CT confirmation of otosclerosis, and therefore, were excluded from the study. The remaining 13 patients' data were analyzed. Nine patients had a mixed hearing impairment at least on one side, while eight patients had a bilateral mixed hearing loss and one patient had a sensorineural hearing loss on one side. Four patients had a bilateral sensorineural hearing loss. Only 1 patient had a canal paresis (CP) at 35 %. None of the patients had any significant directional preponderance (DP). The patient with significant CP (35%) did not show any rotational asymmetry on impulsive rotation. Eleven patients had a rotational chair test. Only one patient had a significant asymmetry to the right at 25.30% (normal range is &lt;20%). Overall, 18% (n = 2) of the radiologically confirmed otosclerosis patients showed an abnormal balance test, including both caloric and rotational tests. More than 80% (n = 9) of the patients with radiological otosclerosis showed balance symptoms.&#x0D; Conclusions: the current study indicates a high prevalence of balance symptoms (n = 9 or 82%) in patients with radiological otosclerosis, although only a small proportion (n = 2 or 18%) showed an abnormal vestibular function on caloric and impulse rotation testing. However, due to a small number of samples, further validation of this result is warranted.&#x0D;

Drug induced sleep endoscopy: its role in evaluation of the upper airway obstruction and patient selection for surgical and non-surgical treatment.

Sleep related breathing disorders cause obstruction of the upper airway which can be alleviated by continuous positive airway pressure (CPAP) therapy, oral devices or surgical intervention. Non-surgical treatment modalities are not always accepted by patients and in order to attain successful surgical outcomes, evaluation of the upper airway is necessary to carefully select the patients who would benefit from surgery. There are numerous techniques available to assess the upper airway obstruction and these include imaging, acoustic analysis, pressure transducer recording and endoscopic evaluation. It is essential to note that the nocturnal obstructive upper airway has limited muscle control compared to the tone of the upper airway lumen during wakefulness. Thus, if one were to attempt to identify the anatomical segments contributing to upper airway obstruction in sleep related breathing disorders; it must be borne in mind that evaluation of the airway must be performed if possible when the patient is awake and asleep albeit during drug induced sleep. This fact as such limits the use of imaging techniques for the purpose. Drug induced sleep endoscopy (DISE) was pioneered at Royal National Throat, Nose and Ear Hospital, London in 1990 and initially introduced as sleep nasendoscopy. The nomenclature and the technique has been modified by various Institutions but the core value of this evaluation technique remains similar and extremely useful for identifying the anatomical segment responsible for obstructing the upper airway during sleep in patients with sleep related breathing disorders. There have been numerous controversies that have surrounded this technique but over the last two decades most of these have been addressed and it now remains in the forefront of methods of evaluating the upper airway obstruction. A variety of sedative agents and different grading systems have been described and efforts to unify various aspects of the technique have been made. This article will look at its usefulness and advantages and will discuss some important contributions made to the field of evaluation of the upper airway using DISE.

Roshini M Alles

Roshini Alles trained in Sri Lanka. On completing a programme of postgraduate training in ear, nose, and throat medicine in Sri Lanka, she expanded her experience by training at St...

Tony R Bull

Tony R Bull was born in 1934, the son of a dentist. He trained at the London Hospital, and after working in Jamaica he was appointed as a consultant surgeon...

Dr Roshini M Alles 1953–2016

It is with great sadness that we announce the death of Dr Roshini Alles, Consultant in Audiovestibular Medicine. Roshini recently retired from the Royal National Throat, Nose and Ear Hospital, but ...

Outcomes in endoscopic sinus surgery: olfaction, nose scale and quality of life in a prospective cohort study.

To determine the efficacy of endoscopic sinus surgery (ESS) on olfactory function in chronic rhinosinusitis patients with nasal polyps (CRSwNP) and without nasal polyps (CRSsNP) and to compare the nasal obstruction and symptom evaluation (NOSE) scale before and after surgery. A prospective cohort study SETTING: Royal National Throat and Nose and Ear Hospital, London UK. One hundred and thirteen patients with CRS; 60 CRSwNP and 53 CRSsNP. Olfaction was measured using both the University of Pennsylvania Smell Investigation Test (UPSIT) and the 'sense of smell' visual analogue scale (VAS). The NOSE scale, the sinonasal outcome test (SNOT 22) and the Lund-Kennedy (LK) surgeon reported scores were also measured pre- and postoperatively at 6 months. The UPSIT psychophysical measurement significantly improved following ESS in the CRSwNP subgroup as did the patients perceived VAS sense of smell. However, in the CRSsNP subgroup, the improved VAS and UPSIT measurements were not significant. The NOSE, SNOT 22 and LK scores all improved significantly. The olfactory improvement as measured by the UPSIT correlated to the SNOT-22, but a correlation between the NOSE score and UPSIT was not found. Endoscopic sinus surgery significantly improved the patient's perceived and measured sense of smell in the CRSwNP subgroup which is the most surgically responsive CRS subgroup. Additionally, improved olfaction in the CRSwNP subgroup is most likely to improve the patient's quality of life. Endoscopic sinus surgery significantly improved the NOSE scale in both CRS subgroups at 6 months following surgery.

Transitional cell tumours of the lacrimal drainage apparatus

Background: Tumours of the lacrimal drainage apparatus (LDA) are very rare, but can be life-threatening. Seventy percent of lacrimal sac tumours are of epithelial origin, and transitional cell tumours represent an interesting sub-group of these epithelial tumours. Methods: A retrospective review of cases of LDA transitional cell tumours co-managed at the Royal National Throat Nose and Ear Hospital and Moorfields Eye Hospital, London. Results: Twenty cases of transitional cell tumours of the LDA were identified, comprising 10 transitional cell papillomas (TCPs) and 10 transitional cell carcinomas (TCCs). All cases were resected through a modified lateral rhinotomy approach. Limited resection of orbital fat with preservation of orbital functions was required for 2 cases of TCC. Fractionated external beam radiotherapy was administered in 7 cases of TCC. The mean follow up was 80 months (range 11 months-16 years). Recurrences were detected in 4 cases, which were managed by further surgery. Two cases have been lost to follow-up, but the 18 other patients are currently alive and disease free. Conclusion: A favourable outcome can be achieved with transitional cell tumours of the LDA when an optimum management plan is followed.

Tissue banking in ENT: challenges and methods

Biobanking is the process of storing high quality human biospecimens alongside linked clinical data, for research purposes. The aim is to identify novel biomarkers with prognostic or diagnostic significance. However, the challenges implicit in the collection and storage of human tissue for research have curtailed the impact of this technique to date. This paper aims to summarise the challenges faced by biobanking within the ENT specialty in the UK, and to present protocols used for the routine collection, freezing and storage of tissue specimens at the Royal National Throat, Nose and Ear Hospital. These protocols could be used to guide other ENT departments (in the UK and worldwide) wishing to initiate the routine collection and storage of tissue samples. Their publication could also help to establish basic standards and ensure consistency in ENT tissue storage. Interviews conducted with industry experts, and a literature review of 'best practice' in biobanking. The ENT specialty must stay abreast of progress in human tissue research in order to ensure the best possible management of its patients. Our protocol for the routine banking of ENT tissue at the Royal National Throat, Nose and Ear Hospital could be used as a template for other ENT departments (in the UK and worldwide) to encourage widespread implementation of high quality tissue banking.

Tomas C. Carvajal, MD (1936 - 2013)

“My Mentor… My Inspiration… My Dad”&#x0D; &#x0D; “The righteous who walks in his integrity—blessed are his children after him! ”&#x0D; Proverbs 20:7 &#x0D; &#x0D; Dr. Tomas Carvajal at 76 years old, had practiced for over 40 years as an Emeritus Consultant at Our Lady of Lourdes Hospital in Sta. Mesa, Manila, where he started his Residency Training. Early on, he learned to love the ENT specialty and underwent preceptorship under the wing of Dr. Ariston Bautista. At that time, there was no training program in the Philippines. He went abroad and was accepted to train in Berlin, Germany at the Rodolf Virchow Krankenhaus Department of Ear Nose and Throat under Professor Peffniz. After his training in Germany, to further hone his knowledge and skills, he underwent post graduate training at the Royal National Ear, Nose and Throat Hospital in London, England and Wakayama Medical Center in Osaka, Japan specializing in Nasal Allergy.&#x0D; On returning to Manila, he was invited to be an Assistant Professor in Otorhinolaryngology at the Far Eastern University – College of Medicine and a Consultant at the FEU Hospital then in Morayta, Manila. He was also appointed Medical Specialist Examiner under the then Ministry of Health. Later, he became the first Chairman of the Department of Ear Nose Throat – Head and Neck Surgery (1986-1993) at the FEU Hospital. During the same time he was also Chairman at the Quirino Medical Center Department of Eye Ear Nose and Throat (EENT).&#x0D; Since then he had helped a lot of people-- including colleagues, friends and neighbors, and he was thus invited by former President Erap Estrada and Senator Jinggoy Estrada to run for city councilor in San Juan City where he served for two consecutive terms (2000-2006).&#x0D; My father lived a fruitful and blessed life. He was loved and praised by everyone. It was he who inspired me to become an ENT doctor, it was he who guided me, giving me pointers during my residency training, and it was he who taught me too about LIFE….&#x0D; “Thank you Dad!”&#x0D;

Transitional cell tumours of the lacrimal drainage apparatus

Tumours of the lacrimal drainage apparatus (LDA) are very rare, but can be life-threatening. Seventy percent of lacrimal sac tumours are of epithelial origin, and transitional cell tumours represent an interesting sub-group of these epithelial tumours. A retrospective review of cases of LDA transitional cell tumours co-managed at the Royal National Throat Nose and Ear Hospital and Moorfields Eye Hospital, London. Twenty cases of transitional cell tumours of the LDA were identified, comprising 10 transitional cell papillomas (TCPs) and 10 transitional cell carcinomas (TCCs). All cases were resected through a modified lateral rhinotomy approach. Limited resection of orbital fat with preservation of orbital functions was required for 2 cases of TCC. Fractionated external beam radiotherapy was administered in 7 cases of TCC. The mean follow up was 80 months (range 11 months-16 years). Recurrences were detected in 4 cases, which were managed by further surgery. Two cases have been lost to follow-up, but the 18 other patients are currently alive and disease free. A favourable outcome can be achieved with transitional cell tumours of the LDA when an optimum management plan is followed.

The ENT emergency clinic at the royal national throat, nose and ear hospital, London: Completed audit cycle

The ENT emergency clinic at the royal national throat, nose and ear hospital, London: Completed audit cycle

Spontaneous silent sinus syndrome (imploding antrum syndrome): case series of 16 patients

Silent sinus syndrome (SSS) is a rare idiopathic collapse of the maxillary sinus and orbital floor. We present the second largest series of sixteen patients with SSS and describe their management. A cohort of 16 patients with spontaneous SSS between 1999 and 2009 were reviewed at the Royal National Throat Nose and Ear Hospital. All patients were initially referred from a postgraduate ophthalmic hospital, Moorfields Hospital. Fourteen patients required endoscopic sinus surgery to re-establish maxillary sinus drainage and the remaining two settled with intranasal medical therapy consisting of steroids and decongestions. Follow- up ranged from 6 months to 4 years with a mean of 2.6 years. An improvement in enophthalmos and was seen in all surgically treated patients with a mean improvement of 2.2mm and range 0.5-4mm. SSS arises from congestion of the ostiomeatal complex resulting in negative pressure within the maxillary sinus and a gradual implosion of the antral cavity. Endoscopic sinus surgery successfully re-establishes maxillary aeration in our series and leads to clinical and aesthetic improvement in the degree of enophthalmos and has avoided the need for orbital floor repair in all but two cases.

Thomas James Wilmot

Thomas James Wilmot (“Tom”) was born in 1920, the third eldest in a family of two boys and two girls. He was born in England but his father was originally...

FNAC of nodular fasciitis mimicking a pleomorphic adenoma: another diagnostic pitfall

CytopathologyVolume 21, Issue 4 p. 276-277 FNAC of nodular fasciitis mimicking a pleomorphic adenoma: another diagnostic pitfall A. M. Silvanto, A. M. Silvanto Department of Cellular Pathology, Royal Free HospitalSearch for more papers by this authorL. Melly, L. Melly Department of Cellular Pathology, Royal Free HospitalSearch for more papers by this authorS. A. Hannan, S. A. Hannan Department of ENT, Royal National Throat, Nose & Ear HospitalSearch for more papers by this authorG. Kocjan, G. Kocjan Department of Cytopathology, University College London Hospital, London, UKSearch for more papers by this author A. M. Silvanto, A. M. Silvanto Department of Cellular Pathology, Royal Free HospitalSearch for more papers by this authorL. Melly, L. Melly Department of Cellular Pathology, Royal Free HospitalSearch for more papers by this authorS. A. Hannan, S. A. Hannan Department of ENT, Royal National Throat, Nose & Ear HospitalSearch for more papers by this authorG. Kocjan, G. Kocjan Department of Cytopathology, University College London Hospital, London, UKSearch for more papers by this author First published: 07 July 2010 https://doi.org/10.1111/j.1365-2303.2009.00706.xCitations: 7 A. M. Silvanto, Department of Histopathology, Royal Free Hospital, Pond Street, London, UKTel.: +44 (0) 20 7830 2227; Fax: +44 (0) 20 7435 3289;E-mail: asilvanto@yahoo.com Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article.Citing Literature Volume21, Issue4August 2010Pages 276-277 RelatedInformation

Difficult Mask Ventilation and Neuromuscular Blockade

We read with interest the article by Kheterpal et al. 1regarding impossible mask ventilation. This is a very important but rare event, and this large study gives us a clear idea about its incidence and, for the first time, what the associated risk factors are.We note that in all but 4 of the 77 cases of impossible mask ventilation, the patients had received neuromuscular blockade “in the process of induction or management of the airway,” with succinylcholine being used in 65 patients and a nondepolarizing agent in the remaining patients. However, it is not clear at what stage of airway management that the neuromuscular blocker was administered in these cases—was it before difficulty with mask ventilation being encountered or given after problems occurred to improve the situation, and did ventilation indeed improve? Furthermore, only 19 patients (25%) proved difficult to intubate, which suggests that there was opportunity for improving the conditions for mask ventilation. Kheterpal et al. do go on to discuss the problem in assessing the role of muscle relaxants in mask ventilation difficulties, but the documentation for each case did not include an assessment of mask ventilation before and after neuromuscular blockade. It would be interesting to note if there is a difference in the incidence of impossible mask ventilation with or without neuromuscular blockade being given at induction (before attempts at mask ventilation). This may be an area for further investigation, although as with this study, a large population sample would be required.In our experience, optimum depth of anesthesia and neuromuscular blockade provide the best conditions for both mask ventilation and tracheal intubation (in patients in whom an awake technique, transtracheal catheter, or awake tracheostomy are not indicated). Neuromuscular blockade given at induction and before attempts at mask ventilation is the most common practice in our institution for patients requiring tracheal intubation. In addition, we have found that using intermittent positive pressure ventilation by means of a Penlon Nuffield 200 ventilator (Penlon Ltd., Abingdon, United Kingdom) while holding a mask is beneficial for assessment of adequacy of mask ventilation and also useful for training. This approach has the advantage of allowing a two-handed mask technique for more challenging airways and continual monitoring of airway pressure from the pressure gauge on the ventilator. Monitoring airway pressure in this way provides an objective measure of the seal that is achieved with the mask and patency of the airway. Mask technique can then be optimized by reference to clinical signs (e.g. , chest expansion), airway pressure/peak pressure, and capnography. We also encourage initial management of the airway without use of an oropharyngeal/Guedel airway to improve and optimize these fundamental airway skills. Mask ventilation is our core skill, and we believe subjective and objective assessment throughout training is required to maintain this art and limit airway disasters.*Royal National Throat, Nose and Ear Hospital, London, United Kingdom. johnmyatt@doctors.org.uk

John Lewis Herbert

After qualifying in 1948 from Guy’s Hospital, London, John Lewis Herbert then qualified in ear, nose, and throat surgery at the Royal National Ear, Nose and Throat Hospital, Gray’s Inn...

Estimating the population incidence of adult post‐intubation laryngotracheal stenosis

Clinical OtolaryngologyVolume 32, Issue 5 p. 411-412 Estimating the population incidence of adult post-intubation laryngotracheal stenosis S.A.R. Nouraei, S.A.R. Nouraei Department of Otolaryngology, Charing Cross HospitalSearch for more papers by this authorE. Ma, E. Ma North West London Unit (Epidemiology), Health Protection AgencySearch for more papers by this authorA. Patel, A. Patel Royal National Throat Nose and Ear Hospital, London, UK E-mail: RN@cantab.netSearch for more papers by this authorD.J. Howard, D.J. Howard Department of Otolaryngology, Charing Cross Hospital Royal National Throat Nose and Ear Hospital, London, UK E-mail: RN@cantab.netSearch for more papers by this authorG.S. Sandhu, G.S. Sandhu Department of Otolaryngology, Charing Cross Hospital Royal National Throat Nose and Ear Hospital, London, UK E-mail: RN@cantab.netSearch for more papers by this author S.A.R. Nouraei, S.A.R. Nouraei Department of Otolaryngology, Charing Cross HospitalSearch for more papers by this authorE. Ma, E. Ma North West London Unit (Epidemiology), Health Protection AgencySearch for more papers by this authorA. Patel, A. Patel Royal National Throat Nose and Ear Hospital, London, UK E-mail: RN@cantab.netSearch for more papers by this authorD.J. Howard, D.J. Howard Department of Otolaryngology, Charing Cross Hospital Royal National Throat Nose and Ear Hospital, London, UK E-mail: RN@cantab.netSearch for more papers by this authorG.S. Sandhu, G.S. Sandhu Department of Otolaryngology, Charing Cross Hospital Royal National Throat Nose and Ear Hospital, London, UK E-mail: RN@cantab.netSearch for more papers by this author First published: 19 September 2007 https://doi.org/10.1111/j.1749-4486.2007.01484.xCitations: 77Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article.Citing Literature Volume32, Issue5October 2007Pages 411-412 RelatedInformation