Fifty Third Annual Meeting
of the
Irish Otorhinolaryngology /
Head and Neck Society
Sir William Robert Wills Wilde
(1815 – 1876)
Lough Erne Resort, Enniskillen, Co. Fermanagh
Friday 5th & Saturday 6th October 2012
Officers
President
:
Mr. T. O’Dwyer
Vice President
:
Mr. J. G. Toner
Secretaries
:
Mr. R. Adair (Northern)
Mr. N. Patil (Southern)
Editor of Proceedings
:
Mr. P. Gormley
Treasurer
:
Ms. Cate Scally
Members :
Mr. M. Donnelly
Mr. E. McNaboe
Mr. D. McShane
Mr. G. O’Leary
Past Presidents
T. G. Wilson
F. A. McLaughlin
R. R. Woods
J. McAuliffe Curtin
D. Craig
Kennedy Hunter
M. J. Roberts
R. S. McCrea
M. O’Brien
R. M. Harvey
A. Blayney
T. Wilmot
E. Fenelon
H. W. H. Shepperd
W. Doyle Kelly
A. C. M. L. Miller
A. Maguire
J. E. T. Byrne
H. Burns
A. Kerr
K. Tobin
J. H. A. Black
M. A. Walsh
D. Adams
A. Blayney
W. Primrose
Wilde Discoursers
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2010
2011
Terence Cawthorne
Ian Simpson Hall
C.P. Wilson
Ronald Macbeth
W.H. Struben
Angell James
Michel Portmann
Howard House
Joseph Ogura
J.P. Hood
Harold F. Schucknecht
Donald F.N. Harrison
Stuart Strong
Douglas Bryce
John Ballantye
Claus Jansen
Gabriel Tucker
L.B.W. Jongkees
Robert Pracy
George Nager
R.B. McDowell
R. Wentges
Victor Goodhill
Douglas Ranger
H. Spondalin
P. Alberti
Tauno Palva
Philip Stell
Dietrich Plester
Arnold G. Maran
David Brain
William Panjee
Tony Bull
Richard. Ramsden
David Kennedy
L. Ryan
Ugo Fisch
R. Goody
E. McKay
J. Fredrickson
Patrick Gullane
William Coman
Thomas McDonald
Trevor McGill
Gilbert Nolst Trenite
George Browning
Kevin Gibbin
Max McCormick
Peter Wormald
Fred Owens
John Watkinson
Program
Thursday 4th October
1600 - 1900
Registration
1900 - 1940
IOS Council Meeting
2000 - 2130
Buffet Dinner
Friday 5th October
0730 - 0850
Registration
0850 - 0900
Welcome by President / Announcements
0900 - 1100
Free Paper Session (Head + Neck)
Chairpersons : Barry Devlin + Mark Rafferty
0900 - 0910
Monitoring Treatment Responses In the Node Positive Neck in Patients
With Oropharyngeal Squamous Cell Carcinoma
Phoebe Roche, James Paul O Neill, Tadgh O Dwyer
Mater Hospital
OBJECTIVES: Oropharyngeal squamous cell carcinoma accounts for
between 15 and 20 % of all head and neck cancers. Approximately 85
% of all oropharyngeal tumors will present with nodal metastases. Over
the last decade, there has been a significant rise in its incidence and
there is controversy over its management. The aim of this paper, is to
review our practise, in monitoring patients with a history of nodal
disease due to oropharyngeal primary.
METHODS: A five-year audit of all patients treated for oropharyngeal
squamous cell carcinoma with nodal disease at the Mater Hospital is
presented along with a review of the recent literature.
RESULTS: According to the Mater Hospital Head and Neck cancer
registry, a total of 94 patients (age range 40 – 82) were diagnosed with,
and treated for oropharyngeal cancer in our hospital between July 2007
and July 2012. Both HPV positive and HPV negative tumors were
represented within the cohort.
CONCLUSION: Our patients are followed by a multidisciplinary team
and positron emission tomography PET CT at 12 weeks following their
primary therapeutic modality. Patients with residual disease then
proceed with salvage surgery.
0910 - 0920
Role of Sestamibi and PTH assay in parathyroid surgery
Ramesh Gurunathan 1, Gillian Taylor 2 & Greg McBride 3
1, 2 - Registrars in ENT; 3 - Consultant ENT Surgeon
Altnagelvin Hospital, Londonderry
Background:
Parathyroid surgery for hyperparathyroidism has moved from
traditional four gland exploration to minimally invasive procedure with
advent of better imaging tools, intraoperative PTH monitoring and
endoscopic techniques. In our hospital parathyroid operation is
accomplished with preoperative Sestamibi and serum PTH monitoring
at D1 post-op. Intra-operative PTH assay is done only in selected
patients.
Aim:
1. Analyse the outcome of parathyroid surgery at our Hospital
2. To correlate pre-operative Sestamibi localisation of adenoma with
operative findings
Method:
Retrospective chart review of 32 patients had parathyroid operations
from 2009 to 2012.
Results:
Majority of referrals came through GP and seen at Joint Endocrinology
& ENT clinic but occasional referrals from renal, urology, orthopaedics
and surgical admissions. Half presented with incidental hypercalcemia
and other half had varied clinical presentations like calculi, renal
failure, fractures, fatigue, dehydration, acute abdomen etc.
Majority (24/32) were females. Age ranged from 22 to 88 with mean of
58. Average operative time was 50 minutes with incision length from
2.5 to 4 cms. Two patients needed 2nd exploration. Postoperative PTH
and calcium levels returned to normal in 31/32 patients. Of 32 patients,
sestamibi localisation was positive in 20 patients (63%) and correlated
100% with surgical findings. In patients with negative scan, 4 gland
explorations were done. Inferior gland pathology is found in two thirds
with left inferior in majority.
Conclusion:
In our view, a preoperative Sestamibi scan is sufficient in majority of
patients. 4 gland explorations with intraoperative PTH assay are useful
in selective patients with negative scan.
0920 - 0930
Chemoradiation in Elderly Patients with Locally Advanced Head and
Neck Cancer: A Population-Based Analysis of Treatment Patterns and
Adverse Events
Caitriona B. O’Neill, James P. O’Neill, Shrujal S. Baxi, Coral L.
Atoria, Martin C. Henman, Eric J. Sherman, Nancy X. Lee, Elena B.
Elkin
Objective: Concurrent chemoradiation (CTRT) is a standard treatment
for patients with locally advanced squamous cell carcinoma of the head
and neck cancer (LAHNSCC). Our objectives were to characterize
patterns of CTRT use, identify trends in the selection of concurrent
chemotherapy, and to assess the nature and frequency of
hospitalizations for acute treatment-related adverse events in older
patients with LAHNSCC.
Methods: Using SEER cancer registry data linked with Medicare
claims, we identified patients aged 66 years or older with LAHNSCC
diagnosed 1999-2007. We identified trends in CTRT use and the use of
specific chemotherapeutic agents. Hospitalizations or emergency room
(ER) visits for chemotherapy-related adverse effects were also
evaluated.
Results: 4,939 LAHNSCC patients were identified, of whom 1,086
(22%) received CTRT. Over time there was a significant increase in the
proportion treated with CTRT (p<0.0001). The proportion of patients
receiving cetuximab increased 42% in the three year period, 20052007. Sixty-three percent of CTRT patients had a hospital admission or
ER visit for an acute treatment-related toxicity and 12% of these
patients died in hospital.
Conclusions: Although CTRT use is increasing in older patients, acute
treatment-related admissions are substantial. Treatment selection is
complex and must look beyond chronologic age and consider
individual patient factors, such as functional status and personal
preference, as well as institutional factors, patient resources, support
services and costs.
0930 - 0940
Developing an Airway Alert System (AAS) for post-operative head
and neck patients
T. Ashfield 1, D. Chatterjee 2, B. Shephard 2, I. Ahmad 2,
S. Tricklebank 2 & R. Oakley 1
Departments of ENT, head & neck surgery 1 and anaethetics 2
Guy’s and St. Thomas’ NHS Foundation Trust, London, UK
Objective
The Fourth National Audit Project of the Difficult Airway Society
(NAP4) demonstrated that post-operative major head and neck surgery
patients were the group at greatest risk of acute airway events.
Improvements in identification of, and planning management for
difficult airways were key recommendations.
Audit of practice within our own unit confirmed these national
observations, highlighting the need for improvement. We developed
the AAS to improve identification and planning for difficult airways in
post-operative head and neck patients.
Methods
AAS is divided into three phases; risk stratification, planning and
continuing review. Key airway safety issues are reviewed and recorded
by the anaesthetic, surgical and critical care teams, and patients deemed
high risk are placed into one of three groups, according to the nature of
the anticipated difficulty. A daily checklist is employed to ensure that
the airway plan is current and specified equipment is at the bedside.
The system also triggers precautions that remain in place until it is
deemed appropriate to 'de-escalate'.
Results
Current understanding and confidence in difficult airway management
amongst ICU staff was poor prior to introduction. AAS is now in place
and we aim to improve this situation and ultimately improve patient
safety.
Conclusions
Practical, airway skills whilst central to managing a difficult airway are
only successful in concert with clear strategy. This system places clear
plans at the bedside that are reviewed daily. We have shown that AAS
is deliverable, easy to use, and is likely to patient safety in this high
risk group.
0940 - 0950
GENE MUTATION ANALYSIS OF NASAL MUCOSAL
MALIGNANT MELANOMAS
M Moran, AP Kelly, WJ Primrose, MA Catherwood, JA James
Objectives:
Correlation of pathological characteristics of nasal melanomas with
clinical data, in order to investigate a role for gene mutation analysis as
a prognostic biomarker for this tumour group. With nasal melanomas it
is more difficult to assess the widely accepted grading systems such as
Clark level of invasion or surface ulceration, which are used in
cutaneous melanomas.
Methods:
Patients with a diagnosis of nasal malignant melanoma were identified
for a ten-year period between 2000 and 2010.
Results:
The group of patients identified comprised 8 males and 9 females, with
a mean age at diagnosis of 69.1 years. Histopathological sections were
reviewed for these patients, in particular the immunohistochemistry
analysis for markers such as S100, HMB-45 and Melanin-A. In
addition, the samples underwent additional molecular tests for BRAF
genetic mutations, on the basis that these mutations have been
implicated as prognostic indicators in other (cutaneous) melanomas.
23.5% of the patients had BRAF mutations detected.
Conclusions:
Nasal malignant melanoma is a disease entity that is difficult to treat
successfully, and patients often undergo a combination of surgery and
chemoradiotherapy in an attempt to control tumour growth and
metastasis. This study illustrates the heterogeneity of disease within a
cohort of patients with nasal melanoma, and it is hypothesised that a
stratified medicine approach to treatment of mucosal melanomas such
as these could be enhanced by greater understanding of genes and
pathways implicated in the development and spread of melanoma. The
genetic mutation analysis for this subset will be correlated with clinical
outcomes including overall survival.
0950 - 1000
PREVALENCE
OF
MULTIPLE
SYNCHRONOUS
OR
METACHRONOUS PRIMARY SQUAMOUS CELL CARCINOMA
OF THE UPPER AERODIGESTIVE TRACT
J Kulasegarah, C Timon
Objective
The elevated risk of second primary malignancy (SPM) in patients with
head and neck squamous cell carcinoma (HNSCC) is well established.
Despite the advances in locoregional control achieved by modern
surgery and chemoradiation, survival with HNSCC has not
meaningfully improved, in part due to continuing risk of development
of SPMs in these patients. We aim to determine the prevalence of SPM
over a period of 12 years and also to explore the role of HPV in lesions
of the head and neck.
Methods
A retrospective study of patients diagnosed with HNSCC between
January 2000 and Jun 2012 was conducted in St. James’s Hospital and
Royal Victoria Eye and Ear Hospital. We aim to perform p16
immunohistochemistry, HPV DNA extraction and genotyping on all
histological samples in the future.
Results
We identified 60 patients over a period of about 12 years (2000 –
2012). 10 females and 50 males between the ages of 36 to 78 (mean
59) were reviewed. Among them, there were 17 pts with synchronous
tumours and 43 pts with metachronous tumours. We had 10 pts with
SPM in the lung, 2pt in the oesophagus and 48pts within the head and
neck region. Among the 60pts with SPM, we had 10 patients with a
third primary malignancy and 1 pt with a fourth primary malignancy.
Conclusion
No comprehensive data have been reported on the risk of SPM among
HPV-positive and HPV-negative HNSCC, although Licitra et al
observed a non-significant trend toward lower SPM risk in patients
with HPV-positive disease.
1000 - 1010
MOLECULAR PREDICTORS SHOULD BE PART OF HEAD &
NECK CANCER PROTOCOL?
Mohammad Habibullah Khan, Michael Walsh
OBJECTIVE: The accepted universal method of staging head and neck
cancer has been the TNM staging system. The main deficiency of that
system is that it does not take into account the biological markers of the
tumour. Molecular staging is now part of the accepted protocol in
breast, lung and colon cancer staging. We propose that molecular
predictors for example - P53 and EGFR should be part of head and
neck cancer protocol.
METHODS: We have undertaken a retrospective study of a cohort of
T2 laryngeal SCC patients who had failed primary chemotherapy and
radiation treatment. They all showed recurrence with the necessity for
total laryngectomies. Biopsy specimens were analysed for molecular
and genetic markers.
RESULTS: These will be discussed at meeting.
CONCLUSIONS: Although TNM classification will retain its
significance, it is now becoming possible by using molecular markers
to acquire biological information about host and tumour and eventually
to optimise the choice of treatment.
1010 - 1020
An Audit Comparing FNAC & Core Biopsy in the Management of the
Thyroid Nodule
JM Adams, M Korda
OBJECTIVE
British thyroid association 2007 thyroid cancer guidelines suggest
FNAC as the first line investigation of choice in the assessment of
thyroid lumps/goitre. Core biopsy is often used as a second line tissue
sampling technique when FNAC is inadquate or indeterminate. We
aimed to compare the two techniques as practiced in our trust with
respect to rate of sample inadequacy and/or insufficiency.
METHODS
A retrospective case review was performed of all thyroid tissue
sampling procedures trust-wide over a 6 month period. Data retrieved
included patient demographics, type and number of tissue sampling
technique, specialty & seniority of performer, results of each, further
steps in management, and eventual surgical specimen in those patient
proceeding to surgery. The rates of insufficient & inadequate samples
were calculated.
RESULTS
A total of 106 thyroid tissue sampling procedures in 86 patients were
undertaken over the 6 month period out-lined, of which were 77 FNAC
& 29 core biopsies. There were no complications recorded. The overall
rate of Thy1 FNAC (excluding Thy1c) was 26% (20/77). This dropped
to 18.5% (10.54) for USS guided FNAC. For core biopsy, the
inadequate/insufficient rate was 6.9% (2/29).
CONCLUSION
Our data suggest that USS guided core biopsy of thyroid returns
significantly lower rates of inadequate/insufficient samples. Cost
benefit analysis would be required to determine if USS guided core
biopsy may be a more appropriate first line investigation.
1020 - 1030
Risk factors for salivary fistula after total laryngectomy Basheeth.N, Sheahan.P, O’Leary.G
Objectives
To evaluate risk factors for development of pharyngocutaneous fistula
after total laryngectomy in patients with squamous cell carcinoma of
the larynx.
Methods
Retrospective chart review of patients undergoing total laryngectomy
for squamous cell carcinoma of larynx between 1996-2011 in Cork
Head and Neck Cancer Centre. Patients with pharyngeal primaries or
undergoing total pharygectomy and / or oesophagectomy were
excluded.
Results
Eighty-four patients underwent total laryngectomy during the study
period. 13 patients with hypopharynx primaries were excluded. Of the
remaining 71 patients, 27 underwent primary total laryngectomy, and
44 underwent salvage laryngectomy after failed radiotherapy (31) or
chemoradiotheray (13). 18 (25%) of patients developed a salivary
fistula. The incidence of fistula was 11.1% (3/27) in the primary
laryngectomy group, and 34.1% (15/44) in the salvage laryngectomy
group (p=0.047). Among patients undergoing salvage laryngectomy,
the interval between completion of radiation and total laryngectomy
was significantly lower in patients developing fistula than those who
did not (8.1 months versus 22.6 months, p=0.01). The likelihood of
fistula was not significantly affected by radiation dose (p=0.49);
chemotherapy concurrent with radiation (p=0.32); pre-operative
tracheostomy (p=0.72); performance of primary tracheo-oesophageal
puncture (p=0.32); performance of simultaneous bilateral neck
dissection (p=0.35); or use of pectoralis major myogenous flap (p=1.0).
Conclusion
The risk of pharyngocutaneous fistula is higher in salvage
laryngectomy than in primary laryngectomy. The interval between
completion of radiotherapy and total laryngectomy appears to be a
significant risk factor for development of pharyngocutaneous fistula in
salvage cases.
1030 - 1040
MINIMALLY
INVASIVE
PARATHYROIDECTOMY
PARATHYROID ADENOMA
CWP Kelly, CY Eng, MS Quraishi
FOR
Objective:
Parathyroid surgery is the acceptable definitive treatment for primary
hyperparathyroidism (pHPT) due to parathyroid adenoma. Minimally
Invasive Parathyroidectomy (MIP) has an excellent cure rate and
minimal morbidity. We aim to demonstrate the safety, efficacy and
subjective patient satisfaction of MIP and investigate the accuracy of
pre-operative radiological localisation in relation to operative findings.
Methods:
A retrospective case-note review of patients who underwent MIP for
pHPT due to solitary parathyroid adenoma from April 2006 to October
2011 was performed. All patients were initially investigated by an
endocrinologist to confirm pHPT with pre-operative localisation
imaging using ultrasound scan (USS) and 99mTc-sestamibi (MIBI).
Open mini-incision parathyroidectomy (O-MIP) with intra-operative
frozen section was performed in our centre.
Results:
One hundred and forty three patients were included with an average
age of 62.3 years. Pre-operative USS and MIBI scans were concordant
in 69% of cases. In combined modality (USS and MIBI), localisation
was 94.8% There was 95.5% identification of parathyroid tissue
confirmed by intra-operative frozen section.. Ninety percent of patients
were treated as a day case. The overall mean operative time was 66
minutes. The mean pre-operative calcium level was 2.98 mmol/l and
the short-to-medium term mean calcium level was 2.49 (Paired t-test,
p=0.000). There was no recurrent laryngeal nerve injury or other
significant complication.
Conclusion:
MIP confers significant advantages over the traditional gold standard
treatment of bilateral neck exploration. Accurate localisation is the key
to successful MIP. In experienced hands, ultrasound and MIBI may be
the only pre-operative investigations required for accurate localisation.
1040 - 1050
Adult Recurrent Laryngeal Papillomatosis
Fei Tan, John Russell
Objective:
Recurrent laryngeal papillomatosis (RLP) is a chronic disease of viral
etiology that occurs in both children and adults. The ultimate goal of
surgical therapy is to maintain a safe airway while avoiding excessive
scarring and maintaining useful vocal cord function. No single type of
therapy has been consistently effective in eradicating RLP. Strides are
being made in learning more about the natural history of this disease.
This audit reviews current management of RLP in St Vincent’s
University Hospital (SVUH).
Methods:
A retrospective study confined to 16 patients who first attended SVUH
ENT OPD between 01 Jan 2003 and 20 July 2012 with a histological
diagnosis of laryngeal papillomatosis. Derkay’s scoring system with
both clinical and anatomical components was used to evaluate the
severity of patient’s RLP throughout their management and follow up
in SVUH. A time curve of Derkay’s score was generated for every
patient.
Results:
Intra- and inter-patient variability are observed. This is demonstrated
on both qualitative time curves and quantitative average intervals for
surgeries (from 6.4 weeks to 5.3 years). Female patients have much
younger onset than male patients. 92% patients were happy with their
overall voice quality at the end of the audit. No malignant
transformation is discovered.
Conclusions:
Each RLP patient has a unique time pattern of disease growth, which
mandates a customized management plan.Our treatment is mainly
improving patient’s voice and function rather than for airway
urgency.Derkay’s scoring system is helpful in planning treatment.
Information from this audit is useful in consenting for surgery.
1050 - 1100
The ‘Unknown Primary’ and the impact of human papilloma virus in
metastatic squamous cell carcinoma lymph nodes.
James Paul O'Neill, Andrea Wang, Ronald Ghossein*, Luc Morris,
Snehal Patel, Jatin Shah, Dennis Kraus**
* The Department of Pathology, Memorial Sloan Kettering Cancer
Center, New York, USA
** The Department of Head and Neck Surgery, North Shore-LIJ Health
System
Objective: This analysis investigated possible associations between
HPV status, smoking history and survival outcome in patients with
neck metastasis and carcinoma of unknown primary.
Methods: Carcinoma of unknown origin diagnosed from patients
between 2002 and 2008 within MSKCC who had formalin-fixed and
paraffin-embedded metastatic lymph node samples from modified
radical neck dissections. HPV fluorescence in situ hybridization (FISH)
and p16 immunohistochemistry (p16 IHC) were performed. Results
were compared with survival, age, race, gender, tobacco use, alcohol
use, and nodal stage.
Results: Over 50% of patients ‘unknown’ primary appears to be of
oropharyngeal origin. Overall survival appeared to be superior in
patients with <10 pack-years smoking history and HPV+/p16+ disease.
Conclusions: The 'Unknown Primary' is a misnomer and more correctly
termed the 'Undiscovered Primary'. Smoking status should be
considered as a prognostic factor in patients with, along with HPV
DNA status.
1100 - 1130
Coffee Break
1130 - 1300
Free Paper Session (Rhinology)
Chairpersons : Brendan Hanna + Kieran O’Driscoll
1130 – 1140
Endoscopic Sphenopalatine Artery Ligation – a four year experience at
one institution
Eadaoin O’Cathain, Patrick Sheahan
South Infirmary Victoria University Hospital, Cork
OBJECTIVE
Epistaxis accounts for a large proportion of emergencies seen by ENT
specialists on-call. Here we discuss our experience of endoscopic
sphenopalatine artery (SPA) ligation for control over recalcitrant
epistaxis over the last four years.
METHODS
Retrospective review of case notes of patients who underwent SPA
ligation between October 2008 and September 2012.
RESULTS
27 patients underwent SPA ligation during the study period. 56% had
medical comorbidity. 26% were on anticoagulants. Three quarters of
patients had been packed multiple times prior to surgery. Seven
patients underwent concomitant septoplasty at the time of SPA ligation.
One patient underwent simultaneous anterior ethmoid artery ligation.
The SPA was controlled by electrocautery in 11% of cases, and by
surgical clips in 89%. In 4 (15%) cases, the nose was packed at the end
of surgery. 5 (18.5%) patients were re-packed after surgery with
Merocel packs due to persistent oozing. One patient returned to theatre
for anterior ethmoidal and internal maxillary artery ligation. The
success rate of SPA ligation was 78% (21/27). The average hospital
stay was 3 days. 9.5% of patients had medical complications that
required a longer hospital stay.
CONCLUSIONS
SPA ligation is an effective procedure for control of recalcitrant
epistaxis, and should be considered early in the management of
epistaxis to avoid morbidity from repeated nasal packing.
1140 - 1150
THE USE OF CT IN MANAGEMENT OF SINUS DISEASE;
DIFFERENCES BETWEEN SPECIALITIES.
C O’Rourke, S Ryan, A Rehman, JE Fenton
Objective:
The management of chronic rhinosinusitis has traditionally been the
preserve of Otolaryngologists but recently there has been an anecdotal
shift in this concept with an increasing contribution from respiratory
physicians. The aim of this study is to compare the indications, results
and outcomes of patients undergoing investigation of paranasal sinus
disease with computed tomography (CT) requested by the two separate
specialities.
Methods:
This study was a retrospective analysis of 80 CT sinus scan reports
over a two year period, which were ordered by otolaryngology (Group
1) and pulmonary (Group 2).
Results:
They were 50 female and 30 male, a ratio of 1.7:1. The most common
indicators for CT from group one were chronic sinusitis (n=16; 40%),
nasal polyps (n=10; 25%) and rhinorrhea (n=6; 15%). versus
rhinorrhea (n=16; 40%), persistent cough with post-nasal drip (PND)
(n=12; 30%) and recurrent respiratory tract infections (n=12; 30%) in
group 2. There was a significantly higher positive finding rate on CT
sinus ordered by otolaryngologists (90% v 70%; p=0.023). Group 1
also showed a significant difference in positive findings that were
directly related to indication (78% v 63%; p=0.043). The mean Lund &
Mackay score for group 1 was significantly higher than that of group 2
(8 v 4; p=0.0026)
Conclusion:
Our results show that there were significantly higher positive CT
findings, consistent with indicators used for the study, when ordered by
otolaryngologists. CT may be an overused diagnosis tool for
management of sinus disease by Pulmonary Rhinologists
1150 - 1200
SEPTAL SURGERY - THE FIRST DECADE OF SIMULATION; DO
TRAINEES FEEL APPROPRIATELY TRAINED?
S Gupta BSc MBBS MRCS, P S Phillips FRCS, F Salim, C Hopkins
FRCS, R Oakley FDSRCS FRCS (Orl-HNS) PG Cert Med
Objectives
The proportion of trainees in training reporting feeling appropriately
trained when performing their first solo septoplasty, a core ENT
procedure, in 2001 were compared with those in 2011. The changes in
the use of simulated surgery and other training tools and their impact
on the level of trainees feeling appropriately trained were analysed.
Methods
A postal questionnaire (sent to all ENT trainees in 2001) was circulated
to all ENT registrars training in the UK in 2011 asking whether they
felt appropriately trained before their first solo septoplasty, and what
training tools they had been exposed to to simulate this operation prior
to performing it.
Results
Of 337 trainees, 222 responded (65%) as compared to 167 of 223
(74.9%) in 2001. Of these, 173 trainees had been trained solely in the
UK. 105 of these (60.7%) felt appropriately trained when performing
their first septoplasty. Exposure to training courses, cadaveric
dissections and endoscopic septoplasties had increased since 2001.
There was a significant association between feeling appropriately
trained and being trained by a rhinologist (P<0.0001), being trained in
steps (P<0.0001), attending a course (P=0.0076), seeing or doing the
dissection on a cadaver (P=0.0044, P=0.0076), and seeing flaps raised
endoscopically (P=0.0003). Watching septoplasty internet videos and
dissecting biological models was not significantly associated with
feeling appropriately trained.
Conclusions
The use of tools simulating septal surgery has become more
widespread over the last decade. The number of trainees reporting
feeling inadequately trained when performing this core ENT operation
for the first time remains disappointingly high.
1200 - 1210
ANTERIOR SKULL BASE TUMOURS : OUR EXPERIENCE
Mohammad Habibullah Khan, Peter D Lacy
OBJECTIVE: Anterior craniofacial resection has become a standard
procedure for management of lesions of the anterior skull base. During
the last few years, modifications of the classic anterior craniofacial
resection have been reported. With the introduction of endoscopic sinus
techniques and instrumentation, surgeons have begun to use
endoscopic approaches for management of anterior skull base lesions.
METHOD: A retrospective study of patients with endonasal and skull
base tumours treated in our department with endoscopic technique.
RESULTS: All the patients who underwent endoscopic approach for
skull base tumour, had a short hospital stay, no external scars, speedy
recovery, a quick return to their activities and no evidence of
recurrence, on their surveillance so far.
CONCLUSION: We propose that endoscopic approach to skull base
tumours is safe and this strategy facilitates superior visualization,
avoids craniofacial incisions, and preserves local structures. Although
we do not consider this approach a replacement for the traditional
anterior craniofacial resection, it is an important adjunct in the skull
base surgeon's armamentarium.
1210 - 1220
Nasal Septal Perforation Repair: One Surgeon's experience.
A. O'Kane, A. Kelly, D. McCaul, S. Hall
Objective
Surgical management of septal perforation is considered difficult. The
procedure can be technically challenging with a relatively poor success
rate. Numerous surgical techniques are described in the literature but
no standardized surgical protocol has been established. We present one
surgeon’s experience of septal perforation repair over a 10-year period.
Method
We performed a retrospective study of 52 patients with nasal septal
perforations who underwent surgical repair between April 2002 - April
2012. These were carried out by a single surgeon, in a single unit.
Aetiological factors, patient symptoms and perforation size were
recorded. Postoperative results were evaluated.
Results
Of the 52 patients who underwent surgery 39 had complete follow-up
and of these 88 % were found to have a successful repair. The followup period varied from a minimum of 2 weeks to a maximum of just
under 3 years with a mean follow up period of 7 months. Best results
were seen with a 5-layer closure, including an interposition cartilage
graft. No significant complications resulted from surgery.
Conclusion
This is one of the largest single centre studies of surgical septal
perforation repair performed. We describe a technique which is proven
reliable and with a high success rate.
1220 - 1230
Nasal Melanoma Pathology Reporting: Left in the Dark?
Andrew Kelly, Mr Michael Moran (BHSCT and Queen’s University
Belfast), Jacqueline A James (BHSCT and Queen’s University Belfast)
OBJECTIVES
To audit the suitability of the current Royal College of Pathologists
minimum dataset for the histopathological reporting of common skin
cancers document for mucosal melanomas.
METHODS
Patients with a diagnosis of nasal malignant melanoma were identified
for a ten-year period between 2000 and 2010. The histopathology
reports were analysed to assess their compliance with the published
Royal College of Pathologists minimum dataset for malignant
melanomas. Where possible, the report for the resection specimen was
used, as it was regarded that this form provided the most
comprehensive account of the tumour characteristics.
RESULTS
16 patients were identified who had a diagnosis of new or recurrent
nasal mucosal melanoma since the year 2000. All available
histopathology reports were reviewed for these patients, which were
compiled by one of five consultant pathologists, with joint reporting in
some cases. None of the reports included all of the criteria
recommended in the minimum dataset for the reporting of malignant
melanoma.
CONCLUSIONS
Nasal mucosal melanoma is a rare but important disease entity with
notably poor clinical outcomes. Specific aspects of the malignant
melanoma minimum dataset are inappropriate for the assessment of
mucosal tumours, and the results highlight a potential benefit of having
a minimum dataset specific to mucosal melanomas.
1230 - 1240
The Beaumont Hospital experience of the endoscopic endonasal
transsphenoidal approach to the sellar region for the resection of
pituitary lesions.
Mr. Tom Moran, Mr. Peter Lacy, Mr. Donncha O’ Brien
Objective
As a modality for the treatment of pituitary tumours, there have been
numerous refinements to the surgical approach. Pituitary surgery has
been revolutionized by the introduction of the endoscope and
minimally invasive surgery to the pituitary gland.This study aims to
compile and evaluate the outcomes of all of the minimally invasive
pituitary surgery procedures performed at our institution.
Methods
This is a retrospective evaluation of all 80 patients who have
undergone transsphenoidal hypophysectomy under the combined care
of the ENT and Neurosurgical departments of Beaumont hospital.
Patient demographics, the characteristics of the pituitary lesions and the
intraoperative and postoperative complications were compiled and
discussed.
Results
78 patients operated on over 4 years, 67% had total clearance, 24% had
subtotal clearance and 4.8 had partial clearance. 3 complications, 3.5
days post op inpatient stay. This compares favourably with similar
international studies.
Conclusion
The endoscopic endonasal transsphenoidal approach to the sellar region
for resection of pituitary lesions is a safe procedure in experienced
hands. A coordinated team approach drawing on the expertise of both
the endoscopic rhinologist and the neurosurgeon is optimal to achieve
the best outcome for the patient.
1240 - 1250
PATIENT SATISFACTION FOLLOWING MANIPULATION
UNDER ANAESTHETIC FOR NASAL FRACTURES
N Foden, C Igwe, N Mehta, T Joseph
OBJECTIVE
Nasal fractures are seen commonly in ENT urgent referral and
outpatient clinics. Closed reduction or manipulation under anaesthetic
(MUA) of a fractured nose is performed for functional or cosmetic
reasons. We sought to ascertain patient satisfaction following MUA
and determine the likelihood that further surgery would be required.
METHODS
A retrospective review of all adult patients who underwent MUA nose
for nasal fractures at a single centre over a one-year period (April
2011-March 2012) was undertaken. A structured interview was carried
out by telephone by a single interviewer.
RESULTS
97 patients underwent MUA of a fractured nose over the period.
Interviews were successfully performed with 68 (70%) patients. 68
(100%) indicated a cosmetic reason for undergoing MUA whilst 49
(72%) also reported functional reasons. 13 (19%) reported no
improvement in cosmesis following the procedure and 18 (37%) were
dissatisfied with their functional outcome. 33 (68%) would consider
further surgery, of which 18 (26%) had already sought further advice
regarding this.
CONCLUSIONS
Although MUA for a fractured nose is an acceptable treatment in the
first instance we found a number of patients to be dissatisfied. A
substantial number would consider revision surgery. This has important
consequences for funding in an economic environment where access to
a number of procedures, including septorhinoplasty, are being scaled
back. It is essential that all patients undergoing MUA following a nasal
fracture are informed that the procedure may not result in a favourable
outcome and that revision surgery may be required at a later stage.
1250 - 1300
ADENOIDECTOMY:
ASSESSING
THE
TECHNIQUES AND COMPLICATIONS
R Caffrey, A McGreevy, C Jackson, C Scally
INDICATIONS,
Objectives
Adenoidectomy is a common surgical procedure in children and
currently there are no national guidelines on its indications. We audited
adenoidectomy practice in our local unit, which included indications,
method and complications.
Methods
Retrospective case note review of patients listed for adenoidectomy
over a one year period in a district general hospital.
Results
178 patients were included, of whom 134 (75.3%) underwent
adenoidectomy. The majority (127) (94.8%) performed by curettage.
The commonest presenting complaint was recurrent tonsillitis, and in
28 patients this was the only documented symptom. This was followed
by glue ear symptoms, nasal symptoms, snoring and various others.
The overall complication rate was 6.7%, with adenoidal bleeding
occurring in one patient (0.7%).
Conclusion
Adenoidectomy is a frequently performed procedure with a low
complication rate. This study does highlight a varied approach to
indications for adenoidectomy. We present our adenoidectomy
guidelines, which we hope will improve the consistency of patient care.
1300 - 1400
Lunch
1400 - 1420
Annual General Meeting
1420 - 1530
CME - Frontiers in endoscopy
Chairpersons : Robin Adair + Nash Patil
Sinus endoscope optics research do you know where you are looking?
- Paul White
An update on sialendoscopy
- Aongus Curran
Challenges for the rhinologist and skull base surgeon
- Brendan Hanna
1530 - 1600
Coffee Break (Poster Adjudication - Cate Scally + Marcus Choo)
1600 - 1700
Free Paper Session (Otology)
Chairpersons : Ted McNaboe + Mary Bresnihan
1600 - 1610
MASTOID SURGERY IN AN ONLY OR BETTER HEARING EAR
M. Sadadcharam, R. McConn-Walsh
Objective
The patient with cholesteatoma in an only or better hearing ear presents
a management dilemma. The aim of surgery is to remove disease
entirely and preserve or indeed improve hearing
Methods
This was undertaken as a retrospective study in conducted in a
university-based tertiary referral centre. Our experience with surgical
management of twenty patients with cholesteatoma in an only or better
hearing ear is presented. The location and extent of cholesteatoma, the
type of operation performed, and post-operative hearing results are
presented
Results
Throughout our series, there was no documented loss of bone
conduction thresholds and the hearing in all patients was either
preserved or improved
Conclusions
The present series confirms that hearing can be preserved or indeed
improved in patients undergoing mastoid surgery in an only or better
hearing ear. This should be undertaken in a tertiary referral centre
1610 - 1620
OUTCOMES OF OSSICULOPLASTY IN THE PAEDIATRIC
POPULATION
TS Ahmed, N Seymour, H Daya
OBJECTIVE
Although most ossiculoplasties are performed in adults, the procedure
is occasionally performed in children. Ossiculoplasty is considered
successful if useful hearing is restored. This can be determined both
subjectively and objectively. This study aims to investigate clinical
outcomes following paediatric ossiculoplasty and identify factors
predicting hearing results.
METHODS
All children undergoing ossiculoplasty between 2001 and 2011 at our
hospital were identified from clinical coding databases. A retrospective
chart review was performed and data including operative findings, type
of prosthesis used and pre and post-operative pure tone audiometric
thresholds were extracted.
RESULTS
Twenty-two children (mean age 10.8, range 3-18) underwent 28
ossiculoplasty procedures. The majority had undergone treatment for
cholesteatoma. Thirteen individuals were fitted with a total ossicular
replacement prosthesis (TORP) and 9 were fitted with a partial
ossicular replacement prosthesis (PORP). Seventeen ossiculoplasties
(60.7%) resulted in hearing improvement with a mean of 5.5 dB (SD
14.1 dB): in 15 (89%) this improvement was deemed to be ‘useful’ as
assessed with the Glasgow benefit plot. Three ossiculoplasties (10.7%)
resulted in no hearing change and 8 procedures (28.6%) resulted in
audiometric threshold worsening, of which recurrent cholesteatoma
was present in 4 cases.
CONCLUSIONS
Ossicular reconstruction following tympanomastoid surgery is helpful
in improving hearing outcomes. Patients undergoing reconstruction
with a PORP, where the stapes suprastructure was preserved, were
more likely to have an improvement. There is also some association
between cholesteatoma recurrence and poorer hearing outcomes in this
series: these patients were more likely to require TORP prostheses and
undergo revision ossiculoplasty.
1620 - 1630
The development of an accelerometer based biofeedback device
for the management of BPPV
F O’Duffy and T O’ Connor 1, P Breen2, D O’ Keefe1, G O’ Laighin2.
Keogh I. J.1
1.
Academic Department of Oto-Rhino-Laryngology, Head & Neck
Surgery, National University of Ireland, Galway, Ireland.
2.
School of Engineering & Informatics, National University of
Ireland Galway, University Road, Galway, Ireland.
Background:
The management of posterior semicircular canal Benign Paroxysmal
Positional Vertigo (BPPV) has been revolutionised by the Epley
manoeuvre. This manoeuvre provides immediate relief from symptoms
of BPPV in up to 90% cases. However, many cases still relapse,
requiring repeated manoeuvres. It is our view that there is potential to
develop a head worn accelerometer based bio feedback device for the
management of BPPV.
The aim of our study was twofold. Firstly to develop and modify, using
existing accelerometer framework, a device for the measurement of
real-time angular changes which occur during vestibular manoeuvres,
Head Position Recording Device (HPRD). Secondly, to compare using
the HPRD the angular accuracy obtained in performing a Clinician
guided Epley manoeuvre against the angular accuracy obtained by
using a home treatment device “Dizzy-Fix”.
Study Design:
The accelerometer device chosen as the basic framework for the
development of the HPRD was the SHIMMER™, a wearable, wireless
health sensing platform. The SHIMMER™ device can record and
transmit physiological and kinematic data in real-time.
Software used for data collection and interpretation was the Eyesweb
Open Platform package. With the merging of the SHIMMER™ device
for data collection and the Eyesweb open frame software for data
processing, an early prototype of the HPRD was produced.
The HPRD was worn by 10 healthy subjects who underwent clinician
guided bilateral Epleys manoeuvres. They also wore the device for
bilateral self performed Epleys manoeuvres using Dizzyfix.
Results:
Our results demonstrate the highly-accurate angular measurement and
orientation capabilities of the head worn HPRD, developed at our
institution. We identified a greater degree of accuracy in the Dizzy-Fix
guided Epley manoeuvre group, over the Clinician-guided manoeuvre.
Conclusions:
This study highlights the potential of a novel technology, HPRD in the
future management of BPPV. Using the HPRD our study has
established that the commercially available device; Dizzyfix, achieves
greater angular accuracy in the performance of a PRM over the
traditional Clinician-guided manoeuvre.
1630 - 1640
TRANS CANAL CONCHAL
MYRINGOPLASTY- AN AUDIT
CB Heffernan, BJ Conlon
CARTILAGE
UNDERLAY
OBJECTIVES
The senior surgeon utilises a trans canal conchal cartilage underlay
myringoplasty technique for small dry posterior tympanic membrane
perforations. The cartilage is sized and then tabs fashioned around the
edge of it to allow easier insertion through the perforation while
preventing it falling out of the middle ear. Our aim is to audit all
patients who underwent this procedure in our institution over the past
six years.
METHODS
Patients who underwent all types of tympanoplasty were identified
from theatre logbooks and the HIPE system. A chart review then
isolated those patients who had this specific procedure. Post-operative
audiograms and otoscopic photographs were reviewed.
RESULTS
10 patients were identified. These patients were chosen based on the
fact they had isolated dry tympanic membrane perforations with no
mucosal disease. All patients tolerated the procedure well with no early
post-operative complications. At the three-month post-operative clinic
follow-up all patients had intact tympanic membranes and no
deterioration in their audiograms.
CONCLUSIONS
This method of preparing the cartilage graft is innovative and effective.
Trans canal conchal cartilage underlay myringoplasty is a useful
procedure for patients with dry central tympanic membrane
perforations especially those with multiple comorbidities. . As there is
no need for a post auricular incision or tympanomeatal flap it lends
itself to a shorter operation, smaller scars and quicker recovery but with
high success rate.
1640 - 1650
PETROUS APEX LESIONS; THE EXPERIENCE OF A NEUROOTOLOGY AND SKULL BASE MDM
M. Sadadcharam, M. Javadpour, D. Rawluk, R. McConn-Walsh
Objective
The petrous apex is a relatively inaccessible region of the medial skull
base surrounded by a number of important vascular and neural
structures. Lesions arising in or spreading to the petrous apex cause
varied and occasionally severe clinical sequelae, which typically result
from mass effect or direct invasion of the cranial nerves, brainstem, or
internal carotid artery. Because it is relatively inaccessible, the petrous
apex is not amenable to direct examination. As such, imaging with CT
and MRI plays an important role in diagnosis and characterization of
lesions occurring there.
Methods
A retrospective study conducted in a university-based tertiary referral
centre
Results
Fifty one patients with various petrous apex pathologies were
reviewed. The most common presenting symptoms were hearing loss,
dizziness, headaches, and tinnitus. The commonest lesions were
petrous apex cholesteatomas, cholesterol cysts and metastatic lesions.
The differentiating radiologic features of each were noted. Asymmetric
pneumatisation, retained secretions and marrow gave radiographic
findings commonly over-diagnosed as lesions of the petrous apex
Conclusions
Lesions of the petrous apex can be diagnosed accurately by CT and
MRI. Where possible, both imaging modalities should be obtained as
they provide complimentary information. If only one imaging modality
is available, the preference should be for MRI (T1, T2 and T1 with
gadolinium enhancement).
1650 - 1700
AUDIT OF AETIOLOGY OF GENETIC HEARING LOSS IN
CHILDREN WHO A RECEIVED COCHLEAR IMPLANT
BETWEEN JANUARY 2006- DECEMBER 2011
Doyle S., Leonard J., Viani L.
Objective:
The BAAP published comprehensive guidelines in 2009 which looked
at the investigation of children with profound sensorineural hearing
loss. Using these recommendations we performed an audit to look at
aetiological investigations performed on children who received a
cochlear implant between 2006 and 2011 at the National Cochlear
Implant unit.
Methods:
58 patient histories were reviewed.
Data was retrieved from clinic and inpatient notes, correspondences
and results stored in the charts.
Results:
7 children had a diagnosis at the time of referral. 2 children were from
consanguineous relationships.
Of the 51 remaining children 38 (74%) were referred to genetics, 19 of
the 58 had a family history of hearing loss, 39 did not.
21 of the children had specific aetiological investigations.
35 (60%) were referred to ophthalmology for assessment of suspected
syndromes.
10 (17.2%) children had an ECG performed to rule out specific
potential associated cardiac anomalies.
Conclusion:
Of the 58 children, there was a high rate of referral to genetics and
Ophthalmology.
A comprehensive guideline is needed for investigating these children.
This has been implemented since March 2012 with the introduction of
a clinic to formally investigate these children.
The guidelines and protocols for investigation of suspected genetic
hearing loss are described but we plan to develop guidelines to look
and genetic and non- genetic causes of sensorineural hearing loss.
1900 - 2000
Drinks Reception
2000 - 2230
Wilde Discourse: Mr. Richard Canter (Bath, UK)
followed by:
Gala Dinner (Black Tie) / President’s speech
Saturday 6th October
0730 - 0900
Registration
0900 - 1100
Free Paper Session (Paediatric + General + Head / Neck)
Chairpersons : Turlough Farnan + Peter Walshe
0900 - 0910
BOTOX: A WRINKLE FREE APPROACH TO MANAGING
DROOLING
K. Davies, T. O Dwyer
Objective:
1. To evaluate the efficacy of submandibular botox injections in the
management of sialorrhoea
2. Assess its role in the long-term management of this condition.
Methods:
Retrospective review of a paediatric patient population with sialorrhoea
treated by injection orowf Botox® into the submandibular salivary
glands between 2005 and 2012. Efficacy and long term effect was
evaluated with a pre and post procedure parental quality of life
questionnaire.
Results
73 injections were performed in 35 patients aged two to 21 years with a
beneficial effect in 75% of cases. Three patients developed significant
swallowing difficulties requiring NG feeding. Other minor
complications included four patients noticing a change in the
consistency of secretions. Long-term cure was achieved in 16 cases.
The most effective protocol was injection of 50 units of botulinum
toxin into each submandibular gland under ultrasound guidance.
Conclusion
The treatment of sialorrhoea by Botox® injections into the
submandibular salivary glands is an effective and repeatable procedure.
It plays a vital role in the management algorithm of sialorrhoea at our
institution. Our results, complications and management will be
discussed.
0910 - 0920
SURGICAL MANAGEMENT OF OTITIS MEDIA
EFFUSION (OME) IN BELFAST TRUST, 2011-2012
N McCay, F Toner, K Trimble
WITH
OBJECTIVE
Assess current practice against the recommendations of NICE CG60
guidelines on indications for surgical management of OME in children.
METHODS
Retrospective chart review of all children under 7 years of age having
insertion of ventilator tubes between September 2011 and March 2012.
RESULTS
107 children had surgery during the 6 month period with clinical
history and examination involving general developmental status in
64%, general upper respiratory health in 74.5% and otoscopy in 98% of
cases.
Hearing testing was performed in 76.6% of cases and tympanometry in
97%. 67% of children had a documented 3 month persistence of
bilateral OME and 45% had a hearing level of 25-30 dB or worse in the
better ear.
CONCLUSIONS
Based on information recorded in patient charts 55% of children
undergoing surgery for bilateral OME did not meet the NICE
guidelines for intervention and 35.4% of children had not had hearing
tested prior to surgery.
0920 - 0930
Audiological And Otological Outcomes In Children With A History Of
Cleft Palate
A. Doyle, P Roche, A. McGillivary, M. Earley, A. Blayney
OBJECTIVE: To document the audiological and otological outcomes
of a cleft palate cohort, and to review trends in the patterns of hearing
loss and middle ear pathology. To establish the differences in outcomes
based on severity of cleft.
METHODS: A retrospective review of 166 cases of cleft palate with or
without cleft lip was performed. The initial and final 4-point audiogram
on the hospital chart was recorded, along with corresponding
tympanogram and E.N.T surgical data.
RESULTS: Of the 166 cases identified on the cleft database, 103
patients (51 females and 52 males) were eligible for inclusion. The
mean age at final audiogram was 10.3 years. The majority of this
cohort had cleft of the secondary palate (n=29). 55.3% patients were
found to have normal hearing bilaterally at their last audiogram (n=57).
No patients were found to have severe or profound hearing loss. 15.5%
of patients had used at least one hearing device at some point in their
care, (n=16).
CONCLUSIONS: The severity of the middle ear disease experienced
by our patients appeared to be related to the degree of tissue loss seen
with the various cleft classifications but despite variation amongst the
cohort, the majority had a normal final audiogram.
0930 - 0940
PAEDIATRIC AIRWAY CLINIC: THE EVER-EVOLVING
DIVERSIFICATION OF ITS ROLE
D Fitzgerald, H Rowley
Department of Otolaryngology, Head and Neck Surgery
Temple Street Children's University Hospital, Dublin 1
OBJECTIVES:
To assess the evolution of the role of the paediatric neck and airway
clinic, at The Children’s University Hospital, Temple Street, in the
context of an increasingly varied neonatal and paediatric population.
METHODS:
A retrospective review was conducted of attendances at the clinic, over
a ten year period, with a view to assessing case load and changing
complexity. Referral patterns, presenting complaints and related
diagnoses were correlated with clinical findings and outcomes, and
surgical requirements.
FINDINGS:
In the initial years, management of relatively non-complex problems
such as laryngomalacia, or the monitoring of children with
tracheostomies, comprised the majority of cases. More recently, in
particular in the past two years, there has been a marked increase in the
complexity of our patients, correlating with the acquisition of new
subspecialties linked to our centre. In addition to referring specialties
already well-established, such as the Cleft Palate Clinic, we now
collaborate with the Paediatric Transplant team, Craniofcial Unit,
Maxillofacial and Neurosurgeons, amongst others.
CONCLUSIONS:
The Paediatric Airway Clinic now has a very diverse patient
population, necessitating evolution of the service to provide ever more
specialised expertise, in order to deal with new clinical challenges
presenting themselves on an increasingly frequent basis. The provision
of services to newly emerging subspecialties has lead to non-complex
patients having to wait significantly longer for initial assessment.
0940 - 0950
MANAGEMENT OF THE OTOLARYNGOLOGIC FEATURES OF
RARE CRANIOFACIAL SYNDROMES
CB Heffernan , DJ Murray, H Rowley
OBJECTIVES
Our otolaryngology department works closely with the national
craniofacial service. Craniofacial syndromes have numerous
otolaryngology features due to their common embryological origin.
Our department previously looked at the most common craniofacial
syndrome which is Pierre Robin. Now we are auditing the rarer
syndromes that we encounter such as Apert’s, Pfeiffer’s and
Crouzon’s. We aim to give an overview of our involvement in the
management of these rare syndromes.
METHODS
The craniofacial surgery department has a database of all their patients.
We have retrospectively reviewed this database to identify those who
required input from the otolaryngology department. We cross
referenced this data with that from our airway database and the HIPE
service. The patients with Pierre Robin were excluded. We reviewed
the patients’ cases notes and our airway database.
RESULTS
Thirty patients were identified who presented to this department
between 1990 and 2011. These patients had seven different syndromes
with Crouzon’s being the most common. Data regarding airway
management and hearing difficulties was collected. The most common
procedures required were tracheostomy, choanal dilatation and
ventilation tube insertion. All patients were followed until sixteen years
of age after which they were transferred to adult services.
CONCLUSION
Craniofacial syndromes though complex can have excellent outcomes
if managed in a multidisciplinary setting. Thorough airway assessment
and management is the most important initial step. Also early
audiological assessment is essential to prevent speech and language
delay.
0950 - 1000
GUIDELINES FOR THE INVESTIGATION AND MANAGEMENT
OF HAEMANGIOMA OF THE HEAD AND NECK
E Phelan, K Davies, P Lenane, H Rowley
Objectives:
1.
Review the current investigations and management of
paediatric head and neck haemangiomas
2.
Highlight the role of the paediatric ENT surgeon as part
of the multidisciplinary team approach in the management of this
condition
Methods:
Retrospective chart review of all paediatric head and neck
haemangioma patients presenting to or referred to the ENT outpatients.
Results:
Over forty children with head and neck haemangiomas over a 2 year
period were indentified. The management protocol including
indications for imaging, imaging type and other preliminary
investigations were reviwed. Current indications for use of propanolol
in each case was also analyzed.
Conclusion:
The investigations and management of head and neck haemangiomas
has changed in the last number of years, however the paediatric ENT
surgeon remains a crucial member of the multidisciplinary approach in
the management of these difficult cases.
1000 - 1010
Improving Care For Thyroid Cancer Patients
Phoebe Roche, James Paul O Neill, Siobhan Mc Quaid, Tadgh O
Dwyer, Helena Rowley
Department of Otolaryngology Head and Neck Surgery, Mater
Hospital
INTRODUCTION & OBJECTIVES: The incidence of thyroid
carcinoma is now triple that of thirty years ago, and with approximately
56000 predicted cases in the US alone in 2012, it is now widely
recognized as the fastest rising human cancer in the world. The aim of
this study to examine the impact of recent changes we have made in the
management of thyroid cancer patients in our department .
METHODS: A review of the recently established protocols, guidelines
and identified caseload of the Combined Thyroid MDT is performed
and the impact of the establishment of a comprehensive thyroid cancer
database and dedicated thyroid cancer clinic on patient care is
evaluated.
RESULTS: In total, sixty-five patients were treated for thyroid cancer
between July 2007 and July 2012 across a variety of specialties at the
Mater Hospital. Well-differentiated carcinoma accounted for
approximately 89%, and females’ outnumbered males by over 2:1.
New protocols and guidelines have been generated through the recently
established MDT and the Endocrinology-Otolaryngology clinic with a
view to improving future outcomes.
CONCLUSION: Increasingly, patients with thyroid cancer are being
referred to the Head and Neck Surgeon. We advocate a
multidisciplinary approach, as it enables accurate stratification of
patients, and effective implementation of evidence-based care in our
practice.
1010 - 1020
IS SYSTEMATIC IDENTIFICATION OF ALL 4 PARATHYROID
GLANDS NECESSARY DURING TOTAL THYROIDECTOMY? A
PROSPECTIVE STUDY
Rania Mehanna MB, Naveed Basheeth MB, Matthew S Murphy MB
MRCPI*, Patrick Sheahan MD FRCSI (ORL-HNS) (corresponding
author)
Department of Otolaryngology – Head & Neck Surgery and
*Department of Endocrinology
South Infirmary Victoria University Hospital, Cork, Ireland
Introduction:
Routine identification of all 4 parathyroid glands has been advocated as
a means of reducing rates of postoperative hypocalcaemia and
inadvertent parathyroidectomy. The object of the present study was to
investigate whether identification of more parathyroid glands during
thyroidectomy performed by capsular dissection technique had any
impact on incidence of postoperative hypocalcaemia and unintentional
parathyroid resection.
Study Design:
Prospective cohort study of consecutive patients undergoing total
thyroidectomy by capsular dissection technique over a 3-year period.
Exclusion criteria included performance of concomitant central neck
dissection; hyperparathyroidism; revision surgery; and invasive cancer.
Methods:
The number of parathyroid glands identified intraoperatively was
recorded. No effort was made to find glands that were not obviously
apparent during the course of dissection. Patients were not placed on
routine calcium supplementation.
Results:
The final study population consisted of 126 patients. The mean number
of parathyroid glands identified was 2.3. The incidence of biochemical
(any postoperative calcium < 2 mmol/L) and clinical hypocalcaemia
was 22.2% and 10.3%, respectively. Patients in Group A (0-2
parathyroids identified) had a significantly lower incidence of clinical
hypocalcaemia than patients in Group B (3-4 parathyroids identified)
(3.2% versus 17.1%) (p=0.02). The differences in biochemical
hypocalcaemia were not significant (16.1% versus 28.1%, p=0.13). The
incidence of inadvertent parathyroidectomy was 9.5%. There was no
difference between the groups in incidence of inadvertent
parathyroidectomy (9.7% versus 9.4%, p=1.0).
Conclusions:
Routine identification of all 4 parathyroid glands is not necessary in
thyroidectomy performed using capsular dissection technique.
1020 - 1030
AUDIT OF INCLUSION CRITERIA FOR TONSILLECTOMY
G Ferguson, PR Bell, SJ Hall
OBJECTIVE: Tonsillectomy is one of the most common operations
performed worldwide, but it is not without risk. Evidence-based
guidelines exist to aid clinicians in identifying patients who would
benefit from surgery. An audit was conducted to assess the inclusion
criteria used in selecting patients for tonsillectomy.
METHOD: 100 sets of patient notes were randomly selected for
patients undergoing tonsillectomy in the preceding 12-month period.
The outpatient notes were scrutinized including assessment of the
general practitioners referral letter, the consultation note and final
clinic letter. The inclusion criteria used for selecting patients for
tonsillectomy were compared with existing national guidelines.
RESULTS: Seventy-seven percent of patients who underwent
tonsillectomy met the inclusion criteria outlined by at least one of the
nationally used guidelines. Eleven percent of those undergoing
tonsillectomy had other indications including symptoms of upperairway obstruction associated with tonsillar hypertrophy that are not
included in national guidelines. The remaining twelve percent of
patients did not have sufficient information documented in either the
general practitioners referral letter or the clinic notes to adequately
assess the decision for surgery.
CONCLUSION: Suitability of tonsillectomy should be determined by
clinicians based on what is appropriate for each individual patient. We
recommend that departmental guidelines are regularly reviewed to
improve cost-effectiveness and to ensure the highest levels of patientsafety are achieved. We also recommend the provision of departmental
guidelines to local general practitioners to ensure patients are not
inappropriately referred to the Otorhinolaryngology service.
1030 - 1040
Improving tracheostomy decannulation in recalcitrant cases using the
comprehensive dynamic airway assessment (CDAA)
T. Ashfield 1, B. Shephard 2, D. Chatterjee 2, L. Clark 3, I. Ahmad 2,
R. Oakley 1
Department of head and neck surgery 1, Department of anaesthesia 2,
Guy’s Hospital, Department of speech and language therapy 3, King’s
College Hospital, London, UK
Objectives
Prolonged tracheostomy is associated with morbidity, mortality and
increased length of stay. Fibre-optic endoscopy (FE) is advocated for
such cases but is limited to the supraglottic airway. Anaesthetists
commonly perform fibre-optic intubation under local anaesthesia.
CDAA introduces this method to the ward setting, allowing conscious
assessment of the entire upper airway. CDAA been performed in cases
of failed tracheostomy decannulation, enabling decannulation under
direct vision if appropriate.
Methods
FE is used to assess the entire supra- and sub-glottic airway including
dynamic cord function. Through video presentation we demonstrate the
following procedure. Co-phenylcaine is administered to the nasal
cavity and atomised 4% Lidocaine to the laryngopharyngeal mucosa.
Pulse oximetry is used and no sedative agents are given. CDAA is
performed after 15 minutes and a diagnosis for failed decannulation
can be made or refuted. The tracheostomy can be decannulated under
direct vision if indicated.
Results
Outcomes of 213 post critical-care tracheostomised patients were
audited from April 2009-April 2012. Twenty-seven(13%) patients
failed decannulation due to reduced airflow. Of these, 23 underwent
conventional review and FE which yielded a 17%(4) decannulation
rate; 2 of the remainder subsequently died with tracheostomy in-situ.
Since its inception in August 2011, 8 patients have undergone CDAA
with a 75%(6) in-procedure decannulation rate.
Discussion
CDAA has been successfully applied to a heterogeneous group. It is a
significant development in improving outcomes for patients with
complex tracheostomies. It requires minimal resource, is versatile and
exploits skills available to the otolaryngologist. CDAA could form an
integral part of all decannulation protocols.
1040 - 1050
The Robotic Head and Neck Surgeon
James Paul O’Neill, Dennis Kraus
Memorial Sloan Kettering Cancer Center
New York, USA
Abstract:
Introduction: Transoral robotic surgery (TORS) provides access to the
oral cavity, oropharynx, hypopharynx, larynx, parapharyngeal space
and skull base vial the oral aperture.
Methods: We performed a variety of TORS manoeuvres over 2011
within our department. These included robotic platform operational
skills, set up of the patient side system, and extirpation of malignant
tumours of the oral cavity and laryngopharynx on 15 patients. We then
recorded the operative and post-operative course of these patients.
Results: 14 patients had successful oncological resection of their
tumours without positive margins. The robotic laryngectomy was
abandoned and converted to an open standard technique. Post operative
morbidity included secondary haemorrhage and a temporary
tracheostomy on 2 patients.
Conclusions: Experienced clinical judgment, surgical skills, and
oncologic principles are necessary for the needs of the individual
cancer patient A learning platform exists for robotic surgical
techniques. We would encourage the IOS to embrace Robotics and
introduce these novel techniques for Otolaryngology, Head and Neck
Surgical trainees.
1050 - 1100
Novel Strategies In The Management Of Anaplastic Thyroid
Carcinoma
A Dias, M Alhashemi, ER Dorris, P Smyth, M Flanagan, V
McEneaney, J O’Leary, O Sheils
Introduction
Thyroid carcinoma is the most common endocrine malignancy.
Papillary thyroid carcinoma(PTC) is the most common type of thyroid
cancers. Current treatment strategy is based on surgical removal of the
thyroid gland with adjuvant radioiodine ablation of remnant cancer
cells. BRAFV600E mutation is a common mutation found in PTC and
poorly differentiated anaplastic thyroid carcinoma(ATC). BRAFV600E
mutation causes activation of the Mitogen-activated Protein
Kinase(MAPK)/Extracellular signal-regulated kinase(ERK) signaling
pathway, causing tumorigenic transformation of the cell. This
constitutive activation causes a downregulation of iodine-metabolizing
genes(TSHR) in the thyroid tumor cells leading to loss of radioiodine
avidity, rendering treatment ineffective.
Aim
To evaluate the expression of Thyroid stimulating hormone
receptor(TSHR) in an anaplastic thyroid cancer cell line carrying
BRAFV600E mutation and to investigate the effect of MEK inhibition
on TSHR expression by suppressing the MAPK/ERK pathway using
the selective MEK inhibitor PD0325901.
Method
The new generation slective MEK inhibitor PD0325901 was used to
block the MAPK/ERK pathway in an anaplastic thyroid carcinoma cell
line carrying BRAFV600E mutation and a normal transformed cell
line. TSHR expression was assessed using TaqMan RT-PCR and
immunofluorescence confocal imaging.
1100 - 1130
Coffee Break
1130 - 1300
CME Session
Chairpersons : Greg McBride + Martin Donnelly
1130 - 1200
Guest Lecture
Paediatric DCR - Paul White
1200 - 1230
The IOS Debate : Day Case Tonsillectomy
Joe Toner, Belfast (for) / Helena Rowley, Dublin (against)
1230 - 1300
Current Training in ORL
Richard Canter (UK) / Michael Walsh (Ireland)
1300 - 1330
Closing Speech
Best Paper Prize (Sponsored by Tekno Surgical)
Best Poster Prize
1330 - 1430
Luncheon Meeting - Irish Institute of Otolaryngology
Notes for paper presenters:
Each talk has been allocated ten minutes - eight for delivery and two for
questions/discussions. A bell will sound at the end of eight minutes, and again at nine.
There is a best paper prize, and points will be deducted for exceeding your time. In order
to ensure a smooth changeover between talks, we suggest you send us your presentation in
slide format to info@iosconference.org at the earliest. You will always receive an
acknowledgement. If you do not, it means that your slides have not transmitted
successfully. Please note that anyone who sends on their presentation must also bring a
copy of it to the meeting.
The person in charge of audio-visual facilities at the conference is Ollie O’Flanagan. If
you have specific queries regarding format, video-clips, Apple Macs, etc., do contact him
at ooflanagan@rcsi.ie immediately (his mobile number should you need it is 00 353 87
9672013). Anyone wishing to use an Apple Mac must bring along the VGA conversion
dongle that comes with the Mac.
Mr. Flanagan will be available to load slides at the venue on Thursday 4 October between
6 pm and 7.30 pm, and again on Friday / Saturday mornings between 8 am and 9 am; and
during refreshment breaks on each of these two days. Please ensure you meet up with him
and give him your slides well in advance of your slot. It will not be possible to do this at
other times, and especially not at the start of your presentation.
The best paper will be announced at the end of the conference on Saturday afternoon.
Notes for poster presenters:
Please ensure your poster is put up by 9 am on Friday 5 October. The judges will visit the
display later that day during the second coffee break (3.30 to 4 pm) and may wish to speak
to you regarding your material - you should be available at the poster at this time to give a
short presentation (max. three minutes) should you be required.
The best poster prize will be announced at the end of the conference on Saturday
afternoon, and attracts a prize.
Trade Exhibition
Allergy Therapeutics plc.
Arthrocare
Audico Limited
Baxter Healthcare Ltd.
Cochlear Europe Ltd
Covidien Ireland Commercial Ltd
Endosurgical Ltd
Fannin Limited
HC21 Healthcare
Irish Hospital Supplies Ltd.
Johnson & Johnson Medical Ireland
Meda Health Sales
Medserv Limited
Medtronic Ltd.
A. Menarini
MSD Ireland Ltd
Murray Surgical Ltd.
NeilMed European Division
Omega Financial Management
Pharmed Holdings Limited
Radiesse Voice
Sword Medical
Synthes Medical Ireland
Tekno Surgical
Vista Pharmaceuticals