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OBJECTIVE: The World Health Organization 'Surgical Safety Checklist' has been adopted by UK surgical units following National Patient Safety Agency guidance. Our aim was to assess compliance with our local version of this Checklist. METHODS: Otolaryngology trainee doctors prospectively assessed compliance with the local Checklist over a six-week period. A staff educational intervention was implemented and the audit was repeated 12 months later. RESULTS: A total of 72 cases were assessed. The initial audit found that: 44 per cent of procedures were undocumented at 'Sign in'; 'Time out' was inappropriately interrupted in 39 per cent of cases; the procedure started before Checklist completion in 33 per cent of cases; and the 'Sign out' was not read out in 94 per cent of cases and was not fully documented in 42 per cent of cases. Following education, re-audit indicated that overall compliance had improved from 63.7 per cent (± 8.9 per cent standard error of the mean) to 90.4 per cent (± 2.7 per cent standard error of the mean). CONCLUSION: Our completed audit cycle demonstrated a significant improvement in Checklist compliance following educational intervention. We discuss barriers to compliance, as well as strategies for quality improvement, and we call for other surgeons to similarly publish their Checklist experience and assess its impact on surgical outcomes.

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BACKGROUND: The hoarse voice is a common presentation in the adult ENT clinic. It is estimated that otolaryngology/voice clinics receive over 50 000 patients with dysphonia each year. Good vocal function is estimated to be required for around 1/3 of the labour force to fulfil their job requirements. The assessment and management of the patient with a hoarse voice is potentially a complex and protracted process as the aetiology is often multi-factorial. This article provides a guide for the clinician in the general ENT clinic to make a concise, thorough assessment of the hoarse patient and engage in an evidence based approach to investigation and management. METHOD: Literature search performed on 4 October 2008 using EMBASE, MEDLINE, Cochrane databases using subject headings hoarse voice or dysphonia in combination with diagnosis, management, investigation, treatment, intervention and surgery. RESULTS: General vocal hygiene is beneficial for non organic dysphonia but the evidence base for individual components is poor. There is a good evidence base for the use of voice therapy as first line treatment of organic dysphonia such as vocal fold nodules and polyps. There is little evidence for surgical intervention as first line therapy for most common benign vocal fold lesions. Surgery is, however, the treatment of choice for hoarseness due to papillomatosis. Both CO(2) laser and microdissection are equally acceptable modalities for surgical resection of common benign vocal fold lesions. Laryngopharyngeal reflux is commonly cited as a cause of hoarseness but the evidence base for treatment with gastric acid suppression is poor. Despite the widespread use of proton pump inhibitors for treating laryngopharyngeal reflux, there is high quality evidence to suggest that they are no more effective than placebo. CONCLUSION: A concise and thorough approach to assessment in the general ENT clinic will provide the diagnosis and facilitate the management of the hoarse voice in the majority of cases. Voice therapy is an important tool that should be utilised in the general ENT clinic and should not be restricted to the specialist voice clinic. If there is no improvement after initial measures, the larynx appears normal and/or the patient has failed initial speech & language therapy, referral to a specialist voice clinic may be helpful. More research is still required particularly with regard to laryngopharyngeal reflux which is often cited as an important cause of hoarseness but is still poorly understood.

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INTRODUCTION: Due to problems with long waiting times for assessment of vertiginous patients (more than 24 weeks), we changed practice and instituted a pre-ENT balance clinic assessment; we then audited the results. In particular, we looked at the subgroup with benign positional paroxysmal vertigo. METHODS: One hundred and fifteen patients were seen at the pre-ENT balance clinic from October 2003 to September 2004. Those diagnosed with benign positional paroxysmal vertigo received particle repositioning therapy at the same clinic and did not subsequently need ENT assessment. RESULTS: By the end of the audit period, waiting times were reduced to three weeks, and more than one-quarter of vertiginous patients (i.e. those diagnosed with benign positional paroxysmal vertigo) did not need to be reviewed at an ENT clinic. CONCLUSION: We believe this to be the first study to present prospective data showing that patients with benign positional paroxysmal vertigo may be safely diagnosed and effectively managed at a pre-ENT balance clinic.

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Sebaceous carcinoma of the nose is rare. Here the authors present a case of a 71-year-old man who presented with a mass in the right nasal vestibule. This was removed and a nasolabial flap used to reconstruct the defect. Histology revealed a sebaceous carcinoma. At follow-up, three months later, a new lesion had appeared in the opposite nostril which when removed proved to be a second sebaceous carcinoma. This multi-focal presentation in the nose has not been described in the literature before.

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We report the case of a 57-year-old patient with a presumed developmental anomaly of the medial orbital wall. The resultant protrusion of orbital contents into the ethmoidal complex was clearly demonstrated on coronal computed tomography (CT) scans of the paranasal sinuses. This anomaly presents a high risk of iatrogenic injury to the medial rectus and orbit during functional endoscopic sinus surgery and has not previously been described.

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This paper presents an interesting case of a severe spontaneous haemorrhage within the parotid gland in an adult. A rapidly enlarging parotid mass with absence of causative trauma, inflammation or vascular abnormality, raised the suspicion of a neoplasm. Ultrasound, computed tomography (CT) and tissue biopsy, however, have shown only changes suggestive of previous haemorrhage and no evidence of malignancy. A 30-year review of the literature revealed no similar case reported previously.

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Congenital anosmia is well described in conjunction with various sexual and other developmental abnormalities and has been reported to run in families. Congenital anosmia occurring as an isolated defect in a single family member is extremely rare, and tends to present late. We describe a case of a five year old girl with congenital anosmia and we outline the investigations which should be undertaken in such cases.

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We report a case of parapharyngeal abscess complicating an elective tonsillectomy in a healthy thirty-three-year-old woman. The clinical features and management of this very rare complication are discussed. In addition, we review the possible aetiology and pathogenesis of this potentially life-threatening condition.

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We report an unusual case of thrombosis of a dilated external jugular vein presenting as a hard neck mass of sudden onset. The lesion's presentation, investigation, treatment and pathology are discussed.

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Oncocytic metaplasia in laryngeal epithelium is uncommon. Oncocytes have been described in the lining of laryngeal cysts and such cysts have been reported in the literature under a variety of names. There is an ongoing debate about the exact nature of 'oncocytic cysts', which tend to be solitary. An unusual case of multiple oncocytic cysts of the larynx is described. The pathology and treatment are discussed.

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We report a rare case of a mucocele occurring in a naturally compartmentalized maxillary sinus in a 50-year-old woman. Sinus computerized tomography (CT) showed the antrum to be divided by a vertical bony septum, producing a mucocele within an isolated and non-draining anterolateral compartment. Accidental trauma to the thin bony shell precipitated rapid swelling of the pre-existing mass, leading to her initial consultation. A wide sublabial surgical approach allowed complete excision with a good cosmetic result.

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The 'Taiwan tube' is an inexpensive pneumatic artificial larynx made in Taiwan. The device, which is a tracheo-oral shunt containing a resonator, is popular with laryngectomees in Hong Kong. This paper reports its use and describes its working dynamics which compare favourably with those of other forms of voice restoration.

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High resolution ultrasound is a promising technique in the assessment of laryngeal carcinoma, yet few published studies have appeared concerning its use. We set out to assess if ultrasound could correctly identify the site and size of known lesions, if unsuspected extralaryngeal spread or nodal involvement could be shown and if the results could be used to influence patient management. Fourteen patients with advanced laryngeal cancer (Stage T2 or above) were prospectively evaluated by systematic ultrasound technique, with the sonologist blind to the clinical findings. The results were correlated with clinical assessment and with histopathological findings in six patients who subsequently underwent surgery. Eleven of 14 tumours were visible on ultrasound and the site and size correctly identified in each. Unsuspected extralaryngeal spread was found in four cases increasing the tumour stage to T4; spread to the pre-epiglottic space was also shown in four cases. Nodal staging was correctly raised in two cases and incorrectly in one. Patient management was significantly influenced in 8/14 cases. Ultrasound can identify the majority of laryngeal tumours of Stage T2 and above, and detect extralaryngeal spread. Small tumours may not be visible but in this preliminary study, ultrasound complemented the clinical assessment and was useful in patient management.

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A 6-month prospective audit of the otolaryngology emergency workload in a district general hospital was undertaken. A total of 742 cases was referred of whom 193 (26%) were children (< 16 years). The male to female ratio was equal, and 69% of cases were referred from the accident and emergency department. Although most conditions were minor enough to be managed in the ward treatment room and either discharged (40%) or followed up as outpatients (27%), more than one-quarter of patients (28%) needed management by a post-fellowship ENT surgeon. Of the patients, 31% (230/742) were admitted, of whom 107 (46%) required an operation under general anaesthesia. The consequent ENT emergency workload represented 24% of all new patient referrals, 20% of ENT ward admissions and 10% of ENT surgical procedures.

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Arthrogryposis multiplex congenita (AMC) is a rare congenital syndrome consisting of two or more joint contractures in different parts of the body. Otolaryngological abnormalities have been previously described in a significant proportion of cases. However, to date, the only frequent otologic deformity recorded in the published literature has been low-set ears. We present a case with a combination of AMC and a bilateral conductive hearing loss due to an unusual middle ear deformity. To our knowledge, no such case has been previously reported.

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An absent gag reflex is often employed clinically as an indicator of aspiration risk. Dysphagia clinic records of 120 neurological patients who had undergone speech therapy and ENT assessment, followed by videofluoroscopy, were retrospectively analysed to ascertain if any link between an absent gag reflex and aspiration could be demonstrated. No association between an absent gag reflex and aspiration or laryngeal overspill was found (Mann-Whitney U-test; 2-tailed P = 0.11). Abnormalities on indirect laryngoscopy were seen in 34/120 patients (28%), and these were more closely related to aspiration risk (Mann-Whitney U-test: 2-tailed P = 0.06). An absent gag reflex is not a useful predictor of aspiration, and assessment of the gag reflex should not be relied upon to predict airway safety. However, indirect laryngoscopy is a useful adjunct to standard speech therapy assessment of the dysphagic patient.

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Over the eight-year period to May 1991, 256 patients were referred for post-laryngectomy voice rehabilitation. Videofluoroscopy identified 81 (32 per cent) who required pharyngeal myotomy for a spastic pharyngo-oesophageal segment. Forty-two of these (37 male, 5 female and average age 63 years) had their surgery performed at this unit with a complication rate of 17 per cent and an average post-operative stay of 10 days (range 4-41 days). The place of the operation for pharyngeal myotomy in post-laryngectomy voice rehabilitation is discussed.

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Recurrent or persistent carcinoma of the nasopharynx or naso-ethmoid region occurs even after combined surgery and radical external irradiation. The confined bony access and proximity of vital structures may compromise resection margins. Brachytherapy using implantable radioactive gold or iodine seeds is a useful adjunct to the skull base surgeon in eliminating residual microscopic disease. We report nine cases with recurrent or persistent disease of the nasopharynx or naso-ethmoid regions treated with brachytherapy with encouraging results.

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