Abstracts of the 14th British Academic Conference in
ABSTRACTS
Otolaryngology Posters Clinical Audit and Practice
F001
The use of acupuncture point P6 stimulation in the
prevention of post-operative nausea and vomiting in
tonsillectomy/adenotonsillectomy patients an audit
based on recommendations from SIGN clinical guideline
117
Fu, B., Hili, S. & Davis, J.
Objectives: In the Scottish Intercollegiate Guidelines Network (SIGN)
clinical guideline 117: Management of sore throat and indications for
tonsillectomy A national clinical guideline published in April 2010
(http://www.sign.ac.uk/pdf/sign117.pdf), stimulation of acupuncture
point P6 was given a Grade B recommendation for the prevention of
Post-operative Nausea and Vomiting (PONV) in patients undergoing
tonsillectomy/adenotonsillectomy where anti-emetic drug prophylaxis is
not suitable. We are interested in finding out whether this is a common
practice in our local hospitals.
Methods: All anaesthetic practitioners of a district general hospital
(DGH) in Kent, UK were invited to complete a questionnaire regarding
the practice of acupuncture in preventing PONV in tonsillectomy/ade-
notonsillectomy patients.
Results: There were 53 participants, with a 100% response rate: 17%
trainees <ST3, 13% trainees ST3-8, 21% Staff Grade, and 49% Consul-
tants. Although 58% of participants had been practising anaesthesia for
over 10 years, only 25% were aware of this guideline. Three consultants
(6% of the cohort) were acupuncture practitioners, although only one
participant (2% of the cohort) practiced acupuncture as per the SIGN
clinical guideline 117.
Conclusions: If our hospital is representative of DGHs in the UK, we
thus concluded that there is a general lack of awareness about the possi-
ble benefits of acupuncture related to ENT procedures in anaesthetic
practice. Combined with lack of training and limited resources, this is
preventing a practice which might be beneficial in patients not tolerating
pharmacological methods, who are at high risk of developing PONV, or
likely to suffer complications related to PONV.
F002
Assessing satisfaction of ISCP users in Otorhinolaryn-
gology
Fu, B., Amin, K., Hili, S. & Davis, J.
Objectives: Using the Intercollegiate Surgical Curriculum Project (ISCP)
is compulsory for all surgical trainees, as set out in the Gold Guide A
Guide to Postgraduate Specialty Training in UK. We were interested in
ENT trainees/trainers experience with its usage.
Methods: A Survey Monkey electronic questionnaire was distributed to
Association of Otolaryngologists in Training (AOT) members and ENT
consultants in Kent, Surrey, and Sussex.
Results: There were 86 respondents, of which 91% used ISCP. This
included 55% trainees and 45% trainers. Eighty-seven per cent felt the
125 trainee fee to be too high. On average during a month, 51% did
12 Work Based Assessments (WBAs). Fifty-three per cent used
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 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
<10 min for completing one WBA and 41% used 1020 min. There
were mixed responses to users feeling of usefulness and satisfaction for
each type of WBAs. Forty-seven per cent encountered problems with
ISCP usage. Sixty-five per cent have contacted ISCP in the past: 57% by
telephone, 37% by email and 12% by online feedback. Fifty-eight per
cent gave an overall satisfaction in using ISCP of five or less out of 10.
Conclusions: Our survey, although small, is the first one conducted
amongst Otolaryngologists. This showed the overall user satisfaction to
be sub-optimal. Possible solutions may include the introduction of spe-
cialty-specific WBAs, fewer tick boxes when completing WBAs, better
integration with other surgical logbooks and websites, and a reduction
of the JCST trainee fee. We are aware that the ISCP website is constantly
changing, and that some of the suggestions made here may already be
being built into the future system upgrades.
F003
An audit on timing of postoperative radioiodine
remnant ablation administration in patients with
differentiated thyroid carcinomas in East and West
Kent
Fu, B., Black, M. & Davis, J.
Objectives: To look at existing guidelines/evidence in the optimal timing
of postoperative Radioiodine Remnant Ablation (RRA) administration
in Differentiated Thyroid Carcinomas (DTC) patients and to compare
our current practice against this.
Methods: Retrospective study.
Results: No recommendation was found in the medical literature, the
British Thyroid Association guideline (2007), and the American Thyroid
Association guideline (2009). A consensus of a 12-week-standard
(84 days) was made by the local Thyroid Disease Orientated Group.
There were a total of 82 patients identified in the period of January
2008December 2009. The Female : Male ratio was 3.3 : 1. Age ranged
from 17 to 88, with a mean of 53. Histological cell types included: Papil-
lary (38%), Follicular (29%), Papillary with Follicular variant (20%),
and Hurtle Cell (10%). Operations performed included: 46% Hemithy-
roidectomy followed by Completion Thyroidectomy,33% Total Thyroid-
ectomy, 9% Hemithyroidectomy followed by Completion
Thyroidectomy/Level VI Dissection, 7% Total Thyroidectomy/Level VI
Dissection, 4% Total Thyroidectomy/Unilateral Modified Radical Neck
Dissection, and 1% Isthmusectomy followed by Completion Left/Right
Hemithyroidectomy. Timing between completion of surgical treatment
and commencement of RRA ranged from 3 to 278 days, with a mean of
66 days. Sixty-eight per cent of RRA was administered within the 12-
week-standard. Twenty-two per cent of RRA was administered between
12 and 16 weeks. Ten per cent of RRA was administered after 16 weeks.
Conclusions: It can be extrapolated that a significant delay in RRA in
DTC patients would have a negative impact on outcome as is observed
in the case of postoperative radiotherapy in other head and neck
cancers. This audit has formed the baseline for auditing DTC patient
outcome in the future.
17
18 Clinical Audit and Practice
F004
Optimising the dictation and clarity of letters
Khan, S., Mckay-Davies, I. & Porter, G.
Objectives: To reduce typing time per letter, whilst improving clarity of
dictation and communication of key points to GPs.
Methods: Completed audit cycle analysing typing time per letter, word
count and clarity of 88 general ENT clinic letters before, and 69 letters
after implementation of a standardised dictation protocol.
Results: The average reduction in typing time was 20.4 sec per follow-up
patient letter and 3.2 sec for a new patient letter. Overall there was an
average reduction in typing time of 29.2 sec per clinic letter irrespective
of the nature of the appointment. Eighty-six per cent of clinicians consis-
tently applied the bullet-point intervention to their dictation practice.
Conclusions: Introduction of a universal dictation protocol is an effec-
tive measure for increasing letter clarity, reducing secretarial workload
and reducing delays in communication to GPs. Additionally, the stan-
dardized protocol offers a framework for dictation, which may be useful
for medical trainees.
F005
WHO pauses in our theatre?
McMurran, L. & Crampsey, D.
Objectives: To investigate the utilisation and recording of surgical check-
lists in the ENT department of a large university teaching hospital over
a 3 month period.
Methods: Five hundred and five patient operative records were exam-
ined for documentary evidence of a surgical pause. Information on the
urgency of the case, location, method of anaesthesia and responsible
consultant were also noted.
Results: Of 505 records 456 (90.3%) recorded a surgical pause. This was
further examined; revealing 90.9% of elective procedures recorded a surgi-
cal pause, versus 65% of emergency cases. 90.8% of general anaesthetic
procedures were compliant, compared to 74.1% of local anaesthetic cases.
Compliance amongst responsible consultants varied from 81.8% to 100%.
We also noted variance in the method and quality of data recording.
Conclusions: The WHO Safe Surgery Saves Lives surgical checklist has
been shown to reduce surgical mortality and inpatient complications. It
has been adopted by the Scottish Patient Safety Programme, which
requires all surgical procedures under NHS Scotland include a surgical
pause. Currently this department is not seen to meet this national stan-
dard.
Studying the rates of compliance found for different procedures, we have
identified several factors which show potential for intervention. Clini-
cians have a responsibility to ensure that Clinical Safety initiatives are
implemented. When part of a national clinical standard, they must also
ensure accuracy in recording for audit purposes.
We suggest simple changes in order to improve compliance and thereby
improve patient safety.
F006
ENT training and the independent sector
Parmar, A., Armstrong, A. & Drysdale, A.
Objectives: To ascertain the level of ENT training taking place in Inde-
pendent sector treatment centres (ISTC) across the UK.
Methods: All 29 ISTCs were contacted for a telephone interview with
their general managers. A telephone interview was carried out. All 29
ISTCs were successfully contacted.
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
Results: Twenty-four out of 29 ISTCs carried out elective ENT proce-
dures which ranged from tonsillectomy, adenoidectomy, septoplasty,
myringoplasty, grommets and functional endoscopic sinus surgery.
Out of the 24 ISTCs none of them had any surgical ENT trainees
present
Conclusions: The role of the Independent sector in providing NHS
funded ENT treatment is increasing. The training opportunities available
within the independent sector have not been utilised with no trainees
present at ISTCs. Training provision needs to be a consideration when
commissioning private providers for NHS funded work.
F007
Improving the standards of medical documentation in
an ENT ward
Qureishi, A., Fernando, M. & Jones, N.
Objectives: Our department noted significant insufficiencies in the accu-
racy, accessibility and clarity of inpatient medical notes, leading to delays
on ward rounds and during emergency assessment. Our objectives were
to quantify the problem and identify a means of correcting this, thereby
improving the efficiency of ward rounds and availability of information
in an emergency.
Methods: A prospective audit was undertaken with a proforma designed
using Royal College of Surgeons and General Medical Council guidelines
on medical records and notes. During a 1 month period 50 inpatient
medical notes were assessed and the results reported at a departmental
meeting. Upon completion results were distributed amongst ward staff,
a clearer labelling system was introduced and junior doctors asked to file
notes immediately. A re-audit of 50 inpatients was undertaken after
3 months using a similar proforma.
Results: Overall significant improvements were noted. The presence and
availability of an initial clerking and examination improved by 28% and
36% respectively. The ability to locate notes improved by 24%, there
were 42% less loose sheets and chronology improved by 40%. The aver-
age time taken to find relevant information decreased by 1 min 39 sec.
Conclusions: In the current financial climate there are fewer clerical staff
available to organise medical notes, as a result vital information can be
lost or difficult to find. By highlighting the importance of medical notes
and making simple recommendations the quality and accessibility of
medical records can be improved, increasing time for patient care during
ward rounds and information easily accessible during emergency care,
research and clinical audit.
F008
A two cycle audit of consent in elective ENT surgery
Qureishi, A., Monkhouse, A. & Ramsden, J.
Objectives: To assess the consent process for patients undergoing elective
ENT surgery using national guidelines.
Methods: A retrospective audit was undertaken using a proforma
designed using Department of Health and General Medical Council
guidelines. In both audit cycles 40 sets of patient notes were randomly
selected for patients undergoing tonsillectomy, panendoscopy, myrin-
goplasty or septoplasty. There were a number of criteria assessed includ-
ing clarity, indication, risks and provision of copies/advice leaflet. After
analysis of the results and presentation a new intranet site was developed
and pre-printed consent stickers produced to improve clarity and the
quality of written information. A re-audit using identical criteria was
undertaken 3 months later.
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Results: Initial results: 5% of patients were informed of general risks of
surgery, 44% received a copy, 70% signed and printed their names, 5%
of consent forms were complete in all criteria.
Re-audit results: General risks were mentioned 97.5% of the time, 55%
received a copy, 100% signed and printed their names, 12.5% of forms
were complete in all criteria. Only 2.5% of the forms re-audited used
stickers, it was not possible to quantify the value of the website.
Conclusions: Although the provision of information relating to general
risks improved significantly other improvements were less substantial.
This audit highlights the difficulties faced in implementing change to
practice and how initially favourable interventions lose support as clini-
cians revert to previous methods. Whilst the use of information technol-
ogy is encouraged within the NHS, its effects will only reflect the
willingness of doctors prepared to realise its full potential.
F009
Anti-platelet drugs in elective ENT surgery
Savage, J. & Parmar, A.
Objectives: To ascertain current pre operative management of patients
on anti-platelet drugs undergoing elective ENT surgery in the UK.
Methods: An online survey was distributed to the Expert Panel of ENT-
UK, the British Association of Otolaryngologists Head and Neck Sur-
geons between 13th January 2011 and 15th February 2011.
Results: Three hundred and three members were contacted and the
response rate was 55% (167 replies), 78% of whom were Consultants.
Ninety per cent asked their patients to stop anti-platelet drugs prior to
an elective procedure. Nine per cent did not stop Clopidogrel or Aspi-
rin. Nasal and Head and Neck surgery was the commonest reason for
stopping medication, with endoscopy being the least common. Twenty
per cent were unsure what bridging therapy was. Nine per cent had
reported some kind of adverse effect of stopping anti-platelet drugs such
as CVA/TIA. The commonest consequence of continuing medication
was haematoma. Seventy-two per cent would recommence medication
within 3 days after surgery while 23% would restart it immediately.
Forty-five per cent of departments had no protocols in place but 86%
would welcome a protocol.
Conclusions: There is very little literature on anti-platelet medications
and ENT surgery. Abrupt cessation of anti-platelet drugs in patients with
coronary artery disease can have serious rebound effects. An increasing
number of patients have an indication for anti-platelets and thus their
management is crucial. Most consultants have welcomed a protocol for
anti-platelet management.
The outcomes of this paper have allowed patients to be classified into
high and low risk categories. Appropriate recommendations for the pre
operative anticoagulation for each group have been suggested.
F010
Improving quality of care post functional endoscopic
sinus surgery
Abdul Halim, S., Ed, T., Mckay-Davies, I.
& Langton-Hewer, C.
Objectives: To elucidate the extent to which postoperative instructions
affect patient understanding and compliance, and to ascertain the degree
of utilisation of primary care services post-functional endoscopic sinus
surgery (FESS).
Methods: Retrospective postal and telephone questionnaire examining
all aspects of postoperative care including: GP usage, adequacy of
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 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
Clinical Audit and Practice 19
instructions given, and compliance with douching, steroid and antibiotic
prescriptions.
Results: Although most patients enjoy an uneventful postoperative
recovery, 22% attended their GP, and 58% of these were subsequently
prescribed antibiotics for presumed infection. A small proportion was
excessively applying topical nasal steroids, and a fifth of patients did not
receive any written instructions. Of those who did, 17% found them to
be confusing.
Conclusions: GP utilisation and follow-up post-FESS surgery could
potentially be reduced by clearer, more standardized postoperative
instructions, which stress the expected postoperative course and provide
precise information on how to use the prescribed treatments.
F011
Completing the audit cycle: the impact of an electronic
reporting system on the feedback loop in surgical
specialities
Mandavia, R., Yassin, G. & Dhar, V.
Objectives: Whilst the feedback loop of incident reporting improves
patient care, its execution is often insufficient. The literature mainly
focuses on incident reporting, with little emphasis on incident evalua-
tion and action. Further, little data is available concerning the impact
of electronic reporting. We investigated the feedback loop in the ENT,
General Surgery and Orthopaedics surgical departments before and
after our intervention the implementation of an electronic reporting
system.
Methods: Data was collected from the Risk Department before and after
our intervention. Data was analysed in terms of: percentage of incident
reports evaluated; percentage of incident reports resulting in action;
whether correlations existed between incident severity and action taken.
Results: Prior to our intervention, 43% and 40% of incidents reported
were evaluated and acted upon respectively. Further the more severe the
incident, the less likely that it be evaluated or acted upon. Following our
intervention, the number of incidents reported increased by 198%. One
hundred per cent of incidents were evaluated and 66% were acted upon.
More severe incidents continued to be less likely acted upon than less
severe incidents.
Conclusions: Our first cycle demonstrated poor evaluation and action
rates of reported incidents. Our intervention resulted in a large increase
in the number of incidents reported. Further, incident evaluation rates
met our gold standard and incident action rates significantly increased.
We believe that our intervention resulted in considerable improvements
in patient safety and we recommend the use of electronic systems in
place of paper-based systems. However we recommend that action be
prioritised according to risk assessment score.
F012
Pre-operative tests in thyroid and parotid patients
Banigo, A. & Siddiq, M.A.
Objectives: To conduct an audit on the implementation of National
Institute for Health and Clinical Excellence (NICE) pre-operative guide-
lines, tailored by ENT-UK, on patients undergoing thyroid and parotid
surgery in our trust.
Methods: Retrospective analysis of patients clinical records.
Results: Between February 2011 and July 2011, 14 patients underwent
grade 3 ENT surgery in our trust; eight hemithyroidectomies, five parot-
idectomies and one sistrunks operation. Thirteen of the 14 patients
20 Clinical Audit and Practice
(92.8%) had all the recommended tests by NICE, and one patient had a
non-recommended test. At re-audit between September 2011 and Febru-
ary 2012, the total number of patients is 16; eight parotidectomies, six
hemithyroidectomies, two sistrunks. Fifteen of the 16 patients (93.6%)
had all the recommended tests, and none of the 16 patients underwent
any non-recommended tests. There was a 75% reduction in the number
of unnecessary ECGs performed. Only one of the total 30 patients
required a two night inpatient stay post-operatively; the rest were dis-
charged the day after surgery.
Conclusions: Our institution continues to improve in compliance with
the NICE and ENT-UK guidelines. One of the aims of these guidelines
is to predict and avoid any complications that may affect a patients
admission for surgery and their post-operative recovery; we currently
have one of the lowest operation cancellation rates for clinical reasons in
the country at 0.34%. The staff at the pre-operative clinic also perform
health promotion advice and tests, which would justify some Primary
Care Trust (PCT) funding for the service.
F013
Comparison between an inexpensive LED headlight and
a purpose built surgical headlight on users visual
acuity and colour vision
Street, I., Sayles, M., Nistor, M. & McRae, A.R.
Objectives: ENT trainees often need the use of a headlight. Purpose
built surgical headlights are provided at the workplace but often are
not immediately available, particularly when on-call. Light Emitting
Diode (LED) headlights can now be obtained easily at a very reason-
able price. We analysed users visual acuity and colour vision when
using a purpose built headlight compared to an inexpensive LED head-
light.
Methods: We recruited 50 volunteers from amongst the NHS staff work-
ing at our hospital. The same room was used for testing, with a standard
minimal amount of background light for all subjects. Subjects were
randomised to use either the LED or surgical headlight first. Near visual
acuity was assessed using a standard reading acuity card, then colour
vision was assessed using the standard Ishihara test. These tests were
performed with both types of headlight.
Results: Visual acuity readings were compared using the Wilcoxon
signed rank test; no statistical difference between headlights was shown.
Colour vision testing gave identical results with both headlights and was
not subjected to statistical analysis.
Conclusions: Visual performance is not affected to any statistically sig-
nificant degree when using an inexpensive LED headlight. We would
assure trainees using such headlights that the light quality and brightness
does not hinder their on-call work.
F014
Routine examination of the upper airways: a postal
survey of centres treating adult obstructive sleep
apnoea in England
Lim, J.-H., Oko, M. & Chani, K.
Objectives: Obstructive sleep apnoea (OSA) treatment is provided by
different specialties, mainly respiratory physicians and otolaryngologist.
British Thoracic Society (BTS) guidelines for upper airway examination
deem flexible nasoendoscopy as optional. We would like to investigate
the variation in clinical practise between centres.
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
Methods: All hospitals in England treating obstructive sleep apnoea were
identified using the Choose and Book system. A postal survey was sent
to each unit inquiring about routine examinations of the upper airways,
the anterior and posterior nasal space, examination of the oropharynx,
use of flexible nasoendoscope and bronchoscopy. The medical specialty
treating OSA was inquired.
Results: A total of 90 surveys were sent and n = 63 (70%) were
returned. Two (3%) did not state any specialty. N = 58 (92%) centres
had input from respiratory physicians, n = 20 (30%) by otolaryngolo-
gist, n = 9 (14%) by dental faculty. N = 47/61 examined the upper
airway, n = 33/61 examined the anterior nasal space, n = 12/61 used
a flexible nasoendoscope to examine the posterior nasal passage,
n = 49/61 examined the oropharynx and n = 0/61 routinely broncho-
scope patients. For centres with otolaryngology expertise n = 11/20
examined the post nasal space. 8/17 of centres with combined otolar-
yngology and respiratory medicine expertise and three centres with
only otolaryngology input examined the post nasal space. 1/41 centres
with only respiratory medicine expertise examined the post nasal
space
Conclusions: There is a variation in the use of a flexible nasoendoscope
among the specialties treating sleep apnoea. Respiratory physicians were
less likely to examine the post nasal space compared to otolaryngologist.
Consensus of routine upper airway examination among clinicians is
needed.
F015
Procedures of limited clinical benefit: an audit of
listing tonsillectomies in the face of evolving guidelines
Kara, N., Lawley, A., Kullar, P., Veer, V. & Carrie, S.
Objectives: In 2010, NHS North of Tyne (NoT) reviewed the allocation
of central funding for a number of operative procedures. Regarding ton-
sillectomy for recurrent tonsillitis, it was concluded that there is insuffi-
cient evidence of clinical effectiveness and it may only be funded in
accordance with the guidance.
Methods: Taking this into account, the aim of this audit was to assess
our practice to ensure:
1 Patients were listed for tonsillectomy in accordance to new local
guidelines.
2 Relevant documentation was appropriate.
The NoT Guidelines quote similar criteria to the SIGN (Scottish Inter-
collegiate Guidelines Network) Guidelines on Tonsillectomy, and our
practice was compared with this standard. All patients were expected to
comply 100% with guidelines, and the gold standard for documentation
was also set at 100%.
Results: The first 4-week cycle demonstrated only 60% of cases had doc-
umented evidence of meeting all four listing criteria. Findings were pre-
sented and distributed to the department, and listing criteria were
displayed in each of the clinic rooms as a quick reference guide. Practice
was re-audited over a second 4-week period. Documented evidence for
compliance with all four listing criteria rose from 60% to 81.5%.
Encouragingly, there was specific reference to listing criteria in 37% of
cases.
Conclusions: In the current financial climate specialist services are under
intense scrutiny, and need to demonstrate that they continue to provide
clinically appropriate treatment. Accurate documentation is therefore
essential, and requires an increased awareness and participation from cli-
nicians. This can be effectively achieved through departmental audits, as
we have successfully demonstrated here.
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F016
The use of a surgical cricothyroidotomy model as part
of a departmental induction improves the confidence
of junior doctors to perform the procedure
Killick, N., McNeill, E., Erskine, S., ONeill, S. & Yates, P.
Objectives: Surgical cricothyroidotomy is recognised as a reliable means
of securing an airway in an emergency. The technique requires only a
rudimentary knowledge of neck anatomy. As such it can be taught to
staff members from different specialties providing cross cover at night.
The training of staff in this technique requires the use of an animal lar-
ynx or the purchase of commercially available artificial trainers at con-
siderable expense. The sourcing of animal cadavers is time consuming
and requires considerable preparation. Friedman et al have demonstrated
the use of simple artificial trainers to be as effective as expensive simula-
tors for the acquisition of cricothyroidotomy skills. Here we show how
relatively inexpensive models created with materials readily available
form most otolaryngology wards and theatres can be utilised to give
new staff an opportunity to practice a valuable skill.
Methods: The confidence of junior doctors to perform a surgical crico-
thyroidotomy was assessed using a 10 point scale. They received a short
teaching session including a description of the anatomical landmarks.
This was followed by a demonstration and practical session using a cric-
othyroidotomy model. The questionnaire was then repeated.
Results: The results show an improvement in the confidence of junior
doctors to locate the cricothyroid membrane and perform a surgical
cricothyroidotomy.
Conclusions: We believe we have shown the surgical cricothyroidotomy
model to be an inexpensive means of training junior doctors to per-
form a useful but rarely performed procedure. We believe this skill
should be taught as part of the induction of all doctors providing cover
at night.
F017
Are UK Otorhinolaryngologists maintaining their
research output?
Kulkarni, K. & Silva, P.
Objectives: Pressure on trainees to demonstrate evidence of publications
in support of specialist training applications represents a growing chal-
lenge. In the general surgical and anaesthetic literature there has been a
decline in research output originating from the United Kingdom (UK).
With growing financial constraints and service demands it is of concern
that this decline may be a trend echoed within sub-specialities such as
Otorhinolaryngology. This study aimed to confirm or refute this fear.
Methods: This retrospective study analysed ten globally leading Otorhi-
nolaryngology journals and two leading UK journals, based on highest
journal impact factor. Citable research output was analysed from four
individual years, over a 10-year period, to determine absolute output,
geographical mix and article type.
Results: UK and Ireland share of research output increased 22.8%
among the leading ten global journals, but fell 28.6% amongst the lead-
ing two UK journals. The converse was true for the United States of
America (USA) and Canada, whose output fell 12.4% among the leading
global journals, but increased 167.9% among the leading UK journals.
European and Rest-of-World output increased in both, the leading glo-
bal (10.4%, 56.1%) and leading UK (5.7%, 90.1%) journals. Articles cat-
egorised as research remained the most prevalent.
Conclusions: The results are encouraging for UK Otorhinolaryngologists
and refute the fall in UK research output observed by other studies. In
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 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
Clinical Audit and Practice 21
the face of growing challenges it is important that this trend is main-
tained, such that the fate befallen other specialities is not mirrored
within Otorhinolaryngology.
F018
Knowledge of end of life issues within an otolaryngol-
ogy department
McNeill, E. & Regnard, C.
Objectives: Otolaryngologists are exposed to end-of-life issues when
managing patients with head and neck cancer, but also with patients
presenting for routine or emergency procedures. As a legal act of Parlia-
ment, the Mental Capacity Act (MCA) is the gold standard for clinical
practice in end-of-life care. Clinicians should have a working knowledge
of the Act, particularly regarding principles of best interests, advance
decision validity and resuscitation. This audit aims to assess and
improve the level of clinical knowledge on these subjects within our
department.
Methods: A fictional case report of a patient with laryngeal cancer, con-
taining issues related to the MCA, was constructed. Sixteen true-or-false
questions based on the case report were completed by 21 otolaryngolo-
gists and scores calculated. The clinicians were then provided with a
summarised version of the MCA and a written discussion of the case
report. The report was discussed in an audit meeting and individually.
A second set of questions were completed on the clinical application of
the MCA. Individual and average scores were re-calculated, and com-
pared.
Results: The percentage of correct answers from the initial questionnaire
ranged from 38% to 88% (mean 65%). Following discussion and provi-
sion of written information, an improvement in knowledge was demon-
strated by higher individual and average scores (53100%, mean 73%).
Conclusions: Knowledge of the Mental Capacity Act is essential to pro-
vide dignified end-of-life care. This study suggests there is room for
improvement in the knowledge of otolaryngologists in these subjects but
this can be achieved simply within the department.
F019
Post-operative follow-up of patients changing
practice to cope with demand
Bewick, J., Ewart, S. & Lyons, M.
Objectives: To identify the rate of inappropriate outpatient appoint-
ments following elective surgery in a District general ENT department
and methods of improving follow-up.
Methods: Elective operating lists from Cycle 1 (September 2009Decem-
ber 2009) and Cycle 2 (September 2010 and October 2010 following
clinic template change and clerical staff education) were used to identify
a random selection of patients under the care of all four consultants in
the department. Using the PAS computer system the dates of post-oper-
ative follow-up appointments were identified. This was then correlated
with the outpatient appointment ordered on the discharge summary by
the operating surgeon.
Results: In total 117 patients in Cycle 1 and 189 patients in Cycle 2
were audited.
Thirty-one patients and 41 patients in cycle 1 and cycle 2 respectively
were deemed not to require routine outpatient follow-up. Three patients
and four patients in cycle 1 and cycle 2 respectively, were private
patients followed-up elsewhere.
22 Clinical Audit and Practice
Eighty-three patients and 144 patients in cycle 1 and cycle 2 respectively
therefore required outpatient appointments. During cycle 1 41/83
(49.1%) patients had appropriate outpatient appointments. Following
change of the clinic template 131/144 (90.1%) patients had appropriate
follow-up.
Conclusions: Lack of appropriate follow-up for patients can be consider-
able and go undetected as patients are often not seen by the operating
surgeon in the follow up clinic. With fairly simple changes to clinic tem-
plates, departments can significantly improve patient follow-up by
ensuring ample post-operative appointments are available and ensuring
clerical staff use these appropriately.
F020
Long-term compliance and device longevity in use of
mandibular advancement splints for snoring and sleep
apnoea
Molony, N. & Harper, R.
Objectives: Define long-term Compliance rates, Effectiveness, and Dura-
bility of device for Mandibular Advancement Devices (MADs) used in
the treatment of (1) Adult tongue-based snoring and (2) Mild Adult
Obstructive Sleep Apnoea (OSA).
Methods: Retrospective Telephone or Postal Questionnaire of 148
patients, 70 fitted between 2 and 3 years previously, and 78 fitted
between 3 and 4 years previously. Seventy per cent (104) were simple
snorers while 44 (30%) had mild OSA.
Results: Response rate was 84%. While 60% were still wearing the
device at least one night per week over 3 years later, only 30% used it
daily. Snoring was reduced or stopped in 50%, statistically significant if
the null hypothesis proposes no difference from treatment with MAD
(chi-squared test). Forty-two per cent had jaw or dental pain but 52%
no problems. The OSA cases had statistically significantly better figures
for waking refreshed and having no daytime somnolence than without
(v2 < 0.05, 1 df). MADs used every night needed re-making on average
after 18 months.
F021
Does tonsillectomy improve quality of life in adults? A
systematic literature review
Andreou, N., Hadjisymeou, S. & Panesar, J.
Objectives: To determine whether performing tonsillectomy will improve
Quality of Life (QOL) in adults suffering from chronic or recurrent ton-
sillitis. QOL should not be confused with patient satisfaction which is
closely related to how satisfied the patient is with the level of service
received.
Methods: A systematic literature search of Medline and Pubmed was
conducted in order to identify all the relevant studies that measure QOL
directly.
Results: In total, eight studies were identified. The Glasgow Benefit
Inventory (GBI) and the Short Form (SF) were the main methods used
to measure QOL changes. Tonsillectomy is likely to improve the overall
QOL as it will particularly improve the physical and general health of
patients. The social benefits of tonsillectomy appear to be non-signifi-
cant. The effects are likely to be long lasting and have a greater impact
on younger patients. The presence of co-existing chronic conditions and
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
the severity of the infective symptoms due to tonsillitis are also strong
influencing factors.
Conclusions: Effective provision of health care is increasingly related to
prudent allocation of scarce resources. Therefore, decisions to perform
tonsillectomy as a treatment for chronic sore throat should be based on
the chances of success of the operation. The long-term success of tonsil-
lectomy largely depends on the patients QOL improvement.
F022
Emergency department secondment: an alternative to
extended junior doctor surgical cross-cover in ENT and
beyond?
Williams, R., Droog, S. & Hope, A.
Objectives: Derriford Hospital, ENT and plastics directorate faced an
enforced 17% reduction of their junior doctor cadre. Such reductions
along with the impact of the European Working Time Directive and
ongoing financial constraints have been shown to be detremental to sur-
gical training and patient care. The literature warns of the dangers of
increasing surgical cross-cover, resulting in junior doctors covering ENT
with inadequate training, working outside their sphere of interest. A
novel solution was required to maintain surgical training and provide
continued service provision.
Methods: A 6-week prospective audit of night ENT and plastics junior
doctors activity revealed under-utilisation of the service with junior
doctor spare capacity. As a result, a system of night time Emergency
Department secondment was created. The night ENT and plastics junior
doctors became based in the Emergency Department, seeing relevant
patients directly without the need for referral. Inpatient needs were met
by recalling this junior doctor to the ward as required. Set periods were
timetabled for handover and a robust system of clinical supervision was
established.
Results: Two 6-week cycles of post-intervention prospective analysis of
the service and audit against Emergency Medicine Clinical Quality Indi-
cators revealed: the ENT and plastics directorate maintained their spe-
cialist junior doctor service at night whilst achieving savings; increased
junior doctor pay, increased training opportunity; and the ED gained
improved quality indicators with reduced double clerking.
Conclusions: The utilisation of well constructed rosters and novel service
laydown can minimise impact of dwindling junior doctor numbers.
F023
Functional outcome and survival rate for oral and
oropharyngeal carcinoma
Stankovic, P., Stankovic, M., Petrovic, D., Vuckovic, I.,
Pesic, Z. & Milisavljevic, D.
Objectives: To compare surgical and non surgical treatment modalities
for oral and oropharyngeal squamous cell carcinoma, especially concern-
ing survival and functional outcome.
Methods: A retrospective review of the clinical records of 260 patients
treated for oral and oropharyngeal malignant rumors from 1998 to 2007
was made. Totally 98 patients were treated only with surgery, 117 with
surgery and radiotherapy, and 45 only with radiotherapy. Postoperative
clinical examination was made during 5 years with documentation of:
complications, quality of life and survival rate.
Results: Postoperative wound infection occurred in 5.6% of the patients.
Adequate oral intake was achieved in 95.1%, and 92.4% were decanulat-
 2012 The Authors

ed. Reduction of saliva was significantly altered after radiotherapy on
UW-QOL scale. Five year survival rate closely correlated to the T status
and tumor Stage, and was worse for oropharyngeal carcinoma when
compared to oral carcinoma cases.
Conclusions: Oropharyngeal cancer has worse prognosis and more com-
plications of surgical treatment than oral cancer. Quality of life is similar
after surgical and nonsurgical treatment of these cancers, but surgery
with or without postoperative radiotherapy offers better results than ini-
tial radiotherapy.
F024
Histopathological profile of salivary gland tumors in
Ilorin, Nigeria
Sulyman, A., Ganiyu, R., Kazeem, I., Shola, A.
& Habeeb, O.
Objectives: This paper endeavors to document the histopathological pro-
file of salivary gland neoplasms in Ilorin, north central Nigeria.
Methods: This study included patients with primary epithelial salivary
gland neoplasms between 2001 and 2010 at the University of Ilorin
teaching hospital, Ilorin, Nigeria. H&E stained slides of all specimens
were reviewed by the pathologists based on the 2005 WHO classification
of head and neck tumors criteria. Non neoplastic salivary tumours were
excluded from the study and Immunohistochemistry was not employed,
as this diagnostic technique is not available in our laboratory. Informa-
tion regarding age, gender, and anatomical location of the tumors was
collected from the patients hospital records
Results: Fifty-six patients were seen and the age range is 3.577 years
with a mean age of 38.62 years (SD = 18.4 2.5) and a peak inci-
dence in the age range 3140 years. The overall sex differentiation for
all the salivary gland tumours showed 24 males to 32 females with a
male to female ratio of 1.0 : 1.3. Histologically, pleomorphic adenoma
constituted the largest in 62.5% and mucoepidermoid tumour in
37.5%.
Conclusions: Most of the tumours were benign with pleomorphic ade-
noma being the commonest and mucoepidermoid the commonest
malignant tumours with an overall female preponderance as reported
earlier from different parts of Nigeria. The outcome from this study
proved the earlier reports that there are a number of histopathological
variations between the salivary gland tumors in black populations and
those from the Caucasians.
F025
Impact of introducing the productive operating theatre
programme on teamwork climate
Awad, Z., Heywood, R., Gosai, K. & Jayaraj, S.
Objectives: The Productive Operating Theatre (TPOT) programme was
introduced to our unit to improve the safety of care, team performance
and staff wellbeing.
The objective of this study was to investigate the impact of introducing
TPOT on teamwork climate.
Methods: A prospective survey of theatre staff was carried out using the
14 item teamwork survey from the University of Texas before (55 staff)
and after (44 staff) introducing TPOT.
Results: While there were only minor changes to staff perception of
teamwork climate as a whole (MannWhitney U P = 0.3466), the indi-
vidual question scores were higher (Wilcoxon P = 0.0176) in the second
 2012 The Authors
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
Clinical Audit and Practice 23
group. We also found a better perception of the reliability of handover
after TPOT was introduced (P = 0.0455).
Conclusions: TPOT improves certain aspects of teamwork climate, espe-
cially handover of information. It requires regular monitoring with staff
involvement to achieve its highest potential.
F026
Diagnostic yield of a one-stop neck lump clinic
Al Hamarneh, O., Liew, L. & Shortridge, R.
Objectives: Diagnostic clinics for patients with neck lumps were estab-
lished across the UK in response to NICE guidance on cancer services.
The principal aim of this study was to evaluate the output of the rapid
access one-stop neck lump clinic. An analysis of patients demographics,
diagnostic tests and the ability to reach a diagnosis on the day was con-
ducted
Methods: A prospective cohort study of patients attending a one-stop
neck lump clinic over a period of 30 months. Patients characteristics,
diagnostic tests and outcomes were recorded and data analysed.
Results: Of 333 patients, n = 65 (20%) had no lump, n = 214 (64%)
had a benign lump and n = 54 (16%) had a malignant lump. Older
patients and a history of smoking both were found to be significantly
higher when a malignant lump was diagnosed when compared to a
benign lump. In the benign lump group, freehand FNAC was adequate
in 87% (n = 48/55). USS-guided FNAC was adequate in 74% (n = 32/
43). Diagnosis was confirmed on the day for the majority of the patients
(n = 178, 84%). In the malignant lump group, freehand FNAC had an
accuracy of 82% (n = 28/34). USS-guided FNAC had an accuracy of
81% (n = 17/21). Diagnosis on the day was confirmed for 74% of the
patients (n = 40).
Conclusions: The clinic in our unit achieved an overall 84% diagnostic
yield on the day. Outcomes regarding age, sex, smoking, size and site of
neck lumps and accuracy of FNAC were in line with published data. We
recommend our model to run a one-stop neck lump clinic due to its
high diagnostic yield.
F027
Audit of patient satisfaction of a pioneering Combined
Rhinology Clinic at the Royal Lancaster Infirmary
Ahmed, S., Ruane, S. & Gardner, A.
Objectives: Our objectives were to evaluate which healthcare profession-
als were referring patients and to assess whether patients found seeing a
multidisciplinary team of respiratory, ENT and allergy specialists in a
one stop clinic useful. It was also to determine whether amalgamating
investigations, diagnosis and treatment into one clinic is beneficial and
how we could improve the service to enhance patient satisfaction.
Methods: Over a 20 month period, a retrospective cohort of 69 Com-
bined Rhinology Clinic patients were identified using Lorenzo clinic lists.
Patients were sent a survey comprising of 12 questions, with a covering
letter and self-addressed stamped return envelope. Over a 6 weeks per-
iod, 36% of the sample cohort responded and their answers were anony-
mously collected using Excel.
Results: The majority of referrals were from primary care GPs. All
patients that responded found that seeing a team of multidisciplinary
specialists in the clinic useful, and over 90% found having amalgamated
investigations/diagnosis/treatment useful. Over 40% would recommend
the clinic to other similar patients. However 35% of patients were less
than satisfied with clinic follow-up system.
24 Clinical Audit and Practice
Conclusions: Although a small cohort study, results indicate that
patients are satisfied with one stop, combined, nature of the clinic. Data
suggests the follow up procedure and clinic environment needs improve-
ment, and we aim to re-audit these variables in the future.
F028
Systematic review and meta-analysis of the use of
tranexamic acid in tonsillectomy
Chan, C.C., Chan, Y.Y. & Tanweer, F.
Objectives: Post-tonsillectomy haemorrhage is a serious complication
that can lead to fatality despite the fact that tonsillectomy is one of the
commonest procedures performed in otolaryngology. Tranexamic acid
(TXA) is a potent antifibrinolytic agent in controlling postoperative
haemorrhage. This study aims to evaluate the role of TXA in tonsillec-
tomy by systematic review and meta-analysis.
Methods: Searches were performed in MEDLINE, EMBASE, Web of Sci-
ence and the Cochrane Library. Study selection, data extraction and
quality assessment were conducted independently by two reviewers.
Mean difference (MD) in volume of blood loss were calculated with
95% confidence interval (CI). Risk ratio (RR) with 95% CI were com-
puted using random effects for the risk of post-tonsillectomy haemor-
rhage.
Results: We identified a total of seven studies in this review. Two stud-
ies (n = 180) compared the effects of TXA on volume of blood loss.
Meta-analysis of these studies showed a significant decrease in the mean
blood loss of 33 mL (95% CI )43 to )23, P < 0.00001, heterogeneity
I2 = 0%). Five studies (n = 1670) compared the number of patients
with post-tonsillectomy haemorrhage between TXA and control groups.
TXA does not reduce the post-tonsillectomy haemorrhage rate signifi-
cantly (RR = 0.51, 95% CI 0.251.07, P = 0.08, heterogeneity I2 = 49%)
in the study group.
Conclusions: TXA led to a significant reduction of tonsillectomy
blood loss volume but had no impact on the rate of patients with
post-tonsillectomy haemorrhage. This systematic review demonstrated
the lack of recent evidence, therefore a large and well-designed
randomised controlled trial is needed to investigate the risks and ben-
efits of TXA.
F029
Patient information delivery for endoscopic sinus
surgery, website versus printed patient leaflet
Henney, S. & Pothier, D.
Objectives: Most patients want information prior to undergoing a surgi-
cal procedure. This information is traditionally provided either verbally
or via printed leaflets. It is accepted that clinicians and patients alike use
websites to gain information. Endoscopic sinus surgery (ESS) is com-
monly performed with well recognised significant risks. This study aims
to determine, which mode of delivery of information is more acceptable,
usable and leads to better recall of complications.
Methods: A multicentre randomised controlled trial was used to com-
pare modes of delivery of information. Adult patients (1865 years),
were randomly allocated to receive pre-operative information regarding
endoscopic sinus surgery, either via a website (n = 20) or in print
(n = 20). The recruiting centres were Otorhinolaryngology Departments,
University Hospital Birmingham and University Hospital of North
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
Staffordshire. Primary outcomes measured were readability, usability and
recall of complications assessed by questionnaire.
Results: Fifty patients were recruited, 40 of whom were included in the
study, meeting the power criteria set.
There were 18 male and 22 female patients ranging in age from 21 to
76. Overall patients found either a printed leaflet or a website readable
and were satisfied with the usability of both modes. There were similar
rates of recall of complications with pre-operative patient information in
both arms of the study.
Conclusions: This trial evaluated the effectiveness of website based infor-
mation compared to patient information printed leaflets using question-
naires following surgery. The findings help tailor the provision of pre-
operative information for patients undergoing ESS.
F030
Improving consenting practice in ENT surgery-
measures that lead to effective change
Ridyard, E., Varadarajan, V., Lobo, C., Hargreaves, S. &
Umapathy, N.
Objectives: To measure consenting standards of common ENT proce-
dures in a foundation trust department and implement effective mea-
sures to improve and standardise consenting practice.
Methods: Consenting standards were compiled from ENT UK/British
Association of Head and Neck Surgery (BAOHNS) patient leaflets for
tonsillectomy, grommet insertion, septoplasty, rigid oesophagoscopy,
functional endoscopic sinus surgery (FESS) and mastoidectomy. Pro-
spective analysis of complications documented on consent forms was
performed (n = 56). Deficient areas were raised amongst the department
and pre-prepared stickers were produced for use on consent forms. A
second prospective data cycle (n = 59) was collected and analysed using
chi-squared testing.
Results: Improvements were seen in the vast majority of complications
consented for. Statistically significant improvements were measured for
septoplasty [cosmetic change (P = 0.05), teeth numbness
(P = 0.0010)] and mastoidectomy [dizziness (P = 0.01), tinnitus
(P = 0.05), ear dressing reaction (P = 0.001)]. Some percentage
decreases were seen for grommet insertion [infection ()10%)] and
rigid oesophagoscopy [perforation ()25%)].
Conclusions: A wide variety of consenting practice was measured.
Improvement was seen in the vast majority of complications consented
for. New doctors starting midway during the second data cycle may be
responsible for the reduction in some standards. Sticker use was non-
mandatory, and may be made mandatory to further improve stan-
dards.
F031
One On, One Off: a model for safe and efficient
paediatric ENT surgery
Walker, D., Cartwright, S., Blanshard, J. & Spraggs, P.
Objectives: To demonstrate a system for efficient theatre session man-
agement using a One on, One off approach to achieve up to 10 cases
per session, and to outline the business case to implement the required
changes.
Methods: Paediatric cases for routine otolaryngology procedures are
allocated for surgery on a dedicated paediatric list. The day surgery
ward is transformed to Paediatrics Only and staffed by Paediatric
Nurses. Two Paediatric trained Anaesthetists and two Operating
 2012 The Authors

Department Practitioners (ODPs) are assigned to the list, to allow a
One On, One Off system i.e. the next patient anaesthetised by the
time the previous case leaves theatre. Patient Level Costing (PLC) was
analysed over a 2 year period to assess full procedural expenditure.
This was compared against income per case and the cost of providing
extra staff.
Results: Over a 2 year period, the average number of cases for a single
theatre session was 7.9 (range 310), compared to 4 on an equivalent
session at a neighbouring hospital. The average case overlap time was
1.84 min (range )5.35 to 8). This additional activity generated extra
gross income of 20004000 per list, depending on case mix, with net
profit far exceeding the cost of providing extra staff. There were no
adverse outcomes during this time period.
Conclusions: This model, easily applied to other surgical specialities,
can drive down waiting lists, increase efficiency and improve revenue.
The business case for supplying extra Anaesthetic staff is clear and
provides fast turnaround whilst maintaining patient safety and
training.
F032
Computer tomography (CT) paranasal sinus imaging for
chronic rhinosinusitis (CRS) are we meeting the Royal
College of Radiologists guidelines? The Freeman
experience
Ramakrishnan, Y., Veeratterapillay, S., Zammit-
Maempel, I. & Carrie, S.
Objectives: 1 To determine the proportion of CT paranasal sinus scans
requested for CRS symptoms preceeded by nasoendoscopy and medical
treatment.
2 To establish the proportion of patients with CRS symptomology
undergoing surgery.
Methods: Setting: Tertiary centre.
A cohort of 100 random patients recruited from general ENT clinics
undergoing CT paranasal sinus in 2011. Known pituitary or nasal
tumours were excluded. Symptomology, nasoendoscopy, medical treat-
ment and whether patients proceeded to surgery were recorded.
Results: Ninety-two patients with CRS polyp met the eligibility crite-
ria. Four per cent (n = 4) patients did not undergo nasoendoscopy, 30%
(n = 28) had normal findings, 23% (n = 21) were rhinitic with 42%
(n = 39) had mucopus, polyps or mucus trail.
In terms of medical management, 11% (n = 10) did not have any, 29%
(n = 27) had topical treatment, 23% (n = 21) had <6 weeks antibiotics
4 weeks steroid drops, 14% (n = 13) had oral steroids and 9% (n = 8)
had >6 weeks antibiotics.
Those with positive findings on nasoendoscope were more likely to
have a positive scan (72%) compared to those with normal nasoendo-
scope findings (32%). Approximately 33% (n = 30) underwent surgery.
Those with positive findings on nasoendoscopy were more likely to
undergo surgery (40%) compared to those with normal findings
(21%).
Conclusions: Approximately 40% of CRS patients did not have optimal
medical treatment prior to scans. A normal endoscopy cannot assure a
normal CT. Thus, symptoms, endoscopy and CT findings are comple-
mentary in the evaluation of the CRS patient.
 2012 The Authors
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
Clinical Audit and Practice 25
F033
Can anticoagulant and antiplatelet medications be
continued in the majority of patients admitted with
epistaxis?
Biggs, T., Baruah, P., Mainwaring, J., Harries, P.
& Salib, R.
Objectives: There are currently no published guidelines for the contin-
ued use of anticoagulant and antiplatelet medications in those admitted
with epistaxis. This audit implements new guidelines and assesses their
impact.
Methods: One hundred admitted epistaxis patients presenting to the
University Hospital Southampton were studied (50 within each cycle).
Second cycle occurred after implementation of new guidelines formu-
lated by Otolaryngology and Haematology departments.
Results: Fifty-eight per cent of patients were on some form of anticoag-
ulant or antiplatelet medication. The number of patients ceasing medica-
tion on admission dropped from 72% to 23% for aspirin and from 75%
to 50% for clopidogrel, between audit cycles. In the 1st cycle warfarin
was withheld for <3 days in only 30% rising to 67% on re-audit. There
was no statistically significant increase in re-admission, transfusion, re-
bleeding, surgical intervention, re-packing or length of admission rates
between audit cycles (P-values 0.231).
Conclusions: Guidelines have been produced with the input of the hae-
matology and ENT departments to guide use or discontinuation of anti-
platelet and anticoagulant medication in admitted epistaxis patients.
This has resulted in a rise in continuing aspirin and clopidogrel, and a
reduction in time for withholding warfarin. These guidelines are unique
within the literature and will have an impact within the wider UK envi-
ronment. It is hoped that by implementing these guidelines in depart-
ments across the country potential complications resulting in
unnecessarily stopping important medications will be reduced. This
audit proves this can be done without increasing the rates of re-bleeding
and re-admission following hospital discharge.
F034
Can the absolute lymphocyte count predict Epstein
Barr related infectious mononucleosis, eradicating the
need for monospot testing?
Biggs, T., Bird, J., Baruah, P., Harries, P. & Salib, R.
Objectives: Infectious mononucleosis (IM) is best known as a clinical
syndrome caused by EpsteinBarr virus (EBV). It is characterized by
fatigue, malaise, fever, sore throat and generalized lymphadenopathy.
EBV causes more than 90% of cases of infectious mononucleosis. Studies
have suggested using the lymphocyte to white count ratio to aid in the
diagnosis of IM. This study aims to examine the use of the absolute
lymphocyte count as a predictive marker of EBV related IM cases.
Methods: Seven hundred and twenty-six consecutive patients undergo-
ing monospot and full blood count testing at the University Hospital of
Southampton (UHS) were included. The study ran between 1st October
2011 and 20th January 2012. Monospot results were compared to the
total lymphocyte count to assess the predictive correlation.
Results: Patients with an absolute lymphocyte count of >4 10*9/L dis-
played a positive predictive value of 53.2%. Patients with an absolute
lymphocyte count of <4 10*9/L had a negative predictive value of 99.1%
(sensitivity of 84% and a specificity of 94.5%).
Conclusions: This study draws the conclusion that if the lymphocyte
count <4 10*9/L the patient is 99.1% likely to be IM negative. If the
lymphocyte count is >4 10*9/L, further IM testing will be required to
26 Clinical Audit and Practice
rule out Epstein Barr related IM. This study provides a simple and
highly accurate negative predictive ability to assess those unlikely to be
suffering from EBV related IM. By using this method 1938 monospot
tests could be prevented within a year at UHS alone, resulting in signifi-
cant laboratory savings if multiplied across the country.
F035
CT sinus scans in otolaryngology
Bondin, D., Saiu, D. & Jones, P.
Objectives: Patients presenting with symptoms of chronic rhinosinusitis
(CRS) commonly undergo CT scan of their paranasal sinuses. Studies
have shown that approximately 30% of asymptomatic patients have have
positive findings on CT sinuses and current consensus is that these
should be reserved for patients who are non-responsive to medical treat-
ment and where surgery has been planned.; not for diagnostic purposes
as CRS should be primarily a clinical diagnosis. Our audit aims to estab-
lish what proportions of scans are deemed unjustified according to the
above consensus.
Methods: Prospective audit of 100 consecutive CT scans requested for
patients with nasal symptoms between January 2009 and January 2010
from the ENT out-patient clinics at South Manchester University Hospi-
tals. A proforma was used to collate demographic, clinical information
and to record dates of events.
Results: Eighty per cent of scans were requested during first consulta-
tion. Seventy-four per cent requested for CRS polps; 8% for recurrent
acute sinusitis. Thirty per cent were requested for operative planning;
68% for diagnostic purposes. Forty per cent of patients end up having
surgery; 40% medical; 20% no treatment. Only 30% were appropriately
ordered according to the above consensus, and 14% actually altered
management plans.
Conclusions: Far too many scans were inappropriately requested in this
department especially during first visit. This involves substantial financial
costs to the trust especially in this financial climate as well as unneces-
sary radiation exposure (>100 X-rays) to patients. As these scans are
becoming more readily available, they are far too often used for diagnos-
tic reasons often at patients instigation. We recommend a national audit
to further evaluate this problem on a broader scale.
F036
Patient expectations in outpatient care
Virk, J., Awad, Z. & Singh, A.
Objectives: To evaluate patients expectations in a teaching district gen-
eral hospital outpatient department.
Methods: Observational study in the form of a survey completed by any
consenting adult patient attending any of four different outpatient clinic
areas.
Results: One hundred and seventy-nine patients (47% male; 53%
female) completed our survey and were new (42%) or follow up (58%)
patients. Ninety-two per cent had received a letter inviting them to their
appointment and 86% had a specific consultant name on the letter.
Twenty-six per cent said the letter did not explain that the patient may
not see the consultant during their visit. Sixty-one per cent expected to
see the consultant, 28% were happy to see a doctor supervised by the
consultant and 11% were happy to see any doctor without supervision.
Ninety per cent thought the seniority of the clinician was important.
Sixty-eight per cent expected to see the same clinician at a follow up
appointment and 84% thought this was important. Sixty-four per cent
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
said they are unlikely or would never ask a clinician about their seniority
and 20% were unlikely or would never ask to see the consultant. Eighty-
seven per cent expected to be seen within 30 min and 84% expected the
consultation to last up to 30 min.
Conclusions: The understanding of patients needs and expectations by
healthcare providers and patients awareness of the resources available
can together lead to mutual involvement in achieving patient satisfac-
tion.
F037
Provision of undergraduate otorhinolaryngology
teaching within General Medical Council approved UK
medical schools: what is current practice?
Khan, M. & Saeed, S.R.
Objectives: Despite longstanding concern, provision of undergraduate
ENT teaching has not improved in response to the aims of the UK Gen-
eral Medical Councils initiative Tomorrows Doctors. Previous studies
have demonstrated poor representation of ENT within the undergradu-
ate curriculum. We aimed to identify current practice in order to estab-
lish undergraduate ENT experience across UK medical schools, a timely
endeavour in light of the General Medical Councils new 20112013
education strategy.
Methods: Questionnaires were sent to ENT consultants, medical school
deans and students. All schools with a clinical curriculum were anony-
mously represented. Our outcome measures were the provision of man-
datory or optional ENT placements, and their duration and content.
Results: A compulsory ENT placement was available to over half (53%)
of the students. Ten of the 26 participating schools did not offer an
ENT attachment. The mean mandatory placement was 8 days. Overall,
38% of students reported a satisfactory compulsory ENT placement.
Most ENT consultants questioned considered that newly qualified doc-
tors were not proficient in managing common ENT problems that did
not require specialist referral.
Conclusions: Little improvement in the provision of undergraduate ENT
teaching was demonstrated. An increase in the proportion of students
undertaking ENT training is necessary. Time and curriculum constraints
on medical schools mean that optimisation of available resources is
required.
F038
Analgesic regimen and readmission following
tonsillectomy
Kishikova, L., Smith, M. & Fleming, J.
Objectives: To define the analgesic regimen given following tonsillec-
tomy in a large ENT department and correlate this with readmission for
secondary complications.
Methods: Case notes for patients undergoing tonsillectomy were col-
lected for the period between February and August 2011. Information
was collated and entered into a database including age, gender, opera-
tion type, indication, medications on discharge and details of readmis-
sion. Data was assessed for correlations, particularly that between
readmission and analgesic regimen given following tonsillectomy.
Results: One hundred and twenty-five patients underwent tonsillectomy
within the department during the 6-month period (mean age of
13.8 years, range 3 months65 years). The most common indication for
surgery was recurrent tonsillitis and the majority of procedures were car-
ried out with bipolar dissection. 64.8% of patients were discharged as a
 2012 The Authors

day case. Seventeen different post-operative analgesic regimens were
identified with the most common being a paracetamol and ibuprofen
combination (26.4%). 20.0% of patients had no documented analgesia
on discharge. Thirteen patients (10.4%) were readmitted following dis-
charge from hospital post-operatively, 4 (3.2%) for issues related to
pain. There was no correlation between analgesic regimens and readmis-
sion, including those without formal analgesic prescriptions.
Conclusions: No apparent link between readmission and analgesic regi-
men was identified. The lack of opioid analgesics does not appear to
affect readmission rates. However the vast variation of analgesic regi-
mens and lack of formal instructions for those advised over-the-counter
analgesics has prompted development of a formal step-based protocol.
F039
Can aviation style team training improve safety, quality
and efficiency in the operating theatre?
Khan, I., Changez, H., Owens, D. & McWilliams, B.
Objectives: To evaluate the effectiveness of the introduction of aviation
Crew Resource Management (CRM) training in the surgical operating
theatre setting with the use of tools like the Oxford Non Technical Skills
(NOTECHS) scale to improve theatre and patient safety.
Methods: Extensive literature review of current available evidence was
performed using MetaLib. All articles found within the last 10 years
where the concept of aviation style CRM was applied in the operating
theatre setting were included in the review. The review included five
studies published on this subject.
Results: A survey of 1033 medical staff on operating theatre attitudes
showed that only a third of respondents reported as errors being man-
aged appropriately. Four prospective uncontrolled observational studies
showed significant improvement in the NOTECHS score after aviation
style training was provided to the theatre staff by aviation style interac-
tive teaching sessions on non technical skills such as team working, lead-
ership, basic cognition, situation awareness, operative briefing and
communication.
Conclusions: The Oxford NOTECHs scale has been developed from a
similar tool used in aviation for CRM. This literature review shows posi-
tive impact on theatre safety of observations made by the use of this tool
after aviation style training has been applied. Theatre safety has
improved with the use of simulated theatres for training theatre staff
and the wide spread introduction and acceptance of WHO Surgical
Checklist. However, theatre safety can be made more effective by intro-
ducing similar models of non technical behavioural training which avia-
tion crew have to undertake.
F040
Improving nasendoscopy documentation departmen-
tal practice and minimum dataset recommendation
Ahluwalia, S., Heywood, R., Rana, I. & Papesch, M.
Objectives: Endoscopic visualisation of the upper aerodigestive tract is
standard practice amongst Otolaryngologists.
This is the mainstay of diagnosis and monitoring, particularly in Head
and Neck Oncology clinic, yet documentation of findings remains poor.
We reviewed our practice and improved it by devising a new minimum
dataset to encourage good practice and safe documentation.
Methods: Fifty consecutive notes were examined from patients who had
undergone nasendoscopy in Head and Neck clinic.
Findings were assessed and graded from a score of 22, according to pub-
lished requirements for a minimum dataset.
 2012 The Authors
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
Clinical Audit and Practice 27
A more manageable dataset was discussed and agreed. A departmental
stamp was commissioned (Figure 1). A short presentation at the
monthly meeting discussed previous results and the new method of doc-
umentation.
A month later, 50 notes were examined and assessed for adherence to
the new protocol.
Results: The initial collection demonstrated a mean score of 3 from 22,
range 80, SD 2.3, following implementation of the new minimum data-
set, subsequent collection resulted in a mean of 6 from a possible 10,
range 100, SD 3.9.
Analysis using an unpaired t-test demonstrated a statistically significant
difference P < 0.0001.
Conclusions: Our first data collection showed poor documentation was
commonplace, many simply recorded as NAD or FOL.
Introduction of a 10 point tick box stamped in the notes resulted in
great improvement in documentation. Any abnormality was recorded in
notes as previously.
This project has improved documentation of flexible nasendoscopic
examination findings in our Trust, benefitting both patients and staff.
F041
Clinically diagnosed branchial cysts: should they be fast
tracked?
Lee, R. & Wazeer, Z.
Objectives: To investigate the need to fast track branchial cysts diag-
nosed clinically because metastatic carcinoma in the cervical lymph node
can appear cystic, without a clinically apparent head and neck primary,
leading to delays in investigation and appropriate treatment.
Methods: Records of all patients with a clinical diagnosis of branchial
cyst between 1995 and 2009 were reviewed retrospectively. Patients with
a clinically apparent primary malignancy, a history of head and neck
cancer, and a history of irradiation were excluded from analysis.
Results: Fifty eight patients presented with an initial diagnosis of bran-
chial cyst. All were listed as routine cases for surgery with an average of
10 weeks between the Fine Needle Aspiration Cytology (FNAC) and his-
topathlogy results. Metastatic squamous cell carcinoma was demon-
strated histologically in four patients, and cystic papillary carcinoma of
thyroid in three patients after surgical excision (age range 2861).
Results of preoperative FNAC and imaging were negative for malignancy
in all seven cases. Pan endoscopy with directed biopsies revealed an
occult primary in the nasopharynx in two patients and in the tonsil in
one. No primary was found in one patient, despite repeated examina-
tions and close follow up.
Conclusions: Patients with a clinical diagnosis of branchial cyst should be
investigated and treated on an urgent basis as for malignancies irrespective
of age. Due to hypocellularity of cyst fluid a negative FNAC may be mis-
leading. Excision biopsy with directed biopsies of Waldeyers ring and
ipsilateral tonsillectomy should be performed in all such patients.
F042
Re-audit of urgent suspected head and neck cancer
referrals: from bad to worse!
Ah-See, K.L. & Hurman, D.
Objectives: A previous audit of referrals made via the SeCURE (Sus-
pected Cancer Urgent Referral Electronically) system in 2006/07, found
a low Head and Neck Cancer detection rate (15/190 = 8%). The present
study aimed to re-audit the numbers, diagnostic outcomes and quality
of referrals in 2010/11 for comparison with previous results.
28 Clinical Audit and Practice
Methods: A retrospective review of all SeCURE referrals made to the
Head and Neck Cancer Unit at Aberdeen Royal Infirmary over a
12 month period. Data collected on demographics, symptoms, clinical
signs, investigations and diagnostic outcomes.
Results: Only 23/372 (6%) of referrals resulted in a positive cancer diagno-
sis. Referrals for persistent oral ulceration had the highest positive sensitiv-
ity (23.5%), but other commonly referred alarm symptoms (hoarseness,
neck lump) had poor sensitivity. Many patients were inappropriately
referred, failing to comply with alarm symptoms criteria, for example 9%
of total referrals being made for feeling of something in the throat.
Conclusions: There is evidence of persisting poor compliance with refer-
ral guidelines. The recommended referral criteria and alarm symptoms
continue to demonstrate poor sensitivity for Head and Neck Cancer,
evidenced by the low cancer detection rate. Furthermore, this review
demonstrates that although referral rates have approximately doubled
(from 190 to 372) since the 2006/07 audit, the cancer detection rate has
actually decreased (from 8% to 6%). On the basis of this poor perfor-
mance, a review of the current guidelines and SeCURE system for urgent
cancer referrals is recommended.
F043
Audit of tonsillectomy/adenodectomies in <16 years:
Medical and nursing care pre, intra and post operation
Sonsale, A.P., Neil, F., Montio, M., Ali, S. & Deb, F.
Objectives: This study was to examine the impact of change in paediat-
ric patient admission environment on the post operative recovery.
Methods: To study the impact on paediatric patients of changes in their
admission we conducted a retrospective study comparing a group of
children admitted to a dedicated paediatric elective surgery ward with a
group the following year in which the patients were admitted in make
shift paediatric ward. We were interested in assessing whether the
changes in admission and post operative environment would have any
impact on the post-operative recovery of the children. This retrospective
audit involved children admitted for tonsillectomy with or without ade-
noidectomy over identical 3 months JanuaryMarch in 2007 and 2008,
to examine the post operative recovery and complications.
Results: Both haemorrhage and return to theatre rates increased from
0% to 8% and 6% respectively although neither of these increases can
be seen as statistically significant.
During the period of study the surgeons and surgical methods remained
the same, the only disparity being the environment in which the paedi-
atric patients were looked after the surgery.
Conclusions: There appeared to be a trend toward increased morbidity
in the group of children who were not cared for in a dedicated paediat-
ric ward which further support recommendation (Healthcare commis-
sion) regarding care of children in hospital. This audit confirms the
need for paediatric peri-operative care in child friendly and dedicated
paediatric area for smooth and uncomplicated recovery.
F044
Is it necessary to assess the adequacy of fine needle
aspirate samples in a neck lump clinic? A cost-benefit
analysis based on the East Berkshire Lump in the Neck
Clinic experience
Burgess, C., Dias, L., Maughan, E. & Moorthy, R.
Objectives: This audit project sought primarily to review the diagnostic
adequacy of radiologist-performed fine needle aspirate (FNA) samples
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
obtained in a neck lump clinic over a 6 month period. Factors associ-
ated with non-diagnostic specimens were analysed. A cost-benefit analy-
sis was conducted to determine whether the presence of a cytology
technician to assess FNA adequacy would be a useful addition to the
current clinic setup.
Methods: All ultrasound examinations and associated FNA samples
undertaken at the East Berkshire Lump in the Neck Clinic were reviewed
over a 6 month period by interrogating the local Picture Archiving and
Communication System (PACS) database as well as the electronic cytol-
ogy results database. The electronic casenotes of patients with non-diag-
nostic FNA specimens over this time were reviewed to establish their
outcomes.
Results: Four hundred and twelve ultrasound examinations and 258
FNA procedures were performed over the 6 month period. The overall
non-diagnostic rate was 21%. FNA adequacy was found to be related to
radiologist experience, and the tissue most likely to yield a non-diagnos-
tic FNA was a thyroid cyst. Twenty per cent of non-diagnostic speci-
mens were subsequently found to be associated with malignancy; of
these 64% were lymphomas.
Conclusions: The majority of initially non-diagnostic FNAs are not asso-
ciated with a subsequent diagnosis of cancer. Although the addition of
an on-site cytology technician to assess FNA adequacy may reduce the
non-diagnostic rate of our neck lump clinic, the calculated reduction in
clinic efficiency and patient throughput is likely to outweigh this poten-
tial benefit.
F045
Post tonsillectomy take home analgesics is our
practice standardized and cost efficient?
Mushi, E. & Winter, S.
Objectives: We aimed to assess the variability and cost of take home
post tonsillectomy pain relief medications and improve the cost effi-
ciency and standardization of these prescriptions.
Methods: We retrospectively reviewed pain relief medications prescribed
to take home for adult patients undergoing tonsillectomy in a district
general hospital ENT department. We analysed the duration of the given
analgesics as well as the overall cost. Following the results of our first
cycle we introduced pain relief care bundles and reassessed the prescrip-
tions.
Results: Fifty-one patients prescriptions were initially analysed. There
were 15 variations of pain relief medication bundles amongst eight dif-
ferent drugs. The cost varied between 1.51 and 6.36. Following the
introduction of a post tonsillectomy pain relief bundle the result of the
second cycle of the study showed the latter was used in 96% of the
patients at a total cost of 1.57.
Conclusions: Introducing an analgesic bundle in the department
achieved cost efficient standard prescriptions without compromising the
post operative morbidity rate.
F046
Is the use of steroids in adults admitted with tonsillitis
and peritonsillar abscess appropriate and justified?
Mushi, E. & Morrison, S.
Objectives: We aim to review the current practice in our tertiary centre
ENT department regarding steroid prescriptions in patients admitted
with tonsillitis and/or peritonsillar abscess. Following literature search
we want to establish guidelines on best practice regarding the prescrip-
 2012 The Authors

tion of steroids and evaluate in the second audit cycle the adherence to
those guidelines. Furthermore we aim to assess in the third cycle
whether steroid administration shortens hospital stay by swifter pain res-
olution.
Methods: We conducted a retrospective review of 100 case notes in
order to assess the frequency, dosage, route and indications of steroid
prescription. The results were discussed in the monthly audit meeting.
An extensive literature search was conducted and based on that guide-
lines were established.
Results: Prescription of steroids was shown to be random and prescriber
dependant. Literature search reveals that steroids can improve pain relief
in patients with sore throat. Common opinion is that they ought to be
used with caution as they may mask other signs of severe infection or
abscess.
Conclusions: We are currently compiling prescription guidelines using a
combination of literature search and expert opinion and will be shortly
auditing guideline adherence in order to establish best clinical practice
in our department.
F047
Can the apnoea-hypopnoea index and severity of
obstructive sleep apnoea be predicted from body mass
index and the Epworth sleepiness score?
Dykes, M., Soni-Jaiswal, A. & Kumar, N.
Objectives: The extent of obstructive sleep apnoea (OSA) can be reliably
measured by determining the apnoea-hypopnoea index (AHI). The aim
of this study is to assess if there is a correlation between the AHI and
simple measurable variables including body mass index (BMI), Epworth
sleepiness score (ESS) or in combination to predict the presence of
obstructive sleep apnoea (OSA).
Methods: This is a retrospective study of 50 patients (average age
46.7 12.0 years) with snoring and/or apnoea. Forty-nine patients were
overweight (BMI 2430 in 23 patients) or obese (BMI > 30 in 26
patients) and underwent an apnoeagraph. An apnoeagraph is a test that
is performed on an overnight domiciliary basis and can demonstrate the
extent of OSA through accurate estimation of the AHI. This study aimed
to evaluate a possible relationship in this patient population between
AHI values and BMI, ESS, age. Pearsons correlation and Spearmans
correlation coefficients were calculated.
Results: No linear relationship between AHI and BMI was present.
There was no linear relationship between ESS and age with AHI.
Conclusions: We conclude that it is not possible to predict the AHI and
thus the presence or severity of OSA from ESS, BMI, or age.
F048
Managing acute nasal injury: retrospective study of
practice in a tertiary centre
Kermanshahi, M.S., Dannatt, P., Abdalla, H. & Arshad, F.
Objectives: Nasal Fractures are one of the commonest Emergency
Department (ED) referrals to the ENT outpatients clinic. The aim of
this audit was to evaluate whether nasal injuries are being referred
appropriately to the ear nose and throat clinic within the nationally
agreed time frame (714 days). Furthermore, we devised a referral path-
way for the ED doctors to use.
Methods: We performed a retrospective audit of 49 patients referred to
ENT Casualty clinic over 2 months period for nasal injury. Descriptive
 2012 The Authors
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
Clinical Audit and Practice 29
statistics were used to analyze the data. A referral pathway poster was
devised and placed in the ED. A re-audit was performed in 2 months.
Results: Forty per cent of referred patients had nasal fractures. Seventy
per cent are males. No septal hematomas. Thirty per cent had closed
reduction under local anaesthetic. 40.8% of the referrals were out of date
with an average of 4.85 days interval between time of injury and ENT
Casualty clinic.
Conclusions: We found that the referrals for nasal injuries are too early
which does not allow the swelling to decrease, or allow optimal cosmetic
results. Closed reduction under local anaesthetic seems to be a good
method of management. A marked improvement in the referral system
has been noticed after the minor intervention introduced to the ED.
F049
An audit investigating the effect of the GP proforma
on adherence to the sign guidelines for tonsillectomy
for recurrent tonsillitis
Cartlidge, D. & Robson, A.
Objectives: To compare the effect of introduction of a GP proforma for
referral to ENT outpatient clinic for consideration for tonsillectomy for
recurrent tonsillitis on the adherence to the SIGN guidelines.
Methods: Retrospective audit of patients who underwent tonsillectomy
over 11 months prior to introduction of GP proforma and 11 months
following the introduction of the proforma. Inpatient notes were
retrieved and compared with the SIGN guidelines criteria for tonsillec-
tomy.
Results: Two hundred and ten tonsillectomy patients were reviewed: 103
patients (65.6%) underwent tonsillectomy prior to introduction of the
GP proforma, and 107 patients (62.2%) following introduction of the
proforma. 78.6% of the 210 patients were referred originally by the GP,
but only 23 (27.4%) of 84 patients referred by GP after introduction of
the proforma actually used the proforma. Of the 23 patients referred
with the proforma, documentation of the number of episodes of tonsilli-
tis met the SIGN 117 criteria in 91.4% of cases compared to 45.2% of
patients referred by GPs without the proforma. 69.6% of the 23 patients
referred by the GP proforma had clearly documented disabling episodes
of recurrent tonsillitis whose frequency of episodes were not reducing, as
compared to 60.7% of patients referred by GPs without using the pro-
forma.
Conclusions: Overall adherence to the SIGN guidelines appears better
since the introduction of the GP proforma but low uptake of the pro-
forma was found. GP practices will be requested to use the proforma
more stringently and re-audit will be planned after a suitable time period.
F050
Evaluation of a joint surgeon and radiologist one-stop
clinic in the management of 2 week wait neck lump
referrals.
Takhar, A., Jones, M., Vaidhyanath, R., Conboy, P.
& Alun-Jones, T.
Objectives: Our aim was to demonstrate the efficacy of our joint sur-
geon and radiologist one-stop clinic in assessing neck lumps where
ultrasound and guided fine needle aspiration cytology is available. We
compared this to our conventional outpatients clinic and subsequently
audited the impact of increasing provision of the one-stop model.
Methods: A prospective two cycle audit of new 2 week wait neck lump
referrals between 1st November 2010 and 31st August 2011.
30 Clinical Audit and Practice
Results: A total of 152 patients were referred with a lump, during the
first cycle of the audit 26.4% were seen in a one-stop clinic compared
to 72.5% in the re-audit. 19.7% of patients were diagnosed with cancer
and half were seen in each clinic. The average time to diagnosis across
both audit cycles was 29.1 days in a conventional clinic compared to
10.8 days in the one-stop clinic (P < 0.0001) and the average number
of outpatients appointments required was 1.89 and 1.52 respectively
(P = 0.001). The time to diagnosis for all clinics was reduced from an
average of 24.515.8 days in the re-audit (P < 0.05) and outpatient
appointments reduced from 1.85 to 1.58 (P < 0.05). The longest time to
a cancerous diagnosis was reduced from 107 to 37 days.
Conclusions: Our one-stop clinic is a more efficient way of assessing
neck lump referrals and by increasing provision of such a service we
have significantly reduced the time to diagnosis, and the number of fol-
low up appointments required which has marked benefits to both
patients and limited healthcare resources.
F051
Doctor who?
Amin, N., Bewick, J. & Das-Purkayastha, P.
Objectives: Communication errors are suggested to be at the heart of
many patient complaints within the NHS. Within ENT junior doctors
often treat patients within the outpatient setting. In order to build rap-
port with patients from the outset of any consultation, doctors should
be courteous and polite by introducing themselves.
This study looks at the value patients consider formal introductions are,
whether junior doctors actually do introduce themselves and finally if
they do, does the patient recall the name and position at the end of the
consultation.
Methods: A prospective blinded study over 14 days. Within the outpa-
tient setting, doctors were blindly observed by the clinic nurse and at
the end of the consultation patients were asked to fill a questionnaire
about the consultation.
Results: Eighty-five patients completed the questionnaire.
Patients stated that the importance of knowing their doctors name was
4/5. 95.3% of patients stated their doctor appropriately introduced
themselves
Only 44.7% knew their doctors name, however, 76.5% knew their
named consultant. Twenty-two per cent (11/50) of patients that saw a
middle-grade/SHO knew the name of that doctor and 52% of these
patients knew their consultant but not the doctor they saw.
Conclusions: With the large number of complaints associated with poor
communication it is our duty as doctors to ensure that measures are
taken to address an important communication issue for patients.
Patients stated more regular visualisation of doctors name would help
them remember their doctors name.
F052
Merkel cell carcinoma (MCC): need for a common
protocol
Lembo, F., Domenico, P., Luigi, A., Arianna, M.,
Antonella, C. & Aurelio, P.
Objectives: Merkel-cell carcinoma (MCC) is a rare primary neuroendo-
crine skin cancer and is considered to be the most aggressive cutaneous
malignant tumour. Because of its rarity, management guidelines are not
well defined. We report our experience in the treatment of MCC.
Methods: From January 2000 to January 2010, we treated at Our
Department six patients (3F, 3M; mean age 62 years) with MCC. Five
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
tumours were localized in the head and neck region, and one in the leg.
Mean dimension was 4.6 2.7 cm. In all cases we performed a wide
incision from 1.5 to 2 cm. In five cases a delayed sentinel lymph node
biopsy (SLNB) was performed: four were classified as stage I and were
treated with adjunctive radiotherapy; one patient classified as stage III
was treated with adjunctive chemotherapy. One patient refused SLNB
and we decided, anyway, to perform adjunctive radiotherapy.
Results: To date (minimum follow-up 12 months) all patients treated
by surgery plus adjunctive radiotherapy are alive and free from local or
distance disease. The only patient classified as stage III, died 8 months
later because of metastatic neoplasm diffusion.
Conclusions: In our series, the early diagnosis and the multidisciplinary
approach seem to lead to a better prognosis. We believe that adjunctive
radiotherapy would allow to perform a less aggressive surgical approach,
so loco-regional integrated approach seems a good option to function-
conservative treatment of this kind of head and neck cancer.
F053
Effect of Bupivacaine infiltration post-tonsillectomy on
complications and re-admission rates
Junaid, M. & Takwoingi, Y.
Objectives: There is conflicting evidence regarding the benefit of Bupiva-
caine (Marcain) infiltration post-tonsillectomy. We found no evidence
in literature regarding the effect of Marcain on complications and re-
admission rates. Our aim was to determine the rates of complications
and re-admissions between two surgeon groups (non-Marcain versus
Marcain).
Methods: A retrospective analysis of all tonsillectomies performed in
2010 by four surgeons, two in each group, was undertaken. Patients
were identified using theatre logbooks. Only operations performed by
the named surgeon were included in the study. We used a combination
of case notes and electronic records to collect and analyse data regarding
re-admissions and complications post-tonsillectomy.
Results: A total of 300 tonsillectomies were performed during 2010 in
our hospital. For the purpose of this study, and to ensure consistency,
we only included 195 cases performed by consultant and associate spe-
cialist surgeons. The cohort had a median age of 7 years (range 2
56 years). Group one (non-Marcain) had a total of 97 patients, and
group two (Marcain) had 98 patients. Group one had three episodes of
primary haemorrhage, and group 2 had one (P-value = 0.3685). Sixteen
patients were re-admitted post-operatively, eight in each group. There
were four secondary haemorrhage episodes in each group, and three re-
admissions each for pain.
Conclusions: We found no statistically significant difference in primary
haemorrhage, secondary haemorrhage or re-admission rates between the
two groups. Based on this study, we can conclude that the use of Marc-
ain in tonsillectomy has no significant impact on post-operative morbid-
ity, and its routine use is therefore not recommended.
F054
Is there a requirement for antibiotics prophylaxis
in nasal packing for epistaxis?
Bell, P., Breslin, S., Taylor, G. & Cullen, J.
Objectives: There is a wide variation in UK prescribing practice regard-
ing prophylactic antibiotics for nasal packing in spontaneous epistaxis.
The purpose of this study was to assess the requirement for prophylactic
antibiotics in spontaneous epistaxis treated with nasal packing.
 2012 The Authors

Methods: A retrospective analysis of 80 sets of patient notes over a per-
iod of 6 months was carried out. The requirement for nasal packing,
pack type, duration of packing and hospital stay, antibiotic type and
duration, as well as any complications related to either antibiotic side
effects or nasal packing where recorded.
Results: Ninety per cent of patients attending with epistaxis underwent
nasal packing (89% Rapid Rhino/11% Merocel). The duration of pack-
ing ranged from 1 to 10 days (average 3.3) with hospital stays ranging
from 1 to 10 days (average 3.8). Of those that were packed 83% received
oral antibiotic prophylaxis for between 1 and 7 days with only 7% com-
pleting a full course of oral antibiotics (95% discharged on naseptin).
Over 1% of patients developed complications as a result of antibiotic
use; however no evidence of sinusitis or other complications of nasal
packing were noted.
Conclusions: We have not found any evidence to recommend the rou-
tine use of prophylactic antibiotics for patients requiring nasal packing
for spontaneous epistaxis. In this study approximately 1% of patients
suffered from antibiotic related complications with one patient develop-
ing Clostridium difficile. If antibiotics are commenced a full course
should be completed to help reduce microbiological resistance and avoid
the potential complications associated with multiple courses of
antibiotics.
F055
Tonsillectomy consent: can teaching improve the
consenting process?
Bell, P., Breslin, S., Hamilton, L. & Cullen, J.
Objectives: The purpose of this study was to review the current consent
process in Northern Ireland (NI), find ways to improve efficiency and
standardisation and assess the effect of teaching sessions on the consent-
ing process for tonsillectomy.
Methods: A retrospective analysis of 70 sets of patient notes was carried
out at three ENT centres in NI. Consent forms were scrutinised for com-
plications outlined by ENT UK. Several other components of the consent
form including the timing of consent and the grade of those taking con-
sent was noted. A teaching session on consent was provided at each centre
and a repeat analysis on a further 70 sets of notes performed.
Results: Initial analysis showed 48%, 56% and 66% of consent forms to
have been correctly completed based on the pro forma produced at the
three centres respectively. Following teaching sessions the consent taking
practice across the three centres improved by an average of 9%. There
was considerable variation in the grade of doctor taking consent across
centres with an average of 83% of patients being consented at clinic.
Consent was not documented in any of the patient notes reviewed.
Conclusions: Consent practices vary widely across ENT centres in NI.
Provision of teaching sessions can lead to improvements in the consent-
ing process. We recommend the use of prefabricated consent stickers as
this improves both the efficiency and standardisation of the consent pro-
cess. We also reiterate the need for doctors to document consent in both
the patient notes and the consent form.
F056
Consenting for risk in common ENT operations an
evidence based approach
Smith, M., Lakhani, R. & Bhat, N.
Objectives: To assess the consent process for the four most commonly
performed procedures against the relevant evidence base.
 2012 The Authors
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
Clinical Audit and Practice 31
Methods: Review of the literature (Medline, Embase and Cochrane data-
bases) to obtain information regarding the relevant risks for Grommets,
Tonsillectomy, Septoplasty and Hemithyroidectomy. Thirty consecutive
cases were selected for each type of operation investigated (120 in total)
and consent forms and clinic letters were analysed.
Results: Senior surgeons consented for fewer complications. SHOs
rarely consented. There is limited and variable quality evidence relating
to operative risk. Grommets: Re-operation (30%), discharge (11%) and
tympanosclerosis (2535%) are the most frequently reported complica-
tions in the literature. Residual perforation was most commonly con-
sented for (80%) in our patients with a reported literature rate (LR)
2.2%. Discharge was consented for in 27% of cases. Cholesteatoma was
never consented for despite a 0.7% LR. Tonsillectomy: Bleeding was
reported to occur in 3.5% of tonsillectomy and all our patients were
consented for this. Dental damage (035% LR) was only consented for
in 50%. Only 3% were consented for taste disturbance (LR 8%). Sep-
toplasty: Bleeding (LR 9.125%) was consented for in 97% of our opera-
tions. Septal perforation (77%) and cosmetic change (43%) were the
next most common complications to be consented for in our patients
(LR 510% each). Thyroidectomy: Recurrent laryngeal nerve injury (LR
13%) was consented for in all our patients. Hypocalcaemia and hypo-
thyroidism (LR 1.1% and 14.3%) were almost never consented for.
Conclusions: Published data suggests that some complications that are
currently infrequently consented for should routinely appear on the con-
sent form.
F057
Tonsillectomies: are they being delayed since becoming
a procedure of low clinical priority (PLCP)?
Duodu, J., Dalton, L. & Hampal, S.
Objectives: The objective of this study was to ascertain if tonsillectomies
are being delayed since becoming PLCPs.
Methods: A retrospective case-note review was carried out on 50 tonsil-
lectomy cases before (Group A) and 50 tonsillectomy cases after (Group
B) the introduction of policy changes deeming tonsillectomy a PLCP in
April 2010. Data collection included age at operation, gender, referring
primary care trust (PCT), complications, and dates of referral, first clinic
visit, primary care trust approval and operation.
Results: Both cohorts had similar demographics and waiting times
between referral and clinic appointment. However, Group A waited a
mean 52 days between listing and having their tonsillectomy, whilst
Group B waited a mean 94 days. Within Group B, patients came from
five PCTs, of which one (PCT1) required prior approval for each case.
Interestingly, when PCT1 was compared with the others in Group B
(PCT25 collectively), PCT1 had the longest mean waiting time of
101 days compared to 78 days.
Conclusions: Since tonsillectomies became PLCPs, patients are waiting
longer, especially those under PCT1 as approval is sought for each case.
No documented interim hospital visits or complications were found,
however increased morbidity in the community is likely during this delay.
F058
Hoarseness secondary to haemodialysis
Santhirakumar, M., Phua, C. & Karagama, Y.
Introduction: Hoarseness is a common occurrence and can have major
impact on a patients quality of life. We report a rare case of hoarseness
secondary to haemodialysis.
32 Clinical Audit and Practice
Methods: Case report: A 62 year old gentleman was referred by his
GP with hoarseness related to the onset of haemodialysis. He under-
goes dialysis three times a week and describes developing hoarseness
at the end of each session which persists until just before the next
session. He is dialysis dependent due to hepato-renal syndrome and
acute tubular necrosis. He also suffers atrial fibrillation, alcoholic liver
disease and is a non-smoker. On fibreoptic nasoendoscopy performed
after a dialysis session, he had incomplete glottis closure due to bow-
ing of vocal cords. CT neck and thorax showed no abnormalities.
The patient underwent speech therapy with little improvement. Dis-
cussion with nephrologists concluded that it was not possible to
change his dialysis regime. The patient subsequently underwent injec-
tion laryngoplasty with Calcium Hydroxyapatite with marked improve-
ment of his symptoms. Follow up at 3 weeks showed sustained
improvement.
Results: A literature search resulted in one article which demonstrated
60% of patients suffer post-dialysis hoarseness and showed decrease in
vocal fold thickness post-dialysis [1]. It is therefore postulated that dialy-
sis causes dehydration of the Reinkes space affecting the vocal fold
thickness and the patients voice [1]. This is a likely explanation for our
patients hoarseness.
Conclusions: Hoarseness caused by haemodialysis is very much an
uncharted territory. Further study is under progress to determine its
prevalence and factors leading to this occurrence.
F059
Simulation of airway emergencies in otolaryngology:
the Freeman experience
McNeill, E., Ramakrishnan, Y., Killick, N. & ONeill, S.
Objectives: The ability to appraise and manage airway emergencies is
critical in otolaryngology. The traditional surgical training model of see
one, do one, teach one has limitations in such relatively infrequent sce-
narios. Trainees may acquire airway skills at practical courses, using
mannequins and animal models. High-fidelity simulation mannequins
are gaining prominence in testing clinical and decision-making skills in
realistic training scenarios, but are largely the preserve of anaesthesists.
Cost issues and the need for specialist equipment means access to
resources can be limited. We have developed a low-fidelity training pro-
gramme that is easily accessible to trainees and simple to administrate,
with the objective of increasing confidence of participants in managing
airway emergencies.
Methods: Participants: Trainees in Otolaryngology and Anaesthesia in a
tertiary referral hospital.
A half-day programme in managing airway emergencies was developed
between the Otolaryngology and Anaesthetic departments. The technique
of surgical cricothyroidotomy was taught, using an artificial larynx
model. Algorithms based on two complex airway scenarios (blocked/dis-
placed tracheostomy and cant intubate, cant ventilate) were discussed.
The trainees then completed moulage scenarios with verbal feedback
from supervising senior doctors. Confidence in managing airway emer-
gencies was evaluated prior to and following training using a Likert
scale.
Results: Previous exposure to airway emergencies was variable between
trainees. Universally, the trainees described a marked improvement in
confidence following the practical and moulage sessions.
Conclusions: A low-fidelity simulation-based training of airway emer-
gencies can be effective in improving the confidence, knowledge and
technical skills of Otolaryngology and Anaesthesia trainees.
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
F060
Quality of life of binaural versus monaural hearing aid
use
Walijee, H., Davies, N. & J Howarth, A.
Objectives: The audiological benefits of binaural hearing aid (HA) use
are well recognised. This study looks at the difference in quality of life
(QoL) for binaural versus monaural HA use. This has not previously
been described.
Methods: An analysis of a random selection of patients with bilateral
sensorineural hearing loss attending for HA fitting over a 5 year period
was carried out prospectively. The Glasgow Hearing Aid Benefit Profile
(GHABP) was used to assess QoL prior to, and 6 months following HA
fitting for patients with both monaural and binaural aids
Results: Amongst the 350 patients looked at, 195 were binaural fits and
155 monaural fits. No significant difference was seen in QoL (P = 0.749
calculated using unpaired T-test). Subgroup analysis demonstrated no
difference in QoL with degree of hearing loss, age, or change in hearing
disability following HA fitting.
Conclusions: Although NICE guidelines recommend binaural HA fitting,
this study demonstrates that this may not significantly improve quality
of life. It is important to distinguish audiological benefit from real-world
benefit. Since 1.4 million individuals in England and Wales currently
have HA, there is a significant cost implication in the provision of bin-
aural HA for every patient. This may be difficult to justify at a time of
increasingly limited resources unless there is a clear benefit to the
patient.
F061
Complete audit cycle achieving the commissioning for
quality and innovation payment framework (CQUIN)
for venous thromboembolism (VTE) assessment for
adult ENT admissions
Carr, E., Hoskison, E. & Marshall, A.
Objectives: Venous thromboembolism (VTE) causes significant morbid-
ity and mortality in the NHS. An estimated 25 000 NHS inpatients in
England died from VTE related complications in 2005. VTE prevention
is a clinical priority with National Institute of Clinical Excellence (NICE)
guidelines on its prevention and treatment. The Commissioning for
Quality and Innovation payment framework (CQUIN) is a reward
scheme which pays an increment to providers if they achieve agreed
goals, including reducing VTE related morbidity and mortality in adult
inpatients. This is measured by the percentage of patients undergoing a
VTE risk assessment upon admission. Local payment is rewarded if
>90% of patients are assessed monthly.
Methods: Adult ENT inpatients were risk assessed for VTE upon admis-
sion at Nottingham University Hospitals between April and July 2011.
Compliance with the CQUIN target was assessed weekly using a com-
puter generated programme. Interventions were installed and the audit
repeated from August to November 2011.
Results: During the first 4 months of VTE risk assessment, a mean per-
centage achieved was 64.8%. Post interventions, this increased to a mean
percentage of 92%, achieving the CQUIN target.
Conclusions: Compliance with the CQUIN targets can be achieved
through interventions including checking that the correct cohort of
patients is being assessed, education of junior doctors at induction and
a systematic review and modification of the computer algorithm used
for data analysis.
 2012 The Authors

F062
Evaluating the quality of Internet health resources
in ear, nose and throat surgery
Goslin, R.A. & Elhassan, H.A.
Objectives: Many patients use the Internet as a source of health advice,
despite its content being unregulated and uncontrolled. We evaluated
the quality of written information about ear, nose and throat (ENT)
conditions available to patients on the Internet.
Methods: The terms cholesteatoma, sinusitis and tonsillitis, repre-
senting three common ENT conditions, were entered separately into the
search engine Google. Websites satisfying the inclusion criteria from the
first 30 results of each search were evaluated for content quality using
the DISCERN rating instrument.
Results: Of the 90 websites identified, a total of 66 (73.3%) satisfied the
inclusion criteria and were suitable for analysis. Out of a maximum
score of 80, the mean overall DISCERN score was 40 (range 1868). The
DISCERN instrument rated websites as excellent (1.5%), good (15.2%),
fair (28.8%), poor (31.8%) and very poor (22.7%).
Conclusions: There is variability in the quality of written information
about ENT conditions on the Internet; the majority (54.5%) is poor or
very poor and only 16.7% of ENT websites were good or excellent. ENT
professionals may be required to identify quality information resources
for patients or be vigilant to information gleaned from inadequate
websites.
F063
Audit of surgical management of otitis media with
effusion
Dhillon, B. & Easson, A.
Objectives: We aimed to audit local practice against NICE Guidance on
surgical management of Otitis Media with Effusion (OME). We looked
at the documentation of insertion criteria, examination findings and
adherence to the guidance for grommet insertion.
Methods: Data was collected using proforma based on NICE Guidelines.
Patients identified as having undergone myringotomy and grommets.
Case notes reviewed for data collection.
Results: Forty-four patients identified, age range 214 years old. Forty
patients had documentation of main symptoms associated with OME,
the most common being poor listening skills, hearing fluctuation and
recurrent ear infections. Thirty-two per cent had no documentation of
ear examination while 55% had documented tympanic membrane evi-
dence of OME. Ninety-one per cent had no documentation regarding
upper respiratory health and 98% had no documentation of general
development. 81.8% had documented tympanogram data and 84.1%
had documented audiogram data pre-operatively. Only 63.6% cases ful-
filled NICE criteria based on hearing levels and 40.9% based on symp-
toms duration. Thirty-four per cent had adjuvant adenoidectomy at
time of grommet insertion. Average time to follow-up was 12.07 weeks
and 61% cases showed improvement in hearing levels at time of follow-
up. Rate of grommet extrusion was 3.313.8% and infection rate was
3.5%.
Conclusions: Our audit results show that there is poor documentation
of examination findings in notes and clinic letters. Also audiometric data
was not available in all cases eventhough it is a criteria for grommet
insertion. The majority of patients showed a benefit following insertion
which maintains it a good intervention in OME with hearing impair-
ment.
 2012 The Authors
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
Clinical Audit and Practice 33
F064
Correlation of fine needle aspiration cytology with
histopathologic results in the management of a series
of benign parotid gland tumours
Velala, S., Olaleye, O. & Cable, H.
Objectives: To ascertain correlation between the pre-operative FNAC
results of benign parotid gland tumours with the final histopathologic
diagnoses following surgery.
Methods: A retrospective review of both FNAC and histopathologic
results of 56 benign parotid gland tumours managed between January
2006 and January 2011.
Results: Fifty-six parotid tumours with both fine needle aspiration cytol-
ogy (FNAC) and corresponding histopathology results were reviewed.
Age range 1881 years with male: female ratio of 1 : 1.2. Surgery per-
formed was superficial parotidectomy (51), total parotidectomy (3),
lumpectomy (1) and cystectomy (1).
FNAC results included (N = 56): Pleomorphic adenoma (40), Warthins
tumour (12), abscess (2), Monomorphic adenoma (1), Benign cyst (1),
Final histopathologic results confirmed all the 56 tumours (100%) as
benign and confirmed 49/56 (87.5%) FNAC results in 36/40 Pleomor-
phic adenomas, 11/12 Warthins tumour, 1/2 abscess, 1/1 monomorphic
adenoma, and 0/1 benign cyst. Five inconclusive FNAC results were
excluded from this analysis but were confirmed on histopathology as
Pleomorphic adenoma (3), Warthins tumour (1) and chronic inflam-
mation (1).
7/56 (12.5%) FNAC results were incongruous with the histopathologic
results. Of the seven incongruous FNAC results, there were pleomorphic
adenoma (4) finally confirmed on histopathology as monomorphic basal
cell adenoma (3) and reactive benign lymph node (1).
Conclusions: This study demonstrates 100% identification of benign par-
otid disease by FNAC and 87.5% correlation of FNAC from benign par-
otid tumours with final histopathologic results, consistent with current
literature. A recent meta-analysis confirms FNAC remains a very useful
diagnostic tool in the management of parotid tumours especially in dif-
ferentiating benign from malignant disease.
F065
Basic management of epistaxis in Russells hall hospital
emergency department
Ewan, L. & Jindal, M.
Objectives: To identify the standard of basic management of epistaxis in
RHH A&E and the indications for referral to inpatient ENT services and
outpatient follow up clinic.
Methods: This was a retrospective study of 35 patients presenting with
epistaxis or nosebleed. Management was audited against standard
practice identified in current literature.
Results: Of 35 patients with epistaxis 15 were admitted under ENT with
anterior nasal packing in place. Of those discharged, five were referred
to an ENT clinic for management of risk factors for epistaxis. One hun-
dred per cent had basic observations performed in A&E. Seventy-four
per cent of practitioners identified risk factors for epistaxis and 60%
commented on the bleeding point. Only 28% commented on the likely
quantity of blood loss. Of 15 patients presenting with active bleeding, 9
(64%) were given IV access. Of these, six patients were given IV fluids.
Routine blood tests were performed in 54% (19). One hundred per cent
of patients on warfarin had an INR check. The interventions used by
A&E practitioners for the 15 patients with active bleeding were either
anterior nasal packing (40%, six patients) or nasal cautery (27%, four
34 Clinical Audit and Practice
patients). Thirty-three per cent of patients with active bleeding had no
definitive intervention before referral to ENT.
Conclusions: Risk factors for epistaxis were consistently identified and
IV access was gained appropriately in the majority with active bleeding.
Improvements include better quantification of haemorrhage, early defini-
tive management in A&E and provision of cohesive advice for patients
on discharge from A&E. This audit will be repeated following provision
of advice and further training to A&E SHOs.
F066
A year in the life of an ENT theatre an audit of
practice a decade apart
Parker, W., Beckett, V., Parker, G. & Parker, A.
Objectives: To compare ENT theatre activity in a large teaching hospital
over a 10 year period and determine the important changes and impact
on practice.
Methods: We obtained records for an ENT theatre undertaking adult
and paediatric surgery pertaining to a 12 month period and recorded
patient age and procedures performed (n = 938). This was repeated for
a similar period 10 years later (n = 1117, total 2055). We chose 1960
and 1970 because the separation in time reflected exciting developments
in the specialty e.g. grommets, stapedectomy.
Results: Adenotonsillectomy was the commonest procedure (28% of all
procedures 1960, 22% 1970). The return to theatre rate for this proce-
dure reduced over time (3.3%, 0.43%) and has been maintained. Ade-
noidectomy alone became more popular over time (0.9%, 3.0%). Major
head and neck procedures were rare (0.1%, 0.1%). Modified radical
mastoidectomy (0.9%, 1.4%) largely superseded the radical operation
(1.8%, 0.3%). Grommets became popular during this decade (0%,
5.4%). Fenestration (0.6%, 0.1%) and stapes mobilisation (4.7%, 0.0%)
were the surgical treatments for otosclerosis in 1960, replaced by stape-
dectomy (0.1%, 1.7%) by 1970. The first stapedectomy in Sheffield was
carried out on a 53 year old male in 1960, 4 years after the first in the
world.
Conclusions: Over this decade the shape of ENT surgery changed signifi-
cantly. Better techniques permitted more delicate and complex proce-
dures, laying the foundation for modern otorhinolaryngology and
subsequent microscopy, imaging and excisional techniques. Surgeons
should be aware of this medical and technical evolution with subsequent
benefit to clinical practice.
F067
Audit of division of tongue ties in a single consultants
clinic
Dhillon, B., Dawson, R. & Clarke, S.E.
Objectives: To assess indications for tongue ties in line with NICE Guid-
ance. To assess main clinical findings on examination and outcome from
procedure.
Methods: Patients identified from database kept by consultant in clinic
(January 2008December 2011). A retrospective analysis of clinical notes
and clinic letters undertaken to obtain information for audit. Patients
were contacted where available to assess outcome of procedure (all
patients consented for involvement in audit at time of consultation).
Results: Sample size 118 patients, three of whom did not have complete
information available. Mean age of infant at time of presentation to
clinic was 21.97 days (range 4179 days old). Main complaints by
mother were poor latch (94.07%), prolonged feeding time (71.19%),
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
failure to thrive/gain weight (16.1%), nipple soreness (31.36%). At time
of presentation patients were being fed alone or in combination by
breast (74.58%), expressed breast (50.85%) or formula (33.9%). The
main findings on examination were tongue tie (100%) and high arched
palate (16.52%). After division, 76.52% found immediate improvement
in breast-feeding, 20% of the children were too tired to feed in clinic,
and 3% found no improvement. Division was performed by the consul-
tant (90.43%), middle grade (4.35%) or supervised trainee (5.22%).
Conclusions: Procedure has good rate of positive outcome when done
appropriately for indication. No associated morbidity seen in our patient
set. Limitation of this audit is not including patients who did not
require procedure to comment on rate of appropriate referrals; also no
access to initial referral letter to assess quality of referral.
F068
An audit on the use of caloric testing in the
management of dizziness
Davey, S. & Kirkland, P.
Objectives: Patients referred to ENT clinic with dizziness continue to
account for a significant proportion of GP referrals. Caloric testing is
often used as confirmatory evidence of a vestibular aetiology. The objec-
tives were (1) to retrospectively assess the need for caloric testing at our
District General Hospital, and (2) to ascertain whether referrals were
made appropriately.
Methods: Two sets of standards were devised, those set locally by our
department and others from the British Society of Audiologys guidelines
on vestibular function testing (2010). The department of Audiology pro-
vided a computer spreadsheet of all patients tested between October
2009 and October 2010.
Results: A total of 31 referrals were made between the ENT department
and Audiology during the time period. Approximately two thirds of
referrals were females. Fewer than 70% of tests requested were carried
out, with 47.4% of these proving to be abnormal. The mean length of
time from first clinic appointment to discharge was approximately
28 weeks, this being notably longer when compared with non-referred
cases. Of the patients that were tested, 58% had no alteration to their
management. A significant proportion of patients symptoms resolved
during the waiting period (average wait 105 days).
Conclusions: It is the conclusion of this audit, that many patients were
subjected to a prolonged illness during the interval between referral and
testing. Implementation of our recommendations resulted in, (1) reduced
length of symptoms, (2) greater efficiency of the Audiology department,
and (3) considerable cost saving as new equipment not required.
F069
Pre- and post-operative assessment of voice in
thyroidectomy patients: an audit cycle
Dixon, H., Amin, N., Lindisfarne, E., Gibbins, N.
& Harries, M.
Objectives: Recurrent laryngeal nerve damage is a potentially devastating
complication of thyroidectomy and can end a career for the professional
voice user. Thyroidectomy is performed by both ENT and general sur-
geons. The British Association of Endocrine and Thyroid Surgeons
(BAETS) recommend pre-operative laryngoscopy in thyroidectomy patients.
We present a closed-loop audit of pre-operative fibreoptic vocal cord
checks to determine whether implementation of a rapid-access otolaryn-
gology voice assessment service improves the rate of pre-operative checks.
 2012 The Authors

Methods: Data were collected retrospectively from thyroidectomies per-
formed within the Brighton and Sussex University Hospitals Trust over
a 1 year period (Period 1-P1). Data were analysed, a rapid-access otolar-
yngology voice assessment service instigated, data disseminated to both
ENT and general surgery departments, and a re-audit performed over
the subsequent 6-month period (Period 2-P2).
Results: Eighty-nine patient notes were assessed in P1, and 26 over P2.
Pre-operative vocal cord check rate increased from 87.6% (78/89) to
92.3% (24/26). Post-operative documentation of voice increased from
68.5% (61/89) to 96.1% (25/26). The rate of patients with post-operative
dysphonia referred to an ENT/Voice clinic appointment improved from
50% (9/18) to 100% (3/3).
Conclusions: The otolaryngology voice assessment service improved the
trusts pre-operative assessment of vocal cords by facilitating easy access
to flexible nasoendoscopy, especially for the general surgeons. Dissemi-
nation of the original audit data and education of the departments
about current guidelines improved documentation of post-operative
assessment of voice. Management of dysphonia post-op improved dra-
matically with easier access to ENT/Voice clinics.
F070
Measuring outcomes in rhinology benefits and
problems
Calder, N.
Objectives: To assess the subjective benefit reported by patients undergo-
ing common rhinological procedures and to explore the practicalities of
this audit process in measuring surgeons performance.
Methods: SNOT 22 (Sino Nasal Outcome Test 22) scores were collected
prospectively pre-operatively and 3 months post-operatively for all
patients undergoing elective rhinological surgery under one consultant
over a 2 year period. Patients undergoing surgery for tumours, epistaxis
or diagnostic purposes were excluded. NOSE (Nasal Obstruction Symp-
tom Evaluation) scores were collected prospectively pre op and
3 months post op for patients undergoing septal surgery.
Results: Complete data was available for 39 of 54 patients (72.2%)
undergoing surgery for chronic rhinosinusitis with polyps. The mean
improvement in SNOT 22 scores was 29.9 (range 85 to )29). Complete
data was available for 11/23 patients (47.8%) undergoing surgery for
chronic rhinosinusitis without polyps. The mean improvement in SNOT
22 scores was 16.5 (range 53 to )14). In patients undergoing septal sur-
gery, complete data was available for 43/58 (74.1%) for SNOT 22 and
33/58 (56.9%) for NOSE. The mean improvement in SNOT 22 was 16.5
(range 70 to )27) and for NOSE was 8.1 (range 17 to )3).
Conclusions: This prospective study demonstrated a clinically significant
improvement in patient reported outcome scores for common rhinologi-
cal procedures. It is hoped that this simple process of prospective clini-
cal audit will enable surgeons to compare surgical outcomes with their
peers and form an important component of appraisal. This study high-
lighted the issue of loss to follow-up, a limiting factor in any audit of
surgical outcomes.
F071
Audit on pre operative investigations in ENT
Shilpa, P., Revelle, L.W. & Stephen, K.
Objectives: Our aim of the audit was to compare our practice with
NICE guidelines on Pre operative tests. The guideline is re designed by
ENT-UK.
 2012 The Authors
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
Clinical Audit and Practice 35
Methods: We have done a retrospective audit on 50 adult patients admit-
ted for elective surgery over a period of 3 months. We have divided our
patients into four groups based on ASA grade and Surgery grade.
Results: We have analysed our results based on the grade of surgery and
ASA grade and we have also considered associated risk with cardiovascu-
lar, respiratory and renal disease. Our results have shown that we were
100% compliant with Blood gas, sickle cell test and urine analysis. We
are also 98% compliant in chest x-ray investigation. We have consis-
tently over investigated our patients with Full blood count, Coagulation
screening and pulmonary function tests.
Conclusions: We can utilise the resources effectively by investigating
patients optimally in the pre operative clinic.
F072
ENT cross-cover survey: factors that influence trainees
confidence levels in managing common ENT on-call
emergencies
Hettige, R., Pankhania, M., Patel, K., Demetriou, V.
& Draper, M.
Objectives: The aim of this study was to ascertain the factors most
important in determining the confidence amongst 1st tier ENT on-call
trainees.
Methods: Fifty trainees across three hospitals selected a single preferred
response from a possible four regarding commonly encountered ENT
emergencies. Self-expressed-confidence in handling these scenarios was
also established. Their responses were compared to demographic data
including grade of trainee, specialty, surgical examinations done and
previous ENT experience, along with the perceived attitude to further
training.
Results: The Foundation Year 2 (FY2) trainees were the least confident
in their own abilities. Core Trainees from Year 1 (CT1s) were more
likely to call for senior input as a first-line. The main predictors for a
trainee to select the single preferred response was prior ENT experience
or currently being in an ENT rotation, regardless of grade of trainee and
completion of the MRCS Part 1 or/and 2.
Conclusions: The implementation of the European working-time direc-
tive and the Modernising Medical Careers initiative in the UK has led
to increases in out of hours cross-speciality cover, by a range of junior
grades. Targeted teaching and adequate support is sought after and
should be offered to the 1st-tier to provide safe on-call cover and ade-
quate training.
F073
Effectiveness of a SHOW system are patients
informed about their MRI IAMs (magnetic resonance
imaging, internal auditory meatus) results in a timely
manner?
Konieczny, K. & Pringle, M.
Objectives: Assess effectiveness of a SHOW system in informing patients
about their MRI IAMs results in timely manner (<6 weeks) and reduc-
ing number of unnecessary ENT clinic follow up appointments.
Methods: The following sources were used to collect the data: Show
database, PACS (Picture Archiving and Communication Systems) and
Patients Letters systems, clinical notes.
Number of days between the scan report and the results being conveyed
to patients was analyzed. It was noted whether patient was informed via
36 Clinical Audit and Practice
letter or brought back to clinic and then given the result (attempt to
assess whether or not the follow up visit was avoidable).
Results: Ninety-six cases were reviewed. The period in which the results
were communicated ranged from 3 to 321 days (average 80.1, median
60). Thirty per cent of patients were informed within the desired
6 weeks. Fifty-one outpatient appointments were saved.
Conclusions: SHOW system was designed to avoid unnecessary follow
ups and ensure that patients receive the results of their investigations.
It should be used where treatment can be completed in one visit and
the only outstanding feature is investigation results.
Involving the patient adds an extra safety net to the process.
Doctors need to action results in a timely manner
New doctors, nurses and receptionists need to be educated about process
and its importance.
F074
Eye care management in bells palsy: an ENT perspective
Siddiq, S., Trotter, M. & Reuser, T.
Objectives: Bells palsy is the commonest form of isolated facial nerve
palsy. Most patients are referred in the first instance to ENT depart-
ments and the primary goal during recovery is to prevent sight-threaten-
ing corneal complications.
Methods: A retrospective analysis of patient records from October 2007
to November 2009, referred with Bells palsy to an ENT department
within a major Foundation Trust in Birmingham was conducted. Case
records were assessed for documentation of patient education, prescrip-
tion of topical eye medicaments, eye assessment and specialist referral.
Results: Of 64 patients referred with Bells palsy, 63% had a docu-
mented House-Brackmann score with assessment of corneal sensation in
one case. Eye drops were prescribed in 54% of patients, 22% advised to
tape eye and 27% to use eye patch/pad. Three patients were referred to
Ophthalmology, one noted to have a corneal scar.
Conclusions: The study highlights key deficiencies in ocular care and
suggests a corneal risk stratification protocol. Patients presenting with
BALD, (poor Bells phenomenon, Absence of corneal sensation, Lagoph-
thalmos or Dry eye) require prompt referral.
F075
Pro-forma based documentation in head and neck MDT
Giblett, N., Mendis, D., Munonyara, M. & Hari, C.
Objectives: To compare local services of Head and Neck Cancer Man-
agement against national expectations set by DAHNO (Data for Head
and Neck Oncology). To compare local performance pre- and post-
implementation of a standardised MDT pro-forma.
Methods: This retrospective re-audit gathered data from the records col-
lected at departmental MDT meetings. Standards were taken from the
clinical lines of enquiry that are published annually to identify key
aspects that reflect the quality of local head and neck cancer services.
Initial audit inclusion criteria consisted of all new head and neck cancer
diagnoses for the year 2010 (pre-implementation), findings were pre-
sented and implementations suggested. Data was then extended to
include all new head and neck cancer diagnoses for the year 2011 (post-
implementation) as a comparative study.
Results: Two hundred and eight cases were identified in total, 95
cases in 2011 and 113 cases in 2010. Ninety-four (99%) and 99
(88%) cases were discussed at MDT respectively. The reporting of
TNM staging improved with 77 (82%) cases identified for the year
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
2011 compared with 71 (62%) cases for the preceding year, now
above national standards of 79%. Of those undergoing treatment in
2011, 62 patients (65%) were seen by a clinical nurse specialist
(CNS) prior to commencement and 38 patients (40%) underwent
pre-treatment dietetic assessment. In comparison, only 50 patients
(54%) were seen by a CNS and not a single dietetic assessment was
completed in 2010.
Conclusions: Previous shortfalls have been vastly improved with the
installment of an MDT pro-forma, it is therefore proposed that a stan-
dardised pro-forma should be employed nationally.
F076
Assessment of tumour marker monitoring in thyroid
cancer
Giblett, N. & Siddiq, S.
Objectives: The British Thyroid Association (BTA) published national
guidelines in 2007 (Guidelines for Thyroid Cancer Management) with
specific reference to measurement and interpretation of serum thyro-
globulin (Tg) in Thyroid cancer patients. This audit aims to assess cur-
rent practice in the monitoring of thyroglobulin (Tg) within a West
Midlands teaching hospital and provide departmental guidelines. Specific
assessment included; whether Tg is monitored, time between treatment
and initial assessment of Tg and time-interval of continued monitoring
according to initial Tg result.
Methods: Inclusion criteria consisted of all new thyroid cancer patients
diagnosed during 2010. Data regarding diagnosis and treatment was
gathered from the patients clinical notes. Serum Tg monitoring was col-
lated from biochemistry records in iSOFT clinical manager.
Results: Nineteen patients were identified in total, of which 17 patients
Tg was assessed post-treatment. Initial assessment of thyroid status was
not performed in the ideal time range in 82% of patients. There was a
tendency to monitor Tg too frequently (66%) in Tg positive patients. In
contrast, TSH stimulated Tg monitoring was under performed in Tg-
negative patients (37.5% only). Management of high risk patients was
performed well, with further assessment appropriately conducted in all
patients fulfilling criteria.
Conclusions: The monitoring of Tg is complex and a high level of
understanding is required to adhere to the BTA guidelines, which are
supported by the British Association of Endocrine and Thyroid Sur-
geons. It is proposed that shortfalls locally should be addressed with the
instatement of a standardised pro-forma.
F077
An audit of out-patient procedure clinical coding
Mirza, S., Kamal, S., Manickavasagam, J. & Gregory, S.
Objectives: Clinical coding of an out-patient procedure such as a flexible
laryngoscopy produces a Health Resource Group (HRG) code with a
specific payment tariff that the hospital receives. Our aim was to review
the out-patients clinical coding in our ENT department and discover
whether there was scope for improving the accuracy of coding and
income tariffs.
Methods: We retrospectively reviewed the clinic letters of 10 out-patient
sessions for each of three consultants (Otologist, Rhinologist and Head
and Neck Surgeon). A database of patient demographics and out-patient
procedure(s) was formed and compared with the coded data.
Results: In the 30 clinics reviewed there were 143 new patients and 227
follow-ups giving a total of 370 patients, of which 214 (58%) had an
 2012 The Authors

out-patient procedure. There were 22 (10%) cases where the out-patient
procedure had not been coded; and 20 (9%) cases where the coding had
been incorrect. The total loss in tariff was 2314. This would extrapolate
to a potential loss of 110K over the financial year.
Conclusions: There is significant scope for improving the recording and
coding of outpatient procedures to optimise income tariffs.
F078
Patients preferences for how pre-operative patient
information should be delivered
Bird, J., Reddy, V., Bennett, W. & Burrows, S.
Objectives: Good quality patient information helps patients prepare for
operations and involves them in decision-making. This can improve
medical outcomes, reduce patient anxiety and provide patients with
information that they want. The aim of this study is to establish
patients preferences for preoperative patient information and their
thoughts on the role of the internet.
Methods: Consecutive adult patients undergoing elective ENT surgery
were invited to take part in this survey study by nursing staff on the
preadmission unit on the day of surgery. Participants completed a
questionnaire recording patient demographics, operation type, quality
of the information leaflet they had received, access to the internet
and whether they would be satisfied accessing pre-operative informa-
tion online.
Results: Respondents consisted of 52 males and 48 females. Sixteen per
cent were satisfied to receive the information online only, 24% wanted a
hard copy only and 60% wanted both. Younger patients are more likely
to want online information in stark contrast to elderly patients who pre-
ferred a hard copy. Patients aged 5080 years would be most satisfied
with paper and internet information as they were able to pass on the
web link to friends and family who wanted to know more. Thirty-seven
per cent of people were using the internet to further research informa-
tion on their condition/operation. However, these people wanted infor-
mation on reliable online sources to use.
Conclusions: ENT surgeons should be alert to the appetite for online
information and identify links that are reliable to share with patients.
F079
One-stop triple-imaging: the way forward in head and
neck cancer management?
Randhawa, P., Li, J., Vaz, F., Lechner, M., Morley, S.
& Beale, T.
Objectives: Head and neck cancer affects approximately 815 per
100 000 of the United Kingdom population and delay in diagnosis is
major factor in the poor survival outcomes. Obtaining radiology can
be the step that delays the patient through a cancer pathway. At our
institution we provide a one-stop triple scanning radiology service
i.e. one stop ultrasound + fine needle aspiration, magnetic resonance
imaging and computed tomography. Our aim was to assess the effec-
tiveness of this service in expediting the patient through the cancer
pathway.
Methods: We conducted a retrospective review of our 2-week clinic
before and after the introduction of the triple scanning radiology ser-
vice.
Results: A total of 70 patients with a head and neck cancer were
included in this study. Thirty-six patients were identified before the
introduction of the triple scanning service and 34 patients after. The
 2012 The Authors
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
Clinical Audit and Practice 37
time taken through all steps of the cancer pathway were reduced; mean
time to obtain imaging (7.9 versus 0.8 days (P < 0.002); average time to
obtain a biopsy (18.3 versus 11.2 days; P < 0.001); time to diagnosis
(25.4 versus 16.5 days; P < 0.0003); commencement of treatment (53.6
versus 33.6 days; P < 0.004)
Conclusions: The introduction of the one-stop triple scanning radiol-
ogy service at our centre has significantly reduced the time taken for
patients progress through the cancer pathway. We feel this is something
all Head and Neck cancer units should consider adopting to aid the
rapidity of processing the patient with a new diagnosis of Head and
Neck cancer.
F080
ENT emergency clinic activity
Virk, J., Elmiyeh, B. & Singh, A.
Objectives: To elicit data as regards number of patients seen per clinic,
source of the referrals, common complaints and number of follow up
appointments; to elucidate appropriateness of referrals and number
booked directly into main outpatients; to assess whether more clinics
were required.
Methods: A closed loop audit, each over a 3 month period was per-
formed. Between cycles, guidelines for accepting, documenting and
booking referrals including recommendations to reduce follow ups safely
and redirect inappropriate referrals to main outpatients alongside proto-
cols for otitis externa management were made; local GPs and A&E staff
were also given consultant teaching sessions.
Results: Re-audit v 1st audit: Clinic activity 7.2 versus 9.8; Follow ups
45 versus 158; Direct outpatient bookings 15 versus 59; Number of re-
referrals by GP: 15 versus 1; A&E and GP main referrers (95%); com-
mon complaints: otitis externa, foreign bodies, epistaxis, nasal trauma
(but less inappropriate referrals: 21 versus 89).
Conclusions: We can work together to improve patient care and save
money (by reducing unnecessary follow ups and providing evidence that
increasing clinics not required) as well as generate income (by gaining
re-referrals and GP referrals to main outpatients) for the trust. It also
highlights that clinical governance has an integral role to play in main-
taining and driving forward the standard of care whilst having an aware-
ness to utilise resources available and funded for. We also reflected on
the importance of interacting and working with our colleagues in man-
agement rather than remaining a separate, clinical arm of the NHS to
achieve the best possible care.
F081
Patient reported outcome measures for paediatric
adenotonsillectomy surgery
Virk, J., Randhawa, P. & Benjamin, E.
Objectives: To elucidate the impact of throat disorders on quality of life
of children and to assess the effectiveness of clinical intervention (sur-
gery).
Methods: The T14 survey, a validated outcome measure, was completed
pre and post operatively by the parents of patients at 0 and 3 months;
the tool has 14 items (05 rating).
Results: A total of 20 completed responses have been collected thus far,
with a mean score of 42.3 pre operatively and 7.4 postoperatively
(P < 0.05).
Conclusions: Quality of life is severely affected by both infective and
obstructive throat disorders in children. Surgical intervention produces
38 Clinical Audit and Practice
marked and significant improvement in these symptoms, validating the
role of surgery and its clinical effectiveness.
F082
Patient reported outcome measures for paediatric sino-
nasal surgery
Virk, J., Elmiyeh, B. & Benjamin, E.
Objectives: To elucidate the impact of sino-nasal disorders on quality of
life and to assess the effectiveness of clinical intervention (surgery).
Methods: The SNOT22 survey, a validated outcome measure, was com-
pleted pre and post operatively by patients at 0 and 3 months; the tool
has 22 items (05 rating).
Results: A total of 35 completed responses have been collected thus far,
with a mean score of 45.6 pre operatively and 20.7 postoperatively
(P < 0.05).
Conclusions: Quality of life is severely affected by sino-nasal disorders in
adults. Surgical intervention produces marked and significant improve-
ment in these symptoms, validating the role of surgery and its clinical
effectiveness.
F083
A study into factors contributing to patient satisfaction
at outpatient clinic; comparison between central and
peripheral clinics.
Moore, A. & Balaji, N.
Objectives: Assess patient satisfaction at an ENT clinic. Calculate the dif-
ferences in satisfaction between a central and peripheral clinic. Deter-
mine the factors contributing to patient satisfaction.
Methods: Patients attending an otolaryngologists clinic were rando-
mised to the central or peripheral group. The central clinic was con-
ducted at a large hospital and the peripheral clinic was conducted at a
small, outlying facility. Patient satisfaction was assessed using a modified
Improving Practice Questionnaire.
Results: One hundred and forty-three consecutive patients were sur-
veyed. The two groups were comparable in age, sex and previous
attendance, however, the peripheral clinic was significantly further
away from the patients home address (P = 0.018). Overall satisfaction
was not significantly different between the two groups. Eight variables
related to housekeeping aspects were significantly (P < 0.05) in favour
of the peripheral clinic: hours, time, comfort, wait, etc. There was no
significant difference (P > 0.05) in variables related to the doctor-
patient consultation (ability, reassurance, warmth, etc) between the
two clinics. Ordinal logistic regression found the most powerful pre-
dictors of overall satisfaction to be related to the doctor-patient con-
sultation: (Kruskals Gamma) warmth (0.96), listening (0.95),
explanation (0.94), respect (0.96), reassurance (0.96) and ability
(0.97). Conversely variables related to housekeeping aspects were poor
predictors of overall satisfaction: comfort (0.44) and waiting time
(0.41).
Conclusions: This study demonstrates the relative importance of the
doctor-patient relationship on patient satisfaction when compared to
traditional measures of satisfaction such as waiting time and comfort.
The patients estimation of the surgeons ability and consideration leads
to higher satisfaction and perception of quality than comfort and wait-
ing times.
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
F084
Audit of CT scanning of paranasal sinuses in patients
referred with facial pain
Amir, I., Yeo, J.C.L., Vallamkondu, V. & Ram, B.
Objectives: To assess the appropriateness and outcome of sinuses CT
scans in patients with facial pain based on the International Headache
Society (IHS) criteria and European Position Paper on Chronic Rhinosi-
nusitis and Nasal Polyps (EPOS) guidelines.
Methods: The first cycle of audit was performed on 50 patients with
facial pain who underwent CT scanning. The findings on nasendoscopy,
Lund-Mackay scores (LMS) of the scans and management of these
patients were analysed. Following implementation of the IHS and EPOS
criteria, 50 consecutive patients were re-audited.
Results: In the first cycle, 14% of patients had positive nasendoscopic
findings. Thirty patients had LMS of 0 and only eight showed significant
changes (LMS 8) on their scans. In the second cycle, only 10 patients
fulfilled the EPOS criteria for CT scanning and four of them showed sig-
nificant changes. The remaining patients in this cycle were diagnosed
and treated for non-sinogenic causes. Sixty-eight per cent of all patients
also complained of at least one rhinological symptom.
Conclusions: Applying the IHS and EPOS criteria has reduced the num-
ber of inappropriate CT scans requests and allowed consideration of
non-sinogenic aetiologies.
F085
Evaluating the use of simulation in facilitating training
in airway assessment
Pal, R. & Zarod, A.
Objectives: Simulation is playing an increasingly important role in
medical education, but has significant resource implications. In otolar-
yngology, current simulation strategies are directed at higher surgical
trainees, in domains such as temporal bone dissection. Basic proce-
dures are still learnt by traditional methods of observation and dem-
onstration. We aim to demonstrate the validity and benefit of
simulation in teaching flexible nasoendscopy (FNE) and airway
assessment, prior to its introduction into the core surgical teaching
programme.
Methods: We performed a prospective study comparing traditional
demonstration and audiovisual teaching against the use of a simula-
tion lab with a SimMan in teaching foundation and core trainees to
perform FNE and airway assessment. Trainees (n = 28) were rando-
mised into two groups of 14, each undergoing either simulation train-
ing or observational training following an audiovisual presentation.
Following completion of training, participants were assessed by a
blinded trainer in performing FNE and airway assessment against
domains determined by the Intercollegiate Curriculum Surgical Pro-
gramme (ISCP).
Results: The simulation group had a higher mean (3.7 versus 3.2) and
median (4 versus 3) competence score, and more regularly performed all
the required steps for airway assessment and FNE as compared to the
non-simulation group. Competence was graded on a scale of 14 as per
ISCP website, and seven steps in performing and documenting airway
assessment with FNE were required.
Conclusions: This study demonstrates that simulated airway scenarios
using a SimMan provide an improved learning environment in com-
parison to traditional techniques, and should be integrated into the sur-
gical curriculum.
 2012 The Authors

F086
The sensitivity of the 2 week wait referral process of
patients with hoarseness: results and suggestions for
improvement
Gibbins, N., Joshi, A., Leong, A., Kapoor, K., Weighill, J.,
Lew-Gor, S., Jacob, A., Simo, R., Jeannon, J.-P.
& Oakley, R.
Objectives: Determine sensitivity of 2 week wait referrals for hoarseness,
analyse patient data and suggest changes to referral criteria to increase
sensitivity of referrals.
Methods: Prospective multicentre audit between three teaching hospitals
[Guys Hospital (London), University Hospital Lewisham (London) and
Royal Sussex County Hospital (Brighton)] over a 3 month period.
Patients referral data was analysed. Age, sex, duration and type of
symptoms, occupation, and smoking and drinking history were assessed.
Clinical examination findings were noted.
Results: Fifty-nine patients data were analyzed. Twelve per cent (7/59)
had suspicious examination findings and 8% (5/59) had cancer. All of
those diagnosed with cancer were over 50 and had smoking history
>20 pack/years. Only 33% (2/6) had a history of alcohol use. All
patients with cancer had constant symptoms.
Conclusions: The authors suggest that adjustment of the NICE guide-
lines may increase the sensitivity of the referral pattern for hoarseness.
Those with hoarseness not fulfilling the referral criteria should be
referred to either a general ENT or a specialist voice clinic.
F087
Laryngeal mask airways and the use of a Boyle-Davis
gag: is there a learning curve? A prospective analysis
of surgical technique in ENT surgery
Hettige, R., Pankhania, M., Demetriou, V. & Draper, M.
Objectives: A Re-inforced Laryngeal Mask Airway (RLMA) has been
presented as an efficient alternative to Endotracheal Tube (ETT)
insertion during ENT surgery. Our study was to identify whether the
experience of the operating surgeon was relevant to the frequency of
the RLMA kinking causing airway obstruction or subsequent change
to an ETT.
Methods: Data was prospectively collected for all patients undergoing an
ENT procedure with the use of a Boyle-Davis gag under a general anaes-
thetic initially securing the airway with a RLMA, over 18 months. Infor-
mation was gathered regarding patient demographics (Age, Mallampati
Grade), grade of surgeon, grade of anaesthetist securing the airway,
LMA size inserted, and any adjustments to the airway needed during the
operation. The grade of surgeon was then further corroborated with the
total number of tonsillectomies previously performed to reflect experi-
ence.
Results: The experience of the surgeon had a statistically significant
effect on the frequency of adjustments needed to the RLMA and need
for subsequent intubation, with novice trainees experiencing more diffi-
culties. Interestingly, grade of anaesthetist also had an effect. Patient
demographics demonstrated little in the way of statistical significance.
Conclusions: This study supports the theory that there is a learning
curve associated with the use of RLMAs, and specific focus on
teaching these techniques to ENT and anaesthetic trainees needs to be
emphasised for safe airway management and effective perioperative
conditions.
 2012 The Authors
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
Clinical Audit and Practice 39
F088
How to achieve huge cost savings in ENT outpatients
Khan, A., Stimpson, P., Talwar, R. & Patel, N.
Objectives: To improve the financial health of the ENT department, we
audited the process of coding for outpatient procedures in our off-site
service.
Methods: We identified all procedures conducted during 1 week in
ENT outpatients. The proportion of these that were correctly coded
for were then analysed. These were matched to official tariff details as
per the Payment By Results system to ascertain potential financial
savings.
Results: One hundred and two patient encounters were identified and
of these, 85 electronic records were available. The five most common
procedure types were recorded electronically (aural de-waxing, nasal
cautery, flexible nasendoscopy (FNE), fine needle aspiration and skin
prick allergy testing). The most common procedure performed was FNE
and this also had the highest associated coding tariff. After extrapolating
the costs of the procedures performed in a year, against those that were
correctly coded for, we identified a potential shortfall in our billing of
approximately 270 000.
Conclusions: Given the challenging financial climate, all departments
need to identify areas in which they can become more financially effi-
cient. We have identified an area of potential huge savings and have
implemented changes accordingly. This audit highlights an issue of sig-
nificance to ENT departments nationally.
F089
Standardising reporting in paediatric neck ultrasound: a
two-cycle audit
Fraser, L., ONeill, K., Locke, R., Attaie, M., Irwin, G.,
Kubba, H. & MacGregor, F.B.
Objectives: Ultrasound can be a useful imaging tool for the initial inves-
tigation of neck lumps in children but is known to be operator depen-
dent. We aimed to compare the quality and content of reporting in
paediatric neck ultrasound before and after the introduction of a report-
ing protocol.
Methods: We performed a prospective 8-month audit assessing the
content of paediatric neck ultrasound reports requested in our tertiary
referral paediatric otolaryngology service. We assessed reports arising
from three different clinical scenarios: non- acute cervical lymphade-
nopathy, midline neck lumps and acute cervical lymphadenitis with
suspected abscess formation. We found wide variation in report con-
tent and inconsistent reporting of certain radiological features. In
response to this we performed a literature search to identify key, clin-
ically relevant ultrasonographic features in each of the clinical scenar-
ios and then in consultation with our radiology colleagues, devised a
protocol to facilitate the reporting of these key features. Quality and
content of reports were then prospectively reaudited over a further 8-
month period.
Results: Forty-nine reports were assessed before and 58 after introduc-
tion of the reporting protocol. Fishers exact test was used to analyze
the data. We found a statistically significant (P < 0.05) improvement
in the frequency of reporting of various key features such as nodal
distribution, shape, echogenicity, calcification, necrosis and vascular
pattern.
Conclusions: The introduction of a reporting protocol has streamlined
the reporting of paediatric neck ultrasound within our department, lead-
ing to an improvement in clinical practice.
40 Clinical Audit and Practice
F090
What effect has the introduction of primary care trust
restrictions had on tonsillectomies?
Chow, V. & McGilligan, J.
Objectives: The current financial situation demands NHS cost savings
without causing detriment to the quality of healthcare delivered. The
UK Health Select Committee has suggested creating savings by disinvest-
ment and restricting interventions deemed of low clinical value or low
priority procedures (LPP) such as tonsillectomies. Specific Primary Care
Trusts (PCT) permission for funding must be sort by clinicians for each
individual tonsillectomy. This process adds extra time in administration
and extends waiting time for surgery whilst approval is sought. This
study aims to look at numbers of tonsillectomies performed prior to the
LPP being introduced and compares these numbers to the same time
span following implementation.
Methods: Over 4 months doctors working in the otolaryngology depart-
ment at Brighton and Sussex University Hospitals were prospectively
observed for the outpatient time spent on patients who were deemed to
require a tonsillectomy. The observed doctors were blind to the study as
not to provide bias. To assess the effect of the new PCT funding restric-
tion, data on the total number of tonsillectomies performed between
May 2005 and March 2011 was acquired.
Results: The study demonstrated a 7% rise in administrative workload
with the introduction of a LPP criteria form and no significant changes
in the number of tonsillectomies performed pre and post LPP.
Conclusions: Application of LPP restrictions on tonsillectomies has
shown little benefit in reducing the number of tonsillectomies performed
and therefore costs. The results suggest that LPP restrictions have meant
that more time during consultations is spent on additional extraneous
administration.
F091
A closed audit cycle: suction diathermy adenoidectomy
ensuring consultant led training
Allin, D., Stephens, J. & Mace, A.
Objectives: NICE guidelines recommend that only surgeons with specific
training should perform suction diathermy adenoidectomy, and that the
usual arrangements for clinical governance and audit should be in place.
Our interpretation of this is that all trainees in our unit should be
trained in the procedure by a consultant.
Methods: An initial audit was carried out assessing junior training in
diathermy adenoidectomy. Subsequent to this a training event was
organised.
Results: Initial audit revealed that only 20% of SHO (F2-CT2) level
trainees and 80% of Registrar level (ST3 and above) trainees had had
specific training in the procedure by a consultant. Suction adenoidec-
tomy is a procedure frequently performed by SHO and SpR level train-
ees. Therefore this proportion was deemed to be insufficient. A
departmental training event was organised with consultant led teaching.
This was facilitated with the use of a polystyrene head model and a
video-linked headlamp to enable trainees to visualise the procedure. This
also allowed the consultant to assess how the trainees performed. Subse-
quent re-audit showed that 100% of trainees in our department have
now had consultant training in suction diathermy adenoidectomy.
Conclusions: Training in our department in the use of suction dia-
thermy adenoidectomy was found to be deficient compared to NICE
guidelines. This was remedied with a formal teaching session making use
of a novel teaching tool. All trainees have now had senior training in
the procedure.
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
F092
Otolaryngology services for impact foundation UK on
the Jibon Tari (the Boat of Life, the only floating
hospital providing ENT services in the world) and
Chuadanga Masud Memorial Hospital, Bangladesh
Kamal, S. & Kamal, S.A.
Objectives: The objective is to report the activity of the ENT team for
Impact UK. Impact UK is a charitable organisation established in 1982,
run by the late Sir John Wilson. It has established two hospitals in Ban-
gladesh to prevent/cure hearing disability, blindness and congenital
orthopaedic anomalies. The prevalence and extent of ENT pathology
was determined whilst rendering services in the rural settings of the
country to a populace who are otherwise unable to access hospital medi-
cal care.
Methods: The UK operating team consisted of a Consultant ENT Sur-
geon from Devon, a consultant Anaesthetist from Sussex, and an ENT
London trainee, for Impact UK, aiming to prevent avoidable medical
disability. One hundred and forty-eight ENT patients were selected by
the local general practitioners in two different villages. Over 14 days,
these patients were assessed and listed for surgery. Audiology facilities
were also available
Results: The age range of patients was 642 years. In total, there were
59 otological conditions consisting of cholesteatoma, chronic suppura-
tive otitis media, otitis media with effusion, osteomas, subtotal and total
perforations often with sensorineural hearing loss; and 19 cases of nasal
conditions included rhinosporiodosis, nasal polyposis, and post trau-
matic fractured noses.
Conclusions: There is a vast population living in rural Bangladesh with
untreated ENT pathology. Young patients were selected to improve their
condition allowing them to return to work; older patients were excluded
from surgical treatment but issued hearing aids to reduce the disability.
We highly recommend clinicians to work in the developing world to
provide rural communities access to surgical healthcare
F093
Emergency surgery audit of royal college surgeons
standards for unscheduled care in an ENT tertiary
referral centre
Mulla, O.
Objectives: It was recognised that emergency surgical care is currently
sub-optimal leading to inappropriate mortality rates and increased care
costs. In response, the Royal College of Surgeons of England (RCSEng)
produced guidance with regards to unscheduled care in a surgical envi-
ronment. This document (February 2011) defines best practice principles
for each surgical specialty.
We wanted to assess if the ENT department at Leeds General Infirmary
is meeting the RCSEng standards.
Methods: All acute ENT admissions during November 2011 were retro-
spectively reviewed. Patients were identified from doctor handover lists,
ward register and acute theatre register. Results were presented and dis-
cussed at departmental clinical governance meeting in December 2011.
A second cycle using the same methods was undertaken for the month
of January 2012
Results: Fourteen best practice principles were audited. In cycle 1, 11
of 14 principles were achieved with the department failing on endo-
scopic evaluation of epistaxis, assessment facilities and joint ENT-pae-
diatric education. Cycle 2 demonstrates an improvement with 12 of
14 principles met. In cycle 2, not all patients received endoscopic
 2012 The Authors

evaluation of epistaxis however there was a 100% increase in those
that did
Conclusions: Audit of defined best practice allows departments to iden-
tify their weaknesses and correct these. In our department these princi-
ples were audited, results discussed, awareness raised and a second cycle
is showing an improvement. Despite these improvements we question if
all principles are necessary and actually how practical they are.
F094
Personal practice audit: patient perspectives of an
otolaryngology core trainee
Mulla, O.
Objectives: It is universally recognised that feedback is important to
develop as a clinician and as an individual. Feedback usually comes from
our trainers but rarely from our patients other than the occasional thank
you card (or complaint!). My aim was to assess what my patients
thought of my management within the ENT casualty clinic.
Methods: An anonymous questionnaire was given to all patients after
their consultation and they were asked to deposit this questionnaire out-
side the clinic room or give to the nurses. To ensure anonymity patients
were assured them that their responses would not be seen until after the
clinic session. There were five questions centred around communication
skills, pain and professionalism.
Results: A total of 25 questionnaires were analysed with 20 patients
agreeing or strongly agreeing that they received a clear explanation, they
were dealt with professionally and they would return for another consul-
tation. Of these the majority were otitis externa and epistaxis. There
were two nasal injuries. Five patients were dissatisfied with their consul-
tation and these were all related to nasal injuries.
Conclusions: Patient feedback is as important as trainer feedback if
not more so. From this personal practice audit nasal injuries have been
identified as a learning point and extra guidance has been sought on
manipulation and communication when explaining the management
outcomes. This audit has directly led to a change in practice and will be
re-audited in the future.
F095
Improving the management of pinna abscess a case
series
Hussain, K., Mulla, O., Nix, P., Sandoe, J. & Kaye, T.
Objectives: To assess if our institution is appropriately managing pinna
abscesses.
If auricular perichondritis is left untreated or sub optimally managed
the development of a subperiosteal abscess with potential cartilage loss
and gross cosmetic defect may ensue.
Methods: A retrospective review was conducted to identify the cause,
microbiology, management and outcome of patients presenting with
pinna abscess over a 5-year period at a tertiary hospital.
Results: All 17 patients underwent incision and drainage of their abscess
at least once. Fourteen patients had microbiology samples; 10 culture-
positive. The commonest pathogen was Pseudomonas aeruginosa (5).
Four patients developed an abscess secondary to ear piercing; they all
were all culture positive for Pseudomonas aeruginosa. A range of initial
empirical therapy was used; appropriately in only one case. Eight
patients developed complications.
Conclusions: Pseudomonas aeruginosa is associated with pinna abscesses,
particularly caused by ear piercings. Suboptimal antimicrobial manage-
 2012 The Authors
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
Clinical Audit and Practice 41
ment was associated with poor outcomes. We recommend clinicians
review their empirical treatment of pinna abscesses and have systems to
act on microbiology results. Clinicians must consider Pseudomonas
aeruginosa when managing resistant cases of abscesses or due to ear
piercings.
F096
Variation in practice an analysis of Scottish surgical
profiles ENT data
Yeo, J.C.L., Ah-See, K.W & MacKenzie, K.
Objectives: To determine the accuracy of NHS Grampian data reported
by the Information Service Division (ISD) and to record the appropri-
ateness of listing of patients for tonsillectomy with reference to the Scot-
tish Intercollegiate Guidelines Network (SIGN).
Methods: Retrospective review of case notes and surgical records of
patients who had undergone tonsillectomy between March 2007 and
March 2008 in NHS Grampian.
Results: Between March 2007 and March 2008, 509 tonsillectomy cases
were performed in NHS Grampian. This corresponded to the data
received from ISD. Eighty-seven per cent of tonsillectomies performed
were compliant with SIGN guidelines.
Conclusions: The Scottish otolaryngology clinicians have found the
reporting of the intervention rates stimulating and challenging. Discus-
sion of the surgical profile project regularly at national specialty meet-
ings resulted in a preliminary detailed targeted audit of those who were
persistent outliers for tonsillectomy. This refuted the presumed reasons
for this variation, namely inaccurate figures from ISD and inappropriate
listings by clinicians.
F097
Financial implications of having a tongue-tie division
service
Argiris, K., Bestman, B.E. & Padgham, N.D.
Objectives: Tongue-ties, a common finding in the paediatric age group,
are often encountered by otolaryngologists including other specialists.
Because of their shared nature, patient pathways are commonly not
developed that would facilitate their assessment and subsequent division.
In the East Kent area such a service exists and our aim was to demon-
strate the financial implications of setting it up, even when compared to
the other common paediatric procedures.
Methods: We retrospectively collected our data for the period of January
2011December 2011. All routine, high volume ENT procedures that
were performed in the Trust over the past year were recorded. The tariff
for each type of procedure included in the study was used to calculate
the net income for the Trust. All the collected data was derived from
the Trusts Finance department and the waiting list office.
Results: We included only high volume procedures (i.e. >100 in a year)
in this study. In terms of numbers we performed 266 tongue-tie division
procedures that were comparable to the other high volume procedures
(tonsillectomy, grommet insertion, septoplasty and FESS). Tonsillecto-
mies were the most common procedure whereby 450 were performed.
In terms of income our tongue-tie service contributed about 10% of the
total. Further comparative data will be provided.
Conclusions: Setting up a tongue-tie division service may benefit ENT
departments financially. Moreover it is a quick and safe procedure that
is beneficial to patients.
42 Clinical Audit and Practice
F098
An audit of the tympanomastoid template and
subsequent revision
Theokli, C., Toma, S., Gluckman, P. & Kanegaonkar, R.
Objectives: A standardised template has been used at our institution for
documenting middle ear and mastoid surgery in a graphical format. Its
use has been shown to improve documentation of operative findings but
not necessarily the documentation of the operative procedure itself.
Modifications to the template have been undertaken with the aim of
addressing this and other issues.
Methods: The International Otology Database was used to construct a
list of 35 items of information deemed essential to document accurately
middle ear/mastoid surgery. Twenty operation notes using the original
template were compared with the documentation achieved with the new
version.
Results: Details of the procedure, the state of the ossicular chain
(both intra- and post-operatively), and patient details were all signifi-
cantly (P < 0.05) better documented when using the new proforma.
There was no significant worsening of documentation in any of the
individual data sets when using the new template compared with the
original.
Conclusions: The revised template offers more space and greater
prompts to achieve full documentation of middle ear/mastoid surgery.
Its use is a unique tool, designed to offer greater accuracy, under-
standing and continuation of care in patients undergoing otological
surgery.
F099
Reducing admission rates and length of stay in
epistaxis
Munn, C., Gillespie, L. & Das, P.
Objectives: Epistaxis is the most common emergency in otorhinolaryn-
gology. Evidence suggests that 90% of bleeds are anterior, and should be
amenable to cautery or simple control methods. In practice, the admis-
sion rates do not always reflect these statistics, and inappropriate admis-
sions adversely affect both patient outcomes and NHS resources. We
wanted to assess factors contributing to admission and length of stay
(LOS), and to determine whether a simple proforma could improve out-
comes or provide cost savings.
Methods: A retrospective audit was performed on all epistaxis patients
over a 4 month period. Eighty cases were analysed for management by
accident and emergency staff and ENT staff, to identify factors signifi-
cantly impacting on LOS. A proforma was then implemented and man-
agement was reanalysed to assess the impact on admission rates and
LOS.
Results: In the retrospective study, an admission rate of 80% and mean
LOS of 1.76 days was observed. Failure to undertake rhinoscopy and
cautery was found to significantly increase LOS. Nasal tampon insertion
by A&E significantly reduced the rate of rhinoscopic examination. Intro-
duction of the proforma demonstrated an increased rate of rhinoscopy
and cautery, even in those who underwent nasal tampon insertion by
A&E. This had a positive impact on outcomes, with reduced admission
rates and reduced LOS.
Conclusions: This audit suggests that a simple proforma to prompt ENT
staff and guide management of epistaxis is able to reduce admission
rates and decrease length of stay, improving patient experience and pro-
ducing cost savings.
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
F100
The cost effectiveness of running a rapid access neck
lump clinic
Khalid-Raja, M. & Uppal, H.A.S.
Objectives: The National Institute for Clinical Excellence (NICE) pro-
duced guidelines on Improving outcomes in Head and Neck cancer in
November 2004. They proposed that in addition to the 2 week urgent
cancer referral for neck lumps persisting beyond 3 weeks, rapid-access
neck lump clinics are set up.
An audit of the one stop neck lump clinic at the University Hospital of
North Staffordshire was conducted.
Methods: A proforma was designed and 37 patient notes from a
12 months period were reviewed.
Results: Twenty-five were female and 12 were male. Thirty-four patients
were seen within 2 weeks. The clinical diagnosis in 12 was reactive
lymphadenopathy, in five salivary gland pathology, two thyroid gland
and four benign disease. Five out of the 37 were clinically normal neck
with no palpable swelling. Three were thought to be lymphoma and in
six no diagnosis was given. Sixteen patients had an ultrasound guided
FNAC, the sample inadequacy was four out of 16 (25%). Fourteen
patients were discharged the same day. The cancer hit rate was two out
of 37 (5%). These two cancer patients were managed within the 31/62
government target.
Conclusions: The one stop neck clinic is classed as a multidisciplinary
clinic so attracts a higher tariff than standard clinics. The cost continues
to increase as the patient undergoes same day ultrasound neck and
cytology reports plus/minus imaging of chest. The patients journey then
involves follow up the same afternoon for results and management deci-
sions.
This audit questions the cost efficiency of the one stop neck lump clinic.
F101
A re-audit on the decontamination of the on-call
fibreoptic laryngoscope at the ENT department of the
Newcastle Upon Tyne NHS Trust Hospitals
Veeratterapillay, S., Neil, K. & Gerrard, S.
Objectives: Our ENT department carries an out-of-hours fibreoptic
laryngoscope for emergencies and uses chlorine dioxide (Tristel) wipes
or endoscope sheaths for decontamination. An initial audit in November
2011 showed that documentation could be improved- in 23% of entries,
patient details were incomplete. Sixty-eight per cent had incomplete data
on practising clinician. There was no documentation of location in 52%
and no documentation of time and date in 50% of entries. The method
of decontamination was not documented in 27% of cases. Sheaths were
preferred over the more cost-effective wipes (33% versus 17%). This was
presented at the departmental meeting and we implemented guidelines
for documentation. We carried out a re-audit to assess the changes.
Methods: Our re-audit was again based on the ENT UK Guidelines for
cleaning fibreoptic laryngoscopes 2005. We carried out a retrospective
audit over a 1-month period. The following data were gathered from the
logbook accompanying the laryngoscope: patient details, location, date,
time, practising clinician and method of decontamination.
Results: Thirty entries were audited. Patient details were complete in
100%. Documentation of date had improved to 87%. There was proper
documentation of location in 53% and practising clinician in 73%. The
decontamination method was not documented in 6% of cases; Tristel
wipes were used in 70% and sheaths were used in 23%.
 2012 The Authors

Conclusions: While there are no reports of cross infection from use of
laryngoscopes, it remains important to decontaminate them. In our
department, education about decontamination and documentation, and
the implementation of clear guidelines accompanying the laryngoscope
significantly improved clinical practice and record keeping.
F102
Trends in advertised NHS otolaryngology consultant
posts 20072011
Maqsood, S., Hughes, J. & Vaz, F.
Objectives: To examine the number and sub-specialty nature of substan-
tive NHS otolaryngology consultant post advertised over the last 5 years
in comparison to number of current trainees approaching completion of
training (CCT).
Methods: BMJ career archive (paper and electronic) was searched for
substantive consultant posts in otolaryngology all over United Kingdom
between 2007 and 2011. 20022005 data is included from a previous
study. Data for 2006 was incomplete from this study and unavailable
from the BMJ.
Results: Sub-specialty trend analysis has shown that Head and Neck
trainees are in most demand, accounting for around 30% of the
advertised posts over the 5 year period. General otolaryngology (33%),
Otology (16%), Paediatrics (11%), Rhinology (9%) and Voice (2%)
account for the remaining proportions of the overall job market.
Conclusions: This study confirms previous findings of a reduction in
substantive advertised consultant posts despite pledges in The NHS Plan
(2000) to increase the workforce. This trend of reduced consultant post
availability has synchronised perniciously with an expansion of higher
trainee numbers.
F103
Sensitivity, specificity and non diagnostic rates of fine
needle aspiration in head and neck patients
Paterson, P., Ferguson, L., Boyd, D., Chalmers, E.,
Little, M. & Carton, A.
Objectives: To establish the diagnostic accuracy of fine needle aspiration
cytology (FNAC) within the head and neck department of a district gen-
eral hospital and determine whether adjustments could be make to
improve the service.
Methods: Retrospective review of PACS database containing all ultra-
sound scans listed as ultrasound head and neck with fine needle aspira-
tion/biopsy from June 2008 until June 2011. A random selection of 294
FNA procedures were analysed. Patient demographics, site of FNAC and
cytological results were recorded and compared with final histological
results when available.
Results: Of the 294 FNA procedures 39% were non-diagnostic
(n = 114). With the non-diagnostic procedures removed, statistical anal-
ysis was performed on those patients who had a diagnostic FNA and
subsequent surgery producing a final histological specimen (n = 60).
Sensitivity, specificity, accuracy, positive predictive value (PPV) and neg-
ative predictive values (NPV) were 79%, 94%, 87%, 92% and 83%
respectively. Of the non-diagnostic group 35 patients had final pathology
for comparison, with 31% (n = 11) having a malignant final histopatho-
logical specimen.
Conclusions: Our departments diagnostic rates of FNAC in head and
neck masses are comparable with the national averages quoted in the lit-
erature. To reduce the number of non-diagnostic procedures, core
 2012 The Authors
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
Clinical Audit and Practice 43
needle biopsy after failure of FNA to provide a diagnosis has been intro-
duced. Further evaluation on the management of non-diagnostic proce-
dures is ongoing.
F104
Use of the tonsil outcome inventory in adults undergo-
ing elective tonsillectomy a prospective study
Erskine, S., Kwong, F.N.K., Robinson, G., Powell, E.,
Moor, J. & Wilson, J.
Objectives: To evaluate use of the Tonsil Outcome Inventory (TOI-14)
in determining the benefit of elective tonsillectomy amongst adults.
Methods: TheT-14 questionnaire is often used to determine throat-
related quality of life (QoL) and benefit of tonsillectomy in a paediatric
population; there is little comparable research amongst adults, with no
single validated tool yet in general use. The TOI- 14 is a validated tool
for assessment of throat-related QoL in adults. Patients from two hospi-
tals in the North East of England completed the questionnaire prior to
undergoing elective tonsillectomy and will repeat this 6 months post-
operatively. An age/gender matched control group of healthy volunteers
were also assessed.
Results: Total: 35 patients, 35 controls (both 24 females, 11 males);
mean age patients 23.7 years, controls 23.5 years. Indications for tonsil-
lectomy: recurrent tonsillitis (20), recurrent tonsillitis and sleep breath-
ing problems (10), sleep breathing problems only (1), other (4). The
surgical patients had a significantly higher overall score: 55.2/100 versus
16.3/100 (P = 0.000) and significantly higher scores for all questions
other than dry throat (no significant difference). No significant differ-
ences by indication for surgery. Female patients had a higher mean
scores than males for sore throat (4.2 versus 2.5, P = 0.004) and swal-
lowing difficulties (3.5 versus 2.2, P = 0.017). No significant control
gender differences.
Conclusions: TOI-14 detects significant differences in throat-related QoL
between those undergoing tonsillectomy and controls. A validated
throat-specific tool will help to standardise the evaluation of throat-
related QoL and optimise indications for and benefits from adult tonsil-
lectomy.
F105
Estimating blood loss during adenotonsillectomy/tonsil-
lectomy: how accurate are ENT surgeons?
Okonkwo, O., Jayesh, D. & John, M.
Objectives: Tonsillectomy/Adenotonsillectomy is one of the most com-
monly performed ENT operations. A large proportion of these opera-
tions are on paediatric patients where a quantitative small volume of
blood loss may be a significant proportion of circulating blood volume.
As part of the WHO checklist, the surgeon is required to estimate blood
loss. The aim of this study was to determine how accurate ENT surgeons
were as estimating blood loss at the end of operation.
Methods: Prospective data collection on 20 consecutive patients under-
going a tonsillectomy/adenotonsillectomy. Data included demographic
details, surgical technique, seniority of surgeon, estimated and actual
blood loss after the procedure. Wilcoxon signed pairs rank test was used
to assess statistical significance of results.
Results: Twenty patients selected with an age range of 18 months
25 years. Sixteen bilateral tonsillectomies and four adenotonsillectomies.
The mean estimated blood loss was 102 mL with a range of 0600 mL;
and mean measured blood loss was 107 mL with a range of 4462 mL.
44 Clinical Audit and Practice
Blood loss was over estimated in 55% (11) cases and underestimated in
45% (9) of cases. Wilcoxon matched pairs signed rank test showed no
significant difference (P = 0.8124) between estimated and measured
blood loss. There was no correlation between grade of operator and abil-
ity to estimate blood loss.
Conclusions: There was no significant difference between estimated and
measured blood loss, indicating that the surgeons in this cohort are able
to estimate blood loss with reasonable accuracy. In this study grade of
operator experience does not correlate with ability to estimate blood
loss.
F106
Management of accessory parotid gland tumours
Alaani, A., Alaani, A., Oakley, R., Jeannon, J.P.
& Simo, R.
Objectives: Discuss our experience in management experience of acces-
sory parotid gland tumours.
Methods: Seven patients treated between 2003 and 2007, are included in
this study. The tumour was on the right side in four patients and on the
left side in the rest of them. The age range of the patients at the time of
presentation was from 18 to 45 year, with a mean of 41.
Results: The tumours were excised either intra-oral approach (two
patients) or by external approach (five patients). The choice of the
approach was determined by the tumour location in relation to the
check and oral cavity. The facial nerve and parotid ducts were identified
in the patients treated by Blair incision approach. The facial tumour was
deep to the facial nerve in one patient and at same level of the facial
nerve in three patients. The tumour was found to be either superior to
the parotid duct (three patients) or below the ducts in (two patients).
The post-operative facial nerve function was grade I in five patients and
grade II in 1. One patient had grade IV facial nerve palsy which
improved to grade II. Complications included seroma/sialoma in three
patients. All excised tumours were benign pleomorphic adenoma and
none of them had recurred.
Conclusions: Pleomorphic salivary adenomas of the accessory parotid
gland are rare. The outcome is usually satisfactory but surgeons treating
these patients need to be aware of the anatomical relationship of these
tumours locations to minimize complications and provide these patients
a satisfactory outcome.
F107
Thyroglossal duct cyst carcinoma current management
strategy
Alaani, A., Nixon, I., Jeannon, J.P., Ngu, R., Chandra, A.,
Odell, E., Mohan, H. & Simo, R.
Objectives: Review the clinical presentation, diagnosis and management
strategy of thyroglossal duct cyst carcinoma between 1998 and 2011.
Methods: Six patients were diagnosed with thyroglossal duct cyst carci-
noma between 1998 and 2009. The age range of patients was from 31 to
66 years with mean age mean of 41. Patients presented with midline
neck swelling with or without thyroid nodules.
Results: All patients were treated surgically either by single-stage surgery
(total thyroidectomy and excision of the thyroglossal cyst in two
patients) or staged surgeries (excision of the cyst followed by total thy-
roidectomy in four patients). The two-stage surgery approach was
adopted when the diagnosis of thyroglossal cyst carcinoma was not evi-
dent on FNAC or when patients were referred from other units after the
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
diagnosis of thyroglossal cyst carcinoma. All patients received radioactive
iodine treatment and TSH suppression. All the patients achieved full
recovery and no recurrence was reported during the fellow up period.
Conclusions: Careful investigation of thyroglossal cysts in adult patients
prior to surgery is important to rule out the presence of malignant
change. This would avoid subjecting the patient to multiple surgeries.
The prognosis of patients with thyroglossal duct cyst carcinoma is excel-
lent.
F108
Current management of carotid blow-out
Alaani, A., Gibbins, N., Oakley, R., Jeannon, J.P.
& Simo, R.
Objectives: To describe our experience in management of CBS and for-
mulate a management algorithm to deal with this condition using a sys-
tematic approach.
Methods: Ten patients (eight males and two females) suffered CBO
between January 2010 and February 2012. The age range was between 43
and 70 years. The patients presented with either oral or external bleed-
ing. Patients were categorized into two main groups and treated accord-
ing to the current management protocol.
Results: Six patients had advanced head and neck cancer (stage III
and IV) and four patients had stage I and II. Seven patients had
either radiotherapy (RT) or chemo-radiotherapy (CRT) followed by
surgery. One patient had surgery initially followed by radiotherapy
and one patient has surgery for the primary tumour followed by re-
excision of tumour recurrence. Only one patient did not have surgery
and had chemo-radiation with curative intent. Four patients treated
conservatively, two patients had repair of the carotid artery, one
patient had ligation of the artery, three patients had embolisation of
the carotid artery. Patients treated surgically died after the treatment.
Two patients who had embolisation were discharged from the hospital
and died in the community from tumour recurrence. One patient
developed stroke post-embolisation and was discharged for rehabilita-
tion.
Conclusions: Carotid artery rupture is rare but an increasing complica-
tion in head and neck surgery in patients who have undergone previous
RT or CRT. CBO carries a very poor prognosis. Radiological treatment
carries a better outcome. Medical and nursing staff should be provided
with clear protocol regarding the management of CBO.
F109
Minimally invasive parathyroidectomy: a 5 year surgical
experience
Hussain, K., Al-Shakarchi, J. & Rehman, A.
Objectives: Primary hyperparathyrodism is usually caused by a single
parathyroid adenoma. Traditionally parathyroidectomy has involved
bilateral neck explorations for assessment of all four glands. More
recently minimally invasive parathyroidectomy (MIP) has been advo-
cated as a safer procedure. In our study, we aim to report our experi-
ence of MIP in a single centre district hospital.
Methods: Using our endocrine database, we identified 158 patients who
had parathyroidectomy for primary hyperparathyrodism since 2006. A
retrospective review of case notes and electronic patient records was per-
formed for demographic, clinicopathological characteristics, operative
findings, operative procedure, radiological findings and outcome vari-
ables including pre and post operative serum calcium levels.
 2012 The Authors

Results: The patients had a mean age of 60.5 years old (range
1783 years) with a male to female ratio of 1 : 2.4. Conversion from a
minimally invasive procedure to bilateral exploration was carried out
in 30 patients (19%). Intra-operative adjunct in the form of histologi-
cal frozen section was only used in 24% of patients. Correlation
between radiological finding and exact operative finding was found in
76% of patients, with the correct side found in 84%. The majority of
patients (91%) had a successful return to normocalcaemia at day 1
post op. A single patient suffered from a hoarse voice following
surgery.
Conclusions: Our study confirms that minimally invasive parathyroidec-
tomy can be carried out effectively in a district hospital without the rou-
tine use of intra-operative adjunct. We also confirm that use of both
ultrasound and MIBI together is the best way to confirm the targeted
gland for resection.
F110
The ward round assessment tool (WrAT) a new work
based assessment tool
Danino, J., Kumar, S. & Skinner, D.
Objectives: 1 Ensure trainees receive teaching, assessment and feedback
on conducting ward rounds.
2 Pilot new WBA and assess competency undertaking ward rounds.
3 Ensure patient centred management, involvement and safety.
4 Ensure effective communication between all staff.
Methods: The WrAT is composed in a similar layout to the current
work based assessments already in use on the ISCP website and is an
amalgamation of the current procedure based assessment (PBA) and
mini clinical examination exercise (Mini-CEX) We aimed for the tool to
be generic so that all specialities could adopt it. The tool was trialled by
otolaryngology trainees across the region were asked to participate. Feed-
back from both trainees and trainers was collected via two methods.
Results: Ten otolaryngology trainees were assessed by various Consul-
tants who observed a routine working ward round. Of the ten trainees,
seven received a level 3 appropriate for central ST training and three
received level 4 appropriate for certificate for completion of training.
Feedback:Trainees felt the assessment encouraged consultant participa-
tion on ward rounds as well as teaching post ward round. Trainers com-
mented that the tool gave them an opportunity to teach.
Conclusions: The WRAT will ensure better teaching, supervision and
assessment of trainees in an integral part of the surgical day. The tool
encourages interaction between trainee and trainer as well as better com-
munication between trainee, junior doctors, patients and nursing staff.
We envisage this tool being used in conjunction with web based assess-
ment sites in multiple specialities and can easily be adapted to be speci-
ality specific.
F111
Clinical ENT training as a percentage of the
undergraduate medical curriculum
Davies, K. & Elhassan, H.
Objectives: Exposure to clinical Ear, Nose and Throat (ENT) at under-
graduate level in UK medical schools is lacking despite the prevalence of
ENT conditions encountered when working in a number of non-ENT
specialities. Fifty per cent and 25% of General Practice (GP) consulta-
tions with children and adults respectively involve ENT, and with three
in five medical students entering GP, undergraduate ENT will be
 2012 The Authors
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
Clinical Audit and Practice 45
pertinent to future careers. We aimed to quantify the percentage of clin-
ical ENT in the UK undergraduate medical curriculum.
Methods: A questionnaire was emailed to 30 UK Medical Schools to
determine the time spent in ENT as a percentage of the curriculum
duration, other specialties combined with ENT, and any differences
between the teaching in undergraduate and graduate entry programmes.
A request for the ENT timetable was also sent.
Results: Responses were received from 22 out of 30 (73%) medical
schools. Clinical ENT accounted for an average 0.85% of undergraduate
course duration, based on 17 (57%) medical schools. Undergraduate
clinical ENT training consisted of an average total of 4.00 clinics, 1.57
theatre sessions, 0.79 ward based sessions, and 4.21 tutorials or lectures,
based on 14 (47%) medical school timetables.
Conclusions: There is a discrepancy between the percentage of under-
graduate teaching dedicated to clinical ENT <1% and the large pro-
portion of ENT in GP consultations. In view of this we believe that
adequate time is not allocated to undergraduate ENT training.
F112
Telephone triage in the management of patients with
nasal injuries
Dias, L., Maughan, E., Kisha, A. & Moorthy, R.
Objectives: To assess whether emergency clinic appointments could be
avoided by implementing a telephone-based pathway utilising patient
self-assessment of nasal injuries.
Methods: A retrospective review of patient records established what pro-
portion of patients referred to emergency clinic required an MUA for
nasal fracture. Following initial audit the pathway was introduced:
Patients with swelling in injuries <1 week old had telephone consulta-
tion including Patient Recorded Outcome Measures (Group A). Patients
with clear deviation or presenting >1 week were referred directly to
clinic (Group B). All patients received information leaflets after initial
emergency department assessment. MUA rate, requirement for clinic
review and comparison with purely clinic-based assessment was audited.
Four months later, patients discharged after telephone consultations
were re-assessed and a second cycle was also performed.
Results: Three months before the pathway was introduced, 67 patients
were referred to clinic. Forty-three patients (64%) did not require sur-
gery. Three months post-implementation of the pathway, 67 patients
were audited prospectively; 44 patients (66%) did not require interven-
tion. Thirty-six patients (54%) underwent telephone follow-up, of which
23 were discharged. Thirteen patients were assessed in clinic of which
nine underwent MUA (26%) versus 14 from Group B (45%); P = 0.02.
All patients had their surgery performed within 2 weeks of injury.
Conclusions: Telephone consultation, information leaflet and PROMS in
the assessment of nasal fractures is an adequate and efficient method of
reviewing patients who present within 1 week of injury, reducing clinic
demand by 34%. It safely triages those requiring further intervention
into an acute clinic for rapid assessment for MUA.
F113
A survey of the learning resources currently used by
otolaryngology trainees
Roper, A., Laha, S. & Kumar, N.
Objectives: To establish which learning resources are the most utilised
among otolaryngology speciality trainees, in particular whether newer
methods of learning have superceded more conventional resources.
46 Clinical Audit and Practice
Methods: Web based survey completed by otolaryngology speciality
trainees in the North West Deanery.
Results: A high proportion of respondants (90.0%) still use conventional
text books compared to 40.9% using online text books. All respondants
use eMedicine-Medscape with a high proportion using non-specialised
sources such as Wikipedia (81.8%) and YouTube (68.2%). When asked
to rate their preferences, online journals were the first choice with text
books coming second. In addition to using a computer, 76.2% used a
smart phone and 52.4% used a tablet.
Conclusions: While electronic resources are widely used, conventional
text books and paper journals still have a place in the battery of learning
resources used by otolaryngology trainees. General electronic resources
such as search engines and Wikipedia seem to be used in preference to
some specialist resources e.g. The Otorhinolaryngolgist, doctors.net.uk.
We wonder whether this is due to accessabiltiy.
There was a disparity between then number of trainees who used a smart
phone and the number who used mobile applications (18.2%). This sug-
gests an area where resources could be developed, particularly with a view
to make better use of the specialist learning resources available.
F114
The financial cost of readmission for post tonsillectomy
bleeds
Parmar, A., Muir, J., Hanks, K.A. & Evans, K.
Objectives: To assess the impact of the governments new policy of not
paying for readmissions within 30 days following elective surgery. Specif-
ically looking at Post Tonsillectomy bleeds in a District general hospital.
Methods: This study was carried out at The Department of ENT,
Gloucester Royal Hospital, UK.
This was a prospective study between February 2011/2012. All surgeons
undertaking tonsillectomy were asked to fill out our audit pro-forma.
The hospital informatics department were approached to provide infor-
mation with regards to secondary readmission rates. The hospitals read-
missions officer was approached to work out the exact amount of
financial loss due to readmissions post tonsillectomy.
Results: In total 460 patients underwent tonsillectomy. There were 58
admissions in total for post operative bleeding. Fifty-three were treated
conservatively while five returned to theatre. This represents a loss of
33 000 to our ENT department under new government policy
Conclusions: This study demonstrates the impact of new government
policy on a DGH ENT Department. The national tonsillectomy audit
provides ample evidence demonstrating the degree of post tonsillectomy
bleed that should be considered as acceptable. This evidence should be
presented to the department of health in order to provide an acceptable
level of post tonsillectomy bleed that is not financially penalised.
F115
Laryngeal cancer social marketing project
Rafferty, A., Greensmith, M., Robinson, S. & Jose, J.
Objectives: The Humber and Yorkshire Coast Cancer Network area has a
higher than average rate of head and neck cancer mortality with frequent
late stage presentation. This campaign aimed to raise public awareness of
the signs and symptoms of laryngeal cancer, to increase earlier presenta-
tion to primary care and appropriate referrals to secondary care.
Methods: A social marketing campaign was launched using mixed media
approaches including a website (www.getitchecked.co.uk), Facebook page
and YouTube Channel. Four electoral wards with high incidences of
cancer were targeted. Street teams delivered brief on-street interventions
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
and training was provided in general practices. The campaign was pro-
moted on local news programmes, by professional football clubs and
using billboards.
A cancer awareness measure (CAM) survey was undertaken pre and post
campaign. Numbers of referrals for suspected head and neck malignan-
cies and trends in the stage at diagnosis before and after the intervention
are compared.
Results: The overall recall of the advertising campaign was 37%. Of the
respondents that recalled the advertising 43% recognised the main mes-
sage was to attend a GP with the symptoms of cancer. Fifteen per cent
discussed the campaign with a friend or family member and 4% visited
the GP to discuss associated symptoms. Results of referral numbers and
stage at diagnoses are available from April 2012.
Conclusions: Earlier presentation of laryngeal cancer has a significant
impact on morbidity and mortality. Preliminary post-intervention results
are promising and suggest social marketing campaigns may have a role
to play in increasing public awareness and facilitating early diagnosis.
F116
FNA versus frozen section for branchial cysts an audit
of clinical practice
Begbie, F. & Clark, L.
Objectives: We sought to investigate the correlation between fine-needle
aspiration cytology (FNAC), frozen section and formal histology in prac-
tice. Branchial cleft cysts (BCC) result from a failure of involution of the
branchial cleft in embryonic development. Management involves FNAC
and surgical excision. However, FNAC is often equivocal since metastatic
squamous cell carcinoma (SCC) may mimic BCC cytologically and a
definitive diagnosis can only be made on formal histological examina-
tion. Frozen section specimens may be of use intra-operatively in direct-
ing further surgical management prior to formal histology.
Methods: Thirty-one cases with a diagnosis of BCC on FNAC or formal
histology from 2003 to 2011 were reviewed retrospectively and their
demographic, FNAC, frozen section and formal histology data recorded.
Reports for FNAC, frozen section and formal histology were compared.
Results: Age ranged from 19 to 66 (Mean 39.55). Twenty-two (71%)
were male and 9 (29%) female. Nineteen (76%) cases showed positive
correlation for a diagnosis of BCC between FNAC and formal histology.
Two important cases of negative correlation involving SCC were
observed. One had FNAC diagnosis of SCC with formal histology of
BCC; and one had FNAC diagnosis of BCC with formal histology of
SCC. Seven (100%) BCC cases that had frozen section reports showed
positive correlation with formal histology.
Conclusions: The age-old problem of differentiating BCC from SCC in
clinical practice still persists. In this series, frozen section correlated
100% with final histology. We therefore suggest that frozen section
should be routinely performed to assist in decision-making about further
surgical treatment with the patient still on the table.
F117
Day case tonsillectomy: an audit of unplanned
admissions to inpatient post-operative care.
Amiraraghi, N. & Calder, N.J.
Objectives: From January 2008 to 2011, 1969 tonsillectomies were per-
formed in NHS Lanarkshire, 247 (12%) as a day case and 62 of those
247 were admitted overnight. An overnight stay costs NHS Lanarkshire
an additional 114 per patient. We reviewed these cases to ascertain rea-
 2012 The Authors

sons for the unplanned admissions, to implement change, improve
patient care and reduce costs to the trust in the future.
Methods: A retrospective review of medical and electronic records of
the 62 patients who were admitted following day case tonsillectomy was
carried out. Thirty-one patients were planned admissions, thus excluded.
Results: The unplanned admission rate was 12.5%. The majority of
unplanned admissions fell within the 1620 age range. The main reason
was post-operative nausea and vomiting (PONV) (n11/31, 35%). Other
reasons included, one primary haemorrhage, nursing concern regarding
possible post-operative ooze (n8), pain (n6), difficult procedure (n3)
and unable to ambulate (n2). Of all 31 cases only three patients received
intravenous dexamethasone at time of induction.
Conclusions: Our selection protocol for day case tonsillectomy is ade-
quate and our unplanned admission rate is comparable to results dem-
onstrated within current literature. We should work with our
anaesthetic colleagues to implement change and increase the number of
patients receiving intravenous dexamethasone at time of induction, with
a view to reducing PONV and pain, as per Scottish Intercollegiate
Guidelines Network guidelines.
F118
Is the 2 week-wait referral system an efficient method
of detecting head and neck cancer?
Joshi, H. & Mcpartlin, D.
Objectives: Head and neck cancers are rare malignancies with many
symptoms being the same for both benign and malignant conditions.
Some malignancies present with vague symptoms leading to potential
late referral and diagnosis. We aimed to identify the efficacy of the
2 week-wait (2WW) referral system in the detection of head and neck
cancer in patients attending a district general hospital in rural England.
Methods: A retrospective audit was carried out looking at all 2WW
referrals in a period from August 2010 to July 2011. The number of
malignancies were identified and also those malignancies identified that
were not referred under the 2WW system. The notes of all detected
malignancies were reviewed.
Results: A total of 362 patients were referred with 98.70% being seen
within the 14 day target. There were eight malignancies identified in this
group giving a pick-up rate of 2.2%. There were a further nine malig-
nancies diagnosed in the same time period that were referred to the
clinic as either routine or urgent referrals. Analysis of these notes
showed that 89% of cases had symptoms indicating referral under the
2 week-wait system would have been appropriate. All patients were
referred by a general practitioner.
Conclusions: The 2WW system is not an efficient means of detecting
head and neck cancer in our population group. Failure to recognise
symptoms or poor understanding of the referral guidelines are possible
reasons for delayed diagnosis of these conditions which can possibly be
addressed by further education of primary care doctors.
F119
A completed audit cycle of ear, nose and throat theatre
pathway
Kulloo, P., Masood, A. & Pfleiderer, A.
Objectives: Our objective was to assess any delay in theatre session start
time for Ear, Nose and Throat (ENT) operating lists.
Methods: ENT theatre sessions over a 2-week period in a district general
hospital were reviewed against the standard that ideally a theatre session
should start at the planned starting time without any delay. The theatre
 2012 The Authors
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
Clinical Audit and Practice 47
session start time was re-audited 8 months later after the conversion of
part of an ENT ward into an admission bay designated to streamline
pre-operative patients admission. The data for this audit was obtained
from Theatre Man which is a theatre management software used in the
hospital trust.
Results: A total of 14 theatre sessions and 44 patients were audited in
the first cycle (C1). A total of 17 sessions and 58 patients were audited
in the second cycle (C2). There was an improvement in the mean time
taken for the patient to arrive to the anaesthetic room after being sent
for by the theatre nurse (C1 = 23; C2 = 19 min). The mean time for the
patient to be brought into the operating room after the scheduled the-
atre session start time improved markedly (C1 = 22; C2 = 11 min).
Conclusions: The establishment of a dedicated admission bay for pre-
operative patients proved successful in reducing the delay in starting a
theatre session. This intervention was simple, cheap and effective. Our
audit has shown that by careful re-allocation of already available
resources, we can provide a more efficient health service.
F120
Audit of thyroid function testing post-radiation for
head and neck cancer in a tertiary referral centre
Kulloo, P. & Paleri, V.
Objectives: Our primary aim was to audit thyroid function testing fol-
lowing radiotherapy treatment for patients with head and neck cancer in
a tertiary referral centre against British Thyroid Association (BTA)
guidelines. Our secondary aim was to review the thyroid status of the
patients who had thyroid function tests (TFT) during their follow-up
after radiotherapy.
Methods: A retrospective audit involving patients who had radiotherapy
treatment for head and neck cancer over a 1-year period in a tertiary
referral centre was undertaken. The patients were identified from the
Data for Head and Neck Oncology (DAHNO) database. The audit data
was obtained from clinic letters and blood test results of patients.
Results: One hundred and forty-five patients with non-thyroid head and
neck cancer had radiotherapy over a 1-year period. After excluding
patients with prior thyroid disease, laryngectomy and those who died
before 12 months following end of radiotherapy, there were 99 patients
who received radiotherapy with or without chemotherapy or non-laryn-
gectomy surgery. Only 27 patients (27%) had TFT follow-up post-neck
irradiation which is below recommended BTA guidelines. Out of these
27 patients, six patients (22%) were hypothyroid.
Conclusions: Our audit shows that compliance with the BTA guidelines
was suboptimal. Moreover, it reinforces pre-existing evidence that hypo-
thyroidism is a complication of radiotherapy treatment for head and
neck cancer. In order to avoid missing a diagnosis of hypothyroidism on
such patients, we suggest writing to the general practitioner to check
TFT every 12 months post-radiotherapy. A re-audit following implemen-
tation of this intervention is recommended in about 1824 months.
F121
Multidisciplinary difficult airway simulation training:
2 year evaluation and validation of a novel training
approach
Mehta, N., Claire, B., Laurence, B., Heather, M.
& Taran, T.
Objectives: Simulation training has been adapted by medical education-
alists from the aviation industry and is a useful tool in investigating and
preparing for emergency situations, by acting as a team dress rehearsal.
48 Clinical Audit and Practice
A novel multi-disciplinary approach to difficult airway simulation train-
ing involving a crisis resource management strategy is presented and
assessed.
Methods: The authors have devised and run a multi-disciplinary difficult
airway simulation course for 2 years at a single training centre. Over this
period the course has run six times with 78 candidates (28 Anaesthetic
trainees, 18 ENT trainees, 19 theatre nurses and 13 operating theatre
practitioners).
The course comprised of 68 difficult airway simulations (using a Laer-
del SimMan2 mannequin remote controlled by a driver) with two
teams moving through the simulations over half a day. The simulation
lasted 20 min and was followed by 40 min of in-depth structure
Results: A 100% candidate feedback response rate demonstrated that
simulations were highly realistic in replicating the stress of live situa-
tions; that universally all multi-disciplinary candidates training needs
were met; and that clinical knowledge, teamwork, leadership and
non-technical skills were enhanced, as well as the mutual understand-
ing and respect between related medical and non-medical team mem-
bers.
Conclusions: Successful management of a difficult airway situation
requires rapid evaluation, effective communication, strong leadership
and teamwork, as well as knowledge of local environment and equip-
ment. The results emphatically demonstrate the universal success of this
multi-disciplinary training method for all team members, regardless of
hierarchical position or background.
F122
Audit on primary care nurse practitioners referrals to
ENT clinic
Abelardo, E., Howarth, A. & Thomas, M.A.
Objectives: Nurse practitioners are vital in health care delivery in United
Kingdom. This audit aimed to determine the quality of referrals sent by
primary nurse practitioners to ENT secondary care.
Methods: Referral letters from six GP surgeries sent to ENT team based
in a district hospital were prospectively collected during a 12-month
period (February 2011January 2012). Sixty five referrals from 11 nurse
practitioners were reviewed.
Results: The most common reasons for referral were recurrent sore
throat (15.3%), ear infection (15.3%), and nasal congestion (10.7%).
The problems identified were unclear reason for referral (12.5%), his-
tory not described (21.9%), multiple unrelated symptoms and unfo-
cused history (18.4%), examination not described (50.0%), impression
not described (49.5%), administered primary care not described
(39.4%), patient-driven referrals (35.3%), case not discussed with GP
(69.3%), referral to unnamed ENT consultant (82.8%), and re-referrals
of cases previously seen in the ENT clinic (20%). There were signifi-
cant number of inappropriate referrals such as bilateral hearing loss in
elderly which should have been referred straight to audiology depart-
ment, cases involving possible malignancies which should be handled
by the GP, request for tonsillectomy with no consideration of the pub-
lished NICE guidelines, no medications initiated for rhinitis, among
others. Overall, there were 82.8% incomplete referrals and 23.4% inap-
propriate referrals.
Conclusions: The quality of primary nurse practitioners referral to ENT
clinic needs improvement. The contents should be enhanced, and complex
cases need discussion with GP. The issues involved in this practice are
teamwork, regulation to practice, communication, professional conflict,
professional relationship, professional competence, and accountability.
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
F123
Towards a clinical score sheet to diagnose glandular
fever
Abelardo, E., Davies, P., Salamat, A., Arnott, J.
& Jaramillo, M.
Objectives: Infectious mononucleosis is often difficult to differentiate
clinically from acute tonsillitis since the presenting signs and symptoms
are quite similar. Based on our local experience, Monospot Test takes 2
3 days for results, making it irrelevant to influence acute care manage-
ment. Recent studies reported high correlation of the disease with pres-
ence of fibrinous membranes in the post-nasal space, elevated serum
alanine aminotransferase (ALT), and high lymphocyte-white cell count
ratio (L/WCC). This study aimed to generate a score sheet to diagnose
glandular fever based on history, clinical examination and routine blood
tests.
Methods: A retrospective study was performed on 63 consecutive cases
of glandular fever (positive Monospot Test) and 65 consecutive cases of
acute tonsillitis (negative Monospot Test) admitted at district general
hospital from 2006 to 2012. The clinical and serological characteristics
were identified and compared.
Results: Strong predictors of glandular fever were age group (1525)
(P < 0.05), whitish exudates on tonsils (P < 0.05), elevated ALT
(P < 0.01), normalised lymphocytosis (L/WCC ratio of >0.35 and >0.5)
(P < 0.05 and P < 0.01), and normal neutrophil count (<12) (P < 0.05).
Examination of the post-nasal space using nasoendoscope was not well
documented. Degree of relevance was statistically analysed and assigned
to each parameter.
Conclusions: A score sheet based on clinical examination and routine
blood tests to establish glandular fever was generated. This quick and
inexpensive tool would be relevant in the early phase of management of
sore throat, especially those suspected to have glandular fever. Further-
more, this could save money for the NHS. Further study to validate the
score sheet is underway.
F124
An audit of ENT specialist trainee follow-up rates and
reducing unnecessary outpatient follow-ups
Wu, K., Wu, K., Wong, W., Eng, C.-Y., Irune, E.,
Chetwood, A. & Mirza, S.
Objectives: To audit the follow-up rates of ENT specialist trainees with
the aim of reducing unnecessary follow-ups.
Methods: We calculated the specialist trainee general adult ENT clinic
follow-up rates for three consecutive trainees, by sampling, at the begin-
ning of their 6 month attachment and compared this to the rates at the
end of their placement.
Results:
SpR1-cycle 1 The follow up rate decreased from 43 out of 71 patients
(61%) at the beginning of the attachment to 39 out of 92 patients
(42%) by the end.
This was achieved by the trainer reviewing clinic letters with written
feedback.
SpR 2-cycle 2 The follow up rate decreased from 44 out of 75 patients
(59%) at the beginning of the attachment to 14 out of 41 patients
(34%) by the end. As well as regular feedback, written guidelines were
given to the trainee on commencement of the post.
SpR 3-cycle 3 The follow up rate decreased from 22 out of 65 patients
(34%) at the beginning of the attachment to 18 out of 67 patients
(27%) by the end. Clear instructions at the beginning of the attachment
 2012 The Authors

as well as regular oral and written feedback achieved an even lower fol-
low-up rate.
Conclusions: By written guidelines, clear verbal instructions, feedback in
clinic, and written feedback of clinic letters, the follow-up rates of train-
ees can be reduced, thereby improving efficiency.
F125
Increasing incidence and survival of thyroid cancer in
the West of Scotland
Clark, L., Townsley, R., Konstantinidis, G., Oozeer, N.
& Reed, N.
Objectives: To audit the incidence and survival of thyroid cancer in the
West of Scotland.
Methods: A database of all thyroid cancers treated in the West of Scot-
land between 1990 and 2011 was used to access patient details which
were anonymised before analysis. The overall incidence, survival and the
disease free survival was calculated using the KaplanMeier method.
Results: The figures show increasing incidences especially for papillary
cancer over the last 20 years. The average age for all 1496 thyroid can-
cers was 58, with papillary cancer occurring most commonly in the
youngest. KaplanMeier survival and disease free curves, for each histo-
logical subtype have been created and show increasing survival.
Conclusions: Evolution in clinical practice may have been a major factor
responsible for the increased thyroid cancer incidence. On the other
hand, it seems unlikely that a recognized environmental risk factor in
Scotland, such as radiation exposure or iodine supplementation, can
explain the increase although Chernobyl did affect the West coast of
Scotland and it has taken until 2011 for all farms to be able to sell their
animals for human consumption. Despite the increased incidence of thy-
roid cancer, there has been a decrease in overall mortality from this
malignancy, with improved survival estimates at 1, 5 and 10 years.
F126
Patients attitudes towards trainee involvement in
otolaryngologic surgical procedures
Grover, N. & Burton, M.
Objectives: To study the attitudes of patients towards the involvement
of trainees in otolaryngologic surgical procedures.
Methods: Questionnaire survey of 100 patients, undergoing intermediate
otolaryngologic surgical procedures.
We determined patient attitudes to: a trainee performing any surgery,
undertaking a procedure on them and how views changed depending on
supervision.
Results: Ninety-five per cent of patients agreed that trainees should
operate under supervision but only 68% agreed to trainees performing
their specific operation. Ninety-seven per cent of patients favoured
supervised operating with only 30% happy with an unsupervised but
competent trainee operating alone (but only 8% when concerning their
own procedure). Prior to signing their consent form 65% were aware
that a trainee would be involved.
Conclusions: Training opportunities may be reduced if patients are
reluctant to allow trainees to operate. This should not deter surgeons
from discussing all aspects of the operation including the involvement
of trainees with patients pre-operatively. A pre-operative discussion by
both the consultant and trainee may permit greater understanding and
increase confidence in patients about the roles of different doctors in the
surgical team.
 2012 The Authors
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
Clinical Audit and Practice 49
Those units which allow unsupervised trainee operating might reappraise
their practice.
F127
Are we following low priority treatment pathways for
functional endoscopic sinus surgery at the Royal
National Throat Nose and Ear Hospital?
Hamilton, N., Rennie, C., Bohm, N. & Hannan, A.
Objectives: 1 Determine adherence of General Practitioners and ENT cli-
nicians to the Procedures of Limited Clinical Effectiveness Pathway for
the referral and treatment of chronic rhinosinusitis (NHS North Central
Thames PCT, June 2011) at the Royal National Throat Nose and Ear
Hospital (RNTNE).
2 To determine length of delay from GP referral to ENT outpatient
appointment before and after the introduction of the pathway in
patients undergoing functional endoscopic sinus surgery (FESS).
Methods: The case notes of patients undergoing endoscopic sinus sur-
gery at the RNTNE 3 months before and after the introduction of the
pathway were reviewed. GP referral and ENT clinic letters were used to
compare management against the guidance criteria presented in the
pathway.
Results: Adherence to criteria on the diagnosis, assessment and initial
treatment of chronic rhinosinusitis in primary care improved following
the introduction of the pathway. The proportion of referred patients
that met the referral criteria fell from 95% to 85% after the pathway was
introduced. All patients undergoing FESS met the criteria for proceeding
with surgery both before and after the introduction of the guidelines.
The mean duration of referral to first outpatient appointment was simi-
lar in both groups (32 versus 33 days).
Conclusions: The low priority treatment pathway for FESS improved the
initial management in primary care but did not appear to have a benefi-
cial effect on referrals or surgical intervention. The introduction of the
pathway did not influence the time period from referral to clinic
appointment.
F128
An audit of the clinical coding of pituitary operations
Mirza, S., Mirza, S., Manickavasagam, J. & Sinha, S.
Objectives: Clinical coding of an operation produces a Health Resource
Group (HRG) code with a specific payment tariff that the hospital
receives. We commenced a two surgeon, Neurosurgeon and Otorhino-
laryngologist Transnasal Endoscopic Skull-Base service in 2009.
Our aim was to review the clinical coding of our pituitary surgeries and
discover if there was scope for improving the accuracy of coding and
income tariffs.
Methods: We retrospectively reviewed the clinical coding of pituitary
surgeries from September 2009 to July 2011 (23 months). A database
was obtained including the following information, operation description,
primary operation code and description, diagnosis, HRG code and tariff.
Results: There were 55 pituitary cases, of which 44 coded for a total tar-
iff of 5892, eight coded for only 1934, two coded for 8836 and one
coded for 2418. The variation was due to differences in diagnosis
codes, presumably from a coding anomaly. Over the studied period this
resulted in a tariff reduction of 27 222. Two cases had their coding
adjusted to achieve optimal coding and an improved tariff of 7916.
50 Clinical Audit and Practice
Conclusions: Currently coding a diagnosis of acromegaly and pituitary
gigantism or Cushings syndrome unspecified instead of benign neo-
plasm of the pituitary currently reduces the tariff by up to 3958.
F129
A quantitative analysis of Youtube as a resource for
surgical education
Phillips, T.I., Elhassan, H.A. & Whittet, H.B.
Objectives: Procedure based assessments (PBAs) are workplace based
assessment tools used in surgical training by the Royal Colleges of Sur-
geons. Each surgical subspecialty has its separate PBAs to evaluate the
surgical technique of trainees. We surveyed the availability of online
operative videos, using the Youtube website, for each specialty.
Methods: A list of PBAs for all nine surgical subspecialties was extracted
from the online Intercollegiate Surgical Curriculum Programme
(www.iscp.ac.uk). Search terms were derived from the PBA titles for
each procedure excluding potentially nebulous terms. Youtube searches
were subsequently conducted and the number of video results was
recorded. The results were recorded and analysed in Microsoft Excel.
Results: 92.6% of PBAs were available online. ENT has 47 PBAs, with
98% of these available in 8215 Youtube videos. Specialties were ranked
according to videos/procedure ratio. The specialty with the highest video
density was Maxillofacial Surgery (875.5 videos/procedure), the lowest
video density belonged to Urology (35.6 videos/procedure). The T&O
curriculum is completely covered (20 853 videos, 100% PBAs). Neuro-
surgery had a paucity of material, having the highest number of proce-
dures with no videos at all.
Conclusions: There is a wealth of surgically based operative videos freely
available on Youtube. These videos represent a new, valuable and poten-
tially underused resource for self directed learning for surgical trainees.
The online videos can aid teaching of surgical technique, though qualita-
tive studies will need to be completed. With the relative lack of material
in otolaryngology there is an opportunity to produce footage, expand
portfolios and share techniques
F130
Sinus and nasal polyposis surgery: University Hospital
North Staffordshire compliance with the EPOS 3 (Euro-
pean position paper on rhinosinusitis and nasal polyps
2007)
Young, E., Khalid-Raja, M., Isles, M. & Rowland, G.
Objectives: To evaluate UHNS compliance with the EPOS-3 guidelines
in the diagnosis, treatment and follow up care of patients with chronic
rhinosinusitis and nasal polyposis. To demonstrate improved practice on
re-audit.
Methods: Cycle 1: Retrospective case note review of all patients under-
going FESS between October 2009 and January 2010. Data was collected
on length of symptoms, presenting complaint and severity of symptoms,
findings on examination, non-surgical treatment prior to surgery follow-
up care. Cycle 2: Retrospective case note review of all patients undergo-
ing FESS between January and June 2011.
Results: Cycle 1: 51 FESS operations were performed. We demonstrated
poor compliance with EPOS-3 with only 49% compliance with diagnos-
tic criteria, 22% compliance with listing criteria and 35% compliance
with follow-up care. To improve compliance, flowcharts of EPOS-3
guidelines were placed in our clinic rooms and our findings were pre-
sented at our monthly audit meeting. In addition, proformas were filled
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
out in clinic for each patient being listed. Cycle 2: 28 operations were
performed. Cycle 2 demonstrated improved compliance with both diag-
nostic and decision to list criteria (96% and 61% respectively). There
was still poor compliance with guidelines regarding follow-up care
(11%) particularly in providing nasal steroids and douching post sur-
gery.
Conclusions: This audit has demonstrated significant improvement in
compliance with EPOS-3 guidelines, however improvements can be
made with regards to follow-up care following surgery.
F131
Role of estimation of arterial blood gases in the
management of stridor
Kamath, M.P., Hegde, M.C., Sreedharan, S., Bhojwani,
K., Vamadevan, V. & Vijayadev, V.K.
Objectives: The primary objective was to assess the usefulness of arterial
blood gases in aiding emergency airway procedure, in patients presenting
with acute clinical stridor. Additionally, epidemiological data, etiological
associations, prognostic indices and the clinical outcomes were reviewed
in these patients.
Methods: A prospective study was conducted involving 72 patients pre-
senting with Stridor in the emergency setting at a tertiary referral hospi-
tal. At presentation, they were independently evaluated by three trained
observers and clinically categorized into different grades, based on sever-
ity. These patients were also reclassified by the investigators utilizing
their arterial blood gas values (pH, Po2, Pco2). Treatment was instituted
and stridor was managed adequately. Interobserver variability was statis-
tically assessed in comparison with the objective classification defined by
arterial blood gases.
Results: Kappa coefficient of agreement between the three trained
observers was found to be 0.014, indicating poor interobserver reliability
for the working clinical classification. However, arterial blood gas analy-
sis revealed that six patients were in respiratory failure, 19 progressing
towards impending failure and 47 without any evidence of respiratory
failure. Hence, we complied by the latter analysis in planning manage-
ment. Laryngomalacia in children and hypopharyngeal malignancies in
adults were found to be the most common causes of Stridor in our
study.
Conclusions: Clinical assessment of stridor can often be misleading and
lead to delay in instituting emergency airway surgery. Early detection of
impending respiratory failure with Blood gas analysis may be proposed
as an objective tool, to decide the appropriate treatment in upper airway
obstruction.
F132
Analysis of 15 years of clinical negligence claims
following tonsillectomy in England
Mathew, R., Walker, D., Black, D., Gutierrez, T.,
Valentine, P. & Pitkin, L.
Objectives: To determine the characteristics of medical negligence claims
following tonsillectomy in England.
Methods: Claims relating to tonsillectomy between 1995 and 2010 were
obtained from the National Health Service Litigation Authority database.
The number of open and closed claims was determined and data were
analysed for primary injury claimed, outcome of claim and associated
costs.
Results: Over 15 years there were 40 claims of clinical negligence
related to tonsillectomy representing 7.7% of all claims in otolaryngol-
ogy. There were 34 closed claims of which 32 (94%) resulted in pay-
 2012 The Authors

ment of damages. The median cost per claim was 20 100 and the
highest cost for a claim was 1.39 million. Post operative bleeding was
the most common injury with delayed recognition and treatment of
bleeding alleged in most cases. Nasopharyngeal regurgitation as a result
of soft palate fistulae or excessive tissue resection was the next com-
monest cause of a claim. Other injuries claimed included dentoalveolar
injury, burns, tonsillar remnants, temperomandibular joint dysfunction
and retained swabs. Inadequate informed consent was claimed in five
cases.
Conclusions: Clinical negligence claims following tonsillectomy are
uncommon but have a high success rate. Although post operative bleed-
ing is the most common cause of negligence claims, a significant pro-
portion of claims are due to rare complications of surgery. Informed
consent should be tailored to the individual patient and should include
a discussion of common and serious complications.
F133
GP lead follow-up of patients undergoing grommet
insertion
Harris, R., Maleki-Toyserkani, S. & Patel, N.
Objectives: Due to financial constraints, ENT departments are having
to rely more on general practitioners for long-term follow-up of
grommets after the first post-operative clinic appointment. The consis-
tency of information provided in the form of aftercare advice varies
widely which causes confusion amongst GPs with regards to ongoing
management. The aim of this audit is to establish current practice and
formulate a standardised letter to communicate information to the
GP.
Methods: Patients undergoing grommet insertion for persistent otitis
media with effusion were studied over a 1-month period. Post-operative
discharge summary as well the follow-up letter to the GP were collated
retrospectively and studied for details of follow-up plan and manage-
ment of common complications.
Results: Thirteen patients underwent grommet insertion. Age ranged
from 2 to 71 years. Eleven patients were correctly followed up at
3 months, two were followed up at 6 weeks. Side of operation was
recorded in 12, and post-operative audiogram findings were recorded in
six of the letters. No advice was given on management of complications
and only one letter provided a plan for structured GP follow-up and cri-
teria for referral back to ENT care.
Conclusions: Ongoing GP management of grommets offers financial and
logistical benefits to the ENT department as well as providing conve-
nient continuity of care to the patient. A standardised discharge letter
minimises confusion over GP-lead care and more effort is needed to
promote its success. Prospective monitoring is under way to re-audit
compliance and improve communication of information.
F134
Opportunistic hearing screening in elderly inpatients
Ramdoo, K., Dale, O. & Corbridge, R.
Objectives: This study aims to determine prevalence of occult hearing
loss in elderly inpatients and to evaluate feasibility of opportunistic hear-
ing screening in elderly inpatients.
Methods: Subjects over the age of 70 were recruited from the elderly
care wards at the Royal Berkshire Hospital between July and September
2011. A ward based hearing screen was performed to identify individuals
with hearing loss. This comprised a subjective assessment of hearing dis-
 2012 The Authors
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
Clinical Audit and Practice 51
ability, and a whisper test. Subjects who failed the whisper test or
reported hearing difficulties were offered audiological assessment includ-
ing pure tone audiometry.
Results: Hearing screening was performed on 51 patients, aged between
70 and 95. Twenty-one patients (41%) reported hearing loss, and 16
(31%) failed the whisper test. This resulted in 37 patients (73%) being
referred for audiological assessment. Sixteen patients (31%) were found
to have aidable hearing loss. As a result of this study, 10 patients were
fitted with hearing aids (20%).
Conclusions: This study highlights that there is a high incidence of
occult hearing loss in elderly inpatients, and suggests that consideration
should be given to opportunistic hearing screening, to address this
unmet need.
F135
Estimated numbers of tracheostomies performed and
managed in critical care units in England.
McGrath, B.
Objectives: Extrapolate from a high quality database of critical care
admissions in the North West of England to estimate numbers of percu-
taneous and surgical tracheostomies performed and managed in critical
care units in England.
Methods: Greater Manchester critical care network MIDAS database
was interrogated for all admissions between 1 January 2010 and 25
January 2012 using Microsoft Excel. Hospital Episode Statistics (HES)
is a data warehouse for NHS hospitals in England. The Intensive
Care National Audit and Research Centre (ICNARC) collects data
from selected critical care units. Neither HES nor ICNARC collect
airway data but can be used to estimate national admissions and bed
usage.
Results: Eight Trusts (comprising 17 individual units in 11 hospitals,
providing 154 beds) submitted data to MIDAS. A total of 84 623 bed
days for 16 589 admissions were analysed. There was a mean of 64
tracheostomies per ICU per year (60 percutaneous). A patient with a
tracheostomy remained in ICU for a mean of 12.0 days, 9.1 of which
were receiving advanced respiratory support. Crudely extrapolating from
HES, we estimate 16 238 tracheostomies were managed in England dur-
ing 2009/10 (15 382 percutaneous). We can similarly estimate from
ICNARC that each ICU in England can expect to manage between 48
and 51 tracheostomies per year (4648 percutaneous).
Conclusions: Approximately 15 000 percutaneous tracheostomies are
managed (and probably performed) in Englands critical care units. By
comparison, HES recorded 5704 surgical tracheostomies performed in
2009/10. A national tracheostomy database would allow appropriate fol-
low up and provide denominator data for incidents occurring in patients
with tracheostomies.
F136
The disinfection of flexible fibre-optic nasendoscopes
out-of-hours: a completed national audit.
Radford, P., Unadkat, S., Rollin, M. & Tolley, N.
Objectives: Audit of out-of-hours endoscope disinfection practice in
England, against a previously published first cycle (Kanagalingam et al.
2002), with the 2005 ENT-UK guidelines as the key intervention.
52 Clinical Audit and Practice
Methods: Confidential telephone survey of the 104 ENT units in Eng-
land out-of-hours, replicating exactly the methods of the first cycle. The
primary clinician on-call for each department answered questions cover-
ing access to flexible endoscopes, training in their use, disinfection pro-
cedures, storage, and audit trail. Additional information regarding the
trainee grade of the respondent and their cross-covering duties were also
gathered. Responses were collated and compared to first-cycle results
and published guidance.
Results: Seventy-two of 104 units agreed to participate. Ninety-three
per cent had access to an endoscope out-of-hours, but in only 71%
had the on-call clinician received training in its use. The on-call clini-
cian was expected to clean the endoscope in 43% of units; however,
the proportion of these having received training in this activity
remained inadequate (37%), despite showing improvement over first-
cycle results (12%). Twenty-seven per cent of units used an inade-
quate method of disinfection out-of-hours, compared to 54% in the
first-cycle results. One confounding factor on this lack of improve-
ment may be the increase in cross-cover out of hours with 68% of
responders covering one or more other specialties and the concomi-
tant lack of ENT experience in juniors covering ENT from another
specialty
Conclusions: An overall moderate improvement in the safety of out-of-
hours upper aerodigestive endoscopy in the past 10 years cannot obscure
the urgent need for universal compliance with national guidelines, to
minimise patient risk.
F137
Improving appropriateness of referral to ENT
emergency clinic: a completed audit loop
Daultrey, C., Buck, D., Gwyn, G., Al Hamarneh, O.
& Trotter, M.I.
Objectives: The aim of this study was to assess whether appropriateness
of referrals could be improved in a single ENT unit, (Heart of England
Foundation Trust), through implementation of a structured emergency
clinic referral system.
Methods: Initial audit of the emergency clinic service was undertaken
prospectively, over a 2 week period. Case notes were reviewed to assess
appropriateness of referral. Standards were assessed with reference to
previously published departmentally-developed guidelines. After the ini-
tial audit a comprehensive implementation plan was developed and
three A&E departments and all GPs in the two large primary care trusts
were engaged and contacted regarding the changes to the service and
referral pathways. Three months after implementing the change, a sec-
ond prospective audit was undertaken. Data was analysed using simple
statistical methods and the P-value was considered significant when
<0.05.
Results: In the initial audit, 133 patients were included. Inappropriate
referrals were 40% (n = 53) and of these patients 68% (n = 36) were
deemed not an emergency. Three months after changes to the referral
system were implemented; re-audit was undertaken for a period of
2 weeks. Eighty-six patients attended the emergency clinic during this
period. Inappropriate referrals on this occasion comprised 16% of
attendees (n = 14). The change of inappropriate referrals was found to
be statistically significant (v2 of 14.29, P < 0.01).
Conclusions: The results showed a clear, statistically significant improve-
ment in referral appropriateness as the unstructured, first come, first
served clinic system was replaced by an appointment based system, with
clinician screening of referrals.
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
F138
Penetrating neck injury in South West London and a
proposed management guideline for the UK
Moore, A., Siau, R., Ahmed, T., Tostevin, P.
& Lee, M.S.W.
Objectives: Penetrating neck injuries (PNI) are uncommon in the UK.
The majority of guidelines are from the USA or South Africa. No UK
national guidelines exist. Increasing urban violence in the UK has lead
to an increase in PNI. There is a need to develop a PNI guideline that
reflects the pathology and experience in the UK.
Methods: A retrospective review of all penetrating neck injuries man-
aged at St Georges Hospital over an 18 month period was undertaken.
Data collected included patient demographics, mechanism of injury,
investigations, multidisciplinary team involvement and management.
Clinical activity data was correlated to current worldwide literature and
a flow-chart style clinical guideline was produced.
Results: Twenty-five PNIs were managed over an 18 month period.
Sixty-eight per cent were male, 32% female with a mean age of 36 years.
The mechanism of injury included deliberate self-harm (48%), stab
wounds (32%), gunshot wounds (4%), shotgun wounds (4%) and other
accidental causes (12%). Fifty-two per cent of wounds were superficial
to platysma. Forty-eight per cent of deep wounds had CT. Fifty-eight
per cent of patients with deep wounds also had panendoscopy. Interven-
tional radiology was used in one case (4%) and a single case was man-
aged jointly with the vascular team (4%).
Conclusions: UK ENT surgeons have limited exposure to neck trauma
and dedicated head and neck out-of-hours cover is uncommon. There is
a need for UK PNI guidelines that reflect local pathology and experi-
ence. The St Georges PNI guideline can be used to facilitate assessment,
documentation and management of what is a relatively infrequent emer-
gency presentation.
F139
Quality of the referral documents from general
practitioners to department of otolaryngology:
a cross-sectional study
Biswas, D., Wilkinson, J. & Dugar, J.
Objectives: There has been always issues regarding the information we
receive through the referral documents; which has impact on our time
management, triage, risk strategy and finally patients satisfaction. In this
study we tried to examine the essential information in the General prac-
titioners (GP) letter against a set national guideline (SIGN 31).
Methods: 1st part: Prospective review of 100 GPs referral letter (non
2 weeks target) during July and August 2011 using a set proforma.
2nd Part: All Primary care centres in our region were contacted to
understand the process of referral. We reviewed their computer software
system if any to find out any room for improvement.
3rd Part: All proposals have been presented in the GPs local meeting.
4th Part: Re-audit to assess the change of the practice.
Results: There was no one set proforma for referral in practice at the
present time. More than 65% of the letters lacks some important infor-
mation includes NHS number, age, allergy. Two major software systems
are used EMIS and VISION. Re-audit showed a significant improve-
ment in the communication system, particularly where software was
used (91%).
Conclusions: Discussion between primary and tertiary care is important
to improve the quality of the communication; which is paramount for
patients care. Improving awareness of importance of essential informa-
 2012 The Authors

tion for referral among the GP colleagues through friendly local meeting
can change our practice. In this DNAage, it is advisable to use correct
format of the software to generate referral letters, which is easier,
quicker and more informative.
F140
Throat swab for bacteriological culture in the manage-
ment of acute tonsillitis is it necessary?
Biswas, D., Zaman, A., Rao, J. & Siddiqui, N.
Objectives: This study was conducted to investigate whether there is a
correlation between bacterial culture from the tonsillar surface and the
tonsillar core in patients who underwent tonsillectomy for recurrent
tonsillitis.
Methods: 1st arm: We carried out a survey on the present practice of
the throat swabs sent by the general practitioners over a period of
6 months. 2nd arm: A Tonsillar surface and core tonsillar swabs were
taken on 28 patients who underwent tonsillectomy using a standard
swab for bacteriology culture.
Results: 1st arm: Antibiotics treatment for acute tonsillitis was started
before getting microbiology report in all cases and microbiology culture
report did not influence choice of antibiotics or caused change of treat-
ment plan in this survey.
2nd arm: Pathogenic bacteria were isolated in 15 out of 28 patients and
no bacteria were isolated in 13 of the patients. Out of the 15 patients
with pathogenic bacterial growth, seven patients grew similar pathogenic
bacteria; however eight patients did not show any correlation in bacterial
isolates of surface and core swabs (53%).
Conclusions: Tonsillar swabs may not be a reliable form of investigation
in isolating the pathogenic bacteria responsible for acute tonsillitis. Man-
agement of acute tonsillitis was found to be based on the clinical find-
ings and not on the microbiology report.
F141
Day case hemithyroidectomy- the Scottish experience
Kasbekar, A.V., Lupton, K., Macallister, K., Yaneza, M.,
Blacoe, D. & Kang, S.
Objectives: To evaluate our new patient pathway that practices day-case
hemithyroidectomy.
Methods: We undertook a prospective re-audit of patients undergoing
primary hemithyroidectomy over 2 years (20102011) and compared it
to the first cycle in 20082009. Procedures were by a single surgeon and
anaesthetist. A drain was never used. In the latest audit cycle, all patients
underwent a standardised anaesthetic and surgical procedure including
pain and nausea management. Patients completed questionnaires at dis-
charge and at follow-up 12 weeks postoperatively.
Results: The first cycle (54 patients) demonstrated that a third of
patients stayed at least one night and two thirds stayed two nights or
more. Following a new protocol, the latest audit cycle (62 patients)
demonstrated a 75% day-case rate. Ninety-eight per cent of the day-case
patients were happy (questionnaire scoring 8/10 or greater), to be dis-
charged on the day of surgery. Of the 25% who stayed over night, 50%
had surgery in the afternoon compared to 21% in the day-case group.
Patients needing overnight admission tended to use analgesia for a
longer duration (4 versus 6 days). Eighty per cent of all patients did not
need opiod analgesia. Five per cent had problems with postoperative
pain and nausea and were likely to stay overnight. There were no read-
 2012 The Authors
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
Clinical Audit and Practice 53
missions. Subjective and objective patient experience data will be dis-
cussed as well as our hemithroidectomy patient pathway.
Conclusions: Successful day case hemithyroidectomy relies on preopera-
tive counseling, specific anaesthesia techniques, meticulous surgery and
careful patient selection. Day case hemithyroidectomy can be safely
undertaken in the vast majority and is highly desirable by patients.
F142
A completed audit cycle: how efficient are ENT
theatres?
Galm, T., Doshi, J. & Ahmad, I.
Objectives: The aim of this audit was to determine the efficiency of
planned operating activity in ENT theatres, the cost-analysis of cancelled
operations and identify areas for improvement.
Methods: A retrospective analysis of elective ENT operating lists over a
3 month period at a district general hospital. Data collected included
number of patients that were listed to have an elective ENT operation,
the number of patients that did not have their operation, the reasons for
not operating and the subsequent cost analysis
Results: A total of 752 patients were listed for planned surgery. Fourteen
per cent did not have their surgery. The main reason for not operating
was due to the patient being unfit. The cost of not operating over the
3 months period was 146 768. Following changes to practice revenue
improved by 54%.
Conclusions: Poor administration control was the main cause of ENT
operating theatre inefficiency.
F143
A prospective audit of timing of drain removal in head
and neck surgery to standardise practice for operation
specific care pathways in a tertiary referral centre
Edmond, H., Glyn, T., Simons, M., Tabares, N., Gibbins, N.
& Oakley, R.
Objectives: 1 Establish consistent practice in timing of drain removal
bespoke to different Head and Neck procedures undertaken.
2 Assess 8 h drainage figures as an indicator for drain removal.
Methods: Three 6 week cycles of prospective data collection are
reported.
In Cycle 1, 24 and 8 h totals (midnight to 0800) were recorded. Drains
were removed when 24 h output <30 mL.
In Cycle 2, drains were clamped when 8 h output <10 mL. This mim-
icked early removal but allowed us to unclamp the drain if a collection
developed.
In Cycle 3 the operations were stratified. Drains from simpler proce-
dures (single gland and/or neck dissection) were removed when 8 h total
<10 mL.
Results: Cycle 1: Demonstrated that drain output tails off suddenly, as
captured by recording 8 h figures.
Cycle 2: 16/40 drains met criteria for clamping. Seven of these 16 were
removed early rather than clamped. There were no complications associ-
ated with this. A further seven were clamped. There were two collections
in clamped drains.
Cycle 3: 10/25 drains were removed following the new protocol. Seven
further drains were removed on 8 h output, but not day 1 post-surgery
despite being eligible. In these 7, delay in removal was on operating sur-
geons instructions. No complications were recorded.
54 Clinical Audit and Practice
Conclusions: In some head and neck procedures drains may be safely
removed at least 1 day early when 8 h output <10 mL. Through audit
we have established a consensus on timing of drain removal, stratified
by different types of Head and Neck surgical procedures. Standardising
practice may facilitate early removal, enhance patients recovery and
enable earlier discharge.
F144
Audit of the otolaryngology walk-in urgent referral
clinic
Khalil, S., Saeed, H.S., Siddiqui, J. & Saeed, S.R.
Objectives: The aim of this audit is to review the activity of the walk-in
urgent referral otolaryngology clinic in a tertiary referral centre.
Methods: This is a prospective audit of all patients attending the
urgent referral clinic (URC) between 13th and 24th February 2012. An
audit form was completed for each patient attending the clinic. Data
collected included demographic data, source of referral, referring diag-
nosis, presenting symptoms, procedures performed and outcome of
consultation.
Results: One hundred and eighty-six patients were reviewed in the URC
during the 2 weeks audit period (18 clinics). There were 150 new refer-
rals and 36 review patients. One hundred and twenty-two patients were
referred by their GP and 42 patients were referred from the accident
and emergency department. The outcome of consultation was: 88
patients were discharged, 49 patients were reviewed within 2 weeks and
seven patients were admitted to hospital. Thirty-four referrals (19.3%)
did not meet the referral criteria for the URC.
Conclusions: The walk-in urgent referral clinic offers a valuable service
for the management of common otolaryngology emergencies. This audit
highlights the need to increase the awareness of GPs and A&E depart-
ments regarding the referral criteria in order to optimize the utilization
of this service.
F145
Variation in rates of sinus surgery in England: a 5-year
quantitative study
Bohm, N., Swift, S., Ceney, A., Eve-Jones, S., Birchall, M.
& Lund, V.
Objectives: To analyse absolute rates of endoscopic sinus surgery (ESS)
nationally and directly standardized rates at Primary Care Trust (PCT)
level in England following the publication of revised European Position
Paper on Rhinosinusitis (EPOS) 2007 guidelines.
Methods: Hospital Episode Statistics (HES) data from 2007 to 2011 for
England were collected and analysed for Operating Procedure Codes
Supplement 4 (OPCS-4) codes for elective ESS agreed with the Profes-
sional Association of Clinical Coders-UK (PACC-UK). Absolute num-
bers of ESS were calculated nationally. At PCT level the number of
procedures were adjusted for age/sex variation in the resident population
creating a standardised rate of activity per thousand resident population.
Results: Nationally a large increase in the absolute number of total sur-
gical and endoscopic procedures was seen for the quarter MarchJune
2008. Total activity increased by over 900%, then remained stable at this
level. There has been a steady increase in percentage of endoscopic pro-
cedures. For PCTs maximum and minimum rates of standardized activ-
ity vary widely. When analysed by degree of variation (maximum
variation/minimum variation) and smoothed by rolling year, variation is
seen to steadily reduce.
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
Conclusions: The sharp increase in sinus surgery activity 6 months after
the publication of EPOS guidelines is likely to represent a change in
coding behaviour as opposed to clinical practice. PACC-UK has high-
lighted that there is no standardized coding for ESS, which is problem-
atic for research based on HES data. Further work is needed to
standardise coding and clinical recording in operation notes if variation
and implementation of guidelines is to be understood.
F146
Would you invest in an NHS trust? An economic analy-
sis of the vulnerabilities, micro and macroeconomic
exposure faced by an NHS trust compared to its nearest
competitor
Raja, H.
Objectives: To assess the whether it is possible to generate economic
surplus as an NHS trust.
Methods: Two competing trusts were assessed for vulnerability and eco-
nomic exposure by analysis of the Return on Capital Employed (ROCE)
with Healthcare Commission (HCC) data, 10 year Government Gilted
Bond rates and GDP from 2004 to 2009.
Results: There is a negative relationship between ROCE and HCC qual-
ity of care data and little correlation with GDP. Government Bonds give
a better rate
Conclusions: The Trusts are Vulnerable and being forced to provide non
profitable services. They are being out competed on the profitable ser-
vices and the suppliers can dictate terms. The penalties of failing to meet
targets drives up costs to more than the service pays and due to the
macroeconomic meltdown, the price paid for these services will be
reduced as well. They are in strategic hell, heavily exposed to the market
place and exposed via the government to the macroeconomy. They have
heavy government and public interference and scrutiny. The strategies
implemented will be necessary to stay afloat rather than make supernor-
mal profits. Investment will be for the common good not profit gener-
ation.
F147
Hospital-wide audit of gastrostomy complications:
before and after the implementation of national
patient safety agency (NPSA) recommendations for the
early detection of gastrostomy complications
Slovick, A., Pang, J. & Tatla, T.
Objectives: 1 To evaluate radiology inserted gastrostomy (RIG) and per-
cutaneous endoscopic gastrostomy (PEG) complication rates before and
after hospital-wide gastrostomy care education and protocol intranet
publication.
2 To compare local complication rates against national standards.
Methods: Data were retrospectively collected on 271 patients undergoing
RIG/PEG/open gastrostomies before (1 June 20081 June 2010) and
after (1 August 20101 February 2011) training at Northwick Park Hos-
pital. Those with incomplete case notes were excluded (n = 75). Data
collected included: gastrostomy type (PEG/RIG/open); indication; spe-
cialty; operator grade; prophylactic antibiotics; complications. Results
were compared using Fishers exact test, expressed as before versus after.
Results: One hundred and ninety-six gastrostomies were recorded, 140
before and 56 after gastrostomy education. Demographics were compa-
rable between both groups (P < 0.05), as were referral indications.
 2012 The Authors

Patients received PEGs (72%before, 66%after); RIGs (27% before, 30%
after) or open gastrostomies (1%before, 4%after). Despite education,
complication rates/month rose: PEGs 8.311.2%, (P > 0.05) and RIGs
529%, (P < 0.01). Average number of PEGs/month rose from 3 to 6
and RIGs from 1.5 to 2.8 (P < 0.05). One hundred per cent made com-
plete recoveries, with no gastrostomy-related mortalities. Local complica-
tion rates (before and after) were comparable with published standards
(P < 0.05).
Conclusions: Head and neck cancer patients are often highly malnour-
ished, requiring gastrostomies for optimization before cancer treatment.
Local concerns regarding head and neck gastrostomy complications
prompted this audit. Despite trust-wide gastrostomy education, gastros-
tomy complication rates rose. Increased numbers of gastrostomies/
month, without increased stoma care nurse provision, could explain this.
This audit has led to the introduction of another stoma care nurse,
which will augment NPSA guideline implementation by promoting
nurse-led education in early recognition and prevention of complica-
tions, to enhance patient safety.
F148
An effective method for continuing, prospective audit
of post-tonsillectomy haemorrhages
Simons, A. & Motamed, M.
Objectives: To devise a user friendly and accurate system to allow con-
tinuous, prospective departmental audit of post-tonsillectomy bleeding
(PTB) in order to compare to the National Tonsillectomy Audit (NTA)
haemorrhage rates.
Methods: Cycle 1: Retrospective audit of PTB was attempted over a 6-
month period but was abandoned as it became apparent that data was
incomplete and very cumbersome to collect. Recommendation was to
devise a prospective user friendly and accurate method.
Cycle 2: A Microsoft Access database was constructed in order to col-
late PTB prospectively. Data inputted prospectively was analysed for the
period between June 2010 and May 2011. Relevant data included; date,
method of tonsillectomy, grade of surgeon and management of haemor-
rhage.
Results: A total of 375 tonsillectomies were performed. 4.5% experi-
enced PTB (1.3% primary and 3.2% secondary). These cases had all
been performed with cold steel dissection and bipolar haemostasis. PTB
were higher compared to NTA rates. Statistical analysis performed to
allow for smaller sample size gave P = 0.018, thus the difference is sig-
nificant.
Conclusions: Traditional PTB data is collected informally and presented
monthly at Clinical governance meetings. The use of an Access database
allows easy prospective data collection and analysis for the purpose on
on-going audit.
F149
Provision of out-of-hours ENT facilities in North
England
Wilkie, M. & Lightbody, K.
Objectives: Competent management of ENT emergencies out-of-hours
relies on availability of dedicated treatment areas with specialised equip-
ment and appropriately trained care providers. This was emphasised in
the recent Royal College of Surgeons (RCS) standards for unscheduled
surgical care, and recommendations for out-of-hours facilities have been
 2012 The Authors
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
Clinical Audit and Practice 55
published previously. This study evaluated the availability of such facili-
ties within Mersey, North West and Northern deaneries.
Methods: Telephone questionnaires of all hospitals providing an out-of-
hours ENT service in Mersey, North West and Northern regions
(n = 35) were undertaken. Questionnaires were answered by the ENT
first-on-call doctor at each hospital, and were conducted by the study
authors.
Results: The mean number of hospitals covered by out-of-hours ENT
units was 1.5. 47.6% of hospitals had a dedicated ENT ward with acute
beds and ENT-trained nurses, while 81.0% of units had access to a dedi-
cated treatment area out-of-hours, 88.9% of which were felt to be kept
well stocked. All hospitals had out-of-hours access to nasal specula, cau-
tery, anterior nasal packs, local anaesthetic spray, suction, and adrena-
line. Availability of rigid endoscopes was 28.6%, flexible nasendoscopes
85.7%, headlights 81.0%, microscopes 71.4%, microsuction tips 85.7%,
ototopical antimicrobials 71.4%, Magills forceps 81.0%, and Heliox
23.8%. Of those providing paediatric ENT cover, 14% had a separate
treatment area.
Conclusions: Not all ENT units have appropriately equipped out-of-
hours facilities, which may compromise emergency patient care. There is
a need for nationally agreed guidelines stating the minimum equipment
and assistance required to provide a safe, adequate and suitable out-of-
hours service.
F150
Audit of flexible OGD for laryngopharyngeal reflux
Narayan, J. & Mitchell-Innes, A.
Objectives: To evaluate the FOGD (Flexible Oesophagogastroduodenos-
copy) service offered by the ENT department; to determine the benefits
of FOGD in LPR; Could TNE (Transnasal Esophagoscopy) be an alter-
native?
Methods: Retrospective data was collected of FOGD performed from
December 2008 to August 2011. Patients who underwent FOGD by an
ENT surgeon for symptoms of LPR presenting to the ENT clinic were
included. These patients were either on or subsequently started on PPI
(Proton Pump Inhibitors). Some also had speech therapy. Endoscopy
was audited against JAG (Joint Advisory Group) guidelines for OGD.
Data was collected included findings, management and follow up.
Results: Analysis focussed on impact on treatment. Data was compared
to the literature. Preliminary analysis suggested the majority had symp-
tom control with initial treatment. About 30% required further investi-
gations or management. Cost benefit is discussed and TNE as an
alternative.
Conclusions: This project will give further insight into the Flexible OGD
service provided by the ENT department. The recommendations should
be beneficial to stakeholders in improving service to patients. Areas for
further cost effective improvements in service will be identified.
F151
ENT out of hours cross-cover by non-ENT junior doctors
at a District General Hospital (DGH): before and after a
compulsory induction in ENT emergency management
with local guideline production
Magill, J., Slovick, A. & Daly, N.
Objectives: 1 To compare the management of common ENT emergen-
cies by ENT and non-ENT junior doctors in a DGH.
56 Clinical Audit and Practice
2 To evaluate management of common ENT emergencies before and
after compulsory ENT emergency training.
Methods: Data were prospectively collected on management of all
patients referred to ENT out-of-hours to West Middlesex hospital before
(7 October 201110 December 2011) and after (19 December 201118
February 2012) implementation of compulsory ENT induction training
for all surgical juniors and publication of new local emergency protocols.
Patients managed by A&E alone or requiring telephone advice were
excluded. Management was compared against ENT emergency protocols
and deviations from this were deemed a mismanagement. Results were
compared using Fishers exact test.
Results: One hundred and two referrals were recorded in total (n = 55
before, n = 47 after). ENT junior doctors saw 24% and 26% of the out-
of-hours referrals before and after. Overall, 38% of ENT out-of-hours
referrals were mismanaged before and 19% after (P < 0.05) implementa-
tion of training. Ninety-five per cent of the mismanaged cases were seen
by non-ENT junior doctors before and 100% after. Common sub-opti-
mal management included: no quinsy aspiration, omission of nasoen-
doscopy or key medications. Major adverse events included: patient
discharged with merocel in-situ and pinna haematoma not drained; both
without follow-up.
Conclusions: On-call ENT care is often provided by junior doctors
cross-covering diverse specialties with little ENT experience. Biswas et al
reported 42% felt uncomfortable managing common ENT emergencies.
Our study demonstrated that structured induction programmes pro-
vided key knowledge and skills, thereby reducing mis-management and
improving safety. We recommend that induction training should be
mandatory for all doctors covering ENT.
F152
Evaluation of patient satisfaction with written follow
up
Iqbal, I. & Murrant, N.
Objectives: There is increasing pressure from purchasers of healthcare
on acute NHS trusts to reduce New:Follow-up ratios. In our department
selected patients are followed up by letter rather than in outpatients.
Our aim was to evaluate patient satisfaction with this practice and to
assess any potential benefits or risks.
Methods: Fifty patients receiving written follow up over a 6 month per-
iod from January to June 2011 were randomly selected. A telephone sur-
vey was completed. Patients were asked if they were satisfied with the
care they received, if they felt they received the right amount of infor-
mation, if a clinic follow up would have been preferred, if they knew
how to arrange further review and how they would describe the overall
care received.
Results: Thirty-five responses were recorded as six patients declined to
participate and nine were unavailable. Eighty per cent of patients were
completely satisfied with the care received, 17% were satisfied to some
extent and 3% were not satisfied. Eighty-six per cent felt they received
adequate information. Only 14% would have preferred a further outpa-
tient appointment. However 26% did not know how to proceed if there
were any further problems. All patients described the care received as
either satisfactory (17%), good (31%), or very good (52%). There were
no adverse outcomes as a result of this practice.
Conclusions: The study demonstrates that with careful patient selection
this method of follow up is satisfactory and acceptable to patients. It is
also safe and has significant implications for reducing costs whilst main-
taining excellent healthcare.
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
F153
Expediting cervical lymph node biopsies a completed
audit cycle
Dimbleby, G., Golding, L., Al Hamarneh, O. & Ahmed, I.
Objectives: Cancer waiting targets set by the Department of Health
Cancer Plan recommend that referral to diagnosis should be within
31 days.
The aim of this audit was to establish the departments waiting times for
cervical lymph node biopsy, comparing results to these guidelines. A re-
audit following a change to the referral system was performed.
Methods: A retrospective audit recorded the number of days from refer-
ral to date of biopsy. All modes of referral for lymph node biopsy were
included between May and December 2010. A proforma for referral was
introduced and made available to hospital departments and then booked
for biopsy by a co-ordinator. A prospective re-audit was completed
between March and September 2011.
Results: The first audit showed that the national guidelines were not
met (median = 74 days, IQR = 47113 for all diagnoses and med-
ian = 103 days, IQR = 74133 for lymphomas).
Re-audit demonstrated a statistically significant reduction in the median
number of days for all diagnoses (22.5 for all modes of referral, 18 for
the proforma), as well as lymphomas (18 for all modes of referral, eight
for the proforma), (P < 0.01, Mann Whitney U Test).
Conclusions: Introducing a proforma for lymph node biopsy and a des-
ignated co-ordinator has streamlined the service, significantly reducing
patient waiting times. We recommend this as an efficient mode of refer-
ral for meeting guidelines and improving patient care.
F154
Patients attitudes to confidentiality: an out-patient
survey
Neil, F., Chinedu, I., Anooj, M. & Taran, T.
Objectives: Confidentiality is central to trust between doctors and
patients (GMC). We sought to assess patients attitudes towards and
understanding of confidentiality and to highlight any specific concerns
regarding their own confidentiality.
Methods: A voluntary survey was completed by patients who attended
the ENT outpatients department at a single centre.
Results: Two hundred and fifty surveys were completed. Ninety-five
per cent rated confidentiality as moderately/very important, however
55% felt that concerns about confidentiality would not prevent them
disclosing information. Forty-nine per cent believe their casenotes are
always dealt with confidentially. A majority (60%) would be happier
to take part in research if confidentiality was ensured. Eighty-two per
cent could not give an example of when confidentiality may be legally
breached. Finally, over half (52%) feel that their information is more
likely to be breached when it is held or transferred electronically with
a statistical difference between older and younger age groups
(P = 0.017).
Conclusions: Whilst a majority of patients consider confidentiality to be
very important, there is little awareness regarding legal breaches of con-
fidentiality. The electronic transfer of patients casenotes is a cause of
concern for patients. This has implications for ENT departments, both
in the traditional setting and with certain services potentially moving
into the community. In order to underline the importance of the doctor
patient relationship, it is imperative that confidentiality is upheld to the
highest degree and new ways may have to be developed to ensure this
happens in an era of widely disseminated and electronically held infor-
mation.
 2012 The Authors

F155
Patient reported outcomes for the treatment of head
and neck cancer
Charlett, S., Desouky, O., Coatesworth, A. & Nicolaides, A.
Objectives: The aim of this study was to assess the impact of treatment
for head and neck cancer on quality of life using the Glasgow Benefit
Inventory (GBI).
Methods: Patients attending the Head and Neck Multi-Disciplinary
Clinic at York Hospital over a 6 month period were invited to complete
the GBI. Inclusion criteria were patients who had completed treatment
for head and neck cancer and had a minimum follow-up of 2 months.
The intervention was considered to be the oncological treatment pack-
age, which could include surgery, radiotherapy, chemotherapy, other
prescribed medications, and support from other health professionals.
Medical records were also reviewed for each patient.
Results: Complete data was collected for 46 patients. Seventy per cent
were male. Patient ages ranged from 35 to 83 years. Length of follow-up
after treatment ranged from 2 months to 10 years. All patients had
received treatment with curative intent. Physical health, general health
and total scores remained unchanged suggesting that patients felt neither
better nor worse for the treatment they had undergone, while social sup-
port scores increased (subscale score + 40).
Conclusions: Although the study has several limitations, it highlights
some points of interest. Firstly, patients reported a large improvement in
social support after treatment for head and neck cancer. Secondly,
although overall quality of life did not change, this could be viewed as a
positive finding considering the morbidity associated with treatment,
and that all patients were living with a cancer diagnosis and were not
considered cured.
F156
Improving survey response rate lessons we have
learned
Salim, F., Phillips, P.S., Gupta, S. & Oakley, R.
Objectives: To compare a web-based and postal survey and to examine
the factors influencing response rate.
Methods: Two surveys were carried out of otolaryngology trainees expe-
rience of septoplasty training, with identical questions. One was carried
out via web link circulated to trainees via representative organisations.
The other was posted to individual trainees via their hospital ENT
department, using individually addressed hand-written envelopes, with
one reminder. Cost, time, response rate and responses were compared
between the two groups
Results: Response rate for the web-based survey was 51%, whereas that
for the postal survey was 65%. Budget for the web-based survey was 50
pounds, whilst that for the postal survey was 500 pounds. The web-
based survey took 2 h to construct, and 2 h to send out. The postal sur-
vey took 2 h to produce and approximately 15 h to send out. Responses
to the surveys were not significantly different in terms of trainee year of
training or response to questions, although the web-based survey had a
significantly greater number of blank responses.
Conclusions: Despite the ubiquity of electronic communication, our
postal survey gave a better response, and enabled more accurate target-
ing of trainees. The similar responses suggested that a similar population
was accessed by both surveys. However, the postal survey required sig-
nificant extra time and expense. The electronic logbook and other trai-
nee communication interfaces may mean that in the future electronic
 2012 The Authors
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
Clinical Audit and Practice 57
surveys can be more accurately targeted and achieve a response rate
comparable with postal surveys
F157
Clinician contact time in ENT theatres
Ashraf, N., Awad, Z. & Jayaraj, S.
Objectives: 1 Ascertain the average operating theatre times for common
elective ENT procedures and combinations.
2 Establish the most useful time bracket to use when predicting theatre
time per case in order to optimise utilisation of theatre lists.
Methods: A retrospective analysis from a computerised database of 2000
consecutive cases between May and November 2009 was conducted to
establish the length of theatre time for common ENT procedures and
combinations. The first and third quartiles were used for the analysis
because of the wide distribution of data. All 16 operating surgeons within
the department were asked to predict the length of each procedure using
established time slots. The mode of these estimated time slots were com-
pared with the actual times ascertained from analysis of the database.
Results: A total of 1266 patients who underwent 18 procedures and
combinations were included after applying exclusions. There was good
consensus between clinicians in the department when predicting times
for 16 procedures. Two procedures not reaching consensus were
excluded. When using Clinician Contact Time, 11 out of 16 procedures
were underestimated by up to 30 min.
Conclusions: We selected, as the most useful time bracket, the Clinician
Contact Time; when one to one clinician care is required. This is a bet-
ter indicator than surgical procedure duration or time spent inside the-
atre. In individual surgical units, clinicians should review the range of
actual operating times for common ENT procedures, which can aid in
optimising utilisation of theatre time.
F158
Safe discharge of head and neck cancer patients: an
audit of ward staff awareness
Jackson, L., Newman, J. & Lester, S.
Objectives: With the move to a combined surgical and ENT ward and a
mixing of nursing skill sets we identified a potential clinical risk with
the safe discharge of ENT patients requiring tracheostomy and PEG
feeding. Where previously nurses had been aware of the necessary stan-
dard of patient training and information provided to the patient and
the community, this was no longer guaranteed. We therefore created a
multidisciplinary checklist to ensure safe discharge and set a standard as
100% compliant.
Methods: All qualified staff on duty in a single week were asked to com-
plete a questionnaire assessing knowledge of equipment and procedures
required for safe discharge, and self assessment of confidence in achiev-
ing this (on a visual analogue scale from 1-10). Results were reviewed
and focussed training provided to staff. A discharge checklist was intro-
duced to patient notes and a second audit cycle completed
Results: Responses were received by > 80% of qualified staff of duty
during the audit period (19 first cycle, 18 second). Average confidence
in nurses with no ENT experience increased from 4 10 (range 1-10), to
7.5 10 (range 6-10) after training. The implementation of a discharge
checklist was found to be useful by all nurses who had used it at the
point of re-audit and 100% compliance was achieved.
Conclusions: Merging of ENT wards creates issues of clinical risk to
Head and Neck cancer patients. Regular training and support of nursing
58 Clinical Audit and Practice
staff is paramount to ensure the highest level of care, and safe discharge
of these patients.
F159
ENT cross-cover audit
Yassin, G., Barraclough, J.P. & Morgan, D.W.
Objectives: The European Working Time Directive (EWTD) and the
need to make a National Health Service (NHS) efficiency saving of
20 billion by 2015 has necessitated out-of-hours cross-cover of the
ENT (Ear, Nose and Throat) speciality by other surgical speciality
Senior House Officers (SHO). In the highly specialist arena of ENT it
is important the out-of-hours SHO has the necessary skills to perform
the initial assessment and management of the commonly presenting
conditions/emergencies. Our objective was to assess the confidence of
ENT cross-cover SHOs in managing common/emergency ENT presen-
tations.
Methods: A questionnaire, with a confidence score of 05 (0 = no confi-
dence and 5 = totally confident) for 15 ENT management skills, was cir-
culated. A score of 3 or greater was deemed acceptable confidence in
performing the task. Following this a 45 min teaching intervention was
implemented and the survey subsequently repeated.
Results: Prior to the intervention, only one out of 15 skills received an
average confidence score of 3 or greater, the range of scores were 1.3
3.3. Therefore, the standard was achieved in 6.7%. Following the teach-
ing intervention the standard was achieved in 13/15 skills, 86.7% with
an average increase in confidence by 1.2 points on the 05 scale. Micros-
copy and nasendoscopy were the only skills to remain with a score
below 3.
Conclusions: In conclusion, there is a strong need to ensure training of
all SHOs covering ENT out of hours. From this audit, it has been shown
that a simple teaching session, including opportunity to handle instru-
ments and ask questions was effective at improving confidence in man-
aging common/emergency presentations. However, effectively teaching
skills such as nasendoscopy or use of the microscope requires more
training. As a result of this study, it is recommended to have repeat
teaching sessions for each new cohort of SHOs cross-covering ENT but
they be supplemented by a practical session on the use of the micro-
scope and nasendoscopy.
F160
Audit of follow-up appointments in ear, nose and
throat outpatient clinics in a district general hospital
Kulloo, P., Smith, D. & Prinsley, P.
Objectives: To evaluate current Ear, Nose and Throat (ENT) outpatient
clinic appointments in a district general hospital with a view to reducing
unnecessary follow-up appointments.
Methods: This was a retrospective audit involving 55 follow-up patients,
seen in four different ENT consultants clinics over a 1-week period.
The following information was obtained from the patients clinic letters
and medical notes: diagnosis, reason for initial follow-up given, results
of investigations, outcome of the current appointment- whether dis-
charged or given subsequent follow-up.
Results: The 55 follow-up patients were grouped according to their
diagnoses. Thirty-one (56%) of them were given a subsequent follow-up
appointment. The reasons were initiation of different treatment for per-
sistent/worsening symptoms, need for further investigation or surgery
and as part of routine post-operative follow-up. Of the 24 who were
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
discharged from clinic, 12 patients (50%) had normal investigations
(histology, audiogram, radiology imaging), four were post-op (one post-
septoplasty and three post-coblation) and eight patients symptoms had
resolved after treatment.
Conclusions: Fifty per cent of the discharged patients were reassured
with normal investigations before discharge. It might have been possible
to avoid these appointments by informing patients by an alternative
means. We suggest the establishment of a nurse-led telephone service for
such patients. This would reduce clinic Did Not Attend patients. More-
over, by training nurses, a nurse-led clinic can be created for certain
post-operative patients. This would further decrease waiting times in
Consultant clinics. We recommend a re-audit in about 12 months after
this intervention to assess if the service provision in ENT outpatient
clinics is more efficient.
F161
Audit of CT paranasal sinus scan requesting
Flook, E. & Daudia, A.T.
Objectives: To assess the indications given for requesting a CT scan of
the paranasal sinuses within a whole general ENT department, and to
judge their adherence to recognised guidelines (EPOS2007). To improve
adherence to guidelines.
Methods: A retrospective audit of CT scan of paranasal sinus requests
within ENT and from the whole East Lancashire Hospital Trust for a
3 month period. A review of the CT paranasal scan request cards and
analysis of the patients clinical notes.
The indications (documented clinical findings and suspected diagnosis
and plan for medical treatment or functional endoscopic sinus surgery)
were recorded to compare with the EPOS scheme guidance.
A distinction between Chronic Rhinosinusitis (with or without polyps)
and other cases was highlighted so that the EPOS guidance was applied
appropriately.
Departmental teaching and laminated EPOS flowcharts were instituted
in all clinic rooms and a re-audit was performed.
Results: Large proportion of scans were being requested that are not
within the guidance from the EPOS2007. From overall patient outcomes
it seems as though many scans do not alter patient management and are
not used in surgery. No correlation between Dr grade and guidance
compliance was seen.
Re-auditing demonstrated Instituting departmental teaching and refer-
ence guidelines improved the proportion of inappropriately requested
CT scans of paranasal sinuses.
Conclusions: There is definite gain in departmental education to reduce
the number of CT scans of paranasal sinuses that are requested inappro-
priately and do not alter patient management.
F162
Best intervention for a suspected fish bone in throat
Shakeel, M., Mahalingappa, Y.B., Naismith, D.R.,
Vallamkondu, V. & Veitch, D.Y.
Objectives: To establish the best intervention to help the patients pre-
senting with a suspected fish bone (FB) stuck in the throat.
Methods: Retrospective chart review of patients presenting to our
department with a suspected FB stuck in throat, over 3 years (2009
2011). The information collected includes demographics, presentation,
investigation findings and management. Excel was used for data collec-
tion and analysis.
 2012 The Authors

Results: A total of 73 patients were identified, 34 male and 39 females.
All of these patients attended with a feeling of FB stuck in their throat
after they had eaten the fish, common ones being Haddock, Salmon and
Mackerel. Majority of the patients were able to localise the feeling or
pain in their throat, presented within 24 h of the onset of symptom to
accident and emergency (A&E) department, had tried and failed the
conventional measures to dislodge the FB.
Out of 73 patients, 65 underwent trans nasal flexible pharyngolaryngos-
copy and 40 patients underwent plain X-ray of the lateral neck by the
A&E before they were referred to us. A total of 27 patients (37%) were
noted to have some pathology; fish bone in 15 and some bruising in the
upper aerodigestive tract was noticed in 12 patients. The fish bones were
removed trans orally in the clinic.
Conclusions: In our experience trans nasal pharyngolaryngoscopy is the
single best intervention for the patients presenting with a suspected fish
bone in their throat. This enables us not only to find and remove the
fish bone but also helps visualisation of any mucosal damage present.
F163
Venous thromboembolism in elective ENT surgery
a completed audit cycle of practice
Lakhani, R., Bromby, A., Yung, M. & Hilger, A.
Objectives: To assess and improve compliance with ENT UK/NICE
venous thromboembolism (VTE) guidelines for ENT.
Methods: Two-cycle audit comparing VTE risk assessment and prophy-
laxis against the ENT UK/NICE guidelines.
Results: First Cycle 23 adult patients (eight consecutive operating
lists) were audited against the ENT UK/NICE guidelines. Only 3/23
VTE risk assessment forms were fully completed. 8/23 patients had
identifiable risk factors for VTE. Only 1/8 had a risk assessment per-
formed. 2/8 received mechanical prophylaxis, 15/23 had no identifiable
risk factors. Of these 10/15 had measures to avoid dehydration, 0/15
were encouraged to mobilise early, 1/15 received a VTE information
leaflet.
Implementation of changes Departmental meeting, allocation of
responsibility for VTE risk assessment and educational poster. Second
Cycle 27 adult patients (10 consecutive operating lists) were audited
against the ENT UK/NICE guidelines. 26/27 VTE risk assessment forms
were fully completed. 9/27 patients had identifiable risk factors for VTE.
All patients received mechanical prophylaxis, had measures to avoid
dehydration and were encouraged to mobilise early. 18/27 had no iden-
tifiable risk factors. Of these 14/18 had measures to avoid dehydration,
17/18 were encouraged to mobilise early and 17/18 received mechanical
prophylaxis. All patients received a VTE information leaflet.
Conclusions: A marked improvement in adherence to the ENT UK/
NICE VTE guidelines was seen through the implementation of simple
changes. Although the risk of VTE in elective ENT surgery is low adher-
ence to the guidelines is important as the consequences of VTE are sig-
nificant and can be avoided through risk assessment.
F164
Are we still following the national prospective tonsil-
lectomy audit recommendations? A completed audit
cycle of tonsillectomy at a district general hospital
Lakhani, R., Huggins, M. & Salam, M.
Objectives: To assess and improve compliance to the National Prospec-
tive Tonsillectomy Audit (NPTA 2005) recommendations.
 2012 The Authors
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
Clinical Audit and Practice 59
Methods: Two-cycle audit of compliance to NPTA recommendations.
All patients undergoing tonsillectomy (October-December 2010) were
highlighted. Those patients re-admitted with complications of tonsillec-
tomy were evaluated in more detail. Recommendations for change were
made. Re-audit of the same data for patients undergoing tonsillectomy
(January and March 2011) was carried out.
Results: First cycle 76 patients underwent tonsillectomy (October-
December 2010). 7/76 patients had secondary haemorrhage. 6/7 had the
grade of the surgeon recorded. The method of dissection was recorded in
4/7 cases. No comment was made regarding the difficulty of dissection in
any of the readmitted cases. The method of haemostasis was not recorded
in 3/7 patients and in the other 4/7 bipolar diathermy and ties were used.
The power setting for diathermy was not recorded in any of the cases.
Implementation of changes The NPTA findings and recommendations
were presented and implemented at the departmental audit meeting. Sec-
ond cycle 68 patients underwent tonsillectomy (MayJuly). No patients
were re-admitted with complications. Ten patients were selected at ran-
dom to evaluate further. All patients had the grade of surgeon, method
of dissection and the method of haemostasis recorded. All procedures
were performed using cold steel dissection. Bipolar diathermy was used
in 1/10 and the power setting was recorded in all patients.
Conclusions: Simple changes have improved compliance with the NPTA
recommendations and which have been shown to decrease the chance of
secondary haemorrhage post-tonsillectomy.
F165
HIV pre-exposure prophylaxis or post-exposure prophy-
laxis: time to reconsider the best option for surgeons
Sethi, N., Sethi, G. & Edwards, S.
Objectives: The aim of this presentation is to review the current evi-
dence for the use of antiretroviral pre-exposure prophylaxis (PreP) in
HIV prevention to try and answer whether this should be made available
for surgeons.
Methods: A medline search was performed using the keywords: HIV,
pre-exposure prophylaxis, post-exposure prophylaxis and surgery.
Results: HIV positive patients with high viral load represent a potential
risk to the surgeon. The current standard of care is post-exposure pro-
phylaxis for surgeons. Recent evidence has suggested PreP is very effec-
tive at preventing onward transmission of HIV. It has shown
effectiveness at providing protection against acquisition of HIV in men
who have sex with men. Conclusions from this data can be applied to
other at risk groups including the surgeon operating on high-risk
patients. PreP is a better alternative for surgeon requiring as few as
4 days treatment (compared with 1 month for post-exposure prophy-
laxis) reducing side effects and cost. It may also have the beneficial effect
of improving HIV testing and risk assessment in ENT.
Conclusions: We suggest there is a strong case for the use of pre-expo-
sure prophylaxis in surgical practice. In addition to universal precautions
this would provide improved protection for all surgeons.
F166
Preoperative temporal bone CT informative or
deceptive?
Sethi, N. & Kayarkar, R.
Objectives: Computed Tomography (CT) has been used in the assess-
ment of temporal bone anatomy and disease for three decades. It is
increasingly being used as a routine part of preoperative work up for
60 Clinical Audit and Practice
mastoid surgery to predict any bony erosions complicating cholestea-
toma that may be found intraoperatively. This study aimed to evaluate
how reliable CT is in this regard.
Methods: Intraoperative findings during mastoid surgery performed by
the senior author between January 2007 and June 2011. Details of the
integrity of the ossicular chain, tegmen tympani, facial nerve canal and
lateral semicircular canal were recorded. These were compared to the
preoperative CT findings.
Results: One hundred and fifty-seven mastoid operations were per-
formed with corresponding preoperative CT. One patient was excluded
due to poor CT images. CT was found to have 35% sensitivity for ossic-
ular chain erosion, 11% sensitivity for facial nerve canal dehiscence,
14% sensitivity for lateral semicircular canal fistula and 15% sensitivity
for tegmen tympani dehiscence.
Conclusions: This study shows how important it is for surgeons to be
wary of the preoperative CT showing no complications of cholesteatom-
a. It is imperative to maintain meticulous, safe surgical technique to
avoid complications of mastoid surgery.
F167
Do PCT referral pathways for adenotonsillectomy alter
individual patient care?
Cunningham, A., Bohm, N. & Andrews, P.
Objectives: Audit of ENT compliance with the (adeno)tonsillectomy
referral pathway within NHS North Central London (NCL), which has
undergone three changes in the last 18 months. Our aim is to address
the issues of effective clinical care pathways for acute sore throat and
sleep-disordered breathing, local conversion rates, and shared decision-
making.
Methods: The two preceding NCL Low Priority Treatment referral pro-
cesses were compared with the current pathway. The initial GP referral
letter, correspondence with the Referral Management Centre (RMC) and
with ENT was reviewed. We examined all outpatient referrals to our
ENT Department over a 2 week period 3 months after alteration of the
pathway.
Results: The ratio of referrals for adenotonsillectomy to new ENT out-
patient appointments for each arm was 0.20 (September 2010), 0.13
(August 2011) and 0.34 (November 2011). The conversion rate of refer-
ral to surgery for each period is 63%, 27% and 44%. Almost 100% of
those listed met national guidance but only 59% met NCL criteria. Fif-
teen per cent met the threshold criteria but were not listed directly.
Eighty-five per cent of these were managed conservatively and 15%
declined surgery. There was no evidence of the required documentation
from ENT to the RMC regarding the decision to operate.
Conclusions: We are experiencing frequent changes to referral processes
in this era of looming GP commissioning. Our audit, although only a
small snapshot of one PCT cluster, shows that these changes may have
little impact on the actual care delivered to patients. Our aim is to close
the audit cycle following consultation with the ENT clinicians involved.
F168
Procedures of limited clinical effectiveness: have they
altered operative activity at a London tertiary referral
ENT centre?
Siddiqui, J. & Rennie, C.
Objectives: Our objectives were to audit the effects of the new healthcare
concept of Low Priority Procedures or Procedures of Limited Clinical
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
Effectiveness on Ear, Nose and Throat (ENT) operative activity at a
London tertiary referral centre. Over the last 2 years, a gradual change
in both local and national healthcare guidelines has deemed certain
operative procedures as procedures of limited clinical effectiveness.
Strict referral guidelines were introduced for consideration of these pro-
cedures, and to secure funding from primary care if they are performed.
Methods: The numbers of common paediatric and adult ENT operative
procedures performed at a London tertiary referral centre in the month
of October 2010 were compared with the month of October 2011.
Audited procedures were tonsillectomy, adenoidectomy, and myringoto-
my and ventilation tube insertion, and any combination of these proce-
dures. All of these procedures are deemed to be of limited clinical
effectiveness, and now have strict referral guidelines.
Results: There was little change in the numbers of the audited proce-
dures in October 2010 compared with October 2011, for both adult and
paediatric patients.
Conclusions: The minimal change in operative practice seen in our cen-
tre, over a year during which restrictive referral guidelines were imple-
mented, brings into question the awareness of clinicians of these
guidelines. It is not clear what proportion of these procedures have been
funded by primary care. Continuation of the audit spiral is necessary to
fully understand the implication of these guidelines for our clinical prac-
tice, and the economic ramifications of them.
F169
Day-case cochlear implantation: the Oxford experience
Kaleva, A., Mawby, T. & Ramsden, J.
Objectives: To determine the safety of day-case cochlear implantation.
Methods: A retrospective review of all cochlear implants performed dur-
ing a 3 year period. Data was collected from the hospital admissions
records and combined with theatre records to identify additional infor-
mation. Clinical notes were reviewed to clarify ambiguities in the elec-
tronic records.
Results: One hundred and seventeen patients underwent cochlear
implants. Sixty-seven were adult 50 were paediatric. Twenty-three
patients were discharged the same day as their operation. None of the
day-case patients were re-admitted but one patient from the overnight
cohort was readmitted the day after discharge. Length of operation was
not correlated with duration of stay. No complications related to day-
case surgery were identified. Factors that prevented same-day discharge
were co-morbidities and distance to travel home.
Conclusions: Day-case cochlear implantation has been gradually intro-
duced at Oxford over the past 3 years. With increasing experience in an
adult population this is now becoming standard practice for the paediat-
ric patients as well. It has proved to be a safe and cost-effective option
in both adult and paediatric patients. This will free up bed spaces and
save money in an era of limited financial resources.
F170
Audiology referrals to the ENT department: a new
pathway for asymmetric sensorineural hearing loss
(ASHL)
Mawby, T., Chawdhary, G. & Deepak, G.
Objectives: To streamline management of ASHL patients, reduce outpa-
tient episodes and expedite patient processing.
Methods: All audiology to ENT referrals over a 5 week period were
audited against British Academy of Audiology Guidelines (2009) for type
 2012 The Authors

and appropriateness. Subsequently a new evidence based pathway was
introduced, enabling referral of selected patients with ASHL directly by
audiology for Magnetic Resonance Imaging (MRI) scan. A repeat audit
was subsequently performed to close the loop. Patients entering the new
audiology pathway were also audited for appropriateness and eventual
outcome over a 3 month period.
Results: In a 5 week period 25 audiology to ENT referrals made.
Ninety-two per cent met guidelines. Thirty-two per cent were for ASHL.
Following introduction of the new pathway almost a 50% reduction in
referrals to ENT was observed. Over 3 months, 23 patients entered the
new pathway. All met the selection criteria for entry. Of these, 21
patients (91%) were discharged after consultant MRI review with letter
alone without the need for an appointment. Eleven patients had inciden-
tal clinically insignificant MRI findings. One new vestibular schwannoma
was detected and referred for ENT clinic appointment.
Conclusions: Introduction of a new ASHL pathway has dramatically
reduced audiology to ENT referrals and enabled the majority of patients
on the pathway to be discharged without a formal ENT appointment
and within the 18 week limit. This will free up approximately eight new
patient out-patient appointments per month and reduce the time from
referral to discharge.
F171
Day case adenotonsillectomy: an audit of our service
Jackson, L., Wallace, H. & Kundu, S.
Objectives: Studies into day case tonsillectomy have shown that the risk
of reactionary haemorrhage is small, ranging from 0.49% to 3.9% in the
U.K. In our trust, a day case adenotonsillectomy service has recently been
introduced. This study audited the acceptability of our selection process,
readmission and bleed rates in the first 18 months of this service.
Methods: Selection criteria were developed for potential day case
patients. These included reference to age, Weight, diagnosis, co-morbid-
ity status and social circumstances. Data was collected prospectively
from March 2010 to November 2011. Information was collected on dis-
section method, grade of surgeon, delayed discharge, readmission rate
and return to theatre for arrest of bleeding.
Results: Seventy-nine tonsillectomies were performed (46 Cold steel, 33
Diathermy, 65 Lower poles tied). Two required overnight admission.
One patient returned to theatre for arrest of haemorrhage and one was
readmitted within 7 days (pain). Sixty-six Adenoidectomies were per-
formed (33 suction diathermy, 33 curettage). Six required overnight
admission. One patient was returned to theatre for arrest of bleeding
and none were readmitted within 7 days of discharge
Conclusions: Our overall primary bleed rate was 1.5%. Our 24 h Read-
mission rate was 6.2%. None of our patients represented with secondary
bleeding within 7 days of discharge. These figures are comparable with
the literature on day case tonsillectomy. With appropriate patient selec-
tion, these preliminary results indicate that adenoidectomy is also suit-
able as a day case procedure.
F172
How to avoid the pitfalls of prescribing to athletes in
this Olympic year
Vasani, S., Mace, A. & Smith, R.
Objectives: This July London will become the first city to host the mod-
ern Olympic Games three times. The influx of athletes to Great Britain
will be considerable.
 2012 The Authors
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
Clinical Audit and Practice 61
A positive doping test or adverse analytical finding can have severe
ramifications for an athletes career.
It is essential that clinicians are familiar with the rules and procedures
by which prescribing to these individuals are governed. Many drugs
commonly prescribed to treat ENT conditions are subject to strict con-
ditions.
Doctors must also comply with GMC requirements which have recently
been clarified in this area.
Methods: In this presentation we clarify both the rules governing the
prescribing of common ENT medications and the latest publications
from the General medical council with regards to Sports Medicine and
its stance on doctors involved in doping cases.
Results: Topical nasal steroids are now freely permitted. They are how-
ever on the monitoring program.
Other glucocorticosteroids including prednisolone and dexamethasone
remain prohibited in competition when administered by oral, intrave-
nous, intramuscular or rectal routes.
Almost all nasal decongestants have stimulant properties and are largely
prohibited In-competition. Rules governing their use are constantly
changing. We clarify current status.
We also clarify the position of other ENT and related drugs including
Beta Agonists and Opiates and cocaine.
Conclusions: The World Antidoping Code and Prohibited list is fre-
quently updated. We provide a very timely update for ENT and allied
professionals to avoid the pitfalls associated with prescribing to
athletes.
F173
True operating time in the NHS
Karamchandani, D., Greenbank, A. & Thompson, A.
Objectives: Financial pressures in the modern NHS have led to
greater emphasis on efficiency and theatre utilisation whilst maintain-
ing high standards of care and safety. Productive theatres require a
short patient turnaround and anaesthetic time. Our aim was to evalu-
ate the actual time allocated to operating in a routine theatre ses-
sion. A few studies have shown that actual operating time in many
cases is about half of the allocated time due to delays in patient turn-
around.
Methods: This was a prospective study which reviewed the times the
patient was sent for, the anaesthetic time undertaken and the actual
operating time obtained in a standard ENT half day list. The data
was collected over a 2 month period. The theatre and anaesthetic staff
were unaware of the collection process so as to reduce observation
bias.
Results: We analysed data from 50 operating theatre sessions and cor-
related the time taken for patient preparation with patient factors and
factors such as having a trainee anaesthesist in theatre. We found a
significant disparity between the predicted time for theatre preparation
as compared to the actual time. The mean time taken for patient
preparation was approximately 25 min while it was estimated to be
15 min.
Conclusions: This study highlights the need for efficiency in theatre
turnaround time and shows the reality of increased safety checklists. It is
important to identify the factors contributing to reducing patient flow
in theatre. One of the key factors affecting costs is theatre time and any
delays significantly affect the costs incurred.
62 Clinical Audit and Practice
F174
Management of common ENT conditions in primary
care
Karamchandani, D. & Wren, S.
Objectives: A significant proportion of the workload faced by GPs is
made up of common ENT conditions. Increasingly over the last few
years, a proportion of GP trainees have undertaken placements in ENT
to gain experience in this subspecialty. This experience is invaluable to
allow a smooth interface between primary and secondary care. We
aimed to evaluate management of common ENT conditions in primary
care.
Methods: Questionnaires were handed out to practicing GPs and Emer-
gency Nurse Practitioners (ENPs). The questionnaire reviewed the man-
agement of common ENT conditions which included otitis externa,
acute sinusitis and epistaxis. We also inquired whether they had previ-
ous ENT experience and if they felt a placement in ENT would be bene-
ficial as part of GP training.
Results: The questionnaires were filled by 100 GPs and 25 ENPs.
There was great variability noted in the management of these com-
mon conditions within these groups. Approximately 20% of practicing
GPs failed to accurately manage some of these common ENT condi-
tions such as epistaxis as compared to 40% in the ENP group. Inter-
estingly, approximately 40% of GPs would treat acute sinusitis with
oral antibiotics as their first line of management and 20% would refer
directly to ENT. There were significant differences noted in the accu-
racy of management when comparing GPs with or without ENT expe-
rience.
Conclusions: Greater understanding and knowledge of ENT conditions
in primary care would help improve the quality of care and reduce inap-
propriate referrals. We strongly feel that a placement in ENT would be
beneficial to future GPs.
F175
ENT radiology in primary care
Karamchandani, D., Dmitropoulos, G. & Thompson, A.
Objectives: GP practices are one of the main determinants of health care
utilisation. The new changes in the NHS have further highlighted the
importance of practice based commissioning. The time taken for radio-
logical investigations significantly affects us meeting the waiting time tar-
gets. We aim to evaluate whether greater emphasis on management in
primary care has resulted in more radiological investigations being car-
ried out prior to specialist input.
Methods: We undertook a retrospective evaluation of ENT radiological
requests by GPs in a district general hospital over the last 4 years. We
evaluated all common ENT radiological investigations which included
ultrasound imaging, CT and MRI scans. We analysed the results of the
investigations requested and the referrals pattern. We also evaluated the
impact on patient management.
Results: There was an approximate fourfold rise in the number of inves-
tigations requested by GPs from 2007 to 2010 (138544). CT scan
requests were increased by 284%, Ultrasound requests by 575% and
MRI by almost 1000%. The most significant increase was observed in
the MRI of the head and Ultrasound of the neck. The rate of positive
results (demonstrating abnormal pathology) of the investigations ranged
from 60% to 70%.
Conclusions: There has been a significant increase over the last few years
in the radiological requests made directly by GPs. In a number of cases,
it resulted in improving the timeframe between referral and treatment,
while in others it resulted in unnecessary referrals and inappropriate
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
investigations. The discrepancy in the referral patterns highlights the
need for appropriate request guidelines in primary care.
F176
The epidemiology of head and neck cancer in the Hull
and East Yorkshire region
Murphy, J., Rafferty, A., Rawnsley, T. & Jose, J.
Objectives: The prognosis and treatment of head and neck cancer var-
ies depending on the stage at which it is detected. Considerable fund-
ing is dedicated to primary preventative measures and education to
pick these cancers up early or even prevent them. To that end this
study was performed to identify the geographical areas in the Hull
and Yorkshire Coast Cancer Network most affected by head and neck
cancer, which cancers presented at a later stage and the social groups
most affected.
Methods: After gaining regional ethics committee approval, the senior
author extracted data from the local Head and neck cancer database of
all patients treated in Hull and East Yorkshire hospitals from November
2004 to November 2009. Cancer related information was obtained from
multidisciplinary meeting records, patient centre records and case files.
Data collected included age, gender, place of residence, cancer subsite,
cancer stage and occupation.
Results: During the study period 511 patients were treated for head and
neck cancer. Notes with sufficient detail were available in 464 cases. Lar-
yngeal cancer was the most common cancer in this dataset with 181
cases, followed by hypopharyngeal cancer with 108 cases. Of the 106
council wards studied 65 wards had fewer than five cases whilst nine
wards saw between 10 and 19 cases each.
Conclusions: With this epidemiology study we were able to identify
trends in the prevalence of cancers of different subsites. This study will
help us address inequalities, develop commissioning priorities and
strengthen patient involvement in influencing changes to the service.
F177
Trust-wide audit of patient advice liaison service
referrals in an ear nose and throat department
Farboud, A., Seyan, G. & Benjamin, E.
Objectives: To assess the nature of referrals received via the Patient
Advice Liaison Service (PALS) and to implement recommendations to
improve the quality of care received by patients.
Methods: A retrospective audit of PALS referrals received from 04/2009
to 02/2011 was carried out. Recommendations were made to improve
standards of patient care. These were implemented with posters in wait-
ing areas and following presentation at Trust-wide meetings. The second
part of the cycle was performed, assessing data from 03/2011 to 06/2011,
thus completing the loop. The rate and number of PALS referrals
received in the ENT department were directly compared to other medi-
cal and surgical specialities.
Results: The greatest improvement was in the staff attitude category
which had no complaints following re-audit. In addition, four other
categories of referrals (appliances and equipment; information, assis-
tance and support; policy and commercial decisions; professional
expertise) received no referrals following the second part of the audit
cycle. Fewer referrals were received regarding incorrect patients infor-
mation. Referrals about outpatient appointments and overall clinical
care remained high.
 2012 The Authors

Conclusions: Following recommendations, there were improvements in
the rate of referrals received for some categories. Long term effects of
recommendations made will be considered following the second cycle.
F178
Current UK undergraduate training in otolaryngology:
a 10 year national review
Bannister, M.
Objectives: To asses for changes in otolaryngology training in United
Kingdom (UK) medical schools, the influence of student selected mod-
ules (SSM) and how this has changed since the original survey in
2002.
Methods: The survey was conducted from January to February 2012 by
telephone using a proforma based on that used in the original survey by
Mace and Narula. This comprised seven questions on attachment com-
pulsion, frequency, duration, formal assessment inclusion, which special-
ities the attachment was combined with and SSM availability in
otolaryngology in the UK.
Results: All 30 medical schools now have a compulsory otolaryngology
clinical attachment. Two (6.7%) offer the attachment in two different
academic years. The average attachment length is 9 days. Over 50%
include some form of assessment. The attachment is most commonly
combined with general surgery. Almost 60% offer a SSM in otolaryngol-
ogy, the average length of which remains 25 days.
Variations exist within individual medical schools because of undergrad-
uate allocation to different sectors within the area that a school can
provide clinical attachments. Variations in otolaryngology services in
individual sectors limit attachment duration and SSM availability.
Conclusions: Undergraduate otolaryngology training has increased in the
previous 10 years through increased curriculum allocation and SSMs.
Wide variation can exist though.
F179
Improving the GP VTS training experience in ENT
Bannister, M.
Objectives: To assess the common weaknesses in GP VTS training in the
United Kingdom and make suggestions for improvements.
Methods: Qualitative interviews were performed with nine GP trainees
in two different training schemes in the north of England over a
12 month period of time.
Results: Reasons for GP trainee dissatisfaction centred on poor place-
ment organisation and educational value. Poor organisational factors
included placement induction, clinical duties conflicting with mandatory
teaching sessions and placements being too service orientated. GP train-
ees felt that learning opportunities and teaching sessions rarely met the
general practice curriculum requirements. No GP trainee reported being
formally taught the full ENT examination. It was felt that GP trainee
needs were placed behind those of core surgical trainees. GP trainees felt
that they would benefit from being given a reading list prior to starting
the placement. 66.7% would rather have undertaken an additional ENT
placement than an additional medical placement to gain additional
experience.
Conclusions: GP trainees may benefit from formal induction pro-
grammes with instruction in ENT emergency care, full ENT examination
teaching including pathology detection, exclusion from theatre duties in
exchange for extra outpatient experience and symptom-based teaching
sessions rather than teaching on specific conditions.
 2012 The Authors
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
Clinical Audit and Practice 63
F180
Income loss to ENT departments through patient
readmission
Bannister, M. & Karagama, Y.
Objectives: To asses for potential income loss to otolaryngology
departments by inappropriate coding of patients hospital admissions.
Methods: Two ENT Consultant firms were reviewed retrospectively over
a 6 month period between August 2010 and January 2011 using both
theatre lists and the hospital discharge summary system.
Results: Five hundred and seventy-two operations were performed dur-
ing the 6 month period. Nine patients (1.57% to total) were readmitted
to hospital within 30 days of discharge. Three (33% of total) readmis-
sions were due to post-operative haemorrhage following tonsillectomy.
Three (33%) readmissions were due to admission to the hospital medi-
cal admission unit with exacerbations of chronic disease or new medical
problems unrelated to surgery. One (11%) readmission each was due to
a different ENT operation being performed within 30 days, inappropri-
ate admission for suture removal and analgesic control following tonsil-
lectomy. The total potential income loss was 11994, 8355 (69.7%) of
which was due to unrelated medical admissions or inappropriate ENT
admission to hospital.
Conclusions: ENT departments should be aware of unfair income losses
due to unrelated admissions to hospital within 30 days of discharge fol-
lowing surgery and should challenge their local managers about the
implementation of such a policy to avoid income loss to their hospital
trust and department.
F181
Audit of magnetic resonance imaging for vestibular
Schwannoma
Rajeev, M., Babur, S., Karakitsou, M. & Mehta, S.
Objectives: To determine the number, cost and outcome of MRI screen-
ing for vestibular schwannoma (VS).
To assess whether published audiological screening criteria are effective
in our patient population.
Methods: This audit was conducted across two different NHS trusts.
MRI scans of the internal auditory meatus requested by the ENT depart-
ments in the year 2011 were reviewed. Scans requested for monitoring
of already diagnosed VS and for cholesteatoma were excluded. Data was
obtained from patient case notes. We tested three published audiological
screening criteria on our patient population to determine which was the
most sensitive.
Results: A total of 1187 scans were requested by the ENT department in
2011 of which 78 were excluded. Of the remaining 1109 scans, 12 new
cases of VS were detected. The most common reason for scanning was
asymmetrical sensorineural hearing loss (SNHL) followed by unilateral
tinnitus and vertigo. Significant pathology related to the patients symp-
toms were detected in two other cases a glomus jugulare tumour and
lung metastasis to the cerebello-pontine angle. Median VS size was
15 mm (range 977 mm). All patients with VS had asymmetric SNHL.
Applying the audiological screening criteria of Gimsing 2010 yielded the
best sensitivity at 100%. The cost per positive scan was calculated at
10 139.
Conclusions: The detection rate of VS on MRI in our department is
similar to that published in the literature. Screening based on
audiological thresholds is feasible and will help to standardise manage-
ment.
64 Clinical Audit and Practice
F182
Comprehensive dynamic airway assessment (CDAA) for
patients with tracheostomies recalcitrant to standard
decannulation protocols
Ashfield, T., Clarke, L., Ahmad, I. & Oakley, R.
Objectives: Failed tracheostomy decannulation is common and current
methods of examining the airway are not ideal: conventional flexible
nasendoscopy allows a view of the supraglottic larynx only whilst pan-
endoscopy under general anaesthetic has inherent risks and doesnt allow
assessment of dynamic collapse. Although fit for decannulation, patients
may retain their tracheostomy with increased morbidity, mortality and
length of hospital stay (LOS).
The CDAA allows dynamic assessment of the subglottis and upper tra-
chea under local anaesthetic. It has been adapted from the technique of
awake fibre-optic intubation used by anaesthetists to manage difficult
airways. This pilot study will explore the feasibility of CDAA in enabling
decannulation of patients with longstanding tracheostomy recalcitrant to
standard decannulation protocols.
Methods: Pulse oximetry monitoring is used and the equipment for re-
cannulation is available. Co-phenylcaine spray is administered to the
nose, 15 min later atomised Lidocaine 4% solution is administered to
the larynx and subglottis via the nasopharynx. A cough response indi-
cates lower airway deposition.
Once anaesthetised, a flexible nasendoscope is introduced and supra-
glottic examination is performed. Dynamic assessment of the cords is
made prior to passing further into the sub-glottis and upper trachea.
The scope is then passed through the tube itself to complete the
assessment. An adequate examination allows confident immediate dec-
annulation.
Results: This technique has been widely tolerated and employed in six
cases of failed decannulation. Five were decannulated immediately.
Conclusions: This innovative approach to examining the airway
improves rates of decannulation, facilitating discharge into primary care,
drastically reducing LOS and the cost implications thereof.
F183
Audit of student satisfaction with ENT Surgery under-
graduate teaching
Carr, E., Jones, M., Pankhania, M., Ali, K. & Pau, P.
Objectives: To audit the satisfaction of medical students with their
workbook and lectures.
Methods: An anonymous structured questionnaire filled in by medical
students at the end of their attachment. The standard was set as 4 (max-
imum score 5) which equated to students being satisfied with the lec-
tures and finding the workbook good.
Results: One hundred and twenty-nine medical students filled in ques-
tionnaires before the intervention and 109 medical students filled in
the questionnaire after the intervention. Preintervention results showed
an average score of 3.66 for satisfaction with the lectures and 3.28 for
satisfaction with the workbook. As this failed to meet our standard the
workbook was rewritten and the series of lectures revised. Post inter-
vention results showed satisfaction with the lectures at 4.14 and 4.39
for the workbook. The difference was statistically different
(P < 0.0001).
Conclusions: We have statistically improved the satisfaction of stu-
dents with the workbook and lectures of their ENT surgery attach-
ment.
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
F184
Peer to peer cross-cover SHO teaching an
underutilised and useful educational tool
Singh, N., Varadarajan, V. & Liew, J.
Objectives: To measure the effectiveness of peer to peer SHO teaching
in improving the confidence and knowledge of cross-cover trainees out
of hours.
Methods: A prospective 3 month study following six cross-cover Max-
Fax SHOs (dentally trained and cross covering ENT) was undertaken.
Confidence levels in dealing with a medical emergency (ECG changes in
ST elevation MI) and an ENT emergency (acute paediatric epiglottitis)
were measured via a secure online questionnaire. A senior ENT SHO
was selected to provide teaching on the above topics, then confidence
levels were reassessed.
Results: The response rate to both online questionnaires was 100%.
Before the teaching sessions, 100% did not feel confident in identifying
ST elevation on ECGs and 83.3% were not confident in the initial man-
agement of acute paediatric epiglottitis. All respondents agreed that peer
to peer teaching would improve the quality of patient care and service
provided. After interactive teaching sessions, marked improvement was
demonstrated with 83.3% confident in identifying ST elevation on ECGs
(P-value: 0.0152) and 66.6% felt confident in the initial management of
paediatric epiglottitis (P-value: 0.242).
Conclusions: Senior SHO led departmental peer to peer teaching is a
useful tool in improving confidence in out of hours cross-cover trainees.
F185
Nasogastric (NG) tube insertion: are we documenting it
correctly?
Crockett, A., Pritchard, L. & Doshi, J.
Objectives: To compare current practice in our institution to national
guidelines produced by the National Patient Safety Agency (NPSA).
Methods: Audit of current practice against guidelines highlighted in the
NPSA safety alert update 2011 (Reducing the harm caused by misplaced
nasogastric feeding tubes in adults, children and infants).
We randomly selected 21 patients over 2 months with NG tubes in-situ.
We then compared the documentation in the patients notes with the
NPSA guidelines.
Results: All documentation following NG insertion was complete
according to local hospital guidelines however less than half of the
patients had the recommended NPSA documentation. In particularly the
length of the NG tube from nose-earlobe-xisphisternum (NEX) length
was not documented in any of the patients.
Conclusions: We have highlighted this to the trust and are introducing a
simple sticker/proforma to be placed in the notes at the time of NG
insertion based on NPSA guidance.
F186
A quantitative analysis of variation data for ventilation
tube insertion rate in England for otitis media with
effusion and acute otitis media
Bohm, N., Swift, S., Ceney, A., Birchall, M. & Narula, A.
Objectives: To analyse and compare variation in VT insertion rates for
acute otitis media (AOM) and otitis media with effusion (OME).
Methods: Hospital Episode Statistics (HES) data from 2006 to 2011 for
England were analysed for Operating Procedure Codes Supplement 4
 2012 The Authors

(OPCS-4) code D151 for patients diagnosed with International Classifi-
cation of Diseases 10 (ICD10) codes for AOM and OME as agreed with
the Professional Association of Clinical Coders UK (PACC-UK). Data
were analysed giving population directly standardized rates (for age and
sex) for children under the age of 14 by PCT.
Results: AOM rates peaked in the second quarter 2008/09. They cur-
rently show overall decline but large variation between maximum and
minimum rates at PCT level (at least 20 fold) persists. Average insertion
rate for OME showed a marked increase between the first quarter 2007/
08 and first quarter 2008/09 that has now declined, with an overall
increase in average rate since 2007. Maximum and minimum rates for
OME have increased with persistent large variation in rates.
Conclusions: Clear National Institute of Clinical Excellence guidelines
for OME were published in 2008; none exist for AOM. Despite guid-
ance, variation persists in OME intervention rates, with the average rate
of procedures having risen. This concerns commissioners, who view this
as increasing procedure numbers with little standardization of practice,
equating it to poor value and quality. Where and why variation occurs,
how this equates to value and confounding factors such as private prac-
tice rates and paediatric clinic access need better understanding to allow
for informed discussion with commissioners.
F187
Comparative study of fine needle aspiration cytology
(FNAC) and final histology results in thyroid disease
McSorley, A., Bhat, N. & Yadlapalli, S.
Objectives: This study aims to establish the following:
1 The correlation between FNAC and final histology.
2 The number of non-diagnostic specimens.
3 Complication rates following thyroid surgery.
Methods: Retrospective review of 200 patients who underwent thyroid
lobectomy or total thyroidectomy. A total of 111 patients underwent
FNAC. Data were collected on the following areas:
1 FNAC result.
2 Technique USS guided or not.
3 Final histology.
Results: USS guidance was used in 36 (32%) of patients. A total of 61
(55%) of FNACs were classed as non-diagnostic. Forty-two per cent USS
guided FNAC are classed as Thy 1, compared to 55% non-USS guided
FNAC. Of these patients, five were subsequently found to have malignant
histology. Fourteen patients had an FNAC classed as Thy 2, with three
diagnosed with malignancy on final histology. In 10 (10%) cases FNAC
results did not correlate to final histology, seven of which were benign
and three malignant (Papillary carcinoma: 1, Follicular carcinoma: 2).
Conclusions: Over half of all FNAC samples (55%) were classed as Thy
1. This figure is higher than the estimated 1020% suggested in other
studies. Eight per cent of these patients were ultimately found to have
malignancy. In the case of Thy2 FNAC results, three patients (21%)
were subsequently found to have malignant final histology. This raises
questions about the presumed benign nature of the pathology in these
groups and whether operative intervention should be considered.
F188
An unusual parotid sinus
Pace-Balzan, A., Falconer, D.T. & Tsioulos, K.
Objectives: To describe an unusual discharging facial sinus.
Methods: A 50 year old female with a discharging right facial sinus is
described. CT scan identified the underlying cause.
 2012 The Authors
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
Clinical Audit and Practice 65
Results: Successful treatment followed diagnosis of the underlying cause.
Conclusions: An unusual facial sinus is described.
F189
Consenting practice of ENT trainees: to what extent is
trainee involvement disclosed?
Yang, W.-Y. & Ghosh, S.
Objectives: General Medical Council and Department of Health guide-
lines state it is good practice to inform the patients about trainee
involvement in their operations on obtaining their consent. We assessed
to what extent ENT trainees disclose their involvement in operations
when obtaining consent.
Methods: A 6-question questionnaire was sent via email to 22 ENT
trainees in Northern Deanery, and 14 ENT registrars in Yorkshire Dean-
ery.
Results: The response rate was 69%. Of the respondents, 46% consis-
tently informed patients about trainee involvement in operations. Only
28% felt the complexity of operations influenced their decision to dis-
close trainee involvement. Subgroup analysis showed there was no sta-
tistically significant difference between junior and senior trainees in
trainee involvement disclosure (P = 0.394). If the trainees informed
patients about who the operator will be, it was more likely for them
to also disclose their own involvement, which was statistically signifi-
cant (P = 0.0414). Many trainees also felt that the no guarantee of a
particular surgeon clause in the National Health Service consent form
implied possible trainee involvement even if they did not specify it
verbally.
Conclusions: A significant proportion of the ENT trainees are not dis-
closing their involvement in operations to patients. The rate of trainee
involvement disclosure is not related to the seniority of trainee or com-
plexity of operations, but is related to operator disclosure. This may sug-
gest trainee involvement disclosure is not dependent on the level of
confidence of trainees but on the approach and attitude towards con-
senting process.
F190
Use of Good surgical practice guidelines to improve the
quality of operation notes
Vallamkondu, V., Barker, P., Protaschik, Y., Shakeel, M.
& Ah-See, K.W.
Objectives: The Royal college of surgeons of England published the doc-
ument Good Surgical Practice in the 2002 which identified standards
for surgeons and their practice. The aim of this exercise was to audit the
quality of operation notes in our department regarding the RCS guide-
lines as a gold standard.
Methods: A prospective audit of operation notes was conducted between
October and November 2011. Information was collected on the 15
parameters according to the RCS guidelines. The results were presented
in the departmental meeting and a change was introduced to use the
OpNote electronic recording of operation notes. The audit loop was
completed by re-auditing the operation notes over next 2 months. Excel
was used for data collection and analysis.
Results: In the 1st stage, a total of 58 operation notes from all surgeons
were audited. The incidence of OpNote use was 10% and 13% of the
hand written notes were not legible. On average, the hand written notes
were 80% complete compared to 100% for OpNote notes. When re-
audited, the use of OpNote was 65% and When OpNote was used, an
66 Clinical Audit and Practice
average of 0.22 fields were missing compared to an average of 3.39 miss-
ing fields when OpNote was not used.
Conclusions: Using the guidelines by the Royal college of surgeons, Eng-
land, we have successfully demonstrated an improvement in the quality
of operation notes. Although, the OpNote system is better but in its
absence, the hand written notes should have all the information as
required by the RCS guidelines.
F191
Fine needle aspiration cytology of thyroid diseases a
2-year experience Peterborough City Hospital
Masood, A. & Pfleiderer, A.
Objectives: To evaluate current practice in Peterborough City Hospital
in identifying suspected cancer in thyroid nodules. Also to assess FNAC
practice and compare to established standards.
Methods: All thyroid FNAC data performed over a 2 year period (Janu-
ary 2009January 2011) were collected retrospectively. It identified
patients (n = 238) that underwent thyroid disease related investigations
US guided FNAC/histology. Cytology results were classified according
to BTA guidelines Thy 15. Comparisons were made to final histological
diagnosis.
Results: Results were found to be comparable with other similar stud-
ies. Audit confirmed that there is a learning curve in diagnosing accu-
rately from FNAC samples as noted by falling THY1 rates and rising
THY2 rates. Also, FNAC with USS guidance increases accuracy of
samples.
Conclusions: Audit of individual hospital cyto-pathology results in thy-
roid diseases gives confidence to surgeons to quote the predictive value
of their investigations. This is essential to improve surgical decision
making and in-turn gives greater confidence to surgeon to provide better
patient care.
F192
Cervical ultrasound (US) in the ENT department: are we
making the most of it?
Erskine, S., Lieder, A., McQueen, A. & Wilson, J.
Objectives: US and US-guided fine-needle aspiration cytology (FNAC)
are the most frequently requested radiological investigation in our unit
(1100/annum). We aimed to assess the appropriateness of our US
usage
Methods: Ninety-two US were performed in October 2011. We reviewed
indications, findings and estimated impact on patient management
Results: Indications included unspecified swellings 42; suspected
thyroid lesions 23; salivary swellings 15; previous head and neck can-
cer 3. Consultant requests constituted 45%, associate specialist 28%,
the remainder were SpR/junior trainees. US contributed positively to the
diagnosis in 92%. A malignancy was subsequently diagnosed in seven
cases, having been identified early by US in five cases.
41.3% of patients were subsequently discharged with no further manage-
ment necessary.
These comprised 50% of those seen by consultants and SpRs but some-
what smaller proportions of those seen by others (v2; P = 0.079 at pres-
ent sample sizes).
FNAC was performed in 27 cases (21 US-guided). FNAC fully matched
the ultrasound findings in 67% and provided additional clinical infor-
mation in 33% of cases. However, of 24% undergoing excision or
biopsy, histology matched cytology in only 55%.
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
Conclusions: Depute the high volumes, US usage emerges as a generally
valuable tool in our ENT unit. More detailed prospective analysis is
required to assess to what extent its findings underpin one-stop manage-
ment of neck lumps. It seems likely that formal guidance on neck lump
pathways would expedite management by most non-consultant clini-
cians. Although the overall FNAC accuracy was disappointing, US
appeared to expedite the identification of malignancy.
F193
An audit of ENT emergency clinic attendance and the
development of a patient pathway algorithm for the
management of otitis externa
Killick, N., Scott, A. & Yates, P.
Objectives: ENT emergency clinics are held in the majority of ENT
departments throughout the country. Staffed by junior trainees they pro-
vide a means of seeing uncomplicated ENT cases promptly. At Freeman
hospital emergency clinics run most days with the majority of patients
presenting with ear pathology. In order to optimise use of these
appointments and prevent serious pathology being missed the following
departmental standard was introduced:
Patients requiring more than two appointments should be seen in a
Consultant clinic.
Methods: Notes for patients attending clinic over 2 week period were
audited. Type of appointment (new/review), site, diagnosis, grade of
doctor and outcome were recorded. A literature search identified several
treatment algorithms for the management of otitis externa (OE) 1,2.
However these algorithms focus on diagnosis and management. Follow-
ing presentation of the first loop of the audit, we introduced a patient
pathway algorithm for the management of OE, involving greater use the
ENT nurse practitioner clinic. Practice was re-audited.
Results: One hundred and eighty-six patients attended the ENT clinic
over a 2 week period. One hundred and thirty-six notes were audited.
Ten per cent (14) of patients seen in the CAS clinic were seen on more
than two occasions. The grade of staff made no difference to outcome.
Majority, 65% (9) are due to otitis externa. Following the introduction of
the pathway the number of patients seen more than twice was reduced.
Conclusions: Our pathway is an effective tool to reduce clinic visits and
has the potential to free up 234 emergency clinic appointments over a
year allowing new patients to be seen earlier.
F194
Daycase thyroidectomy and healthcare resource group
(HRG) 4.0 2012/2013 a cost effective practice?
Ifeacho, S., Kansal, G. & Amen, F.
Objectives: Our objective is to assess the feasibility of setting up a prac-
tice of day surgery hemithyroidectomy and the potential cost benefit
within the constraints of the new Healthcare Resource Groups (HRG)
4.0 2012/13 in a district general hospital.
Methods: We performed a retrospective record review of all hemithyroi-
dectomy patients undertaken in our hospital over a 12-month period.
We analysed the results with respect to strict patient selection criteria,
complications, readmission rates and potential cost benefits.
Results: A total of 41 patients had a hemithyroidectomy over a 12-
month period, nine were male, 32 were female, age range 1788 years.
Eighty-eight per cent of procedures were primary surgery and 12% were
completion hemithyroidectomies. Seventy-three per cent of patients had
an American Society of Anaesthesiologists (ASA) classification recorded,
 2012 The Authors

these were either Grade I or II. The mean operating time was 132 min.
The mean length of stay in hospital was 1.5 days, with a range of
14 days. The rate of complications was 10% and included bleeding and
temporary vocal cord palsy. None of the patients were readmitted to
hospital.
Conclusions: The costs for performing hemithyroidectomies as a day
surgery procedure over the last year would have resulted in a total sav-
ing of 12 500. This study supports day surgery hemithyroidectomy as
cost effective within the latest framework of payment by results.
F195
Effective management of semi acute referrals
OShea, N., Kerr, N. & Drysdale, A.
Introduction: The NHS is under financial strain and experiencing cuts
to our workforce. Hence we must look for ways to provide a more effi-
ciently run service without compromising patient safety and junior doc-
tor training opportunities.
Objectives: The aim was to identify the groups of patients being sched-
uled as ward attendees per week and to consider which these patients
would be more appropriately managed in an alternative setting e.g.
emergency clinic, Consultant clinic, nurse led microsuction clinic, A+E
or in the community.
In our department senior house officer (SHO) numbers are being
reduced from 3 to 2. Hence one SHO will be stretched to cover the
ward, oncall and see the large number of ward attendees with semi acute
problems, dispersed throughout the day. More efficient organisation of
the day to day work load is therefore required audit of ward attendees
over a period of 1 month.
Results: Seventy-four ward attenders were seen by SHOs in 1 month.
Most of these were reattenders or patients that would be more appro-
priately assessed in an emergency clinic run alongside a consultant
clinic to provide advice on further management or a senior second
opinion.
Conclusions: Implementation: Developed a new triage system for semi
acute referrals and organised two new SHO led emergency clinics a
week, supported by a Consultant.
Preliminary results of the reaudit show, (1) A significant reduction in
ward attendees and hence duties are less stretched. (2) Increased SHO
teaching opportunities in a well supported emergency clinic.
F196
Efficacy of Tristel wipes system for nasoendoscope
disinfection
Choudhury, N., Tzanidakis, K., Bhat, S., Weerasinghe, A.
& Marais, J.
Objectives: The Tristel Wipes System is commonly used to disinfect flex-
ible nasoendoscopes. Although its manufacturers (Tristel, UK) claim it
provides safe sterilisation of nasendoscopes, there is however no
reported evidence that evaluates the efficacy of this system in clinical set-
ting. We aimed to evaluate the efficiency of Tristel Wipes for nasoendo-
scope disinfection and identify any significant contamination between
cleaning and using of the instrument.
Methods: Thirty-one cleaning episodes were performed. Each episode
included four swabs for microbiology; two swabs after cleaning, one
from the tip and one from the handle. After cleaning the nasoendo-
scopes, another two swabs from the same areas were obtained before
 2012 The Authors
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
Clinical Audit and Practice 67
usage of the instrument. Microbiology evaluated all swabs for bacterial,
fungal and mycobacterial growth.
Results: One hundred and twenty-four swabs were tested. No swabs
taken from the tips or handles of the nasoendoscopes after cleaning with
Tristel Wipes developed any growth. Also, none of the swabs from the
tips before use to the patient developed any significant growth. However,
two swabs from the handle of the nasendoscopes before use to the
patient developed significant Staphlococcal growth.
Conclusions: In our study, the efficacy of Tristel Wipes to disinfect
nasoendoscopes from bacteria, fungi and mycobacteria was found to be
100%. Between cleaning and using the instrument, there was evidence of
contamination to the handle of the nasoendocope in two cases, but no
contamination at the tip, which is exposed to and in contact with the
patients upper aerodigestive tract. Gloves should be used when handling
the cleaned nasendoscopes, to minimise contamination.
F197
The impact of the rapid diagnostic clinic on patients
journey timelines
Choudhury, N., Hassen, Y., Siddiqui, J., Falzon, A.
& Ghufoor, K.
Objectives: The Rapid Diagnostic Clinic (RDC) was introduced at our
institution to comply with NICE recommendations for improving head
and neck cancer services. It provides a multi-modality assessment for
target head and neck referrals, with on-site sonography and cytology.
Methods: We retrospectively audited all new target referrals seen in the
Head and Neck clinics during a 6 months period and identified some areas
of delay in patients reaching a definitive outcome. Following implementa-
tion of the RDC, we performed a 2nd cycle, prospective audit over
6 months and evaluated its effect on timelines for patients journey, and the
proportion that reached a definitive outcome from their one-stop visit.
Results: One hundred and ninety-seven patients were seen during the
pre-RDC period, and the average time from referral to being seen was
11 days for 2-week wait referrals and 34 days for other referral sources.
During the RDC period, 299 patients were seen. The average waiting
time was reduced to 9 and 23 days respectively. During the RDC period,
over one third of patients utilised the provision of ultrasound FNAC,
and the majority of patients reached a definitive outcome (discharged or
listed for surgery) at the end of their first consultation. This was com-
pared to the pre-RDC period, where the commonest outcome for
patients was referral for an investigation, with a consequently longer
waiting time for surgery.
Conclusions: Our newly established RDC facilitates patients reaching a
definitive management plan. The provision of on-site sonography and
cytology benefits both the patients and the trust by reducing the time
from referral to diagnosis.
F198
Diagnosis and incidence of malignant thyroid nodules
in Jersey
De Cordova, J., Body, S., Hunt, K. & Siodlak, M.
Objectives: To determine the incidence of thyroid cancer in Jersey. To
determine how safe is to perform Thyroid surgery in a small district
hospital. To compare our results with the UK standards.
Methods: Retrospective study and analysis of the Pathology reports data
based from January 2001 to march 2010 was performed.
68 Clinical Audit and Practice
Results: Three hundred and sixteen patients (261 females and 55 males)
with 48.2 years old in average underwent 451 Fine Needle Aspiration
(FNA). The average FNA was 1.42 per patient with 147 of this classified
as Thy 35 (32.5%). After surgery we obtained 52 Histological confirma-
tion of Cancer (11.5%) in 40 females and 12 males (ratio 4 : 1). The risk
of malignancy was 16.45% with a cancer incidence of 5.7 per 100 000
people (3.5 in UK). Two hundred and twelve thyroid surgeries were per-
formed during this time from which 52 (25%) were cancer. As compli-
cations, we found four transitory Recurrent Laryngeal Nerve palsies (2%
versus 9.8% worldwide), no permanent palsies (2.3% worldwide) and
two postoperative haematomas (1% versus 1.8% worldwide).
Conclusions: Jersey Incidence of thyroid cancer is higher than UK and
similar to France. Our rate of diagnosis with FNA is similar than the
rest of the world. Our overall rate of cancer detection and treatment
after surgery is similar and in some cases better than many of the big
cancer centres in the world. Our rate of complications is far less than
the published in the literature.
F199
Is centralised sterilisation of surgical trays appropriate
in the current economic climate?
Takwoingi, Y.M. & Junaid, M.
Objectives: Centralised sterilisation of surgical instruments has become
the established practice in the past few years. The objective of this study
was to establish the state of current practice at our hospital, and to
assess the cost effectiveness of the process.
Methods: A prospective evaluation of practice was undertaken using a
set proforma. The proforma was completed by the senior nurses in the
ENT theatres of Birmingham Treatment Centre, an ambulatory care cen-
tre between the months of July and October 2011.
Results: A total of 107 common ENT operations were included in the
study. The operations included myringoplasty, septorhinoplasty, septopl-
asty, tonsillectomy, Functional Endoscopic Sinus Surgery, and others.
Fifty one per cent of the operations (55 trays) required the opening of
at least one extra set of instruments (range 15) before completing the
surgery. The commonest reason for this was missing instruments from
the trays. Based on the current cost of sterilisation of surgical trays by
BBraun the provider for the Trust, it is estimated that at least 1137.00
in direct cost is spent monthly for processing these extra trays, equating
to around 13 634.00 annually. In practical terms, looking at tonsillec-
tomy as an example it is estimated that around 75 extra trays are
required for 300 tonsillectomies carried out annually in the unit, costing
an extra 1547.00. Indirect costs include lost operating time and pro-
longed general anaesthetic time.
Conclusions: This study has demonstrated that centralised sterilisation
process of surgical trays may not be cost effective or cost effective and
therefore the process needs to be improved.
F200
Aspiration pneumonia in SALT assessed patients with
bulbar palsies: a major cause of readmission to the
neurosurgical high dependency unit
Lowe, N. & Carroll, C.
Objectives: Readmission to the Neurosurgical High Dependency Unit at
a regional centre for neurosurgery was audited to evaluate if a readmis-
sion target of <5% was being achieved and investigate readmission cause
to reduce reoccurrence.
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
Methods: A retrospective audit was performed over a 6 month period.
Patients were identified from admission data. Readmission circumstances
were found from patient records.
Results: 4.89% of patients required readmission (26 out of 470). This
had decreased from 9.6% from an audit 2 years previous. From 20 rea-
sons identified, the top 4 were: seven patients (27%) required a second
surgical procedure; five patients (19%) were step downs from ICU; five
patients (19%) had a CSF infection with a VP shunt; three patients
(12%) with known bulbar symptoms had respiratory compromise.
Conclusions: Recommendation from previous audit was that all patients
should have SALT assessment before oral intake to identify abnormalities
that may increase the chance of aspiration. However, the three patients
with bulbar palsies that were readmitted due to respiratory compromise
had all been assessed by SALT prior to oral intake. These patients were
subsequently nil by mouth and had a nasogastric tube in situ on free
drainage. Despite these measures, aspiration related respiratory compro-
mise (including one respiratory arrest) ensued. This has highlighted that
further methods of reducing the chance of aspiration in at risk patients
needs to be developed with the help of otolaryngologists and SALT.
F265
Adherence to British Thyroid Association guidelines:
fine needle aspirate cytology accuracy in thyroid
disease
Kamal, S., Durham, L. & Larsen, J.
Objectives: The aim of this study is to audit current practice of fine nee-
dle aspirate cytology in thyroid pathology.
Methods: We reviewed 152 fine needle aspirates sent for thyroid cytol-
ogy in 1 year, 2010, in the setting of a university teaching hospital.
Patient demographics, clinical presentation, fine needle aspirate (FNA)
cytology, ultrasound (U/S) guidance during the FNA, outcome including
surgical management and final histology were all recorded.
Results: Fine needle aspirate cytology (FNAC) results were recorded as
recommended by the British Thyroid Association guidelines, by cytopa-
thologists with a special interest in thyroid pathology involved in multidis-
ciplinary team (MDT) meetings. The FNAC was reported in the following
proportions: Thy1 37%, Thy1c 21%, Thy2 16%, Thy2c 15%, Thy3a 2%,
Thy3f 4%, Thy4 0% and Thy5 5%. Sensitivity and specificity was found to
be 100%; the positive predictive value was 100% and the negative predic-
tive value 92%. Ancillary tests were performed when needed to complete
the cytological diagnosis. Thirty-four per cent of all FNAs were U/S
guided; of the false negative cases, 50% were U/S guided FNAs
Conclusions: The audit demonstrated that current practice of FNAC of
thyroid disease was in accordance to set guidelines, and the statistics
correlated with those published. Where appropriate the results of the
thyroid FNAC was used in the planning of surgery. U/S guidance was
not found to affect FNAC accuracy.
F266
Are stricter guidelines on the indications for tonsillec-
tomy causing an increase in acute tonsillitis presenta-
tions to hospital? A National comparison between
England, Wales and Australia
Mcleod, R., Backhouse, S. & Owens, D.
Objectives: SIGN guidelines give clear indications for tonsillectomy
including: seven epidoses of clinically significant sore throat in 1 year or
 2012 The Authors

five episodes each year for 2 years. However, are the indication limits set
for tonsillectomy too strict? This study examines the incidence of acute
tonsillitis with the rates of tonsillectomy on a national scale.
Methods: A retrospective study of data corresponding to tonsillectomy
and acute tonsillitis were identified between April 1999 and March 2009.
This was undertaken using three national electronic patient episode da-
tabases: (1) Patient Episode Database of Wales (PEDW); (2) Health Epi-
sode Statistics (HES) of England and (3) the Australian Institute and
Health and Welfare database (AIHW). Data was explored for total num-
bers of presentations and operations performed. For comparison data
was converted to incidence rate per 1000 population using national pop-
ulation census.
Results: A total of 794 687 tonsillectomies and 536 317 admissions for
acute tonsillitis were identified in the countries examined. Over the
study period the incidence of acute tonsillitis increased in England and
Wales but remained static in Australia. The incidence of acute tonsillitis
was higher in Wales and England when compared to Australia (P < 0.01
and P < 0.05 respectively). The rate of tonsillectomy was lower in Wales
and England when compared to Australia (P < 0.01).
Conclusions: During the study period tonsillectomy rates fell and acute
tonsillectomy presentations increased in England and Wales. No such
changes were identified in Australia. These findings may be associated
with stricter Tonsillectomy guidelines. Further research is needed to
investigate causal factors.
F267
An audit of PCT prior approval tool for tonsillectomy
are we doing too many?
Blenke, E., Hassan, D., Thorne, S. & Okpala, N.
Objectives: Tonsillectomy is one of the most commonly performed ENT
operations. This audit aims to identify whether patients have been listed
appropriately according to Primary Care Trust (PCT) guidelines. The
current climate of restricted financial resources and pending GP com-
missioning demands guidelines are fulfilled to safeguard reimbursement
for performed procedures.
Methods: A retrospective case note review was carried out following a
tonsillectomy audit by the PCT. PCT guidelines were compared with the
ENT UK 2009 guidelines.
Results: Sixteen out of the 19 cases identified by the PCT were traced. The
PCT audit suggested patients either had insufficient number of episodes
or episodes were not disabling. Our case notes review showed that 15 out
of 16 met the criteria. Nine cases had sufficient number of episodes, two
required tonsillectomy for histology, two had upper airway obstruction
and two had disabling tonsillitis. One case did not fulfil the criteria.
Conclusions: The audit shows that most patients are appropriately listed
for tonsillectomy. Clearer communication and better documentation is
necessary to avoid misinformation and debate about reimbursement for
performed work. Education of GPs about the guidelines, referrals and
documentation is important. Approved funding screening form with the
guidelines attached to waiting list cards is an option.
F268
Trends in rates of day case ENT surgery in England
19992011 Identifying opportunities for improvement
Bennett, W.O. & Reddy, V.M.
Objectives: To demonstrate the trends of day case management of com-
mon ENT procedures that may traditionally have required an inpatient
 2012 The Authors
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
Clinical Audit and Practice 69
stay. The purpose of this exercise is to identify opportunities for further
improvements to the rates of day surgery in ENT.
Methods: Data regarding admissions in NHS hospitals in England for
patients undergoing surgical procedures from 1999 to 2011 was retrieved
from Hospital Episode Statistics Online (www.hesonline.nhs.uk). Twelve
ENT procedure categories were studied for trends in the percentage of
cases performed as day cases, and for the percentage change in day cases
performed from 1999 to 2011.
Results: The following list reports the percentage of procedure catego-
ries performed as day cases in 20102011 in ascending order, with the
equivalent values for 19992000 indicated in brackets for comparison;
mastoid surgery 18% (3%), stapedectomy 29% (4%), tonsillectomy
34% (6%), nasal polypectomy 41% (18%), tympanoplasty/myringoplas-
ty 43% (10%), SMR/septoplasty 49% (13%), cervical lymph node
biopsy 67% (44%), adenoidectomy 68% (41%), pinnaplasty 71%
(51%), submucosal diathermy to inferior turbinates 77% (57%), grom-
met insertion 93% (84%) and reduction of fractured nasal bones 95%
(83%).
Conclusions: 0In general, percentage of procedures performed as day
cases increased for all 12 procedure categories from 1999 to 2011. Fur-
ther improvements can be expected as some procedure codes demon-
strate low rates of day case management at present.
F269
The effect of the tonsillectomy SIGN guidelines on the
incidence of hospital admission for tonsillitis and
quinsy
Keh, S.M. & Bennett, A.
Objectives: To audit the incidence of tonsillectomy in our hospital fol-
lowing the SIGN 34 guidelines. To determine whether performing fewer
tonsillectomies has resulted in an increased incidence of tonsillitis and
quinsy admission.
Methods: The audit was carried out looking at tonsillectomy practice
from 1994 to 2011. A change of practice took place following the intro-
duction of SIGN 34 guidelines in Jan 1999. Incidence of tonsillectomy,
tonsillitis and quinsy admission was calculated from the inpatient hospi-
tal database and population estimates were obtained from the General
Register Office for Scotland.
Results: The effect of the SIGN guidelines was to reduce the incidence
of tonsillectomy from 135.6, 136.3, 120.2 per 100 000 populations in
97, 98, 9994.0, 45.7, 67.9 per 100 000 populations in 00, 01, 02.
This effect is statistically significant (P < 0.05). The incidence of tonsilli-
tis went from 187.5, 153.5, 136.2 per 100 000 populations in 97, 98,
99122.2, 73.9, 99.8 per 100 000 populations in 00, 01, 02. The reduc-
tion was statistically significant (P = 0.002). However, there was no sig-
nificant change in the incidence of quinsy (P = 0.62) with 14.8, 18.6,
21.6 per 100 000 population in 97, 98, 99 compared to 23.3, 16.9, 20.5
per 100 000 population in 00. 01, 02. Linear regression analysis
showed a significant correlation between incidence of tonsillectomy and
incidence of tonsillitis in the population (P < 0.0001) but not with inci-
dence of quinsy.
Conclusions: The effect of the SIGN guidelines has had no effect on the
incidence of quinsy but appears to be inversely proportional to tonsillitis
incidence.
70 Clinical Audit and Practice
F270
Have department of health cancer targets improved
care for head and neck cancer patients?
Harrison, L., Mirza, A., Diakos, E., Stapleton, E., McRae, A.
& El-Shunnar, S.
Objectives: To determine whether patients with head and neck malig-
nancy were being assessed and managed within the timeframes set out
in the 2006 Department of Health (DOH) national cancer plan guide-
lines, and to identify reasons behind any delays.
Methods: A retrospective two cycle audit of case notes of all head and
neck cancer patients in Lincolnshire over a 2 year period. Cycle 1 was
over 12 month period from June 2008 to June 2009 and following
national presentation cycle 2 was undertaken over an equivalent
12 month period in 2010. Notes were reviewed for demographics and
compliance with the 2 week wait (2WW), 31 and 62 day treatment tar-
gets. Reasons for delays were noted and data analysed in excel.
Results: There was a 25% increase in the number of confirmed head
and neck cancer patients in 2010. Overall 71% of confirmed cases were
referred by GPs. All 2WW referrals were seen without delay in both
cycles; however 34% of confirmed cancer cases were not referred via the
2WW in 2010, compared to 35% in 20082009. Seventy-three per cent
of patients achieved the 31 day target in 2010 compared to 75.9% in
20082009. There has been an improvement in the 62 day treatment tar-
get with 66.7% receiving timely treatment compared to 51.0% in 2008
2009. The majority of delays were due to patients not being moved onto
pathway once malignancy was confirmed.
Conclusions: Government directives promote target-driven care; however
there remain a substantial proportion of cancer patients being managed
outside this framework and experiencing delays in care.
F271
Electronic logbook coding of operative procedures
are we consistent?
Carswell, A.J., Burrows, S.A., Gillett, S. & Reddy, V.M.
Objectives: Surgical trainees are required to record their operative expe-
rience in a logbook in order to provide evidence of progression of com-
petency. Given that the logbook is integral to demonstrating training, it
stands to reason that this evidence should be robust and valid. As part
of its validity this record should be reproducible and consistent. In order
to investigate this we set about assessing the reliability of coding
amongst ENT trainees and trainers.
Methods: Twenty-eight operative scenarios were presented to ENT sur-
geons from the South West of England. Participants were asked to
record how they felt the trainee described in each scenario should record
the operation in their logbook. The responses were recorded in a Micro-
soft Excel spreadsheet and a multi-rater kappa coefficient was calculated
for all responders, trainer responses only and trainee responses only. A
kappa of 0.7 or greater represents adequate interrater agreement.
Results: Forty-three participants were included in the study. Percentage
of overall agreement and multi-rater kappa coefficients were as follows:
all responders (n = 43, 61%, 0.53), trainers only (n = 10, 68%, 0.62)
and trainees only (n = 24, 64%, 0.57).
Conclusions: This study demonstrates poor reliability of the current sys-
tem of coding the level of supervision in the context of the operative
scenarios that we used. As the logbook of operations is a measure of
suitability for certificate of completion of training, it is important for
the surgical community to debate how levels of supervision should be
recorded in order to improve consistency.
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
F272
Saving cost and decreasing appointments ultrasound
scanning in the Ears, nose and throat outpatient
department for neck lumps
Trivedi, R. & Tahery, J.
Objectives: This study looked at ultrasound scanning (USS) and FNAC
(fine needle aspiration cytology) for neck lumps; to reduce the time
taken for diagnosis, patient anxiety, reduce costs to the trust and reduce
outpatient appointments.
Methods: A retrospective study was carried out between January and
April 2011 at the Countess of Chester hospital. Twenty-three patients
were chosen. Data recorded was: time taken from USS to diagnosis, the
diagnosis and further investigations. Cost of ultrasound scanning and
FNAC in clinic was compared to that of USS and FNAC in the radiol-
ogy department.
Results: Sixty-one per cent received a diagnosis at the time of the clinic
appointment with only 39% having to go on to further investigations.
The average time to receive a diagnosis from initial clinic appointment
was 11 days. Of the 23 patients, 22% had both FNAC and USS. The
costs to the trust were less with scanning in the outpatient department
and follow up appointment numbers halved.
Conclusions: This study showed that the use of USS is beneficial in
the outpatient setting. It dramatically reduces the time taken from
initial appointment to diagnosis. It reduces patient anxiety; as they
need not wait for an outpatient USS in radiology, then wait for
another clinic appointment. This is true in the vast majority of pre-
sentations of neck lumps as the diagnosis on clinic USS was benign.
Therefore, reducing the patient journey, the cost to the department
and trust.
F273
Thyroglossal cyst excision: a decade of experience
Ubayasiri, K., Brocklehurst, J., Judd, O. & Beasley, N.
Objectives: To report a 10-year experience of thyroglossal cyst excision
at Queens Medical Centre, Nottingham, comparing interspecialty out-
comes, practice and technique.
Methods: Retrospective casenote analysis, alongside surgical histopathol-
ogy review for all thyroglossal cyst excisions over the decade 20002010.
This yielded 108 patients with histopathology confirming thyroglossal
cyst.
Results: Mean age of patient was 21 years (range: 1 week76 years).
Fifty-five per cent of patients (n = 59) were <18 years of age. Fifty-one
per cent (n = 55) of patients were male and 49% (n = 53) female. Sixty-
three per cent (n = 70) of all cases were operated on by ENT, 32%
(n = 35) by paediatric surgery, 2% (n = 2) by maxillofacial surgery and
1% (n = 1) by general surgery. ENT undertook 41% (n = 24) of all pae-
diatric cases with paediatric surgery operating on the rest (n = 35). The
primary surgeon was a consultant in 55% (n = 59) of operations and a
registrar in 45% (n = 49). Thyroglossal cysts were ruptured in 19%
(n = 21) of operations during removal. The central portion of the hyoid
bone was not excised in 6% (n = 7) of cases. Ten per cent (n = 11) of
patients suffered postoperative complications, six of which were recur-
rences.
Conclusions: We report a combined recurrence rate of 6% across all
specialities for Sistrunks procedure. This is in keeping with commonly
reported recurrence rates. However, we found central compartment neck
dissection, as a modification of the original Sistrunk procedure, provides
a highly effective method for permanently excising a thyroglossal cyst
 2012 The Authors

and almost eliminates the chance of recurrence. We report recurrence
rates of <1% using this technique.
F274
Does individualised prospective post tonsillectomy
audit reduces complication rates?
Prasai, A., Sayles, M., Kelly, C. & Ahmed, A.
Objectives: The overall complication rate in the national prospective
tonsillectomy audit was 5.2% and the haemorrhage rate was 3.5%. The
haemorrhage rates were lower when cold steel dissection was carried out
with ties and/or electrocautery for haemostasis compared to other meth-
ods of tonsillectomy. Previous departmental audit in 2004, 2005 and
2006 revealed haemorrhage rates of 12.1%, 8.5% and 9.3% respectively.
The last audit in 2006 was carried out prospectively and all surgeons
were audited both individually and collectively and were informed of
their haemorrhage rates. The aim of this study was to re-audit and to
see if individualised post tonsillectomy audit helps to reduce haemor-
rhage rates.
Methods: This was a prospective study carried out for 5 months com-
mencing 16th of February 2010. All patients undergoing tonsillectomy in
this time period were included in this study.
Results: Two hundred and fifty-two patients were included in this study.
The age range of patients was 261 years and there were 19 surgeons of
different grades who carried out the surgery. The overall complication
rate was 6.3% and the haemorrhage rate was 4.8%.
Conclusions: There is reduced haemorrhage rate since 2006. Higher
complication rates were associated with the use of bipolar diathermy in
the inferior poles, bipolar only haemostasis and higher power setting
with the diathermy. Reduced post tonsillectomy haemorrhage rates
could be associated with prospective individualised audit but this does
need to be re-audited.
F275
The use of tracheostomy in major trauma patients
Pilgrim, G., Harrall, K., Burkitt, S. & Arora, A.
Objectives: To establish the rate of tracheostomy and to assess the care
of the tracheostomised patient in the major trauma patient in Intensive
Care.
Methods: All patients admitted to Intensive Care December 20102011
under the code major trauma were included. Basic demographics, injury
severity, length of stay and length of intubation were collected, in addi-
tion to whether they underwent tracheostomy. For those patients that
underwent tracheostomy, time taken for first cuff deflation, rate of com-
plications and rate of decannulation was collected. The study period
ended on discharge from ITU.
Results: One hundred and forty-nine patients were admitted under the
code major trauma in the 12-month study period. Fifty-eight patients
underwent tracheostomy. The average age was 44.5 years (range 1686).
The APACHE score was lower in the group that did not undergo trache-
ostomy (14.3 versus 17.8). Length of intubation was shorter in those
without tracheostomy (2.9 versus 8.2 days), as was length of ITU stay
(4.3 versus 21.8 days).
21/58 patients with tracheostomy started a respiratory wean in ITU; six
were decannulated. Weaning started on average 16 days post insertion.
There were 16 tracheostomy changes; the primary reason was conversion
to a fenestrated tube. There were three trachestomy emergencies but no
tracheostomy related deaths
 2012 The Authors
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
Clinical Audit and Practice 71
Conclusions: A large proportion of major trauma patients undergo tra-
cheostomy. Once a tracheostomy is established, it is unlikely to be
removed within an intensive care setting; however, early weaning is fre-
quently commenced. The next stage of our project is to evaluate the care
of the major trauma patient post discharge from the ITU.
F276
Patient preference for daycase or inpatient
tonsillectomy
Sethi, N., Schofield, S. & Smelt, G.
Objectives: Tonsillectomy is performed as a day-case procedure in many
units in the UK. This has been promoted nationally as part of the Day
Case Surgery Operational Guide. We aimed to assess patient opinions
and preferences after undergoing either day-case or inpatient tonsillec-
tomy.
Methods: Fifty patients having undergone tonsillectomy were randomly
selected. A telephone questionnaire was performed 3 weeks postopera-
tively to find out whether they had the operation as an inpatient or day-
case and whether or not they would have preferred to have the proce-
dure otherwise.
Results: Twenty-eight patients (56%) had tonsillectomy performed as
an inpatient and 22 (44%) as a day-case. Out of the inpatients 19/28
(68%) were happy with inpatient treatment and would not have
wanted to be treated as a day-case whilst 5/28 (18%) would have
preferred day-case treatment. 4/28 (14%) were undecided. Out of
those treated as day-case 7/21 (33%) would have preferred the opera-
tion as an inpatient whilst 14 (67%) were happy with day-case. Only
one patient required readmission to hospital. This was for bleeding at
6 days post-tonsillectomy.
Conclusions: This study demonstrates that though day-case tonsillec-
tomy can be performed safely it is still imperative that we always
remember patient choice and preference in decisions over whether oper-
ations are performed as a day-case or overnight stay.
F277
A selective approach to enteral feeding in head and
neck cancer patients receiving chemo/radiotherapy
Fitzgerald, A., Scollen, K., Carding, P., Miller, T. & Owen, S.
Objectives: Head and neck cancer patients receiving chemo/radiotherapy
often require enteral feeding due to treatment side effects. In our service,
pre-treatment swallowing assessment assists in determining method of
enteral feeding [gastrostomy or nasogastric tube (NGT)]. Our objective
was to document the method and duration of enteral feeding in head
and neck cancer patients who received chemo/radiotherapy on different
treatment regimens.
Methods: Data on the number of patients, method of non-oral feeding
and the duration of enteral feeding were collected for patients who
received chemo/radiotherapy in the first 6 months of 2011 (n = 51). The
patients were divided into two groups; the 6365 Gy and the 50 Gy
group.
Results: In the 6365 Gy group (n = 38), 13 (34%) patients had a pro-
phylactic gastrostomy, 18 (47%) received an NGT and 7 (18%) did not
require enteral feeding. In the 50 Gy group (n = 13), 2 (15%) patients
had a gastrostomy, 1 (8%) had an NGT and 10 (77%) did not require
enteral feeding. The median duration of NGT feeding for the 6365 Gy
group was 8 weeks. Ten patients from the 6365 Gy group continued to
72 Clinical Audit and Practice
require enteral feeding 6 months post-treatment (nine gastrostomy and
one NGT).
Conclusions: In this centre we use a selective approach to determine the
method of nutritional support for patients undergoing chemo/radiother-
apy treatment.
F278
Reducing late cancellations of elective ENT operations:
a service improvement project
Ellis, M. & Vadivale, D.
Objectives: To investigate and reduce the frequency of anaesthetic pre-
assessment issues causing late cancellations of elective ENT operations at
St Georges Hospital, London.
Methods: A retrospective audit of late cancellation of operations in the
department of ENT surgery was carried out over a 6 month period
between March and September 2011. Cases were identified from retro-
spective review of theatre log books. Late cancellation was defined as
abandonment of a procedure on the planned day of surgery. Following
the initial audit a number of changes were made to the SHO led pre-
assessment clinic including introduction of a system for tracking pend-
ing investigations with the aim of reducing late cancellations. The audit
was repeated for a further 6 months following the intervention.
Results: During the pre-intervention period there were 38 late cancella-
tions of which 5 (13.1%) were due to anaesthetic or pre-assessment
issues. All of these were due to inadequate preoperative cardiac investi-
gations in patients with significant cardiac comorbidity. In the post
intervention period there were a total of 52 late cancellations of which 2
(3.9%) were due to pre-assessment or anaesthetic issues. The fall in pro-
portion of pre-assessment issue cancellations did not reach statistical sig-
nificance, (Fishers exact test, P = 0.1). The majority of cancellations in
the pre and post intervention period were due to theatre and bed avail-
ability.
 2012 Blackwell Publishing Ltd Clinical Otolaryngology 37 (Suppl. 1), 1772
Conclusions: Improved tracking of pending pre-operative investigations
appears to confer a reduction in cancelled operations due to pre-assess-
ment issues. However the potential benefit is modest in relation to can-
cellations for other reasons such as bed and theatre availability.
F279
Results of the national paediatric cochlear implant
surgical audit
Broomfield, S.
Objectives: Following the NICE approval of bilateral paediatric cochlear
implantation, the prospective multi-centre National Paediatric Cochlear
Implant Surgical Audit was established, to collect a large dataset of pae-
diatric implantations, and to help inform future surgical practice.
Methods: Data was collected from 14 British cochlear implant centres,
and included simultaneous and sequential bilateral as well as unilateral
implantations. Demographic data collected included age at implantation,
aetiology of deafness, implant type, length of surgery, and the use of
electrophysiological testing and imaging. The range and incidence of
major and minor complications was also recorded and comparison
made with the published literature.
Results: To date, 961 patients (1398 implantations) have been recorded,
including 437 bilateral simultaneous implantations. Age ranged from
4 months to 18 years. The majority of children (83%) had congenital deaf-
ness. Median length of surgery was 4 h 30 min and 2 h 20 min for bilateral
simultaneous and unilateral implantation, respectively. Eighty-one per
cent of cases were discharged on the day after surgery, with 7% done as
day cases and 12% requiring a more prolonged hospital stay. Immediate
major and minor post-operative complications occurred in 0.9% and 3.3%
of cases, respectively. There were no deaths or permanent facial palsies.
Conclusions: Paediatric cochlear implantation is a safe procedure with
an acceptably low incidence of major and minor post-operative compli-
cations.
 2012 The Authors