Essential dataset for ambulatory ear, nose, and throat care in general practice: an aid for quality assessment.
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OBJECTIVE: To describe the documentation of care for the usual range of ear, nose, and throat (ENT) problems seen in primary care as a basis for developing a computerised information system to aid quality assessment. DESIGN: Descriptive study of the pattern of ENT problems and diagnoses and treatment as recorded in individual case notes. SETTING: The primary health care centre in Mjolby, Sweden. PATIENTS: Consultations for ENT problems from a 10% sample randomly selected from all consultations (n = 22,600) in one year. From this sample 375 consultations for ENT problems (16% of all consultations) by 272 patients were identified. MAIN MEASURES: The detailed documentation of each consultation was retrieved from the individual records and compared with the data required for a computer based information system designed to help in quality management. RESULTS: Although the overall picture gained from the data retrieved from the notes suggested that ENT care was probably adequate, the recorded details were limited. The written case notes were insufficient when compared with the details required for a computerised system based on an essential dataset designed to allow assessment of diagnostic accuracy and appropriateness of treatment of ENT problems in primary care. CONCLUSION: There is a gap between the amount and the type of information needed for accurate and useful quality assessment and that which is normally included in case notes. More detailed information is needed if general practitioners' notes are to be used for regular quality assessment of ENT problems but that would mean more time spent on keeping notes. This would be difficult to justify. IMPLICATIONS: The routine information systems used at this primary healthcare centre did not produce sufficient documentation for quality assessment of ENT care. This dilemma might be resolved by specially designed desktop computer software accessed through an essential dataset. (+info)
An analysis of referral patterns for dizziness in the primary care setting.
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BACKGROUND: The majority of balance disorders are non life-threatening and symptoms will resolve spontaneously. However, some patients require further investigation and many disorders may benefit from specialist treatment it is unclear whether appropriate identification and referral of this group of patients presently occurs. AIM: To review the management of patients with symptoms of dizziness within primary care. METHOD: A retrospective review of the management of 503 patients who visited their general practitioner (GP) complaining of dizziness between August 1993 and July 1995. Management was then compared with local criteria. RESULTS: On average, 2.2% of patients per year at the practices studied consulted their GP about dizziness, amounting to 0.7% of all consultations. The most common GP diagnosis was of an ear, nose, and throat (ENT) disorder (33.8%). Similarly, many of the 16% referred were directed to ENT (36%) specialists. The proportion of patients referred was significantly higher in those seeing their GP at least twice, those with symptoms lasting a year or more, or where there were additional symptoms associated with the dizziness, indicative of a cardiac, ENT, or neurological disorder. Compared with the local criteria, 17% of management decisions were deemed inappropriate. The major failing was not referring appropriate patients. This group comprised patients with chronic, non-urgent symptoms, and were significantly older than those appropriately referred. CONCLUSION: Patients with chronic symptoms of dizziness, particularly the elderly, are under-referred for specialist consultation and, therefore, do not have access to appropriate treatment regimes. This suggests a need for further training of GPs and evaluation of therapeutic needs of elderly dizzy patients. (+info)
Nontuberculous mycobacterial infection of the head and neck in immunocompetent children: CT and MR findings.
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BACKGROUND AND PURPOSE: Infections caused by nontuberculous mycobacteria (NTM) commonly manifest as cervicofacial adenitis in otherwise healthy children. The aim of this study was to characterize the imaging findings of NTM infection of the head and neck in immunocompetent children. METHODS: The medical records and imaging examinations (CT in 10, MR in two) were reviewed in 12 immunocompetent children with NTM infection of the head and neck. RESULTS: The usual presentation (n = 9) was of an enlarging, non-tender mass with violaceous skin discoloration, unresponsive to conventional antibiotics. The duration of symptoms was 6 days to 5 months. Imaging revealed asymmetric adenopathy with contiguous low-density ring-enhancing masses in all patients. There was cutaneous extension in 10 patients. Inflammatory stranding of the subcutaneous fat was minimal (n = 9) or absent (n = 2) in 11 patients. The masses involved the submandibular space (n = 3), the parotid space (n = 2), the cheek (n = 1), the anterior triangle of the neck (n = 2), the submandibular and parotid spaces (n = 2), the parotid space and neck (n = 1), and the neck and retropharyngeal space (n = 1). Surgical management included incision and drainage only (n = 2), incision and drainage with curettage (n = 2), excisional biopsy after incision and drainage (n = 1), excisional biopsy only (n = 5), superficial parotidectomy only (n = 1), and superficial parotidectomy with contralateral excisional biopsy (n = 1). All patients improved in response to surgery and long-term antimycobacterial antibiotics. CONCLUSION: NTM infection of the head and neck has a characteristic clinical presentation and imaging appearance. Recognition of this disease is important; appropriate treatment is excision and, in selected cases, antimycobacterial therapy. (+info)
Otorhinolaryngology.
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Otorhinolaryngology, a product of the early 20th century, developed from the joining together of the separate departments of otology, whose practitioners were surgeons, and laryngology which was managed by physicians who also treated diseases of the nose and chest. The 20th century opened with brave attempts to perform skilful surgery under conditions of primitive anaesthesia and no antibiotics. The stimulus of two world wars led to significant advances in technology and greater opportunities to explore new and resurrect old surgical procedures. The discovery of antibiotics saw an end to acute mastoiditis and the complications of otitis media and sinusitis, as well as a decline in the number of tonsillectomy and adenoidectomy operations. Over the last 30 years the specialty has undergone dramatic development and has taken advantage of new advances in endoscopy, microsurgery, the use of lasers, cytotoxic drugs, flap reconstruction and microchip technology. During the same period, although still calling themselves otorinolaryngologists, individual surgeons have subspecialised in otology, otoneurosurgery and skull-base surgery, head and neck surgery, phonosurgery, rhinology and facioplastic surgery, and paediatric otothinolaryngology. Each of these subspecialties has its own societies and specialist journals. (+info)
Headache as a manifestation of otolaryngologic disease.
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Headache can be caused by a multitude of factors, but experienced physicians accustomed to treating patients with headache are adept at making an accurate diagnosis. Occasionally, however, a patient has an unusual presentation of headache or facial pain. In these cases, it can be difficult to classify the etiology of the headache despite the performance of a thorough physical examination and the acquisition of appropriate diagnostic tests. Awareness of some of the otolaryngologic diseases that can manifest as facial pain or headache may help the physician better diagnose and treat this complex problem. (+info)
Otolaryngology consultations by real-time telemedicine.
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We aimed to assess the value of real-time telemedicine using low cost videoconferencing equipment for otorhinolaryngology consultations. A general practitioner, using low cost videoconferencing equipment, presented patients to an otorhinolaryngologist. After history taking and clinical examination, investigations were requested if required and a diagnosis and management plan formulated. The patients were then seen, by the same otorhinolaryngologist, for a conventional face-to-face consultation. Differences in the history, clinical examination and investigation requests were reported. The accuracy of diagnosis and correlation of management plans between the two consultations were analysed. Forty-three patients were admitted to the study but one, a young child, refused examination either by tele-link or the conventional approach and had to be excluded. There were thus 42 patients with 55 diagnoses included in the trial, 26 (62%) females and 16 (38%) males. Age range was 5 months to 70 years. There was no difficulty with any of the patients in obtaining an accurate history and ordering investigations, if required, via the telelink. Clinical examination during the tele-link consultation was inadequate for eight out of the first 20 patients, resulting in a wrong diagnosis in three patients and a missed diagnosis in five patients. All of the next 22 patients had a correct diagnosis and management plan. Comparison of data from the two types of consultation showed that a correct diagnosis and management plan was made in 34 patients. Low cost real-time telemedicine is a useful technique, providing reliable otorhinolaryngology consultations in a general practice setting. However initial difficulties due to inexperience in using the equipment need to be overcome. (+info)
NHS waiting lists and evidence of national or local failure: analysis of health service data.
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OBJECTIVES: To investigate the national distribution of prolonged waiting for elective day case and inpatient surgery, and to examine associations of prolonged waiting with markers of NHS capacity, activity in the independent sector, and need. SETTING: NHS hospital trusts in England. POPULATION: People waiting for elective treatment in the specialties of general surgery; ear, nose and throat surgery; ophthalmic surgery; and trauma and orthopaedic surgery. MAIN OUTCOME MEASURE: Numbers of people waiting six months or longer (prolonged waiting). Characteristics of trusts with large numbers waiting six months or longer were examined by using logistic regression. RESULTS: The distribution of numbers of people waiting for day case or elective surgery in all the specialties examined was highly positively skewed. Between 52% and 83% of patients waiting longer than six months in the specialties studied were found in one quarter of trusts, which in turn contributed 23-45% of the national throughput specific to the specialty. In general, there was little evidence to show that capacity (measured by numbers of operating theatres, dedicated day case theatres, available beds, and bed occupancy rate) or independent sector activity were associated with prolonged waiting, although exceptions were noted for individual specialties. There was consistent evidence showing an increase in prolonged waiting, with increased numbers of anaesthetists across all specialties and with increased bed occupancy rates for ear, nose and throat surgery. Markers of greater need for health care, such as deprivation score and rate of limiting long term illness, were inversely associated with prolonged waiting. CONCLUSION: In most instances, substantial numbers of patients waiting unacceptably long periods for elective surgery were limited to a small number of hospitals. Little and inconsistent support was found for associations of prolonged waiting with markers of capacity, independent sector activity, or need in the surgical specialties examined. (+info)
Expression of somatostatin receptors in inflammatory lesions and diagnostic value of somatostatin receptor scintigraphy in patients with ANCA-associated small vessel vasculitis.
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OBJECTIVE: To assess the usefulness of somatostatin receptor (SSTR) scintigraphy for the evaluation of disease activity in the upper and lower respiratory tract in ANCA-associated vasculitis (AASV). METHODS: Thirty-two consecutive patients with AASV were subjected to SSTR scintigraphy as part of their initial diagnostic evaluation and follow-up. The presence of SSTRs in inflammatory lesions was evaluated with immunohistochemistry in selected cases. RESULTS: In AASV, specificity of SSTR scintigraphy for active vs non-active disease was 96% for pulmonary disease and 100% for ear, nose and throat (ENT) involvement, while sensitivity was 86% and 68%, respectively. Absence of previously present tracer accumulation characterized treatment responders, and treatment resistance was reflected by repeated positive scintigraphy. We could demonstrate the expression of SSTRs in lung and mucosal biopsies obtained from patients with active Wegener's granulomatosis and with microscopic polyangiitis. CONCLUSION: SSTR scintigraphy is useful for the assessment of AASV, indicating disease activity, disease extent and treatment efficacy. SSTRs are expressed in both granulomatous as well as non-granulomatous AASV. (+info)