Regular monitoring and audit of a service are integral to ensuring maintenance of efficiency and standards. This is particularly important where the quality of the service is operator dependent, as is the case in the clinical diagnosis of neck lumps and fine needle aspiration cytology. The one-stop neck lump clinic has now been running in the department for more than 20 months. A previous article described the results of the first phase audit carried out at 6 months and had identified a waiting time to be seen that was longer than that recommended by the British Association of Otorhinolaryngologists, Head and Neck Surgeons. Measures were implemented to reduce this waiting time and a second audit was carried out after another 10 months with the aims of assessing if modification of the means of referral reduces waiting time and if the outcomes of clinical performance in phase 1 could be maintained or improved. We discuss the results of phase 2 in the audit spiral.

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Osteogenesis imperfecta (OI) is a heterogeneous group of connective tissue disorders. The classic triad of blue sclerae, spontaneous fractures and hearing loss is known as the Van der Hoeve and De Kleyn syndrome. Between 1989 and 2000, six patients with OI presented with conductive hearing loss. Five of them proceeded to stapedotomy. All the patients who had surgery had significant hearing gain. None of the patients had any complications. This study presents a higher incidence of spontaneous fractured crura as the cause of the conductive hearing loss than previously reported, and that the presence of a fractured crura with mobile footplate can be anticipated by the presence of a large conductive hearing loss. The pre- and postoperative results are presented and support the view that stapes surgery in OI can have encouraging results, provided the operator anticipates the possibility of a fractured crura and a mobile footplate.

There is a growing trend towards day case surgery and departments are constantly under pressure from Health Trusts to perform more day case procedures. Adenoidectomy and tonsillectomy are being performed as day case procedures in many centres and literature has suggested that it is safe to do so, provided the population characteristics are favourable. A prospective study of 100 consecutive patients presenting to our department for tonsillectomy or adenotonsillectomy was undertaken to assess the eligibility of our patient group for day surgery. Medical and social history was obtained as per recommended guidelines. Only 27% of our patients were eligible for day surgery and only 17% of parents preferred the option of day case adenotonsillectomy. There is a marked difference between our group and those previously reported in the literature. This regional variation has implications in the safe expansion of day surgical procedures.

The objective of the present study is to propose guidelines to ensure safe practice in teaching centres while allowing endoscopic sinonasal surgery (ESS) training to proceed. A prospective complications audit of ESS procedures was undertaken over a 5-year period (January 1996-December 2000). The results have been used to form specific guidelines for safe and effective ESS training. A total of 500 patients underwent ESS during the 5-year period. The senior author was the main surgeon in 55% of cases with the trainee observing or assisting. A supervised trainee was the main surgeon in 45% of cases. The overall complication rate was 1.2% (n = 6) (i.e. 0.7% for the 815 procedures performed). These were all minor complications. We encountered no major complications in 500 patients over the 5-year period. This audit shows that training need not compromise patient safety provided it is phased and structured. We propose appropriate phases and suggest the minimum requirements for units involved in ESS training.