Discitis is uncommon in children and presents in different ways at different ages. It is most difficult to diagnose in the uncommunicative toddler of one to three years of age. We present 11 consecutive cases. The non-specific clinical features included refusal to walk (63%), back pain (27%), inability to flex the lower back (50%) and a loss of lumbar lordosis (40%). Laboratory tests were unhelpful and cultures of blood and disc tissue were negative. MRI reduces the diagnostic delay and may help to avoid the requirement for a biopsy. In 75% of cases it demonstrated a paravertebral inflammatory mass, which helped to determine the duration of the oral therapy given after initial intravenous antibiotics. At a mean follow-up of 21 months (10 to 40), all the spines were mobile and the patients free from pain. Radiological fusion occurred in 20% and was predictable after two years. At follow-up, MRI showed variable appearances: changes in the vertebral body usually resolved at 24 months and recovery of the disc was seen after 34 months.

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Early diagnosis of vestibular schwannoma (VS) has increased in recent years because of increased longevity and availability of magnetic resonance imaging (MRI). Initial conservative radiological surveillance is often requested by patients and physicians to establish whether these tumors are growing before embarking on intervention. Initial observation of at least 1 year in all small VS was therefore recommended by some authors. We evaluated our prospective skull base database of VSs that were managed with initial radiological surveillance to establish when this policy should be abandoned and what predicts future growth. Fifty-four consecutive patients with VS in our institution who were managed by initial yearly MRI scanning were studied. The MRI data were collected prospectively and analyzed by Kodak CareStream viewing software where VS maximum diameters in three perpendicular planes and volume were calculated. One patient was excluded from the analysis as he had only one MRI follow-up. The median age of the 53 patients was 59 years (range, 26 to 86 years), 25 were males and 28 were females, and 33 were under 65 years of age; 18 VSs were extracanalicular, 18 were intracanalicular, and 17 extended both inside and outside the canal; 21 VSs were 1.2 cm 3 or less, 22 were 1.2 to 4 cm 3 , and the rest were >4 cm 3 . Using volumetric analysis, 29.72% of conservatively managed VS grew by at least 2 mm per year, and 70.82% did not grow in 5 years. Age, gender, symptoms, and side did not predict future growth. However, growth in the first year was a strong predictor of future growth (p < 0.001) and initial volume was also a strong predictor of future growth (p < 0.05). Twenty-nine percent of observed VSs grew by at least 2 mm per year in the first 5 years of surveillance. As the growth rate is slow, initial radiological surveillance is justified in elderly patients and patients with small VSs and nonserviceable hearing. Growth in the first year was a strong predictor of future growth. The reported treatment effect should be interpreted in the light of 70.24% of VSs that either shrink or do not change in the first 5 years.

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Practitioners in the UK can be excused for being confused when it comes to the appropriate use of topical antibiotics for discharging ears. The two groups of antibiotics used topically in the ear are aminoglycosides and quinolones. Confusion over their use arises from two points of contention. Firstly, is the fact that because of potential ototoxicity the data sheets for topical aminoglycosides advise against their use in the presence of a non-intact tympanic membrane. Secondly, quinolones are not licensed for aural topical use in the UK. These issues are discussed in detail in a review article by Harris and colleagues.

Although previous retrospective studies have identified a link between smoking and peritonsillar abscess formation, this has not been tested in a prospective study. In this month's issue of The Journal of Laryngology & Otology, Schwarz et al. investigate whether smoking increases the risk of peritonsillar abscess formation. 1 The authors of this study identified a statistically significant association between peritonsillar abscess formation and smoking (p = 0.025), in agreement with previous retrospective studies. 2 Of the 325 cases of peritonsillar abscess in the National Prospective Quinsy Audit, 17 per cent of patients had a smoking history, although a smoking history was not independently predictive of a 30-day adverse event. 3 The authors of this latest study postulate that smoking leads to injury of the oropharyngeal mucosa, thereby increasing the likelihood of developing abscess formation. Smoking may also increase the risk of abscess formation by altering the tonsillar bacterial flora and/or the local and systemic immunological milieu. Waiting lists for elective surgery are a topical issue in many publicly funded healthcare systems. In order to reduce waiting times for surgery, McLaren et al. introduced a pathway for audiologists to directly schedule children for grommet insertion meeting National Institute for Health and Care Excellence Clinical Guideline 60 ('CG60'). 4 Prior to implementation of the new pathway, mean duration between the first audiology appointment and grommet insertion was 294.5 days. Implementation of the new pathway led to a significant reduction in the time interval between the first audiology appointment and surgery (mean duration of 232 days, a reduction of 62.5 days; p = 0.024). The authors stress that the ultimate decision regarding surgery still rests with ENT specialists. In addition, the new pathway places greater responsibility on the audiology team regarding surgerybased treatments. Indeed, this may account for the low number of patients adopting the new pathway. Alternatively, the low numbers being referred directly for grommets by the audiology team may reflect a tighter adherence to National Institute for Health and Care Excellence guidelines by audiologists following a strict protocol. Other ENT departments may choose to adopt such a pathway in order to improve service provision, following consultation with their local audiology departments. Finally, Noor et al. review the indications for panendoscopy in the investigation of patients with newly diagnosed head and neck squamous cell carcinoma. 5 Obtaining a tissue diagnosis was still the most common indication for panendoscopy. 6 However, the authors conclude that panendoscopy remains paramount in the assessment of suitability for transoral robotic surgery and in the investigation of an unknown primary. 7 Interestingly, the authors identified only a 1.1 per cent risk of synchronous second primary tumour, of which all were P16 negative, suggesting that the increase in human papillomavirus related disease is responsible fo...

Optimising care in an age of austerity: patientreported outcome measures in paediatric ENT, journal bias, tonsillectomy and endoscopic ear surgeryWhen resources are in short supply, it is particularly important to focus care on areas of greatest need, monitor outcomes in a reliable fashion and, where possible, apply the principles of evidence-based medicine. Data on interventions (particularly those which are for publication) should be unbiased. Unfortunately, monitoring outcomes is expensive in terms of resources and staff time, as is auditing, and much of our practice is therefore experience-based rather than evidence-based. When did you last see a routine post-tonsillectomy case as a follow-up patient in your publicly funded clinic? How do our trainees learn what is 'normal' after surgery if they never see their patients unless complications occur?This issue of The Journal of Laryngology & Otology has a review from Newcastle and Carlisle, which surveys patient-reported outcome measures. 1 It highlights the variety of measures available, the lack of universal adoption, the problems with validity and reliability, and the need for both general and disease-specific questionnaires, as well as the need for paediatric style rather than adult questionnaires. Many readers will be familiar with the 'T-14' Paediatric Throat Disorders Outcome Test questionnaire, used in paediatric tonsillectomy cases; 2 fewer will be aware of one for adult mastoid cavity care. 3 There is a long way to go before patientreported outcome measures can be relied upon in the way that we hope for.When evidence on treatment outcomes gets as far as an otolaryngology journal, how reliable is that? If the paper by Kaper et al. 4 is taken at face value, then the answer is disappointing. ENT journals cannot compete with general medical journals for impact factor, but can strive harder to ensure that reporting of treatment outcomes reaches acceptable standards.A paper from Geelong, Australia, in this issue of The Journal, studied 2863 patients over 16 years after tonsillectomy, all of whom stayed in hospital at least 1 night, and evaluated risk factors for the requirement of in-patient stay. 5 The results agreed closely with current UK guidelines, and confirm that, for the great majority of cases, day surgery is acceptable. The mention of tranexamic acid use routinely after tonsillectomy echoes recent publications. 6 On a brighter note, the

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