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Clin. Otolaryngol. 2011, 36, 57–64

The gold standard in airway maintenance is translaryngeal endotracheal intubation, but this is not without its complications. Trauma to the upper airway as a result of the act of endotracheal intubation is a common event in adults undergoing procedures under general anaesthesia. Sites requiring attention during intubation include the laryngeal apparatus, the pharynx and oral cavity as well as the nasal cavity when nasopharyngeal intubation is performed. Patients can present with a range of symptoms which can make assessment and management challenging. Dysphonia, throat pain and dysphagia are the commonest presenting complaints. Patient-related factors, intubation technique and other anaesthetic-related conditions can be a cause of trauma, if not adequately considered before intubation. All patients should be carefully examined preoperatively and their past medical history obtained. Patient demographics, comorbidities, existing airway pathology and presence of reflux should be noted. Trauma prevention strategies should be in place to eliminate avoidable complications. Potential difficult airway cases should be flagged up and adequately prepared for, in anticipation of intubation difficulties that can lead to trauma. The majority of injuries will resolve spontaneously with conservative management. Persistent symptomatology, usually secondary to laryngeal injuries, requires prompt referral to an ear nose and throat specialist with an interest in laryngology for further assessment and treatment.

KEYPOINTS: Endoscopic ligation of the sphenopalatine artery (ESPAL) has recently become the treatment of choice for refractory epistaxis. This paper reviews the background, indications and potential complications of ESPAL. The main focus of this article is an online video tutorial on the anatomy and surgical technique of ESPAL. Web links lead to video clips of operative steps and therefore this paper should be read in front of a computer with access to the Internet. To study the techniques the links detailed below should be followed. (For computers running RealPlayer software the .wmv extension in each of these links should be replaced with the .rm extension.) * Incision, http://nhsgg.org.uk/content/streams/Figure3.wmv * Flap elevation, http://nhsgg.org.uk/content/streams/Figure4.wmv * Pedicle location, http://www.nhsgg.org.uk/content/streams/Figure5.wmv * Clip application, http://www.nhsgg.org.uk/content/streams/Figure6.wmv.

Asthmatic smokers have poor symptom control and accelerated decline in lung function. A reduced ratio of matrix metalloproteinase (MMP)-9/tissue inhibitors of metalloproteinases (TIMPs) in nonsmokers with asthma has been implicated in airway remodelling. We tested the hypothesis that sputum MMP-9 activity/TIMPs ratios are reduced in smokers compared with never-smokers with asthma and are associated with reduced lung function and altered computed tomography (CT) measures of airway wall dimensions.Lung function, airway dimensions by CT, and induced sputum concentrations (and activity) of MMP-9 and TIMP-1 and -2 were measured in 81 asthmatics and 43 healthy subjects (smokers and never-smokers). Respiratory epithelial MMP9 and TIMP mRNA was quantified in 31 severe asthmatics and 32 healthy controls.Sputum MMP-9 activity/TIMP-1 and TIMP-2 ratios, and nasal epithelial MMP9/TIMP1 and MMP9/ TIMP2 expression ratios were reduced in smokers with asthma compared with never-smokers with asthma. Low sputum ratios in asthmatic smokers were associated with reduced post-bronchodilator forced expiratory volume in 1 s (FEV1), FEV1/forced vital capacity ratio and segmental airway lumen area.The association of a low sputum MMP-9 activity/TIMP-1 ratio with persistent airflow obstruction and reduced CT airway lumen area in smokers with asthma may indicate that an imbalance of MMP-9 and TIMPs contributes to structural changes to the airways in this group. @ERSpublicationsIn asthmatic smokers, a low sputum MMP-9 activity/TIMP-1 is associated with spirometric and CT airway narrowing

Several arachidonic acid metabolites and enzyme transcripts involving both lipoxygenase and cyclooxygenase pathways are increased in smokers with asthma and differ from never smokers with asthma. Possibly targeting specific lipoxygenase and cyclooxygenase pathways that are activated by asthma and cigarette smoking may optimize therapeutic responses.

Intensive surgical skills courses have become an essential part of surgical skill acquisition for surgeons in training. There is a need to monitor the value of these courses in terms of skill attainment. The aim of this study was to determine the effectiveness of skills-laboratory-based training in rigid bronchoscopy and bronchial foreign body removal. Bronchoscopies were recorded, analysed and categorized by a single observer according to time to completion and four predetermined parameters of surgical error. An overall quality score was obtained by simple summation of the number of errors and determined as acceptable or unacceptable (scoring 0 or 1 respectively). The data was analysed using a t-test for paired groups. P < 0.05 was considered to be significant. In total, 20 trainee otolaryngologists performed 80 separate bronchoscopies. The time to complete the task pre versus post training showed significant improvement; P < 0.001. The overall quality score pre training was 66 and post training 17; P < 0.001. We conclude that intensive surgical simulation-based courses appear to be an effective means of training surgical trainees in surgical skill proficiency.

Post-tonsillectomy haemorrhage is the principal complication that can occur following tonsillectomy. The consequences for the patient can include hospital admission, blood transfusion, return to theatre for arrest of haemorrhage and rarely mortality. 1 It is therefore of vital importance to accurately determine the rate of post-tonsillectomy haemorrhage and to identify factors that would decrease its incidence. The National Prospective Tonsillectomy Audit (NPTA), published in 2005, was conducted with the aim of addressing these issues. 2 It