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Janet Wilson qualified from Edinburgh University Medical School in 1979. In 1995 she was appointed Prof of Otolaryngology Head and Neck Surgery at Newcastle University and Hon Consultant Otolaryngologist at the Freeman Hospital, Newcastle upon Tyne. Author of over 200 scientific papers, Janet’s research interests include voice disorders, swallowing, snoring, medically unexplained symptoms and the development of patient reported outcomes. Janet is Chief Investigator on two UK multicentre randomised controlled trials – see www.TOPPITS.co.uk and www.NATTINA.com. Janet is past president of the British Laryngological Association, the Otolaryngological Research Society, the North of England Surgical Society, the Laryngology and Rhinology Section of the Royal Society of Medicine and the Edinburgh Harveian Society. The Challenges of Surgical Evidence Gathering Otolaryngologists are increasing called to produce evidence of their effectiveness and cost effectiveness. In head and neck cancer, patients who might have benefitted from surgical treatments were disadvantaged for decades in part through lack of skill in research design and interpretation by head and neck surgical oncologists. Novel laser and robotic technologies struggled to become established as surgeons faced the challenges of new skills acquisition versus evidence gathering. More rigorous ethical demands nowadays preclude surgical research methods that were perfectly acceptable 30 years ago. However several recent head and neck cancer trials such as PATHOS and PET-Neck illustrate a new wave of research savvy and appropriately funded studies by head and neck surgeons. Others such as the TUBE trial have floundered yet also give valuable lessons for future trials.
Equally important is the accrual of evidence on cost-effectiveness of ‘high volume low risk’ ORL interventions. We have used lessons learnt from the NESSTAC RCT of childhood adenotonsillectomy, to mount a UK wide RCT of tonsillectomy in adults with recurrent sore throat (www.NATTINA.com). Feasibility ground work, qualitative preliminary data gathering, and patient and public involvement all underpinned a UK septoplasty RCT (NAIROS), presently in set-up. Without robust evidence, such operations are vulnerable to be dismissed by funders as ‘procedures of limited clinical value’.
Mucus - Friend or Foe?
Ventilator-acquired pneumonia is the most commonly fatal infection in critical care units. Our data suggest that there is transient impairment of innate immunity in intubated patients, who have an influx of subglottic neutrophils. The phagocytic function of these neutrophils seems adversely affected by the high mucin concentrations present (notably the gel forming MUC5AC and MUC5B) together with their related inflammatory mediators).
Throat clearing consistently emerges as the commonest symptom in the voice clinic. Our qualitative study of attenders at a dedicated ‘catarrh clinic’ showed that many patients are repelled by their airway mucus, and feel stigmatised by their coughing bouts. Some show evidence of autonomic dysfunction, sometimes iatrogenic.
Yet mucus is also host to a wealth of defensive mechanisms, both physical and immunological. We have investigated sinonasal and upper airway mucus in health and disease - our current projects include attempts to define a ‘biosignature’ for chronic rhinosinusitis Airway Surface Liquid which will more accurately discriminate patients with active inflammation from whose symptoms appear disproportionate to their physical signs or CT findings.
Finally – every otolaryngologist needs a ‘universal toolkit’ for those patients with little evidence of disease yet whose lives seem blighted by their upper airway secretions.
Throat Symptoms – What’s the Risk? The referral of UK patients with throat symptoms has been totally transformed by the current fast- track two week maximum wait pathway for suspected head and neck cancer. Consequences include increased patient anxiety and distorted clinical priorities. A major review of the impact of this system has now stratified the relative risk of specific symptoms and proposes a refinement of head and neck fast track referral guidance
For some benign conditions, the risk of over-investigation persists, despite clear cut evidence to the contrary. Over-investigation of symptoms like globus merely reinforces the patient’s belief that something is seriously amiss, but undiscovered. The ‘laryngopharyngeal reflux’ diagnosis is increasingly made in primary care. Empirical proton pump inhibitor therapy is popular, but has little evidence and increasingly recognised risks. We are in the final stages of recruitment to a national trial of PPI in throat symptoms (www.TOPPITS.co.uk).
Oesophagogastric cancer remains a late diagnosis –early warning red flags remain elusive. We have used the Comprehensive Reflux Symptom Scale (CReSS) at presentation in 114 oesophago-gastric cancer patients to date. Preliminary data show comparable CReSS upper airway and pharyngeal subscale scores to benign gastroenterology diagnoses, but with lower mean oesophageal scores. Four eating related items were more cancer specific. A recent primary care algorithm may also prove a useful screening adjunct for otolaryngologists.
Transnasal Oesophagoscopy – For and Against The unit in Newcastle upon Tyne has one of the highest levels of TNO (TNE) in the UK, using a non-channelled, sheathed scope, which has a clear business case within the NHS internal market in England. We have audited over 500 cases with a very simple, prospective recording system. The investigation has a positive impact on the patient pathway, and has helped reduce the rate of more hazardous, now obsolete, examinations such as barium swallow and ‘pharyngo-oesophagoscopy’. TNO can offer early relief in bolus obstruction and is useful for secondary tracheo-oesophageal puncture post laryngectomy.
Other centres have a preference for the unsheathed, channelled scope. This offers the potential for biopsy but has a much slower turnaround time, requiring an endoscope washer-disinfector and storage cabinet. Without multiple endocopes, only small numbers of patients can be accommodated in any one clinic
Lower oesophageal pathology in the UK is now 20 times commoner than postcricoid pathology. TNO passage is akin to flexible laryngoscopy in level of difficulty. Can we afford NOT to use it? The procedure is well tolerated, although in elderly patients it may be advisable to monitor oxygen saturation.
However, TNO capabilities are not same as oesophagogastroduodenoscopy – a technique that ORL residents should endeavour to familiarise themselves with.
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