their hair regularly with no ear protection and reported

no problems with their cavity.

Fifteen children (33%) did not swim and the three

main reasons stated were (i) episodes of recurrent

otorrhoea with water exposure, (ii) worry about the risk

of ear infections should they swim even though they had

not tried swimming and (iii) a dislike of swimming.

None of the children who had ever tried swimming

reported vertigo. Operation groups for each of these

reasons are summarised in Table 1.

We conclude that having a mastoid cavity does not

necessarily preclude patients from swimming. There is

evidence to suggest that patients with a small cavity mas-

toidectomy are able to enjoy swimming with a stable and

trouble free cavity.5 It is our practice to monitor these

cavities for up to 18 months and once they are proven to

be stable and self cleansing we allow our patients to

commence swimming without restriction.

Conflict of interest

None to declare.

Visvanathan, V., Kubba, H. & Morrissey, M.S.C.Department of Paediatric Otolaryngology, The Royal Hospital for

Sick Children, Yorkhill, Glasgow, Scotland, UK.

E-mail: Vikranth@hotmail.co.uk

References

1 El-Silimy O., Smelt G.J.C. & Bradley P.J. (1986) Swimming with

a mastoid cavity. What are the risks? Clin. Otolaryngol. 11, 209–

212

2 Glasscock M.E. (1982) Surgical technique for open mastoid pro-

cedures. Laryngoscope 92, 1440–1442

3 Jackson C.G., Glasscock M.E., Nissena J. et al. (1985) Open mas-

toid procedures; contemporary indications and surgical tech-

niques. Laryngoscope 95, 1037–1043

4 Bingham B.J.G., Chevreton E. & Firman E. (1988) Water contam-

ination and swimming with the open mastoid cavity. Clin. Oto-

laryngol. 13, 347–350

5 Yung M.W. (1996) Small cavity mastoidectomy – 5 year review.

Clin. Otolaryngol. 21, 24–29

Audit of diathermy usage, readiness and complications inENT theatres

9 March 2011

Sir,

Anecdotally there are often issues with correct function-

ing of the diathermy. Surgeons of all specialties experi-

ence problems ranging from lack of availability of

diathermy at the start of a case or problems during the

procedure, resulting in anaesthetic time being prolonged

and delaying throughput of patients. In light of the

National Patient Safety Agency’s WHO surgical safety

checklist1 and the introduction of The Productive Operat-

ing Theatre in September 2009 by the NHS Institute for

Innovation and Improvement(http://www.institute.nhs.

uk/quality_and_value/productivity_series/the_productive_

operating_theatre.html 21 sept 2009), we are increasingly

aware of the importance of safety and efficiency in

theatres. We present a completed audit cycle of

readiness and problems with diathermy during ENT

theatre lists.

Materials and methods

Prospective data was collected over a 1-month period for

all cases involving diathermy use in ENT theatres at Sout-

hend University Hospital. The ENT surgeons collected

data blinded from all other theatre staff. The data was

presented, changes implemented and after a 3-month

window ENT theatres were re-audited.

Table 1. Reasons stated by children with mastoid cavities for not undertaking swimming

Variables Atticotomy Atticoantrostomy

Modified radical

mastoidectomy

Recurrent otorrhoea with exposure to water – 2 2

Wary about otorrhoea 5 – 4

Not keen on swimming – – 2

CO

RR

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ER

S

288 Correspondence

� 2011 Blackwell Publishing Ltd • Clinical Otolaryngology 36, 280–298

Results

Cycle 1: There were 83 episodes involving diathermy,

60 bipolar and 23 monopolar. In 26 ⁄ 83 procedures –

31.33% there was a problem with the diathermy.

Actions and Changes implemented.

• Education on setting up monopolar suction diathermy.

• Education for the surgeons on over heating of bipolar

diathermy during repeated persistent use.

• After 100 uses bipolar forceps are meant to be

replaced, it was agreed that any damaged ⁄ faulty forceps

would be replaced when next identified during use.

• Decision to include diathermy in the pre-operative

check. The operating surgeon, scrub nurse and the runner

go over which type of diathermy will be needed for the

procedure, safe positioning of the monopolar plate and

required diathermy settings.

Cycle 2: There were 85 episodes involving diathermy, 74

bipolar and 11 monopolar. In 10 ⁄ 85 procedures – 11.8%

there was a problem with the diathermy. Figure 1 is a com-

parison of the results for cycle 1 and the re-audit cycle 2.

Discussion

In the initial audit there was a problem with the

diathermy in 31.33% of cases. After implementation of

changes and increased awareness of the problem, at

re-audit this had been reduced to 11.8%. This is a

significant improvement (Z = 2.903).

The diathermy was not ready at the start of cases for a

number of reasons. These included its use not being

anticipated, the diathermy not being plugged in or turned

on and the pedal not being in reach of the surgeon. At

initial audit this occurred in >25% of cases but on

re-audit this had been reduced to 6%. This is a marked

improvement, which has helped to reduce surgical delay

and frustration.

The number of problems with diathermy during a

procedure was 5 ⁄ 83 in cycle 1 and 5 ⁄ 85 for cycle 2 – no

improvement. There were fewer problems with the

diathermy forceps not meeting (three compared to five

episodes) and these faulty forceps should now have been

replaced hopefully resulting in a reduction in problems

with the forceps in future.

Conclusion

Delays with diathermy occur astonishingly frequently and

can result in prolonged anaesthetic time and frustration

for the surgeons. We suggest that by routinely including

diathermy in the pre-operative check then delays are

reduced and operating theatre efficiency improves.

Conflict of interest

None to declare.Powell, H.R.F., Watters, G.W.R. & Philpott, J.M.

Southend University Hospital, Prittlewell Chase, Westcliff-on-Sea,

Essex SS0 0RY, UK.

E-mail: harry.powell@nhs.net

Reference

1 WHO Surgical safety checklist – NRLS-0861-WHO-surgical-sa�SA-2009-01-26-v1.pdf. http://www.nrls.npsa.nhs.uk/resources/?

entryid45=59860.

Neostigmine and FESS

30 March 2011

Sir,

We want to remind the ENT and rhinology audience

about the possible side effects of certain anaesthetic drugs

and the confusion that can be created, especially

when used in Functional Endoscopic sinus surgery

(FESS).

68.7

88

25.3

66 6

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1st cycle 2nd cycle

Problems during

Not ready

No problems

Fig. 1. Results for cycles 1 and 2, before and after implementa-

tion of changes.

CO

RR

ES

PO

ND

EN

CE

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ET

TE

RS

Correspondence 289

� 2011 Blackwell Publishing Ltd • Clinical Otolaryngology 36, 280–298