344. Paediatric Ear, Nose & Throat Surgery

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344. Paediatric Ear, Nose & Throat Surgery

 

 

CATEGORY: Medical & Medicine – 500 Courses

COURSE NUMBER: 344

FEES: 555/- INR only

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BOOKS/ MANUALS: Pages

Syllabus

TABLE OF CONTENTS ……………………………………………………………………………………………….V
LIST OF TABLES………………………………………………………………………………………………………..X
LIST OF FIGURES……………………………………………………………………………………………………XIV
LIST OF MAPS ……………………………………………………………………………………………………….XVI
LIST OF ABBREVIATIONS ……………………………………………………………………………………….XVII
ABSTRACT…………………………………………………………………………………………………………..XVIII
THESIS DECLARATION …………………………………………………………………………………………….XX
GRANTS AND AWARDS ………………………………………………………………………………………….XXI
PRESENTATIONS…………………………………………………………………………………………………..XXII
ACKNOWLEDGEMENTS………………………………………………………………………………………..XXIV
SECTION I: BACKGROUND AND LITERATURE REVIEW……………………………………………… 1
CHAPTER 1: AN OVERVIEW………………………………………………………………………………………. 3
1.1 Introduction…………………………………………………………………………………………….. 3
1.2 Purpose of the Thesis……………………………………………………………………………….. 5
1.2.1 Key Aims………………………………………………………………………………………. 5
1.2.2 Key Objectives………………………………………………………………………………. 6
1.2.3 Research Questions……………………………………………………………………….. 7
1.3 Thesis Structure……………………………………………………………………………………….. 7
1.4 Ethical Approvals……………………………………………………………………………………. 10
CHAPTER 2: A BACKGROUND TO THE SURGICAL PROCEDURES…………………………………… 13
2.1 Anatomy Overview…………………………………………………………………………………. 13
2.1.1 Adenoid and Tonsils …………………………………………………………………….. 13
2.1.2 Middle Ear and Eustachian Tube……………………………………………………. 14
2.2 Surgical Overview: Indications and Guidelines…………………………………………… 16
2.2.1 Tonsillectomy ……………………………………………………………………………… 16
2.2.2 Adenoidectomy …………………………………………………………………………… 19
2.2.3 Myringotomy with/without Tympanostomy Tube Insertion……………… 20
2.3 Indications For Surgery: Incidence, Prevalence and Burden of Disease…………. 24
2.3.1 Acute Otitis Media and Otitis Media with Effusion…………………………… 24
2.3.2 Tonsillitis…………………………………………………………………………………….. 26
2.3.3 Sleep Disordered Breathing…………………………………………………………… 26
2.3.4 Conclusion ………………………………………………………………………………….. 27
2.4 Indications For Surgery: Risk Factors ………………………………………………………… 28

2.4.1 Acute Otitis Media………………………………………………………………………..28
2.4.2 Otitis Media with Effusion ……………………………………………………………..33
2.4.3 Tonsillitis……………………………………………………………………………………..36
2.4.4 Sleep Disordered Breathing……………………………………………………………37
2.4.5 Conclusion……………………………………………………………………………………38
2.5 Surgical Overview: Outcomes Following Surgery…………………………………………38
2.5.1 Tonsillitis……………………………………………………………………………………..38
2.5.2 Sleep Disordered Breathing……………………………………………………………39
2.5.3 Otitis Media …………………………………………………………………………………40
CHAPTER 3: A LITERATURE REVIEW OF THE SURGICAL PROCEDURES …………………………..43
3.1 Introduction……………………………………………………………………………………………43
3.2 Epidemiology: Tonsillectomy with/without Adenoidectomy ………………………..46
3.2.1 Europe and the United Kingdom…………………………………………………….49
3.2.2 The North American Continent ………………………………………………………50
3.2.3 Australia, including South Australia…………………………………………………50
3.3 Epidemiology: Myringotomy with/without Tympanostomy Tube Insertion……58
3.3.1 Europe and the United Kingdom…………………………………………………….59
3.3.2 The North American Continent ………………………………………………………59
3.3.3 Australia, South Australia ………………………………………………………………60
3.4 The Deficiencies of the Current Epidemiological Literature ………………………….67
3.5 Parental Expectations and Experiences: A Systematic Review………………………73
3.5.1 Introduction…………………………………………………………………………………73
3.5.2 Research Protocol…………………………………………………………………………74
3.5.3 Quality Appraisal…………………………………………………………………………..76
3.5.4 Data Analysis and Interpretation…………………………………………………….77
3.5.5 Discussion ……………………………………………………………………………………86
SECTION II: THE EPIDEMIOLOGY OF EAR, NOSE, AND THROAT SURGERY IN
CHILDREN …………………………………………………………………………………………………………….93
CHAPTER 4: THE SOUTH AUSTRALIAN EPIDEMIOLOGY ……………………………………………….95
4.1 Introduction……………………………………………………………………………………………95
4.1.1 Aim and Objectives……………………………………………………………………….96
4.2 Methods ………………………………………………………………………………………………..97
4.2.1 Study Design ………………………………………………………………………………..97
4.2.2 Research Setting …………………………………………………………………………..97
4.2.3 Study Sample ……………………………………………………………………………….98
4.2.4 Dataset………………………………………………………………………………………104
4.2.5 Data Analysis………………………………………………………………………………104
4.3 Results …………………………………………………………………………………………………106
4.3.1 Study Sample ……………………………………………………………………………..106

4.3.2 Surgical Procedure Combinations…………………………………………………111
4.3.3 Surgical Procedure Funding and Hospital Locality …………………………..111
4.3.4 Annual Incidence ………………………………………………………………………..114
4.3.5 Age and Sex-Specific Incidence …………………………………………………….118
4.3.6 Cumulative Incidence ………………………………………………………………….123
4.3.7 Indications for Surgery ………………………………………………………………..125
4.4 Discussion…………………………………………………………………………………………….129
4.4.1 Tonsillectomy, Adenoidectomy, and Adenotonsillectomy ……………….129
4.4.2 Myringotomy with/without tympanostomy tube insertion ……………..135
4.4.3 Conclusions………………………………………………………………………………..139
CHAPTER 5: THE AUSTRALIAN EPIDEMIOLOGY ………………………………………………………..141
5.1 Introduction………………………………………………………………………………………….141
5.1.1 Aims and Objectives……………………………………………………………………142
5.2 Methods………………………………………………………………………………………………143
5.2.1 Study Design ………………………………………………………………………………143
5.2.2 Research Setting…………………………………………………………………………145
5.2.3 Study Sample……………………………………………………………………………..146
5.2.4 Dataset………………………………………………………………………………………148
5.2.5 Data Analysis ……………………………………………………………………………..150
5.3 Results…………………………………………………………………………………………………153
5.3.1 Study Population ………………………………………………………………………..155
5.3.2 Incidence by State ………………………………………………………………………157
5.3.3 Incidence by State and Calendar Year……………………………………………159
5.3.4 Incidence by State and Sex…………………………………………………………..161
5.3.5 Incidence by State, Sex and Age……………………………………………………165
5.3.6 Incidence by Hospital Sector………………………………………………………..170
5.3.7 Funding Source…………………………………………………………………………..170
5.3.8 Cumulative Incidences…………………………………………………………………174
5.3.9 Socioeconomic Profile of Population …………………………………………….177
5.3.10 ENT Consultant Workforce…………………………………………………………..183
5.4 Discussion…………………………………………………………………………………………….187
CHAPTER 6: A SPATIAL ANALYSIS OF SOUTH AUSTRALIA…………………………………………..199
6.1 Introduction………………………………………………………………………………………….199
6.1.1 Aims and Objectives……………………………………………………………………199
6.2 Methods………………………………………………………………………………………………200
6.2.1 Study Design ………………………………………………………………………………200
6.2.2 Research Setting…………………………………………………………………………201
6.2.3 Data Extraction…………………………………………………………………………..205
6.2.4 Database Structure……………………………………………………………………..206

6.2.5 Data Manipulation and Analysis……………………………………………………206
6.2.6 Data Visualisation ……………………………………………………………………….208
6.3 Results …………………………………………………………………………………………………210
6.3.1 Study Population…………………………………………………………………………210
6.3.2 Metropolitan Adelaide ………………………………………………………………..212
6.3.3 Rural and Remote South Australia ………………………………………………..222
6.4 Discussion …………………………………………………………………………………………….224
SECTION III: PARENTAL EXPERIENCES AND EXPECTATIONS ………………………………….239
REFLEXIVITY STATEMENT………………………………………………………………………………………240
CHAPTER 7: PILOT STUDY………………………………………………………………………………………243
7.1 Introduction………………………………………………………………………………………….243
7.1.1 Aims and Objectives ……………………………………………………………………243
7.2 Methods ………………………………………………………………………………………………243
7.3 Results …………………………………………………………………………………………………248
7.3.1 Review of the Question Set………………………………………………………….248
7.3.2 Demographics of the Pilot Study Participants…………………………………250
7.4 Discussion …………………………………………………………………………………………….253
CHAPTER 8: THE EXPERIENCES AND EXPECTATIONS OF PARENTS/CARERS………………….257
8.1 Introduction………………………………………………………………………………………….257
8.1.1 Aims and Objectives ……………………………………………………………………258
8.2 Methods ………………………………………………………………………………………………259
8.2.1 Study Design ………………………………………………………………………………259
8.2.2 Research Setting …………………………………………………………………………259
8.2.3 Participants………………………………………………………………………………..259
8.2.4 Data Collection……………………………………………………………………………262
8.2.5 Data Management and Analysis……………………………………………………266
8.3 Results …………………………………………………………………………………………………268
8.3.1 Demographic Characteristics: Children ………………………………………….270
8.3.2 Demographic Characteristics: Interviewees……………………………………276
8.3.3 Theme 1: Impact on the Family- “It turns her into a little bitch”……….278
8.3.4 Theme 2: Cues to Seek Intervention – ‘Enough’s Enough’ ………………..292
8.3.5 Theme 3: Expectations of the Healthcare System – ‘There’s light at
the end of the tunnel’…………………………………………………………………………….298
8.4 Discussion …………………………………………………………………………………………….309
8.4.1 Impact on the Family …………………………………………………………………..309
8.4.2 The Cues to Seek Intervention………………………………………………………313
8.4.3 The Expectations of the Healthcare System……………………………………315
8.4.4 An Understanding of the Clinical Practice Guidelines………………………318

8.4.5 Study Limitations………………………………………………………………………..320
8.4.6 Conclusion …………………………………………………………………………………321
SECTION IV: DISCUSSION…………………………………………………………………………………….323
CHAPTER 9: DISCUSSION……………………………………………………………………………………….325
9.1 Overview ……………………………………………………………………………………………..325
9.2 Main Findings……………………………………………………………………………………….326
9.2.1 The Epidemiology of ENT Surgery in South Australia……………………….326
9.2.2 South Australia has a Higher Incidence of Paediatric ENT Surgery…….330
9.2.3 Geographical Variations Exist Across South Australia………………………334
9.2.4 Financial Burden is the Main Cue to Seek Surgical Intervention ……….336
9.3 Study Limitations…………………………………………………………………………………..340
9.3.1 Secondary Data…………………………………………………………………………..340
9.3.2 Qualitative Research …………………………………………………………………..343
9.4 Opportunities for Further Research…………………………………………………………344
9.4.1 Geographical Differences…………………………………………………………….344
9.4.2 Interviews with Medical Practitioners …………………………………………..345
9.4.3 Adolescent Tonsillectomy ……………………………………………………………347
9.5 Policy Implications…………………………………………………………………………………349
9.6 Conclusions…………………………………………………………………………………………..351
SECTION V: REFERENCES AND APPENDICES…………………………………………………………353
REFERENCES………………………………………………………………………………………………………..355
APPENDICES ………………………………………………………………………………………………………..399
APPENDIX A: LITERATURE REVIEW……………………………………………………………………399
APPENDIX B: SUPPORTING DOCUMENTATION…………………………………………………..401
APPENDIX C: STATISTICAL SOFTWARE PROGRAMMING CODE …………………………….407
APPENDIX D: RESEARCH FORMS……………………………………………………………………….440
APPENDIX E: TABLES……………………………………………………………………………………….446

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