To quote, ‘This is a unique study guide that provides a concise review of high yield otolaryngology topics’. That is quite a claim, as there is no lack of books hoping to assist examination revision in our specialty. I confess I almost wondered if ‘high yield’ referred more to potential income, and never really followed that phrase. Even to an Irishman, the Atlantic is widening.
I was impressed that the author completed this work whilst still a fifth year resident in Iowa. He is now a Fellow in Ann Arbor, Michigan, a setting that many of us recall fondly.
This book is aimed at advanced trainees facing exit exams, or the more senior amongst us threatened with recertification tests of knowledge (gulp, it is coming!). There is much that does not translate into UK practice but, fortunately, on the first page the author introduces us to PSH, NKDA, ROS and HPI in our record-taking.
There are 44 clinical vignettes, each with a brief introduction, then a series of questions and model answers, to guide one through management. Treatment options are particularly well covered and, in each case, the author provides a thoughtful case summary.
The cover promised colour images, but I found none. Indeed, my greatest concern was the reproduction of what are truly monochrome (not black and white, but grey) images throughout. A cleft lip and an atypical mycobacterial neck lesion are so dark as to be almost indecipherable. I took a lay second opinion from my wife, who pronounced them awful, and my two 18-year-old sons, who felt they looked like bad photocopies. They truly do.
I concentrated on otology, as I can claim some limited expertise there. Errors have crept in which careful proofreading really should have spotted. A patient with a left sensorineural hearing loss shows a Weber test which ‘lateralized to the left ear (AD)’ [sic]. Now, I can accept that this ear might show a (false) Rinne negative, but the D in AD refers to Dexter, which is either Latin for right or a totally daft but irresistible TV series. I had not come across KITTENS before, for one's diagnostic sieve, but once told that the K stands for ‘kongenital’, I can see why. The advice can be confusing. For idiopathic sudden sensorineural hearing loss, the suggestion is that ‘labs’ are unnecessary unless the need is already clinically obvious. This is then followed by a long list of labs, seeking conditions largely occult! MRI seems fine for ISSNHL, but ABR is lauded elsewhere, curiously in the vignette with the tumour.
It seemed odd in CSOM to have to enquire about temporomandibular perforation, and to see it again in the differential diagnosis. I have seen the TMJ dehiscent into the external canal, with a salivary leak, but not too often. The perils of audio-typing, that tympanic membrane should then become temporomandibular. A febrile patient with a chronically painful ear pouring pus suggested to me dural irritation, which is not suggested, but certainly is not typical of a glomus tympanicum, which is. The coverage of otosclerosis is excellent, but I seemed to be detecting some inconsistency as I read on.
Facioplastics is clearly this author's field, and there is also a fine section on trauma, particularly good on securing the airway. I confess I scanned the rest, but did laugh on reading a vignette entitled ‘Paranormal sinus malignancy’. Not the X Files I suspect, but ‘paranasal’. There is a patient with OSA who turns out, as is mentioned in passing, to be a bus driver. You can imagine the depth of work-up that follows, but guess what issue is never addressed? It may be safer to walk than to use public transport in Iowa!
A case of Wegener's granuloma perhaps best summed up what this text lacks. The book draws heavily on textbook knowledge, but the art of applying that knowledge only comes with experience (and there is probably a peak in that, at some stage in one's career). This is a ‘barn-door’ case of WG clinically, we even have every blood test back as positive. The question then is, what is the next most appropriate step? The answer given is a biopsy. Now, we all know that the chance of anything from the nose really contributing to diagnosis is pretty remote and usually delayed. What needs to be stressed here is the need to initiate treatment at the first suspicion. I have learnt the hard way not to even wait for the cANCA results in an obviously sick patient, but to take the blood samples and admit that day for steroids. One patient on renal dialysis, four days after I had seen him in the clinic and diagnosed WG but waited for the tests to come back, taught me.
I have been very critical here of what is generally a good text, but there are errors that simple proofreading could have spotted and corrected. It is easier to pronounce with authority in a multi-author textbook, exploiting subspecialty expertise. That comes with seniority, and then you get the pearls of wisdom. I am sure we will hear much more of this author.
