Conjoint Professor Paul Walker

This chapter considers what makes our contemporary era, herein termed post-modern, different from earlier eras, and why we therefore need to move from appeal to a substantive ethical framework, to an active process of moral decision making. Thus, the move is from ego to alterity (otherness) in the notion of dialogic consensus. Dialogic consensus is derived from Jürgen Habermas¿ notions of discourse theory of morality and communicative action. Recognition of our inter-connectedness is important for Habermas because of its contribution to normativity, in that it serves as a motivator to act, consequent upon a sense of oughtness or shouldness. His discourse theory of morality requires that the consequences for all persons affected must be considered, while his principles of communicative action imply that the discourse is based upon consensus, subsequent to inclusive, non-coercive and reflective dialogue. Intersubjective consensus after dialogue within the relevant community imbues the decision with normative force that, in turn, renders the process one which is action-guiding. Habermas¿ discourse theory of morality generalises and expands the Kantian categorical imperative, as determined by ethical monologue, to a wider consensus-seeking dialogue. Thus, consensual agreement is reached about what constitutes morally-correct action. Relocating decision making from a monological space, into one characterised by dialogue within the stakeholder community, is especially appropriate to the clinical encounter. This form of moral decision making is at the heart of the notion of dialogic consensus.

This chapter begins with an exploration of ethical decision making through the Classical period, the Medieval period, and the Modern period of our history. It then considers the workings of three normative frameworks in the secular Western tradition that, historically, have been important in guiding decisions in medical ethics. These are deontology, teleology, and virtue ethics. The deontological framework predicates moral permissibility on the intrinsic nature of the Act. The teleological framework predicates moral permissibility on the consequences of the Act. The virtue ethical framework focuses on the character of the agent. They are substantive¿by which we mean that they are stand-alone frameworks. In considering deontological principles, specific attention is given to philosophical principles which help determine who actually is a person from a moral decision-making perspective, and how we might make moral decisions at the end-of-life, for example in Intensive Care Units (ICUs). In considering teleological principles, aspects of triage are discussed. Under the virtue ethics framework, the Good of the patient is the ultimate purpose of medicine, and empathy, compassion and care are proposed to guide normative moral decision-making in clinical situations. Finally, the theistic framework of the Islamic-Judaeo-Christian tradition is considered.

This chapter explores some practical difficulties that will inevitably be encountered in the clinical setting characterized by expanded technological capacity and value pluralism within the stakeholder group. Responding to these entails more intensive analysis of the Habermasian notions of discourse theory of morality and communicative action, and especially aligning them with his theory of the ways of knowing. By basing the dialogue around a way of knowing characterized by self-reflectivity, each member of the stakeholder group can be: (1) facilitated in seeing technological capacity as merely a factor to be considered¿but not necessarily the determinative factor; and, (2) to take better account of the interpretations offered by other members of the decision-making group. That is, without listening, there can be no knowing. It makes sense that we cannot have a discussion about morals if we do not have the words for the concepts and if we do not agree about the meanings of the words. We will argue that, practical difficulties in achieving the ideal dialogue notwithstanding, the process described herein has both applicability and great merit for moral decision making in clinical settings.

This chapter considers the four principles that have been distilled from the normative frameworks identified in the previous chapter, proposed as ways of guiding practical decision making in medical ethics. These are respect for autonomy, non-maleficence, beneficence, and justice. They have had considerable influence on moral decision making in clinical situations, and, at a minimum, they offer a common ethical language amongst clinicians. Shortcomings in their theoretical and practical application will be identified. Various understandings of autonomy¿considered to be first amongst the four principles¿will be considered. Critical re-examination suggests that our traditional understanding of autonomy is impoverished and requires re-evaluation. What is formed herein as the proportionist approach seeks a virtuous mean or balance-point in maoral decision making that takes account of the frameworks and principles identified in this and the previous chapter but in a way that is more grounded in the realities of the modern era (as will be expanded upon in the following chapters). It seeks to balance intrinsic rules and empirical consequences, hence utilizing but also going beyond the bounds of the deontological and teleological frameworks alone. Its starting point is the actual reality of the patient in their situation. It is put into clinical practice via a process we term dialogic consensus, a term we explore in Chaps. 4 and 5.

Objectives: Recent publications have identified different rates of postoperative hemorrhage between "cold" tonsillectomy techniques and "hot" tonsillectomy techniques, generally identifying lower bleeding rates after cold techniques. Data from a prospective institutional review were analyzed to determine the relative risk factors for post-tonsillectomy hemorrhage among different techniques and by different age groups. Materials and Methods: At the co-located John Hunter Hospital and John Hunter Children's Hospital, data were collected prospectively over a period of five years to allow a nonrandom comparison between a nondiathermy dissection technique for tonsillectomy with a monopolar diathermy technique in the management of nonmalignant disease of the tonsils, in children and adults, by determining complications in the first 28 days after surgery. Results and Conclusions: One thousand one hundred thirty-three consecutive cases were analyzed. The primary post-tonsillectomy hemorrhage rate was 0.2% for blunt dissection plus diathermy hemostasis and 0.3% for monopolar diathermy dissection plus hemostasis. Monopolar diathermy had a lower rate of secondary postoperative hemorrhage, requiring readmission (4.2% compared with 5.4% for blunt dissection plus diathermy hemostasis) and a lower rate for readmission for observation alone (2.1% compared with 4.2%) but had a higher risk of returning to surgery (1.6% compared with 1.04%) and a higher risk of blood transfusion (0.49% compared with 0.2%). These differences, however, did not reach statistical significance (Yates ¿2), and neither did the relative risk between the two techniques. Two-way analysis of variance among secondary post-tonsillectomy hemorrhage complications by technique and by age groups shows a highly statistically significant difference by age group (analysis of variance, 3 df, F = 9.509, P < 0.001), much more so than technique. © 2007 American Academy of Otolaryngology-Head and Neck Surgery Foundation.

A 13 year old child with cystic fibrosis presented with an aural polyp which proved to be associated with cholesteatoma. Despite the expectation that the excessively viscid secretions characteristic of cystic fibrosis would make the middle ear cleft vulnerable to Eustachian tube obstruction and hence middle ear disease, literature review suggests that this is not the case. Factors thought to protect the temporal bone from middle ear disease may include the degree of pneumatisation, reduced goblet cell numbers, and altered roles of mucin genes. Cholesteatoma in a child with cystic fibrosis has not previously been reported. CT and MRI were used to confirm the diagnosis prior to mastoidectomy. Imaging correlates of cholesteatoma and other middle ear pathologies on CT and various MRI protocols are tabulated.

Objectives: To review the clinical presentation, surgical treatment and outcome of a single surgeon's experience with paediatric congenital cholesteatoma of the middle ear. Materials and methods: Surgical databases were accessed for the period 1994-2003 to identify those children who had a congenital cholesteatoma. Diagnosis was confirmed histopathologically. Details of presentation, surgical management, progress and outcomes were extracted and analysed. Results: Fifteen congenital cholesteatomas were identified. Median age at diagnosis was 3.8 years. Two were intra-tympanic and 13 were mesotympanic. Of these, 5 were localised to the antero-superior quadrant. Three initial surgical approaches were utilised - endomeatal for intra-tympanic cholesteatomas, endaural superior tympanomeatal flaps if the extent of spread was thought to be limited to the mesotympanum, and post-auricular approach to mastoidotomy if spread was thought to be beyond the mesotympanum. The 2 approached endomeatally were cured. Of 10 approached via endaural tympanotomy, 8 were cured via this approach, 1 recurred and came to modified radical mastoidectomy for cure, and 1 was converted to post-auricular mastoidotomy. Four were approached via post-auricular tympanotomy. One came to intact canal wall mastoidectomy to encompass spread and was cured, and 3 came to modified radical mastoidectomy for cure. Of the series, 4 eventually came to modified radical mastoidectomy for cure (3 as the initial procedure and 1 to salvage recurrence). All children swim unprotected but only 10 of 15 have normal heating in the operated ear. Conclusion: Assessment of the extent of spread determines the choice of initial operative approach. Localised, smaller, and intact lesions do better. Thus early diagnosis is likely to result in better outcomes.

Objectives: To follow persistent perforations following spontaneous extrusion of a Ventilation Tube (VT) in a Paediatric tertiary care setting in order to determine which factors are predictive for residual perforation after spontaneous extrusion, to examine the natural history of spontaneous healing of the perforation, and to determine which factors may be predictive for the subsequent healing of a perforation. Materials and methods: A prospective series of 80 perforations in 70 children after spontaneous extrusion of their VTs was followed. The 80 ears in which VT extrusion was complicated by residual perforation were compared with the 50 ears which extruded leaving an intact tympanic membrane. The 50 self-paired ears were compared. The 80 perforations were followed for spontaneous healing. The group which eventually healed was compared with the group which did not heal. The design of VT, number of prior VTs, age, and operative findings at the time of insertion (tympanic membrane condition, position, presence of tympanosclerosis, and the fluid aspirated) were recorded. Duration in-situ before extrusion on both the perforated side and the intact side were determined. Spontaneous closure rates, and the duration the residual perforation remained open before healing were determined. Analysis was via two-tailed t-tests and chi-squared analysis. P values are reported. Results: The only factors associated with a residual perforation after extrusion were thin or atrophic, and retracted or atelectatic tympanic membranes (p<.001). Neither age (p=.028), duration in-situ (p=.89), design (p=.899), nature of fluid (p=.281), nor tympanosclerosis (p=.21) were significantly associated with residual perforation. Of the 13 VTs which remained in-situ more than 24 months, 70% were complicated by residual perforation, with a bi-modal peak incidence at 3 and 36 montfis duration. Fifty-two perforations were followed until they healed spontaneously. Sixty-five percent healed - 60% within 6 months and 81% by 12 months. No factors were identified as predictive for eventual healing of the post VT extrusion perforation. Conclusions: Insertion of VTs should avoid areas of thinning or atrophy, retraction or atelectasis. It may be appropriate to offer surgical removal of a VT in-situ more than 24 months to reduce the risk of residual perforation. A majority of post-extrusion perforations eventually heal spontaneously. No predictive factors for eventual healing were identified.

Acute epiglottitis is now rarely diagnosed since Haemophilus influenzae (type b) was routinely included in the childhood immunization schedule. This report describes a case of vaccination failure in an immunised 11 month old child presenting with acute respiratory distress. The differential diagnosis and management of acute epiglottitis in a child is reviewed. This case highlights the ongoing presence of acute epiglottitis amongst the immunised population, and the importance of considering it in the differential diagnosis of any child presenting with acute respiratory distress.

Cysts of the base of tongue are rare in the paediatric population. Lesions in this region present a diagnostic challenge and should be assessed carefully prior to any surgical intervention. Previous reports have detailed a number of different approaches to surgical excision of these lesions. In the present report we present two cases of successful microlaryngoscopic suspension and laser excision of giant mucous containing cysts of the base of tongue. This technique has merit in reducing postoperative morbidity and avoiding the problems associated with previously described methods of excision.

Persistent bilateral mucopurulent rhinorrhoea in a child suggests sinusitis. Sinusitis in children varies in its presentation and severity. Advances in imaging and telescopic nasendoscopy are increasing our knowledge about the pathogenesis. Much of the management can be completed by the child's family doctor, with recourse to an otolaryngologist only in the uncommon instance when nonoperative management is unsuccessful.

One of the roles of the pediatric otolaryngologist in the neonatal intensive care unit (NICU) is the assessment and management of the neonate who fails a trial of extubation. This paper reviews the recent 5-year institutional experience at The Hospital for Sick Children, Toronto, with neonates who failed extubation and who subsequently underwent diagnostic endoscopy. One hundred twenty-eight neonates from the NICU underwent diagnostic endoscopy. Of these, 58 neonates underwent diagnostic endoscopy for failure to extubate. Nine neonates were extubated after diagnostic endoscopy and retrial (16% of the series). Eleven neonates were extubated after additional endoscopic procedures (19% of the series). Twenty-four neonates underwent anterior cricoid split, of whom 20 or 83% (34% of the series) were eventually successfully extubated with no further airway intervention required during the study period (minimum 6 months¿ follow-up). Eleven neonates underwent tracheotomy (19% of the series). Four neonates underwent another external procedure to allow extubation (7% of the series). Three neonates died while still intubated (5% of the series). Our management of the neonate who fails a trial of extubation is discussed. © 1993, SAGE Publications. All rights reserved.

A 10-year retrospective study of the management of airway obstruction in 26 infants with Pierre Robin sequence was made. It was not possible when the infant was first seen to assess the future severity of the airway obstruction but later 3 distinct groups could be identified according to the airway management which had become necessary. The deaths from respiratory obstruction indicate the prime importance of airway management. Laryngoscopy for intubation or endoscopic evaluation was often difficult and sometimes could not be achieved. 'Awake intubation' without general anesthesia has proved to be safer and less difficult using a special purpose slotted laryngoscope. Airway management should be individualized following the progressive sequence of posturing in the prone position, nasopharyngeal tube, endotracheal intubation and tracheotomy until successful control is achieved as indicated by the clinical features and pulse oximetry. © 1991.

The relationship of a number of nutritional parameters to mortality and sepsis was assessed in a group of 82 patients requiring total parenteral nutrition (TPN). Duration of TPN ranged from 9 to 105 days with a mean of 32.3 days. Parameters assessed were serum albumin, transferrin, absolute lymphocyte count (ALC), delayed hypersensitivity skin test reaction, mid-arm muscle circumference, triceps skin-fold thickness and weight. Combinations of parameters were found to be more useful than single parameters. The only single parameter of significance was ALC. The best overall predictor of death and/or sepsis was a combination of reduced serum albumin, transferrin, ALC and anergy, which was found to be related to a significantly higher mortality (P= 0.002) and incidence of septic complications (P= 0.003). This combination of parameters also had the best specificity (90%), accuracy (79%) and positive predictive value (65%) for prediction of death and/or sepsis. Increasing age was also found to be associated with a higher mortality (P < 0.001) and increased incidence of septic complications (P= 0.01). Copyright © 1986, Wiley Blackwell. All rights reserved