We have performed sleep nasendoscopy on 54 adult snorers in whom obstructive sleep apnoea had been excluded by an overnight sleep study. The purpose of the study was to identify the site or sites of noise production in each case. This was successfully achieved in 50 of the 54 and 70% showed palatal flutter snoring only. In a further 20%, palatal flutter snoring was combined with evidence of noise generation at another site. The second site was supraglottic in 10%, tonsillar in 8% and tongue base in 2%. The tongue base was also the sole site of noise generation in 8% and the epiglottis was the sole site in 2%. This study suggests that sleep nasendoscopy can identify different mechanisms of snoring in individual patients. This information is likely to be of use in formulating a logical surgical treatment plan.

There is a paucity of studies on patient-reported outcome measures in adult tonsillectomy. Our aim was to add to the body of health-related quality of life (HRQOL) evidence on adult tonsillectomy at a time when this intervention is being branded a low priority treatment in the United Kingdom (UK). We designed a prospective questionnaire study that was carried out in two UK district general hospitals. 41 patients were recruited into the study and completed a pre-operative short form 36 questionnaire. All 41 were contacted at least 1 year after tonsillectomy and were asked to complete the same SF-36 questionnaire and three additional HRQOL questions. There was a significant improvement in quality of life shown by both the mean SF-36 scores and the HRQOL questions. The SF-36 summary measures and the total SF-36 scores improved significantly (p < 0.01). The study emphasises the importance of tonsillectomy being available on the National Health Service to adults with recurrent tonsillitis. This proven quality of life improvement is also highly likely to confer a secondary health economic benefit from less GP attendances and fewer missed work days.

Inherited bleeding disorders are frequently considered an absolute contraindication to tonsillectomy and other ENT procedures. Over a 15-year period we have performed ten elective tonsillectomies and five bilateral myringotomies on children with inherited bleeding disorders. All procedures were carried out with the close co-operation of the Haematology Department in the hospital. All patients underwent uneventful surgery. One patient returned after tonsillectomy with a secondary haemorrhage which did not require surgical intervention. We present our team approach to the management of these children and demonstrate that necessary surgical intervention can be undertaken safely in this select group of patients.

Claims have been made for the potential of acoustic rhinometry (AR) in the evaluation of adenoidectomy patients. Little evidence has been presented to support such claims, and evidence is accumulating that AR is inaccurate in reflecting anatomical reality in the nasopharynx. We set out to establish whether acoustic rhinometry studies could predict operative decision-making sufficiently for it to be of assistance to the clinician, despite these theoretical and practical obstacles. A total of 101 patients aged 2-13 years were examined by AR using the impulse technique. Parameters were chosen from the area-distance function to indicate nasopharyngeal volumes and areas (decongested and non-decongested). This information was compared with findings at EUA (examination under anaesthesia-obstruction categories: A-'good airway' to D-'severe obstruction'), operative decision (2 categories-'obstructive' = remove, versus 'non obstructive' = leave in situ) and parents' symptom scores. Twenty-one patients were also evaluated post-operatively. There was considerable overlap between the AR parameters in the groups classified at EUA as 'obstructive' or 'non obstructive', but this overlap diminished after decongestion. Logistic regression demonstrated that the decongested volume and area parameters were of significant predictive value with respect to operative decision (odds ratio for unit change in volume = 0.82; 95% C.I. = 0.70-0.97; p = 0.018). Parents' analogue scores for snoring and for [snoring+obstruction+ mouthbreathing] were also of significant predictive value. The presence of rhinitis diminishes the predictive value of AR. Acoustic rhinometry has potential as a pre-operative evaluation of the nasopharyngeal airway in adenoidectomy candidates, but the predictive value is low unless combined with clinical factors.

Editor-News that pressing financial problems have caused NHS trusts in Suffolk to set new "thresholds" to treatments such as joint replacements reinforces concerns raised by a recent BMA survey of medical directors of trusts in which over a third of respondents anticipated reductions of key services in response to funding shortfalls. What has hitherto escaped comment is how cuts in services are far more likely to be felt in some parts of the country than others.Deficits in the NHS are invariably presented as a problem of financial mismanagement, but the pattern of deficits shows that the current resource allocation model discriminates against particular communities. According to the recently published accounts for 3 89 out of 303 (30%) English primary care trusts ended the year in deficit. The table shows how 301 of these trusts are distributed accorded to fifths of deprivation and rurality.Primary care trusts serving populations that are in both the most rural and the least deprived fifth were most likely to be in financial difficulties. Seventeen of the 25 (68%) in this category were in deficit. These trusts received the lowest funding allocation per head (£995). By contrast, only 3% (one of 34) of the primary care trusts serving populations that are in both the most urban and the most deprived fifths failed to break even in 2004-5. These trusts received the highest funding allocations per head (£1405).This shows that poor financial management can at best only partly explain why some trusts are in deficit. The pattern of deficits implies that NHS funding provides insufficient resources for rural areas, for comparatively affluent areas, and, most particularly, for areas that are both rural and affluent. The risk is that such measures will result in NHS services being subject to a new postcode lottery, in which rural residents are more likely to lose out. Sheena Asthana professor of health policy