Over the years I have been involved in a large number of international consensus meetings, usually attended by people from a wide range of specialities and nationalities. They require considerable diplomacy and leave one with an enormously increased admiration for the UN peacekeepers. I have spent many hours of my life in front of flipcharts devising algorithms.
That said, to paraphrase a bumper sticker, ‘Surgeons do it quicker’ and it is worth remembering that the surgical bladder will always trump the physician’s if there is an impasse in the decision-making process.
The very first consensus meeting I ever put together and chaired in the early 1990s was also the first one on rhinitis. The International Consensus Report of the Diagnosis and Management of Rhinitis was rapidly followed by variations on the theme, eventually endorsed by the WHO and transformed into ARIA (Allergic Rhinitis and its Impact on Asthma), which has had a massive global impact on the management of this disease. It undergoes regular updates and has helped to reinforce the ‘one airway’ concept of considering the upper and lower respiratory tract as a single organ.
Over time, we were spurred on to organise other consensus groups, guidelines and position papers covering anatomical terms in the nose and sinuses, diagnostic tools and radiological reporting of CT scans, endoscopic management of tumours in this region, and perhaps most importantly, ‘rhinosinusitis’, which encompassed acute and chronic infection and inflammation with and without nasal polyps. This culminated in EPOS (the European Position Paper on Rhinosinusitis and Nasal Polyps), an evidence-based document produced under the aegis of two European organisations, first published in 2005 and chaired by Professor Wytske Fokkens and myself. Since then, it has gone through several iterations, taking into account the increasing number of randomised placebo-controlled trials and systematic reviews which have been performed in attempts to scientifically fill in the gaps. It has also significantly broadened its authorship to include experts from all relevant medical specialities – including ENT, allergy, immunology, pulmonology, primary care and pharmacy – and, importantly, patients. With contributors from 70 countries, it has also been translated into multiple languages. Much remains to be done, on the ‘more we know, the less we know’ principle, but we have moved a long way from the unsupported opinion and speculation of the past. In 2005, there were 650 references; in EPOS 2020, there were over 3000. EPOS is one of the things with which I am most proud to be associated.
"If not, gentlemen, in the words of Rhett Butler in Gone with the Wind, ‘frankly I don’t give a damn!"
However, back in the early days of endoscopic sinus surgery, Ian Mackay and I devised a very simple scoring system for the amount of opacification on a CT scan of the sinuses, the endoscopic appearances of the nose and the extent of the surgical procedure. We knocked it up on the back of an envelope one morning over coffee and were quite surprised when it caught on. This was largely due to its simplicity and reproducibility – something, as Ian would say, that ‘the man on the Clapham omnibus could do’ with minimal training. There were of course other staging and scoring systems, mainly American, around at the time, but all were much more complicated. I was duly invited to a task force of the American Academy of Otorhinolaryngology and Head and Neck Surgery in Washington, which had been convened to decide which system would be recommended by the academy for future rhinology studies. We sat round the table, listening to all the proponents extol the virtues of their personal scoring systems and then I was asked by the chair whether I thought that the Lund-Mackay score should be used. I thanked them for considering our system and said that we would be very happy if they chose to endorse it for its obvious merits. Then I laughed and, with careful timing, said, “If not, gentlemen, in the words of Rhett Butler in Gone with the Wind, ‘frankly I don’t give a damn!’” There was a stunned silence, following which the Lund-Mackay score (LMS) carried the day, though possibly as a default position to offend everyone and no one amongst my American colleagues. I can honestly say that if I had £5 for every time the LMS has been used, I could have retired a very long time ago.
This series of stories is dedicated to those of you with whom some of these moments were shared (or endured) and, above all, to my amazing and long-suffering husband, David Howard. Most of you know him as an exceptional head and neck surgeon but, since Covid, he has been involved in a large multi-speciality international charitable project reintroducing negative pressure non-invasive breathing support which could transform the management of respiratory disease all round the world. If you are interested, please visit www.exovent.org for further information and, if you enjoy the stories, please consider donating to the charity through the Exovent website (Click DONATE on the home page drop down menu).
