A common otological problem in primary and secondary care is otitis externa, and it is remarkable that there are so many problems in management associated with this condition. There appears to be a confusing mismatch between guidelines, routine specialist advice and what actually happens day to day in primary care. This issue's ‘paper of the month’ is a study from Newcastle upon Tyne,^{Reference Mohammed, Mather, Lumb, Butler and Wilson1} which spells out the nature of these difficulties in no uncertain terms and should be widely read. The ‘price’ paid for the misuse of oral antibiotic therapy in the wider population administered for this condition could be considerable, and not just in terms of (wasted) money paid out; it also includes difficulties with the antimicrobial management of infections affecting other parts of the body, as well as the most lethal form of otitis externa, necrotising (‘malignant’) otitis externa, which has been the topic of many recent articles in The Journal of Laryngology & Otology, including guidelines from 2020.^{Reference Hopkins, Bennett, Henderson, MacSween, Baring and Sutherland2}

Surgery of the nasal septum has historically been over-used. In addition, outcome discussions during conversations with patients for pre-operative consent can often leave something to be desired, and have a tinge of optimism. The Journal has previously published articles on this topic.^{Reference Marshall, Johnston and Jones3,Reference Winterton, Alaani, Loke and Bem4} The current issue includes a study from Norway, in which a large cohort of septoplasty patients were reviewed using a questionnaire completed at 6–12 months and at 3–4 years.^{Reference Haye, Døsen, TarAngen, Gay, Egeland and Shiryaeva5} The validity of such questionnaires has previously been established.^{Reference Haye, Døsen, Tarangen and Shiryaeva6} The results showed a significant, although not radical, fall-off in positive outcomes between the two assessments, somewhat less than other studies have shown, and may reflect careful pre-operative patient selection by the clinicians involved. One interesting finding was that the change in outcomes over time was not significantly affected by whether or not turbinate surgery was included with septoplasty.^{Reference Seden, Araz Server, Yigit and Misir7} The conclusion that outcomes are better in patients whose noses are more blocked before surgery chimes with previous studies.

Laryngeal dysplasia is a condition with a considerable propensity to transform to invasive squamous carcinoma, and the monitoring and treatment of this condition occupies much of a laryngologist's time.^{Reference Sadri, McMahon and Parker8} A study from Belfast, Northern Ireland,^{Reference Donaldson, McCadden, Napier and Tan9} examined a large cohort of affected patients, and found a malignant transformation rate of 21.8 per cent, slightly higher than some estimates.^{Reference Weller, Nankivell, McConkey, Paleri and Mehanna10} One important point in the authors’ conclusions is that each of the severity types (mild, moderate and severe) behave as distinct entities in relation to prognosis and malignant transformation, with moderate dysplasia having a higher rate of malignant transformation in this series than had been expected.

Sleep-disordered breathing in children has a considerable effect on the quality of life of the child and family.^{Reference Mitchell and Kelly11} Furthermore, it creates much anxiety in parents, and is increasing in prevalence along with increasing childhood obesity, but it is readily amenable to surgery – usually adenotonsillectomy.^{Reference Marcus, Moore, Rosen, Giordani, Garetz and Taylor12} The Journal has documented the increasing interest in using tonsillotomy in place of tonsillectomy.^{Reference Sakki, Roine, Mäkinen, Sintonen and Nokso-Koivisto13} This issue has another thought-provoking paper on the topic from Newcastle upon Tyne, which examines treatment pathways for children with suspected sleep-disordered breathing.^{Reference Haighton, Watson, Wilson and Powell14} This qualitative study involved interviewing parents and professionals from primary and secondary care; the accounts will strike a chord with anyone who has been involved with these patients and families. The messages are not at all comfortable to read and there seems every reason to suppose that they are widely applicable to other geographical areas. Parents are worried that their child will stop breathing and do not always feel listened to; even when they are listened to, the professional may not be well enough aware of the condition to deal with it effectively. The central message from the study is that there is a clear need for guidelines to help parents and professionals navigate their way through system, which at present seems very unsatisfactory, to benefit this vulnerable group of patients.