Incisionless Otoplasty: Illustrating the Importance of Critical Appraisal of National Treatment Guidelines for Head and Neck Surgery

National guidelines serve an important role in steering clinical practice. Accordingly, it is the duty of clinicians practicing evidence-based medicine to scrutinize and evaluate such guidelines to ensure that these recommendations are as firmly rooted as possible in the evidence available at the time so as to be useful to both surgeons and patients considering any procedure. In March 2012, the UK National Institute for Health and Care Excellence (NICE) published Interventional Procedure Guidance (IPG) 422, "Incisionless otoplasty:" The guidance states, "Incisionless otoplasty comprises a variety of surgical techniques, carried out via minimal percutaneous access, that have been poorly described in the evidence, which includes a very small number of patients. The evidence on efficacy and safety is inadequate both in quality and quantity, and therefore the procedure should only be used with special arrangements for clinical governance, consent and audit or research:' I We examined the evidence presented in this guideline to determine whether the information presented was suitably researched, focused on the subject of discussion, and well referenced, and therefore would serve as a suitable platform on which to base clinical practice. Although uncommonly performed in the present day, this procedure for correction of prominent ears using a minimally invasive approach has historical roots at our institution and, accordingly, we were interested in how clinicians elsewhere might perceive the technique. NICE guidelines are widely regarded as excellent sources of rigorously researched, evidence-based guidance and advice, and they shape practice within the National Health Service and beyond. The panel of specialist advisors who compiled this IPG 422 consisted of two plastic surgeons with a specialist interest in ear surgery and one ear, nose, and throat surgeon with an ear interest. One of these specialist advisors had performed an incisionless otoplasty at least once, but the other two had never performed the procedure. The literature search undertaken (listed in Appen-