Does it take a village to write a case report?

LETTERS TO THE EDITOR Does it take a village to write a case report? To the Editor: I just finished reading Dr Har-El’s commentary, “Does It Take a Village to Write a Case Report?” (1999;120:787-8). The title suggests that there are too many authors on case reports; however, the commentary mainly explores the contribution case reports make to the literature. Dr Har-El states, “This Journal has done a great job of publishing clear guidelines for authors who plan to write a case report. The guidelines specify the length of the manuscript, number of words, number of figures, and number of references. This certainly has helped me in reviewing manuscripts, providing constructive criticism, and suggesting revisions.” I fail to see the link between restricting the quantity of words, figures, and references in a case report and the quality of the case report. The guidelines enable case reports to be rejected (or returned for revision) on objective criteria without being read by a reviewer, but do they increase the quality of the case report? Is it more difficult to provide constructive criticism or suggest revisions on a 2000-word manuscript than on a 700-word manuscript? I wonder why a review of the literature is worthwhile if the authors can report 6 or more cases but is not valuable if there are fewer cases (according to a personal communication with Dr Holt, any report up to and including 5 patients is a case report). If something is a very rare entity, knowing the state of the literature does have value. I do not question encouraging authors to use word economy. I would posit that all manuscripts should be no longer than what is needed to communicate the ideas efficiently. However, this should be applied to all manuscripts, be it for a case report of 1 patient or a series of 10,000 patients. I applaud the editor’s desire to increase the quality of the case reports; however, I am not sure that limitation of the length of case reports will achieve this goal. The quality will improve by peer review, not by using word counts on the word processor. In his description of the case report guidelines, Dr Har-El omitted what I think is the only necessary guideline. Only a “report of a truly unique, highly relevant, and educationally valuable case” should be submitted.1 If a case report meets these criteria, what else is needed? Underlying this commentary is the sentiment that case reports are not as great a contribution to the literature as other types of manuscripts. I think that manuscripts should be judged on an individual basis and not by type. Certainly, a well-written case review can be more worthwhile than a poorly written small series. I am not sure any more conclusions can be drawn from a series of 6 patients than can be drawn from a single case. Some clinical entities, especially complications, can be presented only in a case review format. Case April 2000

reports allow a global accumulation of experience of rare entities that can lead to a better understanding of these entities. For instance, “Brachial Cleft Cyst Carcinoma: Myth or Reality?”2 could not have been examined without the 43 previous cases reported in the literature. The commentary states, “Case reports also give young physicians and private practitioners who do not have access to academic clinical or basic science research the opportunity to participate in scientific medical writing and publishing.” I suggest that case reports allow young and old, private and academic physicians the opportunity to make a contribution to the literature. Certainly, case reports such as a palate perforation from cocaine abuse3 or a bilateral chylothorax complicating radical neck dissection4 would be considered contributions to the literature. Finally, the guidelines seem to apply only to case reports written by United States or Canadian authors. The case report criteria should be applied to all cases published in the Journal, regardless of the country of origin of the article. International case reports published in the Journal do not meet the same word count and restriction of figures and references (eg, Llorente et al5). Mark J. Syms, MD Assistant Clinical Professor of Otolaryngology John A. Burns School of Medicine University of Hawaii at Manoa Honolulu, HI 23/8/104320 doi:10.1067/mhn.2000.104320 REFERENCES 1. Instructions for authors. Otolaryngol Head Neck Surg 1999; 120(6):16A-18A. 2. Sing B, Balwally AN, Sundaram K, et al. Brachial cleft cyst carcinoma: myth or reality? Ann Otol Rhinol Laryngol 1998;107: 519-24. 3. Sastry RC, Lee D, Har-El G. Palate perforation from cocaine abuse. Otolaryngol Head Neck Surg 1997;116:565-6. 4. Har-El G, Segal K, Sidi J. Bilateral chylothorax complicating radical neck dissection: report of a case with no concurrent external chylous leakage. Head Neck Surg 1985;7:225-30. 5. Llorente JL, Suarez C, Ablanedo P, et al. Hemangiopericytoma of the parapharyngeal space. Otolaryngol Head Neck Surg 1999; 120:531-3.

Author’s Reply: Since the publication of my commentary, I have received many letters and telephone calls from academicians, private practitioners, and manuscript reviewers, offering a wide range of comments and suggestions. It seems that my short communication (11⁄2 pages, 1 author!) has touched a painful issue. I am glad I have this opportunity to expand the discussion on this topic. I would like to respond to the comments of Dr Syms and others. Many of Dr Syms’ comments state the obvious, and I certainly agree that we need to publish quality case reports. However, other comments require discussion. Otolaryngology–Head and Neck Surgery 619