Epistaxis management at Guy's Hospital, 2009-2011: full audit cycles

Endoscopic Sphenopalatine Artery Ligation: General Applicability in a Teaching Unit

BACKGROUND:

Endoscopic sphenopalatine artery ligation (ESPAL) is the intervention of choice for refractory epistaxis in specialist ear, nose and throat (ENT)units and should be within the repertoire of competencies for all ENT trainees. Following its recent incorporation within the United Kingdom competency-based training syllabus as an explicit outcome standard, the ESPAL is not uncommonly being delivered by trainees under appropriate supervision. We assessed the efficacy and outcome of ESPAL in epistaxis management within our teaching hospitals.

METHODS:

Retrospective, structured review of all ESPAL procedures performed for epistaxis between December 2005 and December 2013. The techniques of ligation, operator grade, and outcome were studied.

RESULTS:

Sixty-five patients (41 male:24 female; average age of 58.2 years) were identified in whom 67 artery ligations were performed (63 unilateral; 2 bilateral). Overall, success rate of ESPAL was 92.3% (60/65), with 5 rebleed cases recorded within 30 days of the primary procedure. Sixteen (24.6%) underwent "clipping," 26 (40.0%) had diathermy ligation, 18 (27.7%) had both clipping and diathermy, and in 5 (7.7%) patients, the ligation technique was not recorded. In 31 (47.7%) of 65 cases, a consultant was the principal surgeon. The remaining 34 (52.3%) of 65 cases were performed by trainees with (24, 70.6%) or without (10, 29.4%) supervision. There was no correlation between rebleed and operators' grade, level of supervision, or ligation technique.

CONCLUSION:

With appropriate training, ESPAL can achieve hemostasis in teams of varying grades of operators without significant reduction in outcome. To further enhance the technical learning curve, the utility of simulation-based training could offer continuous and longitudinal development of skills.

Prophylactic systemic antibiotics for anterior epistaxis treated with nasal packing in the ED

BACKGROUND

Emergency Department (ED) patients presenting with spontaneous epistaxis who have anterior nasal packing are routinely prescribed systemic prophylactic antibiotics in spite of the lack of supporting evidence-based literature. Although there is literature that discusses infection rates with nasal packing for epistaxis and prophylactic antibiotics prescribing practices of otolaryngologists, this is the first study to our knowledge that examines the practices of emergency physicians.

OBJECTIVES

The main objective of this study was to compare the infection rate between patients who were and were not prescribed prophylactic systemic antibiotics for anterior nasal packing in spontaneous epistaxis and to examine current management practices of antibiotic prescribing for these patients.

METHODS

A retrospective review of ED patients ≥ 18 years old with the discharge diagnosis of epistaxis was performed over a 5-year period. Patients who had multiple visits to the ED for epistaxis or recent nasal or sinus surgery were excluded.

RESULTS

Over half of the patients, 57/106 (53.7%), who had anterior packing were prescribed prophylactic systemic antibiotics. Of these patients, 69/106 (65%) returned for a follow-up visit. There were no documented infections for any of these patients regardless of whether or not they were prescribed antibiotics. There was no significant difference with respect to rate of infection found between these two groups (the p-value = 0.263).

CONCLUSION

The absence of infection supports previous findings and suggests that prophylactic antibiotic use for nasal packing in spontaneous epistaxis patients is not necessary. Further randomized controlled studies are necessary to definitively support this practice change.

Endoscopic sphenopalatine artery ligation for acute idiopathic epistaxis. Do anatomical variation and a limited evidence base raise questions regarding its place in management?

BACKGROUND

Endoscopic sphenopalatine artery ligation is widely accepted as effective and safe for acute spontaneous epistaxis that is unresponsive to conservative management. As with many new procedures, it has been progressively adopted as common practice, despite a limited evidence base for its efficacy. Early reviews called for comparative trials to support its adoption, but subsequent literature largely consists of case series and narrative reviews. These have attempted to derive an algorithm to establish its place in management, but consensus is still lacking. Intuitively, although there are theoretical objections, an operation regarded as relatively simple, fast and safe hardly seems to demand high-level evidence of efficacy. Rhinologists may be influenced by years of personal experience and success with the technique. However, estimates of the effect size and the added contribution to traditional surgical management are lacking. If the procedure could be shown to dramatically influence outcome, it should be standard practice and indispensable for all patients requiring operative intervention.

OBJECTIVES

This paper systematically examined the literature, appraising the anatomical basis for such an approach and evidence for its efficacy. It questions whether any units unable to consistently offer endoscopic sphenopalatine artery ligation should be undertaking surgical management of acute epistaxis.

Evaluation of a novel high-fidelity epistaxis task trainer

OBJECTIVES/HYPOTHESIS

To assess the efficacy of a novel high-fidelity epistaxis simulator in teaching epistaxis management to junior otolaryngology head and neck surgery residents.

STUDY DESIGN

Prospective cohort study.

METHODS

A novel high-fidelity epistaxis task trainer was developed using a cadaver head, intravenous tubing, and a food coloring-filled saline bag to emulate blood. Learners were instructed on two techniques of nasal packing (formal nasal pack and nasal tampon) for the management of epistaxis using the task trainer. Learners were videotaped attempting to pack the nose of the task trainer pre- and postintervention (verbal instruction, and practice time with task trainer). Five board-certified otolaryngologists (blinded to pre- and postintervention status) evaluated the packing technique using standardized subjective outcome measures.

RESULTS

There were 13 junior otolaryngology residents enrolled in the study. This cohort showed a statistically significant increase in global rating scores (P < 0.05) in all items measured for both packing methods.

CONCLUSION

This novel cadaveric epistaxis simulator has been successful in teaching and the practical application of various skills in epistaxis management. This task trainer appears to confer an educational benefit in technical skills acquisition in novice learners. Further studies are needed to determine long-term skill retention. Simulation is a promising educational adjunct that effectively enhances epistaxis management skills acquisition while maximizing patient safety.

LEVEL OF EVIDENCE

NA. Laryngoscope, 126:1501-1503, 2016.

A multi-centre audit of epistaxis management in England: is there a case for a national review of practice?

OBJECTIVE

The ENT-UK Clinical Audit and Practice Advisory Group initiated a pilot audit to investigate variance in epistaxis management between six units nationwide.

METHOD

All patients with a diagnosis of epistaxis who were admitted for in-patient care at six ENT departments between November 2011 and February 2012 were prospectively enrolled.

RESULTS

A total of 166 patients were included in the study. Variance was demonstrated between the six units in a number of the key outcome areas. Twenty-eight per cent of patients were identified as eligible for operative intervention for epistaxis in one unit, compared with only 12.5 per cent in another.

CONCLUSION

There are measurable, patient-relevant outcomes to assess epistaxis management and these can highlight areas of potential improvement. This pilot audit gives a snapshot of modern practice, which shows variance between the six units assessed. A national audit may allow us to improve patient experience and maximise efficiency in delivering emergency care in our most common patient encounter.