The management of posterior epistaxis in the United Kingdom, a national survey

Background: Posterior bleeds account for 5% of epistaxis. The patient cohort is often elderly and has significant co-morbidities. Such cases have been managed historically with urinary catheters, held in place with umbilical clips. Recently bespoke, double balloon, posterior packs have been utilised. The treatments remain in clinical equipoise with no gold standard or clear national guideline. Methodology: A ten question survey was sent out through www.surveymonkey.com. Attempts were made to contact all Trusts in the United Kingdom via the ENT on call service. A comparison of treatment costs was made. Results: 112 responses have been received. 54% of respondents reported a preference for bespoke posterior pack insertion, only 12% preferred catheters. Twice as many respondents have seen complications from urinary catheters: 14% vs 29%. The availability of posterior packs is inconsistent: 30% of respondents were not aware of the packs or reported them unavailable in their hospital. Conclusions: This survey provides the first comparison of the techniques in the United Kingdom. Bespoke packs have a lower complication rate and are preferred by ENT clinicians on the front line of patient care. We recommend that all UK trusts should stock posterior packs which should be used as first line treatment for cases of posterior epistaxis.

Exploring the association between ingestion of foods with higher potential salicylate content and symptom exacerbation in chronic rhinosinusitis. Data from the National Chronic Rhinosinusitis Epidemiology Study

INTRODUCTION

Pharmacological salicylates are known to trigger respiratory exacerbations in patients with Non-Steroidal Exacerbated Respiratory Disease (N-ERD), a specific phenotype of Chronic Rhinosinusitis (CRS) and asthma. The impact of dietary sources of salicylates across subgroups of CRS is not well understood. The hypothesis is that in patients with nasal polyps present, there is likely to be a higher incidence of symptom exacerbation due to dietary salicylates regardless of any known response to pharmacological salicylate.

METHODS

The Chronic Rhinosinusitis Epidemiology Study (CRES) was a questionnaire-based case-control study which sought to characterise the UK CRS population in terms of sociological, economic and medical factors. Using specific questions to examine participant responses relating to symptom exacerbation from food groups thought to be high in salicylate content, this analysis of the CRES database sought to compare an estimate of the prevalence of dietary sensitivity due to food with higher potential salicylate content across patients with CRS with (CRSwNPs) and without nasal polyposis (CRSsNPs) and with allergic fungal rhinosinusitis (AFRS).

RESULTS

The CRSwNPs group were significantly more likely than controls to report symptom exacerbation due to ingestion of food groups with higher potential dietary salicylate content. The same trend was observed amongst CRSsNPs participants to a lesser degree. Reported response to the individual specific food groups wine, nuts, spicy foods, fruit and vegetables demonstrated that a statistically significant proportion of CRSwNPs and AFRS participants reported sensitivity to wine.

CONCLUSIONS

This analysis suggests that there is an association between symptom exacerbation in response to food products with higher potential salicylate content, specifically wine, in CRS patients both with and without nasal polyposis when compared to controls, but especially in the CRSwNPs and AFRS phenotypes. Further studies are needed to detail if this relationship represents a causal relationship to dietary salicylate. The data present the possibility that a wider group of CRS patients may elicit salicylate sensitivity than those with known N-ERD.

Chronic rhinosinusitis and mood disturbance

BACKGROUND

This study is part of the Chronic Rhinosinusitis Epidemiology Study (CRES). The overarching aim is to determine factors that influence the onset and severity of chronic rhinosinusitis (CRS). The aim of this analysis is to determine whether those with CRS are more likely to report psychiatric morbidity and in particular mood disturbance compared with healthy controls.

METHODS

CRES consists of a study-specific questionnaire regarding demographic and socioeconomic factors and past medical history as well as a nasal symptom score (SNOT-22) and SF-36 (QoL - quality of life tool). Both of these tools contain mental health or emotional well-being domains. Participants were specifically asked whether they had ever consulted with their General Practitioner for anxiety or depression. Questionnaires were distributed to patients with CRS attending ENT outpatient clinics at 30 centres across the United Kingdom from 2007-2013. Controls were also recruited at these sites. Patients were divided into subgroups of CRS according to the absence/presence of polyps (CRSsNPs/CRSwNPs) or allergic fungal rhinosinusitis (AFRS).

RESULTS

Consultations with a family physician for depression or anxiety were higher amongst those with CRS than controls, but this was only significant for those with CRSsNPs. Odds ratio (OR) for CRSsNPs vs controls: 1.89; OR for CRSwNPs: 1.40. Patients with CRS showed significantly higher mental health morbidity than controls across the mental health and emotional wellbeing domains of the SF-36 and SNOT-22. Mean difference in the mental health domain of SF-36 was 8.3 for CRSsNPs and 5.3 for CRSwNPs. For the emotional domain of SNOT-22, differences were 7.7 and 6.3 respectively.

CONCLUSIONS

Depression and anxiety are significantly more common in patients with CRS compared to healthy controls, especially in those with CRSsNPs. This added mental health morbidity needs consideration when managing these patients in primary and secondary care settings.

A cross sectional analysis of a case-control study about quality of life in CRS in the UK; a comparison between CRS subtypes

BACKGROUND

The Sinonasal Outcome Test (SNOT-22) has been used as a patient reported outcome measure to grade symptom severity before and after treatment for chronic rhinosinusitis (CRS).

METHODOLOGY

This analysis uses data from the CRS Epidemiology Study (CRES). The overarching aim of CRES was to determine factors that influence the onset and severity of CRS. A study-specific questionnaire including SNOT-22 was distributed to patients with CRS attending ENT clinics across 30 centres in the United Kingdom. The aim of this analysis was to compare SNOT-22 scores between those with different types of CRS to determine any differences present in the total score or the subdomains and to assess whether any differences varied according to gender.

RESULTS

There were a total of 1249 CRS participants in the following subgroups: CRS without nasal polyps (CRSsNPs) (n=553), CRS with nasal polyps (CRSwNPs) (n=651), allergic fungal rhinosinusitis (AFRS) (n=45). Since there were differing gender ratios in each subgroup, males and females were analysed separately. The mean and standard deviation for SNOT-22 was: males CRSsNP 41.1 (21.0), CRSwNP 41.7 (20.5); females CRSsNP 49.6 (19.7), CRSwNP 49.5 (22.9). In the nasal domain, those with CRSwNP scored more highly than those with CRSsNP; for males 18.1 (8.1) vs. 15.9 (7.9); for females 19.6 (8.0) vs 16.7 (7.5).

CONCLUSIONS

Patients with CRSwNPs report higher symptom scores in the nasal domain of SNOT-22 than those with CRSsNPs with women in both subgroups reporting higher total scores than men.

Cost-efficiency of endoscopic and external dacryocystorhinostomy

Background:

In most centres in the United Kingdom, endoscopic dacryocystorhinostomy is currently undertaken as a joint operation between ophthalmologists and otolaryngologists. The addition of an extra surgeon, the use of endoscopic equipment and the relatively lower success rate of this procedure made us compare endoscopic dacryocystorhinostomy and external dacryocystorhinostomy with regards to costs and income for our hospital.

Methods:

All 38 primary endoscopic dacryocystorhinostomy cases performed in our centre in 2001–2003 were retrospectively compared with the 49 external dacryocystorhinostomy cases performed in 1993–2000. Cost–income calculations were made based on: rate of local anaesthesia, success rate, rate of day case admission, hospital reference cost for dacryocystorhinostomy, and the income per case extracted from national tariffs (based on the Health Resources Group). Also, the average number of cases per session was used to calculate the income gained per session for each method.

Results:

The following rates between the endoscopic and the external dacryocystorhinostomy were found: local anaesthesia, 29 vs 6 per cent, respectively; day-case operation, 95 vs 12 per cent, respectively; and success rate, 87 vs 94 per cent, respectively. The average number of endoscopic dacryocystorhinostomy cases conducted in a single theatre session was twice that of external dacryocystorhinostomy cases. Endoscopic dacryocystorhinostomy generated approximately twice the income of external dacryocystorhinostomy (£6585 vs £3292, respectively).

Conclusion:

Endoscopic dacryocystorhinostomy is more cost-effective than external dacryocystorhinostomy, despite having a lower success rate and greater usage of resources, as the endoscopic procedure generates more income. This is mainly due to the higher number of cases per session and the higher rates of local anaesthesia and day case operations possible.

Post-tonsillectomy morbidity statistics: are they underestimated?

Background:

Post-tonsillectomy morbidity statistics are obtained when patients present to hospital with complications. The two common morbidities are pain and haemorrhage. Hospital-recorded morbidity rates may be an underestimation, as some patients are treated by general practitioners and are therefore not included in hospital audits.

Methods:

Prospective, cohort, questionnaire study to assess: the post-tonsillectomy haemorrhage rate (i.e. actual rate versus hospital recorded rate); and the number of patients with post-operative pain and/or bleeding who were treated with antibiotics by their general practitioner.

Results:

The response rate was 76 per cent (70/92). The actual rate of secondary haemorrhage was three times that noted in the hospital records (15.7 vs 5.7 per cent, respectively). Fifteen patients (21 per cent) required extra analgesia after discharge. General practitioners prescribed antibiotics for pain alone in six patients (11 per cent).

Conclusion:

The actual post-tonsillectomy haemorrhage rate is much higher than that recorded in hospital statistics. General practitioners differ in their treatment of post-tonsillectomy patients presenting with pain alone; some prescribe antibiotics in addition to analgesia.

Grisel syndrome: a delayed presentation in an asymptomatic patient

Grisel syndrome is a rare condition characterised by atlanto-axial subluxation following an inflammatory process in the head and neck region. It occurs more commonly in children and usually presents with cervical pain and torticollis, in addition to symptoms of the primary infection. We present the case of an asymptomatic 78-year-old man who was incidentally found to have atlanto-axial subluxation on a routine follow-up computed tomography scan, three months following successful treatment of a skull base infection. This case emphasises the importance of appropriate follow-up imaging for patients with skull base infections, even if they respond clinically to medical treatment.

How we do it: cost-benefit analysis of implementing a telephone review system in an ENT outpatient setting

There is an increasing pressure on the National Health Service (NHS) hospital consultants to reduce the waiting times. We have used an optional telephone review for a certain number of our outpatients so as to reduce the need for their in-person attendance. The result of our study, which was conducted in two phases, showed that almost half of the telephone follow-up patients (48%) were discharged over the phone. There was a direct saving of approximately 30 pounds per patient having a telephone follow-up.

Silencing the snorers: no gain without pain?

Objective: To compare the estimated effects of conservative surgery to those of a mandibular advancement splint (MAS) in the treatment of habitual snoring.

Method: Prospective, observational, non-randomized cohort study.

Results: Adequate follow-up data were available for 88 participants (23 following coblation, 65 after provision of an MAS). The mean reduction in snoring symptoms inventory (SSI) score for the 23 subjects undergoing coblation was 9.83 (± standard deviation 11.43). Reported pain duration was greatest with uvula amputation, but uvula coblation did not always adequately reduce its bulk. Of the 65 MAS patients, 39 (60 per cent) used the device regularly, with a mean fall in SSI of 12 (±16.4, p = 0.001). Approximately one in four patients in both groups achieved a significant fall in SSI (>15 points), and the measured effect sizes were close to 0.75 for both treatments.

Conclusions: Mandibular advancement splints and coblation have similar efficacies. However, their efficacy does not match that of radical surgery.

Conservative management of epistaxis: are we putting patients at risk of developing venous thromboembolic complications?

A retrospective study of 1585 patients, admitted with epistaxis to a busy District General Hospital in the United Kingdom between 1990 and 2000, was undertaken in order to identify the relationship between hospital admission for epistaxis and the development of a venous thromboembolic event. Only one person (0.06%) developed pulmonary embolus (PE) within 6 weeks of hospital admission. No one developed a deep vein thrombosis (DVT). This compares with the incidence of DVT and fatal PE in the general population. In our study population, the incidence of both PE and DVT was found to be no greater than that seen within the community and certainly less than the incidence seen within a group of high risk hospitalised patients. We conclude that hospital admission for epistaxis does not place the patient at increased risk of thromboembolic disease.

Cochlear implantation in patients with MELAS syndrome

MELAS syndrome (mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes) is a rare congenital disorder of mitochondrial DNA (mt-DNA). Patients with this syndrome may present to the otolaryngologist with sensorineural hearing loss (SNHL) that is genetic in origin. Mitochondrial cytopathies can present with a variety of symptoms, but they occasionally present with SNHL as their first manifestation. Two cases of MELAS patients who responded well to cochlear implantation are presented. A review of the literature is also carried out focusing mainly on diagnosis, anesthetic considerations and management of these patients.