The relationship between serum urea levels and outcome in acute epistaxis

OBJECTIVES

To establish whether, for the patient presenting with epistaxis, there is a relationship between clinical outcome and serum urea levels measured on initial attendance at the accident and emergency (A&E) department.

METHODOLOGY

Records were reviewed from all patients attending a single teaching hospital A&E department between 1st January 2010 and 11st February 2011 with a diagnosis of epistaxis. Patients were analysed according to their admission serum urea and creatinine levels and then grouped according to clinical outcome.

RESULTS

We identified 278 patients (145 males, 133 females), 82 of which required hospital admission. Eleven required blood transfusion, and five required surgical arrest of the haemorrhage. No patients died. Serum urea and creatinine levels were measured in 119/278 patients. The mean serum urea level was significantly higher in patients admitted for further management of epistaxis than in patients who were discharged from the A&E department (9.35 mmol/l vs. 6.74 mmol/l, respectively; p = 0.003). There was no significant difference in mean serum urea levels between patients who were transfused and patients who were not, or between patients who went to the operating theatre and patients who did not.

CONCLUSIONS

Elevated serum urea levels on hospital admission are related to more severe clinical outcome in epistaxis.

Otolaryngology WBAs in the Wales Deanery: the first six years

‘The provision of excellent care for the surgical patient, delivered safely, is at the heart of the curriculum.’ 1 Workplace-based assessments (WBAs) are an integral part of the assessment component of the UK’s intercollegiate surgical curriculum. The curriculum is web-based and accessed through www.iscp.ac.uk .

Can early second-look tympanoplasty reduce the rate of conversion to modified radical mastoidectomy?

CONCLUSIONS

Combined approach tympanoplasty (CAT) allows for successful treatment of cholesteatoma with rates of recurrent and residual disease comparable to open mastoid surgery. Early timing of second-look procedures allows easier removal of any recurrent or residual disease, which reduces the conversion rate to open mastoidectomy.

OBJECTIVES

The aims of the study were to report the rates of recurrent and residual cholesteatoma following primary CAT surgery and to report the rate of conversion to a modified radical mastoidectomy.

METHODS

This was a retrospective review of a single surgeon series between 2006 and 2012.

RESULTS

In total 132 second-look operations were undertaken, with a mean interval between primary surgery and second-look procedures of 6 months. The rate of cholesteatoma at second-look surgery was 19.7%, which was split into residual disease (10.6%) and recurrent disease (9.09%). New tympanic membrane defects with cholesteatoma were considered as recurrent disease. Residual disease was defined as cholesteatoma present behind an intact tympanic membrane. The majority of recurrent and residual disease was easily removed at second look (73.1%). Only four cases were converted to a modified radical mastoidectomy (3%) and three cases required a third-look procedure.

Patterns of hospital admission with epistaxis for 26,725 patients over an 18-year period in Wales, UK

INTRODUCTION

Epistaxis is the one of the most common otorhinolaryngology emergencies. This study examined the age and sex distribution of all patients admitted with epistaxis to National Health Service (NHS) hospitals in Wales, UK, over a period of 18 years and 9 months.

METHODS

The Patient Episode Database for Wales was examined for all patient admissions with a diagnosis of epistaxis between April 1991 and December 2009. The age and sex of these patients was recorded and the proportion of the underlying population affected was calculated by comparing admission rates to the population data derived from the 1991 and 2001 national population censuses for Wales.

RESULTS

A total of 26,725 patients were admitted to NHS hospitals in Wales with epistaxis over the period studied. The proportion of the population admitted with epistaxis increased from the age of 40 onwards. For all ages except patients in the 10-14 years group, a higher proportion of the male population was admitted with epistaxis than the comparable female population. This discrepancy was most pronounced between the ages of 15 and 49 years, with the female-to-male ratio of hospital admissions with epistaxis being 0.55. These ages (15 and 49 years) approximate the average age of menarche and menopause respectively in the UK.

CONCLUSIONS

Women of menstrual age have fewer hospital admissions with epistaxis. This may be due to oestrogens providing protection to the nasal vasculature (as they do to other areas of the vascular tree).

Muckle-Wells syndrome: a treatable cause of congenital sensorineural hearing loss

Muckle-Wells syndrome (MWS) is a rare autosomal dominant condition with variable expression. It is a subset of auto-inflammatory diseases characterised by recurrent inflammatory crises and is associated with chronic recurrent urticaria, sensorineural deafness, periodic arthritis and secondary amyloidosis. The diagnosis of MWS is a clinical one with sufferers classically presenting in childhood with a moderate fever and non-pruiginous urticaria. We describe a case of a six-year-old girl who was successfully diagnosed and treated with Anakinra. Muckle and Wells originally described this syndrome in 1962; however, only recently was it discovered to be genetically linked to chromosome 1q44 and subsequently to missense mutations in the CIAS1/NALP3/PYPAF1 gene. Since then, treatment has evolved and it remains one of few treatable causes of congenital profound sensorineural hearing loss.

An assessment of the validity of tympanometry compared to myringotomy performed under a nitrous oxide-free general anaesthetic

To assess the validity of tympanometry as a test for the presence of middle ear effusion using a 'gold-standard' of myringotomy performed after a nitrous oxide-free general anaesthetic, we performed a prospective validity study comparing tympanometry traces obtained immediately pre-operatively from patients undergoing grommet insertion, with the otomicroscopic findings at myringotomy. Nitrous oxide was omitted from the anaesthetic gaseous mixture as it has been reported to displace middle ear effusions. One hundred and seventy-two patients (aged 1.5-15 years) with a clinically assessed 3 month history of middle ear effusion were included in the study. Sensitivity and specificity of a Jerger classification Type B tympanometric trace for the presence of middle ear effusion were 0.73 and 0.84, respectively. We conclude that tympanometry is a valid test in assessing the presence of middle ear effusion compared to a 'gold standard' of myringotomy performed after a nitrous oxide-free general anaesthetic.

Middle meningeal artery hemorrhage: An incorrect name

Extradural hemorrhage is most commonly assumed to result from a middle meningeal artery rupture. This article challenges that assumption. The meningeal vasculature of 29 cadaveric specimens was examined macroscopically and microscopically at the level of the greater wing of the sphenoid bone and foramen spinosum. It was observed that the middle meningeal artery is accompanied by a pair of dural sinuses throughout the majority of its course, thus making exclusively arterial rupture an anatomical improbability. Furthermore, as these dural sinuses pass caudally through the foramen spinosum with the middle meningeal artery, they were seen to diverge to form a plexiform arrangement around the artery. This has not been reported before.