Coronavirus disease 2019: changing the future of emergency epistaxis management.

BACKGROUND: Acute epistaxis can be a life-threatening airway emergency, requiring in-patient admission. The coronavirus disease 2019 pandemic placed significant strain on hospital resources, and management has shifted towards an out-patient-centred approach. METHODS: A five-month single-centre retrospective study was undertaken of all epistaxis patients managed by the ENT department. A pre-coronavirus disease 2019 pandemic group was managed with pre-existing guidelines, compared to new guidelines for the coronavirus disease 2019 pandemic group. A telephone survey was performed on out-patients with non-dissolvable packs to assess patient comfort and satisfaction. RESULTS: A total of 142 patients were seen. The coronavirus disease 2019 pandemic group had significantly more patients aged over 65 years (p = 0.004), an increased use of absorbable dressings and local haemostatic agents (Nasopore and Surgiflo), and fewer admissions (all p < 0.0005). Rates of re-presentation and morbidity, and length of hospital stay were similar. The telephone survey revealed out-patient management to be efficacious and feasible. CONCLUSION: The coronavirus disease 2019 pandemic has shifted epistaxis management towards local haemostatic agents and out-patient management; this approach is as safe and effective as previously well-established regimens.

Improving the management of suspected tonsillitis and peritonsillar abscess referred to ENT - a coronavirus disease 2019 service improvement.

BACKGROUND: The impact of coronavirus disease 2019 on healthcare has led to rapid changes in otolaryngology service provisions. As such, new standard operating procedures for the management of suspected tonsillitis or quinsy were implemented in our centre. METHODS: A retrospective audit was performed of acute referrals to ENT of patients with suspected tonsillitis, peritonsillar cellulitis or quinsy, during the 10 weeks before (group 1) and 10 weeks after (group 2) implementation of the new standard operating procedures. RESULTS: Group 2 received fewer referrals. Fewer nasendoscopies were performed and corticosteroid use was reduced. The frequency of quinsy drainage performed under local anaesthetic increased, although the difference was not statistically significant. Hospital admission rates decreased from 56.1 to 20.4 per cent, and mean length of stay increased from 1.13 to 1.5 days. Face-to-face follow up decreased from 15.0 to 8.2 per cent, whilst virtual follow up increased from 4.7 to 16.3 per cent. There were no significant differences in re-presentation or re-admission rates. CONCLUSION: Management of suspected tonsillitis or quinsy using the new standard operating procedures appears to be safe and effective. This management should now be applied to an out-patient setting in otherwise systemically well patients.

ENT training amongst general practitioners: results from a questionnaire.

OBJECTIVES: To evaluate the level of undergraduate and post-graduate ENT exposure amongst general practitioners and their perceived quality of this training. A secondary aim was to examine whether general practitioners believe ENT department based rotations should remain in the undergraduate curriculum. METHOD: An online questionnaire-based survey was sent to general practices in England. RESULTS: A total of 417 general practitioners completed the questionnaire. Sixty-seven per cent had completed an ENT rotation at medical school whereas 27 per cent had undertaken a postgraduate placement in ENT. Fifty-one per cent had received post-graduate teaching in ENT, mainly in the form of lectures. The majority of general practitioners were not satisfied with their training in ENT at undergraduate and post-graduate levels. Eighty-five per cent of general practitioners believed formal hospital-based ENT training should remain in the undergraduate curriculum. CONCLUSION: General practitioners reported insufficient exposure to ENT during both post-graduate and undergraduate training. Proposals to outsource undergraduate ENT teaching to affiliated departments such as general practice are of concern.

Endoscopic transnasal image-guided approach to diagnosis in orbital apex and optic canal lesions.

OBJECTIVE: Prompted by a recurring skull base multidisciplinary team debate on the necessity of securing a definitive tissue diagnosis before initiating treatment for lesions of the orbital apex, a review of anterior skull base procedures over an 11-year period was undertaken. METHODS: Data collected prospectively on cases from 2006 to 2017 were analysed. Presenting symptoms, imaging and histology findings, outcomes, complications, and impact on treatment were evaluated. All surgery was carried out endoscopically with the aid of image guidance. RESULTS: Twenty-one patients undergoing endoscopic orbital apex and/or optic canal biopsy were included. The mean patient age was 49 years. Five malignant tumours were identified, five benign tumours, seven infective cases (two tuberculosis and five fungal) and two cases of immunoglobulin G4 related disease. Two patients had non-diagnostic biopsies (one lesional) and were treated successfully as Tolosa-Hunt syndrome cases. CONCLUSION: A successful diagnosis was achieved in nearly all cases without adverse impact, other than one cerebrospinal fluid leakage case. Management was directly influenced by the outcome in all cases.

Necrotising otitis externa in the immunocompetent patient: case series.

BACKGROUND: Necrotising otitis externa can be a devastating form of otitis externa. It typically tends to affect patients who are immunocompromised or diabetic. To date, there is very little in the literature about necrotising otitis externa in the immunocompetent patient population. CASE REPORTS: The present paper discusses both the clinical and radiological findings in three cases of necrotising otitis externa in an immunocompetent patient cohort. The common factor among all three patients was their advanced age. CONCLUSION: Diagnosing necrotising otitis externa can be challenging because of the potentially non-specific symptoms and the absence of early radiological signs, particularly if patients are neither immunocompromised nor diabetic. Elderly patients should be considered in the same light as immunocompromised and diabetic patients in the context of necrotising otitis externa.

Disinfection of flexible fibre-optic endoscopes out-of-hours: confidential telephone survey of ENT units in England - 10 years on.

OBJECTIVE: To audit out-of-hours flexible endoscope disinfection practice in England and compare the findings with a previously published first audit cycle, with the 2005 ENT UK guidelines as the key intervention. METHODS: A telephone survey of the 104 ENT units in England was conducted out-of-hours, replicating the first cycle. The on-call clinician answered questions concerning access to flexible endoscopes, training, disinfection procedures and record keeping. Information regarding the clinician's trainee grade and their cross-covering duties was also acquired. Responses were compared to the first cycle results and published guidance. RESULTS: In total, 72 of the 104 units agreed to participate. The on-call clinician cleaned the flexible endoscope in 43 per cent of units. However, adequate training in disinfection only occurred in a minority of units (37 per cent), though this was an improvement from the first cycle (12 per cent). Furthermore, 27 per cent of units used an inadequate method of disinfection out-of-hours. One confounding factor may be the increase in cross-cover out-of-hours, with 68 per cent of respondents covering one or more other specialties. CONCLUSION: An overall moderate improvement in the safety of out-of-hours endoscopy in the past 10 years cannot obscure the urgent need for universal compliance with national guidelines.

Probable mechanisms underlying interallelic complementation and temperature-sensitivity of mutations at the shibire locus of Drosophila melanogaster.

The shibire locus of Drosophila melanogaster encodes dynamin, a GTPase required for the fission of endocytic vesicles from plasma membrane. Biochemical studies indicate that mammalian dynamin is part of a complex containing multiple dynamin subunits and other polypeptides. To gain insight into sequences of dynamin critical for its function, we have characterized in detail a collection of conditional and lethal shi alleles. We describe a probable null allele of shi and show that its properties are distinct from those of two classes of lethal alleles (termed I and II) that show intergroup, interallelic complementation. Sequenced class I alleles, which display dominant properties, carry missense mutations in conserved residues in the GTPase domain of dynamin. In contrast, the sequenced class II alleles, which appear completely recessive, carry missense mutations in conserved residues of a previously uncharacterized "middle domain" that lies adjacent to the GTPase region. These data suggest that critical interactions mediated by this middle domain are severely affected by the class II lethal mutations; thus, the mutant sequences should be very useful for confirming the in vivo relevance of interactions observed in vitro. Viable heteroallelic combinations of shi lethals show rapid and reversible temperature-sensitive paralytic phenotypes hitherto only described for the ts alleles of shi. When taken together with the molecular analysis of shi mutations, these observations suggest that the GTPase domain of dynamin carries an intrinsically temperature-sensitive activity: hypomorphic mutations that reduce this activity at low temperatures result in conditional temperature-sensitive phenotype. These observations explain why screens for conditional paralytic mutants in Drosophila inevitably recover ts alleles of shi at high frequencies.