Prevention of chronic rhinosinusitis.

Prevention of chronicity of disease and minimising its impact with individualized treatment is a fundamental tenet of precision medicine. A review of the literature has been undertaken to explore how this may apply to chronic rhinosinusitis (CRS). Prevention may be thought of across 3 main domains. Primary prevention of CRS focuses on the avoidance of exposure to environmental factors associated with increased incidence of disease. This includes avoidance of tobacco smoke and occupational toxins. Although allergic rhinitis, respiratory infections and gastro-oesophageal reflux have been shown to be risk factors, there is no evidence as yet that treatment of these conditions is associated with reduced incidence of CRS. Secondary prevention of CRS is concerned with detecting a disease in its earliest stages, intervening to achieve disease and symptom control and preventing future exacerbations. Evidence based guidelines facilitate early diagnosis and appropriate use of medical and surgical interventions. In the future the use of endotypes to direct optimal is like to allow more clinically and cost-effective use of current and emerging treatments, such as monoclonal antibodies. Tertiary prevention aims to minimise the impact of an ongoing illness or injury that has lasting effects. Anxiety and depression have been shown to be associated with symptom amplification and may require treatment. The role of disease-related factors such as the role of the microbiome and osteo-neogenesis in the development of chronicity, and the development of severe combined upper airway disease needs further research.

CHronic Rhinosinusitis Outcome MEasures (CHROME), developing a core outcome set for trials of interventions in chronic rhinosinusitis.

STATEMENT OF PROBLEM: Evaluating the effectiveness of treatments in chronic rhinosinusitis (CRS) have been limited by both a paucity of high quality randomised trials, and the heterogeneity of outcomes in those that have been reported. Core outcome sets (COS) are an agreed, standardized set of outcomes that should be measured and reported by future trials as a minimum and will facilitate future meta-analysis of trial results in systematic reviews (SRs). We set out to develop a core outcome set for interventions for adults with CRS. METHOD(S) OF STUDY: A long-list of potential outcomes was identified by a steering group utilising a literature review, thematic analysis of a wide range of stakeholders' views and systematic analysis of currently available Patient Reported Outcome Measures (PROMs). A subsequent e-Delphi process allowed 110 patients and healthcare practitioners to individually rate the outcomes in terms of importance, on a Likert scale. MAIN RESULTS: After 2 rounds of the iterative Delphi process, the 54 initial outcomes were distilled down to a final core-outcome set of 15 items, over 4 domains. PRINCIPAL CONCLUSIONS: The authors hope inclusion of these core outcomes in future trials will increase the value of research on interventions for CRS in adults. It was felt important to make recommendations regarding how these outcomes should be measured, although additional work is now required to further develop and revalidate existing outcome measures.

Recurrent epistaxis: predicting risk of 30-day readmission, derivation and validation of RHINO-ooze score.

BACKGROUND: To derive and validate a predictive scoring tool (RHINO-ooze score) with good sensitivity and specificity in identifying patients with epistaxis at high risk of 30 day readmission and to enable risk stratification for possible definitive intervention. METHODS: Using medical databases, we searched for factors influencing recurrent epistaxis. The information ascertained together with our analysis of retrospective data on patients admitted with epistaxis between October 2013 and September 2014, was used as the derivation cohort to develop the predictive scoring model (RHINO-ooze score). The tool was validated by performing statistical analysis on the validation cohort of patients admitted with epistaxis between October 2014 and October 2015. Multiple linear regressions with backwards elimination was used to derive the predictive model. The area under the curve (AUC), sensitivity and specificity were calculated. RESULTS: 834 admissions were encountered within the study period. Using the derivative cohort (n= 302) the RHINO-ooze score with a maximum score of 8 from five variables (Recent admission, Haemorrhage point unidentified, Increasing age over 70, posterior Nasal packing, Oral anticoagulant) was developed. The RHINO-ooze score had a chi-square value of 99.72 with a significance level of smaller than 0.0001 and hence an overall good model fit. Comparison between the derivative and validation groups revealed similar rates of 30-day readmission between the cohorts. The sensitivity and specificity of predicting 30-day readmission in high risk patients with recurrent epistaxis (RHINO-ooze score equal/larger than 6) was 81% and 84%, respectively. CONCLUSIONS: The RHINO-ooze scoring tool demonstrates good specificity and sensitivity in predicting the risk of 30 day readmission in patients with epistaxis and can be used as an adjunct to clinical decision making with regards to timing of operative intervention in order to reduce readmission rates.

Peri-operative complications of sphenopalatine artery ligation: a 10-year series from two secondary care centres.

BACKGROUND: There is currently limited evidence regarding the potential complications of sphenopalatine artery ligation. The post-operative outcomes at two secondary care centres over a 10-year period were reviewed. METHODS: A retrospective review was undertaken of patients undergoing emergency and elective sphenopalatine artery ligation between January 2011 and January 2021. Their demographics, peri-operative care and post-operative outcomes were recorded. The median follow-up time was 54 days (range, 0-2657 days). RESULTS: Ninety-one patients were included. Four patients (4.4 per cent) had a septal perforation at post-operative review. Nineteen patients (20.9 per cent) had post-operative bleeding that extended their in-patient stay, with five patients (5.5 per cent) requiring revision surgery. Pre-operative non-dissolvable nasal packing was used a median of 1 time (range, 0-8 times). CONCLUSION: Further research on outcomes of sphenopalatine artery ligation is needed. Pre-operative non-dissolvable nasal packing, concurrent septal surgical procedures, surgical techniques, and co-morbidities such as hypertension represent potential confounding factors that could not be further assessed in this small, retrospective study.

The relationship between pressure and volume when using Rapid Rhino(r) packs in the management of epistaxis.

Despite the popularity of Rapid Rhino packs, there are no clear guidelines regarding the volume of air to be inflated when used in the management of epistaxis. The manufacturers suggest that subjective assessment by pilot cuff palpation is used to guide inflation. However, studies have clearly demonstrated that clinicians are poor at judging balloon pressure by pilot cuff palpation when used in other settings. Our objective was to investigate the relationship between the volume of air inflated and the resultant intra-nasal pressure generated by nasal balloon packing. Twelve healthy subjects were packed with 5.5 cm Rapid Rhino packs, which were connected to a manometer and 20 ml syringe via a 3-way tap in a closed circuit. Increments of 2.5 mls of air were inflated and the resultant intra-nasal pack pressure was measured. There appeared to be a linear relationship between increasing volume and pack pressure. However, between individuals, there was a large variation in the intra-nasal pack pressure produced for a given fixed volume of air inflated. This is presumably due to variations in nasal anatomy. It may be that a manometer-measured, pressure guided nasal pack inflation technique would represent best practice, especially for less experienced staff.

Improving tracheostomy care: a prospective study of the multidisciplinary approach.

OBJECTIVES: Suboptimal standards in tracheostomy care have been highlighted as a growing concern in view of the increasing demands for intensive care services. Our objective is to assess the impact of our model for tracheostomy care on patients with short-term tracheostomies (<4 months in situ) following their discharge from the intensive care unit. The model has three components: The St Mary's tracheostomy care bundle checklist, a dedicated tracheostomy multidisciplinary team and an educational programme. DESIGN: A 38-month prospective cohort study. SETTING: A London Teaching Hospital. PARTICIPANTS: A total of 102 patients with tracheostomy within the 19-month pre-intervention cohort and 95 patients in the 19-month post-intervention cohort. MAIN OUTCOME MEASURES: The number of clinical incidents, mean time taken for decannulation, mean total tracheostomy time and total number of days spent in the intensive care unit were assessed before and after the intervention. RESULTS: Time to decannulation following intensive care unit discharge decreased from 21 to 11 days, as did the mean total tracheostomy time, from 34 to 25 days (both statistically significant with a P < 0.0001 Mann-Whitney U-test). The number of critical incidents, which included all patients prior to exclusion, substantially declined following the introduction of intervention from 58 to 7 in the second year after intervention. CONCLUSIONS: A multidisciplinary care model significantly expedited the decannulation process and reduced the overall time that a tracheostomy was in situ. The intervention was associated with a reduction in clinical incidents and shorter intensive care unit admissions, which can be associated with significant monetary savings.

Driving standards in tracheostomy care: a preliminary communication of the St Mary's ENT-led multi disciplinary team approach.

OBJECTIVES: To assess tracheostomy care and improve standards following the introduction of an ENT-led multidisciplinary tracheostomy ward round service. DESIGN: Prospective third cycle audit. SETTING: Tertiary academic London hospital serving an inner city population of multi-ethnic background (St Mary's Hospital, Paddington, London). PARTICIPANTS: Patients with a tracheostomy discharged from ITU to general wards. IMPLEMENTED ACTIONS: Establishment of an ENT-led Tracheostomy Multidisciplinary Team (TMDT). Weekly TMDT ward round to manage patients with a tracheostomy. ENT-led educational and training sessions for allied healthcare professionals. MAIN OUTCOME MEASURES: Compliance with local tracheostomy care guidelines (St Mary's tracheostomy care bundle) and time to tracheostomy tube decannulation. RESULTS: Preliminary results of 10 patients show improved compliance with tracheostomy care guidelines, established in 2004, rising to 94%. Average time to decannulation was significantly reduced from 21 to 5 days (P-value = 0.0005, Mann Whitney Wilcoxon Test). The mean total tracheostomy time was reduced from 34 to 24 days although this was not statistically significant (P-value = 0.13, Mann Whitney Wilcoxon Test). CONCLUSIONS: The introduction of regular ENT-led multidisciplinary input for patients with a tracheostomy significantly improved compliance with nursing care standards. There was also a reduction in the total length of time tracheostomy tubes remain in situ, with time to decannulation significantly reduced.

A survey of how and why medical students and junior doctors choose a career in ENT surgery.

OBJECTIVE: To ascertain determinants of an interest in a career in ENT surgery through a survey of medical students and junior doctors. METHODS: A survey was administered, comprising Likert scales, forced response and single option questions, and free text responses, at five different courses or events for those interested in a career in ENT. RESULTS: The survey had an 87 per cent response rate; respondents consisted of 43 applicants for national selection, 15 foundation doctors and 23 medical students. The most important factors that encourage ENT as a career included: the variety of operative procedures, work-life balance, inherent interest in this clinical area and inspirational senior role models. Exposure to ENT in undergraduate or post-graduate training is critical in deciding to pursue this specialty. CONCLUSION: It is important to promote those aspects of ENT surgery that attract people to it, and to argue for greater exposure to ENT during undergraduate and post-graduate training.

The dangers of kite flying: pseudoaneurysm of the facial artery following blunt trauma.

OBJECTIVE: Pseudoaneurysms of the facial artery are an extremely rare development after blunt trauma. This paper aims to demonstrate the challenges faced during the diagnosis and subsequent management of this unusual cause of neck swelling. METHOD: We report the presentation, examination, investigation, management and potential complications of a case of facial artery pseudoaneurysm secondary to blunt arterial trauma, sustained from the string of a flying kite. We also review some of the relevant literature on this subject. CONCLUSIONS: Although a traumatic pseudoaneurysm is a rare occurrence in the facial region, the inclusion of this lesion in the differential diagnosis of soft tissue lesions caused by blunt trauma is important if the serious consequences of haemorrhage or thromboembolic disease are to be avoided. Prompt access to radiological imaging, and multi-disciplinary team input, are essential for effective diagnosis and management.