Epistaxis: A guide to assessment and management.

Is your patient's nosebleed a self-limiting occurrence, or a sign of something more worrisome? And which treatments are best in which situations?

Assessment of human sinus cavity air volume using tunable diode laser spectroscopy, with application to sinusitis diagnostics.

Sinusitis is a very common disease and improved diagnostic tools are desirable also in view of reducing over-prescription of antibiotics. A non-intrusive optical technique called GASMAS (GAs in Scattering Media Absorption Spectroscopy), which has a true potential of being developed into an important complement to other means of detection, was utilized in this work. Water vapor in the frontal sinuses, related to the free gas volume, was studied at around 937 nm in healthy volunteers. The results show a good stability of the GASMAS signals over extended times for the frontal sinuses for all volunteers, showing promising applicability to detect anomalies due to sinusitis. Measurements were also performed following the application of a decongestion spray. No noticeable signal change was observed, which is consistent with the fact that the water vapor concentration is given by the temperature only, and is not influenced by changes in cavity ventilation. Evaluated GASMAS data recorded on 6 consecutive days show signal stability for the left and right frontal sinus in one of the test volunteers.

Co-phenylcaine Forte spray: innovative ways of minimising cost.

OBJECTIVE: To investigate whether multiple-use Co-phenylcaine Forte® spray was more cost-effective than single-use vials. METHODS: A literature review was conducted to determine the risk of cross-contamination associated with multiple-use topical nasal anaesthetic spray. The costs of multiple-use Co-phenylcaine Forte and single-use co-phenylcaine were compared, and potential savings were calculated. The cost of procuring these drugs from other sources was also examined. RESULTS: Switching to multiple-use Co-phenylcaine Forte spray would lead to at least 40 per cent savings if bought from our local retailer. Potential savings of more than 70 per cent could be made if the drugs were procured from sources other than our local distributor. CONCLUSION: Multiple-use Co-phenylcaine Forte spray is safe to use and more cost-effective than single-use vials. This paper illustrates how money can be saved within the National Health Service through changes in drug procurement. Similar cost savings to those calculated for our department could be made in other ENT departments nationally, depending on their annual consumption of co-phenylcaine.

An assessment of the quality of care provided to orthognathic surgery patients through a multidisciplinary clinic.

The quality of care delivered to 74 patients undergoing orthognathic surgery was assessed using a patient satisfaction questionnaire and data collected from hospital case records. Surgical complications, hospital services, patient satisfaction, and impact on quality of life, were the main aspects considered. The majority of patients reported that their treatment objectives had been achieved and that they were satisfied with the quality of care provided. The main concern of the patients regarding the clinic was the waiting time before an appointment could be offered. Eating and breathing difficulties and low mood after surgery were the main reported complications. Sixty-three patients experienced post-operative weight loss. The importance of a nutritious, high calorie soft diet should be emphasised and the use of menthol inhalations following maxillary osteotomies should be considered more frequently. Clinicians should be aware of post-operative low mood, which may require psychological support. We developed a sensitive assessment battery with comprehensive parameters to audit quality of orthognathic surgery service, and recommend that a similar approach should be considered by teams which undertake management of orthognathic patients.

Assessment of nasal spray deposition pattern in a silicone human nose model using a color-based method.

PURPOSE: To develop a simple and inexpensive method to visualize and quantify droplet deposition patterns. METHODS: Deposition pattern was determined by uniformly coating the nose model with Sar-Gel (a paste that changes from white to purple on contact with water) and subsequently discharging sprays into the nose model. The color change was captured using a digital camera and analyzed using Adobe Photoshop. Several tests were conducted to validate the method. Deposition patterns of different nasal sprays (Ayr, Afrin, and Zicam) and different nasal drug delivery devices (Afrin nasal spray and PARI Sinustar nasal nebulizer) were compared. We also used the method to evaluate the effect of inhaled flow rate on nasal spray deposition. RESULTS: There was a significant difference in the deposition area for Ayr, Afrin, and Zicam. The deposition areas of Afrin nasal spray and PARI Sinustar nasal nebulizer (2 min and 5 min) were significantly different. Inhaled flow rate did not have a significant effect on the deposition pattern. CONCLUSIONS: Lower viscosity formulations (Ayr, Afrin) provided greater coverage than the higher viscosity formulation (Zicam). The nebulizer covered a greater surface area than the spray pump we evaluated. Aerosol deposition in the nose model was not affected by air flow conditions.

Clinical assessment of nasal decongestion test by VAS in adolescents.

Nasal airflow, as measured by rhinomanometry, is frequently impaired in allergic rhinitis (AR). The decongestion test evaluates whether the application of an intranasal vasoconstrictor drug increases nasal airflow. The aim of this study was to verify the suitability of the use of the visual analogue scales (VAS) as a surrogate for rhinomanometry in the decongestion test assessment in adolescents with atopic rhinitis. Forty adolescents [16 males and 24 females, mean age 15 (s.d. 2) yr] with AR were studied. Nasal symptoms, VAS, rhinomanometry, and nasal decongestion test were assessed in all patients. A significant association was observed between VAS and nasal airflow after performing the decongestion test (Spearman's r is -51.7%, p < 0.001). The associated sensitivity and specificity were 84.8 (95% confidence interval, CI 68.1-94.8) and 85.7 (95% CI 42.2-97.6), respectively. The corresponding area under the receiver operating characteristic (ROC) curve of 0.83 (95% CI 0.67-0.93) indicated a good discriminating ability for the decongestion measured on the VAS scale. In conclusion, the use of VAS appears as clinically relevant, in that it allows, with a fair reliability, to perform the decongestion test in the absence of rhinomanometry.

Clinical assessment of a nasal decongestion test by visual analog scale in allergic rhinitis.

BACKGROUND: Nasal airflow, as measured by rhinomanometry, is frequently impaired in allergic rhinitis (AR). The decongestion test evaluates whether the application of an intranasal vasoconstrictor drug increases nasal airflow. That allergy is characterized by inflammation and that the response to the decongestion test correlates with the grade of inflammatory reaction has previously been shown. The aim of this study was to verify the suitability of the use of the visual analog scales (VASs) as a surrogate for rhinomanometry in the decongestion test assessment in patients with persistent allergic rhinitis. METHODS: One hundred three patients (mean age, 23 years [2.24 SD]) were studied. Nasal symptoms, VAS, rhinomanometry, and nasal decongestion test were assessed in all patients. RESULTS: A significant association was observed between VAS and nasal airflow after the decongestion test (Spearman R = -33.3%; p < 0.001). Moreover, a significant inverse association between changes in decongestion measures was detected, with a Spearman R = -64.7% (p < 0.001). The associated sensitivity was of 92.5%, and the specificity for this test was 60.0%. The corresponding area under the receiver operating characteristic curve was 0.81. CONCLUSION: The use of VAS for assessing the decongestion test appears clinically relevant in that it allows, with a fair degree of reliability, such a test to be performed in the absence of rhinomanometry.

[Rhinitis medicamentosa in cytological assessment of the nasal mucosa]. / Polekowy niezyt nosa w cytologicznej ocenie blony sluzowej nosa.

Long term use of topical vasoconstrictors for the nose may result in rhinitis medicamentosa, the rebound swelling of the nasal mucosa. Usually discovery of any underlying reason for decongestant use is impossible, therefore treatment could be problematic. The aim of this study was to establish the nasal mucosal cytology of patients with rhinitis medicamentosa and evaluation of usefulness of exfoliative cytology in diagnostics of underlying reason of nasal decongestants overuse. All patients had a history of six months regular use of popular intranasal alpha-adrenomimetics. All patients have used them constantly with different frequency in 24 h, but always before sleep. The exfoliative cytology was used as a method of nasal mucosa evaluation. Normal cytograms in rhinitis medicamentosa were in 16.4%. Cytograms of 13.4% patients showed a significant number of eosinophils and 29.9% predominant of squamous metaplasia. The study showed that the majority of cytograms in rhinitis medicamentosa indicates nasal mucosa injury. Method of the exfoliative cytology could facilitate the establishment of the underlying cause of intranasal decongestants overuse.

Comparison of cefuroxime with or without intranasal fluticasone for the treatment of rhinosinusitis. The CAFFS Trial: a randomized controlled trial.

CONTEXT: It is not known whether intranasal corticosteroids are beneficial to treat acute rhinosinusitis in patients with a history of chronic or recurrent sinus symptoms. OBJECTIVE: To assess whether the addition of an intranasal corticosteroid to antibiotic therapy affects the speed and rate of recovery of such patients with acute rhinosinusitis. DESIGN, SETTING, AND PATIENTS: A double-blind, randomized, placebo-controlled multicenter trial of 95 patients (median age, 39 years) with a history of recurrent sinusitis or chronic rhinitis and evidence of acute infection by sinus radiograph or nasal endoscopy, which was conducted from October 1998 through April 2000 at 22 sites (12 primary care and 10 otolaryngology). INTERVENTION: Two puffs (total dose, 200 microgram) of fluticasone propionate (n = 47) or placebo nasal spray (n = 48) in each nostril once daily for 21 days; all received 2 puffs of xylometazoline hydrochloride in each nostril twice daily for 3 days and 250 mg of cefuroxime axetil twice daily for 10 days. MAIN OUTCOME MEASURE: Time to clinical success (patient reported cured or much improved) during telephone follow-up at 10, 21, and 56 days. RESULTS: A total of 88 patients (93%) completed follow-up. Patients recorded their symptoms, work assessment, and compliance during the 3-week treatment phase. Patients receiving fluticasone achieved a significantly higher rate of clinical success than patients receiving placebo (93.5% vs 73.9%; P =.009). Patients treated with fluticasone improved significantly more rapidly (median of 6.0 days to clinical success) vs patients in the placebo group (median of 9.5 days; P =.01). CONCLUSIONS: The addition of fluticasone to xylometazoline and antimicrobial therapy with cefuroxime improves clinical success rates and accelerates recovery of patients with a history of chronic rhinitis or recurrent sinusitis who present for treatment of acute rhinosinusitis.

Cost-effective pharmacotherapy for allergic rhinitis.

This article provides guidelines for pharmacotherapy to maximize symptom relief from allergic rhinitis. Consideration of frequency, severity, and site of symptoms is important in directing pharmacotherapy efficacy and maximizing cost-effectiveness. The agents available include antihistamines, decongestants, steroids, mast cell stabilizers, anticholinergic agents, and mucolytics. Appropriate indications for each and combinations of various agents are discussed within the context of drug efficacy, side effects, affordability, and ease of compliance. The direct and indirect costs of allergic rhinitis are not well delineated but are explored to put the costs of therapy in perspective.

Correlations between subjective sensation of nasal patency and rhinomanometry in both unilateral and total nasal assessment.

The correlation between rhinomanometry and subjective sensation of nasal obstruction was studied. Patients assessed their nasal airway patency using a visual analogue scale (VAS). The VAS results and rhinomanometry correlated better when unilateral nasal obstruction was evaluated compared to total nasal evaluation. When rhinomanometric data were divided into four clinically relevant grades of obstruction (very patent, normal, obstructed and very obstructed) and the quartiles of the VAS results were compared to these, the agreement was good or fairly good in 75-85% of cases. A similar result was also encountered when, in an experimental study, 30 individuals were asked to breathe through four artificial nose models with a varying inner diameter of 9-3 mm. Again, most subjects assessed these models logically, but in 11% of the cases the subject assessed the narrowest tube as patent or the widest tube as very obstructed. Our results prove the necessity of having some sort of objective method to evaluate nasal patency; if we rely only on the patient's sensation, we may get a misleading picture of his nasal function.

Consumo de medicamentos por prescriçäo médica num centro de saúde do município de Ribeiräo Preto - SP, 1988 / Consumption of medicine by prescription of pedriatrians in the Health Service at Ribeiräo Preto - SP, 1988

Estudo desenvolvido num Centro de Saúde do Município de Ribeiräo Preto -SP. Foram levantados dados de prontuário médico de crianças atendidas no período de abril a dezembro de 1988, segundo os grupos etários e por sexo, objetivando de início estudar a demanda do consumo de medicamento pela populaçäo infantil de um Centro de Saúde Escola e tentar extrapolar para os demais serviços públicos de Assistência Primária à Saúde na área de pediatria desta cidade, com a finalidade de padronizar os tipos de medicamentos mais consumidos por esta populaçäo. Evidenciou-se que, segundo o sexo, 220 (52,0 por cento) eram do sexo masculino e 202 (48,0 por cento) do sexo feminino. Quanto ao número de consultas por sexo e faixas etárias, observamos que foi o grupo de 1 a 4 anos o que mais consultou: 306(72,5 por cento). E segundo o sexo, a maior percentagem foi para o masculino, 163(74,1 por cento). Quanto ao número e tipo de exames laboratoriais solicitados pelos pediatras, temos: o exame de fezes de rotina, com 314(40,7 por cento); em seguida, o hemograma, 249(32,3 por cento). No grupo de crianças de 1 a 4 anos houve maior solicitaçäo de exames - 317(77,3 por cento) para o sexo masculino e 258(71,4 por cento) para o feminino. Na distribuiçäo das crianças, segundo o tipo de medicamento prescrito por sexo e grupos etários, observamos que as vitaminas e antianêmicos foram os medicamentos mais prescritos para ambos os sexos, com 143(21,5 por cento) para o masculino e 113(19,6 por cento), para o feminino; em seguida os vermífugos, 124(18,0 por cento) para o sexo masculino e 102(17,7 por cento) para o feminino. Quanto aos grupos etários, foi o de 1 a 4 anos o que mais consumiu medicamentos, 903(72,8 por cento); seguido do grupo de 5 a 9 anos, 227(18,3 por cento)