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.

Osteomark: a surgical navigation system for oral and maxillofacial surgery.

The purpose of this project was to test a surgical navigation tool designed to help execute a surgical treatment plan. It consists of an electromagnetically tracked pencil that is used to mark bone intraoperatively. The device was tested on a precision block, an ex vivo pig mandible and during performance of six endoscopic vertical ramus osteotomies on pig cadavers. The difference between actual pencil position and that displayed by the computer was measured three times each at ten 2mm holes on the block (n=30 observations) and on the ex vivo mandible (n=11 measurements). Errors between planned and actual osteotomy locations for the cadaver procedures were measured. The mean distance between known and displayed locations was 1.55 ± 0.72 mm on the precision block and 2.10 ± 0.88 mm on the pig mandible. The error measured marking the same point on the block multiple (n=5) times was 0.58 ± 0.37 mm. The mean error on the simulated osteotomies was 2.35 ± 1.35 mm. Osteomark was simple to use and permitted localisation of holes and osteotomies with acceptable accuracy. In the future, the device and algorithms will be revised to further decrease error and the system will be tested on live animals.

Nasal craniopharyngioma: case report and literature review.

OBJECTIVE: We report the first case in the English language literature of an adamantinomatous infrasellar craniopharyngioma, and we describe our management strategy. CASE REPORT: A 46-year-old woman presented with a six-month history of left-sided nasal obstruction and epistaxis. Rhinological examination revealed a left-sided, polypoidal lesion lying medial to the middle turbinate. An urgent examination under anaesthesia was organised; biopsies were considered characteristic of craniopharyngioma. Magnetic resonance imaging and computed tomography demonstrated a well defined, heterogeneous, infrasellar mass centred in the midline, extending anteriorly into the left nasal cavity and posteriorly encasing both internal carotid arteries. Craniofacial resection was performed via a midfacial degloving approach, with adjuvant radiotherapy. The patient was disease-free one year post-operatively. CONCLUSION: Craniopharyngiomas should be considered in the differential diagnosis of a unilateral nasal polyp. Although technically benign, they are locally aggressive. Therefore, we recommend complete excision with adjuvant radiotherapy if margins are involved or close.

Inflammatory myofibroblastic tumour of the tonsil: case report and literature review.

OBJECTIVE: We present the first reported case in the English language literature of an inflammatory myofibroblastic tumour of the right tonsil in a young, pregnant woman, and we report a management strategy for this enigmatic entity. CASE REPORT: A 28-year-old, pregnant woman presented with a 10-day history of odynophagia despite a course of antibiotics. Examination revealed a grade II, erythematous right tonsil with ulceration on the upper pole. A biopsy was arranged, and initial evaluation was suggestive of spindle cell carcinoma. However, this diagnosis was reviewed after immunohistochemical staining confirmed an inflammatory myofibroblastic tumour. Subsequent complete excision was undertaken using CO2 laser. CONCLUSION: Clinically, inflammatory myofibroblastic tumour of the tonsil is known to be locally aggressive and can present in a manner not dissimilar to a high grade carcinoma of the tonsil. As a result, the recommended treatment is complete local excision with careful follow up.

Sensitivity and responsiveness of the Medical Research Council dyspnoea scale to the presence and treatment of adult laryngotracheal stenosis.

OBJECTIVES: To assess the sensitivity and responsiveness of the Medical Research Council (MRC) scale, a psychophysical dyspnoea assessment instrument to the presence and treatment of adult laryngotracheal stenosis. DESIGN: Prospective observational study. SETTINGS: Tertiary/National referral airway reconstruction centre. PARTICIPANTS: Fourty tracheostomy-free patients undergoing endoscopic airway examination/laryngotracheoplasty. MAIN OUTCOME MEASURES: Demographic and clinical information, obtained from patient records, lesion severity, which was recorded intraoperatively, standard spirometry, which was measured preoperatively, and the MRC dyspnoea scale, which was administered preoperatively and at the first outpatient visit 4-6 weeks later. RESULTS: There were 16 males and 24 females. Mean age at presentation was 44 +/- 14 years (+/- SD). Postintubation stenosis was the commonest aetiology (73%) followed by idiopathic subglottic stenosis and Wegener's Granulomatosis. Six patients were examined post-treatment and had minimal residual stenosis and the remaining patients had glottic stenosis (n = 11) or Myer-Cotton Grade I (n = 8), II (n = 7) or III (n = 8) tracheal stenoses. Pre-treatment MRC dyspnoea scores and the degree of change in the MRC score following treatment strongly correlated with pre-treatment stenosis severity (r = 0.75 and r = -0.71 respectively; P < .001). Moreover statistically significant correlations existed between preoperative peak expiratory flow and forced expiratory volume in 1 s and preoperative MRC dyspnoea scores (r = -0.34 and r = -0.35 respectively; P < 0.05). DISCUSSION: Exertional dyspnoea is the hallmark symptom of laryngotracheal stenosis and for many patients it is the primary cause of disability. These findings confirm that the MRC dyspnoea scale is an appropriate outcome instrument for assessing dyspnoea associated with this condition.