Endoscopically managed giant frontoethmoidal osteoma with orbital extension.

A patient in his 20s presented with a change in the appearance of his left eye with evidence of relative afferent pupillary defect. Imaging revealed a giant frontoethmoidal osteoma, a benign sinonasal tumour, invading three-quarters of the orbit. Multidisciplinary discussion involving opthalmology, maxillofacial surgery, neurosurgery and otolaryngology resulted in the decision to attempt entirely endoscopic excision of this lesion, which was performed with successful outcomes. This case demonstrates how a sinonasal osteoma should be considered in the differential diagnosis for a patient presenting with proptosis or other eye signs suggestive of compression of the orbital compartment. This case report and literature review highlights the possibility of managing giant sinonasal osteomas with orbital extension through a completely endoscopic approach.

Anti-thrombotics and their impact on inpatient epistaxis management: a tertiary centre experience.

INTRODUCTION: Epistaxis represents a massive burden upon NHS resources. Despite being an extremely common reason for emergency ENT admissions, there remains significant variation in its management. Although the evidence base is continually growing, there appears to be a lack of guidance towards managing anti-coagulants and anti-platelet medications and identifying patient-specific outcomes in this setting. Epistaxis has long been associated with a multitude of risk factors but none have shown consistent, direct correlation. MATERIALS AND METHODS: We aimed to identify if the use of anti-thrombotic medication was associated with a longer length of hospital admission or conferred a higher requirement for nasal packing, re-packing, surgery or re-admission. We conducted a retrospective analysis of 100 consecutive adult patients admitted over a 6-month period. Statistical analysis was conducted using SPSS software. RESULTS: Sixty-five percent of patients were taking anti-thrombotic medication. The variability of admission INR values in those taking warfarin did not relate with any outcome measure. There was no statistical difference between patients taking anti-thrombotic medication and those who do not, with regards to our primary outcome measures. Re-admission rates within 28 days were found to be 13%, with anti-thrombotic medication use and pre-existing cardiovascular disease recognised as commonly encountered risk factors. Three percent of patients required surgical intervention. Eight percent of patients required re-packing, with a Rapid Rhino chosen in all instances. CONCLUSION: The use of anti-thrombotic medication is not associated with increased morbidity or increased rate of complications. Anti-thrombotic usage and more than one medical co-morbidity increase the risk of re-admission within 28 days.

A Retrospective Clinical Audit of Outcomes of Cochlear Implantation in Children with Multiple Disabilities in Comparison with Normal Implantees: A South Indian Experience.

AIMS: Cochlear implantation (CI) is established as a standard remedy for children with congenital bilateral profound hearing loss to attain hearing perception and thereby develop speech and language. A subgroup includes children with multiple disabilities in whom the implant helps to improve their quality of life and also of their families via enhanced communication skills. Cochlear implants today form an integral part of their multi-handicap rehabilitation process. MATERIAL AND METHODS: A retrospective cohort study was carried out on children with and without multiple handicaps who have received cochlear implantation at the cochlear implant clinic of MERF, Chennai, India over the past decade. Category of Auditory Performance (CAP) scores, Speech Intelligibility Rating (SIR) scores, and also Meaningful Auditory-Integration Scale (MAIS) and Meaningful Use of Speech Scale (MUSS) scores were compared at set time frequencies of 6 months and 12 months post-implantation between the two groups of implanted children. RESULTS: All the four CAP, SIR, MAIS and MUSS scores showed improvement over time with auditory and speech therapy in both groups of children as reflected by the improvement in their quality of life. The normative group of implantees showed better improvement compared to the group of children with multiple disabilities. CONCLUSION: Intensive habilitation is essential especially for children with multiple disabilities who have received cochlear implantation in which their special needs are addressed individually and optimised for the best outcome. The study shows that restoration of the special sense of hearing helps as a remedy to alleviate their other multi-handicaps to a notable extent.

Sublingual immunotherapy vs placebo in the management of grass pollen-induced allergic rhinitis in adults: A systematic review and meta-analysis.

INTRODUCTION: Allergic rhinitis (AR) is a common inflammatory condition of the nasal mucosa affecting approximately 20% of the population worldwide. Current therapies include intranasal antihistamines, corticosteroids, subcutaneous and sublingual immunotherapy (SLIT). This review and meta-analysis assess the efficacy of SLIT in the management of grass pollen-induced AR in adults. METHODS: Ovid EMBASE, Ovid EBM Reviews, Cochrane Central Register of Controlled Trials, Ovid MedLine and PubMed were searched using the following terms: 'sublingual immunotherapy', 'SLIT', 'rhinitis', 'allergic rhinitis', 'rhinosinusitis' and 'rhino-conjunctivitis'. All included studies were double-blind, placebo-controlled and randomised trials. Primary outcome was symptom score and secondary outcome included quality of life and safety profile. Meta-analysis of symptom improvement was carried out. RESULTS: Six studies were identified with 979 subjects randomly allocated to SLIT and 992 to a placebo control. All studies reported an improvement in symptoms with SLIT, with five reaching statistical significance (P < .05). Four studies reported statistically significant improvement in quality of life (P < .05). Oral pruritus was the most common adverse event reported. The overall risk of bias was high in 50% of the studies. CONCLUSIONS: Sublingual immunotherapy was a safe and effective treatment for grass pollen-induced AR in adults, and therefore, consideration should be given to its use for moderate-to-severe disease in the UK-wide population.

Intractable chronic otitis media, rhinosinusitis and facial palsy: a case of active granulomatosis with polyangiitis.

Granulomatosis with polyangiitis (GPA) is a rare systemic disease of unknown aetiology, characterised by necrotising granuloma formation and diffuse vasculitis. It typically affects the upper and lower respiratory tract in addition to the kidneys. Without treatment, the 2-year mortality rate exceeds 90%. We describe a presentation of intractable serous otitis media, rhinosinusitis, fever and unilateral facial palsy in an 18-year-old man with learning difficulties, which highlights the need for a high index of suspicion in diagnosing and treating this enigmatic disease.

A rare case of non-clostridial infection in a non-diabetic patient.

A 76-year-old man presented with neck swelling associated with pain and fever. On examination, there was a submental neck swelling. His initial CT scan showed multiloculated abscess centred in the left submandibular gland. He remained febrile despite on intravenous ceftriaxone and metronidazole. A repeat CT scan revealed significant worsening with multiple pockets of fluids with gas locules in the deep neck spaces. He subsequently underwent neck exploration and drainage of neck abscess. Extensive necrotic tissue was found intraoperatively and thick pus was drained from the bilateral parapharyngeal, submental spaces and anterior mediastium. Pus culture profusely grew of Eggerthella species. Patient recovered well following further intravenous antibiotic therapy. Diabetes mellitus and odontogenic infections are the common risk factors in deep neck infections. Our patient is however non-diabetic and edentulous. Current case is presented to serve as a rare case of neck abscess with unusual cause in a non-diabetic patient.

An algorithm recommendation for the pharmacological management of allergic rhinitis in the UK: a consensus statement from an expert panel.

Allergic rhinitis is a frequent presenting problem in primary care in the UK, and has increased in prevalence over the last 30 years. When symptomatic, patients report significant reduction in their quality of life and impairment in school and work performance. Achieving adequate symptom control is pivotal to successful allergic rhinitis management, and relies mostly on pharmacotherapy. While it is recognised that most mild-moderate allergic rhinitis symptoms can be managed successfully in primary care, important gaps in general practitioner training in relation to allergic rhinitis have been identified. With the availability of new effective combination therapies, such as the novel intranasal formulation of azelastine hydrochloride and fluticasone propionate in a single device (Dymista®; Meda), the majority of allergic rhinitis symptoms can be treated in the primary care setting. The primary objective of this consensus statement is to improve diagnosis and treatment of allergic rhinitis in primary care, and offer guidance on appropriate referral of difficult-to-treat patients into secondary care. The guidance provided herein outlines a sequential treatment pathway for allergic rhinitis in primary care that incorporates a considered approach to improve the management of allergic rhinitis symptoms and improve compliance and patient satisfaction with therapy. Adherence with this care pathway has the potential to limit the cost of providing effective allergic rhinitis management in the UK by avoiding unnecessary treatments and investigations, and avoiding the need for costly referrals to secondary care in the majority of allergic rhinitis cases. The fundamentals presented in this consensus article should apply in most health-care settings.

Septoplasty with concomitant inferior turbinate reduction reduces the need for revision procedure.

OBJECTIVE: Septoplasty is an accepted and common surgical intervention to improve the nasal airway. However, the role of concomitant surgery on the inferior turbinate remains debated. This study aims to investigate if the inferior turbinate surgery at the time of septoplasty would impact on the likelihood of revision nasal surgery - septoplasty or septorhinoplasty. STUDY DESIGN: Retrospective review of consecutive patients undergoing septoplasty with or without inferior turbinate reduction over 12 years (1998 - 2010) at Aberdeen Royal Infirmary. METHODS: Patients were identified from the theatre log books and were excluded if they underwent any other nasal procedure. Data collected include demographics, type of primary surgery, and grade of surgeon along with revision nasal surgery in this cohort. RESULTS: 2168 eligible patients with a mean age of 39 years were investigated. Two groups were identified: Group A, with 788 patients who underwent septoplasty only, and Group B, in which 1380 patients underwent septoplasty with concomitant inferior turbinate reduction. The majority of operations were performed by the surgeons in training. The incidence of revision surgery was 5.1 % (21 revision septoplasties and 19 corrective septorhinoplasties) in Group A compared to 2.2 % (20 revision septoplasties and 10 corrective septorhinoplasties) in Group B. CONCLUSION: Based on this study, it would appear that concomitant inferior turbinate reduction may decrease the likelihood of revision nasal surgery.

Periorbital emphysema after dive barotrauma without radiological evidence of paranasal sinus injury.

BACKGROUND: Scuba diving has increased in popularity since its invention in 1943, with over 21 million PADI registered members worldwide. Injuries to the paranasal sinuses caused by barotrauma are the second most common after injury to the middle ear. CASE REPORT: In this paper we present a case of unilateral periorbital surgical emphysema in a 23-yr-old male commercial scuba diver with minimal symptoms following an uneventful 13-ft (4-m) dive. The only symptoms experienced were pain and pressure over the right maxillary sinus and retrorbitally. Imaging with computed tomography showed no fracture of his paranasal sinuses. DISCUSSION: The authors recommend that a high index of suspicion for paranasal sinus barotrauma should be maintained in all patients reporting minor symptoms after diving (even to shallow depths) to facilitate rapid clinical diagnosis and prompt medical management.

Audit of CT scanning of paranasal sinuses in patients referred with facial pain.

BACKGROUND: Computed tomography (CT) scans are performed by some clinicians in the belief that they are a useful primary investigation in patients with facial pain. OBJECTIVE: To assess the appropriateness and outcome of sinuses CT scans in patients with facial pain based on the European Position Paper on Chronic Rhinosinusitis and Nasal Polyps (EPOS) 2007 guideline and International Headache Society (IHS) criteria for diagnosing and investigating rhinosinusitis. METHODOLOGY: The first cycle of audit was performed on 50 patients with facial pain who underwent CT scanning. The findings on nasal endoscopy, Lund-Mackay scores (LMS) of the scans and management of these patients were analysed. Following implementation of the IHS and EPOS criteria, 50 consecutive patients were re-audited. RESULTS: In the first cycle, 16% of patients had positive nasal endoscopic findings. Thirty patients had LMS of 0 and only 9 showed significant changes (LMS ≥ 8) on their scans. In the second cycle, only 10 patients underwent CT imaging as per EPOS guideline and 4 of them showed significant changes. The remaining 80% of patients in this cycle were diagnosed and treated for non-sino- genic causes. CONCLUSION: Applying the IHS and EPOS criteria has reduced the number of inappropriate CT scans requests and allowed consideration of non-sinogenic aetiologies.

Use of complementary and alternative medicine by patients attending a rhinology outpatient clinic.

BACKGROUND: There are 50,000 practitioners of complementary and alternative medicine (CAM) within the United Kingdom. The current U.K. prevalence of CAM use is reported to be 25% and is rising. The national expenditure on CAM is an estimated pound1.6 billion. The aim of this study was to explore the pattern of CAM use in patients attending a rhinology outpatient clinic in Aberdeen. METHODS: Questionnaires were provided to 100 patients over a 2-month period. The questionnaire consisted of demographic sections and whether they had ever used CAM from a list of 49 herbal and nonherbal alternative therapies. Subjects were also asked why they used CAM, where they learned of CAM, whether they found it efficacious, and whether their general practitioner was aware they were using it. RESULTS: One hundred subjects completed questionnaires. Patients attending the clinic were suffering from the most common rhinological complaints including rhinosinusitis and nasal polyps. Sixty-five percent of patients had ever used CAM. Women were statistically significantly more likely to use CAM than men (p = 0.012). Patients who were employed were more likely to use CAM, but there was no significant difference in CAM usage depending on marital status, social class, and age. Only 6% of patients felt CAM use was definitely ineffective. Only 43% of users of CAM had informed their doctor about its use. CONCLUSION: CAM usage is growing in popularity. All health care professionals should be aware of this and of the potential for adverse drug reactions occurring. The dangers of noncompliance with conventional medications should be emphasized to CAM users.

Montelukast as an adjunct to oral and inhaled steroid therapy in chronic nasal polyposis.

OBJECTIVE: To examine the potential of montelukast, a leukotriene receptor antagonist, as an adjunct to oral and inhaled steroid in subjects with chronic nasal polyps. STUDY DESIGN: Prospective, randomized controlled trial. SUBJECTS AND METHODS: Thirty-eight consecutive adult patients with bilateral nasal polyps were randomized into two groups. Eighteen subjects were treated with oral prednisolone for 14 days and budenoside nasal spray for 8 weeks. Twenty subjects received similar treatment with additional oral montelukast for 8 weeks. Subjects completed a modified nasal ICSD symptom score at 8 and 12 weeks after beginning treatment and the SF-36 quality of life questionnaire at 12 weeks. RESULTS: Symptom scores improved in both groups after treatment. Subjects treated with montelukast reported significantly less headache (P = 0.013), facial pain (P = 0.048) and sneezing (P = 0.03) than controls. Four weeks after completing treatment, no significant differences were recorded. CONCLUSION: Montelukast therapy may have clinical benefit as an adjunct to oral and inhaled steroid in chronic nasal polyposis, but effects are not maintained after cessation of treatment.

Incidental magnetic resonance image sinus abnormalities in asymptomatic Australian children.

Plain X-rays, computed tomography (CT) and magnetic resonance imaging (MRI) scans performed for non-ENT reasons often reveal incidental sinus mucosal changes. These changes need to be correlated clinically before diagnosing rhinosinusitis. This study examined the prevalence of such changes in MRI scans in children up to age 16. Scans were scored using an adapted Lund-Mackay classification and were positive when one or more sinuses showed abnormalities. Randomly selected scans in the retrospective arm revealed a prevalence of 20 of 62 (32.3 per cent). In the prospective arm 45 of 60 children were defined as truly asymptomatic, of which 14 scans (31 per cent) were positive. Other studies in adults and children using CT and MRI report a prevalence range of roughly 30 to 45 per cent. This variability may be attributed to differences of study design, definitions of population age, definitions of asymptomatic and definition of abnormal sinus. Other plausible factors to explain regional differences are climate and frequency of upper respiratory tract infections.

A randomized control trial of surgical task performance in frontal recess surgery: zero degree versus angled telescopes.

The use of angled telescopes in frontal recess surgery has the theoretical advantage of improved visualization in areas characterized by reduced access such as the frontal recess. However, their use also is accompanied by the disadvantage of increased visuospatial distortion. To examine the surgical error and task performance of angled telescopes when compared with the use of the 0 degree telescope in frontal recess surgery, we carried out a surgical controlled trial on a cadaveric specimen. Ten surgeons performed randomly predetermined surgical tasks on both sides of the frontal recess. The surgical tasks were divided into three components (passing, grasping, and withdrawing) for analysis. Our study revealed significant difficulty passing instruments with the highly angled 70 degrees telescope as implied by the increased passing time ratio (p = 0.000). This was associated with significant risk of passing instruments blindly (p = 0.011), resulting in significant surgical error of hits to the middle turbinate (p = 0.005). This study also showed that use of less-angled telescopes (30 and 45 degrees) in frontal recess surgery does not appear to be associated with these risks.