G W McGarry

Prospective Clinical Study of Bleeding Sites in Idiopathic Adult Posterior Epistaxis

OBJECTIVES: The precise identification of the bleeding point is important to the efficient management of epistaxis. Our hypothesis was that the septum was the commonest bleeding site. STUDY DESIGN AND SETTING: This was a prospective clinical study of 50 consecutive adult idiopathic posterior epistaxis patients carried out in a busy teaching hospital. METHODS: The nasal cavity was inspected with endoscopy to identify the site of bleeding before any intervention. The location of bleeding sites was recorded on a proforma. RESULTS: Of bleeding sites posterior to the piriform fossa, 94 percent were identifiable, with 70 percent arising from the septum. CONCLUSIONS AND SIGNIFICANCE: This is the largest prospective study of the bleeding site in adult patients with posterior epistaxis and the only one with a well-defined population. The vast majority of posterior bleeding sites can be identified by endoscopy without general anesthesia. The septum should be examined closely in cases of idiopathic bleeding.

The precision of four commonly used surgical landmarks for locating the facial nerve in anterograde parotidectomy in humans.

In addition to using intra-operative facial nerve monitoring in helping to locate the position of the facial nerve in anterograde parotidectomy, numerous soft tissue and bony landmarks have been proposed to assist the surgeon in the early identification of this nerve. There is still dispute within the literature as to the most effective method, if any, of locating the nerve. The purpose of this study was to measure the distance (in twenty-six embalmed cadavers) from four of the most commonly used surgical landmarks to the main trunk of the facial nerve-the posterior belly of digastric muscle (PBDM), the tragal pointer (TP), the junction between the bony and cartilaginous ear canal (EAM) and the tympanomastoid suture (TMS). The main trunk of the facial nerve was found 5.5+/-2.1mm from the PBDM, 6.9+/-1.8 mm from the TP, 10.9+/-1.7 mm from the EAM and 2.5+/-0.4 mm from the TMS. From this, the TMS can be used as a reliable indicator for locating the main trunk of the facial nerve. In addition, this study also demonstrated a statistically significant difference between the sexes in relation to the two bony landmarks used here, the EAM and the TMS, with the facial nerve found further away from those landmarks in females compared to males. With the advent of 3D construction and reformatting of images, these values may come to the forefront in pre-operative planning for locating the facial nerve in anterograde parotidectomy.

The frontal osteoplastic flap: does it still have a place in rhinological surgery?

OBJECTIVE To review outcomes and complications in a series of adults undergoing a frontal osteoplastic flap procedure without obliteration, for endoscopically inaccessible sinus disease. MATERIAL AND METHOD Retrospective case note review of patients treated at Glasgow Royal Infirmary between January 2004 and October 2008. RESULTS Ten patients were identified (age range 19-81 years, mean age 46.3 years). No major intra- or post-operative complications occurred. There were three minor complications: superficial discharging wound, forehead swelling and haematoma. CONCLUSION The frontal osteoplastic flap still has a role in frontal sinus surgery. With minor technical modifications, this procedure may be performed with minimal complication and morbidity for patients with endoscopically inaccessible frontal sinus disease.

Image guidance in rhinology and anterior skull base surgery: five-year single institution experience

OBJECTIVES We examined our experience of image guidance surgery in rhinology, and compared image guidance surgery cases with non-image guidance cases. We also audited our practice against the American Academy of Otolaryngology-Head and Neck Surgery image guidance surgery guidelines. METHOD The study employed a single institution retrospective approach comprising 174 image guidance surgery patients (106 males and 68 females) and 134 non-image guidance surgery patients (75 males and 59 females). RESULTS In the image guidance surgery group, tumour operations represented 45 per cent of cases (55 per cent were non-neoplastic). Basic, intermediate and advanced (structured classification) procedures represented 19 per cent, 24 per cent and 61 per cent, respectively. Five minor complications were recorded. In non-image guidance surgery, tumour operations represented 8 per cent of cases (92 per cent were non-neoplastic). Basic, intermediate and advanced procedures represented 73 per cent, 12 per cent and 15 per cent, respectively. One minor complication was observed. CONCLUSION We report the largest series of image-guided ENT surgical procedures in the UK. In the cases we examined, image guidance surgery was predominantly used in advanced procedures and tumour surgery.

Spectrum of nasal disease in an asthma clinic: when is an ENT opinion indicated?

AIMS To characterise the spectrum of nasal symptomatology and nasendoscopic abnormalities seen in patients attending an asthma clinic, and to relate these symptoms to the likelihood of finding nasendoscopic abnormalities which merit treatment. METHODS Forty-three patients attending a problem asthma clinic were enrolled in an observational study. Cardinal nasal symptoms--obstruction, congestion, hyposmia, rhinorrhoea, sneezing, epistaxis or other symptoms--were graded as none (zero), mild (one), moderate (two) or severe (three), giving a maximum nasal symptom score of 21. Asthma symptoms and lung function were measured. Nasendoscopy was then performed. RESULTS Obstruction was the most common cardinal nasal symptom (seen in 15 patients), the median nasal symptom score was 5.3 (range zero to 14) and only three patients had no nasal symptoms. There was no correlation between nasal symptom score and severity of asthma symptoms or forced expiratory volume in one second. Twenty-two patients had a normal appearance on ENT examination (median nasal symptom score four). The nasendoscopic abnormalities seen comprised polyps (n = 8; median nasal symptom score five), deviated nasal septum (n = 7; median nasal symptom score four), oedematous mucosa (n = 4; median nasal symptom score seven) and other abnormalities (n = 2). Individual nasal symptoms were poor predictors of individual nasal pathologies, with hyposmia the best individual predictor of any abnormality (positive predictive value 80 per cent). The presence of a combination of symptoms increased the likelihood of any nasendoscopic abnormality, with obstruction, rhinorrhoea and hyposmia together having a positive predictive value of 100 per cent. CONCLUSIONS Nasal symptoms are much more frequent than structural abnormalities in patients attending a problem asthma clinic. The threshold for ENT referral should be lower when the patient complains of a symptom complex including hyposmia. Furthermore, concurrent hyposmia, obstruction and rhinorrhoea should be seen as an indication for ENT referral.