Stephen Lo

The use of camera mobile phone to assess emergency ENT radiological investigations.

Objectives:  To determine the accuracy of assessment of common ENT emergency radiological investigations using mobile phone digital images.

Epistaxis: Are temperature and seasonal variations true factors in incidence?

OBJECTIVE To investigate the previously documented inverse association between ambient temperature and presentation rates for patients with epistaxis and seasonal variation of emergency presentation rates for patients with epistaxis. STUDY DESIGN A retrospective analysis of all consecutive emergency patients with epistaxis presenting to hospital from the community over a five-year period, 1997-2002 (1830 days), including those who required admission to hospital with epistaxis over the same period. Patients in whom there was a clear aetiology for the epistaxis (traumatic, recurrent, iatrogenic, coagulopathic and hypertensive) were excluded. SETTING A tertiary referral centre in south-west London serving a population in excess of 2.8 million. METHOD A retrospective analysis of all patients presenting or admitted to St Georges Hospital with epistaxis over a five-year period. Daily ambient temperature readings from London Heathrow airport were recorded for the same period. Presentations were correlated with monthly temperature variations and the month itself. Statistical analysis with Pearsons correlation coefficient was performed. RESULTS 1373 patients with epistaxis presented to our department, of whom 386 (28.1 per cent) were admitted to hospital. No correlation is seen between ambient temperature and presentation rate for patients with epistaxis. No seasonal preponderance is noted for presentation rate (Pearson r = 0.160, p = 0.221) in this series. CONCLUSION To our knowledge, this is the largest study to date examining ambient temperature association and epistaxis, and the first to investigate presentation rate in place of admission rate. We feel that the exclusion of all patients with epistaxis not admitted to hospital introduces a bias. In this series, there is no correlation between ambient temperature, seasonal preponderance, presentation rate or admission rate for patients with epistaxis. This is contrary to previously reported findings. We do not support the view that there is a relationship between epistaxis and temperature or seasonal variation. This contradicts the current belief that incidence of epistaxis displays seasonality, and has implications for the allocation of resources for healthcare provision within ENT departments.

Prospective study of the risk of not using prophylactic antibiotics in nasal packing for epistaxis

BACKGROUND There is wide variation in UK prescribing practice regarding prophylactic antibiotics for nasal packing in spontaneous epistaxis. There are few published cases of infective complications in such patients. METHOD This prospective study examined 149 consecutive patients admitted to a tertiary otorhinolaryngology centre with spontaneous epistaxis, who underwent nasal packing, over a six-month period. In the first three-month period, 78 patients were routinely prescribed prophylactic antibiotics; in the second three months, 71 patients were not routinely prescribed antibiotics. Exclusion criteria included antibiotics prescribed for unrelated pathology and post-operative epistaxis. Signs and symptoms of acute otitis media, sinusitis and toxic shock syndrome were assessed using clinical examination and a questionnaire. RESULTS Fourteen of the 149 patients experienced otalgia, most commonly following posterior nasal packing. No patient in either group had evidence of any infective complication. CONCLUSION We do not recommend the routine prescription of prophylactic antibiotics for patients undergoing nasal packing for spontaneous epistaxis.

Localisation of heme oxygenase isoforms in allergic human nasal mucosa

Carbon monoxide (CO) is an endogenously produced gas mediator produced by heme oxygenase (HO). Like nitric oxide (NO), CO is produced in the nasal mucosa. Given that induced NO synthase (iNOS) expression in nasal mucosa has been found to be up-regulated in allergic rhinitis, the current study investigated the expression of HO isoforms in allergic human nasal mucosa. Immunohistochemical staining for type 1 and 2 HO isoforms were carried out in nasal inferior turbinate mucosa from six patients with persistent allergic rhinitis, and compared with six control patients without nasal allergy. Focal and weak expression of HO-1 was observed in seromucous glands, with no difference between allergic and control specimens. Vascular endothelium, erythrocytes, smooth muscle and inflammatory cells (except macrophages) in the allergic group exhibited stronger HO-1 immunoreactivity compared to the control. Minimal expression was found in the respiratory epithelium in either group. Intravascular HO-1 expression was found in the allergic mucosa only. Intense HO-2 immunoreactivity was observed in the respiratory epithelium, vascular endothelium and seromucous glands in both allergic and control groups with no differences in intensity. In conclusion, unlike iNOS, HO-1 is minimally expressed in the nasal respiratory epithelium of either group. However, our findings suggest that it may be involved in the inflammatory process of allergic rhinitis at the submucosal level.

A prospective comparative study to examine the effects of oral diazepam on blood pressure and anxiety levels in patients with acute epistaxis

OBJECTIVE To examine the effects of oral diazepam on blood pressure and anxiety in patients with acute epistaxis. STUDY DESIGN AND SETTING A prospective comparative study in an otorhinolaryngology tertiary referral centre. PARTICIPANTS Patients with acute epistaxis requiring hospital admission. INTERVENTION Oral diazepam. MAIN OUTCOME MEASURES Anxiety and blood pressure levels. RESULTS 32 patients received diazepam and 45 did not (control). On average, patients were hypertensive on admission (mean [standard deviation (SD)] systolic blood pressure diazepam group=157 mmHg [26], control=152 mmHg [23]; diastolic blood pressure diazepam group=87 mmHg [16], control=87 mmHg [18]). Both groups showed significant blood pressure reduction on discharge (p<0.0001) but the difference in mean blood pressure reduction between the two groups was insignificant (systolic blood pressure p=0.16, 95% confidence interval [CI]=-5 to +19 mmHg; diastolic blood pressure p=0.43, 95% CI=-8 to +10 mmHg). Anxiety was significantly lower on discharge (p<0.0001) but the difference in mean fall in anxiety scores between the two groups was insignificant (p=0.08, 95% CI=0 to +2). There was no significant correlation between total diazepam and changes in blood pressure (systolic blood pressure p=0.32; diastolic blood pressure p=0.65) or anxiety (p=0.73), nor between blood pressure and anxiety on admission (systolic blood pressure p=0.45; diastolic blood pressure p=0.72). CONCLUSIONS Elevated blood pressure and anxiety in acute epistaxis patients reduced on epistaxis resolution irrespective of oral diazepam use. The elevated blood pressure does not appear to be directly related to anxiety.

Nasolacrimal Tuberculosis: Case Report Highlighting the Need for Imaging in Identifying and Managing it Effectively

Purpose: To report a rare case of nasolacrimal tuberculosis, conduct a literature review, and to suggest an optimal management plan. Methods: A 39-year old Zimbabwean female presented with a 3-year history of left epiphora, haemolacria and medial canthal mass. On ophthalmic examination there was no lateral displacement of the left globe. The initial management was external dacryocystorhinostomy. Histology of the biopsy was inconclusive and her symptoms did not improve. This prompted a referral to otolaryngology. Nasal examination revealed a friable mass of the middle turbinate. CT scan showed paranasal sinus and lacrimal sac destruction and lateral displacement of the globe. Endoscopic sinus surgery confirmed the CT findings, allowed a biopsy taken, and the histology showed prominent caseating granulomatous inflammation. Microbiological cultures confirmed nasolacrimal tuberculosis. Conclusion: We report a case of primary tuberculosis affecting the nasolacrimal apparatus presenting with a medial canthal mass. This report highlights the need for high index of suspicion, and initial CT imaging in order to avoid invasive procedures such as external dacryocystorhinostomy, which may cause extra surgical morbidity and delay diagnosis and treatment.

Does Hydrogen Peroxide Mouthwash Improve the Outcome of Secondary Post-Tonsillectomy Bleed? A 10-year Review:

Objective: To determine whether hydrogen peroxide (H2O2) mouthwash influences the outcome of secondary post-tonsillectomy hemorrhage in children. Study Design: Ten-year retrospective study of all children with secondary post-tonsillectomy hemorrhage. Setting: Tertiary otolaryngology center. Results: Of the 156 patients, 59 received H2O2 and 97 did not. All patients received broad-spectrum intravenous antibiotics. The average rehospitalization duration due to hemorrhage was 1.7 days (H2O2 group) and 1.6 days (control group). In the H2O2 group, 8.5% required surgery, compared with 10.3% in the control group. Further hemorrhage episodes requiring readmission occurred in 3.4% of the H2O2 group and 3.1% of controls. There was no difference between the 2 groups in rehospitalization duration (P = 0.49), rate of surgical intervention (P = 0.85), and rate of readmission with further hemorrhage (P = 0.92). Conclusion: Hydrogen peroxide mouthwash does not improve the outcome of secondary post-tonsillectomy hemorrhage in pediatric patients. Significance: This study does not support the common practice of treating post-tonsillectomy hemorrhage with H2O2.

Superglue (cyanoacrylate) in the nose.

A 47-year-old man was undergoing treatment of nasal polyposis with steroid nose drops (Vista, Martindale, UK). One evening he accidentally instilled superglue (Loctite) into both of his nostrils having mistaken it for his nasal medication. He presented as an ENT emergency with severe pain and complete blockage of the nose. Examination confirmed complete nasal obstruction with both nasal fossae occluded by a solid hard mass of dried cyanoacrylate glue. Attempted removal under local anaesthesia was abandoned because of severe discomfort. The patient was therefore admitted for endoscopic removal under general anaesthesia with local vasoconstriction using topical 2% lignocaine and 1:1000 adrenaline. A dried superglue cast was carefully mobilised and removed from each side of the nose with minimal trauma to the nasal mucosa (Fig 1A). The patient was advised to continue to use his nasal steroid medication to reduce the inflammation and irritation caused by the glue, and to douche the nose with saline to prevent crusting. Subsequent outpatient review demonstrated no long-term sequelae.

Immunolocalisation of heme oxygenase isoforms in human nasal polyps

BACKGROUND Carbon monoxide is an endogenous vasodilator gas produced by the enzyme heme oxygenase (HO). HO is expressed in human nasal mucosa, but its pathophysiological role in nasal inflammatory diseases is not fully understood. The aim of this study was to detect and compare the expression of HO-1 and -2 isoforms in nasal polyps with normal nasal mucosa. METHODS Immunohistochemical analysis using antibodies specific for HO-1 and -2 was conducted on nasal polyps from nine patients with allergic nasal polyposis, and on normal nasal mucosa from six controls. RESULTS Intense HO-1 immunoreactivity was observed in nasal polyp epithelium but was absent in normal nasal mucosa. HO-2 staining was observed in respiratory epithelium, vascular endothelium and seromucous glands, with no difference observed between nasal polyps and normal nasal mucosa. CONCLUSIONS HO-1 expression is up-regulated in nasal polyp epithelium, supporting the theory that respiratory epithelium plays a role in the pathogenesis of nasal polyposis.

Constitutive (HO-2) and inducible (HO-1) haem oxygenase in pleomorphic adenomas of the human parotid: an immunocytochemical study

This study examines the expression HO-1 and HO-2 isozymes in human parotid pleomorphic adenomas. They are members of the heat shock protein family, and are thought to play a role in the regulation of tumoral blood flow. Immunocytochemistry using antibodies specific for HO-1 and HO-2 were undertaken in 12 pleomorphic adenoma specimens, all sections of which contained adjacent normal salivary tissue. Normal salivary gland acini and ducts displayed significantly stronger immunoreactivity for HO-2 compared to tumour cells (p < 0.001). Expression for HO-1 was minimal in both normal salivary gland acini and tumour cells with no difference (p = 1.000). However, positive staining for HO-1 was seen in normal salivary ducts and in pleomorphic adenomas showing ductal differentiation. In conclusion, this is the first study to examine the expression of HO-1 and HO-2 within normal salivary glands and pleomorphic adenomas. Our findings suggest that HO may be implicated in the pathogenesis of salivary pleomorphic adenomas.