T.C. Biggs

Treatment algorithm for oral anticoagulant and antiplatelet therapy in epistaxis patients

BACKGROUND AND OBJECTIVES There is currently little published guidance on the management of anticoagulant and antiplatelet medication in patients admitted with epistaxis. The routine practice of withholding such medication in an attempt to control the epistaxis is common in the UK. However, this practice is not evidence-based, is often unnecessary, and can be associated with significant morbidity. This study introduces a treatment algorithm for oral anticoagulant and antiplatelet therapy in epistaxis patients, validated through a completed audit cycle. METHODS One hundred patients admitted with epistaxis to the University Hospital Southampton NHS Foundation Trust were studied via a two-audit cycle covering the implementation of a new treatment algorithm formulated jointly by the otolaryngology and haematology departments. RESULTS On admission, 58 per cent of patients were taking some form of anticoagulant or antiplatelet medication. The number of patients having such medication withheld decreased significantly between the two audits, for all drugs studied (i.e. aspirin, clopidogrel and warfarin). There was no significant increase in re-bleeding or re-admission rates between the audits. CONCLUSION Implementation of this treatment algorithm would help standardise management for epistaxis patients taking anticoagulant or antiplatelet drugs, and should reduce morbidity associated with unnecessary routine discontinuation of such medication.

Controversies in the management of acute tonsillitis: an evidence-based review

Patients admitted with acute tonsillitis generate a substantial workload for the National Health Service (NHS), placing huge financial pressures on an already overstretched budget.

Implementation of an evidence‐based acute tonsillitis protocol: Our experience in one hundred and twenty‐six patients

1 Caldwell G.W. (1893) Two new operations for obstruction of the nasal duct, with preservation of the canaliculi.Am. J. Ophthalmol. 10, 189–192 2 Tsirbas A.&Wormald P.J. (2003) Endonasal dacryocystorhinostomy with mucosal flaps. Am. J. Ophthalmol. 135, 76–83 3 Ressiniotis T., Voros G.M., Kostakis V.T. et al. (2005) Clinical outcome of endonasal KTP laser assisted dacryocystorhinostomy. BMC Ophthalmol. 5, 2 4 Unlu H.H., Toprak B., Aslan A. et al. (2002) Comparison of surgical outcomes in primary endoscopic dacryocystorhinostomy with and without silicone intubation. Ann. Otol. Rhinol. Laryngol. 111, 704– 709 5 Woog J.J., Kennedy R.H., Custer P.L. et al. (2001) Endonasal dacryocystorhinostomy: a report by the American Academy of Ophthalmology. Ophthalmology 108, 2369–2377 6 Watkins L.M., Janfaza P. & Rubin P.A. (2003) The evolution of endonasal dacryocystorhinostomy. Surv. Ophthalmol. 48, 73– 84 7 Onerci M., Orhan M., Ogretmenoglu O. et al. (2000) Long-term results and reasons for failure of intranasal endoscopic dacryocystorhinostomy. Acta Otolaryngol. 120, 319–322 8 SmirnovG., TuomilehtoH., TerasvirtaM. et al. (2008) Silicone tubing is not necessary after primary endoscopic dacryocystorhinostomy: a prospective randomized study. Am. J. Rhinol. 22, 214–217 9 Unlu H.H., Gunhan K., Baser E.F. et al. (2009) Long-term results in endoscopic dacryocystorhinostomy: is intubation really required? Otolaryngol. Head Neck Surg. 140, 589–595

Adult acute rhinosinusitis

A 35 year old woman presents to her general practitioner with a 10 day history of worsening nasal congestion, purulent nasal discharge, and frontal headaches. ### Ask about Rhinosinusitis (including nasal polyps) is an inflammatory condition of the nose and paranasal sinuses. Diagnosis requires at least two symptoms, one of which must be nasal discharge or obstruction, with the others comprising facial pain or smell disturbance. Acute rhinosinusitis is defined as symptoms lasting less than 12 weeks with complete resolution and can be subdivided into Chronic rhinosinusitis (with or without polyps) is defined as more than 12 weeks of symptoms without complete resolution. The following points are important within the history in acute rhinosinusitis:

Improving postoperative pain control in paediatric tonsillectomy through use of a specialist information leaflet: Our experience in 43 patients.

Abstract Tonsillectomy is the most common surgical procedure performed within the UK, and is commonly associated with uncomfortable post-operative pain(6) . The optimum method of dissection is currently the use of cold steel, which has been shown to reduce both the risk of secondary haemorrhage, and to a degree, post-operative pain, mainly through the avoidance of bipolar diathermy(6,7) . Regular analgesia is the mainstay of treatment in the post-operative period, together with antibiotics in the advent of bleeding or infection. This article is protected by copyright. All rights reserved.

Procedures of limited clinical value in ENT: What effect has there been on operating numbers?

*Miss Fenella Shelton, Core Surgical Trainee in ENT, Department of ENT Surgery, Portsmouth Hospitals NHS Trust, Portsmouth, UK **Mr Timothy C Biggs, NIHR Academic Clinical Fellow and ENT Specialist Registrar, Department of ENT Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK ***Mr Arthur Henderson, ENT Specialist Registrar, Department of ENT Surgery, Great Western Hospitals NHS Foundation Trust, Swindon, UK ****Mr Nimesh N Patel, Consultant Otorhinolaryngologist, Department of ENT Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK

C‐reactive protein and coagulation studies in secondary post‐tonsillectomy haemorrhage – need for routine testing? Our experience in 93 patients

Dear Editor, Tonsillectomy is one of the commonest surgical procedures. The most serious risk associated with the procedure is postoperative haemorrhage which in severe cases can lead to death (mortality rate of 1 in 40 000). Posttonsillectomy haemorrhage (PTH) is traditionally classified as either primary or secondary. Primary haemorrhage is defined as bleeding within the first 24 h of surgery, usually as a result of slipped ligation ties, inadequate cauterisation or sudden increase in blood pressure resulting in clot breakdown and haemorrhage. Secondary haemorrhage which is much more common represents bleeding presenting more than 24 h following surgery (usually between days 5 and 10 post-surgery), possibly secondary to localised infection within the tonsillar fossa. The national prospective tonsillectomy audit identified that the overall risk of postoperative haemorrhage was 3.5%, irrespective of surgical method, with 0.9% of patients requiring surgical arrest of haemorrhage within 28 days of their initial operation. The Emergency and Otolaryngology departments are responsible for the assessment and management of secondary PTH, as these patients present with acute blood loss and often signs of hypovolaemic shock. Initial assessment and resuscitation include intravenous access, fluid resuscitation and blood testing. Blood tests commonly performed include full blood count, C-reactive protein (CRP), urea and electrolytes, clotting screen and group and save (or cross-match depending on estimated blood loss). This study examines whether routine CRP and coagulation studies are actually indicated in this group of patients, and whether they influence the clinical management. Materials and methods

Accuracy of drain readings by surgical healthcare professionals

1 Elsheikh M.N., Elsherief H.S. & Elsherief S.G. (2006) Cartilage Tympanoplasty for management of tympanic membrane atelectasis: is ventilatory tube necessary? Otol. Neurotol. 27, 859–864 2 Borgstein J., Stoop E., Halim A. et al. (2008) The extraordinary healing properties of the pediatric tympanic membrane: a study of atelectasis in the pediatric ear. Int. J. Pediatr. Otorhinolaryngol. 72, 1789–1793 3 Blaney S.P., Tierney P. & Bowdler D.A. (1999) The surgical management of the pars tensa retraction pocket in the child–results following simple excision and ventilation tube insertion. Int. J. Pediatr. Otorhinolaryngol. 50, 133–137 4 Srinivasan V., Banhegyi G., O’Sullivan G. et al. (2000) Pars tensa retraction pockets in children: treatment by excision and ventilation tube insertion. Clin. Otolaryngol. Allied Sci. 25, 253– 256 5 Walsh R.M., Pracy J.P., Harding L. et al. (1995) Management of retraction pockets of the pars tensa in children by excision and ventilation tube insertion. J. Laryngol. Otol. 109, 817–820 6 Kristensen S. (1992) Spontaneous healing of traumatic tympanic membrane perforations in man: a century of experience. J. Laryngol. Otol. 106, 1037–1050 7 LouZ.C., Tang Y.M.&Yang J. (2011) Aprospective study evaluating spontaneous healing of aetiology, size and type-different groups of traumatic tympanic membrane perforation. Clin. Otolaryngol. 36, 450–460 8 Borgstein J., Gerritsma T.V., Wieringa M.H. et al. (2007) The Erasmus atelectasis classification: proposal of a new classification for atelectasis of the middle ear in children. Laryngoscope 117, 1255–1259 9 Iacovou E., Vlastarakos P.V., Papacharalampous G. et al. (2013) Is cartilage better than temporalis muscle fascia in type I tympanoplasty? Implications for current surgical practice. Eur. Arch. Otorhinolaryngol. 270, 2803–2813 10 Mundra R.K., Sinha R. & Agrawal R. (2013) Tympanoplasty in subtotal perforation with graft supported by a slice of cartilage: a study with near 100% results. Indian J. Otolaryngol. HeadNeck Surg. 65, 631–635

Response to: Murray A. RE: Procedures of limited clinical value in ENT: what effect has there been on operating numbers?

Sir, I wish to comment on the article by Ali et al. published in your journal. This article is critical of a paper published in your journal by Coles, Lutman & Buffin in 2000 that has acquired widespread use in medico-legal circles dealing with noiseinduced hearing loss [NIHL] and came to be known as the CLBGuidelines. This paper deals with the diagnosis of noiseinduced hearing loss on the balance of probability but does not quantify the degree of such loss (paras. 1.1). The criticism by Ali et al. is twofold. Firstly, that the CLB Guideline uses anchor points at 1 & 8 kHz which is not appropriate for estimation of the amount of noise damage. This is totally irrelevant as the Guidelines do not claim to quantify NIHL. The second criticism is that the CLBGuidelines do not use the compression factor. This is also irrelevant for exactly the same reason as above: that is, the Guidelines are not concerned with estimation of the degree of NIHL. The clinician can add comment on the compression factor in appropriate cases. Its effect is usually small and difficult to interpret. The Guidelines recognise the likely presence of small degrees of noise damage at the anchor points and allow a change of anchor points in individual cases if 1 and/or 8 kHz are not appropriate (Note 10). If it is felt that the Guidelines are too generous or too harsh in certain cases, the clinician can always add comment. It is a pity that Ali et al. offer no constructive alternative.

Implications of inaccurate venous thromboembolism risk assessments in ENT practice: our experience in eighty six patients.

apy, 73% received all planned courses of chemotherapy, and only 41% received the full dose of cetuximab, mainly due to dermatological toxicity. Projected 2year survival is 59% for the radiotherapy combined with chemotherapy patients and 38% for the radiotherapy combinedwith cetuximab patients. Survival of primary radiotherapy combined with chemotherapy patients was significantly better than in 1998–2002. • Treatment of locally advanced head and neck squamous cell carcinomawith radiotherapy combinedwith chemotherapy or radiotherapy combined with cetuximab is feasible and effective in daily clinical practice. Adequate selection of patients andmaximal supportive treatment are essential.