Telephone survey to review patient satisfaction with telephone follow-up consultation in an ENT setting. Dr. M. Groarke, Miss A. Harrison, Mr. Y. Karagama
Tameside General Hospital, Manchester
Introduction: With increasing pressures on the National Health Service (NHS) to reduce waiting times for operations and outpatient appointments alternative methods of reviewing patients in a safe, timely and suitable manner are necessary. Our hospital was struggling to meet demands and follow-up patients in a timely manner. With a view to resolving such issues, clinics involving an ENT Consultant Surgeon conducting telephone consultations with patients were piloted.
Objective: To review patient satisfaction with a follow-up telephone consultation service and assess the practicalities of telephone consultations as a follow-up method in place of hospital out-patient clinic appointments.
Method: Thirty-eight patients were scheduled for telephone consultations with an ENT Consultant Surgeon in December 2014 and April 2015. Following the telephone consultation they were contacted and asked for feedback regarding the service using a 5 point feedback questionnaire. Patients were encouraged to give comments regarding the process.
Results: Twenty-nine patients responded to the follow-up questions. Of these, 97% expressed their satisfaction with the service and had no concerns regarding being contacted via telephone. Moreover, the vast majority of patients contacted expressed that they preferred this method of follow-up.
Conclusion: Overall, patients’ were satisfied with the follow-up telephone consultation service and it appears, from this study, to be a potentially viable option for certain patient groups. It may be a safe and cost effective alternative to hospital out-patient review.
Evaluating the use of Floseal haemostatic matrix in the treatment of epistaxis: a prospective, control-matched longitudinal study
Affiliation: Department of ENT and Head and Neck Surgery, Aintree University Hospital NHS Foundation Trust, Liverpool, L9 7AL, United Kingdom
Introduction: Epistaxis is a common cause of emergency admissions in ENT. The use of Floseal haemostatic matrix in the treatment of epistaxis has been investigated in a number of studies in North America. We aimed to report a UK-based experience in the context of the current UK management paradigm.
Methods: The study was designed as a prospective, unrandomised, control-matched longitudinal study. Cases were matched to controls in order to reduce the risk of bias.
Results: The overall treatment success rate for Floseal was 75%, similar to the rates reported by studies based in North America. Nasal packing carried a success rate of 85% and there was no statistically significant difference between the success rates of both treatments.
Anecdotally, Floseal is successful at arresting epistaxis in patients who experience treatment failure with silver nitrate cautery. It can also be used successfully in thrombocyctopenic patients. There was a trend towards a shorter LoS in the Floseal group, but this was not statistically significant. The 7-day readmission rate was 10% for both groups.
Conclusion: This controlled study demonstrates that Floseal has a similar treatment success rate to nasal packing and that there may be a trend towards a shorter length of stay.
Best Supportive Management for Adults Referred with Tonsillopharyngitis – The BeSMART
Project Phase One: A Multicentre Observational Study Jessica Veitch1, 6, Costas Mamais1, 2, Ewan McChesney1, 3, Navdeep S Upile1, 4, Casey
Vaughan1, 5, Jonathan Abbas1, 7, Anne Markey1, 8, Mark Evans1, 3, Jamie Thomas1, 3, Andrew S
1. Mersey ENT Research Collaborative 2. Aberdeen Royal Infirmary, Aberdeen 3. Aintree
University Hospital, Liverpool 4. Arrowe Park Hospital, Wirral 5. Leighton Hospital, Crewe 6.
Royal Liverpool University Hospital, Liverpool 7. Salford Royal Hospital, Salford 8. Warrington Hospital, Warrington
Tonsillopharyngitis is the most common ENT emergency admission. 74,092 episodes were
recorded in England in 2013-14, representing over £51.5 million in NHS expenditure. Despite
this, there is a surprising paucity of evidence addressing the supportive management of
tonsillopharyngitis in secondary care. We therefore set up a multi-phased project, beginning
with a multicentre retrospective observational study.
Work was coordinated through our trainee research collaborative. The project was registered at six institutions and cases were identified. Anonymised data including patient
consensus spreadsheets, followed by statistical analysis (α=0.05).
Data from 151 patients has been analysed to date. Female:male ratio was 2:1 and median
age was 26 years. There was no significant association between length of stay (LoS) and age
(p=0.085); gender (p=0.468); seeing an ENT doctor directly (p=0.838) or the seniority of the
doctor initially seen (p=0.174).
Prescription of ‘escalation’ medications was not associated with a shorter LoS, such as
codeine (p=0.153) and corticosteroid (p=0.876). Interestingly, longer LoS was associated with administration of NSAIDs (p=0.002), topical benzydamine (p<0.001) and intravenous fluid (p<0.001). Fluid prescription was significantly associated with tachycardia on admission
(p=0.030), whereas NSAID and benzydamine prescriptions were not (p=0.992 and p=0.797
respectively). This may indicate either prescribers’ response to patient condition.
The results yield valuable insights into current practice. Often-prescribed therapies such as
corticosteroid may not be as effective as previously believed. Prospective studies are
required to provide robust evidence for the best supportive management of this common ENT emergency.
Incidental findings on MRI scans of patients with audiovestibular symptoms
Htun HM, Mui S L, Hans P
Blackpool Victoria Hospital, Blackpool, Lancashire, UK
Introduction: Magnetic Resonance Imaging (MRI) is considered the gold standard in detecting cerebellopontine angle (CPA) or internal acoustic meatus (IAM) lesions such as vestibular Schwannoma in patients presenting with unilateral audiovestibular symptoms - sensorineural deafness, tinnitus and vertigo. However, vestibular Schwannoma is rare in both patients with audiovestibular symptoms and in the healthy population. It is therefore much more likely for otolaryngologists to encounter the report of an incidental finding in the imaged brain than a vestibular Schwannoma itself.
Aim: To determine the frequency of these incidental findings and to determine the best next steps in counselling and investigations when they arise.
Materials and methods: We retrospectively reviewed all MRI IAM scan reports during a 3 month period at the Radiology department at Blackpool Victoria Hospital, Blackpool, Lancashire, UK, noting relevant IAM and incidental findings.
Results and conclusion: Out of the 109 scans, eight scans were reported to have ‘abnormal’ IAM - one was found to have a small vestibular schwannoma (0.9%) and seven had vascular loops (6.4%). The remaining 101 scans were reported as having ‘normal’ IAM (92.7%). However, two scans needed further action as a deep lobe parotid tumour and an empty sella with benign intracranial hypertension were found (1.8%). 45 of the 101 scans (41.3%) showed various incidental findings such as age related ischaemic changes and small vessel disease, sinonasal disease and benign neurological pathologies. 54 of them (53.5%) were found to be entirely normal.
Our study demonstrated that almost half of the scans were reported with incidental findings albeit only two patients needed further action. Otolaryngologists should have a basic understanding of the significance of the most commonly encountered incidental findings, and be able to appropriately counsel their patients with reassurance or an initial explanation of the implications of the finding and any onward referral.
Prognostic value of the neutrophil to lymphocyte ratio in laryngeal squamous cell carcinoma patients
B.Y.W. Wong, N.D.Stafford, V.L.Green, J.Greenman
Background. The neutrophil to lymphocyte ratio (NLR) has been found to be predictive of survival outcome in a range of tumours. The purpose of this study was to investigate the prognostic value of pre-treatment (NLR) in laryngeal squamous cell carcinoma (LSCC) patients.
Methods. A retrospective analysis of 140 LSCC patients treated between 2005 and 2010 in the Hull and East Yorkshire Hospitals NHS Trust was carried out. Patient records were evaluated and both pretreatment neutrophil and lymphocyte counts were documented together with survival data, gender, smoking status, nodal status and disease staging.
Results. An elevated NLR was significantly associated with advanced disease stage, e.g. node positive and tumours Stage III & IV. In addition a high NLR was significantly associated with poor overall survival but not disease free survival on multivariate analysis, with the greatest significance seen in patients with the highest NLR.
Conclusion. Pretreatment NLR may serve as a useful prognostic marker in LSCC, however a large prospective study is required to determine an optimal NLR cut-off value.
Cohort study comparing the diagnostic potential of computed tomography and magnetic resonance imaging in the management of paranasal sinus disease
Harris R1, Markose G2, Bernstein J3, Bury RW1
Blackpool Victoria Hospital 1
Royal Bolton Hospital 2
Toronto University Health Network 3
Introduction :CT is currently the imaging modality of choice for diagnosis and follow-up of sinus disease and pre-operative planning. Historically, MRI has been considered inferior to CT. Our aim is to compare the diagnostic potential of CT and MRI in paranasal sinus disease.
Methods :40 patients with suspected sinusitis underwent coronal CT followed immediately by T1 and STIR MRI sequences. Scans were reviewed by a single radiologist blinded to the clinical history. Inter-examination agreement was calculated as the kappa statistic using Stata11 software.
Results :CT is superior to MRI in delineating fine bony structures however there is good agreement between MRI and CT over disease extent and soft tissue structures. MRI was only marginally longer (15min) than CT (10min).
Conclusion:MRI should be considered an alternative first line diagnostic tool in: 1) the young 2) dental implants 3) orbital complications 4) assessing therapeutic success. CT should be reserved for pre-operative planning in order to restrict radiation exposure.
Title: Bioplastique (polymethylsiloxane elastomer) in the treatment of Patulous Eustachian Tube Dysfunction.
Authors: Alastair White, Okechukwu Okonkwo, Simon Hargreaves.
Objective: Patulous Eustachian tube is a clinical diagnosis that is poorly understood with no definitive treatment. Patients’ quality of life can be severely affected by their symptoms and there is little evidence surrounding current treatment. Recent studies have suggested a benefit from Bioplastique (polymethylsiloxane elastomer) injections to the Eustachian tube cushions.
Method: We performed a retrospective case series analysis using a modified Cambridge Otology Quality of Life questionnaire. 9 patients clinically diagnosed with PET to assess the impact of the procedure on their perception of their symptoms.
Results: In the major symptoms that describe this condition 44% of patients described an improvement in their symptoms of autophony and 33% described an improvement in their symptoms of aural fullness. 79% of patients experienced some symptom resolution in at least 1 symptom category. One patient claimed complete resolution of all symptoms.
Conclusion: Benefit derived from this procedure is variable but with careful patient selection it can be a useful tool in the management of a difficult cohort of patients.
A Rapidly Resolving Neck Mass
Siau R.T.K., Khan M.M, Kaushik, V.
Stockport NHS Foundation Trust
Introduction: Multidisciplinary correlation of patient history, examination findings, pathology and imaging is necessary in diagnosing a new neck mass. We report an atypical case of an evolving neck mass where examination and pathology findings were limited, and clinical and radiological findings were not consistently in correlation. We use this case to highlight the diagnostic dilemma when managing a patient with these challenges.
Methods: Case report.
Results: An anxious but otherwise healthy 19-year old woman was referred with a three-week history of rapidly enlarging right level II cervical mass. The patient declined fiberoptic laryngoscopy and fine-needle aspiration in clinic, and thus panendoscopy and excision of the mass under general anaesthesia was planned. Ultrasonography was suggestive of a 4.2cm parotid cyst. MRI of the neck reported a 5cm mass of jugulodigastric lymph nodes with cystic development. On the day of surgery, the mass had clinically resolved and a repeat MR scan which was initially reported as normal, demonstrated a much smaller residual lesion in right jugulodigastric region.
Conclusion: Many patients suffer from some degree of medical anxiety, which can contribute to diagnostic difficulties. Lack of pathological diagnosis can lead to over-reliance on radiological reporting, which is operator dependent and can be misleading. We describe an unusual case causing multiple diagnostic and management dilemmas, requiring a multidisciplinary approach to formulate a differential diagnosis of this unusual presentation, and influence onward management.
Customised ENT Clerkings and An Online 'Clerking Collaborative'
Ahmad Hariri, Rachel Edmiston, Navin Mani, Simon Lloyd
Introduction: Clerking proformas are frequently used in the acute hospital setting to provide a template for complete assessment. Much variation remains in the format of such proformas and they frequently fail to account for local and speciality specific factors. We develop and pilot a customised ENT clerking proforma and create a national online 'clerking collaborative'.
Methods: Junior doctors were asked to complete mock clerkings for 6 common acute ENT presentations by traditional methods (freehand) followed by annotation of a custom designed diagram of the head and neck. Participants were timed and asked to complete a feedback questionnaire. A senior ENT clinician provided structured feedback for the quality of each clerking.
Results: Nine doctors participated in the exercise. Overall, pre-drawn diagrams provided accurate representations of the clinical scenarios and were easier to complete than free drawings. Pre-drawn diagrams took less time and improved legibility and quality of documentation as assessed by the senior clinician.
A website (www.MyClerking.co.uk) was created to disseminate the clerking proforma and allow other clinicians to contribute ideas and improvements.
Conclusion: Accurate and legible clerkings are essential across all specialities allowing continuity of care and management. This is particularly important in ENT where illustrations are used to demonstrate clinical findings. Our pre-drawn diagrams speed up the clerking process and allow for more accurate depiction of findings.
We have designed an online 'clerking collaborative' where doctors around the world can download our clerking proforma and also amend/upload their own customised proforma for others to use.
The Accuracy of MRI in Predicting Extracapsular Spread in Neck Nodes
Mr Benjamin Wood, Medical Student Professor Kenneth MacLennan, Professor of Histopathology Dr Henry Wood, Senior Research Fellow Professor Pamela Rabbitts, Professor of Experimental Therapeutics Mr Neeraj Sethi, Clinical Research Fellow
Affiliation: Leeds Teaching Hospitals NHS Trust Great George St Leeds
Introduction: Extracapsular lymph node spread (ECS) is well known as a fundamental negative prognosticator in head and neck squamous cell carcinoma (HNSCC). Being able to identify patients that will have nodal metastases with ECS could improve treatment stratification and outcomes.
We aimed to determine if magnetic resonance imaging (MRI) was a reliable predictor of the presence of ECS in patients with HNSCC. We present the preliminary results of this study.
Methods: Patients with HNSCC were retrospectively identified from the Leeds pathology archive. These patient records were then interrogated to identify those that had undergone cervical MRI preoperatively. The radiology report was then compared to the definitive histopathology report for the presence of ECS.
Results: Eighty-three patients with oral squamous cell carcinoma were identified, who had undergone preoperative cervical MRI and had definitive histopathology. Of these patients, 28/83 (34%) had pathological ECS present and 26/83 (31%) had pathological nodal metastases without ECS. In terms of predicting nodal metastases MRI correctly identified 36/54 (sensitivity 65% and specificity 71%) patients with pathological nodal metastases it failed to predict ECS in any of the patients with pathological ECS (sensitivity 0% and specificity 91%).
Conclusion: The preliminary results of this study support the notion of elective treatment to the neck for all patients at risk of nodal metastases, rather than relying on preoperative imaging. They also highlight the need for research into predictive markers of nodal metastases and ECS to try and reduce treatment-related morbidity for those without metastases and target more aggressive treatment regimes appropriately.
Clinically Relevant Anatomical Variations of the Neck
Elliot Heward, Ingrid Gouldsborough
Affiliation: University of Manchester, University Hospital of South Manchester
Introduction: Anatomical variation of the vascular and neural structures of the neck can lead to unnecessary complications when treating cancer metastasis, thyroid pathology and managing neck trauma. Injury to the superior thyroid artery (STA) and hypoglossal nerve are potentially avoidable complications, which increase post-operative morbidity. The aim of this study was to identify whether the anatomical variation of the common carotid artery bifurcation (CCB) level alters the anatomy of the STA and hypoglossal nerve.
Methods: Bilateral neck dissection was performed on 24 embalmed human cadavers (18 male, 6 female). The level of the CCB was classified in relation to the anterior laryngeal structures. The origin of the STA and distance between the CCB and the hypoglossal nerve was documented.
Results: The STA branched from the common carotid artery (CCA) in 67%, CCB in 10% and external carotid artery in 23% of the specimens. When the CCB level was located more superiorly the STA was significantly more likely to branch from the CCA (p<0.05) and the hypoglossal nerve was significantly closer to the CCB (p<0.01).
Conclusion: These findings contradict anatomical texts that state that the STA most frequently branches from the external carotid artery. In addition, it suggests that if a patient possess a raised CCB level surgeons should be aware that the STA is more likely originate from the CCA and that the hypoglossal nerve may be exposed. Knowledge of these anatomical variations is necessary to operate in a safe manner and to retain a bloodless surgical field.
Functional endoscopic sinus surgery - An audit of new day case service in our Trust
With growing trend towards day case surgery in UK, we started functional endoscopic surgery (FESS) as planned day case procedure at University Hospital of North Durham and audited the delayed/readmission rates to evaluate the safety of the service.
A prospective audit on 50 patients was carried out over 3 years. Data was collected from a proforma completed by the operating surgeon. Patients were observed for 6 hours postoperatively before discharge. Nasal preparation, procedure type, nasal packing, delayed discharge and readmission data were recorded
All patients were adults (17-76 years) with 21 females and 29 males.94% were operated on by senior medical staff and 6% by trainees under supervision. The anaesthetist grade was Consultant for all cases.
76% procedures were bilateral and 24% unilateral.82% were primary and 18% revision procedures. Nasal preparation was with co-phenylcaine (Lignocaine5% with phenylephrine) in 64% and 4% cocaine in 36%.80% were FESS polypectomy and 32% additional nasal procedures with FESS.
60% required nasal packing. 58% had dissolvable and 35% had nasal tampons which were removed after 4 hours in most cases; 1 patient had BIPP packing inserted. 3 patients had nasal packs for 48 hours.
There were 4 delayed discharges and no re-admissions. Among the delayed discharges 3 were primary and 1 revision surgery. One patient had BIPP pack intraoperatively and other 3 patients bled on removal of nasal tampons and had to be repacked.
FESS as day case procedure is safe. No single criteria could be identified for the delayed discharge.
Sore Throats do not need A&E
Jay Goswamy, John Guirguis, Jonathan Hobson
University Hospital of South Manchester
Introduction: Emergency departments across the United Kingdom are under strain due to the volume of attendances. Community pharmacists have been postulated as one potential solution. The 'think pharmacy first' campaign saw billboards in highly visible places around Manchester. A key message being that many emergencies can be managed outside of the emergency department. Sore throats do not need a and e whilst an interesting play on words may give the wrong impression. We attempted to scrutinise the emergency visits of patients attending a busy tertiary-level emergency department to determine whether such a statement could put patients at risk.
Material and Methods: By assessing the codes used during a patient visit from reason for emergency department (ED) attendance, through to the reason for admission and any interventions required we determined the necessity for ED attendance. All of those attending with 'sore throat' a 3-month period were included.
Results: In the first quarter of 2015, 223 patients were included. Of those 95 required inpatient admission and 32 required an intervention that could not have taken place outside of the hospital environment.
Discussion and Conclusion: Although the presence of a sore throat is common it may point to a serious underlying pathology. The 14% requiring an inpatient intervention are the focus of this report. We discuss these conditions, how they present and the morbidity, and potential mortality associated with their inappropriate management.