Exploring subconscious bias.

BACKGROUND: Implicit biases may lead to subconscious evaluations of a person based on irrelevant characteristics such as race or gender. This audit investigates the presence of implicit bias in the management of patients who missed appointments in our department. METHODS: This study retrospectively analysed discharge rates in 285 patients who missed an out-patient appointment between 1 May 2020 and 1 April 2021 at Guy's and St Thomas' Hospital. After reading the patients' names, 285 patients were categorised into genders, and ethnic categories of: White British; Black, Asian and minority (non-White) ethnic ('BAME'); and other White. RESULTS: There were no differences in discharge rates in terms of self-reported ethnic and gender groups. However, patients perceived as White British were less likely to be discharged when compared to patients perceived as Black, Asian and minority ethnic (35 per cent vs 58 per cent). Discharge rates for perceived gender did not differ. CONCLUSION: Implicit bias may influence decision-making regarding whether to rebook a patient after missing an appointment.

Sequential cohort study comparing chlorine dioxide wipes with automated washing for decontamination of flexible nasendoscopes.

INTRODUCTION: Flexible nasoendoscope is an important tool in otorhinolaryngology practice. The endoscope needs to be decontaminated prior to use in the next patient. The 2005 ENT-UK guidance for cleaning fibre-optic laryngoscopes stated that the ideal disinfecting agent and process should be effective and have low capital and maintenance costs. OBJECTIVE: To compare the efficacy and cost-effectiveness of chlorine dioxide wipes versus automated washer, for decontamination of flexible nasendoscopes. METHODS: A sequential cohort, in vitro study was performed to test the efficacy of chlorine dioxide wipes and automated washer. Costs were also calculated. RESULTS: After deliberate bacterial contamination of the nasendoscope and subsequent decontamination, swab samples from the endoscope showed Staphylococcus epidermidis growth in 2 per cent (1/50 swabs) of the chlorine dioxide wipe group and in 28 per cent (14/50 swabs) of the automated washer group (p = 0.00). Based on a projected 10-year cost calculation, the automated washer was cheaper. CONCLUSION: Further studies are required to test whether these results are replicable. A similar study should be performed using real patients, to check the significance of improper decontamination.

Hoarseness secondary to haemodialysis: case report and literature review.

INTRODUCTION: Hoarseness is common and can have a major impact on patients' quality of life. We report a rare case of hoarseness secondary to haemodialysis. CASE REPORT: A 62-year-old man described developing transient hoarseness after haemodialysis sessions, which he underwent three times weekly. Fibre-optic nasendoscopy showed incomplete glottis closure due to bowing of the vocal folds. A computed tomography scan of the neck and thorax was unremarkable. Speech therapy was unhelpful. The renal physicians concluded that no change could be made to his dialysis regime. The patient subsequently underwent injection laryngoplasty with calcium hydroxylapatite, with marked improvement of his symptoms. DISCUSSION: A literature search found one relevant article reporting that 60 per cent of patients suffered post-dialysis hoarseness and decreased vocal fold thickness. It is postulated that dialysis causes dehydration of Reinke's space, affecting vocal fold thickness and the patient's voice. CONCLUSION: Hoarseness caused by haemodialysis is uncharted territory. Further research is required to determine its prevalence and contributing factors.

Study of microbial spread when using multiple-use nasal anaesthetic spray.

BACKGROUND: Current economic constraints have led to the emergence of reusable anaesthetic sprays with replacement nozzles (Xylocaine) as an alternative to disposable anaesthetic solutions (Co-phenylcaine) for rhinological procedures. The former costs 213.84 per year vers12,047.69 for the latter, at equivocal doses. However, research regarding the sterility of such instruments is limited. The aim of this in vitro study was to determine whether bottles of Xylocaine could pose a risk of cross-infection to patients. METHODS: Two techniques were used. The first was to introduce nozzles into methylene blue and fluorescein dyes, and then analysing the anaesthetic solutions using spectrophotometry for assessment of colour change indicating retrograde contamination. The second method involved spraying Xylocaine into cultures of Staphylococcus aureus with concurrent nozzle changes. This was repeated over a 36-day-period. Sterility checks were performed on the Xylocaine before and after inoculation into the culture. RESULTS: None of the anaesthetic solutions showed the presence of dyed saline following spectrophotometric analysis. No S. aureus was isolated from any of the 30 spray bottles cultures over the 36-day trial period. CONCLUSION: It was demonstrated that using the Xylocaine spray with disposable nozzles for each patient should not pose a cross infection risk to patients.

Intranasal delivery of drugs to eustachian tube orifice.

BACKGROUND: Intranasal medication administration which aims to deliver to the eustachian tube orifice has been adopted for the management of a number of otological conditions, acting via a reduction in tubal oedema and improved ventilation. Evidence for the optimal head position for such drug administration is limited. We compared four different positions and also assessed spray versus drop formulation, to determine optimal delivery conditions. METHODS: Prospective, five-period, cross-over study using methylene blue dyed saline in a drops or spray container. Five healthy volunteers tested the Mygind, Ragan, Mecca and 'head back' head positions. Nasal spray drug delivery in the most effective head position was then compared with drops drug delivery (administered in the head back position). Intranasal delivery was assessed photographically using a 30° rigid naso-endoscope. RESULTS: Maximal nasal drops delivery was achieved with the Mygind and Ragan positions. Drops were more successful than spray in reaching the eustachian tube orifice. CONCLUSION: The Mygind and Ragan positions are best for eustachian tube orifice drug delivery, and drops preparations are better than spray preparations.

Inflation of Foley catheters for postnasal packing.

BACKGROUND: Foley catheters are commonly used to control posterior epistaxis in most ENT departments. There are very few studies of the ideal substance for inflating Foley catheters for posterior epistaxis. This in vitro study compared the effects of water, saline and air in delivering effective tamponade. METHODS: Three groups of five Foley catheters each were filled with 10 ml of water, saline or air. Forty-eight hours later, the residual volume was aspirated and measured. RESULTS: At 48 hours, the following residual volumes were aspirated: air, 0 ml; saline, 8.5 ml; and water, 8.7 ml. CONCLUSION: This study shows that air is not suitable for inflating Foley catheters, as they had spontaneously deflated when assessed 48 hours after inflation. We hypothesise that water is a better Foley catheter inflation fluid than saline. We recommend a larger, in vivo study to ascertain the benefits of these Foley catheter inflation substances in curtailing epistaxis in the clinical setting.

Observational study of bone-anchored hearing aid infection rates using different post-operative dressings.

INTRODUCTION: Avoidance of infection at the implant site is a crucial element to the success of bone-anchored hearing aid (BAHA) implantation. However, little evidence exists to suggest the best post-operative wound dressing to use. MATERIAL AND METHODS: We report our experience with 160 consecutive BAHA patients, using four types of post-operative BAHA wound dressing (Tri-adcortyl, Mepitel, Allevyn, and Acticoat 7 with Allevyn). Patients were reviewed at week one and week two post-operatively. Infection was defined as a positive wound swab culture or evidence of cellulitis at the BAHA site. RESULTS: Post-operative BAHA infection rates were 16 per cent, 50 per cent, 10 per cent and 5 per cent, for each of the four dressings respectively, and the mean number of additional visits to wound care clinic were 1.5, 3.7, one and 0.4, respectively. DISCUSSION: Acticoat 7 with Allevyn produced the lowest infection rate and thus became the dressing of choice for our BAHA programme.

Avoiding alar necrosis with post-nasal packs.

Foley's catheter is used for post-nasal packing in severe epistaxis. Various methods have been described for securing the catheter in position, all of which can be associated with patient discomfort, risk of alar necrosis or unsightliness. We describe a new method to secure the Foley's catheter without these problems. The ribbon gauze used for anterior nasal packing is tied over the catheter in multiple knots to secure it in place. This has been successfully tried on over 50 patients.

Conservative management of epistaxis: are we putting patients at risk of developing venous thromboembolic complications?

A retrospective study of 1585 patients, admitted with epistaxis to a busy District General Hospital in the United Kingdom between 1990 and 2000, was undertaken in order to identify the relationship between hospital admission for epistaxis and the development of a venous thromboembolic event. Only one person (0.06%) developed pulmonary embolus (PE) within 6 weeks of hospital admission. No one developed a deep vein thrombosis (DVT). This compares with the incidence of DVT and fatal PE in the general population. In our study population, the incidence of both PE and DVT was found to be no greater than that seen within the community and certainly less than the incidence seen within a group of high risk hospitalised patients. We conclude that hospital admission for epistaxis does not place the patient at increased risk of thromboembolic disease.

Massive recurrent epistaxis from non-traumatic bilateral intracavernous carotid artery aneurysms.

Recurrent epistaxis may rarely follow traumatic intracavernous carotid artery aneurysm. This occurs nearly always after head injury and is usually associated with fracture of the skull base. Severe torrential epistaxis due to non-traumatic intracavernous carotid artery aneurysm is extremely uncommon and potentially fatal, with only a few cases having been reported in the literature. We present the case of a 23-year-old female with a history of recurrent severe epistaxis and otalgia due to bilateral intracavernous carotid artery aneurysms, illustrating the diagnostic difficulties. The radiological investigations and the management of the patient are discussed and relevant literature is reviewed.

Recurrent periorbital cellulitis in a child. A random event or an underlying anatomical abnormality?

We present a case of recurrent periorbital cellulitis in a child. From the age of 2 years the child was admitted with periorbital cellulitis a total of six times with the first five episodes responding to conservative management with intravenous antibiotics. On the sixth admission endoscopic surgical treatment was carried out. Two abnormalities were noted: an anatomically abnormal uncinate process and an isolated abscess in an ethmoidal cell. It is believed that the abnormal uncinate process caused obstruction of the osteomeatal area, predisposing to recurrent peri-orbital cellulitis. We discuss the importance of early imaging and surgery in recurrent periorbital cellulitis.

Are nasal fractures being referred appropriately from the accident and emergency department to ENT?

OBJECTIVE: Nasal trauma does not always require ENT clinic follow-up. We assess the appropriateness of referral to the ENT department from A&E of suspected nasal fractures. METHOD: The 342 case notes of patients referred to ENT from A&E with suspected nasal fractures were reviewed. The patients were divided into groups depending on whether or not they showed clinical features in A&E. RESULTS: Patients showing clinical features in A&E initially were significantly [P < .005] more likely to attend their clinic appointment than those without clinical features. They were also significantly more likely [P < 0.001] to undergo surgical correction of their nose. CONCLUSIONS: Suspected nasal fractures following trauma should be referred to ENT only if they show clinical features on presentation to A&E. For patients developing clinical features over the next 3 weeks a telephone number should be given to the patient for rapid access to the ENT clinic.

A systematic approach to the nasendoscopic examination of the larynx and pharynx.

Several nasendoscopic techniques have been described to improve the view of different anatomical subsites when assessing the laryngopharynx. A prospective study was undertaken to compare and evaluate the views obtained with each of the different techniques employed in the nasendoscopic examination of the upper aero-digestive tract. No visualization manoeuvres were found to be beneficial in improving the view of the tongue base; however, tongue protrusion did improve the view of the valleculae. Both the post-cricoid and the upper oesophageal sphincter were best seen when the trumpet manoeuvre was performed along with skin traction of the anterior neck. Pyriform apices were best viewed when the trumpet manoeuvre was coupled with head turn - a manoeuvre we believe not to have been recorded in the literature previously with respect to this topic. The authors present a systematic routine for examining the upper aero-digestive tract by nasendoscope on the basis of obtaining the best view for each anatomical subsite.

Magnetic nasal foreign bodies: a result of fashion mania.

The fashion of body piercing among adults has encouraged children to have similar procedures or imitate them by applying small magnets to sustain the jewelery used in piercing in position [Emerg. Med. J. 19 (2002) 71]. We present cases of children who have placed magnets on their nasal alae that became misplaced on to the nasal septum causing severe pain and in some cases nasal bleeding and septal perforation. We describe management of these cases.

Hairy polyp of the oropharynx in a newborn: a case report.

An unusual case of an oropharyngeal mass in a neonate causing intermittent airway obstruction during the first 24 hours following delivery is presented. This mass was confirmed to be a hairy polyp. We discuss the incidence, histology and peri-operative management of this unusual lesion.

Short-term and long-term physical effects of exposure to CS spray.

CS gas (2-chlorobenzylidene malonitrile) is widely used in an incapacitant spray that causes intense lacrimation, blepharospasm and burning sensations in the throat and nose. Questions have been raised about its safety. We obtained information on short-term and long-term symptoms, and performed ear, nose and throat examinations and respirometry at 8-10 months, in 34 young adults who had been exposed to CS spray in a confined space during a confrontation with police. The group was subdivided into those who had been sprayed directly on the face (n=10) and those exposed indirectly. At one hour, all but 2 individuals still had symptoms; respiratory and oral symptoms were significantly more prevalent in the directly exposed group. At one month, only oral symptoms were significantly more prevalent. At 8-10 months, symptoms were still reported but there were no differences between the groups and clinical examinations revealed no specific abnormalities. There was no convincing evidence of long-term physical sequelae from exposure to CS spray.

Lobular capillary haemangioma of the nasal vestibule: a rare entity.

The authors report a case of an 8-year-old boy with lobular capillary haemangioma (LCH) of the nasal vestibule presenting with nasal blockage, nasal discharge and epistaxis. LCH of the nasal vestibule is rarely reported in the English literature, and the authors feel that it should be considered in the differential diagnosis of lesion of the nasal vestibule. Unnecessary investigations could be avoided if its diagnosis is considered, especially in children.

Neuromuscular hamartoma of the cochlear nerve: a rare occurrence in the internal auditory meatus.

The authors present a case of neuromuscular hamartoma of the cochlear nerve, an unusual occurrence in the internal auditory meatus (IAM). A review of the literature shows no previous report of neuromuscular hamartoma of the cochlear nerve. This tumour was clinically and radiologically difficult to distinguish from acoustic neuroma. It is important to consider the diagnosis of these rare small tumours pre-operatively, as it may be appropriate to manage this conservatively.