Clopidogrel versus low-dose aspirin as risk factors for epistaxis.

OBJECTIVES: To quantify the relative risk of epistaxis for patients taking low-dose aspirin or clopidogrel compared to patients taking neither drug. DESIGN: Case-control study. SETTING: Primary care. PARTICIPANTS: 10,241 patients from three GP practices in the West Midlands. MAIN OUTCOME MEASURES: Epistaxis resulting in presentation to the GP, attendance at Accident & Emergency, or referral to ENT outpatients. RESULTS: There was a significant difference in the proportion of patients with epistaxis across the three groups (chi(2) = 84.1; 2 degrees of freedom; P < 0.000001). Relative risk of epistaxis was increased in both the aspirin (RR = 9.04; 95% CI = 5.13-15.96) and clopidogrel (RR = 6.40; 95% CI = 2.33-17.56) groups compared to the no drug group. There was no increased risk of epistaxis with aspirin compared to clopidogrel (RR = 1.4; 95% CI = 0.6-3.4). CONCLUSION: There is an increased risk of troublesome epistaxis in patients taking aspirin or clopidogrel. There is no significant difference in risk of epistaxis between the two drug groups.

Does asbestos cause laryngeal cancer?

Asbestos is a known carcinogen. Its role in the aetiology of laryngeal cancer has been investigated and debated for the last three decades. Here, we consider much of the published evidence from post-mortem studies, cross-sectional, case-control and cohort studies. We feel that the weight of evidence does not support a causal association for asbestos with laryngeal cancer. The 'positive studies' raise important questions regarding an association; the opportunity may present itself to answer some of these as the incidence of asbestos-related malignancy is increasing in the UK and Europe.

A survey of contemporary management of frontal sinus disease in the United Kingdom.

Surgery for frontal sinus disease historically has required an external approach. With the advent of endoscopic sinus surgery, endoscopic treatment for various frontal sinus pathologies has been described. This survey examined how widespread the use of endoscopy in frontal surgery has become. We were interested both in the acute emergency situation and in the more chronic situations such as mucocoeles. The replies of 266 practising United Kingdom surgeons to a postal questionnaire were evaluated. While 45% of surgeons regularly practise functional endoscopic sinus surgery (FESS), approximately 25% would attempt endoscopic drainage of acute frontal sinusitis and most perform an external trephine. Most surgeons also rely on external approaches to manage mucocoeles or pyocoeles (54%), although some (39%) attempt endoscopic drainage if the cyst lies sufficiently medially. Even with recurrent or intractable disease one-third attempt endoscopic surgery. When external surgery is used in the United Kingdom, only a small number of surgeons favour obliteration.

The contemporary practice of functional endoscopic sinus surgery: a nationwide survey.

Recent years have seen a rapid growth in the practice of functional endoscopic sinus surgery (FESS). Its introduction into clinical practice has, however, been conspicuous by an absence of good scientific evidence that it is superior to previous techniques. This postal questionnaire survey aimed to identify the diversity in the practice of FESS at a national level and, as a result, highlights areas of patient management requiring standardization. All full members of the British Association of Otolaryngologists--Head and Neck Surgeons (BAO-HNS) were contacted, 64% responded: 14% of surgeons do not always perform preoperative computerized tomography (CT) scanning; only 25% use grading systems for symptoms and/or CT assessment; a wide variety of topical agents are used both before and after operation; nearly half (47%) no longer operate principally under endoscopic vision but via TV monitors; and the majority of surgeons review patients more than 1 week after surgery with a minority advocating earlier postoperative assessment.

A qualitative assessment of randomized controlled trials in otolaryngology.

In 1996 the CONSORT statement made recommendations on the strict reporting of randomized controlled trials (RCT). This will facilitate the future assessment of such trials and will highlight those trials that have been performed suboptimally and whose results may be biased. We have devised a scoring system, based on CONSORT, to assess RCT quality and by reading each original paper in full we have now assessed the quality of trials published from 1966 to 1995. The mean score for trials identified was 7.3 out of a maximum 12 points. No one journal was significantly better than the others. Trials in rhinology are reported better than head and neck oncology trials (mean scores 7.6 and 6.5 respectively). The past 30 years has not seen an improvement in the quality of the trials. The reporting of RCTs in the ENT literature is poor. CONSORT guidelines now exist and trialists are encouraged to adopt them when conducting future clinical trials.

Hodgkin's lymphoma of the nasopharynx.

The lymphoid tissues of Waldeyer's ring, including the nasopharynx, are very rare sites for Hodgkin's disease and are considered to be relatively resistant to it. This report of a case of Hodgkin's disease of the post-nasal space demonstrates the difficulty of making the diagnosis histologically and the characteristic immunohistochemical features of this disease. Before immunohistochemistry became so widely available, some authors speculated it might be underdiagnosed (Eavey and Goodman, 1982; O'Reilly and Kershaw, 1987). Judging by its continued rarity, this appears not to be the case.

On which day is pain worst following adult tonsillectomy?

Anecdotal evidence from several ENT departments suggests that pain following tonsillectomy is worst on the second and/or third days after surgery. This study tests this hypothesis. A pilot study with 19 subjects suggested this theory might well be true. A fuller study was then carried out on 91 subjects with standardised surgical and anaesthetic techniques, and standardised analgesia for five days postoperatively. Pain on the second and third postoperative days was compared with that eight hours after the operation and on the first, fourth and fifth postoperative days. No statistically significant difference was found. There is increasing pressure for early discharge from hospital after surgery. If pain following tonsillectomy is not going to become worse at home, this will tend to make early discharge more acceptable to patients.

KTP laser assisted excision of glomus tympanicum.

A 39-year-old female with a two-year history of mild hearing loss and discomfort on air flight descent was found to have a pulsatile mass behind an intact tympanic membrane. A suspected diagnosis of glomus tympanicum was confirmed by computed tomography (CT) scan imaging. The lesion filled the mesotympanum and hypotympanum but the jugular bony plate was intact, confirming the tympanic site of the lesion. This very vascular tumour was exposed by a tympanomeatal flap and the KTP laser used to shrink and coagulate the tumour progressively with minimal haemorrhage and blood loss. Complete excision of the lesion was achieved without the need for bony removal, and with minimal blood loss. The use of the KTP laser to coagulate this vascular lesion allowed safe removal of the tumour and avoided the need for extended facial recess or hypotympanotomy surgery.

Trends in randomized controlled trials in ENT: a 30-year review.

There is a growth in the demand for clinical practice to be evidence based. Recent years have seen a rise in the number of randomized controlled clinical trials (RCTS). Such trials while acknowledged as the gold standard for evidence can be difficult to perform in surgical specialities. We have recently identified a low proportion of RCTS in the otolaryngology literature. Our aim was to identify any trend in the number of published RCTS within the ENT literature over a 30-year period and to identify which areas of our speciality lend themselves to this form of study design. A Medline search of 10 prominent journals published between 1966 and 1995 was performed. Two hundred and ninety-six RCTS were identified. Only five were published before 1980. Two hundred (71 per cent) of RCTS were in the areas of otology and rhinology. An encouraging trend is seen in RCTS within ENT literature.

Is there an evidence base for the practice of ENT surgery?

In order to assess the strength of the 'evidence base' for the practice of otolaryngology a review of recent journal articles was undertaken. A review of all articles published during the period 1990-1994 in five major general otolaryngology journals was performed. The articles were classified according to a standardized scheme from the abstract or, if necessary, the full paper. Papers were grouped into observational studies (descriptive or analytical, hypothesis-testing), controlled trials, randomized controlled trials, audits, non-clinical and others. One true meta-analysis was found. Randomized controlled trials comprised 0.7%-4% of articles across the journals studied; other controlled trials comprised 0.8-2%; and other analytical studies 7.6-21.9%. Very few true audits were seen. Descriptive studies were by far the commonest type of paper seen. This literature review suggests there is a poor evidence base for our specialty if one regards randomized controlled trials as the gold standard.

Is the nasopharynx warmer in children than in adults?

Recent studies on the aetiology of the Sudden Infant Death Syndrome (SIDS) have suggested that some of these deaths are the consequence of an overwhelming inflammatory response to the production of pyrogenic toxins from bacteria colonizing the upper respiratory tract, particularly the nasopharynx. The pyrogenic toxins of Staphlococcus aureus, one of the likelier bacterial candidates, are only produced in temperatures of over 37 degrees C. This study examined nasopharyngeal temperatures in children. It is a preliminary study to develop an accurate means to measure how close to 37 degrees C the nasopharyngeal temperature lies in infants at the age when SIDS deaths occur. Following a pilot study and power calculation, measurements of nasopharyngeal temperature were made on 30 apyrexial children aged 4-10 years and 30 adults with no nasal pathology, undergoing surgery under general anaesthesia, using an accurately sited thermocouple probe. The mean temperature in children (35.64 degrees C) was significantly higher than in adults (34.01 degrees C). Comparable measurements attempted with the same subjects awake gave similar results.

Balance after stapedectomy: the measurement of spontaneous sway by posturography.

Sway was measured by static posturography in 25 patients undergoing stapedectomy, 16 first-side and nine second-side operations. Measurements were taken pre-operatively and at 1 week and 6 months after surgery, 25 age-matched controls were also tested. In both the first and second side groups, sway was greater at 1 week after surgery than pre-operatively when relying on vestibular function alone (P = 0.01 first-side, 0.05 second-side, 0.01 both sides taken together). By 6 months, sway measurements were no longer significantly different from pre-op or control values. Thus, it appears that there is a measurable increase in patients' sway following stapedectomy but this is well compensated by visual and proprioceptive information, and resolves fully with time. Patients undergoing a second side stapedectomy do not appear to fare worse than those undergoing first-side surgery.