Assessment and management of vestibular migraine within ENT.

OBJECTIVE: Vestibular migraine is a newly recognised and debilitating condition. This article aims to provide an overview of what is known of vestibular migraine, delineating its diagnostic criteria and presenting some initial management strategies to aid ENT professionals in delivering optimal care when patients first present to the otolaryngology clinic. METHOD: Although traditionally underdiagnosed, there are now clearly defined diagnostic criteria to aid accurate diagnosis of vestibular migraine. RESULTS: A detailed history and clinical examination are the cornerstone of the diagnostic process, but supportive evidence is required from appropriate audio-vestibular tests and imaging. CONCLUSION: This is a unique condition that commonly initially presents to ENT. This article provides a summary of diagnostic and management strategies to facilitate early diagnosis and first-line treatment that can be employed in general ENT settings, which may be particularly useful given the limited availability of specialist audio-vestibular medicine and neuro-otology services.

Developing an implementation intervention for managing acute vertigo in the emergency department.

BACKGROUND: There are evidence-based bedside tests for diagnosing acute vertigo, but no evidence-based strategies to support clinicians in implementing them. The purpose of this study was to design an implementation strategy for treating acute vertigo by examining current facilitators and barriers to using these tests in the ED using the principles of implementation science. METHODS: A survey was developed using the Theoretical Domains Framework and Consolidated Framework for Implementation Research to examine barriers and facilitators for using HINTS+ (head impulse, nystagmus, test of skew, plus hearing) and Dix-Hallpike tests. The survey was sent to emergency clinicians (ECs) in a teaching hospital in London, UK, between May and September 2022. Semistructured interviews were conducted simultaneously, and data examined using direct content analysis. Implementation strategies were then selected based on the Expert Recommendations for Implementing Change framework. RESULTS: Fifty-one ECs responded to the survey and six ECs volunteered for interview. Less than half reported using the bedside tests to make a diagnosis. The most common barriers were beliefs about complexity, a lack of supporting materials, memory, lack of skills and negative experiences. The interview data revealed negative beliefs about the necessity, validity, safety and practicality. There were also barriers in the ED environment (eg, lack of space). There was a strong perception that the current approach to managing acute vertigo needed to change and ECs view this as part of their professional role and responsibility. Based on clinician input, the authors selected strategies to improve diagnostic efforts, which included guidelines for training, developing vertigo champions, protocols, memory aids, audit and feedback. CONCLUSION: This study found several barriers to managing acute vertigo such as memory constraints, and inadequate supporting materials and training, although a robust desire for change. The implementation strategy's initial phase is described, which must now be tested.

Subcutaneous drain insertion in patients with post-operative extensive subcutaneous surgical emphysema: a single centre experience.

OBJECTIVE: Extensive surgical subcutaneous emphysema (ESE) albeit a benign condition could cause patients distress and in many cases temporary vision impairment. We describe the role and value of early subcutaneous drain insertion (SCD) in the management of ESE and patients' experience in this cohort study. METHODS: Extensive surgical subcutaneous emphysema is that which extends to the neck and/or the peri-orbital region. A cohort study of a prospectively collected data was conducted between December 2009 and January 2012. All patients with extensive post-operative surgical emphysema who had SCD (size ≥24 French gauge) were included. RESULTS: 1069 thoracic procedures were performed. 21 patients (1.96 %) were diagnosed with extensive surgical emphysema, there were 16 males, median age was 65 (54-82 years). There were 16 VATS and 5 open procedures. All patients had chest surgical emphysema, 16 patients had peri-orbital and neck swelling and 5 had neck swelling. Surgical emphysema occurred within a median of 3 days post-operatively. 14 (67 %) patients had 1 subcutaneous drain inserted, and 7 (33 %) had bilateral SCD insertion (1 drain each side). 19 (90 %) patients experienced improvement of their symptoms with resolution of neck and peri-orbital swelling within 1 day of SCD insertion, 2 patients had their symptoms improved within 2 days. All patients were satisfied with the outcome following insertion of SCD. CONCLUSIONS: ESE should always be investigated and treated promptly. Early SCD insertion has a valuable role in the management of ESE with improvement of patients' experience.