BACKGROUND:The mainstay of management of epistaxis refractory to first aid and cautery is intranasal packing. This review aimed to identify evidence surrounding nasal pack use. METHOD:A systematic review of the literature was performed using standardised methodology. RESULTS:Twenty-seven eligible articles were identified relating to non-dissolvable packs and nine to dissolvable packs. Nasal packing appears to be more effective when applied by trained professionals. For non-dissolvable packs, the re-bleed rates for Rapid Rhino and Merocel were similar, but were higher with bismuth iodoform paraffin paste packing. Rapid Rhino packs were the most tolerated non-dissolvable packs. Evidence indicates that 96 per cent of re-bleeding occurs within the first 4 hours after nasal pack removal. Limited evidence suggests that dissolvable packs are effective and well tolerated by patients. There was a lack of evidence relating to: the duration of pack use, the economic effects of pack choice and the appropriate care setting for non-dissolvable packs. CONCLUSION:Rapid Rhino packs are the best tolerated, with efficacy equivalent to nasal tampons. FloSeal is easy to use, causes less discomfort and may be superior to Merocel in anterior epistaxis cases. There is no strong evidence to support prophylactic antibiotic use.

Background: Cauterisation techniques are commonly used and widely accepted for the management of epistaxis. This review assesses which methods of intranasal cautery should be endorsed as optimum treatment on the basis of benefits, risks, patient tolerance and economic assessment. Method: A systematic review of the literature was performed using a standardised methodology and search strategy. Results: Eight studies were identified: seven prospective controlled trials and one randomised controlled trial. Pooling of data was possible from 3 studies, yielding a total of 830 patients. Significantly lower re-bleed rates were identified ( p < 0.01) using electrocautery (14.5 per cent) when compared to chemical cautery (35.1 per cent). No evidence suggested that electrocautery was associated with more adverse events or discomfort. Limited evidence supported the use of a vasoconstrictor agent and operating microscope during the procedure. The included studies had considerable heterogeneity in terms of design and outcome measures. Conclusion: Consistent evidence suggests that electrocautery has higher success rates than chemical cautery, and is not associated with increased complications or patient discomfort. Lower quality evidence suggests that electrocautery reduces costs and duration of hospital stay.

BACKGROUND:Trans-oral surgical and non-surgical management options for oropharyngeal squamous cell carcinoma (OPSCC) appear to offer similar survival outcomes. Functional outcomes, in particular swallowing, have become of increasing interest in the debate regarding treatment options. Contemporary reviews on function following treatment frequently include surrogate markers and limit the value of comparative analysis. OBJECTIVES OF REVIEW:A systematic review was performed to establish whether direct comparisons of swallowing outcomes could be made between trans-oral surgical approaches (trans-oral laser microsurgery (TLM)/trans-oral robotic surgery (TORS)) and (chemo)radiotherapy ((C)RT). TYPE OF REVIEW:Systematic review. SEARCH STRATEGY:MEDLINE, Embase and Cochrane databases were interrogated using the following MeSH terms: antineoplastic protocols, chemotherapy, radiotherapy, deglutition disorders, swallowing, lasers, and trans-oral surgery. EVALUATION METHOD:Two authors performed independent systematic reviews and consensus was sought if opinions differed. The WHO ICF classification was applied to generate analysis based around body functions and structure, activity limitations and participation restriction. RESULTS:Thirty-seven citations were included in the analysis. Twenty-six papers reported the outcomes for OPSCC treatment following primary (C)RT in 1377 patients, and 15 papers following contemporary trans-oral approaches in 768 patients. Meta-analysis was not feasible due to varying methodology and heterogeneity of outcome measures. Instrumental swallowing assessments were presented in 13/26 (C)RT versus 2/15 TLM/TORS papers. However, reporting methods of these studies were not standardised. This variety of outcome measures and the wide-ranging intentions of authors applying the measures in individual studies limit any practical direct comparisons of the effects of treatment on swallowing outcomes between interventions. CONCLUSIONS:From the current evidence, no direct comparisons could be made of swallowing outcomes between the surgical and non-surgical modalities. Swallowing is a multidimensional construct, and the range of assessments utilised by authors reflects the variety of available reporting methods. The MD Anderson Dysphagia Inventory is a subjective measure that allows limited comparison between the currently available heterogeneous data, and is explored in detail. The findings highlight that further research may identify the most appropriate tools for measuring swallowing in patients with OPSCC. Consensus should allow their standardised integration into future studies and randomised control trials.

Clinical OtolaryngologyVolume 42, Issue 5 p. 1030-1033 Correspondence: Our Experience The value of direct audiology access for magnetic resonance imaging: an audit of 40 cases N. Dawe, Corresponding Author N. Dawe n.dawe@nhs.net Health Education England North East (HEENE), Newcastle upon Tyne, Tyne and Wear, UK Department of ENT, The Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, UK Correspondence: N. Dawe, Health Education England North East (HEENE), Department of ENT, Freeman Road, Newcastle upon Tyne, Tyne and Wear NE7 7DN, UK. Tel.: 0191 2336161; e-mail: n.dawe@nhs.netSearch for more papers by this authorP. Bosson, P. Bosson Department of Audiology, Newcastle upon Tyne, Tyne and Wear, UKSearch for more papers by this authorM. Toepoel, M. Toepoel Department of Audiology, Newcastle upon Tyne, Tyne and Wear, UKSearch for more papers by this authorC. Hickling, C. Hickling Department of Audiology, Newcastle upon Tyne, Tyne and Wear, UKSearch for more papers by this authorJ. Hill, J. Hill Department of ENT, The Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, UKSearch for more papers by this authorS. Carrie, S. Carrie Department of ENT, The Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, UKSearch for more papers by this author N. Dawe, Corresponding Author N. Dawe n.dawe@nhs.net Health Education England North East (HEENE), Newcastle upon Tyne, Tyne and Wear, UK Department of ENT, The Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, UK Correspondence: N. Dawe, Health Education England North East (HEENE), Department of ENT, Freeman Road, Newcastle upon Tyne, Tyne and Wear NE7 7DN, UK. Tel.: 0191 2336161; e-mail: n.dawe@nhs.netSearch for more papers by this authorP. Bosson, P. Bosson Department of Audiology, Newcastle upon Tyne, Tyne and Wear, UKSearch for more papers by this authorM. Toepoel, M. Toepoel Department of Audiology, Newcastle upon Tyne, Tyne and Wear, UKSearch for more papers by this authorC. Hickling, C. Hickling Department of Audiology, Newcastle upon Tyne, Tyne and Wear, UKSearch for more papers by this authorJ. Hill, J. Hill Department of ENT, The Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, UKSearch for more papers by this authorS. Carrie, S. Carrie Department of ENT, The Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, UKSearch for more papers by this author First published: 20 October 2016 https://doi.org/10.1111/coa.12782Citations: 1Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Citing Literature Volume42, Issue5October 2017Pages 1030-1033 RelatedInformation

Background: Eosinophilic oesophagitis is a chronic, immune/antigen-mediated oesophageal disease, only recently, but increasingly, recognised in the world literature. It is diagnosed and managed primarily by medical gastroenterologists and allergy specialists, and is a distinct disease entity, affecting both children and adults. Few studies have been published in otolaryngology journals, although otolaryngologists will encounter patients with undiagnosed eosinophilic oesophagitis. Patients may present with dysphagia, bolus obstruction or with other ENT disorders, such as atopic rhinitis, reflecting the underlying systemic allergic disorder.Objective: This paper systematically reviews the evidence base published on the epidemiology, clinical presentation, diagnosis, treatment and prognosis of eosinophilic oesophagitis, particularly as it relates to otolaryngology practice.

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Dear Editor, Evaluation of paediatric patients for tonsillectomy is primarily based on the Scottish Intercollegiate Guidelines Network (SIGN) guidance 117, updated in 2010, with surgery reserved for at least moderately severe tonsillitis. These guidelines provide an evidence-based framework for ENT specialists to follow and are frequently used by primary care clinicians to ensure appropriateness of referral to secondary care. A 2009 ENT-UK position paper has defined the role of tonsillectomy based on available evidence and addressed the assertions of commissioning groups at the time that the procedure is both unnecessary and over-utilised. Published HES data from this time and in subsequent years have confirmed the suspicions of ENT clinicians that stricter control over access to tonsillectomy is impacting patients by leading to increased admissions for medical management of tonsil disease and quinsy (HES online). These changes have occurred at a time of increasing financial scrutiny within the NHS that has led to tighter controls over the availability of several procedures that are viewed to have limited or questionable positive economic impact. Continued emphasis on cost savings and the ongoing widespread use of the term ‘procedures of limited clinical value’ remain a concern for interventions such as tonsillectomy that are considered to provide a quality of life benefit, but for which limited published evidence exists. Restricting access to these procedures goes against a ‘duty of public involvement and consultation by PCTs in the planning and changing of service provision’, which has not occurred. The ‘T-14 tool’ (Appendix 1) is a validated, patientreported outcome measure (PROM), completed by the parents of the child. It is composed of 14 questions relating to the spectrum of tonsillitis symptoms and sequelae from sore throat to time off school, with each question scored from 1 to 5. It has been developed to measure changes in healthrelated quality of life (HR-QOL) before and after tonsillectomy. It is an accepted ENT-UK audit tool, validated for the UK population. The authors stated that the intentions of the tool were to measure the severity of throat disorders influencing the HR-QOL of affected children. The tool was not intended to provide cut-off values to guide management decisions; however, increased uptake and further refinement of this tool may enable its use to better select those children who will experience the greatest HR-QOL gain from tonsillectomy. Current guidelines and protocols fail to address the unmeasured social, educational and economic costs in pursuing a conservative approach versus an operative one. The T-14 tool has been used in Sunderland Royal Hospital, a district general hospital (DGH), to audit HRQOL improvements in children undergoing tonsillectomy for either obstructive or infective symptoms.

Background: Cricopharyngeal dysfunction following head and neck cancer treatment may lead to a significant reduction in oral intake. Carbon dioxide laser is an established procedure for the treatment of non-malignant cricopharyngeal disorders. We report our experience of laser cricopharyngeal myotomy with objective swallowing outcome measures, before and after treatment.Methods: We identified 11 patients who had undergone carbon dioxide laser cricopharyngeal myotomy for dysphagia following radiotherapy, with or without chemotheraphy between January 2006 and July 2011. We analysed the swallowing outcomes following carbon dioxide laser cricopharyngeal myotomy by retrospective grading of pre- and post-procedure videofluoroscopic swallowing study of liquids, using the validated Modified Barium Swallow Impairment Profile.Results: The median Modified Barium Swallow Impairment Profile score was 13 pre-myotomy and 10 post-myotomy. This difference between scores was non-significant (p = 0.41). The median, cricopharyngeal-specific Modified Barium Swallow Impairment Profile variables (14 and 17) improved from 3 to 2, but were similarly non-significant (p = 0.16). We observed the improved Modified Barium Swallow Impairment Profile scores post-procedure in the majority of patients.Conclusion: Endoscopic carbon dioxide laser cricopharyngeal myotomy remains a viable option in treatment-related cricopharyngeal dysfunction; its targeted role requires further prospective study. Objective analysis of the technique can be reported using the validated Modified Barium Swallow Impairment Profile.

Objective: To describe a case of unwitnessed lithium ion disc battery ingestion, with a review of radiology findings and current best practice management.Case report: A three-year-old girl presented following ingestion of a foreign body, which her four-year-old brother claimed was a one pound coin. The patient was managed non-urgently and transferred for specialist ENT assessment 6 hours following the initial ingestion, with no evidence of airway compromise. A corroded battery was removed from the level of the cricopharyngeus after 8 hours, with an associated circumferential mucosal burn.Conclusion: There is increasing concern regarding the acknowledged rising incidence of lithium ion disc battery ingestion. The lack of a high index of suspicion and the inability to recognise subtleties on imaging may lead to suboptimal management with a higher degree of unnecessary immediate and delayed morbidity. The recently published American Academy of Pediatrics Guidelines may guide the approach to managing battery ingestions.