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Objectives To assess the efficacy and implementation of an epistaxis symptom diary in the management of a child with de-novo HHT type 1. HHT is a cause of chronic, severe epistaxis which can lead to significant physical and psychogical morbidity. We propose that the use of symptom diaries can reduce associated patient morbidity and aid physicians in treatment planning. Participants We discuss an independently developed symptom diary for a 10-year-old girl with HHT, Patient x (“xxx”), and its subsequent impact. Including its uses for surgical and medical treatment planning. Design A patient developed epistaxis symptom diary was designed to including nosebleed timing and side of onset, estimated severity, exacerbating / trigger factors and use of medications. A phenomenological qualitative approach was taken to assessing the impact of the diary on “xxx’s” physical and psychological wellbeing. Setting “xxx’s” diary is a novel symptom diary for patients with of chronic epistaxis and HHT which can improve patient engagement with treatment, foster lifestyle changes, and aid clinicians in promoting tailored patient-centred care. Main outcome measures “xxx’s” diary has proved to be an extremely useful tool for patient xxx, her parents and her ENT team, having improved both her physical and psychological wellbeing. Results and Conclusions We would recommend detailed symptom monitoring for all patients with severe epistaxis and HHT and suggest “xxx’s” diary as a template for this.

BACKGROUND Chronic rhinosinusitis (CRS) refractory to medical and surgical treatment is challenging. It impacts patients' quality of life significantly. The pathophysiology of CRS has some similarities to allergic asthma and allergic rhinitis (AR) and includes eosinophilia, T-helper cell 2 cytokines, and local immunoglobilin E formation. Monoclonal antibody therapy has been used successfully in asthma and AR and more recently in CRS. Our was aim to systematically review the literature and identify the role of monoclonal antibodies (MAbs) in the treatment of CRS with polyps (CRSwNP) and without polyps (CRSsNP), especially with regard to comparability with current medical treatment, efficacy, and risk of complications. In addition, the role of surgery and biologics was evaluated. METHODS We identified at total of 5341 relevant studies after a comprehensive database search. Six studies met the inclusion criteria, all 6 randomized, controlled trials. RESULTS Treatment with omalizumab and mepolizumab demonstrated improvements in endoscopic nasal polyp score (EPS) and symptoms score in patients with CRSwNP when compared with placebo. Reslizumab reduced nasal polyp size in patients with raised intranasal interleukin-5 levels. Dupilumab treatment resulted in a 70% reduction in EPS compared with 20% in the placebo group (p < 0.001). These MAbs target different inflammatory markers involved in the pathophysiology of CRSwNP. None of the studies reported on CRSsNP or combined surgery with biologics. No severe adverse events were reported. CONCLUSION Evidence demonstrates that use of MAbs leads to clinical improvement in CRSwNP. However, further research is required to determine their long-term effects, comparability to other medical treatments, and potential side effects.

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.

Objective This review aims to investigate and compare the effectiveness of endoscopic drainage techniques against external drainage techniques for the treatment of orbital and subperiosteal abscesses as a complication of rhinosinusitis. Introduction Transnasal endoscopic drainage and external drainage techniques have been used in the management of subperiosteal orbital abscesses secondary to rhinosinusitis. Each of these approaches has its own advantages and disadvantages, with extensive literature describing each technique separately. However, there is a lack of guidance in the studies on assessing and comparing the safety, effectiveness and suitability of these techniques. This review aims to compare the effectiveness of these techniques based on measuring outcomes in the literature such as: length of postoperative hospital stay, rate of revision surgery and complication rates. Inclusion criteria Eligible studies will include people of all ages diagnosed with subperiosteal abscess, orbital abscess or cavernous sinus thrombosis (Chandler stages III-V) secondary to rhinosinusitis disease, who have also undergone drainage via either an endoscopic approach, external approach or combined surgical approach. Methods A comprehensive search of both published and unpublished literature will be performed to uncover studies meeting the inclusion criteria. Reference lists of studies included in final analyses will also be manually searched and subject matter experts contacted to investigate other sources of literature. Two reviewers will screen studies and a third reviewer will resolve disagreements. Studies will, where possible, be pooled in statistical meta-analysis with heterogeneity of data being assessed using the standard Chi-squared and I tests.

Objective: This study assesses the efficacy of alar suspension sutures in the management of nasal valve collapse causing nasal obstruction. These sutures are inserted between the vestibular skin and lateral crura and hitched to the periosteum of the medial inferior orbital margin; this is a variation of the alar (change everywhere) suspension suture technique. Method: A retrospective review of patients who underwent alar suspension suture insertion between January 2009 and December 2010 in the management of nasal obstruction was undertaken. Symptoms of nasal obstruction were assessed using the Visual Analogue Scale (VAS) and peak inspiratory flow rate (PIFR). This was measured preprocedure and repeated at 3, 6, and 12 months postoperatively. Results: A total of 35 patients were identified, and 26 were included in the study; 90% of patients were satisfied with the outcome of surgery, supported by improvement in the VAS and PIFR scores. The mean difference in VAS preprocedure and postprocedure was 4.97 ( P value = 0.00), and the average improvement in PIFR was 25.5 L/min ( P value = 0.00). Conclusion: Our study shows a significant improvement in patient’s symptoms following insertion of alar suspension sutures. It is, therefore, a reliable, safe, and effective technique in treating nasal obstruction secondary to nasal valve collapse.

The aim of this study is to identify the demographics and epistaxis burden of hereditary hemorrhagic telangiectasia (HHT). A questionnaire was sent to participants with HHT who were recruited from a prospectively maintained respiratory clinic data base in a tertiary hospital. Details on demographics, HHT symptoms, family history, epistaxis severity, and treatment received were recorded. There were 34 of 60 responses (57%). Two responses were from families of the deceased. Of the 32 evaluable patients (men, 14; women 18), the average age was 51 years (range, 23–78 years). The average age of HHT diagnosis was 31 years (range, 3–61 years). The diagnosis of HHT was made by the respiratory team in 13 patients; neurologist (2); ear, nose, and throat (ENT) specialist (4); general practitioner (5); hematologist (4); gastroenterologist (1); and not mentioned in two patients. Twenty-seven of 32 patients (84%) had a positive family history of HHT. Only 13 patients had formal genetic testing (4 endoglin, 1 activin receptor–like kinase, 8 unknown gene). All patients who presented to the respiratory clinic had a background of epistaxis, which was noted on presentation. The average age at initial epistaxis was 14 years (range, 2–50 years). The frequency of epistaxis was daily 63% (n = 20), weekly 9% (3), monthly 16% (5), and a few times a year 10% (3), and unstated in one patient. Nine of 32 patients (28%) required a transfusion. Six patients thought that they were unable to perform daily activities due to epistaxis. Only 15 of 32 patients (47%) were under the care of an ENT specialist. The treatment plan for epistaxis management was deemed good by 7 patients, adequate in 8, poor in 6, and not stated by 11 patients. In conclusion, this survey is the first to quantify the epistaxis burden within the northeast of England. The management of epistaxis needs specific education and treatment to optimize the quality of life among these patients.