bluuebunny/crossref_metadata_2025 huggingface dataset:
1464 Breaking Tradition – A Rural DGH’s Experience of The Management of Acute Appendicitis During the First Wave of the COVID-19 Pandemic
Authors: Zahari F , Byrne H , Roslan F , Ali M , Mitrofanova O , Da Silva Bento E , Rao M
Published: October 2021

Aim

Acute appendicitis (AA) is the most common abdominal surgical emergency in the UK and traditionally, operative management is the mainstay of treatment. However, during the first wave of the COVID-19 pandemic, ACPGBI discouraged laparoscopy, due to potential risks of aerosol viral transmission. We aimed to review clinical outcomes of patients treated for AA at our DGH prior to and after the change in ACPGBI guidance.

Method

The first 30 patients treated for AA prior to (Group A) and following the update in ACPGBI guidance (Group B), were identified.

Results

Group A: 7% managed conservatively vs 93% operative management. Group B: 74% managed conservatively vs 26% operative management. No statistically significant difference was seen in the rate of post-operative complications, or readmission. In Group B, of those managed conservatively and then readmitted, 75% underwent an operation (RR < 1.00). The average length of stay (LOS) of those managed conservatively in Group A was 3.5 days vs 2.4 days in Group B (p < 0.05). Statistically significant differences in LOS were also observed in patients who underwent surgery - Group A 5.5 day vs 8.25 days in Group B (p < 0.001).

Conclusions

In conclusion, the change in ACPGBI guidance in the early stages of the COVID-19 pandemic, saw statistically significant differences in LOS at our DGH. A shorter LOS in those conservatively managed in Group B could be explained by hospital bed pressures. An increase in LOS for Group B patients with operative management is understandable, as only cases of complicated AA, or those readmitted underwent emergency surgery.
1544 The Doctor Will Call You Now – Patients’ Perspective of The Implementation of Telephone Clinics in the COVID-19 Era
Authors: Chawla A , Byrne H , Rao M
Published: October 2021

Aim

During the first wave of the COVID-19 pandemic, clinical guidelines advised the implementation of remote consultations with the aim of preventing viral transmission. Guidance included the introduction of telephone clinics and in March 2020, these were initiated for General Surgery at our rural DGH. The aim of this study was to review patients’ perspectives of these remote consultations.

Method

Using telephone clinic schedules, the first 100 patients of the telephone clinics were retrospectively identified. A survey was created using Google forms and questions covered patient demographics, as well as patients’ opinions on the organisation and efficacy of the clinic. The survey was completed via a telephone conversation with each patient between June to August 2020.

Results

72 patients consented to participate (age range: 24-80 years; 65% female). 44% of consultations were follow up, with 23% of patients having their initial appointment remotely. Although 82% of patients were able to discuss all concerns, nearly half of patients (43%) felt not having a face-to-face appointment affected their consultation. 78% of patients preferred remote consultations during the pandemic, but beyond this specific situation, 53% felt that in the future they would still prefer a face-to-face consultation. 57.6% of patients rated the newly implemented telephone consultations as 10/10.

Conclusions

The majority of patient feedback was positive. However, outside of the COVID-19 pandemic, our patients would prefer the traditional face-to-face consultation format. This outcome has been demonstrated in other similar studies worldwide, as it enables patients to be examined by and meet their surgeon prior to potential surgery.
1569 Paediatric Upper Limb Fracture Manipulation in A Children’s Emergency Department: Practice Changes During The COVID-19 Pandemic
Authors: Derias M , Amen J , Morrissey N , Alexander-Harvey G , Porter J , James Kyle , Crompton T , Maripuri S
Published: October 2021

Background

Trauma theatre time is valuable and previous studies reported cost of £24.77/minute. BSUH Children’s emergency department (CED) guidelines were implemented in December 2016, allowing reduction of forearm and distal radius (DR) fractures in CED using 70% nitrous (N2O) sedation. Due to COVID-19 pandemic and the risks associated with aerosol generating procedures as well as staffing levels, CED shifted to using 50%N2O with or without intranasal fentanyl.

Method

Relevant fractures presenting to CED from Feb-Dec 2020 were identified and compared to previous years. Demographics, treatment modality, timings, and outcomes were reviewed for 275 patients.

Results

In 2017-2018, 56% were manipulated in CED under 70%N2O (compared to only 3% in 2016). The main barrier identified was shortage of doctors trained in sedation to supervise use of 70%N20. In 2020, 101 patients were suitable for manipulation in CED. 64 had DR fractures, 37 midshaft fractures, 65 were male. Mean age: 10 years. 92 patients (91%) were manipulated in CED/fracture clinic. One was under 70%N2O; the rest used 50%N2O with or without intranasal fentanyl. 8 (9%) had manipulation under GA. Of those manipulated in CED, 3 were re-manipulated in clinic for cast problems. A typical MUA takes 30minutes indicating a saving of £743 per case; therefore, £68,356 over the study period.

Conclusions

Paediatric upper limb fracture manipulation in CED under N2O is effective and provides significant cost savings. Due to changes related to COVID-19 pandemic, considerably more patients in 2020 were safely treated in CED/clinic. Using 50%N2O improves uptake due to lower staffing requirements.
1706 Is A “COVID-19-Free” Hospital the Answer to Resuming Elective Surgery During the Current Pandemic? Results from The First Available Prospective Study
Authors: Gammeri E , Cillo G M , Sunthareswaran R , Magro T
Published: October 2021

Background

Resumption of elective surgery during the current coronavirus disease 2019 (COVID-19) pandemic crisis has been debated widely and largely discouraged. This prospective cohort study aimed to assess the feasibility of resuming elective operations during the current and possible future peaks of COVID-19 pandemic.

Method

Data were collected during the peak of the first pandemic in the United Kingdom on adult patients who underwent elective surgery in a “COVID-19-free” hospital from April 8 to May 29, 2020. The study included patients from various surgical specialities. Non-elective and pediatric cases were excluded. The primary outcome was 30-day mortality postoperatively. Secondary outcomes were the rate of COVID-19 infections, new onset of pulmonary symptoms after hospitalization and requirement for admission to the intensive care unit.

Results

309 consecutive adult patients were included in this study. No patients died nor required intensive care unit admission. Operations graded “Intermediate” were the most performed procedures. One patient was diagnosed with COVID-19 infection after being transferred to the nearest local emergency hospital for management of postoperative pain and was successfully treated conservatively on the ward. No patient developed pulmonary complications. Three patients were admitted for greater than 23 hours. Twenty-seven patients (8.7%) developed complications. Complications graded as 2 and 3 according to the Clavien-Dindo classification occurred in 14 and 2 patients, respectively.

Conclusions

This prospective study shows that, despite the severity and high transmissibility of novel coronavirus 2 diseases, “COVID-19-free” hospitals can represent a safe setting to resume many types of elective surgery during the peak of a pandemic.
90 Penetrating Abdominal Trauma: Comperative Study Between Operative and Conservative Management
Authors: Shalaby A , Ibrahim M , El Faioumy T , Elmessiry M
Published: October 2021

Aim

to Assess the feasibility and safety of selective non-operative management in penetrating abdominal injuries and to identify a protocol for selection of patient’s candidates for non-operative management.

Method

In this comparative study 40 abdominal stab victims (admitted to Emergency Department of Alexandria Main University Hospital) were selected during 6 months period where 20 patients were suitable for non-operative management according to strict selection criteria whereas the other 20 patients were operated according to clinical and/or radiological indications or on basis of department protocol, the results were compared in view of final outcome.

Results

In our study, 15 patients were assigned for operative management according to selected clinical and/or radiological indications only 3 of them (20%) had non-therapeutic laparotomies, On the other hand, five patients were explored on basis of department protocol in violation of our indications for exploration; four of them (80%) were non-therapeutic. So, the rate of non-therapeutic laparotomies was significantly higher when done mandatory without selected clinical and radiological indications.

Conclusions

Assessment of vital signs together with abdominal examination are the most important and dependable tools in decision making in penetrating abdominal trauma patients. Patients with shock on admission (but responding to resuscitation), proved low grade solid organ injury (by CT), and proved intraperitoneal collection (by US or CT) could be managed conservatively regarding that they remain vitally and clinically stable. If failure of conservation occurs, it is usually during the 1st 24 hours after admission.
447 Evaluation of JPI System as Prognostic Tool in Cases of Perforation Peritonitis
Authors: Singh N , Singh B J , Sharma A , Khalsa M S , Singh H
Published: October 2021

Aim

Perforation peritonitis is a commonly encountered condition in surgical practice in any hospital. One of the reasons for high mortality in these conditions is lack of risk stratification resulting in delay in providing adequate management, although a number of scoring systems are available to stratify these patients according to severity, but most of these cannot be used in developing countries like India due to their dependency on sophisticated investigation which are usually lacking in most parts of these countries. This study aims to evaluate a simple scoring system for peritonitis.

Method

Fifty cases with diagnosis of peritonitis coming to Government Medical College, Amritsar were stratified according to Jabalpur peritonitis Index and their outcome was examined.

Results

Mortality steadily increases with increase in JPI score. Patients with JPI score of < 9 and >9 had mortality rate of 2.5% and 60% respectively)(p < 0.01) and similarly morbidity of 30% and 80% (p < 0.0001).Duration of pain >24 hours, age >50 years, mean SBP <100 mmHg, serum creatinine >1.5 mg/dl, respiratory rate >24/min, heart rate >110/min and feculent exudate intra operatively were found to be independently significant factors in predicting the mortality among the study population. For a score of 9, the sensitivity was 85.7%, specificity was 90.7% and positive predictive value for mortality is 40% and negative predictive value of 97.5%.

Conclusions

This study proves that JPI scoring system is a simple and effective tool for assessing the morbidity and mortality in patients with peritonitis.
1078 Enteric Duplication Cyst in An Adult: Presenting with Diarrhea and Vomiting
Authors: Wintrip D
Published: October 2021

Intestinal duplication cysts are rare disease entirety, most commonly presenting in childhood. The incidence is 1:4,500 births, with a slight male predominance. They can occur anywhere along the alimentary tract, 35% occur in the ileum and 10% in jejunum. Diagnosis can prove challenging as they can present with a vast variation of symptoms and mimic other pathologies.

A 29-year-old male presented to A&E following a collapse. He had been suffering of diarrhoea and vomiting with lower abdominal discomfort. The patient was otherwise fit and well and no surgical history. On physical examination his abdomen was generally tender with no peritonism but was tachycardic, tachypneic but normotensive. His blood pressure dropped to 70/56, heart rate 130 and temperature increased to 41.2 degrees. A CT abdomen and pelvis with contrast was subsequently performed while on intensive care. There was a huge fluid-filled structure almost filling the entire pelvis and right side of the abdomen measuring up to 18cm in transverse diameter and 38cm longitudinally. The fluid filled structure appeared to communicate with a loop of small bowel in the right iliac fossa. There was no sign of obstruction.

Due to the CT findings and the patient’s clinical status a laparotomy was performed. A large congenital duplication cyst was seen which was adherent to 40cm of the small bowel. The section of bowel was 130cm distal to the DJ flexure. The small bowel including the cyst was resected and hand sewn end-to-end anastomosis performed.
1111 Shifting the Paradigm of Abscess Treatment – From Theatre to Clinic
Authors: Newitt L , Stewart C , Wei R
Published: October 2021

Aim

Treatment of skin and soft tissue abscesses forms a substantial part of the emergency general surgery workload. Abscesses account for approximately 2% of presentations to Accident and Emergency, with 0.9% of patients requiring surgical intervention. Incision and drainage is often performed in theatre and may necessitate admission to hospital, impacting bed space and theatre availability. This study aims to identify if the introduction of a clinic-based abscess service could reduce the number of abscess drainages in theatre without compromise to clinical outcomes.

Method

Retrospective data was collected for patients undergoing abscess treatment at Musgrove Park Hospital (Taunton) in September 2019. Subsequently, a Nurse-led abscess drainage pathway was initiated in Emergency Surgery Ambulatory Clinic (ESAC) encompassing initial assessment and drainage at the bedside. Prospective data was then collected for abscesses drained in theatre and ESAC during September 2020 and compared with data from 2019.

Result

22 abscess drainages were performed in September 2019 vs 25 in September 2020. 8 cases were carried out in theatre during September 2020, with the rest being treated in ESAC. Of those who were treated in clinic (n = 17), admission was prevented in 16 patients. Readmission rates were similar between ESAC (16%) and theatre (18.1%).

Conclusions

A clinic-based abscess service is achievable and prevents unnecessary use of theatres and hospital admissions, with comparable re-presentation rates. A nurse led approach also relieves pressure on Doctors during busy surgical on calls. Nonetheless, a larger data set would be needed to consolidate the findings from this study.
1404 NELA Risk Mortality Scores from Admission to Theatre in Emergency Gastrointestinal Perforation – A Retrospective Cohort Study
Authors: Misbert E , Hughes M , Burke J , Schofield C , Young A
Published: October 2021

Background

Patients with acute abdominal pathology requiring emergency laparotomy who experience a delay to theatre have an increased risk of morbidity, mortality and complications. The aim of this study was to assess delay, from symptom onset to theatre in patients with gastrointestinal perforation and its effect on perioperative risk.

Method

A single-centre retrospective study was performed in the Leeds Trust Hospitals, UK investigating the NELA database for patients requiring emergency laparotomy for perforated gastrointestinal viscus who presented to the acute surgical unit or emergency department between 1st February 2018 and 31st January 2020.

Results

101 patients met the inclusion criteria (47% F and 53% M), mean age 59 [21-91]. 37% of patients’ NELA scores worsened from admission to pre-op (median change of + 5.9% IQR 1.3-11.5]), 14% stayed the same and 49% improved (median change of -4.4%[IQR 0.4-9.1]) 3% had their NELA score documented at the time of consent. 18% did not wait for a CT report or went straight to theatre. Mean time from admission to scan report was 9.3 hours (0.9-22.0). Median time from symptom onset to presentation (2 days [IQR 1-13]) was greater in patients with an Index of Multiple Deprivation Decile of 1-5, (n = 64, median 2 days [IQR 1-6]) compared to those in deciles 6-10, (n = 37, median 1 day[IQR 1-3]), p = 0.097.

Conclusions

NELA mortality risk score changes from presentation to surgery in patients with acute gastrointestinal perforation requiring emergency laparotomy. There is suggestion that delay in symptom onset to presentation may correlate with Index of Multiple Deprivation Decile.
1553 Non-Operative Management of Acute Appendicitis at A Major Trauma Centre – A Retrospective Case Series
Authors: Chong S J K , Kaur M , Palmer C , Jaunoo S
Published: October 2021

Aim

The recent CODA trial concluded that appendicitis patients with confirmed faecolith are at higher risk of appendicectomy and complications than those without faecolith. A retrospective case series of patients undergoing non-operative management of appendicitis at a major trauma centre was conducted to determine the success of non-operative management, defined as lack of operative management within 30 and 90 days of diagnosis, and the impact of presence of faecolith on outcomes.

Method

All patients who received a working diagnosis of appendicitis over a 16-week period between March and June 2020 were identified and their electronic records interrogated for: preliminary and final diagnoses; imaging modality and result; operative or non-operative initial treatment strategy; final treatment strategy; and histopathology results where applicable. Patients who received an initial operative treatment strategy were excluded. Patients for whom appendicitis was not confirmed on either imaging or histopathology were excluded.

Results

24 patients received an initial non-operative treatment strategy and were eligible for inclusion. 15 patients (62.5%) underwent successful non-operative management. The remaining 9 patients (37.5%) required operative management within 30 days. Presence of faecolith was confirmed in 9 patients (37.5%). 3 patients (33%) with presence of faecolith required operative management, while 3 patients (25%) without presence of faecolith required operative management. 1 patient with confirmed faecolith developed a large intra-abdominal abscess while undergoing a non-operative treatment strategy and subsequently required right hemicolectomy.

Conclusions

The majority of our eligible appendicitis patients were successfully managed non-operatively. Presence of faecolith in acute appendicitis is associated with increased risk of requiring operative management.
1575 Predictive Ability of Neutrophil-To-Lymphocyte Ratio in Acute Appendicitis
Authors: Nawaz G , Qayum M , Hajibandeh S , Hajibandeh S
Published: October 2021

Aim

Neutrophil-to-lymphocyte ratio (NLR) predicts both diagnosis and severity of appendicitis. We aimed to evaluate accuracy of NLR to predict acute appendicitis and whether it can distinguish between uncomplicated and complicated appendicitis.

Method

Patients of any age and gender presenting with clinical history of acute appendicitis over a 4 month period were included. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of NLR were evaluated considering the cut-off values of 4.7 for acute appendicitis and 8.8 for complicated appendicitis.

Results

A total of 54 patients were included. Thirty-eight patients had acute appendicitis of whom 21 (55.2%) had complicated appendicitis. NLR was associated with sensitivity of 89.4%, specificity of 81.2%, PPV 91.8%, NPV of 76.5%, and accuracy of 87.0% for acute appendicitis. Moreover, it was associated with sensitivity of 61.4%, specificity of 78.9%, PPV 76.5%, NPV of 65.2%, and accuracy of 70.0% for complicated appendicitis.

Conclusions

NLR has acceptable sensitivity, specificity, PPV, NPV and accuracy to predict uncomplicated and complicated appendicitis with relatively better ability to predict the former. NLR can be utilised for prioritising cases for surgery, for monitoring conservatively treated patients and for patients who do not routinely undergo CT scan (pregnant or paediatric patients).
457 The Effect of Biochemical Adversity of Primary Hyperparathyroidism on Preoperative Imaging (SPECT-CT and US Parathyroids)
Authors: Durand C , Anderson H , Simpson D , Gull S , Oprean R , Lim K , Lee F , Kakos C , Cvasciuc T
Published: October 2021

Aim

Primary hyperparathyroidism (PHPT) is a common endocrine disorder, with an estimated incidence of 1/500 women and 1/2000 men older than 40 years. Several factors influence the positivity of preoperative scans including serum calcium, PTH and vitamin D levels, and gland size. The aim of our study is to examine the effect of biochemical adversity of primary hyperparathyroidism on preoperative imaging (SPECT-CT and US parathyroids).

Method

Retrospective study of 176 parathyroidectomies (2017-2020) in a tertiary referral centre with biochemistry, SPECT-CT, US parathyroids and histology outcomes being recorded. Failed parathyroidectomies were excluded.

Results

Patients were divided into 4 groups based on the preoperative calcium levels (normocalcemia <2.6, 3.4%; mild 2.60-2.79, 51.1%; moderate 2.80-2.99, 31.2%; severe >3.0 mmol/l, 14.2% of patients). Age (p-0.0297), preoperative vitamin D (p-0.03) and PTH levels (p-0.0001) were different while SPECT-CT positivity (p-0.29) weight of gland (p-0.015) and US positivity (p-0.09) were similar within the subgroups. Looking at the whole group, patients with positive SPECT-CT have a larger weight (p < 0.0001) while preoperative PTH levels was higher for the positive SPECT-CT patients (p-0.0289). No relation was identified between calcium levels and SPECT-CT positivity (p-0.18). No significance between preoperative vitamin D and positivity of US and SPECT-CT within the study group were noted.

Conclusions

Serum PTH levels and weight of the gland are directly correlated with positivity of preoperative imaging. Preoperative calcium and vitamin D levels correlates indirectly with the severity of the disease but did not influence the preoperative imaging positivity.
1108 Comparing the Accuracy of Ultrasonography and Nuclear Imaging Scan in Preoperative Localisation of Parathyroid Lesions in Patients with Primary Hyperparathyroidism
Authors: Jayawardena P , Peris R , Rafie A
Published: October 2021

Aim

Parathyroidectomy remains the only method to cure Primary Hyperparathyroidism. Preoperative localisation of the lesion is vital for successful surgical management. The preferred initial preoperative imaging is an ultrasound scan (USS) of the neck. NICE recommends a second preoperative imaging modality to guide the surgical management. This study was conducted to compare the effectiveness of USS of the neck and SPECT scan in the preoperative localisation of parathyroid lesions in a single Teaching Hospital.

Method

A retrospective study performed included a cohort of patients between 2018 and 2020. 31 patients that underwent elective focussed parathyroidectomy were followed up. Data on preoperative investigations including USS of the neck and SPECT and final histological diagnosis of the specimen was captured using the hospital’s electronic medical records Quadramed.

Results

Both USS and SPECT scan correctly identified the nature and location of the lesion in only 35.4% patients. USS alone correctly identified the nature and location of the lesion in 50.0% patients whereas SPECT was 46.7%. USS incorrectly identified the nature or the location of the lesion in 33.3% patients whereas SPECT was 40.0%. Interestingly, the USS did not identify any abnormal pathology in 5 patients and SPECT in 4 patients, although all 9 showed pathological histology findings.

Conclusions

Data collected shows that either scan alone would not be sufficient to confirm the absence of parathyroid pathology. A second scan decreases the likelihood of missing any abnormal pathology. However, in patients with a high clinical suspicion abnormality cannot be ruled out despite having two negative scan results.
168 Emergency Medicine Clinicians’ Confidence in Managing Epistaxis Is Improved by A Simple Intervention: A Closed-Loop Quality Improvement Study
Authors: Banhidy N , Jamshaid S
Published: October 2021

Aim

Epistaxis is a common, potentially life-threatening presentation in the Emergency Department (ED) with an incidence of 108/100 000 population per year. 85% of all patients presenting with epistaxis are managed by ED clinicians without specialist input or admission. Guidelines exist from ENT UK on epistaxis management, however awareness of these guidelines, nuances in techniques and levels of confidence by ED clinicians is not known. This quality improvement study aims to assess the confidence of ED clinicians in managing epistaxis, and investigate whether this could be improved through educational intervention.

Method

A single-centre, prospective, baseline audit was conducted following local approval. An initial questionnaire assessed knowledge of appropriate Hippocratic first aid method for epistaxis, alongside individual confidence in providing epistaxis prevention advice. The educational intervention included a 30 minute interactive tutorial on epistaxis during the local department teaching for ED clinicians. The audit loop was then closed by repeating the questionnaire.

Results

Pre- (n = 20) and post- (n = 8) intervention questions were completed by ED clinicians. Knowledge scores of appropriate epistaxis first aid provision increased from 53% pre-intervention to 88% post-intervention. Reported confidence in providing epistaxis prevention advice also increased from a mean score of 2.7 pre-intervention to 4.1 post-intervention on a 5-point Likert scale.

Conclusions

ED clinicians generally lack knowledge on appropriate first aid techniques on managing epistaxis and confidence in providing epistaxis prevention advice. Both of these parameters may be improved by simple educational interventions which may be implemented nationally.
515 Patient Satisfaction on Drainless Outpatient Parotidectomy
Authors: Maniam P , Flach S , Hey S Y , Owusu-Ayim M , Manickavasagam J
Published: October 2021

Background

Parotidectomy is commonly performed as an inpatient procedure due to drain insertion. However recent evidence suggests that drainless outpatient parotidectomy is a safe option with comparable postoperative complication and hospital readmission rates to inpatient parotidectomies.

Aim

Patient satisfaction on outpatient parotidectomy is unclear and this study aims to report patients’ perspective and satisfaction on drainless outpatient parotidectomy.

Method

Anonymous ‘Core questionnaire for the assessment of Patient Satisfaction’ (COPS) for general Day care (COPS-D) questionnaire survey was completed by patients who underwent drainless same day parotidectomy at Ninewells Hospital, Dundee from June 2018 to October 2020. Patient satisfaction on different aspects of their outpatient parotidectomy journey (e.g., pre-admission, admission on ward, in-theatre experience, nursing care, pain control and overall satisfaction) were scored using a five-point Likert scale.

Results

A total of 31 drainless outpatient parotidectomies were performed and 28 patients completed the patient satisfaction survey. The majority of patients were highly satisfied (i.e., scored 5/5) with their preadmission visit (79.5%), admission on the ward (84.5%), operating room experience (96.4%), nursing care (83.9%), medical care (87.5%), information received (75.0%), autonomy (79.8%) and discharge and after care (61.9%). Despite preferring drainless parotidectomy, 16/28 (57.1%) patients either stayed for less than 23 hours or preferred to stay overnight stay in the hospital for non-surgical reasons.

Conclusions

Outpatient parotidectomy is well received by patients and the majority of patients preferred drainless parotidectomy over inpatient parotidectomy with drains.
695 Photo-otoscopy Audit: A Review of Change in Departmental Practice Due to COVID-19
Authors: Chan K Y , Thornton H , Gordon C , Ishii H , Clark M
Published: October 2021

Background

Photo-otoscopy is a new service set up during the COVID-19 pandemic, with the view to minimise unnecessary appointments, protect vulnerable patients, and optimise efficiency of ENT-outpatient appointments. The objectives are to assess rate of diagnostic photos and investigate how to improve this service.

Method

First cycle was performed between June and July and second cycle between October and December 2020. All patients attending Audiology who had a photo taken were included. Photos were analysed based on a number of variables to identify the proportion of diagnostic and non-diagnostic photos. First cycle highlighted a few changes to practice that were then instigated for second cycle.

Results

324 patients and 232 patients were included in first and second cycle respectively. 17 operators/audiologists were involved. There is slight improvement in percentage of diagnostic photos in second cycle compared to first (30.6% to 31.9% in right ear and 23.5% to 35.8% in left ear). Percentages of non-diagnostic photos with blurriness as sole reason have increased compared to first cycle. Percentages of non-diagnostic photos with all 3 variables present have reduced significantly. Mean percentage of acceptable photos per operator have also improved. 8 out of 10 ENT consultants/registrars found the service useful.

Conclusions

Rate of diagnostic photos remained low (<40%) despite implementation of changes to practice from first cycle. 38% of non-diagnostic photos were wax-related. There is significant variation in rate of diagnostic photos due to its operator-dependent nature. Given the expansion of telemedicine, there is definitely scope for future development for photo-otoscopy.
709 A Prospective Analysis of Post-Tonsillectomy Haemorrhage and Hospital Reamission Rates in A Tertiary Pediatric Centre
Authors: Thompson N , Street I
Published: October 2021

Introduction

Tonsillectomies are one of the most commonly performed procedures., with one particular leading tertiary paediatric centre performing 1,067 tonsillectomies within the last year. Post-tonsillectomy haemorrhage is a considerable complication leading to further primary care costs, readmission, and surgical intervention. Previous national audits have suggested that post-tonsillectomy haemorrhage rates are between 3.0-3.5%1 and readmission rates are approximately 8.8%2.

Aim

Assess post-tonsillectomy haemorrhage and readmission rates at a leading tertiary paediatric centre.

Method

A prospective phone survey was completed for every patient receiving a tonsillectomy 6 weeks post-operatively, using a 2-month inclusion period.

Results

Of the 51 patients included, 51 responded to phone survey. The total post-tonsillectomy haemorrhage rate was 23.5%. Of the 51 respondents, 10 (19.6%) were readmitted through A&E, all of which had extracapsular tonsillectomies. 1 (10%) of those readmitted had further surgical intervention whilst the remaining 9 (90%) were treated conservatively. A further 4 (7.8%) attended their GP, with 3 (75%) of those requiring antibiotics.

Conclusions

This data shows that both the post-tonsillectomy haemorrhage and readmission rates at the tertiary paediatric centre were higher than the national average. We suggest that previous national data audits describing bleeding rates lack the granularity to reveal true post-operative complication rates. Our prospective cohort has demonstrated that there may be a large proportion of patients with morbidity that never reach the attention of the ENT surgeon and additionally that subgroups in particular may benefit from interventions designed to minimise patients’ post-operative risks, including specific perioperative management and advice.
909 ENT Telephone Clinic During COVID-19 Pandemic
Authors: Sargsyan N , Karunaratne D , Masani A , Yousif M
Published: October 2021

Introduction

In response to the COVID-19 pandemic, ENT services in NHS hospitals have fundamentally changed the way they function. Focus is narrowed on emergency care and cancer care, with cancellation of most elective procedures. In response to this, 2 week wait (2ww) ENT telephone clinics were set up.

This project reviewed the effectiveness of ENT telephone clinic appointments in managing 2ww referrals and to determine whether the introduction of 2ww telephone clinics improves patient waiting times and appropriates of referrals.

Method

Retrospective review of ENT telephone clinic 2ww referral outcomes at Eastbourne District General Hospital and the effectiveness of managing these patients.

Results

A total of 58 ENT Telephone Clinic 2ww referrals from the GP were reviewed. After a telephone consultation 63% of patients were referred to 2ww imaging, from which 70% were discharged following imaging. 83% of patient offered face to face appointment following imaging, required further investigation or treatment, again reducing delay in diagnosis.

Conclusions

Telephone clinic is an effective way of managing 2ww referral patients. In the ongoing pandemic, telephone clinics will be used to manage cancer pathways. This study shows that a large number of patients are discharged after imaging following a telephone clinic. Further study is required to determine whether low scoring patients on symptom-based risk calculators for cancer referrals could be directly referred to imaging to avoid delay in diagnosis, reduce anxiety as well as allow appropriate resource allocation.
1121 Single Use Nasal Endoscopes – A Review of The Cost and Organisational Implications Based on Department Size
Authors: Wallace J , Evans V , Sanu A , Howard A , Berry S
Published: October 2021

Aim

Single use nasal endoscopes have become increasingly popular since the COVID-19 pandemic. By avoiding the risk of cross contamination and reducing exposure by eliminating the need for re-processing, the disposable scopes have clear safety benefits. Despite ENT UK guidelines recommending that disposable nasal endoscopes be available in every department for use in emergencies, they have often been considered prohibitively expensive. The aim of this study was to analyse the costs associated with traditional nasal endoscopes and compare them to the single use scopes.

Method

A micro costing exercise was undertaken in three ENT departments: 2 university hospitals, and 1 district general hospital. The outcomes were compared and discussed with relation to the logistics of the departments, as well as organizational considerations.

Results

Cost per procedure varied according to the reprocessing methods used in the different departments. The cost of the disposable nasal endoscopes appears high, however there are many hidden costs associated with the traditional scopes, which can be difficult to quantify accurately.

Conclusions

Although disposable endoscopes appear costly, reprocessing and frequent repairs required for re-usable scopes account for the comparable cost per procedure. The high risk of COVID-19 transmission from examining the upper aerodigestive tract means that the safety benefits bear more weight in the current climate. However, concerns regarding environmental impact, image quality and storage of examinations also need to be considered.
1184 Operation Note – Are We Documenting Accessibility to The Larynx
Authors: Motter D , Williams H
Published: October 2021

Introduction

Diagnostic laryngeal procedures are often done under general anaesthesia to aid in assessment and management of laryngeal lesions. Obtaining tissue samples for histology is an extremely important tool used to aid in further surgical planning. Documentation of accessibility to the larynx is paramount to patient care and future surgical planning. We aimed to highlight operative notes for those undergoing diagnostic procedures and assess whether sufficient detail is documented. The Royal College of Surgeons recommends that all operative notes must be comprehensive and “all problems/complications” must be documented for good practice.

Method

We carried out a 3-month retrospective data collection on patients who have undergone diagnostic laryngeal procedures at the Royal Glamorgan Hospital. We included microlaryngoscopies, panendoscopies and laser-specific procedures. We accessed the theatre booking system and retrieved the operation notes.

Results

During the 3-month period, 33 procedures were undertaken. 52% of the operative notes did not document level of accessibility. 48% of the operative notes included the level of accessibility, highlighting keywords such as “good access”, “difficult access” and “difficult access but possible for laser therapy”.

Conclusions

Documentation of intra-operative findings can aid further surgical management and help prepare the surgeon and theatre staff. It is especially important in patients who have vocal cord lesions that might benefit from laser therapy. We recommend documenting the intubation grade (Malampati Score) and accessibility to the larynx.
1384 Managing Peri-Orbital and Orbital Cellulitis: A New Multi-Specialty Care Pathway
Authors: Karim S , Halliday C , Patel K , Acharya V
Published: October 2021

Aim

1) To review current practice in the diagnosis and management of peri-orbital and orbital cellulitis in children at a London University Teaching Hospital. 2) To design and implement a streamlined, multi-specialty care pathway to improve the quality of care.

Background

Clinical differentiation between peri-orbital cellulitis and orbital cellulitis is often difficult, especially in young children. Early recognition and aggressive, multi-specialty treatment are required in order to prevent any vision and life-threatening sequelae.

Method

A retrospective case note analysis was performed for all paediatric patients with suspected peri-orbital or orbital cellulitis over a nineteen-month period. Extensive literature review was undertaken to ascertain current best practice in diagnosis and management. A streamlined, multi-specialty care pathway was developed, ratified by specialist departments, and introduced to optimise safety and quality of care.

Results

The results correlate with trends found in recent literature. 94.3% of patients had a blood culture taken with only 9.1% being positive. There were inadequate eye (37.1%) and endonasal (17.1%) cultures. Wide variation was noted in the criteria for imaging and in the antibiotic regimen used. 25.7% of patients received any nasal treatment. Suboptimal specialist review was identified in both orbital (60%) and peri-orbital (50.0%) cellulitis.

Conclusions

The new care pathway clearly informs investigation and empiric treatment based on initial risk stratification. The paediatric team is now the main, named care provider responsible for coordinating specialist input.
1426 Assessing the Impact Of COVID-19 On ENT Referrals at A West London General Practice
Authors: Jegatheeswaran L , Choi B , Rocha M F , Green A
Published: October 2021

Aim

The COVID-19 pandemic has resulted in initial GP consultations being conducted via telephone. This quality improvement initiative quantified this impact on ENT referrals conducted at a West London GP, using education to improve awareness of the relevant NICE guidance to reduce inappropriate referrals.

Method

An initial retrospective audit comparing number and urgency of ENT referrals and the appropriateness of ENT referrals (using NICE guidance) during the face to face (F2F) period (August 2019 – February 2020) and telephone period (March – September 2020) was performed. Results were presented locally to GPs, with education measures on relevant NICE guidance implemented. Further PDSA cycles occurred during October and November 2020.

Results

In total, 16 ENT referrals were made during the F2F period (routine n = 15; urgent n = 1); 3 were inappropriate. 31 referrals were made between March and September 2020 (routine n = 27, urgent n = 2, 2WW n = 2); 4 were inappropriate. Further cycles in October 2020, and November 2020 identified 13 referrals (routine n = 10, 2WW n = 3), and 2 referrals (routine n = 2) respectively. 1 inappropriate referral was made during October and none in November.

Conclusions

Locally, it appears that the number of routine referrals has increased since the advent of the initial lockdown. This may be partially explained by the practice losing the ability to perform some ENT services, such as ear wax micro-suctioning. Education to increase awareness of relevant guidance has been shown to reduce the number of inappropriate referrals to ENT services.
1452 How Did We Nose? COVID Adaptation of Our Nasal Fracture Service
Authors: Kumaresan K , Jones H
Published: October 2021

Introduction

Nasal fractures are a common ENT emergency that present to ED typically with a history of trauma. They can leave behind functional problems with breathing and can be cosmetically very deforming. For this reason, they need to be managed appropriately by the specialist team. In UHS, Southampton Hospital these patients were initially followed up by Care UK but during COVID, in order to minimise patient contact we came up with a modified patient initiated follow up pathway. (PIFU)

Method

Based on commonly agreed departmental guidelines:

We looked at the statistics from 2019 and compared it with data from August – October 2020 and reviewed all patients who presented via ED and GP to us with nasal fractures visa image and telephone review and face to face meetings over a 3-month period.

Results

Despite lower attendances in ED during months of lockdown we still had 48 patients in 3 months i.e., nearly 4 patients every week. 50% did not initiate follow up. Of the patients who initiated follow up a third required MUA of which one was under general anaesthesia. All patients were treated within 21 days.

Conclusions

Our modified management pathway is compliant with the guidelines despite some consultations via telephone calls and image reviews.
1477 Epistaxis Management During The COVID-19 Pandemic First Wave- Do We Need to Admit Patients with Rapid Rhinos? A Complete Loop Audit
Authors: McCrossan S , O'Doherty K , Adair R
Published: October 2021

Introduction

Epistaxis is a common ENT emergency, which if management requires nasal-packing, usually results in an inpatient admission. We audited our management of nasal-packing practices in the pre- and intra-pandemic era.

Method

Review of medical notes including patient demographics, reason for admission, time of admission, bed-day numbers, management plan and 30-day mortality and morbidity (M&M). 1st-cycle- January 2020, 2nd-cycle during the 1st-wave of the COVID-19 pandemic April-June 2020. Change implemented- patients were sent home with their nasal-pack in-situ.

Results

Pre-pandemic we admitted 100% (n = 15) of patients requiring rapid-rhino (RR) insertion compared to 7% (n = 1) of patients during the 1st-wave with an average age of 69 and 74-years respectively. 67% of patients in each group were on an antiplatelet or anticoagulant. Most common co-morbidities were hypertension (67%v40%), atrial-fibrillation (27%v53%) and cognitive impairment (13%v20%). 60% of patients attended in the out-of-hours period (5pm-8am). There was no difference in M&M. Bed-day average was 3.9-days and 2-days in the first and second groups. In the first group 5 patients (33%) needed arterial ligation with only one (7%) patient in the second group requiring ligation.

Conclusions

RR insertion and discharge with outpatient follow up is safe with no difference in M&M. Total bed-days were 57v4 bed-days in group one compared to group two, with £222/bed-day (NICE costings statement) the total-price was £12654v£888. We hope that the traditional approach of admitting every patient with RR may be reconsidered as the standard and only required when necessary.
1578 Advances in Facial Nerve Monitoring Parameters During Vestibular Schwannoma Surgery
Authors: Aladham Y
Published: October 2021

Aim

To evaluate the effectiveness of multi-channel electromyographic monitoring of the facial nerve in improving the detection of mechanically elicited EMG activity and providing new predictive criteria for post-operative facial nerve function.

Method

The Study was conducted on 20 patients undergoing vestibular schwannoma resection in a tertiary referral cerntre. All patients were subjected to facial nerve monitoring during the surgery by a 5-channel setup monitoring the frontalis, O.oculi, nasalis, O.oris, and mentalis muscle. Mechanically elicited EMG activities of the monitored facial muscles were recorded for analysis. After tumour removal, the facial nerve was stimulated proximal to the tumour site using two different types of probes: Prass and flush-tip. Post-operative facial nerve function was assessed using House-Brackmann scale immediately post-operatively and after six months and correlated to the study tested parameters.

Results

The use of 5-channel montage led to significantly higher sensitivity in detecting mechanically elicited EMG activity than would have been possible with the ordinary 2-channel one. Mentalis muscle showed significantly higher number and amplitude of spontaneous EMG activities than other facial muscles. Positive correlation was found between the proximal threshold and the post-operative facial nerve outcome. The Prass stimulator showed significantly lower threshold than the ball-tip probe.

Conclusions

The use of multi-channel facial nerve monitoring allowed earlier and more efficient monitoring of the facial nerve. The use of the Prass stimulator is more accurate and correlates more with the real threshold needed for post-resection stimulation of the facial nerve than the ball-tip.
1603 A Google Trends Analysis of Interest in Ear, Nose and Throat Surgery During The COVID-19 Pandemic
Authors: Williams C Y K , Ferreira A F , Townson A T , Pace A
Published: October 2021

Aim

The COVID-19 pandemic has had wide-ranging effects on healthcare, society and everyday life. As the public’s health priorities shift, we sought to investigate the resulting impact of COVID-19 on global interest in Ear, Nose and Throat (ENT) surgery.

Method

We used Google Trends to examine worldwide search interest in the following core ENT operations following the onset of the COVID-19 pandemic: Tonsillectomy, Adenoidectomy, Thyroidectomy, Rhinoplasty, Septoplasty, Functional Endoscopic Sinus Surgery, Mastoidectomy, and Tympanoplasty. Bayesian structural time-series models were used to generate counterfactual time series, and relative differences between observed and expected search interest were calculated. Causal effects were subsequently determined, along with 95% CIs and posterior probabilities. R version 4.0.3 was used for analyses.

Results

Search interest in all measured ENT procedures was significantly reduced at the onset of the COVID-19 pandemic. Interest in Rhinoplasty recovered after 8 weeks and continued to rise to a peak of 27% greater than expected, with a cumulative Relative effect of + 11% [95% CI: 3.9%, 20%]. In contrast, significantly reduced search interest was observed for all other procedures analysed (Relative effect, range: -16% to -36%, all p values < 0.05).

Conclusions

Our findings suggest divergent changes in public interest in common ENT procedures. While all other ENT operations investigated were less frequently searched following the pandemic onset, interest in Rhinoplasty at times increased to over 25% greater than expected. This could represent a shift in patient attitudes to disorders of the Ear, Nose and Throat and warrants further investigation at the individual-level.