NEW SNOT FORCE STUDY PUBLISHED!
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Are antibiotics were necessary with nasal packing?
OBJECTIVE: Nonabsorbable nasal packing is often placed for the treatment of epistaxis or after sinonasal or skull base surgery. Antibiotics are often prescribed to prevent toxic shock syndrome (TSS), a rare, potentially fatal occurrence. However, the risk of TSS must be balanced against the major risk of antibiotic use, specifically Clostridium difficile colitis (CDC). The purpose of this study is to evaluate in terms of cost-effectiveness whether antibiotics should be prescribed when nasal packing is placed.
STUDY DESIGN: A clinical decision analysis was performed using a Markov model to evaluate whether antibiotics should be given.
SETTING: Patients with nonabsorbable nasal packing placed.
METHODS: Utility scores, probabilities, and costs were obtained from the literature. We assess the cost-effectiveness of antibiotic use when the risk of community-acquired CDC is balanced against the risk of TSS from nasal packing. Sensitivity analysis was performed for assumptions used in the model.
RESULTS: The incremental cost-effectiveness ratio for antibiotic use was 334,493 US dollars (USD)/quality-adjusted life year (QALY). Probabilistic sensitivity analysis showed that not prescribing antibiotics was cost-effective in 98.0% of iterations at a willingness to pay of 50,000 USD/QALY. Sensitivity analysis showed that when the risk of CDC from antibiotics was greater than 910/100,000 or when the incidence of TSS after nasal packing was less than 49/100,000 cases, the decision to withhold antibiotics was cost-effective.
CONCLUSIONS: Routine antibiotic prophylaxis in the setting of nasal packing is not cost-effective and should be reconsidered. Even if antibiotics are assumed to prevent TSS, the risk of complications from antibiotic use is of greater consequence.
LEVEL OF EVIDENCE: 3a.
Otolaryngol Head Neck Surg. 2021 Feb 16:194599820988740. doi: 10.1177/0194599820988740. Online ahead of print.
PMID:33588621 | DOI:10.1177/0194599820988740
Thomas Higgins, MD, MSPH
Snot Force Alliance Inc
Physicians must first protect themselves with the right gear or personal protective equipment (PPE). A standard surgical mask, gown, gloves, and face-shield can protect against virus particles in droplets. But smaller particles, called aerosols, require more heavy-duty airborne protection. So, is the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmitted by droplets or aerosols? 239 scientists certainly felt strongly enough that it’s airborne, writing a letter to the World Health Organization (WHO).
Our research group set out to investigate the droplet and aerosol risks from routine procedures performed within the nose.
The good news first.
We found that there really wasn’t much droplets or splatter unless you used the drill outside the nose, suggesting that it functions as a barrier that protects us during surgery. The icing on the cake is that using a suction device in the nose completely eliminated all droplet contamination.
The bad news?
Our second study confirmed we were generating aerosols. Drilling bone in the nose produced the most aerosols. Most of these particles were less than 1 micron! Thankfully, all three suction devices we tested were effective in reducing aerosols, and the surgical smoke evacuation system placed right outside the nose seems to be the best at it.
Why is this important?
The WHO now says that airborne transmission of SARS-CoV-2 can occur during aerosol-generating procedures (AGP). We believe this is why it is important to establish which procedures are AGPs. Because, after all, we can only take care of our patients if we stay healthy.
Dhruv Sharma, MD
I am a resident physician at the Indiana University School of Medicine Department of Otolaryngology - Head and Neck Surgery
The image in this blog is distributed under the terms of the Creative Commons Attribution 4.0 License (https://creativecommons.org/licenses/by/4.0/) which permits any use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).
Some ear symptoms are ultimately related to the nose, our research group found. The intertwined anatomy and physiology of these two body parts makes for a logical association. The nose is connected to the ear via a functional tube called the Eustachian tube. This tube helps ventilate, drain, and maintain an equilibrium of air pressure in the middle ear. It opens in the back of the nose called the nasopharynx. If something were to block that opening, the system gets backed up, causing increased ear pressure and ear fluid.
We have known that one of the causes of ear infections or persistent middle ear fluid in kids is obstruction of the Eustachian tube from the adenoids, which are in the nasopharynx. Thus, performing an adenoidectomy is one of the treatments for chronic ear fluid in kids.
Our research group set out to see if chronic rhinosinusitis affected ear symptoms in adults and our findings were significant. We found that, in patients with chronic rhinosinusitis, ear symptoms and nose/sinus symptoms were strongly correlated. So, those with worse sinus symptoms seemed to have worse ear symptoms.
We also looked at how sinus surgery affected ear symptoms. In this study, 80% of the patients had improvement in ear symptoms with sinus surgery alone and 60% had complete resolution (or normalization) of their ear symptoms!
So, we have found it important to ask questions about both nose and ear symptoms because treating the nose is often the answer to solving certain ear problems.
We’re putting together a team with a nose-worthy mission of fighting all that is s-naughty. Puns aside, our goal is to create a network of like-minded medical professionals across multiple different specialties to educate our peers and our patients and to advance our field by collaborating on cutting edge research together. All the while, our priority will be to have fun and make meaningful connections. Join the SNOT FORCE and add comments below.