Tonsillitis

Tonsillitis is often managed in the primary care setting, but up to 60 000 patients are admitted to UK hospitals each year with swallowing difficulties or systemic upset that cannot be managed by general practitioners.^{Reference Millington and Phillips4}

The Portsmouth tonsillitis protocol, first published in 2013,^{Reference Bird, Biggs, Schulz, Lower, Faris and Repanos5} suggests a treatment algorithm for patients presenting to hospitals with tonsillitis (Figure 1). Their results showed a reduction by more than half of their admission rate and more than half the length of in-patient stay for admitted patients. The protocol advocates aggressive, early treatment with intravenous antibiotics, steroids, analgesics and fluids, followed by prompt (at 2 hours) review to re-assess the patient and consider sending them home.

Fig. 1. The Portsmouth tonsillitis protocol. Reproduced with permission.^{Reference Bird, Biggs, Schulz, Lower, Faris and Repanos5} IV = intravenous; PO = per oral; PR = per rectum; BP = blood pressure; bpm = beats per minute; QDS = four times daily; BD = twice daily; TDS = three times daily

This approach has been validated by Harris and Ashman^{Reference Harris and Ashman6} who demonstrated a 42 per cent early discharge rate in patients treated with a similar protocol, with zero re-admissions. Perkins et al.^{Reference Perkins, Ray Brown, Pohl, McLaren, Powles and Thorley7} also showed similar results with their protocol, halving the length of admission and more than halving the admission rate. Larger studies have similarly demonstrated a decrease in admission rate with the introduction of an ambulant management pathway.^{Reference Mohammed, Jin, Masterson and Wickstead8}

One of the benefits of the Portsmouth tonsillitis protocol is that it does not require any specialist procedures or interventions, and could possibly be offered in an ambulatory care setting if resources allowed. This would be particularly beneficial in the current environment where we are trying to limit the mixing of patients potentially at risk of Covid-19 with those not at risk. Tonsillitis patients could potentially be kept in separate (out-patient or ambulatory) parts of the hospital, and away from ENT wards. ENT wards, with nurses experienced in tracheostomy management, may soon become a critical resource that needs to be managed appropriately.

Current ENT UK guidance in the context of Covid-19 advocates starting treatment based on history alone (as relevant examination is potentially aerosol-generating). Should examination be necessary, personal protective equipment, including a filtering facepiece code 3 (FFP3) or equivalent mask, should be worn.⁹ A similar treatment strategy to the Portsmouth tonsillitis protocol is suggested, with intravenous antibiotics, intravenous steroids and fluid resuscitation, but they also advise testing these patients for Covid-19, as is now standard practice across the UK for all potential hospital admissions. After 3–4 hours of observation, if the patient is able to tolerate oral intake, discharge home is advised.

Peritonsillar abscess

These patients are more usually managed as in-patients in the UK, as they can be more unwell than those with ‘uncomplicated’ tonsillitis (e.g. significant odynophagia, trismus and high temperatures).^{Reference Harris and Ashman6,Reference Al Yaghchi, Cruise, Kapoor, Singh and Harcourt10} However, out-patient management pathways exist for these patients; these were initially developed overseas,^{Reference Garas, Ifeacho, Cetto, Arora and Tolley11,Reference Mehanna, Al-Bahnasawi and White12} but later applied to UK populations.^{Reference Herzon13,Reference Stringer, Schaefer and Close14} Some evidence suggests that as few as 12 per cent of patients who have successful needle aspiration of pus require in-patient admission.^{Reference Ophir, Bawnik, Poria, Porat and Marshak15}

Peritonsillar abscess patients present more challenges than patients with uncomplicated tonsillitis for many reasons. The former patients are often more unwell and more in need of resuscitation because of dehydration. However, once a diagnosis of quinsy is made, and pus has been released by whatever method (discussed below), treatment is essentially the same as for tonsillitis: intravenous antibiotics, steroids, analgesics and fluid resuscitation. The above studies all demonstrate that if patients are able to swallow after aspiration, then discharging them with oral antibiotics and appropriate safety-netting advice is a robust, evidence-based management plan.

The critical difference in management is the need for a more specialist intervention (i.e. drainage of pus). Most centres advocate the use of needle aspiration of any collection, although an incision and drainage procedure has comparable results.^{Reference Herzon13} Most junior ENT team members are more comfortable with needle aspiration, and it is a more commonly performed technique that is well tolerated by patients.^{Reference Al Yaghchi, Cruise, Kapoor, Singh and Harcourt10} This is something that could easily be performed in an ambulatory setting, away from emergency departments. The individuals can then be managed as out-patients with careful safety netting, on the proviso that they are more likely to require admission because of swallowing difficulties than uncomplicated tonsillitis patients.

These pathways universally recommend confirming the diagnosis of quinsy with the aspiration of pus. If attempted aspiration is unsuccessful, further attempts are possible, or incision and drainage can be considered. Naturally, imaging should be contemplated for recalcitrant cases, or if an alternative diagnosis such as a parapharyngeal abscess or malignancy is suspected.

Epistaxis

Epistaxis is the most common reason for referral to ENT specialists in the UK, with about 25 000 acute presentations to NHS hospitals a year.¹⁶ Over 90 per cent of bleeding is from the anterior part of the nose (most commonly Little's area), with the remaining 10 per cent being posterior bleeds, which are more likely to require hospitalisation.^{Reference Womack, Kropa and Stabile17}

Epistaxis patients should not be underestimated by ENT teams – patients with significant epistaxis are often elderly, frail, co-morbid and taking one or more antiplatelet or anticoagulant medications, and can be a challenge to manage effectively. The UK national epistaxis audit suggests that 51 per cent of patients presenting to hospital with epistaxis are on anticoagulants or antiplatelet medications, and the median age of epistaxis patients is 73 years (interquartile range, 62–82).¹⁶ Patients on anti-thrombotic medication also take longer to achieve successful haemostasis and to safely discharge than those not on medication.

First-line treatment for epistaxis remains ‘gold standard’ first aid.^{Reference Tunkell, Anne, Payne, Ishman, Rosenfeld and Abramson18} This involves sitting the patient upright and applying firm pressure on the fleshy part of the nose for at least 20 minutes, while keeping the patient calm (to minimise hypertension). Patients are advised to spit out any blood (as it is emetogenic and vomiting would increase blood pressure).^{Reference Tunkell, Anne, Payne, Ishman, Rosenfeld and Abramson18}

If first aid measures fail, topical treatment such as cautery (e.g. with silver nitrate) or application of topical vasoconstrictors (e.g. adrenaline-soaked cotton wool) is second-line treatment. Cautery is effective and safe, but it requires relative haemostasis, as active bleeding will wash the silver nitrate away. The cauterisation of large areas or bilateral parts of the septum is not advised given the risk of necrosis and perforation.

Rapid Rhino^™ nasal tamponades have altered the management of epistaxis since their introduction.^{Reference Moumoulidis, Draper, Patel, Jani and Price19,Reference Iqbal, Jones, Dawe, Mamais, Smith and Williams20} They are comparatively well tolerated by patients, and easier to apply than previous methods of anterior and posterior nasal packing. Their ease of use has some drawbacks though; notably, non-specialists can pack a nose prior to referral to the ENT department. This makes discharging patients more difficult, as the pack traumatises the nasal mucosa, and makes identification of a bleeding point more complex. Many ENT units advocate leaving packs in situ for 24–48 hours after insertion, to allow the mucosa to heal and ensure haemostasis is secure. Some centres commence the patient on prophylactic antibiotics to mitigate the risk of toxic shock syndrome in these patients, although evidence is lacking.^{Reference Lange, Peeden and Stringer21}

Evidence suggests that the majority of re-bleeding occurs less than 4 hours after pack removal.¹⁶ Therefore, for select patients (e.g. presenting in the morning, with appropriate home support), there may be a role for ambulatory observation of these patients after pack removal and topical treatment by an ENT specialist. This does not necessarily have to be on a ward; a ‘short stay’ unit or other ambulatory care setting would be appropriate for some of these patients. Depending on local provision and service requirements, direct or early referral to ENT by the emergency department for patients with epistaxis could be considered, allowing early specialist topical intervention and hopefully, with that, a lower admission rate.

Some groups of patients may not be suitable for packing because of absolute or relative contraindications. These might include patients with very low platelet counts, base of skull fractures or hereditary haemorrhagic telangiectasia, or patient refusal. Floseal® may be useful in such cases.

Floseal is a haemostatic agent (thrombin and a gelatine matrix). It has been used in the primary management of epistaxis patients when conservative measures such as direct pressure and cautery have failed.^{Reference Wakelam, Dimitriadis and Stephens22} These researchers demonstrated a success rate of Floseal of 90 per cent, and the mean length of hospital stay for these patients was 2.75 hours. They also reported high levels of patient satisfaction with Floseal over packing. The researchers reported treatment success after pack removal in patients who had been packed prior to specialist review. In the haemorrhagic telangiectasia population, Floseal has been used in the domiciliary setting, with success at reducing admissions and high patient satisfaction.^{Reference Warner, Halliday, James and de Carpentier23} In that study, Floseal was applied by patients or family members after receiving appropriate training, suggesting that high levels of expertise are not required for it to be effective. Floseal does come with cost implications (approximately £100 per unit),^{Reference Wakelam, Dimitriadis and Stephens22} but this compares favourably with the cost of an overnight admission to hospital (approximately £220 per night at least).²⁴

Adjuncts and alternatives to packing other than Floseal are also available. For example, topical and systemic tranexamic acid is used in select patient groups.¹⁶ The national epistaxis audit found that tranexamic acid use was associated with longer haemostasis times and high re-bleeding rates, but it was being used in patients who were more unwell, and this may represent a confounding factor.¹⁶ Use of topical tranexamic acid has been shown to reduce length of stay in emergency departments and decrease re-presentation rates, and it gives higher patient satisfaction rates than standard care.^{Reference Gottlieb, DeMott and Peksa25–Reference Kamhieh and Fox27} Support for systemic tranexamic acid in epistaxis cases is more equivocal, but there is some evidence to support its use in select cases to reduce re-bleeding rates (e.g. in haemorrhagic telangiectasia), and there is no convincing evidence of adverse events when used for epistaxis.^{Reference Kamhieh and Fox27,Reference Geisthoff, Seyfert, Kübler, Bieg, Plinkert and König28}

Other topical haemostatic agents, such as microporous polysaccharide hemospheres (e.g. Arista^™ absorbable haemostatic powder), are licensed to control bleeding in certain surgical settings.^{Reference Bruckner, Blau, Rodriguez, Suarez, Ngo and Reardon29} However, good quality randomised, controlled trials have not been conducted for these products in the context of epistaxis, and any use in this context would be ‘off licence’. It is notable that their use is not described in the national epistaxis audit,¹⁶ and the British Rhinological Society multidisciplinary consensus document describes a paucity of quality evidence for these products at this time.³⁰ As such, we cannot make any recommendations as to their use.

Current ENT UK guidance in the context of Covid-19 advocates the stepwise approach described above,³¹ but only favours admission if the patient has required bilateral packing, has significant medical co-morbidities or if surgical intervention may be required. Patients whose bleeding is controlled with unilateral packing and without significant co-morbidities can be safely discharged and reviewed by the ENT department the following day.

The authors are unaware of any published protocols for out-patient epistaxis management prior to the Covid-19 pandemic. This is probably because these patients can be complex with co-morbidities, and are often older and lack support at home to facilitate discharge. If epistaxis is appropriately controlled with topical methods, then discharge home should clearly be the goal.

The pros and cons of packing are discussed above. Once a patient was packed, a period of observation in a ward setting was the current standard of care in the UK.¹⁶ The national epistaxis audit concluded that removing packs at the initial ENT review was a reasonable strategy in selected patients,¹⁶ and did not significantly increase the length of hospital stay or re-admission rates.

While the British Rhinological Society acknowledge that there are no nationally agreed guidelines on the management of epistaxis, their multidisciplinary consensus recommendations are supportive of the stepwise approach to epistaxis management detailed above.³⁰ The British Rhinological Society document also accepts that many of its recommendations are made with weak evidence, and innovative approaches generating new evidence should be encouraged.

Now is an excellent opportunity for innovation in the health system, with most ENT departments working in entirely different ways to before the Covid-19 pandemic. The management of acute epistaxis is one example of a condition where safe discharge is possible, but new protocols and evidence would be welcomed.