Objectives The aim of this study was to assess the efficacy of a new emergency department intervention for the management of epistaxis, aiming to reduce epistaxis admissions. Design Tranexamic acid (TXA) (500mg/ml) soaked NasoPore® packing was in the pathway for epistaxis which did not terminate following 10 minutes of simple first aid. The pathway was utilised for adult patients presenting with non-traumatic, anterior epistaxis. Pre- and post-implementation admission rates and re-attendance rates were recorded by retrospective audit at a large central London hospital. Results Epistaxis admissions were reduced by 51.7% (p<0.05) following the implementation of the TXA-soaked NasoPore® pathway. Conclusions The significant reduction in epistaxis admissions demonstrates that this intervention is beneficial for patient outcomes. This has the potential to be introduced in other A&E departments and also pre-hospital settings.

AIM Current guidelines advocate ‘one-stop’ neck lump assessment for cancer referrals. We pilot a novel pre-clinic ultrasound pathway, present the outcomes and discuss strengths and limitations especially in view of the current COVID-19 pandemic. METHODS Patients referred by the GP on a two-week-wait cancer pathway with a ‘neck lump’ were allocated pre-clinic ultrasound scans followed by an ENT clinic appointment. Demographics, patient journey details and outcomes were collected and analysed. RESULTS 99 patients underwent pre-clinic ultrasound assessment by a specialist consultant radiologist an average of 8.02 days after referral with 30 (30.3%) also undergoing biopsy. Patients were followed-up 14.1 days (range 2 – 26 days) after initial referral. In 92.9% of patients, a positive impact was achieved; at the first clinic appointment 45 patients were discharged (45.5%), ten were listed for surgery (10.1%), a cancer diagnosis was made in a further 12 patients (12.1%), 6 patients (6.1%) were referred onwards to another speciality and 19 patients (19.2%) were taken off the cancer pathway and followed up routinely. In four patients, it was retrospectively felt that ultrasound was not indicated as the referral did not accurately reflect the patient’s presenting complaint or examination findings. Repeat ultrasound was inadvertently requested for one patient. Two patients were reviewed prior to biopsy results being available leading to an additional appointment being required. CONCLUSION Pre-clinic ultrasound scanning is an alternative to the current ‘one-stop’ neck lump pathway. Our results demonstrate a reduction in clinic visits, quicker diagnosis and low proportion of unnecessary scans. Our proposed pathway requires minimal service restructuring and has added potential cost savings. We have found it to be effective during the COVID-19 pandemic in minimising the face-to-face consultations and the number of aerosol generating procedures (AGPs). Further refinement is needed to streamline and make the process more robust. A larger study with direct comparison to the ‘one-stop’ clinic is required to assess further strengths and limitations.

Introduction: Litigation against the National Health Service (NHS) in England is rising, costing £2.4 billion in 2018/19. The aim of this study was to determine the incidence and characteristics of otolaryngology clinical negligence claims in England. Methods: A retrospective review was undertaken of all clinical negligence claims in England held by NHS Resolution relating to otolaryngology between April 2013 and April 2018. Analysis was performed using information for cause, patient injury and claim cost. Where claim information was adequately detailed, the authors categorised claims by subspecialty, diagnosis and operation. Results: A total of 727 claims were identified with an estimated potential cost of £108 million. From these, 463 were closed claims. Including open claim reserves, the mean cost of a claim was £148,923. Head and neck surgery was the subspecialty with the highest number of claims (n=313, 43%) and highest cost (£51.5 million) followed by otology (n=171, £24.5 million) and rhinology (n=171, £13.6 million). Over half of claims were associated with an operation (n=429, 59%) where mastoid surgery (n=46) and endoscopic sinus surgery (n=46) were equally associated with the greatest number of claims. The most frequent reasons for litigation included failure or delay to diagnose (n=178, 25%) failure or delay to treat (n=136, 19%), intra-operative complications (n=130, 18%) and failure of the consent process (n=107, 15%). Discussion: Clinical negligence claims in otolaryngology are related to several different components of patient management and is not limited to post-operative complications. This study highlights the importance of robust pathways in outpatient diagnostics and the consenting process, especially in the high-risk speciality of head and neck surgery, in order to deliver better patient care and reduce the impact of litigation.