The management of patients with posterior epistaxis remains a challenging problem for the ENT surgeon. In most units, failure of conservative management results in more invasive techniques, involving either major artery ligation or percutaneous embolization of the internal maxillary artery. However, there are complications in more than 25% of patients undergoing these techniques. Endoscopic ligation of the sphenopalatine artery (ELSPA) is emerging as a minimally invasive alternative. We report our experience of ELSPA in 13 patients with a mean follow-up of 13 months. Epistaxis was controlled in 92% and to date no complications have been associated with the procedure. We conclude that ELSPA is a treatment option that is easy to perform and is safe and effective for patients with refractory posterior epistaxis.

Background: Oral and topical corticosteroids, and antibiotics form the mainstay medical treatment of chronic rhinosinusitis (CRS).Clinical outcomes vary depending on the chosen therapy, resident microbiome and disease phenotype. We conducted a doubleblinded, placebo-controlled Randomised Controlled Trial (RCT) to investigate effects of medical therapy on clinical outcomes and associated microbiome shifts.Methodology: Fifty eligible patients (CRS with and without polyps) were treated for 3 weeks after randomisation into 3 arms: namely oral prednisolone, topical budesonide irrigations and oral doxycycline; each with appropriate placebo. Clinical scoring and microbiome swabs were performed on enrolment, at treatment completion and 3-weeks post treatment completion. Microbiome analysis was performed using the llumina-MiSeq next generation sequencing platform and QIME-2 pipeline.Results: Significant improvement in clinical scores was observed in prednisolone and budesonide arms at treatment completion but not with antibiotic. Sub-group analysis showed more pronounced effects in patients with polyposis. Corynebacterium and Staphylococcus species predominated, with variable bacterial relative abundance among different treatments at all time-points.The only significant microbiome finding was an increase in bacterial diversity in topical budesonide group immediately after treatment, which returned to baseline 3-weeks post treatment. Conclusion:Clinical improvement was significant with oral and topical steroid but not empirical antibiotic. Although there were some associated microbiome changes with the various treatments, we could not ascertain the consistency of these and whether they do have a clinical significance at all.

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The MEL procedure has no adverse effects on the mucociliary clearance of the frontal sinus at 3 months postoperatively. Irrigation of the frontal sinus in the immediate postoperative period showed a trend toward improved postoperative mucociliary function at 3 months.