The challenge of performing mastoidectomy using the operating microscope with coronavirus disease 2019 personal protective equipment (PPE).

OBJECTIVE: Mastoidectomy is considered an aerosol-generating procedure. This study examined the effect of wearing personal protective equipment on the view achieved using the operating microscope. METHODS: ENT surgeons assessed the area of a calibrated target visible through an operating microscope whilst wearing a range of personal protective equipment, with prescription glasses when required. The distance between the surgeon's eye and the microscope was measured in each personal protective equipment condition. RESULTS: Eleven surgeons participated. The distance from the eye to the microscope inversely correlated with the diameter and area visible (p < 0.001). The median area visible while wearing the filtering facepiece code 3 mask and full-face visor was 4 per cent (range, 4-16 per cent). CONCLUSION: The full-face visor is incompatible with the operating microscope. Solutions offering adequate eye protection for aerosol-generating procedures that require the microscope, including mastoidectomy, are urgently needed. Low-profile safety goggles should have a working distance of less than 20 mm and be compatible with prescription lenses.

Dizziness, driving, and the Driver and Vehicle Licensing Agency: audit of advice given to patients, and design of a patient information leaflet.

BACKGROUND: Evidence from the literature shows that clinicians' knowledge of rules and legislation surrounding driving can often be poor. A closed-loop audit was conducted to gauge the level of driving advice given to patients with dizziness. METHODS: The clinical notes of 100 patients referred to the vertigo clinic at a tertiary referral centre were retrospectively searched for evidence of driving advice. Education sessions were undertaken and a patient information leaflet was developed before a second cycle of the audit. RESULTS AND CONCLUSION: The proportion of patients having documented evidence of receiving driving advice increased from 6.3 per cent to 10.4 per cent. It is therefore clear that, despite this improvement, a significant proportion of patients' notes did not contain documentation about driving. This is likely because of many reasons, including individual interpretation by clinicians. This paper provides a reminder of the rules, and discusses their interpretation and implementation in an increasingly medicolegal environment.

Results of a prospective surgical audit of bilateral paediatric cochlear implantation in the UK.

BACKGROUND: Following the approval of bilateral paediatric cochlear implantation in 2009, the prospective multi-centre UK National Paediatric Cochlear Implant Audit was established to collect a large dataset of paediatric implantations. The aim of the surgical part of the audit, reported here, was to collect data on surgical practice, outcomes and complications. METHODS: Data from 14 surgical centres was collected prospectively, including simultaneous and sequential bilateral as well as unilateral implantations. Data collected included age at implantation, aetiology of deafness, implant type, duration of surgery, the use of electrophysiological testing, and the use of pre- and post-operative imaging. Details of major and immediate minor complications were also recorded. RESULTS: 1397 CI procedures in 961 CI recipients were included; 436 bilateral simultaneous, 394 bilateral sequential, 131 unilateral. The overall major complication rate was 1.6% (0.9% excluding device failure) and was similar following bilateral CI compared to sequential and unilateral CI. CONCLUSION: This prospective multi-centre audit provides evidence that bilateral paediatric CI is a safe procedure in the UK, thus endorsing its role as a major therapeutic intervention in childhood deafness.

Primary endoscopic repair of intermediate laryngeal clefts.

INTRODUCTION: Traditionally, small laryngeal clefts may be closed endoscopically, while larger clefts necessitate an open anterior approach. We report the presentation, evaluation and outcome following endoscopic surgical repair of a series of laryngeal clefts. METHOD: Retrospective study of children treated in a tertiary referral centre between 2003 and 2008. The presenting symptoms, patient demographics, cleft type, surgical outcome and complications were evaluated. RESULTS: Seven children underwent primary endoscopic repair of their laryngeal clefts (four Benjamin-Inglis type III clefts and three type II clefts). Presenting symptoms included stridor, cough and cyanosis with feeds, swallowing problems, weak cry, and recurrent lower respiratory tract infection. Treatment was ultimately successful in six of the seven children; treatment was ongoing for the remaining child, who underwent subsequent revision surgery via an open approach. Two children went on to require a second endoscopic repair, and two underwent an open repair of a residual defect. One child required a tracheostomy for failed extubation in the post-operative period. CONCLUSION: Endoscopic repair is a safe, useful technique in the management of laryngeal clefts. Laryngeal clefts must be excluded in a child presenting with persistent aerodigestive tract symptoms, as described here.

12 minute consultation: a patient with nasal crusting.

BACKGROUND: Nasal crusting is frequently encountered by the otorhinolaryngologist and often requires no specific treatment. It is, however, important to carry out a full history and examination, followed by appropriate investigations, in order to detect the small number of cases in which crusting is caused by systemic or malignant disease. METHODS: This review was based on a literature search last performed on 30th July 2009. The MEDLINE, EMBASE and Cochrane databases were searched using the subject headings (nasal crusting OR crusts) and in combination with diagnosis, therapy and surgery. Similar searches were performed for relevant diseases, e.g. Wegener's granulomatosis, sarcoidosis. Results were limited to English language articles including clinical trials, meta-analyses, systematic reviews and review articles. Relevant references from selected articles were reviewed. RESULTS: Knowledge of the causes of nasal crusting will help to target the history, examination and investigation of patients with this condition. Screening tests for systemic conditions can be useful but most have limited sensitivity and must be interpreted cautiously. Nasal septal biopsy is indicated when there is a suspicion of malignancy, or to support a suspected diagnosis of vasculitis. The treatment offered depends upon the cause of crusting and the severity of symptoms. CONCLUSION: A careful and thorough history and examination, and targeted investigation, of the patient with nasal crusting will ensure correct diagnosis and treatment of patients with this common condition.

Endovascular management of the carotid blowout syndrome.

Bleeding from the carotid artery or its branches ('carotid blowout') is a well recognized complication following treatment or recurrence of head and neck cancer. The traditional surgical treatment for carotid blowout is often technically difficult and is associated with an unacceptably high morbidity and mortality. The majority of such patients are currently treated conservatively with end of life supportive measures. We report the case of a young patient with recurrent supraglottic carcinoma complicated by carotid blowout on two separate occasions over a five month period, which was successfully treated endovascularly under local anaesthetic, without neurological sequelae. With the continuing development of interventional radiology, endovascular techniques are now emerging as a viable, low morbidity treatment option in selected patients.

Circulating factors and insulin resistance. I. A novel myoinositol 1,2-cyclic phosphate phosphoglycan insulin antagonist from human plasma is elevated in noninsulin-dependent diabetes mellitus.

A novel low mol wt inositol phosphoglycan inhibitor (M tau 1200-1500) of insulin action in rat adipocytes has been partially purified from normal human plasma. This inhibitor, termed fraction V after the first purification step and fraction V3 after the second, is different from other reported serum insulin antagonists. It contains myoinositol, galactosamine, and mannose in approximate molar ratios of 1:1:3.3. The myoinositol has a 1,2-cyclic phosphate substituent, which is essential for the inhibitory activity. Its inhibitory activity is significantly elevated (161%, P < 0.05 for fraction V; 278%, P < 0.05 for fraction V3) in plasma of humans with noninsulin-dependent diabetes mellitus as compared with plasma of nondiabetic controls. These findings represent the first report of a naturally occurring mammalian inositol 1,2-cyclic phosphate containing phosphoglycan related to insulin action.

Characterization of an antibody to the cross-reacting determinant of the glycosyl-phosphatidylinositol anchor of human membrane dipeptidase.

A polyclonal antiserum raised to the phospholipase C-solubilized form of membrane dipeptidase (EC 3.4.13.11) purified from human kidney was found to cross-react with unrelated trypanosomal and porcine glycosyl-phosphatidylinositol anchored proteins. Those antibodies recognising the cross-reacting determinant (CRD) were isolated by chromatography on a column of immobilized phospholipase C-solubilized porcine aminopeptidase P (EC 3.4.11.9), and the epitopes involved in the recognition were then characterized by immunoelectrophoretic blot analysis and by a competitive ELISA. The phospholipase C-solubilized forms of human and porcine membrane dipeptidase, porcine aminopeptidase P and trypanosome variant surface glycoprotein were recognised by the anti-CRD antiserum, and this recognition was abolished by prior treatment of the proteins with either mild acid or nitrous acid. In contrast, the detergent-solubilized, membrane-forms of human and porcine membrane dipeptidase were not recognised. Of a range of components of the glycosyl-phosphatidylinositol anchor, only inositol 1,2-cyclic monophosphate and the insulin-mimetic disaccharide, glucosaminyl-1,6-inositol 1,2-cyclic monophosphate, inhibited in the micromolar range the binding of the anti-CRD antiserum to immobilized porcine aminopeptidase P. These results indicate that the major epitope recognised by this anti-CRD antiserum is the inositol 1,2-cyclic monophosphate formed on phospholipase C cleavage of the glycosyl-phosphatidylinositol anchor.

Characterization of antibodies to the glycosyl-phosphatidylinositol membrane anchors of mammalian proteins.

Two polyclonal antisera were raised in rabbits to the phospholipase C-solubilized forms of pig renal dipeptidase (EC 3.4.13.11) and pig aminopeptidase P (EC 3.4.11.9). These antisera were purified and shown to cross-react with other glycosyl-phosphatidylinositol (G-PI)-anchored proteins isolated from pig, human and trypanosomes. The epitopes involved in this cross-reactivity were characterized by Western-blot analysis after mild acid or nitrous acid treatment of the G-PI-anchored proteins and by a competitive e.l.i.s.a. with other G-PI-anchored proteins and individual components of the anchor structure. These studies revealed that the primary epitope for both antisera is the inositol 1.2-(cyclic)monophosphate that is formed on phospholipase C cleavage of the intact G-PI anchor. Other minor epitopes, such as phosphoethanolamine, probably involve side-chain modifications to the core anchor structure that may be species-specific.