A rare presentation of spontaneous splenic rupture from plasma cell leukaemia-a case report.

Spontaneous/atraumatic splenic rupture is rare, and often associated with underlying infectious disease, or haematological malignancy. Plasma cell leukaemia (PCL) is a rare and aggressive subtype of multiple myeloma, with a higher prevalence of hepatosplenomegaly with a bleeding diathesis from secondary to thrombocytopaenia. We report the case of an 82-year-old male presenting to the emergency department with altered mentation and complaints of left abdominal pain. He presented with haemorrhagic shock. Imaging revealed a spontaneous splenic rupture. He underwent emergency laparotomy and splenectomy for which the histopathology yielded a diagnosis of PCL as the cause for rupture. He received four courses of bortezomib and hyperCVAD 1A therapy. After a long 64-day admission, he recovered well and was discharged home with outpatient haematology/oncology follow-up.

An unusual case of pilonidal p16 positive squamous cell carcinoma-a case report.

Basaloid squamous cell carcinoma (BSCC) is a rare and aggressive variant of squamous cell carcinoma. It is commonly seen in the oropharynx and strongly associated with p16-expressivity and high-risk human papilloma virus (HPV). We report the first case of primary cutaneous p16-positive BSCC in an elderly woman, with a background of chronic inverse psoriasis of the natal cleft. P16-expressivity is a common surrogate marker for oncogenic HPV16, routinely tested for oropharyngeal/anogenital squamous cell carcinoma. This is not routinely done for primary cutaneous disease. Pilonidal disease is uncommon in the elderly population, and malignant transformation is rarer still. Surgical resection is considered the mainstay of treatment for primary cutaneous BSCC, however due to this patient's broad distribution of cutaneous field change and p16-expressivity, she was effectively treated with primary radiotherapy. This is a unique case of malignant transformation of pilonidal disease in an atypical demographic, with a rare/aggressive disease variant.

Modelling the effects of post-FESS middle turbinate synechiae on sinonasal physiology: A computational fluid dynamics study.

OBJECTIVE(S): Chronic rhinosinusitis (CRS) is common and often requires surgical intervention. Surgical failure may lead to persistent symptoms and recalcitrant disease, often secondary to synechiae between the middle turbinate (MT) and lateral nasal wall. Synechiae prevention techniques have been extensively investigated, however evidence for the effect of synechiae on sinonasal physiology is lacking. We aimed to model the effects of MT synechiae on a post-functional endoscopic sinus surgery (FESS) sinonasal cavity using computational fluid dynamics (CFD). METHODS: DICOM data from a CT-sinus of a healthy 25-year-old female was segmented to create a three-dimensional model. Virtual surgery was performed to simulate a "full-house" FESS procedure. Multiple models were created, each with a single unilateral virtual MT synechia of varying extent. CFD analysis was performed on each model and compared with a post-FESS control model without synechiae. Airflow velocity, humidity and mucosal surface and air temperature values were calculated. RESULTS: All synechiae models demonstrated aberrant downstream sinonasal airflow. There was reduced ventilation of the ipsilateral frontal, ethmoid and sphenoid sinuses, with a concentrated central "jet" in the middle meatus region. Effects were proportionate to the size of synechiae. The impact on bulk inspired airflow was negligible. CONCLUSION: Post-FESS synechiae between the MT and lateral nasal wall significantly disrupt local downstream sinus ventilation and nasal airflow. These findings may explain the persistent symptoms seen in post-FESS CRS patients with MT synechiae, reinforcing the importance of prevention and adhesiolysis. Larger cohort studies with multiple models of actual post-FESS patients with synechiae are required to validate these findings.

Review article: Topical antibiotic treatments for acute otitis externa: Emergency care guidelines from an ear, nose and throat perspective.

Acute otitis externa (AOE), also known as 'swimmer's ear', is a common acute problem. It is one of the most common ED presentations. Atypical organisms, recalcitrant disease and antibiotic options contribute to making AOE a clinical challenge. There are a number of red flags associated with AOE which require consideration when treating patients with AOE. We discuss an evidence-based approach to management of AOE in the emergency setting, with indications for specialist referral.