Morell Mackenzie and Crown Prince Frederick: an unpublished manuscript from the Royal Society of Medicine Library.

The story of Morell Mackenzie and his involvement in the case of Crown Prince Frederick III (the future Emperor of Germany) is as well known as it is controversial. The consequences of the case were profound, both medically and politically. Most documents concerning the case are affected by varying degrees of bias, and as a result our understanding of the true events is incomplete. We present a brief summary of the case, and review an unpublished manuscript which adds to our understanding of the events. This manuscript is supportive of Mackenzie's early management of the Crown Prince's illness and acknowledges the importance of the case in medical history.

Updated surgical experience with bone-anchored hearing aids in children.

BACKGROUND: We present the results of a retrospective review of children undergoing implantation with bone-anchored hearing aids (BAHAs) at the Great Ormond Street Hospital for Children. METHODS: The case notes of 71 children undergoing BAHA placement at the Great Ormond Street Hospital for Children between December 1990 and August 2002 were reviewed. Outcome measures included hearing thresholds, incidence of fixture loss, skin reaction and need for revision. Quality of life outcomes were also measured. RESULTS: Eighty-five ears had been implanted. Fifty-four per cent of children had experienced no complications, 42 per cent had required revision surgery and 26 per cent had experienced fixture loss at some point. Young age at implantation was associated with an adverse outcome. Trauma and failure of osseointegration had been the commonest reasons for failure. A skin reaction around the abutment had occurred at some point in 37 per cent of children but had persisted for longer than six months in only 9 per cent; this had been associated with fixture loss. The use of fixture site split skin grafts had reduced problems with skin hypertrophy and hair overgrowth. Hearing thresholds when using BAHAs had been comparable to those when using bone conduction hearing aids. However, BAHAs had significant additional benefits in terms of sound quality, ease of use and overall quality of life. CONCLUSION: Bone-anchored hearing aids provide significant benefits over other types of hearing aid, both audiologically and in terms of quality of life. Careful selection of candidates and meticulous follow up are required in order to minimize complications.

Pneumocephalus--an unreported risk of Valsalva's manoeuvre following cochlear implantation.

We describe a case of pneumocephalus as an unusual early postoperative complication following cochlear implantation. The aetiology of this condition we attribute to the patient's habit of 'ear popping' using Valsalva's manoeuvre.

The laryngeal mask airway in tonsillectomy: the surgeon's perspective.

The laryngeal mask airway presents certain advantages in the management of the airway during general anaesthesia. However, from the surgeon's perspective, there have been reports of problems occurring when the laryngeal mask airway is used in tonsillectomy. This study of 90 patients undergoing tonsillectomy suggests that surgical access is inferior with a laryngeal mask airway and the weight of tonsillar tissue excised is less. In addition the laryngeal mask airway needs to be changed to an endotracheal tube during the procedure in 11.4% of patients.

Is local anaesthesia actually beneficial in flexible fibreoptic nasendoscopy?

Although the application of a topical local anaesthetic before fibreoptic nasendoscopy is routine practice in many otolaryngological outpatients, the actual benefit to the patient of this procedure remains in doubt. Eighty-two patients were recruited in this double-blind randomized control trial which compared the patients' experiences of fibreoptic nasendoscopy with nasal preparations of Xylocaine (lidocaine), normal saline, and no spray to the nose and throat. A visual analogue scoring system was used to determine scores for the overall unpleasantness of procedure, receiving a spray, and taste of the spray, and pain. This study has shown significantly worse overall experience (P = 0.001) and pain (P = 0.048) scores for Xylocaine spray versus no spray. It is concluded that the routine use of topical local anaesthetics within the nose before routine fibreoptic nasendoscopy is not only of no value, but actually makes the experience worse for the patient.

Contact dermatitis with cervical lymphadenopathy following exposure to the hide beetle, Dermestes peruvianus.

Contact with beetles of the family Dermestidae can produce a variety of disorders including skin, gastrointestinal and respiratory tract disease. Dermatological disorders include dermatitis, vesicular, pustular and vasculitic lesions. In addition, there may be pruritus, desquamation and urticaria. We report a patient who developed dermatitis, a vasculitic eruption, cervical lymphadenopathy and pulmonary nodular interstitial infiltration as a result of contact with the 'hide beetle' Dermestes peruvianus.

Infectious pseudomonas subglottic stenosis occurring in a patient with acquired immunodeficiency syndrome.

Pseudomonas aeruginosa is emerging as an increasingly common opportunistic infective agent in the immunocompromised human immunodeficiency virus (HIV) positive patient (Kielhofner et al., 1992). Improvements in the prevention and treatment of opportunistic infections in HIV and acquired immunodeficiency syndrome (AIDS) has led to longer life expectancy (Graham et al., 1992), and this has changed the incidence of Pseudomonas aeruginosa infection in this population (Baron and Hollander, 1993). We present a case of a patient with AIDS who developed a fulminant Pseudomonas aeruginosa stenosing subglottic infection. We are unaware of any previous reports of this particular manifestation of Pseudomonas aeruginosa infection.

Ancient schwannoma masquerading as parotid pleomorphic adenoma.

Pleomorphic adenoma of the parotid gland is common. We report a typical case of a parotid gland swelling which clinically, radiologically and cytologically represented a pleomorphic adenoma. Only following surgical excision and histological examination however, was the true diagnosis of ancient schwannoma made. Benign peripheral nerve sheath tumours should always be considered in the differential diagnosis of parotid gland tumours.

Emergency tracheostomy in general practice.

We set out to review the need for general practitioners (GPs) to be skilled at forming an emergency alternative airway by assessing mortality figures for acute airways obstruction. We also solicited the views of 100 GPs on the theory and practice of emergency tracheostomy and assessed whether they considered they were equipped to carry out such a procedure in the community. The results suggest a significant number of deaths of otherwise young and healthy individuals could be avoided by training community practitioners in emergency alternative airway formation. The results showed a marked lack of confidence in the practice of emergency airway formation and few GPs felt able to carry out the procedure. They indicated an overwhelming interest in receiving further education on the subject. We recommend that formal training programmes in the techniques of emergency airway formation should be available for community GPs.

Subglottic stenosis secondary to tuberculosis.

Although the incidence of laryngeal tuberculosis has been declining over the past 30 years, it should still be considered in the differential diagnosis of patients with laryngeal pathology. In contrast to the pre-chemotherapy era, few, if any, signs of pulmonary tuberculosis are seen in such cases, and presentation is similar to either chronic non-specific laryngitis or carcinoma. The subglottis is a site rarely involved in laryngeal tuberculosis. Tissue biopsy and culture are diagnostic and a full course of antituberculous chemotherapy usually resolves the condition. Airway insufficiency due to fibrosis, however, often necessitates surgical intervention. We present a case where the only laryngeal manifestation of tuberculosis was subglottic stenosis.

An in vitro study of tracheostomy tube cuff herniation and inflation characteristics.

Seven of the most commonly used tracheostomy tubes used in the UK were tested for cuff herniation and creasing in synthetic tracheas corresponding to the shapes and sizes found in vivo. Results demonstrated that only two tubes of one particular brand herniated and that creasing occurred in tubes disproportionately large for the trachea used. A discussion of modern tracheostomy tube manufacture is included.

Analysis of rhinomanometric data based upon a model of nasal airflow and logarithmic transformation of the data.

Estimation of nasal airflow, flow asymmetry and nasal valve stiffness was performed using anterior rhinomanometry in a group of 12 normal subjects and a group of 12 patients suffering from nasal obstruction. The method, based upon a simplified mathematical model of nasal airflow and utilizing logarithmic transformation of inspiratory pressure and flow data, improved the sensitivity and specificity of rhinomanometry and gave a more comprehensive index of nasal function.

Malignant otitis externa in HIV and AIDS.

Malignant otitis externa is a necrotising infection of the external ear canal which may spread to include the mastoid and petrous parts of the temporal bone, leading to skull base osteomyelitis. It is almost exclusively caused by infection with Pseudomonas aeruginosa, and usually occurs in elderly non-insulin-dependent diabetic patients. However isolated cases have been reported in a small number of non-diabetic patients, particularly in children who are immunocompromised due to malignancy, malnutrition and severe anaemia. In 1984 a case of malignant otitis externa was reported in a child with an acquired immunodeficiency syndrome (AIDS)-like illness, prior to identification of the human immunodeficiency virus (HIV). Since that time further sporadic cases of this invasive infection have been reported in HIV and AIDS. We present two further cases and also a review of the current literature.

Frequency of osteoarthritis in hysterectomized women.

A previous retrospective study reported a 2-fold increase in hysterectomy rates in women outpatient clinical attenders with osteoarthritis (OA) compared to controls. Our study was undertaken to confirm the findings of a previous case-control study which suggested hysterectomy to be a risk factor for OA. A retrospective cohort study design was used that would reduce the problems of selection bias. One hundred and sixty-two women who had undergone a hysterectomy between 1978 and 1979 (current mean age 53.8) and 164 controls (mean age 54.1) were examined for peripheral joint OA between 1988 and 1989. The screening method was identical for both groups and included a questionnaire, systematic examination of certain joints and radiographs of hands and knees. Women with a previous hysterectomy were found to have significantly higher rates of clinical signs of knee OA and 1st carpometacarpal (CMC) OA than control women without hysterectomy. The results were confirmed when OA was classified by the presence of symptoms alone, and when only radiologically confirmed clinical cases were included. The application of radiological criteria showed significantly smaller medial joint spaces (by digital image analysis) in hysterectomized women, although no differences were found using the Kellgren and Lawrence grading system. The increased risk for knee and CMC persisted after adjustment for possible confounders including age, obesity, parity and smoking status. By contrast frequency of distal interphalangeal and proximal interphalangeal involvement was lower, though not significantly so, than in controls.