Serotonin syndrome: take a closer look at the unwell surgical patient.

This article describes the sequence of acute clinical deterioration seen in a head and neck oncology patient who developed serotonin syndrome peri-operatively. It highlights the clinical dilemma that can be encountered when a septic picture masks the onset of serotonin syndrome and reinforces the importance of awareness of the potential interactions and side effects associated with drugs that surgeons prescribe. We discuss the pathophysiology, causal factors, clinical presentation and diagnosis of serotonin syndrome as well as highlighting some of the dilemmas that this condition presents in the surgical setting.

The adherence to guidelines for facial radiography in an Accident & Emergency Department.

OBJECTIVES: To evaluate the degree of adherence to guidelines for facial radiography. METHODS: A retrospective review of 1538 facial radiographs from a consecutive series of 414 patients attending the Accident & Emergency Department of the North Staffordshire Hospital with suspected facial injuries over a 6 month period was undertaken. Information on age, sex and aetiology of injury was recorded along with the type of view and total number of films taken. The results were compared with guidelines from the Department of Oral & Maxillofacial Surgery. RESULTS: Almost one-half of all injuries were due to assault. There was general adherence to the guidelines in terms of the number of films taken for mid-face and mandibular fractures. CONCLUSIONS: There was a good adherence to the guidelines in terms of the number of films taken for midface and mandibular fractures. However, a small number of patients were still being exposed to a high radiation dose where combinations of skull and facial views were taken. Guidelines need to be subjected to regular audit.

A morphological study of the thoracic duct at the jugulo-subclavian junction.

Chylous fistulae are uncommon but serious complications of neck surgery, occurring with an incidence of 1-3% after radical neck dissection. The majority occur on the left side (75-92%) and are due to damage to the terminal segment of the thoracic duct as it drains into the great veins of the neck in the region of the venous angle. The risk of trauma to the terminal thoracic duct may be influenced by anatomical variations. The macroscopic arrangement of the termination of the thoracic duct in the left neck was examined in 24 UK cadavers. Twenty-one ducts terminated as a single vessel, two ducts showed a bifid termination and one duct had three terminal branches. The precise site of termination was variable. Five thoracic ducts showed branching and reanastamosing patterns prior to their termination, irrespective of the number of terminal branches. Subsidiary cervical lymph trunks were identified in four dissections. These variations are described and their relevance to surgery involving the left side of the neck is discussed.

Recurrent buccal space abscesses: a complication of Crohn's disease.

A patient is described with generalized gastrointestinal involvement by Crohn's disease. Symptoms of recurrent ulceration and mucosal tags are well-described oral manifestations of Crohn's disease; however, in our patient recurrent facial abscesses, which required extraoral drainage, also developed. This complication has not previously been reported.

Hazard warning. A case of postoperative pulmonary barotrauma.

A case is described in which extensive pulmonary barotrauma occurred due to the application of a face mask to an indwelling cuffed endotracheal tube. The design of the mask is such that a seal was made between the mask and the tube. The design of mask is widely used in theatre recovery areas and clinicians are alerted to this potential hazard.

Recurrent oral carcinoma in Ferguson-Smith disease.

A patient with multiple self-healing squamous cell carcinomas of the skin is presented. Mucous membrane involvement in this condition is very uncommon and the lesions may show aggressive behaviour.

Orbital decompression of dysthyroid eye disease.

Two cases of Graves ophthalmopathy (GO) are presented, both of which required orbital decompression. The indications for orbital decompression and techniques used are discussed and the advantages of inferior orbitotomy presented.