Drain Usage in Head and Neck Surgery: A National Survey of Thirty-five Surgeons across Ten Units

Introduction Drain usage is commonplace in head and neck surgery. There is an increasing body of literature disputing their routine placement in certain procedures. The aim of this study is to explore modern-day practice in terms of drain usage and the use of haemostatic agents. Methods A simple questionnaire was devised and sent to 35 ENT Surgeons across 10 units nationally. Results There was an overall response rate of 77.1% (n=27). There was considerable heterogeneity amongst surgeons in terms of indication for insertion, how the decision is made to remove the drain and if any alternative/adjunctive haemostatic agents are being used. Discussion The management of drains is poorly defined and guidelines are lacking. With increased pressure on resources, the risk of infection and discomfort to the patient, further reflection is required to evaluate if careful patient selection rather than habitual drain insertion in every case is more appropriate.

Polyps, grommets and eosinophilic granulomatosis with polyangiitis.

OBJECTIVE: To explore the link between nasal polyposis, refractory otitis media with effusion and eosinophilic granulomatosis with polyangiitis. METHODS: A retrospective observational study was carried out of patients diagnosed with refractory otitis media with effusion necessitating grommet insertion and who had nasal polyps. Patients were evaluated to determine if they fulfilled the diagnostic criteria of eosinophilic granulomatosis with polyangiitis. RESULTS: Sixteen patients (10 males and 6 females) were identified. The mean age of grommet insertion was 45.4 years. The mean number of grommets inserted per patient was 1.6. The mean number of nasal polypectomies was 1.7. All 16 patients had paranasal sinus abnormalities and otitis media with effusion, 14 had asthma, 9 had serological eosinophilia and 7 had extravascular eosinophilia. Nine patients met the diagnostic criteria for eosinophilic granulomatosis with polyangiitis. CONCLUSION: The co-presence of nasal polyps and resistant otitis media with effusion should raise the possibility of eosinophilic granulomatosis with polyangiitis.

The Westaby T-Y tracheobronchial stent in otolaryngology.

The Westaby T-Y tracheobronchial silicone stent can be used for the relief of upper airway obstruction beyond the limit of a standard tracheostomy tube. We report on our experience in the use of the Westaby tube in 10 patients over a five-year period. The general features of the tube, indications for its use, and its method of insertion are described. The versatility and advantages over other stents are discussed. Two cases reports are described and the clinical course and outcomes of the individual patients are outlined.

Primary distension of the guttural pouch lateral compartment secondary to empyema.

A 6-year-old, 420-kg quarter horse gelding was presented with a 2-month history of difficulty swallowing and dyspnea. The horse was diagnosed with a right guttural pouch empyema with many large chondroids. Two surgeries were required to completely remove all the chondroids from what proved to be a primary distension of the guttural pouch lateral compartment.

Sinogenic brain abscess.

The otolaryngological contribution to the combined treatment of intracranial suppuration secondary to sinusitis can vary from observation to external approach sinus exploration. Limited surgical intervention using the endoscopic approach, in conjunction with neurosurgical drainage, has recently been adopted at our department as the initial therapeutic strategy in the management of such cases. A retrospective analysis of the otolaryngological input into the treatment of 16 patients with sinogenic brain abscess at the Department of Otolaryngology/Head and Neck Surgery, Beaumont Hospital, Dublin, Ireland is presented. This study reveals that it is generally a disease of young adult males without an antecedent history of sinus disease and that Strep. Milleri is the most common causative organism. It is demonstrated that there is a lack of a consistent approach to the management in the acute phase and that there is an inadequate initial radiologic evaluation of the paranasal sinuses. There are two forms of presentation: 1) an ENT complaint with development of an abscess, and 2) an idiopathic abscess with subsequent identification of a paranasal sinus infective source. Extensive initial intervention seems to be associated with an increased incidence of revision surgery, thus suggesting that a limited endoscopic approach combined with neurosurgical drainage is the optimal course in the first-line management of sinogenic abscess.

Occult pharyngeal perforation secondary to 'pencil injury'.

Palatopharyngeal injuries due to impaction of rigid objects held in the mouth are common. Most are essentially innocuous injuries requiring no specific treatment. However, there is the potential for perforation of the pharyngeal wall with the subsequent development of serious infection such as retropharyngeal abscess or mediastinitis. This possibility is more likely to be suspected in the presence of a visible laceration or puncture wound at the site of impact in the mouth or pharynx. We report three cases in which occult pharyngeal perforation occurred without any clinical signs of breech of the pharyngeal wall. In all cases a lateral soft tissue neck X-ray was diagnostic of perforation, showing the presence of retropharyngeal air. We, therefore, advocate the routine performance of soft tissue neck X-rays in all patients who present with a history of falling on a rigid object held in the mouth.

Predicting mandibular invasion in mouth cancer.

This study assesses the role of orthopantomography, computerized tomography and intra-operative assessment in predicting the presence and extent of mandibular invasion by mouth tumours. Forty patient's with squamous carcinoma of the oral cavity and oropharynx were studied. All had pre-operative orthopantomography and computerized tomography as well as intra-operative assessment of mandibular invasion and these factors were compared with the actual histological invasion to assess the role of each test. This study found that negative radiology is useful for excluding cortical invasion and as might be expected is of no real value in excluding periosteal invasion, a positive orthopantomogram accurately predicts invasion at least into the cortex, however, a positive CT must be judged cautiously due to false positives and intra-operative assessment by an experienced operator is a useful adjunct to radiology.

The influence of bismuth subgallate and adrenaline paste upon operating time and operative blood loss in tonsillectomy.

The aims of this study were to demonstrate the effect of bismuth subgallate and adrenaline paste application to the tonsillar fossae on operating time and peroperative blood loss during tonsillectomy. Ninety-eight patients were included in a prospective randomized trial. Bismuth subgallate powder is mixed with 10 ml of normal saline and 0.03 ml of 1:1000 adrenaline to make a paste. This paste is used as a topical haemostatic agent during tonsillectomy. Bismuth subgallate activates Factor XII and therefore accelerates the coagulation cascade. Adrenaline causes vasoconstriction and promotes platelet aggregation. The application of bismuth subgallate and adrenaline paste to the tonsillar fossae during tonsillectomy reduces operating time by 23 per cent for Consultant staff (p < 0.05) and 32 per cent for Junior staff (p < 0.05). Blood loss is reduced by 21 per cent (p > 0.05), for the average paediatric tonsillectomy.

Personality and spirituality: comparative TATs of high-achieving Rajneeshees.

The Thematic Apperception Test (TAT) was administered to followers of Bhagwan Shree Rajneesh in their commune in central Oregon. The Rajneeshee subjects had been high achievers (with advanced degrees and/or previous incomes greater than 30,000 dollars in 1984 dollars). Later, TATs were administered to persons matched for gender, age, education, and occupation but not involved in new religions. The final matched sample included 24 men and 20 women, half of whom were Rajneeshees. TATs were coded for a variety of formal variables as well as personality ratings. Though the analysis showed no between-group differences on most variables, significant mean differences occurred on ratings of unusual conditions, quest, and narcissism, with Rajneeshees higher than comparison subjects. Gender differences in personality variables were not conspicuous. Factor analysis established a strong productivity element. Card 16 (the blank card) provided the greatest number of differences.

Sugar content and activity of sucrose metabolism enzymes in milled rice grain.

Most rice (Oryza sativa L.) cultivars grown in the United States were selected for endosperm starch properties and not soluble sugar content. The minor pool of soluble sugar may affect the qualities of rice as a food. Some cultivar variation in soluble sugar content was detected in milled grain, essentially the starchy endosperm, of long grain varieties. Milled grain of cultivars Lemont and Texmati had a soluble sugar content of 0.21 and 0.35% (w/w), respectively, on a fresh weight basis. The dorsal portion of the milled grain contained the greatest amount of soluble sugar, approximately tenfold the amount found in the central core of the grain. Extracts of the milled grain contained sucrose-phosphate synthase (EC 2.4.1.14) and sucrose synthase (EC 2.4.1.13) activities, which were separated by anion exchange chromatography. The presence of sucrose-phosphate synthase in the rice endosperm suggested a mechanism for sucrose accumulation which might be involved in carbon partitioning during grain development.

Pyrophosphate and fructose 2,6-bisphosphate effects on glycolysis in pea seed extracts.

The participation of pyrophosphate-dependent phosphofructokinase (PPi-PFK) in plant glycolysis was examined using extracts from pea seeds (Pisum sativum L. cv Alaska). Glycolysis starting with fructose 6-phosphate was measured under aerobic conditions as the accumulation of pyruvate. Pyruvate accumulated in a medium containing PPi and adenosine diphosphate at about two-thirds of the rate in a medium containing adenosine diphosphate and adenosine triphosphate (ATP). The PPi-dependent pyruvate accumulation had the same reactant requirements and sensitivity to glycolysis inhibitors, sodium fluoride, and iodoacetamide, as the well-established ATP-dependent glycolysis. Added fructose 2,6-bisphosphate stimulated both the PPi-dependent pyruvate accumulation and PPi-PFK activity whereas this modulator had no effect on ATP-dependent glycolysis or ATP-PFK. Collectively these results demonstrate a PPi-dependent glycolytic pathway in plants which is responsive to fructose 2,6-bisphosphate.

Regulation of pea seed pyrophosphate-dependent phosphofructokinase: Evidence for interconversion of two molecular forms as a glycolytic regulatory mechanism.

Two molecular forms of pyrophosphate-dependent phosphofructokinase (PP(i)-PFK; pyrophosphate:D-fructose-6-phosphate 1-phosphotransferase; EC 2.7.1.90) have been found whose activity depends upon association and dissociation characteristics regulated by fructose 2,6-bisphosphate (Fru-2,6-P(2)). PP(i)-PFK was purified 200-fold from cotyledons of germinating pea seeds and found to exist in two interconvertible molecular forms. The two forms of PP(i)-PFK have sedimentation coefficients of 6.3 and 12.7 S during ultracentrifugation in sucrose density gradients and also differ both in sensitivity to the activator Fru-2,6-P(2) and in affinity for the substrate fructose 6-phosphate. The major component of enzyme activity is in the large form (12.7 S), but the small, less-active, form (6.3 S) predominates when the enzyme preparation is extracted and stored in buffer without Fru-2,6-P(2) and glycerol. Urea (1 M) or pyrophosphate (20 mM) treatment results in at least a 50% loss of activity in the glycolytic direction, whereas these treatments had much less influence on the gluconeogenic direction activity. Concomitant with the loss of glycolytic activity the enzyme dissociates into the small form. Fru-2,6-P(2) stabilizes the large form of the enzyme against the dissociating effects of pyrophosphate and prevents the inactivation in the glycolytic direction during either urea or pyrophosphate treatment. The small molecular form of the enzyme is converted into the large form in the presence of Fru-2,6-P(2). We propose that glycolytic and gluconeogenic hexose metabolism in plants includes a regulatory mechanism induced by Fru-2,6-P(2) that involves the interconversion of two molecular forms of PP(i)-PFK.

Measurement of the pyrophosphate content of plant tissues.

Pyrophosphate (PPi) was measured in pea (Pisum sativum L.) and corn (Zea mays L.) tissues by using an enzymic method based on PPi-dependent phosphofructokinase (PPi-PFK). Different organs of pea and corn seedlings were extracted to determine if PPi is present in sufficient amounts to serve as a substrate for the PPi-PFK activity in these tissues. The amount of PPi is at least 14% to 70% that of the ATP content in shoots and roots of peas and corn; and, for various plant tissues, ranges from 5 to 39 nanomoles of PPi per gram fresh tissue weight. We conclude that PPi is available as a substrate for the glycolytic function of PPi-PFK in plants. Furthermore, the presence of substrate amounts of PPi in plant tissues implies that plant energetics also must be evaluated in terms of PPi as an energy source and phosphate donor.

Fructose 2,6-bisphosphate and the regulation of pyrophosphate-dependent phosphofructokinase activity in germinating pea seeds.

THE ACTIVITY OF PYROPHOSPHATE: d-fructose-6-phosphate-1-phosphotransferase (EC 2.7.1.90, PPi-PFK) in cotyledons and sprouts of germinating pea seeds (Pisum sativum cv Alaska or Green Arrow) increases rapidly during the first 2 to 3 days after imbibition and then declines to a lower activity. The reaction toward fructose 1,6-bisphosphate formation is activated greatly by fructose 2,6-bisphosphate (fru 2,6-P(2)); however, the sensitivity of the enzyme's activity to fru 2,6-P(2) activation changes during germination.The cotyledon enzyme was partially purified and exists in two forms apparently with different molecular weights. The large form shows little sensitivity to fru 2,6-P(2), while the small form shows a high sensitivity to this effector (K(a) = 15 nanomolar). Gel filtration experiments indicate that fru 2,6-P(2) is involved in converting the small form into the large form. We propose that the interconversion of two forms of the PPi-dependent PFK by fru 2,6-P(2) is one mechanism for regulating glycolysis during seed germination.

Epidemic hepatitis A from cockles.

Early in 1981, cases of hepatitis possibly associated with the consumption of cockles were reported mainly from south-east England. A case-control study was undertaken in 19 local authority districts. Between Nov. 1, 1980, and April 30, 1981, 424 cases of infective jaundice were formally notified and case-finding yielded 26 additional cases. 42.6% of those with hepatitis and 17.5% of the controls reported consumption of cockles. There was a statistically significant association between infective jaundice and the consumption of cockles but not other sea foods. The cockles had probably been insufficiently processed and stricter controls on treatment of such shellfish are needed.

Oxidation of NAD(P)H in a Reconstituted Spinach Chloroplast Preparation Using Ascorbate and Hydrogen Peroxide.

The conversion of fructose-1,6-bisphosphate to glycerate-3-phosphate (PGA) was studied in a reconstituted spinach (Spinacia oleracea L.) chloroplast preparation to determine whether a chloroplast-localized NAB(P)H-oxidizing system (Kow, Smyth, Gibbs 1982 Plant Physiol 69: 72-76 with substrates of ascorbate, NAD(P)H, and H(2)O(2) could serve as a coupling enzyme in the recycling of NAD(P)H. The rate of PGA formation was monitored as an indicator of NAD(P) generation. With NAD as a cofactor, ascorbate enhanced PGA formation, and an additional increase resulted upon addition of glucose-glucose oxidase, a H(2)O(2)-generating enzyme. This increase in PGA formation due to H(2)O(2) was eliminated by the addition of catalase. With NADP and ferredoxin as cofactors, the recycling of NADP apparently was catalyzed both by ferredoxin-NADP reductase coupled to O(2) and by the NAD(P)H-oxidizing system.It was concluded that the oxidation of NAD(P)H by a system using ascorbate and H(2)O(2) can serve as a means of recycling NAD(P)H but that another reaction involving ascorbate and NAD(P)H may also function in the spinach chloroplast.

Oxidation of reduced pyridine nucleotide by a system using ascorbate and hydrogen peroxide from plants and algae.

A NAD(P)H oxidizing system (NAAP) was detected and partially purified from leaves of spinach and Sedum praealtum, seeds and leaves of pea and cells of green and red algae which oxidized NAD(P)H in the presence of ascorbate and H(2)O(2).The partially-purified spinach system had substrate K(m) values of 5 micromolar for NADH, 50 micromolar for H(2)O(2), and 300 micromolar for l-ascorbic acid at the pH optimum of 6.8. NADH was a better electron donor than NADPH. Among other electron donors, isoascorbic acid had considerable activity but hydroquinone and resorcinol had only weak activities. The enzyme was inhibited by cyanide, alpha,alpha'-dipyridyl, and mono-and di-thiol reagents. Inhibition by thiol-reagents was partially restored by Fe(2+) as was enzymic activity lost following dialysis against buffer.Subcellular localization studies with spinach and S. praealtum leaves indicated that a portion of the cell's NAAP was in the chloroplast fraction. Photosynthetic conditions resulted in a decrease in this activity solubilized from spinach and S. praealtum chloroplasts. The presence of 3-(3,4-dichlorophenyl)-1,1-dimethylurea or Fe(2+) in the incubation medium eliminated the light-mediated inhibition of NAAP.NAAP may function in the recycling of NAD(P)H generated in the dark within the chloroplast. Inasmuch as all preparations of NAAP contained ascorbate peroxidase activity, the data do not rule out the possibility that NAAP is the same protein as ascorbate peroxidase or, alternatively, a combination of ascorbate peroxidase and some other enzyme.

Effects of Boron Deficiency on Rubidium Uptake and Photosynthesis in the Diatom Cylindrotheca fusiformis.

Culturing the diatom Cylindrotheca fusiformis under boron-deficient conditions leads to changes in (86)Rb uptake and photosynthesis prior to any effect on the rate of cell division. The influx rate of (86)Rb into boron-deficient cells was 79% of the control rate after 5 to 5.5 hours culture. Despite lowered (86)Rb influx, however, boron-deficient diatoms accumulated more (86)Rb than did control cells; this was due to the deficient cells' lower efflux rate. After 24 hours culture, boron-deficient cells had accumulated 30% more (86)Rb than had control cells, while releasing (86)Rb at only one-half the control rate. Increased photosynthetic rates were another effect of boron deficiency during this early stage of culture. Prior to 20 hours boron-deficient culture, diatoms had photosynthetic rates 37% greater than those of control cells. Corresponding to the increase in photosynthesis, boron-deficient diatoms had 12% more carbohydrate than control cells after 16 hours culture.