Management of severe and symptomatic primary hyperparathyroidism in the first trimester of unplanned pregnancy.

Summary: Primary hyperparathyroidism (PHP) is the most common aetiology for hypercalcaemia. The incidence of PHP in pregnant women is reported to be 8/100 000 population/year. It presents a threat to the health of both mother (hyperemesis, nephrolithiasis) and fetus (fetal death, congenital malformations, and neonatal severe hypocalcaemia-induced tetany). However, there is a lack of clear guidance on the management of primary hyperparathyroidism in pregnancy. In this study, we describe the case of a 26-year-old female patient who presented with severe hypercalcaemia secondary to PHP and underwent successful parathyroid adenectomy under local anaesthesia. Learning points: Primary hyperparathyroidism is a rare complication in pregnancy, but the consequences for mother and fetus can be severe. A perceived risk of general anaesthesia to the fetus in the first trimester has resulted in a general consensus to delay parathyroid surgery to the second trimester when possible - although the increased risk of fetal loss may occur before planned surgery. If the patient presents with severe or symptomatic hypercalcaemia, minimally invasive surgery under local anaesthetic should be considered regardless of the gestational age of the pregnancy.

The water penetration of different ventilation tubes.

The insertion of middle ear ventilation tubes remains one of the most common procedures for ENT surgeons. A common concern amongst patients undergoing such procedures is the effect on their ability to partake in swimming and other water sports. Currently there is little evidence comparing the penetration ability of different water solutions encountered by swimmers. This study compares the water penetration of four different water solutions for Shah, mini-Shah, T tube and titanium bobbin ventilation tubes. A model was constructed to replicate a grommet inserted through a tympanic membrane using a syringe barrel, latex membrane and one of the ventilation tubes. Four solutions (sea water, chlorinated water, freshwater and soapy water) were then pipetted down the barrel until penetration of the tube occurred. The volume required for penetration was recorded. For all tubes soapy water was the most penetrating, followed by seawater. Titanium bobbins required significantly less of each solution for penetration. Mini-Shah grommets required significantly more of all solutions except soapy water for penetration to occur. Shah grommets were more resistant to chlorinated and sea water than T tubes. Mini-Shah grommets appear to protect against water penetration into the middle ear cleft and their use should be considered in patients who are keen water-sport enthusiasts. Furthermore, swimmers in sea or chlorinated water seem to be at higher risk than freshwater swimmers. Titanium bobbins were relatively easily penetrated by all four solutions and should be avoided in keen swimmers.

Spectral-Domain OPTICAL COHERENCE TOMOGRAPHY of a Macular Fold AFTER Retinal Detachment Repair.

PURPOSE: We report a case with a dry macular fold after retinal detachment repair using spectral-domain optical coherence tomography images (SD-OCT) to evaluate details of the retinal architecture before and after surgical management. METHODS: A 62-year-old man diagnosed with macula-threatening rhegmatogenous retinal detachment underwent primary vitrectomy with an encircling sclera buckle. On post-operative day 5, he was noted to have developed a juxtafoveal retinal fold. SD-OCT was used to image the retinal fold and documented apposition of the retinal layers and discontinuity within the photoreceptor layer in the vicinity of the retinal fold. RESULTS: The attempts to detach and unfold the retina appeared minimally successful intraoperatively. However, as the gas bubble decreased, the retinal fold was noted to have resolved. Repeat SD-OCT documented flattening of the retinal fold with a well-preserved photoreceptor layer. CONCLUSION: This outcome suggests the possibility of delayed postoperative success in flattening a retinal fold despite resistance to manipulation and failed attempts during the course of the surgery. To our knowledge, this is the first report that demonstrates this finding within the macular architecture after retinal detachment surgery in vivo using spectral-domain optical coherence tomography. These findings may have an important role in management of these cases and may become prognostic indicators based on the alterations in retinal anatomy demonstrated by high-resolution imaging.

Audiological implications of earplugs used for the prevention of aural exostoses.

External auditory canal exostoses may be a preventable disease, so it is surprising that the regular use of water precautions is not greater among surfers. One reason for this is the impairment of hearing whilst wearing earplugs. The objective of this study is to establish the hearing impairment of commonly available earplugs used by surfers. Staff and patients with normal hearing were recruited to have pure tone audiometry performed multiple times, initially with no earplugs, and subsequently with earplugs. Three earplug types were tested which differed in their nature and material (prefabricated elastomer, custom-fitted silicone, and custom-fitted acrylic). Vented and non-vented forms of the earplugs were tested. 30 normal hearing ears were included. Two-tailed paired t-tests comparing hearing thresholds between different earplugs identified that the elastomer earplugs caused the least hearing impairment (p < 0.001). There was no significant difference in hearing thresholds between vented and non-vented elastomer earplugs (p = 0.148), but the difference between vented and non-vented forms of other earplugs was statistically significant (silicone p = 0.010, acrylic p = 0.018). Prefabricated ear plugs produce less hearing impairment than other commonly available earplugs. A customised earplug made of hard material causes the greatest impairment of hearing. We therefore recommend that for aquatic sports where hearing is important, a soft prefabricated earplug is preferable.

Recurrence of food bolus impaction of the oesophagus: a retrospective observational study.

BACKGROUND: Most cases of oesophageal food bolus impactions (FB) are one-off events, but recurrence is recognised. The aims of this study are to establish the recurrence rate of food bolus impaction and to identify features associated with recurrence. METHODS: Clinical records of all FB cases were reviewed and the following information was recorded (patient identifier, age, gender, dates of admission, history of oesophageal pathologies). Results of investigations were also recorded (contrast swallow, endoscopies, oesophageal manometry and pH studies). Cases were coded according to the most common oesophageal pathologies. RESULTS: 99 patients fulfilled inclusion criteria and consisted of 65 males and 34 females. Recurrence was noted in 9 patients who did not demonstrate any significant difference compared with cases suffering a single episode of FB in terms of age (Median 61 years IQR 49-79 years, Mann-Whitney U test 374.5, p = 0.71) or gender (recurrences in 3/34 females and 6/65 males, Pearson chi-square test 0.004, p = 0.99). 86 patients had investigations performed. Logistic regression demonstrated that hiatus hernia was the only oesophageal pathology demonstrating statistical significance in its association with FB recurrence (odds ratio 4.77 95% CI 1.15-19.82, p = 0.032). All other variables (oesophageal pathologies, age and gender of patients) were not statistically significant (p > 0.35). CONCLUSION: The rate of recurrence of FB in our study group was 9%. Hiatus hernia was the only oesophageal pathology associated with recurrence of FB. It is not possible to draw any conclusions regarding the role of hiatus hernia in the causation of recurrence of FB.

Benign paroxysmal positional vertigo nurse-led follow-up clinic.

Patients with benign paroxysmal positional vertigo (BPPV) often require multiple appointments for treatment with Epley manoeuvres. Waiting times for medical follow up can be very long. To reduce waiting times and increase availability of ENT outpatients' appointments, a nurse-led dizziness clinic (NLDC) to follow up BPPV patients was established. Prospective audit of 99 consecutive patients attending the NLDC, at which patients are assessed and treated, was conducted. Non-responders are redirected for further medical review. 99 patients were seen in 200 appointments in the NLDC from July 2007 to May 2009. The mean time to NLDC was 16 days. 67 patients were discharged from the NLDC free of symptoms. Cost analysis revealed savings of £3,800. A survey of NLDC attendees revealed that the care they received was rated as excellent, very good or good by 92% of patients. In conclusion, the NLDC is an innovation which increases availability of ENT outpatient appointments. This is acceptable to patients and is a natural extension of the roles of ENT nurse practitioners which could be implemented in other ENT departments.

The incidence and success of treatment for severe chronic groin pain after open, transabdominal preperitoneal, and totally extraperitoneal hernia repair.

BACKGROUND: Chronic groin pain (CGP) is a significant cause of postoperative morbidity after inguinal hernia repair. Open, transabdominal preperitoneal (TAPP), and totally extraperitoneal (TEP) repair are all commonly performed methods of herniorrhaphy. The aim of this study was to compare the frequency of attendance at a chronic pain clinic (CPC) for CGP after open, TAPP or TEP repair. METHODS: A retrospective review of all inguinal hernia repairs between January 1997 and December 2006 identified patients attending the CPC for CGP post-herniorrhaphy. In this study CGP post-herniorrhaphy was defined as pain that limited daily activities despite simple analgesia thereby requiring referral to the specialist CPC following surgical review. RESULTS: A total of 8513 patients underwent 9607 inguinal hernia repairs; 6497 (75.5%) were open, 1916 (22.3%) were TAPP, and 198 (2.3%) were TEP. Of these, 46 (0.71%) open, 22 (1.15%) TAPP, and 6 (3.03%) TEP repairs required attendance at CPC. A statistically significant difference in frequency of CPC attendance following laparoscopic versus open (P = 0.008), TEP versus open (P < or = 0.001), and TEP versus TAPP repair (P = 0.027) was observed. After an average of 1 year, 69% of patients were discharged symptom-free from the CPC. In 16%, CGP resolved prior to CPC attendance. CONCLUSIONS: In contrast to previous reports, laparoscopic hernia repair is associated with a greater frequency of attendance at CPC than open repair, a finding that merits further investigation. Of those requiring treatment, the majority were discharged pain-free after an average of 1 year.

Using keywords to predict the need for an audiogram: an analysis of referral letters using logistic regression.

BACKGROUND: Otolaryngology clinics are often booked without considering the distribution of work for doctors and audiologists. This causes inefficiencies of time and human resources. This may be due to clinics being booked before referrals have been triaged to identify whether a hearing test, known as a pure tone audiogram (PTA), is indicated. A model that can predict the need for PTA without clinician-led triage could be useful to address these booking issues. OBJECTIVE: To establish if it is possible to predict whether a referred patient requires a PTA based on occurrences of words in the referral letter. METHOD: Binary logistic regression analysis of 500 letters of referral for otolaryngology outpatients. The derived model was then tested on 50 referral letters. All the referral letters were reviewed by clinicians and classified according to whether or not a PTA would be required. RESULTS: The regression model correctly predicted requirement for a PTA in 42 of 50 referral letters (84%), with a sensitivity of 91% and specificity of 82%. CONCLUSION: The model is able to predict requirement for a PTA from referral letters with a high degree of accuracy. This method may have a role in assisting administrative/clerical staff or non-specialist clinicians to book appropriate ear, nose and throat (ENT) clinic appointments, with or without a PTA. As a result, workload would be distributed more evenly, through the clinic for both otolaryngologists and audiologists, increasing efficiency.

Conservative management of warthin tumour.

BACKGROUND: Warthin tumour (WT) is usually treated by surgery to establish a histologic diagnosis. Conservative management is considered appropriate for patients with significant comorbidities, making anesthesia high risk. Preoperative fine-needle aspiration cytology (FNAC) is useful in diagnosing WT, making conservative management an option. In our institution, patients with an FNAC diagnostic of WT have the option of conservative management. METHOD: Retrospective review of cases of WT over 10 years (1996-2006) to study the demographics of patients treated conservatively and surgically and to establish the accuracy of FNAC. RESULTS: Eighty-six cases of WT were identified during the study period for which FNAC was diagnostic, of which 58 cases (67.4%) were treated conservatively and 28 cases (32.6%) were treated by superficial parotidectomy. A further seven cases of WT were diagnosed on histology as the corresponding FNAC was incorrect in two cases and nondiagnostic in five cases. With regard to WT, FNAC in our unit had a sensitivity of 80% and a specificity of 100%. Females accounted for 54.7% of cases, which is much higher than previously reported and likely reflects the high prevalence of smoking among females in Liverpool. CONCLUSION: Conservative management for WT on the basis of a diagnostic FNAC was employed in 67.4% of cases. This included young patients who preferred to avoid surgery. Conservative management is a viable option if reliable cytologic reporting is available.