Eustachian Tube dysfunction in chronic rhinosinusitis: pre and post-operative results following endoscopic sinus surgery, a prospective study.

BACKGROUND: Prospective study investigating the incidence of concurrent Eustachian Tube dysfunction (ETD) in patients with CRS refractory to medical therapy, and the effect of Endoscopic Sinus Surgery (ESS) on ETD in this patient group. METHODS: Prospective study of 57 CRS patients. Outcome measures were SNOT-22 and ETDQ-7 questionnaires, tympanometry and Valsalva manoeuvre recorded pre-operatively and at 3 and 9 months post ESS. RESULTS: There was a moderate positive correlation between pre-operative ETDQ-7 and SNOT 22 scores (r equals 0.5715, p less than 0.0001). 68% of patients recorded positive ETDQ-7 scores pre-operatively, mean equals 20.6 (SD plus or minus 10.34). Mean ETDQ-7 scores were significantly lower at 3 months; mean equals 11.4 (SD plus or minus 5.65) (P less than 0.0001) and 9 months mean equals 11.4 (SD plus or minus 6.15) (P less than 0.0001) following ESS. Type A tympanograms increased form 76.6% pre-operatively, to 94.5% at 3 months and 96% at 9 months. Reported positive Valsalva increased from 38% pre-operatively to 96% at 3 and 9 months. Mean ETDQ-7 scores were higher in the CRSwNP group; 24.34 (SD plus or minus 9.2) compared to the CRSsNP group; 18.11 (SD plus or minus 10.3), (p equals 0.6101). 16 patients in the cohort had existing diagnoses of asthma, of which 4 had documented aspirin sensitivity. The mean pre-operative SNOT-22 score in this overall subgroup was 64.81 (SD equals plus or mins 20.13) compared with 49.07 (SD equals plus or minus 21.37) in non-asthmatic patients (p equals 0.0168). CONCLUSIONS: We found a high incidence of concurrent ETD symptoms in patients with severe CRS, which improve following ESS. Further research is required to better understand the association between CRS and ETD in order to provide effective treatments.

Informing ENT training bootcamps - operating out-of-hours: a multicentre prospective evaluation.

OBJECTIVE: ENT specialty trainees are invited to national bootcamps to prepare for critical events to which they may have never been exposed. Here, we evaluate the frequency of out-of-hours ENT operations and the level of supervision provided to inform aspiring trainees and the national bootcamps. METHODS: Information on all ENT operations performed out-of-hours was prospectively recorded by trainees in Kent, Surrey and Sussex over seven months. RESULTS: There was a 100 per cent response rate. The trainee was the most senior surgeon present for 48.4 per cent of out-of-hours operations. Four of the six most frequently performed out-of-hours operations are not included in the ENT indicator procedures, and two are not included in the national ENT bootcamps. CONCLUSION: Trainees should be aware of the most common procedures they may be expected to perform out-of-hours. Training in these should be provided prior to the commencement of specialty training. The audit design can be replicated across surgical specialties.

Displaced transverse laryngeal fracture from attempted hanging.

Laryngeal fractures are life-threatening injuries, frequently associated with long-term morbidity. We present a case of a man sustaining a displaced laryngeal fracture and rupture of supraglottic structures following attempted suicide by hanging from a bridge. His injuries included a tear of the thyrohyoid membrane, avulsed epiglottis and complete autopharyngotomy. All laryngeal functions were significantly impaired. Early tracheostomy, careful surgical repair, extensive multidisciplinary team (MDT) input and intensive rehabilitation all contributed towards a successful recovery. By 7 months following the initial injury, the patient had achieved excellent breathing and voicing, and a safe and competent swallow despite the extent of his initial injuries. This case demonstrates the importance of early airway management in laryngeal trauma and the role of surgical management in conjunction with swallow rehabilitation. Fundamentally, an MDT approach is essential for the holistic management of patients with laryngeal trauma.

Facial trauma aggravating paediatric orbital cellulitis.

We describe a case of paediatric orbital cellulitis with subperiosteal abscess following blunt facial trauma. Clinical features of orbital cellulitis developed on day 1 post-trauma. A subperiosteal collection subsequently formed lateral to the globe, causing significant ocular compromise. Surgical drainage and sinus washout were performed via external incisions, with satisfactory outcome. This case highlights how trauma may represent a non-sinogenic aggravating factor in orbital cellulitis. We describe how a subperiosteal abscess may vary depending on its aetiology, and how the surgical approach can be modified to locate and drain a laterally sited subperiosteal abscess.

Recurrent epistaxis secondary to nasal haemangioma with a misleading CT angiogram.

The majority of epistaxes are anterior in nature, resolve with simple first aid measures and require no further follow-up. However, some cases pose more of a diagnostic challenge and prove resistant to standard investigation and treatment. We present a case of recurrent epistaxis, refractory to multiple treatment modalities and with CT imaging suggestive of a vascular aetiology which was ultimately disproved. The case highlights the shortcomings of CT imaging and importance of thorough examination technique. Nasal haemangiomas are a rare but recognised cause of epistaxis and should be considered in refractory cases.

Fungal malignant otitis externa.

An 89-year-old man presented to the outpatient clinic with a 2-month history of persistent unilateral left-sided otalgia, otorrhoea and reduced hearing despite oral and topical antibiotics. Treatment was protracted, requiring a 4-month hospital admission for intravenous antifungal medication as well as 3 further months of oral antifungal treatment. We describe the clinical presentation, complications and treatment of this potentially fatal condition in the context of an unusual, and easily missed, causative organism.

Go-karting injury: a case of laryngeal trauma.

We report a case of accidental strangulation and crush injury to the anterior neck resulting in laryngeal trauma. This extremely uncommon mechanism of injury provides a safety warning regarding precautions with neck wear, and the unusual resulting injury represents an opportunity to review best practice in management of laryngeal trauma.

Peri-operative management of high-risk paediatric adenotonsillectomy patients: A survey of 35 UK tertiary referral centres.

INTRODUCTION: Peri-operative management of high-risk paediatric patients undergoing adenotonsillectomy for treatment of obstructive sleep apnoea varies between tertiary referral hospitals. 'Day of surgery cancellation' (DoSC) rates of up to 11% have been reported due to pre-booked critical care being unavailable on the day of surgery as a result of competing needs from other hospital departments. We report the results of a survey of peri-operative management in UK tertiary care centres of high-risk paediatric patients undergoing adenotonsillectomy for obstructive sleep apnoea (OSA). METHODS: An 8-point questionnaire was developed using a cloud-based software platform (www.surveymonkey.com). A web-link to the survey was embedded in a customised e-mail which was sent via secure server to the Clinical Leads for Paediatric Otolaryngology at 35 United Kingdom (UK) Tertiary referral centres. RESULTS: The survey response rate was 60% (n = 21). Almost all (94.1%) of centres considered paediatric critical care facilities to be limited, with 70.6% (n = 12) stating that DoSC often occurred due to unavailable paediatric critical care capacity. There was variation between tertiary referral units in the practice applied for pre-booking critical care beds (our survey identifies 6 variations) (Table 1). The most frequent selection method reported (47.1%) was at the discretion of the booking clinician at the time of listing the patient for surgery. CONCLUSION: In the context of limited critical care resources, variation in practice and difficulty in accurately predicting which patients will require post-operative critical care beds, a review and consensus on best practice in the peri-operative management of high risk paediatric adenotonsillectomy patients may offer a safe means of reducing cancellations and improving patient care, resource allocation and hospital efficiency.

Ancient schwannoma of the cervical sympathetic chain.

Ancient schwannomas exhibit characteristic histological features. Fine-needle aspiration cytology (FNAC) is of limited use. Radiological evidence demonstrating displacement of blood vessels may aid diagnosis of schwannoma. Malignant transformation of ancient schwannoma has been reported. Surgical excision carries a high risk of postoperative Horner's syndrome.

Presentation of Mycobacterium abscessus infection following rhytidectomy to a UK plastic surgery unit.

We report the presentation of a patient to a UK plastic surgery unit with Mycobacterium abscessus infection following a facelift surgery in Southern India. Treatment was protracted requiring surgical debridement and 6 months of antibiotics including a 3-week hospital admission for intravenous antibiotic therapy. We describe the clinical presentation, diagnosis and treatment of this unusual microorganism with reference to more familiar pyogenic infections.

Paradoxical air embolism and neurological insult during removal of a pulmonary artery catheter introducer.

A 54-year-old man was admitted to the intensive care unit following cardiac surgery. On day 6 postoperatively, approximately 2-3 min following the removal of the pulmonary artery (PA) catheter introducer sited in the right internal jugular vein, the patient became agitated, confused and then unresponsive. He was urgently moved onto the bed, laid supine, sedated with a propofol infusion, intubated and mechanically ventilated. A bedside transthoracic echocardiogram revealed extensive multiple air emboli in all cardiac chambers and review of the patient's intraoperative imaging confirmed the presence of patent foramen ovale (PFO). The following morning, sedation was discontinued and the trachea extubated. The patient was later transferred to the ward and then discharged home with no evidence of neurological deficit. This case reminds us of the importance of strict adherence to safety protocols when manipulating centrally positioned catheters and the high prevalence of undiagnosed PFO.

Extracellular fluid volume in patients with cancer.

AIMS: Cancer patients may have extracellular fluid volume (ECV) abnormalities that potentially invalidate glomerular filtration rate (GFR) measured using the slope-intercept technique. The aim was to test this concern by measuring ECV in cancer patients in comparison with noncancer patients and healthy kidney donors. METHODS: GFR was measured with Cr-EDTA and the slope-intercept technique in patients from two hospitals, the first using three samples (540 adults, including 382 with cancer, and 124 children, including 40 with cancer) and the second using four samples (256 adults, including 132 with cancer and 75 donors), scaled to body surface area (BSA) of 1.73 m and corrected using Brochner-Mortensen's equations (GFR/BSA). GFR/ECV was measured from the exponential rate constant with an appropriate one-compartment correction. ECV/BSA was calculated as the quotient, GFR/BSA:GFR/ECV. ECV was also expressed in adults in relation to lean body mass and in children as a fraction of ECV estimated from height and weight (eECV). RESULTS: In men from both centres, neither ECV/BSA nor ECV/lean body mass showed an increase in cancer patients. In women from both centres, however, they were both significantly higher in cancer patients than in noncancer patients and, in centre 2, than in donors. In children from centre 1, ECV/BSA, but not ECV/eECV, was significantly higher in cancer patients. CONCLUSION: ECV is expanded in female cancer patients but not male cancer patients. ECV may be expanded in children with cancer but the recorded difference in ECV/BSA is probably related to differences in patient size and a nonproportionate relationship between ECV and BSA.