Child abuse and fabricated or induced illness in the ENT setting: a systematic review.

BACKGROUND: Child maltreatment is persistently under-recognised. Given that a third of maltreated children may return with serious or fatal injuries, it is imperative that otolaryngologists who are in frequent contact with children are able to detect maltreatment at first presentation. OBJECTIVE OF REVIEW: This review aims to identify ENT injuries, signs or symptoms that are indicative of physical abuse or fabricated or induced illness (child maltreatment). TYPE OF REVIEW: Systematic review. SEARCH STRATEGY: An all-language search, developed in Medline Ovid and consisting of 76 key words, was conducted of published and grey literature across 10 databases from inception to July 2015, for primary observational studies involving children aged <18 years. EVALUATION METHOD: Each relevant article underwent two independent reviews with full critical appraisal, applying strict quality standards. RESULTS: Of the 2448 studies identified and screened, 371 underwent full review, resulting in 38 included studies that detailed 122 maltreated children. Pharyngeal perforations (n = 20) were the most frequent abusive ENT injury, predominantly affecting neonates and infants, presenting with dysphagia, drooling, haemoptysis and surgical emphysema. At least 52% of children with abusive pharyngeal injuries had additional co-existent injuries. The majority of ear injuries were inflicted to the external ear (n = 11) and included auricular deformity, abrasions, petechiae, lacerations and burns. Fabricated or induced illness cases presented most commonly with recurrent, unexplained otorrhoea or ENT lesions that failed to heal despite appropriate therapy. CONCLUSIONS: All clinicians should be familiar with the signs of child maltreatment. Pharyngeal injuries, or injuries to the external ear, presenting in young children without an explicit history of witnessed injury should prompt a child protection referral for full evaluation. Likewise, children who present with recurrent, or apparently intractable symptoms and signs despite appropriate treatment, should raise the possibility of fabricated or induced illness, and discussion with a child protection specialist is advised. Early recognition of possible child maltreatment and instigation of appropriate safeguarding measures are essential to prevent repetition and escalation of injury. This is of paramount importance to otolaryngologists, who have the potential to identify these children in their practice.

Asthma characteristics and biomarkers from the Airways Disease Endotyping for Personalized Therapeutics (ADEPT) longitudinal profiling study.

BACKGROUND: Asthma is a heterogeneous disease and development of novel therapeutics requires an understanding of pathophysiologic phenotypes. The purpose of the ADEPT study was to correlate clinical features and biomarkers with molecular characteristics, by profiling asthma (NCT01274507). This report presents for the first time the study design, and characteristics of the recruited subjects. METHODS: Patients with a range of asthma severity and healthy non-atopic controls were enrolled. The asthmatic subjects were followed for 12 months. Assessments included history, patient questionnaires, spirometry, airway hyper-responsiveness to methacholine, fractional exhaled nitric oxide (FENO), and biomarkers measured in induced sputum, blood, and bronchoscopy samples. All subjects underwent sputum induction and 30 subjects/cohort had bronchoscopy. RESULTS: Mild (n = 52), moderate (n = 55), severe (n = 51) asthma cohorts and 30 healthy controls were enrolled from North America and Western Europe. Airflow obstruction, bronchodilator response and airways hyperresponsiveness increased with asthma severity, and severe asthma subjects had reduced forced vital capacity. Asthma control questionnaire-7 (ACQ7) scores worsened with asthma severity. In the asthmatics, mean values for all clinical and biomarker characteristics were stable over 12 months although individual variability was evident. FENO and blood eosinophils did not differ by asthma severity. Induced sputum eosinophils but not neutrophils were lower in mild compared to the moderate and severe asthma cohorts. CONCLUSIONS: The ADEPT study successfully enrolled asthmatics across a spectrum of severity and non-atopic controls. Clinical characteristics were related to asthma severity and in general asthma characteristics e.g. lung function, were stable over 12 months. Use of the ADEPT data should prove useful in defining biological phenotypes to facilitate personalized therapeutic approaches.

An evidence-based approach to the management of snoring in adults.

BACKGROUND: Snoring is frequently encountered by the otolaryngologist. Given its significant impact on quality of life and that it is a symptom of sleep-related breathing disorders, diagnosis and treatment are of major importance. In particular, the diagnosis should aim to distinguish between simple snoring and obstructive sleep apnoea. This article aims to provide a systematic, concise and evidence-based method of managing the adult patient with snoring. METHOD: This review was based on a literature search last undertaken on 30 June 2014. The MEDLINE, EMBASE and Cochrane databases were searched using the subject headings snoring and obstructive sleep apnoea in adults in combination with classification, diagnosis, investigations, management, treatment and surgery. Results were limited to English language articles including case series, clinical trials, randomised controlled trials, meta-analyses, systematic reviews and review articles. Relevant references from selected articles were also reviewed. RESULTS: The majority of published literature for snoring is of level II/III evidence and that for obstructive sleep apnoea being of level I/II, with 36 relevant randomised controlled trials identified. The diagnosis of obstructive sleep apnoea involves thorough clinical assessment and typically a sleep study. Snoring may be managed with lifestyle modification, intra-oral devices or by surgical intervention, with continuous positive airway pressure being the treatment of choice for moderate-to-severe obstructive sleep apnoea. CONCLUSIONS: A structured history of snoring and its associated symptoms, comprehensive examination including flexible laryngoscopy and sleep studies where relevant, in addition to targeted investigations, should lead to the correct diagnosis and appropriate management.

Left atrial appendage thrombus with resulting stroke post-RF ablation for atrial fibrillation in a patient on dabigatran.

Dabigatran etexilate is licensed for use in prevention of deep venous thromboembolism and in prevention of stroke and systemic embolism in nonvalvular atrial fibrillation (AF). It has also been used in patients for other indications as a substitute for warfarin therapy because it requires no monitoring; one group being patients undergoing radiofrequency (RF), ablation for AF, although there have been no consensus guidelines with regards to dosage and timing of dose. We report the case of a patient with documentary evidence of left atrial appendage (LAA) thrombus formation and neurological sequelae post-RF ablation despite being on dabigatran. This case highlights the concern that periprocedural dabigatran may not provide adequate protection from development of LAA thrombus and that a standardised protocol will need to be developed and undergo large multicentre trials before dabigatran can be safely used for patients undergoing RF-ablation.

12-minute consultation: an evidence-based approach to the management of dysphagia.

BACKGROUND: Dysphagia is frequently encountered by the otolaryngologist and due to its diverse aetiologies often poses a diagnostic challenge. Of particular importance in diagnosis is to distinguish between oropharyngeal and oesophageal dysphagia. This article aims to provide a systematic, concise and evidence-based method of managing the patient with dysphagia. METHOD: This review was based on a literature search last undertaken on 15 January 2013. The MEDLINE, EMBASE and Cochrane databases were searched using the subject heading dysphagia in combination with classification, diagnosis, investigations, management, treatment and surgery. Results were limited to English language articles including case series, clinical trials, randomised controlled trials, meta-analyses, systematic reviews and review articles. Relevant references from selected articles were also reviewed. RESULTS: The majority of published literature for dysphagia is of level II/III evidence, with 16 relevant randomised controlled trials identified. The clinical history is of paramount importance in delineating the cause of dysphagia. There is no significant difference regarding the diagnostic efficacy of fibreoptic endoscopic evaluation of swallowing compared to videofluoroscopy, and where indicated and practicable, these investigations complement each other. In general, structural causes of dysphagia are managed surgically, whereas swallowing therapy is efficacious in managing dysphagia due to neuromyogenic disorders. CONCLUSIONS: A structured history of dysphagia and its associated symptoms, flexible laryngoscopy and endoscopic assessment of swallowing where relevant in addition to targeted investigations should lead to the correct diagnosis and appropriate management.

Assessing the accuracy of tympanometric evaluation of external auditory canal volume: a scientific study using an ear canal model.

Tympanometric evaluation is routinely used as part of the complete otological examination. During tympanometric examination, evaluation of middle ear pressure and ear canal volume is undertaken. Little is reported in relation to the accuracy and precision tympanometry evaluates external ear canal volume. This study examines the capability of the tympanometer to accurately evaluate external auditory canal volume in both simple and partially obstructed ear canal models and assesses its capability to be used in studies examining the effectiveness of cerumolytics. An ear canal model was designed using simple laboratory equipment, including a 5 ml calibrated clinical syringe (Becton Dickinson, Spain). The ear canal model was attached to the sensing probe of a Kamplex tympanometer (Interacoustics, Denmark). Three basic trials were undertaken: evaluation of the tympanometer in simple canal volume measurement, evaluation of the tympanometer in assessing canal volume with partial canal occlusion at different positions within the model, and evaluation of the tympanometer in assessing canal volume with varying degrees of canal occlusion. 1,290 individual test scenarios were completed over the three arms of the study. At volumes of 1.4 cm(3) or below, a perfect relationship was noted between the actual and tympanometric volumes in the simple model (Spearman's ρ = 1) with weakening degrees of agreement with increasing volume of the canal. Bland-Altman plotting confirmed the accuracy of this agreement. In the wax substitute models, tympanometry was observed to have a close relationship (Spearman's ρ > 0.99) with the actual volume present with worsening error above a volume of 1.4 cm(3). Bland-Altman plotting and precision calculations provided evidence of accuracy. Size and position of the wax substitute had no statistical effect on results [Wilcoxon rank-sum test (WRST) p > 0.99], nor did degree of partial obstruction (WRST p > 0.99). The Kamplex tympanometer accurately and precisely assesses ear canal volume in the scientific model in both simple and partially occluded wax substitute scenarios up to a volume of 1.4 cm(3). These findings suggest that the Kamplex tympanometer could be used as an effective objective tool in evaluating the efficacy of topical cerumolytics in both laboratory and human models.

Ménière's disease clinical subtypes in a population from the USA.

OBJECTIVE: To ascertain the distribution of Ménière's disease phenotype subgroups in a US-based cohort, based on a recently introduced classification scheme utilising a Spanish and Portuguese cohort. METHODS: A retrospective, cross-sectional, single-institutional chart review was conducted. The electronic medical records of Ménière's disease patients were identified using International Classification of Diseases codes at a tertiary referral centre and reviewed to extract subgroup-defining features. Patients with definite Ménière's disease as per American Academy of Otolaryngology-Head and Neck Surgery criteria were categorised into one of five subgroups, for unilateral and bilateral Ménière's disease. RESULTS: Eighty-one patients with definite Ménière's disease were identified. Seventy-two cases of unilateral Ménière's disease were observed: 52.8 per cent were type 1, 20.8 per cent were type 2, 4.2 per cent were type 3, 18.1 per cent were type 4, and 4.2 per cent were type 5. This cohort differed significantly in distribution to a comparison Mediterranean cohort (p < 0.01). Nine cases of bilateral Ménière's disease were observed. CONCLUSION: The distribution of unilateral Ménière's disease subtypes in this US population was different from that observed in a European population.

An animal tissue simulation assessing three directional displacement forces on five common tracheostomy securing techniques.

Introduction Several methods of securing a tracheostomy tube have been described in the literature including using ties or tapes around the neck and suturing the plastic flange to the neck in various ways. However, there are no wet lab-based studies to objectively determine the force required to displace the tracheostomy tube using different securing techniques. Ours is the first animal tissue simulation study published in the literature. Methods A simulated tracheostomy stoma was created on a sheep neck model. A tracheostomy tube was inserted into the stoma and secured using various methods. Tension tests were conducted to significantly displace the tube from the stoma. Each technique was repeated six times on different sheep necks. All results were analysed using SPSS®. Results Repeat measurements indicated that the largest displacement forces come from an oblique direction while the lowest force values were found at the lateral angle. Averages of displacement showed that medially placed sutures required the largest forces in comparison with other securing methods. Wilcoxon signed-rank testing indicated that medial and continuous suture security resists displacement at forces that otherwise displace flange and interrupted sutures. Conclusions This study has shown that any type of securing suture requires a greater displacement force than the strap of the tracheostomy tube holder alone. Medially placed sutures require a greater displacement force than those placed laterally. Displacement in the lateral direction requires the least force in comparison with movement at perpendicular or oblique angles.

International survey and consensus (ICON) on ambulatory surgery in rhinology.

OBJECTIVES: Day-case surgery is the gold standard to several surgical procedures in Rhinology. However, few data and guidelines have been published except in the Anglo-Saxon countries and France. The aim of this survey was to propose a list of issues arising during day-case surgery in order to analyze the different constraints encountered around the world. MATERIAL AND METHOD: It was a prospective multicenter international email survey. The method was based on the formalized expert consensus methodology. A list of 11 issues was based on literature data and was sent by e-mail to 265 key opinion leaders (KOL) who attended the IFOS congress. RESULTS: The response rate was 20% from 27 countries without statistical difference between continents concerning the score on each item. The mean age of KOL was 50±10 years. Their mean length of experience was 21±10 years. Issues in relation with technical resources and experience showed that the last time at which ambulatory surgery in the day is possible was 4:00 PM but responses varied depending the availability of technical resources. Bleeding or hematoma occurred most frequently between the third and fourth postoperative day whatever the surgical procedure. A strong agreement and consensus was obtained concerning the nasal packing, septal contention and their schedule of removal which were not a contraindication of day-case. Also 75% of participants were agreeing with a therapeutic education program to improve the performance of postoperative care and decrease readmission rates. A relative agreement without consensus were obtained for the distance between the day-case unit and home, the role of surgery duration and the impact of anticoagulant and/or antiplatelet drugs in overnight admission and readmission rates. CONCLUSION: Practice varies widely owing to local organization constraints and the availability of a dedicated day-case unit seems to be the main limiting factor.

Aqueous seed extract of Hunteria umbellata (K. Schum.) Hallier f. (Apocynaceae) palliates hyperglycemia, insulin resistance, dyslipidemia, inflammation and oxidative stress in high-fructose diet-induced metabolic syndrome in rats.

ETHNOPHARMACOLOGICAL RELEVANCE: Hunteria umbellata is used in the management and treatment of diabetes and obesity in Nigeria. This study evaluates the effect of aqueous seed extract of Hunteria umbellata on insulin resistance, dyslipidemia, inflammation and oxidative stress in high-fructose diet-induced metabolic syndrome MATERIALS AND METHODS: Rats were randomized into seven groups (A-G). Control (group A) and group C rats received control diet for nine weeks while rats in groups B, D - G were placed on high-fructose diet for 9 weeks. In addition to the diets, groups C - F rats orally received 400, 100, 200 and 400mg/kg body weight aqueous seed extract of Hunteria umbellata for 3 weeks starting from 6th - 9th week. RESULTS: High-fructose diet (when compared to control rats) mediated a significant (p<0.05) increase in body weight, body mass index and abdominal circumference. Similarly, levels of blood glucose, insulin, leptin, adiponectin and insulin resistance were increased. It also caused a significant increase in the levels of cholesterol, triglycerides, low-density lipoprotein cholesterol, very low-density lipoprotein cholesterol, atherogenic index, cardiac index and coronary artery index while high-density lipoprotein cholesterol was decreased significantly. Levels of proinflammatory factor, tumour necrosis factor-α, interleukin-6 and 8 were also increased by the high fructose diet. Moreover, it mediated decrease in activities of superoxide dismutase, catalase, glutathione peroxidase, glutathione reductase, glucose 6-phosphate dehydrogenase and level of glutathione reduced. Conversely, levels of malondialdehyde, conjugated dienes, lipid hydroperoxides, protein carbonyl and fragmented DNA were elevated. Aqueous seed extract of Hunteria umbellata significantly ameliorated the high fructose diet-mediated alterations. CONCLUSIONS: From this study, it is concluded that aqueous seed extract of Hunteria umbellata possesses hypoglycemic, hypolipidemic and antioxidants abilities as evident from its capability to extenuate insulin resistance, dyslipidemia, inflammation and oxidative stress in high-fructose diet-induced metabolic syndrome rats.

Intracorneal hemorrhage secondary to aphakic contact lens wear.

Two cases of intracorneal hemorrhage developing as a complication of aphakic contact lens use are reported. Patient 1 had a penetrating keratoplasty to restore vision and therefore the histologic examination could be performed on the corneal button. In patient 2 the contact lens use was discontinued with partial resolution of the intracorneal hemorrhage and the patient then underwent a secondary intraocular lens implantation with good visual results.

Aboulia: neurobehavioural dysfunction of dopaminergic system?

Recent advances in the understanding of the neural substrates of goal-directed behaviour have created new interest in unlocking the mystery behind those disorders that are characterized by poverty of thought and action. In this review, various studies will be considered which proffer converging evidence that the dopaminergic brain circuitry running from ventral tegmental areas in the midbrain, via nucleus accumbens in the forebrain, to the frontal cortex, tends to produce aboulia when its restitutive function fails. Such aboulic deficits occur in various neurological and psychiatric disorders in which they have profound implications for the patients' management, rehabilitation and social interactions. We begin by examining the consequences of dopamine agonism and antagonism in pre-clinical studies and draw on the inferences that can be made from studies in humans. We then go on to discuss aboulic features in neuropsychiatric conditions, focusing on clinical manifestation, animal models, abnormal dopamine activity and pharmacological interventions.

Attitudes of Omani physicians to people with epilepsy.

OBJECTIVE: This study reports the results of a questionnaire design to elicit doctors views about epilepsy. METHODS: Sixty-two percent of medical staff working in different regions of Oman responded. The questionnaire covered certain topics regarding the source of the knowledge of the doctors on seizure disorders and the personalities and behavior of people with epilepsy. RESULTS: The study suggests that although doctors in Oman gained knowledge on epilepsy prior to medical education, more doctors judged people with epilepsy `negatively` compared to `positively` for normal people. CONCLUSION: A developing country such as Oman needs to inculcate perceptions and attitude that are more realistic amongst their doctors toward people with epilepsy.

Pediatric ocular injuries from airsoft toy guns.

PURPOSE: To report ocular injuries caused by airsoft guns in children. METHODS: A retrospective chart review of pediatric patients who sustained ocular injuries related to airsoft guns between November 2005 and December 2007. Place of trauma, presenting symptoms and signs, surgical interventions performed, and final visual outcome were reviewed. RESULTS: Thirty-two patients with a mean age of 8.8 ± 4.0 years (range: 1.5 to 18 years) were examined; 28 were boys (87.5%). Presenting visual acuity ranged from hand motions to 20/20 and could not be assessed in 2 patients. Hyphema was a common finding that was present in 24 cases, corneal abrasions were present in 10 cases, and raised intraocular pressure was present in 7 cases. Seven patients presented with traumatic cataract, and two had iridodialysis. Immediate surgical intervention was performed in 7 patients and 7 patients were scheduled for elective surgery. The patients presented after an average of 1.9 ± 1.9 days (range: 4 hours to 6 days) after the injury. Average follow-up was 18 days (range: 7 days to 5 months). Final visual acuity was 20/200 or worse in 5 patients, 20/40 or better in 23 patients, and could not be assessed in 2 cases. CONCLUSION: Airsoft guns can cause a variety of serious injuries, sometimes necessitating operative intervention. The long-term morbidity from some of these injuries is significant. Airsoft guns are capable of inflicting serious and permanent ocular damage.

Bacterial and fungal endophthalmitis in upper Egypt: related species and risk factors.

OBJECTIVE: To study risk factors, contributing factors of bacterial and fungal endophthalmitis in Upper Egypt, test the isolated species sensitive to some therapeutic agents, and to investigate the air-borne bacteria and fungi in opthalmology operating rooms. METHODS: Thirty one cases of endophthalmitis were clinically diagnosed and microbiologically studied. Indoor air-borne bacteria and fungi inside four air-conditioned operating rooms in the Ophthalmology Department at Assiut University Hospitals were also investigated. The isolated microbes from endophthalmitis cases were tested for their ability to produce some extracellular enzymes including protease, lipase, urease, phosphatase and catalase. Also the ability of 5 fungal isolates from endophthalmitis origin to produce mycotoxins and their sensitivity to some therapeutic agents were studied. RESULTS: Results showed that bacteria and fungi were responsihle for infection in 10 and 6 cases of endophthalmitis, respectively and only 2 cases produced a mixture of bacteria and fungi. Trauma was the most prevalent risk factor of endophthalmitis where 58.1% of the 31 cases were due to trauma. In ophthalmology operating rooms, different bacterial and fungal species were isolated. 8 bacterial and 5 fungal isolates showed their ability to produce enzymes while only 3 fungal isolates were able to produce mycotoxins. Terbinafine showed the highest effect against most isolates in vitro. CONCLUSIONS: The ability of bacterial and fungal isolates to produce extracellular enzymes and mycotoxins may be aid in the invasion and destruction of eye tissues. Microbial contamination of operating rooms with air-borne bacteria and fungi in the present work may be a source of postoperative endophthalmitis.