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.

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.

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.

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.

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.

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.

Variable degree of liver involvement in siblings with PiZZ alpha-1-antitrypsin deficiency-related liver disease.

PiZZ alpha-1-antitrypsin deficiency is the commonest genetic cause of chronic liver disease, but only 10-15% of PiZZ individuals develop liver disease in childhood. Studies have demonstrated varying patterns of disease progression within siblings with the PiZZ phenotype. We retrospectively analysed the case-notes of all patients diagnosed with PiZZ A1ATD between 1978-2002 and compared the pattern of liver disease between affected siblings. We identified 29 families with more than 1 child with the PiZZ phenotype. Twenty-one (72%) PiZZ siblings of the 29 probands had liver disease, which was concordant for severity in 6 (29%), while 8 (28%) had no liver involvement. Five of 7 children requiring liver transplantation had siblings with no persistent liver dysfunction. This study suggests that there is a variable degree of liver involvement in siblings with PiZZ A1ATD-related liver disease and environmental and/or other genetic factors must be involved in determining disease severity.

Glycosylated hemoglobin and lipoproteins in patients with premature hair grayness.

OBJECTIVES: The aim of this study was to estimate glycosylated hemoglobin, fasting blood sugar and lipid profile in patients with premature grayness of hair. METHODS: This study was carried out from October 1999 and May 2000, at the Dermatology and Venereology Outpatient Clinic of Baghdad Teaching Hospital, Iraq. Sixty patients with premature grayness of hair and 20 healthy individuals were included in this study. The levels of glycosylated hemoglobin, fasting blood sugar, serum triglyceride, total serum cholesterol, high-density lipoprotein-cholesterol, and atherogenic index were assessed for both patients and control. RESULTS: The mean level of glycosylated hemoglobin in patients with premature grayness of hair was 4.84 +/- 0.46, and the mean level of fasting blood sugar in patients with premature grayness of hair was 83.25 +/- 8.67. Both these parameters were significantly higher in patients with premature grayness of hair than that of the control. Also, it was found that these parameters were positively correlated to the severity of the disease. The level of high-density lipoprotein-cholesterol was significantly lower in patients with premature grayness of hair compared to control. CONCLUSIONS: The discovery of elevated glycosylated hemoglobin in patients with premature grayness of hair was similar to what has been reported in diseases with possible auto-immune etiology such as vitiligo. These changes together with the well-documented association between premature grayness of hair and autoimmune diseases can support the autoimmune etiology of premature grayness of hair.

Solvation descriptors for the polychloronaphthalenes: estimation of some physicochemical properties.

Solvation descriptors for the 75 polychloronaphthalenes have been derived from literature data on various properties. These descriptors (S, the dipolarity/polarizability; B, the hydrogen bond basicity; L, the logarithm of the gas-hexadecane partition coefficient; E, the excess molar refraction; V, the McGowan volume) have been used to estimate properties that may be environmentally relevant. Thus, for all 75 polychloronaphthalenes, we estimate values for the water-octanol partition coefficient, as log POCT, the aqueous solubility, as log S, the gas-water partition coefficient, as log KW, and the gas-dry octanol partition coefficient, as log KOCT. We further show that it is trivial to estimate other properties for all 75 polychloronaphthalenes; these properties include a number of gas-solvent and water-solvent partitions, air-plant and water-plant partitions, and permeation of human skin from water.

A case of bilateral ptosis with unsteady gait: suggestibility and culture in conversion disorder.

We report a case of a 14-year-old girl who presented, following a sudden onset, with bilateral ptosis, gait disturbance, difficulty swallowing and loss of appetite, right hypochondriacal pain, and frontal headache. Protracted neurological and medical examinations were unremarkable; neither was precipitating psychological stresses evident. The condition, which manifest as typical conversion disorder, lasted for one year. "Treatment" involving electrical stimulation of both eyes muscles and legs with positive reassurance resolved the symptom. This case supports the view that conversion disorder, not only involves a strong element of suggestion, but also incorporates socio-cultural sanctioned prescription.

Psychosocial aspects of epilepsy in Oman: attitude of health personnel.

PURPOSE: To assess with a questionnaire the awareness and attitudes of the doctors in Oman toward epilepsy. Attitudes of society toward epilepsy have a wide-ranging influence, affecting issues as diverse as compliance with treatment and doctor--patient communication. Recent studies in both developing and developed countries suggest that within the medical profession, there is a lack of knowledge and negative attitudes toward people with epilepsy (PWE). There are no equivalent studies for Oman or the Arab world. METHODS: The questionnaire included queries on the backgrounds of the physicians, including their training and qualifications, the main sources of their knowledge of epilepsy, as well as their perceptions of the attributes and care requirements of PWE. RESULTS: Sixty-two percent (n=121) of those questioned, who were medical personnel working in different regions of Oman, responded. The results suggest that, despite coming from diverse cultural backgrounds and nationalities, the practicing doctors in Oman gained knowledge of epilepsy much earlier than did their counterparts in developed countries. The majority of the respondents thought that PWE have more propensities toward dysfunctional personality and behavioral characteristics than do "normal" people. On questions relating to public image, our respondents opined that, although the general public is negative toward PWE, the realities regarding PWE should be publicized because PWE are capable of having a normal family life and being an integral part of society. CONCLUSIONS: In spite of having an earlier exposure to seizures and sympathetic acceptance of PWE, negative views still persist on matters related to cognitive and behavior domains. It is concluded that a developing country such as Oman must inculcate more realistic perceptions and attitudes among their doctors toward PWE.

Vipassana meditation:: A naturalistic, preliminary observation in Muscat.

OBJECTIVES: To assess the effects of Vipassana meditation on the physical and psychological health in a multi-ethnic population in the city of Muscat. METHOD: The subjects were participants of a Vipassana meditation course taught in a ten-day residential retreat. Self-assessments of health-related parameters and physical and psychological symptomatology were collected from them before and immediately after the course. A control group was tested for a similar time interval. RESULTS: Immediately after their 10-day training, the Vipassana participants assessed themselves significantly higher compared to their levels prior to the course, suggesting that the 10 days' practice had significantly improved their physical and psychological well-being. The control group did not exhibit such changes. CONCLUSION: The present preliminary findings, juxtaposed with the results of studies from other parts of the world, suggest that the practice of Vipassana meditation may help mitigate psychological and psychosomatic distress.