Does synchronous nasal surgery increase the risk of post-operative haemorrhage in adult patients undergoing tonsillectomy?

Otolaryngologists occasionally perform simultaneous procedures on their patients, the indication being co-existent pathology. This is not a universally accepted practice as some feel that the post-operative morbidity is increased in such patients. Tonsillectomy is a common otolaryngological procedure and the main life-threatening complication, haemorrhage is easily identifiable. This study compares the incidence of post-operative haemorrhage requiring admission in patients undergoing tonsillectomy alone with that in patients undergoing tonsillectomy and nasal surgery. A retrospective study was undertaken of all adult patients undergoing tonsillectomy alone or tonsillectomy and synchronous nasal surgery in Aberdeen Royal Infirmary. Seventy-one patients (34 male) with a mean age of 23 years underwent tonsillectomy and synchronous nasal surgery over a nine-year period 1991-1999. The commonest nasal procedure was reduction of the inferior turbinates (in 48 cases). Three hundred and ninety-eight patients (131 male) with a mean age of 23 years underwent tonsillectomy alone over a nine-month period, July 1998 to April 1999. The incidence of post-tonsillectomy haemorrhage in the synchronous nasal surgery group was 12.7 per cent (9 out of 71) compared with four per cent (16 out of 398) in the tonsillectomy alone group (p <0.01, Chi-squared test). There was no difference in hospital stay between the two groups (mean two days). Synchronous nasal surgery increases the incidence of post-tonsillectomy haemorrhage.

The use of topical nasal anaesthesia before flexible nasendoscopy: a double-blind, randomized controlled trial comparing cophenylcaine with placebo.

The objective was to evaluate the necessity to use topical nasal anaesthesia before flexible nasendoscopy and to compare its use with placebo. The study was carried out using a double-blind randomized controlled trial, with three treatment arms, at the out-patient department at Raigmore Hospital, Inverness. The participants were 90 patients attending the otolaryngology out-patient department who required flexible nasendoscopy as part of their assessment. Each participant was randomized to one of three groups. Group 1 received cophenylcaine spray, group 2 received a placebo spray, and group 3 received no nasal preparation. Flexible nasendoscopy was carried out via a stated protocol and the patient's diagnosis and findings were discussed in the usual way. After the consultation, the patient filled in a questionnaire marking answers on a visual analogue scale. The main outcome measures were pain and overall unpleasantness of procedure. Patient anxiety and willingness to be examined again in the same way if necessary were also assessed. Ease of examination and quality of view were asked from the operator's perspective. The mean scores on a visual analogue scale showed the main outcome measures to be as follows. Pain score measured 1.7 for cophenylcaine, 2.1 for no spray and 2.2 for placebo. Overall unpleasantness scores were 2.0 for cophenylcaine, 1.9 for no spray and 2.4 for placebo. On a visual analogue scale of 0-10, none of these mean main outcome measures reached levels of significance. It was concluded that the use of cophenylcaine spray before flexible nasendoscopy does not give significant advantages over the use of no nasal preparation.

Lateral rhinotomy through nasal aesthetic subunits. Improved cosmetic outcome.

The traditional lateral rhinotomy incision described originally by Moure in 1902 has proved a versatile approach to the mid-facial skeleton. It is not, however, without its complications, particularly poor cosmesis due to depression of the nasofacial groove. In one series 10 per cent of patients developed wound complications. We present our modification of the lateral rhinotomy incision, that takes account of the nasal aesthetic subunits by placing the incision between the dorsal and side wall nasal subunits with extension inferiorly along the alar groove. From November 1994 to February 2001, a retrospective review of case notes showed that 20 patients underwent modified lateral rhinotomy incision for a variety of pathology. Ten cases were for transitional papilloma, nine for malignant disease and one for chronic osteitis of the maxilla and ethmoids post-trauma. Follow up ranged from two weeks to five years. In five cases we were able to preserve the bony piriform aperture without compromising the excision or exposure. We believe that preservation of the bony piriform aperture will further enhance the overall cosmesis and nasal function. No complaints related to the incision were recorded. Our experience with the modified lateral rhinotomy incision has been very satisfactory. It provides good exposure, a low complication rate and excellent cosmetic outcome without undue technical difficulty. It is our preferred incision for all surgery on the mid-facial skeleton and anterior skull base.

Z-meatoplasty technique in endaural approach mastoidectomy.

Creating an adequate meatoplasty is an important and integral part of a mastoidectomy. It allows ventilation of the ear canal but also provides for an easy access for visualizing and cleaning the mastoid cavity. There are numerous techniques for performing a meatoplasty. We describe our method of utilizing the endaural incision and superiorly based tympanomeatal flap incision to create an easy and effective Z-meatoplasty.

The use of toluidine blue gargles to aid the detection of impacted pharyngeal fish bones.

Fishbone impaction is a common clinical problem. In most cases careful examination pinpoints the impacted bone which can then be removed. If no bone is detected a distinction must be drawn between mucosal abrasion mimicking fishbone impaction and a fine or deeply impaled fishbone eluding detection. We present a new method that may be helpful in the detection of pharyngeal fishbones.

Complications after subfascial carpal tunnel release.

The two cases we report reiterate the dangers of performing a carpal tunnel release through a small transverse or longitudinal incision at the wrist crease. We concur with other authors that this method of carpal tunnel release has an unacceptably high complication rate, and its potential risks do not justify its use.

Impaired mobility: Guillain-Barré syndrome.

Guillain-Barré syndrome (GBS) is a complicated degenerative disorder which can be chronic or acute in nature. Its etiology is unclear although it has been associated with both cell- and humoral-mediated autoimmune mechanisms. Pathophysiologic effects of the disease include inflammation, demyelination of peripheral nerves, loss of granular bodies and degeneration of the basement membrane of the Schwann cell. This results in ascending paralysis and loss of cranial nerve function. Manifestations may be acute or chronic, and temporary or permanent, depending upon the degree of neuronal destruction. Due to the pervasive nature of GBS, nursing care is a challenge. Assessment of motor, respiratory and cardiac function is of key importance. Total care of the patient focuses on risks related to impaired mobility and ineffective airway clearance. Psychosocial care and patient education are also integral components of care.

Autonomic dysfunction and silent myocardial ischaemia on exercise testing in diabetes mellitus.

The incidence and mechanism of painless myocardial ischaemia on exercise testing in diabetic patients is not clear. Therefore, two studies were performed. Retrospectively, all exercise tests carried out in our hospital during the past 5 years were reviewed for silent ischaemia. Prospectively, diabetic patients with known or suspected coronary artery disease underwent autonomic function testing and a second exercise test. Of 1653 exercise tests reviewed, 247 were positive (ST depression greater than 0.1 mV). Of the 29 diabetic patients with positive tests 20 (69%) had painless ST depression, compared with 77 (35%) of the 218 non-diabetic patients (p less than 0.001). The diabetic patients with painful and painless ST depression were comparable for age, sex, therapy, but the 20 with no pain on exercise testing had a longer duration of diabetes and a higher incidence of microvascular complications than the 9 with pain (70 vs 22%, p less than 0.05). In the prospective study, 12 of 30 diabetic patients with positive exercise tests had pain in association with ST depression and 18 had no pain. Six patients had mild and 12 severe autonomic neuropathy on formal testing. Twelve had no autonomic dysfunction. Eleven (92%) of 12 patients with severe neuropathy had painless ST depression, compared with 7 (39%) of 18 without severe neuropathy (p less than 0.01). Thus, silent myocardial ischaemia on exercise testing is common among patients with diabetes mellitus and is associated with severe autonomic dysfunction.

Does beta adrenergic blockade influence the prognostic implications of post-myocardial infarction exercise testing?

The influence of beta blockade on the ability of ST depression, during pre-discharge exercise testing, to predict coronary anatomy and subsequent complications was studied in 300 consecutive post-infarct patients, 125 of whom underwent cardiac catheterisation. At the time of exercise 62 patients were taking a beta blocker. The exercise test had a higher sensitivity in predicting multivessel disease in patients who were not taking beta blockers than in patients who were (95% v 76%). beta Blockade did not, however, influence the ability of the test to identify patients at risk of subsequent cardiac events (sensitivity 84% and 85% respectively). These results suggest that it is not necessary to stop treatment with beta blockers before predischarge exercise testing of patients who have had an acute myocardial infarction.

A randomized trial of the efficacy and acceptability of a pen injector.

A controlled trial of pen injection of insulin was performed in 78 patients, with assessment of metabolic control and lifestyle. After a 6-week run-in period, during which control was optimized, the patients were randomized, either to stay on a twice daily insulin regimen (n = 37), or to change to a three times daily pen regimen with human ultralente at night (n = 41). Over the 20 weeks, there was no significant change in mean glycosylated haemoglobin (syringe, mean +/- SD, 11.1 +/- 2.5% to 10.9 +/- 2.0%; pen, 11.3 +/- 2.6% to 11.2 +/- 2.0%), in blood glucose profiles or in frequency of hypoglycaemic attacks in either group. A self-completed questionnaire demonstrated high patient satisfaction with the pen injector (NovoPen), 78% for effect on lifestyle and 81% for increased flexibility. Ninety-five percent preferred the pen injector regimen to conventional treatment and stayed on it.

Which exercise test variables are of prognostic importance post-myocardial infarction?

The prognostic value of parameters noted on pre-discharge exercise testing was assessed in 300 survivors of acute myocardial infarction. Exercise testing was performed at a mean of 9 days post-infarction. Each patient's data were studied for the presence of ST-segment depression or elevation greater than or equal to 0.1 mV in any of the 12 leads recorded, angina pectoris, exertional hypotension and duration of exercise. The patients were followed for a mean of 12 months and the incidence of death, reinfarction, angina pectoris, heart failure and coronary revascularization procedures was noted. All variables studied, other than the presence of exercise-induced ST-segment elevation, were significantly associated with the occurrence of subsequent cardiac events (P less than 0.001). Exercise-induced ST-segment depression identified 80% of patients who developed complications and was significantly more sensitive than any of the other variables as a prognostic marker (P less than 0.05). The finding of angina pectoris, an abnormal blood pressure response or a limited exercise tolerance in association with exercise-induced ST-segment depression heightened the prognostic implications of this variable.

Does acute-phase beta-blockade reduce mortality in acute myocardial infarction by limiting infarct size?

The mechanism by which early intervention with beta-blockers reduces mortality in acute myocardial infarction is unclear. Therefore the effects of intravenous, followed by oral, metoprolol on indices of infarct size were studied in a double-blind fashion with a median delay of 6.75 hours from onset of symptoms. In 129 patients peak enzyme release and QRS score on the electrocardiogram were assessed, while myocardial perfusion score on thallium-201 scintigraphy was studied in 45 patients. There was a close correlation between all the indices of infarct size. While the correlation coefficients did not appear to be influenced by metoprolol treatment, the slope of the regression was affected. Peak aspartate aminotransferase and lactic dehydrogenase were lower by 11 and 7%, respectively, in the metoprolol-treated group, but no reduction was noted in QRS score or in thallium-201 perfusion defect size in the actively treated group. Thus, it seems likely that early intervention with metoprolol in acute myocardial infarction reduces mortality, not by limiting infarct size, but by some other mechanism.

Reciprocal change, exercise-induced ST segment depression and coronary anatomy: are they related in the post-infarct patient?

1. The relationship of reciprocal change on the electrocardiogram, at the time of acute myocardial infarction, to exercise-induced ST segment depression and coronary anatomy was studied in 125 post-infarct patients. 2. Eighty-three patients had reciprocal changes, 90 had exercise-induced ST depression and 72 had both of these findings. 3. Patients with reciprocal changes had larger myocardial infarctions, as assessed by peak enzyme release and ejection fraction, than patients without this finding. 4. Multi-vessel disease was significantly more common among patients with reciprocal changes and those with exercise-induced ST depression compared with patients without these findings. 5. The exercise test was more sensitive and had a higher predictive accuracy than reciprocal change when electrocardiographic changes were compared with findings at coronary angiography. 6. With both tests the antero-lateral leads were significantly more sensitive, but less specific, than the inferior leads in classifying patients. 7. Thus while both tests yielded information with regard to coronary anatomy in post-infarct patients, the exercise test was a better predictor of coronary anatomy than reciprocal change. 8. Therefore, reliance should not be placed on the presence or absence of reciprocal change alone when assessing patients for further investigation after myocardial infarction.

Plasma catecholamine levels in acute myocardial infarction: influence of beta-adrenergic blockade and relation to central hemodynamics.

In a prospective study, 20 patients with acute myocardial infarction were randomly assigned in a double-blind fashion to treatment with intravenous metoprolol followed by oral metoprolol or placebo. All patients underwent hemodynamic monitoring for 24 hours. Plasma adrenaline and noradrenalin levels were estimated at baseline (mean 6.0 +/- 0.9 hours from onset of symptoms) and at 1 and 24 hours after the start of therapy. Plasma adrenaline and noradrenalin levels were elevated in all but one patient, with a further increase at 1 hour after administration of metoprolol (p less than 0.05). At baseline pulmonary capillary wedge pressure was directly related to both plasma adrenaline (r = -0.44; p less than 0.05) and noradrenalin levels (r = -0.44; p less than 0.05). There was also an inverse relationship between stroke volume index and the plasma noradrenalin level (r = -0.44; p less than 0.05) but not the plasma adrenaline level. These relationships were lost after the baseline measurements. However, between baseline and 1 hour there was a close relationship between the change in systemic vascular resistance and the changes in both adrenaline (r = -0.48; p less than 0.05) and noradrenalin levels (r = -0.66; p less than 0.01). Thus, in the early stages of myocardial infarction high plasma catecholamine levels are associated with the hemodynamic markers of severe left ventricular damage. Beta-adrenergic blockade with metoprolol produced a further increase in catecholamine levels that was associated with an increase in systemic vascular resistance.