How we do it: A novel approach to the skin--abutment interface of the bone-anchored hearing aid: use of local skin flaps.

Various techniques involving skin grafts have been described to obtain thin hairless immobile skin at the abutment interface of the bone-anchored hearing aid (BAHA), but none are without significant complications such as necrosis and/or infection leading to total graft failure. A novel technique involving four local thin skin flaps was developed to prevent serious complications. The procedure essentially involves raising skin flaps at the intradermal level leaving the hair follicles in the subcutaneous tissue, which is subsequently excised. We have used the skin-flap approach around 21 BAHAs on 19 patients (two patients had bilateral devices) and the only complications were minor skin loss immediately adjacent to the implants in two patients and mild skin infections, which settled with topical antibiotics, in three patients. The innovative technique described is simple and straightforward, and does not require any special instrumentation. Furthermore, it may have specific advantages, in terms of morbidity, over contemporary skin grafting methods primarily because of the retained intrinsic blood supply of the skin flaps.

Keratosis obturans and external ear canal cholesteatoma: how and why we should distinguish between these conditions.

Keratosis obturans and external ear canal cholesteatomas have been considered as separate entities for the last 20 years, after being regarded as variations of the same disease for at least 87 years. While both disorders are distinct, they do have some overlapping characteristics which may make it difficult to reach a definite diagnosis. This review explores the diagnostic dilemmas which may arise, and discusses the classification, aetiology, pathogenesis and management of these conditions. We concur that external ear canal cholesteatoma and keratosis obturans are different conditions and conclude that the presence of osteonecrosis and focal overlying epithelial loss are the most reliable features favouring the diagnosis of external ear canal cholesteatoma over keratosis obturans. Furthermore, whilst keratosis obturans can be managed successfully by regular aural toilet, external ear canal cholesteatoma may require surgical intervention depending on the extent of the disease.

Intranasal schwannoma in a young woman.

A rare case of a schwannoma arising from the middle meatus in a 24-year-old woman is reported. The patient presented with a 12-month history of right-sided nasal obstruction, rhinorrhoea, anosmia, headache and recurrent minor nosebleeds. Examination of the right nasal cavity revealed a polypoidal mass. Computerised tomography showed the mass completely occluding the nasal passage with evidence of a secondary maxillary sinusitis. She underwent a complete intranasal excision of the polypoidal mass which was arising from the right middle meatus. The histological features of the lesion were consistent with a schwannoma including diffuse immunoreactivity for S-100 protein. This case illustrates the need to consider schwannoma, amongst many other lesions, in the differential diagnosis of a unilateral nasal mass and reinforces the established principle of sending all material removed from the nose for histological examination.

A rare case of a pedunculated lipoma in the pharynx.

While lipomas on the trunk and limbs are common, they are rare in the upper aerodigestive tract. A case is reported of an 18 cm long pedunculated lipoma arising from the hypopharynx in a 73 year old man. The tumour was asymptomatic until it appeared in the mouth of the patient after a coughing episode.

Extraluminal migration of a coin in the oesophagus of a child misdiagnosed as asthma.

Ingestion of a foreign body, the commonest being a coin, is a common problem in children. In most cases the coin will pass uneventfully through the gastrointestinal tract. However, on rare occasions it may become lodged in the oesophagus with subsequent extraluminal migration with the potential for serious complications such as vascular fistula or chronic suppurative infection. A case is presented of extraluminal migration of a coin in the oesophageal associated with abscess formation in a 15 month old boy. This case is particularly important because the presenting symptom of wheezing led to the erroneous diagnosis of asthma, which resulted in a three month delay in investigation and treatment. In addition, it raises the issue of whether to perform chest radiography on newly diagnosed asthmatic patients to rule out the presence of a foreign body and thereby prevent serious complications.

Effect of bombesin on core temperature in rats: studies involving radiotelemetry.

The effect of centrally administered bombesin on core temperature was investigated in rats which had been chronically fitted with a cannula in the third cerebral ventricle and with an intraperitoneal temperature-monitoring radiotransmitter. Intracerebroventricularly administered bombesin (0.01, 0.1 or 1 microgram) resulted in hypothermia, the duration and depth of the effect being a function of the dose. The use of telemetry minimized experimental interventions in this study; the results demonstrate that the hypothermic response to bombesin is not dependent upon exposure to a low ambient temperature, food restriction or insulin treatment as suggested by previous studies involving measurement of core temperature by a rectal probe.