Myasthenia gravis presenting during general anaesthesia for oesophagoscopy--a cautionary tale.

We report myasthenia gravis presenting as dysphagia of acute onset in a 56-year-old female who had no other stigmata of the disease and who was generally well despite rheumatoid arthritis and hypothyroidism. She recovered respiratory function following a general anaesthetic for oesophagoscopy only when antimyasthenic treatment was instituted. She remains well to date. In patients who are known to have autoimmune diseases and who present with dysphagia, features of myasthenia gravis should be specifically sought.

Glossopharyngeal schwannoma presenting as gagging dysphagia.

A case of cervical glossopharyngeal schwannoma presenting with gagging dysphagia is presented. Treatment was by total excision of the schwannoma following which the patient made a good recovery. To our knowledge, this is the first report of gagging dysphagia associated with a glossopharyngeal schwannoma.

Obstructive sleep apnoea in children undergoing routine tonsillectomy and adenoidectomy.

Sleep screening was used to discover the incidence of sleep apnoea in 50 children undergoing routine adenotonsillectomy for recurrent upper respiratory tract infections, randomly selected from the waiting list. Preoperative assessment included a detailed parental history, physical examination, and lateral cephalometry, in order to identify factors that might alert the clinician to a diagnosis of obstructive sleep apnoea. There were 2 equal groups of snorers and non-snorers (grade 0); 1 patient was found to have the sleep apnoea syndrome (IV), 9 patients had obstructive snoring with apnoeic episodes (III), 3 patients had snoring with a disrupted sleep pattern (II), and 12 patients snored with no disruption of sleep (I). In identifying patients with apnoea, a history of snoring was unhelpful, whereas one of breathing irregularities was found to be highly specific. Nasal obstruction correlated poorly; however, there was a significant relationship between tonsillar position and size and sleep grade (Chi-squared P less than 0.01). Stepwise regression analysis showed a large contribution to the grading was made by the size of the oropharyngeal airway measured by lateral cephalometry. The children in grade II-IV were re-studied 3 months post-operatively and all reverted to grades 0 or I.

Assessment of chronic snorers.

Snorers represent a heterogenous group that require adequate assessment before recommending surgical treatment. There are unfortunately no specific features either in the history or physical examination that might predict those chronic snorers with obstructive sleep apnoea. We have used trained observation together with pulse oximetry ('sleep screening') and fibreoptic nasendoscopy with Muller manoeuvre in our unit to assess snorers. This combination is a reliable means of distinguishing apnoeic patients from simple snorers and determining the level of the obstructing segment. We report our experience in using these methods in the management of 71 chronic snorers. We stress the value of conservative management, and emphasize that obesity, habitual alcohol ingestion and nasal obstruction should be corrected before embarking on pharyngeal surgery.

Direct in vivo evidence for mast cell degranulation during allergen-induced reactions in man.

There is little or no direct in vivo evidence in man to support the involvement of mast cell-mediator release in the pathogenesis of immediate allergic reactions. We have performed a within-subject controlled study to determine the changes that occur in nasal mast cells during allergen-induced rhinitis. Twelve subjects with asymptomatic rhinitis were studied. Nasal biopsy specimens were obtained from each subject after a control solution (isotonic saline, 0.9% w/v) had been nebulized into one nostril and allergen solution (freeze-dried allergen extract reconstituted with isotonic saline) into the other. The tissues obtained were fixed in Carnoy's solution and stained with the alpha-naphthol AS-D chloroacetate esterase reaction (N AS-D CA ER). Mast cells were counted under light microscopy in the epithelium and lamina propria, and the integrity of each cell was assessed. No significant differences were found in the number of epithelial or lamina propria mast cells in biopsy specimens obtained after saline or allergen administration. However, the number of degranulated mast cells after allergen provocation (89%) was significantly greater than after instillation of control solution (15%) (p = 0.003). Changes of mast cell degranulation after allergen provocation were confirmed by electron microscopy. In six nonatopic, control subjects without rhinitis, there was no significant difference between the percentages of degranulated mast cells after allergen provocation (25.8%) and instillation of saline (24.3%). This study provides direct in vivo evidence for allergen-induced mast cell activation in man.