Blunt neck trauma at a level I trauma centre: six-year retrospective case note review.

BACKGROUND: Blunt neck trauma can cause serious morbidity and mortality rates of up to 40 per cent, but there is a paucity of literature on the topic. METHOD: A retrospective case note review was performed for all blunt neck trauma cases managed at the Queen Elizabeth Hospital Birmingham between 1st January 2011 and 31st December 2017. RESULTS: Seventeen cases were managed, with no mortality and limited morbidity. Most patients were male (70.6 per cent) and road traffic accidents were the most common cause of injury (41.2 per cent). The median age of patients was 40.6 years (range, 21.5-70.3 years). Multidetector computed tomography angiography of the neck was performed in 9 patients (52.9 per cent) with 'hot' reports made by on-duty radiology staff matching consultant reports in all but 1 case. Six patients underwent operative exploration yielding a negative exploration rate of 33.3 per cent. Imaging reports matched operative findings in 3 cases (60 per cent). CONCLUSION: Blunt neck trauma is uncommon but usually presents in polytrauma. Imaging has inaccuracies when compared with operative findings, regardless of radiological experience.

Litigation trends and costs in otorhinolaryngology.

BACKGROUND: Litigation in surgery is increasing and liabilities are becoming unsustainable. This study aimed to analyse trends in claims, and identify areas for potential risk reduction, improved patient safety and a reduction in the number, and cost, of future claims. METHODS: Ten years of retrospective data on claims in otorhinolaryngology (2003-2013) were obtained from the National Health Service Litigation Authority via a Freedom of Information request. Data were re-entered into a spreadsheet and coded for analysis. RESULTS: A total of 1031 claims were identified; of these, 604 were successful and 427 were unsuccessful. Successful claims cost a total of £41 000 000 (mean, £68 000). The most common areas for successful claims were: failure or delay in diagnosis (137 cases), intra-operative problems (116 cases), failure or delay in treatment (66 cases), failure to warn - informed consent issue (54 cases), and inappropriate treatment (47 cases). CONCLUSION: Over half of the claims in ENT relate to the five most common areas of liability. Recent policy changes by the National Health Service Litigation Authority, over the level of information divulged, limits our learning from claims.

Initial experience of a rapid-insertion bone-anchored hearing system: series of 20 consecutive implants.

Objective: The loading of bone-anchored hearing system sound processors usually occurs two to three months after surgical implant. This study examined a new bone-anchored hearing system coupling mechanism that permits loading at two weeks post-implantation without compromising osseointegration. Methods: Twenty implants were implanted into 15 patients. The interval between operation and time of processor loading was recorded, along with the cause of any delay and any late complications. Results: Two patients were fitted with implants at seven and nine weeks. The delay was a result of administrative errors; the patients reported no skin problems. Of the remaining 17 implants, 8 processors were fitted at 2 weeks, 1 at 3 weeks, 4 at 4 weeks, 3 at 7 weeks and 1 at 8 weeks. For those nine implants fitted later than two weeks, the delay was because of incomplete skin healing. Conclusion: The Oticon Medical Xpress system allowed processor loading at two weeks post-operatively, providing skin healing was adequate. Early loading occurred in approximately half of the patients. All patients were fitted within the two to three months traditionally allowed. Prolonged skin healing time was the main reason for the delayed fitting of sound processors.

A smart micro-drill for cochleostomy formation: a comparison of cochlear disturbances with manual drilling and a human trial.

BACKGROUND: Cochleostomy formation is a key stage of the cochlear implantation procedure. Minimizing the trauma sustained by the cochlea during this step is thought to be a critical feature in hearing preservation cochlear implantation. The aim of this paper is firstly, to assess the cochlea disturbances during manual and robotic cochleostomy formation. Secondly, to determine whether the use of a smart micro-drill is feasible during human cochlear implantation. MATERIALS AND METHODS: The disturbances within the cochlea during cochleostomy formation were analysed in a porcine specimen by creating a third window cochleostomy, preserving the underlying endosteal membrane, on the anterior aspect of the basal turn of the cochlea. A laser vibrometer was aimed at this third window, to assess its movement while a traditional cochleostomy was performed. Six cochleostomies were performed in total, three manually and three with a smart micro-drill. The mean and peak membrane movement was calculated for both manual and smart micro-drill arms, to represent the disturbances sustained within cochlea during cochleostomy formation. The smart micro-drill was further used to perform live human robotic cochleostomies on three adult patients who met the National Institute of Health and Clinical Excellence criteria for undergoing cochlear implantation. RESULTS: In the porcine trial, the smart micro-drill preserved the endosteal membrane in all three cases. The velocity of movement of the endosteal membrane during manual cochleostomy is approximately 20 times higher on average and 100 times greater in peak velocity, than for robotic cochleostomy. The robot was safely utilized in theatre in all three cases and successfully created a bony cochleostomy while preserving the underlying endosteal membrane. CONCLUSIONS: Our experiments have revealed that controlling the force of drilling during cochleostomy formation and opening the endosteal membrane with a pick will minimize the trauma sustained by the cochlea by a factor of 20. Additionally, the smart micro-drill can safely perform a bony cochleostomy in humans under operative conditions and preserve the integrity of the underlying endosteal membrane.

Bismuth iodoform paraffin paste hypersensitivity reactions in mastoid cavities following isolation of mucosal lining: a series of 587 patients.

AIM: (1) To assess hypersensitivity to bismuth iodoform paraffin paste impregnated ribbon gauze following its use in packing canal wall down mastoidectomy cavities; (2) to determine if isolation of the skin and mucosa from the pack, using thin Silastic sheeting and Cortisporin ointment, reduces hypersensitivity reactions, compared with a previous series; and (3) to review the literature and to determine if bismuth iodoform paraffin paste hypersensitivity precludes the consumption of seafood (due to its high iodine content). MATERIALS AND METHODS: All patients undergoing canal wall down mastoidectomy with intra-operative bismuth iodoform paraffin paste packing between 1985 and 2009 were identified and reviewed. RESULTS: Of 587 patients identified, the overall bismuth iodoform paraffin paste reaction rate was 1 per cent. All reactions were in patients undergoing revision mastoidectomy procedures, giving a reaction rate for revision procedures of 2.4 per cent. CONCLUSION: Reactions are an uncommon event following post-operative mastoid cavity packing using bismuth iodoform paraffin paste. Reaction rates may be lowered by preparing the cavity with Silastic sheeting and Cortisporin ointment prior to packing, thus isolating the skin and mucosal surfaces. Development of such a reaction does not preclude the consumption of seafood.

Robotics can lead to a reproducibly high-quality operative result for ear, nose, and throat patients.

The success rates and morbidity of operations on the ear, nose, and throat (ENT) have improved markedly in the last 20-25 years. This has been largely due to improved vision, by microscopes and endoscopes, and has led to a greatly reduced hospital stay. During this time there has been minimal improvement in surgical tools. This paper discusses the need for robotic tools, detailing the clinical constraints that proposed solutions need to adhere to, and presenting a recently trialled micro drilling robot for creating a cochleostomy in the cochlear implant procedure.

The effect of operating time on surgeons' muscular fatigue.

INTRODUCTION: A study was completed to determine if operating has an effect on a surgeon's muscular fatigue. SUBJECTS AND METHODS: Six head and neck surgery consultants, two ENT registrars, 20 normal controls from two tertiary referral centres in the West Midlands participated in the study. Electromyography (EMG) measurements were taken throughout a day of operating and fatigue indices were compared to controls performing desk work. RESULTS: The percentage changes in mean frequency of muscular contractions were examined; there was no significant difference in fatigue levels between consultants and registrars. Operating led to an increase in fatigue in all subjects, compared to no increase in controls performing desk work. It was also found that the brachioradialis muscle is used more than the mid-deltoid muscle and, hence, fatigues at a faster rate. CONCLUSIONS: Surgeons should be aware that their muscular fatigue levels will increase as an operation progresses; therefore, if possible, more complex parts of the operation should be performed as early as possible, or, in the case of a very long operation, a change in surgeon may be necessary.

An autonomous surgical robot for drilling a cochleostomy: preliminary porcine trial.

OBJECTIVE: To produce an autonomous drilling robot capable of performing a bony cochleostomy whilst minimising the damage to the underlying cochlear endosteum. DESIGN: In this laboratory based study, a robotic drill was designed to measure the changes in force and torque experienced by the tool point during the drilling process. This information is used to predict the point of breakthrough and stop the drill prior to damaging the underlying endosteal membrane. SETTING: Aston University. PARTICIPANTS: Five porcine cochleas. MAIN OUTCOMES MEASURES: An assessment was made of whether a successful bony cochleostomy was performed, the integrity of endosteal membrane was then assessed. RESULTS: The autonomous surgical robotic drill successfully performed a bony cochleostomy and stopped without damaging the endosteal membrane in all five cases. CONCLUSIONS: The autonomous surgical robotic drill can perform a cochleostomy whilst minimising the trauma to the endosteal membrane. The system allows information about the state of the drilling process to be derived using force and torque data from the tool point. This information can be used to effectively predict drill breakthrough and implement a control strategy to minimise drill penetration beyond the far surface.

Empty sella syndrome associated with a hyperfunctioning microadenoma invading the clivus.

The empty sella syndrome is usually associated with normal pituitary function. If dysfunction is present, this is commonly hypofunction. Hyperfunctioning microadenomas have been described in the presence of the empty sella syndrome. We present the first reported cases of a microadenoma invading the clivus associated with an empty sella.

ENT challenges at the small scale.

BACKGROUND: In this paper we consider two relatively frequently performed operations in the field of ear, nose and throat (ENT) surgery and consider how they could be improved by using robotic applications. We consider currently available robots and propose theoretical robotic solutions. METHODS: The application of robotic systems for both cochlear implantation and endoscopic sinus surgery was considered. Currently available robotic systems were reviewed and those with potential use in ENT surgery were identified. For aspects of operations where there is no available technology, hypotheses are presented on how robots could help. RESULTS: Three robotic systems were identified with potential usage in ENT: the Pathfinder neurosurgical robot, the Acrobot knee replacement system and the autonomous smart drill for drilling a cochleostomy. CONCLUSIONS: The challenge for the future of ENT is being able to perform tasks beyond the level of human perception and abilities. The examples presented here demonstrate that microtechnologies could be used to reduce complications, decrease operating time and improve clinical results.

Total serum IgE and IgE antibodies specific to house dust mite found in two aged-matched cohorts of children with and without otitis media with effusion.

OBJECTIVES: To determine whether otitis media with effusion (OME) is associated with elevated serum immunoglobulin E (IgE) and IgE specific for house dust mite. DESIGN: Forty-seven children who had evidence of bilateral OME, both otoscopically and on tympanometry, on two separate occasions, 3 months apart were admitted for ventilation tubes. Forty-eight children admitted for minor eye surgery who had otoscopically normal ears and no history of middle ear problems were used as controls. Bloods samples were taken under anaesthesia. Total IgE and IgE radioallergosorbent test (RAST) to house dust mite was measured by the Pharmacia Unicap 100 system. The results from the two groups were compared. SETTING: Birmingham Children's Hospital. PARTICIPANTS: Children between the ages of 3 and 10. Children with Down's syndrome, cleft lip and palate, ciliary abnormalities, known immunodeficiencies and cardiac abnormalities were excluded. MAIN OUTCOME MEASURES: Total IgE and RAST to house dust mite. A RAST of >0.35 was taken to be positive. RESULTS: There was no statistical difference between the control and study groups for the total IgE. Six children from both study and control groups had a raised house dust mite RAST. There was no difference in the levels between either group. CONCLUSIONS: Our findings indicate that there is no direct relationship between OME and biochemical evidence of allergy, specifically to house dust mite.

Pre-menstrual syndrome--are gonadotropins the cause of the condition?

It is proposed that premenstrual syndrome results from the action of elevated gonadotropin levels in various tissues of body other than their natural target organs. These levels are derived from an increased sensitivity to estrogen after pregnancy, childbirth, etc., particularly with respect to the positive feedback on gonadotropin release from the pituitary. Estrogen in conjunction with gonadotropin-releasing hormone (GnRH) releases excessive amounts of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) at ovulation and in the premenstrual phase (post-menopausal patients have greatly elevated gonadotropins and can also demonstrate cyclic symptoms). Gonadotropin action via adenylate cyclase in the adrenal cortex elevates cortisol, while antagonism of parathyroid hormone action on bone gives rise to hypocalcemia. The physiological and psychological symptoms may thereby be explained.

Hypoxic cell sensitization to radiation damage by a new radiosensitizer: cis-dichloro-bis(1-(2-hydroxyethyl)-2-methyl-5-nitroimidazole-N3)platinum(II) (flap).

A new, stable platinum coordination complex (FLAP) containing the 5-nitroimidazole, metronidazole, has been prepared and characterized. The square-planar platinum(II) complex has two metronidazole molecules and two chlorine atoms in the cis configuration. The properties of FLAP differ significantly from metronidazole alone or other platinum complexes tested in the same system. It has a low toxicity towards Chinese hamster ovary cells and is a very effective radiosensitizer toward hypoxic cells in vitro: a one-h pretreatment with a non-toxic dose of 50 microM gave an enhancement ratio of 2.4. No potentiation of aerated cells to X-irradiation damage was observed after a similar schedule of pretreatment at the higher dose of 100 microM FLAP.