Oxymetazoline nasal spray three times daily for four weeks in normal subjects is not associated with rebound congestion or tachyphylaxis.

Topical decongestants are available over the counter and provide rapid relief of nasal obstruction for conditions of short duration, for example the common cold. Manufacturers' recommendations are that topical decongestants should not be used regularly for more than 1 week in view of the risk of rebound mucosal hyperaemia with persistent nasal obstruction and refractoriness to further effects of decongestants. For this reason we performed a randomised double-blind placebo-controlled trial in 30 normal adult subjects with 0.05% oxymetazoline nasal spray 2 sprays (0.1 ml/spray) to each nostril 3 times daily over an extended period of 4 weeks. Degree of nasal blockage was assessed before and after 4 weeks treatment and for 2 weeks following discontinuation of treatment. Outcome measures included diary symptom scores and measurements of nasal peak inspiratory flow, airway resistance (using posterior active rhinomanometry) and volume (using acoustic rhinometry). Nasal patency was assessed at baseline and 15 minutes after oxymetazoline challenge at each clinic visit. Results demonstrated no significant increases in subjective nasal blockage throughout the 6 weeks study period in either oxymetazoline- or placebo-treated subjects. No significant differences were observed between groups for baseline measurements of nasal peak inspiratory flow, airway resistance or volume at each clinic visit. A highly significant decongestant effect of oxymetazoline was observed at each clinic visit with changes in all 3 measurements for both treatment groups, again with no significant differences between groups. In summary, in normal subjects, we identified no significant nasal blockage or impaired decongestant response to oxymetazoline following 4 weeks treatment with oxymetazoline compared to matched placebo nasal spray.

Acute pulmonary oedema complicating adenotonsillectomy for obstructive sleep apnoea.

Acute pulmonary oedema can sometimes complicate adenotonsillectomy carried out for obstructive sleep apnoea. Early recognition and adequate oxygenation are the key to management. We report such a case; the pathophysiology and management of this rare complication of a common procedure are discussed.

The radiological appearances after the endoscopic crico-pharyngeal myotomy: Dohlman's procedure.

The treatment of pharyngeal pouches (Zenker's Diverticulum) may be by either open surgical or endoscopic techniques. The endoscopic Dohlman's procedure is an ideal technique in the elderly. However, confusion has been created by the persisting presence of the pouch on the postoperative barium examination, creating the impression of surgical failure. We describe the subtle radiographic findings of the postoperative barium swallow by comparing pre- and postoperative examinations which may be used to indicate the success of the procedure. These include demonstration of the reduced height of the partition wall, the ease of passage of the barium down the ooesophagus and the height of barium supported in the substance of the residual pouch.

Tracheal ring rupture and herniation during percutaneous dilatational tracheostomy identified by fibreoptic bronchoscopy.

We present a case of rupture and herniation of cartilaginous tracheal rings into the lumen of the trachea that was noticed as an incidental finding during bronchoscopy after percutaneous dilatational tracheostomy. While percutaneous methods of tracheostomy formation gain popularity in intensive care settings, the number of reported problems associated with this technique continue to grow. We propose that fibreoptic bronchoscopy used routinely with percutaneous tracheostomy formation will identify a number of complications involving the tracheal skeleton.

A prospective randomized controlled trial comparing the use of merocel nasal tampons and BIPP in the control of acute epistaxis.

A prospective study was undertaken to compare the efficacy of Merocel nasal tampons to BIPP (Bismuth Subnitrate and Iodoform Paste) impregnated ribbon gauze in the control of acute epistaxis requiring hospital admission. A total of 50 patients presenting with severe epistaxis was treated with either merocel nasal tampons, or BIPP. The groups did not differ significantly in terms of age, sex distribution, aetiology or severity of the bleed. There was no significant difference in efficacy or patient tolerance of either treatment. It was concluded that Merocel nasal tampons should be considered effective in the first line treatment of severe epistaxis uncontrolled by simple measures. Their ease of insertion makes them suitable for use in the accident and emergency department or in general practice.

Endoscopic fenestration of choanal atresia.

We report two cases of unilateral choanal atresia and one of choanal stenosis treated successfully by endoscopic fenestration, with no recurrence at a mean follow-up of 18 months. Rigid endoscopy and axial CT scanning confirm the clinical diagnosis and this technique avoids the need for stenting or prolonged post-operative stay.

Peritoneal cystic mesothelioma: an electron microscopic and immunohistochemical study of two male patients.

The clinical, pathological, and ultrastructural features of two cases of peritoneal cystic mesothelioma occurring in men were studied. The results of immunohistochemical staining for CAM 5.2, epithelial membrane antigen, carcinoembryonic antigen, and Factor VIII related antigen are reported for the first time and compared with the staining results of two peritoneal cystic lymphangiomas. Although resembling cystic lymphangioma by light microscopy, cystic mesothelioma may have a greater tendency for local recurrence. Staining for CAM 5.2 or epithelial membrane antigen may facilitate the differentiation of these two entities.

Anticoagulant and antiheparin activities of a pentosan polysulphate.

Pentosan polysulphate (PPS, Hemoclar, MW 6,700) was observed to have a low affinity for ATIII-Sepharose eluting at 0.3M NaCl. Tested in vitro it had, as previously reported, a low potency as an anticoagulant, about 10 times less than heparin on a weight for weight basis. Only the KCCT was affected by low concentrations of PPS unlike heparin by which both thrombin time and KCCT were affected. Upon injection of PPS subcutaneously (50mg) the heparin activity measured by chromogenic anti factor Xa and by KCCT was in the ratio of 2:1. When injected intravenously (40mg) into 3 healthy volunteers a significant prolongation of a modified prothrombin time was observed in 2 subjects. When PPS was added to heparin containing plasma it was observed to completely inhibit heparin at low concentrations (2:1 on a weight to weight basis) when measured in the thrombin and prothrombin time but not in the KCCT. The antiheparin effect of PPS was also observed in a purified system in obviating the heparin potentiation of the rate of inhibition of thrombin by antithrombin III. Observations showed that at higher concentrations of PPS it acted by directly inhibiting thrombin without the intervention of antithrombin III but also to potentiate the rate of fibrin monomer polymerization.

Low-molecular-weight heparin and prevention of postoperative deep vein thrombosis.

The efficacy of low-molecular-weight heparin as a prophylactic agent was assessed in 150 consecutive patients over the age of 40 undergoing major abdominal surgery. Fifty of these patients received 1250 activated partial thromboplastin time (APTT) units of low-molecular-weight heparin every 12 hours: three developed isotopic deep vein thrombosis, which was confirmed by phlebography in two cases. The other 100 patients received a single injection of 1850 APTT units of low-molecular-weight heparin. Three of them developed isotopic deep vein thrombosis; phlebography failed to confirm the presence of thrombi in each case. None of the 150 patients studied died from fatal or contributory pulmonary emboli. Low-molecular-weight heparin was not associated with any increase in preoperative or postoperative bleeding. The effect of equal amounts of postoperative bleeding. The effect of equal amounts of low-molecular-weight heparin and unfractionated heparin on the coagulation mechanism during surgery was investigated in another 30 patients. The clotting assays and results of in-vivo platelet function tests indicated that both preparations produced similar effect. Intragroup comparisons, however, showed significant differences in the anti-factor Xa activity, lipoprotein lipase release, and plasma prekallikrein concentrations. A single injection of low-molecular-weight heparin daily is a convenient way of preventing deep vein thrombosis in high-risk patients undergoing major abdominal surgery.