Throat swabs taken on the operating table prior to cleft palate repair and their relevance to outcome: a prospective study.

OBJECTIVE: The main objective of this study was to determine whether bacteria cultured from oral swabs taken at the time of surgery predicted postoperative fistula formation. DESIGN: The study was a prospective longitudinal audit. SETTING: The setting was a designated U.K. N.H.S. cleft center. PATIENTS: Subjects consisted of the patients of a single cleft surgeon who were undergoing surgery for cleft palate repair or cleft fistula repair. INTERVENTIONS: Oral microbiological swabs were taken from patients while they were on the operating table just before surgery. MAIN OUTCOME MEASURES: The results from microbiological culture of the swabs were recorded, as was the presence or absence of a fistula at 6 months postoperatively. Additional collected information was related to the severity of the cleft, whether the operating microscope was used during surgery, and whether the patient had developed a postoperative upper respiratory tract infection. RESULTS: Positive swab cultures were not significantly associated with fistula formation. Use of the operating microscope was not associated with an increase or decrease in the number of fistulas. A fistula developed in all patients who experienced a postoperative upper respiratory tract infection. CONCLUSIONS: The practice of performing routine preoperative mouth swabs should be abandoned because the presence of bacteria in the mouth does not increase the risk of fistula formation.

Unblocking the nose by unplugging the ear: the use of foam ear defenders as a splint following secondary cleft rhinoplasty.

OBJECTIVE: The functional and aesthetic result from secondary cleft rhinoplasty is commonly impaired by a bulge in the lateral nasal vestibule, which can relapse in the postoperative period despite careful intraoperative correction. We aim to improve our results by using a foam ear defender as a postoperative splint to prevent relapse. DESIGN: Case series of 10 patients with photographs of a typical clinical case. INTERVENTIONS: The postoperative nasal pack was exchanged with a foam ear defender on day 5. The splint was worn continuously for 3 to 4 weeks, then nightly for 3 months. The splint was changed daily by the patient. MAIN OUTCOME MEASURES: The results were assessed clinically by the senior author. RESULTS: The patients had little or no recurrence of the lateral vestibular bulge following nasal splintage. CONCLUSIONS: Foam ear defenders are a simple, cheap, and comfortable method to provide splintage to the nasal vestibule following secondary cleft rhinoplasty.

A triage system for referrals of pediatric skull deformities.

The clinical pathways for craniosynostosis and nonsynostotic skull deformity are entirely different. At the Dutch Craniofacial Center (DCFC), all patients were assessed in the same multidisciplinary craniofacial clinic, a common practice in countries with developed health care. However, the high volume of referrals of nonsynostotic cases frequently resulted in the capacity of these clinics being exceeded, with some patients being assessed in the general pediatric plastic surgery clinic instead. In these general clinics, not all the multidisciplinary team members are routinely present, so patients with craniosynostosis had to make a second journey for further assessment, causing inconvenience, expense, and potential delay in treatment. With triage at the community level unreliable and triage at clinic level inefficient, we decided to trial a triage system to increase efficiency and to ensure patients enter the correct clinical pathway earlier.The 2 craniofacial secretaries were issued with a flowchart to be completed for each new referral. The flowcharts were designed to triage the patients into true craniosynostosis with an appointment for the multidisciplinary clinic or nonsynostotic deformity with an appointment with the craniofacial nurse practitioner (CNP). During a 3-month period, 107 referrals were made. The triage category listed on the initial flowchart for each patient was compared, with the final diagnosis made in the multidisciplinary and CNP clinics.None of the patients triaged as nonsynostotic deformity on the flowcharts were found to be true craniosynostosis after clinical assessment by the CNP. Radiographic assessment or assessment by the craniofacial surgeons in the DCFC confirmed this.The flowchart questionnaire used at the DCFC is a highly sensitive and therefore safe method for detecting craniosynostosis. It has helped to improve efficiency by ensuring patients are seen in an appropriate setting.

CO2 laser ablation of lymphangioma circumscriptum of the scrotum.

Lymphangioma circumscriptum (LC) is an uncommon skin condition characterized by large muscular-coated lymphatic cisterns that lie deep with in the subcutaneous tissue and communicate with dilated dermal lymphatics. Patients suffer from edema and lymphatic leakage. Surgical excision and reconstruction is the gold standard for therapy. However, this can be mutilating. The authors present a patient who suffered widespread disease of his scrotum who had excellent symptomatic relief by treatment with the CO(2) laser.

Dermal changes in the lower leg skin of patients with venous hypertension.

Patients with chronic venous disease may develop characteristic changes in the skin of the lower limb known as lipodermatosclerosis (LDS). The affected skin becomes indurated and pigmented and often ulcerates. The degree of induration associated with LDS correlates directly with ulcer formation and leads to a subsequent delayed rate of healing. However, there is limited information regarding the cellular and molecular events that lead from venous dysfunction to LDS development. This article reviews the current knowledge of the clinical progression of chronic venous disease, summarizing the histological findings from these authors' laboratory and other studies on LDS, and offers possible mechanisms to explain the fibrotic changes associated with this condition.