Comparison of intranasal medication delivery devices before and after functional endoscopic sinus surgery using Phacon sinus surgery models.

OBJECTIVE: Functional endoscopic sinus surgery for chronic rhinosinusitis improves sinus drainage and intranasal medication delivery. This study compares medication delivery with commonly used devices in normal and altered anatomy (post functional endoscopic sinus surgery) using sinus surgery models (Phacon). METHODS: Medication delivery was simulated via nasal drops, nasal spray and an irrigation device (Neilmed Sinus Rinse). Coverage was then calculated from endoscopic pictures taken at various anatomical sites in the normal nose and post functional endoscopic sinus surgery. RESULTS: In the normal nose, nasal spray did not penetrate the sphenoid sinus, and drops bypassed the vestibule anteriorly. Neilmed Sinus Rinse provided superior coverage at the sphenoid site following sphenoidectomy and the frontal site following Draf III. After ethmoidectomy, nasal drops overall provided less coverage than the other methods. CONCLUSION: Neilmed Sinus Rinse generally provided the best distribution, followed by the nasal spray and then nasal drops. The type and extent of surgery also affects medication delivery.

#10-Year Challenge: Local anaesthetic for post-tonsillectomy pain: Update meta-analysis.

INTRODUCTION: Adequate management of post-tonsillectomy pain is an important consideration in postoperative management after tonsillectomy. A 2008 meta-analysis showed that the use of local anaesthetic either by infiltration or topical application reduced postoperative pain. OBJECTIVES: To review the current evidence for the use of local anaesthetic as a means of reducing post-tonsillectomy pain and compare current evidence to the previous meta-analysis 10 years ago. METHOD: Systematic literature searches of MEDLINE [*"ANESTHETICS, LOCAL"/ AND *TONSILLECTOMY/], EMBASE [*"LOCAL ANESTHETIC AGENT"/ AND *TONSILLECTOMY/] and PubMed [(Tonsillectomy).ti,ab AND (Local Anaesthetic).ti,ab OR (Local Anesthetic).ti,ab]. A meta-analysis of randomised control trials assessing the use of local anaesthetic agents for post-tonsillectomy pain. RESULTS: Twenty-three studies were included in the meta-analysis. Overall, local anaesthetic, applied topically or infiltrated, significantly reduces pain scores compared with controls at 4-6 hours [-0.65 (95% CI: -0.77; -0.53)]; 24 hours [-0.50 (95% CI: -0.66, -0.35)]; and 5-7 days [-0.78 (95% CI: -0.90, -0.65)] (standardised mean differences). CONCLUSION: Current studies suggest that use of peri-operative local anaesthetic during tonsillectomy does improve postoperative pain outcomes. The limitations of the analysis are as follows: all studies are small, and a multi-centred larger trial is recommended to guarantee statistical reliability. There was no description of significant adverse side effects from local anaesthetic use.

Fifteen-minute consultation: The infant with a neck lump.

Studying head and neck anatomy may be a distant memory and clinicians can struggle with how to approach neck lumps diagnostically. This article gives a brief guide to common (and rare but serious) causes of neck lumps in infancy, their identification and management.

Gorlin-Goltz syndrome: first reported case of bullae in the lungs complicated with tension pneumothorax.

A 13-year-old girl was referred by her general practitioner with acute worsening exertional dyspnoea and sudden onset of left-sided chest pain. There was no associated trauma, palpitations or syncope. Clinical examination revealed that the left lung was hyper-resonant on percussion with reduced air entry on auscultation. Chest X-ray showed a left tension pneumothorax. She was treated conservatively with chest drain. Follow-up X-ray revealed multiple bullae within her left lung. Unfortunately, she redeveloped a pneumothorax and was sent to a tertiary centre. She was under the care of the paediatric cardiothoracic surgeons who organised a CT thorax and performed a lobectomy to remove the bullae. She was discharged from the tertiary centre and currently being followed up under the care of the paediatrician in the district general hospital. She have not developed any further pneumothoraxes.

Correction to: An exotic abscess within the United Kingdom from The Gambia: a case report.

CORRECTION: In the publication of this article [1], there is an error in an authors name.The error: 'Estelle Hong How' Should instead read: 'Estelle How-Hong'This has now been included in this erratum.

Longest delayed hemothorax reported after blunt chest injury.

INTRODUCTION: Blunt chest injury is a common presentation to the emergency department. However, a delayed hemothorax after blunt trauma is rare; current literature reports a delay of up to 30days. We present a case of 44-day delay in hemothorax which has not been previously reported in current literature. CASE REPORT: A 52-year-old Caucasian male first presented to the emergency department complaining of persistent right sided chest pain 2weeks after having slipped on a wet surface at home. His initial chest X-ray showed fractures of the right 7th and 8th ribs without a hemothorax or pneumothorax. He returned 30days after the initial consultation (44days post-trauma) having increasing shortness of breath. A chest X-ray this time revealed a large right hemothorax and 1850ml of blood drained from his chest. There was a complete resolution of the hemothorax within 48h and the patient was discharged after a 6-week follow-up with the chest physicians. DISCUSSION: Delayed hemothorax after blunt trauma is a rare clinical occurrence but associated with significant morbidity and mortality. The management of delayed hemothorax includes draining the hemothorax and controlling the bleeding. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians should be vigilant and weary that hemothorax could be a possibility after a chest injury despite a delay in presentation. A knowledge of delayed hemothorax will prompt physicians in providing important advice, warning signs and information to patients after a chest injury to avoid a delay in seeking medical attention.

An exotic abscess within the United Kingdom from The Gambia: a case report.

BACKGROUND: Furuncular myiasis is a parasitic infection of a live mammal by fly larvae commonly seen in Africa. However, with an increase in international tourism, there is a significant rise in exotic infection in non-endemic areas which can pose a diagnostic challenge to doctors and potentially lead to delay in treatment. From the current literature, only 12 cases were reported in the UK. CASE PRESENTATION: We report an unusual case of multiple abscesses in a 32-year-old white British woman presenting to our Emergency department in the UK after returning from a holiday in The Gambia, West Africa. She did not complain of systemic symptoms and was otherwise fit and healthy with no significant past medical history. During examination, two maggots were expressed from the abscesses by applying lateral pressure to each lesion. The larvae were found to be Cordylobia anthropophaga. She was discharged with antibiotics to prevent secondary infection with no further follow-up. CONCLUSION: With globalization, the need for increasing awareness of tropical diseases has become important to win the battle against future epidemics.

Unusual Case of a Proptosed Eye: Isolated Right Maxillary Neurofibroma.

Neurofibroma is a slow growing benign tumour of the peripheral nerve sheath which is frequently associated with neurofibromatosis type 1 (Prakash et al., 2014). Isolated solitary occurrence of neurofibroma in the maxillary sinus is rare with only 29 reported cases in the literature. We present a rare case of a 70-year-old gentleman who was referred to ENT with a right maxillary sinus neurofibroma with extension into the right inferior orbit. He has significant proptosis, ptosis, and limitation in abduction of the right eye. He has a complicated past history of multiple neurofibromas which were completely excised. Craniofacial MRI shows a large mass filling the right maxillary antrum extending anteriorly into subcutaneous tissue towards nasal ala and posterolaterally into inferior temporal fossa and superiorly into orbit and cavernous sinus involvement. Biopsy of the right maxillary mass revealed cellular spindle cell tumour with wavy collagen bundles within myxoid stroma which is consistent with a neurofibroma. Patient's case was discussed in the skull-base MDT and he has been referred to a specialist center for surgical removal of the neurofibroma with reconstructive surgery. Despite the rarity of this disease, otorhinolaryngologist should consider a possibility of neurofibroma of the paranasal sinuses.

Nicorandil-induced penile ulceration: a case report.

BACKGROUND: Penile ulceration in older patients is commonly neoplastic or infective. However, there are rarer causes of these ulcerations that we have to exclude. We present a rare complication of penile ulceration secondary to nicorandil, a nicotinamide ester. CASE PRESENTATION: An 86-year-old white British man was referred with a bloody discharge from under his phimotic foreskin and a lump on the shaft of his penis for the past year. He had angina which has been controlled with nicorandil for the past 5 years. A surgical biopsy of the ulcer showed inflammation with no evidence of malignancy. His penile ulceration spontaneously resolved when he stopped his nicorandil treatment. CONCLUSIONS: Nicorandil-induced ulceration is a rare complication; however, it should not be missed in a clinical setting. If there is any doubt about the cause of penile ulceration, then referral to dermatology or urology for consideration of biopsy is essential.

Dual pathology-An unreported case.

INTRODUCTION: Symptomatic biliary disease in children and young adults requiring surgical intervention are uncommon. However even rarer is the occurrence of a spontaneous gallbladder necrosis in a child. We report a case of spontaneous necrosis in a child with no apparent causative factors. CASE: Fit and well 16 year-old boy presented with acute generalized lower abdominal pain. Examination revealed mild epigastric pain with rebound tenderness and guarding of the right iliac fossa. Diagnostic laparoscopy showed a necrotic gallbladder and incidental finding of a Meckel's diverticulum. He had a cholecystectomy and Meckel's diverticulum resection. Patient recovered uneventfully and was discharged home. He was reviewed 2 months later and recovered well with no evidence of any post-operative complication. He was discharged without any further follow up. DISCUSSION: Gall bladder necrosis is a rare cause of an acute abdomen. We present the first reported case of a spontaneous gallbladder necrosis with no apparent cause. Literature review showed various causes of gall bladder necrosis including trauma, acalculous cholecystitis, gallbladder torsion, gangrenous cholecystitis and etc. CONCLUSION: We report a case of spontaneous gallbladder necrosis in a young healthy male with no family history of thrombotic disorders or any history of sepsis, intervention, trauma and no obvious underlying anatomical or histological abnormalities. This is an exceedingly rare pathology and one would be forgiven for not including it on the list of a differential diagnosis in such circumstance. However it is important to send tissue sample to exclude any underlying histological aetiological factors.