Since the last issue of the Annals, the following letters have been published on our website <http://www.rcseng.ac.uk/publications/eletters/>:
letter . 2006 Nov;88(7):686. doi: 10.1308/003588406X152125
letter Ann R Coll Surg Engl. 2006 Nov;88(7):686. doi: 10.1308/003588406X152125
We read with interest the article from Charalambous et al. Clinical decision-making protocols are increasingly gaining acceptance as the standard by which patients are managed in hospitals in the UK. This is especially apparent when it relates to requesting further investigations such as radiographs in trauma patients. These clinical guidelines, in the main, are aimed at improving clinical effectiveness by reducing the numbers of unnecessary investigations, and in these cases reducing the amount of radiation exposure.
We recently encountered a male patient who had a metallic foreign body (segment of a metal key) embedded in the retromandibular space following an alleged assault. The injury was initially overlooked as the patient was intoxicated and a poor historian, with no obvious evidence supporting the presence of this foreign body. This patient had no clinical signs of a facial fracture. Therefore, based on guidelines (ie in the absence of parameters suggestive of facial bony injuries) it was thought that this patient did not require radiographic investigations, and was discharged. However, had plain facial radiographs been taken at his initial visit this would have facilitated the early diagnosis of the metallic foreign body, and undoubtedly avoided the subsequent delay in definitive management. Although guidelines need to be adhered to, this example of the delayed identification of a metallic foreign body highlights that stringent protocols for radiographic investigation may not always be in the best interest of the patient.
Sound clinical judgement should dictate patient care, in view of the shift in the aetiology of facial injuries in the UK, where increasing numbers of acute presentations are associated with excessive alcohol consumption.1 Furthermore, given the recent government introduction of extended licenses to drinking establishments it is likely to be more common for clinicians to encounter such patients, who may present a diagnostic challenge for the aforementioned reasons. We believe that the key factor in the assessment of foreign bodies in cervico-facial trauma is the request of a plain x-ray, particularly when the history is unavailable or unreliable.
Footnotes
Reference
- 1.Hutchison IL. The BAOMS United Kingdom survey of facial injuries part 1: aetiology and the association with alcohol consumption. Br J Oral Maxillofac Surg. 1998;36:3–13. doi: 10.1016/s0266-4356(98)90739-2. [DOI] [PubMed] [Google Scholar]
letter Ann R Coll Surg Engl. 2006 Nov;88(7):686. doi: 10.1308/003588406X152125
While it is reasonable to expect advanced colorectal cancers to be more symptomatic, it is difficult to understand why fresh rectal bleeding was more likely to be associated with early (rather than advanced) colorectal cancers. Why should early tumors be more predisposed to haemorrhage? Perhaps benign disease (diverticular disease, haemorrhoids etc) coexist frequently with early colorectal cancer.1 This is not mentioned in the study. This raises the possibility that some early cancers may have been incidental findings in the investigation of benign rectal bleeding.
Furthermore, the proportion of Duke's A cancers in this study (30%) is significantly higher than in previously published studies, and even colorectal cancer screening pilot studies.2,3 Does this suggest that screening questionnaires may be more effective than faecal occult blood (FOB) and selective endoscopy in identifying early cancers? I think not! Was this due to selection bias?
For example, the four Duke's A cancers resected following ‘downstaging’ short-course neoadjuvant radiotherapy, considering that they were T2 stage post-radiotherapy, what were respective preoperative Duke's stages, and how was this determined? And what would be the effect of excluding them from the analysis?
Footnotes
Comment on Smith D, Ballal M, Hodder R, Soin G, Selvachandran SN, Cade D. Symptomatic presentation of early colorectal cancer. Ann R Coll Surg Engl 2006; 88: 185–190. doi: 10.1308/003588406X94904
References
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letter Ann R Coll Surg Engl. 2006 Nov;88(7):686. doi: 10.1308/003588406X152125
We read with interest your article on facial blushing. We appreciate that the presence of facial blushing can cause considerable social and psychological problems for the patient, but don't think that the use of endoscopic sympathectomy as a first line treatment is justified from the results published in your study, especially since some would argue that endoscopic sympathectomy in the treatment of facial blushing is a cosmetic rather than medical procedure.
Although there can be no doubt that the use of the endoscopic approach carries less risks to the patient than an open one,1 we think the treatment for facial blushing should be psychological and behavioural in the first instance.2 Only when these non-invasive methods have failed, can surgery be contemplated.
We applaud the time and effort that went into carrying out this project. However, there were a few points that we would like to raise. Firstly, post-procedure assessment of symptom change and complications involved the use of a visual analogue and Leikert scale respectively. We feel a more objective assessment could have been used because both scales in this particular study are largely dependent on psychological factors: whether the patient thought the procedure improved his or her symptoms Sweating could have been measured by electric conduction studies; and the extent of, or changes in facial blushing by several methods such as skin colour changes using colourimetry,3 laser Doppler to look at skin perfusion;4 or even indirectly, by looking at skin temperature changes using special skin temperature probes.5 The use of these objective methods would have yielded results that reflected actual post-operative physiological changes, which may have contradicted what the patient ‘feels’.
Secondly, the improvement in the severity scale for patients with both facial blushing and hyperhidrosis, as stated by the paper, did not separate the two. Did the patient feel better because there was less hyperhidrosis or facial blushing, or both? I think this is an important point since facial blushing is being assessed.
Finally, the study's aim was to look at the use of endoscopic sympathectomy in the treatment of facial blushing, and the final conclusion was that ‘facial blushing can, therefore, be considered as an indication for BETS on its own merit when not associated with hyperhidrosis’. This conclusion, however, is only based on a sample size of 12 patients, in whom facial blushing was their only symptom (out of a total of 59 patients who had facial blushing as a symptom). This number is far too small to make any conclusions regarding risks or benefits, and reduces the power of the study.
I hope our comments are given consideration in future studies.
Footnotes
Comment on Adair A, George ML, Camprodon R, Broadfield JA, Rennie JA. Endoscopic sympathectomy in the treatment of facial blushing. Ann R Coll Surg Engl 2005; 87: 358–360. doi: 10.1308/003588405X60597
References
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letter Ann R Coll Surg Engl. 2006 Nov;88(7):686. doi: 10.1308/003588406X152125
Banga et al draw attention to the variation in equipment and staff availability to deal with airway emergencies on ENT wards in the UK.1 They choose the ‘Minitrach’ (jet ventilation catheter) for a cricothyroidotomy device in their Oxford airway box, and this is the only one listed in their survey. The current version uses a Seldinger technique, dilation and passage of a 4.0mm tube. The airway resistance is sufficiently low to allow acceptable gas exchange via an Ambu(tm) bag system in the short term and a jet ventilator is not needed.
Other cricothyroidotomy devices are available. In a comparison of the Minitrach and a catheter-over-needle system (Melker), the authors conclude that the Minitrach was unsuitable for emergency (catheter) cricothyroidotomy by inexperienced practitioners and the Melker device was ‘quick, safe and reliable’.2 The Difficult Airway Society has comprehensive guidelines on the ‘cannot intubate, cannot ventilate’ scenario.3 For surgical (scalpel) cricothyroidotomy, they advise the ‘four-step approach’.4
In any airway emergency, the practitioner must be resourced (with the correct equipment), able (trained to use it) and willing to act appropriately. We call this the ‘RAW approach’ and can be used in a variety of clinical situations.
Footnotes
Comments on Banga R, Thirlwall A, Corbridge R. How well equipped are ENT wards for airway emergencies? Ann R Coll Surg Engl 2006; 88: 157–160. doi: 10.1308/003588406X95066
References
- 1.Banga R. How well equipped are ENT wards for airway emergencies? Ann R Coll Surg Engl. 2006;88:157–160. doi: 10.1308/003588406X95066. [DOI] [PMC free article] [PubMed] [Google Scholar]
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Ann R Coll Surg Engl. 2006 Nov;88(7):686. doi: 10.1308/003588406X152125
We read with interest the correspondence from Clark et al. While we have found the Minitrach system is an acceptable one we are always keen to look at other methods that may enhance the safety of our patients.
We feel that the authors have missed the point of our paper. It showed that inexperienced doctors are currently staffing the ENT wards. These doctors are often called first to a patient showing signs of airway difficulty. These airway problems are often sorted out without the need to involve anaesthetists who are busy in theatre or running to true ‘crash calls’ elsewhere. Unfortunately however, in some circumstances patients do deteriorate very quickly and the attending doctor needs to know how to deal with the situation. The appropriate training is essential and familiarisation with airway equipment and when it should be used is paramount. We agree that our anaesthetic colleagues are trained in difficult airway management. However, As ENT surgeons, we do have the responsibility to ensure that the staff looking after our patients are familiar with assessing the airways and understand the basic practices of surgical airway management. We are disappointed that our colleagues do not see that this requires us all to work together as a team.
Ann R Coll Surg Engl. 2006 Nov;88(7):686. doi: 10.1308/003588406X152125
We read with interest the paper by Banga et al. The authors note that ENT wards are staffed, out of hours, by a variety of junior doctors with little or no previous experience of ENT patients. Our concern is the suggestion that untrained doctors be provided on the ward with advanced equipment that they are likely never to have seen before, in a situation of a rapidly deteriorating or obstructed airway. This seems strange in the least or dangerous at worst.
Doctors who are both well trained and skilled in the management of difficult airways (usually called anaesthetists) should be asked to manage such patients. Anaesthetists are taught from an early stage to recognise the compromised airway, move the patients to a place of safety (usually theatres) and are drilled in the management of difficult and failed intubation. The theatre environment is well equipped and staffed with experienced personnel to manage difficult and obstructed airways.
We feel the authors would be better served by developing guidelines to help junior doctors identify an obstructing airway at an earlier stage, and move patients to a place of safety involving their anaesthetic colleagues at the outset.
letter Ann R Coll Surg Engl. 2006 Nov;88(7):686. doi: 10.1308/003588406X152125
It was stated the aim of this study was to ascertain the accuracy of diagnostic ultrasound in the assessment of the occult and groin herniae, having previously demonstrated its efficacy in diagnosing the type of clinical groin herniae. It had been found previously that occult herniae had provided a further diagnostic problem.
I found the conclusions to be somewhat inconclusive and in an attempt at clarification may I send for your consideration a letter by this writer that was printed in the British Journal of Urology in May 2005, pointing out the common neuro-anatomy of the male genitalia and the groin areas1. Failure to appreciate this can be expensive.
No doubt the present regrettable habit to neglect detailed teaching of anatomy both to medical students and to postgraduate students working for higher degrees is responsible for these diagnostic clangers.
Footnotes
Comment on Bradley M, Morgan J, Pentlow B, Roe A. The positive predictive value of diagnostic ultrasound for occult herniae. Ann R Coll Surg Engl 2006; 88: 165–167. doi: 10.1308/003588406X95110
Reference
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Ann R Coll Surg Engl. 2006 Nov;88(7):686. doi: 10.1308/003588406X152125
The purpose of the study was to answer the question whether ultrasound had a role in diagnosing the occult herniae in those patients where the clinical diagnosis had been raised. This study used all types of abdominal and groin occult herniae involving a male and female population. Thus there was only a relatively small group of male patients with unexplained groin pain that did not spontaneously resolve. The clinical assessment was conducted by experienced surgeons who only sent patients for ultrasound imaging that they thought had possible clinical symptomatology that could be caused by occult herniae. They would not be referring imaging cases for this study in those male patients who had prostatic referred symptoms. The conclusion to the above authors' study therefore is clearly stating that dynamic ultrasound has a role in assessing those patients who were selected by experienced surgeons with the clinical diagnosis of occult herniae and in those males in the population there has been prior exclusion of a prostatic cause of the symptoms.