Cocaine-associated Eustachian tube stenosis causing chronic 'glue ear': a rare cocaine-induced destructive lesion

BACKGROUND

Cocaine is one of the most used recreational drugs. Whilst medical uses exist, chronic recreational nasal use of cocaine is associated with progressive destruction of the osseocartilaginous structures of the nose, sinuses and palate - termed cocaine-induced midline destructive lesions.

CASE REPORT

A 43-year-old male with a history of chronic cocaine use, presented with conductive hearing loss and unilateral middle-ear effusion. Examination under anaesthesia revealed a completely stenosed left Eustachian tube orifice with intra-nasal adhesions. The adhesions were divided and the hearing loss was treated conservatively with hearing aids. Whilst intra-nasal cocaine-induced midline destructive lesions are a well-described condition, this is the first known report of Eustachian tube stenosis associated with cocaine use.

CONCLUSION

This unique report highlights the importance of thorough history-taking, rhinological and otological examination, and audiometric testing when assessing patients with a history of chronic cocaine use. This paper demonstrates the complexity of managing hearing loss in such cases, with multiple conservative and surgical options available.

The quality and readability of patient information provided by ChatGPT: can AI reliably explain common ENT operations?

PURPOSE

Access to high-quality and comprehensible patient information is crucial. However, information provided by increasingly prevalent Artificial Intelligence tools has not been thoroughly investigated. This study assesses the quality and readability of information from ChatGPT regarding three index ENT operations: tonsillectomy, adenoidectomy, and grommets.

METHODS

We asked ChatGPT standard and simplified questions. Readability was calculated using Flesch-Kincaid Reading Ease Score (FRES), Flesch-Kincaid Grade Level (FKGL), Gunning Fog Index (GFI) and Simple Measure of Gobbledygook (SMOG) scores. We assessed quality using the DISCERN instrument and compared these with ENT UK patient leaflets.

RESULTS

ChatGPT readability was poor, with mean FRES of 38.9 and 55.1 pre- and post-simplification, respectively. Simplified information from ChatGPT was 43.6% more readable (FRES) but scored 11.6% lower for quality. ENT UK patient information readability and quality was consistently higher.

CONCLUSIONS

ChatGPT can simplify information at the expense of quality, resulting in shorter answers with important omissions. Limitations in knowledge and insight curb its reliability for healthcare information. Patients should use reputable sources from professional organisations alongside clear communication with their clinicians for well-informed consent and making decisions.

Should Sedillot's triangle be used for central venous cannulation? A cadaveric study

Central venous access remains an integral part of perioperative and intensive care, and several methods have been described to locate the internal jugular vein (IJV) prior to cannulation. The apex of Sedillot's triangle between the manubrial and clavicular heads of the sternocleidomastoid (SCM) muscle is a commonly used anatomical landmark for a central percutaneous approach to the IJV, but the literature highlights failures and complications when adopting this method. This cadaveric study was designed to investigate the usefulness of Sedillot's triangle to locate the IJV. Sixty-one cadavers were used for investigation at the University of Cambridge Human Anatomy Centre. Sedillot's triangle was dissected and a pin was inserted in a sagittal plane at the apex of the triangle. The location of the pin in relation to the IJV was recorded. The distance between the sternal and clavicular heads of SCM was also measured. In total, the pin inserted at the apex of Sedillot's triangle pierced the IJV in 72/117 (61.5%) of dissections, with 71.4% on the right and 52.5% on the left. There was important variation in SCM anatomy, and there was no gap between its two heads in 12% of the neck dissections. We demonstrate an overall poor success rate of the central percutaneous approach using Sedillot's triangle, although our findings are limited being a simulated cadaveric study. We support education and use of ultrasound in addition to landmark techniques to aid the safe insertion of central venous catheters.

Surgical management of pneumomediastinum in the COVID-19 patient

As the SARS-CoV-2 virus continues to infect millions of people worldwide, the medical profession is seeing a wide range of short-term and long-term complications of COVID-19. One lesser-known complication is that of pneumomediastinum. This is a rare, but significant, complication defined by the presence of air in the mediastinum with an incidence of 1.2 per 100 000. Described mortality rate is 30%, increasing to 60% in patients with concomitant pneumothoraces. Management of pneumomediastinum is typically conservative, but in cases of extensive subcutaneous emphysema, cardiac or airway compression, life-saving surgical decompression is necessary. We report a case of pneumomediastinum secondary to COVID-19, requiring a surgical approach not described in pneumomediastinum secondary to COVID-19. The case demonstrates the importance of prompt diagnosis and management, as well as the potential for good clinical outcome in selected patients.

Exploring communication difficulties with deaf patients

One in five people in the UK are deaf, with hearing loss affecting more than 70% of people over the age of 70. Despite this being a higher prevalence than asthma, heart disease or diabetes, deaf people experience persistent health inequalities with poorer experiences and outcomes in disease prevention and management. Clear communication and patient engagement with health are key to better outcomes. Nonetheless, there exist cultural, educational and organisational barriers when addressing communication with patients with hearing loss.Foundation doctors have regular and prolonged contact with their patients, and often feel underprepared when interacting with patients with hearing loss. This article aims to highlight these communication barriers and suggest changes for improvement.Improvement will require adaptations from both individual and organisational perspectives, with patient care as a clear focus for change.

258 Are Electronic Algorithmic Referral Systems the Future of Triage? Evaluating the Use of The Oxford Acute Referrals System (OARS) For Plastic Surgery

Introduction

A traditional referral involves transfer of information over a telephone call and is typically documented in an unstructured format on paper notes, producing poor continuity of referrals between shifts, increasing the risk of error, and compromising patient safety. The Oxford Acute Referrals System (OARS) is an electronic platform that keeps a complete record of referrals, whilst providing the referring clinician with step-by-step specialist advice according to inbuilt BSSH guidelines. This audit demonstrates our experience of its’ use in a tertiary centre Plastics department.

Method

One week of referrals in 2019, prior to the implementation of OARS, were compared with the equivalent week in 2020 once OARS was established. Data was collected retrospectively using electronic patient records.

Results

In one week in 2019, 120 cases were reviewed in the emergency clinic compared with 155 OARS referrals for the equivalent week in 2020. Following OARS implementation, 69% of referred cases did not footfall in the emergency clinic. 46% were managed locally with specialist advice from Plastic Surgery. 10% were brought directly into a theatre list, of which 7% were subsequently treated conservatively. A Plastic surgery consultant reviewing OARS referrals taken by juniors, changed the decision of how or where to manage the patient in 6% of cases.

Conclusions

OARS is an effective triage system that has considerably reduced footfall in the emergency clinic, whilst simultaneously expediting patient care down the correct treatment pathway. Its use led to safe management of patients remotely, which has important implications during a pandemic.

A Global Survey of Reproductive Specialists to Determine the Clinical Utility of Oxidative Stress Testing and Antioxidant Use in Male Infertility

Purpose

The use of antioxidants is common practice in the management of infertile patients. However, there are no established guidelines by professional societies on antioxidant use for male infertility.

Materials and Methods

Using an online survey, this study aimed to evaluate the practice pattern of reproductive specialists to determine the clinical utility of oxidative stress (OS) testing and antioxidant prescriptions to treat male infertility.

Results

Responses from 1,327 participants representing 6 continents, showed the largest participant representation being from Asia (46.8%). The majority of participants were attending physicians (59.6%), with 61.3% having more than 10 years of experience in the field of male infertility. Approximately two-thirds of clinicians (65.7%) participated in this survey did not order any diagnostic tests for OS. Sperm DNA fragmentation was the most common infertility test beyond a semen analysis that was prescribed to study oxidative stress-related dysfunctions (53.4%). OS was mainly tested in the presence of lifestyle risk factors (24.6%) or sperm abnormalities (16.3%). Interestingly, antioxidants were prescribed by 85.6% of clinicians, for a duration of 3 (43.7%) or 3–6 months (38.6%). A large variety of antioxidants and dietary supplements were prescribed, and scientific evidence were mostly considered to be modest to support their clinical use. Results were not influenced by the physician's age, geographic origin, experience or training in male infertility.

Conclusions

This study is the largest online survey performed to date on this topic and demonstrates 1) a worldwide understanding of the importance of this therapeutic option, and 2) a widely prevalent use of antioxidants to treat male infertility. Finally, the necessity of evidence-based clinical practice guidelines from professional societies is highlighted.

Idiopathic premature ovarian failure: what is the most suitable ovarian stimulation protocol?

OBJECTIVE

To evaluate the ovarian response to ovarian stimulation in women with idiopathic premature ovarian failure (POF) in a prospective, controlled, and sequential crossover pilot study.

MATERIALS AND METHODS

Ten women with idiopathic premature ovarian failure and normal karyotype were included in the study. Phase I was comprised of three consecutive control cycles consisting each of estrogen progestin sequential therapy. Phase II was comprised of three consecutive treatment cycles combining the use of gonadotropin-releasing hormone agonist (GnRHa) in the background of estrogen priming, followed by gonadotropin ovarian stimulation and corticosteroid immunosuppression.

RESULTS

Ovulation rates in the treatment cycles (0/10; 0%) did not differ from control cycles (0/10; 0%).

CONCLUSIONS

The findings of this pilot study showed that the combination of estrogen priming, corticosteroid immune-suppression, GnRHa pituitary desensitization, and followed by gonadotropin ovarian stimulation is ineffective in restoring ovarian function in women with idiopathic POF.