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Introduction Infectious mononucleosis (IM) is a common viral illness that predominantly causes sore throat, fever and cervical lymphadenopathy in adolescents and young adults. Although usually a benign, self-limiting disease, it is associated with a small risk of splenic rupture, which can be life-threatening. It is common practice therefore to advise avoiding vigorous physical activity for at least 4–6 weeks, however this is not based on controlled trials or national guidelines. We reviewed published case reports of splenic rupture occurring in the context of IM in an attempt to ascertain common factors that may predict who is at risk. Method A search of MEDLINE and EMBASE databases was performed for case reports or series published between 1984 and 2014. In total, 52 articles or abstracts reported 85 cases. Data was extracted and compiled into a Microsoft Excel® spreadsheet. Results The average patient age was 22 years, the majority (70%) being male. The average time between onset of IM symptoms and splenic rupture was 14 days, with a range up to 8 weeks. There was a preceding history of trauma reported in only 14%. Abdominal pain was the commonest presenting complaint of splenic rupture, being present in 88%. 32% were successfully managed non-operatively, whereas 67% underwent splenectomy. Overall mortality was 9%. Conclusions and recommendations From our data, it appears that men under 30 within 4 weeks of symptom onset are at highest risk of splenic rupture, therefore particular vigilance in this group is required. As cases have occurred up to 8 weeks after the onset of illness, we would recommend avoidance of sports, heavy lifting and vigorous activity for 8 weeks. Should the patient wish to return to high risk activities prior to this, an USS should be performed to ensure resolution of splenomegaly. The majority of cases reviewed had no preceding trauma, although previous studies have suggested this may be so minor as to go unnoticed by the patient. It is therefore prudent to warn patients about the symptoms of splenic rupture to ensure prompt presentation and minimise treatment delay rather than focusing purely on activity limitation.

The management of four cases of lateral sinus thrombosis (LST) over a four-year period at the Royal Darwin Hospital is presented in this retrospective review. The patients were aboriginal and presented with otalgia, otorrhoea and sepsis. Two cases had an associated complication of an otitic hydrocephalus and a subperiosteal abscess. Cholesteatoma was found in three cases. Computed tomography (CT) scan confirmed the LST in three cases. Three patients were anaemic and thrombocytopenic. All patients had positive blood cultures. The organismswere predominantly mixed anaerobes and Bacteroides species. Three patients were managed surgically as a two-stage procedure. One patient was managed as a single-stage procedure with a modified radical mastoidectomy. Therapeutic anticoagulation was utilized in one case. There were no deaths. The prognosis of LST is good if treatment is instituted early with broad-spectrum intravenous antibiotics and surgery. Therole of clot removal at surgery and the use of anticoagulation are discussed in this paper.

Persistence of the buccopharyngeal membrane (BPM) also called the oropharyngeal membrane is a rare congenital oropharyngeal anomaly. We report a case of an adult aboriginal male patient with a membrane that closed his oropharyngeal isthmus except for a 2 cm diameter central perforation. The patient had no symptoms related to this membrane and no other congenital anomalies were found. This finding has not previously been reported in an adult. The embryology and management of this rare condition is discussed.

Objectives To evaluate the use of the retrolabyrinthine approach (RLA) combined with endoscopy with particular reference to preservation of cranial nerve function and completeness of excision in surgery of epidermoid cysts. Methods A retrospective study was performed on a series of 8 consecutive patients of whom 7 have undergone surgery. Main outcome measures Measures include audiological and neurological status preoperatively and postoperatively, size of the lesion, the surgical approach, completeness of excision, and operative morbidity. Results The tumors were all large, ranging from 2 × 3 cm to 6 × 6 cm. Presenting symptoms were headache (75%), dysequilibrium (62%), trigeminal nerve palsy (38%), abducens nerve palsy (25%), and, rarely, auditory symptoms. Seven patients underwent surgery, 5 by the RLA, 1 by a translabyrinthine approach (TLA), and 1 by a transcochlear approach. Complete excision was achieved in 5 of the 7 patients. A transtentorial approach was combined in 2 cases (1 RLA, 1 TLA). Endoscopy was used in 3 cases. It allowed a complete tumor excision. One case of keratinous meningitis was observed. Trigeminal nerve function returned to normal in all patients. Postoperative facial nerve function was grade I in 5 cases and grade III in 2 cases. Hearing was preserved in 3 cases as class A, 1 case as class B. In the 2 cases presenting with abducens nerve palsy preoperative symptoms were initially aggravated before returning to normal function by 1 year postoperatively. The RLA with endoscopy allowed less invasive surgery and preservation of hearing in 4 of the 5 cases where it was attempted. Tumor control appeared better than with the suboccipital approach. Mortality and postoperative morbidity also appear reduced. Conclusion RLA combined with endoscopy should be considered as the standard approach for excision of epidermoid cysts. Extension of this approach into a TLA or transcochlear approach will depend on preoperative difficulties and preoperative hearing.

The study goal was to demonstrate that blink reflex analysis can predict postoperative facial nerve outcome in cerebellopontine angle tumor surgery.In an open and prospective study conducted at a single tertiary care center over 3 years, 91 subjects with a vestibular schwannoma filling the internal auditory meatus were enrolled and operated on via a translabyrinthine approach. The difference in latency of the early response (DeltaR1) of the blink reflex between the pathologic side and the healthy side was calculated in every patient during a complete electrophysiologic examination of the facial nerve performed on the day before surgery. MIN OUTCOME MEASURES: DeltaR1 was compared with the other preoperative data (tumor volume, facial function), with the perioperative observations (difficulties with the dissection of the facial nerve), and especially with the postoperative status after 1 year. The statistical study was conducted using polynomial regression.Patients with a negative or zero DeltaR1 have normal facial function at 1 year. For those with a positive DeltaR1 the outcome is not favorable unless the tumor is small. For patients presenting with an immediate complete facial paralysis, the value of DeltaR1 is also indicative of facial function outcome.Statistical analysis shows that the blink reflex, through DeltaR1, has an excellent prognostic value in anticipating the difficulties with facial nerve dissection and postoperative facial function after 1 year.

Background Meningitis is the most common life-threatening infection occurring as an early postoperative complication of neurotologic surgery. From January to March 2001, Staphylococcus aureus intracranial infection developed in three patients; two cases were consecutive. Methods All staff members involved in surgery on any of the three patients had nasal swabs for S. aureus. The three patient isolates and all S. aureus isolates from staff members were typed by pulsed-field gel electrophoresis. Operating room procedures were reviewed. Results All three patient isolates were identical by pulsed-field gel electrophoresis. Six staff members (40%) were found to be S. aureus carriers. The isolate from one staff members was identical to the patient isolates. A procedure audit of the operating room revealed several breaks in recommended practice. The staff carrier was immediately removed from patient care duties, given decolonization therapy, and treated for chronic rhinosinusitis. Practice changes in the operating room were implemented. Conclusions S. aureus remains a common cause of surgical site infections. S. aureus carriage is common, and carriers with intercurrent respiratory infections have increased shedding and are a higher risk to patients. Proper use of barrier devices and consistent hand hygiene reduce bacterial contamination of the wound. Current operating room technology involves technical personnel not traditionally trained in operating room procedures. Epidemiologic investigation may be delayed if operating room records are incomplete with respect to these personnel. Molecular typing of bacterial isolates can identify common source outbreaks and effectively focus investigations.

Sommaire Ojectif: Determiner le taux de recidive regionale pour les melanomes avec ganglions positifs traites par evidement cervical. Devis: Etude retrospective de l'experience d'une institution de soins tertiaires. Methodes: Nous avons revu les dossiers de tous les patients ayant subi un evidement cervical entre 1990 et 1997 au Sunny-brook and Women's Health Sciences Center. Nous avons analyse les donnees avec la methode de Kaplan-Meier. Resultats: Trente-et-un patients etaient porteurs de metastases cervicales de melanome. Le taux de recidive regionale etait de 31% a 5 ans. Le delai-moyen avant recidive etait de 78 mois. Conclusion: L'evidement cervical seul est probablement approprie pour certains patients mais ceux qui presentent une pathologie plus avancee beneficieront d'une therapie adjuvante comme la radiotherapie.

EDITOR,--We are concerned by Andy Adam's statement that the correct position for the tip of long term central venous …