There is a soft tissue density swelling extending down from glottic level and occupying the posterior half of the larynx; the air density can be seen to deviate around the mass. The calcification visible in the laryngeal cartilage is normal.

A CT scan was then performed. The image shown is a coronal section. Note the mass in the left subglottic region of the larynx.

This was assumed to be squamous cell carcinoma. She was transferred to a tertiary centre for further care.

During inspiration the extrathoracic airways (i.e. the larynx and trachea) become narrower, whereas the intrathoracic airways become wider. In expiration the opposite happens, so bronchi become narrower and upper airways get wider. The features of obstruction and hence the symptoms get worse depending on which of the ‘tubes’ is narrowed.

This is guttate psoriasis. This characteristically develops as a sudden onset rash, of ‘salmon coloured’ slightly scaly, slightly itchy spots. They have a sharp edge, with healthy skin in between. The spots are primarily focussed on the trunk and proximal limbs.

80% of these rashes have a proceeding streptococcal infection 2-3 weeks earlier, although other infections have also been linked to it. It is also linked to plaque psoriasis, and an HLA susceptibility has been identified. It usually affects young people aged 10-40 years.

About two-thirds resolve spontaneously over weeks to months. Better prognosis is linked to younger age, and a high ASO titre.

As for plaque psoriasis, exposure to sunlight helps, as does UVB treatment, topical steroids or coal-tar preparations. In rare severe cases immunosuppressant drugs may be needed. Clearance of chronic streptococcal carriage in the throat can also help.

As CT scans are not ‘painful procedures’ options include:

A. Pharmacological options: including etomidate, ketamine, benzodiazepines, chloral hydrate, opiates, and anti-histamines (eg diphenhydramine). Although the use of many of these drugs for infants is restricted in many UK Emergency Departments.

B. Non-pharmacological options include:
Swaddling, calm and quiet environment, ‘non-nutritive suckling’ and oral sucrose.

Small amounts of sweet solutions, such as oral sucrose, in an infant’s mouth reduce procedural pain. The mechanism is an orally mediated increase in endogenous opioid. The analgesic effects last 5-8 minutes, making it an ideal strategy for management of short term pain. Sucrose is more effective if given with a dummy as this promotes non-nutritional sucking which contributes to calming. Oral sucrose is most effective in the first month of life, but it has also been shown to have analgesic and calming effects up to 18 months of age.

Miliary tuberculosis (TB).
This is the widespread dissemination of Mycobacterium tuberculosis. This arises when a tuberculous lesion in the lungs drains into a pulmonary vein. From here the bacilli are carried to the left side of the head, and from there disseminated throughout the body. It affects about 1.5% of all TB patients. Miliary TB is usually diagnosed from the CXR showing ‘millet-like’ 1-5mm opacities throughout the lung fields, however it can affect any organ.
Differential diagnosis of a CXR like this could include: ARDS, Pneumocysitis i pneumonia, lymphangitic spread of cancer (eg, thyroid carcinoma, malignant melanoma), viral/fungal pneumonia, hypersensitivity pneumonitis

Fundoscopy can reveal retinal tubercles, abdominal examination can elicit hepato-splenomegaly and ECG can be used to evaluate for the presence of a pericardial effusion.

The adrenals. An Addisonian crisis may result.

In general wounds to the face rarely become infected. However there are patient and wound factors that increase the risk of infection. Patient factors: diabetes, chronic renal failure, malnutrition, steroids, immunosuppressants, connective tissue disorders, elderly. Wound factors: presence of tissue destruction and wounds due to bites, particularly human bites.Patients with these factors should be considered for prophylactic antibiotics. In the case of human bites, a review of the use of antibiotics has been published as part of the Best Bets series: see link

No. Human saliva contains both a large number and large range of organisms. Infections can include Staphylococcus, streptococci, anaerobes including bacteroides and peptostreptococcus, and the slow growing gram negative, Eikenella corrodens.

Options include co-amoxiclav, doxycycline, and third generation cephalosporins.

Pneumomediastinum. This arises from the rupture of an alveolus, with air tracking back along the fascial planes associated with the bronchi and pulmonary vessels to reach the mediastinum. It has similar causes as pneumothoraces, and it is associated with coughing, asthma and COPD. It is also associated with cocaine sniffing because of the alveolar damage which can result. The average age at presentation is about 30, but some cases occur in COPD at an older age.
Most present with pleuritic-type chest pain which can radiate to the back. Surgical emphysema in the neck can be present. An interesting sign (Hamman’s crunch) of crepitus on auscultation during systole, is sometimes heard.

This is generally a benign condition, but tension in the air filled planes compressing the trachea has been reported. Spontaneous resolution is to be expected.

This is due to the extreme flattening of the diaphragm in COPD. This causes the ‘slips’ of diaphragm muscle passing to the ribs and costal cartilages to become higher than the dome of the diaphragm and to become silhouetted against pulmonary air.

Nitric oxide (NO) is released by enzymatic action on GTN. NO acts as a local signalling molecule in vessels, being released by the endothelium to cause smooth muscle relaxation and vasodilation. So GTN increases NO levels, increasing vessel dilatation. The main action in pulmonary oedema is to dilate capacitance vessels in the legs, reducing pre-load; there is also an effect on after-load. Although the stroke volume is unchanged, the myocardial workload, and hence oxygen consumption, is reduced.

GTN, in common with other nitrates, has a gradually declining effect over several weeks. This phenomenon is known as drug tolerance or tachyphylaxis; larger doses are needed to achieve the same effect. The problem is reduced, for example with transdermal patches, if they are removed at night.

The main other use of GTN is to relax the anal sphincter to allow healing of anal fissures. It has also been added to condoms to increase vasodilation and hence improve erectile performance. Its major non-medical use is an explosive. Following it’s discovery in 1847, it was Alfred Nobel (of Nobel prize fame) who developed it’s commercial use. The pure form is highly explosive if shaken. Nobel made it more stable by mixing it with clay to form dynamite. It was the headaches suffered by those who handled GTN which led ultimately to it’s medical exploitation for angina in 1887.

The mouthparts of ticks are barbed, so can easily be left behind in the skin, to become a source of infection. If the tick is pulled by the body, then the head and mouthparts may separate off. So the mouthparts need to be grasped close to the skin, fine forceps are ideal, with a good light and magnification (eg from an otoscope) . It is not clear whether twisting, or gradual traction are best – strong views are held on both options. However it is likely that simple traction is adequate, and that this will cause the tick to release its grasp.

There are a large number of different tick species across the UK, the majority of which do not transmit Lyme Disease. See Link. However several types can, and are not fussy what they bite. The commonest tick to bite humans in the UK is the Sheep Tick, a species of Ixodid ‘hard’ tick, which can transmit Lyme Disease. Although at one time Lyme Disease was considered a risk only around the New Forest, it is now known to occur more widely, particularly in areas where deer are found. So many areas of the UK are at risk, although around 50% of cases arise in Southern England. The tick waits on the tip of a blade of grass, and attaches to passing animals or clothing.

Lyme Disease is caused by a spirochaete, Borrelia burgdorferi. About 1,500 laboratory diagnoses of this condition are made in the UK each year, and the incidence has been increasing. It starts as a expanding raised red rash around the bite site, after an incubation of 3 to 30 days. Other symptoms vary widely but generally include feeling unwell, flu-like, with muscular aches and pains. If untreated chronic problems may develop, including cardiac conduction disorders, skin atrophy, joint swelling and neurological complications. Neurological complications can be subtle, like those of neurosyphilis, another spirochaete. See Link. Diagnosis can be difficult, and is clinical in the early stages. Serology can help later. A number of antibiotics are effective, including doxycycline.

Main causes of sudden painless bilateral blurred vision are: a) papilloedema, b) cerebrovascular accident (usually causes homonymous blurring), c) drugs (eg atropine-like, particularly in eye drops), and d) sudden refractive changes associated with diabetes.

With this patient the visual impairment was not homonymous (ie in part of the visual field), her only new treatment was thyroxine (which should not affect vision), and her retina was normal.

The likely cause was diabetes. Her blood glucose was 24.4 mmol/l. (Her urine dip stick showed maximum glucose and ketones).

Diabetes and thyroid disease are linked. This may partly be explained by autoimmune factors. Diabetics are three times as likely as others to have hypothyroidism.

The size is based on the measurement of the thickness of the rim of air around the lung at the level of the hilum; <2cm indicates a small pneumothorax, >2cm a large one. So in this case it is defined as a small pneumothorax.

As the patient is symptomatic with shortness of breath, regardless of the size of the pneumothorax, this requires intervention. In the case of a primary spontaneous pneumothorax this would be in the form of needle aspiration at the level of the 2nd intercostal space, mid-clavicular line with a wide bore cannula.

In contrast to the old guidelines, needle aspiration would not be repeated unless there was a technical fault with the 1st attempt i.e. the cannula kinked, this patient would need to undergo chest drain insertion. Interestingly 1/3 patient’s chest wall thickness at this point is greater than 5cm and the average cannula length is 4.5cm.

The new guidelines have indentified an entity called a catamenial pneumothorax which occurs within 72 hours of females starting their periods and is thought to be secondary to small endometrial deposits in the pleural causing the pneumothorax. The initial management is the same.