A retrospective study was carried out in Oman to determine the incidence of neural tube defects (NTD) and congenital hydrocephalus (CH) and to identify any possible associations. National data retrieved from hospital records revealed the incidence of NTD in Oman to be comparatively low (1.25 per 1000), but the incidence of CH was much higher than that seen in Western Europe (0.44 per 1000) and was found to be associated with high rates of other congenital anomalies and neonatal death. There were no specific environmental factors associated with NTD and high environmental temperatures during the tropical desert summer (temperatures reach 48 degrees C) were excluded as a causative factor. In spina bifida families, later born children were more likely to be affected and there was also an association with increased maternal but not paternal age. Much higher consanguinity rates were noted in families with NTD and CH than in the general population.

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In a series of 68 operations for insertion or revision of cerebrospinal fluid shunts the incidence of infection was reduced from 20% in controls to 4.2% when systemic and intrathecal or intra-shunt gentamicin prophylaxis was employed. The only infection occurring in the latter group was due to an organism resistant to gentamicin. No reduction in infection rate was noted when povidone iodine was instilled into the wounds.

The rapid propagation of small electronic gadgets and toys controlled by alkaline batteries has brought these potentially lethal objects within the reach of small children whose natural instinct is to put everything into the mouth. Tracheooesophageal fistula caused by alkaline battery ingestion is a rare complication but highlights the hazards of ignoring these foreign bodies. Case reportA 16-month-old girl was admitted with dysphagia of 4 weeks' duration. Chest radiography showed a coin-shaped foreign body in the upper oesophagus ( Figure I ) , which was removed endoscopically. The object was a 1-cm diameter watch battery which the child had swallowed several weeks earlier.Postoperatively, the child continued to have feeding problems which failed to resolve with nasogastric feeds. A barium swallow showed a large tracheo-oesophageal fistula at the level of the thoracic inlet ( Figure 2). Nasogastric feeding was continued, and chest physiotherapy and antibiotics were commenced to improve her nutritional and respiratory status.Three weeks later, via a right-sided cervical approach, a I-cm diameter fistula was found between the trachea and the oesophagus. The fistula was divided and the defects repaired with 4-0 silk sutures. A postoperative oesophageal leak closed spontaneously, and a repeat contrast study was satisfactory. Oral feeding was re-established, but 6 weeks later the child was readmitted with a radiologically confirmed recurrent fistula.Re-exploration revealed a 3-mm diameter tracheo-oesophageal fistula which was divided. The trachea and oesophagus were completely separated over a 5-cm length and the defects were repaired with 4-0 polydiaxonone sutures. A 5-cm square patch of GORE-TEX" (W. L. Gore and Associates Incorporated) was laid in between the trachea and oesophagus and was sutured to the trachea.A temporary oesophageal leak occurred after operation but a contrast study 6 weeks later failed to detect recurrence of the fistula. The symptoms of coughing with feeds persisted and a repeat study confirmed a second recurrence of the tracheo-oesophageal fistula. The child was then referred to the Hospital for Sick Children, Great Ormond Street, for further management.The recurrence of the tracheo-oesophageal fistula was confirmed endoscopically. A ureteric catheter was passed into the oesophagus through the fistula at bronchoscopy, via a transverse cervical incision; the trachea and oesophagus were exposed with considerable difficulty because of dense fibrosis and the fistula was identified. The tracheal defect was repaired with interrupted 4-0 Prolene(* (Ethicon Ltd., Edinburgh, UK) sutures. A 3-cm length of oesophagus including the fistula was resected and an end-to-end anastomosis was performed in two layers with 4-0 polyglycolic acid sutures. Omohyoid muscle was mobilized and placed between the trachea and oesophagus.Repeat endoscopy at 3 weeks confirmed successful repair. The child remains symptom-free 9 months after operation.

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