Tracheo-arterial fistula after tracheostomy causing massive haemorrhage is fortunately rare, but can be serious and often fatal. Brachiocephalic trunk is commonly at risk of erosion because of its close relation with the trachea. Factors responsible for fistula are pressure from tube rubbing on the trachea and adjacent vessel, infection, malignant neoplastic invasion of a vessel near the trachea and low tracheostomy. We present a rare case of massive arterial bleeding which happened on the second day and recurred on fifth day, because of slippage of the ligature from the thyroid artery, causing aspiration and death. A low tracheostomy below the third ring should be avoided. If there is bleeding, as a first-aid measure the cuff should be over inflated without removing the tracheostomy tube.

To examine the incidence of haemorrhage following tonsillectomy, to explore the usefulness of antibiotic in preventing postoperative haemorrhage and to examine if the haemorrhage depended on the level of expertise of the surgeon. A retrospective review analysing tonsillectomy method, the rate secondary haemorrhage, the grade of operating surgeon. A v 2 analysis was used to determine the statistical difference between the haemorrhage rates of different tonsillectomy methods. One thousand three hundred and thirty-six tonsillectomies were performed during this period by four different methods: 615 by cold steel dissection, 582 by Coblation, 32 by bipolar dissection and 107 by Helica thermal coagulation. 621 tonsillectomies were performed by Consultant grade and middle grades performed 693 operations. 124 patients (9.3 %) were readmitted with haemorrhage. The secondary haemorrhage requiring surgery for controlling bleeding for cold steel dissection method was 1.5 % compared to 6.7 % for coblation method (P \ 0.01 %), 6.3 % for bipolar dissection and 1.9 % for Helica thermal coagulation method. Overall consultants had a post tonsillectomy haemorrhage rate of 5.5 % and middle grades had a rate of 3.7 %. 86.5 % of the patients were already on routine prophylactic oral antibiotics at the time of presentation with haemorrhage needing surgical arrest and 13.5 % were not on antibiotics (P \ 0.05 %). There was statistically significant difference in secondary haemorrhage rate between coblation and cold steel dissection methods. Coblation tonsillectomies had an increased need for operative intervention to control secondary haemorrhage. Routine use of antibiotic and expertise of operating surgeon had no bearing on secondary haemorrhage rate.

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Bilateral myringotomy with insertion of ventilation tube (grommet) is the most common surgical procedure done on children under general anaesthetic. A prospective study was conducted on children undergoing grommet insertion to ascertain any relationship between exposures of passive smoking to the outcome of grommet insertion. Six hundred and six children (with 1174 ears) who underwent grommet insertion for recurrent secretory otitis media were followed up till the grommets were extruded. Thirty-three children (65 per cent), whose mothers smoked when they were pregnant, had bilateral narrow external ear canals. The median survival rate of grommet was 59 weeks in children who were exposed to passive smoking as compared to 86 weeks for non-exposed children and the extrusion rate of grommet was 36 per cent higher at the end of one year if both parents smoked compared to the non-smoking group. Post-extrusion myringosclerosis was 64 per cent if both parents smoked and less than 20 per cent if neither parents smoked. It is concluded that post-operative infection rate, attic retraction, post-extrusion myringosclerosis and permanent perforations of tympanic membrane were more common in children exposed to passive smoking. The study provides further support to professional and governmental advice that passive smoking is harmful.

To assess the validity of tympanometry as a test for the presence of middle ear effusion using a 'gold-standard' of myringotomy performed after a nitrous oxide-free general anaesthetic, we performed a prospective validity study comparing tympanometry traces obtained immediately pre-operatively from patients undergoing grommet insertion, with the otomicroscopic findings at myringotomy. Nitrous oxide was omitted from the anaesthetic gaseous mixture as it has been reported to displace middle ear effusions. One hundred and seventy-two patients (aged 1.5-15 years) with a clinically assessed 3 month history of middle ear effusion were included in the study. Sensitivity and specificity of a Jerger classification Type B tympanometric trace for the presence of middle ear effusion were 0.73 and 0.84, respectively. We conclude that tympanometry is a valid test in assessing the presence of middle ear effusion compared to a 'gold standard' of myringotomy performed after a nitrous oxide-free general anaesthetic.

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