Drain, don't probe

INTRODUCTION Surgery for ingrowing toenails carries a significant re-operation rate. We reviewed our departmental figures to assess the optimal management of these patients. PATIENTS AND METHODS We performed a 10-year retrospective review of all patients undergoing surgery for ingrown toenails (IGTN) in order to determine the operations most commonly used and the re-operation rate of each of these procedures. RESULTS A total of 880 procedures were performed on 414 patients. The median age at operation was 8.5 years. About half (48%) of children underwent two or more procedures with wedge excision and phenol application being the most common initial and repeat procedure. Recurrent surgery was most likely following plain avulsion or wedge avulsion without phenol application. Excision of the nailbed with phenol application had the lowest recurrence rate at 18.4%. CONCLUSIONS We recommend wedge resection with phenol application as first-line treatment with simple avulsion reserved for severely infected toes. Total nail bed excisions should be reserved for patients with significant on-going morbidity associated with IGTN. Families must be made aware of the likely outcome of IGTN surgery and the choice of operation must be tailored to the individual.

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The results of a prospective study of 20 cases of newly diagnosed Hirschsprung's disease (nine of whom developed enterocolitis) and 10 normal controls showed no variations in the bacterial flora (including Clostridium difficile) in the stools of the groups studied. Viral studies showed that rotavirus was present in the stools of seven of the nine cases of enterocolitis during the episode. We suggest that Hirschsprung's enterocolitis may have a complex infective aetiology and that rotavirus plays a part.

SUMMARYTo assess the reasons for and outcomes of referrals concerning the foreskin, 100 consecutive patients seen in paediatric clinics were followed to discharge.18 referrals were for circumcision on religious grounds. Of the other 82, the main reason for referral was nonretractability or phimosis. At clinic, 24 (29%) of these were deemed normal for age, 31 (38%) were treated with topical steroid (successfully in 25), 9 (11%) were listed for preputioplasty, 7 (9%) were listed for adhesiolysis, 7 (9%) were listed for circumcision, and 4 were listed for other forms of surgery. 6 patients were identified as having balanitis xerotica obliterans (BXO), a condition that had not been suggested on referral.With the advent of new treatments for foreskin disorders, circumcision is decreasingly necessary. Knowledge of the natural history of the foreskin, and the use of topical steroids, could shift the management of paediatric foreskin problems from the hospital outpatient department to primary care. BXO is not sufficiently recognized as a form of phimosis that requires operation.

To assess the reasons for and outcomes of referrals concerning the foreskin, 100 consecutive patients seen in paediatric clinics were followed to discharge. 18 referrals were for circumcision on religious grounds. Of the other 82, the main reason for referral was non-retractability or phimosis. At clinic, 24 (29%) of these were deemed normal for age, 31 (38%) were treated with topical steroid (successfully in 25), 9 (11%) were listed for preputioplasty, 7 (9%) were listed for adhesiolysis, 7 (9%) were listed for circumcision, and 4 were listed for other forms of surgery. 6 patients were identified as having balanitis xerotica obliterans (BXO), a condition that had not been suggested on referral. With the advent of new treatments for foreskin disorders, circumcision is decreasingly necessary. Knowledge of the natural history of the foreskin, and the use of topical steroids, could shift the management of paediatric foreskin problems from the hospital outpatient department to primary care. BXO is not sufficiently recognized as a form of phimosis that requires operation.

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SUMMARY Scrotal swelling is a common cause of referral to the paediatric surgical services in Edinburgh, constituting 12% of total admissions. Of these, 2818 (65%) were in boys under the age of 5 years, with a wide variety, including inguinal hernias, hydroceles, testicular torsion, tumours, and some interesting but uncommon conditions. A retrospective study was performed over a 12 year period to assess the incidence, aetiology, mode of presentation, disease, and management of scrotal swellings in boys under 5. Although most of the causes of these swellings were easily elucidated from a history and clinical examination, it was apparent that a high level of suspicion was also necessary to ensure that more serious problems did not go undetected.This paper studies the incidence, aetiology, disease, mode of presentation, and management of scrotal swellings presenting over a 12 year period in boys under the age of 5 years.A total of 37 001 patients were admitted to the paediatric surgical wards in Edinburgh (Royal Hospital for Sick Children, Western General Hospital, and Leith Hospital) over this period. Of these, 4341 were due to scrotal swelling, and 2818 of the scrotal swellings were in boys under 5.The case notes of these patients admitted due to scrotal swelling were examined and assessed by the author and the findings presented. FindingsInguinal hernia. A total of 2031 inguinal hernias were seen in boys under 5 during the 12 years. These constituted 60% of the total inguinal hernias seen. There was, incidentally, an overall boy:girl ratio of 4:1 in the paediatric age group over this period also. Details of these hernias are given in Table 1.Hydroceles. A total of 753 hydroceles in the under 5s were operated on during this period (86% of the total hydroceles seen). Of these, 507 (67%) were right sided, 185 (25%) left sided, and 61 (8%) bilateral.Testicular torsion. Altogether, 25 cases of testicular torsion (or torsion of testicular appendages) were seen within the age group of this study (56% of the total seen). Details of these are given in Table 2.