Patients frequently present to the emergency department for removal of foreign bodies from the nose or ear. Early descriptions of foreign body removal from Roman times include "An insect must first be killed with vinegar and then removed with a probe; the patient should be encouraged to sneeze or better still he should be bound to a table with the aVected ear downwards and the table struck with a hammer so that the foreign body may be shaken out of the ear". 1Little scientific evidence regarding the best method of foreign body removal exists. The diverse nature of the problem has precluded randomised controlled trails and the medical literature consists mainly of anecdotal case reports. Unfortunately it sometimes seems as if the cavalier attitude to these problems has changed little from those 2000 years ago. The following review attempts to provide a logical, up to date approach to this common complaint. MethodsMedline 1966 to August 1998 was searched using the OVID interface and the search terms [{exp foreign bodies OR foreign body.mp} AND {exp nose OR nose.mp OR exp ear OR ear.mp}] LIMIT to human and English language. All appropriate articles were retrieved and further searched for relevant references, which were in turn followed up until a complete picture of all previous literature was assembled. These papers were supplemented by information from major ear, nose, and throat (ENT) and emergency medicine textbooks. Aetiology and epidemiologyPatients presenting with foreign bodies in the nose or ear are predominantly children in the 2 to 8 age group.2 Foreign bodies in the nose are less common than those in the ear and occur almost exclusively in children. The earliest presentation is likely to be around the age of 9 months when a child develops a pincer grip, allowing easy manipulation of small objects.

BackgroundPostoperative deaths and neurological injury have resulted from hyponatraemia associated with the use of hypotonic saline solutions following surgery. We aimed to determine the rates and types of intravenous fluids being prescribed postoperatively for children in the UK.MethodsA questionnaire was sent to members of the British Association of Paediatric Surgeons (BAPS) and Association of Paediatric Anaesthetists of Great Britain and Ireland (APAGBI) based at UK paediatric centres. Respondents were asked to prescribe postoperative fluids for scenarios involving children of different ages. The study period was between May 2006 and November 2006.ResultsThe most frequently used solution was sodium chloride 0.45% with glucose 5% although one quarter of respondents still used sodium chloride 0.18% with glucose 4%. Isotonic fluids were used by 41% of anaesthetists and 9.8% of surgeons for the older child, but fewer for infants. Standard maintenance rates or greater were prescribed by over 80% of respondents.ConclusionMost doctors said they would prescribe hypotonic fluids at volumes equal to or greater than traditional maintenance rates at the time of the survey. A survey to describe practice since publication of National Patient Safety Agency (NPSA) recommendations is required.

A case of domestic violence is reported. The patient presented with the triad of injuries associated with the shaking of infants: retinal haemorrhages, subdural haematoma, and patterned bruising; this has been described as the shaken adult syndrome. This case report reflects the diYculties in diagnosing domestic violence in the accident and emergency setting. (J Accid Emerg Med 2000;17:138-139) Keywords: domestic violence; women; assault Domestic violence is an under-reported and major public health problem that often first presents to the accident and emergency (A&E) department. It accounts for half of all violent crimes against women, and two deaths per week have been linked to domestic violence in Britain.1 Indeed, the Department of Health has issued statements to ensure health professionals are aware of domestic violence in this context when patients present with consistent traumatic injuries. 2The following case report reflects the diYculties in diagnosing domestic violence in the A&E setting, and stresses the timely referral of such patients to the relevant authorities. Case reportA 34 year old woman was brought to the A&E department by ambulance at 0400 hours with head injuries. When handed over from the ambulance crew an assault was queried, although the patient later stated she had fallen down stairs after moderate alcohol ingestion.Her initial blood pressure was 119/72 mm Hg, pulse 88 beats/min, her pupils were equal and reactive directly and consensually, and her Glasgow coma score was 13/15 (she was confused and was opening her eyes to command). Examination of the head showed bilateral periorbital ecchymoses, nasal bridge swelling and epistaxis, a right frontal abrasion, and an occipital scalp haematoma. Ecchymoses were also noted on her back and buttocks, being linear in fashion on both upper arms, and her underpants were torn. Initial skull and facial x ray films were normal, and she was admitted under the care of A&E for neurological observations.Over the next 24 hours, her Glasgow coma score improved to 15/15, but she had vomited five times and complained that her vision remained blurred. Visual acuity was only hand movements in the right eye and finger counting in the left. Ophthalmological review confirmed both retinal and preretinal haemorrhages in the right eye and a retinal haemorrhage on the left. Both maculae were aVected by the haemorrhage (fig 1). Haematological investigations, including a full blood count and a clotting screen, were within normal parameters, and computed tomography of the head revealed a small left temporal subdural haemorrhage with adjacent oedema.It was only after 48 hours and repeated advice that she should seek help and report the injuries to the police, that she admitted that domestic violence had occurred.Ongoing police and consultant medical review showed photographic evidence of patterned bruising to the upper arms, and also several circular burns to the face and arm, similar to the type caused by the deliberate Five weeks after the initial injury s...

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