This study aimed to develop and evaluate a low-cost orbital prosthesis for simulation of endoscopically assisted intra-orbital anterior ethmoidal artery ligation.

A low-cost orbital prosthesis was built and evaluated by ENT surgical trainees. Feedback was given following the assessment in the form of a face validity questionnaire.

Results were scored on a Likert scale of 1–7 (low to high). Trainees had limited exposure to the procedure (40 per cent) and predominantly low levels of confidence (mean, 3.67) that correlated with a lack of first-hand experience. The anatomy and likeness to human tissue of the prosthesis were both ranked highly, with mean scores of 5.0 and 4.93, respectively.

The results of this study support the idea that a simple anatomical prosthesis for the simulation of endoscopic anterior ethmoidal artery ligation can be created with potential value to otolaryngology surgical training. To the authors’ knowledge, this is the first documentation of simulated surgical epistaxis management using an artificial anatomical model.

There is currently limited evidence regarding the potential complications of sphenopalatine artery ligation. The post-operative outcomes at two secondary care centres over a 10-year period were reviewed.

A retrospective review was undertaken of patients undergoing emergency and elective sphenopalatine artery ligation between January 2011 and January 2021. Their demographics, peri-operative care and post-operative outcomes were recorded. The median follow-up time was 54 days (range, 0–2657 days).

Ninety-one patients were included. Four patients (4.4 per cent) had a septal perforation at post-operative review. Nineteen patients (20.9 per cent) had post-operative bleeding that extended their in-patient stay, with five patients (5.5 per cent) requiring revision surgery. Pre-operative non-dissolvable nasal packing was used a median of 1 time (range, 0–8 times).

Further research on outcomes of sphenopalatine artery ligation is needed. Pre-operative non-dissolvable nasal packing, concurrent septal surgical procedures, surgical techniques, and co-morbidities such as hypertension represent potential confounding factors that could not be further assessed in this small, retrospective study.

There is variation regarding the use of surgery and interventional radiological techniques in the management of epistaxis. This review evaluates the effectiveness of surgical artery ligation compared to direct treatments (nasal packing, cautery), and that of embolisation compared to direct treatments and surgery.

A systematic review of the literature was performed using a standardised published methodology and custom database search strategy.

Thirty-seven studies were identified relating to surgery, and 34 articles relating to interventional radiology. For patients with refractory epistaxis, endoscopic sphenopalatine artery ligation had the most favourable adverse effect profile and success rate compared to other forms of surgical artery ligation. Endoscopic sphenopalatine artery ligation and embolisation had similar success rates (73–100 per cent and 75–92 per cent, respectively), although embolisation was associated with more serious adverse effects (risk of stroke, 1.1–1.5 per cent). No articles directly compared the two techniques.

Trials comparing endoscopic sphenopalatine artery ligation to embolisation are required to better evaluate the clinical and economic effects of intervention in epistaxis.

Endoscopic sphenopalatine artery ligation is widely accepted as effective and safe for acute spontaneous epistaxis that is unresponsive to conservative management. As with many new procedures, it has been progressively adopted as common practice, despite a limited evidence base for its efficacy. Early reviews called for comparative trials to support its adoption, but subsequent literature largely consists of case series and narrative reviews. These have attempted to derive an algorithm to establish its place in management, but consensus is still lacking. Intuitively, although there are theoretical objections, an operation regarded as relatively simple, fast and safe hardly seems to demand high-level evidence of efficacy. Rhinologists may be influenced by years of personal experience and success with the technique. However, estimates of the effect size and the added contribution to traditional surgical management are lacking. If the procedure could be shown to dramatically influence outcome, it should be standard practice and indispensable for all patients requiring operative intervention.

This paper systematically examined the literature, appraising the anatomical basis for such an approach and evidence for its efficacy. It questions whether any units unable to consistently offer endoscopic sphenopalatine artery ligation should be undertaking surgical management of acute epistaxis.

To report previously unreported complications of bilateral sphenopalatine artery ligation.

We present the case of a 45-year-old man who underwent bilateral sphenopalatine artery ligation to control intractable posterior epistaxis. After four months, he re-presented with nasal obstruction and crusting.

Examination under general anaesthesia showed posterior septal perforation and bilateral necrosis of the lower parts of the middle turbinates. The necrotic parts were excised. The patient had no more complaints.

Following sphenopalatine artery occlusion, ischaemic necrosis is a potential risk in anatomical areas that receive their only arterial supply from this artery. The staging of bilateral sphenopalatine artery occlusion needs to be studied.

More than a century has passed since Emil Theodor Kocher first described the use of ‘Kocher's thyroid dissector’ to secure the superior thyroid pedicle.

Despite the technological advances in thyroid surgery, the dissector remains an extremely useful instrument. This paper describes a modified use of the dissector, and reports on how this facilitates safer and easier surgery.

Application of this simple, modified technique can improve the safety and efficiency of thyroid surgery, with negligible financial outlay.

Surgical ligation of patent ductus arteriosus is considered when medical treatment fails or is contraindicated. This study aims to determine the mortality and morbidity of preterm neonates referred for patent ductus arteriosus ligation.

A prospective study was conducted in the East of England to follow the outcome of premature infants under 37 weeks’ gestation undergoing patent ductus arteriosus ligation. A standardised proforma was used to collect information before and after the procedure.

A total of 102 premature infants were recruited, and patent ductus arteriosus ligation was performed in 92. Surgical complications occurred in 8.7% (8/92), which included pneumothorax (5/8), recurrent laryngeal nerve palsy (2/8), and chylothorax (1/8). Morbidity outcome data were not available for all infants. The incidence of chronic lung disease was 88% (88/99); intraventricular haemorrhage was 49% (49/100); necrotising enterocolitis 39% (39/99), and retinopathy of prematurity 42% (41/97). The overall mortality rate in our study was 7.8% (8/102). Mortality rate in infants who had patent ductus arteriosus ligation was 4.3% (4/92). The 30-day survival rate after ligation was 99% (91/92). Beyond 30 days post-ligation, three infants died from other causes that were not directly related to surgery.

Patent ductus arteriosus ligation in premature infants is associated with low mortality and complication rates; however, there is a high incidence of neonatal morbidity. Surgical capacity for patent ductus arteriosus ligation needs to be carefully planned nationally as the duration of “waiting time” and transport to another surgical centre could adversely affect outcomes in this high-risk population.

To perform surgical closure of a clinically significant arterial duct on children in a third world country.

An arterial duct is one of the most common congenital cardiac defects. Large arterial ducts can cause significant pulmonary overcirculation, causing symptoms of congestive cardiac failure, ultimately resulting in premature death. Closure of an arterial duct is usually curative, allowing for a normal quality of life and expectancy. In western countries, arterial duct closure in children is usually performed by deployment of a device through a catheter-based approach, replacing previous surgical approaches. In third world countries, there is limited access to the necessary resources for performing catheter-based closure of an arterial duct. Consequently, children with an arterial duct in a third world country may only receive palliative care, can be markedly symptomatic, and often do not survive to adulthood.

We assembled a team of 11 healthcare workers with extensive experience in the medical and surgical management of children with congenital cardiac disease. In all, 21 patients with a history of an arterial duct were screened by performing a comprehensive history, physical, and echocardiogram at the Angkor Hospital for Children in Siem Reap, Cambodia.

A total of 18 children (eight male and ten female), ranging in age from 10 months to 14 years, were deemed suitable to undergo surgery. All patients were symptomatic, and the arterial ducts ranged in size from 4 to 15 millimetres. Surgical closure was performed using two clips, and in four cases with the largest arterial duct, sutures were also placed. All patients had successful closure without any significant complications, and were able to be discharged home within 2 days of surgery. Of note, four children with arterial ducts died in the 5 months before our arrival.

Surgical closure of an arterial duct can be performed safely and effectively by an experienced paediatric cardiothoracic surgical team on children in a third world country. We hope that our experience will inspire others to perform similar missions throughout the world.

Multiple surgical procedures have been advocated for the management of problematic drooling in neurologically impaired children. Parotid duct ligation is a quick and simple operation conducted via an intra-oral approach and usually performed simultaneously with other procedures. In this study, we aimed to evaluate the effectiveness of parotid duct ligation as a discrete procedure.

All children who underwent bilateral parotid duct ligation as the solitary operative intervention at that time, between February 2003 and September 2006, were included in the study.

Ten children were studied. Surgery was successful in 80 per cent of cases. One patient (10 per cent) had a post-operative wound infection.

Bilateral parotid duct ligation is an effective yet conservative operation for drooling in neurologically impaired children. It requires minimal surgical dissection and has a low morbidity rate. It should be considered as a potential first-line procedure in children who aspirate, and as a further surgical option in anterior droolers or those who continue to drool unacceptably following prior surgical intervention.

To identify measurements that may help intra-operative localisation of the sphenopalatine foramen.

The study used three-dimensional surgical navigation software to study radiological anatomy, in order to define the distances and angulations between identifiable bony landmarks and the sphenopalatine foramen.

The distance from the anterior nasal spine to the sphenopalatine foramen was 59 mm (±4 mm; inter-observer variation = 0.866; intra-observer variation = 0.822). The distance from the piriform aperture to the sphenopalatine foramen was 48 mm (±4 mm; inter-observer variation = 0.828; intra-observer variation = 0.779). The angle of elevation from the nasal floor to the sphenopalatine foramen was 22° (±3°; inter-observer variation = 0.441; intra-observer variation = 0.499).

The sphenopalatine foramen is consistently identifiable on three-dimensional, reconstructed computed tomography scans. Repeatable measurements were obtained. The centre point of the foramen lies 59 mm from the anterior nasal spine at 22° elevation above the plane of the hard palate and 48 mm from the piriform aperture. We discuss how these data could be used to facilitate intra-operative location of the sphenopalatine foramen in difficult cases.