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Objectives: Current Accreditation Council for Graduate Medical Education (ACGME) requirements allow PGY-1 otolaryngology-head and neck surgery (ORL-HNS) residents to spend 6 months on service, prompting reconsideration of educational best practices for the first-year resident experience. The aim of this study was to determine feasibility and value of a 1-month PGY-1 otolaryngology clinical skills rotation integrated with anesthesiology to complement clinical ORL-HNS rotations. Methods: Our institution developed a 1-month rotation focusing on procedural simulation and airway management as a collaborative effort between ORL-HNS and anesthesiology. Logistics of curriculum design and implementation in the first 2 years are described. Learner outcome measures include pre- and postintervention Likert scale measures of knowledge and confidence. Statistical assessment of curriculum efficacy includes Wilcoxon sign rank test and effect size (Cohen’s d). Results: The described rotation was successfully implemented for 8 entering PGY-1 residents in the 2016-2017 and 2017-1018 academic years. Learners reported significant improvement in knowledge and confidence (5-point Likert scale, all P < .0001) in each of the following grouped domains following the intervention: anesthesia skills (pre 2.79, post 4.02), anesthesia knowledge (pre 2.31, post 3.50), anesthesia overall preparedness (pre 2.75, post 4.04), otolaryngology skills (pre 2.90, post 4.19), otolaryngology scenarios (pre 2.80, post 4.00), and otolaryngology overall preparedness (pre 2.38, post 3.75). Very large effect sizes (Cohen’s d, range = 1.6-2.9) were observed. Conclusion: Changing rotation structure in ORL-HNS training programs provides an opportunity to develop novel rotations with high educational impact. Early outcome data suggest that the described clinical skills rotation is practically feasible and was perceived to have measurable value as part of the PGY-1 curriculum.

Purpose: As the COVID-19 pandemic has unfolded, there has been growing recognition of risks to the anesthesia and surgical teams that require careful consideration to ensure optimal patient care. Airway management and other head and neck procedures risk exposure to mucosal surfaces, secretions, droplets, and aerosols that may harbor the SARS-CoV-2 virus. This review provides guidance on optimal practice approaches for performing patient evaluation and management of head and neck procedures with the shared goal of providing safe and effective patient care while minimizing the risk of viral transmission. Methods: The scientific literature was evaluated, focusing on strategies to reduce risk to health care workers involved in airway management and head and neck surgery. The search strategy involved curating consensus statements and guidelines relating to COVID-19 or prior coronavirus outbreaks in relation to aerosol-generating procedures (AGPs) and other high-risk procedures, with the search restricted to the scope of head and neck anesthesia. A multidisciplinary team analyzed the findings, using iterative virtual communications through video conference, telephone, email, and shared online documents until consensus was achieved, loosely adapted from the Delphi technique. Items without consensus were so indicated or removed from the manuscript. Results: Health care worker infection and deaths during the COVID-19 pandemic and prior outbreaks mandate robust standards for infection control. Most head and neck anesthesiology procedures generate aerosols, and algorithms may be modified to mitigate risks. Examples include preoxygenation before induction of anesthesia, rapid sequence induction, closing circuits expeditiously, and consideration of apneic technique for surgical entry of airway. Rescue measures are also modified, with supraglottic airways elevated in the difficult airway algorithm to minimize the need for bag mask ventilation. Personal protective equipment for AGPs include fit-tested N95 mask (or purified air positive respirator), gloves, goggles, and gown for patients with known or suspected COVID-19. Meticulous donning and doffing technique, minimizing personnel and room traffic, diligent hand hygiene, and social distancing all can decrease risks. Perioperative management approaches may differ from commonly employed patterns including avoidance of techniques such as jet ventilation, high-flow nasal oxygen and instead utilizing techniques with a closed ventilatory circuit and secured endotracheal tube, minimizing open suctioning, and preventing aerosolization at emergence. Recommendations are made for the following head and neck procedures and considerations: primary airway management; high-flow nasal oxygen delivery; jet ventilation for laryngotracheal surgery; awake intubation; transnasal skull base surgery; tracheostomy; and use of personal protective equipment. COVID-19 testing may facilitate decision making, but it is currently often unavailable and urgency of surgical treatment must be considered. Conclusions: During pandemics, head and neck anesthesia and surgical teams have a duty to not only provide high quality patient care but also to ensure the safety of the health care team. Several specific perioperative approaches are recommended that have some variance from commonly employed practices, focusing on the reduction of AGP to minimize the risk of infection from patients with known or suspected COVID-19 infection.

BackgroundMultiple attempts at tracheal intubation are associated with mortality, and successful rescue requires a structured plan. However, there remains a paucity of data to guide the choice of intubation rescue technique after failed initial direct laryngoscopy. The authors studied a large perioperative database to determine success rates for commonly used intubation rescue techniques.MethodsUsing a retrospective, observational, comparative design, the authors analyzed records from seven academic centers within the Multicenter Perioperative Outcomes Group between 2004 and 2013. The primary outcome was the comparative success rate for five commonly used techniques to achieve successful tracheal intubation after failed direct laryngoscopy: (1) video laryngoscopy, (2) flexible fiberoptic intubation, (3) supraglottic airway as part of an exchange technique, (4) optical stylet, and (5) lighted stylet.ResultsA total of 346,861 cases were identified that involved attempted tracheal intubation. A total of 1,009 anesthesia providers managed 1,427 cases of failed direct laryngoscopy followed by subsequent intubation attempts (n = 1,619) that employed one of the five studied intubation rescue techniques. The use of video laryngoscopy resulted in a significantly higher success rate (92%; 95% CI, 90 to 93) than other techniques: supraglottic airway conduit (78%; 95% CI, 68 to 86), flexible bronchoscopic intubation (78%; 95% CI, 71 to 83), lighted stylet (77%; 95% CI, 69 to 83), and optical stylet (67%; 95% CI, 35 to 88). Providers most frequently choose video laryngoscopy (predominantly GlideScope® [Verathon, USA]) to rescue failed direct laryngoscopy (1,122/1,619; 69%), and its use has increased during the study period.ConclusionsVideo laryngoscopy is associated with a high rescue intubation success rate and is more commonly used than other rescue techniques.

External laryngeal trauma is a rare but potentially fatal event that presents several management challenges. This retrospective observational case series conducted at a level-1 trauma center over a 12-year period consists of 62 cases of acute external laryngeal trauma. Patient demographics, mode and mechanisms of injury, presenting signs and symptoms, initial imaging results, airway management, time to surgical management, and 6-month outcomes including airway status, deglutition status, and voice quality were investigated. No difference was found in mortality or 6-month outcomes between patients requiring surgical repair and/or tracheostomy versus patients with less severe injuries managed conservatively.

Background and objectives Recognizing the risk of fire during laser procedures involving the airway, the American Society of Anesthesiologists (ASA) developed recommendations designed to promote safe practice and reduce burn injuries. The aim of this study was to identify how reported anesthetic management of airway laser endoscopies in pediatric patients aligns with the ASA Practice Advisory (ASA-PA). Methods An online survey was created in an iterative process, pilot-tested, and distributed using the Society for Pediatric Anesthesia's (SPA) membership email list. Responses were analyzed using descriptive statistics. Results Responses from 322 respondents were included, 296 (92%) of whom participated in pediatric laser airway procedures. Fifty-nine respondents (20%) reported the use of an inspired fraction of oxygen (FiO 2 ) of 90% or greater during laser activation in patients with a native airway, and 101 (34%) reported not waiting after the reduction of the FiO 2 and laser activation in the airway. Sixty-four (36%) of respondents reporting the use of a non-laser-safe tube during laser airway cases did so due to a lack of availability of a laser specific tube or size limitations. Six respondents (2%) reported an airway fire during a laser procedure in a child under their care. Conclusions Our results indicate that, in general, pediatric anesthesiologists do not adhere to the ASA-PA in several important aspects. Possible explanations might be knowledge deficiencies about the Practice Advisory or a perceived limited clinical applicability in the pediatric setting. Regardless, airway fires during laser airway surgeries in this population do occur, emphasizing the need for safe practice standards for both anesthesiologists and surgeons.

Background: Research regarding difficult mask ventilation (DMV) combined with difficult laryngoscopy (DL) is extremely limited even though each technique serves as a rescue for one another. Methods: Four tertiary care centers participating in the Multicenter Perioperative Outcomes Group used a consistent structured patient history and airway examination and airway outcome definition. DMV was defined as grade 3 or 4 mask ventilation, and DL was defined as grade 3 or 4 laryngoscopic view or four or more intubation attempts. The primary outcome was DMV combined with DL. Patients with the primary outcome were compared to those without the primary outcome to identify predictors of DMV combined with DL using a non-parsimonious logistic regression. Results: Of 492,239 cases performed at four institutions among adult patients, 176,679 included a documented face mask ventilation and laryngoscopy attempt. Six hundred ninety-eight patients experienced the primary outcome, an overall incidence of 0.40%. One patient required an emergent cricothyrotomy, 177 were intubated using direct laryngoscopy, 284 using direct laryngoscopy with bougie introducer, 163 using videolaryngoscopy, and 73 using other techniques. Independent predictors of the primary outcome included age 46 yr or more, body mass index 30 or more, male sex, Mallampati III or IV, neck mass or radiation, limited thyromental distance, sleep apnea, presence of teeth, beard, thick neck, limited cervical spine mobility, and limited jaw protrusion (c-statistic 0.84 [95% CI, 0.82–0.87]). Conclusion: DMV combined with DL is an infrequent but not rare phenomenon. Most patients can be managed with the use of direct or videolaryngoscopy. An easy to use unweighted risk scale has robust discriminating capacity.

Lean is a management system designed to enhance productivity by eliminating waste. Surgical practice offers many opportunities for improving efficiency. Our objective was to determine whether systematic implementation of lean thinking in an academic otolaryngology operating room improves efficiency and profitability and preserves team morale and educational opportunities.In an 18-month prospective quasi-experimental study, a multidisciplinary task force systematically implemented lean thinking within an otolaryngology operating room of an academic health system. Operating room turnover time and turnaround time were measured during a baseline period; an observer-effect period in which workers were made aware that their efficiency was being measured but before implementing lean changes; and an intervention period after redesign principles had been used. The impact on teamwork, morale, and surgical resident education were measured during the baseline and intervention periods through validated surveys. A profit model was applied to estimate the financial implications of the study.There was no difference between the baseline and observer-effect periods of the study for turnover time (p = 0.98) or turnaround time (p = 0.20). During the intervention period, the mean turnover time and turnaround time were significantly shorter than during the baseline period (29 vs 38 minutes; p0.001 and 69 vs 89 minutes; p0.001, respectively). The composite morale score suggested improved morale after implementation (p = 0.011). Educational metrics were unchanged before and after implementation. The annual opportunity revenue for the involved operating room is $330,000; when extrapolated throughout the operating rooms, lean thinking could create 6,500 hours of capacity annually.Application of lean management techniques to a single operating room and surgical service improved operating room efficiency and morale, sustained resident education, and can provide considerable financial gains when scaled to an entire academic surgical suite.

Introduction The Glidescope video laryngoscope has been shown to be a useful tool to improve laryngeal view. However, its role in the daily routine of airway management remains poorly characterized. Methods This investigation evaluated the use of the Glidescope at two academic medical centers. Electronic records from 71,570 intubations were reviewed, and 2,004 cases were identified where the Glidescope was used for airway management. We analyzed the success rate of Glidescope intubation in various intubation scenarios. In addition, the incidence and character of complications associated with Glidescope use were recorded. Predictors of Glidescope intubation failure were determined using a logistic regression analysis. Results Overall success for Glidescope intubation was 97% (1,944 of 2,004). As a primary technique, success was 98% (1,712 of 1,755), whereas success in patients with predictors of difficult direct laryngoscopy was 96% (1,377 of 1,428). Success for Glidescope intubation after failed direct laryngoscopy was 94% (224 of 239). Complications were noticed in 1% (21 of 2,004) of patients and mostly involved minor soft tissue injuries, but major complications, such as dental, pharyngeal, tracheal, or laryngeal injury, occurred in 0.3% (6 of 2,004) of patients. The strongest predictor of Glidescope failure was altered neck anatomy with presence of a surgical scar, radiation changes, or mass. Conclusion These data demonstrate a high success rate of Glidescope intubation in both primary airway management and rescue-failed direct laryngoscopy. However, Glidescope intubation is not always successful and certain predictors of failure can be identified. Providers should maintain their competency with alternate methods of intubation, especially for patients with neck pathology.

Postoperative nausea and vomiting is common after cardiac surgery and may contribute to significant morbidity. Gastric decompression during anesthesia has been used for postoperative nausea and vomiting prophylaxis in shorter duration noncardiac surgery with conflicting results. We tested the hypothesis that gastric decompression during elective coronary revascularization surgery with cardiopulmonary bypass and continued afterwards until tracheal extubation would reduce the incidence of vomiting or retching and nausea. In a prospective, randomized, cohort study, 104 patients with at least 2 Apfel's risk factors for postoperative nausea and vomiting were allocated to receive a gastric tube on free gravity drainage after induction of anesthesia (n = 52) or to a control group (n = 52). The gastric tube was removed simultaneously with tracheal extubation postoperatively. The primary outcome measure was the incidence of vomiting or retching. Secondary outcomes included the incidence and severity of nausea measured on a visual analog scale. The incidence of vomiting or retching was 13.4% in patients with gastric decompression, compared with 11.5% in the control group (P = 0.7). Similarly, there was no statistically significant difference between the two groups in the incidence of nausea (32.7% versus 25.0%, P = 0.6), median severity of nausea on a visual analog scale at 12 h (25; range, 0-55 mm versus 30; range, 0-60 mm, P = 0.4), or antiemetics administration (38.5% versus 28.8%, P = 0.3). Continuous gastric decompression during coronary revascularization surgery and afterwards until tracheal extubation did not reduce the incidence of vomiting or retching or the incidence and severity of nausea in these patients.

We describe a pilot study investigating the airway techniques used in the anesthetic management of subglottic stenosis. We searched the electronic clinical information database of the University of Michigan Health System for cases of subglottic stenosis in patients undergoing surgery. Demographics, airway techniques, incidence of hypoxemia, and technique failure were extracted from 159 records. A lower incidence of hypoxemia was found between the 4 most commonly used techniques and the less common techniques. We detected no difference in outcome between individual techniques. This study suggests a larger prospective multicenter study is required to further investigate these outcomes in patients with subglottic stenosis.

Background Research regarding difficult mask ventilation (DMV) combined with difficult laryngoscopy (DL) is extremely limited even though each technique serves as a rescue for one another. Methods Four tertiary care centers participating in the Multicenter Perioperative Outcomes Group used a consistent structured patient history and airway examination and airway outcome definition. DMV was defined as grade 3 or 4 mask ventilation, and DL was defined as grade 3 or 4 laryngoscopic view or four or more intubation attempts. The primary outcome was DMV combined with DL. Patients with the primary outcome were compared to those without the primary outcome to identify predictors of DMV combined with DL using a non-parsimonious logistic regression. Results Of 492,239 cases performed at four institutions among adult patients, 176,679 included a documented face mask ventilation and laryngoscopy attempt. Six hundred ninety-eight patients experienced the primary outcome, an overall incidence of 0.40%. One patient required an emergent cricothyrotomy, 177 were intubated using direct laryngoscopy, 284 using direct laryngoscopy with bougie introducer, 163 using videolaryngoscopy, and 73 using other techniques. Independent predictors of the primary outcome included age 46 yr or more, body mass index 30 or more, male sex, Mallampati III or IV, neck mass or radiation, limited thyromental distance, sleep apnea, presence of teeth, beard, thick neck, limited cervical spine mobility, and limited jaw protrusion (c-statistic 0.84 [95% CI, 0.82-0.87]). Conclusion DMV combined with DL is an infrequent but not rare phenomenon. Most patients can be managed with the use of direct or videolaryngoscopy. An easy to use unweighted risk scale has robust discriminating capacity.

Multiple attempts at tracheal intubation are associated with mortality, and successful rescue requires a structured plan. However, there remains a paucity of data to guide the choice of intubation rescue technique after failed initial direct laryngoscopy. The authors studied a large perioperative database to determine success rates for commonly used intubation rescue techniques. Using a retrospective, observational, comparative design, the authors analyzed records from seven academic centers within the Multicenter Perioperative Outcomes Group between 2004 and 2013. The primary outcome was the comparative success rate for five commonly used techniques to achieve successful tracheal intubation after failed direct laryngoscopy: (1) video laryngoscopy, (2) flexible fiberoptic intubation, (3) supraglottic airway as part of an exchange technique, (4) optical stylet, and (5) lighted stylet. A total of 346,861 cases were identified that involved attempted tracheal intubation. A total of 1,009 anesthesia providers managed 1,427 cases of failed direct laryngoscopy followed by subsequent intubation attempts (n = 1,619) that employed one of the five studied intubation rescue techniques. The use of video laryngoscopy resulted in a significantly higher success rate (92%; 95% CI, 90 to 93) than other techniques: supraglottic airway conduit (78%; 95% CI, 68 to 86), flexible bronchoscopic intubation (78%; 95% CI, 71 to 83), lighted stylet (77%; 95% CI, 69 to 83), and optical stylet (67%; 95% CI, 35 to 88). Providers most frequently choose video laryngoscopy (predominantly GlideScope [Verathon, USA]) to rescue failed direct laryngoscopy (1,122/1,619; 69%), and its use has increased during the study period. Video laryngoscopy is associated with a high rescue intubation success rate and is more commonly used than other rescue techniques.

Background The purpose of our study was to organize the literature regarding the efficacy of modern videolaryngoscopes in oral endotracheal intubation, then perform a quality assessment according to recommended external criteria and make recommendations for use. Methods Inclusion criteria included devices with recent studies of human subjects. A total of 980 articles were returned in the initial search and 65 additional items were identified using cited references. After exclusion of articles failing to meet study criteria, 77 articles remained. Data were extracted according to the rate of successful intubation and improvement of glottic view compared with direct laryngoscopy. Studies were classified according to whether they primarily examined subjects with normal airways, possessing risk factors for difficult direct laryngoscopy, or following difficult or failed direct laryngoscopy. Results The evidence of efficacy for videolaryngoscopy in the difficult airway is limited. What evidence exists is both randomized prospective and observational in nature, requiring a scheme that evaluates both forms and allows recommendations to be made. Conclusions In patients at higher risk of difficult laryngoscopy we recommend the use of the Airtraq, CTrach, GlideScope, Pentax AWS and V-MAC to achieve successful intubation. In difficult direct laryngoscopy (C&L >/= 3) we cautiously recommend the use of the Airtraq, Bonfils, Bullard, CTrach, GlideScope, and Pentax AWS, by an operator with reasonable prior experience, to achieve successful intubation when used in accordance with the ASA practice guidelines for management of the difficult airway. There is additional evidence to support the use of the Airtraq, Bonfils, CTrach, GlideScope, McGrath, and Pentax AWS following failed intubation via direct laryngoscopy to achieve successful intubation. Future investigation would benefit from precise qualification of the subjects under study, and an improvement in overall methodology to include randomization and blinding.

This chapter provides a brief overview of otolaryngologic emergencies. Complete or partial airway obstruction is common in ENT practice and anesthesiologists are familiar with a variety of measures, such as tracheal intubation, to deal with this event. Intubation is often needed in cases of angioedema; this will usually be performed under topical anesthesia with the patient awake or lightly sedated. Airway-related bleeding may occur spontaneously, as with a bleeding tumor, as a consequence of anticoagulation (e.g. for atrial fibrillation), or following surgery (e.g. after UVPP surgery). Posterior epistaxis may be particularly severe, may be accompanied by hematemesis or melena, and may require general anesthesia and intubation as part of the treatment. Airway-related infections such as epiglottitis, retropharyngeal abscess and Ludwig's angina constitute an emergency airway. One approach commonly taken in such cases is awake intubation, especially in conjunction with a fiberscope.

Background Videolaryngoscopy presents a new approach for the management of the difficult and rescue airway. There is little available evidence to compare the performance features of these devices in true difficult laryngoscopy. Methods A prospective randomized crossover study was performed comparing the performance features of the Macintosh Laryngoscope, Glidescope, Storz CMAC and Storz DCI videolaryngoscope. Thirty anesthesia providers attempted intubation with each of the 4 laryngoscopes in a high fidelity difficult laryngoscopy manikin. The time to successful intubation (TTSI) was recorded for each device, along with failure rate, and the best view of the glottis obtained. Results Use of the Glidescope, CMAC and Storz videolaryngoscopes improved the view of the glottis compared with use of the Macintosh blade (GEE, p = 0.000, p = 0.002, p = 0.000 respectively). Use of the CMAC resulted in an improved view compared with use of the Storz VL (Fishers, p = 0.05). Use of the Glidescope or Storz videolaryngoscope blade resulted in a longer TTSI compared with either the Macintosh (GLM, p = 0.000, p = 0.029 respectively) or CMAC blades (GLM, p = 0.000, p = 0.033 respectively). Conclusions Unsurprisingly, when used in a simulated difficult laryngoscopy, all the videolaryngoscopes resulted in a better view of the glottis than the Macintosh blade. However, interestingly the CMAC was found to provide a better laryngoscopic view that the Storz DCI Videolaryngoscope. Additionally, use of either the Glidescope or Storz DCI Videolaryngoscope resulted in a prolonged time to successful intubation compared with use of the CMAC or Macintosh blade. The use of the CMAC during manikin simulated difficult laryngoscopy combined the efficacy of attainment of laryngoscopic view with the expediency of successful intubation. Use of the Macintosh blade combined expedience with success, despite a limited laryngoscopic view. The limitations of a manikin model of difficult laryngoscopy limits the conclusions for extrapolation into clinical practice.

In this focused review, we discuss an algorithm specifically for the unanticipated difficult intubation in obstetrics. This generic algorithm emphasizes a standardized and prespecified sequence of interventions to provide safe, efficient, and effective airway management for the emergency obstetric surgical patient. Individual institutions and anesthesia providers are encouraged to use this framework to select specific pieces of equipment for each step, and to create regular opportunities for all obstetric anesthesia providers to become facile with each airway device and to integrate the algorithm under simulated conditions.

When the first asylums opened, around 1800, mania was a generic term for insanity. Philippe Pinel’s Treatise on Insanity that appeared in 1800was accordingly namedTrait e sur la Manie. For 2000 years before Pinel, the chief determinant of diagnosis in medicine lay in the visible presentation of the patient. These visible presentations could lead to reliable diagnoses of tumours, diabetes, catatonia, epilepsy and insanity. The visible presentations of insanity involved flushing, overactivity and maniacal behaviour. Mania was diagnosed in patients who were overactive and who might now be seen as having schizophrenia, depression, delirium, senility, imbecility and other conditions. Pinel took a stand on the importance of science in medicine, and was the first to call for an Evidence Based Medicine. Faced with patients hospitalized for years, he was the first to incorporate the course of apatients’disorders into his diagnostic considerations. He recorded outcomes where patientswere treated or left untreated, andnoting responses followed by relapses, argued that some disorders were periodic or recurrent and that the vast majority of available treatments made the underlying condition worse. When a final and more complete version of his treatise was published in 1809, it distinguished in its title, Trait e M edico-Philosophique sur l’Ali enation Mentale ou la Manie, between insanity in general and a new, more specific diagnosis of mania [1]. Once this distinction was made, and mania was separated out from idiocy dementia and melancholia, the rates of admission formania settled at approximately 50% of all admissions in asylums in Europe and America until around 1900. While asylumnomenclature remained relatively constant for a century, there was an evolution in the thinking about insanity. The idea that theremight be a distinctmood faculty that could be disordered in its own right was put forward in the 1830s by one of Pinel’s pupils, Jean-Dominique Etienne Esquirol, who described profound sadness – lypemanie – as a distinct disorder. The notion of a disease entity took shape in the 1850s when two of Esquirol’s pupils, Jean-Pierre Falret and Jules Baillarger, both described disorders that laid the basis for what became circular insanity. Falret outlined folie circulaire; Baillarger termed his disorder folie a double forme [2]. The idea that mania or insanity might give rise to protean manifestations had posed little difficulty, but as clinicians moved towards the concept of a disease entity, they had difficulties with the idea that two clinical states that looked so different might be presentations of the same underlying disease state. In their efforts to overcome these conceptual problems, both Falret andBaillarger posited a disorderwith alternating cycles of mania and melancholia of fixed length and with fixed intervals between episodes. But crucially if neither the superficial features of mania nor the superficial features of melancholia accounted for the disorder, then some common ground between them must be responsible for the disorder. Some substrate must be diseased. The new disorder was not one that commanded clinical attention. Both men conceded that what they were describing was a rare condition. The condition described was moreover at this point not clearly a mood disorder. Others described alternating or circular insanity. None of these states were bipolar affective disorder, as that termwould be understood today. The first to approach modern bipolar disorder was Karl Kahlbaum who in 1883 described cyclothymia. Where circular insanity was a psychotic disorder, with regular and stable features that led todegeneration, cyclothymiawas for Kahlbaum a specific mood disorder from which patients could recover. Kahlbaum also introduced disease course as a classificatory principle, but this was resisted. Most academics at the time expected a localization of clinical features in different brain areas to provide the key to unlocking the mysteries of mental illness rather than disease course. However disease coursewas used byCharcot to distinguish between hysteria and Tourette’s syndrome, and later to distinguish between Alzheimer’s and Creutfeld-Jacob disease.

Objectives: We describe the manifestations, diagnosis, and treatment of rare head and neck infections caused by Mycobacterium chelonae, including a case of maxillary osteitis and skull base osteomyelitis. Methods: A comprehensive literature search (MEDLINE from 1951; BIOSIS from 1969; EMBASE from 1980) was performed for the presentation, diagnostic evaluation, and outcomes of patients with M chelonae infections. Results: We report 4 cases of M chelonae infection, including a nasal abscess following septorhinoplasty with a cartilaginous graft, a case of chronic unilateral nasal obstruction, and the first reported cases of skull base osteomyelitis and maxillary osteitis secondary to M chelonae. All 4 cases involved immunocompetent individuals. Conclusions: Mycobacterium chelonae should be considered in cases of abscesses that persist despite broad-spectrum intravenous antibiotics, and in cases of maxillary sinusitis with bony involvement that do not respond to traditional treatment methods.

Establishing that a circadian rhythm is abnormal tells us little about the cause, which can arise from changes in the patient's lifestyle, irregularities of the body clock or a malfunction in the process of entrainment of the clock. In a clinical context, such a range of possible explanations implies differences in the most appropriate mode of treatment. Against this background, the conventional view that the underlying abnormality in endogenous depression is due to a disorder of the body clock is challenged. The challenge is based on difficulties of interpretation of the clinical data and the results of studies on circadian rhythms in patients. It is suggested that the state of the circadian system in depression resembles its state in healthy individuals after time-zone transitions or in shift work maladaptation syndrome and that this disturbance should be seen as resulting from changes in the phasing of external zeitgebers rather than from an abnormality in the clock itself.

A group of 43 student nurses were studied before and immediately after their first eight weeks of nightwork. Volunteers answered questions about their general health, sleep, and eating habits, as well as their social lives and relationships with friends. In all measures there was a deterioration produced by nightwork. About half the subjects volunteered the view that the forthcoming nightwork would cause a decline in the standard of their lifestyle or that it would improve now that nightwork had finished. This subgroup showed a significantly greater deterioration in interpersonal relationships, even though general health status was not significantly different. These results indicate that the problems associated with nightwork can arise before coping mechanisms can be expected to have been devised, and even in anticipation of nightwork. They imply that counselling is needed before nightwork is actually started.