368
Journal of the Royal Society of Medicine Volume 85 June 1992
Unilateral choanal atresia I read with interest the case report by Booth and Drake-Lee (October 1991 JRSM, p 622) and feel that some comments would be pertinent. The development of increasingly sophisticated imaging techniques has resulted in high resolution computerized tomography becoming the method of choice for the demonstration of choanal atresia. However, the illustration presented does not, as claimed, demonstrate the atresia but simply some reduced radiolucency in the region of the middle meatus and no obvious middle turbinate. The appropriate investigation should be an axial view of the nasal cavity, as only such an image taken at right angles rather than tangential to the obstructive membrane can be sure to demonstrate the lesion. In addition only such a technique will indicate with certainty whether the obstruction is bony or membranous, an important point from the point of view of planning surgery. Only one or two axial slices taken in a plane avoiding the orbits is necessary for the diagnosis to be confirmed, but the technique presented inevitably involves the use of more slices, all crossing the orbit. This is a most important consideration in days when we should be aiming to submit our patients, and in particularly radio-sensitive areas such as the eye, to the minimum possible amount of irradiation. Walsgrave Hospital J M STANSBIE Clifford Bridge Road Walsgrave, Coventry CV2 2DX
How to avoid pitfalls in ethnic medical history, examination and diagnosis I regret that Dr Qureshi (February 1991 JRSM, p 65) has failed to avoid the pitfall of using the word 'English' on six or seven occasions, when he really means 'British'. I am afraid my colleagues in Scotland, Wales and Northern Ireland would not be at all pleased- although we all have a common English language. GEORGE E SPEAR
Kelvedon, Essex C05 9AE
Doctors' dress Further to the correspondence on the matter of doctors' dress (February 1992 JRSM, p 120), I wonder whether other readers share my concern about the informality of dress worn by both nursing and medical staff in certain psychiatric hospitals rendering them indistinguishable from each other, especially in the absence of a name badge. For visitors it is often
difficult to identify which are the patients and who are the carers. An elderly husband brought his wife to a psychiatric hospital for review when she had been on home leave but still not technically discharged from inpatient care. She suffered from early dementia and he was finding her pathological nagging intolerable. He was spoken to by a young woman whom he assumed was a nurse, not realizing that she was one of the medical staff. He never therefore unburdened his full frustrations and the depth of his feelings and so never made a request that she should be readmitted, as he intended. Consequently they returned home together and the following day he strangled her. I believe that a simple uniform for psychiatric nurses and possibly the doctors together with name badges would help to maintain a feeling of professionalism, pride in one's job as well as making identification easier. There are many excellent instances of discreet staff uniforms, as used by airlines and certain retail stores, which look smart without being threatening or intimidating. R M WHIT1NGTON
Coroner's Court Newton Street Birmingham B4 6NE
Neonatal cleft lip repair The report of a single case (February 1992 JRSM, p 108), suggesting that neonatal cleft repair held a family together, cannot be left unchallenged. Not infrequently, the parents of a newborn cleft child react initially by 'rejection' but within 2-3 days, with support and informed counselling by those who will be caring for the baby, they accept the baby completely and any family divisions are healed. Long term rejection of a baby with a cleft is extremely rare. While the arguments for and against neonatal repair will continue, the importance of good quality postnatal care, advice and support cannot be over-emphasized. Of perhaps more interest in the paper is the psychological effect of prenatal diagnosis by ultrasound. In this case, the false negative obviously increased parents' distress at birth. Other parents benefit from prior knowledge so that they can prepare themselves adequately with the help of organizations such as CLAPA. On the other hand, some may undergo unnecessary stress. It is probably much easier to bond to a cleft baby than to try to come to terms with a cleft ultrasound. This could usefully be the basis of a good psychological study. B C SOMMERLAD
Regional Plastic Surgery Unit St Andrew's Hospital, Billericay, Essex
Journal of the Royal Society of Medicine Volume 85 June 1992
Unilateral choanal atresia I read with interest the case report by Booth and Drake-Lee (October 1991 JRSM, p 622) and feel that some comments would be pertinent. The development of increasingly sophisticated imaging techniques has resulted in high resolution computerized tomography becoming the method of choice for the demonstration of choanal atresia. However, the illustration presented does not, as claimed, demonstrate the atresia but simply some reduced radiolucency in the region of the middle meatus and no obvious middle turbinate. The appropriate investigation should be an axial view of the nasal cavity, as only such an image taken at right angles rather than tangential to the obstructive membrane can be sure to demonstrate the lesion. In addition only such a technique will indicate with certainty whether the obstruction is bony or membranous, an important point from the point of view of planning surgery. Only one or two axial slices taken in a plane avoiding the orbits is necessary for the diagnosis to be confirmed, but the technique presented inevitably involves the use of more slices, all crossing the orbit. This is a most important consideration in days when we should be aiming to submit our patients, and in particularly radio-sensitive areas such as the eye, to the minimum possible amount of irradiation. Walsgrave Hospital J M STANSBIE Clifford Bridge Road Walsgrave, Coventry CV2 2DX
How to avoid pitfalls in ethnic medical history, examination and diagnosis I regret that Dr Qureshi (February 1991 JRSM, p 65) has failed to avoid the pitfall of using the word 'English' on six or seven occasions, when he really means 'British'. I am afraid my colleagues in Scotland, Wales and Northern Ireland would not be at all pleased- although we all have a common English language. GEORGE E SPEAR
Kelvedon, Essex C05 9AE
Doctors' dress Further to the correspondence on the matter of doctors' dress (February 1992 JRSM, p 120), I wonder whether other readers share my concern about the informality of dress worn by both nursing and medical staff in certain psychiatric hospitals rendering them indistinguishable from each other, especially in the absence of a name badge. For visitors it is often
difficult to identify which are the patients and who are the carers. An elderly husband brought his wife to a psychiatric hospital for review when she had been on home leave but still not technically discharged from inpatient care. She suffered from early dementia and he was finding her pathological nagging intolerable. He was spoken to by a young woman whom he assumed was a nurse, not realizing that she was one of the medical staff. He never therefore unburdened his full frustrations and the depth of his feelings and so never made a request that she should be readmitted, as he intended. Consequently they returned home together and the following day he strangled her. I believe that a simple uniform for psychiatric nurses and possibly the doctors together with name badges would help to maintain a feeling of professionalism, pride in one's job as well as making identification easier. There are many excellent instances of discreet staff uniforms, as used by airlines and certain retail stores, which look smart without being threatening or intimidating. R M WHIT1NGTON
Coroner's Court Newton Street Birmingham B4 6NE
Neonatal cleft lip repair The report of a single case (February 1992 JRSM, p 108), suggesting that neonatal cleft repair held a family together, cannot be left unchallenged. Not infrequently, the parents of a newborn cleft child react initially by 'rejection' but within 2-3 days, with support and informed counselling by those who will be caring for the baby, they accept the baby completely and any family divisions are healed. Long term rejection of a baby with a cleft is extremely rare. While the arguments for and against neonatal repair will continue, the importance of good quality postnatal care, advice and support cannot be over-emphasized. Of perhaps more interest in the paper is the psychological effect of prenatal diagnosis by ultrasound. In this case, the false negative obviously increased parents' distress at birth. Other parents benefit from prior knowledge so that they can prepare themselves adequately with the help of organizations such as CLAPA. On the other hand, some may undergo unnecessary stress. It is probably much easier to bond to a cleft baby than to try to come to terms with a cleft ultrasound. This could usefully be the basis of a good psychological study. B C SOMMERLAD
Regional Plastic Surgery Unit St Andrew's Hospital, Billericay, Essex
