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314
CASE LETTERS
TABLE 1.
Imaging modality sensitivity and specificity for sialolithiasis
Imaging modality
Sensitivity
Plain film radiography3 Digital subtraction sialography3 MR sialography3 US4 CT5
Specificity
60–90% 96–100%
NA 88–98%
80–100% 59.1–93.7% 100%
80–98% 80–100% 75–90%
3.
4.
NA, not available.
lar ramus.6 Furthermore, in some settings, US availability is limited especially during off-hours. In cases where there is clinical concern for deep neck extension or lymphadenopathy or when US is unavailable, noncontrast CT should be considered. Non-contrast CT can assess shape, size and number of calculi as well as provide soft tissue detail that allows for evaluation of complications including those extending to bone, neck and pharynx. However, its use should be limited given the high-dose radiation involved.3,6 Initial treatment of acute obstructive sialadenitis consists of antibiotics, warm compresses, antiinflammatory medications and sia-
lagogues. Large obstructive stones might necessitate removal once the active infection has subsided. Specific extraction technique depends on the location, size and shape of the calculi and might include lithotripsy, interventional radiologic stone removal, sialendoscopy or gland excision.1
Competing interests None declared.
References 1. Armstrong MA, Turturro MA. Salivary gland emergencies. Emerg. Med. Clin. North Am. 2013; 31: 481–99. 2. Hoffmann B. Sonographic bedside detection of sialolithiasis with
5.
6.
submandibular gland obstruction. Am. J. Emerg. Med. 2011; 29: 574.e575– 577. Sobrino-Guijarro B, Cascarini L, Lingam RK. Advances in imaging of obstructed salivary glands can improve diagnostic outcomes. Oral Maxillofac. Surg. 2013; 17: 11–9. Jäger L, Menauer F, Holzknecht N, Scholz V, Grevers G, Reiser M. Sialolithiasis: MR sialography of the submandibular duct – an alternative to conventional sialography and US? Radiology 2000; 216: 665–71. Bryan RN, Miller RH, Ferreyro RI, Sessions RB. Computed tomography of the major salivary glands. AJR Am. J. Roentgenol. 1982; 139: 547– 54. Burke CJ, Thomas RH, Howlett D. Imaging the major salivary glands. Br. J. Oral Maxillofac. Surg. 2011; 49: 261–9.
Eveline HITTI, Cynthia SALLOUM and Afif Jean MUFARRIJ Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon doi: 10.1111/1742-6723.12219
Party bubbles: Friend or foe? A conjunctival burn in a paediatric emergency department Dear Editor, Chemical ocular burns are a true ophthalmological emergency,1 accounting for nearly 10% of all ocular trauma.2 Alkali injuries occur more frequently than acid burns and are more detrimental.3 While blowing soap bubbles (‘Just married®’, Unique Industries, Philadelphia, PA, USA) to distract a toddler during a medical examination, a paediatric ED staff member sustained painful splashback of bubbles into her right eye. Immediate irrigation of the
eye and conjunctival fornices with ocular irrigating solution (Eyestream®, Alcon Laboratories, Sydney, NSW, Australia) was followed by application of topical amethocaine 1% and further irrigation with sterile 0.9% sodium chloride. Two bulbar conjunctival burns to the right eye were visible on fluorescein staining (Fig. 1). The palpebral conjunctivae, cornea and limbal regions were intact, with no retained solid particles on lid eversion. Visual acuity was 6/6 bilaterally. Topical antibiotic ointment (chloramphenicol), oral ascor-
bic acid supplement and oral pain relief were administered with full recovery after 72 h, disappearance of the burns (Fig. 1), no residual scarring or change in visual acuity. Laboratory analysis (Trace Inorganic Laboratory, NSW Forensic & Analytical Science Service, NSW, Australia) of the causative bubble sample and a second type of bubbles used in our ED (‘Party bubbles®’) demonstrated neutral pH reading (pH 7) for both samples, in contrast to tear film pH 8 (litmus paper) after initial irrigation. Levels of fluoride (F), nitrate
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
315
CASE LETTERS
Figure 1. Conjunctival burn to the right eye. At the time of injury (top row) and after 72 h (bottom row).
(NO3), chrome (Cr) and chloride (Cl) were low, excluding the presence of hydrofluoric acid (HF), nitric acid (HNO3), chromic acid (H2Cr04) and hydrochloric acid (HCl). Both samples contained anionic surfactants and significant amounts of sulfate (SO4) and sodium (Na), suggesting that a sulphonated detergent most likely was the causative substance for the alkali conjunctival injury. No skin irritation occurred when applied to the skin of two volunteers. Soap bubbles are an efficient distraction tool for children during medical examination or procedures. One ocular alkali burn from brown soap is reported,4 but not from commercially available bubbles. Whereas ‘soap’ did not generate skin irritation, it was the evident cause of this conjunctival burn. Highly irritating acids such as HF, HNO 3 , H 2 Cr0 4 and HCl were not present in high concentration in these bubbles. The falsely alkaline pH reading of the tear film (mean normal tear pH = 75)
illustrates the occurrence of erroneous pH reading; the most likely reason in our case being a too small tear film sample. Other error sources include too large samples, samples taken too quickly after irrigation or use of faulty material. The most reliable method in the ED seems to be direct pH measurement of appropriately sized tear film samples with valid litmus paper. The causative bubble bottle was labelled ‘non-toxic’, most likely referring to ingestion. However, the potential danger of chemical burns caused by direct contact with the bubbles might have been unknown. We suggest that a safe distance is kept between the bubbles and the operator or child’s eyes to reduce the risk of injury. Children’s play with bubbles should be supervised. In case of ocular chemical injury, immediate abundant irrigation of the eye, until neutralisation of the tear surface pH is obtained, has the greatest impact on prognosis.4 Treatment should be completed by topical antibiotics, oral vitamin C supplement to enhance collagen formation, adequate lubrication to prevent formation of symblepharon6 and oral analgesia. Topical anaesthetic agents might cause corneal epithelial toxicity, secondary bacterial infection and scarring.7 In our ED, after giving advice to all staff, we have continued to use bubbles and have not recorded further incidents. We illustrate the hazard of potentially severe eye injury from soap bubbles commonly used in paediatric EDs. Caution is advised with this distracting tool for children.
Acknowledgement Internal funding was provided for payment of the laboratory bubble analysis.
Competing interests None declared.
References 1. Tuft SJ, Shortt AJ. Surgical rehabilitation following severe ocular burns. Eye 2009; 23: 1966–71. 2. Connor AJ, Severn P. Use of a control test to aid pH assessment of chemical eye injuries. Emerg. Med. J. 2009; 26: 811–2. 3. Das S, Chohan A, Snibson GR, Taylor HR. Capsicum spray injury of the eye. Int. Ophthalmol. 2005; 26: 171–3. 4. Maudgal PC. Ocular burn caused by soft brown soap. Bull. Soc. Belge Ophtalmol. 1996; 263: 81–4. 5. Abelson MB, Udell IJ, Weston JH. Normal human tear pH by direct measurement. Arch. Ophthalmol. 1981; 99: 301. 6. Ikeda N, Hayasaka S, Hayasaka Y, Watanabe K. Alkali burns of the eye: effect of immediate copious irrigation with tap water on their severity. Ophthalmologica 2006; 220: 225–8. 7. Kuckelkorn R, Schrage N, Keller G, Redbrake C. Emergency treatment of chemical and thermal eye burns. Acta Ophthalmol. Scand. 2002; 80: 4–10.
Ruth M LÖLLGEN,1,2 Vicky Hsin-Ju LU,3,4 Lauren MIDDLEBROOK,1 Naren GUNJA5,6 and Mary MCCASKILL1 1 Emergency Department, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia, 2Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia, 3 Department of Ophthalmology, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia, 4Department of Ophthalmology, Sydney Eye Hospital, Sydney, New South Wales, Australia, 5NSW Poisons Information Centre, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia, and 6 Discipline of Emergency Medicine, Sydney Medical School, Sydney, New South Wales, Australia doi: 10.1111/1742-6723.12228
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
314
CASE LETTERS
TABLE 1.
Imaging modality sensitivity and specificity for sialolithiasis
Imaging modality
Sensitivity
Plain film radiography3 Digital subtraction sialography3 MR sialography3 US4 CT5
Specificity
60–90% 96–100%
NA 88–98%
80–100% 59.1–93.7% 100%
80–98% 80–100% 75–90%
3.
4.
NA, not available.
lar ramus.6 Furthermore, in some settings, US availability is limited especially during off-hours. In cases where there is clinical concern for deep neck extension or lymphadenopathy or when US is unavailable, noncontrast CT should be considered. Non-contrast CT can assess shape, size and number of calculi as well as provide soft tissue detail that allows for evaluation of complications including those extending to bone, neck and pharynx. However, its use should be limited given the high-dose radiation involved.3,6 Initial treatment of acute obstructive sialadenitis consists of antibiotics, warm compresses, antiinflammatory medications and sia-
lagogues. Large obstructive stones might necessitate removal once the active infection has subsided. Specific extraction technique depends on the location, size and shape of the calculi and might include lithotripsy, interventional radiologic stone removal, sialendoscopy or gland excision.1
Competing interests None declared.
References 1. Armstrong MA, Turturro MA. Salivary gland emergencies. Emerg. Med. Clin. North Am. 2013; 31: 481–99. 2. Hoffmann B. Sonographic bedside detection of sialolithiasis with
5.
6.
submandibular gland obstruction. Am. J. Emerg. Med. 2011; 29: 574.e575– 577. Sobrino-Guijarro B, Cascarini L, Lingam RK. Advances in imaging of obstructed salivary glands can improve diagnostic outcomes. Oral Maxillofac. Surg. 2013; 17: 11–9. Jäger L, Menauer F, Holzknecht N, Scholz V, Grevers G, Reiser M. Sialolithiasis: MR sialography of the submandibular duct – an alternative to conventional sialography and US? Radiology 2000; 216: 665–71. Bryan RN, Miller RH, Ferreyro RI, Sessions RB. Computed tomography of the major salivary glands. AJR Am. J. Roentgenol. 1982; 139: 547– 54. Burke CJ, Thomas RH, Howlett D. Imaging the major salivary glands. Br. J. Oral Maxillofac. Surg. 2011; 49: 261–9.
Eveline HITTI, Cynthia SALLOUM and Afif Jean MUFARRIJ Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon doi: 10.1111/1742-6723.12219
Party bubbles: Friend or foe? A conjunctival burn in a paediatric emergency department Dear Editor, Chemical ocular burns are a true ophthalmological emergency,1 accounting for nearly 10% of all ocular trauma.2 Alkali injuries occur more frequently than acid burns and are more detrimental.3 While blowing soap bubbles (‘Just married®’, Unique Industries, Philadelphia, PA, USA) to distract a toddler during a medical examination, a paediatric ED staff member sustained painful splashback of bubbles into her right eye. Immediate irrigation of the
eye and conjunctival fornices with ocular irrigating solution (Eyestream®, Alcon Laboratories, Sydney, NSW, Australia) was followed by application of topical amethocaine 1% and further irrigation with sterile 0.9% sodium chloride. Two bulbar conjunctival burns to the right eye were visible on fluorescein staining (Fig. 1). The palpebral conjunctivae, cornea and limbal regions were intact, with no retained solid particles on lid eversion. Visual acuity was 6/6 bilaterally. Topical antibiotic ointment (chloramphenicol), oral ascor-
bic acid supplement and oral pain relief were administered with full recovery after 72 h, disappearance of the burns (Fig. 1), no residual scarring or change in visual acuity. Laboratory analysis (Trace Inorganic Laboratory, NSW Forensic & Analytical Science Service, NSW, Australia) of the causative bubble sample and a second type of bubbles used in our ED (‘Party bubbles®’) demonstrated neutral pH reading (pH 7) for both samples, in contrast to tear film pH 8 (litmus paper) after initial irrigation. Levels of fluoride (F), nitrate
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
315
CASE LETTERS
Figure 1. Conjunctival burn to the right eye. At the time of injury (top row) and after 72 h (bottom row).
(NO3), chrome (Cr) and chloride (Cl) were low, excluding the presence of hydrofluoric acid (HF), nitric acid (HNO3), chromic acid (H2Cr04) and hydrochloric acid (HCl). Both samples contained anionic surfactants and significant amounts of sulfate (SO4) and sodium (Na), suggesting that a sulphonated detergent most likely was the causative substance for the alkali conjunctival injury. No skin irritation occurred when applied to the skin of two volunteers. Soap bubbles are an efficient distraction tool for children during medical examination or procedures. One ocular alkali burn from brown soap is reported,4 but not from commercially available bubbles. Whereas ‘soap’ did not generate skin irritation, it was the evident cause of this conjunctival burn. Highly irritating acids such as HF, HNO 3 , H 2 Cr0 4 and HCl were not present in high concentration in these bubbles. The falsely alkaline pH reading of the tear film (mean normal tear pH = 75)
illustrates the occurrence of erroneous pH reading; the most likely reason in our case being a too small tear film sample. Other error sources include too large samples, samples taken too quickly after irrigation or use of faulty material. The most reliable method in the ED seems to be direct pH measurement of appropriately sized tear film samples with valid litmus paper. The causative bubble bottle was labelled ‘non-toxic’, most likely referring to ingestion. However, the potential danger of chemical burns caused by direct contact with the bubbles might have been unknown. We suggest that a safe distance is kept between the bubbles and the operator or child’s eyes to reduce the risk of injury. Children’s play with bubbles should be supervised. In case of ocular chemical injury, immediate abundant irrigation of the eye, until neutralisation of the tear surface pH is obtained, has the greatest impact on prognosis.4 Treatment should be completed by topical antibiotics, oral vitamin C supplement to enhance collagen formation, adequate lubrication to prevent formation of symblepharon6 and oral analgesia. Topical anaesthetic agents might cause corneal epithelial toxicity, secondary bacterial infection and scarring.7 In our ED, after giving advice to all staff, we have continued to use bubbles and have not recorded further incidents. We illustrate the hazard of potentially severe eye injury from soap bubbles commonly used in paediatric EDs. Caution is advised with this distracting tool for children.
Acknowledgement Internal funding was provided for payment of the laboratory bubble analysis.
Competing interests None declared.
References 1. Tuft SJ, Shortt AJ. Surgical rehabilitation following severe ocular burns. Eye 2009; 23: 1966–71. 2. Connor AJ, Severn P. Use of a control test to aid pH assessment of chemical eye injuries. Emerg. Med. J. 2009; 26: 811–2. 3. Das S, Chohan A, Snibson GR, Taylor HR. Capsicum spray injury of the eye. Int. Ophthalmol. 2005; 26: 171–3. 4. Maudgal PC. Ocular burn caused by soft brown soap. Bull. Soc. Belge Ophtalmol. 1996; 263: 81–4. 5. Abelson MB, Udell IJ, Weston JH. Normal human tear pH by direct measurement. Arch. Ophthalmol. 1981; 99: 301. 6. Ikeda N, Hayasaka S, Hayasaka Y, Watanabe K. Alkali burns of the eye: effect of immediate copious irrigation with tap water on their severity. Ophthalmologica 2006; 220: 225–8. 7. Kuckelkorn R, Schrage N, Keller G, Redbrake C. Emergency treatment of chemical and thermal eye burns. Acta Ophthalmol. Scand. 2002; 80: 4–10.
Ruth M LÖLLGEN,1,2 Vicky Hsin-Ju LU,3,4 Lauren MIDDLEBROOK,1 Naren GUNJA5,6 and Mary MCCASKILL1 1 Emergency Department, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia, 2Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia, 3 Department of Ophthalmology, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia, 4Department of Ophthalmology, Sydney Eye Hospital, Sydney, New South Wales, Australia, 5NSW Poisons Information Centre, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia, and 6 Discipline of Emergency Medicine, Sydney Medical School, Sydney, New South Wales, Australia doi: 10.1111/1742-6723.12228
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
