Introduction: We present a case of accelerated tibial fracture union in the third trimester of pregnancy. This is of particular relevance to orthopaedic surgeons, who must be made aware of the potentially accelerated healing response in pregnancy and the requirement for prompt treatment.

To assess the validity of tympanometry as a test for the presence of middle ear effusion using a 'gold-standard' of myringotomy performed after a nitrous oxide-free general anaesthetic, we performed a prospective validity study comparing tympanometry traces obtained immediately pre-operatively from patients undergoing grommet insertion, with the otomicroscopic findings at myringotomy. Nitrous oxide was omitted from the anaesthetic gaseous mixture as it has been reported to displace middle ear effusions. One hundred and seventy-two patients (aged 1.5-15 years) with a clinically assessed 3 month history of middle ear effusion were included in the study. Sensitivity and specificity of a Jerger classification Type B tympanometric trace for the presence of middle ear effusion were 0.73 and 0.84, respectively. We conclude that tympanometry is a valid test in assessing the presence of middle ear effusion compared to a 'gold standard' of myringotomy performed after a nitrous oxide-free general anaesthetic.

A 79-year-old man who came to a general surgical clinic for evaluation of his asymptomatic bilateral inguinal herniae was noticed incidentally to have a swelling over his right temporal bone (Figure 1). The patient had injured his head 6 weeks previously following a fall, and this was thought by the GP to be a small haematoma that would eventually settle. Since then, the swelling had progressively become larger and tender. On examination, he had a 3 cm diameter pulsatile mass over his temporal bone, which on clinical grounds represented a superficial temporal artery pseudoaneurysm. With the view that the aneurysm was likely to enlarge and rupture, it was arranged for the patient to undergo an urgent operation to remove it. A cervical block supplemented by 10 ml 1% lignocaine locally was used as the patient was unfit for a general anaesthetic. A transverse incision was made just anterior to the tragus in order to ligate the superficial temporal artery, thus gaining proximal control of the blood supply to the pseudoaneurysm. Excision of the pseudoaneurysm (Figure 2) was then undertaken through a second elliptical incision over the swelling. Distal ligation was not required as the lumen of the superficial temporal artery was obliterated. The patient recovered well from the operation and was discharged on the same day.