SummaryThis is a case report of an 80-year-old woman who presented to the ENT services with multiple non-specific upper aerodigestive tract symptoms. Despite extensive investigation and treatment, her symptoms remained unalleviated with significant impact on the psychological morbidity. During a routine flexible nasoendoscopy for worsening globus pharnygis, a mass was noted in the right Rosenmþller's fossa, where the Eustachian tube leaves the lateral wall of the nasopharynx. A CT scan showed this to be a 10 mm calcified entity within the right Eustachian tube. It was subsequently removed under local anaesthesia providing much relief to the patient. Histology showed this mass to be a rhinolith. BACKGROUND

Learning objectivesBy reading this article you should be able to:Recall the key features that may indicate impending airway obstruction in a patient with acute neck trauma. Explain the principles of managing a patient with a threatened airway resulting from neck trauma. Distinguish the key features of the Advanced Trauma Life Support (ATLS) primary survey that are pertinent to patients with acute neck trauma. Outline the next steps in management of acute neck trauma after completing the primary survey and securing the airway.As a narrow conduit for the major blood vessels, aerodigestive tract, and neurological structures passing between the head and the torso, the neck is an especially hazardous area for traumatic injuries. Injuries in this area can be complex to manage, and airway management maybe particularly perilous.Common causes of neck trauma include road traffic collisions (RTCs), sporting injuries, and interpersonal violence. Sadly, interpersonal violence is a global problem. Whilst reported rates are highest in South Africa, Central and South America, the incidence of interpersonal violence rates is increasing in Europe. 1,2 In the year ending March 2019, there were approximately 47,000 offences involving a knife or sharp object in England and Wales; the highest number since comparable data have been recorded (March 2011). 3 It is becoming increasingly likely that anaesthetists, as part of James Shilston FRCA FFICM is a dual trainee in anaesthesia and intensive care medicine in the East Midlands, UK.David L Evans FRCA is an RAF consultant anaesthetist at Nottingham University Hospitals NHS Trust, which is a regional major trauma centre covering a population of around 4 million people. He also provides military medical support to multiple theatres of conflict including Afghanistan. Anthony Simons FRCS-ORL HNS is a consultant head and neck surgeon based at Nottingham University Hospitals NHS Trust who has an interest in airway and head and neck oncologyDavid A Evans FRCA is a consultant anaesthetist at Nottingham University Hospitals NHS Trust with interests in major trauma and head and neck anaesthesia Key pointsThe management of blunt and penetrating neck trauma can be complex and frequently requires close collaboration between anaesthesia and surgical teams. Adherence to Advanced Trauma Life Support (ATLS) principles is fundamental, with an emphasis on early assessment of the airway.The key principles of airway management are to identify any airway injuries and where possible ensure that the tip of the tracheal tube is positioned distal to the site of the injury without causing further airway trauma. If airway injury is suspected, the best ways to secure the airway in a cooperative patient are by awake fibreoptic intubation or awake surgical tracheostomy under local anaesthesia. Severe injuries require immediate surgical exploration. In less emergent situations CT scanning plays a valuable role in planning appropriate further management.

Oh et al., who concluded that fixed time-interval oral analgesia is superior to on-demand oral analgesia [3], and therefore the way we have written this in our manuscript is indeed incorrect. However, this correction does not change our recommendations or the guideline because only one study has been published demonstrating the positive effect of fixed time interval oral analgesia administration. Further studies are required to confirm these results before they can be incorporated into the guideline.