A 50-year-old woman was admitted to the intensive care unit (ICU) for a life-threatening exacerbation of asthma requiring intubation and ventilation for 7 days. On day 8, she was stepped down from the ventilator via the insertion of a tracheostomy to aid weaning. It was initially decided that a percutaneous tracheostomy would be attempted on ICU, however, following further consideration, it was decided that due to anatomical factors (short neck) a surgical tracheostomy would be performed by the ear, nose and throat (ENT) team. A periprocedural USS was not performed. At surgery, instead of identifying two superficial anterior jugular veins lying on each side of the trachea, one large anterior jugular vein (median vein) was found overlying the entire anterior surface of the trachea. Had a PCT been attempted without an ultrasound scan being performed, this vessel would have been punctured, creating a significant bleed that could have placed the patient's airway and/or circulatory system at risk.

Pneumatosis intestinalis (PI) is defined as the presence of gas within the serosal or mucosal layer bowel wall. This sign is usually found upon radiographic imaging and is most commonly secondary to acute gastro-intestinal ischaemia. Fifteen per cent of cases can present with a primary condition called pneumatosis cystoides intestinalis (PCI). PCI is usually a benign condition and patients are usually asymptomatic. Portal venous gas (PVG) or the presence/accumulation of free gas within the hepatic portal vein. It is most commonly associated with acute bowel ischaemia, and when seen in the presence of ischaemia the mortality rate is between 75 and 90%. Other associations include mechanical causes (e.g. obstruction), chemotherapy, liver transplant and diverticulitis. Benign PI has previously been described with PVG, but usually in the presence of other associated conditions such as AIDS, malignancy or chemotherapy. Some examples have been described without these associations, but not with free intra-peritoneal air. We describe a case of PCI and PVG with pneumoperitoneum, investigations and ongoing management.

Patients undergoing nasal surgery have historically been routinely followed up in consultant led clinics some months after surgery. It has been noted that a significant proportion of these patients either did not attend these appointments or did not require them, impacting on the efficiency of ENT outpatient clinics. A quality improvement project was undertaken to assess this problem and to propose a new patient pathway whereby patients are contacted by ENT nursing staff by telephone three months following surgery. During these telephone conversations only 9.5% of patients requested outpatient follow-up and all of these patients were discharged upon their follow-up. The project demonstrates that nurse-led follow up is an efficient, effective and safe way of managing patient care post-nasal surgery.

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