The Journal of Craniofacial Surgery
Volume 26, Number 6, September 2015
DISCUSSION Early diagnosis and management of the nasal fractures are imperative to avoid subsequent nasal deformities. The nasal septum is commonly involved in nasal bone fractures. The incidence of septal fractures in patients with simple nasal fracture is considerably high and reported between 40% and 96%.2 –4 Fry3 showed the incidence of complete septal fractures in patients with nasal bone fractures as 6% and the incidence of incomplete septal fractures and septal deformities as high as 80%. The septal fractures are usually unrecognized and untreated at the time of the injury.2 Minor septal injuries, particularly in the children, however, may result in major sequela in the adulthood. Multiple reconstructive procedures may be needed to correct these deformities.5,6 Fractures in the other parts of the cartilage skeleton of the nose are less known and rarely reported. Avulsion of the upper lateral cartilages resulting from direct trauma has been noted in the literature.1 But, to our knowledge, the fracture of the medial crus of the lower lateral cartilage has never been reported before. Untreated nasal fractures may subsequently cause deformities and deviations, which lead to functional and cosmetic problems. Appropriate repositioning of all bony and cartilagenous structures should be aimed in the treatment of nasal fracture to obtain optimal results. Fatma Betul Tuncer, MD Marmara University School of Medicine Istanbul, Turkey [email protected] Melekber Cavus Ozkan, MD Ozhan Bekir Celebiler, MD Department of Plastic Reconstructive and Aesthetic Surgery Marmara University Hospital Istanbul, Turkey
REFERENCES 1. Parkes ML, Kanodia R. Avulsion of the upper lateral cartilage: etiology, diagnosis, surgical anatomy and management. Laryngoscope 1981;91: 758–764 2. Rhee SC, Kim YK, Cha JH, et al. Septal fracture in simple nasal bone fracture. Plast Reconstr Surg 2004;113:45–52 3. Fry H. The importance of the septal cartilage in nasal trauma. Br J Plast Surg 1967;20:392–402 4. Hwang K, You SH, Kim SG, et al. Analysis of nasal bone fractures: a six-year study of 503 patients. J Craniofac Surg 2006;17:261–264 5. Alvarez H, Osorio J, De Diego JI, et al. Sequelae after nasal septum injuries in children. Auris Nasus Larynx 2000;27:339–342 6. Sayin I, Yazici ZM, Bozkurt E, et al. Nasal septal hematoma and abscess in children. J Craniofac Surg 2011;22:e17–e19
Awake Nasotracheal Fiberoptic Intubation With Different Conscious Sedation Techniques To the Editor: In the recent article by Eftekharian et al1 assessing performance of different conscious sedation techniques for awake #
2015 Mutaz B. Habal, MD
Correspondence
nasotracheal fiberoptic intubation in patients with difficult airway by temporomandibular joint ankylosis, they concluded that remifentanil was the best agent, because it provided shorter intubation time, better intubation conditions, and least patient’s complaint. Given that difficult airway algorithms recommend awake intubation as the gold standard for difficult airway management,2,3 their findings have potential implications. In our view, however, there are several aspects of this study that need to be clarified and discussed before adoption into routine practice. First, in materials and methods, the authors did not specify the experience of intubators in the nasotracheal fiberoptic intubation. The experience and competence with the airway devices are critical for their successful use, especially when there is a difficult airway.4 For the results of a comparative airway management study to be valid, participants must be equally proficient with tested airway device to avoid bias. We are concerned that unequally proficient of intubators with the nasotracheal fiberoptic intubation would have contributed to their findings. Second, other than sedation managements, awake patients also rarely allow the airway to be instrumented without adequate airway topical anesthesia. Thus, effective airway topical anesthesia is mandatory for the comfort of the awake patient and subsequent successful instrumentation.5 In this study, Eftekharian et al used several techniques for airway topical anesthesia, such as direct application of lidocaine to the nasal mucosa, gargling of lidocaine, and airway nerve blocks. However, it was unclear how the anesthetists judged adequacy of airway topical anesthesia before commence of fiberoptic intubation. We believe that addressing this issue would further clarify the transparency of this study. Third, the authors stated that loss of eyelash reflex and Ramsay Sedation Score 4 were used as the start points for nasotracheal fiberoptic intubation. According to the results provided in their Table 2, however, most patients only had Ramsay Sedation Scores 1–2. That is, most fiberoptic intubation had been initiated before the targeted sedation degree was achieved. Furthermore, Ramsay Sedation Score is a 6-point scoring system, with a score range of 1 to 6.6 We are very interested in knowing why 22.2% of patients receiving remifentanil or ketamine had a Ramsay Sedation Score 0. Fourth, this study had not provided a power analysis of sample size. Actually, estimation of proper sample size in the design of a randomized double-blind study is an important prerequisite to avoid type 2 statistical errors in the analysis of study results. The study by Eftekharian et al seems no enough power to show differences among 3 groups in the Ramsay Sedation Score, patient discomfort, respiratory complications, and postoperative dissatisfaction of patients. Thus, we agree with Eftekharian et al that large randomized controlled trials are still needed to provide more definitive evidence that remifentanil is the best agent for conscious sedation of awake nasotracheal fiberoptic intubation in patients with difficult airway. Finally, the authors stated that all patients were premedicated with midazolam 0.05 mg/kg IV and fentanyl 0.1 mg/kg IV, 5 minutes before this study was conducted. The dose of fentanyl is evidently too large. Rui Ping Li, MD Fu Shan Xue, MD Gao Pu Liu, MD Chao Sun, MD Department of Anesthesiology Plastic Surgery Hospital Chinese Academy of Medical Sciences and Peking Union Medical College Beijing, People’s Republic of China [email protected]; [email protected]
2029
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Correspondence
Volume 26, Number 6, September 2015
REFERENCES 1. Eftekharian HR, Zarei K, Arabion HR, et al. Remifentanil, ketamine, and propofol in awake nasotracheal fiberopticintubation in temporomandibular joint ankylosis surgery. J Craniofac Surg 2015;26:206–209 2. American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway. A report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 1993;78:597–602 3. American Society of Anesthesiologists Task Force on Management of the Difficult Airway. American Society of Anesthesiologists Task Force on Management of the Difficult Airway: Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2003;98:1269–1277 4. Behringer EC, Kristensen MS. Evidence for benefit vs novelty in new intubation equipment. Anaesthesia 2011;66(Suppl 2):57–64 5. Simmons ST, Schleich AR. Airway regional anesthesia for awake fiberoptic intubation. Reg Anesth Pain Med 2002;27:180–192 6. Ramsay MA, Savege TM, Simpson BR, et al. Controlled sedation with alphaxalone-alphadolone. BMJ 1974;2:656–659
Bone Healing in the Surgical Treatment of Dentigerous Cysts in Critically Ill Patients To the Editor: Dentigerous cyst (DC) is a pathologic entity that arises from cells of the dental follicle that surrounds the crown and it is attached to the neck of an unerupted tooth.1 It is one of the most common odontogenic cysts in the jaws bones, and generally it is one of the most frequent oral lesions.2 These lesions are often asymptomatic and they may grow up massively causing an extensive erosion of the bone tissue. Surgical management of these lesions has been based on different approaches: enucleation, decompression, or marsupialization.3,4 In these situations, a conservative approach with marsupialization could decrease morbidity and determine a reduction of lesion’ size.5 Moreover, sometime, those lesions occur on patients affected by worst general condition. The ASA physical status classification is a system that gives the clinicians the possibility of evaluating the fitness condition before the surgery. Only the patient involved on the class 1 can be considered healthy person.5,6 The aim of this study was to evaluate clinical parameters in debilitated patients, classified as classes 3–4 of ASA physical state, with extensive dentigerous cyst after surgical marsupialization. A common protocol of investigation was prospectively applied to 32 patients classified as ASA 3–4 according to the ASA physical status classification. All the patients needed to treat large mandibular cyst. An informed consent was obtained from all patients included in this study. Inclusions criteria were as follows: presence of dentigerous cyst with impacted teeth confirmed through postoperative histological investigation; lesion’s size greater than 3 cm revealed with radiological examinations (orthopantomography X-rays, CT dental scan); presence of systemic disease that enables a specialist in anaesthesiology to classify them as ASA 3–4; presence of a postoperative followup at least of 1 year; presence of a postoperative radiological examination carried out after about 12 months from surgical act. ASA 3–4 has been defined as follows: patients with severe systemic disease (ASA3) and patients with severe systemic disease that is a constant threat to life (ASA4) (Fig. 1).6,7 Marsupialization consists of viewing and isolating the cyst wall; subsequently, it was cut to facilitate decompression of the cavity
2030
FIGURE 1. (A) Preoperative orthopanoramic X-rays show a large lesion involved the inferior third molar located in the inferior left margin of the mandible. (B) Postoperative orthopanoramic X-rays show the large bone defect. (C) One year follow-up orthopanoramic X-rays underline the excellent healing of the bone tissue.
and drained the liquid contents. Afterward, tooth was extracted along with a little portion of the cystic wall; that was submitted to histological examinations. Then, a suture of cystic epithelium has been connected with the epithelium of oral mucosa to allow a wider communication of the cyst cavity with mouth. The opening was maintained through packing with iodoform gauze. This medication was weekly replaced and the cavity was washed with antibiotic solution to prevent postsurgical infection. As mentioned above, pre- and postoperative orthopantomography X-rays were used for the evaluation of the amount of bone regeneration after marsupialization. The evaluation was performed using the method of Anavi et al.8 In brief, maximal horizontal and vertical lengths were measured on panoramic radiograph, and then those values were multiplied to obtain the standard lesion area index (SLAI) in centimeter. SLAI postsurgery was then subtracted to presurgical values to obtain the percentage of reduction of the infected area (POR). Healing was so classified according to Nakamura et al:9 good reduction (bone apposition > ¼ 80%); moderate reduction (bone apposition >50>80%); poor reduction (bone apposition
Volume 26, Number 6, September 2015
DISCUSSION Early diagnosis and management of the nasal fractures are imperative to avoid subsequent nasal deformities. The nasal septum is commonly involved in nasal bone fractures. The incidence of septal fractures in patients with simple nasal fracture is considerably high and reported between 40% and 96%.2 –4 Fry3 showed the incidence of complete septal fractures in patients with nasal bone fractures as 6% and the incidence of incomplete septal fractures and septal deformities as high as 80%. The septal fractures are usually unrecognized and untreated at the time of the injury.2 Minor septal injuries, particularly in the children, however, may result in major sequela in the adulthood. Multiple reconstructive procedures may be needed to correct these deformities.5,6 Fractures in the other parts of the cartilage skeleton of the nose are less known and rarely reported. Avulsion of the upper lateral cartilages resulting from direct trauma has been noted in the literature.1 But, to our knowledge, the fracture of the medial crus of the lower lateral cartilage has never been reported before. Untreated nasal fractures may subsequently cause deformities and deviations, which lead to functional and cosmetic problems. Appropriate repositioning of all bony and cartilagenous structures should be aimed in the treatment of nasal fracture to obtain optimal results. Fatma Betul Tuncer, MD Marmara University School of Medicine Istanbul, Turkey [email protected] Melekber Cavus Ozkan, MD Ozhan Bekir Celebiler, MD Department of Plastic Reconstructive and Aesthetic Surgery Marmara University Hospital Istanbul, Turkey
REFERENCES 1. Parkes ML, Kanodia R. Avulsion of the upper lateral cartilage: etiology, diagnosis, surgical anatomy and management. Laryngoscope 1981;91: 758–764 2. Rhee SC, Kim YK, Cha JH, et al. Septal fracture in simple nasal bone fracture. Plast Reconstr Surg 2004;113:45–52 3. Fry H. The importance of the septal cartilage in nasal trauma. Br J Plast Surg 1967;20:392–402 4. Hwang K, You SH, Kim SG, et al. Analysis of nasal bone fractures: a six-year study of 503 patients. J Craniofac Surg 2006;17:261–264 5. Alvarez H, Osorio J, De Diego JI, et al. Sequelae after nasal septum injuries in children. Auris Nasus Larynx 2000;27:339–342 6. Sayin I, Yazici ZM, Bozkurt E, et al. Nasal septal hematoma and abscess in children. J Craniofac Surg 2011;22:e17–e19
Awake Nasotracheal Fiberoptic Intubation With Different Conscious Sedation Techniques To the Editor: In the recent article by Eftekharian et al1 assessing performance of different conscious sedation techniques for awake #
2015 Mutaz B. Habal, MD
Correspondence
nasotracheal fiberoptic intubation in patients with difficult airway by temporomandibular joint ankylosis, they concluded that remifentanil was the best agent, because it provided shorter intubation time, better intubation conditions, and least patient’s complaint. Given that difficult airway algorithms recommend awake intubation as the gold standard for difficult airway management,2,3 their findings have potential implications. In our view, however, there are several aspects of this study that need to be clarified and discussed before adoption into routine practice. First, in materials and methods, the authors did not specify the experience of intubators in the nasotracheal fiberoptic intubation. The experience and competence with the airway devices are critical for their successful use, especially when there is a difficult airway.4 For the results of a comparative airway management study to be valid, participants must be equally proficient with tested airway device to avoid bias. We are concerned that unequally proficient of intubators with the nasotracheal fiberoptic intubation would have contributed to their findings. Second, other than sedation managements, awake patients also rarely allow the airway to be instrumented without adequate airway topical anesthesia. Thus, effective airway topical anesthesia is mandatory for the comfort of the awake patient and subsequent successful instrumentation.5 In this study, Eftekharian et al used several techniques for airway topical anesthesia, such as direct application of lidocaine to the nasal mucosa, gargling of lidocaine, and airway nerve blocks. However, it was unclear how the anesthetists judged adequacy of airway topical anesthesia before commence of fiberoptic intubation. We believe that addressing this issue would further clarify the transparency of this study. Third, the authors stated that loss of eyelash reflex and Ramsay Sedation Score 4 were used as the start points for nasotracheal fiberoptic intubation. According to the results provided in their Table 2, however, most patients only had Ramsay Sedation Scores 1–2. That is, most fiberoptic intubation had been initiated before the targeted sedation degree was achieved. Furthermore, Ramsay Sedation Score is a 6-point scoring system, with a score range of 1 to 6.6 We are very interested in knowing why 22.2% of patients receiving remifentanil or ketamine had a Ramsay Sedation Score 0. Fourth, this study had not provided a power analysis of sample size. Actually, estimation of proper sample size in the design of a randomized double-blind study is an important prerequisite to avoid type 2 statistical errors in the analysis of study results. The study by Eftekharian et al seems no enough power to show differences among 3 groups in the Ramsay Sedation Score, patient discomfort, respiratory complications, and postoperative dissatisfaction of patients. Thus, we agree with Eftekharian et al that large randomized controlled trials are still needed to provide more definitive evidence that remifentanil is the best agent for conscious sedation of awake nasotracheal fiberoptic intubation in patients with difficult airway. Finally, the authors stated that all patients were premedicated with midazolam 0.05 mg/kg IV and fentanyl 0.1 mg/kg IV, 5 minutes before this study was conducted. The dose of fentanyl is evidently too large. Rui Ping Li, MD Fu Shan Xue, MD Gao Pu Liu, MD Chao Sun, MD Department of Anesthesiology Plastic Surgery Hospital Chinese Academy of Medical Sciences and Peking Union Medical College Beijing, People’s Republic of China [email protected]; [email protected]
2029
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Correspondence
Volume 26, Number 6, September 2015
REFERENCES 1. Eftekharian HR, Zarei K, Arabion HR, et al. Remifentanil, ketamine, and propofol in awake nasotracheal fiberopticintubation in temporomandibular joint ankylosis surgery. J Craniofac Surg 2015;26:206–209 2. American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway. A report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 1993;78:597–602 3. American Society of Anesthesiologists Task Force on Management of the Difficult Airway. American Society of Anesthesiologists Task Force on Management of the Difficult Airway: Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2003;98:1269–1277 4. Behringer EC, Kristensen MS. Evidence for benefit vs novelty in new intubation equipment. Anaesthesia 2011;66(Suppl 2):57–64 5. Simmons ST, Schleich AR. Airway regional anesthesia for awake fiberoptic intubation. Reg Anesth Pain Med 2002;27:180–192 6. Ramsay MA, Savege TM, Simpson BR, et al. Controlled sedation with alphaxalone-alphadolone. BMJ 1974;2:656–659
Bone Healing in the Surgical Treatment of Dentigerous Cysts in Critically Ill Patients To the Editor: Dentigerous cyst (DC) is a pathologic entity that arises from cells of the dental follicle that surrounds the crown and it is attached to the neck of an unerupted tooth.1 It is one of the most common odontogenic cysts in the jaws bones, and generally it is one of the most frequent oral lesions.2 These lesions are often asymptomatic and they may grow up massively causing an extensive erosion of the bone tissue. Surgical management of these lesions has been based on different approaches: enucleation, decompression, or marsupialization.3,4 In these situations, a conservative approach with marsupialization could decrease morbidity and determine a reduction of lesion’ size.5 Moreover, sometime, those lesions occur on patients affected by worst general condition. The ASA physical status classification is a system that gives the clinicians the possibility of evaluating the fitness condition before the surgery. Only the patient involved on the class 1 can be considered healthy person.5,6 The aim of this study was to evaluate clinical parameters in debilitated patients, classified as classes 3–4 of ASA physical state, with extensive dentigerous cyst after surgical marsupialization. A common protocol of investigation was prospectively applied to 32 patients classified as ASA 3–4 according to the ASA physical status classification. All the patients needed to treat large mandibular cyst. An informed consent was obtained from all patients included in this study. Inclusions criteria were as follows: presence of dentigerous cyst with impacted teeth confirmed through postoperative histological investigation; lesion’s size greater than 3 cm revealed with radiological examinations (orthopantomography X-rays, CT dental scan); presence of systemic disease that enables a specialist in anaesthesiology to classify them as ASA 3–4; presence of a postoperative followup at least of 1 year; presence of a postoperative radiological examination carried out after about 12 months from surgical act. ASA 3–4 has been defined as follows: patients with severe systemic disease (ASA3) and patients with severe systemic disease that is a constant threat to life (ASA4) (Fig. 1).6,7 Marsupialization consists of viewing and isolating the cyst wall; subsequently, it was cut to facilitate decompression of the cavity
2030
FIGURE 1. (A) Preoperative orthopanoramic X-rays show a large lesion involved the inferior third molar located in the inferior left margin of the mandible. (B) Postoperative orthopanoramic X-rays show the large bone defect. (C) One year follow-up orthopanoramic X-rays underline the excellent healing of the bone tissue.
and drained the liquid contents. Afterward, tooth was extracted along with a little portion of the cystic wall; that was submitted to histological examinations. Then, a suture of cystic epithelium has been connected with the epithelium of oral mucosa to allow a wider communication of the cyst cavity with mouth. The opening was maintained through packing with iodoform gauze. This medication was weekly replaced and the cavity was washed with antibiotic solution to prevent postsurgical infection. As mentioned above, pre- and postoperative orthopantomography X-rays were used for the evaluation of the amount of bone regeneration after marsupialization. The evaluation was performed using the method of Anavi et al.8 In brief, maximal horizontal and vertical lengths were measured on panoramic radiograph, and then those values were multiplied to obtain the standard lesion area index (SLAI) in centimeter. SLAI postsurgery was then subtracted to presurgical values to obtain the percentage of reduction of the infected area (POR). Healing was so classified according to Nakamura et al:9 good reduction (bone apposition > ¼ 80%); moderate reduction (bone apposition >50>80%); poor reduction (bone apposition
