Letters to the Editor CONGENITAL TORTICOLLIS Dear Editor,
plaster ca st over a long period of time .
T
I had the experience of assisting in the surgery of a young probable rejected in recruitment because of congenital torticollis, The lower end of sternocleiomastoid was divided. The results were far from satisfactory.
his is with reference to the case report Congenital Torticollis ' MJ AFI 2000; 56: 55 -56. Congenital torticollis persisting into adolescence and adulthood usually reveals fibrosis of not only the sternocleidomastoid muscle, bu t also the layers of the deep fascia including the carotid sheath [1]. It can be associated with ipsilateral facial hemihypoplasia, plagiocephaly, head turned away from the side of the mass and occasionally ipsilateral trapezius atrophy or cervical vertebral abnormality which should be ruled out by an X-ray of the cervical spine [2]. Good results can only be obtained if, along with the sternocleidomastoid muscle, the layers of the deep fascia and cartoid sheath can be carefully divided followed by intensive physiotherapy and a
References 1. Congenital Torticollis. Farquharsons' Textbook of OperativeSurgery, 8th ed, pg 291. 2. Cervical Anomalies,Sabiston Textbookof Surgery. 19th ed VoI-2,pg
1263.
MajKJSINGH Graded Specialist (Surgery), 153 General Hospital, C/O 56 APO
Reply Dear Editor,
I
thank Major KJ Singh for reading the article and expressing his view s on the management of congenital torticollis persisting into ado lescence. Congential torticollis is a condition due to developmental aplasia of the muscles and the other soft tissue structures on the affected side of the neck may be involved with the passage of time . [IJ I agree with the reader that it may be associated with ipsilateral facial hemihypop lasia, plagiocephaly, head turned away from the side of the mass and occasional ipsilateral trapezius atrophy or cervical vertebral abnormality [2J which were ruled out by x-ray of the cervical spine. Cervical spine subluxations associated with childhood torticollis are usually rotatory, occur at the CI-C2Ievel, and are best known as atlanto-axial rotatory subluxations. [3J If the subluxation persists, it may be described as an atlanto-axial rotatory fixation [4J. In this particular patient, on exploration there was no shortening of scalenus anterior or contracture of the soft tissue e.g. carotid sheath or deep fascia, hence only the heads of sternocliedornastoid were divided. Results of surgery were satisfactory in this patient and there was no recurrence of the deformity on follow up. This was
possibe due to intensive physiotherapy and wearing of torticollis harness. It is important to safeguard the internal jugular vein, spinal accessory nerve and phrenic nerve. Open surgery is preferred as subcutaneous tenotomy is a blind technique and should be avoided in children.
References I. Saunders RA. Roberts EL. Abnormal head posture in patients with fourthcranial nerve palsy Am Orthop J 1995;45:24-33.
2. R. Kendrick State, Jcfery C, Posnick, Derek C, Armstrong. Cervical spine subluxation associated with congenital muscular torticollis and craniofacial assymetry. Plastic and Reconstructive Surgery 1993;91:1187-95. 3. Bredenkamp JK, Maceri DR. Inflammatory torticollis in children. Arch. Otolaryngol. Head Neck Surgery 1990;116;310-4. 4. FieldingJW, Hawkins RI. Atlanto-axialrotatory fixation.J Bone Joint Surg (Am) 1977;59-A:37-44.
Lt Col S CRAWLA Classified Specialist (Surgery), Military Hospital,Bhopal-462031.
INCIDENCE AND ETIOLOGY OF RESPIRATORY DISTRESS IN NEWBORN Dear Editor,
T
his is in reference to the article titled 'Incidence and Etiology of Respiratory distress in newborn'[I).
Following comments are offered for review by authors.
1. The clinical diagnosis of respiratory distress in a neonate is usually assessed by the Downe's score which is as under:Parameter
0
Cyanosis
None None
Retractions Gruming Air entry Respiratoryrate
2
Clear
In room air Mild Audible with stethoscope Decreased/delayed
80 or apnea
Score : > 4 == Clinical respiratory distress; monitor arterial blood gases 8 == Impending respiratory failure This scoring criterion is usually adopted for making initial diagnosis and also for management protocols. 2. There are several reports on the incidence of respiratory distress syndrome in Indian literature. In fact in a similar study from the same center [2], the authors have observed similar pattern of etiological factors (respiratory distress was hyaline membrane disease (18%), followed by wet lung syndrome (14%), meconium aspiration (12 %), asphyxia (12%) and septicemia (8%). In 8 babies, a lung biopsy (postmortem) was done to confirm the diagnosis. In a study on neonatal autopsy, the authors correlated clinical and autopsy findings. There were 23 neonatal autopsy studies out of 43 neonatal deaths during the period from Jan 1991 to Sept93. Common antemortem diagnosis included meconium aspiration syndrome, respiratory distress syndrome and aspiration syndrome. MJAFI, Vol. 57, NO. I . 2001
92
Letters to the Editor
Hyaline membrane disease was confirmed on autopsy study [3]. In an another epidemiological study, the single most important factor contributing to the mortality was respiratory distress (29.3%) followed by sepsis (24.4%) and birth asphyxia (16.2%) [4]. 3. Inclusion criteria for hyaline membrane disease need to be specified. Usual criteria adopted is clinical and radiographic diagnosis of RDS, requiring mechanical ventilation and FiO:! > 0.3. The reason for variation in reporting RDS is highlighted by the fact that there is no uniform protocol for diagnosis as has been well brought out by the authors in their introductory comments. 4. The study has been designed in the format of a descriptive cross sectional one. This design gives an idea of prevalence of disease and not incidence. To be scientifically correct, such study should define the population from whom the study sample will be selected, period of study, methodology ofselection of study sample,
define the disease to be studied and lay down the diagnostic criteria.
References 1. Nagendra K. Wilson CG, Ravichader B, Sood S, Singh SP. Incidence
andetiologyof respiratory distressin newborn. MJAFl 1999;55:331-3. 2. Malhotra AK, Nagpal R, Gupta RK, Chhajta DS, Arora RK. Respiratory distress in new born.treated with ventilation in a level II nursery. Indin Pediatr 1995;32(2):207-1 L 3. Sarna MS, Sarli A, Duua AK, Kumari S. Neonatalmortality pauerns in an urbanhospital. Indian Pediatr 1991;28(7):7l9-24. 4. Raghukaman TS, Daljit Singh,Jalpota YP, MenonPK. Clinico-Pathological correlation in neonatal autopsies. MJAFI 1996;~:19"22.
GpCaptTSRAGHURAMAN Senior Advisor (Pediatrics), Command Hospital (Air Force), Bangalore-560007.
Reply Dear Editor, This refers on observation made in Letter to Editor in reference to the article titled "Incidence and "Etiology of Respiratory Distress in New Born".
I. The clinical diagnosis of respiratory distress in new born was made by using criteria described in standard pediatric pulmonology text book [I] and Downe score is used for facilitating the clinical diagnosis of respiratory failure and not respiratory distress as such [2]. 2, Aim of our study was to determine the etiological factors in respiratory distress in newborn, especially the incidence of hyaline membrane disease and not treatment modalities or their efficacy. 3. Standard inclusion criteria for all the etiological factors of
respiratory distress in newborn have been used in our study, however the same were not mentioned in material and methods because of space constraints. 4. Our study design gives an idea ofincidence and not prevalence of respiratory distress in newborn as defined in standard textbook [3].
References I. Barry V, Kirkpatrics, Respiratory distress in newborn. In Kernig's
Disorders of the respiratory tract in children6th ed. 1998:332. 2. GellisS5, KaganBM. Asthama. In current paediatric therapy 12thed. 1986;637. 3. Park K. Epidemiological studies. In Park's textbookof preventive and socialmedicine 15thed,1997:52-3.
DESIGN MODIFICATION OF THE BACKREST OF HOSPITAL BEDS IN THE ARMED FORCES: A PROPOSAL Dear Editor,
T
he basic hospital bed (ordinance stores) is an iron/alloy based structure. The head end has an adjustable backrest, which is adjustable both in the vertical plane as well as the angle of inclination. There is essentially no design flaw in the backrest, However, the beds are painted white from one end to other in preparation for staff visits/inspections, Over a period of time, because of the white paint the backrest refuses to adjust in all the desirable places, even the screw for tightening does not work. All this (done in the good spirit of making the bed look as 'White' as possible) leads to the not so recommendable uncommon sight and uncomfortable for the patients - the uls backrest, with a propensity to dangle at difficult angles. Despite being a witness to so many of these in the SSQs and have worked all these years, the impact ofan U/S backrest had not affected me. It took the admission of my daughter to a tertiary care hospital
for me to realise that the discomfort a patient had to undergo with such a backrest and a simple design modification could provide a very simple practical solution to this problem. Making the adjustable/sliding rod of pure stainless steel, instead of cast iron at present will serve two purposes :(a) It will not need to be re-painted as the steel would always remain 'stainless' and presentable. (b) It will have the same strength as the cast iron. The other design modification is to do away with the use of screws to fix the backrest at appropriate angles. Appropriate slots can be made on both the sliding rod as well as the 'back' portion of the backrest with steel hooks provided to lock in.
WgCdrNTANEJA Classified Specialist (Aerospace Medicine), 15 Sqn, Air Force, C/056, APO.
MJAfI. VOL 57, NO. I, 2001
plaster ca st over a long period of time .
T
I had the experience of assisting in the surgery of a young probable rejected in recruitment because of congenital torticollis, The lower end of sternocleiomastoid was divided. The results were far from satisfactory.
his is with reference to the case report Congenital Torticollis ' MJ AFI 2000; 56: 55 -56. Congenital torticollis persisting into adolescence and adulthood usually reveals fibrosis of not only the sternocleidomastoid muscle, bu t also the layers of the deep fascia including the carotid sheath [1]. It can be associated with ipsilateral facial hemihypoplasia, plagiocephaly, head turned away from the side of the mass and occasionally ipsilateral trapezius atrophy or cervical vertebral abnormality which should be ruled out by an X-ray of the cervical spine [2]. Good results can only be obtained if, along with the sternocleidomastoid muscle, the layers of the deep fascia and cartoid sheath can be carefully divided followed by intensive physiotherapy and a
References 1. Congenital Torticollis. Farquharsons' Textbook of OperativeSurgery, 8th ed, pg 291. 2. Cervical Anomalies,Sabiston Textbookof Surgery. 19th ed VoI-2,pg
1263.
MajKJSINGH Graded Specialist (Surgery), 153 General Hospital, C/O 56 APO
Reply Dear Editor,
I
thank Major KJ Singh for reading the article and expressing his view s on the management of congenital torticollis persisting into ado lescence. Congential torticollis is a condition due to developmental aplasia of the muscles and the other soft tissue structures on the affected side of the neck may be involved with the passage of time . [IJ I agree with the reader that it may be associated with ipsilateral facial hemihypop lasia, plagiocephaly, head turned away from the side of the mass and occasional ipsilateral trapezius atrophy or cervical vertebral abnormality [2J which were ruled out by x-ray of the cervical spine. Cervical spine subluxations associated with childhood torticollis are usually rotatory, occur at the CI-C2Ievel, and are best known as atlanto-axial rotatory subluxations. [3J If the subluxation persists, it may be described as an atlanto-axial rotatory fixation [4J. In this particular patient, on exploration there was no shortening of scalenus anterior or contracture of the soft tissue e.g. carotid sheath or deep fascia, hence only the heads of sternocliedornastoid were divided. Results of surgery were satisfactory in this patient and there was no recurrence of the deformity on follow up. This was
possibe due to intensive physiotherapy and wearing of torticollis harness. It is important to safeguard the internal jugular vein, spinal accessory nerve and phrenic nerve. Open surgery is preferred as subcutaneous tenotomy is a blind technique and should be avoided in children.
References I. Saunders RA. Roberts EL. Abnormal head posture in patients with fourthcranial nerve palsy Am Orthop J 1995;45:24-33.
2. R. Kendrick State, Jcfery C, Posnick, Derek C, Armstrong. Cervical spine subluxation associated with congenital muscular torticollis and craniofacial assymetry. Plastic and Reconstructive Surgery 1993;91:1187-95. 3. Bredenkamp JK, Maceri DR. Inflammatory torticollis in children. Arch. Otolaryngol. Head Neck Surgery 1990;116;310-4. 4. FieldingJW, Hawkins RI. Atlanto-axialrotatory fixation.J Bone Joint Surg (Am) 1977;59-A:37-44.
Lt Col S CRAWLA Classified Specialist (Surgery), Military Hospital,Bhopal-462031.
INCIDENCE AND ETIOLOGY OF RESPIRATORY DISTRESS IN NEWBORN Dear Editor,
T
his is in reference to the article titled 'Incidence and Etiology of Respiratory distress in newborn'[I).
Following comments are offered for review by authors.
1. The clinical diagnosis of respiratory distress in a neonate is usually assessed by the Downe's score which is as under:Parameter
0
Cyanosis
None None
Retractions Gruming Air entry Respiratoryrate
2
Clear
In room air Mild Audible with stethoscope Decreased/delayed
80 or apnea
Score : > 4 == Clinical respiratory distress; monitor arterial blood gases 8 == Impending respiratory failure This scoring criterion is usually adopted for making initial diagnosis and also for management protocols. 2. There are several reports on the incidence of respiratory distress syndrome in Indian literature. In fact in a similar study from the same center [2], the authors have observed similar pattern of etiological factors (respiratory distress was hyaline membrane disease (18%), followed by wet lung syndrome (14%), meconium aspiration (12 %), asphyxia (12%) and septicemia (8%). In 8 babies, a lung biopsy (postmortem) was done to confirm the diagnosis. In a study on neonatal autopsy, the authors correlated clinical and autopsy findings. There were 23 neonatal autopsy studies out of 43 neonatal deaths during the period from Jan 1991 to Sept93. Common antemortem diagnosis included meconium aspiration syndrome, respiratory distress syndrome and aspiration syndrome. MJAFI, Vol. 57, NO. I . 2001
92
Letters to the Editor
Hyaline membrane disease was confirmed on autopsy study [3]. In an another epidemiological study, the single most important factor contributing to the mortality was respiratory distress (29.3%) followed by sepsis (24.4%) and birth asphyxia (16.2%) [4]. 3. Inclusion criteria for hyaline membrane disease need to be specified. Usual criteria adopted is clinical and radiographic diagnosis of RDS, requiring mechanical ventilation and FiO:! > 0.3. The reason for variation in reporting RDS is highlighted by the fact that there is no uniform protocol for diagnosis as has been well brought out by the authors in their introductory comments. 4. The study has been designed in the format of a descriptive cross sectional one. This design gives an idea of prevalence of disease and not incidence. To be scientifically correct, such study should define the population from whom the study sample will be selected, period of study, methodology ofselection of study sample,
define the disease to be studied and lay down the diagnostic criteria.
References 1. Nagendra K. Wilson CG, Ravichader B, Sood S, Singh SP. Incidence
andetiologyof respiratory distressin newborn. MJAFl 1999;55:331-3. 2. Malhotra AK, Nagpal R, Gupta RK, Chhajta DS, Arora RK. Respiratory distress in new born.treated with ventilation in a level II nursery. Indin Pediatr 1995;32(2):207-1 L 3. Sarna MS, Sarli A, Duua AK, Kumari S. Neonatalmortality pauerns in an urbanhospital. Indian Pediatr 1991;28(7):7l9-24. 4. Raghukaman TS, Daljit Singh,Jalpota YP, MenonPK. Clinico-Pathological correlation in neonatal autopsies. MJAFI 1996;~:19"22.
GpCaptTSRAGHURAMAN Senior Advisor (Pediatrics), Command Hospital (Air Force), Bangalore-560007.
Reply Dear Editor, This refers on observation made in Letter to Editor in reference to the article titled "Incidence and "Etiology of Respiratory Distress in New Born".
I. The clinical diagnosis of respiratory distress in new born was made by using criteria described in standard pediatric pulmonology text book [I] and Downe score is used for facilitating the clinical diagnosis of respiratory failure and not respiratory distress as such [2]. 2, Aim of our study was to determine the etiological factors in respiratory distress in newborn, especially the incidence of hyaline membrane disease and not treatment modalities or their efficacy. 3. Standard inclusion criteria for all the etiological factors of
respiratory distress in newborn have been used in our study, however the same were not mentioned in material and methods because of space constraints. 4. Our study design gives an idea ofincidence and not prevalence of respiratory distress in newborn as defined in standard textbook [3].
References I. Barry V, Kirkpatrics, Respiratory distress in newborn. In Kernig's
Disorders of the respiratory tract in children6th ed. 1998:332. 2. GellisS5, KaganBM. Asthama. In current paediatric therapy 12thed. 1986;637. 3. Park K. Epidemiological studies. In Park's textbookof preventive and socialmedicine 15thed,1997:52-3.
DESIGN MODIFICATION OF THE BACKREST OF HOSPITAL BEDS IN THE ARMED FORCES: A PROPOSAL Dear Editor,
T
he basic hospital bed (ordinance stores) is an iron/alloy based structure. The head end has an adjustable backrest, which is adjustable both in the vertical plane as well as the angle of inclination. There is essentially no design flaw in the backrest, However, the beds are painted white from one end to other in preparation for staff visits/inspections, Over a period of time, because of the white paint the backrest refuses to adjust in all the desirable places, even the screw for tightening does not work. All this (done in the good spirit of making the bed look as 'White' as possible) leads to the not so recommendable uncommon sight and uncomfortable for the patients - the uls backrest, with a propensity to dangle at difficult angles. Despite being a witness to so many of these in the SSQs and have worked all these years, the impact ofan U/S backrest had not affected me. It took the admission of my daughter to a tertiary care hospital
for me to realise that the discomfort a patient had to undergo with such a backrest and a simple design modification could provide a very simple practical solution to this problem. Making the adjustable/sliding rod of pure stainless steel, instead of cast iron at present will serve two purposes :(a) It will not need to be re-painted as the steel would always remain 'stainless' and presentable. (b) It will have the same strength as the cast iron. The other design modification is to do away with the use of screws to fix the backrest at appropriate angles. Appropriate slots can be made on both the sliding rod as well as the 'back' portion of the backrest with steel hooks provided to lock in.
WgCdrNTANEJA Classified Specialist (Aerospace Medicine), 15 Sqn, Air Force, C/056, APO.
MJAfI. VOL 57, NO. I, 2001
