- Email: [email protected]
Cervical Fluorosis: A Lurking Peril
e72
LETTERS TO THE EDITOR
operations with single-lung deflation such as thoracoscopic sympathectomy. Uğur Temel, MD* Serkan Kaya, MD† S. Faruk Yücesoy, MD‡ H. Şebnem Yeltepe Türk, MD‡ Naim Ediz‡ *Thoracic Surgery Clinic, Beyoğlu Hospital Group Şişli Etfal Education and Research Hospital †Thoracic Surgery Clinic, Liv Hospital ‡Anestesiology and Reanimation Clinic, Beyoğlu Hospital Group Şişli Etfal Education and Research Hospital İstanbul, Türkiye Fig 1.
EZ-blocker with its 2 cuffs.
years. It provides bilateral lung ventilation separately without any additional manipulation. It has 2 extensions sitting on the tracheal bifurcation that permits deflating the desired lung by inflating its cuff (Figure). It can be placed through a singlelumen endotracheal tube. Fiberoptic bronchoscopy may be needed for verification of placement. However, it is possible that the 2 extensions may stick together and enter the same mainstem bronchus. EZ-blocker may only be used to block the mainstem bronchus and to achieve a total lung collapse, so selective block of a single lung lobe is not possible with EZblocker. EZ-blocker can be placed by a physician blindly in case of an emergency if it is necessary and saves time.4 It also provides simplicity and comfort when both lungs need to be inflated and deflated in turns. Vegh et al have used EZ-blocker on 10 patients who have needed SLV.5 They have underlined the usage of EZblocker on difficult intubation cases and emergency surgery because of the shortened time of placement and fast deflation of the lung. Mourisse et al have compared DLET and EZblocker on 100 patients for SLV. They found that the placement of the EZ-blocker time was longer. Besides, sore throat and hoarseness were found to be fewer among the EZblocked patients.6 Ruetzler et al have compared EZ-blocker and DLET on 40 patients for SLV.7 Although placement of EZ-blocker time was longer, there was no difference in confirmation with fiberoptic bronchoscopy and quality of deflation. The authors have used EZ-blockers in 14 patients who had thoracoscopic sympathectomy for regional hyperhidrosis. All placements of the EZ-blockers were verified with fiberoptic bronchoscopy. Successful SLV was performed during the entire duration of the operations. The average time of placement for the EZ-blocker was 5.1 ⫾ 3.7 minutes. The device has maintained its position during patient position change. There was no need to reintubate for the other side. When it is done for the first lung ventilation, the other lung deflation is performed just by changing the inflated cuff. No hoarseness or sore throat was seen postoperatively. The authors think that EZ-blocker is easy to use and is the most appropriate device for these
REFERENCES 1. Krasna MJ: Thoracoscopic sympathectomy: A standardized approach to therapy for hyperhidrosis. Ann Thorac Surg 85: 764-767, 2008 2. Zhong T, Wang W, Chen J, et al: Sore throat or hoarse voice with bronchial blockers or double-lumen tubes for lung isolation: A randomised, prospective trial. Anaesth Intensive Care 37:441-446, 2009 3. Campos JH: Which device should be considered the best for lung isolation: Double-lumen endotracheal tube versus bronchial blockers. Curr Opin Anaesthesiol 20:27-31, 2007 4. Mungroop HE, Wai PT, Morei MN, et al: Lung isolation with a new Y-shaped endobronchial blocking device, the EZ-Blocker. Br J Anaesth 104:119-120, 2010 5. Végh T, Juhász M, Enyedi A, et al: Clinical experience with a new endobronchial blocker: The EZ-blocker. J Anesth 26:375-380, 2012 6. Mourisse J, Liesveld J, Verhagen A, et al: Efficiency, efficacy, and safety of EZ-blocker compared with left-sided double-lumen tube for one-lung ventilation. Anesthesiology 118:550-561, 2013 7. Ruetzler K, Grubhofer G, Schmid W, et al: Randomized clinical trial comparing double-lumen tube and EZ-Blocker for single-lung ventilation. J Anaesth 106:896-902, 2011 http://dx.doi.org/10.1053/j.jvca.2013.06.017
Cervical Fluorosis: A Lurking Peril To the Editor: We read with great interest the letter by Li et al in the April 2013 issue of the Journal.1 We appreciate the courage of the authors in reporting post operative quadriplegia. Many articles have been published with cervical canal stenosis as a predisposing factor for postoperative quadriplegia following CABG.2–4 A recently published closed claims analysis by Hindman and colleagues also emphasized the contribution of cervical canal stenosis to postoperative neurologic deterioration.5 The published reports are only a tip of the iceberg. The actual incidence of quadriplegia following surgery on locations remote from the cervical spine is often underreported for medical-legal reasons. Several claims included in the report by Hindman also were not reported.5 We would like to bring
e73
LETTERS TO THE EDITOR
to the attention of the readers the importance of possible neurologic deterioration due to fluorosis. This is a frequent cause of cervical myelopathy in several parts of Asia and Africa but is sparsely reported in western literature.6 Fluorosis is an endemic problem in India, especially so in the states of Andhra Pradesh, Uttar Pradesh, Rajasthan, and Gujarat. Our institute, being a tertiary care center in the state of Andhra Pradesh caters to a large volume of fluorotic cervical disease. Neurologic manifestation appears within 10 to 15 years of exposure to fluoride or even earlier in manual laborers or in hot climatic conditions.7 Fluorosis is associated with diffuse ossification of both the posterior longitudinal ligament and the yellow ligament flavum simultaneously.8,9 Therefore, these patients are at particularly high risk of cervical cord injury during positioning for airway instrumentation, placing neck catheters and surgery. Although there are no published reports of neurologic deterioration following noncervical surgeries with this condition, it is possible that such a situation frequently is encountered by anesthesiologists working in areas endemic to fluorosis. In our experience, most patients with fluorotic spine, although previously asymptomatic, present with neurologic deterioration following minor trauma. There is also a high incidence of postoperative deterioration following cervical surgery in fluorotic cervical spine. The mechanical causes of neurologic deterioration in these chronically compressed cords are well recognized, but the role of hypotension and reduced cervical cord perfusion is underestimated in most reports. We wish to emphasize the contribution of several perturbations in blood pressure that occur during off-pump CABG and the resulting hypoperfusion of the cervical cord that may aggravate neurologic injury. Further neck positions that distort the cervical canal cause narrowing of the cord blood vessels and add to the risk. Because of the earlier age of onset as compared to other causes of cervical canal stenosis, large asymptomatic population, and absence of radiologic changes until the late phase,10 the underlying pathology is likely to be overlooked. An unrecognized cervical pathology with the diffuse nature of bony and ligamentous changes9 places these patients at higher risk, as the precautions are not likely to be observed. Thus, a high degree of suspicion with meticulous history taking of even vague musculoskeletal symptoms is required in patients in endemic areas. A routine screening of all the patients with an MRI of the spine may not be cost effective. Therefore adequate precautions to avoid excessive cervical excursions and distortion of the cervical spine should be taken in all patients from endemic areas for fluorosis during positioning for airway instrumentation, surgery, or neck catheter placement to reduce the possibility of neurologic deterioration. Prachi Kar, MBBS, MD Padmaja Durga, MBBS, MD Ramachandran Gopinath, MBBS, MD Nizams Institute of Medical Science Andhra Pradesh, India
REFERENCES 1. Li CC, et al: Quadriplegia after off-pump coronary artery bypass surgery: Look before you place the neck in an extended position. J Cardiothorac Vasc Anesth 27:e16-e17, 2013
2. Fujioka S, et al: Tetraplegia after coronary artery bypass grafting. Anesth Analg 97:979-980, 2003 3. Hwang NC, Singh P, Chua YL: Quadriparesis after cardiac surgery. J Cardiothorac Vasc Anesth 22:587-589, 2008 4. Naja Z, et al: Tetraplegia after coronary artery bypass grafting in a patient with undiagnosed cervical stenosis. Anesth Analg 101: 1883-1884, 2005 5. Hindman BJ, et al: Cervical spinal cord, root, and bony spine injuries: A closed claims analysis. Anesthesiology 114:782-795, 2011 6. Reddy DR: Neurology of endemic skeletal fluorosis. Neurol India 57:7-12, 2009 7. Haimanot RT: Neurological complications of endemic skeletal fluorosis, with special emphasis on radiculo-myelopathy. Paraplegia244-251, 1990 8. Gupta RK, et al: Compressive myelopathy in fluorosis: MRI. Neuroradiology 38:338-342, 1996 9. Rao BS, Taraknath VR, Sista VN: Ossification of the posterior longitudinal ligament and fluorosis. J Bone Joint Surg Br 74:469-470, 1992 10. Czerwinski E, et al: Bone and joint pathology in fluorideexposed workers. Arch Environ Health 43:340-343, 1988 http://dx.doi.org/10.1053/j.jvca.2013.07.002
Pneumothorax After Pacemaker Implantation: A Diagnostic Value of Sonography
To the Editor: Pneumothorax is a life-threatening complication in patients who have been admitted to the recovery room. The early detection and treatment of pneumothorax can prevent severe progression into tension pneumothorax, and toward this end, lung sonography may have a significant role.1 The advantages of lung sonography include its dynamic nature being performed in real-time during tidal ventilation, which is in contrast to static imaging methods.2 The presence of visceral pleura moving against parietal pleura, or lung sliding, should be looked for. When air is present in the pleural cavity, it commonly is found in the nondependent parts of the thorax; therefore, in the supine patient, the anterior chest should be examined first when pneumothorax is suspected. This case highlights the importance of the prompt diagnosis of pneumothorax using lung sonography. A 70-year-old woman with a history of ischemic heart disease was admitted after cardiac dual-chamber pacemaker implantation. Left subclavian vein access for an introducer was used. On arrival at the recovery room her vital signs were stable. Dyspnea was noted after endotracheal tube removal. The patient’s respiratory status continued to worsen and required the use of increasingly higher concentrations of inspired oxygen (FIO2). A pulmonary catastrophe was suspected, and sonography examination was performed. Sonography of the right hemithorax showed normal aerated lung tissue and presence of the lung sliding (Video 1). Lung ultrasound of the left side showed the presence of A-lines and the absence of the lung sliding (Video 2). M-mode modality was used, and a “stratosphere sign” for left hemithorax was found (Fig 1). These signs are typical for pneumothorax. Transthoracic
LETTERS TO THE EDITOR
operations with single-lung deflation such as thoracoscopic sympathectomy. Uğur Temel, MD* Serkan Kaya, MD† S. Faruk Yücesoy, MD‡ H. Şebnem Yeltepe Türk, MD‡ Naim Ediz‡ *Thoracic Surgery Clinic, Beyoğlu Hospital Group Şişli Etfal Education and Research Hospital †Thoracic Surgery Clinic, Liv Hospital ‡Anestesiology and Reanimation Clinic, Beyoğlu Hospital Group Şişli Etfal Education and Research Hospital İstanbul, Türkiye Fig 1.
EZ-blocker with its 2 cuffs.
years. It provides bilateral lung ventilation separately without any additional manipulation. It has 2 extensions sitting on the tracheal bifurcation that permits deflating the desired lung by inflating its cuff (Figure). It can be placed through a singlelumen endotracheal tube. Fiberoptic bronchoscopy may be needed for verification of placement. However, it is possible that the 2 extensions may stick together and enter the same mainstem bronchus. EZ-blocker may only be used to block the mainstem bronchus and to achieve a total lung collapse, so selective block of a single lung lobe is not possible with EZblocker. EZ-blocker can be placed by a physician blindly in case of an emergency if it is necessary and saves time.4 It also provides simplicity and comfort when both lungs need to be inflated and deflated in turns. Vegh et al have used EZ-blocker on 10 patients who have needed SLV.5 They have underlined the usage of EZblocker on difficult intubation cases and emergency surgery because of the shortened time of placement and fast deflation of the lung. Mourisse et al have compared DLET and EZblocker on 100 patients for SLV. They found that the placement of the EZ-blocker time was longer. Besides, sore throat and hoarseness were found to be fewer among the EZblocked patients.6 Ruetzler et al have compared EZ-blocker and DLET on 40 patients for SLV.7 Although placement of EZ-blocker time was longer, there was no difference in confirmation with fiberoptic bronchoscopy and quality of deflation. The authors have used EZ-blockers in 14 patients who had thoracoscopic sympathectomy for regional hyperhidrosis. All placements of the EZ-blockers were verified with fiberoptic bronchoscopy. Successful SLV was performed during the entire duration of the operations. The average time of placement for the EZ-blocker was 5.1 ⫾ 3.7 minutes. The device has maintained its position during patient position change. There was no need to reintubate for the other side. When it is done for the first lung ventilation, the other lung deflation is performed just by changing the inflated cuff. No hoarseness or sore throat was seen postoperatively. The authors think that EZ-blocker is easy to use and is the most appropriate device for these
REFERENCES 1. Krasna MJ: Thoracoscopic sympathectomy: A standardized approach to therapy for hyperhidrosis. Ann Thorac Surg 85: 764-767, 2008 2. Zhong T, Wang W, Chen J, et al: Sore throat or hoarse voice with bronchial blockers or double-lumen tubes for lung isolation: A randomised, prospective trial. Anaesth Intensive Care 37:441-446, 2009 3. Campos JH: Which device should be considered the best for lung isolation: Double-lumen endotracheal tube versus bronchial blockers. Curr Opin Anaesthesiol 20:27-31, 2007 4. Mungroop HE, Wai PT, Morei MN, et al: Lung isolation with a new Y-shaped endobronchial blocking device, the EZ-Blocker. Br J Anaesth 104:119-120, 2010 5. Végh T, Juhász M, Enyedi A, et al: Clinical experience with a new endobronchial blocker: The EZ-blocker. J Anesth 26:375-380, 2012 6. Mourisse J, Liesveld J, Verhagen A, et al: Efficiency, efficacy, and safety of EZ-blocker compared with left-sided double-lumen tube for one-lung ventilation. Anesthesiology 118:550-561, 2013 7. Ruetzler K, Grubhofer G, Schmid W, et al: Randomized clinical trial comparing double-lumen tube and EZ-Blocker for single-lung ventilation. J Anaesth 106:896-902, 2011 http://dx.doi.org/10.1053/j.jvca.2013.06.017
Cervical Fluorosis: A Lurking Peril To the Editor: We read with great interest the letter by Li et al in the April 2013 issue of the Journal.1 We appreciate the courage of the authors in reporting post operative quadriplegia. Many articles have been published with cervical canal stenosis as a predisposing factor for postoperative quadriplegia following CABG.2–4 A recently published closed claims analysis by Hindman and colleagues also emphasized the contribution of cervical canal stenosis to postoperative neurologic deterioration.5 The published reports are only a tip of the iceberg. The actual incidence of quadriplegia following surgery on locations remote from the cervical spine is often underreported for medical-legal reasons. Several claims included in the report by Hindman also were not reported.5 We would like to bring
e73
LETTERS TO THE EDITOR
to the attention of the readers the importance of possible neurologic deterioration due to fluorosis. This is a frequent cause of cervical myelopathy in several parts of Asia and Africa but is sparsely reported in western literature.6 Fluorosis is an endemic problem in India, especially so in the states of Andhra Pradesh, Uttar Pradesh, Rajasthan, and Gujarat. Our institute, being a tertiary care center in the state of Andhra Pradesh caters to a large volume of fluorotic cervical disease. Neurologic manifestation appears within 10 to 15 years of exposure to fluoride or even earlier in manual laborers or in hot climatic conditions.7 Fluorosis is associated with diffuse ossification of both the posterior longitudinal ligament and the yellow ligament flavum simultaneously.8,9 Therefore, these patients are at particularly high risk of cervical cord injury during positioning for airway instrumentation, placing neck catheters and surgery. Although there are no published reports of neurologic deterioration following noncervical surgeries with this condition, it is possible that such a situation frequently is encountered by anesthesiologists working in areas endemic to fluorosis. In our experience, most patients with fluorotic spine, although previously asymptomatic, present with neurologic deterioration following minor trauma. There is also a high incidence of postoperative deterioration following cervical surgery in fluorotic cervical spine. The mechanical causes of neurologic deterioration in these chronically compressed cords are well recognized, but the role of hypotension and reduced cervical cord perfusion is underestimated in most reports. We wish to emphasize the contribution of several perturbations in blood pressure that occur during off-pump CABG and the resulting hypoperfusion of the cervical cord that may aggravate neurologic injury. Further neck positions that distort the cervical canal cause narrowing of the cord blood vessels and add to the risk. Because of the earlier age of onset as compared to other causes of cervical canal stenosis, large asymptomatic population, and absence of radiologic changes until the late phase,10 the underlying pathology is likely to be overlooked. An unrecognized cervical pathology with the diffuse nature of bony and ligamentous changes9 places these patients at higher risk, as the precautions are not likely to be observed. Thus, a high degree of suspicion with meticulous history taking of even vague musculoskeletal symptoms is required in patients in endemic areas. A routine screening of all the patients with an MRI of the spine may not be cost effective. Therefore adequate precautions to avoid excessive cervical excursions and distortion of the cervical spine should be taken in all patients from endemic areas for fluorosis during positioning for airway instrumentation, surgery, or neck catheter placement to reduce the possibility of neurologic deterioration. Prachi Kar, MBBS, MD Padmaja Durga, MBBS, MD Ramachandran Gopinath, MBBS, MD Nizams Institute of Medical Science Andhra Pradesh, India
REFERENCES 1. Li CC, et al: Quadriplegia after off-pump coronary artery bypass surgery: Look before you place the neck in an extended position. J Cardiothorac Vasc Anesth 27:e16-e17, 2013
2. Fujioka S, et al: Tetraplegia after coronary artery bypass grafting. Anesth Analg 97:979-980, 2003 3. Hwang NC, Singh P, Chua YL: Quadriparesis after cardiac surgery. J Cardiothorac Vasc Anesth 22:587-589, 2008 4. Naja Z, et al: Tetraplegia after coronary artery bypass grafting in a patient with undiagnosed cervical stenosis. Anesth Analg 101: 1883-1884, 2005 5. Hindman BJ, et al: Cervical spinal cord, root, and bony spine injuries: A closed claims analysis. Anesthesiology 114:782-795, 2011 6. Reddy DR: Neurology of endemic skeletal fluorosis. Neurol India 57:7-12, 2009 7. Haimanot RT: Neurological complications of endemic skeletal fluorosis, with special emphasis on radiculo-myelopathy. Paraplegia244-251, 1990 8. Gupta RK, et al: Compressive myelopathy in fluorosis: MRI. Neuroradiology 38:338-342, 1996 9. Rao BS, Taraknath VR, Sista VN: Ossification of the posterior longitudinal ligament and fluorosis. J Bone Joint Surg Br 74:469-470, 1992 10. Czerwinski E, et al: Bone and joint pathology in fluorideexposed workers. Arch Environ Health 43:340-343, 1988 http://dx.doi.org/10.1053/j.jvca.2013.07.002
Pneumothorax After Pacemaker Implantation: A Diagnostic Value of Sonography
To the Editor: Pneumothorax is a life-threatening complication in patients who have been admitted to the recovery room. The early detection and treatment of pneumothorax can prevent severe progression into tension pneumothorax, and toward this end, lung sonography may have a significant role.1 The advantages of lung sonography include its dynamic nature being performed in real-time during tidal ventilation, which is in contrast to static imaging methods.2 The presence of visceral pleura moving against parietal pleura, or lung sliding, should be looked for. When air is present in the pleural cavity, it commonly is found in the nondependent parts of the thorax; therefore, in the supine patient, the anterior chest should be examined first when pneumothorax is suspected. This case highlights the importance of the prompt diagnosis of pneumothorax using lung sonography. A 70-year-old woman with a history of ischemic heart disease was admitted after cardiac dual-chamber pacemaker implantation. Left subclavian vein access for an introducer was used. On arrival at the recovery room her vital signs were stable. Dyspnea was noted after endotracheal tube removal. The patient’s respiratory status continued to worsen and required the use of increasingly higher concentrations of inspired oxygen (FIO2). A pulmonary catastrophe was suspected, and sonography examination was performed. Sonography of the right hemithorax showed normal aerated lung tissue and presence of the lung sliding (Video 1). Lung ultrasound of the left side showed the presence of A-lines and the absence of the lung sliding (Video 2). M-mode modality was used, and a “stratosphere sign” for left hemithorax was found (Fig 1). These signs are typical for pneumothorax. Transthoracic