- Email: [email protected]
Propranolol—An aid to microvascular surgery
Letters to the Editor / British Journal of Oral and Maxillofacial Surgery 46 (2008) 170–172
E-mail address: [email protected] (P. Scolozzi) Available online 5 July 2007 doi: 10.1016/j.bjoms.2007.05.006
Migration of Coe-pak dressing into the nasal floor following excision of soft tissue palatal lesion A 70-year-old lady had a fibro epithelial polyp excised from the hard palate. A Coe-pak dressing was placed into the defect to minimise post-operative discomfort. On review there was an oral–nasal fistula with necrotic bone surrounding the defect. An orthopantomograph showed the Coe-pak dressing in the nasal floor (Fig. 1). This was retrieved and the
Fig. 1. Radio-opaque shadow of Coe-pak in left floor of nose (arrow).
defect closed using a palatal rotation flap. The fistula healed with no complications. To our knowledge, this is the only reported case of a dressing eroding through intact palatal periosteum and bone. We cannot tell whether the bone became necrotic after the polyp was excised followed by migration of the Coe-pak dressing into the floor of the nose or whether the dressing induced bone necrosis possibly by its exothermic setting reaction.
171
Maxillofacial trauma in India Sir, We read with interest the article published in June 2006, Three-year review of facial fractures at a teaching hospital in northern Iran (M.H. Kadkhodaie). The authors have mentioned “We do open reductions with rigid fixation, which are costly, time consuming and cause considerable morbidity”. I have serious reservations about the statement. In a tertiary care centre in India, we treat a large number of facio-maxillary injuries. We use titanium miniplates for plating all fractures, mandibular, maxillary and zygomatic. The exposures we use are along cosmetic lines, intra-oral for mandibular fractures, subcilliary for orbital rim fractures and floor reconstruction. The zygomatic fractures are raised by the Gillies approach, but the fracture is again plated after first ensuring occlusion. The use of plates has increased our efficiency, as we feel they are much easier to use, ensure better results, are much faster to use than interosseous wires, and provide far more rigid fixation than wires. I don’t understand what the authors mean by “more morbidity”. In our experience, these procedures have virtually no morbidity, as they allow a shorter period of IMF, allowing earlier return to diet, with better maintenance of oral hygiene. The fractures heal more quickly. If the technique is faulty, then, problems of malunion and infection will occur, but we have not had such problems. In addition these techniques can easily be learnt by junior colleagues. I would like a detailed description of the morbidity and how authors found this procedure to be more time consuming. Amit Gupta (MS) ∗ Department of Plastic Surgery, LNH, Delhi, India ∗ Tel.:
+91 11 26255859. E-mail address: [email protected] Available online 21 August 2007 doi: 10.1016/j.bjoms.2007.07.001
Aleid ∗
Wesam Phillip Ameerally Department of Maxillofacial Surgery and Head & Neck Oncology, Northampton General Hospital, Billing Road, Northampton NN1 5BD, United Kingdom ∗ Corresponding
author at: Department of Maxillofacial Surgery, Northampton General Hospital, Billing Road, Northampton NN1 5BD, United Kingdom. Tel.: +44 7901577275. E-mail address: [email protected] (W. Aleid) Available online 20 July 2007
doi: 10.1016/j.bjoms.2007.05.013
Propranolol—An aid to microvascular surgery Essential tremor (ET) is the most common movement disorder. It is a syndrome of unknown pathophysiology characterized by progressive postural and/or kinetic tremor, usually affecting upper extremities.1 Despite a wealth of anecdotal reports on the efficacy of propranolol in reducing tremor during microvascular surgery there is no published account. A randomised double blind crossover study by Elman et al. carried out on ophthalmic surgery residents showed that Propranolol 40 mg administered orally 1 h prior to a microsurgical session significantly decreases tremor and anxiety in the surgeon without untoward effects.2 A similar study
172
Letters to the Editor / British Journal of Oral and Maxillofacial Surgery 46 (2008) 170–172
by Humayun et al. on another group of ophthalmic surgery residents compared magnitude of tremor following ingestion of placebo versus caffeine versus propranolol and reaches an identical conclusion.3 These findings can be extrapolated to microvascular surgery where equivalent dexterity is desirable. A small single dose of Propranolol could reduce hand tremor during microvascular surgery with no ill effects. Propranolol, a lipid soluble beta-blocker crosses the blood–brain barrier easily and helps control the involuntary, movements of ET. It is the first line drug in the treatment of ET at a typical maintenance dose of 40 mg orally BD and the average reduction in tremor is 50–60%.4 However, propranolol may not be suitable for surgeons with asthma, cardiac conduction disorders, diabetes mellitus and peripheral vascular disease. Possible side effects may include dizziness, fatigue, diarrhoea, nausea, glycaemic changes and male sexual difficulties. Surgeons contemplating reduction of tremor with Propranolol should not self medicate; instead, their GP should be consulted for advice.
References 1. Burke D, Hauser RA. Essential tremor. http://www.emedicine.com/ NEURO/topic129.htm. 2. Elman MJ, Sugar J, Fiscella R, Deutsch TA, Noth J, Nymberg M, et al. The effect of propranolol versus placebo on resident surgical performance. Trans Am Ophthalmol Soc 1998;96:283–91, discussion 291–4.
3. Humayun MU, Rader RS, Pieramici DJ, Awh CC, de Juan Jr E. Quantitative measurement of the effects of caffeine and propranolol on surgeons hand tremor. Arch Ophthalmol 1997;115(3):371–4. 4. Esential tremor. Pharmacological treatments WeMove 2006 Worldwide Education and Awareness for Movement Disorders. http://www.wemove.org/et/et pt.html.
Liviu M. Hanu-Cernat ∗ Department of Maxillofacial Surgery, Russells Hall Hospital, Dudley Group of Hospitals, Dudley DY1 8HQ, United Kingdom Khalleek-ur Rehman Ganeshwaran Sittampalam Department of Maxillofacial Surgery, New Cross Hospital, Royal Wolverhampton Hospitals, Wolverhampton WV10 0PQ, United Kingdom Nicholas M. Whear Department of Maxillofacial Surgery, Russells Hall Hospital, Dudley Group of Hospitals, Dudley DY1 8HQ, United Kingdom ∗ Corresponding author. E-mail address: [email protected] (L.M. Hanu-Cernat) Available online 24 September 2007 doi: 10.1016/j.bjoms.2007.07.210
E-mail address: [email protected] (P. Scolozzi) Available online 5 July 2007 doi: 10.1016/j.bjoms.2007.05.006
Migration of Coe-pak dressing into the nasal floor following excision of soft tissue palatal lesion A 70-year-old lady had a fibro epithelial polyp excised from the hard palate. A Coe-pak dressing was placed into the defect to minimise post-operative discomfort. On review there was an oral–nasal fistula with necrotic bone surrounding the defect. An orthopantomograph showed the Coe-pak dressing in the nasal floor (Fig. 1). This was retrieved and the
Fig. 1. Radio-opaque shadow of Coe-pak in left floor of nose (arrow).
defect closed using a palatal rotation flap. The fistula healed with no complications. To our knowledge, this is the only reported case of a dressing eroding through intact palatal periosteum and bone. We cannot tell whether the bone became necrotic after the polyp was excised followed by migration of the Coe-pak dressing into the floor of the nose or whether the dressing induced bone necrosis possibly by its exothermic setting reaction.
171
Maxillofacial trauma in India Sir, We read with interest the article published in June 2006, Three-year review of facial fractures at a teaching hospital in northern Iran (M.H. Kadkhodaie). The authors have mentioned “We do open reductions with rigid fixation, which are costly, time consuming and cause considerable morbidity”. I have serious reservations about the statement. In a tertiary care centre in India, we treat a large number of facio-maxillary injuries. We use titanium miniplates for plating all fractures, mandibular, maxillary and zygomatic. The exposures we use are along cosmetic lines, intra-oral for mandibular fractures, subcilliary for orbital rim fractures and floor reconstruction. The zygomatic fractures are raised by the Gillies approach, but the fracture is again plated after first ensuring occlusion. The use of plates has increased our efficiency, as we feel they are much easier to use, ensure better results, are much faster to use than interosseous wires, and provide far more rigid fixation than wires. I don’t understand what the authors mean by “more morbidity”. In our experience, these procedures have virtually no morbidity, as they allow a shorter period of IMF, allowing earlier return to diet, with better maintenance of oral hygiene. The fractures heal more quickly. If the technique is faulty, then, problems of malunion and infection will occur, but we have not had such problems. In addition these techniques can easily be learnt by junior colleagues. I would like a detailed description of the morbidity and how authors found this procedure to be more time consuming. Amit Gupta (MS) ∗ Department of Plastic Surgery, LNH, Delhi, India ∗ Tel.:
+91 11 26255859. E-mail address: [email protected] Available online 21 August 2007 doi: 10.1016/j.bjoms.2007.07.001
Aleid ∗
Wesam Phillip Ameerally Department of Maxillofacial Surgery and Head & Neck Oncology, Northampton General Hospital, Billing Road, Northampton NN1 5BD, United Kingdom ∗ Corresponding
author at: Department of Maxillofacial Surgery, Northampton General Hospital, Billing Road, Northampton NN1 5BD, United Kingdom. Tel.: +44 7901577275. E-mail address: [email protected] (W. Aleid) Available online 20 July 2007
doi: 10.1016/j.bjoms.2007.05.013
Propranolol—An aid to microvascular surgery Essential tremor (ET) is the most common movement disorder. It is a syndrome of unknown pathophysiology characterized by progressive postural and/or kinetic tremor, usually affecting upper extremities.1 Despite a wealth of anecdotal reports on the efficacy of propranolol in reducing tremor during microvascular surgery there is no published account. A randomised double blind crossover study by Elman et al. carried out on ophthalmic surgery residents showed that Propranolol 40 mg administered orally 1 h prior to a microsurgical session significantly decreases tremor and anxiety in the surgeon without untoward effects.2 A similar study
172
Letters to the Editor / British Journal of Oral and Maxillofacial Surgery 46 (2008) 170–172
by Humayun et al. on another group of ophthalmic surgery residents compared magnitude of tremor following ingestion of placebo versus caffeine versus propranolol and reaches an identical conclusion.3 These findings can be extrapolated to microvascular surgery where equivalent dexterity is desirable. A small single dose of Propranolol could reduce hand tremor during microvascular surgery with no ill effects. Propranolol, a lipid soluble beta-blocker crosses the blood–brain barrier easily and helps control the involuntary, movements of ET. It is the first line drug in the treatment of ET at a typical maintenance dose of 40 mg orally BD and the average reduction in tremor is 50–60%.4 However, propranolol may not be suitable for surgeons with asthma, cardiac conduction disorders, diabetes mellitus and peripheral vascular disease. Possible side effects may include dizziness, fatigue, diarrhoea, nausea, glycaemic changes and male sexual difficulties. Surgeons contemplating reduction of tremor with Propranolol should not self medicate; instead, their GP should be consulted for advice.
References 1. Burke D, Hauser RA. Essential tremor. http://www.emedicine.com/ NEURO/topic129.htm. 2. Elman MJ, Sugar J, Fiscella R, Deutsch TA, Noth J, Nymberg M, et al. The effect of propranolol versus placebo on resident surgical performance. Trans Am Ophthalmol Soc 1998;96:283–91, discussion 291–4.
3. Humayun MU, Rader RS, Pieramici DJ, Awh CC, de Juan Jr E. Quantitative measurement of the effects of caffeine and propranolol on surgeons hand tremor. Arch Ophthalmol 1997;115(3):371–4. 4. Esential tremor. Pharmacological treatments WeMove 2006 Worldwide Education and Awareness for Movement Disorders. http://www.wemove.org/et/et pt.html.
Liviu M. Hanu-Cernat ∗ Department of Maxillofacial Surgery, Russells Hall Hospital, Dudley Group of Hospitals, Dudley DY1 8HQ, United Kingdom Khalleek-ur Rehman Ganeshwaran Sittampalam Department of Maxillofacial Surgery, New Cross Hospital, Royal Wolverhampton Hospitals, Wolverhampton WV10 0PQ, United Kingdom Nicholas M. Whear Department of Maxillofacial Surgery, Russells Hall Hospital, Dudley Group of Hospitals, Dudley DY1 8HQ, United Kingdom ∗ Corresponding author. E-mail address: [email protected] (L.M. Hanu-Cernat) Available online 24 September 2007 doi: 10.1016/j.bjoms.2007.07.210