- Email: [email protected]
Response to research letter titled “Severe transient hypertension after greater palatine foramen block in a patient taking midodrine”
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Letters to the Editor / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 32 (2011) 631–636
and science of facial rejuvenation. Our research efforts, and those of Pausch et al, are both early steps by surgeons seeking objective data with which to better educate our patients and guide our practice of facial rejuvenation. It is our hope that the study method we used can be enhanced by the criticisms of Pausch et al and used by other researchers to expand this field of inquiry, as we seek to provide improved counseling and superior overall results for patients seeking rejuvenation of the aging face. Kian Karimi, MD Division of Facial Plastic and Reconstructive Surgery Department of Otolaryngology-Head and Neck Surgery University of Toronto School of Medicine Robert T. Adelson, MD Division of Facial Plastic and Reconstructive Surgery Department of Otolaryngology University of Florida College of Medicine Gainesville, FL E-mail address: [email protected] doi:10.1016/j.amjoto.2010.09.004 Treatment of sleep-disordered breathing: a concern To the Editor: I read the recent publication on treatment of sleepdisordered breathing by Fibbi et al [1]. Fibbi et al concluded that “RFVR is preferable because it is simpler to perform and less invasive than lingual suspension (LS), and it can be repeated over time” [1]. Indeed, there are many concerns for judging which the better method is. A sense of simplicity and invasiveness of the procedure have to be more systematically assessed. In addition, there should be additional information on comparison of cost effectiveness and cost utility between the 2 techniques. The total numbers of subjects in this work are quite few; hence, the conclusion might not be reliable. The authors also mentioned that the 2 techniques can be quickly performed and simple. These should be clarified. Indeed, performing either LS or radiofrequency volume reduction has to take a good patient preparation, and the tools in each procedure have to be available. Editor's Note: The original author did not respond to requests to address issues presented. Viroj Wiwanitkit Wiwanitkit House Bangkhae, Bangkok, Thailand E-mail address: [email protected] doi:10.1016/j.amjoto.2009.11.011
Reference [1] Fibbi A, Ameli F, Brocchetti F, et al. Tongue base suspension and radiofrequency volume reduction: a comparison between 2 techniques for the treatment of sleep-disordered breathing. Am J Otolaryngol 2009; 30:401-6.
Response to research letter titled “Severe transient hypertension after greater palatine foramen block in a patient taking midodrine” To the Editor: We read with interest the letter of Rizzi et al [1], which describes a severe hypertensive reaction with tachycardia after injection of 1.5 cm3 of 1% lidocaine with 1:100 000 U epinephrine into the greater palatine foramen. The patient received 10 mg of midodrine, an antihypotensive agent, on the morning of surgery. We feel a number of issues highlighted in this letter merit further consideration. Midodrine is used in a number of common chronic conditions that predispose patients to hypotension [2]. It is a short acting agent with a half-life of approximately 4 hours [2]. It has been shown to be effective at relieving hypotensive symptoms [3]. It is commonly administered to patients during the morning and middle of the day, but not at night, to avoid supine hypertension, itself a commonly occurring complication of autonomic dysfunction. Therefore, withholding administration of midodrine on the morning of a surgical procedure is usually sufficient to avoid a hypertensive reaction as described in this case. Although many patients receiving midodrine develop adverse effects (particularly pruritus and piloerection), hypertension is far less common that the authors state. In the 2 studies quoted [3,4], the number of patients who developed supine hypertension secondary to midodrine was in fact less than 10% and not 25% to 75%, quoted by Rizzi et al [1]. We believe it is also worth noting that a similar hypertensive reaction can occur as a complication of injection of local anesthetic agents containing epinephrine. In individual cases, evaluation of the patient's heart rate may help determine whether a hypertensive reaction is occurring as a complication to midodrine therapy. Midodrine does not commonly cause tachycardia because its adrenergic effects are mediated principally at α1 but not at β adrenergic receptors. Epinephrine exerts an agonist effect at both α and β adrenergic receptors. Therefore, tachycardia is more likely to occur secondary to epinephrine administration than midodrine. We agree with Rizzi et al [1] that avoiding concomitant use of midodrine and vasoconstrictor containing anesthetic agents is appropriate to minimize the risk of a hypertensive reaction. However, given this agent's short half-life, we believe that, for most patients, even those for whom
Letters to the Editor / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 32 (2011) 631–636
use of vasoconstrictor containing anesthetic agent is indicated, withholding administration of midodrine on the morning of surgery is sufficient precaution to avoid a hypertensive reaction. Paula Casserly, MRCSI, MCh Gerard O’Leary, FRCS (ORL) Department of Otolaryngology and Head & Neck Surgery South Infirmary & Victoria Hospital Old Blackrock Road, Cork, Republic of Ireland E-mail address: [email protected] Alan Moore, MB, FRCPI Department of Medicine Royal College of Surgeons in Ireland Dublin 2, Republic of Ireland doi:10.1016/j.amjoto.2010.09.015 References [1] Rizzi MD, Wiel RJ, Lorenz RR. Severe transient hypertension after greater palatine foramen block in a patient taking midodrine. Am J Otolaryngol 2010;31:67-9. [2] Kearney F, Moore A. Pharmacological treatment of orthostatic hypotension in older adults. Exp Rev Cardiovasc Ther 2009;7:395-400. [3] Low PA, Gilden JL, Freeman R, et al. Efficacy of midodrine vs. placebo in neurogenic orthostatic hypotension. J Am Med Assoc 1997;277: 1046-51. [4] Jankovic J, Gilden JL, Hiner BC, et al. Neurogenic orthostatic hypotension: a double-blind, placebo controlled study with midodrine. Am J Med 1993;95:38-48.
Authors' reply to commentary entitled “Response to research letter titled ‘Severe transient hypertension after greater palatine foramen block in a patient taking midodrine’” To the Editor: We are grateful for the thoughtful criticism expressed by Casserly et al of our article regarding the potential risk of midodrine use in surgical patients. We further appreciate the fact that the apparent point of their letter converges well with the intended message of our article. That is, midodrine is a potentially dangerous drug in surgical patients, especially when the operation will require the use of a vasoconstrictor such as epinephrine. If possible, the drug should be withheld perioperatively when use of such vasoactive agents is anticipated. The additional details that have been provided regarding the pharmacokinetics of the drug and the suggested duration of its withholding preoperatively are welcome additions to our comments. As stated in our article, we agree with Casserly et al that our patient's hyperdynamic reaction cannot be attributed to midodrine administration alone. Our speculative assertion
635
was that midodrine may have been acting in concert with epinephrine's well-known adrenergic effects in a patient with autonomic dysfunction, where hypertension while supine is known to occur in the absence of any pharmacologic therapy. We restate that our patient's reaction was likely a combination of these elements and that it may have been avoided by preoperatively discontinuing midodrine. The authors correctly point out that the articles by Low et al [1] and Jankovic et al [2] cite an incidence of supine hypertension of less than 10% with midodrine use. We quoted an incidence in the literature of 25% to 75% in our article. Our reference citation for these numbers should have additionally borne the reader to the article in our bibliography by Chaimberg et al [3] that cites this range in their review. The Physicians' Desk Reference [4] states that supine hypertension occurs in 22% of patients taking a 10-mg dose and 45% of patients taking a 20-mg dose. Hurst et al [5] reported an incidence of supine hypertension with midodrine use of 75%, although this was a small series. A more recent review by Pathak et al [6] reported that the overall incidence of adverse drug reactions, including supine hypertension, exceeds 80% in patients taking midodrine. These authors suggested that adverse events from antihypotensive agents such as midodrine are likely to have been underestimated and have recommended a reevaluation of their safety. In sum, although midodrine's efficacy is well established in the treatment of orthostatic hypotension, there are adverse effects that have the potential to cause serious harm to some surgical patients. Our article was intended to alert surgeons with little experience with prescribing this drug that withholding it perioperatively may enhance patient safety. To this end, we are grateful to Casserly et al for reinforcing our message. Mark D. Rizzi, MD Childrens Hospital of Philadelphia Philadelphia, PA, USA E-mail address: [email protected] Robert J. Weil, MD Brain Tumor and Neuro-Oncology Center Cleveland Clinic Cleveland, OH, USA Robert R. Lorenz, MD Head and Neck Institute Cleveland Clinic Cleveland, OH, USA doi:10.1016/j.amjoto.2010.11.012 References [1] Low PA, Gilden JL, Freeman R, et al. Efficacy of midodrine vs. placebo in neurogenic orthostatic hypotension. JAMA 1997;277:1046-51.
Letters to the Editor / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 32 (2011) 631–636
and science of facial rejuvenation. Our research efforts, and those of Pausch et al, are both early steps by surgeons seeking objective data with which to better educate our patients and guide our practice of facial rejuvenation. It is our hope that the study method we used can be enhanced by the criticisms of Pausch et al and used by other researchers to expand this field of inquiry, as we seek to provide improved counseling and superior overall results for patients seeking rejuvenation of the aging face. Kian Karimi, MD Division of Facial Plastic and Reconstructive Surgery Department of Otolaryngology-Head and Neck Surgery University of Toronto School of Medicine Robert T. Adelson, MD Division of Facial Plastic and Reconstructive Surgery Department of Otolaryngology University of Florida College of Medicine Gainesville, FL E-mail address: [email protected] doi:10.1016/j.amjoto.2010.09.004 Treatment of sleep-disordered breathing: a concern To the Editor: I read the recent publication on treatment of sleepdisordered breathing by Fibbi et al [1]. Fibbi et al concluded that “RFVR is preferable because it is simpler to perform and less invasive than lingual suspension (LS), and it can be repeated over time” [1]. Indeed, there are many concerns for judging which the better method is. A sense of simplicity and invasiveness of the procedure have to be more systematically assessed. In addition, there should be additional information on comparison of cost effectiveness and cost utility between the 2 techniques. The total numbers of subjects in this work are quite few; hence, the conclusion might not be reliable. The authors also mentioned that the 2 techniques can be quickly performed and simple. These should be clarified. Indeed, performing either LS or radiofrequency volume reduction has to take a good patient preparation, and the tools in each procedure have to be available. Editor's Note: The original author did not respond to requests to address issues presented. Viroj Wiwanitkit Wiwanitkit House Bangkhae, Bangkok, Thailand E-mail address: [email protected] doi:10.1016/j.amjoto.2009.11.011
Reference [1] Fibbi A, Ameli F, Brocchetti F, et al. Tongue base suspension and radiofrequency volume reduction: a comparison between 2 techniques for the treatment of sleep-disordered breathing. Am J Otolaryngol 2009; 30:401-6.
Response to research letter titled “Severe transient hypertension after greater palatine foramen block in a patient taking midodrine” To the Editor: We read with interest the letter of Rizzi et al [1], which describes a severe hypertensive reaction with tachycardia after injection of 1.5 cm3 of 1% lidocaine with 1:100 000 U epinephrine into the greater palatine foramen. The patient received 10 mg of midodrine, an antihypotensive agent, on the morning of surgery. We feel a number of issues highlighted in this letter merit further consideration. Midodrine is used in a number of common chronic conditions that predispose patients to hypotension [2]. It is a short acting agent with a half-life of approximately 4 hours [2]. It has been shown to be effective at relieving hypotensive symptoms [3]. It is commonly administered to patients during the morning and middle of the day, but not at night, to avoid supine hypertension, itself a commonly occurring complication of autonomic dysfunction. Therefore, withholding administration of midodrine on the morning of a surgical procedure is usually sufficient to avoid a hypertensive reaction as described in this case. Although many patients receiving midodrine develop adverse effects (particularly pruritus and piloerection), hypertension is far less common that the authors state. In the 2 studies quoted [3,4], the number of patients who developed supine hypertension secondary to midodrine was in fact less than 10% and not 25% to 75%, quoted by Rizzi et al [1]. We believe it is also worth noting that a similar hypertensive reaction can occur as a complication of injection of local anesthetic agents containing epinephrine. In individual cases, evaluation of the patient's heart rate may help determine whether a hypertensive reaction is occurring as a complication to midodrine therapy. Midodrine does not commonly cause tachycardia because its adrenergic effects are mediated principally at α1 but not at β adrenergic receptors. Epinephrine exerts an agonist effect at both α and β adrenergic receptors. Therefore, tachycardia is more likely to occur secondary to epinephrine administration than midodrine. We agree with Rizzi et al [1] that avoiding concomitant use of midodrine and vasoconstrictor containing anesthetic agents is appropriate to minimize the risk of a hypertensive reaction. However, given this agent's short half-life, we believe that, for most patients, even those for whom
Letters to the Editor / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 32 (2011) 631–636
use of vasoconstrictor containing anesthetic agent is indicated, withholding administration of midodrine on the morning of surgery is sufficient precaution to avoid a hypertensive reaction. Paula Casserly, MRCSI, MCh Gerard O’Leary, FRCS (ORL) Department of Otolaryngology and Head & Neck Surgery South Infirmary & Victoria Hospital Old Blackrock Road, Cork, Republic of Ireland E-mail address: [email protected] Alan Moore, MB, FRCPI Department of Medicine Royal College of Surgeons in Ireland Dublin 2, Republic of Ireland doi:10.1016/j.amjoto.2010.09.015 References [1] Rizzi MD, Wiel RJ, Lorenz RR. Severe transient hypertension after greater palatine foramen block in a patient taking midodrine. Am J Otolaryngol 2010;31:67-9. [2] Kearney F, Moore A. Pharmacological treatment of orthostatic hypotension in older adults. Exp Rev Cardiovasc Ther 2009;7:395-400. [3] Low PA, Gilden JL, Freeman R, et al. Efficacy of midodrine vs. placebo in neurogenic orthostatic hypotension. J Am Med Assoc 1997;277: 1046-51. [4] Jankovic J, Gilden JL, Hiner BC, et al. Neurogenic orthostatic hypotension: a double-blind, placebo controlled study with midodrine. Am J Med 1993;95:38-48.
Authors' reply to commentary entitled “Response to research letter titled ‘Severe transient hypertension after greater palatine foramen block in a patient taking midodrine’” To the Editor: We are grateful for the thoughtful criticism expressed by Casserly et al of our article regarding the potential risk of midodrine use in surgical patients. We further appreciate the fact that the apparent point of their letter converges well with the intended message of our article. That is, midodrine is a potentially dangerous drug in surgical patients, especially when the operation will require the use of a vasoconstrictor such as epinephrine. If possible, the drug should be withheld perioperatively when use of such vasoactive agents is anticipated. The additional details that have been provided regarding the pharmacokinetics of the drug and the suggested duration of its withholding preoperatively are welcome additions to our comments. As stated in our article, we agree with Casserly et al that our patient's hyperdynamic reaction cannot be attributed to midodrine administration alone. Our speculative assertion
635
was that midodrine may have been acting in concert with epinephrine's well-known adrenergic effects in a patient with autonomic dysfunction, where hypertension while supine is known to occur in the absence of any pharmacologic therapy. We restate that our patient's reaction was likely a combination of these elements and that it may have been avoided by preoperatively discontinuing midodrine. The authors correctly point out that the articles by Low et al [1] and Jankovic et al [2] cite an incidence of supine hypertension of less than 10% with midodrine use. We quoted an incidence in the literature of 25% to 75% in our article. Our reference citation for these numbers should have additionally borne the reader to the article in our bibliography by Chaimberg et al [3] that cites this range in their review. The Physicians' Desk Reference [4] states that supine hypertension occurs in 22% of patients taking a 10-mg dose and 45% of patients taking a 20-mg dose. Hurst et al [5] reported an incidence of supine hypertension with midodrine use of 75%, although this was a small series. A more recent review by Pathak et al [6] reported that the overall incidence of adverse drug reactions, including supine hypertension, exceeds 80% in patients taking midodrine. These authors suggested that adverse events from antihypotensive agents such as midodrine are likely to have been underestimated and have recommended a reevaluation of their safety. In sum, although midodrine's efficacy is well established in the treatment of orthostatic hypotension, there are adverse effects that have the potential to cause serious harm to some surgical patients. Our article was intended to alert surgeons with little experience with prescribing this drug that withholding it perioperatively may enhance patient safety. To this end, we are grateful to Casserly et al for reinforcing our message. Mark D. Rizzi, MD Childrens Hospital of Philadelphia Philadelphia, PA, USA E-mail address: [email protected] Robert J. Weil, MD Brain Tumor and Neuro-Oncology Center Cleveland Clinic Cleveland, OH, USA Robert R. Lorenz, MD Head and Neck Institute Cleveland Clinic Cleveland, OH, USA doi:10.1016/j.amjoto.2010.11.012 References [1] Low PA, Gilden JL, Freeman R, et al. Efficacy of midodrine vs. placebo in neurogenic orthostatic hypotension. JAMA 1997;277:1046-51.