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Tympanic membrane rupture after anesthesia with nitrous oxide
343
CURRENT LITERATURE
Clinical Assessment of Hematocrit and Hemoglobin. Ashcraft KE et al. Anesthesiol Rev 9:37, 1982 The need for laboratory determination of hemoglobin and hematocrit for the preoperative evaluation of ASA I and II patients is questioned. A study was made of 445 pediatric patients whose hemoglobin was clinically assessed by the color of the conjunctiva, tongue, and nailbeds. Results indicated the clinical evaluation to be over 98% accurate relative to a minimum safe level of 9.3 g/100 ml. The authors present the clinical determination as a safe and cost-effective alternative to laboratory determination.--MARK STEINBERG
were affected 50% of the time. The differential diagnosis of fifth cranial nerve dysfunction includes a variety of pathologic conditions in addition to connective tissue diseases. These include bone disease, tumors, infections, vascular abnormalities, and a variety of other disorders. Patients with PSS and trigeminal neuropathy had an increased incidence of Sjdgren’s syndrome, hypergammaglobulinemia, polymyositis, leukopenia, and hypothyroidism. These patients had elevated sedimentation rates and serum antiribonucleoprotein levels. This combination of findings suggests an autoimmune process in the pathogenesis. Further studies, including clinicopathologic correlations, are necessary to elucidate this relationship.PHYLLIS CLARK
Reprint requests to Dr. Ashcroft: Department of Anesthesiology, Arkansas Children’s Hospital, 804 Wolfe St., Little Rock, AR
7220I. Tympanic Membrane Rupture After Anesthesia With Nitrous Oxide. Perreault L, Normandin N, Plamondon L, Blain R, Rousseau P. Girard M, Forget G: Anesthesiology 57:325, 1982 Rupture of the tympanic membrane during anesthesia with nitrous oxide has been reported. The authors report such a case following anesthesia in which nitrous oxide was used. The patient, part of a study evaluating middle ear pressures, was undergoing a nephrectomy. She had experienced discharge from both ears during childhood. A trachea1 intubation was used, and anesthesia was maintained with 66 to 70% nitrous oxide and 0.5 to 1% halothane. Thirty minutes after induction, middle ear pressure increased to over 40 cm H,O. In the recovery room it decreased rapidly to -45 cm H,O after 30 minutes. Normal pressure curves disappeared on the right. Otoscope examination revealed a 2 mm perforation in the middle of a neomembrane of the eardrum. The eustachian tube was obstructed. The authors conclude that nitrous oxide in high concentrations should be avoided in patients having pathologic problems of the middle ear.-JOSEPH E. VAN SICKELS Reprint requests to Dr. Perreault: Department of Anesthesia, Maisonneuve-Rosemont Hospital. 5415, I-Assomption Boulevard. Montreal, PQ. Canada HIT 2M4. Trigeminal Neuropathy In Progressive Systemic Sclerosis. Farrell DJ, Medsger T. Am J Med 73:57, 1982
Neurologic manifestations are seldom observed to accompany progressive systemic sclerosis (PSS). Most large series of patients with PSS in the literature not only have poorly documented neurologic exams but predate modern serologic evaluations. Trigeminal sensory neuropathy has been generally accepted as a feature of the disease. This article describes the clinical features, natural history, and laboratory associations of fifth cranial nerve sensory dysfunction in a prospective study of patients with PSS. Four hundred forty-two patients with PSS were evaluated. Twenty-five adequately reported cases of PSS with trigeminal neuropathy were identified in the literature. In this series, 16 (4%) of the patients experienced trigeminal sensory complaints. There was no sex predilection. Symptoms associated with PSS were generally noted initially. The trigeminal sensory dysfunction was as often bilateral as unilateral; the second and third divisions were both affected in 83% of the patients. All divisions
Reprint requests to Dr. Medsger, Jr.: Division of Rheumatology Clinical Immunology, 985 Scaife Hall, University of Pittsburgh School of Medicine, Pittsburgh. PA 15261.
Transoral Inferior Alveolar Neurorrhaphy via a Sag ittal Split. Wessberg GA, Epker B. J Maxillofac Surg 10: 173. 1982 An approach for transoral inferior alveolar nerve neurorrhaphy is described. The technique is presented as an alternative to the submandibular and buccal decortication approach. Exposure of the nerve is via a sagittal split osteotomy. The technique is modified by extension of the buccal osteotomy to 1 cm proximal to the mental foramen, and by decortication, which completely releases the nerve. This permits improved access for either primary reanastomosis or grafting procedures. The improved visualization enables the use of an operating microscope, thus promoting a tension-free reanastomosis. The disadvantages of the approach include the necessity for maxillomandibular fixation and the increased susceptibility to pressure stimulation because of the superior repositioning of the nerve.-MARK STEINBERG Reprint requests to Dr. Epker: Director, Oral and Maxillofacial Surgery, John Peter Smith Hospital. I500 South Main Street, Fort Worth. TX 76104.
Titanium Implants Permanently Skin. Branemark PI, Albrektsson constr Surg 1617, 1982
Penetrating Human T. Stand J Plast Re-
The possibility of using titanium as a permanent implant penetrating human skin was investigated. In one study of eight human volunteers, the upper arm was used as the implant site; in another trial, patients with impaired hearing had implants anchored in the temporal bone with external hearing aids attached. The upper arm implants showed no inflammatory or other adverse soft tissue effects for follow-up periods of seven to 25 months, and the temporal implants were functioning without problems for follow-up periods of 38 to 50 months. These favorable results are believed to be connected to the material (nonalloyed titanium), the design of the implant, and minimal trauma during surgery. The results of this paper suggest new treatment possibilities with external prostheses anchored to the skeleton via mechanical connections that penetrate the skin, in cases of severe facial injury.CHARLES LRINGCOLD Reprint requests to Drs. Branemark and Albrektsson: Department of Anatomy. University of Goteborg. Goteborg. Sweden.
CURRENT LITERATURE
Clinical Assessment of Hematocrit and Hemoglobin. Ashcraft KE et al. Anesthesiol Rev 9:37, 1982 The need for laboratory determination of hemoglobin and hematocrit for the preoperative evaluation of ASA I and II patients is questioned. A study was made of 445 pediatric patients whose hemoglobin was clinically assessed by the color of the conjunctiva, tongue, and nailbeds. Results indicated the clinical evaluation to be over 98% accurate relative to a minimum safe level of 9.3 g/100 ml. The authors present the clinical determination as a safe and cost-effective alternative to laboratory determination.--MARK STEINBERG
were affected 50% of the time. The differential diagnosis of fifth cranial nerve dysfunction includes a variety of pathologic conditions in addition to connective tissue diseases. These include bone disease, tumors, infections, vascular abnormalities, and a variety of other disorders. Patients with PSS and trigeminal neuropathy had an increased incidence of Sjdgren’s syndrome, hypergammaglobulinemia, polymyositis, leukopenia, and hypothyroidism. These patients had elevated sedimentation rates and serum antiribonucleoprotein levels. This combination of findings suggests an autoimmune process in the pathogenesis. Further studies, including clinicopathologic correlations, are necessary to elucidate this relationship.PHYLLIS CLARK
Reprint requests to Dr. Ashcroft: Department of Anesthesiology, Arkansas Children’s Hospital, 804 Wolfe St., Little Rock, AR
7220I. Tympanic Membrane Rupture After Anesthesia With Nitrous Oxide. Perreault L, Normandin N, Plamondon L, Blain R, Rousseau P. Girard M, Forget G: Anesthesiology 57:325, 1982 Rupture of the tympanic membrane during anesthesia with nitrous oxide has been reported. The authors report such a case following anesthesia in which nitrous oxide was used. The patient, part of a study evaluating middle ear pressures, was undergoing a nephrectomy. She had experienced discharge from both ears during childhood. A trachea1 intubation was used, and anesthesia was maintained with 66 to 70% nitrous oxide and 0.5 to 1% halothane. Thirty minutes after induction, middle ear pressure increased to over 40 cm H,O. In the recovery room it decreased rapidly to -45 cm H,O after 30 minutes. Normal pressure curves disappeared on the right. Otoscope examination revealed a 2 mm perforation in the middle of a neomembrane of the eardrum. The eustachian tube was obstructed. The authors conclude that nitrous oxide in high concentrations should be avoided in patients having pathologic problems of the middle ear.-JOSEPH E. VAN SICKELS Reprint requests to Dr. Perreault: Department of Anesthesia, Maisonneuve-Rosemont Hospital. 5415, I-Assomption Boulevard. Montreal, PQ. Canada HIT 2M4. Trigeminal Neuropathy In Progressive Systemic Sclerosis. Farrell DJ, Medsger T. Am J Med 73:57, 1982
Neurologic manifestations are seldom observed to accompany progressive systemic sclerosis (PSS). Most large series of patients with PSS in the literature not only have poorly documented neurologic exams but predate modern serologic evaluations. Trigeminal sensory neuropathy has been generally accepted as a feature of the disease. This article describes the clinical features, natural history, and laboratory associations of fifth cranial nerve sensory dysfunction in a prospective study of patients with PSS. Four hundred forty-two patients with PSS were evaluated. Twenty-five adequately reported cases of PSS with trigeminal neuropathy were identified in the literature. In this series, 16 (4%) of the patients experienced trigeminal sensory complaints. There was no sex predilection. Symptoms associated with PSS were generally noted initially. The trigeminal sensory dysfunction was as often bilateral as unilateral; the second and third divisions were both affected in 83% of the patients. All divisions
Reprint requests to Dr. Medsger, Jr.: Division of Rheumatology Clinical Immunology, 985 Scaife Hall, University of Pittsburgh School of Medicine, Pittsburgh. PA 15261.
Transoral Inferior Alveolar Neurorrhaphy via a Sag ittal Split. Wessberg GA, Epker B. J Maxillofac Surg 10: 173. 1982 An approach for transoral inferior alveolar nerve neurorrhaphy is described. The technique is presented as an alternative to the submandibular and buccal decortication approach. Exposure of the nerve is via a sagittal split osteotomy. The technique is modified by extension of the buccal osteotomy to 1 cm proximal to the mental foramen, and by decortication, which completely releases the nerve. This permits improved access for either primary reanastomosis or grafting procedures. The improved visualization enables the use of an operating microscope, thus promoting a tension-free reanastomosis. The disadvantages of the approach include the necessity for maxillomandibular fixation and the increased susceptibility to pressure stimulation because of the superior repositioning of the nerve.-MARK STEINBERG Reprint requests to Dr. Epker: Director, Oral and Maxillofacial Surgery, John Peter Smith Hospital. I500 South Main Street, Fort Worth. TX 76104.
Titanium Implants Permanently Skin. Branemark PI, Albrektsson constr Surg 1617, 1982
Penetrating Human T. Stand J Plast Re-
The possibility of using titanium as a permanent implant penetrating human skin was investigated. In one study of eight human volunteers, the upper arm was used as the implant site; in another trial, patients with impaired hearing had implants anchored in the temporal bone with external hearing aids attached. The upper arm implants showed no inflammatory or other adverse soft tissue effects for follow-up periods of seven to 25 months, and the temporal implants were functioning without problems for follow-up periods of 38 to 50 months. These favorable results are believed to be connected to the material (nonalloyed titanium), the design of the implant, and minimal trauma during surgery. The results of this paper suggest new treatment possibilities with external prostheses anchored to the skeleton via mechanical connections that penetrate the skin, in cases of severe facial injury.CHARLES LRINGCOLD Reprint requests to Drs. Branemark and Albrektsson: Department of Anatomy. University of Goteborg. Goteborg. Sweden.