Magnetic resonance imaging in the evaluation of occult submucous cleft palate.

OBJECTIVE: To explore the application of magnetic resonance imaging (MRI) in the evaluation of patients with occult submucous cleft palate and to use the MRI information obtained to aid in the treatment decision to perform surgery versus behavioral speech therapy. DESIGN: Prospective study with magnetic resonance (MR) images of subjects suspected of having occult submucous cleft palate. SETTING: Hospital and university-based. PATIENTS: Two girls who were 4 years old at the time of palatal surgery. INTERVENTION: Furlow double-opposing Z-plasty. MAIN OUTCOME MEASURES: MR images and clinical speech evaluations. RESULTS: MR images provided evidence of an interruption of levator veli palatini muscle tissue in the midline and a substantial attachment of levator muscle tissue to the posterior border of the hard palate. In addition, MR images for both subjects demonstrated remarkably similar bilateral encapsulating sheaths that contained nonmuscular tissue, as confirmed subsequently during surgery. The encapsulating sheaths interrupted the normal progression of the levator muscle sling across the midline. The MR images led to the decision to perform surgery instead of speech therapy. Hypernasality was markedly reduced in both subjects after surgery. CONCLUSIONS: MRI is an effective technique for diagnosing occult submucous cleft palate and may be an important aid in the treatment decision regarding surgery versus behavioral speech therapy for patients diagnosed with occult submucous cleft palate.

Intramuscular ketamine, midazolam, and glycopyrrolate for pediatric sedation in the emergency department.

PURPOSE: The safety and efficacy of a new sedation technique for children with facial injuries in the emergency department were prospectively evaluated. MATERIALS AND METHODS: Thirty-seven children between the ages of 12 months and 7 years old who required sedation for minor surgical procedures were administered an intramuscular injection of ketamine (3 mg/kg), midazolam (0.05 mg/kg), and glycopyrrolate (0.005 mg/kg). A second 1-mg/kg intramuscular injection of ketamine alone was given if needed. Pulse rate, cardiac rhythm, respiratory rate, oxygen saturation, side effects, and behavior were recorded. RESULTS: Satisfactory sedation was achieved after a single injection in 32 children; five others required a second ketamine injection (1 mg/kg). Onset of anesthesia occurred within 6 minutes in 73% of the children who received one injection, and there were generally adequate working conditions for 30 minutes. The average time from initial injection to discharge was 76 minutes. Results of physiologic monitoring, behavioral ratings, and side effects are reported. Emergence delirium and hallucinations were not observed. Ketamine reliably produced dissociative anesthesia without loss of respiratory drive or protective airway tone. Midazolam reduced the incidence of ketamine-induced dysphoric reactions and muscular hypertonicity. CONCLUSION: The use of intramuscular ketamine, midazolam, and glycoyrrolate is a safe, effective, and practical approach to managing selected pediatric injuries in the emergency department. Advanced airway management proficiency is recommended for use of this technique.

Utility of capnography in predicting venous carbon dioxide partial pressure in sedated patients during outpatient oral surgery.

Twelve ASA class I patients scheduled for removal of third molars under intravenous sedation were included in the study. Samples for venous blood gas analysis were drawn every 5 minutes and the venous partial pressure of carbon dioxide was compared to the end-tidal CO2 recorded from a modified nasal cannula at the same time the samples were drawn. Correlation analysis was performed using the Pearson correlation coefficient. The overall correlation between end-tidal CO2 and PVCO2 was .54 (P = .0001). The results of the investigation indicate that through simple modifications of the end-tidal CO2 monitoring device, the correlation between end-tidal CO2 and serum PCO2 in a nonintubated patient can be improved.

Incidence of hypoxemia in the postanesthetic recovery room in patients having undergone intravenous sedation for outpatient oral surgery.

This study prospectively quantitated the incidence of hypoxia in outpatients in a postanesthetic recovery unit following intravenous (IV) sedation. After identifying the high incidence of hypoxia by the use of pulse oximetry, supplemental oxygen was given to another group of patients and the incidence of the hypoxia was again monitored. Twenty of 100 patients experienced hypoxic episodes in the postanesthetic recovery unit when no supplemental oxygen was administered; only 3 of an additional 100 patients who received supplemental oxygen had episodes of hypoxia. The difference between the groups receiving and not receiving supplemental oxygen was both clinically and statistically significant. As result of this study, the use of supplemental oxygen is recommended for all patients undergoing IV sedation for outpatient oral surgery.

Hemangiopericytoma of the palate: case report.

A case of hemangiopericytoma of the palate is presented. This is a locally aggressive tumor with a high propensity for recurrence and metastasis. Proper management is by wide local excision. Long-term follow-up is mandatory because this neoplasm can recur after several years.

Trends in temporomandibular joint surgery: economic implications and complications.

A 5-year retrospective study of 103 patient records was undertaken. It analyzed the trend toward outpatient surgical management of patients requiring temporomandibular joint arthroplasties and determined the relative economic value and complication rate associated with this trend. Complication rates were not significantly different during the 5-year study interval, and comparative costs to the patient showed a 26% reduction for the 5-year interval.

On the importance of muscle repair in secondary cleft lip deformity.

Generally the evolution of cleft lip repair has included a transition from those methods with primary emphasis on the skin design with intricate flaps, going to further elaborations of carefully designed skin and muscle units but with minimal muscle dissection or intentional reorientation, on to those with greater emphasis on extensive muscle dissection with specific realignment of the orbicularis oris muscle. These latter methods assign to the skin a more complementary role in the plan of correction. This article joins others in which it is now felt that extended dissection and surgical reorientation should be done to include associated involved muscles of the lip, nose, and medial face. In particular, attention to the details of muscle repair as completely as possible, extending to the entire oro-naso-facial complex, seems pertinent in the matter of secondary correction of cleft lip deformities. A review of the anatomy involved, certain surgical philosophy, and examples of illustrated cases are included in this article.

Internal carotid artery thrombosis associated with a fracture.

A case of occlusion of the internal carotid artery after craniocervical trauma with subsequent death of the patient is presented. The patient originally had a mandibular fracture; subsequently an altered sensorium and left-sided hemiparesis developed. The patient died. The typical "lucid interval" was noted. The changes in sensorium are similar to those associated with epidural and subdural hematomas.