Dexmedetomidine vs. Fentanyl-Midazolam Combination to Mitigate the Stress Response in Microlaryngoscopy: A Randomized Double-blind Clinical Trial.

Background: Laryngoscopy is the most painful noxious stimulus during anesthesia and surgery. Dexmedetomidine is increasingly used as a sedative in surgeries involving microlaryngoscopy. Objectives: This study aimed to evaluate the effect of dexmedetomidine and a combination of fentanyl and midazolam on mitigating the stress response in patients scheduled for microlaryngoscopy. Methods: This randomized, double-blind clinical trial enrolled 60 patients (28 males and 32 females) aged 18 - 65 years with the American Society of Anesthesiologists (ASA) physical status I - III. The patients were scheduled for microlaryngoscopy and equally divided into 2 groups. Group D received 1 µg/kg of dexmedetomidine and saline bolus dose over 10 minutes before general anesthesia (GA) induction, followed by 0.5 µg/kg/h of dexmedetomidine and saline infusions after GA induction. Group MF received 0.8 µg/kg of fentanyl plus 0.05 mg/kg of midazolam over 10 minutes before GA induction, followed by 1 µg/kg/h of fentanyl plus 0.05 mg/kg/h of midazolam as an infusion. The heart rate (HR) and mean arterial blood pressure (MAP) pressure were recorded from baseline until the end of surgery. Infusions were stopped at the end of the surgery. Results: The number of patients requiring propofol and intraoperative supplemental propofol was significantly lower in group D than in group MF. The heart rate was significantly lower in group D than in group MF (P = 0.022, 0.048, 0.032, 0.045, 0.041, 0.026, 0.030, and 0.036) from induction until the end of surgery; in addition, it was comparable between both groups at baseline and before induction. MAP was comparable between both groups for all measurements. Conclusions: Dexmedetomidine mitigates the hemodynamic changes related to microlaryngoscopy more effectively than the fentanyl-midazolam combination.

Polyurethane Versus Chitosan-Based Polymers Nasal Packs After Functional Endoscopic Sinus Surgery: A Prospective Randomized Double-Blinded Study.

BACKGROUND: Different packing materials are applied to the nose at the end of surgery to maintain drainage and sinus ventilation of the paranasal sinuses and avoid some complications such as bleeding, infection, crustations, adhesions in the middle meatus and lateralization of the middle turbinate. OBJECTIVE: The study aims to compare the clinical outcomes of two absorbable packing materials, the synthetic polyurethane, and the naturally occurring Chitosan-based polymers (CBP) nasal packs, after functional endoscopic sinus surgery. METHODS: Fifty patients with bilateral chronic rhinosinusitis with nasal polypi were operated with 100 surgical cavities. At the end of the surgery, one side was randomly packed with synthetic polyurethane and the opposite side with CBP nasal pack. Measure their outcomes at week 1, 2, 4, 8 and 12 as the presence of remnants materials in the middle meatus, crustations, adhesions, bleeding, granulations, infection, and general satisfaction of patients. RESULTS: CBP nasal pack shows a statistically significant advantage only in the first two weeks as regard remnants material, crusting and bleeding. All over the 12 weeks, there was no statistically significant difference between the two types of packs as regard granulations, adhesions and infection. In the first month, eight patients of the CBP group experienced bad smell and two patients had watery rhinorrhea as adverse reaction without a statistically significant difference. Patients were generally satisfied without a statistically significant difference between the two types of packs. CONCLUSION: Synthetic polyurethane and Chitosan-based polymers nasal packs are safe and efficient regarding; the mucosal healing, bleeding control, and the overall satisfaction of patients. The CBP showed a higher statistically significant advantage in the first two weeks only regarding the amount of the retained material, crusting as well as bleeding. Patients packed with CBP experienced fish-like smelly odor and watery rhinorrhea but there is no statistically significant difference.

Augmentation of the posterior pharyngeal wall with autologous tragal cartilage for management of velopharyngeal valve insufficiency in adults.

OBJECTIVE: The study aims to evaluate posterior pharyngeal wall augmentation using autologous tragal cartilage graft in adults with velopharyngeal valve insufficiency (VPI). METHODS: The study included 23 patients with VPI (grade I, II, III), with ages ranging from 19 to 45 years. Six patients had previously undergone simple palatoplasty for cleft palate, 8 patients had previously undergone adenotonsillectomy and 9 patients had previously undergone uvulopalatopharyngoplasty (UPPP). The procedure was done by implanting a piece of autologous tragal cartilage in the posterior pharyngeal wall. Patients were followed up for 24 months postoperatively. The evaluation of percent of speech intelligibility and grade of the closure of the velopharyngeal valve using video-nasopharyngoscopy was evaluated preoperatively and postoperatively. RESULTS: Highly statistically significant improvement in the grade of the closure of the velopharyngeal valve (P = 0.009) and percent of intelligibility (P = 0.001) was found after surgery. There were no postoperative airway obstruction or sleep apnea. CONCLUSION: Augmentation of the posterior pharyngeal wall using tragal cartilage is an effective, safe and physiological surgical procedure in the management of VPI in adults who suffered hypernasality following palatal and oropharyngeal surgeries.

Serum indolamine 2,3 dioxygenase as a marker in the evaluation of allergic rhinitis.

BACKGROUND: Allergic rhinitis occurs on exposure to a known allergen and is correlated with a positive skin test and physical examination results. Tryptophan is a substrate of many important proteins, e.g., indolamine 2,3 dioxygenase (IDO). IDO, an immunomodulator, is a metabolic enzyme induced by immune activation. It has a significant role in allergic reactions. T-helper 2 cell is proposed to affect the expression of IDO. AIM: To evaluate IDO levels in patients with allergic rhinitis compared with controls and its relationship to the severity of allergic rhinitis. METHODS: This case-control study included 20 patients who were atopic and with allergic rhinitis who attended the allergy clinic of Ain Shams University Hospitals. Twenty age- and sex-matched patients who were not atopic were included as controls. An allergic rhinitis diagnosis was made according to the Allergic Rhinitis and its Impact on Asthma document. Complete history taking, physical examination, skin-prick test, complete blood cell count, erythrocyte sedimentation rate, total serum immunoglobulin E (IgE), IDO concentration, and nasal smear for eosinophils were done for the patients. RESULTS: There was a significant increase in IDO levels in allergic rhinitis in comparison with subjects without allergy (p < 0.001). IDO was positively correlated with total IgE levels (p < 0.037). There was an insignificant relationship among IDO levels and age, sex, duration of the disease, severity score, nasal and blood eosinophilia, and number of positive allergens. CONCLUSION: IDO plays an important role in patients with atopic symptomatic allergic rhinitis, especially with increased levels of IgE. There is no relationship between IDO levels and severity of disease.