Minimally traumatic submental intubation: a novel dilational technique.

PURPOSE: Submental intubation is widely accepted as a safe and effective alternative to nasal intubation or tracheostomy in head and neck surgery patients. Forceful or careless technique can cause significant bleeding and trauma to the soft tissues at this point, increasing the likelihood of troublesome sublingual haematoma. METHODS: We describe the use of a percutaneous tracheostomy horn (Cook Medical Blue Rhino®) to allow minimally traumatic submental intubation without the need for serial dilations. A patient with severe midfacial injuries requiring surgery was intubated via a standard oral technique. Following this, submental access was achieved using a novel dilational technique with a tracheostomy dilator. This resulted in a very secure and safe submental intubation and unrestricted access to the entire surgical field. RESULTS: The single instrument, one-pass dilation technique to achieve submental intubation was found to be easy, quick, and avoided excessive trauma to the floor of mouth. CONCLUSION: Patients will sometimes require a protected airway that allows surgeons unrestricted and simultaneous access to the dental occlusion, oral cavity, midface, and nose. In our case, this simple, easy, and quick adaptation of an established technique using a tracheostomy dilator is an excellent alternative to the traditional blunt dissection used to achieve submental intubation.

Emergency management for orbital compartment syndrome-is decompression mandatory?

Current guidelines for the urgent management of patients with orbital compartment syndrome include immediate lateral canthotomy and cantholysis, followed by surgical decompression. Medical treatment is also advocated to 'buy time' while preparing the patient for theatre. This consists of high-dose steroids, mannitol, and acetazolamide diuretics to reduce swelling and orbital pressure. It is generally recognized that late or delayed intervention is associated with poor outcomes including blindness. With early presentation, given the potential risk to sight, there is generally a low threshold for treating suspected cases. However, whether or not to treat late cases is more controversial, partly because clinicians could face accusations of medical negligence if they do nothing. The case of a patient who sustained an orbital trauma to his only seeing eye, which resulted in acute proptosis and loss of vision, is presented here. He received no treatment at all for what appeared to be an orbital compartment syndrome secondary to retrobulbar haemorrhage, but surprisingly made a full recovery of vision within 48h. In contrast to the current literature in favour of urgent treatment, this case would appear to cast some doubt over the concept of 'always' treating orbital compartment syndrome and our understanding of the condition.

Safety trial of Floseal(®) haemostatic agent in head and neck surgery.

INTRODUCTION: Floseal(®) can be of value in reducing blood loss and haematoma rates. The manufacturer's warnings include allergic reaction, poor wound healing and intravascular thrombosis. We aimed to determine whether Floseal(®) is safe to use in various head and neck surgery procedures. METHODS: A prospective trial was conducted using Floseal(®) in 42 various consecutive head and neck surgery procedures. Adverse incidents were used as the main outcome measure, including allergic reaction, wound breakdown, wound infection and thrombosis. Secondary outcome measures included haematoma formation, hospital stay, drain times and output. RESULTS: No adverse incidents were recorded in the trial period. Two patients developed haematomas and required surgical exploration where a bleeding vessel was identified and dealt with. CONCLUSIONS: Floseal(®) is safe to be used in head and neck surgery with no adverse effects. A larger number and a control group are required to ascertain its value in reducing blood loss, haematoma formation, drain usage and hospital stay.