Quality of life and symptoms in patients selected for ablation of ventricular extrasystoles: a prospective study.

PURPOSE: Evaluation of the impact of catheter ablation for ventricular extrasystoles (VES) in structurally normal hearts on quality of life (QOL) and symptomatology. METHODS: Symptom analysis assessed with a disease-specific questionnaire, EHRA score for AF, and QOL analysis at baseline and 1 year after ablation. RESULTS: The study enrolled 39 patients between April 2016 and November 2019. Two patients were excluded from further analysis. At baseline, palpitations were reported in 31/37 (84%); syncope in 12/37 (32%); other cardiac symptoms in 33/37 (89%) of patients. The EHRA score was 3 or 4 in 13 patients (35%). With the modified arrhythmia-specific questionnaire (MASQ) psychological and physical scores were 46 and 39%. The overall perception of health in the SF-36 was 56 ± 16%. Ablation was performed in 35/37 (95%). At regular follow-up, symptoms were reported in 14/37 (38%) patients. ECG suggested a good procedural outcome in 65% with VES burden on Holter < 1% in 68%. At follow-up, palpitations were reported in 61% (P < 0.07); syncope in only 1 patient (P < 0.05). The EHRA score was 3 or 4 in only one patient (P < 0.05). MASQ scores improved to 62 and 60% (both p < 0.001). The overall perception of health in the SF-36 became 64 ± 17% (P < 0.02). CONCLUSIONS: Patients with VES suffer from a wide variety of symptoms and have a low quality of life, as demonstrated by the EHRA score and conventional questionnaires. After catheter ablation, palpitations are still reported, but become less frequently present. Syncope becomes rare. Quality of life improves significantly from all perspectives.

Risk factors and time delay associated with cardiac device infections: Leiden device registry.

AIMS: A nested case-control study of 75 patients with cardiac device infections (CDI) and 75 matched controls was conducted to evaluate time course, risk factors, culture results and frequency of CDI. METHODS AND RESULTS: CDI occurred in 75/3410 (2.2%) device implantation and revision procedures, performed between 2000 and 2007. The time delay between device procedure and infection ranged from 0 to 64 months (mean 14 (SD 16)), 21 patients (28%) had an early infection (<1 month), 26 (35%) a late infection (1-12 months) and 28 (37%) a delayed infection (>12 months). Of interest, 18 (24%) patients presented with an infection >24 months after the device-related procedure. Time delay until infection was significantly shorter when cultures were positive for micro-organisms compared to negative cultures (8 (12) vs 18 (18) months, p = 0.03). Pocket cultures in delayed infections remained more often negative (61% vs 23%, p = 0.01). Independent CDI risk factors were: device revision (odds ratio (OR) 3.67; 95% confidence interval (CI), 1.51 to 8.96), renal dysfunction defined as glomerular filtration rate <60 ml/min (OR 4.64; CI, 1.48 to 14.62) and oral anticoagulation use (OR 2.83; CI 1.20 to 6.68). CONCLUSION: CDI occurred in 2.2% of device procedures, with 24% occurring more than two years after the device-related procedure. Renal dysfunction, device revisions and oral anticoagulation are potent risk factors for CDI.

The prognostic significance of changes in X-ray attenuation on CT in established cerebral infarcts.

BACKGROUND: X-ray hypoattenuation on computed tomography (CT) reflects the severity of ischaemic damage after stroke. However, the clinical syndrome and the effect of time influence the visibility of infarcts. This prospective study analyses whether the degree of hypoattenuation on CT at two time intervals after stroke has a predictive value for the clinical outcome. METHODS: 220 consecutive stroke patients were admitted within 24 h after onset with symptoms lasting more than 24 h. The study was restricted to 150 patients displaying an anterior circulation infarct or syndrome. All patients had CT scans without contrast enhancement on day 3 (+/-8 h) and day 10 (+/-8 h) after stroke onset. The degree of X-ray attenuation expressed in Hounsfield units was determined in the centre of the infarct area and compared to that in the corresponding zone of the contralateral hemisphere. The patients were divided into four groups according to their degree of disability at 3 months on the modified Rankin scale as follows: R 0-1, R 2-3, R 4-5 and R 6. RESULTS: Patients in groups R 4-5 and R 6 had the most severe impairment on admission. The average decrease of X-ray attenuation on CT on day 3 was less in patients in group R 0-1, but was not different between the three other groups, while it was significantly correlated with the severity of the disability on day 10. CT X-ray attenuation increased between days 3 and 10 in group R 0-1, was unchanged in group R 2-3 and further decreased in groups R 4-5 and R 6. CONCLUSION: The degree of X-ray attenuation on CT on day 3 allows us to distinguish those patients who will recover more or less completely from those with definite disability, while the CT findings on day 10 allow a more precise prediction of outcome. Increase of X-ray attenuation on day 10 is known as the fogging effect and appears to be a favourable prognostic factor. Fogging is generally considered to be due to macrophage invasion and proliferation of capillaries within the infarct area, but probably also represents partial restoration of some viable tissue.

Development and validation of a high-performance liquid chromatographic method for the determination of gamma-hydroxybutyric acid in rat plasma.

A method for the determination of gamma-hydroxybutyric acid (GHB) in rat plasma was developed using solid-phase extraction (SPE) and high-performance liquid chromatography (HPLC) with UV detection. GHB was isolated from plasma using strong anion-exchange SPE columns. The chromatographic separation was performed on a C18 Aqua column. The lower limit of quantification was 10 microg/ml using 60 microl of plasma. The linearity of the calibration curves was satisfactory as indicated by correlation coefficients of >0.990. The within-day and between-day precision were <10% (n=24), the accuracy was nearly 101%. Plasma concentrations in rats after GHB infusion determined by HPLC-UV were compared with the corresponding concentrations determined with a validated gas chromatographic-mass spectrometric method by orthogonal distance regression. A good correlation was observed and a t-test indicated no significant differences from 0 and 1 for the intercept and slope, respectively.

Effect of maturation and aging on beta-adrenergic signal transduction in rat kidney and liver.

The characteristics of the beta-adrenergic signal transduction system were analyzed in kidney and liver membrane preparations from neonatal (2-3 days), mature (2 months), and old (2 years) rats. When comparing kidneys from adult to neonatal rats, we found a higher beta-receptor density and a higher percentage of beta(1)-receptor subtype, lower immunoreactive G(salpha)-protein, a lower ratio between the high and low molecular weight splice variant of G(salpha), lower immunoreactive G(ialpha)-protein, and lower basal adenylate cyclase activity. When comparing livers from adult to neonatal rats, we found lower beta-receptor density and basal adenylate cyclase activity. Very few differences could be detected when comparing mature to old kidneys or livers. Stimulated adenosine 3',5'-cyclic monophosphate (cAMP) synthesis was tissue- and age-dependent. In liver, G-protein- and beta-receptor-stimulated cAMP synthesis mirrored basal adenylate cyclase activity and was highest in liver from neonatal animals. In contrast, cAMP synthesis was significantly more stimulated in kidneys from mature animals than from neonatal and senescent rats. We conclude that: (i) the stoichiometry of the components within the beta-receptor/G-protein/adenylate cyclase complex is not fixed but is both tissue- and age-dependent; (ii) adenylate cyclase enzyme activity is possibly but not necessarily the rate-limiting step in the beta-receptor-mediated synthesis of cAMP; and (iii) there is in vivo evidence for a preferential co-expression of the large splice variant of the G(s)-protein and beta(2)-receptor subtype. It is speculated that this could have important physiological consequences for the development of the kidney.

Influence of inhibition of nitric oxide synthesis on cardiac function in the newborn lamb after hypoxic-ischemic injury.

The aim of the present study was to investigate the effect of immediate post-hypoxic-ischemic (HI) inhibition of nitric oxide synthesis by N(omega)-nitro-L-arginine (NLA) on cardiac function and reactive oxygen species production. Fifteen newborn lambs were subjected to severe HI. Upon resuscitation 5 received 10 mg NLA/kg, 4 40 mg NLA/kg and 6 a placebo. Left ventricular (LV) contractility, cardiac output (CO), non-protein-bound iron (NPBI), ratio of reduced/oxidized ascorbic acid, alpha-tocopherol, sulfhydryl groups and malondialdehyde were measured before and 15, 60 and 120 min after resuscitation. There was a significant decrease in CO in all 3 groups at 60 min post-HI (p < 0.05). Reactive oxygen species production was also highest at 60 min post-HI (significantly increased NPBI and decrease in sulfhydryl groups in control lambs; p < 0.05). These results suggest neither a positive nor a negative effect of nitric oxide synthesis inhibition on post-HI myocardial performance but may suggest a positive effect of NLA on reactive oxygen species-mediated post-HI damage.

Properties of the ventricular adrenergic signal transduction system during ontogeny of spontaneous hypertension in rats.

The purpose of this study was to characterize adrenergic receptors and associated G proteins in ventricles of spontaneously hypertensive rats (SHRs) at different stages of development. The beta- and alpha1-adrenoceptor densities and subtype distribution, and beta-adrenoceptor-G protein coupling were studied by radioligand binding, and levels of G(Salpha), G(ialpha), and G(q/11alpha) protein species were determined by Western blotting in SHRs and Wistar-Kyoto (WKY) control rats aged 3.5 weeks, 3 months, and 8 months. In 3.5-week-old SHRs, both the beta-adrenoceptor density and the percentage of agonist high-affinity binding sites were higher than in age-matched WKY rats. The beta1/beta2-subtype distribution, the alpha1-adrenoceptor density, and the alpha1B/alpha1A-subtype distribution were similar in rats of both strains at all ages. Although essentially no differences in G(salpha) levels between SHRs and WKY rats were detected, higher G(ialpha) and lower Gq/1alpha concentrations were found in 3.5-week-old SHRs. In 3-month-old SHRs, increased levels of Gq/11alpha proteins were observed. In 8-month-old SHRs, none of the parameters was different from those of controls. We conclude that the differences in properties of the adrenergic signal transduction system between SHRs and WKY rats are exclusively observable before and at the onset of the overt hypertension. Moreover, the hypertensive genotype apparently affects G proteins more readily than adrenoceptors.

2-oxo-3-hydroxy-LSD: an important LSD metabolite?

Recently, certain studies have indicated that 2-oxo-3-hydroxy-LSD is present in urine at much higher concentrations than LSD. We determined LSD and 2-oxo-3-hydroxy-LSD in urine by GC-MS (Hewlett Packard 5970) after solid phase extraction on SPEC.PLUS MP1 disks (3 mL, 30 mg, Ansys, Irvine, CA, USA), using the method recommended for amphetamines and derivatisation with BSTFA. For 2-oxo-3-hydroxy-LSD-bis-TMS, the ions with m/z of 309 and 499 were used as quantification and confirmation ion respectively. In four samples containing between 561 and 7007 pg/mL of LSD, 2-oxo-3-hydroxy-LSD concentrations between 8021 and 28466 pg/mL were found, i.e. 4 to 41 times higher than the LSD concentrations. 2-oxo-3-hydroxy-LSD does not seem to be conjugated. These results indicate that 2-oxo-3-hydroxy-LSD, is present in urine in much higher concentrations than LSD, which could facilitate confirmation of positive screenings and increase detection times.

Penetration of gentamicin and ofloxacin in human vitreous after systemic administration.

BACKGROUND: Data on the penetration of antibiotics into the aqueous humor in man and animals, as well as on the intravitreal penetration in animals, are numerous. Data on their intravitreal penetration in humans, however, are sparce. The intravitreal penetration of gentamicin was studied in different ocular pathologies to see whether these alter the vitreal pharmacodynamics. The intravitreal penetration of ofloxacin, a fluoroquinolone, was determined to see whether levels sufficient to treat infectious endophthalmitis could be reached. METHODS: The intravitreal penetration of gentamicin and ofloxacin was studied in patients undergoing pars plana vitrectomy for various ocular pathologies. Those with recent hemorrhages and those already receiving general antibiotic treatment were excluded. RESULTS: Gentamicin was found to penetrate the vitreous very poorly. No difference could be found between the various pathologies: trauma, diabetes, proliferative vitreoretinopathy, longstanding vitreous hemorrhage and macular pucker gave the same poor penetration. The ofloxacin levels were higher but did not reach the MIC90 levels of most organisms involved in bacterial endophthalmitis. CONCLUSION: The hemato-ocular barrier is more difficult to cross than originally thought. Different ocular pathologies do not alter the ocular barrier substantially. Ofloxacin alone does not seem to be sufficient for the treatment of established bacterial endophthalmitis.

Pulmonary oedema, pneumonia and mortality in submersion victims; a retrospective study in 125 patients.

OBJECTIVE: The identification of risk factors contributing to the development of pulmonary oedema, pneumonia and late mortality in submersion victims. DESIGN: A retrospective study of 125 submersion victims. SETTING: The medical intensive care unit in a university hospital. METHODS: Baseline examination on admission consisted of history, physical examination, arterial blood gas analysis and a chest radiograph. Patients were then classified into four groups: class I, baseline examination negative; class II, baseline examination positive, but mechanical ventilation not needed on admission; class III, mechanical ventilation required on admission; class IV, patients suffering from cardiopulmonary arrest. All patients who were not successfully resuscitated or who had expired within 24 h after admission were excluded for determination of the risk of pulmonary oedema and pneumonia. RESULTS: Class I patients did not develop pulmonary complications; neither pulmonary oedema nor pneumonia occurred in this group. In the remaining classes the incidence of pulmonary oedema was 72% and that of pneumonia, 14.7%. Stepwise logistic regression showed that pulmonary oedema was related to the type of water (seawater, ditch water, swimming pool) victims were submerged in and to the neurological state both at the time of rescue and on admission. The development of pneumonia was related to the use of mechanical ventilation (the risk was 52%). Pneumonia was not related to neurological state at the time of rescue or on admission, to body temperature on admission, to the prophylactic administration of antibiotics or to the use of corticosteroids. Mortality was high in class IV patients, but low in all other patients. Early mortality was 18.4% while late mortality was 5.6%. CONCLUSIONS: There is no need to hospitalise submersion victims when there are no signs or symptoms of aspiration upon arrival in the emergency room. All other patients should be admitted to an intensive care unit. The risk of pneumonia is high when mechanical ventilation is necessary. Mortality is high in patients with circulatory arrest on admission, but low in all other patients.

Effect of age on beta-receptors, Gs alpha- and Gi alpha- proteins in rat heart.

beta-adrenoceptors, Gs alpha- and Gi alpha-proteins were investigated in a crude plasma membrane preparation from ventricles of young (2-4 months) and senescent (22-24 months) Wistar rats. Receptor density, ligand affinity and beta 1/beta 2-receptor ratio were independent of the age of the rats. The percentage of beta-receptors coupled to G-proteins increased with age. An age-related increase in the level of Gs alpha (124%) was paralleled by an increase in the ratio between the high and low molecular weight form of Gs alpha. The level of Gi alpha-protein almost doubled (170%) upon aging. We conclude that the age-related differences are small at the level of the beta-adrenoceptor molecule, but that the increase in Gi alpha-proteins could be responsible for the age-related reduction in myocardial inotropic and chronotropic responses. Moreover, we suggest that the changes in degree of high affinity coupling between beta-receptor and Gs-protein are possibly linked to alterations in the ratio between the Gs-molecular weight subtypes.

Hemodynamic and metabolic effects of flunarizine in experimental subarachnoid hemorrhage in dogs.

BACKGROUND AND PURPOSE: Cerebral blood flow and oxygen metabolism were measured and a cerebral angiography was performed in dogs with experimental subarachnoid hemorrhage to assess the relation between arterial narrowing (vasospasm) and the fall of blood flow. Cerebral blood volume and the cerebrovascular CO2 reactivity were also measured to estimate the cerebrovascular reserve. Several groups of dogs were treated with flunarizine in different regimens to assess its possible therapeutic effect. METHODS: The experiments were performed in the three-hemorrhage canine model for subarachnoid hemorrhage. Cerebral blood flow and cerebral oxygen metabolism were measured in anesthetized (nitrous oxide) dogs using positron emission tomography in combination with the 15O steady-state method. Basilar artery diameter was evaluated by digital subtraction angiography. RESULTS: In normal dogs, cerebral blood flow, oxygen consumption, and oxygen extraction ratio were 46.4 +/- 9.0 ml/100 ml per minute, 3.65 +/- 0.76 ml/100 ml per minute, and 39.9 +/- 3.4%, respectively; basilar artery diameter was 1.33 +/- 0.25 mm. Repeated subarachnoid blood injection (3 x 5 ml) reduced basilar artery diameter to < 20% of normal (p < 0.01). Cerebral blood flow was reduced by only 25% (p < 0.001); oxygen consumption was preserved at a low normal level by a 29% compensatory increase of the oxygen extraction (p < 0.001). Cerebral blood volume and cerebrovascular CO2 reactivity remained nearly normal. Early (after the first blood injection) peroral treatment with flunarizine (0.5 mg/kg daily) resulted in less severe basilar artery narrowing (56% of normal; p < 0.05 versus untreated). However, this treatment had no effect on cerebral blood flow, blood volume, oxygen consumption, and extraction. CONCLUSIONS: The observed fall of cerebral blood flow in experimental subarachnoid hemorrhage is not related to arterial narrowing but to an increased cerebrovascular resistance at the level of the small parenchymal vessels, and the latter, in contrast to arterial narrowing, is unaffected by flunarizine.

Digital subtraction in multi-compartment arthrography of the wrist.

In a series of 23 patients with chronic and unexplained painful wrist, three-compartment arthrography was carried out using digital subtraction. Pathologic conditions were disclosed in 19 patients. Digital subtraction both allowed for a stronger diluting of the dye and for the demonstration of a larger amount of lesions of smaller size than conventional wrist-arthrography, as long as motion artefacts had been avoided. Obtaining successive views without having to wait for complete contrast resorption in the injected compartments represents a significant advantage. The importance of three-compartment injection is stressed and the best way to perform the technique is discussed. As it proved to be a fast and reliable examination procedure the authors advocate using digital subtraction arthrography of the wrist whenever the method is available. However, this relatively new technique does not rule out careful correlation between arthrographic findings and clinical complaints.

Ossification of the transverse atlantoid ligament in rheumatoid arthritis.

Ossification of the transverse atlantoid ligament (TAL) is rare. A few cases have been reported by Wackenheim and Dietemann and others. Calcification of the TAL has also been seen in calcium pyrophosphate dihydrate deposition disease. It is important to differentiate this condition from traumatic lesions of the dens axis.

Pharmacological characterization of a beta 3-receptor agonist (BRL 37,344) and a partial agonist (CGP 12,177A) in neonatal rat liver plasma membranes.

The pharmacological properties of BRL 37,344 (sodium-4-(2'-[2-hydroxy-2- (3-chloro-phenyl)ethylamino]-propyl)phenoxyacetatesesquihydrate), a beta 3-selective agonist, and CGP 12,177A) (-)-4-(3-t-butyl amino-2-hydroxypropoxy) benzimidazole-2-one], a non-selective beta-antagonist, recently characterized as a partial beta 3-agonist in rat adipose tissue, were studied in comparison with isoproterenol, a non-selective beta-agonist, in plasma membranes prepared from the livers of newborn rats. Competition binding curves obtained with [125I]iodocyanopindolol ([125I]CYP) as ligand and isoproterenol or BRL 37,344 as competitor were characterized by the presence of a high and a low affinity binding site; the high affinity binding site was no longer detectable when guanidylimidobisphosphate (GppNHp) was present in the incubation mixture. Competition curves with CGP 12,177A were monophasic and independent of GppNHp. In the presence of 10(-7) M of the beta 2-selective antagonist ICI 118,551 [erythro-(+/-)-1-(7-methylindan-4-yloxy)-3-isopropylamino butan-2-ol], a concentration which blocks most of the beta 2-receptors, ligand binding was reduced to 32% of its maximum. Under these conditions, isoproterenol further displaced the ligand, and competition curves still displayed the high and the low affinity binding sites; BRL 37,344, however, caused no further displacement of ligand, except at the highest concentrations. This suggests that BRL 37,344 occupies only the ICI 118,551-sensitive binding sites, i.e. beta 2-receptors. Isoproterenol and BRL 37,344 both stimulated adenylate cyclase (EC 4.6.1.1) activity concentration dependently, although the stimulating effect of BRL 37,344 was about half of what was found for isoproterenol. Furthermore, BRL 37,344 inhibited concentration dependently the isoproterenol-induced stimulation of adenylate cyclase, and the inhibition was dependent on the concentration of isoproterenol. The stimulating effect of isoproterenol and BRL 37,344 on adenylate cyclase was blocked by ICI 118,551, whereas the beta 1-selective antagonist CGP 20,712A ((+/-)-(2-(3-carbamoyl-4-hydroxyphenoxy)-ethylamino)-3-[4-(1-methy l-4- trifluoromethyl-2-imidazolyl)-phenoxy]-2-propanolmethane sulphonate) was ineffective. CGP 12,177A failed to stimulate adenylate cyclase activity. From these results we suggest that BRL 37,344 acts as a beta 2-partial agonist in rat liver. The results obtained with CGP 12,177A are typical for a non-selective beta-antagonist. We therefore conclude that there is no pharmacological evidence for the presence of beta 3-receptors in livers from newborn rats.

Influence of age on the beta 1- and beta 2-adrenergic receptors in rat liver.

The influence of maturation and aging on beta receptors in rat liver was studied. Competition binding experiments with the nonselective beta-antagonist propranolol and the subtype selective antagonists ICI 118,551 (beta 2) ICI 89,406 (beta 1), and CGP 20,712A (beta 1) revealed the presence of a mixed beta 1 and beta 2 receptor population in crude plasma membrane preparations from livers of newborn, mature, and senescent rats. The percentage of beta 1 receptors was lowest in livers from newborn rats and was increased in livers from mature and senescent rats. This increase is caused by a decrease in beta 2 receptor density on maturation, although the beta 1 receptor density is nearly constant throughout the life span of the rat. Isoproterenol-stimulated adenylate cyclase activity was inhibited in livers from senescent rats by propranolol and ICI 118,551 and to a lesser extent by ICI 89,406 and CGP 20,712A. The isoproterenol-stimulated glucose output in hepatocytes from senescent rats was inhibited concentration dependently by propranolol, ICI 118,551, ICi 89,406, and CGP 20,712A. From these results we conclude that beta 1 and beta 2 receptors are present in livers from rats of the three age groups and that the beta 1 to beta 2 receptor ratio is increased in livers from mature and senescent rats compared with newborn rats. Both beta receptor subtypes are linked to the cAMP second messenger system in newborn and senescent rats; beta 1 and beta 2 receptors are equally involved in the regulation of glycogenolysis in hepatocytes from senescent rats.

Elastofibroma dorsi: CT, MR and pathologic study in a new case.

As reported before elastofibroma dorsi is a rare benign tumor of elastic connective tissue with typical clinical and suggestive radiological features. We evaluated the CT and MR characteristics of this periscapular lesion in a new case, before and after contrast enhancement, and tried to determine in how far the nature and extent of the tumor can be predicted.

'High single-dose' European PUVA regimen also causes an excess of non-melanoma skin cancer.

We report the results of a long-term (12.8 years) follow-up study of the detection of malignant and benign skin tumours in patients with psoriasis, who were treated with PUVA according to the European, 'high single-dose' regimen. A total of 13 squamous cell carcinomas (SCC) and 24 basal cell carcinomas (BCC) were diagnosed in 11 of 260 patients. The incidence of both SCC and BCC was increased in comparison with the general Dutch population. The ratio of SCC to BCC in the general population was 1:8 but was 1:2.5 in our study group. A positive correlation was observed between the development of SCC and the total UVA dosage, the age of the patient at the start of the PUVA treatment and a history of arsenic use. This dose-related increase in the incidence of SCC, reported in studies from the U.S.A., has not been found in earlier European studies. The average time period between the start of PUVA therapy and the diagnosis of the first malignant skin tumour was 6.0 years for SCC and 4.7 years for BCC. Among the 49 benign skin tumours were actinic keratoses, a keratoacanthoma and 'PUVA keratoses', a newly described hyperkeratotic lesion, especially found in PUVA-treated patients.

[Oroantral communication and its treatment]. / La communication bucco-sinusale et son traitement.

The most frequent cause of an oroantral perforation is the extraction of an upper molar. In this article, this for a dental practitioner important entity is discussed in detail. After the etiopathology, clinical and roentgenological diagnosis is discussed. As 6.5% of perforations closes spontaneously, the question is raised wether all perforations should be surgically treated. Those different surgical techniques are then described and emphasis is thereby laid on the difference between a mere perforation and a fistula.

[Subcutaneous emphysema of the oral floor during cleaning of a bridge fixed on an IMZ implant. Case report]. / Emphysème sous-cutane du plancher buccal au cours du nettoyage d'un bridge sur implant IMZ. Présentation d'un cas.

A case of subcutaneous emphysema following intraoral elimination of plaque and tooth shading, on a bridge fixed on implants, is presented. An instrument that produces a cleaning spray with a water-air-powder mixture was used. A few minutes after this cleaning procedure there was facial swelling. The patient experienced difficulties in breathing and in swallowing; symptoms of unilateral hearing loss were also noticed. The emphysema lasted for three days. Etiology, diagnosis, differential diagnosis, complications and management are discussed.