Complications of surgical closure of tracheo-cutaneous fistula in pediatric patients - two case reports.

Tracheocutaneous fistula is seen frequently in decannulated children and respiratory complications associated with primary surgical closure can be potentially fatal. Cough is a precipitating factor for an air leak and we report two cases in which this occurred. A tracheotomy was performed on a 5-month-old girl for mechanical ventilation. Decannulation was successful at the first attempt. One year later, she presented with a persistent tracheo-cutaneous fistula. After surgical closure without drainage, she developed subcutaneous emphysema during a coughing episode. Sutures were removed. A 9-month-old boy presented with oxygen-dependence after lung disease and a tracheotomy was performed for respiratory support. Decannulation was successful at the first attempt 6 months later. He developed a pneumomediastinum after surgical closure of a tracheo-cutaneous fistula. Sutures were removed but replacement of a tracheotomy tube was required. In both cases the wounds were allowed to heal by secondary intention.

Chondronecrosis of the cricoid cartilage after intubation. Two case reports.

Chondronecrosis of the cricoid cartilage is a rare complication of intubation. The records of two children were reviewed. An 8-month-old girl with myelomonocytic leukaemia developed chondronecrosis 10 days after a 2-day period of ventilation. A 4-year-old girl comatose after poisoning by the histamine antagonist, alimemazine, developed chondronecrosis after a 2-day period of intubation. The complication was suspected when extubation led to dyspnoea owing to laryngeal stridor and was confirmed by direct laryngoscopy. We review the development of the condition, the causative factors, treatment and prevention.

Laryngotracheal stenosis in children after intubation. Report of five cases.

Acquired laryngotracheal stenosis is a serious long term complication of tracheal intubation with an incidence of 0.7 to 8% in intubated children. We report five cases of subglottic stenosis over a 4.5-year period and review the pathology and pathogenesis of the condition. A diagnosis of subglottic stenosis was suspected when extubation failed due to the onset of dyspnoea or laryngeal stridor. An incidence of 0.9% of all intubated children was observed. We conclude that the main components contributing to stenosis are pathologies with decreased mucosal capillary perfusion pressure and intubation conditions.

[Unilateral nasal obstruction,. An unusual complication of nasotracheal intubation]. / Obstruction nasale unilatérale. Une complication inhabituelle de l'intubation nasotrachéale.

Partial avulsion of the middle turbinate is an unusual complication of nasotracheal intubation, while minor nasal mucosal trauma is common. We report a case in a 25 year-old healthy-woman, diagnosed four years after nasotracheal intubation for removal of wisdom teeth under general anaesthesia, consisting in a unilateral nasal obstruction related to partial avulsion of the middle turbinate.

[Iatrogenic laryngotracheal stenosis. A follow-up of 20 recent cases]. / Sténoses laryngo-trachéales iatrogènes. Suivi de l'évolution de 20 cas récents.

The aim of this study was to analyse the follow-up of patients with a history of endotracheal intubation and/or tracheotomy because of respiratory distress, surgical necessity or long-term resuscitation. Twenty adults were followed up in a ENT facility for laryngeal or tracheal stenosis, of which 7 cases were diagnosed during 1994. This study shows that, in patients with a history of intubation, or intubation followed by tracheotomy, the stenosis developed within two months after resuscitation with a favourable outcome. After tracheotomy only, the stenosis developed later (2 months or more) with more recurrences. The diagnosis of stenosis was made on gradual or acute dyspnea. While respiratory resuscitation methods are essential and often life-saving, they are not without complications. Laryngeal and tracheal stenosis could be largely prevented by more careful techniques of endotracheal intubation and tracheotomy. Periodic endoscopic airway surveillance is useful to detect stenosis even when there is no clinical symptom.

[Use of the PVC, a laryngoscope for difficult intubation]. / Utilisation du PCV, laryngoscope pour intubation difficile.

The PCV (Piquet-Crinquette-Vilette) laryngoscope has been designed for use in difficult endotracheal intubation in the adult. Its blade, 170 mm long, is curved, narrow (12 mm internal diameter) and semicircular in cross-section, like a closed C. An 8 mm endotracheal tube can be pushed through this blade. There is a cold light source. The use of this blade requires a teeth protector. The epiglottis will be lifted directly, and the blade will be moved into the vestibule, stopping short of the vocal cords. The endotracheal tube will then be introduced into the laryngoscope blade which guides it in between the cords. Once the tube has been checked to be within the trachea, the laryngoscope is removed by sliding the blade backwards over the tube. The PCV may be introduced into the mouth either on the right, or on the left, or behind the molar teeth, or between two teeth. It can held with the handle horizontal in case of a prominent sternum. The limits of this tool are a mouth opening of less then 20 mm, and some rare predictable difficulties which require an X-ray assessment to determine the best intubation technique to be used. Of 115 patients with a predicted difficult endotracheal intubation, fifty were intubated with the PCV without any failures. Also, twenty-five patients, out of thirty, were successfully intubated with the PCV after an attempt with a MacIntosh blade had failed. Of these five failures, one was never intubated by any technique whatsoever, two were intubated by fibroscopy and two by the ENT surgeon.

[Cardiomyopathy due to 5-fluorouracil]. / Cardiomyopathie au 5 fluoro-uracile.

We report a new case of myocardiotoxicity due to 5 fluorouracil. A patient shows immediately after the first cure of chemotherapy where 5 fluorouracil was associated with cisplatinum, a circulatory failure which will need a controlled ventilation and a catecholamine treatment. Right catheterization and two-D echocardiography will confirm the alteration of myocardial contractility. The patient condition will favorably and quickly evolve towards normalisation of the cardiac examination at the third week.

Organization of the extensor complex of the digits.

On the basis of 150 dissections the authors show that, on the back of the hand, the tendinous formations ensuring the extension of the fingers can be arranged in four groups of a least two tendons for each finger, excepting the thumb. In the little finger the group comprises a constant tendon, the extensor proper, and two variables, the common extensor and the expansion of the extensor carpi ulnaris. In the index finger the extensor proper and the common extensor nearly always coexist. In the middle finger the great common extensor, sometimes divided, can be accompanied at depth, by an extensor tendon. Finally, in the ring finger, two or three more or less intricate slips are found forming the common extensor. The presence of anastomoses and the numerous slips originating in the tendon-forming band can reduce functional deficiency following the section or rupture of a tendon. On account of these variations the surgeon should operate with caution in tendon transplantations.

[Factors in the stabilization of the ulnar head]. / Les facteurs de stabilisation de la tête ulnarienne.

The authors studied the stability of the ulnar head by dissections of the radio-ulnar joint and experimental ligamentous removals in 150 specimens. They emphasize the importance of the tendon of the extensor carpi ulnaris and medial collateral ligament tightened by Kuhlmann's sling which firmly apply the ulnar head against the anterior edge of the sigmoid potch of the radius. Transsection of the separate fibro-osseous tunnel of the extensor carpi ulnaris with forward creeping of the tendon out of its groove enlarges the size of the gap between extensor carpi ulnaris and extensor digiti quinti; if in addition both fibro-cartilaginous disk and medial collateral ligament are torn, the ulnar head dislocates dorsally. Such a displacement can be obtained by full supination following forced pronation. The volar dislocation of the ulnar head occurs more rarely; it might be caused by insufficient extensor carpi ulnaris and ruptured fibro-cartilaginous disk and yielded by shallow sigmoid notch and blunt anterior border. So muscular structures avoid dorsal displacement of the ulnar head actively whereas only fibro-osseous structures passively prevent from anterior displacement.

[Descriptive and topographical anatomy of the dorsal artery of the foot]. / Anatomie descriptive et topographique de l'artère dorsale du pied (pédieuse).

The authors studied the course of the A. dorsalis pedis in 67 specimens cleared up with formalin and injected with terpentine and minium. The classical statement was found in 44 cases (2/3): the A. dorsalis pedis following the course of the A. Tibialis arise in front of the upper edge of the retinaculum extensorum, ran through the first intermetatarsal space and anastomosed with the A. plantaris lateralis. In 15 cases, it divided into 2 terminale branches - A. dorsalis medialis and lateralis - at 2-3 cm cm beyond its origin. In 6 cases, the artery was tiny and the arterial supply of the dorsum of the foot was mainly provided by both the lateral malleolar and the fibular arteries. Twice, the A. dorsalis pedis ran down into the second intermetatarsal space. The knowledge of these individual variations is to be pointed out by arteriography before using either M. extensor digitorum brevis or skin of the dorsum of the foot as flaps for covering cutaneous defects at the bindfoot.