Induced hypotension for functional endoscopic sinus surgery: A comparative study of dexmedetomidine versus esmolol.

OBJECTIVE: A comparative study to evaluate the efficacy of dexmedetomidine as a hypotensive agent in comparison to esmolol in Functional Endoscopic Sinus Surgery (FESS). METHODS: Forty patients ASA I or II scheduled for FESS were equally randomly assigned to receive either dexmedetomidine 1 µg/Kg over 10 min before induction of anesthesia followed by 0.4-0.8 µg/Kg/h infusion during maintenance (DEX group), or esmolol, loading dose 1mg/kg was infused over one min followed by 0.4-0.8 mg/kg/h infusion during maintenance (E group) to maintain mean arterial blood pressure (MAP) between (55-65 mmHg). General anesthesia was maintained with sevoflurane 2%-4%. The surgical field was assessed using Average Category Scale and average blood loss was calculated. Hemodynamic variables (MAP and HR); arterial blood gas analysis; plasma cortisol level; intraoperative fentanyl consumption; Emergence time and total recovery from anesthesia (Aldrete score ≥9) were recorded. Sedation score was determined at 15, 30, 60 min after tracheal extubation and time to first analgesic request was recorded. RESULT: Both DEX group and E group reached the desired MAP (55-65 mmHg) with no intergroup differences in MAP or HR. The for the quality of the surgical filed in the range of MAP (55-65 mmHg) were <=2 with no significant differences between group scores during hypotensive period. Mean intraoperative fentanyl consumption was significantly lower in DEX group than E group. Cortisol level showed no significant changes between or within groups. No significant changes were observed in arterial blood gases. Emergence time and time to achieve Aldrete score ≥9 were significantly lower in E group compared with DEX group. The sedation score were significantly lower in E group compared with DEX group at 15 and 30 minutes postoperatively. Time to first analgesic request was significantly longer in DEX group. CONCLUSION: Both dexmedetomidine or esmolol with sevoflurane are safe agents for controlled hypotension and are effective in providing ideal surgical field during FESS. Compared with esmolol, dexmedetomidine offers the advantage of inherent analgesic, sedative and anesthetic sparing effect.

Role of topical antibiotic prophylaxis in prevention of bacterial translocation into upper trachea in nasally intubated patients undergoing tonsillectomies.

INTRODUCTION: The human oropharynx and nasopharynx are home of different bacteria and fungi. The initial sterile endotracheal tube (ETT) transfers mechanically the bacteria from the nasopharynx and oropharynx to the sterile tracheobronchial tree. We investigated the efficacy of Neomycin-Bacitracin combination spray in the prevention of this bacterial translocation through its application over and inside the lumen of the endotracheal tubes preoperatively. PATIENTS AND METHODS: Ninety patients aged (from 8 to 15 years) with ASA I and II were randomly assigned into 2 groups (45 patients for each): Group I; patients with naso-tracheal intubation which sprayed by placebo spray (Lidocaine) and group II; with naso-tracheal intubation that sprayed with antibiotic spray (combined Neomycin sulphate and Bacitracin) on the outside wall of the tube and inside its lumen. At the end of surgery and immediately after extubation, swabs were taken from the upper trachea using cotton tipped swab for bacterial growth. Inflammatory biomarkers were assessed preoperatively and postoperatively to detect any laboratory differences between both groups. RESULTS: In the control group, all patients had heavy bacterial contamination and they were at either level 3 or 4 colony forming units. Thirty-two patients (71%) were at level 3 while 13 patients (29%) were at level 4. In the study group, there were 28 (62.2%) patients showed no bacterial growth, 15 (33.3%) patients were level 1, and 2 patients (4.4%) at level 2 colony forming units. There were no clinical differences between the 2 groups. Also, there was no significant difference between the 2 groups regarding to their postoperative body temperature although the inflammatory biomarkers were significantly higher in the control group. CONCLUSION: Bacterial translocation by endotracheal intubation to the tracheobronchial tree could be prevented by local antibiotic spray application to outer and inner walls of the endotracheal tubes.

Stenting the nasopharyngeal isthmus by nasopharyngeal airway after correction of acquired total nasopharyngeal obstruction: surgical procedure and results.

The objective of this study is to describe a simple surgical procedure for management of acquired total nasopharyngeal obstruction in adults. Five patients were diagnosed as having complete nasopharyngeal obstruction over a 3-year period. Three patients previously underwent uvulopalatoplasty, while for the remaining two it was due to pharyngoscleroma. In all the patients, nasopharyngeal obstruction was at the level of the inferior edge of the soft palate. Two of the post-uvulopalatoplasty patients had recurrent obstruction after scar excision and topical application of mitomycin-C without stenting. All the patients were treated surgically by creation of a new anatomical nasopharyngeal isthmus and stenting it by nasopharyngeal airway for 6 months. All the patients experienced satisfactory results and good tolerability to airway placement. The nasopharyngeal airway can counteract the inevitable scar contraction of the new nasopharyngeal isthmus after surgical correction and maintain its patency.

The outcomes for nasal contact point surgeries in patients with unsatisfactory response to chronic daily headache medications.

The nasal contact point may act as a trigger point or peripheral enhancer in patients with chronic daily headaches. A total of 42 patients had unsatisfactory response to medical treatment for chronic daily headache with radiologic evidence of nasal contact point. Of them, 12 (28.5%) patients were positive for the local anesthetic test. Those patients were operated upon to separate this contact by either septoplasties or submucous resections with or without partial turbinectomies. The mean headache frequency was reduced from 22 to 7 days/month. The mean headache severity was reduced from 5.6 to 2.4. Eight (19%) patients became completely free from headache and its medications, six (75%) of them were positive for local anesthetic test. The patients were satisfied with postoperative monotherapy, or headache severity and frequency could be tolerated without medications in 26 (62%) patients. There was no improvement in seven (16.6%) patients and only one patient (2%) became worse. The overall satisfaction was 83 and 81% for positive and negative anesthetic tests, respectively. The average monthly medication cost was reduced from $85 to 32. Nasal contact point surgery for chronic daily headache patients can satisfy them compared to previously unsatisfactory medications. Nasal contact point may contribute to potentiating or triggering chronic daily headache.

Role of intra-operative ultrasound-guided reduction of nasal bone fracture in patient satisfaction and patient nasal profile (a randomized clinical trial).

The objective of this study was to evaluate the benefits of intra-operative ultrasonic guidance in the management of isolated nasal bone fractures. A prospective, randomized, controlled, double blinded study was designed. Sixty-eight patients who had isolated fracture nose were treated by either a simple closed reduction or by ultrasound-guided reduction (34 patients each) with a follow up for an average of 4.5 and 5.5 months, respectively. Post-traumatic and post-reduction nasal profiles were compared (by blinded photographer), and patient's satisfaction was analyzed after reduction in both groups. We used Student's t test for independent groups to compare between the average patient's scores. The average patient's nasal profile score for closed reduction group was 2.31. Thirteen patients (40.6%) had scored 3, 16 (50%) had scored 2, and three (9.4%) patients had scored 1. The average patient's nasal profile score for ultrasonic assisted group was 2.72. Twenty-four patients (75%) had scored 3, 7 (22%) had scored 2, and one (3%) patient had scored 1. The average patient's satisfaction score for closed reduction was 2.62. Twenty-four patients (75%) had scored 3, 4 (12.5%) patients had scored 2, and 4 (12.5%) patients had scored 1. The average patient's satisfaction score for ultrasonic assisted group was 2.78. Twenty-six patients (81%) scored 3, 5 (16%) patients scored 2, and one (3%) patient scored 1. Patients undergoing ultrasonic nasal bone reduction scored significantly better nasal profile scores than patients undergoing simple closed reduction, on the other hand, patient satisfaction scores had no significant difference between both groups. Treating nasal bone fractures with the assistance of intra-operative ultrasound resulted in a significantly better nasal profile appearance, than treating it by simple closed reduction.

Pre-emptive oral dextromethorphan reduces both postoperative and packing removal pain in patients undergoing nasal surgery.

OBJECTIVE: To determine whether premedication with 45 mg of oral dextromethorphan (DM) given 90 minutes prior to nasal surgery decreases postoperative pain and consequently reduces opioid administration and also, if it reduces the pain of pack removal. METHODS: This was a prospective, double blind, randomized, controlled study carried out from January 2007 to March 2008 at Al-Moosa General Hospital, Al-Ahsa, Saudi Arabia, in which 38 patients received oral DM (age 28 +/- 11 years), and 38 patients received placebos (age 26 +/- 10 years). Postoperative pain was assessed using a visual analog scale, and a pain score of > or -5 was treated by a rescue bolus dose of morphine sulfate 2 mg every 10 minutes in the post-anesthesia care unit (PACU) and by one gm of paracetamol in the surgical ward until the score became <5. Pain was also assessed during pack removal. RESULTS: The placebo group had a higher pain score in the PACU, and hence a higher morphine consumption than the DM group (7.3 mg +/- 2.6 versus 4.6 mg +/- 1.2, p=0.03). Pain score in the surgical ward was also higher in the placebo group at 4, 8, 12, and 24 hours, but this was insignificant, and was insignificantly lower only at 18 hours (p=0.26). The placebo group had a higher pain score at pack removal than the DM group (7.8 +/- 11 versus 3.5 +/- 15, p=0.004). CONCLUSION: Preemptive medication with DM reduces opioid administration in the early postoperative period and during pack removal.