Since its original description in 1986 by Hernandez, submental intubation has been used in a wide variety of craniomaxillofacial cases as a way to satisfy both surgeon and anesthesiologist to provide access to necessary surgical sites and airway protection. Many modifications to the original technique have been described. There has been a paucity of plastic surgery literature over the last 10 years that have reviewed the anatomy, technique, and complications. In this article, the authors review the pertinent anatomy related to this method of intubation. A cadaver was used to enhance visualization of important structures and to show the modification used by our group. Submental intubation provides a useful alternative to tracheostomy in several craniomaxillofacial procedures. Our approach uses a reinforced endotracheal tube to prevent kinking and provide additional intraoperative protection of the airway. Submental intubation may be indicated in select patients undergoing craniomaxillofacial surgery. Therefore, it is pertinent to be aware of the important anatomy and the complications of this technique to appropriately counsel patients. Our modification provides safe airway control.
Introduction: Body dysmorphic disorder (BDD) is an obsessivecompulsive related disorder characterized by an individual's preoccupation with the appearance of at least 1 perceived physical flaw. The bodily concerns held by individuals with BDD are largely unnoticeable, if at all, to other individuals. Those living with BDD are compelled to engage in repetitive behaviors or cognitive acts that interfere with daily function and activities. Despite the high prevalence of BDD in patients who seek cosmetic procedures (ie, as high as 1 in 5 such patients) and the availability of validated screening tools for this disorder, implementing a protocol of regularly screening for BDD is only rarely practiced by surgeons. Few studies have investigated its prevalence in the setting of elective dentoalveolar and orthognathic procedures. With the scope of practice of maxillofacial surgeons expanding in recent years to include facial cosmetic procedures, it is becoming increasingly important to screen for such disorders so that patients and physicians can appropriately weigh the risks and benefits of surgical intervention. Methods: We conducted a cross-sectional cohort study (n ¼ 46) consisting of 3 groups of patients, who were seeking either facial cosmetic, orthognathic, or dentoalveolar procedures. All patients in the study were screened for BDD using the Body Dysmorphic Disorder Questionnaire (BDDQ) and assessed for severity of disorder using the BDDQ severity scale. Additional patient variables included age, sex, history of psychiatric diagnosis, primary diagnosis, and type of operation/procedure being sought.Results: Among the 3 groups, patients seeking dentoalveolar surgery were the most represented (67%) in this sample, followed by cosmetic surgery (27%) and orthognathic surgery (6%). Twenty-six female participants and 20 male participants were included, with an overall mean age of 38 years. Two percent of participants carried a previous psychiatric diagnosis and 10.8% of the sample were classified as high-risk for BDD. The group containing the highest proportion of patients at high-risk for BDD were those seeking facial cosmetic procedures (16.7%), followed by those seeking dentoalveolar procedures (10%); none of the patients seeking orthognathic procedures were found to be at high-risk for BDD (0%). Conclusions: The BDDQ is an efficient way to screen for BDD in patients who are seeking orthognathic or facial cosmetic surgery. In our sample, patients presenting to maxillofacial surgeons for facial cosmetic surgery were found to score significantly higher on the BDDQ than those presenting for dentoalveolar surgery. In contrast to results of previous literature, patients seeking orthognathic surgery in our sample demonstrated no elevated risk for BDD, a finding which may be attributable to our small sample size. Ultimately, the data obtained from this study can aid surgeons in identifying patients with BDD in their own surgical practice, so that they may appropriately triage patients who may, or may not, benefit from surgica...
Background: Clostridium perfringens gas gangrene is an extremely rare and fatal infection. Necrosis of the myometrium is rarely seen and has only been recorded in 18 cases to date. Of these 18 reported cases, only 5 have occurred in nonpregnant women. This article presents the 6th case of myometrium necrosis from C. perfringens. Case: A 72-year-old woman, gravida 2, para 2, presented with abdominal pain and vaginal bleeding. After examinations, laboratory testing, and several surgical interventions, she was found to have C. perfringens infection and advanced high-grade serous adenocarcinoma of the endometrium with >50% invasion into the myometrium. Results: Despite the surgical interventions and use of several antibiotics, this patient did not improve. She was weaned from treatment per her advance directive and died after weaning. Conclusions: Awareness of the many etiologies for peritonitis is of great importance when a fatal infection may be the cause of the condition. Correct diagnosis and proper treatment is essential for the survival of patients infected with C. perfringens. (J GYNECOL SURG 32:182)
Pyomyositis is typically thought of as a disease of the tropics. However, it is becoming more prevalent in temperate regions, and may be underdiagnosed. Here, pyomyositis is encountered as a complication of perforated diverticulitis, which has not been previously reported. A 61-year-old Caucasian man initially presented in respiratory distress and was diagnosed with respiratory failure due to COPD exacerbation. The patient was taking high-dose prednisone, 60 mg daily for the past 2 years. Initially, he was afebrile, normotensive, tachycardic to 178 beats/minute and tachypneic to 28 breaths/minute, requiring noninvasive ventilation to maintain oxygenation. Blood tests revealed leukocytosis of 16.7×103/μL, and blood cultures grew Escherichia coli. Broad-spectrum antibiotics were started but leukocytosis and bacteremia persisted on repeated tests. On the seventh hospital day, a CT scan of the abdomen was performed for complaints of abdominal pain, and the patient was diagnosed with Hinchey stage 3 diverticulitis. A Hartmann’s procedure was performed with intraoperative findings of purulent peritonitis. Intraoperative cultures grew E. coli and vancomycin-resistant Enterococcus faecium. The patient continued to have leukocytosis of 15.1×103/μL despite surgical therapy. He began to complain of left lower extremity pain, and a CT scan on hospital day 24 revealed gluteal intramuscular abscesses, which were percutaneously drained. Persistent symptoms prompted another CT scan on hospital day 28, which revealed additional intramuscular abscesses in the vastus lateralis muscle, which was also drained, with subsequent resolution of pain and normalization of inflammatory markers. This is the first case demonstrating pyomyositis as a complication of diverticulitis. While the mechanism of pyomyositis may not be unique, it is important to recognize the potential complications of frequently encountered diseases. In this critically ill and immunosuppressed patient, there was delayed diagnosis of both diverticulitis and pyomyositis, but the patient quickly improved once the diseases were recognized and treated.
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