Epiglottic cysts often cause difficulty in airway management, with potential serious life-threatening complications.1 This case report describes a patient with an epiglottic cyst in whom mask ventilation became difficult after induction of anesthesia. Immediately, an AirWay Scope™ (TMAWS-S100; Pentax, Japan) was inserted orally, and the location of the epiglottis was clarified to assess the reason for difficulty with ventilation. This case demonstrates usefulness of the AirWay Scope in patients with epiglottic cyst.
BackgroundThe antiepileptic drugs carbamazepine and gabapentin are effective in treating neuropathic pain and trigeminal neuralgia. In the present study, to analyze the effects of carbamazepine and gabapentin on neuronal excitation in the spinal trigeminal subnucleus caudalis (Sp5c) in the medulla oblongata, we recorded temporal changes in nociceptive afferent activity in the Sp5c of trigeminal nerve-attached brainstem slices of neonatal rats using a voltage-sensitive dye imaging technique.ResultsElectrical stimulation of the trigeminal nerve rootlet evoked changes in the fluorescence intensity of dye in the Sp5c. The optical signals were composed of two phases, a fast component with a sharp peak followed by a long-lasting component with a period of more than 500 ms. This evoked excitation was not influenced by administration of carbamazepine (10, 100 and 1,000 μM) or gabapentin (1 and 10 μM), but was increased by administration of 100 μM gabapentin. This evoked excitation was increased further in low Mg2+ (0.8 mM) conditions, and this effect of low Mg2+ concentration was antagonized by 30 μM DL-2-amino-5-phosphonopentanoic acid (AP5), a N-methyl-d-aspartate (NMDA) receptor blocker. The increased excitation in low Mg2+ conditions was also antagonized by carbamazepine (1,000 μM) and gabapentin (100 μM).ConclusionCarbamazepine and gabapentin did not decrease electrically evoked excitation in the Sp5c in control conditions. Further excitation in low Mg2+ conditions was antagonized by the NMDA receptor blocker AP5. Carbamazepine and gabapentin had similar effects to AP5 on evoked excitation in the Sp5c in low Mg2+ conditions. Thus, we concluded that carbamazepine and gabapentin may act by blocking NMDA receptors in the Sp5c, which contributes to its anti-hypersensitivity in neuropathic pain.
A surgical needle will generally not penetrate an endotracheal tube (ETT) and intraoperative ETT cuff perforation is uncommon because the cuff, which is the weakest part of the tube, is placed in the subglottic trachea. We report a very rare case, in which an intraoperative airway air leak during maxillary advancement surgery was postoperatively confirmed to be due to ETT cuff deflation because of needle penetration of the cuff pilot line. We also measured the force required to penetrate the wall of the pilot line and the ETT wall, finding that the pilot line is vulnerable to a needle.Keywords: Needle perforation; Cuff deflation; Cuff pilot line; Endotracheal tube cuff CommentaryComplications such as pulmonary infection due to micro-aspiration of oropharyngeal secretions may be associated with insufficient inflation of the cuff of an endotracheal tube (ETT), even in patients undergoing short operations. Thus, we should seal the airway as tightly as possible with the cuff to prevent aspiration of pharyngeal contents into the trachea and enable positive pressure ventilation. Here we report a very rare case of intraoperative airway air leak during maxillary advancement surgery. Postoperatively, the cause was confirmed to be deflation of the ETT cuff due to needle perforation of the cuff pilot line.A 19-year-old man (178 cm/64 kg) with cheilognathouranoschisis had undergone cheiloplasty, veloplasty, and iliac bone grafting to the alveolar cleft palate at the age of 6 months, 18 months and 14 years, respectively. He was scheduled for surgery to advance the maxilla and set back the mandible by sagittal split ramus osteotomy (Le-Fort I, SSRO, rigid fixation) to correct jaw deformity. His cardiac and laboratory examinations were within normal limits.After the ETT cuff was checked for free flow of air, symmetry, and leaks, anesthesia was induced with intravenous propofol, fentanyl, and vecuronium. Nasal intubation was easily accomplished using a size 7.0 mm nasal ETT (Nasal preformed tracheal tube, Sheridan) with clear visualization of the vocal cords by direct laryngoscopy. Anesthesia was maintained with oxygen, air, isoflurane and remifentanil.After suturing the nasal cavity mucosa, the surgeon noticed bubbles of saliva in the patient's mouth, indicating the possibility of an air leak. However, we were unable to find an obvious air leak and peak inspiratory pressure was maintained, so the operation was continued. After completion of surgery, we searched for possible causes of an air leak inside the oral cavity before extubation and confirmed fresh hemorrhage into the pharynx within the operating field. The surgeon applied pressure using gauze, and the hemorrhage subsided after several minutes. Auscultation with a stethoscope revealed the presence of lung crackles, and a large quantity of blood and secretions were aspirated through the ETT. Fortunately, his oxygen saturation (SpO 2 ) remained at over 98% with the fraction of inspired oxygen (FiO 2 ) being 1.0. At this point, we noticed that the pilot balloon was...
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