Airway Management in Reconstructive Surgery for Noma (Cancrum Oris)

Abstract

last skin stitch is rarely more than 15 minutes, the potential for postoperative residual neuromuscular weakness is considerable. Continuous maintenance of deep NMB during laparoscopic surgery should be performed only in settings where clinicians have access to sugammadex, which should be given in doses of 4.0 mg/kg or greater. However, monitoring of neuromuscular function is essential, and because sugammadex is expensive, maintenance of deep block has economic considerations, especially when the actual benefits of deep block may be nonexistent.Little or no evidence suggests that using deep NMB as opposed to a moderate block for laparoscopic surgery will improve surgical operating conditions. Even if deep block is maintained, surgeons will not automatically ask for lower inflations pressures. At this point, in settings where sugammadex is not available and deep NMB is not routinely used for laparoscopic surgery, current practices do not need to be changed. COMMENTThis interesting and provocative article, in my opinion, should be read by all clinicians who administer anesthesia-and surgeons, too! The current authors, who have considerable expertise in the area of NMBs, reviewed the relevant literature to determine whether deep blockade with NMBs is helpful during laparoscopic surgery. They found little or no evidence to support that deep block (as opposed to moderate block) for laparoscopic surgery improves operating conditions. Moreover, even when deep block is maintained, surgeons will not necessarily ask for lower inflation pressures. Importantly, reversal of deep block with an acetylcholinesterase inhibitor is very slow and incomplete, and the likelihood of postoperative residual neuromuscular weakness in these circumstances is high. Therefore, the authors maintain, continuous maintenance of deep block during laparoscopic surgery should only be considered by clinicians who have access to sugammadex, which is not available in the United States and costs approximately $100 per 200-mg single-dose vial.From my perspective, the 2 most important messages promulgated by this article are that monitoring of neuromuscular function is absolutely mandatory when one is administering NMBs and that deep NMB is not a prerequisite for satisfactory muscle relaxation, at least not in the adequately anesthetized patient. 1,2 Comment by Kathryn E. McGoldrick, MD, FCAI(Hon) Disclosure: The author declares no conflict of interest.

Craniofacial and maxillary anomalies: Anesthetic implications and management

“…These challenges get accentuated when such patients present for surgical intervention. [1][2][3][4][5][6] With the advent of modern craniofacial surgical interventions, these facial defects can be corrected to a large extent and can help the person to lead a normal life. Paul Tessier, the father of craniofacial surgery, has suggested various surgical techniques for repair of these defects involving a multidisciplinary approach involving plastic surgeon, neurosurgeon, maxillofacial surgeon, an ophthalmologist, an otolaryngologist, orthodontist, pedodontist, a pediatrician, speech specialist and Numerous congenital and traumatic cranio-maxillary malformations can be encountered in clinical practice, but we are limiting our discussion to the commonly faced anomalies.…”

Treatment of complications following orofacial gangrenous infection in a resource limited setting: Experiences and a proposed classification

“…Administration of general anesthesia remains a challenge in patients with post noma defect as a result of limited mouth opening. Where conventional orotracheal or nasotracheal intubation is not feasible, methods advocated include facemask ventilation, transtracheal jet ventilation, blind nasal intubation, fibreoptic intubation and tracheostomy [18,19] . However, the choice of technique should be individualized (based on parameters such as interincisal distance and ability to subluxate the mandible) rather than generalized [19] .…”

Noma (cancrum oris): An unresolved global challenge

“…If the affected subject survives, the margins of the noma defect heal with extensive fibrosis and scarring resulting in limitation of mouth opening, oral incontinence, difficulty in mastication and speech, and disfigurement . Not uncommonly, mouth opening is severely restricted by the formation of scar tissue between the mandible and the maxilla and zygomatic arch …”

“…The word ‘noma’ originates from the Greek verb ‘nomein’, which means ‘to devour’, reflecting the rapidly progressive, aggressive ‘tissue eating’ nature of the disease; and the name ‘cancrum oris’, a term for noma introduced in Great Britain in the 17th century, is an incorrect use of the Latin term ‘cancer oris’, but which has gained currency despite being ‘an odd grammatical blunder’ . Because of the context in which it almost always occurs, noma has been referred to as the ‘face of poverty’ …”