Temporomandibular joint anatomy: Ultrasonographic appearances and sexual dimorphism.

INTRODUCTION: Temporomandibular joint (TMJ) dysfunction is common, with a greater prevalence in females. While magnetic resonance imaging (MRI) is commonly used for clinical investigation, ultrasonography represents a potential alternative in some clinical scenarios. We designed a protocol for ultrasonographic evaluation of the TMJ and assessed its reliability. Presentation was compared between the sexes to establish whether an anatomical dichotomy underlies the female preponderance of TMJ dysfunction. MATERIALS AND METHODS: Ultrasound imaging of the TMJ was carried out in the longitudinal and oblique planes. Standard images were produced using model skulls and healthy volunteers. Measurements were made between the temporal bone, mandibular condyle, joint capsule and overlying skin, as well as of condylar translation during mouth opening. Both joints were scanned in 50 healthy volunteers. Measurements were repeated to evaluate reliability. A novel classification system was used to assess lateral condylar morphology. RESULTS: The protocol facilitated reliable visualization of key anatomical features of the TMJ (average intraclass correlation coefficient = 0.75, p ¯  = 5.4E-03). Distribution of condylar morphology differed between the sexes. The capsular-cutaneous distance ('joint depth') and condylar-temporal bone distance ('interarticular distance') were significantly greater in males than in females. CONCLUSIONS: Ultrasonography provides reliable views of the TMJ in two planes: longitudinal and oblique. Observed sexual dimorphism in TMJ anatomy might be associated with the female preponderance of dysfunction. With a standardized scanning protocol, ultrasound could provide a rapid, cost-effective alternative to MRI as a point-of-care imaging tool in TMJ clinics.

Acute respiratory failure and mechanical ventilation in pregnant patient: A narrative review of literature.

Physiological changes of pregnancy imposes higher risk of acute respiratory failure (ARF) with even a slight insult and remains an important cause of maternal and fetal morbidity and mortality. Although pregnant women have different respiratory physiology and different causes of ARF, guidelines specific to ventilatory settings, goals of oxygenation and weaning process could not be framed due to lack of large-scale randomized controlled trials. During the 2009 H1N1 pandemic, pregnant women had higher morbidity and mortality compared to nonpregnant women. During this period, alternative strategies of ventilation such as high-frequency oscillatory ventilation, inhalational of nitric oxide, prone positioning, and extra corporeal membrane oxygenation were increasingly used as a desperate measure to rescue pregnant patients with severe hypoxemia who were not improving with conventional mechanical ventilation. This article highlights the causes of ARF and recent advances in invasive, noninvasive and alternative strategies of ventilation used during pregnancy.

Comparison of air-Q and Ambu Aura-i for controlled ventilation in infants: a randomized controlled trial.

BACKGROUND: The air-Q is a new supraglottic airway device (SAD) and has been increasingly used as a primary airway device and as a conduit for tracheal intubation in children as well as in adults. This device has either performed equally or better than other SADs in children. The Ambu Aura-i is a commonly used SAD in children undergoing various short surgical procedures. However, limited literature is available evaluating the safety and efficacy of the air-Q and the Ambu Aura-i in small children. We, therefore, conducted this study to compare the clinical performance of these two airway devices in infants weighing up to 10 kg. Our hypothesis is that air-Q, due to its improved and larger cuff design will yield better airway seal pressures as compared with the Ambu Aura-i. METHODS: Sixty-four ASA I-II infants weighing <10 kg undergoing elective ophthalmic surgery were randomly assigned to receive either an air-Q or the Ambu Aura-i. After induction of general anesthesia (GA) and muscle relaxation, we measured oropharyngeal leak pressure (OLP) as the primary outcome. The secondary end points measured were time to insert, first insertion success rate, fiberoptic grade (FO) of laryngeal view and any other airway complications like trauma, laryngospasm, and desaturation. RESULTS: The air-Q ILA provided significantly higher OLP as compared with the Ambu Aura-i [20.2 ± 4.6 cm H2 O, CI 18.55-21.88; vs 16.2 ± 5.6 cmH2 O, CI 14.27-18.25, P = 0.003; mean difference 4 ± 1.29 cm H2 O, CI 1.41-6.58]. However, the Ambu Aura-i required significantly less time for its insertion (14.6 ± 2.8 s, CI 13.66-15.70; vs 16.3 ± 1.5 s, CI 15.75-16.86, P = 0.005; mean difference 1.625 ±  0.56 s, CI 0.48-2.76). There were no differences in first insertion success rate, FO view, and postoperative complications. CONCLUSION: We conclude that air-Q may be considered superior to Ambu Aura-i in infants for controlled ventilation as it provides higher airway sealing pressures.

Comparison of performance and efficacy of air-Q intubating laryngeal airway and flexible laryngeal mask airway in anesthetized and paralyzed infants and children.

BACKGROUND: Flexible laryngeal mask airway is a commonly used supraglotic airway device (SAD) during ophthalmic surgeries. Air-Q intubating laryngeal airway (ILA) is a newer SAD used as primary airway device and as a conduit for intubation as well. Available literature shows that air-Q performs equal or better than other SADs in children and adults. However, limited data is available using air-Q in infants and small children <10 kg. So, our aim was 'To compare the performance and efficacy of these two devices in infants and small children'. Our hypothesis is that air-Q due to its improved cuff design will yield better airway seal pressures and improved laryngeal alignment as compared to flexible laryngeal mask airway. METHODS: ASA I­II infants and children weighing <10 kg, undergoing cataract or glaucoma surgery, were randomly divided into two groups of 25 each. After induction of anesthesia and muscle relaxation, we measured oropharyngeal leak pressure (OLP), fibre-optic (FO) view of glottis, first insertion success rate, time to insert, and any other complications. RESULTS: There was no difference between the groups in demographic data, first insertion success rate, time to insert, and postoperative complications. Air-Q provided significantly more OLP [21.1 ± 6.4 cmH2O vs 17.4 ± 4.1 cmH2O, P = 0.02] and better FO view of glottis (good view 84% vs 48%, P = 0.0016) as compared to flexible laryngeal mask airway. CONCLUSION: We conclude that air-Q is superior to flexible laryngeal mask airway in providing higher airway sealing pressures and better FO grade of laryngeal view in infants and children.

Not everything is as it seems.

We report a case of a patient operated for shoulder rotator cuff injury under interscalene brachial plexus block and general anesthesia, who developed neurological deficit in the nonoperative upper limb in the immediate postoperative period. As our patient developed neurological deficit on the nonoperative side, it was clear from the beginning that neither the nerve block nor the operative procedure was responsible for it. However, had he developed neurological symptoms on the operative side after having a peripheral nerve block, it would have possibly delayed the timely investigation and diagnosis. This case report underlines the need to keep an open mind when investigating neurological symptoms arising in the perioperative period, rather than assuming it to be secondary to either nerve block or as a complication of surgical procedure.

Middle East respiratory syndrome: A new global threat.

The outbreak of Middle East respiratory syndrome (MERS) is reported from Saudi Arabia and the Republic of Korea. It is a respiratory disease caused by coronavirus. Camels are considered as a source for MERS transmission in humans, although the exact source is unknown. Human-to-human transmission is reported in the community with droplet and contact spread being the possible modes. Most patients without any underlying diseases remain asymptomatic or develop mild clinical disease, but some patients require critical care for mechanical ventilation, dialysis and other organ support. MERS is a disease with pandemic potential and awareness, and surveillance can prevent such further outbreaks.

Anaesthetic management of a child with panthothenate kinase-associated neurodegeneration.

Panthothenate kinase-associated neurodegeneration (PKAN) (Hallervorden-Spatz disease) is a rare autosomal recessive chromosomal disorder characterised by progressive neuroaxonal dystrophy. The characteristic features include involuntary movements, rigidity, mental retardation, seizures, emaciation. The anaesthetic concerns include difficult airway, aspiration pneumonia, dehydration, and post-operative respiratory, and renal insufficiency. We report successful anaesthetic management of a 9-year-old intellectually disabled male child with PKAN, scheduled for ophthalmic surgery under general anaesthesia.

Acquired Tracheo-oesophageal Fistula: A Challenging Complication of Tracheostomy.

Acquired tracheo-oesophageal fistula (TEF) after tracheostomy is a life threatening complication and can occur in about 1% of cases of tracheostomy. Percutaneous tracheostomy was performed in intensive care unit on a 40 years male patient for long-term mechanical ventilation. Subsequently patient developed TEF as the complication of tracheostomy. He was initially managed with endoscopically inserted self expanding plastic stent but later on required surgery for definitive repair. The problems associated with acquired TEF and its management are discussed hereby.