Ultrasound-guided maxillary nerve block: an anatomical study using the suprazygomatic approach.

PURPOSE: Although a maxillary nerve (MN) block reportedly provides satisfactory analgesia for midface surgery and chronic maxillofacial pain syndromes, a safe and reliable MN block technique has not been reported. The goal of this anatomical study was to quantify the various angles and depth of the block needle, as well as to evaluate the impact of volume on the extent of injectate spread that might influence anesthetic coverage and block-related complications. METHODS: Following an ultrasound-guided suprazygomatic MN block with dye injection, a dissection was performed in the pterygopalatine fossa (PPF) of four lightly embalmed cadaveric specimens. Half of the specimens were injected with 5 mL of dye, and the other half with 1 mL of dye. The needle depth was measured from the ultrasound images and using rubber markers. Following injection, dissection was performed to map the area of dye spread. RESULTS: The median [interquartile range (IQR)] distance from the skin to the PPF was 37 [36-43] mm and 47 [40-50] mm by ultrasound and rubber marker methods, respectively. The median [IQR] needle orientation was 14 [11-32] degrees inferiorly and 15 [10-17] degrees posteriorly. The PPF was consistently dyed in the 5 mL group, but sporadically dyed in the 1 mL group. In the 5 mL group, spread outside of the PPF was seen. CONCLUSIONS: We showed that 5 mL of injectate far exceeds the capacity of the PPF, leading to drug spread outside of the PPF. Moreover, we found that 1 mL of injectate largely covered the nerve, suggesting a more efficacious and safer block procedure. This finding will need confirmation in future clinical studies.

Feasibility of awake craniotomy in the pediatric population.

BACKGROUND: Awake craniotomy with direct cortical stimulation and mapping is the gold standard for resection of lesions near eloquent brain areas, as it can maximize the extent of resection while minimizing the risk of neurological damage. In contrast to the adult population, only small series of awake craniotomies have been reported in children. AIMS: The aim of our study is to establish the feasibility of awake craniotomy in the pediatric population. METHODS: We performed a retrospective observational study of children undergoing a supratentorial awake craniotomy between January 2009 and April 2019 in a pediatric tertiary care center. Our primary outcome was feasibility of awake craniotomy, defined as the ability to complete the procedure without conversion to general anesthesia. Our secondary outcomes were the incidence of serious intraoperative complications and the mapping completion rate. RESULTS: Thirty procedures were performed in 28 children: 12 females and 16 males. The median age was 14 years (range 7-17). The primary diagnosis was tumor (83.3%), epilepsy (13.3%), and arterio-venous malformation (3.3%). The anesthetic techniques were asleep-awake-asleep (96.7%) and conscious sedation (3.3%), all cases supplemented with scalp block and pin-site infiltration. Awake craniotomy was feasible in 29 cases (96.7%), one patient converted to general anesthesia due to agitation. Serious complications occurred in six patients: agitation (6.7%), seizures (3.3%), increased intracranial pressure (3.3%), respiratory depression (3.3%), and bradycardia (3.3%). All complications were quickly resolved and without major consequences. Cortical mapping was completed in 96.6% cases. New neurological deficits occurred in six patients (20%)-moderate in one case and mild in 5-being all absent at 6 months of follow-up. CONCLUSION: Awake craniotomy with intraoperative mapping can be successfully performed in children. Adequate patient selection and close cooperation between neurosurgeons, anesthesiologists, neuropsychologists, and neurophysiologists is paramount. Further studies are needed to determine the best anesthetic technique in this population group.

Bilateral suprazygomatic maxillary nerve blocks vs. infraorbital and palatine nerve blocks in cleft lip and palate repair: A double-blind, randomised study.

BACKGROUND: Cleft defects are common craniofacial malformations which require early surgical repair. These patients are at high risk of postoperative airway obstruction and respiratory failure. Cleft surgery may require high doses of opioids which may contribute to these complications. OBJECTIVES: To compare the effectiveness of proximal and distal approaches to blocking the maxillary nerve in patients undergoing cleft lip or cleft palate surgery. DESIGN: Randomised, controlled and double-blind study. SETTING: The current study was carried out in Guwahati (Assam, India) between April 2014 and June 2014. PATIENTS: A total of 114 patients older than 6 months who underwent cleft lip or cleft palate surgery were included. Exclusion criteria included coagulation disorders, peripheral neuropathy or chronic pain syndrome, infection in the puncture site, allergy to local anaesthetics, lack of consent and language problems or other barriers that could impede the assessment of postoperative pain. INTERVENTIONS: Patients were randomly assigned to one of two groups: proximal group (bilateral suprazygomatic maxillary nerve blocks) and distal group (bilateral infraorbital nerve blocks for cleft lip repair and bilateral greater and lesser palatine nerve blocks and nasopalatine nerve block for cleft palate surgery). MAIN OUTCOME MEASURE: The primary endpoint was the percentage of patients requiring extra doses of opioids. Secondary endpoints included pain scores, respiratory and nerve block-related complications during the first 24 h. RESULTS: In the intra-operative period, there was a significant reduction of nalbuphine consumption in the proximal group (9.1 vs. 25.4%, P = 0.02). The percentage of patients requiring intra-operative fentanyl was lower in the proximal group (16.4 vs. 30.5%, P = 0.07). There were no differences in either postoperative pain scores or in postoperative complications. No technical failure or block-related complications were reported. CONCLUSION: Bilateral suprazygomatic maxillary nerve block is an effective and safe alternative to the traditional peripheral nerve blocks for cleft lip and cleft palate surgery, in a mixed paediatric and adult population.

Incidence and timing of hypotension after transcervical carotid artery stenting: correlation with postoperative complications.

OBJECTIVES: To assess the incidence and timing of hypotension after carotid artery stenting (CAS) and its correlation with postoperative complications. BACKGROUND: CAS-associated postoperative hypotension has been linked to surgical morbidity and mortality, especially to stroke and cardiac complications. METHODS: Ninety-seven consecutive patients undergoing transcervical CAS were monitored for at least 12 hr after operation. Hypotension was defined as systolic blood pressure < 90 mm Hg. Patients were divided into three groups: normal blood pressure and early (≤6 hr) and late (>6 hr) hypotension. Complications were recorded. RESULTS: Hypotension occurred in 34% of the patients (early hypotension in 63% of them). Hypotension was recorded in 21.6% of patients during surgery and in 21.6%, 15.5%, and 1.0% at 6, 12, and 24 hr postoperatively. Bradycardia occurred in 26.8% during operation and in 25.8%, 13.4%, and 10.3% at 6, 12, and 24 hr after surgery. Intraoperative bradycardia (P = 0.01) and hypotension (P = 0.02) were predictors of postoperative hypotension. The overall rate of complications was 5% without differences between the study groups. The mean length of stay was 3, 3.6, and 2.8 days in the normotensive, early hypotension, and late hypotension groups, respectively. CONCLUSIONS: Most postoperative hypotension episodes occurred within the first 6 hr, and more than one-third between the 6 and 12 hr post-procedure. All patients with late hypotension were asymptomatic. There was no difference in complications between the study groups. In patients undergoing ambulatory CAS, hemodynamic monitoring in the postoperative period is particularly important during the first 12 hr.

The impact of 1.5-T intraoperative magnetic resonance imaging in pediatric tumor surgery: Safety, utility, and challenges.

Objective: In this study, we present our experience with 1.5-T high-field intraoperative magnetic resonance imaging (ioMRI) for different neuro-oncological procedures in a pediatric population, and we discuss the safety, utility, and challenges of this intraoperative imaging technology. Methods: A pediatric consecutive-case series of neuro-oncological surgeries performed between February 2020 and May 2022 was analyzed from a prospective ioMRI registry. Patients were divided into four groups according to the surgical procedure: intracranial tumors (group 1), intraspinal tumors (group 2), stereotactic biopsy for unresectable tumors (group 3), and catheter placement for cystic tumors (group 4). The goal of surgery, the volume of residual tumor, preoperative and discharge neurological status, and postoperative complications related to ioMRI were evaluated. Results: A total of 146 procedures with ioMRI were performed during this period. Of these, 62 were oncology surgeries: 45 in group 1, two in group 2, 10 in group 3, and five in group 4. The mean age of our patients was 8.91 years, with the youngest being 12 months. ioMRI identified residual tumors and prompted further resection in 14% of the cases. The mean time for intraoperative image processing was 54 ± 6 min. There were no intra- or postoperative security incidents related to the use of ioMRI. The reoperation rate in the early postoperative period was 0%. Conclusion: ioMRI in pediatric neuro-oncology surgery is a safe and reliable tool. Its routine use maximized the extent of tumor resection and did not result in increased neurological deficits or complications in our series. The main limitations included the need for strict safety protocols in a highly complex surgical environment as well as the inherent limitations on certain patient positions with available MR-compatible headrests.

Monopoly Airplane Lands in Esophagus Leading to Difficult Extraction: A Case Report on Anesthesia and Surgical Considerations.

A 2-year-old child presented with an airplane game piece from the board game Monopoly lodged in her esophagus. The airplane's wings, engines, and winglets acted like fish hooks that entered the esophageal mucosa easily but were difficult to extract. Chest radiographs were used to estimate the airplane wingspan dimensions, and a Foley catheter was used to dilate the esophagus to allow foreign body extraction via rigid esophagoscopy with optical forceps. Deliberate deep placement of the endotracheal tube facilitated surgical manipulation. This case report highlights the importance of teamwork, communication, and the involvement of multiple disciplines, each with their unique experience and expertise, to formulate a plan of action for patients during unique surgical emergencies.

Role of Postoperative Antimicrobials in Cleft Palate Surgery: Prospective, Double-Blind, Randomized, Placebo-Controlled Clinical Study in India.

BACKGROUND: The purpose of this study was to determine whether administration of postoperative antibiotics affects the incidence of complications after primary cleft palate repair in a developing area. METHODS: This study was a prospective, double-blind, randomized, placebo-controlled trial composed of 518 consecutive patients who underwent primary cleft palate repair at a single institution. Patients were aged 1 to 43 years at the time of surgery (median, 9 years). The patients were divided randomly into two groups. One group received a 5-day regimen of oral amoxicillin (50 mg/kg/day) postoperatively and the other group received placebo medication. Both groups received a single dose of cefuroxime (30 mg/kg) before incision. Patients and providers were blinded to the randomization. Patients were followed postoperatively for early complications (infection and wound breakdown) and for late complications (palatal fistulas). RESULTS: The incidence of early complications was 13.8 percent among the patients in the placebo group and 8.7 percent among the patients in the antibiotic group (p = 0.175). Fistulas were noted in 17.1 percent in the placebo group and in 10.7 percent in the antibiotic group (p = 0.085). Logistic regression analysis identified visiting surgeons as the only covariate related to early complications (OR, 3.71; p < 0.001). However, the use of placebo (OR, 2.09; p = 0.037), female sex (OR, 2.04; p = 0.047), and Veau III and IV (OR, 3.31; p = 0.004) were observed as factors associated with the incidence of fistulas. CONCLUSION: The authors' results indicate that postoperative antibiotic prophylaxis can reduce the incidence of fistulas after primary cleft palate repair in a developing area.