Junctional Rhythm Preoperatively and During General Anesthesia for Oral and Maxillofacial Surgery.

We report a case of junctional rhythm that occurred both preoperatively and later during a portion of general anesthesia. A 19-year-old woman was scheduled to undergo bilateral sagittal split ramus osteotomy after being diagnosed with a jaw deformity. Preoperative electrocardiography (ECG) revealed a junctional rhythm with a slow heart rate (HR). At 90 minutes after anesthesia induction, local anesthesia with 10 mL of 1% lidocaine and 1:100,000 adrenaline was administered. A junctional rhythm appeared 15 minutes after the local anesthesia. We believe that the atrioventricular nodal pacemaker cells accelerated because of the increased sympathetic activity due to the adrenaline. On the preoperative ECG, the junctional rhythm with slow HR appeared as an escaped beat caused by slowing of the primary pacemaker. Therefore, we think that the preoperative junctional rhythm and the junctional rhythm that appeared during general anesthesia were due to different causes. Understanding the cause of a junctional rhythm could lead to more appropriate treatment. We therefore believe that identifying the cause of the junctional rhythm is important in anesthetic management.

Tension Pneumothorax After Percutaneous Tracheostomy.

A 76-year-old woman with right mandibular gingival cancer was scheduled for surgery. A percutaneous tracheostomy kit was used for tracheostomy under intravenous sedation. After puncturing the cricothyroid membrane, a dilator was inserted along a guidewire. Bucking was observed at the time of insertion of the dilator, despite intratracheal lidocaine spray applied before insertion. After that, the tracheostomy tube was inserted, but no capnographic waveforms appeared when the tube was connected to the anesthesia circuit. Direct macroscopic observation revealed a perforation extending from the posterior wall of the trachea to the anterior wall of the esophagus, which prompted us to request assistance from a thoracic surgeon for treatment before reinserting the tracheostomy tube. After verifying capnographic waveforms on the monitor, anesthesia was induced. Because arterial oxygen saturation was 96% under the administration of pure oxygen, chest radiography was conducted revealing a right pneumothorax. A chest tube was inserted and the patient transported to a nearby general hospital. We suspect that pneumothorax was induced when the integrity of the mediastinal pleura was compromised by mediastinal emphysema because of the injury to the posterior tracheal wall complicated by bucking at the time of insertion of the dilator.

Anesthetic Management of a Patient With Charcot-Marie-Tooth Disease.

Charcot-Marie-Tooth disease (CMTD) is a hereditary peripheral neuropathy and is characterized by progressive muscle atrophy and motor-sensory disorders in all 4 limbs. Most reports have indicated that major challenges with general anesthetic administration in CMTD patients are the appropriate use of nondepolarizing muscle relaxants and preparation for malignant hyperthermia in neuromuscular disease. Moderate sedation may be associated with the same complications as those of general anesthesia, as well as dysfunction of the autonomic nervous system, reduced perioperative respiratory function, difficulty in positioning, and sensitivity to intravenous anesthetic agents. We decided to use intravenous sedation in a CMTD patient and administered midazolam initially and propofol continuously, with total doses of 1.5 mg and 300 mg, respectively. Anesthesia was completed in 3 hours and 30 minutes without adverse events. We suggest that dental anesthetic treatment with propofol and midazolam may be effective for patients with CMTD.

RANKL+ senescent cells under mechanical stress: a therapeutic target for orthodontic root resorption using senolytics.

In dentistry, orthodontic root resorption is a long-lasting issue with no effective treatment strategy, and its mechanisms, especially those related to senescent cells, remain largely unknown. Here, we used an orthodontic intrusion tooth movement model with an L-loop in rats to demonstrate that mechanical stress-induced senescent cells aggravate apical root resorption, which was prevented by administering senolytics (a dasatinib and quercetin cocktail). Our results indicated that cementoblasts and periodontal ligament cells underwent cellular senescence (p21+ or p16+) and strongly expressed receptor activator of nuclear factor-kappa B (RANKL) from day three, subsequently inducing tartrate-resistant acid phosphatase (TRAP)-positive odontoclasts and provoking apical root resorption. More p21+ senescent cells expressed RANKL than p16+ senescent cells. We observed only minor changes in the number of RANKL+ non-senescent cells, whereas RANKL+ senescent cells markedly increased from day seven. Intriguingly, we also found cathepsin K+p21+p16+ cells in the root resorption fossa, suggesting senescent odontoclasts. Oral administration of dasatinib and quercetin markedly reduced these senescent cells and TRAP+ cells, eventually alleviating root resorption. Altogether, these results unveil those aberrant stimuli in orthodontic intrusive tooth movement induced RANKL+ early senescent cells, which have a pivotal role in odontoclastogenesis and subsequent root resorption. These findings offer a new therapeutic target to prevent root resorption during orthodontic tooth movement.

Severe gag reflex during dental treatment associated with hiatus hernia: A case report.

AIMS: This report presents a case wherein severe gagging during dental treatment was linked to hiatus hernia. METHODS AND RESULTS: A 22-year-old man with a severe gagging problem presented with a chief complaint of pain localized to the lower molars. Oral examination revealed inadequate plaque control, demineralization of the enamel surface on buccal-gingival margins of all teeth, and inflamed gingival tissue surrounding the coronal portion of both mandibular third molars; panoramic radiography revealed that they were horizontally impacted. As the patient reported experiencing vomiting and heartburn for the past two months, he was referred to the internal medicine department before scheduling surgical tooth extraction. Hiatus hernia and reflux esophagitis were diagnosed, and the severity of gagging was significantly reduced by modifying the patient's eating behavior and administering a proton pump inhibitor. Although intravenous sedation was still required for surgical extraction of the impacted third molars, preventive treatments, such as tooth cleaning and fluoride application, could be performed without the need for pharmacological intervention. CONCLUSION: While gagging is often attributed to conditioning responses and iatrogenic factors, interdisciplinary consultation for successful management may facilitate the elucidation of local anatomical and systemic causes.

Changes in blood pressure during induction of anesthesia and oral and maxillofacial surgery by type and timing of discontinuation of antihypertensive drugs.

The purpose of this study was to evaluate the effects of an antihypertensive drug class and the timing of discontinuation of antihypertensive therapy on blood pressure during oral and maxillofacial surgery for 129 patients on antihypertensive therapy receiving general anesthesia. Blood pressures at loss of response to stimulation and 5-15 minutes after intubation were significantly lower than those before induction, although the type of antihypertensive therapy did not affect changes in blood pressure. No significant correlation was observed between systolic blood pressure (SBP) on the ward and change in SBP during surgery, though patients with higher blood pressure on the ward tended to exhibit larger differences between SBP on the ward and the lowest SBP during surgery. Frequency of use of vasopressors during surgery was significantly higher in patients who discontinued antihypertensive therapy on the day before surgery than in those who continued antihypertensive therapy on the day of surgery. These findings suggest that appropriate preoperative antihypertensive therapy is important for minimizing change in blood pressure during surgery and preventing perioperative complications. Patients undergoing antihypertensive therapy should be carefully monitored perioperatively by observation for interactions between antihypertensive and anesthetic agents and minimizing interruption schedules for antihypertensive therapy.

[Difficult airway management for general anesthesia in two patients with Kartagener syndrome].

Two patients with Kartagener syndrome were managed under general anesthesia by nasal intubation for sagital split ramus osteotomy. Many episodes of expectoration were encountered in the former patient's perioperative period and the expectoration discharge was inadequate by postoperative nausea, leading to trouble in airway management. In the second patient, tube collapse was caused after intubation by serious nasal cavity strangulation, and re-intubation was necessary. Expectoration is seen resulting from decreased ciliary function with bronchiectasis during anesthetic management of patients with Kartagener syndrome. It is important to prevent lung complications by nausea prevention and pain killing in the postoperative period, in addition to proper suctioning in the perioperative period. Furthermore, there is nasal cavity narrowing by chronic sinusitis. When performing nasal intubation, the difficult airway management is required.

A Case of Cardiac Arrest for 31 Seconds During Recovery After Intravenous Sedation.

A 26-year-old woman with a history of feeling nauseated during dental local anesthesia presented to our clinic for tooth extraction under intravenous sedation. Although she had experienced episodes of neurally-mediated syncope, her symptoms were controlled well with drug therapy, stopped 3 years earlier. No syncope episodes developed over the previous 2 years. Tooth extraction was performed under intravenous sedation without incident. When she was returned to a sitting position after being roused, convulsion, loss of consciousness, and cardiac arrest developed. One week later, similar symptoms occurred immediately after suture removal. We suspect that the change in body position triggered these episodes. It is important to avoid abrupt changes in body position and any other triggers and to administer preventive drugs in patients at high risk of syncope.

Anesthetic Management of Patient With Dravet Syndrome: A Case Report.

Dravet syndrome (DS) is a rare and severe form of epilepsy that begins in infancy. This is particularly burdensome because repeated epileptic seizures lead to cognitive decline. We describe the case of a 12-year-old girl who was diagnosed with DS and was scheduled to have gingival reduction around her mandibular molars. Despite the patient being intellectually disabled, she was able to cooperate somewhat during medical procedures, including intravenous cannulation. Under the assumption that the major problem with anesthesia for DS would be the regulation of body temperature-induced seizures, we used body temperature management equipment to maintain the patient's body temperature during the procedure. We opted for intravenous sedation and administered a total dose of 4.5 mg midazolam throughout the procedure. Anesthesia was completed within 1 hour and 20 minutes without any adverse events. To the best of our knowledge, no previous studies have documented the anesthetic management of DS. In this case, no adverse events occurred perioperatively. However, the patient's temperature rose to that which indicated a slight fever despite the use of a standard cooling technique.

Comparison of the Contact Force Exerted on Teeth by Conventional Macintosh Laryngoscope Versus Video Laryngoscopes.

During laryngoscopy, the laryngoscope blade sometimes comes in contact with the teeth, fracturing or dislocating them. However, no studies have compared the effects of newly marketed video laryngoscopes and the Macintosh laryngoscope (Mac) on teeth. In this study, we measured and compared the force exerted on the teeth of an intubating manikin by the Mac, the Airway Scope (Pentax), and the McGrath MAC (Covidien). The mean force exerted was 141.1 ± 15.7 kg by the Mac, 39.2 ± 10.3 kg by the Airway Scope, and 48.7 ± 6.7 kg by the McGrath MAC. No significant difference was observed between the Airway Scope and the McGrath MAC. When the Mac is inserted, the glottis has to be visually located from outside the oral cavity. However, a significant force is not necessary when inserting video laryngoscopes because a camera is mounted on the blade tip. In this laboratory model, the lower force exerted by the video laryngoscopes should contribute to a reduction in their impact on fracture or dislocation of teeth.

Severe Hyponatremia due to Phlegmonous Trismus.

We describe a patient with dysphagia and trismus associated with lower jaw inflammation due to phlegmon who developed severe hyponatremia from water intoxication due to excessive water intake after diaphoresis caused by abnormally hot weather. A 63-year-old woman presented with severe swelling of the floor of the mouth and trismus. As she had spasms and numbness of the extremities and restlessness and water intoxication caused by excessive water intake was suspected, she was hospitalized for the treatment of inflammation and electrolyte disorder. Although swelling of the floor of the mouth subsided over time after antimicrobial therapy, vomiting, diarrhea, and numbness of the extremities continued. On day 5 of hospitalization, severe vomiting and diarrhea recurred, and serum sodium levels decreased to 108 mEq/L. Decrease in water intake is essential in the treatment of hyponatremia. However, in patients with severe vomiting and diarrhea who can swallow only liquids because of hot weather and eating disorder, the risk of sodium depletion is high. It is important to restore electrolyte balance and fluid volume through supplementation with sodium, chlorine, potassium, and glucose among others, the reduction of intravenous fluid volume, and diuresis in order to correct the sodium level slowly.