Sensitivity and Specificity of US and CT as Diagnostic Tools for Pediatric Lateral Neck Abscesses.

OBJECTIVE: Ultrasound (US) and computed tomography (CT) are commonly used in the diagnosis of pediatric neck abscesses. The objective of this study is to determine the sensitivity and specificity of US and CT in the diagnosis of pediatric lateral neck abscesses, with a secondary objective of evaluating the association of specific clinical features with a positive US or CT scan. STUDY DESIGN: Retrospective review of pediatric patients admitted to a tertiary care center from January 1, 2011, to December 31, 2020, with neck abscesses. SETTING: Tertiary care center. METHODS: The sensitivity and specificity of US and CT were calculated by comparing imaging performed within 24 h of incision and drainage (I&D). Multiple regression was used to evaluate the association of clinical features with a true positive US or CT. RESULTS: There were 171 patients included in this study, with a median age of 1.5 years (interquartile range [IQR]: 1-5 years). I&D was done in 156 patients (91.2%), while 15 (8.8%) were treated with antibiotics. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of US were 69.5%, 80%, 96.6%, and 24.2%. The sensitivity, specificity, PPV, and NPV of neck CT were 95.5%, 80%, 95.5%, and 57.1%. Length of symptoms, skin erythema, and fluctuance were not significantly associated with a positive US (F(3, 82) = 0.24, p = .9, R2 = 0.01) or CT scan (F(3, 30) = 0.84, p = .5, R2 = 0.08). CONCLUSION: Neck US has a low sensitivity for diagnosing pediatric neck abscesses, when compared to CT, but remains a useful initial investigation given its high PPV. Clinicians should have a low threshold for pursuing CT if there is a high suspicion of abscess formation. LEVEL OF EVIDENCE: Level 4.

Choosing Wisely Canada - pediatric otolaryngology recommendations.

The Choosing Wisely Canada campaign raises awareness amongst physicians and patients regarding unnecessary or inappropriate tests and treatments. Using an online survey, members of the Pediatric Otolaryngology Subspecialty Group within the Canadian Society of Otolaryngology - Head & Neck Surgery developed a list of nine evidence based recommendations to help physicians and patients make treatment decisions regarding common pediatric otolaryngology presentations: (1) Don't routinely order a plain film x-ray in the evaluation of nasal fractures; (2) Don't order imaging to distinguish acute bacterial sinusitis from an upper respiratory infection; (3) Don't place tympanostomy tubes in most children for a single episode of otitis media with effusion of less than 3 months duration; (4) Don't routinely prescribe intranasal/systemic steroids, antihistamines or decongestants for children with uncomplicated otitis media with effusion; (5) Don't prescribe oral antibiotics for children with uncomplicated tympanostomy tube otorrhea or uncomplicated acute otitis externa; (6) Don't prescribe codeine for post-tonsillectomy/adenoidectomy pain relief in children; (7) Don't administer perioperative antibiotics for elective tonsillectomy in children; (8) Don't perform tonsillectomy for children with uncomplicated recurrent throat infections if there have been fewer than 7 episodes in the past year, 5 episodes in each of the past 2 years, or 3 episodes in each of the last 3 years; and (9) Don't perform endoscopic sinus surgery for uncomplicated pediatric chronic rhinosinusitis prior to failure of maximal medical therapy and adenoidectomy.

A retrospective evaluation of minimally invasive ponto surgery (MIPS) in two pediatric centers.

BACKGROUND: Percutaneous bone anchored hearing systems have been used effectively for over forty years with low rates of complications. Minimally Invasive Ponto Surgery (MIPS) is a surgical technique performed through a puncture hole that has been reported to minimize soft tissue trauma and decrease operative time. Due to it being a relatively new procedure there remains a paucity of pediatric outcomes data. METHODS: Pediatric patients from two tertiary pediatric otolaryngology centers between 2016 and 2019 who underwent MIPS were included in this study. Charts were retrospectively reviewed for indications for surgery, implant and abutment type, overlying skin thickness, skin-to-skin time, Holgers score at three, six and twelve months, revision surgery and time to abutment fitting. RESULTS: Fourteen patients, two with bilateral procedures met inclusion criteria (mean age = 8.07 ± 2.87years). The mean overlying skin thickness was 5.13 ± 3.18mm. 9.44% of visits had an adverse skin reactionOne patient required surgery forskin overgrowth. One implant loss (6.3%) was reported, following trauma to the abutment. Mean MIPS skin to skin times were 12.4 ± 2.6 min, markedly different that the Baha® Attract and Connect which were 56 and 53 min, respectively. CONCLUSION: This study represents the largest pediatric MIPS cohort to date, and our results are similar to published adult studies.

Quality indicators for the diagnosis and management of pediatric tonsillitis.

INTRODUCTION: Pediatric tonsillitis is encountered frequently across specialties, and while high quality guidelines exist, there is persistent evidence of care which is not evidence based, including antibiotic overprescribing and surgical practice variability. Quality indicators (QIs) can be utilized for initiatives to improve the quality of care and subsequent patient outcomes. We sought to develop pediatric tonsillitis QIs that are applicable across specialties and that cover aspects of both diagnosis and the spectrum of management options. METHODS: A guideline-based approach to QI development was employed. Candidate indicators (CIs) were extracted from international guidelines deemed high quality by two reviewers and evaluated by an eleven-member expert panel consisting of otolaryngology - head & neck surgeons, a pediatrician and a family physician. The final QIs were selected utilizing a modified RAND/UCLA appropriateness methodology. RESULTS: Twenty-six CIs were identified after initial literature review. After the first round of evaluations, the panel agreed on thirteen candidate indicators as appropriate QIs. A subsequent expert panel meeting provided a platform to discuss areas of disagreement, discuss any recently published research, and to brainstorm additional CIs not identified from the guideline extraction. Following the second round of evaluations, the expert panel agreed upon sixteen QIs as appropriate measures of high-quality care. CONCLUSIONS: This study proposes sixteen QIs developed through a multidisciplinary lens to guide practitioners in the diagnosis and management of pediatric tonsillitis. These QIs can be used to improve transparency, accountability, and provide objective data to assist future quality improvement initiatives.

Overnight oximetry in children undergoing adenotonsillectomy: a single center experience.

BACKGROUND: Obstructive sleep apnea (OSA) is the most common indication for adenotonsillectomy in children. Home-based sleep oximetry continues to be used in the diagnosis of pediatric OSA despite a lack of correlation with lab-based polysomnography. This study investigates whether factors influence surgeons in selecting patients for home-based sleep oximetry, how the study findings are used in patient management, and whether abnormal oximetry findings are associated with post-operative complications. METHODS: A retrospective review was performed on children with suspected OSA who had undergone a tonsillectomy and/or an adenoidectomy over a three-year period. Demographic features, comorbidities, pre-operative oximetry results, and post-operative complications were recorded. Data analysis consisting primarily of logistic regression was performed using Stata 12.0 (College Station, Texas). RESULTS: Data was collected from 389 children. Two hundred and seventy-one children underwent pre-operative oximetry (69.7%). There was no significant association between age or the presence of comorbidities and the likelihood of undergoing pre-operative sleep oximetry. The post-operative complication rate was 0.8%. There was no significant association between abnormal sleep oximetry parameters and post-operative complications. Children with one or more abnormal sleep oximetry parameters were more likely to be observed in hospital for at least one night (OR 2.4, p < 0.0001). CONCLUSIONS: Our study suggests that surgeons are using home-based sleep oximetry findings to inform the post-operative care of children with suspected OSA, as those with abnormal home-based sleep oximetry findings were more likely to be observed in hospital. These hospital admissions may be unnecessary given the poor correlation of home-based oximetry and PSG as well as the low rate of serious post-operative complications.

Defining atypical croup: A case report and review of the literature.

BACKGROUND: Croup is a common respiratory illness in children. It presents with a barky cough, stridor and hoarseness occurring secondary to inflammation of the subglottis and larynx. The clinical course of croup is well-described, however atypical presentations pose a diagnostic and management challenge. OBJECTIVES: This case report and systematic review aims to synthesize the published literature on the definition, diagnosis and treatment of atypical croup. STUDY SELECTION: Peer-reviewed journal publications in Ovid MEDLINE® and EMBASE from inception to January 1, 2019 in English, focusing on pediatric patients (<18 years of age) with diagnoses of atypical croup. DATA EXTRACTION: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS: Twelve studies involving 670 patients ranging from 6 months to 11 years of age presenting with atypical croup were selected. A variety of definitions of atypical croup were identified based on recurrence, duration of symptoms, severity, and etiology. Data on the incidence of atypical croup, the overall rates of intubation and tracheostomy, and patient characteristics leading to definitive airway management were not clearly characterized. LIMITATIONS: All studies were case series, case reports or retrospective chart reviews. CONCLUSIONS: Atypical croup is a poorly defined clinical entity that is used to describe recurrent, refractory, or croup-like illness that follows an uncharacteristic natural history. Our case presentation and accompanying literature review highlights the variable, but limited, information available on the diagnosis of atypical croup. Given the commonality of its use in clinical practice, we propose some guidelines around the use of the term 'atypical croup' as well as a management algorithm.

The role of narrative in the development of children's pain memories: influences of father- and mother-child reminiscing on children's recall of pain.

Negatively biased memories for pain (ie, recalled pain is higher than initial report) robustly predict future pain experiences. During early childhood, parent-child reminiscing has been posited as playing a critical role in how children's memories are constructed and reconstructed; however, this has not been empirically demonstrated. This study examined the role of parent-child reminiscing about a recent painful surgery in young children's pain memory development. Participants included 112 children (Mage = 5.3 years; 60% boys) who underwent a tonsillectomy and one of their parents (34% fathers). Pain was assessed in hospital and during the recovery phase at home. Two weeks after surgery, parents and children attended a laboratory visit to participate in a structured narrative elicitation task wherein they reminisced about the surgery. Four weeks after surgery, children completed an established pain memory interview using the same previously administered scales through telephone. Narratives were coded for style (elaboration) and content (pain and emotion) based on coding schemes drawn from the developmental psychology literature. Findings revealed that a more elaborative parental reminiscing style in addition to greater use of emotional words predicted more accurate/positively biased pain memories. Greater parental use of pain words predicted more negatively biased pain memories. Although there were no sex and parent-role differences in pain memory biases, mothers and fathers differed in how they reminisced with their boys vs girls. This research underscores the importance of parent-child reminiscing in children's pain memory development and may be used to inform the development of a parent-led memory reframing intervention to improve pediatric pain management.

Socialization of Pain Memories: Parent-Child Reminiscing About Past Painful and Sad Events.

OBJECTIVE: Parent-child reminiscing about past negative events has been linked to a host of developmental outcomes. Previous research has identified two distinct between-parent reminiscing styles, wherein parents who are more elaborative (vs. repetitive) have children with more optimal outcomes. To date, however, research has not examined how parents and children talk about past painful experiences nor compared parent-child reminiscing about past painful versus other distressing events despite key developmental differences in how young children respond to pain versus sadness in others. This study aimed to fill that gap. METHODS: Seventy-eight children aged 4 to 7 years underwent a tonsillectomy. Two weeks postsurgery, children and one of their parents discussed past autobiographical events (i.e., the tonsillectomy, another painful event, a sad event). Parent-child conversations were coded using established coding schemes to capture parental reminiscing style, content, and autonomy support. RESULTS: Findings revealed robust differences in parent-child reminiscing about painful versus sad events. Parents were less elaborative, used less emotionally negative words and explanations, and were less supportive of their children's autonomy while reminiscing about past painful versus sad events. CONCLUSIONS: These findings demonstrate that through reminiscing, parents may socialize children about pain in a way that is different from other distressing events (e.g., sadness). Future research should examine the influence of differential reminiscing about pain versus sadness on developmental and health outcomes.

Role of anxiety in young children's pain memory development after surgery.

Pediatric pain is common, and memory for it may be distressing and have long-lasting effects. Children who develop more negatively biased memories for pain (ie, recalled pain is higher than initial pain report) are at risk of worse future pain outcomes. In adolescent samples, higher child and parent catastrophic thinking about pain was associated with negatively biased memories for postsurgical pain. This study examined the influence of child and parent anxiety on the development of younger children's postsurgical pain memories. Seventy-eight children undergoing a tonsillectomy and one of their parents participated. Parents reported on their anxiety (state and trait) before surgery, and trained researchers observationally coded children's anxiety at anaesthesia induction. Children reported on their postsurgical pain intensity and pain-related fear for 3 days after discharge. One month after surgery, children recalled their pain intensity and pain-related fear using the same scales previously administered. Results revealed that higher levels of postsurgical pain and higher parent trait anxiety predicted more negatively biased memories for pain-related fear. Parent state anxiety and child preoperative anxiety were not associated with children's recall. Children who developed negatively biased pain memories had worse postsurgical pain several days after surgery. These findings underscore the importance of reducing parental anxiety and effective postsurgical pain management to potentially buffer against the development of negatively biased pain memories in young children.

Novel presentation of cranial fasciitis of the mandible: Case report and literature review.

Cranial fasciitis (CF) is a rare benign fibroblastic lesion of the scalp, most commonly affecting the pediatric population. The authors conducted a literature review and include a summary of reported cases of CF. CF is most commonly located in the parietal and temporal regions of the skull. The majority of cases are found in males and in children under a few years of ago. We describe the clinical, pathological and radiological findings of the first reported case of CF of the mandible. In this case, the patient was a 12 month-old male who presented with a one-month history of a rapidly enlarging mass along his left mandibular ramus. Treatment of CF involves surgical resection and has a low rate of recurrence. The patient in question was managed surgically with no complications and has not had any evidence of disease recurrence.

Endoscope-assisted nasal dermoid excision with an open rhinoplasty approach.

Congenital midline nasal masses have been traditionally excised through rhinotomies and bicoronal incisions. These approaches are disfiguring and potentially morbid, leading pediatric otolaryngologists to seek out less invasive, endoscopic-assisted approaches. Here we present a nasal dermoid excised with a minimally invasive, endoscopic assisted open rhinoplasty approach. The preoperative workup as well as perioperative steps for excision are documented, with the hope that this will assist other practitioners with this approach. An endoscopic open rhinoplasty technique affords excellent visualisation, with a superior cosmetic outcome. A preoperative MRI is essential to ensure the lesion is amenable to this approach.

Are lactoferrin receptors in Gram-negative bacteria viable vaccine targets?

A number of important Gram-negative pathogens that reside exclusively in the upper respiratory or genitourinary tract of their mammalian host rely on surface receptors that specifically bind host transferrin and lactoferrin as a source of iron for growth. The transferrin receptors have been targeted for vaccine development due to their critical role in acquiring iron during invasive infection and for survival on the mucosal surface. In this study, we focus on the lactoferrin receptors, determining their prevalence in pathogenic bacteria and comparing their prevalence in commensal Neisseria to other surface antigens targeted for vaccines; addressing the issue of a reservoir for vaccine escape and impact of vaccination on the microbiome. Since the selective release of the surface lipoprotein lactoferrin binding protein B by the NalP protease in Neisseria meningitidis argues against its utility as a vaccine target, we evaluated the release of outer membrane vesicles, and transferrin and lactoferrin binding in N. meningitidis and Moraxella catarrhalis. The results indicate that the presence of NalP reduces the binding of transferrin and lactoferrin by cells and native outer membrane vesicles, suggesting that NalP may impact all lipoprotein targets, thus this should not exclude lactoferrin binding protein B as a target.

Incidence of children at risk for obstructive sleep apnea undergoing common day surgery procedures.

OBJECTIVE: The purpose of this study was to evaluate the prevalence of sleep-related breathing disorders (SRBD) in children undergoing elective day surgery procedures. METHODS: A validated Pediatric Sleep Questionnaire (PSQ) was distributed to the parents of children aged 2months to 18 years who met inclusion criteria and were undergoing urologic, otolaryngologic, and general surgical day surgery procedures a 3-month period of time. The prevalence of children at risk for pediatric SRBD was determined from PSQ results. RESULTS: From a total of 288 PSQ Questionnaires, 9.1% of urology, 11.1% of general surgery, and 51.9% of otolaryngology patients admitted to day surgery were found to be at risk for sleep disordered breathing. The median PSQ score for the children at risk was 9.2 for urological surgeries, 10.9 for general surgery, and 11.3 for otolaryngological procedures. CONCLUSIONS: There is an increased prevalence of children at risk of SRBD awaiting common day surgery procedures than previously expected based on existing literature. Patients undergoing otolaryngological procedures were at greater risk of sleep-related breathing disorders when compared with patients undergoing urological or general surgical procedures. There may be a role for screening of pediatric patients with a PSQ prior to day-surgery. LEVEL OF EVIDENCE: Type of study: prognosis study, level IV.

The role of bone conduction hearing aids in congenital unilateral hearing loss: A systematic review.

OBJECTIVES: To systematically review the literature on the audiological and/or quality of life benefits of a bone conduction hearing aid (BCHA) in children with congenital unilateral conductive or sensorineural deafness. METHODS: A systematic search was performed according to the PRISMA guidelines using the PubMed, Medline, and Embase databases. Data were collected on the following outcomes of interest: speech reception threshold, speech discrimination, sound localization, and quality of life measures. Given the heterogeneity of the data for quantitative analysis, the results are qualitatively summarized. RESULTS: Eight studies were included in the review. Four studies examined the audiological outcomes associated with bone conduction hearing aid implantation. There was a consistent gain in speech reception thresholds and speech discrimination, especially in noisy environments. Results pertaining to sound localization was inconsistent. The studies that examined quality of life measures reported a high usage rate of BCHAs among children. Quality of life improvements are reported with suggested benefit in the subdomain of learning. CONCLUSION: Given the potential benefits of a BCHA, along with the fact that it can be safely trialed using a headband, it is reasonable to trial a BCHA in children with congenital unilateral deafness. Should the trial offer audiological and/or quality of life benefits for the individual child, then BCHA implantation can be considered.

Rigid bronchoscopy and balloon dilation for removal of aspirated thumbtacks: case series and literature review.

OBJECTIVE: Aspirated thumbtacks can pose unique challenges during removal due to their shape. In particular, the flanges of the thumbtack can readily become trapped by the bronchial mucosa during extrication. We describe our experience of three children from whom aspirated thumbtacks were removed using rigid bronchoscopy following balloon dilation of the airway to reduce bronchial mucosa entrapment. METHODS: This is a retrospective review of three pediatric otolaryngology cases. RESULTS: In all three cases, the thumbtack was successfully removed from various sites within the lower respiratory tract. There were no iatrogenic complications, in particular bronchial wall injury leading to pneumothorax. CONCLUSION: In cases of complicated airway foreign bodies, such as thumbtacks, airway dilation is a useful and safe maneuver that may help facilitate removal.

Kawasaki disease is associated with sensorineural hearing loss: a systematic review.

CONTEXT: Kawasaki Disease (KD), a systemic vasculitis of unknown etiology, has been associated with the development of sensorineural hearing loss (SNHL). KD is primarily a disease of young children, who are the most susceptible to complications from even minimal hearing loss. If there is a connection between KD and the development of SNHL, a better understanding of this relationship may improve our management of this disease and its complications. OBJECTIVE: To perform a systematic review according to a standardized guideline to evaluate the possible association between KD and SNHL. DATA SOURCES: Medline and PubMed online databases were reviewed for appropriate articles. STUDY SELECTION: All studies available in English discussing KD and SNHL were included. DATA EXTRACTION: Studies were assessed primarily for the incidence of SNHL. Where possible, they were assessed for the degree and laterality of the loss, length of follow up and change in hearing over time. RESULTS: 8 studies meeting the criteria were assessed. 3 were case reports, 1 was a case series and the remaining 4 were prospective control trials. 8 patients have been reported as cases, and 240 assessed in PCT. 36% of patients assessed had some degree of SNHL, and overall 14% had evidence of persistent SNHL at follow up. CONCLUSIONS: This systematic review would suggest there is an association between KD and SNHL. It is important for physicians caring for patients with KD to be aware of this complication and consider screening these patients given possible complications of hearing loss in this age group.

Use of a Low-fidelity simulator to improve trans-nasal fibre-optic flexible laryngoscopy in the clinical setting: a randomized, single-blinded, prospective study.

BACKGROUND: Trans-nasal flexible fibre-optic laryngoscopy (TFFL) is an essential skill for otolaryngologists. There is evidence to suggest that simulators help residents acquire procedural skills. The objective of this study was to examine the effect of simulation on endoscopy skill acquistion. METHODS: A randomized controlled trial was conducted utilizing medical students and junior residents with limited experience in TFFL. Learners all performed a baseline endoscopy and were then randomized to receive either 45 minutes of simulation training or not. Following this, a second endoscopy was performed. Time to adequate visualization of the glottis, the percentage of time adequate visualization of the airway was maintained, and the number of collisions with mucosa were analyzed. Qualitative assessments were also obtained from the learner, patient, and staff laryngologist. RESULTS: Time to adequate visualization of the glottis and the number of mucosal collisions were significantly less during the second endoscopy, irrespective of the use of simulation (84.8 sec vs. 68 sec, p < 0.01; 5.0 vs. 3.2, p < 0.01, respectively). Analysis using a two-way ANOVA with interaction established that none of the quantitative measures analyzed in this study improved with the addition of simulation. CONCLUSION: Improvements in time to visualization of the glottis and number of mucosal contacts were seen between the first and second endoscopy irrespective of simulator use. No additional benefit was conferred with the use of a low-fidelity simulator.

Effectiveness of the heat-activated nitinol smart piston stapes prosthesis in stapedectomy surgery.

OBJECTIVE: To compare the SMart piston stapes prosthesis to a standard manual crimp prosthesis on operative time and air-bone gap (ABG) closure in stapedectomy. DESIGN: Retrospective chart review. SETTING: Tertiary referral centre. METHODS: The charts of patients undergoing stapedectomy for otosclerosis were analyzed. We compared the results of 76 patients (80 ears) who received the autocrimping SMart piston prosthesis to those of 21 patients (21 ears) who received the conventional manual crimp Fisch-type prosthesis. Data were analyzed using t-test, chi-square, or two-way analysis of variance where appropriate. MAIN OUTCOME MEASURE: Operative time with ABG closure as a secondary outcome measure. RESULTS: There was a significant difference in operative time between the Fisch-type prosthesis and the SMart piston prosthesis groups. The operation required 28.9 ± 3.2 minutes when using the Fisch-type prosthesis, whereas 21.2 ± 2.4 minutes were needed when using the SMart piston (p < .001). There was a significant improvement in postoperative ABG for both the Fisch-type piston (28.1 ± 3.1 to 9.0 ± 1.4, p < .001) and the SMart piston (25.1 ± 3.7 to 8.2 ± 2.5, p < .001) groups. CONCLUSIONS: Use of the SMart piston prosthesis results in ABG closure similar to that of the traditional Fisch-type prosthesis but offers the added advantage of reduced operative time.

Effect of intraoperative injection of 0.25% bupivacaine with 1:200,000 epinephrine on intraoperative blood loss in FESS.

BACKGROUND: This study was designed to compare differences in intraoperative blood loss, mean arterial blood pressure (MABP), and duration of surgery when 0.25% bupivacaine with 1:200000 epinephrine is injected, preoperatively, versus normal saline (NS), during functional endoscopic sinus surgery (FESS). METHODS: A prospective, double-blind randomized placebo-controlled study was performed. Part I involved 46 patients who were infiltrated with 0.25% bupivacaine with 1:200000 epinephrine on one side of the nose and sterile NS on the other (control). Part II involved 30 patients infiltrated with 0.25% bupivacaine with 1:200000 epinephrine bilaterally and 30 patients with NS bilaterally (control). Patient demographics, preoperative MABP, intraoperative MABP, duration of surgery, and total estimated blood loss (EBL) were recorded for each side (Part I) and case (Part II). RESULTS: For part I, there were 46 patients (mean age, 49 years), 24 women and 22 men. MABP was 72 mmHg for each side (p = 0.97). Preoperative MABP was 93 mmHg. Duration of surgery was 48 minutes for epinephrine side and 45 minutes for control (p = 0.17). Total EBL was 185 mL for the epinephrine side and 197 mL for control (p = 0.53). For Part II, there were 60 patients (mean age, 56 years), 28 women and 32 men. The MABP was 77 mmHg for the epinephrine group and 72 mmHg for control (p = 0.048). Preoperative MABP was 100 mmHg for the epinephrine group and 97 mmHg for control (p = 0.37). Duration of surgery was 2.25 hours for the epinephrine group and 2.08 hours for control (p = 0.17). Total EBL was 589 mL for the epinephrine group and 538 mL for control (p = 0.64). CONCLUSION: There was no significant reduction in intraoperative blood loss during FESS when local anesthetic containing epinephrine was used compared with infiltration with NS. More importantly, Part II shows a significantly higher MABP associated with infiltration of epinephrine. Parts I and II did not show a significant difference in preoperative MABP or duration of surgery.