The effect of head rotation on the diameter of the internal jugular vein: implications for free tissue transfer.

PURPOSE: To determine the effects of medial (inwards) and lateral (outwards) rotation of the head on the transverse diameter of the internal jugular vein. MATERIAL: The original study sample included 26 patients. Duplex ultrasound was used to measure the transverse diameter of the internal jugular vein at a fixed point on either side of the neck. Measurements were taken with the head central (neutral position), rotated laterally and medially. RESULTS: Using Student's t-test we found that lateral rotation of the head produced a reduction in the mean of the transverse diameters of the left and right ipsilateral vein from 6.9 mm to 5.4 mm (p < 0.03) and 5.9 mm to 5.0 mm (p = 0.2173) respectively. One patient excluded from the study because of previous neck surgery showed complete occlusion of the ipsilateral internal jugular vein on lateral rotation of the head. CONCLUSION: There is a possibility that patency of the vein could be compromised if the head is turned laterally. This situation may arise immediately after surgery in the ventilated and paralysed patient when the head may be unsupported. It could be of particular importance if the vein has been used as a recipient vein for free tissue transfer.

Percutaneous dilatational tracheostomy: haemorrhagic complications and the vascular anatomy of the anterior neck. A review based on 497 cases.

In a series of 497 PDT procedures done in the intensive therapy unit at Morriston Hospital between 1992 and 1999, PDT was abandoned because of bleeding in 6 patients and was noted to be a problem in a further 18 cases (overall incidence 4.8%). In all cases, haemorrhage was successfully arrested. Surgical tracheostomy was necessary in 6 of these 24 cases. The source of bleeding in 4 of these patients was attributed to the inferior thyroid vein (2 cases), high brachiocephalic vein, and possibly an aberrant anterior jugular communicating vein, respectively. In one patient, the vessel presumed injured could not be identified and in another patient, bleeding was related to multi-system disease. We conclude that the risk of bleeding, although low, can be minimised if the operator maintains a high index of suspicion for aberrant vascular anatomy and investigates possible abnormalities with diagnostic ultrasound. Injury to vessels low in the neck can be reduced by not fully extending the neck and siting the stoma at the upper tracheal rings. The possibility of developing a tracheoarterial fistula is reduced if the stoma is situated above the 4th tracheal ring and fibreoptic endoscopy is used to confirm correct tracheostomy tube placement.

Evaluating the neck for percutaneous dilatational tracheostomy.

PURPOSE: The aims of this article are to study how variations in the anatomy of the neck may influence the success of percutaneous dilatational tracheostomy (PDT). PATIENTS AND METHODS: Four hundred and ninety-seven patients were included in this study. Patients with a short neck and altered tracheal anatomy were evaluated on the basis of difficulty with PDT, use of long shank tracheostomy tubes, and need for open surgical tracheostomy. RESULTS: 33 (6.6%) patients had an apparently reduced cricoid ring to sternum distance and a deeply lying trachea. Nine of these patients were referred for open surgical tracheostomy. A further five patients had altered tracheal anatomy secondary to disease or surgery. Two of these patients were also referred for open surgical tracheostomy. Thus, unfavourable neck anatomy was responsible for 2.2% (11/497) of patients being referred for open surgical tracheostomy. CONCLUSION: Variations in the anatomy of the neck can make PDT both difficult and hazardous. Patients with a deeply lying trachea may need a long shank tube. Open surgical tracheostomy is indicated in some patients with a deeply lying trachea and conditions producing secondary deformity of the trachea. All patients should have a detailed history and thorough clinical examination of the neck and thorax prior to PDT. The selective use of chest radiography, MRI, and ultrasound assessment prior to PDT can assist in the identification of patients unsuitable for this technique.

Percutaneous dilatational tracheostomy under ultrasound guidance.

Diagnostic ultrasound may be used to assess the suitability of patients for percutaneous dilatational tracheostomy (PDT) in the intensive care unit (ICU). It may identify patients unsuitable for PDT, prevent puncture of aberrant vessels, estimate the distance from the surface of the skin to the trachea, and ensure accurate placement of the needle in the trachea. We conclude that diagnostic ultrasound permits careful evaluation of patients for whom PDT is being considered, and adds to the safety of the procedure.

Orbital emphysema and the medial orbital wall: a review of the literature with particular reference to that associated with indirect trauma and possible blindness.

Orbital emphysema is not an uncommon finding following fractures of the facial skeleton. Both its significance as a threat to sight and its diagnostic value may well be underestimated. Fractures of the paranasal sinuses may occur as a result of indirect trauma. This article reviews the literature on the subject with particular reference to blindness as a possible sequel. Two cases of orbital wall fracture that occurred as a result of indirect trauma and which produced orbital emphysema are discussed.