Klebsiella oxytoca Endocarditis With Complete Heart Block.

Gram-negative bacterial endocarditis causes 5% of all bacterial endocarditis. Among gram-negative bacteria, Klebsiella species are rare causes of native valve endocarditis. Klebsiella oxytoca is an extremely rare subspecies that can infrequently cause endocarditis and is associated with poor outcome. We report a case of Klebsiella oxytoca endocarditis in an elderly man who initially presented with stroke but later developed sepsis and heart block secondary to endocarditis.

A simple solution to a complex position in cleft surgery.

Correct positioning of the surgeon and patient in palate surgery is a problem often faced by the craniofacial surgeon. To achieve the best result, it is essential that the surgeon has direct visualization and sufficient access to the field. We describe a simple solution to this complex problem, which has been used by Dr. Ian Jackson for the last 20 years. We believe the Jackson method of positioning offers good visualization of both anterior and posterior parts of the palate, while minimizing the strain associated with neck extension during conventional positioning in cleft surgery.

Endotracheal tube fixation methods for optimal stability: a comparison of adhesive tape, suture, and tape-suture fixation.

Accidental extubation of an intubated patient is a serious consideration in the surgical patient. Adequate fixation in the intubated patient is essential to prevent potentially life-threatening complications. Several methods of endotracheal tube fixation have been described in the literature. In this study, we examine 3 common methods of fixation: adhesive tape alone, suture, and tape-suture. Testing occurred in a laboratory setting with 2 fresh cadavers. Endotracheal tubes were inserted, using the methods of fixation in question. We subjected each fixation technique to progressively increasing weight to determine which technique is most resistant to accidental removal. We found that fixation of the tube by combining tape around the tube with a suture through the tape is the best noninvasive technique of the 3 methods evaluated in cases where movement of the head is anticipated.

Occipital artery island V-Y advancement flap for reconstruction of posterior scalp defects.

BACKGROUND: The management of the posterior scalp defects with 'similar' tissue can be challenging. Currently available techniques of transposition/rotation result in creation of unwanted dog ears, change in direction of hairs and patches of skin-grafted areas with alopecia. We describe a new method of reconstruction of full-thickness scalp defects in the occipital region by moving the locally available scalp tissue in a V-Y advancement manner. The islanded flap is based upon the ipsilateral occipital artery in the substance of occipitalis muscle. The donor site/s can be closed primarily and the operation performed in a single stage MATERIALS AND METHODS: A total of seven patients have undergone reconstruction in the last 2 years with this technique. The defects in the posterior scalp region resulted either from the electrical burns (two patients), tumour excision (two patients), encephalocoele excision (one patient) or post-traumatic loss of the scalp (two patients). In all the patients the underlying bone was exposed. The remaining scalp tissue in the vicinity of the defect was moved as a V-Y advancement flap either unilaterally or bilaterally depending upon the size of the defect. The pedicle of the flaps contained ipsilateral occipital vessels at the base. The flaps were raised in the subgaleal plane and the pedicle included ipsilateral occipital artery in the substance of the occipitalis muscle. RESULTS: The donor area could be closed primarily in all cases. All the flaps survived completely; one patient had postoperative superficial loss that eventually healed with dressings. All the wounds healed primarily with luxuriant hair growth, except one patient who had partial alopecia in the transferred flap although the flap survived completely. CONCLUSION: The islanded occipital artery V-Y advancement flap provides a one-stage hair-bearing scalp tissue for closure of medium and moderately large defects (up to 7 x 6.5 cm(2)) in the posterior region of the scalp with primary closure of the donor site.

Delayed buccal fat pad herniation: An unusual complication of buccal flap in cleft surgery.

Buccal musculomucosal flap is commonly used in cleft palate surgery for providing additional lining when nasal mucosa is inadequate. We report an unusual complication of progressively increasing fat herniation from the sutured donor site which started appearing on the third postoperative day. This necessitated excision of the protruding fat pad on the seventh postoperative day. The possible mechanism and precautions for prevention of this complication are discussed.

Lateral approach to the levator veli palatini: a preliminary report.

The abnormal anatomy in the cleft palate has been of interest to surgeons for a long time. Different authors have independently evolved the techniques of radical reconstruction of the palatal musculature and have suggested the medial approach to dissect the levator. We hereby report the technique in which the levator is identified through the lateral incision of the soft palate. This lateral approach helps in the complete release of the levator from all abnormal attachments and ensures reconstruction of an effective sling. This technique is of particular benefit in a palate re-repair.

End-of-skin grafts in syndactyly release: description of a new flap for web space resurfacing and primary closure of finger defects.

Treatment of syndactyly necessitates creation of neo-web space and separation of fingers. Traditionally, this has been done by use of flaps taken from the dorsum; the resultant raw areas thus created have been managed by use of skin grafts. The classical teaching has been that the separated fingers will need skin graft as primary closure is not possible. The skin grafts have a tendency to contract and lead to finger flexion contractures and "creep" of the web space. We describe a flap based upon subcutaneous tissue in the web that is moved in a V-Y fashion to resurface the neo-web. The flap donor site can easily be closed primarily. The fingers are then separated; the subcutaneous fat is carefully removed from the finger flaps under magnification to allow primary closure of the finger defects. It has been possible to primarily close the donor site and fingers in all the patients. The procedure has been used in seven patients with 14 web releases. The age varied between 10 months to 3 years. The V-Y advancement flap based upon the subcutaneous pedicle in the region of the web allows adequate creation of a new web space. The careful de-fattening of skin flaps allows the separated fingers to be closed primarily.

Submental tracheal intubation in oromaxillofacial surgery.

BACKGROUND: Oromaxillofacial surgical procedures present a unique set of problems both for the surgeon and for the anesthesist. Achieving dental occlusion is one of the fundamental aims of most oromaxillofacial procedures. Oral intubation precludes this surgical prerequisite of checking dental occlusion. Having the tube in the field of surgery is often disturbing for the surgeon too, especially in the patient for whom skull base surgery is planned. Nasotracheal intubation is usually contraindicated in the presence of nasal bone fractures seen either in isolation or as a component of Le Fort fractures. We utilized submental endotracheal intubation in such situations and the experience has been very satisfying. MATERIALS AND METHODS: The technique has been used in 20 patients with maxillofacial injuries and those requiring Le Fort I approach with or without maxillary swing for skull base tumors. Initial oral intubation is done with a flexo-metallic tube. A small 1.5 cm incision is given in the submental region and a blunt tunnel is created in the floor of the mouth staying close to the lingual surface of mandible and a small opening is made in the mucosa. The tracheal end of tube is stabilized with Magil's forceps, and the proximal end is brought out through submental incision by using a blunt hemostat taking care not to injure the pilot balloon. At the end of procedure extubation is done through submental location only. RESULTS: The technique of submental intubation was used in a series of twenty patients from January 2005 to date. There were fifteen male patients and five female patients with a mean age of twenty seven years (range 10 to 52). Seven patients had Le Fort I osteotomy as part of the approach for skull base surgery. Twelve patients had midfacial fractures at the Le Fort II level, of which 8 patients in addition had naso-ethomoidal fractures and 10 patients an associated fracture mandible. Twelve patients were extubated in the theatre. Eight patients had delayed extubation in the post-operative ward between 1 and 3 days postoperatively. CONCLUSION: In conclusion, the submental intubation technique has proved to be a simple solution for many a difficult problem one would encounter during oromaxillofacial surgical procedures. It provides a safe and reliable route for the endotracheal tube during intubation while staying clear of the surgical field and permitting the checking of the dental occlusion, all without causing any significant morbidity for the patient. Its usefulness both in the emergency setting and for elective procedures has been proved. The simplicity of the technique with no specialized equipment or technical expertise required makes it especially advantageous. This technique therefore, when used in appropriate cases, allows both the surgeon and the anesthetist deliver a better quality of patient care.