Acute Onset of Delayed Facial Nerve Paralysis After an Uncomplicated Total Parotidectomy for an Oncocytoma.

Facial nerve injury is one of the most substantial potential sequelae of parotid surgery. Pulling, stretching, and otherwise disturbing the facial nerve during parotid surgery can lead to post-surgical neural paresis and consequential deficits in facial movement. Furthermore, transection of the main facial nerve trunk or its branches, either purposeful or incidental, can lead to complete paralysis of the related facial musculature. Facial nerve injury is often diagnosed immediately post-operatively as evident by deficits in ipsilateral facial motion on examination of the patient in the recovery unit or, at most, by one week post-operatively. Although delayed onset facial nerve paralysis is seen in traumatic injury and otologic surgery, it is uncommon that facial nerve paralysis presents late after parotid surgery in the absence of hematoma development, viral reactivation, or secondary insult. Here, we present the case of a 70-year-old man developing a delayed acute onset of hemi-facial paralysis 12 days after right-sided total parotidectomy for an oncocytoma; a facial nerve examination done immediately post-operatively and at the one-week post-operative follow-up was found to be normal. The patient was treated with two courses of high-dose oral steroids with close-to-complete resolution.

Use of Flow-Volume Loops on a Mechanically Ventilated Pediatric Patient as a Diagnostic Tool for Fixed Airway Obstruction.

The flow-volume loop (FV-loop) provides a graphical representation of the inspiratory and expiratory flow of both mechanically provided breaths and patient-triggered breaths during invasive mechanical ventilation. The FV-loop on the ventilator-delivered breath displays the active inspiratory flow reflective of lung compliance and the passive expiratory flow reflective of airway resistance. Our case report highlights the importance of the FV-loop in determining a fixed airway obstruction. A five-month-old male presented to the emergency department with worsening respiratory distress in the setting of rhino-enterovirus. He was admitted to the pediatric intensive care unit (PICU) and intubated for acute hypoxic respiratory failure. The findings on his ventilator FV-loop graphics denoted a fixed airway obstruction, as seen by the truncation of inspiratory and expiratory flow. The patient was subsequently found to have a left pulmonary artery (LPA) sling with a vascular ring and several complete tracheal rings. He was transferred to a referral institution for operative management, returned to our PICU, and discharged home after 47 days of hospital management. During mechanical ventilation, FV-loops can be effectively utilized to assist in the diagnosis of fixed intra- or extra-thoracic airway obstructions.