Lee D. Rowe

Complications of Intubation

Endotracheal intubation with current inert low-pressure, high-volume cuffed tubes is a safe procedure associated with few complications in the vast majority of patients. However, complications related to mechanical difficulties and mucosal injury can occur even under ideal circumstances. Immediate complications are primarily associated with problems during intubation and extubation while early and late complications represent the short- and long-term effects of epithelial trauma.

Neonatal Airway Obstruction Secondary to Nasopharyngeal Teratoma

Neoplasms of the nasopharynx are rare in neonates and infants. The most common nasopharyngeal tumors encountered in this age group are teratomata—neoplasms containing multiple heterotopic tissues. Of the four basic histologic types, dermoids are most frequently seen. An unusual case of a true teratoma in a premature infant with severe upper airway obstruction is presented. An extensive review of the world literature confirms the rarity of this lesion.

Upper Airway Obstruction in Infectious Mononucleosis

Life-threatening upper respiratory obstruction is an unusual complication of infectious mononucleosis. Although the majority of fatalities result from progressive bulbar paralysis or the Guillain-Barré syndrome, airway impairment primarily occurs as a result of pharyngeal lymphoid hyperplasia and associated faucial arch edema. Recent experience in a young child with infectious mononucleosis who exhibited progressive hypersomnolence, sleep apnea, and stridor during sleep is presented. In addition, a retrospective analysis of 72 cases of respiratory complications of infectious mononucleosis provides guidelines for specific airway management. Mild upper respiratory obstruction with persistent fever, severe odynophagia, and malaise is treated with parenteral corticosteroids. Immediate tonsillectomy using a halothane and oxygen induction technique is recommended for severe airway occlusion. Tracheotomy is currently reserved for those patients with progressive alveolar hypoventilation, hypercarbia, atelectasis, and bulbar paralysis. In general, tonsillectomy is well-tolerated, eliminating airway obstruction, improving swallowing function, and rapidly resolving pharyngeal discomfort.

Progressive Neonatal Airway Obstruction Secondary to Cervical Thymic Cyst

Cervical thymic cysts are extremely unusual neoplasms that only rarely produce signs and symptoms of upper airway tract compromise. Less than 7% of patients initially have dyspnea or hoarseness. We report the first known case of progressive neonatal airway obstruction secondary to a rapidly enlarging cervical thymic cyst. Because one half of these benign tumors may demonstrate mediastinal extension, computed axial tomography or B-mode ultrasonography or both is recommended prior to surgical excision. Review of the literature confirms that the majority are successfully removed via a transcervical approach without recurrence.

Evaluation and Treatment of Frontal Sinus Fractures

We treated twenty-three patients with blunt or penetrating wounds of the frontal sinus from 1978 through 1983. Nondisplaced anterior wall fractures were observed or explored. Posterior table fractures—with displacement confirmed by computed tomography or polycycloidal tomography—were explored. Either obliteration of the sinus or nasofrontal duct reconstruction with a Sewall-Boyden-McKnaught flap was selected, depending on the magnitude of duct injury. In all cases, the anterior wall was primarily reconstructed. All penetrating wounds with posterior table involvement were treated by cranialization of the frontal sinus and temporalis muscle obliteration of the nasofrontal ducts. Only one case of meningitis occurred, resulting in prolonged hospitalization.

Continuous measurements of skin surface oxygen and carbon dioxide tensions in obstructive sleep apnea

We have found that skin surface electrodes for continuously measuring oxygen (PHO2) and carbon dioxide (PBCO2) tensions provide reliable means of determining whether infants with apnea due to airway obstruction during sleep require treatment.

Transbronchial drainage of pulmonary abscesses with the flexible fiberoptic bronchoscope

Flexible fiberoptic bronchoscopy with multiplanar flouroscopic control is shown to be effective in the transbronchial drainage of pulmonary abscesses. A new technique which permits the intracavitary placement of brush forceps and fine arterial catheters is described. This has facilitated the rapid defervescence of fever and established immediate endobronchial drainage. Seventy percent of patients had complete radiographic closure of their abscess cavities at three months. Clinical findings are presented and the role of aspiration in pathogenesis of pulmonary abscess is stressed.

Adaptation in the Function of Pharyngeal Constrictor Muscles

The palatopharyngeus and pharyngeal constrictor muscles were studied by electromyography (EMG) and by direct observation with a flexible fiberoptic scope in the anesthetized as well as in the alert rhesus monkey. The muscles were monitored to determine the change in their discharge with nasal obstruction, head posture, head extension, and swallowing. The results indicated that certain regions of the middle and inferior pharyngeal constrictors never discharged during deglutition. Extending the head could induce a tonic discharge in fibers of the middle pharyngeal constrictor for the duration of head extension. Placement of water in the hypopharynx not only induced a sustained laryngospasm but also a tonic discharge in the select fibers of the superior and middle pharyngeal constrictors. Changing from a supine to an upright posture, or obstructing the nasal cavity, could induce a rhythmic discharge. These studies indicate that there are functional components of fibers within each of the anatomically recognized pharyngeal constrictors.

Spatial Analysis of Midfacial Fractures with Multidirectional and Computed Tomography: Clinicopathologic Correlates in 44 Cases

The use of conventional tomography and recent application of computed tomography to the assessment of facial injuries permit a more precise preoperative spatial analysis of complex midfacial fractures. Forty-four patients sustaining Le Fort I, II, or III maxillary fractures underwent multidirectional or computed tomography (CT) or both. The patterns of fractures of the maxilla and associated fractures of the mandible, zygomas, nasoethmoidal complex, frontal sinus, skull base, and cranial vault were correlated with surgical or clinical findings or both. In 91% of cases, CT or multidirectional tomography or both correctly identified the spatial pattern of fracture of the maxilla and its supporting pillars. Pure Le Fort II fractures were seen in only nine patients, while an isolated pure Le Fort I or III fracture was not encountered. Le Fort II and III fractures were commonly associated with additional tripod, frontal sinus, or nasoethmoidal complex dislocations.

Computerized Axial Tomography in Inflammatory Pseudotumor of the Orbit

Although thyrotoxicosis and orbital complications of acute ethmoid or frontal sinusitis are among the most common causes of unilateral exophthalmos, inflammatory pseudotumor is frequently accompanied by progressive acute unilateral proptosis. Because the associated chemosis, scleral erythema, and ophthalmoplegia constitute a spectrum of clinical findings present in numerous inflammatory orbital disorders and systemic diseases, the diagnosis of inflammatory pseudotumor is one of exclusion, often requiring orbital biopsy. Four patients without evidence of sinusitis, endocrinopathy, collagen vascular disease, or Wegeners granulomatosis are described. The diagnosis of orbital pseudotumor was disclosed by computed axial tomography, thus avoiding orbitotomy. The finding of scleral and choroidal thickening with enhancement following intravenous contrast injection represents a select group of patients with orbital pseudotumor and differentiates them from patients with endocrine exophthalmopathy or neoplasms. This noninvasive technique is extremely valuable because early diagnosis is critical for successful treatment. All four patients responded dramatically to high-dose corticosteroid therapy. In the absence of significant clinical response, however, Wegeners granulomatosis, lymphoma, and rhabdomyosarcoma, especially in younger patients, must be carefully excluded. Orbital exploration or decompression or both are used when proptosis, headache, or orbital pain does not resolve promptly, visual acuity deteriorates, or the diagnosis remains unknown.