Noah A Sandler

Correlation of inflammatory cytokines with arthroscopic findings in patients with temporomandibular joint internal derangements

PURPOSE The goal of this study was to evaluate the presence of the inflammatory cytokines interleukin-1 beta (IL-1 beta), interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-alpha) within the superior temporomandibular joint (TMJ) space in patients with internal derangements and to compare these values with the pathologic findings seen arthroscopically. PATIENTS AND METHODS Thirty patients with symptomatic TMJ dysfunction and clinical and imaging evidence of internal derangements of the TMJ were evaluated. Before entering the superior joint space with the arthroscope, 2 mL sterile saline was injected and, after 30 seconds of equilibration, was aspirated for analysis. The surgeon then performed diagnostic arthroscopy. The degree of synovitis, degeneration, percent condylar roofing, and any pathologic changes, such as perforations, were recorded. The level of total protein in each sample was ascertained, as well as the levels of IL-1 beta, IL-6, and TNF-alpha. RESULTS Of 30 samples tested, three were discarded because of failure to gain access into the superior joint space. Of the 27 remaining samples, IL-6 showed the closest correlation with the level of acute synovitis demonstrated arthroscopically. Two of the higher IL-6 levels (167 and 324 pg/microg protein) were seen with patients with a significant disc perforation. In patients with a high degree of vascularity, IL-6 was found to be between 0 to 581 pg/microg protein with an average of 80 pg/microg protein and a median value of 43 pg/mg. These values significantly correlated with the degree of vascularity (P < or = .02). This is in comparison with the 10 remaining patients, who showed significantly fewer vascular changes arthroscopically. In these patients, the range of IL-6 was 0 to 35 pg/microg protein, with an average of 19 pg/microg protein and a median value of 14.5 pg/microg. These values significantly correlated with the smaller degree of vascularity (P < or = .02). In seven patients, the role of nonsteroidal antiinflammatory drug (NSAID) use resulted in decreased levels of IL-6, which has been noted in previous studies. In patients with higher rated redundancy of the synovial tissue, the average IL-6 level was 92 pg/microg protein, whereas the median value was 44 pg/microg protein. In patients with little or no redundant synovial tissue, an average IL-6 level of 22 pg/microg protein was present. The median value in these same joints was 15 pg/microg protein. These IL-6 values significantly correlated with the degree of redundancy (P < or = .03). The degree of degenerative change (chondromalacia, fibrillation), disc displacement (roofing), and the presence or absence of adhesions did not significantly affect the levels of IL-6 within the patients studied. The presence of IL-1 beta and TNF-alpha was not found to correlate with the arthroscopic findings in the superior joint space. CONCLUSIONS The presence of IL-6 correlated with the degree of acute synovitis. IL-1 beta and TNF-alpha were not found in significant levels within the superior joint space. These findings correlated with those reported by other investigators. The production of IL-6 by synovial cells and its role in TMJ disease warrants further investigation.

The use of bispectral analysis in patients undergoing intravenous sedation for third molar extractions

PURPOSE The bispectral (BIS) index has been used to interpret electroencephalogram (EEG) recordings to predict the level of sedation and loss of consciousness in patients undergoing general anesthesia. It was the purpose of this project to assess the usefulness of BIS technology in determining the level of sedation in patients undergoing third molar extraction under conscious sedation. PATIENTS AND METHODS Twenty-five subjects undergoing third molar extraction in an outpatient setting were analyzed. The EEG activity was recorded continually during surgery using a microcomputer (Aspect-1050 Monitor; Aspect Co, Natick, MA) with real-time bispectral data obtained by EEG skin electrodes through a frontotemporal montage. The Observers Assessment of Alertness and Sedation (OAA/S) scale was used to subjectively assess the level of sedation observed by the anesthetist before initiating the sedation procedure and then at 5-minute intervals until the end of the procedure. The BIS level was simultaneously recorded. The initial sedation was accomplished using a standard dose of midazolam (0.05 mg/kg) and fentanyl (1.5 microg/kg) followed by a 10- to 30-mg bolus of propofol until a level of sedation at which the patients eyes were closed and he or she was responsive only to vigorous stimulation or repeated loud calling of their name (OAA/S level of 1 to 2). Local anesthesia was then administered. Additional doses of sedative medication (midazolam or propofol) were given during the procedure to maintain the desired level of sedation (an OAA/S level of 2 to 3). The time and dose of the drug given were recorded. The level of sedation based on a single anesthetists interpretation (OAA/S) and the BIS readings were then compared. RESULTS A strong positive relationship between the BIS index and OAA/S readings was found (P < .0001). Pairwise comparisons of mean BIS index and its corresponding OAA/S level were significantly different from each other (P < .003) except for OAA/S levels 2 and 3 (P = .367). CONCLUSION BIS technology offers an objective, ordinal means of assessing the depth of sedation. There was a strong relationship between the objective BIS values and subjective assessment (OAA/S scale) of the depth of anesthesia. This can be invaluable in providing an objective assessment of sedation in oral and maxillofacial surgery where it may be difficult to determine the level of sedation clinically.

Advances in the management of acute and chronic sinusitis.

In recent years, the approach to the patient presenting with symptoms or imaging findings of sinusitis has changed markedly. Alteration in management has occurred not only as a result of advances in diagnosis and treatment, but also because of changes in the microbiology of the disease. Diagnostic advances include the use of computed tomography (CT) imaging as well as antral endoscopy. Treatment alternatives include conservative means using antibiotics, decongestants, and occasionally intranasal vasoconstrictors, or more aggressive measures such as antral aspiration and irrigation with or without nasal antrostomy. The development of resistant bacterial species has altered the recommended firstand second-line therapies used in treating these infections. In addition, the cause, the sinus involved, the setting of the treatment (ie, outpatient versus inpatient), and the chronicity of the condition all affect treatment. Each of these areas is addressed.

Intracranial reduction of an intact mandibular condyle displaced into the middle cranial fossa

Although displacement of the condyle intracranially is a relatively rare event, 1 this type of injury should be suspected when there is a history of the following : 1) severe trauma to the chin ; 2) limitation of opening ; 3) inability to close into occlusion ; 4) deviation of the chin toward the side of the suspected injury ; 5) occlusion only on the side of the suspected injury ; 6) cerebrospinal fluid (CSF) leak from the ear of the involved side ; 7) difficulty in interpreting condylar position on plain radiographs.6 The rarity of this injury, compared with subcondylar fractures, is related to the anatomy of the condylar neck, which is relatively weak compared with the rather dense posterior slope of the mandibular fossa. 2 Predisposing factors include : a thin condylar neck, 3 increased pneumatization of the temporal bone, lack of posterior teeth, or an open mouth position on impact. 4,5 Neurologic signs such as loss of consciousness, nausea, evidence of CSF leak, paresis of facial muscles, or deafness may indicate intracranial violation with resultant injury or edema. 6 Because of fibers from the inferior retina passing along the geniculocalcarine tract (Meyers loop) within the temporal lobe, a contralateral superior quadrantanopsia may ensue. Damage to vascular structures may cause a temporal lobe hematoma, resulting in clinical symptoms of lethargy, restlessness, or combativeness soon after the initial injury. Within a few hours of the formation of the hepatoma, focal neurologic signs may develop. These usually begin with weakness in the face and progress to hemiparesis by about the third day. Pupillary dilitation occurs late in the clinical course of an expanding hematoma. 7 It is recommended that patients undergo a computed tomography (CT) scan of the head and a neurosurgical consult be obtained in a case when there is clinical suspicion of intracranial injury.

The use of maxillary sinus endoscopy in the diagnosis of orbital floor fractures

PURPOSE The goal of the current study was to evaluate the ability to diagnose the presence of an inferior orbital wall fracture through the use of a transantral endoscopy technique at bedside. PATIENTS AND METHODS Seven trauma patients with initial axial computed tomography (CT) scan findings consistent with an orbital floor fracture were studied. Before endoscopy, the patients underwent a coronal CT scan with 3-mm cuts for later comparison with the endoscopic findings. The surgeon performing the endoscopy procedure was blinded to the results of the coronal CT scan. Visual acuity, intraocular pressure, and measurement for enophthalmos were performed before endoscopy. The endoscopic procedure was performed at the bedside using local anesthesia. A trocar was used in the canine fossa to gain access to the maxillary sinus. A 30 degrees and then a 70 degrees endoscope were introduced through the trocar to evaluate the integrity of the orbital floor (ie, maxillary sinus roof). The degree of mucosal injury of the orbital floor and the presence of blood or orbital contents in the sinus were recorded. The ophthalmologic examination was repeated after completion of endoscopy. RESULTS The endoscopic procedure was able to be completed in all patients. There was no change in the ophthalmologic examination in any patient as a result of endoscopy. In six of the seven patients studied, the endoscopic findings correlated with the need for surgical intervention to repair the orbital floor predicted on the basis of coronal CT scan. This was determined by the degree of injury to the orbital floor and the presence of hematoma, exposed bone, or fat. In the remaining case, endoscopy was not diagnostic for the presence of a fracture because only ecchymosis of the orbital floor was noted. CONCLUSIONS The ability to perform endoscopy under local anesthesia at the bedside is useful in those trauma patients whose concomitant injuries may prohibit other diagnostic modalities.

Comparison of propofol and methohexital continuous infusion techniques for conscious sedation.

PURPOSE Methohexital and propofol have been shown to be effective agents for continuous intravenous infusion to produce conscious sedation during oral surgical procedures. The current study was conducted to compare these techniques for intraoperative cardiopulmonary stability, patient cooperation, amnesia, comfort, recovery time, and postoperative nausea and vomiting. METHODS Seventy ASA Class I or Class II patients between the ages of 18 and 40 years, scheduled for surgical extraction of impacted third molars, were entered into the study. Thirty-five patients were assigned to group A (methohexital) and 35 were assigned to group B (propofol). Intravenous sedation was accomplished using premedication with 1.5 microg/kg of fentanyl and 0.05 mg/kg of midazolam followed by the continuous infusion of methohexital or propofol at a rate of 50 microg/kg/min. The infusion was then titrated to 100 microg/kg/min to accomplish a level of sedation in which the eyes were closed and the patients were responsive to verbal commands. Subjects were monitored for variability of heart rate, blood pressure, oxygen saturation, amnesia, comfort, cooperation, nausea and vomiting, and recovery time based on cognitive, perceptual, and psychomotor tests. RESULTS There was no statistical difference between the two medication groups except for heart rate, which was found to increase by 11 beats/min for group A and only three beats/min in group B. CONCLUSION A continuous infusion technique using either methohexital or propofol (50 to 100 microg/kg/min) was found to be safe and effective, with no clinically significant differences in cooperation, cardiopulmonary stability, recovery time, amnesia, comfort, and the incidence of nausea or vomiting. However, the cost-effectiveness of methohexital is superior to that of propofol.

Economic analysis and its application to oral and maxillofacial surgery

PURPOSE Recent clinical publications have increasingly emphasized comparison of cost with benefits in such areas such as drug therapies, surgical procedures, and prophylaxis regimes within certain populations. In the past, cost analysis was based principally on the comparative market price of new treatment compared with standard therapy. Benefits were assessed solely in terms of objective clinical and imaging improvement. Now, issues such as quality of life, early return to occupation, and subjective symptoms of pain and discomfort caused by a treatment are also being critically evaluated. Addressing these latter issues, however, is often complicated and expensive. This article reviews some terms and principles of cost analysis, cost effectiveness, and cost-benefit analysis. Examples are given of recent attempts to quantify costs and benefits for individuals, hospitals, health organizations, and society as a whole. Guidelines are suggested concerning how these studies can be applied to oral and maxillofacial surgery.