Rk Sharma

Text book of Oral and Maxillofacial Surgery

This book presents a detailed and authoritative exposition of basic principles of Oral and Maxillofacial Surgery. From basic oral surgical procedures encountered by general practitioner to advance and complex surgical procedures that need to be referred to oral and maxillofacial surgery specialists, all are covered in sufficient detail with judicious mix of text and illustrations. The features includes exodontia, dental implantology, management of medical emergencies, medicolegal consideration in oral surgery. It covers recent advances on alloplastic materials, bioresorbable plates, distraction osteogenesis, lasers in dentistry, peizoelectric surgery. Complete coverage of all important topics from examination point of view for both undergraduates and postgraduate students is included. Case photographsillustrate the concepts and help the in grasping their significance, Practical and pictographic approach to explanation of surgical procedures provide an edge over the conventional method of learning. Colour illustrations, photographs, pathological pictures, flow charts, boxes and tables are profusely used throughout the text to make relevant clinical situations self explanatory. The emphasis is laid upon the language that is simple, understandable and exclusively designed for the students whilst maintaining its international standards. This book is a must for undergraduate and postgraduate dental students and will prove to be useful for general practitioners also.

Retrospective Study on Efficacy of Intermaxillary Fixation Screws

BACKGROUND We evaluated the efficacy of intermaxillary fixation (IMF) screws in the treatment of mandibular fractures. METHODS Two hundred patients with mandibular fractures, treated by IMF using these screws, were evaluated by pre and postoperative panoramic radiographs. Clinical testing was carried out for vitality and abnormal mobility of teeth adjacent to the site of screw insertions. Other factors such as possible iatrogenic dental injuries, loss, breakage or screw cover by oral mucosa and postoperative occlusion were also studied. RESULT The most important complication noticed was iatrogenic damage to dental roots. CONCLUSION Use of intraoral cortical bone screws for IMF is a valid alternative to arch bars in the treatment of mandibular fractures. Iatrogenic injury to dental roots is the commonest problem which can be minimized by an experienced surgeon.

Ultrasound Guided Central Venous Cannulation

Central venous cannulation is routinely performed in operation theatres and intensive care units. The requirement of catheter in central vein is increasing as large numbers of extensive surgical procedures are being undertaken. In USA approximately 5 million central venous catheters are inserted annually [1]. Any patient staying for more than few days in the intensive care units invariably needs central venous catheter for the purpose of central venous pressure monitoring, vasopressor infusion, parenteral nutrition, or haemodialysis. Routinely, central venous catheters are inserted percutaneously as a blind procedure using anatomical landmarks. Due to underlying anatomical variations this may result in multiple punctures and injury to nearby arteries, nerves, and pleura. Life-threatening complications like pneumothorax and arterial bleeding are known to occur. Mechanical complications are reported to occur in 5 to 19% of patients [2]. In 1984, two-dimensional ultrasound and Doppler techniques were first reported for internal jugular vein (IJV) cannulation. The recent development of portable lightweight ultrasound machines designed specifically for central venous cannulations has made them practical for routine clinical use. The needle can now be inserted under ultra sound guidance, making the procedure extremely safe.

Cold Injuries : The Chill Within.

Cold injuries have had profound effects upon the fighting force and military operations throughout history[1] including our own military experiences from the highest battlefield in the world, Siachen. Cold injuries are as preventable as heat injuries and require the medical services to work closely with the tactical commanders to implement effective prevention strategies[2]. The initial treatment offered by the Regimental Medical Officer (RMO) is crucial to the final outcome. This article attempts to review the various types of cold injuries and identify prevention and treatment strategies. Cold injuries are divided into freezing and nonfreezing injuries (occur with ambient temperature above freezing). They include hypothermia, frostnip, chilblains, immersion foot and frostbite. Exposure to cold can induce Raynauds disease, Raynauds phenomenon and allergic reactions to cold. Other conditions encountered during cold weather operations are acute mountain sickness, psychiatric and psychosocial disorders, snow blindness, and constipation (due to decreased fluid intake).

INCIDENCE OF ANTI-SPERM ANTIBODIES IN INFERTILE MALE POPULATION

The prevalence of anti-sperm antibodies was assessed in 100 patients of male factor infertility. Majority of the patients were in 30-35 years age group. 18% of these patients had anti-sperm antibodies in their seminal fluid and 16% in their serum.

Fat Embolism Syndrome : A Diagnostic Dilemma

Fat embolism syndrome (FES) is a constellation of clinical manifestations following fracture of long bones. In retrospective review, incidence of FES was less than 1% [1]. Fat embolism syndrome is a clinical diagnosis. This condition is often misdiagnosed and fatal if the treatment is delayed. We present two cases of fat embolism syndrome to highlight problems of missed diagnosis. Case 1 A 19 year old male sustained bilateral closed tibial and fibular fracture. Plaster of Paris (POP) slab was applied over both lower limbs and surgery planned. While awaiting fixation of fractures patient developed high grade fever from second day. Surgery was deferred to investigate fever. No specific cause for fever could be found and empirical treatment for malaria administered. Four days after the injury, patient suddenly developed tachypnea (breath rate 55/minute), tachycardia (pulse 145/minute), and altered sensorium. Oxygen saturation on pulse oximetry (SpO2) was 60% with high flow oxygen by facemask. He was intubated and mechanically ventilated with 100 % oxygen using anaesthesia circuit and later placed on ventilator in control mode with positive end expiratory pressure (PEEP). As oxygen saturation did not improve, PEEP was gradually increased to 20 cm of H2O. The high level PEEP resulted in pneumothorax for which an intercostal chest drain was inserted and patient was shifted to a tertiary care hospital. On arrival to the intensive care unit quick clinical evaluation revealed marked pallor, pulse 140/minute, blood pressure of 130/70 mm Hg, SpO2 90%, breath rate and neurological status could not be ascertained as patient was under effect of muscle relaxants. Patient was placed on Seimens Servo i ventilator in synchronized intermittent mandatory ventilation (SIMV) mode with PEEP. Initial ventilator settings were tidal volume 350 ml, mandatory breath rate 16/minute, fraction of inspired oxygen (FiO2) 0.7 and PEEP 10 cm H2O. With these settings peak inspiratory pressure of 23 cm H2O, plateau pressure of 20 cm H2O, mean airway pressure of 12 cm H2O and dynamic compliance of 30 ml/cm H2O was recorded. There were no petechial or subconjuctival haemorrhages. Chest auscultation revealed bilateral extensive crepitations and bronchial breath sounds. Fundoscopy revealed multiple haemorrhages along the vessel in entire field of both eyes. Doppler study of lower limb showed no evidence of venous thrombosis. Investigations revealed haemoglobin (Hb) 6.8 gm %, chest radiograph showed bilateral non homogenous opacities with predominant basal distribution (Fig. 1). Arterial blood gas (ABG) showed pH of 7.25, partial pressure of oxygen in arterial blood (PaO2) 55 mm Hg, partial pressure of carbon dioxide in arterial blood (PaCO2) 35 mmHg, bicarbonate (HCO3) 18 mmol/L and PaO2/FiO2 ratio of 78. Other investigations were within normal limits. Right internal jugular vein was cannulated and central venous pressure (CVP) of 12 cm of saline was recorded. Frank blood was noted on endotracheal suction. Fig. 1 Chest radiograph (antero-posterior view) shows bilateral non homogenous opacities in a predominantly basal distribution On the basis of clinical background, chest radiograph and arterial blood gas analysis report, the case was diagnosed as fat embolism syndrome with acute respiratory distress syndrome (ARDS). Patient was kept sedated, muscle relaxants discontinued and mechanical ventilation continued. Tachycardia and tachypnea settled down after eight hours of ventilation and patient started responding to simple verbal commands. The case was discussed with orthopaedic surgeon for fixation of fractures on fifth day. A consensus decision was taken to wait for some time. Next day while on ventilator, patient suddenly desaturated (SpO2 70%), became restless and developed tachypnea (breath rate 60/minute) and tachycardia (heart rate 150/minute). There were no specific changes on electrocardiogram and transthoracic echocardiography did not show any evidence of right ventricular strain. Patient improved within one hour with readjustment of ventilator settings. This episode was thought to be fresh episode of fat embolism. In view of recurring fat embolism, it was decided to fix fractures early. On sixth day bilateral open reduction and dynamic compression plating of both fractures was done under general anesthesia. Intraoperative course was uneventful. Postoperatively, ventilation, adequate analgesia, and antibiotics were continued. On seventh day patient improved and he was placed on oxygen mask. After eight hours of extubation patient again developed tachycardia, tachypnea, diaphoresis, and mild desaturation (SpO2 90%). This time noninvasive ventilation was used to tide over the crisis. After six hours of mask ventilation SpO2 improved to 97%. Thereafter he made an uneventful recovery.

Walking Epidural : An Effective Method of Labour Pain Relief.

BACKGROUND Labour pain can be deleterious for mother and baby. Epidural analgesia relieves labour pains effectively with minimal maternal and foetal side effects. A prospective open label study was undertaken to ascertain effective dosing regime for walking epidural in labour. METHODS Fifty women with singleton foetus in vertex position were included. Epidural catheter was inserted in L2-3 / L3-4 interspinous space. Initial bolus of 10 ml (0.1% bupivacaine and 0.0002% fentanyl) solution was injected and after the efficacy of block was established, an epidural infusion of the same drug solution was started at the rate of 5 ml/hour. RESULTS In first stage of labour 80% of the parturient had excellent to good pain relief (visual analogue scale 1 to 3) with standard protocol while 20% parturient required one or more additional boluses. For the second stage, pain relief was good to fair (VAS 4-6) for most of the parturient. The incidence of caesarian section was 4% and 6% needed assisted delivery. No major side effects were observed. CONCLUSION 0.1% bupivacaine with 0.0002% fentanyl maximizes labour pain relief and minimizes side effects.

Invasive to Noninvasive Ventilation in Chronic Obstructive Pulmonary Disease.

Patients with acute exacerbation of chronic obstructive pulmonary disease (COPD) may require endotracheal intubation and ventilatory support. But intubation and mechanical ventilation is fraught with dangers. Potential disasters like pneumothorax and hypotension can occur. Also these patients may require long term ventilatory support [1] with associated complications of ventilator associated pneumonia and tracheo-esophageal fistula. Noninvasive ventilation with orofacial or nasal mask avoids the need for endotracheal intubation and reduces the risk of complications associated with mechanical ventilation. Several investigators have studied the use of noninvasive positive pressure ventilation (NPPV) in patients with acute exacerbation of COPD [2, 3]. We present a case that was successfully managed and weaned off early from ventilator using noninvasive positive pressure ventilation.

TRANSVAGINAL SALINE INFUSION SONOHYSTEROGRAPHY: INITIAL RESULTS

Transvaginal sonohysterography was carried out with dynamic instillation of normal saline in the uterine cavity in fourteen infertile patients. Sonohysterography was found to be simple, accurate and specific in delineating endometrial cavity lesions like polyp, submucosal myoma, intrauterine synechiae and endometrial hyperplasia.

UREAPLASMAS UREALYTICUM AND HUMAN INFERTILITY: EFFECT ON SPERMATOZOA MORPHOLOGY

Seminal fluids of 197 males with complaints of involuntary infertility were examined for spermatozoal counts, morphological changes in the spermatozoa and cultured for ureaplasmas and mycoplasmas. In 12, no spermatozoa were present, 29 had a count of less than one million and 156 had more than one million spermatozoa per mL of the seminal fluid. Various morphological changes were detected in the spermatozoa in some cases. U urealyticum and M hominis were grown in 43.15% and 16.75% in comparison to control figures of 15.9% and 11.4% respectively. There was no correlation between growth of ureaplasmas and the spermatozoal count. Among the morphological changes, presence of coiled tails, presence of a fuzzy coat around the tail and microcolonies were highly specific for culture positivity (98.2, 98.2 and 97.35% respectively) but of low sensitivity (55.2%, 14.1% and 8.2% respectively).