The Journal of Craniofacial Surgery
Correspondence
Volume 26, Number 6, September 2015
FIGURE 1. A, Sterile tablespoon retraction of the cheek mucosa and the tongue while performing intraoral bimaxillar fixation and interdental wiring. B, Small size sterile metal tablespoon as globe retractor during zygomatic fracture operation.
Even though we have a full craniofacial surgical set, we sometimes use sterile metal tablespoons for these purposes. We use different sizes of sterile spoons, and we have them as an addition to our set. Larger sizes are especially useful in intraoral tissue retraction. They provide better view with wide area protection of the cheek mucosa and the tongue especially during interdental wiring and splints. Smaller sizes could be used as globe retractors since they provide better exposure than the classic quadrangular globe retractors. Their concave sides have proper sitting surface for the convexity of the globe (Fig. 1). Although they are not professional surgical instruments they are cheap, effective, and could be found easily in the market. We have observed fewer amounts of postoperative complaints such as mucosal tears or labial edema from the patients after surgery. We confidently recommend this instrument especially in the previously mentioned indications to our colleagues.
FIGURE 1. Preoperative (A-C) and postoperative (D-F) pictures of the same patient. A and C, Frontal view. B and E, Profile view. C and F, Basal view.
Candemir Ceran, MD Durdane Keskin, MD Cagla Amutkan Cicek, MD Mustafa Erol Demirseren, MD Department of Plastic Reconstructive and Aesthetic Surgery Ataturk Training and Research Hospital Ankara, Turkey [email protected]
REFERENCE 1. Hupp JR. Intrumentation for basic oral surgery. In: Hupp JR, Ellis E, Tucker MR, eds. Contemporary Oral and Maxillofacial Surgery. 6th ed. St. Louis, MO: Elsevier; 2014:66–87
An Unusual Deformity of the Nose: Medial Crural Fracture To the Editor: Septal fractures frequently accompany nasal bone fractures. Fractures in the other parts of cartilage framework of the nose, however, are rare and less known. Avulsion of the upper lateral cartilages resulting from direct trauma has been described before by Parkes et al.1 To our knowledge, fracture of the medial crus of the lower lateral cartilage, however, has not been reported elsewhere. Here, we report an unusual presentation and treatment of fractured medial crus of lower lateral cartilage.
PATIENT A 29-year-old woman came to our clinic complaining of a mass at her nose. On physical examination, the medial crus of the left lower
2028
FIGURE 2. Intraoperative pictures. A, Placement of the incision over the existing scar. B, The medial crus of the left lower lateral cartilage was split into 2 pieces (shown by the forceps). C, Caudally positioned left lower lateral cartilage on lateral view. D, Medial crural parts of the left lower cartilage were sutured and placed in their anatomic position.
lateral cartilage was displaced inferiorly and protruded from the columella (Fig. 1.A-C). The septum was deviated to the right side. She had a history of fall and possibly, untreated nasal fracture at the age of 10. For treatment of the underlying deformity, the patient underwent operation under general anesthesia. After infiltration of local anesthetic solution (lidocaine and epinephrine, 1:80,000), the existing scar was used for the incision and open rhinoplasty technique was performed (Fig. 2). The anterior septum and medial crura were dissected. The medial crus of left lower lateral cartilage was fractured and split into 2 parts (Fig. 2). The medial part of the medial crus, which was malpositioned in the anterior and caudal direction, repositioned to its anatomic location and sutured to the septum and the lateral part of the medial crus. Transfixation sutures were put to stabilize the anterior septum. Excess part of the expanded skin was excised and the incisions were sutured. The preoperative and 2-month postoperative photographs are shown in Figure 1. #
2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Volume 26, Number 6, September 2015
DISCUSSION Early diagnosis and management of the nasal fractures are imperative to avoid subsequent nasal deformities. The nasal septum is commonly involved in nasal bone fractures. The incidence of septal fractures in patients with simple nasal fracture is considerably high and reported between 40% and 96%.2 –4 Fry3 showed the incidence of complete septal fractures in patients with nasal bone fractures as 6% and the incidence of incomplete septal fractures and septal deformities as high as 80%. The septal fractures are usually unrecognized and untreated at the time of the injury.2 Minor septal injuries, particularly in the children, however, may result in major sequela in the adulthood. Multiple reconstructive procedures may be needed to correct these deformities.5,6 Fractures in the other parts of the cartilage skeleton of the nose are less known and rarely reported. Avulsion of the upper lateral cartilages resulting from direct trauma has been noted in the literature.1 But, to our knowledge, the fracture of the medial crus of the lower lateral cartilage has never been reported before. Untreated nasal fractures may subsequently cause deformities and deviations, which lead to functional and cosmetic problems. Appropriate repositioning of all bony and cartilagenous structures should be aimed in the treatment of nasal fracture to obtain optimal results. Fatma Betul Tuncer, MD Marmara University School of Medicine Istanbul, Turkey [email protected] Melekber Cavus Ozkan, MD Ozhan Bekir Celebiler, MD Department of Plastic Reconstructive and Aesthetic Surgery Marmara University Hospital Istanbul, Turkey
REFERENCES 1. Parkes ML, Kanodia R. Avulsion of the upper lateral cartilage: etiology, diagnosis, surgical anatomy and management. Laryngoscope 1981;91: 758–764 2. Rhee SC, Kim YK, Cha JH, et al. Septal fracture in simple nasal bone fracture. Plast Reconstr Surg 2004;113:45–52 3. Fry H. The importance of the septal cartilage in nasal trauma. Br J Plast Surg 1967;20:392–402 4. Hwang K, You SH, Kim SG, et al. Analysis of nasal bone fractures: a six-year study of 503 patients. J Craniofac Surg 2006;17:261–264 5. Alvarez H, Osorio J, De Diego JI, et al. Sequelae after nasal septum injuries in children. Auris Nasus Larynx 2000;27:339–342 6. Sayin I, Yazici ZM, Bozkurt E, et al. Nasal septal hematoma and abscess in children. J Craniofac Surg 2011;22:e17–e19
Awake Nasotracheal Fiberoptic Intubation With Different Conscious Sedation Techniques To the Editor: In the recent article by Eftekharian et al1 assessing performance of different conscious sedation techniques for awake #
2015 Mutaz B. Habal, MD
Correspondence
nasotracheal fiberoptic intubation in patients with difficult airway by temporomandibular joint ankylosis, they concluded that remifentanil was the best agent, because it provided shorter intubation time, better intubation conditions, and least patient’s complaint. Given that difficult airway algorithms recommend awake intubation as the gold standard for difficult airway management,2,3 their findings have potential implications. In our view, however, there are several aspects of this study that need to be clarified and discussed before adoption into routine practice. First, in materials and methods, the authors did not specify the experience of intubators in the nasotracheal fiberoptic intubation. The experience and competence with the airway devices are critical for their successful use, especially when there is a difficult airway.4 For the results of a comparative airway management study to be valid, participants must be equally proficient with tested airway device to avoid bias. We are concerned that unequally proficient of intubators with the nasotracheal fiberoptic intubation would have contributed to their findings. Second, other than sedation managements, awake patients also rarely allow the airway to be instrumented without adequate airway topical anesthesia. Thus, effective airway topical anesthesia is mandatory for the comfort of the awake patient and subsequent successful instrumentation.5 In this study, Eftekharian et al used several techniques for airway topical anesthesia, such as direct application of lidocaine to the nasal mucosa, gargling of lidocaine, and airway nerve blocks. However, it was unclear how the anesthetists judged adequacy of airway topical anesthesia before commence of fiberoptic intubation. We believe that addressing this issue would further clarify the transparency of this study. Third, the authors stated that loss of eyelash reflex and Ramsay Sedation Score 4 were used as the start points for nasotracheal fiberoptic intubation. According to the results provided in their Table 2, however, most patients only had Ramsay Sedation Scores 1–2. That is, most fiberoptic intubation had been initiated before the targeted sedation degree was achieved. Furthermore, Ramsay Sedation Score is a 6-point scoring system, with a score range of 1 to 6.6 We are very interested in knowing why 22.2% of patients receiving remifentanil or ketamine had a Ramsay Sedation Score 0. Fourth, this study had not provided a power analysis of sample size. Actually, estimation of proper sample size in the design of a randomized double-blind study is an important prerequisite to avoid type 2 statistical errors in the analysis of study results. The study by Eftekharian et al seems no enough power to show differences among 3 groups in the Ramsay Sedation Score, patient discomfort, respiratory complications, and postoperative dissatisfaction of patients. Thus, we agree with Eftekharian et al that large randomized controlled trials are still needed to provide more definitive evidence that remifentanil is the best agent for conscious sedation of awake nasotracheal fiberoptic intubation in patients with difficult airway. Finally, the authors stated that all patients were premedicated with midazolam 0.05 mg/kg IV and fentanyl 0.1 mg/kg IV, 5 minutes before this study was conducted. The dose of fentanyl is evidently too large. Rui Ping Li, MD Fu Shan Xue, MD Gao Pu Liu, MD Chao Sun, MD Department of Anesthesiology Plastic Surgery Hospital Chinese Academy of Medical Sciences and Peking Union Medical College Beijing, People’s Republic of China [email protected]; [email protected]
2029
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Correspondence
Volume 26, Number 6, September 2015
FIGURE 1. A, Sterile tablespoon retraction of the cheek mucosa and the tongue while performing intraoral bimaxillar fixation and interdental wiring. B, Small size sterile metal tablespoon as globe retractor during zygomatic fracture operation.
Even though we have a full craniofacial surgical set, we sometimes use sterile metal tablespoons for these purposes. We use different sizes of sterile spoons, and we have them as an addition to our set. Larger sizes are especially useful in intraoral tissue retraction. They provide better view with wide area protection of the cheek mucosa and the tongue especially during interdental wiring and splints. Smaller sizes could be used as globe retractors since they provide better exposure than the classic quadrangular globe retractors. Their concave sides have proper sitting surface for the convexity of the globe (Fig. 1). Although they are not professional surgical instruments they are cheap, effective, and could be found easily in the market. We have observed fewer amounts of postoperative complaints such as mucosal tears or labial edema from the patients after surgery. We confidently recommend this instrument especially in the previously mentioned indications to our colleagues.
FIGURE 1. Preoperative (A-C) and postoperative (D-F) pictures of the same patient. A and C, Frontal view. B and E, Profile view. C and F, Basal view.
Candemir Ceran, MD Durdane Keskin, MD Cagla Amutkan Cicek, MD Mustafa Erol Demirseren, MD Department of Plastic Reconstructive and Aesthetic Surgery Ataturk Training and Research Hospital Ankara, Turkey [email protected]
REFERENCE 1. Hupp JR. Intrumentation for basic oral surgery. In: Hupp JR, Ellis E, Tucker MR, eds. Contemporary Oral and Maxillofacial Surgery. 6th ed. St. Louis, MO: Elsevier; 2014:66–87
An Unusual Deformity of the Nose: Medial Crural Fracture To the Editor: Septal fractures frequently accompany nasal bone fractures. Fractures in the other parts of cartilage framework of the nose, however, are rare and less known. Avulsion of the upper lateral cartilages resulting from direct trauma has been described before by Parkes et al.1 To our knowledge, fracture of the medial crus of the lower lateral cartilage, however, has not been reported elsewhere. Here, we report an unusual presentation and treatment of fractured medial crus of lower lateral cartilage.
PATIENT A 29-year-old woman came to our clinic complaining of a mass at her nose. On physical examination, the medial crus of the left lower
2028
FIGURE 2. Intraoperative pictures. A, Placement of the incision over the existing scar. B, The medial crus of the left lower lateral cartilage was split into 2 pieces (shown by the forceps). C, Caudally positioned left lower lateral cartilage on lateral view. D, Medial crural parts of the left lower cartilage were sutured and placed in their anatomic position.
lateral cartilage was displaced inferiorly and protruded from the columella (Fig. 1.A-C). The septum was deviated to the right side. She had a history of fall and possibly, untreated nasal fracture at the age of 10. For treatment of the underlying deformity, the patient underwent operation under general anesthesia. After infiltration of local anesthetic solution (lidocaine and epinephrine, 1:80,000), the existing scar was used for the incision and open rhinoplasty technique was performed (Fig. 2). The anterior septum and medial crura were dissected. The medial crus of left lower lateral cartilage was fractured and split into 2 parts (Fig. 2). The medial part of the medial crus, which was malpositioned in the anterior and caudal direction, repositioned to its anatomic location and sutured to the septum and the lateral part of the medial crus. Transfixation sutures were put to stabilize the anterior septum. Excess part of the expanded skin was excised and the incisions were sutured. The preoperative and 2-month postoperative photographs are shown in Figure 1. #
2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Volume 26, Number 6, September 2015
DISCUSSION Early diagnosis and management of the nasal fractures are imperative to avoid subsequent nasal deformities. The nasal septum is commonly involved in nasal bone fractures. The incidence of septal fractures in patients with simple nasal fracture is considerably high and reported between 40% and 96%.2 –4 Fry3 showed the incidence of complete septal fractures in patients with nasal bone fractures as 6% and the incidence of incomplete septal fractures and septal deformities as high as 80%. The septal fractures are usually unrecognized and untreated at the time of the injury.2 Minor septal injuries, particularly in the children, however, may result in major sequela in the adulthood. Multiple reconstructive procedures may be needed to correct these deformities.5,6 Fractures in the other parts of the cartilage skeleton of the nose are less known and rarely reported. Avulsion of the upper lateral cartilages resulting from direct trauma has been noted in the literature.1 But, to our knowledge, the fracture of the medial crus of the lower lateral cartilage has never been reported before. Untreated nasal fractures may subsequently cause deformities and deviations, which lead to functional and cosmetic problems. Appropriate repositioning of all bony and cartilagenous structures should be aimed in the treatment of nasal fracture to obtain optimal results. Fatma Betul Tuncer, MD Marmara University School of Medicine Istanbul, Turkey [email protected] Melekber Cavus Ozkan, MD Ozhan Bekir Celebiler, MD Department of Plastic Reconstructive and Aesthetic Surgery Marmara University Hospital Istanbul, Turkey
REFERENCES 1. Parkes ML, Kanodia R. Avulsion of the upper lateral cartilage: etiology, diagnosis, surgical anatomy and management. Laryngoscope 1981;91: 758–764 2. Rhee SC, Kim YK, Cha JH, et al. Septal fracture in simple nasal bone fracture. Plast Reconstr Surg 2004;113:45–52 3. Fry H. The importance of the septal cartilage in nasal trauma. Br J Plast Surg 1967;20:392–402 4. Hwang K, You SH, Kim SG, et al. Analysis of nasal bone fractures: a six-year study of 503 patients. J Craniofac Surg 2006;17:261–264 5. Alvarez H, Osorio J, De Diego JI, et al. Sequelae after nasal septum injuries in children. Auris Nasus Larynx 2000;27:339–342 6. Sayin I, Yazici ZM, Bozkurt E, et al. Nasal septal hematoma and abscess in children. J Craniofac Surg 2011;22:e17–e19
Awake Nasotracheal Fiberoptic Intubation With Different Conscious Sedation Techniques To the Editor: In the recent article by Eftekharian et al1 assessing performance of different conscious sedation techniques for awake #
2015 Mutaz B. Habal, MD
Correspondence
nasotracheal fiberoptic intubation in patients with difficult airway by temporomandibular joint ankylosis, they concluded that remifentanil was the best agent, because it provided shorter intubation time, better intubation conditions, and least patient’s complaint. Given that difficult airway algorithms recommend awake intubation as the gold standard for difficult airway management,2,3 their findings have potential implications. In our view, however, there are several aspects of this study that need to be clarified and discussed before adoption into routine practice. First, in materials and methods, the authors did not specify the experience of intubators in the nasotracheal fiberoptic intubation. The experience and competence with the airway devices are critical for their successful use, especially when there is a difficult airway.4 For the results of a comparative airway management study to be valid, participants must be equally proficient with tested airway device to avoid bias. We are concerned that unequally proficient of intubators with the nasotracheal fiberoptic intubation would have contributed to their findings. Second, other than sedation managements, awake patients also rarely allow the airway to be instrumented without adequate airway topical anesthesia. Thus, effective airway topical anesthesia is mandatory for the comfort of the awake patient and subsequent successful instrumentation.5 In this study, Eftekharian et al used several techniques for airway topical anesthesia, such as direct application of lidocaine to the nasal mucosa, gargling of lidocaine, and airway nerve blocks. However, it was unclear how the anesthetists judged adequacy of airway topical anesthesia before commence of fiberoptic intubation. We believe that addressing this issue would further clarify the transparency of this study. Third, the authors stated that loss of eyelash reflex and Ramsay Sedation Score 4 were used as the start points for nasotracheal fiberoptic intubation. According to the results provided in their Table 2, however, most patients only had Ramsay Sedation Scores 1–2. That is, most fiberoptic intubation had been initiated before the targeted sedation degree was achieved. Furthermore, Ramsay Sedation Score is a 6-point scoring system, with a score range of 1 to 6.6 We are very interested in knowing why 22.2% of patients receiving remifentanil or ketamine had a Ramsay Sedation Score 0. Fourth, this study had not provided a power analysis of sample size. Actually, estimation of proper sample size in the design of a randomized double-blind study is an important prerequisite to avoid type 2 statistical errors in the analysis of study results. The study by Eftekharian et al seems no enough power to show differences among 3 groups in the Ramsay Sedation Score, patient discomfort, respiratory complications, and postoperative dissatisfaction of patients. Thus, we agree with Eftekharian et al that large randomized controlled trials are still needed to provide more definitive evidence that remifentanil is the best agent for conscious sedation of awake nasotracheal fiberoptic intubation in patients with difficult airway. Finally, the authors stated that all patients were premedicated with midazolam 0.05 mg/kg IV and fentanyl 0.1 mg/kg IV, 5 minutes before this study was conducted. The dose of fentanyl is evidently too large. Rui Ping Li, MD Fu Shan Xue, MD Gao Pu Liu, MD Chao Sun, MD Department of Anesthesiology Plastic Surgery Hospital Chinese Academy of Medical Sciences and Peking Union Medical College Beijing, People’s Republic of China [email protected]; [email protected]
2029
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
