Letters to Editor Page | 305
Cosmetic nose pin: An unusual foreign body Sir, We report an interesting case of lower part of cosmetic nose pin presenting as foreign body just prior to surgery. A 21-year-old female with toxic multi nodular goiter was posted for total thyriodectomy. The patient was wearing nose pin on the left side since 10 years of her age and it was not possible to remove it even after best possible manual efforts in the preoperative preparation. It was decided to remove the nose pin by the conventional method, following general anesthesia and endotracheal intubation as the patient was quiet apprehensive. In this conventional method, two threads are used and one thread is tied on the upper part of the nose pin and the other thread is tied on the lower part. Both threads are then moved in counter directions which unscrew the nose pin and facilitate easy removal. After intubation, the nose pin was removed by the above-mentioned method but the lower part of the nose pin broke off and was fallen into the lower part into the nasal cavity. We have immediately noticed the problem and skiagram of head and neck was done (both anterio-posterior and lateral view). The skiagram lateral view showed [Figure 1] us foreign body in the left nasal cavity at the junction of anterior two third and posterior one third of inferior turbinate in the floor of nose. We have not done fiberoptic because of two reasons: Firstly, it will further push the foreign body further down
and secondly fiberoptic doesn’t have working channel to pull out the foreign body. The foreign body was removed by an innovative technique by passing epidural catheter from left nare and retrieving it from mouth and then tying a small gauze piece soaked with jelly. The epidural catheter was then pulled out through the left nare.We found the lower part of the nose pin glued to the gauze piece (inset Figure 1). We want to emphasize preoperative removal of such ornaments but if somehow it is not possible as it was in our case then such ornaments should be removed with utmost care. The anesthesia team should remain alert during these maneuvers as there is high possibility of misplacement of these objects. Such nasal foreign bodies are typically found around the floor of the nose just below the inferior turbinate [1] as it was in our case also. These objects can cause airway obstruction during extubation or may present as foreign body trachea later [2]. Removal of such foreign bodies is important to avoid cautery burn in the perioperative period and should be done under expert hands. Anesthetic team should remain alert during its removal. To the best of our knowledge, there is no reported literature of the nasal pin acting as foreign body. When faced with such an unanticipated problem, as in our case, the heat of the moment forces us to do maneuvers like fiber-optic laryngoscopy, but we should not push the foreign body further beyond and must confirm the position of foreign body before attempting any maneuver. Not to and never to forget, the return of these ornaments to the patient attendants must be ensured and mentioned in the file for medico legal purposes. Amit Rastogi, Sushil Prakash Ambesh, Kamal Kishore, Rameez Riaz Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
Figure 1: Showing skiagram lateral view and arrow showing the location of lower part of nose pin & inset arrow showing the lower part of nose pin on the gauze piece
Saudi Journal of Anesthesia
Address for correspondence: Dr. Amit Rastogi, 1/131, Vipul Khand 1, Gomti Nagar, Lucknow - 226 010, Uttar Pradesh, India. E-mail: [email protected]
Vol. 8, Issue 2, April-June 2014
Letters to Editor Page | 306 Access this article online
REFERENCES
Quick Response Code:
1.
2.
Kalan A, Tariq M. Foreign bodies in the nasal cavities: A comprehensive review of the aetiology, diagnostic pointers, and therapeutic measures. Postgrad Med J 2000;76:484-7. Horng HC, Hsu YC, Wong CS, Su WF, Cherng CH. Iatrogenic Foreign Body (Cotton Swab) in the Trachea after Nasotracheal Intubation. J Med Sci 2009;29:285-7.
Website: www.saudija.org
DOI: 10.4103/1658-354X.130761
Pulsus alternans: Real and pseudo CASE 1 An 18-year-old male patient was diagnosed as rheumatic heart disease with severe AR and MR. He was on enalapril as vasodilator preoperatively. Pulse was irregular and collapsing. He was scheduled for valve replacement surgery. Preinduction radial arterial line was inserted. Arterial waveform was peculiar — one greater amplitude peak was followed by one lesser amplitude peak alternately [Figure 1]. This was mimicking pulsus alternans.
Figure 1: Arterial waveform with alternate greater and lesser amplitude wave (marked by yellow arrow)
CASE 2 A 60-year-old male patient after coronary artery bypass grafting was having large and small amplitude arterial waveform [Figure 2]. This waveform was appearing as pulsus alternans. Pulsus alternans is generally seen in left ventricle dysfunction. In case 2, ECG rhythm was bigeminy. Every normal QRS was giving rise to normal arterial pulse wave and every premature ventricular contraction was corresponding to lower amplitude arterial wave. This pattern created pulsus alternans. In case 1, as patient was already vasodilated, there was peripheral run off. So diastolic phase of arterial pulse is prolonged, appearing as 2nd lower amplitude arterial wave. This lower amplitude wave did not correspond to QRS in ECG. Such a waveform can be misdiagnosed as pulsus alternans.
Figure 2: Bigeminy ECG rhythm with alternate greater and lesser amplitude wave (marked by yellow arrow)
Address for correspondence: Dr. Monish S. Raut, Department of Cardiac Anesthesia, Dharam Vira Heart Center, Sir Ganga Ram Hospital, Old Rajinder Nagar, New Delhi - 110 060, India. E- mail: [email protected] Access this article online Quick Response Code:
Website: www.saudija.org
Monish S. Raut, Arun Maheshwari Department of Cardiac Anesthesia, Dharam Vira Heart Center, Sir Ganga Ram Hospital, Old Rajinder Nagar, New Delhi, India
Vol. 8, Issue 2, April-June 2014
DOI: 10.4103/1658-354X.130762
Saudi Journal of Anesthesia
Copyright of Saudi Journal of Anaesthesia is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Cosmetic nose pin: An unusual foreign body Sir, We report an interesting case of lower part of cosmetic nose pin presenting as foreign body just prior to surgery. A 21-year-old female with toxic multi nodular goiter was posted for total thyriodectomy. The patient was wearing nose pin on the left side since 10 years of her age and it was not possible to remove it even after best possible manual efforts in the preoperative preparation. It was decided to remove the nose pin by the conventional method, following general anesthesia and endotracheal intubation as the patient was quiet apprehensive. In this conventional method, two threads are used and one thread is tied on the upper part of the nose pin and the other thread is tied on the lower part. Both threads are then moved in counter directions which unscrew the nose pin and facilitate easy removal. After intubation, the nose pin was removed by the above-mentioned method but the lower part of the nose pin broke off and was fallen into the lower part into the nasal cavity. We have immediately noticed the problem and skiagram of head and neck was done (both anterio-posterior and lateral view). The skiagram lateral view showed [Figure 1] us foreign body in the left nasal cavity at the junction of anterior two third and posterior one third of inferior turbinate in the floor of nose. We have not done fiberoptic because of two reasons: Firstly, it will further push the foreign body further down
and secondly fiberoptic doesn’t have working channel to pull out the foreign body. The foreign body was removed by an innovative technique by passing epidural catheter from left nare and retrieving it from mouth and then tying a small gauze piece soaked with jelly. The epidural catheter was then pulled out through the left nare.We found the lower part of the nose pin glued to the gauze piece (inset Figure 1). We want to emphasize preoperative removal of such ornaments but if somehow it is not possible as it was in our case then such ornaments should be removed with utmost care. The anesthesia team should remain alert during these maneuvers as there is high possibility of misplacement of these objects. Such nasal foreign bodies are typically found around the floor of the nose just below the inferior turbinate [1] as it was in our case also. These objects can cause airway obstruction during extubation or may present as foreign body trachea later [2]. Removal of such foreign bodies is important to avoid cautery burn in the perioperative period and should be done under expert hands. Anesthetic team should remain alert during its removal. To the best of our knowledge, there is no reported literature of the nasal pin acting as foreign body. When faced with such an unanticipated problem, as in our case, the heat of the moment forces us to do maneuvers like fiber-optic laryngoscopy, but we should not push the foreign body further beyond and must confirm the position of foreign body before attempting any maneuver. Not to and never to forget, the return of these ornaments to the patient attendants must be ensured and mentioned in the file for medico legal purposes. Amit Rastogi, Sushil Prakash Ambesh, Kamal Kishore, Rameez Riaz Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
Figure 1: Showing skiagram lateral view and arrow showing the location of lower part of nose pin & inset arrow showing the lower part of nose pin on the gauze piece
Saudi Journal of Anesthesia
Address for correspondence: Dr. Amit Rastogi, 1/131, Vipul Khand 1, Gomti Nagar, Lucknow - 226 010, Uttar Pradesh, India. E-mail: [email protected]
Vol. 8, Issue 2, April-June 2014
Letters to Editor Page | 306 Access this article online
REFERENCES
Quick Response Code:
1.
2.
Kalan A, Tariq M. Foreign bodies in the nasal cavities: A comprehensive review of the aetiology, diagnostic pointers, and therapeutic measures. Postgrad Med J 2000;76:484-7. Horng HC, Hsu YC, Wong CS, Su WF, Cherng CH. Iatrogenic Foreign Body (Cotton Swab) in the Trachea after Nasotracheal Intubation. J Med Sci 2009;29:285-7.
Website: www.saudija.org
DOI: 10.4103/1658-354X.130761
Pulsus alternans: Real and pseudo CASE 1 An 18-year-old male patient was diagnosed as rheumatic heart disease with severe AR and MR. He was on enalapril as vasodilator preoperatively. Pulse was irregular and collapsing. He was scheduled for valve replacement surgery. Preinduction radial arterial line was inserted. Arterial waveform was peculiar — one greater amplitude peak was followed by one lesser amplitude peak alternately [Figure 1]. This was mimicking pulsus alternans.
Figure 1: Arterial waveform with alternate greater and lesser amplitude wave (marked by yellow arrow)
CASE 2 A 60-year-old male patient after coronary artery bypass grafting was having large and small amplitude arterial waveform [Figure 2]. This waveform was appearing as pulsus alternans. Pulsus alternans is generally seen in left ventricle dysfunction. In case 2, ECG rhythm was bigeminy. Every normal QRS was giving rise to normal arterial pulse wave and every premature ventricular contraction was corresponding to lower amplitude arterial wave. This pattern created pulsus alternans. In case 1, as patient was already vasodilated, there was peripheral run off. So diastolic phase of arterial pulse is prolonged, appearing as 2nd lower amplitude arterial wave. This lower amplitude wave did not correspond to QRS in ECG. Such a waveform can be misdiagnosed as pulsus alternans.
Figure 2: Bigeminy ECG rhythm with alternate greater and lesser amplitude wave (marked by yellow arrow)
Address for correspondence: Dr. Monish S. Raut, Department of Cardiac Anesthesia, Dharam Vira Heart Center, Sir Ganga Ram Hospital, Old Rajinder Nagar, New Delhi - 110 060, India. E- mail: [email protected] Access this article online Quick Response Code:
Website: www.saudija.org
Monish S. Raut, Arun Maheshwari Department of Cardiac Anesthesia, Dharam Vira Heart Center, Sir Ganga Ram Hospital, Old Rajinder Nagar, New Delhi, India
Vol. 8, Issue 2, April-June 2014
DOI: 10.4103/1658-354X.130762
Saudi Journal of Anesthesia
Copyright of Saudi Journal of Anaesthesia is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
