Letters to Editor
Access this article online Quick Response Code:
Website: www.joacp.org
DOI: 10.4103/0970-9185.137303
Ipsilateral paralysis of hypoglossal nerve following interscalene brachial plexus block Sir, We are reporting an interesting case, where a patient temporarily developed unilateral hypoglossal nerve paralysis following brachial plexus block using interscalene approach. A 15-year-old male patient, who was diagnosed with acute osteomyelitis of right humerus, was posted for emergency incision and drainage of the right upper arm. Preoperative systemic examinations did not find any clinically relevant abnormality. Right-sided brachial plexus block through interscalene approach was chosen to provide anesthesia. The nerve block was accomplished by eliciting paresthesia using a 22-gauge beveled needle followed by injecting 245 mg of lignocaine with adrenaline (7 mg/kg) in 25 ml solution in the interscalene groove at the level of the cricoid cartilage. The direction of the needle was kept caudal and slightly medial. The injected area was compressed by dry gauge pieces keeping the head end of the table 30° elevated, with the idea to spread the drug along the brachial plexus. The nerve block was confirmed by sensorimotor blockade as well as evidence of ipsilateral ptosis. Soon, the patient developed ipsilateral hypoglossal nerve palsy as evident by right-sided deviation of the tongue producing difficulty in articulation. No hoarseness of voice or aphonia was noted. The cough reflex was intact. On clinical examination, other cranial nerves were found to be functioning normally. No swelling or hematoma was found at the injection site. During intraoperative period, the patient, however, needed general anesthesia with intubation as he felt pain and discomfort when the surgical incision was extended downward up to medial epicondylar area. The hypoglossal nerve paralysis disappeared in the postoperative period after about 4 h since its onset, during which the effect of lignocaine also waned. As hypoglossal palsy reversed completely within 4 h of onset further investigations such as ultrasonogram, color Doppler or carotid angiogram were not done. 446
Involvement of hypoglossal nerve in interscalene block is extremely rare and is only once reported where hypoglossal nerve palsy was associated with 10th cranial nerve palsy.[1] In Tapia’s syndrome, the extracranial part of the recurrent laryngeal nerve and the hypoglossal nerve are affected and results in ipsilateral paralysis of the vocal cord and the tongue.[2] It can be unilateral or bilateral. Rhinoplasty/ septorhinoplasty, orotracheal intubation, malposition of the head and neck, compression neuropathy by mass effect, cardiac surgeries were found to be responsible for producing this syndrome.[3-5] Other than pressure neuropathy, dissection of the ascending pharyngeal branch of the carotid artery and direct injury to the nerve are the other possible mechanisms for this syndrome.[1] Hypoglossal nerve damage can be caused by stretching or compression of the nerve against the greater horn of the hyoid bone resulting in neurapraxic type of nerve injury. Recovery is a slow process and can take weeks to months.[4] In our case, the hypoglossal palsy was not associated with recurrent laryngeal nerve palsy and was unilateral. Unlike other studies, the hypoglossal nerve paralysis persisted for a very brief period (about 4 h) and its onset and offset coincided with that of brachial plexus block. Also, the function of hypoglossal nerve recovered without any intervention. These factors led us to conclude the hypoglossal nerve paralysis as a complication of interscalene block. The diffusion of the lignocaine solution to the neighboring area due to manual compression of the drug injection site might have caused the hypoglossal palsy. Although, the direction of the needle was far away from the anatomic site where the hypoglossal nerve rests, possibility of a direct injury by the needle cannot be ruled out. The use of nerve stimulator and ulstrasonogram has increased the success rate of nerve block and reduced the incidence of complications, and should therefore be used in every possible case.[6] Saswata Bharati, Manas Karmakar, Sujata Ghosh Department of Anaesthesiology, Calcutta National Medical College, Kolkata, West Bengal, India Address for correspondence: Dr. Manas Karmakar, Department of Anaesthesiology, Calcutta National Medical College, Kolkata - 700 014, West Bengal, India. E-mail: [email protected]
References 1.
2.
Johnson TM, Moore HJ. Cranial nerve X and XII paralysis (Tapia’s syndrome) after an interscalene brachial plexus block for a left shoulder Mumford procedure. Anesthesiology 1999;90:311-2. Schoenberg BS, Massey EW. Tapia’s syndrome. The erratic evolution of an eponym. Arch Neurol 1979;36:257-60.
Journal of Anaesthesiology Clinical Pharmacology | July-September 2014 | Vol 30 | Issue 3
Letters to Editor 3.
4.
5.
6.
Lykoudis EG, Seretis K. Tapia’s syndrome: An unexpected but real complication of rhinoplasty: Case report and literature review. Aesthetic Plast Surg 2012;36:557-9. Tesei F, Poveda LM, Strali W, Tosi L, Magnani G, Farneti G. Unilateral laryngeal and hypoglossal paralysis (Tapia’s syndrome) following rhinoplasty in general anaesthesia: Case report and review of the literature. Acta Otorhinolaryngol Ital 2006;26:219-21. Nalladaru Z, Wessels A, DuPreez L. Tapia’s syndrome-a rare complication following cardiac surgery. Interact Cardiovasc Thorac Surg 2012;14:131-2. Antonakakis JG, Ting PH, Sites B. Ultrasound-guided regional anesthesia for peripheral nerve blocks: An evidence-based outcome review. Anesthesiol Clin 2011;29:179-91. Access this article online Quick Response Code:
Website: www.joacp.org
DOI: 10.4103/0970-9185.137304
Use of picture archiving and communication system for imaging of radiological films in cardiac surgical intensive care unit Sir, In medical imaging, electronic picture archiving and communication systems (PACS) have been developed in an attempt to provide economical storage, rapid retrieval of images, access to images acquired with multiple modalities, and simultaneous access at multiple sites. Electronic images and reports are transmitted digitally through PACS; this eliminates the need to manually file, retrieve, or transport film jackets. We are using this technology quite successfully in our hospital, especially in Intensive Care Units (ICU).
Histor y of Picture Archiving and Communication Systems The principles of PACS were first discussed at meetings of radiologists in 1982. Cardiovascular radiologist Duerinckx and Pisa first used the term in 1981.[1] Harold glass, a medical physicist working in London in the early 1990s secured UK Government funding and managed the project over many years, which transformed Hammersmith Hospital in London
as the first filmless hospital in the United Kingdom.[2] The first large-scale PACS installation was in 1982 at the University of Kansas, Kansas city. Nowadays, it has become an important component for the functioning of any modern hospital. Picture Archiving and Communication Systems consists of four major components: • Imaging modalities such as computed tomography (CT) and magnetic resonance imaging (MRI). • A secured network for the transmission of patient information. • Workstations for interpreting and reviewing images. • Archives for the storage and retrieval of images and reports. Combined with available and emerging web technology, PACS has the ability to deliver timely and efficient access to images, interpretations, and related data. PACS breaks down the physical and time barriers associated with traditional filmbased image retrieval, distribution, and display. Moreover, it can handle images from various medical imaging instruments, including ultrasound, MR, positron emission tomography, CT, etc. The universal format for PACS image storage and transfer is Digital Imaging and Communications in Medicine.
Clinical Benefits of Picture Archiving and Communication Systems • • • • • • • •
Increased availability of images. Increased processing, no lost film, multiple copies of the same image can be generated. Image manipulation to overcome under or over exposure. Increased speed and quality of reporting. Transmission of the hospital to other hospitals. Digitizing old films. Reliability. Ease of use.
Cost Analysis We performed a small study at our institution. There were about 80 chest radiographs done in our cardiac ICU daily. Therefore, in a month about 2400 radiographs were done. Cost of radiograph if done in a conventional way is as follows: • Cost of one X-ray film = Rs. 40/film. • Cost per day per ICU = 40 × 80= Rs. 3200. • Cost per month per ICU = 3200 × 30= Rs. 96,000. • Cost per bed per month = 96000/44= Rs. 2182. Cost of radiograph if done using PACS is as follows: • Cost of X-ray film — NIL.
Journal of Anaesthesiology Clinical Pharmacology | July-September 2014 | Vol 30 | Issue 3
447
Copyright of Journal of Anaesthesiology Clinical Pharmacology 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.
Access this article online Quick Response Code:
Website: www.joacp.org
DOI: 10.4103/0970-9185.137303
Ipsilateral paralysis of hypoglossal nerve following interscalene brachial plexus block Sir, We are reporting an interesting case, where a patient temporarily developed unilateral hypoglossal nerve paralysis following brachial plexus block using interscalene approach. A 15-year-old male patient, who was diagnosed with acute osteomyelitis of right humerus, was posted for emergency incision and drainage of the right upper arm. Preoperative systemic examinations did not find any clinically relevant abnormality. Right-sided brachial plexus block through interscalene approach was chosen to provide anesthesia. The nerve block was accomplished by eliciting paresthesia using a 22-gauge beveled needle followed by injecting 245 mg of lignocaine with adrenaline (7 mg/kg) in 25 ml solution in the interscalene groove at the level of the cricoid cartilage. The direction of the needle was kept caudal and slightly medial. The injected area was compressed by dry gauge pieces keeping the head end of the table 30° elevated, with the idea to spread the drug along the brachial plexus. The nerve block was confirmed by sensorimotor blockade as well as evidence of ipsilateral ptosis. Soon, the patient developed ipsilateral hypoglossal nerve palsy as evident by right-sided deviation of the tongue producing difficulty in articulation. No hoarseness of voice or aphonia was noted. The cough reflex was intact. On clinical examination, other cranial nerves were found to be functioning normally. No swelling or hematoma was found at the injection site. During intraoperative period, the patient, however, needed general anesthesia with intubation as he felt pain and discomfort when the surgical incision was extended downward up to medial epicondylar area. The hypoglossal nerve paralysis disappeared in the postoperative period after about 4 h since its onset, during which the effect of lignocaine also waned. As hypoglossal palsy reversed completely within 4 h of onset further investigations such as ultrasonogram, color Doppler or carotid angiogram were not done. 446
Involvement of hypoglossal nerve in interscalene block is extremely rare and is only once reported where hypoglossal nerve palsy was associated with 10th cranial nerve palsy.[1] In Tapia’s syndrome, the extracranial part of the recurrent laryngeal nerve and the hypoglossal nerve are affected and results in ipsilateral paralysis of the vocal cord and the tongue.[2] It can be unilateral or bilateral. Rhinoplasty/ septorhinoplasty, orotracheal intubation, malposition of the head and neck, compression neuropathy by mass effect, cardiac surgeries were found to be responsible for producing this syndrome.[3-5] Other than pressure neuropathy, dissection of the ascending pharyngeal branch of the carotid artery and direct injury to the nerve are the other possible mechanisms for this syndrome.[1] Hypoglossal nerve damage can be caused by stretching or compression of the nerve against the greater horn of the hyoid bone resulting in neurapraxic type of nerve injury. Recovery is a slow process and can take weeks to months.[4] In our case, the hypoglossal palsy was not associated with recurrent laryngeal nerve palsy and was unilateral. Unlike other studies, the hypoglossal nerve paralysis persisted for a very brief period (about 4 h) and its onset and offset coincided with that of brachial plexus block. Also, the function of hypoglossal nerve recovered without any intervention. These factors led us to conclude the hypoglossal nerve paralysis as a complication of interscalene block. The diffusion of the lignocaine solution to the neighboring area due to manual compression of the drug injection site might have caused the hypoglossal palsy. Although, the direction of the needle was far away from the anatomic site where the hypoglossal nerve rests, possibility of a direct injury by the needle cannot be ruled out. The use of nerve stimulator and ulstrasonogram has increased the success rate of nerve block and reduced the incidence of complications, and should therefore be used in every possible case.[6] Saswata Bharati, Manas Karmakar, Sujata Ghosh Department of Anaesthesiology, Calcutta National Medical College, Kolkata, West Bengal, India Address for correspondence: Dr. Manas Karmakar, Department of Anaesthesiology, Calcutta National Medical College, Kolkata - 700 014, West Bengal, India. E-mail: [email protected]
References 1.
2.
Johnson TM, Moore HJ. Cranial nerve X and XII paralysis (Tapia’s syndrome) after an interscalene brachial plexus block for a left shoulder Mumford procedure. Anesthesiology 1999;90:311-2. Schoenberg BS, Massey EW. Tapia’s syndrome. The erratic evolution of an eponym. Arch Neurol 1979;36:257-60.
Journal of Anaesthesiology Clinical Pharmacology | July-September 2014 | Vol 30 | Issue 3
Letters to Editor 3.
4.
5.
6.
Lykoudis EG, Seretis K. Tapia’s syndrome: An unexpected but real complication of rhinoplasty: Case report and literature review. Aesthetic Plast Surg 2012;36:557-9. Tesei F, Poveda LM, Strali W, Tosi L, Magnani G, Farneti G. Unilateral laryngeal and hypoglossal paralysis (Tapia’s syndrome) following rhinoplasty in general anaesthesia: Case report and review of the literature. Acta Otorhinolaryngol Ital 2006;26:219-21. Nalladaru Z, Wessels A, DuPreez L. Tapia’s syndrome-a rare complication following cardiac surgery. Interact Cardiovasc Thorac Surg 2012;14:131-2. Antonakakis JG, Ting PH, Sites B. Ultrasound-guided regional anesthesia for peripheral nerve blocks: An evidence-based outcome review. Anesthesiol Clin 2011;29:179-91. Access this article online Quick Response Code:
Website: www.joacp.org
DOI: 10.4103/0970-9185.137304
Use of picture archiving and communication system for imaging of radiological films in cardiac surgical intensive care unit Sir, In medical imaging, electronic picture archiving and communication systems (PACS) have been developed in an attempt to provide economical storage, rapid retrieval of images, access to images acquired with multiple modalities, and simultaneous access at multiple sites. Electronic images and reports are transmitted digitally through PACS; this eliminates the need to manually file, retrieve, or transport film jackets. We are using this technology quite successfully in our hospital, especially in Intensive Care Units (ICU).
Histor y of Picture Archiving and Communication Systems The principles of PACS were first discussed at meetings of radiologists in 1982. Cardiovascular radiologist Duerinckx and Pisa first used the term in 1981.[1] Harold glass, a medical physicist working in London in the early 1990s secured UK Government funding and managed the project over many years, which transformed Hammersmith Hospital in London
as the first filmless hospital in the United Kingdom.[2] The first large-scale PACS installation was in 1982 at the University of Kansas, Kansas city. Nowadays, it has become an important component for the functioning of any modern hospital. Picture Archiving and Communication Systems consists of four major components: • Imaging modalities such as computed tomography (CT) and magnetic resonance imaging (MRI). • A secured network for the transmission of patient information. • Workstations for interpreting and reviewing images. • Archives for the storage and retrieval of images and reports. Combined with available and emerging web technology, PACS has the ability to deliver timely and efficient access to images, interpretations, and related data. PACS breaks down the physical and time barriers associated with traditional filmbased image retrieval, distribution, and display. Moreover, it can handle images from various medical imaging instruments, including ultrasound, MR, positron emission tomography, CT, etc. The universal format for PACS image storage and transfer is Digital Imaging and Communications in Medicine.
Clinical Benefits of Picture Archiving and Communication Systems • • • • • • • •
Increased availability of images. Increased processing, no lost film, multiple copies of the same image can be generated. Image manipulation to overcome under or over exposure. Increased speed and quality of reporting. Transmission of the hospital to other hospitals. Digitizing old films. Reliability. Ease of use.
Cost Analysis We performed a small study at our institution. There were about 80 chest radiographs done in our cardiac ICU daily. Therefore, in a month about 2400 radiographs were done. Cost of radiograph if done in a conventional way is as follows: • Cost of one X-ray film = Rs. 40/film. • Cost per day per ICU = 40 × 80= Rs. 3200. • Cost per month per ICU = 3200 × 30= Rs. 96,000. • Cost per bed per month = 96000/44= Rs. 2182. Cost of radiograph if done using PACS is as follows: • Cost of X-ray film — NIL.
Journal of Anaesthesiology Clinical Pharmacology | July-September 2014 | Vol 30 | Issue 3
447
Copyright of Journal of Anaesthesiology Clinical Pharmacology 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.
