The Journal of Craniofacial Surgery • Volume 25, Number 4, July 2014

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the angle of the mandible and adjacent to the images of C3, C4, or both radiopacities, superimposed over the prevertebral soft tissue.3 Therefore, any craniofacial specialist should recognize calcifications in maxillofacial images, even those accidentally discovered on radiographs for other purposes.

However, there is no doubt that the subject had reached adulthood and had worked, for a long time, a tiring and demanding employment. About the etiology of the ankylosis, a careful analysis has shown a poorly consolidated right arm fracture that seems in favor of a traumatic event.

Júlio César Silva de Oliveira, DDS Department of Surgery and Integrated Clinic Araçatuba Dental School Universidade Estadual Paulista Júlio de Mesquita Filho Sao Paulo, Brazil [email protected]

Paolo Arangio, MD, PhD Valerio Ramieri, MD Department of Maxillofacial Surgery Sapienza-Università di Roma Rome, Italy

Fernanda Brasil Daura Jorge Boos, DDS Julierme Ferreira Rocha, DDS, MSc Daniela Ponzoni, DDS, MSc Francisley Ávila de Souza, DDS, MSc Idelmo Rangel Garcia Jr, DDS, MSc Department of Surgery and Integrated Clinic Araçatuba Dental School Universidade Estadual Paulista Júlio de Mesquita Filho Sao Paulo, Brazil

REFERENCES 1. Friedlander AH, Lande A. Panoramic radiographic identification of carotid arterial plaques. Oral Surg Oral Med Oral Pathol 1981;52:102–104 2. MacDonald D, Chan A, Harris A, et al. Diagnosis and management of calcified carotid artery atheroma: dental perspectives. Oral Surg Oral Med Oral Pathol Oral Radiol 2012;114:533–547 3. Carter LC. Discrimination between calcified triticeous cartilage and calcified carotid atheroma on panoramic radiography. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:108–110

Re: 2000 Years Temporomandibular Joint Ankylosis in Ancient Rome To the Editor: We report some additional information to the article 2000 Years Temporomandibular Joint Ankylosis in Ancient Rome1 as a result of recent studies by the Soprintendenza Speciale per i Beni Archeologici di Roma-Servizio di Antropologia in archaeological excavations near Castel Malnome (Municipio Roma XV). During these archaeological excavations, an imperial age burial of 277 corpses was unearthed. Only 270 were recovered, 263 cremated and 7 buried, with the latter lying in a supine position, except for a young woman who was in a prone position and 2 others who were lying on their right side instead. Dealing with the report of 2 cases of temporomandibular joint ankylosis, further investigation highlighted how one of the 2 was not properly considered as the effect of pathology itself. For this reason, we would like to clarify that we are reporting just 1 case of temporomandibular joint bilateral ankylosis. This skull belonged to a man who was a laborer aged between 30 and 35 years. It showed bilateral bone ankylosis, totally involving articular surfaces, associated with a discrepancy in growth between the maxilla and mandible, which was underdeveloped in sagittal and vertical lengths. This was suggestive for a pathologic process that occurred after the growth peak and before the complete skeletal development.

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Valentino Vellone, MD Department of Maxillofacial Surgery Sapienza-Università di Roma Rome, Italy [email protected] Piero Cascone, MD, PhD Giorgio Iannetti, MD, PhD Department of Maxillofacial Surgery Sapienza-Università di Roma Rome, Italy Paola Catalano, MD Soprintendenza Speciale per i Beni Archeologici di Roma-Servizio di Antropologia

REFERENCE 1. Arangio P, Ramieri V, Vellone V, et al. 2000 Years Temporomandibular Joint Ankylosis in Ancient Rome. J Craniofac Surg 2013;24:1053–1054

Mean Platelet Volume May Not Be Beneficial for the Management of Patients With Adenoid Hypertrophy To the Editor We read with great interest the research article by Kucur et al1 titled Mean Platelet Volume Levels in Children With Adenoid Hypertrophy. The authors investigated whether mean platelet volume (MPV) is higher in patients with adenoid hypertrophy and whether higher MPV levels can be reduced by adenoidectomy. They found that MPV was higher in patients with adenoid hypertrophy than in healthy subjects and that there is a significant reduction in MPV levels after adenoidectomy. They concluded that the measurement of MPV might be a quick, safe, and reliable guide for the assessment of adenoid hypertrophy. We would like to comment on this article. The authors stated that MPV was a marker of platelet function, and their study was the first study to evaluate platelet function by measuring MPV levels in children with adenoid hypertrophy. Firstly, MPV is not a marker of platelet function. The platelet indices including MPV are not used as platelet function tests.2 Turbidimetric platelet aggregometry is the current criterion standard test used to assess platelet function. Beyan et al3 investigated whether platelet indices had a correlation with platelet aggregation responses using turbidimetric platelet aggregometry in healthy adults. They found no © 2014 Mutaz B. Habal, MD

Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

The Journal of Craniofacial Surgery • Volume 25, Number 4, July 2014

correlation between any platelet indices including platelet count, MPV, platelet mass, platelet distribution width, as well as plateletcrit and platelet aggregation responses induced with adenosine diphosphate, collagen, and epinephrine. Recently, De Luca et al4 reported a study that investigated whether MPV was associated with platelet reactivity and the extent of coronary artery disease among patients with diabetes. They performed a cohort study including 1016 consecutive patients with diabetes undergoing coronary angiography. They found that MPV was not related to platelet reactivity and concluded that MPV may not be considered a risk factor for coronary artery disease among patients with diabetes. Therefore, it does not seem possible to use MPV as a marker of platelet function. On the other hand, the reliable detection of MPV is dependent on a number of variables, including time of analysis, method of analysis, anticoagulant used, and specimen storage temperature.5 The MPV is reported routinely in complete blood count, but it is not suitable because ethylenediaminetetraacetic acid (EDTA) induced changes over time.5 Platelet size changes induced by EDTA cause a progressive increase in MPV with impedance technology. When measured by optical methods, the MPV decreases nearly 10% because of a fall in the refractile index of the platelets because of dilution of cytoplasmic contents. Jackson and Carter6 showed that the MPV increases up to 30% within 5 minutes of exposure and increases further by 10% to 15% over the next 2 hours when using the impedance method. Lancé et al7 suggested that timing was important when measuring MPV and that optimal measuring time with EDTA should be 120 minutes after venipuncture. Also, the reference range of MPV is specific to the individual technologies. Different technologies for measuring the MPV give different results. Studies comparing results from these instruments have shown MPV differences of up to 40%.8 Because the measurement times of samples, method of analysis, and used technologies were unknown in this study, the validity and reliability of data were questionable. In conclusion, MPV may not be beneficial for the management of patients with adenoid hypertrophy. Cengiz Beyan, MD Department of Hematology Gulhane Military Medical Academy Ankara, Turkey [email protected]; [email protected] Esin Beyan, MD Department of Internal Medicine Kecioren Training and Research Hospital Ankara, Turkey

REFERENCES 1. Kucur C, Kulekci S, Zorlu A, et al. Mean platelet volume levels in children with adenoid hypertrophy. J Craniofac Surg 2014;25:e29–e31 2. Harrison P. Platelet function testing [UpToDate web site]. Available at: http://www.uptodate.com/contents/platelet-function-testing. Accessed January 17, 2014 3. Beyan C, Kaptan K, Ifran A. Platelet count, mean platelet volume, platelet distribution width, and plateletcrit do not correlate with optical platelet aggregation responses in healthy volunteers. J Thromb Thrombolysis 2006;22:161–164 4. De Luca G, Verdoia M, Cassetti E, et al. Mean platelet volume is not associated with platelet reactivity and the extent of coronary artery disease in diabetic patients. Blood Coagul Fibrinolysis 2013;24:619–624 5. Lancé MD, Sloep M, Henskens YM, et al. Mean platelet volume as a diagnostic marker for cardiovascular disease: drawbacks of preanalytical conditions and measuring techniques. Clin Appl Thromb Hemost 2012;18:561–568

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6. Jackson SR, Carter JM. Platelet volume: laboratory measurement and clinical application. Blood Rev 1993;7:104–113 7. Lancé MD, van Oerle R, Henskens YM, et al. Do we need time adjusted mean platelet volume measurements? Lab Hematol 2010;16:28–31 8. George TI. Automated hematology instrumentation [UpToDate web site]. Available at: http://www.uptodate.com/contents/automated-hematologyinstrumentation. Accessed January 17, 2014

Hypoglossal Paralysis After Intubation for Nasal Surgery To the Editor: Hypoglossal nerve palsy is a multietiologic condition and a rare complication of general anesthesia because XII nerve palsies have more frequently been reported in association with tumors, head trauma, stroke, multiple sclerosis, carotid endarterectomy, Guillain-Barré syndrome, and infection.1–6 The hypoglossal nerve innervates the muscles of the tongue and controls swallowing and speech.4 Hypoglossal nerve palsies usually present unilaterally with signs of dysarthria and dysphagia, and they are frequently associated with involvement of other cranial nerves and neurologic structures.3 The knowledge of the pathway of the hypoglossal nerve is fundamental to hypothesize the mechanism that may be responsible for hypoglossal nerve injury. The XII nerve originates from the hypoglossal nerve nucleus in the medulla oblongata between the olive and pyramid, leaves the cranium through the hypoglossal canal in the occipital bone, and descends between the internal jugular vein and the internal carotid artery until it reaches the lower border of the posterior belly of the digastric muscle, where it turns forward and medially. The nerve then continues anterior and superior to the greater cornu of the hyoid bone and enters the floor of the mouth deep to the posterior margin of the mylohyoid muscle, supplying motor innervation to both intrinsic and extrinsic lingual muscles.1–6 We present a case of isolated unilateral hypoglossal nerve paralysis after an uneventful tracheal intubation for nasal surgery. A 34-year-old man was scheduled for a rhinoseptoplasty with turbinoplasty under general anesthesia because of nasal respiratory insufficiency associated with nasal septal deviation and turbinate hypertrophy. His medical history included arterial hypertension in treatment with β-blockers. He was otherwise well and did not take any regular medication. General anesthesia was induced through intravenous administration of fentanyl 2 mcg/kg and propofol 2 mg/kg, and vecuronium 0.1 mg/kg was used for muscle paralysis and for the prevention of laryngospasm during insertion of the endotracheal tube. Then, a size-4 Macintosh blade was used and an orotracheal intubation was obtained with an 8-mm tube. No problems were encountered during the intubation. The endotracheal tube cuff was inflated, and the cuff air pressure was checked so that it did not exceed 20 cm H2O. Then, proper placement of the endotracheal tube was confirmed by bilateral breath sounds. During surgery, general anesthesia was maintained by sevoflurane in oxygen/air supplemented with remifentanil. The surgery was completed uneventfully within 60 minutes. No significant changes in cardiovascular or respiratory parameters occurred during the operation. The patient’s spontaneous ventilation was satisfactory. Finally, the endotracheal tube was carefully removed and the patient was transferred to the recovery unit. After 2 hours, the patient

© 2014 Mutaz B. Habal, MD

Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

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Mean platelet volume may not be beneficial for the management of patients with adenoid hypertrophy.

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