The Journal of Craniofacial Surgery
Brief Clinical Studies
and tumor cells that were showing extensive erythrocyte extravasation at the subepithelial space (Figs. 2, 3). On immunohistochemical staining, tumor cells were positive for vimentin, CD34, CD31, and HHV-8 and negative for cytokeratin, S-100, desmin, and smooth muscle actin (Figs. 4, 5). A diagnosis of KS was established. Currently, 12 years after the operation, the patient is still free of recurrence. Figures 2 and 3 show spindle-shaped cells (hematoxylin-eosin [H-E], 40 and 100) that were pleomorphic and mitotic; between them, there were vascular ducts. Figures 4 and 5 show immunohistochemical staining, 40, of CD34 and HHV-8.
DISCUSSION In this report, we present an old male patient diagnosed with solitary epiglottis KS. Moritz Kaposi had observed an unusual tumor, a small brownish-red to bluish-red cutaneous nodule that affected mainly the skin of the lower extremities multifocally.2 Until the end of 1970, there were only a few KSs reported in the literature, mostly from the Mediterranean countries, Greece, Italy, Israel, and also from Central Africa. Until 1980, KS was considered a slowly growing malignancy with a multicentric characteristic. In 1981, a dermatologist, Dr Friedman-Kien, discovered some cases of KS in homosexual young men and pointed out the association of KS with AIDS. Several etiopathologic factors were described for the development of KS, such as genetic factors (because of the geographic and racial distribution) and infectious/biologic factors (mainly viruses HIV-1, human papillomavirus, hepatitis B virus, cytomegalovirus, and HHV-6 and Mycoplasma penetrans and Chlamydia trachomatis). In 1994, a new herpes virus, HHV-8, was described by Chang et al. The DNA of this virus was found in tissues of patients with AIDS/KS but not in tissues of patients with only AIDS. The following reports showed that the HHV-8 DNA was traced in all 4 types of KS except in AIDS/KS patients. Since then, HHV-8 was thought be necessary for KS development, and the course of disease is mainly directed by immunity of the patient. The type of KS that is associated with AIDS is reported in western countries to be between 1,000 and 77,000 times more common than the KS not associated with HIV.4 Three clinical forms of KS are reported: localized nodular, locally aggressive, and generalized.4The KS lesions are classified into 6 stages: patch, plaque, nodular, lymphadenopathic, infiltrative, and
& Volume 25, Number 3, May 2014
florid. Type I KS (classic) characteristically shows a slow, indolent course and a tendency to occur multifocally as cutaneous lesions of the lower extremities and the trunk. Visceral involvement is rare but mostly occurs in type II and of course type IV. The lymph nodes, the gastrointestinal tract, and the lungs are the sites that are mostly included in visceral KS. Type II KS (African) has 2 variants: adult (cutaneous) variant and childhood (lymphadenopathic/visceral) variant. Type III KS is mainly associated with transplantation but has been reported in the context of other immunosuppressive conditions/treatment. In contrast to type IV KS, which usually presents as a disseminated, fulminant form, non-AIDS KS rarely affects mucous membranes, and head and neck mucosal involvement is even more rare.5,7
CONCLUSIONS In conclusion, to our knowledge, this is the second reported case of a classic Mediterranean KS located in the supraglottic area. Classic Mediterranean KS should be kept in mind for the differential diagnosis of laryngeal tumors.
REFERENCES 1. Pantanowitz L, Dezube BJ. Kaposi sarcoma in unusual locations. BMC Cancer 2008;8:190 2. Taheri S, Afsharmoghadam N, Berjis N, et al. Solitary laryngeal Kaposi sarcoma in a kidney transplant patient. Iran J Kidney Dis 2012;6:222Y224. Erratum in: Iran J Kidney Dis. 2012 Sep;6(5):395 3. Chang Y, Cesarman E, Pessin MS, et al. Identification of herpes virus-like DNA sequences in AIDS-associated Kaposi’s sarcoma. Science 1994;266:1865Y1869 4. Patrikidou A, Vahtsevanos K, Charalambidou M, et al. Non-AIDS Kaposi’s sarcoma in the head and neck area. Head Neck 2009;31:260Y268 5. Marsot-Dupuch K, Quillard J, Meyohas MC. Head and neck lesions in the immunocompromised host. Eur Radiol 2004;14:E155YE167 6. Angouridakis N, Constantinidis J, Karkavelas G, et al. Classic (Mediterranean) Kaposi’s sarcoma of the true vocal cord: a case report and review of the literature. Eur Arch Otorhinolaryngol 2006;263:537Y540 7. Alkhuja S, Menkel R, Patel B, et al. Stridor and difficult airway in an AIDS patient. AIDS Patient Care STDS 2001;15:293Y295
Transient and Isolated Neurogenic Blepharoptosis After Medial Orbital Wall Reconstruction FIGURE 4. Immunochemical staining-X40: CD34.
FIGURE 5. Immunohistochemical staining: x 40-HHV8.
1106
Hyunsuk Song, MD, Seong Yoon Lim, MD, Myong Chul Park, MD, PhD, Il Jae Lee, MD, PhD, Dong Ha Park, MD Abstract: Neurogenic blepharoptosis related to orbital surgery is very rare and only 1 report was published in the literature. This report presents 1 case of transient and isolated neurogenic blepharoptosis after medial orbital wall reconstruction. A 12-year-old male patient who suffered from periorbital trauma visited our hospital with right periorbital pain. During the physical examination, mild ecchymosis and eyelid edema were reported; however, there were no signs of either limitation of ocular motion or anisocoria. On * 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 3, May 2014
the orbital CT images, a 17 mm 20 mmYsized medial orbital bony defect was observed and the medial rectus muscle and orbital fat were herniated. The operation was performed 12 days after injury and the transcaruncular approach was used to reach the medial orbital wall. After the operation, he had right side blepharoptosis with mild eyelid edema and ecchymosis. However, ocular movement was normal and there were no signs of anisocoria. He did not receive any additional medication for blepharoptosis and was discharged 3 days postoperation. By the ninth day of postoperative recovery, the patient still suffered from right blepharoptosis with no levator palpebrae superioris muscle function. We prescribed a low dose of oral corticosteroid and the patient was monitored on a weekly basis. Finally, he recovered completely with normal symmetric eyelid position and levator function.
Brief Clinical Studies
FIGURE 1. A, Preoperative clinical view. B, Coronal view of preoperative CT. C, Axial view of preoperative CT.
Key Words: Neurogenic blepharoptosis, medial orbital wall
I
solated neurogenic blepharoptosis induced by peripheral oculomotor nerve injury is rare and is usually caused by intracranial compression lesions such as pituitary tumor and intracranial aneurysm, or trauma.1Y3 Neurogenic blepharoptosis related to orbital surgery is very rare, and to the authors’ knowledge, only one other report has been published in the existing literature.4 While Jung and Chi successfully treated postoperative blepharoptosis with early high-dose steroid therapy, this report presents a case of complete neurogenic blepharoptosis recovery without high-dose steroid therapy after medial orbital wall reconstruction.4
FIGURE 2. A, Postoperative day 9: right upper eyelid ptosis was noted. B, Coronal view of postoperative CT. C, Axial view of postoperative CT.
CLINICAL REPORT The patient involved was a 12-year-old boy who was kicked by his friend and suffered from right periorbital pain. During the physical examination, mild ecchymosis and eyelid edema were reported (Fig. 1A); however there were no signs of either limitation of ocular motion or anisocoria. On the orbital CT images, a 17 mm 20 mmY sized right medial orbital bony defect was observed and the medial rectus muscle and orbital fat were herniated through the bony defect (Figs. 1B and C). The defect almost reached the superior orbital wall. The operation was performed 12 days after injury and the transcaruncular approach was used to reach the medial orbital wall. The dissection was made posterior to the Horner muscle in a direction targeted to the posterior lacrimal crest. After reaching the periosteum, the periosteum was incised and elevated. The herniated periorbital tissue was repositioned to its original position and an absorbable plate (Macropore) was inserted to the medial orbital wall defect (Figs. 2B and C). After the operation, the patient suffered from right side blepharoptosis with mild eyelid edema and ecchymosis. However, ocular movement was normal and no anisocoria was reported. At that time, we presumed that blepharoptosis was induced by eyelid From the Department of Plastic and Reconstructive Surgery, Ajou University Hospital, Suwon, Korea. Received December 5, 2013. Accepted for publication January 6, 2014. Address correspondence and reprint requests to Dong Ha Park, MD, Department of Plastic and Reconstructive Surgery, Ajou University Hospital, 164, World Cup Road, Yeongtong-gu, Suwon, Gyeonggi-do, 443-380, Korea; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000719
FIGURE 3. Postoperative day 23: complete recovery from right blepharoptosis.
edema; therefore, the patient was not prescribed any additional medication aside from antibiotics and analgesics. He was discharged on day 3 of postoperative recovery and visited the outpatient clinic on postoperative day 9. At that time, the patient still suffered from right side blepharoptosis with no levator palpebrae superioris muscle function (Fig. 2A). After searching the Medline database, only 1 report was found regarding postoperative blepharoptosis related to orbital surgery, and we then prescribed a low dose of oral corticosteroid (16 mg/day for 5 days), rather than a high dose of steroid.4 Subsequently, the patient was monitored every week until his complete recovery on postoperative day 23 (Fig. 3).
DISCUSSION Operative reconstruction of the medial orbital wall is warranted to prevent enophthalmos and the correction of diplopia, and the transcaruncular approach is widely used for reconstruction.5 The transcaruncular approach to the medial orbital wall was first described in 1998 and complications can include injury of Horner muscle, lacrimal sac, and medial rectus muscle.6 Isolated neurogenic blepharoptosis is seldom encountered, and only one report has been published regarding postoperative neurogenic blepharoptosis after orbital surgery.4 We operated on 72 cases of medial orbital wall fracture between January 2008 and September 2013, and we experienced only 1 case of postoperative blepharoptosis. In this case, the
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
1107
The Journal of Craniofacial Surgery
Brief Clinical Studies
injury site appeared to be the oculomotor nerve branch to the levator palpebrae superioris muscle because other oculomotor nerve functions, including the superior rectus muscle function, were intact. The pathophysiology can be explained by 2 mechanisms. One is neurapraxia caused by pressure-induced ischemia. Because the bony defect was large and extended almost to the superior orbital wall, the area of dissection involved a part of superior orbital wall. The resulting traction of superior orbital content induced local high pressure on the superior branch of oculomotor nerve area. The second is stretching injury of oculomotor nerve branch to the levator palpebrae superioris muscle, resulting from traction of the orbital content. Jung and Chi reported 3 cases of neurogenic blepharoptosis after medial orbital wall reconstruction in which all cases were treated successfully with early high-dose steroid therapy (1 mg/kg per day for 4 days).4 However in our case, without initial high-dose steroid treatment, the patient recovered completely with normal symmetric eyelid position and levator function. This finding proves that isolated neurogenic blepharoptosis after medial orbital wall reconstruction heals spontaneously and is a favorable disease.
REFERENCES 1. Bartleson JD, Trautmann JC, Sundt TM Jr. Minimal oculomotor nerve paresis secondary to unruptured intracranial aneurysm. Arch Neurol1986;43:1015Y1020 2. Small KW, Buckley EG. Recurrent blepharoptosis secondary to a pituitary tumor. Am J Ophthalmol 1988;106:760Y761 3. McCulley TJ, Kersten RC, Yip CC, et al. Isolated unilateral neurogenic blepharoptosis secondary to eyelid trauma. Am J Ophthalmol 2002;134:626Y627 4. Jung JW, Chi MJ. Temporary unilateral neurogenic blepharoptosis after orbital medial wall reconstruction: 3 cases. Ophthalmologica 2008;222:360Y362 5. Baumann A, Ewers R. Transcaruncular approach for reconstruction of medial orbital wall fracture. Int J Oral Maxillofac Surg 2000;29:264Y267 6. Balch KC, Goldberg RA, Green JP. The transcaruncular approach to the medial orbit and ethmoid sinus. A cosmetically superior option to the cutaneous (Lynch) incision. Facial Plast Surg Clin North Am 1998;6:71Y77
A Randomized Controlled Clinical Trial to Evaluate Blood Pressure Changes in Patients Undergoing Extraction under Local Anesthesia With Vasopressor Use Marcelo Jose´ Uzeda,* Brenda Moura,* Rafael Seabra Louro, MD, PhD,Þ Licı´nio Esmeraldo da Silva, PhD,þ Moˆnica Diuana Calasans-Maia, MD, PhDÞ Abstract: The control of hypertensive patients’ blood pressure and heart rate using vasoconstrictors during surgical procedures under anesthesia is still a major concern in everyday surgical practice. This clinical trial aimed to evaluate the variation of blood pressure and
1108
& Volume 25, Number 3, May 2014
heart rate in nonhypertensive and controlled hypertensive voluntary subjects undergoing oral surgery under local anesthesia with lidocaine hydrochloride and epinephrine at 1:100,000 (Alphacaine; DFL, Brazil), performed in the Oral Surgery Department, Dentistry School, Fluminense Federal University. In total, 25 voluntary subjects were divided into 2 groups: nonhypertensive (n = 15) and controlled hypertensives (n = 10). Blood pressure and heart rate were measured at 4 different times: T0, in the waiting room; T1, after placement of the surgical drapes; T2, 10 minutes after anesthesia injection; and T3, at the end of the surgical procedure. A statistically significant difference (P < 0.05) between the groups was found at times T0 and T2 for the systolic pressure but only at time T0 for the diastolic pressure. The assessment of the heart rate of both groups showed a statistically significant difference (P < 0.05) at time T1. An analysis of the employed anesthetic volume indicated no statistically significant difference (P 9 0.05) between the amount administered to nonhypertensive and hypertensive subjects. It was concluded that the local anesthetics studied could safely be used in controlled hypertensive and nonhypertensive patients in compliance with the maximum recommended doses. Key Words: Tooth extraction, hypertension, epinephrine
H
ypertension is the most common cardiovascular disease worldwide and is a major risk factor for complications, such as cerebrovascular accidents and myocardial infarction.1Y5 Despite preventative efforts that follow global trends, previous research has shown that in Brazil, the proportion of Brazilians diagnosed with hypertension increased over 5 years, from 21.6% in 2006 to 23.3% in 2010.1 According to the World Health Organization (WHO), hypertension is indicated by a blood pressure equal to or greater than 140 mm Hg 90 mm Hg. The ideal blood pressure, the condition in which the individual has the lowest cardiovascular risk, is 120 mm Hg 80 mm Hg1Y6 (Table 1). Dental surgical procedures can generate disturbances in many patients who develop psychosomatic changes during treatment. The stress generated by pain, anxiety, and distress can cause changes in blood pressure and heart rate.1Y3,6,7 Subjects with hypertension are part of a special group of patients because these individuals are more likely to experience the complications of hypertensive crises, such as angina, heart attack, and stroke (ischemic or hemorrhagic). Furthermore, high blood pressure may render hemostasis during surgery difficult. The control of blood pressure and heart rate during outpatient surgical procedures in patients with hypertension is a major concern of the oral surgeon in everyday practice, and there is still doubt and uncertainty regarding the use of anesthetics with vasoconstrictors. An anesthetic is usually associated with a vasoconstrictor, such as epinephrine or norepinephrine, which slows systemic absorption by acting on alpha-adrenergic receptors in the smooth muscles of blood vessels, thereby prolonging the action and From the *Dentistry School, †Oral Surgery Department, Dentistry School, and ‡Statistics Department, Fluminense Federal University, Rio de Janeiro, Brazil. Received May 8, 2013. Accepted for publication January 7, 2014. Address correspondence and reprint requests to Dr Moˆnica Diuana CalasansMaia, Av. Rui Barbosa, 582/501, Flamengo, 22250-020 Rio de Janeiro, Brazil; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000736
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Brief Clinical Studies
and tumor cells that were showing extensive erythrocyte extravasation at the subepithelial space (Figs. 2, 3). On immunohistochemical staining, tumor cells were positive for vimentin, CD34, CD31, and HHV-8 and negative for cytokeratin, S-100, desmin, and smooth muscle actin (Figs. 4, 5). A diagnosis of KS was established. Currently, 12 years after the operation, the patient is still free of recurrence. Figures 2 and 3 show spindle-shaped cells (hematoxylin-eosin [H-E], 40 and 100) that were pleomorphic and mitotic; between them, there were vascular ducts. Figures 4 and 5 show immunohistochemical staining, 40, of CD34 and HHV-8.
DISCUSSION In this report, we present an old male patient diagnosed with solitary epiglottis KS. Moritz Kaposi had observed an unusual tumor, a small brownish-red to bluish-red cutaneous nodule that affected mainly the skin of the lower extremities multifocally.2 Until the end of 1970, there were only a few KSs reported in the literature, mostly from the Mediterranean countries, Greece, Italy, Israel, and also from Central Africa. Until 1980, KS was considered a slowly growing malignancy with a multicentric characteristic. In 1981, a dermatologist, Dr Friedman-Kien, discovered some cases of KS in homosexual young men and pointed out the association of KS with AIDS. Several etiopathologic factors were described for the development of KS, such as genetic factors (because of the geographic and racial distribution) and infectious/biologic factors (mainly viruses HIV-1, human papillomavirus, hepatitis B virus, cytomegalovirus, and HHV-6 and Mycoplasma penetrans and Chlamydia trachomatis). In 1994, a new herpes virus, HHV-8, was described by Chang et al. The DNA of this virus was found in tissues of patients with AIDS/KS but not in tissues of patients with only AIDS. The following reports showed that the HHV-8 DNA was traced in all 4 types of KS except in AIDS/KS patients. Since then, HHV-8 was thought be necessary for KS development, and the course of disease is mainly directed by immunity of the patient. The type of KS that is associated with AIDS is reported in western countries to be between 1,000 and 77,000 times more common than the KS not associated with HIV.4 Three clinical forms of KS are reported: localized nodular, locally aggressive, and generalized.4The KS lesions are classified into 6 stages: patch, plaque, nodular, lymphadenopathic, infiltrative, and
& Volume 25, Number 3, May 2014
florid. Type I KS (classic) characteristically shows a slow, indolent course and a tendency to occur multifocally as cutaneous lesions of the lower extremities and the trunk. Visceral involvement is rare but mostly occurs in type II and of course type IV. The lymph nodes, the gastrointestinal tract, and the lungs are the sites that are mostly included in visceral KS. Type II KS (African) has 2 variants: adult (cutaneous) variant and childhood (lymphadenopathic/visceral) variant. Type III KS is mainly associated with transplantation but has been reported in the context of other immunosuppressive conditions/treatment. In contrast to type IV KS, which usually presents as a disseminated, fulminant form, non-AIDS KS rarely affects mucous membranes, and head and neck mucosal involvement is even more rare.5,7
CONCLUSIONS In conclusion, to our knowledge, this is the second reported case of a classic Mediterranean KS located in the supraglottic area. Classic Mediterranean KS should be kept in mind for the differential diagnosis of laryngeal tumors.
REFERENCES 1. Pantanowitz L, Dezube BJ. Kaposi sarcoma in unusual locations. BMC Cancer 2008;8:190 2. Taheri S, Afsharmoghadam N, Berjis N, et al. Solitary laryngeal Kaposi sarcoma in a kidney transplant patient. Iran J Kidney Dis 2012;6:222Y224. Erratum in: Iran J Kidney Dis. 2012 Sep;6(5):395 3. Chang Y, Cesarman E, Pessin MS, et al. Identification of herpes virus-like DNA sequences in AIDS-associated Kaposi’s sarcoma. Science 1994;266:1865Y1869 4. Patrikidou A, Vahtsevanos K, Charalambidou M, et al. Non-AIDS Kaposi’s sarcoma in the head and neck area. Head Neck 2009;31:260Y268 5. Marsot-Dupuch K, Quillard J, Meyohas MC. Head and neck lesions in the immunocompromised host. Eur Radiol 2004;14:E155YE167 6. Angouridakis N, Constantinidis J, Karkavelas G, et al. Classic (Mediterranean) Kaposi’s sarcoma of the true vocal cord: a case report and review of the literature. Eur Arch Otorhinolaryngol 2006;263:537Y540 7. Alkhuja S, Menkel R, Patel B, et al. Stridor and difficult airway in an AIDS patient. AIDS Patient Care STDS 2001;15:293Y295
Transient and Isolated Neurogenic Blepharoptosis After Medial Orbital Wall Reconstruction FIGURE 4. Immunochemical staining-X40: CD34.
FIGURE 5. Immunohistochemical staining: x 40-HHV8.
1106
Hyunsuk Song, MD, Seong Yoon Lim, MD, Myong Chul Park, MD, PhD, Il Jae Lee, MD, PhD, Dong Ha Park, MD Abstract: Neurogenic blepharoptosis related to orbital surgery is very rare and only 1 report was published in the literature. This report presents 1 case of transient and isolated neurogenic blepharoptosis after medial orbital wall reconstruction. A 12-year-old male patient who suffered from periorbital trauma visited our hospital with right periorbital pain. During the physical examination, mild ecchymosis and eyelid edema were reported; however, there were no signs of either limitation of ocular motion or anisocoria. On * 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 3, May 2014
the orbital CT images, a 17 mm 20 mmYsized medial orbital bony defect was observed and the medial rectus muscle and orbital fat were herniated. The operation was performed 12 days after injury and the transcaruncular approach was used to reach the medial orbital wall. After the operation, he had right side blepharoptosis with mild eyelid edema and ecchymosis. However, ocular movement was normal and there were no signs of anisocoria. He did not receive any additional medication for blepharoptosis and was discharged 3 days postoperation. By the ninth day of postoperative recovery, the patient still suffered from right blepharoptosis with no levator palpebrae superioris muscle function. We prescribed a low dose of oral corticosteroid and the patient was monitored on a weekly basis. Finally, he recovered completely with normal symmetric eyelid position and levator function.
Brief Clinical Studies
FIGURE 1. A, Preoperative clinical view. B, Coronal view of preoperative CT. C, Axial view of preoperative CT.
Key Words: Neurogenic blepharoptosis, medial orbital wall
I
solated neurogenic blepharoptosis induced by peripheral oculomotor nerve injury is rare and is usually caused by intracranial compression lesions such as pituitary tumor and intracranial aneurysm, or trauma.1Y3 Neurogenic blepharoptosis related to orbital surgery is very rare, and to the authors’ knowledge, only one other report has been published in the existing literature.4 While Jung and Chi successfully treated postoperative blepharoptosis with early high-dose steroid therapy, this report presents a case of complete neurogenic blepharoptosis recovery without high-dose steroid therapy after medial orbital wall reconstruction.4
FIGURE 2. A, Postoperative day 9: right upper eyelid ptosis was noted. B, Coronal view of postoperative CT. C, Axial view of postoperative CT.
CLINICAL REPORT The patient involved was a 12-year-old boy who was kicked by his friend and suffered from right periorbital pain. During the physical examination, mild ecchymosis and eyelid edema were reported (Fig. 1A); however there were no signs of either limitation of ocular motion or anisocoria. On the orbital CT images, a 17 mm 20 mmY sized right medial orbital bony defect was observed and the medial rectus muscle and orbital fat were herniated through the bony defect (Figs. 1B and C). The defect almost reached the superior orbital wall. The operation was performed 12 days after injury and the transcaruncular approach was used to reach the medial orbital wall. The dissection was made posterior to the Horner muscle in a direction targeted to the posterior lacrimal crest. After reaching the periosteum, the periosteum was incised and elevated. The herniated periorbital tissue was repositioned to its original position and an absorbable plate (Macropore) was inserted to the medial orbital wall defect (Figs. 2B and C). After the operation, the patient suffered from right side blepharoptosis with mild eyelid edema and ecchymosis. However, ocular movement was normal and no anisocoria was reported. At that time, we presumed that blepharoptosis was induced by eyelid From the Department of Plastic and Reconstructive Surgery, Ajou University Hospital, Suwon, Korea. Received December 5, 2013. Accepted for publication January 6, 2014. Address correspondence and reprint requests to Dong Ha Park, MD, Department of Plastic and Reconstructive Surgery, Ajou University Hospital, 164, World Cup Road, Yeongtong-gu, Suwon, Gyeonggi-do, 443-380, Korea; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000719
FIGURE 3. Postoperative day 23: complete recovery from right blepharoptosis.
edema; therefore, the patient was not prescribed any additional medication aside from antibiotics and analgesics. He was discharged on day 3 of postoperative recovery and visited the outpatient clinic on postoperative day 9. At that time, the patient still suffered from right side blepharoptosis with no levator palpebrae superioris muscle function (Fig. 2A). After searching the Medline database, only 1 report was found regarding postoperative blepharoptosis related to orbital surgery, and we then prescribed a low dose of oral corticosteroid (16 mg/day for 5 days), rather than a high dose of steroid.4 Subsequently, the patient was monitored every week until his complete recovery on postoperative day 23 (Fig. 3).
DISCUSSION Operative reconstruction of the medial orbital wall is warranted to prevent enophthalmos and the correction of diplopia, and the transcaruncular approach is widely used for reconstruction.5 The transcaruncular approach to the medial orbital wall was first described in 1998 and complications can include injury of Horner muscle, lacrimal sac, and medial rectus muscle.6 Isolated neurogenic blepharoptosis is seldom encountered, and only one report has been published regarding postoperative neurogenic blepharoptosis after orbital surgery.4 We operated on 72 cases of medial orbital wall fracture between January 2008 and September 2013, and we experienced only 1 case of postoperative blepharoptosis. In this case, the
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
1107
The Journal of Craniofacial Surgery
Brief Clinical Studies
injury site appeared to be the oculomotor nerve branch to the levator palpebrae superioris muscle because other oculomotor nerve functions, including the superior rectus muscle function, were intact. The pathophysiology can be explained by 2 mechanisms. One is neurapraxia caused by pressure-induced ischemia. Because the bony defect was large and extended almost to the superior orbital wall, the area of dissection involved a part of superior orbital wall. The resulting traction of superior orbital content induced local high pressure on the superior branch of oculomotor nerve area. The second is stretching injury of oculomotor nerve branch to the levator palpebrae superioris muscle, resulting from traction of the orbital content. Jung and Chi reported 3 cases of neurogenic blepharoptosis after medial orbital wall reconstruction in which all cases were treated successfully with early high-dose steroid therapy (1 mg/kg per day for 4 days).4 However in our case, without initial high-dose steroid treatment, the patient recovered completely with normal symmetric eyelid position and levator function. This finding proves that isolated neurogenic blepharoptosis after medial orbital wall reconstruction heals spontaneously and is a favorable disease.
REFERENCES 1. Bartleson JD, Trautmann JC, Sundt TM Jr. Minimal oculomotor nerve paresis secondary to unruptured intracranial aneurysm. Arch Neurol1986;43:1015Y1020 2. Small KW, Buckley EG. Recurrent blepharoptosis secondary to a pituitary tumor. Am J Ophthalmol 1988;106:760Y761 3. McCulley TJ, Kersten RC, Yip CC, et al. Isolated unilateral neurogenic blepharoptosis secondary to eyelid trauma. Am J Ophthalmol 2002;134:626Y627 4. Jung JW, Chi MJ. Temporary unilateral neurogenic blepharoptosis after orbital medial wall reconstruction: 3 cases. Ophthalmologica 2008;222:360Y362 5. Baumann A, Ewers R. Transcaruncular approach for reconstruction of medial orbital wall fracture. Int J Oral Maxillofac Surg 2000;29:264Y267 6. Balch KC, Goldberg RA, Green JP. The transcaruncular approach to the medial orbit and ethmoid sinus. A cosmetically superior option to the cutaneous (Lynch) incision. Facial Plast Surg Clin North Am 1998;6:71Y77
A Randomized Controlled Clinical Trial to Evaluate Blood Pressure Changes in Patients Undergoing Extraction under Local Anesthesia With Vasopressor Use Marcelo Jose´ Uzeda,* Brenda Moura,* Rafael Seabra Louro, MD, PhD,Þ Licı´nio Esmeraldo da Silva, PhD,þ Moˆnica Diuana Calasans-Maia, MD, PhDÞ Abstract: The control of hypertensive patients’ blood pressure and heart rate using vasoconstrictors during surgical procedures under anesthesia is still a major concern in everyday surgical practice. This clinical trial aimed to evaluate the variation of blood pressure and
1108
& Volume 25, Number 3, May 2014
heart rate in nonhypertensive and controlled hypertensive voluntary subjects undergoing oral surgery under local anesthesia with lidocaine hydrochloride and epinephrine at 1:100,000 (Alphacaine; DFL, Brazil), performed in the Oral Surgery Department, Dentistry School, Fluminense Federal University. In total, 25 voluntary subjects were divided into 2 groups: nonhypertensive (n = 15) and controlled hypertensives (n = 10). Blood pressure and heart rate were measured at 4 different times: T0, in the waiting room; T1, after placement of the surgical drapes; T2, 10 minutes after anesthesia injection; and T3, at the end of the surgical procedure. A statistically significant difference (P < 0.05) between the groups was found at times T0 and T2 for the systolic pressure but only at time T0 for the diastolic pressure. The assessment of the heart rate of both groups showed a statistically significant difference (P < 0.05) at time T1. An analysis of the employed anesthetic volume indicated no statistically significant difference (P 9 0.05) between the amount administered to nonhypertensive and hypertensive subjects. It was concluded that the local anesthetics studied could safely be used in controlled hypertensive and nonhypertensive patients in compliance with the maximum recommended doses. Key Words: Tooth extraction, hypertension, epinephrine
H
ypertension is the most common cardiovascular disease worldwide and is a major risk factor for complications, such as cerebrovascular accidents and myocardial infarction.1Y5 Despite preventative efforts that follow global trends, previous research has shown that in Brazil, the proportion of Brazilians diagnosed with hypertension increased over 5 years, from 21.6% in 2006 to 23.3% in 2010.1 According to the World Health Organization (WHO), hypertension is indicated by a blood pressure equal to or greater than 140 mm Hg 90 mm Hg. The ideal blood pressure, the condition in which the individual has the lowest cardiovascular risk, is 120 mm Hg 80 mm Hg1Y6 (Table 1). Dental surgical procedures can generate disturbances in many patients who develop psychosomatic changes during treatment. The stress generated by pain, anxiety, and distress can cause changes in blood pressure and heart rate.1Y3,6,7 Subjects with hypertension are part of a special group of patients because these individuals are more likely to experience the complications of hypertensive crises, such as angina, heart attack, and stroke (ischemic or hemorrhagic). Furthermore, high blood pressure may render hemostasis during surgery difficult. The control of blood pressure and heart rate during outpatient surgical procedures in patients with hypertension is a major concern of the oral surgeon in everyday practice, and there is still doubt and uncertainty regarding the use of anesthetics with vasoconstrictors. An anesthetic is usually associated with a vasoconstrictor, such as epinephrine or norepinephrine, which slows systemic absorption by acting on alpha-adrenergic receptors in the smooth muscles of blood vessels, thereby prolonging the action and From the *Dentistry School, †Oral Surgery Department, Dentistry School, and ‡Statistics Department, Fluminense Federal University, Rio de Janeiro, Brazil. Received May 8, 2013. Accepted for publication January 7, 2014. Address correspondence and reprint requests to Dr Moˆnica Diuana CalasansMaia, Av. Rui Barbosa, 582/501, Flamengo, 22250-020 Rio de Janeiro, Brazil; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000736
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
