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1/471. Fatal cardiac ischaemia associated with prolonged desflurane anaesthesia and administration of exogenous catecholamines.

    PURPOSE: Four cardiac ischaemic events are reported during and after prolonged anaesthesia with desflurane. CLINICAL FEATURES: We have evaluated desflurane in 21 consecutive patients undergoing advanced head and neck reconstructive surgery. Four deaths occurred which were associated with cardiac ischaemic syndromes either during or immediately after operation. All patients in the study received a similar anaesthetic. This comprised induction with propofol and maintenance with alfentanil and desflurane in oxygen-enriched air. Inotropic support (either dopamine or dobutamine in low dose, 5 micrograms.kg.min-1) was provided as part of the anaesthetic technique in all patients. Critical cardiovascular incidents were observed in each of the four patients during surgery. These were either sudden bradycardia or tachycardia associated with ST-segment electrocardiographic changes. The four patients who died had a documented past history of coronary heart disease and were classified American Society of Anesthesiologists (ASA) II or III. One patient (#2) did not survive anaesthesia and surgery and the three others died on the first, second and twelfth postoperative days. Enzyme increases (CK/CK-MB) were available in three patients and confirmed myocardial ischaemia. CONCLUSION: These cases represent an unexpected increase in the immediate postoperative mortality for these types of patients and this anaesthetic sequence.
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2/471. Frey's syndrome after carotid endarterectomy.

    Frey's syndrome after carotid endarterectomy (CEA) is due to iatrogenic injury to the auriculotemporal nerve and has not been previously reported. One month after uncomplicated CEA, our patient noted an erythematous flush and copious drainage of clear fluid from the superior portion of his neck wound whenever he ate, or smelled or thought of food. These symptoms lasted for 2 months and eventually resolved without intervention. The cause and treatment of Frey's syndrome is also described.
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3/471. Management of secondary soft-tissue deficits following microsurgical head and neck reconstruction by means of another free flap.

    Secondary soft-tissue deficits may develop following a microsurgical reconstruction in the head and neck region because of inadequate planning or chronic effects of radiotherapy. Although most cases could be managed with alternative methods, free flaps might be necessary in difficult cases. Herein are described 11 cases of microsurgical head and neck reconstruction in which secondary soft-tissue deficits required transfer of another soft-tissue free flap. All patients had malignant tumors treated with surgical resection, and their defects were reconstructed with free flaps. Seven patients received either preoperative or postoperative adjunctive radiotherapy. These patients gradually developed signs and symptoms of soft-tissue deficiency in the reconstructed area, and a soft-tissue free flap transfer was required for treatment within an average of 21.5 months of their initial reconstruction. Five rectus abdominis, one rectus femoris, one latissimus dorsi, one tensor fasciae latae myocutaneous, one radial forearm, one medial arm, and one dorsalis pedis flap were used for this purpose. All flaps survived completely. The average follow-up time was 32 months. Significant improvement was achieved in all cases, and no further major surgical procedures were required. Secondary soft-tissue deficits that could not be predicted or prevented during the initial microsurgical reconstruction may be treated successfully by a subsequent free soft-tissue transfer in selected cases.
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4/471. Use of the flexible cystoscope as a vaginoscope to aid in the diagnosis of artificial sling erosion.

    Two patients with bladder neck suspension by artificial slings presented with complaints of vaginal pain and drainage as well as irritative voiding. Pelvic examination and flexible cystoscopy were negative. Flexible vaginoscopy detected sling erosion in both. Vaginoscopy is a valuable adjunct procedure in detecting this problem.
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5/471. The prevention of irreversible lung changes following reversible phrenic nerve paralysis.

    phrenic nerve paralysis frequently follows operations on the neck such as resection of a cervical or first rib. It all too often passes unrecognised or is incorrectly treated, leading to permanent lung damage which may be severe enough as to result in a functional pneumonectomy. This is particularly unfortunate since the phrenic nerve paralysis is usually temporary. Three case histories are described of reversible paralysis of the phrenic nerve in which, due to prompt diagnosis, the ensuing lung changes were either prevented or immediatley treated. Intermittent assisted respiration with a Monaghan respirator was used to provide nebulised inhalations of mesna several times a day. The method is applicable via a tracheostomy, an endotracheal tube or a simple mouthpiece. The latter is illustrated. The therapy is not hindered by immobilisation of the head and neck and the level of consciousness of the patients is of no importance. Many chest x-rays demonstrate the rapid clearing of the lungs achieved. All three patients were discharged with perfectly normal lungs.
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6/471. The place of irradiation in the treatment of malignant tumors of the salivary glands.

    1. radiation therapy is not indicated after surgical removal with adequate margins of low-grade tumor. 2. radiation therapy is indicated with a) Inadequate surgical margins in low-grade tumors b) All high-grade tumors c) All recurrent malignant tumors 3. Irradiation of nerve pathways is indicated with demonstrated nerve and perineural invasion and/or with adenoicystic carcinoma. 4. Irradiation of the entire ipsilateral neck is indicated a) Wtih high-grade tumors unless radical neck dissection shows negative nodes b) In the place of radical neck dissection.
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7/471. Early postoperative esophageal obstruction caused by enteral feeding concretions in patients who have undergone laryngectomy.

    We report two cases of tube-feeding concretions causing esophageal obstruction in patients after laryngectomy. The cause of tube-feeding concretions is unknown at this time but probably involves esophageal stasis caused by esophageal dysmotility, protein precipitation by acidic gastric contents, tube damage, and concomitant use of sucralfate and other antacids. Although this is a rare complication of nasogastric feedings, the diagnosis should be entertained in cases in which postoperative esophageal obstruction is noted in head and neck surgical patients.
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8/471. Transient mutism resolving into cerebellar speech after brain stem infarction following a traumatic injury of the vertebral artery in a child.

    A 3.7-year-old girl presented with an anterior neck injury followed by progressive subcutaneous emphysema and loss of consciousness. After resuscitation, a laceration on the first tracheal cartilage was closed surgically. As she was extubated one week later, she was found to have right hemiplegia and muteness. MRI showed a T2-bright lesion on the tegmentum of the left midbrain down to the upper pons. Right vertebral angiography disclosed an intimal flap with stenosis at the C3 vertebral level presumably caused by a fracture of the right C3 transverse process later confirmed in a cervical 3D-CT scan. Her muteness lasted for 10 days, after which she began to utter some comprehensible words in a dysarthric fashion. Her neurological deficits showed improvement within 3 months of her admission. Transient mutism after brain stem infarction has not been reported previously. We discuss the anatomical bases for this unusual reversible disorder in the light of previous observations and conclude that bilateral damage to the dentatothalamocortical fibers at the decussation of the superior cerebellar peduncle may have been responsible for her transient mutism.
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9/471. hypoglossal nerve injury as a complication of anterior surgery to the upper cervical spine.

    Injury to the hypoglossal nerve is a recognised complication after soft tissue surgery in the upper part of the anterior aspect of the neck, e.g. branchial cyst or carotid body tumour excision. However, this complication has been rarely reported following surgery of the upper cervical spine. We report the case of a 35-year-old woman with tuberculosis of C2-3. She underwent corpectomy and fusion from C2 to C5 using iliac crest bone graft, through a left anterior oblique incision. She developed hypoglossal nerve palsy in the immediate postoperative period, with dysphagia and dysarthria. It was thought to be due to traction neurapraxia with possible spontaneous recovery. At 18 months' follow-up, she had a solid fusion and tuberculosis was controlled. The hypoglossal palsy persisted, although with minimal functional disability. The only other reported case of hypoglossal lesion after anterior cervical spine surgery in the literature also failed to recover. It is concluded that hypoglossal nerve palsy following anterior cervical spine surgery is unlikely to recover spontaneously and it should be carefully identified.
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10/471. An unusual complication of Cloward's procedure presenting to the otolaryngologist.

    We present the case of a 51-year-old lady who developed a CSF leak following a Cloward's procedure (anterior cervical surgery with fusion), which settled with conservative management. Two months following the surgery she was assessed by an otolaryngologist for persistent dysphagia and a swelling in the anterior triangle of her neck. A computed tomography (CT) scan identified a fluid-filled mass displacing the trachea and communicating with the anterior cervical vertebrae, thus confirming the persistence of a CSF leak.
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