Retropharyngeal hematoma after stellate ganglion block: Analysis of 27 patients reported in the literature

BACKGROUND

Retropharyngeal hematoma (RPH) is rare; however, it causes airway obstruction and can be fatal. Stellate ganglion block (SGB) can cause RPH. The authors analyzed reports of patients with RPH after SGB to clarify the initial symptoms and signs, and the urgency of airway management.

METHODS

MEDLINE and Japana Centra Revuo Medicina were searched for reports of RPH after SGB using the following terms and key words: stellate ganglion block, complication, hematoma, and retropharyngeal hematoma.

RESULTS

The authors found 27 patients with RPH after SGB in the past 40 yr. The initial symptoms included neck pain (n = 10), dyspnea (n = 10), neck swelling (n = 8), and hoarseness (n = 5). The symptoms occurred 2 h or more after SGB in 14 patients (52%). Emergency airway management was needed in 21 patients (78%) because of airway obstruction. Among the 21 patients, orotracheal intubation was attempted first in 17 patients; however, it was unsuccessful in 5 patients who immediately needed emergency tracheostomy. Tracheal intubation was impossible by distortion of the anatomy of the markedly edematous pharyngolarynx. Failed airway management caused one death. There were no statistically significant predictors of the initial symptoms or signs for later emergency airway management.

CONCLUSIONS

RPH after SGB necessitates emergency airway management. Because airway obstruction cannot be predicted by the initial symptoms or signs, emergency airway management tools should be at hand, and the patency of the airway should be continuously evaluated after onset of RPH after SGB.

Severity of skin lesions of herpes zoster at the worst phase rather than age and involved region most influences the duration of acute herpetic pain

Duration of acute herpetic pain (AHP) in 1431 patients for whom treatment was begun within 14 days after the onset of herpes zoster (HZ) was analyzed with respect to age, involved region, and severity of skin lesions. All patients were treated with repeated sympathetic nerve blocks until their pain was almost nil. Severity of the skin lesions at the worst phase was defined as mild when they covered less than one-quarter of the primary dermatome, as severe when they covered more than three-quarters of the primary dermatome, and moderate if they were between mild and severe. Without taking into account the severity of skin lesions, the duration of AHP for those aged 60 years or over and for those with trigeminal involvement was significantly longer than for patients aged under 40 years (P < 0.01 and P < 0.001) and for patients with thoracic (P < 0.001) and lumbosacral (P < 0.01) involvement, respectively. However, duration of AHP was significantly longer with increase in the severity of skin lesions in all age groups (the mild group versus the moderate group, P < 0.01 and P < 0.001; the moderate group versus the severe group, P < 0.01 and P < 0.001). The mean duration of AHP for patients aged 60 years or over with mild skin lesions ranged from 17.4 to 22.9 days, while that for patients aged 30-59 years with severe skin lesions ranged from 37.2 to 50.1 days. In addition, duration of AHP was significantly longer with increase in the severity of skin lesions in all regions (the mild group versus the moderate group, P < 0.01 and P < 0.001; the moderate group versus the severe group, P < 0.05 and P < 0.001). The mean duration of AHP for those with trigeminal involvement with mild skin lesions was 19.5 days, while the range was from 51.3 to 55.0 days for patients with severe skin lesions involving regions other than the trigeminal area. The frequency of severe skin lesions was significantly higher (P < 0.001) in patients aged 60 years or over and in those with trigeminal involvement. Multiple stepwise regression analysis revealed that the most important factors influencing the duration of AHP were the severity of skin lesions of HZ at the worst phase (r = 0.412), age (r = 0.277) and the involved region (r = -0.101). Thus, AHP in the elderly and in cases of trigeminal involvement is longer because of higher frequencies of severe HZ in the elderly and in trigeminal involvement rather than "being aged' and "trigeminal involvement' itself. We propose that one needs to analyze the results of treatment of AHP with respect to the severity of skin lesions at the worst phase.

Factors influencing the duration of treatment of acute herpetic pain with sympathetic nerve block: importance of severity of herpes zoster assessed by the maximum antibody titers to varicella-zoster virus in otherwise healthy patients

Antibody responses to varicella-zoster virus (VZV) were serially investigated by the complement-fixation test in 72 Japanese of both sexes, suffering from herpes zoster (HZ), but otherwise healthy. Our objective was to elucidate whether there were mutual relationships among severities of skin lesion, maximum antibody titers to VZV, and duration of treatment for acute herpetic pain (AHP). Patients were divided into 3 groups: mild group (n = 26), moderate group (n = 26) and severe group (n = 20), according to the severity of the skin lesions. The 3 groups did not differ significantly with respect to age (P greater than 0.6). All patients were treated with regional sympathetic nerve blocks (SNBs) until pain relief was achieved. The durations of treatment for AHP became significantly longer as HZ increased in severity; the mean log10 durations of treatment (+/- S.E.) for the mild, moderate, and severe groups were 1.383 +/- 0.037, 1.616 +/- 0.055, and 1.888 +/- 0.069 days, respectively (P less than 0.01 for the mild group vs. the moderate group, and P less than 0.001 for the moderate group vs. the severe group). Irrespective of age, the maximum antibody titers closely paralleled the severities of the skin lesion of HZ; the mean maximum log2 antibody titers (+/- S.E.) for the mild, moderate, and severe groups were 5.12 +/- 0.24, 6.73 +/- 0.20, and 8.00 +/- 0.18, respectively (P less than 0.001 for the mild group vs. the moderate group and for the moderate group vs. the severe group).(ABSTRACT TRUNCATED AT 250 WORDS)

T-lymphocyte subsets in otherwise healthy patients with herpes zoster and relationships to the duration of acute herpetic pain

T-lymphocyte subsets (CD3, CD4, and CD8 lymphocytes) in peripheral blood, parameters of cell-mediated immunity, were serially measured in 62 otherwise healthy Japanese patients with herpes zoster (HZ), and the findings were compared with those of 20 age-matched healthy controls who had had varicella but not HZ. Our objective was to elucidate whether there were changes in cell-mediated immunity, even in immunocompetent patients with HZ, and to investigate relationships between these variables and the duration of acute herpetic pain (AHP). All the patients underwent repeated sympathetic nerve blocks until pain was relieved. As compared with controls, there were slight increases in the percentages of CD4 lymphocytes (helper/inducer) and highly significant increases in the percentages of CD8 lymphocytes (suppressor/cytotoxic), resulting in marked decreases in CD4/CD8 ratios in the acute phase of HZ. The percentages of CD3 lymphocytes (pan-T lymphocytes) did not differ significantly. The duration of AHP was analyzed in 49 patients in whom T-lymphocyte subsets were measured more than twice. There was a weak but statistically significant positive linear correlation between age and the duration of AHP (r = 0.43, P < 0.01). There were statistically highly significant positive linear correlations between the number of days on which percentages of CD3 (r = 0.72, P < 10(-8)) and CD4 lymphocytes (r = 0.60, P < 10(-5)), and CD4/CD8 ratios (r = 0.62, P < 10(-5)) reached the maximum values after the onset of HZ and the duration of AHP. These correlation coefficients were higher than that between age and the duration of AHP.(ABSTRACT TRUNCATED AT 250 WORDS)

Mexiletine-induced severe skin eruption, fever, eosinophilia, atypical lymphocytosis, and liver dysfunction

A 64-year-old man developed a severe generalized pruritic morbilliform skin eruption, fever, eosinophilia, atypical lymphocytosis, and liver dysfunction 30 days after ingestion of mexiletine, a sodium channel blocker, prescribed to treat postherpetic neuralgia. Following intravenous dexamethasone, body temperature normalized the next day. However, the skin eruption did not disappear completely for 4 weeks. The patch test was positive for mexiletine. Clinical features and the result of patch test indicated that the patient developed hypersensitivity syndrome, a severe adverse cutaneous drug reaction, caused by mexiletine. We propose that mexiletine be added to the list of drugs that can cause severe adverse cutaneous drug reactions and that patients receiving mexiletine be warned to stop taking the drug immediately if a skin eruption occurs.

High thoracic epidural block relieves acute herpetic pain involving the trigeminal and cervical regions: comparison with effects of stellate ganglion block

BACKGROUND AND OBJECTIVES

Stellate ganglion block can promptly relieve acute herpetic pain (AHP) involving the trigeminal and cervical regions. However, repeated blocks are needed to maintain pain relief in most patients with severe AHP. Because continuous epidural block is easily performed using an indwelling catheter, we compared the effect of high thoracic epidural block with that of stellate ganglion block to relieve moderate-to-severe AHP involving these regions.

METHODS

Six patients received stellate ganglion blocks and seven patients received high thoracic epidural blocks. Six milliliters 1% of mepivacaine was given to each patient. Acute herpetic pain was evaluated before and up to 60 minutes after the blocks, using a visual analog scale (VAS) of pain.

RESULTS

There was no significant difference in VAS pain scores before the blocks between the groups, but there were significant (P < .05) decreases in VAS pain scores for both groups between 10 and 60 minutes after the blocks. There were no significant differences in VAS pain scores between the groups after the blocks.

CONCLUSIONS

High thoracic epidural block was as effective as stellate ganglion block in relieving moderate-to-severe AHP involving the trigeminal and cervical regions.

Anesthetic management of a patient with Bartter's syndrome

Bartter's syndrome is a rare disorder characterized by normal or low arterial blood pressure (BP), despite marked elevation in plasma renin activity, angiotensin II (Ang-II), and aldosterone, along with hypokalemic metabolic alkalosis. Perioperative changes in the cardiovascular and renin-angiotensin-aldosterone (RAA) systems in Bartter's syndrome patients are not well understood. We managed a 44-year-old Japanese man with rectal cancer and Bartter's syndrome complicated by renal dysfunction. He underwent anterior resection of the rectum with general anesthesia (50% nitrous oxide-oxygen with 0.5% to 0.8% isoflurane, supplemented with intravenous midazolam and butorphanol). Epidural morphine was given postoperatively. Although BP tended to be lower (75/35 to 110/60 mmHg) during surgery, there were no profound perioperative hemodynamic derangements. Plasma renin activity. Ang-II, and aldosterone values were highest during surgery. These responses of the RAA system to anesthesia and surgery were the same as previously noted in otherwise healthy surgical patients.

[Postherpetic neuralgia]

Varicella-zoster virus (VZV) causes two clinically distinct diseases: varicella and herpes zoster. Herpes zoster, recurrent infection of VZV occurs when the cell-mediated immunity to VZV declines. Since the cell-medicated immunity to VZV declines with aging, herpes zoster occurs more frequently in the elderly. Most frequent and dreaded complication of herpes zoster is postherpetic neuralgia (PHN). The first line of treatment of PHN is medication with tricyclic antidipressants and anticonvulsants. Double-blind studies showed that effective tricyclic antidepressants for the treatment of PHN are amitriptyline and nortriptyline, and effective anticonvulsants gabapentin and pregabalin. When tricyclic antidepressant and/or anticonvulsant cannot relieve PHN, opioids should be considered in some selected patients. Although neuroablative procedures have been performed for the treatment of PHN, their effectiveness was not confirmed by double-blind studies. They rather aggravate PHN with time. Recent research with a live attenuated varicella vaccine to prevent herpes zoster indicated that the vaccine decreased the occurrence of herpes zoster and postherpetic neuralgia by almost half as compared with placebo. Vaccination of high risk subjects with the varicella vaccine seems to be the most effective measure for the prevention of postherpetic neuralgia.

Trimetaphan may cause coronary artery spasm

We describe a patient in whom possible coronary artery spasm occurred during the infusion of trimetaphan. A 55-year-old man with a meningioma was scheduled for surgical excision of the tumour. He denied any previous history of chest pain. Anaesthesia was maintained with nitrous oxide (67%) in oxygen. The blood pressure before commencement of the surgery was 114/70 mmHg, and the pulse rate was 60 beats min-1. The blood pressure rose to 152/94 mmHg (the pulse rate to 62 beats min-1) during incision of the scalp, and intravenous infusion of trimetaphan was initiated. The blood pressure gradually decreased to 113/58 mmHg (the pulse rate 64 beats min-1) 10 min after start of this infusion, and premature ventricular contractions were evident on the electrocardiogram. Trimetaphan was withheld, and lignocaine was given intravenously. The premature ventricular contractions disappeared but ST segments were elevated. Glyceryl trinitrate was then infused intravenously. The ST segments remained elevated for 5 min, were depressed for 2 min and finally became isoelectric. There were no wide swings in blood pressure or pulse rate during the event. Post-operative laboratory examination revealed no evidence of myocardial infarction. Recovery of the patient was uneventful.

Varicella-zoster virus infections during pregnancy: hypothesis concerning the mechanisms of congenital malformations

An analysis of the data on 52 infants whose mothers had contracted varicella during pregnancy revealed that 27 had congenital malformations ascribed to the maternal varicella infections, while another 25 developed herpes zoster in the early postnatal period. Most of the mothers whose infants had congenital malformations had contracted varicella within the first 20 weeks of gestation, whereas most of the mothers whose infants developed herpes zoster had varicella after 21 weeks of gestation. The clinical features of the various congenital malformations and dysfunctions after maternal varicella were diverse; however, there were peculiar segmental manifestations of anomalies of the skin, the peripheral nervous, the autonomic nervous, and the musculoskeletal systems, all of which receive common innervations from the same levels of the spinal cord. Most other dysfunctions may be ascribed to an encephalitis. Therefore, the mechanism of congenital malformations caused by varicella-zoster virus seems to be due not to fetal varicella but to the development of herpes zoster in utero and to an encephalitis associated with herpes zoster. At least one infant had congenital malformations that were due to maternal herpes zoster infection.