Management of persistent chylothorax

The aggressive management of persistent chylothorax is necessary for avoidance of significant morbidity and possible mortality. The failure of TPN and chest tubes to rapidly control a chylothorax should lead to consideration of thoracic duct ligation.

Management of Persistent Chylothorax

The aggressive management of persistent chylothorax is necessary for avoidance of significant morbidity and possible mortality. The failure of TPN and chest tubes to rapidly control a chylothorax should lead to consideration of thoracic duct ligation.

Brown tumor of the mandible

Brown tumor is a focal lesion differentiated from other giant-cell tumors by the presence of hyperparathyroidism. Treatment of brown tumors must be initially directed towards correcting the hyperparathyroidism. Tumor regression may occur with resolution of the hyperparathyroidism. Persistent or large destructive tumors are treated with resection or curettage.

Optimal concentration of epinephrine for vasoconstriction in neck surgery

The addition of epinephrine to local anesthetics decreases bleeding, reduces systemic toxicity, and increases duration of action. However, epinephrine has significant side effects. Four concentrations of epinephrine were compared to determine the minimum concentration required for maximal vasoconstriction. Eighty-one subjects undergoing surgical procedures with general anesthesia were injected with 1% lidocaine containing varying concentrations of epinephrine. Blood flow measurements were then made at 1-minute intervals for 10 minutes using a laser Doppler flowmeter. There were no differences in blood flow reduction between epinephrine concentrations of 1:100,000, 1:200,000, and 1:400,000. However, epinephrine 1:800,000 provided significantly less vasoconstriction. We recommend using an epinephrine concentration of 1:200,000 or 1:400,000 to provide optimal initial hemostasis while minimizing potential side effects.

Isolated subglottic scleroma

Scleroma, more commonly known as rhinoscleroma, is a progressive, chronic, granulomatous disease of the respiratory tract and adjacent tissues. Early diagnosis and prolonged therapy are critical in avoiding its late sequelae. We describe an unusual case of scleroma presenting as worsening chronic lung disease. The variety of clinical presentations and treatment modalities is reviewed.

Reversible Blindness Secondary to Acute Sphenoid Sinusitis

Sphenoid sinusitis is an elusive diagnosis with significant morbidity if not diagnosed and treated promptly. We have reported an unusual case of acute sphenoiditis mimicking Gradenigo's syndrome. This resulted in virtual bilateral blindness that entirely resolved with aggressive surgical and medical treatment. It is recommended that sphenoid sinusitis be strongly considered in patients with acute headache and fever. A detailed cranial nerve examination should be performed, and CT scans of the skull base and paranasal sinuses should be obtained. Immediate surgery is strongly recommended for acute sphenoid sinusitis at the first suggestion of a complication and in those patients not promptly responding to medical therapy. It is apparent that irreversible damage to the optic nerve can occur before the development of gross intraorbital pathology. Therefore we believe that delaying surgery until the visual acuity is worse than 20/60, as advocated by some authors, may not be in the patient's best interest. Surgery should be directed at removing the purulent material, obtaining cultures, removing irreversibly diseased mucosa, and maintaining drainage of the sphenoid sinus.

Effect of local epinephrine on cutaneous bloodflow in the human neck

The effectiveness of local anesthetics is improved by the addition of a vasoconstrictor which increases duration of action and decreases both systemic toxic reactions and local bleeding. Epinephrine, the standard drug for vasoconstriction, has some limitations due to potential dose-related cardiac and local toxic effects. The authors examined the minimal effective epinephrine concentration required for maximal cutaneous vasoconstriction in the human subject so as to limit potential dose-related side effects. In a randomized, double-blinded prospective study, 23 patients undergoing head and neck surgical procedures under general anesthesia were enrolled to quantify the effect of subdermal infiltration of 1% lidocaine with epinephrine at varying concentrations on local cutaneous bloodflow utilizing laser Doppler flowmetry. A comparison of the onset of vasoconstriction and magnitude of diminished bloodflow was made for several commonly used concentrations of epinephrine, with 1% lidocaine and normal saline serving as controls. There were no significant differences (P > .05) between epinephrine concentrations of 1:400,000, 1:200,000, 1:100,000, and 1:50,000 when examining onset and magnitude of vasoconstriction.