Special Anesthetic Techniques in Head and Neck Surgery

Critical airway obstruction, superior vena cava syndrome, and spontaneous cardiac arrest in a child with acute leukemia

We report the unusual presentation of a previously healthy girl with sudden cardiopulmonary arrest caused by acute lymphoblastic leukemia and mediastinal involvement leading to acute tracheal and airway obstruction. Despite active resuscitation and mechanical ventilation, she developed severe cerebral edema as a result of cerebral asphyxia. She also had facial edema caused by superior vena cava obstruction, a high peripheral white cell count with blast differentials, and renal failure. Because of severe asphyxia leading to brain death and renal failure, chemotherapy was withheld. Her white cell count spontaneously reverted to reference range without chemotherapy. This report serves to alert clinicians of the oncological emergency of "superior mediastinal syndrome" causing airway and superior vena cava obstruction leading to death in this potentially curable disease.

Airway management and sedation for pediatric transport

Appropriate airway management is essential for the successful transport of sick children. Airway management begins with a thorough history and physical examination and may proceed to invasive therapeutic interventions. Successful care of the pediatric airway can be achieved only with a thorough knowledge of airway management technique and equipment. In addition, familiarity and understanding of the pharmacologic adjuvants to airway management and sedation will help to achieve the primary objective of any transport team, namely a safe and smooth transport of the critically ill child.

One year's experience in a new dental day-stay unit

The records of six hundred and fifty-five patients treated in the Dental Day-Stay Unit over a twelve-month period were reviewed. 2.1% of 95 patients assessed as suitable for day-stay surgery, and 2.2% of 542 patients not assessed prior to anaesthesia were admitted postoperatively. As an index of outcome, 2.56% of 547 day cases were admitted postoperatively, 0.73% being attributable to anaesthesia. Forty-seven day patients were treated in the dental chair, and 108 were treated as inpatients. Over 37% had at least one concurrent medical problem, while 10.4% were mentally handicapped. Guidelines for day-care selection require that the procedure be straightforward, the patient medically fit, be discharged escorted, and live within a reasonable distance of the hospital. From our study, four specific patient groups are identified. These are: the young and healthy, the mentally handicapped, the medically compromised, and those with airway problems.

Difficult laryngoscopy/intubation: the child with mandibular hypoplasia

The child with mandibular hypoplasia (Treacher Collins syndrome, Pierre Robin sequence, hemifacial microsomia, etc) presents the otolaryngologist and anesthesiologist with considerable problems when direct laryngoscopy and/or endotracheal intubation is attempted. In addition to the small mandible, several other features of these patients contribute to the difficult laryngoscopy: macroglossia, glossoptosis, trismus related to temporomandibular joint abnormalities, and prominent maxilla or maxillary incisors. Most of the techniques that have been described for laryngoscopy/intubation in problem cases are difficult or impossible to use in infants and young children with mandibular hypoplasia. We present a modification of the standard direct laryngoscopic procedure, utilizing the 9-cm anterior commissure laryngoscope and an optical stylet in the task of exposing and intubating the larynx of a child with mandibular hypoplasia.