Medial medullary injury during adenoidectomy

Pupil-Involving Oculomotor Nerve Palsy Following Tonsillectomy and Adenoidectomy

Ocular complications of adenotonsillectomy are rare. The authors describe a 6-year-old boy who developed mydrasis and limitations of supraduction and infraduction after adenotonsillectomy. This was attributed to the hemorrhagic compression of the nerve in the cavernous sinus. This is the first report of pupil-involving oculomotor nerve palsy following adenotonsillectomy. [J Pediatr Ophthalmol Strabismus. 2019;56:e76-e78.].

Grommet and adenoid pain evaluation (GRAPE) study

In the GRAPE study an analysis is made of postoperative pain sensation in children between 6 months and 6 years after adenotomy and placement of ear grommets. Intraoperative treatment with paracetamol versus placebo shows no statistically significant difference in pain between both groups indicating that this type of surgery causes little discomfort and does not require specific intraoperative analgesic treatment.

Regional anaesthesia in neonates, infants and children: an educational review

Prophylactic analgesia with local anaesthesia is widely used in children and has a good safety record. Performing regional blocks in anaesthetised children is a safe and generally accepted practice. When compared with adults, lower concentrations of local anaesthetics are sufficient in children; the onset of a block occurs more rapidly but the duration is usually shorter. Local anaesthetics have a greater volume of distribution, a lower clearance and a higher free (non-protein-bound) fraction. The recommended maximum dose has to be calculated for every individual. Peripheral blocks provide analgesia restricted to the site of surgery, and some of them have a very long duration of action. Abdominal wall blocks, such as transverse abdominis plane or ilio-inguinal nerve block, should be performed with the aid of ultrasound. Caudal anaesthesia is the single most important technique. Ropivacaine 0.2% or levobupivacaine 0.125 to 0.175% at roughly 1 ml  kg⁻¹ is adequate for most indications. Clonidine and morphine can be used to prolong the duration of analgesia. Ultrasound is not essential for performing caudal blocks, but it may be helpful in case of anomalies suspected at palpation and for teaching purposes. The use of paediatric epidural catheters will probably decline in the future because of the potential complications.

Life threatening medullary injury following adenoidectomy and local anesthetic infiltration of the operative bed

OBJECTIVE

To draw attention to a rare, life threatening complication of a rather common procedure, namely medullary injury following adenoidectomy and local anesthetic infiltration of the operative bed.

DESIGN

Case report.

SETTING

A tertiary pediatric critical care unit.

PATIENT

A healthy 7-year-old girl underwent adenoidectomy and local anesthetic infiltration of the adenoid bed with lidocaine and adrenaline. In the recovery room, nystagmus, dysarthria, dyspnea, inability to cough and right hemiparesis were noticed. Because of her inability to remove secretions tracheal intubation was performed, followed by severe, life threatening respiratory failure.

INTERVENTIONS

Tracheal intubation, hemodynamic support, prolonged mechanical ventilation, nitric oxide, and tracheostomy.

CONCLUSION

In children, local anesthetic infiltration of the adenoid bed may cause life-threatening medullary injury and its routine use should be re-considered.

Microsurgical considerations of the anterior spinal and the anterior-ventral spinal arteries

BACKGROUND

There are few data describing the microanatomy of the anterior-ventral spinal (AVSA) and anterior spinal arteries (ASA) and discussing their clinical and surgical implications. We describe the anatomical features of this arterial complex, and highlight their use when planning and performing surgical approaches to lesions involving the ventral aspect of the medulla and the foramen magnum.

METHOD

The microsurgical anatomy and branching pattern of the AVSA and the ASA from fifty human cadaver brain stems is described using a surgical microscope.

RESULTS

We found one anterior-ventral spinal artery at each side in 30 of the brain stems (60%). The ASA was a direct branch emerging from the left vertebral artery (VA) in 15 (30%), from the right VA in 4 (8%), and from the basilar artery (BA) in one brain stem (2%). The previously described as "typical pattern" of the junction of the AVS arteries from both sides, was observed only in 9 brain stems (18%). The anterior communicating spinal artery (ACoSA) was observed in 15 brain stems (30%). Also multiple ACoS arteries were described in one brain stem. Both, the AVSA and the ASA were observed to send long circumferential branches that supplied irrigation to the olive in 42 (84%) brain stems.

CONCLUSIONS

This anatomical study gives important information for a better understanding of the clinical picture of ischemic lesions of the brain stem, such as the medial medullary syndrome, and highlights the remarkable role of the AVSA and ASA as anatomical landmarks during the surgical approaches to lesions involving the ventral aspect of the medulla and the foramen magnum.

Transitory ataxia related to topically administered lidocaine

OBJECTIVE

To report 2 cases of transitory cerebellar ataxia related to lidocaine administered topically for endoscopy. case summaries: Two patients developed transitory cerebellar ataxia a few minutes after local anesthesia using lidocaine 10% spray and lidocaine 2% orally for a bronchoscopy and transesophageal echocardiography. This effect completely disappeared in 3-5 hours. In neither case was an alternate etiology of cerebellar ataxia identified. The second patient had previously experienced a similar reaction to lidocaine.

DISCUSSION

Several central neurologic effects of lidocaine have been reported, but until now, only few cases of cerebellar ataxia. In these 2 cases, the Naranjo probability scale indicated that a probable and a highly probable relationship existed between lidocaine administration and the transitory cerebellar ataxia.

CONCLUSIONS

Cerebellar ataxia may occur after local anesthesia with lidocaine; therefore, care must be taken to avoid overdose, even when administered topically.