Metastasis of malignant melanoma of the nasal mucosa to the small intestine

Malignant melanoma of the mucous membranes is rare and has a very poor prognosis. When localized in the nose, the tumor becomes apparent late in the course of the disease with nasal obstruction and epistaxis. Distant metastases are uncommon, but any organ of the body can be involved. A case of a malignant melanoma of the nasal mucosa with metastasis to the small intestine is presented, and the natural history of the metastatic disease is discussed.     

Stability of mRNA from the Clostridium sporogenes phage F1

A case of rhinosporidiosis occurring in an immigrant from India is presented along with a review of the disease. Rhinosporidiosis most commonly involves the nose, and presents as a friable papillomatous mass causing nasal obstruction, epistaxis, purulent discharge, and headache may also occur. The treatment of choice is surgical excision with cauterization of the base.     

Collapse of the nasal endotracheal tube in the nasal cavity

A 27-year-old female with maxillary maldevelopment was admitted for mandibular sagittal splitting osteotomy with mandibular progeny. General anesthesia was induced with 100 mg of propofol and 8 mg of vecuronium. When a soft and preformed 7.0 mm North-Polar-nasotracheal tube (Portex) was inserted into the nasopharynx through the left nasal cavity, it was very difficult to advance beyond the choana. After nasotracheal intubation, the buking became harder than before when she had been ventilated with a face mask. The peak airway pressure had reached higher than 50 cmH2O with ventilation of 500 ml tidal volume. Bronchoscopy revealed that the fiberscope (3.5 mm O.D.) could not go through the choanal stenosis, because it was too narrow. Therefore, she had to be intubated by a spiral tube, 6.0 mm I.D., through the other nasal cavity with assistance of bronchoscopy, instead of the North-Polar-tube. So, we have to pay attention to the possibility of compression and collapse of a soft nasotracheal tube in the nose of the patient with choanal stenosis due to maxillary maldevelopment.     

Prolonged survival in a patient with sinonasal teratocarcinosarcoma with cranial extension. Case report

Sinonasal teratocarcinosarcoma is a rare malignant neoplasm characterized by the combined histological features of carcinosarcoma and teratoma. The primary symptoms of this tumor are usually nasal obstruction and epistaxis, and a nasal cavity mass is the most common clinical finding. The authors describe an exceptionally rare case in which the patient presented with massive intracranial extension and exhibited confusion as an initial symptom. He subsequently underwent combined radical surgery and radiation therapy and has remained free of disease for 31 months. The surgical approach to the lesion, histological features, and clinical course are detailed.     

Effects of nasal packing on eustachian tube function

Eustachian tube function was assessed by tympanometry in 47 patients (94 ears) with anterior nasal packing placed after nasal surgery and in 12 patients (24 ears) requiring anterior and posterior packing for epistaxis. Twenty-four of the 94 ears (25.5%) in patients with anterior packing exhibited reductions in middle ear pressure (greater than or equal to --100 mm H2O), whereas 12 of 13 ears (92.3%) ipsilateral to and six of 11 ears (45.4%) contralateral to the posterior pack demonstrated comparable reductions in middle ear pressure. The observation that posterior packing is associated with a greater incidence of eustachian tube dysfunction than anterior packing suggests that the mechanism of this dysfunction may be related to stasis in the peritubal lymphatic plexus rather than to nasal obstruction per se.     

Doxapram reversal of respiratory failure in a patient refusing assisted ventilation

A 75-year-old man with severe chronic obstructive pulmonary disease and epistaxis experienced progressive respiratory failure after receiving an injection of meperidine and hydroxyzine in preparation for nasal packing. The patient and his family refused endotracheal intubation; despite aggressive medical care, he continued to deteriorate toward an expected fatal outcome. An i.v. infusion of doxapram hydrochloride at 2 mg/min rapidly reversed his downhill course and hypercarbic coma. This case illustrates the potential usefulness of doxapram in the emergency setting. The mechanism of action, indications, dosing methods, and potential side effects of this agent are discussed.     

Emergency airway management

Maintenance of the airway is the most important and one of the most challenging functions that an emergency physician has to perform. This article is a review of the various techniques that can be used by both emergency and nonemergency physicians to secure the airway. It includes standard orotracheal intubation, nasotracheal intubation, fiberoptic intubation, and cricothyroidotomy. The medications used in these procedures and in rapid sequence intubation are discussed.     

Long-term cardiovascular role of nitric oxide in conscious rats

Twenty-eight non-allergic subjects suffering from mono- and bilateral chronic nasal respiratory obstruction underwent investigation employing routine semeiological examination. The real cause of the obstruction, however, was not ascertained. The subjects underwent nasal endoscopy employing rigid fiberoptics and, on the grounds of the findings, a cat scan of the nasal fossae in coronal projection, was made. The results of the study revealed involvement of the middle meatal area in 63% of bilateral nasal obstructions (B.N.O.) and in 77.7% of the monolateral obstructions (M.N.O.). Choanal pathology was evident in 21% of the B.N.O., while isolated upper and posterior deviations of the septum were present in 23.6% of the B.N.O. and in 22.5% of the M.N.O. Meatal involvement was due to the presence of anatomic changes of the middle turbinate (m.t.) such as concha bullosa, paradoxical deviation of the m.t. and of the uncinate process. Moreover, small "mucosal polyps" were also noticed in this meatal area. Cat scans, performed on 18 of these 28 patients, confirmed and defined meatal alterations found with endoscopy in 16 cases. In the remaining 2 cases, cat scans showed a thickening of the mucosal+bony tissues of the m.t. The Authors did not consider CT necessary in 10 subjects in that endoscopy sufficed in explaining obstruction symptoms.     

Endoscopic sinus surgery for chronic sinusitis in children

Anatomical features show maxillary sinus to be most commonly involved during childhood chronic sinusitis. Fifty-one cases who failed to respond to medications and irrigation were selected to undergo the middle meatal antrostomy under endoscopy. The majority of them had maxillary sinusitis. 10 cases had middle turbinate edema and polyps. 6 had ethmoiditis. After operations, signs of headache eliminated in 20 cases, nasal obstruction in 43 cases and yellowish discharge in 37 cases. The operative results were satisfactory. It is demonstrated that endoscopic sinus surgery is an ideal therapy for the treatment of childhood chronic maxillary sinusitis at present.     

Nasal fibreoptic tracheal intubation in anaesthetised patients breathing via a modified laryngeal mask airway

A modified laryngeal mask airway was used to facilitate nasotracheal intubation with a fibreoptic laryngoscope. A size 4 laryngeal mask airway was modified by creating a defect at the base of the stem and removing the bars to allow passage of the fibreoptic laryngoscope from the nasopharynx to the larynx. The laryngeal mask airway cuff was split and the cut edges were sealed with silicone. This design allowed the cuff to function normally and allowed removal of the split laryngeal mask airway after the tracheal tube had been 'railroaded' into place. Thirty-four patients were studied. The split laryngeal mask airway was easily inserted with satisfactory airway maintenance in 32 patients. Nasal airway endoscopy and laryngoscopy were successfully achieved with the split laryngeal mask airway in place in 31 of 32 patients. Railroading the tracheal tube over the fibreoptic laryngoscope with the split laryngeal mask airway in place was successful in all 31 of these patients. This prototype split laryngeal mask airway allows good airway maintenance while fibreoptic nasotracheal intubation is performed.     

Risk factors of recurrence in 157 MB/PNET patients treated in one institution

BACKGROUND: Epistaxis is one of the most common otolaryngological emergencies. In cases of bleeding from the anterior or the lower posterior part of the nose, epistaxis could usually be treated with cauterization and anterior or posterior nasal packing. More invasive methods of treatment are the endonasal coagulation of the sphenopalatine artery and the transantral ligation of the maxillary artery. Bleeding from the upper posterior part of the nose usually originates from the anterior and the posterior ethmoidal artery. In most cases a specific styptic treatment in the upper posterior part of the nose is not possible because of a diffuse bleeding from the ethmoidal arteries into the ethmoidal sinus and the lateral wall of the nasal cavity. In this study the endoscopic ethmoidectomy is presented as the therapy of epistaxis from the ethmoidal arteries. PATIENTS AND RESULTS: In the retrospective study the charts of twenty patients with intractable epistaxis from the upper posterior part of the nasal cavity were reviewed. In all cases the bleeding could not be controlled with anterior and posterior nasal packing. In seventeen patients the bleeding could be controlled with a unilateral or bilateral endoscopic ethmoidectomy (average follow-up: 36.5 months). Three patients who complained of a coagulopathy and an arterial hypertonia developed diffuse recurrent bleeding from multiple sources. In one case the recurrent bleeding was controlled by an unilateral transantral ligation of the maxillary artery and a bilateral revision of the ethmoidectomy. In two patients the recurrent bleeding was treated with bilateral posterior nasal packing. CONCLUSION: The endoscopic ethmoidectomy is an efficient therapy of intractable epistaxis from the ethmoidal arteries if systemic coagulopathy and arterial hypertonia are excluded. The ethmoidectomy can be performed by any head and neck surgeon who is familiar with endonasal surgery.     

Difficult tracheal intubation with von Recklinghausen disease

We experienced a case of difficult tracheal intubation in a 15-year-old boy with von Recklinghausen disease scheduled for resection of a right neck tumor. His scoliosis made it difficult to intubate and to manage airway because he easily developed dyspnea. We tried nasotracheal intubation with the patient awake under sedation using a bronchofiberscope, but we found an unexpected tumor jeopardizing his airway patency near his vocal cord. Preoperative examination of a tumor in the airway is essential in the anesthetic management of the patients with von Recklinghausen disease.     

Hemangiopericytoma-like intranasal tumors. A clinicopathologic study of 23 cases

The clinical, microscopic, and gross pathologic features of 23 cases of intranasal hemangiopericytoma-like tumors are reviewed and studied. When in the nasal cavity, these lesions often originated in a paranasal sinus and extended into the nasal cavity secondarily. They occurred most commonly in adults in the sixth and seventh decades of life; there was no significant sex predilection. Twenty-two of the 23 patients were Caucasian. These patients most commonly had symptoms of nasal obstruction and epistaxis. Clinically the lesions were generally thought to represent allergic polyps. Although appearing microscopically as non-differentiated spindle-cell neoplasms, these lesions showed little nuclear or cytoplasmic pleomorphism, minimal mitotic activity, and no necrosis or hemorrhage or other evidence of anaplasia found in malignant tumors. Follow-up data showed no evidence to suggest a malignant or biologically unpredictable lesion. Nineteen of 22 cases followed showed no recurrence regardless of the treatment; those that recurred did so locally. No metastasis or other form of aggressive behavior attributed to hemangiopericytomas in other anatomic locations was seen in this series. Another case, diagnosed as a malignant hemangiopericytoma of the nasal cavity, showed dissimilar and anaplastic histologic features. This case metastasized and is discussed, though not included in this study.     

Nasotracheal intubation in calves

Nasotracheal intubation can be accomplished in calves by use of a silicone nasotracheal tube of a Murphy design. For intubation, the calf's head and neck should be extended to facilitate tube passage through the naris into the ventral meatus and then through the larynx into the trachea. Preanesthetic medication may assist in tube passage by decreasing the alertness of the calf and decreasing the ability of the calf to swallow the tube into the esophagus. Nasotracheal intubation allows the inhalant anesthetic agent to be delivered with minimal room pollution and less stress to the calf. It would be useful for oral surgery when an orotracheal tube would obstruct the surgical site.     

The phenomenon of paradoxical nasal obstruction

Some patients with a fixed uninasal obstruction in whom the normal or patent side becomes temporarily obstructed because of the nasal cycle, and in whom the total nasal resistance is elevated, complain of nasal obstruction. It is when the normal side responds to the congestive phase of the nasal cycle that the patient becomes symptomatic; hence, the term "paradoxical nasal obstruction." Rhinomanometric tests, serial tomography, and direct patient observation allow confirmation of the phenomenon of paradoxical nasal obstruction.     

Integration of stress research in rheumatoid arthritis: from Alexander to Zautra and back again

Patients with nasal obstruction often have associated snoring. It is uncertain whether surgery, which relieves the nasal obstruction, will also relieve the snoring. We have reviewed 96 patients who complain of both nasal obstruction and snoring and who underwent nasal surgery. Snoring was completely relieved in 48 patients (50%), was less loud in a further 38 patients (40%), unchanged in 8 patients, and louder in 2. Patients who had nasal polypectomy as part of their nasal surgery obtained the greatest snoring relief. The relationship between nasal obstruction and snoring is complex and the alteration of airflow patterns after nasal surgery is postulated to be important in influencing snoring relief. This study suggests that, when snoring and nasal obstruction coexist, nasal surgery should be considered as the first line of surgical treatment.     

A rare complication of the use of a finger cot to protect the cuff of a tracheal tube during nasotracheal intubation

Some anesthetists in Switzerland and elsewhere use a finger cot to protect the cuff of the endotracheal tube during nasotracheal intubation. In the presented report the finger cut was lost during the procedure and the patient presented 3 months later with a lateral neck mass. The finger cot was found within that mass at exploration. Apart from the other potential risks of this manoeuvre, this severe complication should incite caution against the practice described above.     

Epistaxis and hypertension

The status of nose bleeding as a symptom of high blood pressure has been studied in patients admitted because of epistaxis. Twenty-six patients with a factor predisposing to nasal bleeding had age- and sex-adjusted systolic and diastolic scores similar to those of the general population. One hundred and sixty-eight patients with no such factor formed a different population with significantly higher age- and sex-adjusted systolic and diastolic scores. It is concluded that epistaxis is a true symptom of hypertension.     

Endoscopic transseptal sphenopalatine artery ligation for intractable posterior epistaxis

The rigid nasal endoscope was used through a transseptal approach to reach the sphenopalatine foramen and to ligate its artery in 9 patients with intractable posterior epistaxis. Immediate and complete cessation of the bleeding uniformly occurred, except in 1 case, in which there was persistent bleeding on endoscopic examination of the nasal cavity at the end of the procedure. The ligature was checked and the artery was reclipped. Thereafter, the patient's recovery was uncomplicated and free of further epistaxis. Endoscopic transseptal sphenopalatine artery ligation offers a reliable option in the treatment of intractable posterior epistaxis. The submucoperiosteal dissection reduces bleeding, shortens operation time, and allows relatively easy identification of the sphenopalatine foramen. The procedure allows direct positive control of the major vessel supplying the posterior nasal cavity. It avoids the complications associated with transantral and pterygopalatine fossa surgery.     

Visualization of serum albumin on electrophoretic gels using the specific ligand bilirubin

Although oral clonidine premedication is known to reduce the hemodynamic response under general anesthesia, effects of the hemodynamic response during sedated fiberoptic nasal intubation have not yet been examined. Our aim was to compare the effects of clonidine premedication on hemodynamic responses with those of atropine and hydroxyzine premedication during sedated fiberoptic nasal intubation. Thirty adult patients were randomly assigned to one of two groups: Group 1 patients (n = 15) were premedicated with atropine sulfate (0.01 mg/kg) and hydroxyzine hydrochloride (1mg/kg) intramuscularly, and group 2 patients (n = 15) were premedicated with clonidine (5 micrograms/kg) orally. We compared the hemodynamic response and sedation level in fiberoptic nasal intubation between the two groups. there were no significant differences in sedation levels and postoperative complaints between the two groups. But the oral clonidine premedication (Group 2) blunted hemodynamic changes during the fiberoptic intubation. No profound hypotension or marked bradycardia was noted in group 2. We concluded that the oral clonidine premedication might contribute to hemodynamic stability during sedated fiberoptic nasal intubation.