Head Extension Research Articles

Evaluation of bedside tests and proposal of a model for predicting difficult laryngoscopy: an observational prospective study☆

Background and objectivesThe prediction of difficult laryngoscopy is based on tests that assess anatomic characteristics of face and neck. We aimed to identify the most accurate tests and propose a multivariate predictive model. MethodsThis prospective observational study included 1134 patients. Thyromental Distance (TMD), Sternomental Distance (STMD), Ratio of Height-to-Thyromental Distance (R-H/TMD), Neck Circumference (NC), Ratio of Neck Circumference-to-Thyromental Distance (R-NC/TMD), Hyomental Distance with head in Neutral Position (HMD-NP) and at Maximal Extension (HMD-HE), Ratio of Hyomental Distance at Maximal head extension-to-hyomental distance in neutral position (R-HMD), Mallampati Class (MLC), Upper Lip Bite Test (ULBT), Mouth Opening (MO) and Head Extension (HE) were assessed preoperatively. A Cormack-Lehane Grade ≥ 3 was defined as Difficult Laryngoscopy. Sensitivity, specificity, positive and negative predictive values were assessed for all tests. Multivariate analysis with logistic regression was used to create the predictive models. ResultsA model incorporating MLC, ULBT, HE, HMD-HE and R-NC/TMD showed high prognostic accuracy; x2(5) = 109.12, p < 0.001, AUC = 0.86, p < 0.001). Its sensitivity, specificity and negative predictive value were 82.3%, 74.8% and 97.4%, respectively. A second model including two measurements not requiring patient’s cooperation (R-NC/TMD and HMD-HE) exhibited good prognostic performance; x2(2) = 63.5, p < 0.001, AUC = 0.77, p < 0.001. Among single tests, HE had the highest sensitivity (78.5%) and negative predictive value (96%). ConclusionsA five-variable model incorporating MLC, ULBT, HE, HMD-HE and R-NC/TMD showed satisfyingly high predictive value for difficult laryngoscopy. A model including R-NC/TMD and HMD-HE could be useful in incapable patients. The most accurate single predictor was HE.

Postural control in male ten-pin bowlers of different level of competitiveness

Ten-pin bowling is considered a highly skilled recreational activity with players demonstrating various anthropometric and physiological characteristics. The purpose of the current study was to assess both static and dynamic body balance, in ten-pin bowlers of different level of competitiveness. Thirty four ten-pin bowlers who competed at a high (Level-A, n=17) and a lower level (Level-B, n=17) as well as eighteen individuals without experience in ten-pin bowling (Non-bowlers) participated in the study. Static balance was determined based on the anteroposterior (APd) and mediolateral displacement (MLd) of the center-of-foot-pressure (CoP) that was recorded during single-leg-stance with open and close eyes as well as with open eyes and head extension. Dynamic balance was determined based on the APd and MLd of CoP as well as the normalized distances reached during execution of the Star Excursion Balance Test (SEBT) in the posterior, posterolateral and lateral directions. Significantly better dynamic balance, in terms of the distances reached during SEBT execution, was demonstrated by Level-A bowlers compared to Level-B bowlers and Non-bowlers. The differences between groups regarding APd and MLd, during both static and dynamic balance testing, were in general not significant. Our findings revealed that ten-pin bowlers who compete at a higher level demonstrate better dynamic balance ability. Sports scientists and coaches should be aware of these differences to optimize performance or distinguish ten-pin bowlers with different level of competitiveness.

Principles of Subglottic and Tracheal Visualization with Transnasal Flexible Laryngoscopy

The subglottic area and trachea are important parts of the upper airway, and can be visualized easily using transnasal flexible laryngoscopy (TFL). The aim of this study was to develop a clinical grading system to assist in documentation of the subglottic area and trachea with TFL, and to demonstrate the basic principles of visualization of these anatomic areas as a laryngology practice. The TFL videos of 100 randomized patients were evaluated by three laryngologists. The simple head extension (SHE) position and flexion position (FP) were applied to the patients during the visualization of the subglottic area and trachea. A paired t test was used to compare the grades of the subglottic and tracheal view according to the SHE and FP scores. This study examined 50 male and 50 female patients ranging in age from 28 to 83 years (mean age: 50.09 ± 13.05 years). For the SHE and FP, the numbers of patients constituting grade 1 were 2 and 35, grade 2 were 2 and 37, grade 3 were 30 and 19, and grade 4 were 41 and 9, respectively. There was a statistically significant difference between SHE and FP (P < 0.05). The k score was 0.785 between the ratings of observer 1 and observer 2; 0.771 between observer 1 and observer 3; and 0.757 between observer 2 and observer 3 (P < 0.001). This new grading system for the visualization of the subglottis and trachea can help physicians assess and identify the upper airways, and FP provides a better subglottic and tracheal view than SHE.

A comparison of anti-whiplash seats during low/moderate speed rear-end collisions

Objectives: The Insurance Institute for Highway Safety (IIHS) rates automotive seats as good, acceptable, marginal, and poor on their abilities to prevent whiplash injuries during rear-end collisions. The goal of this study was to compare the performance of some good- and poor-rated seats at speed changes below 16 km/h where some whiplash injuries occur.Methods: A BioRID II anthropometric test device (ATD) underwent rear-end collisions from 2 to 14 km/h while seated on one of two Volvo Whiplash Prevention seats (WHIPS), a Saab Active Head Restraint seat (SAHR), or a General Motors High Retention seat (GMHR). The WHIPS and SAHR seats were rated good whereas the GMHR seat was rated poor by the IIHS. The ATD’s kinematics, kinetics and three neck injury criteria were evaluated across the range of collision severities.Results: Most of the head and torso kinematics, kinetics and injury criteria exhibited graded responses with increasing collision severities. Only head extension angle remained relatively similar across all speed changes. Differences between the good- and poor-rated seats were most apparent in the upper neck loads and moments, and head retraction for speed changes greater than 6 km/h.Conclusions: The relatively similar occupant responses across all seats could explain the marginal reductions in whiplash injury risk between good- and poor-rated seats in field studies. Further research into the design of anti-whiplash devices is required to better understand the link between occupant response and injury, and to better mitigate the risk of whiplash injuries during rear-end collisions.

Endotracheal Tube Migration Associated With Extension During Tracheotomy.

Tracheotomy is occasionally performed to prevent postoperative airway obstruction especially for invasive surgical procedures involving head and neck cancer. When performed under general anesthesia, attention must be paid to avoid rupture of the tracheal tube cuff during the incision into the trachea. In this study, changes in the position of the endotracheal tube tip during extension of the head and neck for a tracheotomy were investigated. Twelve patients underwent placement of a tracheotomy during surgical procedures for oral cancer. After nasal intubation, the distance between the tube tip and the carina was measuring using a fiberoptic scope with the patient's head placed at an angle of 110°. Patients were repositioned for tracheotomy by placing a pillow under the shoulders and extending the head and neck at an angle of 140°. The distance measurements were subsequently repeated. The difference between the first and second measurements was calculated and analyzed statistically using a paired t test. On average the patients were 69.5 ± 9.0 years in age. The distance between the tube tip and the carina at an angle of 140° (3.6 ± 1.1 cm) was significantly longer than that at an angle of 110° (1.7 ± 1.0 cm) (p < 0.001). The migration in the positioning of the endotracheal tube tip was 1.9 ± 0.7 cm (range: 0.7-3.7 cm) upon extension. In 3 cases, the tube cuff was ruptured during incision of the trachea. The endotracheal tube tip may migrate in the cephalad direction approximately 2 cm as a result of the extension of the patient's head and neck during a tracheotomy. Therefore, consideration should be given to advancing the endotracheal tube tip towards the caudal side and to confirming the position of the tube and cuff during a tracheotomy.

Development of a scoring system for predicting difficult intubation using ultrasonography.

Background and Aims: Ultrasound measurement of anterior neck soft tissue thickness by skin to epiglottis distance (SED) has been shown to predict difficult laryngoscopy. In this study, we developed an airway scoring system incorporating SED into three clinical predictors and assessed whether it would improve accuracy in prediction of difficult intubation.Methods:Mentohyoid distance, mandibular subluxation, head extension and ultrasound measurement of skin to epiglottis distance were measured a day before surgery in 310 adult patients. During direct laryngoscopy, Cormack–Lehane grading was noted (Grade 1 and 2 = Easy, Grade 3 and 4 = Difficult). We constructed a score named MSH, which included mentohyoid distance, mandibular subluxation and head extension. Then, SED was added to the MSH score to form another new score named USED-MSH. Student's t-test, Mann-Whitney U test and Chi-square test or Fisher exact tests were used. Both scoring systems were compared under the receiver-operating characteristic curve and area under the curve (AUC) were calculated.Results:Difficult intubation was observed in 62/310 patients (20%). The AUC for USED-MSH score was greater than the MSH score (0.93, 95% CI [0.89–0.97] vs 0.76, 95% CI [0.69–0.84], P value <0.001). USED-MSH score had higher sensitivity (93.6% vs 59.7%) and lower specificity (85.9% vs 91.1%) with similar positive predictive value (62.7% vs 62.4%) in comparison with MSH score.Conclusion: An airway scoring system using the ultrasound measurements of skin-to-epiglottis distance along with the clinical predictors would be helpful in the prediction of difficult intubation.

Comparison of palm print test with other difficult intubation prediction tests in patients with diabetes mellitus

Prediction of difficult intubation has critical importance in anesthesia practice. Diabetic patients usually have limited joint mobility which limits the head and neck extension during laryngoscopy. On the day prior to surgery, the patients who had diagnosis of diabetes mellitus at least for one year, were examined by an investigator by using palm print test (PPT) and other standard assessment indices. The investigator assigned a score to each evaluation indices. PPT was found to have better sensitivity (0.944), spesivity (0.692), positive predictive value (0.895) and negative predictive value (0.818) than standard assessment tests (p < 0.01). PPT should be kept in mind as a viable and easy-to-perform test for predicting difficult intubation of patients with Diabetes Mellitus.

LATERAL POSITION IN CHILDREN DURING HEAD MRI UNDER GENERAL ANESTHESIA FOR PREVENTION OF UPPER AIRWAY COMPLICATIONS

Background : Magnetic resonance imaging is essential investigation method for central nervous system lesions. Closed space and loud noise inside magnetic resonance machine can cause sense of fear in children, so it is common practice to use sedation or general anesthesia in children undergoing magnetic resonance imaging. For safe general anesthesia management endotracheal intubation or laryngeal mask airway placement are recommended. However not all magnetic resonance imaging offices are supplied with compatible equipment and often general anesthesia is provided on spontaneous breathing through natural airways. In emergency medicine lateral position can prevent upper airway complications such as obstruction, aspiration, cough and laryngospasm. The aim of our study was to compare incidence of upper airway complications in children in supine and lateral position undergoing head magnetic resonance imaging under general anesthesia. Materials and methods : Forty-one children undergoing elective head magnetic resonance imaging under general anesthesia were randomized into 2 groups: “Supine” and “Lateral”. Children under general anesthesia were left breathing spontaneously in supine or right lateral decubitus position with slight head and neck extension. Vital signs monitoring included ECG, SpO2, blood pressure and sidestream capnography. Episodes of desaturation, obstruction, apnea, need for airway manipulations such as Guedel airway or laryngeal mask airway placement, suctioning and manual ventilation were registered. Results : Incidence of upper airway complications and need for airway manipulations were significantly lower in “Lateral” group. Number of patients with no complications was significantly higher in “Lateral” group. Mean number of any complication per one patient in “Lateral” and “Supine” groups was 0.1 and 2.4 respectively. Number needed to treat of lateral position for total absence of complications was 1.3 and risk reduction of having any complication was 75.8%. Conclusion : Lateral position is simple maneuver that allows to decrease number of upper airway complications, upper airway manipulations and to increase safety of children undergoing head magnetic resonance imaging under general anesthesia on spontaneous breathing through natural airways.

Effects of prone positioning with neck extension on intracranial pressure according to optic nerve sheath diameter measured using ultrasound in children.

Optic nerve sheath diameter has been used for measure of intracranial pressure. The aim of this study was to evaluate the effect of prone positioning with neck extension on intracranial pressure in infants undergoing craniosynostosis surgery and to determine precautions using optic nerve sheath diameter measurement. We enrolled 30 infants who were scheduled for correction of craniosynostosis in which planning included the prone position with neck extension. Optic nerve sheath diameter (anterior/lateral transbulbar approach) was measured 5 times in each eyeball at the following time points: 15min after intubation in supine position as the baseline value (supine 1); 10min after final surgical position before skin incision (prone); and 10min after returning to supine position at the conclusion of surgery (supine 2). Hemodynamic parameters, airway peak pressure, oxygen saturation, and ETCO2 were monitored. Data were analyzed using repeated-measures multivariate analysis of variance to evaluate the effect of different positions under anesthesia on changes in using optic nerve sheath diameter and P < 0.05 was considered to be statistically significant. There was no difference in optic nerve sheath diameter after prone position with neck extension in all the measure. After surgery, optic nerve sheath diameter was decreased compared with the preoperative baseline values (Rt anterior/lateral 5.6/5.5: 5.4/5.2; Lt anterior/lateral 5.6/5.5: 5.4/5.3, P < 0.05, respectively). In conclusion, prone positioning with head extension did not further increase intracranial pressure, although the surgical procedure could reduce intracranial pressure in the immediate postoperative period in infants undergoing craniosynostosis surgery.

Mandibular advancement impairs swallowing ability more than head extension but less than mouth opening in the supine position

Mandibular advancement in the supine position may influence swallowing during dental treatment under intravenous sedation. This study investigated the influence of mandibular advancement in the supine position on swallowing ability, compared with head extension and mouth opening. The water swallowing test was performed in 13 healthy, awake, supine, adult subjects under four head and mandibular positions. An electromyogram of the suprahyoid muscles was recorded; the duration and peak amplitude were examined. A greater volume of water remained in the mouth during mouth opening and mandibular advancement relative to the neutral position; the volume in the mandibular advancement position was larger and smaller than that in the head extension position and during mouth opening, respectively. The duration of the electromyogram in the head extension position was longer than that in the mandibular advancement position, without differences in the amplitude. Thus, swallowing ability in the supine position was more impaired with mandibular advancement, relative to neutral and head extension positions, but less than that observed with mouth opening. Although unconfirmed by electromyogram, our findings suggest that head extension might improve airway patency by reducing the impairment of swallowing ability compared with mandibular advancement.

The effect of altered head and tongue posture on upper airway volume based on a validated upper airway analysis-An MRI pilot study.

To determine the influence of altered head or tongue posture on upper airway (UA) volumes using MRI imaging based on a new objective and validated UA evaluation protocol. One supine CBCT and five sagittal MRI scans were obtained from ten subjects in different head and tongue positions: (a) supine neutral head position (NHP) with the tongue in a natural resting position with the tip of the tongue in contact with the lingual aspect of the lower incisors (TRP); (b) head extension with TRP; (c) head flexion with TRP; (d) NHP with the tip of the tongue in contact with the posterior edge of the hard palate (THP); and (e) NHP with the tip of the tongue in contact with the floor of the mouth in contact with the caruncula sublingualis. Based on a validated CBCT UA analysis, the retropalatal, oropharyngeal and the corresponding total volumes were measured from each MRI scan. Wilcoxon signed-rank test was applied to determine the statistically significant difference in mean volume between the baseline head and tongue posture (NHP with TRP) and the other postures. Five females and five males with a mean age of 46.5±13.7years volunteered for this pilot study. UA volumes, particularly the oropharyngeal volume, increased significantly with head extension and NHP with THP and decreased significantly with head flexion. Altered head and tongue posture proved to affect UA volumes, thus representing confounding variables during three-dimensional radiographic image acquisition.

Preparation for Advanced Airway Management: Pre-oxygenation and Positioning

Preoxygenation allows a margin of safety prior to establishing control of a patient’s airway. Effective preoxygenation is influenced by careful technique, respiratory physiology, blood oxygen content, and total body oxygen consumption. Total body oxygen consumption is increased in the pregnant, pediatric, and obese populations, making maintenance of oxygenation more difficult during apnea. In addition to a standard facemask, advanced equipment such as high-flow nasal cannula, THRIVE, and various mask variants may be used. Positioning of a patient for advanced airway management affects preoxygenation, respiratory mechanics, and the conditions for establishing a definitive airway. The “triple airway support” maneuver consists of head extension, neck flexion, and protrusion of the mandibular teeth over the upper teeth; and provides effective mechanics for positive-pressure mask ventilation. Patients with potentially unstable cervical spines present additional challenges and, especially in emergency situations, require careful negotiation of priorities. Common maneuvers such as head tilt, jaw thrust, cricoid pressure, and manual in-line stabilization can cause motion in the unstable cervical spine with uncertain effects. This review contains 7 figures, 5 tables, and 43 references. Keywords: preoxygenation, functional residual capacity, blood oxygen content, alveolar fraction of oxygen, total body oxygen consumption, high-flow nasal cannula, apneic oxygenation, sniffing position, triple airway support maneuver, manual in-line stabilization

Remplissage Procedure: When and How?

Hill-Sachs lesions were first described in 1940 as grooved defect in the posterior aspect of the humeral head associated with traumatic anterior glenohumeral dislocation. The reported incidence of ...

Diastolic dysfunction is initiated by cardiomyocyte impairment ahead of endothelial dysfunction due to increased oxidative stress and inflammation in an experimental prediabetes model

Coronary microvessel endothelial dysfunction and nitric oxide (NO) depletion contribute to elevated passive tension of cardiomyocytes, diastolic dysfunction and predispose the heart to heart failure with preserved ejection fraction. We examined if diastolic dysfunction at the level of the cardiomyocytes precedes coronary endothelial dysfunction in prediabetes. Further, we determined if myofilaments other than titin contribute to impairment. Utilizing synchrotron microangiography we found young prediabetic male rats showed preserved dilator responses to acetylcholine in microvessels. Utilizing synchrotron X-ray diffraction we show that cardiac relaxation and cross-bridge dynamics are impaired by myosin head displacement from actin filaments particularly in the inner myocardium. We reveal that increased PKC activity and mitochondrial oxidative stress in cardiomyocytes contributes to rho-kinase mediated impairment of myosin head extension to actin filaments, depression of soluble guanylyl cyclase/PKG activity and consequently stiffening of titin in prediabetes ahead of coronary endothelial dysfunction.

Study Regarding the Imaging and Functional Evaluation in the Rehabilitation of Balance in Patients with Ischaemic Stroke

The present study is based on the paraclinical and functional evaluation of a sample of 66 subjects with ischaemic stroke, to monitor the evolution of their functional parameters. The tests concerning the variation of barycentre speed within the support polygon and the curve length were conducted using the GPS 400 Posturograph, which provided us with information related to the balance of the subjects in an orthostatic stance with eyes open, with eyes closed, looking to the right, looking to the left, head tilted to the right, head tilted to the left, head in extension. Our findings highlight the balance re-education capacity of the subjects with ischaemic stroke through individualised physical therapy programs.

A new CT dynamic maneuver “Mouth Opened with Tongue Extended” can improve the clinical TNM staging of oral cavity and oropharynx squamous cell carcinomas

ObjectivesCross sectional imaging is mandatory for oral cavity and oropharynx head and neck squamous cell carcinoma's (ooSCC) local extension and TNM staging. However a complex anatomy and frequent dental metallic artifacts make it difficult. This study assesses the clinical benefit of “Mouth Open with Tongue Extended” dynamic maneuver at CT (CTmote) as compared to the conventional CT (CTconv) and MRI. MaterialRetrospectively, 58 patients with histologically proven ooSCC (oral cavity: 34; oropharynx: 24) were included in the study. All had endoscopy with biopsies, MRI, CTconv and an CTmote acquisitions. Data were splitted in 3 datasets and 2 independent radiologists performed readings blindly. Gold standard was pTNM in 31% of cases; otherwise cTNM obtained at multidisciplinary team meeting with endoscopy and mapping biopsies were used. ResultsCTmote was feasible for all patients including those already treated by surgery or radiotherapy. Exact TNM staging was obtained in 68%, 83%, 83% for CTconv, CTmote and MRI respectively. The best exam ratings at paired wise comparisons were 3%, 47%, 50% for CTconv, CTmote and MRI respectively. CTmote and MRI observer agreements, image quality and confidence ratings, were comparable and higher compared to CTconv (p < 0.001). ConclusionsCTmote improves oral cavity and oropharynx tumour stage assessment compared to CTconv with performances close to those of MRI examination. In clinical practice, combining both CT with MOTE maneuver and MRI seems to be the optimal imaging strategy for local staging.

Functional Modules of Pharyngeal Swallowing Mechanics.

ObjectivesThe present retrospective cohort study aims to test the hypothesis that elements of swallowing mechanics including hyoid movement, laryngeal elevation, tongue base retraction, pharyngeal shortening, pharyngeal constriction, and head and neck extension can be grouped into functional modules, and that these modules are predictably altered in disease states.MethodsModified barium swallow video clips of a thick and a thin liquid swallow from 40 normal patients and 10 dysphagic post‐treatment oropharyngeal head‐and‐neck cancer (HNC) patients were used in this study. Coordinate locations of 12 anatomical landmarks mapping pharyngeal swallowing mechanics were tracked on every frame during the pharyngeal phase of each swallow using a custom‐made MATLAB tool. Morphometric modularity hypothesis testing was performed on these coordinate data to characterize the modular elements of swallowing function in each cohort using MorphoJ software.ResultsThe elements of normal swallowing can be grouped into four functional modules including bolus propulsion, pharyngeal shortening, airway protection, and head and neck posture. Modularity in HNC patient showed an intact airway protection module but altered bolus propulsion and pharyngeal shortening modules. To cross‐validate the alteration in modules, a post hoc analysis was performed, which showed significantly increased vallecular (P < .04) and piriform (P < .05) residue but no significant change in aspiration status in the HNC cohort versus controls.ConclusionsThis study suggests that while pharyngeal swallowing mechanics is highly complex, the system is organized into functional modules, and that changes in modularity impacts swallowing performance. This approach to understanding swallowing function may help the patient care team better address swallowing difficulties.Level of Evidence2b

Evaluation of diazepam-ketamine combination for immobilization of African land tortoise (&lt;i&gt;Testudo graeca&lt;/i&gt;)

Zoo and wildlife practitioners are constantly exposed to persistent dangers during physical restraint of wild animals. Chemical immobilization in reptiles is unpredictable due to their ectothermic nature. This study aims to determine a safe and effective anesthetic protocol for immobilization in chelonians and other reptiles. Varied doses of diazepam ketamine combinations were administered and evaluated in 16 healthy land tortoises ( Testudo graeca ). The tortoises were divided into four groups (4 per group) labeled DK-1 through DK-4. DK-1 had a combination of 44mg/kg of ketamine with 0.25mg/kg of diazepam. DK-2 had 22mg/kg of ketamine with 0.25mg/kg of diazepam. DK-3 had 44mg/kg of ketamine with 0.5mg/kg diazepam while DK-4 had 22mg/kg of ketamine with 0.5mg/kg of diazepam. Anesthetic effects were monitored to determine the duration required for partial extension of the head and limbs, full extension of limbs, and complete recovery from anesthesia. These visual inspection of partial recovery and full extension were adapted as surface and deep anaesthesia respectively in describing the depth of anaesthesia. All the time intervals were recorded in minutes, and summarized as mean and standard deviation. ANOVA was used to test for significance across the groups. Full extension of head and limbs was achieved within mean periods of 10, 15.5 and 13 minutes in DK-1, DK-3 and DK-4 respectively. Tortoises in DK-2, which were only sedated, demonstrated only surface depth of anaesthesia. Complete recovery occurred in mean periods of 128, 25, 158 (p < 0.05) and 132 minutes for groups DK-1, DK-2, DK-3, and DK-4 respectively. Diazepam-Ketamine anaesthetic cocktail provides a safe protocol for chemical restraint in tortoises. A higher dose of diazepam produced a longer duration of complete recovery. Keywords : Anaesthesia, Diazepam, Immobilization, Ketamine, Testudo graeca

Open bite and cervical column: is there a relationship?

Introduction: Cervical column is one of the elements of the craniofacial system, which contains three major structures: occipito-atlanto-axial joint, temporomandibular joint and hyoid bone. These structures communicate with vertebral column across muscles and ligaments. According to several studies, cranio-cervical morphology depends on many factors, including age [1], malocclusion, and gender [2]. Changes in cervical column morphology may be present in individuals with normal craniofacial morphology [3]. Materials and methods: This study evaluated 1162 profile radiographs of individuals that attended the orthodontist at the Clínica Dentária Egas Moniz, between November and December 2017. The following inclusion criteria were applied: individuals without prior orthodontic treatment, age between 8 and 18 years-old; profile radiographs with C1-C4 perceptible, overbite less than 3 mm (Group 1) and overbite between 3–5 mm (Group 2), selecting 335 individuals. After that, we proceeded to the cephalometric analysis, with Solow and Tallgren analysis [4]. A request was submitted to the Ethics Committee of Instituto Universitário Egas Moniz and the research was approved with procedure nº 593. Results: In the correlation between age and postural variables, in open bite individuals, there was a significant correlation between age and the variables A-N-Pog, Overbite, Mx-VER, OPT-HOR, and CVT-HOR. When evaluated the influence of overbite on gender, it was verified that female was significative differences in the variables Mx-Md, SN-VER, Mx-VER, SN-OPT, Mx-OPT, SN-CVT, Mx-CVT, OPT-HOR. When evaluated the influence of gender on overbite, it was verified that group 1 had significant differences between male and female in the variables SN-Mx, SN-VER, SN-OPT, Mx-OPT, SN-CVT, Mx-CVT, OPT-HOR, CVT-HOR. Discussion and conclusions: Analyzing the results, as age increase, mandible adopts a more posterior position and promotes a class II pattern, mandible rotation and more cervical vertebral inclination, leading to head extension and cervical lordosis less pronounced. These results suggest that when age increases C2 and C4 tend to be more inclined, not affecting the other values. Thus, cervical vertebral inclination may be consequence of growth and development of individuals, which adopts a more inclined position, and this accentuates cervical inclination may be due to the time that the individual presents the pathology. When evaluating the individuals without open bite, we verify that female present more inclination of C4, and C2 presents similar values in both genders. In this reasoning, C4 inclination may be due to lack of muscular tissue in the neck, and the C2 inclination maintained may be due to atlanto-occipital joint which has more broad movements and functions, and changes provoked by external factors affect C2. If we analyze open bite group, female persists with C4 and C2 more inclined, suggesting that overbite influence C2 too. Thus, in individuals of feminine gender, the presence of open bite causes more inclination of C2 and female present tendentially more C4 inclination, but when an open bite is present, it affects more C2 than C4.

HYPOMAGNESEMIC TETANY IN CAMEL CALVES (CAMELUS DROMEDARIUS): CLINICAL CONSEQUENCES AND TREATMENT OUTCOMES

Camels are the top herds wealth in Saudi Arabia, since is considered as heavy animal population, breeding resist more dangerous diseases. This clinical study was delineated to explain the clinical presentation of hypomagnesaemia in camel calves and to evaluate the efficacy of treatment with magenesium therapy. The investigation was performed in central Saudi Arabia during the period from November 2017 to October 2018. Twenty-seven dromedary camels, 3-6months of age were included in this study on the basis of clinical and treatment outcomes during the period from November 2017 to October 2018. Animals were allocated to two groups, the first group (n = 5) was considered as healthy (control) animals. The second group (n = 22) was clinically showing signs of hypomagnesemis. Allanimals were subjected to biochemical analysis of serum and ruminal fluid. Therapeutic response of the clinically affected animals was assessed after intravenous injection of 100 ml calcium-magnesium preparation intramuscularly. injection of 10ml Vitamin B complex, and oral administration of 2gm Mg sulphate orally for five consecutive days. Clinically affected camels revealed tetany, star gazing, episodes of convulsions with erected ears and tail, extension of head and neck, widening and dilatation of nares. Serum and ruminal fluid analysis revealed a significant decreased (p&lt;0.05) in Mg, Ca, and Phosphorus (P) in clinically affected cases compared to control and treated groups.Total protein (TP), globulin, albumin, , urea and creatinine were significantly higher in clinical cases compared to treated cases. In conclusion, the hypomagnesemic tetany had a high occurrence in camel calves 3-6 month of age . Furthermore, the treatment regieme of hypomagnesemic tetany had agood threrapeutic response.Key words: biochemical tests; camel calves; hypomagnesemic tetany; Saudi Arabia