Mandibular Subluxation Research Articles

Chylopericardium In a Young Woman Revealing A Mediastinal Cystic Lymphangioma: A Case Report

Isolated chylopericardium due to mediastinal cystic lymphangioma is a rare entity. We report a case of asymptomatic chylopericardium in an 18 years old female with no history of trauma, thoracic surgery, malignancy, infection, or tuberculosis sand who presented with cardiomegaly noticed on chest x-ray before surgery of mandibular subluxation. Echocardiography showed a large number of pericardial effusions and pericardiocentesis yielded 1.25 L of milky-colored fluid which showed a triglyceride level of 4.82 g/L and cholesterol of 0.29 g/L with a cholesterol to triglyceride ratio of <1, characteristic of the chylous fluid. Chest computed tomography showed a huge mediastinal cystic lymphangioma. The patient successfully responded to continuous pericardial drainage and a medium-chain triglyceride diet then she was referred to the thoracic department for surgery. This type of case risks being misdiagnosed as tuberculosis, especially in countries where tuberculosis is endemic. Therefore, assessing pericardial fluid for chyle is crucial.

The SedUROscopy Project: Sedation conducted by nurses supervised by the anaesthetist at a Lithotripsy and Endourology Unit in Spain

AbstractThe increased demand for simple, yet invasive and sometimes painful urological procedures in our unit, coupled with a relative lack of anaesthetists, prompted the search for appropriate safe alternatives to current practice, so to enable efficient, satisfactory, and safe interventions for patients. In response to this need, the Four‐Phase SedUROscopy Project has been developed, a plan in which identified Urology nurses take on a more active role in the anaesthetic procedure at the Lithotripsy and Endourology Unit. The aim of the project is to establish a specific care model that ensures the safety and satisfaction of patients undergoing minor endourological procedures, whilst also optimizing resources and empowering nurses and their practice. The SedUROscopy Project started with the training of five nurses (Phase 1: Theory). Subsequently, one of the nurses then began her practical course (Phase 2: up to 200 sedations). She carried out 90 sedations in patients in preparation for minor procedures. Remifentanil and Propofol were administrated using Target Controlled Infusion (TCI) pumps. The initial target plasma propofol concentration was 2 μg/ml, and the remifentanil one was 1 μg/ml. Doses were adjusted to achieve the right sedation. ECG, pulse oximetry, non‐invasive blood pressure and end‐tidal CO2 were monitored. Up to 10 different procedures were carried out. There were 37 oxygen desaturation events (41%), however they were solved with chin lift manoeuvres and mandibular subluxation (8.88%), use of Guedel tube (21.1%) and manual ventilation (11.1%). The intervention of the anaesthetist was not required in any of the cases, and all the patients involved in the sample were discharged the same day, free of any anaesthetic problem at all (100%). As the surveys indicated, the levels of satisfaction expressed by both patient and staff performing the technique were high (98%). The sedation performed by trained urology nurses using TCI has resulted in a provision of safe and effective procedures. Likewise, the patients' satisfaction was ensured. In conclusion, this model represents an optimal use of resources: not only because just a single anaesthetist could supervise two operation theatres, but also nurses could control the patients pain due to their knowledge of endourological procedures and the sedation technique.

Acesso cirúrgico ao segmento cervical distal da artéria carótida interna e à bifurcação carotídea alta – revisão integrativa da literatura e proposta de protocolo

Several different maneuvers have been described for obtaining access to the distal cervical segment of the internal carotid artery or to a high carotid bifurcation. However there are different approaches to systematization of these techniques. The objective of this study is to review the techniques described and propose a practical protocol to support selection of the most appropriate technique for each case. The review is based on the results of database searches on PubMed Central, the Virtual Health Library (BVSalud), and SciELO for articles on the subject published in English or Portuguese from 1980 to 2021. Among the different maneuvers described, it appears reasonable that the first two steps should be to obtain access at the sternocleidomastoid muscle, followed by section or retraction of the digastric muscle posterior belly. If needed, temporary unilateral mandibular subluxation is an additional resource that is preferable to division of the styloid apparatus process, because of its lesser potential for morbidity. Even wider exposure can be obtained using mandibular osteotomies.

Surgical access to the distal cervical segment of the internal carotid artery and to a high carotid bifurcation - integrative literature review and protocol proposal.

Several different maneuvers have been described for obtaining access to the distal cervical segment of the internal carotid artery or to a high carotid bifurcation. However there are different approaches to systematization of these techniques. The objective of this study is to review the techniques described and propose a practical protocol to support selection of the most appropriate technique for each case. The review is based on the results of database searches on PubMed Central, the Virtual Health Library (BVSalud), and SciELO for articles on the subject published in English or Portuguese from 1980 to 2021. Among the different maneuvers described, it appears reasonable that the first two steps should be to obtain access at the sternocleidomastoid muscle, followed by section or retraction of the digastric muscle posterior belly. If needed, temporary unilateral mandibular subluxation is an additional resource that is preferable to division of the styloid apparatus process, because of its lesser potential for morbidity. Even wider exposure can be obtained using mandibular osteotomies.

A case of pregabalin addiction.

Pregabalin, a gamma-aminobutyric acid analog, is a new-generation anticonvulsant that acts by reducing the release of glutamate, noradrenaline, and substance P. Apart from use as concomitant therapy in partial epilepsy, it is used in the treatment of treat neuropathic pain, fibromyalgia, and generalized anxiety disorder. Experimental studies have claimed its usefulness in the treatment of benzodiazepine dependence and withdrawal, as well as preventing relapse in alcohol-dependence patients.[12] Pregabalin use in primary health care has increased recently. In therapeutic dosage, chances of addiction are unlikely. However, there are few reports of addictive potential of the drug when prescribed in higher amount.[3] A case of pregabalin addiction is presented because of its rarity in India. A 32-year-old married male, an operation theater assistant, reported with the complaints of regular use of tablet pregabalin for the past 7 years. Initially, the patient was prescribed tablet gabapen 300 mg bd for chronic pain following traumatic mandibular subluxation. After taking the medication for 3 months, he perceived improvement in his pain. He also felt energetic. When he stopped taking tablet gabapen, he experienced fatiguability and irritability. Since tablet gabapen was costly and he had easy access to tablet pregabalin, he started consuming pregabalin. However, he was not getting the same effect, so he kept increasing the dosage and eventually was consuming 20 tablet/day. At this dose, he used to feel energetic, elated, had increased work performance, and was appreciated by his seniors. His appetite increased significantly. Over the course of 7 years, he experienced diminishing effect, so he gradually increased the dosage to 40 tablet/day. Finally, he was caught stealing drugs and was removed from the job. To satisfy his craving, he started taking loans and sold household articles, and consequently, his family abandoned him. He then tried stopping tablet pregabalin for a few days, but he experienced low mood, irritability with decreased sleep, and appetite, so he restarted taking the tablets. His friend eventually brought him to the psychiatric center. Past and family history was not significant. No history of other substance use was reported. His physical examination and routine investigations were within normal limits. Electroencephalogram showed right frontocentral abnormality. On mental status examination, he was in contemplation stage of motivation. He was admitted and was started on tablet oxcarbazepine 150 mg bd, tablet clonazepam 0.25 mg tds, and tablet tryptomer 10 mg along with psychotherapy. Gradually, his craving reduced and he has maintained abstinence for 3 months after discharge. A systematic review of 106 studies on PubMed/Scopus did not find credible evidence of a strong addictive power of gabapentinoids, due to their limited rewarding properties, few relapses, and the very few cases with gabapentinoid-related behavioral dependence symptoms in patients without a history of substance abuse/dependence. Further, there were no reports of people seeking treatment for abuse of gabapentinoids.[4] Our patient was strongly addicted, felt euphoric and energetic due to the drug, gave history of relapse, and came for treatment. It is assumed that gabapentinoid pharmacodynamics possibly include brain's drug-reward pathways.[5] Physicians prescribing gabapentins should carefully evaluate any history of substance misuse before starting the drug. Furthermore, they should be able to promptly identify signs of pregabalin/gabapentin misuse, while providing assistance in tapering off the medication.[6] The tendency to downplay the addiction potential of gabapentinoids should cease forthwith. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

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.

Extending the boundaries of carotid body tumor excision with a maxillofacial surgeon

Introduction: Carotid body tumor (CBT) excision at times requires a multidisciplinary approach. Requests for mandibular swing or mandibular subluxation were received by the department of dental and oral surgery to aid in CBT excision. Methods: Patients who were referred between March 2013 and April 2018 were retrospectively reviewed. Criteria for deciding between mandibular swing and mandibular subluxation for each patient were identified and outcome of the decision was analyzed. Follow-up period was 6 months to 5 years. Results: Of 53 patients operated during the study, 16 patients were referred for intraoperative assistance. Of the 16 patients, 10 were Shamblin 3 with 2 of these being redo cases and others were Shamblin 2. In all cases, the length of internal carotid artery (ICA) from the base of the skull was 1.5 cm or less. Mandibular swing was performed in three patients, all for Shamblin 3 with two of them being the redo cases, and mandibular subluxation was done for 13 patients. One patient who underwent mandibular swing and two patients who had mandibular subluxation had transient hypoglossal nerve palsy and all of them recovered. None of the patients for whom a mandibular swing was done had marginal mandibular nerve weakness. One patient lost a tooth at the mandibular osteotomy site. All patients had an acceptable scar. Among the patients who underwent mandibular subluxation, one patient had postoperative temporomandibular joint pain, which gradually subsided over 3 weeks. Conclusions: Mandibular swing and mandibular subluxation help provide the vascular surgeon with the additional space needed when excising CBTs, which extend close to the base of the skull with 1.5 cm or less of ICA from the base of the skull. The maneuvers help easier dissection and reconstruction of the ICA, reduce nerve injury and operating time, and reduce hospital stay and therefore cost to the patient.

Carotid Body Tumors

Carotid body tumors (CBTs) are derived from parasympathetic autonomic nervous system cells and are the most common type of head and neck paragangliomas, accounting for 65-80% of lesions. CBTs may occur sporadically, may be familial with identified gene mutations on the succinate dehydrogenase subunit, or a component of familial neuroendocrine syndromes. Environments or medical conditions leading to chronic hypoxia can increase the risk of CBTs. The differential diagnosis of CBT include other neck masses such as enlarged lymph nodes or other neck tumors. Computed tomography or magnetic resonance angiography is often diagnostic as CBTs cause a characteristic splaying of the carotid bifurcation. The degree of encasement of the carotid arteries is classified by Shamblin Type I-III, and the higher Shamblin category correlates to highest risk of nerve injury after surgical resection. All tumors should be removed in healthy patients, with observation or radiotherapy reserved for high-risk or elderly asymptomatic patients. Tumor embolization may be considered in CBTs larger than 4cm. Resection, with or without tumor embolization, requires adequate exposure of the distal carotid with consideration of nasotracheal intubation or mandibular subluxation. The surgeon must be prepared to resect and replace the carotid artery in large CBTs using techniques similar to carotid endarterectomy to reduce stroke risk. Cranial nerves should be carefully exposed and preserved during a systematic dissection. Despite careful resection, cranial nerve injury may be as high as 30-40%, although only 5% are permanent. Stroke risk (1%) and mortality (&lt;1%) are low. KEY WORDS: Carotid body tumor, succinate dehydrogenase, Shamblin Type, neuroendocrine tumors, parasympathetic autonomic nerve cells, tumor embolization

Anaesthetic management in the excision of large carotid body tumours: Surgeons perspectives

Objective(s): Carotid body tumours (CBT) are considered rare. Surgical excision is the treatment of choice and poses many anaesthetic challenges especially in large tumours. In this paper we present our experience of anaesthetic management of CBT which is one of the largest series on management of large (Shamblin II, III) tumours in the world. Design: Retrospective cohort, Instituitional Review Board (IRB) Approved. Setting: Single-Centre Tertiary care institute in South India. Participants: Patients undergoing operative intervention for carotid body tumours. Interventions: nil, observational. Results: 66 tumours were excised in 62 patients (27 female, 39 male). The average age was 37.5. All tumours presented with a slow growing neck mass.7 patients complained of pain,as the presenting symptom. 2 were malignant, all were non-functional. 4 presented with preoperative neurological dysfunction- 2 with cranial nerve palsy following excision of contralateral CBT and 2 with resolved stroke following preoperative embolization. Nasotracheal intubation with mandibular subluxation was performed in 5. The average operating time was 2.5 hours. Average blood loss was 900 ml (200- 5000ml). Perioperative blood or product requirement varied from no transfusion to one patient with a very large (20cm tumour) requiring transfusion of a total of 20 products. Clamping of the carotid was necessary in 22 patients. 3 patients received heparin prior to clamp. There were 4 perioperative strokes, none of whom had any precipitous intraoperative hypotension. Transient postoperative cranial nerve palsy/paresis occurred in 50% with permanent cranial nerve deficits in 5%. There was no perioperative mortality. Tracheostomy was required in one patient for bilateral vocal cord palsy. Conclusions: Several preoperative ,intraoperative and postoperative management points (airway, intraoperative blood loss, stroke, cranial nerve dysfunction ,blood pressure control), are specific to the management of carotid body F tumours.Increased awareness of these specific scenarios and appropriate management ensures minimal perioperative morbidity and mortality.

Efficacy of Mandibular Subluxation for Carotid Endarterectomy with Combined Fixation Using Interdental Wire and Putty

Bifurcation of the carotid artery at a cephalic location greatly increases the risk associated with carotid endarterectomy (CEA). Mandibular subluxation (MS) can improve access to the cephalic location; however, the benefits of MS remain unclear. The present study objectively assessed the efficacy of MS. MS was performed with only wire fixation of healthy teeth in four patients (Group A), with wire fixation reinforced by inserting Coltoflax® putty between healthy teeth in 17 patients (Group B), and with wiring between maxillary and mandibular screws reinforced by inserting Coltoflax® putty between the wires in five edentulous patients (Group C). Pre- and postoperative axial computed tomography angiography images at the level of the tip of the mastoid process were used to compare the following measurements: mastoid-mandible distance between the anterior margin of the mastoid process and posterior margin of the mandible; and mastoid-internal carotid artery-mandible (MIM) angle between the line connecting the anterior margin of the mastoid process and the center of the internal carotid artery, and the line connecting the posterior margin of the mandible and the center of the internal carotid artery. MS increased the overall mastoid–mandible distance by 5.7 ± 3.1 mm. The increase was significantly greater in Group B (6.7 ± 2.0 mm) than in Group A or C (4.0 ± 4.1 mm) (P=0.032). MS increased the overall MIM angle by 13.3 ± 7.9o. MS with the combination of wire with Coltoflax® putty offered the widest surgical corridor for CEA.

Mandibular Subluxation as an Adjunct in Very Distal Carotid Arterial Reconstruction: Incidence of Peripheral and Cerebral Neurologic Sequelae in a Single-Center Experience

The location of the carotid bifurcation and a very distal extension of internal carotid atherosclerotic disease may challenge vascular surgeons performing carotid endarterectomy (CEA) by increasing technical difficulty and possibly the incidence of cranial nerve damage or palsies. The objective of the present study is to report on the safety of CEA with mandibular subluxation (MS) and to compare results of CEA in 2 groups of patients treated by standard CEA or by MS-CEA according to rates of major neurologic complications, death, and the occurrence of postoperative peripheral nerve palsy. Between July 2000 and June 2012, 1,357 CEAs were performed. MS was additionally used in 43 patients. Only patients with primary atherosclerotic internal carotid artery (ICA) lesions in the 2 groups (38 in the MS-CEA group and 1,289 in the standard CEA group) were considered for comparative analysis. MS-CEA patients were more frequently male (P = 0.03), presented more frequently with symptomatic lesions (P = 0.007), longer lesions (P = 0.01), and had common ICA bypass implantation (P = 0.02). Mean follow-up was 68.75 ± 37.87 months (range: 1-144 months). No perioperative neurologic mortality and no prolonged discomfort related to MS was recorded. The overall neurologic morbidity rate (major stroke/minor stroke/transient ischemic attach) was comparable in the 2 groups (P = 0.78). The overall immediate peripheral nerve injury rate was 7.89% in the MS-CEA group and 5.27% in the standard CEA group (P = 0.73). Three cases of permanent dysphonia in the standard CEA group (0.23%) and 1 case of dysphagia in the MS-CEA group (2.63%) were reported at follow-up (P = 0.24). MS-CEA can be a very useful technical adjunct for high-located carotid bifurcations or challenging carotid lesions, with an overall risk comparable to that of standard CEA.

I-gel™ supraglottic airway in clinical practice: a prospective observational multicentre study

The i-gel™ supraglottic airway device has been studied in randomized controlled studies, but it has not been evaluated in a large prospective patient cohort. Therefore, we performed this prospective multicentre observational study to evaluate success rates, airway leak pressure, risk factors for i-gel failure, and adverse events. With Ethics Committee approval and waiver of patients' consent, data about anaesthesia providers, patient characteristics, and the performance of the i-gel were recorded in five independent hospitals in Switzerland over a period of 24 months. We analysed success rates, leak pressures, adverse events, and risk factors for failure. Data from 2049 i-gel uses were analysed. Patients' mean age was 47 (range 6-91) yr. The primary i-gel success rate without changing size was 93%; the overall success rate was 96%. Insertion was deemed very easy or easy in 92%. The mean airway leak pressure was 26 (8) cm H(2)O. The mean anaesthesia time was 67 (42) min. Risk factors associated with i-gel failure were males (P<0.001), impaired mandibular subluxation (P=0.01), poor dentition (P=0.02), and older age (P<0.01). Adverse events recorded were laryngeal spasms (n=25, 1.2%), blood stained airway devices (n=79, 3.9%), transient nerve damage (n=2, 0.1%), one case of transient vasovagal asystole, and one glottic haematoma. The i-gel is a reliable supraglottic airway device failing in <5% and providing high airway leak pressures. Males, impaired mandibular subluxation, poor dentition, and older age are risk factors associated with primary device failure. Serious adverse events are rare.

Improved exposure for carotid endarterectomy

Carotid endarterectomy continues to be an operation that is widely employed and associated with excellent outcomes. Challenges to attain adequate field visualization do occur. A new retracting device is described that vastly improves operative field visualization, particularly in the upper area where high lesions and limited cervical mobility can restrict or hamper technical maneuvers. Complex maneuvers such as mandibular subluxation or osteotomy may be obviated.

I-gel Has High Success for Elective Intubations

In this large study, the i-gel was associated with a 93% first-attempt success rate and few complications. Researchers prospectively evaluated 2049 i-gel supraglottic airway device insertions in elective surgery patients at 5 Swiss hospitals over a 24-month period. After induction of anesthesia, operators recorded data on operator specialty and experience, patient characteristics, airway assessment, anesthesia management, and perioperative complications. The first-attempt i-gel success rate was 93%, and the overall success rate was 96%. Risk factors for first-attempt i-gel failure were male sex, older age, poor dentition, and impaired mandibular subluxation. Mean airway leak pressure was 26 cm H2O. Providers classified 92% of insertions as easy or very easy. Complications included mucosal injury (3%), sore throat (2%), laryngospasm or bronchospasm (1%), nerve injury (2 patients), and glottic hematoma (1 patient). One patient suffered an asystolic cardiac arrest but had return of spontaneous circulation 1 minute later. Comment: Although this study is subject to selection bias, the large number of insertions shows that the i-gel is associated with high success (>93%) and relatively minor complications in an elective surgery population. The leak pressure is comparable to that for a standard laryngeal mask airway. Based on these results, the i-gel is a reasonable choice for emergency airway management in patients without a predicted difficult airway.

Management of Carotid Artery Stenosis: A Review.

Carotid endarterectomy clearly benefits high stroke-risk patients, but its value for asymptomatic patients is still being debated. If a high exposure is necessary for redo procedures or distal aneurysms, mandibular subluxation and styloidectomy may be required. Perioperative mortality and morbidity are acceptably low. Restenosis occurs in few patients.http://link.springer-ny.com/link/service/journals/00547/bibs/8n3p139.html

Mandibular subluxation stabilized by mouthpiece for distal internal carotid artery exposure in carotid endarterectomy

The standard approach for carotid endarterectomy cannot provide adequate exposure of the distal internal carotid artery in the presence of high cervical carotid bifurcation or high plaque. Limited accessibility of the distal internal carotid artery has resulted in the development of various operative techniques. Mandibular subluxation is the most simple and least invasive technique, but it does require invasive maneuvers, such as wiring, to stabilize the mandible. We use a mouthpiece made by the dentist to stabilize the mandible in the physiologic subluxated position. This technique provides an adequate exposure of the distal internal carotid artery as with the other methods, and the risk of morbidity is very low.

CLINICAL EFTECTIVENESS OF ACUPUNCTURE FOR MANDIBULAR SUBLUXATION AND DISLOCATION

Dislocation or subluxation of mandible could occur suddenly without Patient's awareness of its forthcoming. Patient may discover suddenly during yawning, laughing, or when the mouth is wide open that he or she could not close the jaw. It may cause serve anxiety and apprehension, that may put the patient in such a nervous state that may worsen the condition, and also may spastically tense the muscles associated with dislocation. We treated 37 patients in the past and found that, although five patients could be manipulated to have their dislocated jaw reduced to the normal state, we found that a majority of the cases could not be manipulated without supplementing with other adjunctive methods such as acupuncture at the pertinent acupoints, or injections of local anesthetic around the temporomandibular joint area. Twenty-seven patients were successful to have the dislocation or subluxation reduced, five patients required local anesthetic for reduction and 1 patient had to have the reduction done in the operating room under deep sedation. We found acupuncture is valuable in reducing the mandibular subluxation and dislocation. Three acupoints in calming down the patients were a valuable aid during treatment. LI 4 which is known to reduce pain in head and neck region could increase pain threshold and decrease anxiety associated with discomfort encountered during reduction treatment. Additional acupoints such as P 6 (Neikuan), Ext 1 (Yintang), and H 7 (Shenmen) are valuable for the patients who are tense and nervous. Those acupoints are also could be utilizied as additional aid to ease the spasm of the muscles associated with subluxation and dislocation. Post-operative care includes stabilization at the head and neck region.

Mandibular subluxation for distal internal carotid artery exposure in edentulous patients

Four patients with high internal carotid artery (ICA) occlusive disease were indicated for surgical endarterectomy and needed additional exposure besides regular head rotation and extension. When indicated, in our clinic this is usually achieved by mandibular subluxation with interdental wiring. Due to dental wear and periodontal disease, all 4 patients were edentulous. As a consequence, the technique of interdental wiring could not be used. In this technical note we will explain a method for interarch fixation with the use of two ipsilateral monocortical miniscrews and wiring, and the use of patients' pre-existing mandibular implants and provisional overdenture. This method gives rise to an additional exposure of 15 to 20 mm of the ICA.

頸部内頸動脈狭窄症に対する頸動脈内膜剥離術―安全な手術を目指して工夫していること―

We will outline our surgical techniques and treatment strategies of CEA to prevent peri-operative complications. Between 1997 and 2006, 234 CEAs were performed on 205 patients, 128 of which were symptomatic, while 106 were asymptomatic. Prior to surgery, all patients were screened by cardiologists to elucidate congestive and/or ischemic heart disease (IHD). If coronary artery stenosis was present, it was treated before surgery. CEA was performed under general anesthesia using a “hitch-up” maneuver and with or without shunting according to a number of intraoperative parameters. For high-risk cases with higher carotid bifurcation, we prepared a special mouthpiece to achieve mandibular subluxation and expose the distal ICA for easy access. For patients with long-segmental lesions or contralateral ICA occlusion, and for those who seemed to be intolerant to intraoperative temporary occlusion of the ICA, we used an extracorporeal circulation technique. Postoperative management was as follows: 1) Overnight sedation with intubation to avoid postoperative bleeding and airway obstruction, and 2) SPECT on postoperative days (POD) 1 and 4 to predict hyperperfusion syndrome. Among 128 symptomatic cases, perioperative stroke occurred in 5 (minor stroke in 3 and cerebral hemorrhage in 2 cases), making surgical morbidity and the mortality rate within 1 month of the CEAs 1.7% and 0.4%, respectively. Cranial nerve palsies were seen in 8 cases (6.2%), but all recovered within 1 month. Conversely, 106 asymptomatic cases had no surgical morbidity or mortality except for temporary cranial nerve palsies (6 cases: 5.7%). During the long-term follow-up of 32 months, minor stroke occurred in 2 patients (1.0%), and 12 patients (5.1%) died of causes other than stroke, including 1 myocardial infarction. As for high-risk cases (92 cases), cumulative incidence of adverse events (death, stroke, or myocardial infarction) at 30 days and 1 year after CEAs were 3.2% and 5.4%, respectively, which seemed to be acceptable compared with other clinical trials. CEA prevents strokes (even for high-risk patients) quite effectively if carried out with consistent treatment strategies and appropriate technical devices.

A Multidisciplinary Approach to Carotid Paragangliomas

The surgical management of carotid paragangliomas can be problematic. A multidisciplinary approach was used to include vascular surgery, otolaryngology, and neuroradiology to treat these patients over 9 years. From January 1992 to July 2001, a multidisciplinary team evaluated patients with carotid paragangliomas. Analyzed patient data included age, gender, diagnostic evaluation, tumor size, preoperative tumor embolization, operative exposure, need for extracranial arterial sacrifice/reconstruction, postoperative morbidity including cranial nerve dysfunction, and long-term follow-up. Twenty-five carotid paragangliomas in 20 patients underwent multidisciplinary evaluation and management. Average age was 51 years (range, 28-83 years), and 52% were male. Diagnostic evaluation included computed tomography in 76%, magnetic resonance imaging/magnetic resonance angiography in 52%, catheter angiography in 60%, and duplex ultrasonography in 16%. An extended neck exposure was required in 11 cases (44%), mandibulotomy was used once (4%), and mandibular subluxation was never required. The external carotid artery (ECA) was sacrificed in 8 cases (32%). The carotid bifurcation was resected in 1 patient (4%) requiring interposition reconstruction of the internal carotid artery. Preoperative tumor embolization was performed for 13 tumors (52%). Operative blood loss for patients undergoing preoperative embolization (Group I) was comparable to the nonembolized group (group II): group I lost 365 +/-180 mL versus 360 +/- 101 mL for group II (P = .48). This occurred despite larger tumors (group I - 4.2 cm versus group II - 2.1 cm, P = .03) and a higher mean Shamblin class (group I - 2.5 versus group II - 1.45, P = .001) for group I. There were no perioperative mortalities. Transient cranial nerve dysfunction occurred in 13 CBTs (52%), 2 (8%) of which remained present after 4 months. Patients with carotid paragangliomas benefit from a multidisciplinary team approach. Neuroradiology has been used for selective preoperative embolization, which has decreased estimated blood loss during excision of larger complex tumors. A combined surgical team of otolaryngology and vascular surgery provides for exposure of the distal internal carotid artery as high as the skull base, limited permanent cranial nerve dysfunction, and selective early division and excision of the external carotid artery for complete tumor resection.