Mouth Gag Research Articles

Closure of the Nasal and Buccal Layers in V-Y Pushback Palatoplasty: Use of a Spring Carrier.

The aim of this paper is to re-introduce Kilner and Calnan's technique of closing the nasal and buccal layers in V-Y pushback palatoplasty by using the spring carrier on the mouth gag.After flap elevation and dissection, the first suture is inserted through the nasal layer of the mucosa at the level of the posterior border of the hard palate. This 3-0 stitch is left untied until later. The nasal layer is approximated by inserting a series of 4-0 sutures so that the knots can be tied on the mucosal surface inside the nose. All sutures are inserted before any are tied. The sutures are inserted consecutively, moving from the hard palate region toward the uvula. The sutures may be held on the spring suture carrier attached to the mouth gag; they should be covered by a damp swab. When all sutures have been inserted, they are then tied firmly with three knots, working from behind to forward, and cut short by the surgeon. The buccal layer is closed starting from the uvula and moving toward the hard palate. A series of interrupted mattress sutures are inserted to unite the mucosa and the velar muscles. The inserted sutures are tied before the next stitch. They may be cut by the assistant, leaving 3 to 4 mm beyond the knot.In this technique, the untied sutures could be arranged well on the spring suture carrier attached to the mouth gag. When covered by a damp swab, the catgut sutures did not dry up.

Evaluation of the effect of Boyle-Davis mouth gag on intracranial pressure in patients undergoing adenotonsillectomy by using ultrasonographic optic nerve sheath diameter measurement

ObjectiveWe aimed to evaluate the effect of an increase in intracranial pressure (ICP) due to sympatho-adrenergic response caused by mouth gag and tongue depressor during adenotonsillectomy by measuring the optic nerve sheath diameter (ONSD) by ultrasonographic method. MethodsForty patients (age range 3–12 years) who underwent adenotonsillectomy were included in the study. All patients underwent surgery under general anesthesia with endotracheal intubation. Boyle-Davis mouth gag was used during the procedure. ONSD measurement was performed and a high-frequency linear probe. All ONSD measurements were performed by a single investigator experienced in the use of ultrasound. Ultrasonographically measured ONSD before induction was accepted as baseline (T0) value. Immediately after insertion of the mouth gag (T1), just before removal of the mouth gag (T2), and just before extubation (T3), ultrasonographic measurements of ONSD were recorded. ResultsWhen patients' baseline ONSD values were compared with the values obtained in T1, T2, T3, and a statistically significant increase was detected. The ONSD value measured before removing the mouth gag (T2) was significantly higher than the ONSD value measured immediately after the insertion of the mouth gag (T1). The ONSD value measured just before extubation (T3) and after removal of the mouth gag was significantly lower than the ONSD value (T2) measured just before removal of the mouth gag. When heart rate, mean arterial pressure (MAP), peripheral oxygen saturation (SpO2) values of T0, T1, T2, T3 were compared, any statistically significant difference was not observed. When end-tidal carbon dioxide level (etCO2) and peak inspiratory pressure (PIP) values of T1, T2, T3 were compared, any statistically significant difference was not observed. ConclusionThis study showed that the Boyle-Davis mouth gag used during the adenotonsillectomy operation resulted in a significant increase in the diameter of the optic nerve sheath measured ultrasonographically and increased the ONSD even further during the time the mouth gag was remained in situ. In children with intracranial pathologies who will undergo adenotonsillectomy or those with increased ICP-related risk factors, the risks that may arise from the effect of the Boyle-Davis mouth gag on ICP should be considered.

Lessons from the Holocaust for perinatal care today.

Lessons from the Holocaust for perinatal care today.

Use of a Heister mouth gag as an aid to reduction in open treatment of condylar fracture.

The management of condylar fractures remains controversial. Open treatment of condylar fractures is a routine treatment in cases of displaced or dislocated condylar and subcondylar fractures. Because of the pull of the lateral pterygoid muscle, the condylar fragment is usually located anterior and medial to the mandible. Distraction of the mandible in an inferior direction simplifies proper reduction. Various distraction devices have been described in literature. We describe a technique of using the Heister mouth gag at the surgical site to aid in reduction of displaced dislocated condylar fractures.

The cheek expander enables tonsillectomy with a wide view and working space

ObjectiveTonsillectomy is the most commonly performed otolaryngological surgeries.Although a surgical method had been established, obtaining a clear surgical field still remains problematic, and injury to the corners of the mouth may occur. For safer tonsillectomy, we use a cheek expander coupled with a Davis mouth gag. The devise retract both corners of the mouth to a wide lateral position. We report here our investigation in the application of a cheek retractor for tonsillectomy and also report the advantages of this device. MethodsA series of 13 tonsillectomies (7 adults and 6 children) using the cheek retractor from November 2017 to March 2018 were enrolled for this study. The cheek retractor was applied after the Davis mouth-opening device was in place. We measured the oral angle diameter before and after placement of the cheek retractor. ResultsThis devise increases the width of the visual field 1.6 times and provides a good surgical field. In addition, this device covers the mouth fully and safely, so no lip injury develops ConclusionThe cheek retractor is useful for improving the narrow working space in tonsillectomy.

Standalone Transoral Vertebroplasty for Treatment of Painful Metastatic C2 Lesion: A Case Report

Introduction: Metastatic involvement of the spine may present with pathologic fractures, deformity, neurologic deficit due to vertebral canal compromise, and pain. Pain is usually managed with non-steroidal anti-inflammatory agents, corticosteroid injections, calcitonin, etc. Since the introduction of percutaneous vertebroplasty in 1984, it has proven as an effective armamentarium in the management of painful metastatic spine lesions. Herein, we present a case of breast cancer with osteolytic C2 metastasis, for whom trans-oral vertebroplasty without posterior fusion resulted in long-standing pain control and maintenance of normal motions and stability. Case Presentation: A 41-year-old woman, a known case of breast cancer with severe neck pain for three months, was admitted due to an osteolytic lesion in C2. The pain was incapacitating and resistant to conservative measures. Standalone transoral vertebroplasty resulted in pain control and a three-year follow-up showed durable control of pain. After positioning the patient and insertion of Dingman mouth gag, the oropharynx was prepped and injected with epinephrine/lidocaine solution. Under biplanar fluoroscopic guidance, a needle was introduced into the C2 body through the oropharynx. The lytic lesion was filled with about 2 cc of PMMA cement. The VAS score decreased from 10 prior to operation to 5 immediately after recovery from general anesthesia and improved to 2 after six months. At a 36-month follow-up visit, the VAS score was 0, normal cervical motions were preserved, and lateral neutral and dynamic cervical X-rays disclosed stability. Conclusions: Standalone transoral vertebroplasty can be safely practiced as an effective treatment for painful osteolytic metastases of C2 with normal dynamics.

Oral Lesions in the Bit Area in Finnish Trotters After a Race: Lesion Evaluation, Scoring, and Occurrence.

Oral lesions in the bit area are common in horses, but not comprehensively studied in harness racing horses. This study describes the type and occurrence of oral soft tissue lesions in the area affected by the bit, hereafter called the bit area, in trotters after a race. Based on our results, we suggest a system for scoring lesions according to size, type (bruise or wound), age, and depth (superficial or deep). The data was collected during a welfare program for trotters, conducted by The Finnish Trotting and Breeding Association (Suomen Hippos ry). The rostral part of the mouth of 261 horses (151 Standardbreds, 78 Finnhorses, and 32 ponies) was examined after a race in a systematic manner, using a bright light source without sedation or a mouth gag. The lip commissures (outside and inside), bars of the mandible, buccal area near the second upper premolar teeth, tongue, and hard palate were visually examined; bars of the mandible were also palpated. Points were assigned to every lesion and then added together, such that each horse got an acute lesion score. Based on the score, the horses were divided into four groups (A—D) as follows: Group A, no lesions; B, mild lesions; C, moderate lesions; D, severe lesions. Of all the horses examined, 84% (219/261) had acute lesions in the bit area. In total, 21% (55/261) had mild lesions, 43% (113/261) had moderate lesions, and 20% (51/261) had severe lesions. Visible bleeding outside the mouth was observed in 2% (6/261) of the horses. Further, 5% of the horses (13/261) had blood on the bit when it was removed from the mouth, even though no blood was visible outside the mouth. In conclusion, soft tissue lesions in the bit area were common in the Finnish trotters examined. Moreover, the absence of blood outside the mouth does not rule out serious injuries inside the mouth. The scoring system presented can be used for evaluating the severity of oral lesions in different equestrian disciplines and populations to allow for comparable data across studies.

Prospective comparison of conscious nasal versus oral video upper GI endoscopy in adults

Background: Endoscopy procedures are now becoming a mandate for any upper or lower abdominal conditions in addition to any radiological investigations. Patients have reluctance. It's mainly because of the painful experience they come across during upper GI endoscopy. If pain can be addressed during endoscope then all patients would smile after this procedure. The main objective of the study is to compare nasal endoscopy vs conventional endoscopy in gastrointestinal disorders.Methods: This prospective study was conducted in the department in the department of bariatric and metabolic surgery, Apollo Spectra Hospitals, Chennai. Totally 200 cases were included in the study for the study. Nasal packing was done with xylocaine and oxymetazoline without oral spraying of 10% xylocaine. Oral mouth gag was not inserted in nasal cases. Pain score was primarily used as a scoring method.Results: Comparative study was done for both groups for pain score, gag reflux, nausea, comfort level, voice change, image clarity, intervention procedures, and overall scoring was done. There was a significant advantage in the nasal endoscopy group.Conclusions: More screening endoscopies can be done for a large patient population to diagnose Gastro diseases at an early stage if a painless endoscopy can be offered instead of regular endoscopy hereafter. But however, the endoscopy suite should have regular scope for therapeutic procedures.

Improving exposure for transoral oropharyngeal surgery with the floor of mouth window: a cadaveric feasibility study

BackgroundTransoral robotic and laser surgery is rising in popularity due to the increasing incidence of Human Papilloma Virus (HPV) related oropharyngeal cancer. However, adequate exposure of the tongue base remains a major hurdle in many cases. This study introduces a novel surgical technique called the Floor of Mouth Window, which can be used to improve tongue base exposure at the time of transoral surgery.MethodsThis is a preclinical anatomic cadaver study. Seven fresh cadavers were used for this study. Exposure of the tongue base was compared between conventional mouth gags – the Feyh-Kastenbauer and McIvor – and our novel procedure, the Floor of Mouth Window. Exposure was compared subjectively using endoscopic and extracorporeal photographs, as well as objective measurements of inter-incisor distance, and oral cavity volume.ResultsThe exposure achieved by the Floor of Mouth Window technique was superior to the mouth gags. Inter-incisor distance and oral cavity volume measurements were all more favorable with the Floor of Mouth Window. This technique allowed for successful transoral laser tongue base and tonsil resection without the use of gags or scopes.ConclusionThe Floor of Mouth Window is an adjunctive procedure that simply and reliably improved exposure for transoral oropharyngeal surgery in this cadaveric feasibility study. This improved exposure may help increase the adoption of transoral surgery and reduce the number of aborted cases due to anatomic limitations.

Effects of the addition of low-dose ketamine to propofol anesthesia in the dental procedure for intellectually disabled patients.

BackgroundThis study aimed to examine whether the combination of low-dose ketamine and propofol in deep sedation is clinically useful in controlling the behavior in intellectually disabled patients who are typically extremely noncooperative during dental procedures.MethodsA total of 107 extremely noncooperative intellectually disabled adult patients were analyzed. In all patients, deep sedation was performed using either propofol alone (group P) or using a combination of propofol and 0.2 mg/kg or 0.4 mg/kg ketamine (groups PK0.2 and PK0.4, respectively). The procedures were performed in the order of insertion of nasal cannula into the nostril, attachment of mouth gag, and mouth cleaning and scaling. The frequency of patient movement during the procedures, mean arterial pressure, heart rate, peripheral oxygen saturation, recovery time, discharge time, and postoperative nausea and vomiting were examined.ResultsThe three groups were significantly different only in the frequency of patient movement upon stimulation during single intravenous injection of propofol and scaling.ConclusionFor propofol deep sedation, in contrast to intravenous injection of propofol alone, prior intravenous injection of low-dose ketamine (0.4 mg/kg) is clinically useful because it neither affects recovery, nor causes side effects and can suppress patient movement and vascular pain during procedures.

Development and use of a mouth gag for oral experiments in rats

ObjectiveRodent models such as mice and rats are often used in investigations of the oral cavity in the fields of periodontology and dental anesthesiology. When various treatments are performed in the oral cavity, it is very important to secure the visual field while keeping the animal's mouth fully opened, in order to ensure the consistency of experimental procedures. Therefore, we developed a standardized gag conforming to various degrees of oral cavity size of different aged rats. DesignThe gag was composed of a rectangular incisor-opening frame constructed from a stainless steel wire with retractors and a dial to alter the opening amounts. Wistar rats (n = 5) aged 4, 8, and 12 weeks were used to evaluate the suitability of the gag in oral cavity. As tests for application of gag in intraoral experiments, the ligature placement around the molars, drug injection into the gingiva, measurement of gingival blood flow rate, and installation of stimulation an electrode for somatosensory-evoked potentials into the molar were performed. ResultsAdjusting the opening dial enabled both the maintenance of open state and more favorable intraoral observation compared with tweezers as a control device in all different types of rats. Furthermore, our gag made it possible to facilitate the insertion of diverse instruments into the oral cavity and to achieve various experimental purposes. The stainless-steel gag can also be autoclaved and dry-heat sterilized. ConclusionIt was revealed that our mouth gag can be widely applied to various oral experiments in different old aged rats.

Tonsil surgery: impact of the mouth gag on pharyngeal diameter

Photo documentation of hypertrophic tonsils is requested by some insurance companies to justify reimbursement of tonsillotomy. In 2017, astandardized photo documentation was introduced in tonsillotomy patients to verify the indication and effectiveness of the procedure. Using the archived photo documentation, this study aimed to evaluate the impact of two different positions of the mouth gag on the oropharyngeal airway. Pictures were taken through the operating microscope after insertion of the mouth gag but without suspension (D1), after suspension before tonsillotomy (D2), and after resection of tonsillar tissue with the mouth gag under tension (D3). For each picture, a10-mm scale from asingle-use paper ruler was placed on the uvula. For this retrospective study, the patient's images were inserted into PowerPoint slides. Distances were measured with the use of an inserted rectangular grid. The files of 149patients undergoing tonsillotomy in a6-month period were eligible for evaluation. Gender was balanced. The youngest patient was 16months, the oldest patient 48years old (mean: 6.95years; median: 5years). In all patients, tension of the mouth gag had significantly widened the oropharyngeal diameter (p < 0.001), making the tonsils appear smaller. Suspension of the mouth gag results in asignificant relative "downsizing" of the tonsils due to expansion of the oropharynx. Intraoperative photo documentation should also be performed without suspension of the mouth gag. Further studies may clarify whether stretching of the oropharynx has an impact on the distance between the tonsils and surrounding greater arteries.

Flexometallic versus RAE Endotracheal Tube in Cleft Lip and Palate Surgery

Aim and Objectives: The present study was carried out with an objective to evaluate ease of insertion of catheter and suctioning through Flexo-metallic tube versus Ring Adair Elwin (RAE) tube, to know the incidence of kinking of RAE tube and to note down the endo-bronchial placement of Flexo-metallic versus RAE tube and surgeon’s comfort zone. Methods: A prospective observational randomized study was conducted on 60 ASA grade I and II pediatric patients of age group 4 month to 16 years undergoing cleft lip and palate surgeries. Patients were randomly allocated in two groups of 30 each. Group R: intubated with RAE South pole tube and group F: intubated with flexo-metallic tube. The ease of insertion of suction catheter, ease of suctioning of secretions, refixation required, kinking of tracheal tube, incidence of displacement, airway complications and surgeons’ feedback- Comfort zone were noted. Results: The ease of suctioning through lumen of Tracheal tube was easier in group ‘F’ as compared to RAE tube. No kinking of tracheal tube was found in any group. The displacement of tracheal tube was observed in 2 patients in group ‘R’. Refixation of tracheal tube was required in 2 patients in group ‘R’. Bronchospasm and cough was noted in 1 patient in group ‘R’. No variations in vitals (e.g. blood pressure and heart rate) were observed in any group. Surgical team was comfortable in both groups but more so with Flexo-metallic tracheal tube group. On extubation we found retained secretions at distal portion of RAE tube in 2 patients. Conclusion : Flexometallic tracheal tube provides advantage of easy suctioning of tracheal secretions. Do not kink in mouth gag of surgical field, provides better airway security and stability, less intra-operative manipulation by anaesthetist, less airway complications, provides better surgical field.

The use of laryngeal mask airway for adenoidectomy

ObjectivesAirway management during adenoidectomy is traditionally performed through endotracheal intubation (ETT). Laryngeal mask airway (LMA) may be less stimulating to the airway and allow for shorter overall operating room time. Previous studies report LMA use during adenotonsillectomy. There has been no prior evaluation of LMA use during adenoidectomy alone. In this study, we attempt to identify the rate and contributing factors of LMA failure during adenoidectomy. MethodsAll pediatric patients undergoing adenoidectomy between January 1, 2016 and June 30, 2017 were reviewed. Demographic and clinical data were collected and analyzed to determine the need for conversion to ETT and the occurrence of any complications. ResultsOur study revealed 139 pediatric patients who underwent adenoidectomy during the study period. 110 patients had adenoidectomy performed with LMA and 27 patients had ETT. Two patients (1.8%) required conversion to ETT because of difficulty with ventilation when the mouth gag was in place. There were no complications. Mean operating room time was 20 min less in the LMA group (P < 0.05). ConclusionsThe use of an LMA in adenoidectomy may be a safe and effective alternative to ETT. More study is required to determine overall complication rates.

Lingual Pressure During Dingman-Assisted Cleft Palate Repair: An Investigatory Case Series.

A variety of palatoplasty techniques are used for cleft palate repair, almost all involving a device called the Dingman-Grabb mouth gag ("Dingman") to push the tongue and cheeks out of the way of the operating field. There have been numerous case reports of complications hypothesized to be due to the gag, such as lingual edema and airway obstruction. The purpose of this study is to introduce a technique for monitoring lingual pressure during Dingman-assisted palatoplasty and present preliminary data from a small series. Patients with a cleft palate who underwent palatoplasty with the assistance of a Dingman-Grabb retractor at the Mount Sinai Hospital were eligible. Patients underwent a palatoplasty while having their lingual pressure monitored using a 23-gauge needle inserted into the tongue and connected to a pressure monitor. Three patients were included. Patients 1 and 2 experienced a rapid rise in lingual pressure over the course of the first 45 minutes of the palatoplasty before plateauing until the conclusion of the operation when the Dingman was released. Patient 3 plateaued almost immediately by minute 1 and then had a rise in lingual pressure during the latter half of the operation, reaching a peak pressure immediately before the end of the operation. The present study describes an easy method to monitor lingual pressure that succeeded in measuring such changes throughout 3 palatoplasties and confirming the acute rise in lingual pressure and the potential danger posed to the tongue and the airway through the use of the Dingman.

Comparison of three different adenoidectomy techniques in children - has the conventional technique been surpassed?

IntroductionPharyngeal tonsil hyperplasia is the most frequent cause of nasal obstruction and chronic mouth breathing during childhood. Adenoidectomy is the procedure of choice for the resolution of these symptoms. It is not yet known, however, whether the conventional technique (“blind curettage”) has been surpassed by more modern adenoidectomy techniques (video-assisted, with the aid of instruments). This study aimed to compare the conventional adenoidectomy technique with two other emerging techniques, performed in a reference otorhinolaryngology center. MethodsThis is a prospective and observational study of 33 children submitted to adenoidectomy using 3 different techniques that were followed up for a period of 3 months after surgery. The patients were divided into 3 different groups, according to the adenoidectomy technique: Group A (conventional technique - "blind curettage”); Group B (video-assisted adenoidectomy with microdebrider); Group C (video-assisted adenoidectomy with radiofrequency – Coblation®). The surgical time of each procedure was measured, being considered from the moment of insertion of the mouth gag until complete hemostasis was achieved. The questionnaire for quality of life OSA-18 was applied to all caregivers on the day of the surgery and 30–90 days after the procedure. Postoperative complications were also analyzed. ResultsFor the entire patient sample, there was an improvement in quality of life after the surgery (p < 0.05). When analyzing the evolution of OSA-18 index, all groups showed statistically significant improvement, for all assessed domains. There were no statistically significant differences between the 3 techniques assessed for quality of life improvement after the surgery (p > 0.05). Regarding the duration of the procedure, the conventional technique showed the shortest surgical time when compared to the others (p < 0.05). No postoperative complications were noted, for any patient. ConclusionsThe adenoidectomy resulted in improvement of quality of life, and there were no major postoperative complications, for all operated children, regardless of the technique used. The conventional technique was faster when compared to the more modern adenoidectomy techniques.

Israel rake retractor modification to improve exposure during oropharyngeal surgery on patients with larger body habitus.

Elective oropharyngeal surgery including tonsillectomy and uvulopalatopharyngoplasty performed for obstructive sleep apnea is increasingly performed on patients of larger body habitus. The use of the Crowe-Davis retractor in such patients may be complicated by a large barrel-chest making it difficult to anchor the retractor to the Mayo stand for suspension limiting oropharyngeal exposure. Here, we present a simple modification using the Israel Retractor to facilitate suspension of the Crowe-Davis mouth gag. Operational instructions were followed for Israel retractor modification in oropharyngeal surgery. The Crowe-Davis retractor is able to anchor to the Israel retractor, whose prongs articulate on the Mayo Stand for suspension. This extension allows suspension of patients with larger body habitus in oropharyngeal surgery. Use of the Israel retractor as an extension of the Crowe-Davis retractor handle provides an easy, quick, safe, and reliable method for placing patients of larger body habitus into suspension.

Preparedness of Dammam primary health care centers to deal with emergency cases.

OBJECTIVES:The objective of the study was to assess the availability of human and nonhuman resources for emergency medical services (EMSs) at the primary health care (PHC) level.MATERIALS AND METHODS:A cross-sectional study with mixed research methods (quantitative and qualitative) was carried out in governmental PHC centers in Dammam, Eastern Province of Saudi Arabia, between September 2014 and January 2015. Using systematic random sampling technique, 13 out of 26 PHC centers were included in the study. The study consisted of two main parts: The first involved the completion of an observational checklist to assess the availability and adequacy of human and nonhuman resources (workforce, emergency infrastructure, equipment, drugs and supporting facilities). The second part involved face-to-face interviews with key informants of nurses from the emergency room (ER) in the sampled centers.RESULTS:Analysis of the checklist showed that the total number of physicians “actually” present ranged from 2 to 8 per center and nurses actually present were 4–11 whereas the officially assigned number was 3–12 physicians and 8–17 nurses per center. Only 2 out of 13 (15.4%) centers had a place reserved for EMS in each male and female section. Only 4 (30.8%) PHC centers had a male ER located on the ground floor, near the entrance, and with a separate ramp. None of the centers had the emergency drugs such as metergotamine, calcium chloride, and naloxone. Regarding ER equipment, none of the studied centers had cervical collars, mouth gags, or a tracheostomy sets. Only one (7.6%) center had a functioning fully equipped ambulance. Five (38.46%) centers were equipped with electrocardiogram and X-ray machines. In the interviews, the informants confirmed the deficiencies identified in the checklist.CONCLUSION:Resources for EMS at Dammam PHC centers were deficient in infrastructure and supporting facilities.

Appropriate tongue blade width of the Dingman Mouth Gag for Japanese cleft palate patients with mandibular micrognathia

Appropriate tongue blade width of the Dingman Mouth Gag for Japanese cleft palate patients with mandibular micrognathia

Advantage of Kilner's Modification of Mouth Gag in Reference to Simple Technique Overcoming a Persistent Problem in Cleft Palate Repair.

Advantage of Kilner's Modification of Mouth Gag in Reference to Simple Technique Overcoming a Persistent Problem in Cleft Palate Repair.