Surgical management of Ludwig's angina

BACKGROUND: Ludwig's angina (LA) is a dangerous surgical condition that can cause severe airway compromise and death. There is controversy regarding the best way to manage the airway of patients with LA. Options range from conservative management involving close observation and i.v. antibiotics to airway intervention, including tracheostomy and endotracheal intubation using fibre-optic nasoendoscopy. We present evidence supporting a role for conservative airway management in a select subset of patients. METHODS: This paper reviews 9 years' experience of treating patients with LA at Liverpool Hospital. RESULTS: Twenty-one out of 29 (72%) of our patients were treated conservatively following initial clinical assessment. One of these patients subsequently deteriorated requiring emergency intubation. Of those treated non-conservatively at initial presentation, seven patients were able to be intubated using fibre-optic nasoendoscopy and one patient required tracheostomy under local anaesthesia. CONCLUSION: A general discussion of issues related to the management of LA is presented. Based on our experience we conclude that there is a subset of patients with LA who can be managed safely with conservative management.     

Anesthetic management of a patient with Cockayne's syndrome]

Cockayne's syndrome is a disease of childhood characterized by mental retardation and premature aging. An 11-year-old girl with Cockayne's syndrome underwent general anesthesia for acute appendicitis. Although we had expected the difficulty of intubation because of her small jaw with limited movement, we could visualize her vocal cord, and intubate easily. High peak airway pressure was needed to ventilate her lung after intubation suggesting decreased lung compliance for this syndrome. We have to consider anesthetic problems resulting not only from pediatric but also from geriatric anesthesia for the management of this syndrome.     

Airway management in Ludwig's angina

A 37-year-old 91 kg man presented with features of Ludwig's angina. Anaesthesia for incision and drainage of his submandibular abscess was undertaken by two specialist anaesthetists with an otorhinolaryngological surgeon prepared for immediate tracheostomy. After preoxygenation, gas induction with sevoflurane in oxygen was followed by a gush of pus into the oral cavity and laryngospam causing acute upper airway obstruction. This resolved with 25 mg of suxamethonium and an endotracheal tube was passed into the trachea with difficulty. Options for management of the difficult airway in Ludwig's angina are discussed.     

Anesthetic management of a patient with Coffin-Lowry syndrome]

Coffin-Lowry syndrome (CLS) is characterized by mental retardation, a peculiar face and deformities of the thorax and spine. A 33-year-old female with Coffin-Lowry syndrome (CLS), further complicated with atrial septal defect and ventricular tachycardia, underwent elective surgery for anterior cervical cyst. As difficult intubation had been anticipated, anesthesia was induced with continuous administration of propofol. After confirming that she could be ventilated by mask, vecuronium bromide, midazolam and fentanyl were given. The operation and anesthesia were conducted uneventfully. No complications occurred postoperatively. The use of propofol for slow induction of anesthesia was advantageous for hemodynamic stability in this case.     

Anesthetic management of a patient with severe hyponatremia]

A 79 year old man, with left femoral neck fracture, was scheduled for an elective operation. After admission, severe hyponatremia probably due to diuretics developed. No neurological abnormalities were observed before surgery. He recovered from anesthesia with no problems. But on the 5th postoperative day he showed transient unresponsiveness. Grand mal seizures were also seen after the serum Na level had recovered to around 130 mEq.l-1. This case shows that in the management of severe hyponatremia, the discrimination between acute and chronic hyponatremia seems to be important.     

Anesthetic management of a patient with Saber-sheath trachea]

A 65-year-old man was scheduled for total gastrectomy. Preoperative chest radiograph showed significant narrowing of the trachea. On chest CT scan the trachea was U-shaped (tracheal index = 36%) and was diagnosed as saber-sheath trachea. During general anesthesia we took care to reduce the irritation by the endotracheal tube, particularly during intubation, and to avoid excessively high airway pressure. The trachea was watched carefully by bronchoscopy after intubation and during extubation not to neglect any complication. There was no complication after the operation.     

Anesthetic management of a patient with Sipple syndrome]

Resection of bilateral pheochromocytomas of a 33-year-old man with Sipple syndrome was scheduled. Oral prazosin was started twenty days before the operation and increased to a maintenance dose of 6 mg per day. Oral lavetalol 300 mg per day was added for five days before the operation because prazosin alone was insufficient. Intravascular volume was expanded with two units of stored whole blood per day for four days before the operation for preoperative preparation. Anesthesia was induced with thiamylal 250 mg and vecuronium bromide 9 mg, and maintained with enflurane, nitrous oxide and oxygen. Phentolamine, labetalol and nitroglycerin were used for treatment of hypertensive crises during operation and anesthesia. To combat hypotension which follows the resection of the tumor, continuous infusion of norepinephrine was used for four hours after the operation. There were no hypotensive periods and no complications. After removing bilateral pheochromocytomas of the adrenals, treatment of full adrenocortical replacement therapy was performed. Concurrent use of alpha-and beta-adrenergic blocking agents was important for successful anesthetic management for the resection of pheochromocytoma.     

Anesthetic management of a patient with Dyggve-Melchior-Clausen syndrome]

The Dyggve-Melchior-Clausen syndrome (DMCS) is a rare autosomal recessive skeletal dysplasia characterized by short-trunk dwarfism and mental retardation. A 49-year-old male with DMCS underwent resection arthroplasty for contracture of the right hip joint under general anesthesia using thiamylal, nitrous oxide, sevoflurane, and vecuronium. Although he was assumed to have difficult airway due to short neck, macroglossia, and disturbance of neck flexion, tracheal intubation was not difficult. No complications including malignant hyperthermia were observed during the 95 min of the operation.     

Anesthetic management of a patient with psoriasis arthropathica]

A 37-year-old woman with psoriasis arthropathica associated with aortic regurgitation underwent replacement of her aortic valve. The serum rheumatic factor was negative. HLA-B 27 was demonstrated in HLA analysis. She experienced a sudden onset of dyspnea and cardiac arrest in the hospital. She was hospitalized and found to have severe aortic regurgitation. She had her aortic valve replaced. We paid attention to management of blood pressure not to trigger cardiac ischemia and of skin lesion not to trigger infection and the worsening of skin condition. There are few reports of HLA-B 27 positive psoriasis arthropathica accompanied by aortic regurgitation. However, the present case may suggest that the cardiac study may be required for HLA-B 27 positive psoriasis arthropathica.     

Anesthetic management of a patient with Bartter's syndrome]

A 48-year-old woman with Bartter's syndrome underwent right mastectomy under general anesthesia. Her operative course was uneventful. She was preoperatively complicated with severe hypokalemia but had no signs and symptoms of hypokalemia. In anesthetic care of patients with Bartter's syndrome, even when they have no symptoms of hypokalemia, the meticulous intravenous administration of potassium chloride is required in order to maintain the preoperative level of the serum potassium during anesthesia. In addition, attention should be paid to factors causing an additional reduction in the serum potassium concentration, such as alkalosis, elevated beta 2-adrenergic activity, increased availability of insulin and hypothermia.     

Anesthetic management of a patient with Osler-Weber-Randu disease]

Osler-Weber-Randu disease (Osler disease) is an autosomal dominant disease, sometimes known as hereditary hemorrhagic telangiectasia with its family history. It is not a popular disease and approximately seventy families are known as inheritance lineage in Japan. We experienced anesthetic management of a 49-yr-old woman with Osler disease. She was diagnosed to have the brain abscess following fever and clouding of consciousness for several days and was scheduled for the removal of the abscess. A chest X-ray revealed pulmonary arteriovenous fistula in the right middle lung field. The patient had had life threatening frequent massive bleeding from her nose and/or stomach for the past several years. Her brother and children also had the same symptoms. In addition to Osler disease, the patient had the prolonged coagulation time that was supposed to the due to chronic liver disease. Therefore, fresh frozen plasma (5 units) and platelet concentrates (10 units) were infused during the surgery. Intraoperative blood loss was about 700 grams. We had no difficulties in management of bleeding and respiratory controls during anesthesia.     

Anesthetic management in a patient with Simpson-Golabi-Behmel syndrome]

We report the anesthetic management of a 4-yr-old boy with Simpson-Golabi-Behmel syndrome. This syndrome is an X-linked condition characterized by pre- and postnatal overgrowth with visceral and skeletal anomalies. Affected males have a distinctive facial appearance with wide nasal bridge, anteverted nostrils, wide-open mouth, enlarged tongue, and large protruding maxilla and jaw. Although it had been speculated preoperatively that airway management would be complicated by the macroglossia, there was no difficulty in endotracheal intubation in the present patient. Preparations for difficult airway management should be made by the anesthesiologist before induction of anesthesia.     

Anesthetic management of a patient with right ventricular myxoma]

Right ventricular myxoma in a 79 year old male, whose pulmonary trunk was obstructed by the myxoma, was reported. Myxoma of the heart is rare, and especially right ventricular myxoma is rare. Myxomas of the heart have been reported by thirty-seven authors, but right ventricular myxoma has been reported by only one author. Anesthesia for the removal of right ventricular myxoma must be carried out carefully, because some critical troubles may happen during anesthesia for the resection of the right ventricular myxoma. Particularly, occlusion of the pulmonary artery is the most dangerous complication.     

Anesthetic management of a patient with hypohidrotic ectodermal dysplasia]

Hypohidrotic ectodermal dysplasia (HED) is a rare congenital anomaly complex characterized by hypodontia, hypotricosis and hypohidrosis. There have been only a few reports of anesthetic management of patients with HED. We managed a 20-year-old man with HED, who underwent debridement and skin grafting under epidural anesthesia, without untoward events. Potential problems in anesthetic management of patients with HED are also discussed.     

Anesthetic management of the patient with a permanent pacemaker]

Anesthetic management of two patients with a permanent pacemaker is reported; patient no. 1 had the VVI mode pacemaker and patient no. 2 had the DDD mode pacemaker. In patient no. 1, the hypotensive response of the 'pacemaker syndrome' occurred during general anesthesia. Patient no. 2 had no anesthetic problems but careful attention should be paid to the DDD mode pacemaker, because the newer widely used dual lead systems (DDD) are more susceptible to electromagnetic interference. Anesthetists often encounter patients with pacemakers. Knowledge of pacemakers available of the increasingly wide range is necessary to ensure safe management of these patients, many of whom are frail and elderly.     

Anesthetic management of a patient with postthymectomy myasthenia gravis]

A 56-year-old male who had received total thymectomy for treatment of myasthenia gravis was scheduled for sigmoidectomy under general anesthesia. Since his symptoms had become worse after the thymectomy along with increased anti-acetylcholine receptor antibody titer, preoperatively we could not estimate his sensitivity to non-depolarizing muscle relaxants. We initially tried tracheal intubation without using a non-depolarizing muscle relaxant immediately after intravenous injection of propofol 2 mg.kg-1 and fentanyl 4 micrograms.kg-1. Since the intubation was unsuccessful, however, vecuronium 0.01 mg.kg-1 was repeatedly administered until TOF ratio reached 0%. Successful intubation was performed with 3.5 mg of vecuronium. We conclude that the initial trial of tracheal intubation should be performed without a non-depolarizing muscle relaxant in patients with myasthenia gravis whose symptoms have become worse after thymectomy. If first attempt is unsuccessful, the tracheal intubation should be performed with a smaller dose of vecuronium using an electrical nerve stimulator.     

Anesthetic management of a patient with tetanus using epidural anesthesia]

A 75-year-old woman with breast cancer complicated with tetanus was scheduled for mastectomy. Since severe bradycardia (17 beats.min-1) was detected by preoperative Holter monitoring, a temporary pacing catheter was inserted. She underwent mastectomy under general anesthesia using propofol combined with thoracic epidural anesthesia. She also received postoperative thoracic epidural block. Her perioperative heart rate was 80-105 beats.min-1 and the rhythm was sinus. There was no marked perioperative cardiovascular derangement.     

Anesthetic management of a patient with narcolepsy

We report the anesthetic management of a narcoleptic patient performed using sevoflurane–remifentanil with bispectral index (BIS) monitoring. A 22-year-old man, who was diagnosed with narcolepsy at the age of 17, requested endoscopic sinus surgery, under general anesthesia, for chronic allergic rhinitis. On the morning of the day of operation, he took his daily dose of modafinil, used to control narcolepsy. Anesthesia was induced by 5% sevoflurane and maintained with sevoflurane and continuous infusion of remifentanil and 60% oxygen in conjunction with BIS monitoring. BIS values were between 47 and 58. Duration of surgery was 150 min. After surgery, the patient emerged from anesthesia within 10 min and was extubated. His recovery was uneventful. We found the use of BIS monitoring for titrating sevoflurane concentration in a narcoleptic patient is useful for preventing not only oversedation but also intraoperative awareness caused by the preoperative medication.     

Anesthetic management of a patient with blood coagulation factor XII deficiency]

A 36-yr-old pregnant woman with blood coagulation factor XII deficiency was scheduled to undergo cesarean section. Preoperative blood coagulation scan revealed prolonged activated partial thrombin time of 105.6 s (control, 30.3 s), and a decrease in factor XII level of 3% (normal; 70-120%). Other examinations such as prothrombin time, platelet count and bleeding time were within normal limits. But she reported no history of bleeding. Before the operation, we discussed with obstetricians whether fresh frozen plasma (FFP) should be administered, or not. According to a report, a patient with factor XII deficiency can undergo major surgery without plasma replacement therapy. But another study showed that 15-30% of the factor XII activity was needed for hemostasis. We, therefore, administered 4 units of fresh frozen plasma before the operation. The operation was performed with general anesthesia uneventfully. Generally, a patient with factor XII deficiency has no clinical bleeding problems and unnecessary FFP administration may cause infection. Therefore it is not necessary to administer FFP to this patient.