Sarkoidose der Nase und Nasennebenhöhlen

Backround

The sinonasal system is rarely involved in the clinical picture of sarcoidosis. In the absence of pulmonary disease, sinonasal sarcoidosis is extremely rare.

Patients and methods

Four patients with isolated sarcoidosis of the nose and the sinuses are reported; in one of these patients the histological evidence was found in the mucosa of the nasopharynx.

Results

None of these patients was found to have a pulmonary illness or any other extrapulmonary manifestation of sarcoidosis. Retrospectively, two patients fullfilled the more specific diagnostic criteria for sinonasal sarcoidosis reported in the literature.

Conclusion

Sarcoidosis should be considered in the differential diagnosis of inflammatory sinonasal disease, especially if the mucosa shows signs of granulation, but it should also be considered when an incidental finding of rhinosinusitis is recorded. Rhinosurgical intervention seems to be an appropriate therapy in terms of improving the symptoms of the disease, despite the prolonged period of postoperative healing and the necessity for individual treatment with medication. Following histological confirmation of the diagnosis, adequate medication and further appropriate diagnostic procedures drawing on internal medicine are essential.     

Verhandlungen Ärztlicher Gesellschaften

Ohne Zusammenfassung     

Bordetella pertussis infections and sudden unexpected deaths in children

From December 1990 to November 1993 nasopharyngeal specimens were obtained for culture from 50 children (mean 4.9±3.3 months of age) who had died suddenly.Bordetella pertussis was not isolated. Subsequently, nasopharyngeal specimens for polymerase chain reaction (PCR) analysis were obtained from another 51 victims of sudden death (mean 5.4±4.4 months of age); nine (18%) wereB. pertussis positive.     

Effect of muscle relaxants on intraocular pressure

Since general anesthesia is being used increasingly in ophthalmic surgery, the effects of anesthetic drugs on intraocular pressure (IOP) have to be considered. Competitive neuromuscular blocking drugs either do not affect IOP or produce a slight decrease. Depolarizing muscle relaxants increase IOP. This effect, which is pronounced with succinylcholine, cannot be reliably prevented by any concomitant medication. The new competitive relaxants atracurium and vecuronium provide stable conditions with respect to IOP and systemic circulation, combined with fast onset and intermediate duration of action.     

Preoperative increase in the plasma concentration of free fatty acids during minor elective interventions using a conventional anesthesia technic with enflurane

Plasma concentrations of free fatty acids (FFApl) can be used as a parameter to measure stress. The present study aimed to evaluate the changes in the concentration of FFA during perioperative stress caused by minor elective surgery under a standard anaesthetic technique using enflurane. The premedication administered included heptabarbital on the preoperative night and morphine with promethazine prior to the transfer of the patient to the theatre. Blood samples for the analysis of FFA were obtained from 12 patients at the following times: 1 day preoperatively (control, c), prior to induction of anaesthesia (s1), following the administration of thiopentone (s2), following tracheal intubation (s3), 10 min after the commencement of enflurane administration (s4), following surgical incision (s5), intraoperatively (s6), following extubation (s7), 1 h after extubation (s8), and on the 1st postoperative day (s9). FFA were extracted from plasma with hexane and analysed in duplicate by a specific and sensitive gas-chromatographic assay with flame ionisation detection using pentadecanoic acid as the internal standard. All FFApl from the preoperative day (c) were within normal range. FFA concentrations at s1, s2, s3 and (to a lesser extent) at s4 were statistically significantly increased compared to control values. The maximum concentration of FFA in plasma occurred at s2. A decrease from this maximum was found in samples s4, s5 and s6 (the latter was the minimum intraoperative FFApl). The FFApl levels at s7, s8 and s9 were similar to control. A different response was found for each individual free fatty acid. The maximum increase ranged from 40% (stearic acid) to 300% (oleic acid).(ABSTRACT TRUNCATED AT 250 WORDS)     

Die Wirkung des Alters auf Anschlagszeit und Erholung nach Atracurium,Rocuronium und Vecuronium

Elderly patients may show an age-related decline in physiologic functions, which may be responsible for the prolonged duration of some neuromuscular blocking agents. Previous studies have yielded conflicting results as to the effects of these drugs in the elderly. Methods. After obtaining informed consent and approval of the Ethics Committee, we compared onset and recovery times of single IV doses of atracurium, rocuronium, and vecuronium given to 108 patients divided into three groups according to age (18–50, 51–64, ≥65 years). Following oxazepam premedication and fentanyl and thiopentone induction, patients were randomly allocated to receive atracurium, rocuronium or vecuronium (0.5, 0.6, or 0.1?mg/kg, respectively) in ≤0.8?vol.% enflurane (end-tidal)-nitrous oxide anaesthesia. Muscular relaxation was assessed by electromyographic (EMG) recording of the adductor pollicis muscle after supramaximal single-twitch stimulation of the ulnar nerve every 10?s. Onset time and recovery to 25%, 75% and 90% of twitch control values (DUR25, 75, 90) were recorded. Creatinine clearance predicted from serum creatinine (C_cr) was correlated with recovery from neuromuscular block. Results. Onset time was not different among groups or relaxants. The results showed a prolonged duration of action for atracurium (DUR75, DUR90), rocuronium (DUR25, DUR75), and vecuronium (DUR25) in the elderly. A number of patients did not reach DUR75 or DUR90. There was a significant relationship between age and failure to return to control values during recovery from neuromuscular block, especially after atracurium and rocuronium. C_cr showed a negative correlation with age for all relaxants, but a negative significant correlation between C_cr and recovery was found only for rocuronium. Conclusions. This study suggests that onset time for atracurium, rocuronium and vecuronium is not age-dependent. Recovery was prolonged in the elderly for all three relaxants. This effect appears to be secondary to changes in body composition and function accompanying the aging process. Neither atracurium nor vecuronium depends significantly on the kidney for elimination, but the negative correlation between C_cr and rocuronium suggests an appreciable role for the kidney in the elimination of this relaxant. The long recovery times observed in this study could also be related to enflurane anaesthesia. We suggest that failure of EMG responses to return to baseline values during recovery from neuromuscular block may be related to age, especially for atracurium and rocuronium.     

Qualitätsvergleich von modifizierter Neurolept-, balancierter und intravenöser Anästhesie Teil 1. Studiendesign und Patientenanalyse der Krefelder Studie 1992*

The choice of appropriate anaesthesia in a more or less seriously ill patient requires detailed information on the risk and tolerance of each specific anaesthetic regimen. The objective of this prospective, randomised clinical trial was to test the hypothesis that three regimens of general anaesthesia – neurolept-(NLA), balanced (BAL), and intravenous propofol anaesthesia (IVA) - differ with regard to safety and comfort. The criteria for the intraoperative safety and postoperative comfort of the patients were the incidents, events and complications (IEC) that required medical treatment as well as the evaluation of postoperative complaints by the patients according to the IEC list and patient questionnaires of the German Society of Anaesthesia and Critical Care Medicine (DGAI). Methods. The study duration was about 4?months, from January to April 1992. During this period the patients of all nine operative departments of the hospital received strictly randomised NLA, BAL, or IVA. Patients who had regional anaesthesia or were not capable of understanding the German language, were nonco-operative, or were seriously ill (ASA class?IV to V) as well as children under 18?years of age did not participate in the study. All eligible patients provided their informed consent. Anaesthesia. For premedication 10?mg chlorazepate was administered the night before and on the day of surgery. Anaesthesia was conducted under normoventilation using a mixture of 70% nitrous oxide and 30% oxygen. NLA patients were induced intravenously with 0.2?mg/kg body weight etomidate and received 0.005?mg/kg fentanyl and 0.07?mg/kg droperidol before the start of surgery. The repetition dose was 0.2?mg fentanyl and 2.5?mg droperidol. In the BAL patients the dose of fentanyl and droperidol was reduced to 50% due to the addition of isoflurane up to 1?vol.?%. IVA patients received 2?mg/kg propofol over 3?min followed by an infusion of 3–5?mg/kg per hour together with 0.2?mg fentanyl/h. Neuromuscular blockade was accomplished with vecuronium 0.1?mg/kg. If the blood pressure and heart rate increased by more than 20% of preoperative values, analgesia was reinforced by an additional fentanyl dose. Anaesthesia was subsequently enhanced by increasing the neurolept/propofol/isoflurane dose by up to 50%. Data collection. The following parameters were registered: patients' personal data and physical condition according to ASA classification; the grade of risk according to the Munich risk checklist; the frequency of IEC during surgery; the patients' permanent medications; postanaesthetic vigilance and recovery; the acceptance of the assigned anaesthetic by the physician; the cost of the anaesthetic used; and pre- and postoperative complaints as well as the assessment of anaesthesia by the patient. The statistical evaluation was performed using the chi-square test. Results. A total of 1,346?patients were enrolled in the study; 28 (2%) were excluded because the treatment protocol was changed by the anaesthesiologist. Seventy per cent were recruited from general, gynaecologic, or otorhinolaryngologic surgery. The three anaesthetic regimens (NLA, BAL, and IVA) were used in other departments with the same frequency with the exception of ophthalmology and urology (P>0.1) (Fig.?1). Of the 1,318 eligible patients, 443 received NLA, 443 BAL, and 432 IVA (P=0.8). The distribution of the various parameters was surprisingly similar among the three groups: the average age was 50?years (P=0.91), body weight 71?kg (P=0.33), reference or initial blood pressure 130/80?mm?Hg (P=0.36), average time of anaesthesia 103?min (P=0.82), and all had the same risk score (P=0.42). Sixty per cent were female. An average of 85% of the 18- to 89-year-old patients were considered to be healthy according to the ASA risk classification (P=0.42). However, on applying the Munich risk checklist the average number of healthy individuals was 5% to 10% lower than that of the ASA risk classification. The average quantity of anaesthetics per patient in the NLA group was 7.1?mg droperidol and 0.54?mg fentanyl; in the BAL group the amount could be reduced to 50% by adding isoflurane, and in the IVA group propofol 493?mg/100?min was given with 0.3?mg fentanyl (Fig.?2). The costs of the three regimens were 27.43?DM for NLA, 31.68?DM for BAL, and 43.75?DM for IVA. Conclusion. The remarkably high degree of consistency of the patients' baseline characteristics as well as the equal distribution among the patient groups can be considered optimal randomisation. The present clinical trial compared the safety and tolerance of the three anaesthetic regimens under routine daily conditions. The results of the study should have great clinical significance for the choice of the appropriate anaesthetic regimen while considering safety, tolerance, and cost-benefit aspects.