Clinical trials: dental pain
Harald Breivik, William I Campbell, Michael K Nicholas in Clinical Pain Management, 2008
To reduce variability in pain due to surgical trauma, the surgical technique should be strictly standardized and the operation preferably performed by a single surgeon.27[II] Surgical removal of mandibular impacted third molars is usually performed under local anesthesia using, for example, lidocaine (lignocaine) 20 mg/mL and epinephrine (adrenaline) 12.5 μg/mL (Xylocain–Adrenaline, AstraZeneca, Sweden) block of the nervus alveolaris inferior and infiltration of nervus bukkalis. This technique allows evaluation of baseline pain approximately three hours later.28[II] A 3-to 4-cm soft-tissue incision is performed and the mucoperiosteum reflected to visualize the tooth. Cortical alveolar bone is then removed by burr under saline irrigation and the impacted tooth is sectioned and elevated. Finally, the mucoperiosteal flap is repositioned with sutures and an inlay of a 2 × 1 cm gauze drain saturated with 3 percent chlortetracycline ointment (Terramycin-Polymyxin B, Pfizer, USA) is left in the wound opening. No other antibiotics, sedatives, or other drugs are administered to the patients eligible for trial participation. The procedure should be performed in the morning, so that assessments are taken during the afternoon and early evening for all patients.
Oral Cavity Tumours Including Lip Reconstruction
John C Watkinson, Raymond W Clarke, Terry M Jones, Vinidh Paleri, Nicholas White, Tim Woolford in Head & Neck Surgery Plastic Surgery, 2018
The maxilla comprises the maxillary alveolus and the hard palate. The osseous alveolar process supports the maxillary dentition, being covered by a mucoperiosteum with a stratified squamous epithelium. The maxillary alveolus merges laterally with the buccal mucosa and lips at the gingival sulcus and medially with the hard palate. The alveolar process extends to the upper end of the pterygopalatine arches posteriorly. The hard palate lies within the horseshoe shape of the maxillary alveolus, merging imperceptively with the alveolar mucosa. The hard palate has minor salivary glands located in the submucosa, 33% of palatal tumours being derived from salivary epithelium.182 Posteriorly, the hard palate merges with the soft palate at the posterior edge of the palatine bone. The WHO classifies these anatomical sites as ICD-10 C05.0 (hard palate) and C03.0 (maxillary alveolus).1 Sensory innervation to the maxillary mucosa is by branches of the maxillary division of the trigeminal nerve. The nasopalatine nerve supplies the anterior hard palate, passing through the incisive foramen, the posterior palate being supplied by the paired greater palatine nerves that pass through the greater palatine foraminae. Lymphatic drainage is to the ipsilateral cervical nodes via the submandibular nodes or potentially the retropharyngeal nodes in posteriorly located tumours.
Sinonasal tumours
Neeraj Sethi, R. James A. England, Neil de Zoysa in Head, Neck and Thyroid Surgery, 2020
Surgery is the primary modality of choice. This is performed endoscopically in the vast majority of patients. Simple debridement of the lesion, as in benign polyp disease, leads to an unacceptable recurrence rate. The most important factors in preventing the recurrence of inverted papillomas are the determination of the location of the attachment and the completeness of resection during the primary surgery [22]. It is vital that complete resection of the affected and surrounding mucosa and mucoperiosteum with reduction of underlying bone be performed to minimise recurrence. The majority of inverted papillomas originate from the lateral nasal wall (see Table 13.7). This means a medial maxillectomy would be the minimum operation recommended for these tumours, as these would obtain excision with mucosal and bony margins. The recurrence rate varies in the literature and can be anything up to 25% in definitive surgery and higher in cases where only a limited polypectomy has been performed [23].
Epidural pneumorrhachis, a rare complication of asthma exacerbation
Published in Journal of Asthma, 2019
Tonatiuh Ramses Bedolla-Pulido, Martín Bedolla-Barajas, Tania González-Mendoza, Enndy Hollyver Sánchez-Uribe, Netzahualpilli Delgado-Figueroa, Sandra León-García
Thorax computed tomography (CT) confirmed the presence of air inside the soft tissues and along the fascias of different muscle planes; there was also free air in the different topographies of the mediastinum (Figure 1), underarm regions, both anterior and posterior sides of the thorax, and even in the abdominal cavity. The air in the epidural space was clearly visible (Figure 2); notably, there were air bubbles spreading into the orifices where the sixth and seventh cervical vertebrae meet, towards the epidural area, and over the medullary cavity in the cervical and dorsal regions (Figure 3). CT scan of the paranasal sinuses indicated an increased in size of the inferior nasal turbinates and in the mucoperiosteum thickness of the maxillary and ethmoidal sinuses; air was also found in the infraorbital region. Notably, during his hospital stay, the patient was treated with bronchodilators, systemic steroids, and antibiotics; there was no need for supplemental oxygen. After 24 h of treatment, alleviation in the subcutaneous emphysema began to occur, and his symptoms remitted; thus, he was released from the hospital as a result of his significant improvement. One week later, he was completely symptom free and without evidence of subcutaneous emphysema.
Speech outcomes at 5 and 10 years of age after one-stage palatal repair with muscle reconstruction in children born with isolated cleft palate
Published in Journal of Plastic Surgery and Hand Surgery, 2018
Jill Nyberg, Erik Neovius, Anette Lohmander
All the 88 children received a one-stage palatal repair with muscle reconstruction at a mean age of 13.6 months (SD = 4.6 months). The explanation for late surgery was in one child because of repeated infections and in two children due to late detection of the cleft. The surgical procedure was the same in all children, and two senior surgeons performed all the operations, with each surgeon repairing an equal number of each cleft type. Cleft palate repair was carried out under general anaesthesia according to the technique described by Sommerlad [21,23], using 2.5× magnification loupes. Incision lines were marked on the borders of the cleft and along the medial side of the maxillary tuberosity. In CPS, incision lines were extended ∼1 cm in the midline of the hard palate. Local anaesthetic (marcaine with epinephrine) was injected into the soft and hard palate, and incisions were made according to the markings, and the mucoperiosteum in the hard palate was elevated. Dissection was continued posteriorly between the salivary glands and the muscular layer in the soft palate. The nasal layer and the uvula were sutured with interrupted 4–0 Vicryl™. Additional local anaesthetic was injected into the muscular layer to minimise bleeding. After 5 minutes, the tensor aponeurosis was divided posterior to the hard palate, and the muscles were successively dissected from the nasal mucosa and transposed posteriorly ∼15 mm until the levator muscle was identified. The muscle bulges were then sutured at the midline with interrupted 4–0 Ethilon™. Eventually, the oral layer was sutured with interrupted 4–0 Vicryl™ mattress sutures. Occasionally, in wide clefts, incisions had to be extended medial to the alveolar ridge in order to allow suturing of the oral layer at the junction between the hard and soft palate.
Underwater posterior nasal neurectomy compared to resection of peripheral branches of posterior nerve in severe allergic rhinitis
Published in Acta Oto-Laryngologica, 2021
Seiichiro Makihara, Mitsuhiro Okano, Syotaro Miyamoto, Kensuke Uraguchi, Munechika Tsumura, Shin Kariya, Mizuo Ando
Each operation was performed under general anesthesia. All surgical procedures were performed with a 0-degree nasal endoscope with a diameter of 4 mm. 1:100,000 epinephrine was injected into the inferior turbinate. A vertical incision was made at the anterior inferior turbinate. After the anterior part of the inferior turbinate bone was located, the mucoperiosteum was carefully elevated, and the turbinate bone was removed to reduce the volume of the inferior turbinate (submucous inferior turbinectomy). Then, we could see peripheral branches of the posterior nasal nerve beneath the periosteum usually running along vessels (Figure 1). In the Control group only, peripheral branches of the posterior nasal nerve were coagulated by bipolar cautery and resected. An additional procedure was performed in the Underwater group as a substitute for resection of Peripheral branches of the posterior nasal nerve; a vertical incision was made on the membranous portion of the maxillary sinus. The mucoperiosteal flap was elevated from the anterior part of the perpendicular plate of the palatine bone to the posterior end of the middle meatus (Figure 2). The neurovascular bundle including the posterior nasal nerve trunk was visualized at the sphenopalatine foramen. Saline solution was subsequently infused around the sphenopalatine foramen through the Endo-Scrub Lens Cleaning Sheath (Medtronic ENT, Jacksonville, Florida, USA) mounted on the 0-degree nasal endoscope. Saline was supplied via the Integrated Power Console (IPC System; Medtronic ENT). The tip of the inserted endoscope was filled completely with saline water to make a clear surgical field. To prevent saline solution from draining into the laryngopharynx, the surgeon placed a pharyngeal pack in advance, and the assistant surgeon suctioned the overflowing water in front of anterior nares. The mucoperiosteum around the SPA was separated with malleable bipolar forceps for endoscopes (Fujita Medical Instruments Co., Ltd., Tokyo, Japan). The posterior nasal nerves, SPA, and veins were divided. The posterior nasal nerves and veins were coagulated with bipolar coagulation forceps and resected. The SPA was preserved (Figure 3). A hemostatic agent (oxidized cellulose polymer) was placed around the SPA, and the mucoperiosteal flap was put back to its initial position. A concomitant septoplasty was performed in 16 patients in the Control group (100%) and 26 in the Underwater group (96.3%). Finally, the incision was closed using a 5-0 absorbable suture, and postoperative packing (chitin-coated gauze) was then placed in the common nasal meatus.