The principle of oral appliance (OA) therapy for obstructive sleep apnea syndrome (OSAS) is to open the pharyngeal airway by moving the lower jaw forward. The diameter of the oropharyngeal airway is determined by the size of the soft tissue and the bones surrounding it. We indirectly evaluated the size of the mandible bone around the oropharyngeal airway using the dental arch size measurements. We hypothesized that the wider the diameter of the dental arch size, the higher the therapeutic effect of OAs.
Two-hundred-ninety-four patients were diagnosed by polysomnography and received OA therapy during the study period. Sixty-three of them whose results of dental arch size measurements and apnea hypopnea index (AHI) before and after OA therapy were eligible for this study. The length, anterior and posterior width of the upper and lower dental arches were measured and compared with the AHI before and after OA therapy. Responders were defined by a 50% or greater reduction in the AHI and a decrease to less than five events per hour after undergoing OA therapy.
Of the subjects, 23 had OSAS improved after receiving OA therapy. A multivariate logistic regression analysis confirmed that a lower baseline AHI (events/hour) and wider lower posterior dental arch width (mm) significantly correlated with the outcome (odds ratio, 0.938 and 1.146, 95% CI, 0.883-0.996 and 1.014-1.295, respectively). According to the Youden index, the cutoff value of each factor was 28.3 events/hour (AUC=0.676, sensitivity=0.870, specificity=0.425) and 39 mm (AUC=0.692, sensitivity=0.652, specificity=0.750) respectively.
In conclusion, lower posterior dental arch width and pretreatment AHI were effective in predicting in response to OA therapy.
Hemophilia A is an X-linked hereditary hemorrhagic disorder caused by a defect or deficiency in blood clotting factor Ⅷ. Its main treatment involves periodic replacement of the clotting factor ; however, inhibitors can diminish the effects of treatment. Patients with hemophilia, particularly those receiving inhibitors, must be monitored for bleeding during the perioperative period. Here, we report the anesthetic management of a patient with autism spectrum disorder (ASD) and hemophilia A who was receiving inhibitors.
The patient was an 8-year-old boy. He was being treated with replacement therapy using bypassing agents thrice weekly. Dental treatment was scheduled to be performed under general anesthesia.
We continued to administer a bypassing agent (FEIBA) to manage the bleeding tendency. During the perioperative period, we administered two bypassing agents (FEIBA and Novoseven), carefully intubated the patient, and recommended that the operator use tight sutures. To enable the patient to adapt to the ward and staff, we admitted him to the hospital one day before the scheduled operation.
Prior to the induction of the general anesthesia, we administered FEIBA. Anesthesia was induced using thiopental, remifentanil, atropine, and rocuronium and was maintained using propofol and remifentanil. Additional replacement using Novoseven was provided 6 hours after the administration of FEIBA. On postoperative day 1, FEIBA was periodically administered.
Since patients with ASD have impairments in interpersonal and environmental adaptability, keeping them rested following an operation can be challenging. Hence, patient information should be shared with the involved physicians and staff members to ensure a comfortable and less stressful experience for the patient.
A 68-year-old man with tongue cancer had a condition complicated by graft versus host disease (GvHD), which had developed after a blood-forming stem cell transfusion, and had been receiving long-term immunosuppressant therapy. The patient was scheduled to undergo tongue tumor excision, neck dissection, and rectus abdominis musculocutaneous flap reconstruction under general anesthesia. Complications of GvHD include obliterating bronchiolitis. For the intraoperative artificial respiration, both continuous positive pressure ventilation and recruitment were used to prevent an increase in the airway pressure. A steroid was also administered to induce an anti-inflammatory action, since obliterating bronchiolitis was suspected based on respiratory function tests performed before the operation. Moreover, since decreased lung compliance was suspected, a relatively high plateau pressure and positive end-expiratory pressure were maintained to protect the lungs from damage, since barotrauma can easily occur during artificial ventilation. In general, long-term postoperative artificial ventilation increases the risk of pneumonia. Therefore, efforts to prevent respiratory complications were made to enable the termination of artificial respiration as soon as possible after surgery.
We report the use of general anesthesia in an intellectually disabled patient with right pulmonary agenesis and left bronchial stenosis. A wisdom tooth extraction was performed under general anesthesia in a 17-year-old female weighing 45 kg. Preoperative chest radiography and computed tomography (CT) showed a tracheal deviation and bronchial stenosis of the left main bronchus, respectively. The bronchial stenosis caused the patient to experience stridor and respiratory instability during respiratory efforts. Upon the patient’s entrance to the operating room, gasping respiration and stridor were observed. Prior to the nasotracheal intubation, the patient’s irregular respiration was controlled with oxygen and the slow induction of anesthesia with sevoflurane. The location of the tracheal tube’s distal opening was confirmed using a bronchofiberscope. The anesthesia was maintained using propofol and remifentanil. Thirty minutes after the start of surgery, 1 μg/kg of dexmedetomidine hydrochloride (DEX) was administered over a period of 10 minutes and DEX administration was then continued at a dosage of 0.4 μg/kg/h to prevent agitation during recovery from anesthesia. The patient was sedated following extubation and, in the absence of any observed respiratory difficulties, the administration of DEX was stopped after 5 minutes. The patient’s Observer’s Assessment of Alertness/Sedation (OAA/S) score was 3 upon her return from the operating room, increasing to 4 and then 5 at 30 minutes and 1 hour after surgery, respectively. No abnormalities were observed in the patient’s overall status after surgery, and the patient was discharged on the following day. By using preoperative CT to ascertain the airway morphology, confirming the tracheal tube location using bronchofiberscopy, and administering DEX for postoperative sedation, successful anesthesia was managed without the induction of stridor or respiratory difficulties.
Dravet syndrome (DS) is characterized by severe myoclonic epilepsy, and its onset is most common during infancy. DS is associated with a mutation of the gene coding SCN1A in most patients ; however, its cause remains unclear. The epileptic seizures that are triggered by various causes are drug-resistant and intractable. Status epilepticus can cause severe cerebral function defects and be life-threatening.
We treated a 23-year-old woman with DS who required intravenous sedation and general anesthesia for a dental treatment. She had been taking clonazepam, sodium valproate and topiramate for her epilepsy, but her seizures continued to be triggered semimonthly by seeing objects with a lattice-like pattern and/or in connection with menstruation. She had several dental caries with acute symptoms requiring immediate treatment. Since she had mental retardation and was uncooperative with dental treatment, temporary treatment under intravenous sedation followed by actual treatment under general anesthesia were planned. The timings of both treatments were scheduled so as to avoid her menstrual period, and objects with a lattice-like pattern were removed from the treatment room prior to her entrance. We used propofol for sedation and the induction of general anesthesia and isoflurane for the maintenance of the general anesthesia. A continuous electroencephalogram was monitored using the bispectral index (BIS). No perioperative complications, including seizures, occurred during either treatment.
In the present case, we focused on preventing seizures during the perioperative period. Propofol and isoflurane were useful for intravenous sedation and general anesthesia without triggering epileptic seizures.
Pheochromocytoma is a tumor originating in the adrenal medulla that is known to cause unpredictable severe hypertension. In patients with malignant pheochromocytoma, the removal of the tumor is not indicated and only pharmacologic therapy is conducted, since the effective control of hypertension is unlikely. Here, we report the management of a patient with a malignant pheochromocytoma who underwent oral surgery. The patient was 44 years old and had an apical periodontal cyst. The removal of the cyst was scheduled, and the patient was treated with a high dose of doxazosin for 1 week prior to the operation to promote the adequate control of the patient’s blood pressure during surgery. We planned to monitor the blood pressure and pulse during the operation and to administer as small a dose of adrenaline-containing local anesthetic products as possible. For the initial local anesthesia, 3% mepivacaine solution without adrenaline was submucosally injected at a dose of 5.1 ml. After the injection, no marked change in the blood pressure was noted. During the operation, a total of 5.7 ml of mepivacaine solution was administered for pain control. However, because of insufficient pain control, we added 2.2 ml of 2% lidocaine solution containing 1/160,000 adrenaline. The operation was completed without any adverse events, and no complications occurred after the operation. The administration of adrenaline should be avoided as much as possible because its addition along with endogenous catecholamine from the pheochromocytoma could cause severe hypertension. Therefore, when a local anesthetic containing adrenaline is administered for dental treatments or oral surgeries in patients with pheochromocytoma, it should be carefully injected while monitoring the patient’s blood pressure and pulse.
Subcutaneous and mediastinal emphysema are complications associated with oral and maxillofacial surgery. A 63-year-old male underwent oral surgery under general anesthesia, and an air turbine drill was used for third molar split and extraction. He postoperatively developed massive subcutaneous emphysema extending from his cheeks and neck to his chest wall. A neck and chest computed tomography examination revealed mediastinal emphysema. Accordingly, the patient was transported to the intensive care unit (ICU) under tracheal tube intubation and was treated with antibiotics. The patient tracheal tube was then extubated 4 hours thereafter. As no further complications were observed, the patient was discharged on postoperative day 5. Most cases of subcutaneous and mediastinal emphysema have been reported to be caused by the extraction of wisdom teeth with mandibular impaction and the use of high-speed dental drills. These factors were likely causes in the presently reported patient as well. When patients are exposed to these risks, anesthesiologists should anticipate possible complications, such as mediastinitis and airway obstruction, and should perform intensive care management as applicable. This report describes a patient who developed extensive subcutaneous and mediastinal emphysema after oral surgery performed under general anesthesia who was subsequently admitted to the ICU.
Laryngeal granuloma is a complication that sometimes occurs several months after tracheal intubation. We present the case of a 21-year-old woman with laryngeal pain, a heavy cough, and hoarseness developing 1 month after two orthognathic surgeries and disappearing within 4 months after the surgeries. Previously, general anesthesia had been induced and maintained with air, oxygen, sevoflurane, remifentanil and rocuronium. She had undergone a Le FortⅠ procedure with a sagittal splitting ramus osteotomy. Her trachea had been intubated with a 6.0-mm internal diameter, low-pressure cuffed nasotracheal tube ; no difficulties were encountered during the intubation, and the tube had been fixed so that the superior border of the cuff was located 25 cm from the nose and 3 cm from the vocal cords. The tracheal tube was removed the next morning after postoperative sedative-analgesia following the completion of the surgery. The tracheal intubation time was 23 h, 30 min. Several weeks after extubation, the patient had no complaints of vomiting or nausea.
One month later, however, she became hoarse following a severe cough and was referred to a hospital otolaryngologist for a laryngeal fiberscopic evaluation. Laryngeal granulomas located on bilateral arytenoid cartilages were observed, but no signs of edema or vocal cord paralysis were seen. Conservative treatment consisting of inhaled steroid hormones was administered. The hoarseness and laryngeal granulomas (as confirmed by a otolaryngologist during a laryngeal fiberscopic examination) had both disappeared at 4 months after the surgery. Long-term trachea intubation and the setback of the maxillary bone can result in physical irritation and a narrowing of the inferior pharynx, possibly allowing additional insults to the fragile vocal cords.
Dental anesthesiologists should keep in mind that laryngeal granulomas can develop several months after long-term trachea intubation, and an otolaryngologist should be consulted to enable a laryngeal fiberscopic evaluation, if necessary.
Pulmonary thromboembolism (PTE) can be a fatal complication during the perioperative period of oral surgery. PTE includes symptoms such as chest pain, dyspnea and tachycardia.
We present a case of postoperative PTE after cancer resection of the oral floor performed under general anesthesia. The patient was a 77-year-old woman who underwent cancer resection of the oral floor. She did not exhibit any subjective symptoms suggesting PTE.
The patient did not receive any premedication. General anesthesia was induced with fentanyl, propofol and rocuronium after obtaining peripheral intravenous access. Anesthesia was maintained with desflurane in air and oxygen. The blood pressure was maintained at 80-130/40-70 mmHg, the heart rate was 60-87 bpm, and the Pao2 was 104-159 mmHg. The surgical procedure was completed in about 5 hours without any adverse events. On postoperative day 2, she suddenly complained of dyspnea and lost consciousness. Her Spo2 decreased to 70%, and her D-dimer level increased to 18.4 μg/ml. Enhanced computed tomography revealed an embolism of the right anterior basal artery from the center to the periphery, and she was diagnosed as having PTE. Anti-coagulant therapy with heparin (400-900 U/hour) was started. The treatment was effective, and her condition improved gradually. She was discharged from hospital 34 days after the surgery.
Although PTE is a rare complication, it has a high mortality rate. Consequently, the possibility of PTE after surgery must be kept in mind.
A 56-year-old male patient with myasthenia gravis (MG) and a severe gagging reflex (GR) was scheduled to undergo intravenous sedation (IVS) for dental treatment. The patient had been diagnosed as having MGFA class Ⅱ (anti-acetylcholine receptor antibody, 32.2 nmol/l) at the age of 52 years, and a thymectomy and partial resectioning of the right upper lobe were performed. An immunosuppressant (tacrolimus) and prednisolone were prescribed.
During a first IVS, the mandibular left second molar was extracted. An initial loading dose of dexmedetomidine (Dex) of 6.0 μg/kg/h for 10 minutes and a maintenance dose of 0.6 μg/kg/h were administered. No GR episodes occurred, and the Ramsay sedation score (RSS) was 2 or 3. The Spo2 was 97-98% without oxygen inhalation. Blood pressure and heart rate were reduced, but remained within the standard range. The recovery time was 70 minutes.
A second IVS was performed to obtain snap impressions. An RSS of 4 was maintained using 3 mg/kg/h of propofol with 3 l/min of O2. However, GR occurred the moment the tray was inserted into his mouth. A bolus administration of propofol, resulting in an RSS of 5-6, was needed to control the GR. The airway was secured by mandibular fisting. The recovery time was 40 minutes.
Finally, a third IVS was performed to acquire a precision denture impression. Dex infusion was started, and propofol was required to control the GR. The dosages of both agents were lower than before. The recovery time was 110 minutes.
The present findings suggest that Dex can be safely used in patients with MG without causing respiratory depression. The disadvantage of its use is the time required to recover and its inability to suppress a GR completely. Propofol was useful for controlling the GR in this presently reported patient.
In conclusion, although the exact dosage of each drug nor the administering time is clear, the expected results of the combined IVS is advantages for MG patients with GR.