We report a 19-year-old man who presented with 2 weeks history of fever, myalgia, swelling of the face and body and raised serum CK level. Following partial response to steroids, he deteriorated clinically. On admission, he had an ill look, hepatomegaly, muscle weakness and multiple, fluctuant and non-tender subcutaneous swellings of variable size, over the right forearm and left thigh. Diagnostic procedures revealed it to be tropical pyomyositis due to staphylococcus aureus. He improved completely with parenteral cloxacillin. Reporting of such cases will increase awareness.

Background: Oral cancer surgery with reconstruction is a complex operative procedure with morbidities such as respiratory complications and post‐operative pain. These morbidities may be reduced with appropriate operative and post‐operative pain management. Epidural analgesia provides better pain control than intravenous opioids after major thoraco‐abdominal surgical procedures. We planned to undertake a prospective study to compare the efficacy and side‐effects of epidural morphine analgesia vs. intravenous morphine in patients undergoing oral cancer surgery with pectoralis major myocutaneous flap reconstruction.Methods: Sixty patients undergoing a major surgical procedure for oral cancer with pectoralis major myocutaneous flap reconstruction were prospectively randomized to receive either epidural morphine or intravenous morphine in the post‐operative period. The intensity of pain was assessed daily using a 100‐mm visual analogue scale. The post‐operative side‐effects, time to ambulation, time to tolerate first nasogastric feed, total length of hospital stay and global satisfaction score were recorded.Results: The epidural morphine group had statistically significant lower pain scores at the three evaluation times through the post‐operative 48 h (P < 0.05). However, the mean visual analogue scores were always below 35 in the intravenous morphine group. Patients in the epidural morphine group ambulated and accepted nasogastric feed significantly earlier than those in the intravenous morphine group. The incidence of nausea/vomiting or pruritus, the length of hospital stay and the global satisfaction score were not statistically different between the groups.Conclusion: This study illustrates that epidural morphine offers better pain control than intravenous morphine after oral cancer surgery with pectoralis major myocutaneous flap reconstruction. Nevertheless, both methods appear to provide very good pain relief, and perhaps the extra risks inherent to epidural catheter insertion are not outweighed by the benefits in this type of surgery.

EDITOR: Churg-Strauss syndrome (CSS) is also allergic granulomatosis angitis and the commonest organ involved is the lung. Beside the lung, this syndrome also commonly involves skin, cardiovascular system, kidney, peripheral nervous system and gastrointestinal tract. Traditional format classification of CSS includes six criteria: asthma, eosinophilia >10%, mononeuropathy (including multiplex) or polyneuropathy, non-fixed pulmonary infiltrates on X-ray, paranasal sinus abnormality, and biopsy containing a blood vessel with extra-vascular eosinophils [1]. This syndrome has a very poor prognosis and the cause of death is likely to be related to pulmonary and cardiac disease. This case highlights the anaesthetic considerations in a patient with the CSS. A 36-yr-old female weighing 60 kg, with right-sided carcinoma of breast, stage T4b N2 M0, was scheduled for modified radical mastectomy under general anaesthesia as a semi-emergency due to ulcerated fungated growth. She was suffering from co-morbid conditions including CSS, hypertension, steroid-induced diabetes and mononeuritis multiplex of lower limb. She had a history of bronchial asthma for the last 18 yr and was on bronchodilators with intermittent steroids. She was diagnosed as CSS 4 yr previously when she started complaining of gradually progressive numbness and weakness of both lower limbs followed by upper limb, which was diagnosed as mononeuritis multiplex on nerve conduction velocity and nerve biopsy. Later she developed maculo-papular lesions on both feet and hands and biopsy was suggestive of vasculitis. Her blood picture showed peripheral eosinophilia and subsequently a diagnosis of CSS was made. Her medical history also included ischaemic optic atrophy in the right eye along with probable chronic steroid therapy induced diabetes mellitus and hypertension for 3 yr. She was a non-smoker and consumed no alcohol. There was no past history of tuberculosis. She had received three cycles of chemotherapy with poor response. She was currently on the inhaled steroid budesonide 800 μg 12 hourly and inhaled salbutamol 200 μg 6 hourly. She was also taking oral etophylline and theophylline combination 450 mg along with oral prednisolone 10 mg once a day. Blood pressure (BP) was controlled with enalapril 5 mg once a day orally while blood sugar was well controlled with oral glibenclamide 5 mg once a day. On general physical examination, features suggestive of cushingoid habitus and pedal oedema were present. On airway evaluation, Mallampati Class III, thyromental distance of 6.0 cm with limited neck extension were found. On systemic examination, bilateral diffuse inspiratory and expiratory rhonchi were present. Breath holding time was 5–10 s. Central nervous system examination showed muscle tone with Grade 4/5 or 5/5 power along with some loss of sensation in all four limbs. Her full blood count including total eosinophilic count, liver and kidney function tests along with serum electrolytes were within normal limits. Chest X-ray showed increased bronchovascular markings while computed tomography (CT) scan of chest was normal. Preoperative pulmonary function test showed severe obstruction with FEV1 33%, FVC 43% and FEV1/FVC 65% of the predicted values. Arterial blood gas on room air showed pH 7.408, PaO2 73.9 mmHg, PaCO2 40.3 mmHg and HCO3 24.9 with SaO2 of 95%. Tc-99 m labelled ventriculography showed normal resting left ventricular function. She was premedicated with oral diazepam 5 mg on the night before surgery and on the morning of surgery along with overnight fasting. Oral hypoglycaemic agent was avoided while oral antihypertensive and prednisolone were given on the morning of surgery. All medications for asthma were continued. She received intramuscular promethazine 25 mg and glycopyrrolate 0.2 mg as premedicant. An epidural catheter was placed under local anaesthesia at the T4–T5 interspace for intra- and postoperative analgesia. General anaesthesia was induced with fentanyl 120 μg and propofol 150 mg, and a laryngeal mask size 3.0 was placed after 1.5 mg kg−1 intravenous (i.v.) lidocaine. Monitoring of 5-lead electrocardiogram (ECG), non-invasive BP, SPO2, etCO2, spirometry, airway pressure, temperature, central venous pressure (CVP) and continuous invasive arterial pressure were established (Datex-Ohmeda S/5 monitor). Anaesthesia was maintained with 50% N2O in O2 with isoflurane, maintaining MAC 1.0, along with a propofol infusion and spontaneous respiration. After giving an epidural test dose, supplemental analgesia was provided by 10 mL of 0.125% bupivacaine and repeated just before completion of the surgery. Throughout the intraoperative period peak airway pressure varied between 14 and 20 cmH2 O and haemodynamic variables and arterial blood gas levels were satisfactory. Blood sugar levels were 100–130 mg dL−1. At the end of surgery propofol infusion and isoflurane were stopped and laryngeal mask was taken out in a deep plane of anaesthesia. Oxygen was supplemented by face mask till patient regained full consciousness. The epidural analgesia was continued with 10 mL of 0.125% bupivacaine and 10 μg fentanyl intermittently. Her postoperative period was uneventful. CSS is an uncommon disease characterized by granulomatous vasculitis of multiple organ systems. Asthma is a hallmark feature. The majority of these patients report new onset of asthma that may precede systemic vasculitis by many years [1]. About half of the patients with CSS show non-fixed, patchy pulmonary infiltrates on chest radiograph and these are often associated with fever, cough and dyspnoea [2]. In preoperative evaluation of patient with CSS, pulmonary function tests are necessary for assessing a patient's risk for developing perioperative pulmonary complications. Our patient was a high-risk case for perioperative pulmonary complication as she had uncontrolled asthma before surgery. Pulmonary function tests showed severe airway obstruction even after taking bronchodilator and anti-inflammatory medications. Regional anaesthesia remains the anaesthetic management of choice in asthmatic patients whenever feasible as it avoids tracheal intubation which may itself initiate bronchospasm. In Warner's study of over 1500 patients with asthma, however, the complication rates for general and regional anaesthesia were similar refuting the notion that regional anaesthesia was safer for patients with asthma [3]. Anaesthesia was induced with i.v. propofol and maintained by isoflurane and i.v. propofol infusion along with nitrous oxide and oxygen without paralysing the patient. The patient was pre-oxygenated with 100% oxygen and the airway was secured with the use of laryngeal mask as it is associated with less airway reaction when compared with endotracheal tubes. Although ketamine has bronchodilator effect, it was not used because of the hypertensive nature of the patient. Propofol may be a better choice than thiopental in asthmatic patients and has been reported to be safe in asthmatic patients in spite of the reports to induce histamine release in healthy volunteers [4]. We used isoflurane instead of halothane for maintenance of anaesthesia because there was uncertainty about serum aminophylline. We chose although all volatile anaesthetic agents are bronchodilators and the differences between them with respect to their efficacy in treating bronchospasm are probably clinically insignificant [5]. We did not use neuromuscular blocking agents as there was no need for muscle relaxation for surgery and our patient was adequately anaesthetized with volatile anaesthetic agent and epidural anaesthesia. This also reduced the possibility of airway constriction with the use of anticholinesterase agent used for reversal. Taylor and colleagues reported two cases with CSS who were found to have decreased cholinesterase activity after suspicion of abnormal sensitivity to suxamethonium [6]. Because of the site of surgery in this patient, there might have been decreased postoperative vital capacity and functional residual capacity in the absence of good analgesia. So, before induction of anaesthesia, a thoracic epidural catheter was placed for perioperative analgesia. Other possible benefits of epidural analgesia include decreased bronchial hyper reactivity and good wound healing. A recent study showed that despite sympathetic blockade, high thoracic epidural anaesthesia (TEA) does not increase airway obstruction and evokes only a small decrease in FEV1 as a sign of mild respiratory motor blockade with bupivacaine in patients with severe obstructive pulmonary disease undergoing breast surgery [7]. Gruber also noted that TEA with bupivacaine 0.25% does not lead to unfavourable changes in ventilatory mechanics, inspiratory muscle force generation, and gas exchange even in severely limited chronic obstructive pulmonary disease (COPD) patients [8]. In conclusion, this patient with CSS was successfully managed using combined general anaesthesia and TEA following careful preoperative evaluation and meticulous perioperative management. M. Gurjar S. Bhatnagar S. Mishra V. Jain A. K. Singhal 1Unit of Anaesthesiology, Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India 2Department of Neuroanaesthesia, Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India 3Unit of Anaesthesiology, Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India

OBJECTIVE:This retrospective study aims to describe the airway management and benefits of nasotracheal intubation over tracheostomy in 260 patients with oral cancer undergoing surgery. METHODS AND RESULTS:The medical records of 260 patients undergoing surgery for oral cancer were reviewed for airway management during the perioperative period. Eighteen patients had previous surgery for oral cancer and were scheduled for flap reconstruction, recurrence or other complications. In 28 cases neck movement was restricted and decreased mouth opening was found in 50% of all patients because of a large growth or fixation of tissues of head and neck, oral cavity, pharynx or larynx by tumour, or radiation fibrosis. In 53 patients intubation was undertaken under spontaneous ventilation. In 20 cases the trachea was extubated in the immediate postoperative period. In 220 cases patients were extubated next morning in the intensive care unit. In none of the cases was elective tracheostomy under local anaesthesia performed before surgery for the maintenance of the airway for anaesthesia. Elective tracheostomies were done in 17 cases. Three patients remained intubated for 24-48 h because of a high suspicion of airway obstruction following extubation due to a large pectoralis major flap. These three patients received a tracheostomy because of increased oropharyngeal and laryngeal oedema. In three cases emergency tracheostomies were performed due to upper airway obstruction after extubation and in one case prolonged elective ventilation was required due to severe chest infection. CONCLUSION:Oral cancer patients have a potentially difficult airway but, if managed properly during perioperative period, morbidity and mortality can be reduced or avoided. Oral cancer patients can be managed safely without the routine use of a tracheostomy. Nasotracheal intubation is a safe alternative to tracheostomy in oral cancer patients except in some selected patients.

Purpose: To compare ease of endotracheal intubation with the Intubating Laryngeal Mask Airway (ILMA) tracheal tube (TT; for LMA-Fastrach(TM)) and regular PVC TT (Portex) for nasotracheal fibreoptic intubation in oral cancer patients with a difficult airway.Methods: 40 patients of physical status ASA I-II with a history of previous oral cancer surgery and/or postoperative radiotherapy scheduled for oral cancer surgery were randomly allocated by sealed envelopes to undergo tracheal intubation with either the ILMA TT or a standard TT Ease of nasal passage of the TT and ease of tracheal intubation over the fibrescope was assessed. Peak airway pressures were assessed intraoperatively and postoperatively for 12 hrResults: The use of the ILMA TT increased the ease of nasotracheal intubation by increasing the percentage of successful tube placements at the first attempt (80%) in comparison with standard TT (35%); (P < 0.05). Peak airway pressures were found to remain low with the ILMA TT None of the patients experienced any airway related complications.Conclusions: Use of a soft, flexible, nonkinking ILMA TT with a tapered tip design facilitates passage into the trachea over a fibreoptic bronchoscope and allows maintenance of lower airway pressures. The ILMA TT may be a useful adjunct for management of the difficult airway in oral cancer surgery.

Modified radical mastectomy is associated with a relatively high incidence of postoperative nausea and vomiting (PONV). This study was undertaken to evaluate the comparative profile and efficacy of ondansetron and granisetron to prevent PONV after modified radical mastectomy. In a randomized, double-blind, placebo-controlled trial, sixty female patients received ondansetron 4 mg, granisetron 1 mg or saline intravenously just before induction of anaesthesia (n=20 for each group). A standardized general anaesthetic technique was employed. The incidence of PONV and adverse events were recorded for the first 24h postoperatively. The incidence of PONV was 25% with ondansetron, 20% with granisetron and 70% with saline (P<0.05, Chi-square test with Yates’ correction factor). The incidence of adverse events was comparable among the groups. Ondansetron and granisetron are both effective for reducing the incidence of PONV in female patients undergoing modified radical mastectomy.

Imatinib is a potent drug used in the treatment of all phases of chronic myeloid leukaemia (CML). It is an inhibitor of the protein kinases associated with BCR-ABL and related kinases. Various clinical trials have confirmed the efficacy of imatinib among non-transplant options. It is generally well tolerated. Reported complications include nausea, vomiting, oedema and fluid retention. We report a case of CML in which the patient developed acute pulmonary oedema following imatinib therapy. The probable cause of pulmonary oedema was cardiac morbidity due to imatinib.

Nasotracheal intubation is commonly used in the anaesthetic management of patients undergoing oropharyngeal procedures. The most frequent complication is epistaxis, which occasionally may be troublesome. There have been reports of partial and even total avulsion of turbinates. We report a case of obstruction of a nasotracheal tube by dislocated inferior turbinate that led to ventilation failure. High degree of suspicion led to quick diagnosis of turbinate dislocation and immediate re-intubation saved the life of the patient.

Microalgae has been identified as a potential source in the production of biofuel. Photobioreactors, which are used for microalgae production, normally experience temperature variations over the diurnal cycle due to changes in ambient conditions. Such temperature variations affect microalgae growth since microalgae are sensitive to these temperature variations. Hence, the thermal regulation of photobioreactors to minimize temperature variations will result in higher yield of microalgae. The present research is aimed to investigate a novel approach to thermally regulate photobioreactors using phase change materials (PCM) where the latent heat of the material is exploited as the energy storage mechanism. The present research uses a numerical approach to study the flow and thermal behaviors in a channel with a set of thermal energy storage columns placed at some offset from each other. The research aims to investigate the transient thermal response of the channel flow in the presence of these columns. Open source CFD software, OpenFOAM, is used to numerically simulate flow in a rectangular channel containing offset PCM columns. A parametric analysis to investigate the impact of various operating and geometric properties on the heat transfer to the PCM columns showed that geometric parameters such as the gap and blockage ratios, column aspect ratio, column shape and column arrangement in the channel influence thermal energy storage in PCM-filled columns.

This paper presents a one-dimensional, isothermal, flow analysis of steam and water mixtures in vertical flow passages, of the type found in many engineering applications. Computations have been performed with the aid of a finite-difference procedure and by assuming, one by one, four different flow regimes, viz. bubble, dispersed (droplet), annular and inverse annular. The predictions obtained for the different flow regimes are compared, and found to be significantly different from each other, as expected from physical considerations. It is concluded that the correct specification of flow regimes is important in two-phase flow computations, that the steady-state results obtained are in agreement with existing simple models and that the present numerical procedure is stable and efficient.

The paper presents numerical predictions of boundary layers exhibiting a large variety of streamwise pressure distributions, including those featuring in the Stanford Conference on Turbulent Boundary layers [25]. The model of turbulence employed is one in which the local state of turbulence is characterised by two quantities: the turbulence kinetic energy k and its dissipation rate ϵ. Transport equations for both k and ϵ are solved simultaneously with that for the momentum of mean flow. The computed results are compared with the experimental data; and the agreement is found to be in general good. The empirical constants in the model are the same as those used in earlier applications of the model; thus the applicability of the model is further demonstrated.