Spontaneous pneumomediastinum (SPM) is defined as free air or gas in the mediastinum that is not associated with an obvious cause such as chest trauma. The SPM results from acutely elevated intra-alveolar pressure: The high-pressure gradient between the distal alveoli and the pulmonary interstitium leads to alveolar rupture. This causes free gas to separate through the peribronchovascular fascial sheaths (interstitial emphysema) into the hilum and then into the mediastinum. Once the gas is in the mediastinum, it can travel up to the cervical soft tissues (even the retroperitoneum) producing subcutaneous emphysema. The Macklin effect appears on thoracic computed tomography (CT) as linear air collections adjacent to bronchovascular sheaths. This case report presents CT findings of SPM due to the Macklin effect in three cases and a brief literature review on this subject.

Abstract Background Cardiotoxicity is a well-recognized adverse outcome following adjuvant breast cancer treatment including anthracyclines, trastuzumab, and chest radiation. Its prevention remains an important challenge in clinical practice. We aimed to determine the effectiveness of prophylactic cardioprotective agents in preventing treatment-related cardiotoxicity in women with breast cancer. Methods A systematic review of published literature was conducted by searching PubMed, EMBASE and EBSCO host databases. Studies where prophylactic intervention was given to breast cancer patients without a prior history of heart disease were included. The outcomes of interest were preservation of left ventricular ejection fraction (LVEF), or development of cardiac events. Mean differences (MD) in LVEF, and relative risks (RR) of cardiac events, were evaluated using random-effects models. Results Thirteen randomized controlled trials (RCTs), which used prophylactic beta-blockers, dexrazoxane, angiotensin receptor blockers, angiotensin converting enzyme (ACE) inhibitors or other pharmacologic agents were included. Overall, the use of prophylactic cardioprotective agents resulted in a statistically significant smaller LVEF decline compared to use of placebo (MD = 2.42%, 95% confidence interval (CI): 0.59%-4.24%). While there were 52 cardiac events in the intervention arm (n = 405) compared to 79 in the control arm (n = 396), use of prophylactic cardioprotective agents did not significantly protect against incident cardiac events (RR = 0.63, 95%CI: 0.33-1.22). Conclusions In breast cancer patients without a history of heart disease, use of cardioprotective agents appear to confer only a very marginal protection against LVEF decline, falling below the ideal 10% cardioprotection. However, given the sample number of RCTs in this area, more studies are needed to substantiate the effectiveness of prophylactic cardioprotective agents in prevention of cardiotoxicity in women with breast cancer. Legal entity responsible for the study The authors. Funding Has not received any funding. Disclosure All authors have declared no conflicts of interest.

Background and Objective: Septoplasty operations are associated with moderate to severe postoperative pain which has unfavourable effects on patient's recovery and postoperative outcome. The aim of this study was to compare effects of intravenous paracetamol and dexketoprofen on postoperative analgesia, tramadol consumption and side effects after septoplasty. Methods: In total 72 patients (aged 18-65 years) who had undergone an elective septoplasty from August 2013 to January 2015 in Baskent University Faculty of Medicine, in the Department of Anesthesiology and Reanimation Clinics were included in this study. The patients were randomised into one of two groups: those who received intravenous paracetamol; and those who received intravenous dexketoprofen. All patients were treated with tramadol for 24 hour postoperatively. The primary endpoint was pain intensity as measured by a visual analogue scale (VAS). Tramadol consumption and drug related side effects were also recorded. Results: The pain scores in the dexketoprofen group were significantly lower at recovery, 15 and 30 minutes and two hour (p< 0.05). The pain scores had no difference at other time points. Tramadol consumption in the recovery period was significantly lower in the dexketoprofen group, but cumulative tramadol consumption did not differ between the groups. The incidence of nausea was lower but not statistically significant in the dexketoprofen group at 15 and 30 minutes and two hour. Conclusions: Compared with paracetamol, preemptive dexketoprofen is associated with lower VAS scores and tramadol consumption in the early postoperative period after septoplasty. However, the cumulative tramadol consumption did not significantly differ between the groups.

Coronary artery aneurysm is generally presented as an asymptomatic, incidental angiographic finding and often associated with atherosclerosis. In this study we investigated the correlation of inflammation parameters and non-atherosclerotic isolated coronary artery aneurysm.

BACKGROUND:We investigated the effect of thoracic epidural anesthesia on perioperative blood glucose levels in diabetic patients undergoing cardiopulmonary bypass by continuous insulin infusion according to the Portland Protocol.MATERIAL AND METHODS:Diabetic patients undergoing surgery with cardiopulmonary bypass were assigned to receive either general anesthesia alone (n=40) or general anesthesia with thoracic epidural anesthesia (n=18). Patient data were retrospectively reviewed from prospective chart records used in our anesthesia clinic. In all study patients, insulin infusion with the Portland Protocol was used to maintain stable blood glucose levels. We evaluated blood glucose levels in both groups at 6 time points including before surgery, before cardiopulmonary bypass, during cardiopulmonary bypass, immediately following cardiopulmonary bypass, and on the first and second postoperative days. The amounts of insulin required at the intraoperative period and during two postoperative days were compared between two groups.RESULTS:Groups were similar with respect to the duration of cardiopulmonary bypass, aortic cross-clamping, surgery, and blood glucose levels at any of the 6 time points, mean insulin requirements during intraoperative period and mean insulin requirements and blood glucose levels during the first 2 postoperative days (General anesthesia alone, 189+/-29 mg/dl vs. General anesthesia with thoracic epidural anesthesia, 191+/-19 mg/dl; p=0.782).CONCLUSIONS:In diabetic patients undergoing cardiopulmonary bypass receiving insulin infusion by the Portland Protocol for glycemic control, thoracic epidural anesthesia provides no additional benefit for maintaining blood glucose levels during surgery.

BACKGROUND AND OBJECTIVE:It has been reported that the left molar approach of laryngoscopy can make difficult intubation easier. The aim of this study was to investigate whether left molar approach to laryngoscopy provided a better laryngeal view in cases of unexpected difficult intubation.METHODS:Following the approval of local Ethics Committee and written informed consent from the patients, out of 1386 patients who underwent general anaesthesia for surgery, 20 patients who could be ventilated by face mask but could not be intubated with conventional midline approach on the first attempt were included in the study. Those 20 patients, who had Grade III-IV laryngeal views on laryngoscopy by conventional midline approach, were subjected to left molar laryngoscopy, and their laryngeal views were evaluated. The external laryngeal compression was routinely used to improve the laryngeal view. When endotracheal intubation failed by left molar laryngoscopy, we performed the conventional midline approach again. All data were recorded.RESULTS:Of the 20 patients studied, 18 had a Grade III laryngeal view and two had a Grade IV laryngeal view. Eighteen of them had a better laryngeal view with left molar laryngoscopy. Eleven of the 20 patients underwent successful intubation with the left molar laryngoscopy, which provided a significantly better laryngeal view and success rate of tracheal intubation than did the conventional midline approach (P < 0.01 and P < 0.01, respectively).CONCLUSIONS:Left molar laryngoscopy can make unexpected difficult intubation easier and should be attempted in cases of difficult intubation.

BACKGROUND AND OBJECTIVE:We compared the efficacy of intravenous lornoxicam vs. dipyrone in patient-controlled analgesia for postoperative analgesia.METHODS:The study included 105 patients who had undergone elective septorhinoplasty after receiving general anaesthesia. Patients were divided into three groups to receive lornoxicam (24 mg day(-1)), dipyrone (5 g day(-1)) or placebo. Pain was evaluated using a 0-100 mm visual analogue scale at 2, 4, 6, 8, 12, 16, 20 and 24 h postoperatively. Pethidine (1 mg kg(-1)) was administered intramuscularly to patients requiring rescue analgesia. Pethidine requirements were recorded during the first 24 h postoperatively, and treatment-related adverse effects were noted.RESULTS:Postoperative pain scores were significantly lower with lornoxicam compared with dipyrone at 8 h (P = 0.016). No significant differences regarding pain scores at 2, 4, 6, 12, 16, 20 and 24 h were found. Significantly fewer patients in the lornoxicam group required rescue analgesics (vs. dipyrone, P = 0.046; vs. placebo, P = 0.001); fewer patients in the dipyrone group required rescue analgesics compared with placebo (P = 0.008). Significantly fewer patients in the lornoxicam group had nausea (vs. dipyrone, P = 0.022; vs. placebo, P = 0.006); no significant differences were found between the other two groups. Antiemetic use was significantly lower in the lornoxicam group (vs. dipyrone, P = 0.002; vs. placebo, P = 0.001).CONCLUSIONS:Lornoxicam has better tolerability and is a more effective analgesic than dipyrone when administered by patient-controlled analgesia for postoperative analgesia after septorhinoplasty.

PROBLEM:Nasal intubation is used often by anaesthetists because it offers many advantages; however, rare complications do arise. A 67-year-old man was admitted to our otorhinolaryngology clinic for uvulopalatopharyngoplasty. Nasotracheal intubation was performed without difficulty. At the beginning of surgery, the surgeon noticed that the nasotracheal tube had penetrated the oropharyngeal mucosa through a channel in the retropharyngeal space. METHODOLOGY:The tube was left in place during surgery to prevent bleeding. After surgery, a vertical incision was made through the mucosa surrounding the tube from the inferior pouch up to the nasopharynx to prevent hematoma. RESULT:The patient was extubated without complication and discharged on the second day postoperative. The oropharyngeal mucosa was healed by the 15th day postoperative. CONCLUSION:Nasal intubation tubes should be lubricated and inserted without force; the oropharynx should be examined carefully after intubation to rule out complications.

Diflunisal and lornoxicam are currently available non-steroidal anti-inflammatory drugs (NSAIDs) that have been shown to be effective to various degrees in pain relief when administered either pre-emptively or postoperatively. The pre-emptive analgesic efficacy of diflunisal 1000 mg was compared with that of lornoxicam 16 mg in 40 ASA I patients undergoing surgical removal of bilateral impacted third molars. The impacted third molar teeth on one side were removed at the first surgical appointment using one of the two drug regimens being assessed and the teeth on the contralateral side were removed at a second appointment using the alternate drug regimen; all operations were performed by the same surgeon. Acetaminophen up to 2000 mg daily was provided as rescue medication. The postoperative rescue analgesic consumption was recorded and pain scores were evaluated with a visual analogue scale at 2, 4, 6, 12 and 24 h postoperatively. No statistically significant differences were found between groups with respect to rescue analgesic consumption and postoperative pain scores. Pre-emptive administration of both NSAIDs proved to be effective in the management of pain following the surgical removal of impacted third molar teeth.

Ropivacaine is potentially less cardiotoxic and neurotoxic than bupivacaine. The aim of this study was to compare the effectiveness of ropivacaine 0.25% and bupivacaine 0.25% for surgical anaesthesia and postoperative analgesia during lumbar plexus and sciatic nerve block in high-risk patients. We performed combined lumbar plexus and sciatic nerve blockade on 62 consecutive ASA III or IV patients undergoing unilateral hip or femur surgery. The first 30 patients received bupivacaine (Group 1) and the remaining 32 patients received ropivacaine (Group 2). Perioperative management was otherwise similar. The groups were compared for the time of onset of the block, additional analgesics and sedatives required, time from end of surgery to the first analgesic requirement and the need for rescue analgesia. Ninety percent (29/32) of the patients in the ropivacaine group and 86% (26/30) of the patients in the bupivacaine group reached surgical anaesthesia. The time from the end of the surgery to the first analgesic requirement was similar between the two groups (10.3±5.2 hours for ropivacaine, 11.2±4.6 hours for bupivacaine). There was no statistically significant difference between the two groups in any of the measured variables (P>0.05). The results of this preliminary study suggest that ropivacaine 0.25% is as effective as bupivacaine 0.25% when used for blocking lumbar plexus and sciatic nerve in high-risk patients undergoing hip or femur surgery.

General and regional anesthesia may both be used successfully in donor nephrectomy although the use of regional anesthesia is rare. We compared the remaining kidney function during general (n = 10) versus combined spinal-epidural (n = 10) anesthesia for donor surgery. Blood biochemistry data were collected preoperatively and postoperatively, while renal function was assessed by scintigraphy and urine levels of microalbumin, creatinine, Na, K, Ca and creatinine clearance rate were measured/calculated in 24-hour urine samples collected preoperatively and on postoperative day 2. There were no differences preoperatively and on postoperative day 2 with respect to glomerular filtration rate, microalbuminuria, or creatinine clearance rate (P > .05 for all). There were also no differences between the groups with respect to other scintigraphic findings preoperatively and on postoperative day 2 (P > .05 for all). The results suggest that general or combined spinal-epidural anesthesia for donor nephrectomy have similar effects on the remaining donor kidney function.

To the Editor: Laryngeal granulomas are the most common late complication of endotracheal intubation in adults (1). Intubation-related subglottic granulomas may cause dyspnea. Such lesions reflect severe trauma; airway manipulation during intubation and the smaller dimensions of the female larynx could be contributing factors (2–4). A 50-yr-old woman (weight, 50 kg) was admitted with complaints of abnormal vocal sounds on inspiration, shortness of breath, and hoarseness. According to the patient’s medical records, she had been intubated with a No. 8.0 cuffed endotracheal tube during emergency treatment because of central nervous system trauma 4 mo earlier. Ear, nose, and throat assessment revealed two pedunculated polyploid masses, one on the posterior third of each vocal process. Direct laryngoscopy was performed under general anesthesia (Fig. 1), and the masses were excised by laryngo-microsurgery (Fig. 2). Granulomas of the posterior glottis are mainly seen in males with the exception of postintubation granulomas (3). In contrast, 75% to 90% of all intubation-related laryngeal granulomas reported to date have been in female patients (2). Pontes et al. (3) concluded that the higher frequency of intubation-related granulomas in women is related to lower “glottic proportion” (Fig. 3). Schlesinger et al. (1) and Ishizaki et al. (5) have reported dyspnea with postintubation laryngeal granuloma; however, there is no report of bilateral glottic posterior laryngeal granuloma so large as to cause dyspnea. It should be noted that postintubation laryngeal granuloma could occur after tracheal intubation, especially in female patients, carried out either electively or as an emergency procedure or subsequently during the intensive care period.Figure 1.: A preoperative image of the patient’s larynx during the direct laryngoscopy shows. G = granuloma; L = left; R = right; ET= endotracheal tube (6.5-mm inner diameter).Figure 2.: The image of the patient’s larynx after the granuloma excision shows. L = left; R = right; ET= endotracheal tube. Horizontal arrows show vocal processes.Figure 3.: The drawing of glottic proportion (= A/B) shows. A, Mid-sagittal dimension of the intermembranous portion of the glottis. B, Mid-sagittal dimension of the intercartilaginous portion of the glottis.Cuneyt Yilmazer, MD Department of Otolaryngology Head and Neck Surgery Mesut Sener, MD Department of Anesthesiology and Reanimation [email protected] Ismail Yilmaz, MD Department of Otolaryngology Head and Neck Surgery Baskent University Adana Teaching and Medical Research Center Adana, Turkey

Background and Objectives: The aim of this study was to compare the same volume and concentration of bupivacaine and ropivacaine for interscalene brachial plexus block anesthesia and postoperative analgesia in shoulder surgery.Methods: Forty-four patients scheduled for elective shoulder surgery were prospectively randomized to receive in a double-blind fashion 30 mL of either 0.5% bupivacaine or ropivacaine for interscalene block. The block was prolonged after surgery by using a patient-controlled interscalene analgesia with 0.15% of either bupivacaine or ropivacaine. The mean onset times of surgical blocks were determined after interscalene block. Pain relief was regularly assessed by using a visual analog scale, side effects were noted, and the patients were asked to rate their satisfaction at the end of the study.Results: Two patients with bupivacaine and 1 with ropivacaine failed to achieve surgical block and were excluded. The mean onset times of surgical blocks were 18 12 minutes with ropivacaine and 21 13 minutes with bupivacaine. The pain scores, total volume infused of local anesthetics, incremental dose requested and received, total rescue analgesic, and side effects were similar between the groups. Postoperative pain control was similarly effective and patient satisfaction was high in both groups.Conclusions: This study shows that the same volume and concentration of bupivacaine and ropivacame (30 mL of 0.5%) for interscalene brachial plexus block anesthesia produce similar surgical block. When prolonging the block with a patient-controlled interscalene analgesia infusion, 0.15% bupivacaine or ropivacame provide adequate pain relief, similar side effects, and high patient satisfaction after shoulder surgery.

Various general and regional anesthesia methods are used successfully in living-donor kidneytransplantation. This study compared kidney graft function after general versus combined spinal-epiduralanesthesia for donor nephrectomy. The study groups included recipients who received graftsfrom donors who had undergone nephrectomy under general anesthesia (GA group; n = 10), andrecipients who received grafts from donors who had combined spinal-epidural anesthesia (CSEgroup, n = 10). Standard continuous epidural anesthesia was administered during all transplantations.Graft function was assessed using scintigraphy and Doppler ultrasonography on days 3 and 7. Urinelevels of microalbumin, creatinine, and creatinine clearance rate were measured/calculated in 24-hoururine samples collected on postoperative days 3 and 7. There were no differences on either day 3 orday 7 with respect to glomerular filtration rate, microalbuminuria, or creatinine clearance rate (P > .05for all). There were also no differences between the groups with respect to other scintigraphic findingson day 3 or day 7 (P > .05 for all). Ultrasonography on day 7 showed significantly higher mean peaksystolic flow in the main renal artery in the CSE group than in the GA group (P = .035). The resultssuggest that GA and CSE for donor nephrectomy have similar effects on kidney graft function inrecipients.