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BACKGROUND: Analgesia after pharyngolaryngeal surgery is commonly provided through the i.v. route. The aim of the study was to compare cervical epidural administration of fentanyl with the i.v. route for postoperative analgesia after pharyngolaryngeal surgery. METHODS: In a randomized double-blind study 42 patients received fentanyl via patient-controlled analgesia (PCA) either through the i.v. route (PCA-IV group, n=22) or through the cervical epidural route (PCA-Epid group, n=20). Identical PCA settings were used in the two groups (bolus dose: 1.5 microg kg(-1), bolus: 25 microg, lockout interval: 10 min, maximum cumulative dose: 400 microg per 4 h). Analgesia at rest and during swallowing was evaluated using a visual analogue scale. RESULTS: Analgesia at rest was better in the PCA-Epid group than in the PCA-IV group but only 2 and 6 h after surgery (P<0.02). There was no difference in analgesia during swallowing. Cumulative doses of fentanyl were similar {PCA-Epid group: 1412 microg (912), PCA-IV group: 1287 microg (1200) [median (IQR)]}. The Pa(o(2)) showed a significant decrease between the preoperative and postoperative period, but this decrease was identical in the two groups [PCA-IV-group: 11.47 (2.4) kPa vs 8.27 (0.9) kPa; PCA-Epid group: 11.33 (1.9) kPa vs 9.20 (2.4) kPa for preoperative and postoperative period respectively]. CONCLUSIONS: The study results show that cervical epidural analgesia provides marginally better pain relief at rest with no decrease in the fentanyl consumption. The use of the cervical epidural administration of fentanyl is questionable because of the possible complications of the technique.

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BACKGROUND: Since pre-incisional peritonsillar infiltrations of local anesthetic solutions have been suggested to reduce postoperative pain after tonsillectomy, we compared the efficacy of either pre- or postoperative local anesthetic infiltration upon post-tonsillectomy pain. METHODS: After the induction of general anesthesia, 68 consecutive healthy patients, ranging in age from 8 to 65 years, were randomly allocated to either receive peritonsillar infiltration with 0.25% bupivacaine (group 1) or normal saline (group 2) before incision. A third group (group 3) had their peritonsillar region infiltrated with 0.25% bupivacaine after the completion of surgery but before the patients were awakened from anesthesia. All the patients were treated in the same way in the postoperative period: NSAIDs were given intravenously to adults and rectally to children. Acetaminophen was given intravenously or rectally (children aged < 15 yr) if additional analgesic support was requested by the patient. Additional acetaminophen consumption was recorded daily. Pain scores were assessed on every patient with the use of a visual analogue scale (VAS) at rest, 1, 5, 9, 13, 17, 21 and 36 h after surgery, and also on swallowing during the first postoperative day. RESULTS: Global VAS pain scores were lower in the groups treated with bupivacaine infiltration during the first 24 h after surgery (P < 0.05). Supplementary analgesic consumption was lower in group 3 than in group 2 during the 0-9 h interval immediately following surgery (P < 0.05). There were no statistically significant differences for any other parameters between the 3 groups. CONCLUSION: These results suggest that the timing of peritonsillar infiltration with bupivacaine is not of clinical importance and does not affect the quality of postoperative analgesia in patients undergoing tonsillectomy.

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Regional anaesthesia is not used widely for outpatient nasal surgery. The aim of this study was to determine the role of nasociliary and infraorbital nerve block in 24 patients undergoing nasal surgery comprising: cosmetic or reconstructive surgery of the nose and surrounding soft tissue, polypal removal, turbinectomy, reduction of fractured nasal bones, small tumour resection or emergency surgery on isolated facial lacerations. Mild sedation with midazolam 0.03 mg kg-1 was used before anaesthesia. Nasociliary and infraorbital blocks were technically easy to perform, safe and provided good intraoperative conditions. Only minor complications were observed, including local bruising in eight patients and transient diplopia in one patient. No patient received general anaesthesia, but infiltration of local anaesthetic was necessary in four patients because of incomplete anaesthesia in the surgical area. Operative conditions were judged as good or excellent by surgeons in 20 of 24 patients. Twenty of 24 patients were very satisfied or satisfied with anaesthesia. Duration of surgery exceeding 60 min and excessive bleeding in the nasopharynx were the main limiting factors for the use of facial regional anaesthesia.

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A case is reported of endotracheal tube obstruction due to impaction of a turbinate. This complication occurred during a first attempt of nasotracheal intubation in an ASA 1 18-year-old patient. Once the tube had been inserted into the trachea, manual ventilation was impossible. The diagnosis was made on removal of the completely obstructed tube. Differential diagnosis was sudden severe bronchospasm or a herniated cuff. Anaesthesiologists should be aware of this rare complication when carrying out nasotracheal intubation. Means of prevention are proposed.

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A case is reported of pneumoencephalus occurring after an accidental dural puncture during a cervical epidural puncture using the loss of resistance technique. Six ml of air were injected intrathecally. The patient recovered spontaneously within five days. This complication may occur more frequently than commonly admitted. It may be difficult to differentiate between headache due to pneumoencephalus and that by stretching of the meninges due to cerebrospinal fluid leakage. Only a CT scan can help to answer this question.

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Cervical epidural anaesthesia (CEA) results in an effective sensory blockade of the superficial cervical (C1/C4) and brachial plexus (C5/T1-T2). It is used both intraoperatively and in the treatment of postoperative or chronic pain. The approach to the epidural space at the C7-T1 interspace is not technically difficult. Patients are placed in the sitting position, increasing the negative pressure in the epidural space, with the head flexed on the thorax, in order to open the lowest cervical interspace. A 18-gauge Tuohy needle is inserted by a midline approach into the C6-C7 or C7-T1 interspace. A catheter may be inserted and left in place for postoperative analgesia. Local anaesthetics are administered either alone, or in combination with opiates. The CEA blocks the cardiac sympathetic fibers and consequently decreases heart rate, cardiac output and contractility. The mean blood pressure is unchanged or decreased, depending on peripheral systemic vascular resistance changes. The baroreflex activity is also partly impaired. Sympathetic blockade also decreases myocardial ischaemia. The cardiovascular changes induced by CEA are also partly due to the systemic effect of the local anaesthetic. The respiratory effects are minimal and depend on the extent of the blockade and the concentration of the local anaesthetic. A moderate restrictive syndrome occurs. Since the phrenic nerves originate from C3 to C5, ventilation may be impaired by CEA. Extension of the block may also impair intercostal muscle function, with a risk of respiratory failure when a CEA is used in patients with compromised respiratory function. The potential specific complications, mainly cardiovascular and respiratory, are the exacerbation of the effects of CEA. Side effects such as bradycardia, hypotension and acute ventilatory failure in relation to respiratory muscle paralysis, may be observed. Close monitoring of haemodynamics, respiratory rate and level blockade is required. Cervical epidural anaesthesia may be used either alone, or in combination with general anaesthesia depending on the surgical procedure. This technique seems to be effective in carotid artery surgery since sensitive and reliable information on cerebral function may be obtained. It is also for shoulder and upper limb surgery as well as for pharyngolaryngeal surgery, providing efficient operative anaesthesia and postoperative analgesia. CEA is used for relief of chronic pain in the head and neck or cancer pain due to Pancoast-Tobias syndrome. It seems to be effective for treating pain in patients with unstable angina pectoris or acute myocardial infarction.

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We report the case of a 58-year old man who had been on corticosteroid therapy for several months and presented with cerebral nocardiosis. Computerized tomography showed multiple brain abscesses. As the neurological status was getting worse, several stereotactic needle aspirations were performed, resulting in decompression of the brain and permitting bacteriological examination of the pus. Antibiotic therapy based on sensitivity tests was administered, and cure was obtained in the 4th month of treatment.

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As deafness surgery is subject to the two imperatives of safety and reduction of bleeding, local anaesthesia constitutes a very satisfactory solution. The concomitant administration of Midazolam and Buprenorphine relaxes the patient and ensures analgesia and anterograde amnesia, allowing the surgeon to operate under excellent conditions. Over the last 6 months, except in one subject under the age of 16 years and one psychologically very fragile patient, all surgical operations for deafness, regardless of their importance, have been performed under local anaesthesia improved by means of diazanalgesia. It is probable that in the future, numerous cophosurgeons will adopt a similar protocol.

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