A total of 434 patients admitted to the intensive care unit for mechanical ventilation were followed prospectively to investigate the influence of a nasotracheal tube on the paranasal sinuses. Twenty-five patients died before the examination was completed. The rest were examined for clinical symptoms of sinusitis. If sinusitis was suspected or the patients were intubated for 5 days or more, an x-ray of the sinuses was performed. In patients intubated for less than 5 days (N = 357), sinusitis was clinically suspected in three, but radiographically verified in only one. In patients intubated for 5 days or more (N = 47), 23 (49%) had affection of the paranasal sinuses. Patients needing a nasotracheal tube should be examined for sinusitis if they are intubated for more than 5 days or if unexplained fever, sepsis or purulent nasal secretion develops. If the suspicion is confirmed, the nasotracheal tube should be removed.

A total of 379 patients admitted to the ICU for mechanical ventilation were prospectively investigated for lesions on the nose, nasal cavity, ears and larynx during and after nasotracheal intubation. One to two years later, the surviving patients were questioned to investigate late persisting sequelae. During intubation and up to 5 days following extubation, inflammatory changes and ulceration of the nostrils or nasal septum were found in 76 (20%) and 110 patients (29%), respectively. There were bleedings from the nasal cavity in 67 (19%) and fractures of the conchae in 40 patients (11%). Hoarseness was noted in 135 patients (42%). Inflammatory changes and ulcerations of the nostril and nasal septum were correlated to the duration of intubation. Among the 281 patients included in the follow-up study, 100 (35%) had symptoms from the nose and nasal cavity. Sixty-five (24%) had symptoms related to the ears, 56 (20%) to the maxillary sinus, 81 (29%) to the voice and 90 (32%) to the throat. Increasing duration of intubation was found to be correlated to persisting symptoms from the larynx. Former ulcerations of the nose were associated with a tendency to nasal bleeding. To avoid as many complications as possible from the nose and nasal cavity, we recommend orotracheal intubation. As late sequelae from the larynx increase with the duration of intubation, perhaps tracheostomy should be performed earlier than is general practice today, but that has to be proven in forthcoming studies.

Minitracheotomy (MT) is a new method for the treatment of sputum retention and atelectasis. Through a 1-cm incision in the cricothyroid membrane (coniotomy), a specially designed tube is placed in the trachea, allowing suction to be performed. Fifteen patients, aged 37-78 years (median 62 years), with postoperative sputum retention, atelectasis and imminent respiratory failure, were treated with suction by MT. Thirteen of the patients recovered from their respiratory problems, while two patients had to be treated with intermittent positive pressure ventilation (IPPV). During insertion, one case of external bleeding and one case of subcutaneous and mediastinal emphysema were seen, while no complications were seen during cannulation. The duration of cannulation was 4-38 days (median 10 days). Following decannulation the incisions were airtight within 1 day and healed within 3 days. Ten patients left hospital in good health and five died because of surgical complications and/or cardiovascular failure. MT seems to be effective in the treatment of sputum retention and atelectasis. Advantages over other invasive methods make it a method of first choice. The method involves few complications and is often so effective that avoidance of intubation and IPPV is possible.

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In 20 patients subjected to craniotomy for supratentorial cerebral tumours, the effect of scalp infiltration with bupivacaine before incision was evaluated by measuring mean arterial blood pressure (MABP) and cerebral arterio-venous oxygen content differences (AVDO2) repeatedly during the operation. All patients were given halothane 0.5% anaesthesia. Ten patients were given bupivacaine 0.25% and ten patients were given normal saline for scalp infiltration prior to incision. The study was performed in a double-blind randomized fashion. Significantly higher values of MABP (P less than 0.0005) after incision were found in the saline group compared to the bupivacaine group. Significantly lower values of AVDO2 (P less than 0.0005) after incision were seen in the saline group compared to the bupivacaine group. The results indicate that the increase in MABP associated with a decrease in AVDO2, suggesting an increase in CBF and cerebral hyperperfusion, is reduced by using bupivacaine scalp infiltration prior to incision.