Midbrain hemorrhage causing isolated fourth nerve palsy is extremely rare. Idiopathic, traumatic and congenital abnormalities are the most common causes of fourth nerve palsy. We report acute isolated fourth nerve palsy in an 18-year-old lady due to a midbrain hemorrhage probably due to a midbrain cavernoma. The case highlights the need for neuroimaging in selected cases of isolated trochlear nerve palsy.

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Aim: To study the efficacy of oral clonidine on intraoperative bleeding and consumption of inhalational agent in patients undergoing FESS under general anesthesia. Study Design: Prospective, comparative observational study. Place and Duration of Study: Department of Anesthesiology, AVBRH, from June 2020 to May 2021. Methodology: A total of 30 patients fulfilling inclusion criteria scheduled for FESS were randomly allocated into 2 groups of 15 each; GROUP C (Clonidine group, n=15) who received tab clonidine 5 mcg/kg, 90 minutes before surgery and GROUP M (Multivitamin group, n=15) who received multivitamin tablet. Mean ± standard deviation (SD) or absolute values were used to indicate data; comparison of qualitative data were done using Chi-square test and Fisher’s exact test and quantitative variables using the student ‘t’ Test. P value < 0.05 was taken as statistically        significant. Results: Bleeding was considerably less in the group C [1.65 ± 0.4] as compared to group M [2.20 ± 0.6] and is statistically significant [ P value = 0.006]. The mean MAC value (%) of sevoflurane consumption is lesser in the group C [1.25 ±0.25] than the group M [1.30 ±0.20] but not statistically significant (P value = 0.55). The mean dose (microgram) of fentanyl requirement was more in group M [ 120 ±20] than the group C [100 ± 25] and this was statistically significant (P value = 0.02). Conclusion: Oral Clonidine can be used as an excellent premedication and provides cost effective method to attain controlled hypotension as there is lesser requirement of costly inhalational agent and other analgesic drugs. Also, it maintains better hemodynamic stability with fewer side effects.

Goldenhar syndrome or Oculo-auricular Vertebral Dysplasia (OAVD) is characterized by a wide range of congenital anomalies including ocular, auricular, facial, cranial, vertebral and cardiac abnormalities. Facial and oral abnormalities especially mandibular hypoplasia, micrognathia, high arch palate and limitation of neck movements resulting from vertebral anomalies, the difficult intubation, laryngoscopy and mask ventilation were expected. Hereby, presenting the case report of a 6-year-old male child, known to have goldenhar syndrome, who underwent drainage of left sided brain abscess with external ventricular drain insertion. In view of the anticipated difficult airway and cardiac anomalies, careful preoperative evaluation, preparation and well formulated contingency plans for airway maintenance, endotracheal intubation and intraoperative haemodynamic is required to combat the perioperative anaesthetic challenges in all cases of goldenhar syndrome.

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