The aim of this investigation was to evaluate the role of ultrasonography in avoiding cranial misplacement of the tracheostomy tube and tracheal ring fractures during percutaneous dilatational tracheostomy (PDT). The tracheas of 26 consecutive ICU patients who had undergone PDT but who later died were removed en bloc at autopsy. The tracheas were opened along the membranous portion and the condition of tracheal rings and the site of tracheostomy macroscopically evaluated. The patients were divided in two groups: group A with 15 patients who underwent "blind" PDT and group B with 11 patients who underwent ultrasound-guided PDT. In five (33%) patients from group A, autopsy revealed that the tracheostomy tube was placed between the cricoid cartilage and the first tracheal ring (cranial misplacement) and in six (43%) patients a fracture of one tracheal ring was found. Cranial misplacement of the tracheostomy tube in patients from group B was not found (P < 0.05) and four (36%) patients had a broken tracheal ring (P = NS). The authors maintain that by using ultrasound-guided PDT cranial misplacement of the tracheostomy tube may be entirely avoided.

Anatomy of the periorbital region is very complex. Aesthetic problems that occur in that region have to be thoroughly assessed so that the right choice of treatment can be done. Kpodzo et al published a review of current management for malar mounds and festoons. Due to the variable terminology and nonstandardized treatment algorithm, the incidence of malar aesthetic problems is not known. In that article, they suggested the standardized terminology to be as said:Malar edema: fluid that accumulates below the infraorbital rim above the malar eminence, Malar mound: chronic swelling in the same area, Festoons: cascades of lax skin and/or orbicularis muscle over the malar eminence. 1 Newberry et.al. also published a systematic review and have proposed the term "malar bags" that encompasses all previously mentioned malar pathologies. 2 Kikkawa et al first described the upper border of region involved as orbitomalar ligament (it separates the lower eyelid and malar eminence).In its anatomic position orbitomalar ligament is osteocutaneous ligament. 3 Lower border was first described by Furnas as the mid-cheek fold. 4 Pessa and Garza described it as the malar septum and Muzaffar et al and Mendelson et al defined it as the zygomaticocutaneus ligament. [5][6][7] The etiology of this aesthetic problem is still unknown. Furnas hypothesized that gravity with loss of laxity in the orbicularis muscle leads to its sagging and causes skin to stretch. 8 Goldman showed that transient edema in that area can occur after injection of botulinum toxin type A. 9 It led to the conclusion that muscle pump is an important