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   2016| April-June  | Volume 25 | Issue 2  
    Online since February 13, 2020

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Histopathology practice and training in nigeria - A model
D Sabageh, AO Daramola, O Rotimi
April-June 2016, 25(2):197-200
OBJECTIVES: Contemporary histopathology practice and training in Nigeria have been plagued by the fundamental issue of inadequate exposure to surgical pathology material by both trainees and trainers. This paper critically examines the factors that affect the discipline and profers practical solutions to aid its advancement. MATERIALS AND METHOD: This review is based on the authors experience and observations of histopathology practice in Nigeria. RESULTS: The Nigerian health sector is plagued by many ills including poor funding, weak policies, dilapidated structures, disgruntled and frustrated practitioners, amongst others - and pathologists are not immune to all these. In recent times, there has been a proliferation of accredited training centres as well as medical graduates interested in the specialty of histopathology. The busiest histopathology laboratories in the country ascession between 2200 and 5500 surgical samples yearly. Thus there is inadequate exposure by histopathologists and trainee pathologists to surgical materials with the attendant consequences. Many centres still rely principally on routine haematoxylineosinstains. There are no nationally agreed standard reporting formats for most diseases. CONCLUSION: The development of a deanery or regional system of accredited histopathology laboratories may form the fulcrum for improving the overall quality of histopathological services and training in Nigeria. This will help develop local expertise and ensure adequate exposure to teaching aids and surgical materials. We hope that the proffered solutions will help encourage local pathologists to continue and increase their efforts to raise the profession up to enviable heights.
[ABSTRACT]   Full text not available  [PDF]
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Mentorship in orthopaedic and trauma residency training programme in Nigeria: The residents' perspective
OI Akinmokun, AT Akinsulire, TO Odugbemi, KC Odogwu, SO Giwa
April-June 2016, 25(2):134-141
BACKGROUND Mentorship is important in residency training as it is necessary for personal and professional development of the resident trainees OBJECTIVES This study documents mentorship in orthopaedic residency training programme in Nigeria by assessing the awareness of orthopaedic residents on the role of a mentor, willingness to be mentored and their perceived reasons for the possible lack of mentors/ participation of senior colleagues in a mentorship programme METHOD This was a descriptive cross sectional study of 37 orthopaedic residents attending a revision course of the Faculty of Orthopaedics, National Postgraduate Medical College of Nigeria. Self-administered structured questionnaires were used to collect data. Data obtained was analyzed using SPSS version 21.0. RESULTS The mean age of the respondent was 34.7 ± 4.7 years. The Male: Female ratio was 19:1. The average number of years already spent in the residency programme by the respondents was 2.8 ± 0.9 years. Only 27% of residents had participated in a mentorship programme since they began residency programme but only half were still being mentored at the time of the study. Sixty-five percent reported no formal mentorship programme in their institutions. However, 73% of the respondents would want a formal mentorship programme in their institution. Ninety percent of the respondents desired to be mentored. CONCLUSION Most residents are willing to be mentored. Consultants and trainers should ensure that the trainees are mentored.
[ABSTRACT]   Full text not available  [PDF]
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Prevalence of sickle cell gene among apparently healthy under-two South-East Nigerian children: What is the role of parental premarital counselling and socio-demographic characteristics? A pilot study
Okocha Chide, Onubogu Chinyere Ukamaka, Aneke John, Onah Christian, Ajuba Ifeoma, Ibeh Nancy, Egbuonu Ifeoma
April-June 2016, 25(2):176-181
OBJECTIVE: This cross-sectional descriptive study examined the role of parental premarital counselling and socio-demographic characteristics on the prevalence of sickle cell gene among 82 apparently healthy under-two children. METHODS: Subjects were recruited from under-two children attending child welfare clinic at Nnamdi Azikiwe University Teaching Hospital, Nnewi, South-East, Nigeria. RESULTS: More than half of their mothers were aware of their hemoglobin phenotype (64.6%) and that of their husbands (53.6%). In about half of the families (52.4%), the parents had a premarital counselling intervention against sickle cell disease (SCD). Among the 44 families where parents were aware of their phenotype before marriage, only one couple (2.3%) was at risk of having an offspring with SCD. None of the subjects had SCD and the prevalence of sickle cell trait (SCT) among them was 22%. Premarital counselling intervention in families seemed to increase the prevalence of SCT when compared to those not counselled but this was not statistically significant (p = 0.30). The lower prevalence of SCT among children of more educated women suggests that educational status may affect the distribution of the sickle cell gene in the population. CONCLUSION/RECOMMENDATION: Premarital counselling and screening may be effective in reducing the prevalence of SCD but the higher prevalence of SCT among the population where this intervention occurred portends an ominous sign for the future. Integration of malaria eradication and competent genetic counselling, with avoidance of discrimination against people with SCT or SCD, into screening programmes are essential for reducing the burden and impact of SCD.
[ABSTRACT]   Full text not available  [PDF]
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Percutanous vertebroplasty for vertebral compression fracture in geriatric patients; A report of two cases
E Diamond Tamunokuro, Ogbu Valentine, Ekwe Kingsley, Ogedegbe Felix, Salawu Siddiq
April-June 2016, 25(2):189-191
BACKGROUND: Osteoporotic vertebral fractures are common in the geriatric age group. Treatment options are influenced by the severity of symptoms, the presence or otherwise of spinal cord compression, level of spinal compression, degree of vertebral height collapse and the integrity of the posterior spinal elements. AIM: We report vertebroplasty for compression vertebral fractures in two geriatric patients. CASE REPORT 1: A 94 year old widow presented to our accident and emergency unit with seven hour history of severe localized back pain following trauma. No neurologic deficit. Radiologic evaluation showed compression fracture of the twelfth thoracic vertebra with intact posterior elements. She had T12vertebroplasty using an injectable nonresorbable, vertebroplasty cement the day after the injury. Immediate post operative and three months follow-up reviews showed effective pain relief and progressive independent ambulation. CASE REPORT 2: A 73 year old with sudden onset back pain following trauma. She subsequently had percutanous L1 vertebroplasty after evaluation. Post operative pain relief was significant with a VAS score of -4.0 on day one and -8.0 on day seven. CONCLUSION: Percutanous vertebroplasty offers effective, immediate and sustained pain relief in osteoporotic vertebral fractures.
[ABSTRACT]   Full text not available  [PDF]
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Monthly sulphadoxine-pyrimethamine combinatiled study at the jos universon versus daily proguanil for malaria chemoprophylaxis in sickle cell disease: A randomized controlity teaching hospital
JA Dawam, JK A Madaki, AA Gambazai, ES Okpe, N Lar-ndam, A Onu, M Gyang
April-June 2016, 25(2):119-127
BACKGROUND: Malaria carries a high case fatality among patients with sickle cell disease. In Jos University Teaching Hospital, at the time of this study, the use of Proguanil was the acceptable mode of chemoprophylaxis for preventing malaria in these patients. Intermittent Preventive Treatment (IPT) with Sulphadoxine-Pyrimethamine [SP] has shown great potential for reducing the prevalence of malaria and anaemia among pregnant women, infants and travellers. We hypothesised that monthly SP was superior to daily Proguanil in reducing malaria parasitaemia, clinical malaria attacks and sickle cell crises in such patients. OBJECTIVE: To assess the efficacy and affordability of monthly SP versus daily Proguanil for malaria chemoprophylaxis in patients attending Sickle Cell Clinic at Jos University Teaching Hospital, Plateau State, Nigeria. METHODS: One hundred and fifty four patients [114 children and 40 adults] with Sickle Cell Disease in their steady state were randomized to monthly SP or daily Proguanil for malaria chemoprophylaxis. Active detection of malaria parasite in the peripheral blood and packed cell volumes were done at each monthly visit to the clinic over a period of three months. The primary outcome measure was the proportion of patients with malaria parasite in the peripheral blood at the end of 3 months. The secondary outcome measures included episodes of clinical malaria attacks, frequency and type of sickle cell crises and adverse effects of the medication. RESULTS: Ninety four percent [72/77] of patients in the SP group and 91% [70/77] in the Proguanil group respectively completed three months of follow up. SP reduced the prevalence of malaria parasitaemia by 25% [(14%) 10/72] compared to 6.4% [(30%) 21/70] in the proguanil group. [X2 54; p = 0.01]. Seventeen percent [12/72] of the patients receiving monthly SP had malaria attacks compared to 57% [40/70] on prophylaxis with Proguanil. [X2 =25; p< 0.0003]. Thirty three percent [24/72] of the patients receiving SP had at least an episode of bone pain crises 2 compared to 69% [48/70] of the patients receiving Proguanil. [X =17.6; p<0.0001]. SP was 8 times cheaper than Proguanil. CONCLUSION: Monthly chemoprophylaxis with SP was more efficacious than daily Proguanil in reducing the prevalence of asymptomatic malaria parasitaemia, clinical malaria attack and sickle cell crises in patients with sickle cell disease. SP was 8 times cheaper than Proguanil. No significant side effect was recorded in both groups. The current practice of routinely prescribing daily Proguanil to SCD patients for malaria chemoprophylaxis needs to be reviewed.
[ABSTRACT]   Full text not available  [PDF]
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Dentine hypersensitivity: Real or imagined
Shakeerah O Gbadebo, Folake B Lawal, Modupe O Arowojolu
April-June 2016, 25(2):182-188
BACKGROUND: Dentine hypersensitivity is a common presentation of cause of pain and or discomfort with mastication which has been shown to affect the quality of life of the affected individual. It is also a common cause of presentation at the dental clinics. However, the cause, diagnosis and possible management to give relief can be a dilemma for the clinician who at times may wonder if the sensation the individual is presenting with, is real or imagined. AIM: The purpose of this paper was to review dentine hypersensitivity in view of causes, diagnosis and management. METHODOLOGY: Articles used were found by searching the key words: dentine hypersensitivity, tooth wear lesions, desensitization, gingival recession, treatment of hypersensitivity. RESULT: There are a variety of causes of dentine hypersensitivity with a variety of ways to manage and provide adequate treatment, but the condition must be well understood. CONCLUSION: Many options of treatment are now available to eliminate the pain from dentine hypersensitivity and thus improving the quality of life of these patients because the sensitivity they experience is real.
[ABSTRACT]   Full text not available  [PDF]
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Prevalence and determinants of glucose intolerance among HIV/AIDS patients in North-Central Nigeria: Glucose intolerance in HIV/AIDS patients from North-Central Nigeria
S Reng Rifkatu, E Uloko Andrew, H Puepet Fabian, A Onwuegbuzie Gerald, A Ramalan Mansur
April-June 2016, 25(2):128-133
BACKGROUND: The advent of potent antiviral drugs has revolutionalised the clinical course of HIV / AIDS resulting in increased survival and improved quality of life. Metabolic derangements in HIV infected patients are becoming more common probably due to this increased survival from the use of HAART. There is limited data on the occurrence of glucose intolerance among HIV patients in Nigeria. OBJECTIVE: To determine the prevalence of glucose intolerance and associated risk factors in HIV/AIDS patients. METHODS: Consenting adult HIV patients at the HIV clinic of the Jos University Teaching Hospital (JUTH), Jos , Nigeria were evaluated were evaluated for the presence of glucose intolerance using a 75g oral glucose tolerance test (OGTT). There clinical characteristics, anthropometry, CD4 cell counts and viral load were determined using appropriate standard techniques. Impaired Fasting Glucose (IFG), Impaired Glucose Tolerance (IGT), and Diabetes Mellitus (DM) were defined based on the American Diabetes Association (ADA) cut-off values. RESULTS: Of the 584 patients studied, 384 (130 males and 251 females) with mean±SD age of 38±15 years were HAARTtreated; while 200 (61 males and 139 females) with mean±SD age of 33±17 years were HAART-naive. Overall, the prevalence of GI was 40.4% (IFG) 19.5%, IGT 11.5% and DM 9.4%. The prevalence of IFG (27.1%) and DM (11.2%) in HAART - treated patients were observed and those in HAART-naive patients were (IFG 5.0%,DM 6.0%), p<0.005. IGT was more prevalent in HAART-naive than in HAART-treated patients (19.5%, and 7.3% respectively), p<0.05. The proportions of patients with GI were higher in overweight and obese HAART-treated patients with moderate CD4 cell count (200-500 ×106 cell/L); while in the HAART-naive patients, GI was more prevalent in underweight 6 subjects with CD4 cell count (<200 × 106 cell/L). The Determinants of GI were age, increasing BMI, low CD4 cell count, metabolic syndrome and HAART treatment duration. The independent predictors of glucose intolerance in HIV / AIDS patients were low CD4 cell count and prolonged HAART treatment duration. CONCLUSION: The prevalence of GI among HIV/AIDS patients in North-Central Nigeria is high. Treatment with HAART and low CD4 cell count are strong determinants of glucose intolerance in our HIV / AIDS patients. Regular screening for glucose intolerance among our HIV / AIDS patients is recommended.
[ABSTRACT]   Full text not available  [PDF]
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Clinical practitioners' knowledge of ionizing radiation doses in diagnostic radiology examinations in calabar
NO Egbe, DU Eduwem, OE Ukweh, CH Odumegwu
April-June 2016, 25(2):147-151
BACKGROUND: Observation has shown a preponderance of irrelevant, unjustified and perhaps unnecessary radiological requests in the study area. The consequences of this on the patients' doses and population collective dose may be dire. OBJECTIVE: To assess Clinicians/Referrers' knowledge of radiation doses of patients undergoing radiological examinations. METHODOLOGY: A prospective, non-experimental, cross-sectional survey of clinicians (except radiologists) in various hospitals in Calabar metropolis, Cross River State, Nigeria, was conducted. A pretested and validated questionnaire was designed to extract responses on rating of effective doses for commonly requested imaging examinations, using the value for the posterior-anterior (PA) chest x-ray as reference. Questions on radiosensitivity of different organs, imaging modalities that use ionizing radiation and considerations for the choice of ionizing radiation (IR) based examinations were included. Participants were also asked for their preferred methods of filling any knowledge gap on IR issues. Responses were presented in simple percentages. RESULTS: A total of 104 respondents, made up of 63.5% males and 36.5% females participated in the study. At least 70% and 42% of the respondents, respectively, were aware that Ultrasound and Magnetic Resonance Imaging were not IR based modalities. About 67.3% of the respondents did not know the doses of commonly requested radiological examinations. This result was not dependent on clinicians' demography. A total of 61.5% of the respondents referred patients for IR examinations even when the result was unlikely to alter their diagnosis or treatment; but to reassure the patient (98.8% ), meet expectations of patients (35%) or to give the patient the feeling of being taken seriously (75%). CONCLUSION: Participating Clinicians in this study have showed poor knowledge of radiation doses of commonly requested radiological examinations. Most participants suggested improvement of their knowledge of radiation doses through continuous medical education and by the provision of referral guidelines.
[ABSTRACT]   Full text not available  [PDF]
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An evaluation of intra-operative and post-operative blood loss in total knee arthroplasty at the national orthopaedic hospital, Lagos
ME Ugbeye, WO Lawal, OJ Ayodabo, IP Adadevoh, IJ Akpan, U Nwose
April-June 2016, 25(2):159-163
BACKGROUND: Total knee replacement is a rewarding and reliable procedure, producing a lasting relief to severe knee pains. However, significant blood loss usually in the post-operative period may be a challenge, necessitating prompt restoration of circulating blood volume to minimize morbidity and mortality. The aim of this study was to evaluate blood loss after total knee replacement PATIENTS AND METHODS: A prospective study of blood loss after Total Knee Arthroplasty in 53 patients in the National Orthopaedic Hospital, Lagos. Consecutive patients with established indications, presenting for total knee arthroplasty were recruited into the study after obtaining their consent. RESULTS: The mean intra-operative blood loss was 342.4 mls, with a range of 50 - 1500 mls. The mean post-operative blood loss and total blood loss were 603.6 mls and 940.3 mls respectively, showing a strong positive correlation (r = 0.884, p < 0.01). The average pre-operative and post-operative haemoglobin concentration were 12.5 ± 1.2 g/dl and 9.8 ± 0.9 g/dl, respectively. The mean haemoglobin loss was 2.6 ± 1.2 g/dl (r = 0.46, p < 0.001). CONCLUSION: Post-operative blood loss as measured by suction drainage, is a good predictor of total blood loss, showing a strong and positive correlation.
[ABSTRACT]   Full text not available  [PDF]
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FEV1, FVC, FEV1/FVVC As predictors of rhinitis among saw mill workers in North Central Nigeria
Jacob Amos Dunga, Nura Hamidu Alkali, Yakubu Mamman Adamu, Sule Bathna, Yerima Suleiman, Christian Ukoli, Jafiada Jacob Musa
April-June 2016, 25(2):152-158
BACKGROUND: Rhinitis is one of the commonest occupational related respiratory disorders that is only restricted to the upper airway but can involve the lower respiratory tract with considerable airflow limitation, this study was conducted assess the ventilator function of persons exposed to saw dust with rhinitis symptoms METHODS: This is a cross sectional study carried out among 200 randomly selected saw mill workers and 200 healthy staff of Jos University Teaching Hospital staff in Jos metropolis from September to November 2008. Data on sociodemographic variables, symptoms of rhinitis, etc was obtained using a modified semi structured British medical research council questionnaire while respiratory function data was measured using aspirometry RESULT: A total of 400 responds comprising of 200 saw mill workers and 200 controls participated in this study. Based on diagnostic criteria. 43% of the subjects fit into diagnosis of rhinitis, 33% had asthma symptoms and 24 % did not fit into any category compared to none of < 5%of the control group. The ventilatory function based on FEV1, FVC, FEV1/FVC ratio and PEFR showed a significant decline when matched with controls and predicted value, suggesting an airflow limitation among the rhinitis group. CONCLUSION: Rhinitis associated with wood dust exposure is not restricted to airway but involves the entire respiratory tract with airflow limitation as one of its consequences.
[ABSTRACT]   Full text not available  [PDF]
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Intervertebral disc herniation: Prevalence and association with clinical diagnosis
OD Ray-offor, CM Wachukwu, CC B Onubiyi
April-June 2016, 25(2):107-112
BACKGROUND Low back pain is one of the common health problems encountered in life with intervertebral disc herniation being a common cause of its occurrence. Magnetic resonance imaging has emerged the gold standard for diagnosing a herniated disc. AIMS AND OBJECTIVES To assess the frequency and pattern of occurrence of disc herniation as well as evaluate the association of disc herniation on magnetic resonance imaging with clinical symptoms. METHOD A total of 120 adult patients who came for magnetic resonance imaging scan of the lumbosacral spine for a period of 1year in the department of Radiology University of Port-Harcourt Teaching Hospital. The end plates of 600 lumbar interspaces were graded for type, size and site of lumbar disc herniation. RESULTS: The age distribution of patients was from 18-80 years; mean age was 51.0
[ABSTRACT]   Full text not available  [PDF]
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Effect of education and training on patient referral by public primary health care workers in mushin local government area to state general hospitals
Adetunji Labiran, Bayo Onajole, Oladimeji Adebayo, Ifeanyichukwu Obi, Paul West Okojie, R Okupon, Emmanuel Olukoya, Leslie Omoruyi
April-June 2016, 25(2):164-175
BACKGROUND: Poor referral linkages had been noted and documented by various researchers on the health care delivery system in Nigeria. This study is designed to find out the situation of referral practices and make recommendations on how to improve the situation. MATERIALS & METHODS: A quasi-experimental study was carried out to determine the effect of health education and training on the Knowledge, attitude and practices of patient referral by primary health care workers in Mushin and Surulere Local Government Areas of Lagos State of Nigeria. A total sample of 170 primary health care workers was involved in the study: 85 in each of the Local Government Areas. The study involved three stages, the pre-intervention, the intervention phase, and a post intervention phase of the study. RESULTS: Analysis of the responses of the two groups showed that there was no statistically significant difference in the responses in the areas concerning their attitude towards, and knowledge of patient referral at the pre-intervention phase. In the post-intervention phase the differences in the responses between the two groups in the area of practice of patient referral were statistically significant. In the control group 18.8% of the workers used the two-way referral form in the pre-intervention phase. This rose to 27.1% in the post intervention phase. In the experimental group, 17.5% used the two-way referral form in the pre-intervention phase, and this rose to 69.4% in the post intervention phase. CONCLUSION: The conclusion was that education and training on patient referral could improve the patient referral activities of primary health care workers.
[ABSTRACT]   Full text not available  [PDF]
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Malaria parasitaemia among febrile under-five children at nnamdi azikiwe university teaching hospital, nnewi, South-East, Nigeria
CE Ezeudu, JC Ebenebe, JO Chukwuka, EF Ugochukwu, GI Amilo, OI Okorie
April-June 2016, 25(2):113-118
BACKGROUND: Malaria is an infectious disease caused by Plasmodium and transmitted by the bite of an infected female Anopheles mosquito. It continues to be a global challenge with about half of the world's population being at risk of the disease and under–5 children being the most vulnerable. AIMS AND OBJECTIVES: To determine the prevalence of malaria parasitaemia and some associated symptoms among febrile under-five children presenting at Nnamdi Azikiwe University Teaching Hospital Nnewi, Nigeria. MATERIALS AND METHOD: A total of 200 children under the age of five years were recruited for the study. Data on socio-demographic characteristics and symptoms were collected through interviewer administered questionnaire. They were physically examine and blood sample was collected from each of them. The Blood smear was Giemsa stained and examined microscopically for malaria parasite. RESULT: There were 118 males and 82 females, giving a male: female ratio of 1.44:1. Their ages ranged from 3-59 months and the average age was 27±17.49 months. Those in the age range of 12-23 months and 24-35 months constitute the highest number (23%) each. Forty-seven (23.5%) came from the rural area while 153(76.5%) came from the urban area. Average number of days the subjects had fever before presentation were 3.78±1.95 days with a range of 1-30 0 days. Body temperature ranged from 35.9-40.4°C with average of 37.7±0.8°C. Forty (20%) were positive to microscopy. Those in the age range of 47-59 months have the highest prevalence of malaria. Parasite density ranged from 40-136,000/μL with a mean of 18,687.2±3360/μL. All the children who are positive by microcopy had Plasmodium falciparium as the specie causing malaria. CONCLUSION: Malaria parasitaemia among these under-5 children is 20%.
[ABSTRACT]   Full text not available  [PDF]
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Anomalous renal artery is potential cause of resistant hypertension in a 53 year old patient: Case report
AA Busari, BT Bello
April-June 2016, 25(2):192-196
BACKGROUND: Drug-resistant hypertension can be attributable to secondary hypertension and other causes. Anomalous renal artery is uncommon but can be a potential cause of resistant hypertension. CASE REPORT: We highlight the challenges in management of resistant hypertension and describe its unusual association with renal artery anomaly in 53 years old man who was referred to our nephrology clinic from a peripheral general hospital on account of poorly controlled hypertension. At presentation, BP was severely elevated at 208/100mmHg but no remarkable findings in the rest of the examination. Several investigations done including abdominal ultrasound scan and Computerised Tomography (CT) Renal angiogram revealed a Left anomalous renal artery. Patient declined all suggested urologic interventions and he was then managed conservatively. CONCLUSION: We found that anomalous renal arteries can be a potential cause of resistant hypertension. We therefore recommend ultrasound scan of the abdomen as a screening modality due to its being non-invasive.
[ABSTRACT]   Full text not available  [PDF]
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Complications following nasotracheal intubation using cuffed polyvinyl chloride tube: A prospective cross sectional study
Fidelis A Onyekwulu, Jones N Nwosu, Chibuzo C Uguru
April-June 2016, 25(2):142-146
BACKGROUND To examine the complications following nasotracheal intubation by documenting the nasal traumas observed with the use of untreated cuffed polyvinyl chloride tube in unprepared nostrils. METHODS Patients who had maxillofacial surgeries under general anesthesia, muscle relaxation and nasotracheal intubation were included in the study. Nasotracheal intubation was carried out after induction of anesthesia was effected with intravenous propofol and suxamethonium by an Anesthetist using well lubricated cuffed polyvinyl chloride tube. Sizes 6.0, 6.5 and 7.0mm were inserted in females while sizes 7.0 and 7.5mm were inserted in males. Occasionally, the natural curve of the tube guides it through the cords without the aid of Magill forceps. Anterior rhinoscopy was performed by otolaryngologist 24 hours after surgery. Results were subjected to statistical analysis. RESULTS Sixty four patients were included in the study. They were between the ages of 21 and 63 years (mean 33.2 ± 14.1 years); they were 39 males and 25 females. The most frequently used nasotracheal tube (NT) was size 7.0mm internal diameter. Epistaxis was noticed in 52 (81.2%) patients. There were no statistically significant differences in the incidence of epistaxis observed in males and females, and also between right and left nostrils. A total of 46.8% of nasal trauma were inferior turbinate trauma involving the inferior medial aspect. CONCLUSION The use of untreated cuffed polyvinyl chloride tube for nasotracheal intubation in unprepared nostrils is associated with a high incidence of epistaxis and nasal trauma.
[ABSTRACT]   Full text not available  [PDF]
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