The Role of Ketorolac in the Managementof Patients Who Need Ambulatory Oraland Maxillofacial Surgery Under GeneralAnesthesiaYong-Han Koo, DDS, Hospital of Saint Raphael, 1450Chapel Street, Department of Surgery, Section of Oral &Maxillofacial Surgery, New Haven, CT 06511 (Kelly JP)

Statement of the Problem: Despite a variety of choicesof drugs available for safe and effective maxillofacialprocedures under general anesthesia in the outpatientclinic setting, the most commonly used combination ofdrugs is versed, fentanyl, and propofol. Opioid-respira-tory depression is the most dangerous potential sideeffect. Intraoperative ketorolac has been shown to havea postoperative narcotic-sparing effect. One of the majoradvantages of ketorolac over fentanyl is that it exhibitsno depressant effects of respiratory function. The pur-pose of this study is to determine whether intraoperativeketorolac is an effective substitute for fentanyl in pa-tients undergoing ambulatory oral and maxillofacial sur-gery under general anesthesia.

Materials and Methods: A prospective randomizeddouble-blind study of forty patients with ASA Status I orII, 18 years and older, undergoing extraction of at leastone impacted third molar under general anesthesia wasconducted between July 2005 and December 2005. Pa-tients were randomly assigned to: group 1 (21 patients)who received versed, fentanyl, and propofol or group 2(19 patients) who received versed, ketorolac, and propo-fol. A syringe containing 1 cc of either fentanyl or ke-torolac was prepared and coded by the nursing staff; forgroup 1 patients, 50 mcg fentanyl was administered assoon as iv access was established, and for group 2 pa-tients, 30 mg iv ketorolac was given. All patients weregiven midazolam. For induction and maintenance of gen-eral anesthesia propofol was used throughout the pro-cedure. The surgeon and anesthetist monitored respira-tory status using a precordial stethoscope, direct visual-ization, vital signs, and oxygen saturation. Postoper-atively, both attending surgeon and resident surgeonmade an overall assessment regarding induction, main-tenance, and recovery phases of general anesthesia. As-sessment can be either successful or unsuccessful withcomments. Using Visual Analog Scales, patients recordedtheir pain level eight hours postoperatively.

Method of Data Analysis: Anesthesia records wereused to assess intraoperative findings: surgical time,amount of propofol and versed, recovery time, and im-mediate postoperative nausea and vomiting. The efficacyof general anesthesia provided was determined by theevaluating surgeons’ assessments. The incidence of intra-operative and postoperative complications was also de-termined.

Results: The single intraoperative complication con-

sisted of one episode of termination of general anesthe-sia due to inadequate result within normal doses ofversed, ketorolac, propofol, and local anesthesia. Allpatients reported their pain score for the first eighthours, episode of nausea and vomiting, and the timeuntil taking the first pain medication. Patients in group 2(ketorolac group) reported less postoperative pain (painscale 5.33 versus 5.71). Group 1 (fentanyl group) re-quired more surgical time (38 minutes versus 31 min-utes), longer recovery time (22 minutes versus 18 min-utes), and more versed (3.14 mg versus 2.97 mg). Ingroup 1 (fentanyl group) two patients could not bedischarged for 50 and 60 minutes and one had a severeepisode of nausea and vomiting in the recovery room. Ingroup 2 (ketorolac group) everyone was dischargedwithin 25 minutes after surgery. The reported overallsatisfaction by the attending surgeons regarding group 1and group 2 was 76% and 78% respectively, whereas theresident surgeons’ was 76% and 72%.

Conclusion: Ketorolac appears to be at least as effec-tive as fentanyl during general anesthesia in ambulatoryoral and maxillofacial surgery, proving not only to be aseffective an analgesic as fentanyl but also leading todecreased recovery time and fewer complications suchas nausea and vomiting and, most importantly, respira-tory depression.

References

Alexander R, et al: Comparison of the morphine sparing effects ofdiclofencac sodium and ketorolac tromethamine after major orthope-dic surgery. J Clinical Anesthesia 14:187, 2002

Perrott DH, et al: Office-based ambulatory anesthesia: Outcomes ofclinical practice of oral and maxillofacial surgeons. J Oral MaxillofacSurg 61:983, 2003

Pain Is Associated With EndophyticCancer Growth Pattern in Patients WithOral Squamous Cell Carcinoma BeforeTreatment: Multivariable AnalysisJun Sato, DDS, PhD, Oral Diagnosis and Medicine,Department of Oral Pathobiological Science, North 13,West 7, Kita-Ward, Hokkaido University GraduateSchool of Dental Medicine, Sapporo, Hokkaido 060-8586, Japan (Yamazaki Y; Notani K; Kitagawa Y)

Statement of the Problem: As the mechanisms of can-cer pain are very complex, many factors might affectpain. Although pain is one of the most important factorsto affect quality of life in patients with oral cancer beforetreatment, only a few studies have been done in thisfield. In order to elucidate significant factors associatedwith pain in patients with oral squamous cell carcinoma(SCC) before treatment, this retrospective study wasperformed.

Materials and Methods: Ninety-two patients with pre-viously untreated oral SCC were included in the present

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study. The patients were 69 men and 22 women, with anaverage age of 63 years (range from 30 to 86 years), andwere examined at the Department of Oral Surgery inHokkaido University Hospital from 2000 to 2005. Theprimary sites of the cancer were tongue 42 cases; lowergingiva 18; buccal mucosa 12; floor of the mouth 9;upper gingiva 8; and palate 2. The study populationconsisted of clinical stage I 15 cases; II 26; III 19; and IV31. Presence or absence of pain, including spontaneouspain and function-related pain, in primary site was as-sessed from medical interview before taking biopsyspecimens. The correlations were evaluated betweenpain and some clinicopathologic factors including sex,age, primary sites, T-stage, N-stage, clinical stage anddegree of histological differentiation (1 to 3; 1 � welldifferentiated, 3 � poorly differentiated), as well as clin-ical growth type (exophytic or endophytic) and histo-logical mode of invasion according to Yamamoto et al(four grades system; 1 � well-defined borderline, 4 �diffuse invasion).

Method of Data Analysis: The statistical analyses wereperformed by using chi-square test and multiple logisticregression model. Stat View J-5.0 (Abacus Concepts,Berkeley, CA) was used for all statistical analyses. Pvalues of less than .05 were considered significant.

Results: At initial examination, 61 patients (67%) hadpain. As for the clinical growth type, 43/50 patients withendophytic pattern (86%) and 17/43 patients with exo-phytic pattern (41%) had pain (chi-square test: P lessthan .005). As for the degree of histological differentia-tion, pain was observed in 18/36 tumors (50%) of grade1 (well-differentiated) and 42/55 tumors (76%) of grade2 plus 3 (poor to moderate-differentiated) (chi-squaretest: P less than .01). In regard to the histological modeof invasion, 30/58 tumors (51%) of grades 1 to 3 (lessinvasive) and 30/33 tumors (91%) of grade 4 (diffuseinvasive) had pain (chi-square test: P less than .01).There were no significant correlations between pain andsex, age, primary sites, T-stage, N-stage, clinical stage. Inmultiple logistic regression analysis, the correlations be-tween pain and histological mode of invasion [P � .015,odds ratio � 2.805, 95% confidence interval � 1.222-6.438] as well as clinical growth type [P � .001, oddsratio � 7.990, 95% confidence interval � 2.238-28.5822]were significant.

Conclusion: This study demonstrated that both clini-cal and histological endophytic growth patterns of oralcancer might be significant risk factors for causing painin patients with oral SCC before treatment.

References

Yamamoto E, Kohama G, Sunakawa H, et al: Mode of invasion,bleomysin sensitivity, and clinical course in squamous cell carcinomaof the oral cavity. Cancer 51:2175, 1983

Connelly ST, Schmidt BL: Evaluation of pain in patients with oralsquamous cell carcinoma. J Pain 5:505, 2004

Gellrich NC, Schramm A, Schmalobr D: Pain, function, and psycho-

logic outcome before, during, and after intraoral tumor resection.J Oral Maxillofac Surg 60:772, 2002

Donor Site Morbidity of Ear CartilageAutograftsRobert A. Mischkowski, MD, DDS, Klinik fur Mund-,Kiefer-und Plastische Gesichtschirurgie, Kerpener Str.62, Klinikum der Universitat zu Koln, Koln, NRW50679, Germany (Domingos-Hadamitzky C; SiesseggerM; Kubler AC; Zoller JE)

Statement of the Problem: The external ear provides aversatile cartilage source for reconstructive procedures,especially for augmentative rhinoplasty. This study eval-uates in a structured approach the short term and longterm morbidity associated with ear cartilage harvest us-ing concha, tragus and scapha as donor sites.

Materials and Methods: The study includes 52 patientsin whom cartilage graft from external ear was harvestedbetween February 2001 and June 2005. In all patientsthe morbidity at the donor side in the early postopera-tive follow-up period was assessed. Twenty-eight pa-tients were examined within a follow-up time between 3and 168 months.

Method of Data Analysis: This long term morbidityassessment included documentation of patients’ subjec-tive complaints, clinical examination of the donor siteand anthropometric measurements.

Results: The relevant morbidity factors in the earlypostoperative period were hematoma formation (6.7%)and sensory impairment (3.3%). In long term follow-up,sensory impairment was the most frequent conditionobjectively assessed and subjectively complained of(12.9%). Overall, sensory impairment was confined toconcha as donor site. Anthropometric measurementsshowed in average a difference in the length of theaffected ear compared to the contralateral ear of 1.8 mm,a width difference of 2.5 mm, a difference in tragus/lateral canthus distance of 1.4 mm, and a difference inprotrusion angle of 2.4°. Esthetically relevant complica-tions such as hypertrophic scar formation or changes ofskin texture and pigmentation were rare and their oc-currence restricted to single cases.

Conclusion: Cartilage graft harvest from auricle can beconsidered as a relatively safe procedure with a favorableesthetic outcome.

References

Ortiz-Monasterio F, Olmedo A, Oscoy LO: The use of cartilage graftsin primary aesthetic rhinoplasty. Plast Reconstr Surg 67:597, 1981

Kotzur A, Gubisch, W: Tragal cartilage grafts in aesthetic rhinoplasty.Aesthetic Plast Surg 27:232, 2003

Mitz V, Maladry D: Interet du prelevement du scapha au cours desrhinoplasties secondaires. Ann Chir Plast Esthet 41:68, 1996

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