Anterior Larynx Research Articles

Parotid Lipomas: Case Series and Literature Review – A Case Report

Background: Lipomas are the most frequent neoplasm of mesenchymal origin in the head-and-neck region. Around 15% of lipomas are found in the head-and-neck region. The usual site where lipomas can be found in the head-and-neck region is in the posterior triangle of the neck but they can also be found in the anterior neck, infratemporal fossa, submandibular space, larynx, pharynx, and parotid gland. The incidence of parotid lipoma ranges from 0.6% to 4.4% of all parotid neoplasms. There are two histological variants, focal lipoma and diffuse infiltrating variant. We describe two cases of rare focal lipoma of the parotid gland, therefore, must be reported. As rare as it may appear, existing relevant literature suggest management to includes definitive radiological investigations such as magnetic resonance imaging (MRI) and complete removal of lipoma with or without a cuff of parotid tissue. Case Report: Two cases were identified with a parotid lipoma on final histology. Case 1 is a 57-year-old male with a history of painless left parotid swelling for 2 years, reported to be 5 cm × 4 cm size on ultrasound, therefore, underwent superficial parotidectomy. Case 2 is a 67-year-old male who presented with right parotid swelling for 15 years, reported on ultrasound to be 5 cm × 5 cm, and underwent excision of intraparotid tumor. He later went on to develop breast carcinoma. The facial nerve was intact of both patients. Conclusion: Parotid lipomas are rare entities that should be a differential for clinically soft parotid swellings. Management includes definitive radiological investigations such as MRI and complete removal of lipoma with or without a cuff of parotid tissue instead of regular ultrasound followed by fine-needle aspiration cytology. Although our cases were managed on the same regular outlines, but reporting these cases would suffice the potential role of MRI and computed tomography scan for parotid swelling as per existing literature.

Blockbuster Laryngeal Mask Airway as a Rescue Device in Paediatric Patient with Retrognathia Posted for Microtia Reconstruction Surgery: A Case Report

The first and second branchial arches, along with the first branchial cleft, contribute to the development of ear and mandible. Children with microtia can have retrognathia or micrognathia and have challenging airway management. Managing the airway in these patients presents a significant challenge for anaesthesiologists as they have the potential for upper airway obstruction and challenging tracheal intubation because of facial deformities. Although awake fiberoptic intubation is a well-accepted method for handling difficult intubations, it can be uncomfortable and stressful for paediatric patients. Moreover, it demands expertise and is unsuitable for patients unwilling to undergo awake intubation. This case report highlights the use of the blockbuster Laryngeal Mask Airway (LMA) in an 11-year-old retrognathic child with microtia with anterior larynx scheduled for auricular reconstruction surgery. There was a failure to secure the airway with multiple attempts at traditional intubation and the supraglottic airway device i-gel, as the child had an anterior larynx and Cormack Lehane (CL) grading of 4 on direct laryngoscopy. The blockbuster LMA, distinguished by its innovative design facilitating both ventilation and intubation through an integrated channel, emerged as a pivotal alternative. The supraglottic device is not the technique of choice, but it can definitely be an alternative and could be life-saving in situations where fiberoptic bronchoscopy and tracheostomy are not available.

Can the curved blade be used as a straight blade for an unanticipated anterior larynx during laryngoscopy?

Can the curved blade be used as a straight blade for an unanticipated anterior larynx during laryngoscopy?

Retrospective Investigation of Difficult Airway Cases Encountered in Bursa Uludag˘ University Medical Faculty Operating Room.

Ensuring airway patency and proper management of ventilation by anticipating difficulties that can occur in airway control are vital in preventing anaesthesia-related complications. We aimed to determine the role of preoperative assessment findings in difficult airway management. In this study, critical incident records of difficult airway patients between 2010 and 2020 in the operating room of Bursa Uludag˘ University Medical Faculty were retrospectively analysed. A total of 613 patients, whose records were fully accessible, were grouped as paediatric (under 18 years old) and adult (18 years and over). The success rate for maintaining an airway in all patients was 98.7%. Pathological situations which cause difficult airways were head and neck region malignancies in adult patients and congenital syndromes in paediatric patients. Anatomical reasons that cause difficult airway were anterior larynx (31.1%) and short muscular neck (29.7%) in adult patients and small chin (38.0%) in paediatric patients. A significant statistical relationship was found between difficult mask ventilation and increased body mass index, male gender, modified Mallampati class 3-4, and thyromental distance <6 cm (P = .001, P < .001, P < .001, and P < .001, respectively). The correlation of Cormack-Lehane grading with modified Mallampati classification, upper lip bite test, and mouth opening distance was statistically significant (P < .001, P < .001, and P < .001, respectively). In male patients with increased body mass index, modified Mallampati test class of 3-4 and thyromental distance of < 6 cm should suggest the possibility of difficult mask ventilation. In modified Mallampati classification and upper lip bite tests, the possibility of difficult laryngoscopy should be considered as class increases and mouth opening distance becomes shorter. Preoperative assessment, including a good history taken from the patient and a complete physical examination, is crucial to provide solutions for difficult airway management.

Hedgehog regulation of epithelial cell state and morphogenesis in the larynx.

The larynx enables speech while regulating swallowing and respiration. Larynx function hinges on the laryngeal epithelium which originates as part of the anterior foregut and undergoes extensive remodeling to separate from the esophagus and form vocal folds that interface with the adjacent trachea. Here we find that sonic hedgehog (SHH) is essential for epithelial integrity in the mouse larynx as well as the anterior foregut. During larynx-esophageal separation, low Shh expression marks specific domains of actively remodeling epithelium that undergo an epithelial-to-mesenchymal transition (EMT) characterized by the induction of N-Cadherin and movement of cells out of the epithelial layer. Consistent with a role for SHH signaling in regulating this process, Shh mutants undergo an abnormal EMT throughout the anterior foregut and larynx, marked by a cadherin switch, movement out of the epithelial layer and cell death. Unexpectedly, Shh mutant epithelial cells are replaced by a new population of FOXA2-negative cells that likely derive from adjacent pouch tissues and form a rudimentary epithelium. These findings have important implications for interpreting the etiology of HH-dependent birth defects within the foregut. We propose that SHH signaling has a default role in maintaining epithelial identity throughout the anterior foregut and that regionalized reductions in SHH trigger epithelial remodeling.

Paediatric anterior larynx: presentations, associations and a review of the literature.

The literature on the entity of the anterior larynx (AL) is restricted to little evidence on the difficulty encountered in exposing the larynx for intubation, perioperative morbidity and mortality, and scant reports on its prevalence in general adults and children. Here, we describe the prevalence of AL in a series of children presenting with aerodigestive symptoms and explore its association with functional abnormalities, congenital and structural anomalies or conditions. Tertiary paediatric centre. We conducted a retrospective case-control study. Using a prospectively collected surgical database, we identified patients diagnosed with AL (Grades IIb-III-IV Modified Cormack-Lehane scale) and sex and age-matched controls who had undergone full airway endoscopy for aerodigestive symptoms. We collected the demographics, presentations, associated diagnoses and investigations. We compared the proportion of patients with large airway abnormalities and dysmorphism and estimated the prevalence of AL. Over a 5.5-year period, 58 children with AL (28 females, mean age 0.38years) were matched with 58 controls (mean age 0.42years). Although both groups presented with permutations of stridor, respiratory failure, cyanotic spells, swallowing and feeding difficulties and SDB, AL presented much more with swallowing and feeding problems (33 vs. 20, p<.05). There were significantly more children with dysmorphism in the AL group (29 vs. 9, p<.05). The prevalence of AL was 4.9% (SE 0.0063). AL was detected in 4.9% of a sample of children who had undergone airway examination for aerodigestive symptoms. It is significantly associated with dysmorphism, and swallowing difficulties that warrant instrumental evaluation.

Hyo-Mental Angle and Distance: An Important Adjunct in Airway Assessment of Adult Mucopolysaccharidosis.

Background: Mucopolysaccharidosis (MPS) is a rare congenital lysosomal storage disorder with complex airways. High anterior larynx is assessed by thyromental distance (TMD) nasendoscopy. A simpler method to assess this hyoid bone is described. The distance between the central-hyoid and symphysis of the mandible (hyo-mental distance; HMD) and inclination of this line to the horizontal axis (hyo-mental angle; HMA) in neutrally positioned patients is investigated. Methods: HMA, HMD in MPS, and non-MPS were compared, and their correlation with height and weight were assessed. Results: 50 adult MPS patients (M = 32, F = 18, age range = 19–66 years; mean BMI = 26.8 kg/m2) of MPS I, II, III, IV, and VI were compared with 50 non-MPS (M = 25, F = 25; age range = 22–84 years; mean BMI = 26.5 kg/m2). Mean HMA in MPS was 25.72° (−10 to +50) versus 2.42° (−35 to +28) in non-MPS. Mean HMD was 46.5 (25.7–66) millimeters in MPS versus 41.8 (27–60.3) in non-MPS. HMA versus height and weight showed a moderate correlation (r = −0.4, p < 0.05) in MPS and no significant correlation (r < 0.4, p > 0.05) in non-MPS. HMD versus height and weight showed no correlation (r < 0.4, p > 0.05) in both groups. Conclusions: HMA seems more acute in MPS despite nearly the same HMD as non-MPS, signifying a high larynx, which may be missed by TMD.

New Approach Methodology for Assessing Inhalation Risks of a Contact Respiratory Cytotoxicant: Computational Fluid Dynamics-Based Aerosol Dosimetry Modeling for Cross-Species and In Vitro Comparisons.

Regulatory agencies are considering alternative approaches to assessing inhalation toxicity that utilizes in vitro studies with human cells and in silico modeling in lieu of additional animal studies. In support of this goal, computational fluid-particle dynamics models were developed to estimate site-specific deposition of inhaled aerosols containing the fungicide, chlorothalonil, in the rat and human for comparisons to prior rat inhalation studies and new human in vitro studies. Under bioassay conditions, the deposition was predicted to be greatest at the front of the rat nose followed by the anterior transitional epithelium and larynx corresponding to regions most sensitive to local contact irritation and cytotoxicity. For humans, simulations of aerosol deposition covering potential occupational or residential exposures (1–50 µm diameter) were conducted using nasal and oral breathing. Aerosols in the 1–5 µm range readily penetrated the deep region of the human lung following both oral and nasal breathing. Under actual use conditions (aerosol formulations >10 µm), the majority of deposited doses were in the upper conducting airways. Beyond the nose or mouth, the greatest deposition in the pharynx, larynx, trachea, and bronchi was predicted for aerosols in the 10–20 µm size range. Only small amounts of aerosols >20 µm penetrated past the pharyngeal region. Using the ICRP clearance model, local retained tissue dose metrics including maximal concentrations and areas under the curve were calculated for each airway region following repeated occupational exposures. These results are directly comparable with benchmark doses from in vitro toxicity studies in human cells leading to estimated human equivalent concentrations that reduce the reliance on animals for risk assessments.

Application of High-Frequency Transcutaneous Electrical Nerve Stimulation in Muscle Tension Dysphonia Patients With the Pain Complaint: The Immediate Effect

The aim of the present study was to investigate the immediate effect of the application of high-frequency Transcutaneous electrical nerve stimulation (TENS) in muscle tension dysphonia (MTD) patients with the pain complaint. Thirty patients with MTD, 10 men and 20 women with a mean age of 36.40 ± 5.76 years, participated in the study. The patients were randomized into two groups: (1) Treatment group (TENS) (10 women and 5 men) and (2) Sham TENS group (10 women and 5 men). The treatment group (TENS) received a unique 20-minute session of high-frequency TENS. The sham TENS group was treated in the same condition as the treatment group and received a unique 20-minute session of high-frequency TENS, but no stimulation was given. Auditory-perceptual assessments, acoustic voice analysis, vocal tract discomfort (VTD), and musculoskeletal pain were used to compare the patients pre- and post-treatment. There was a significant improvement in the asthenia parameter of auditory-perceptual assessment in the TENS group. This improvement in asthenia was significant when comparing the TENS group with the sham TENS group. These differences in the asthenia were not significant after using Holm-Bonferroni correction. A comparison of the VTD before and after the TENS application showed there was a significant reduction in the severity of the symptoms (burning, tight, dry, pain, tickling, sore, irritable, and lump in the throat). When comparing the TENS group with the sham TENS group, improvements in burn, tight, dry, pain, and irritable items of VTD were observed. However, after applying the Holm-Bonferroni correction, only reductions in dry and pain items remain significantly different between the groups. After the TENS application, the pain intensity was significantly reduced in the anterior and posterior neck, larynx, submandibular, masseter, temporal region, and upper back. After applying the Holm-Bonferroni correction, pain intensity reduction was significant in the anterior neck and larynx. When comparing the TENS group with the sham TENS group, pain intensity was reduced significantly in the larynx of the TENS group. This difference between the two groups was not significant after using Holm-Bonferroni correction. The pain and VTD assessments in the present study were performed using valid and reliable self-reported scales (NMSQ-E and VTD). High-frequency TENS can be used in the voice treatment program of patients with MTD. MTD patients with pain complaint reported that their vocal tract discomfort and pain were decreased following the high-frequency TENS. Notably, these positive effects were obtained after a single session of high-frequency TENS application.

Difficult airway intubation simulation using Bonfils fiberscope and rigid fiberscope for surgical training

IntroductionPediatric otolaryngologists are frequently called to assist in difficult airway management in newborns with Pierre Robin Sequence (PRS) who have microretrognathia, glossoptosis, and an anterior larynx. The Bonfils fiberscope (BF) is a curved rigid scope designed to provide superior visualization in the anterior larynx. Objective(1) to assess whether BF provides an improvement in intubation success rate, time to intubation, or airway visualization as compared to rigid fiberscope (RF) in a difficult airway simulation setting and (2) to determine whether a training program for BF can improve time to intubation through practice trials. MethodsSix right-handed trainees completed five trials on each of the three following airway models using the BF and RF: normal anatomy, anterior larynx and PRS. The normal larynx model was intubated only with RF. Main outcome measures were the time needed for tracheal intubation and Cormack–Lehane classification (1–4). ResultsThe majority of the intubation trials showed a statistically significant difference between first and last completion times (p < .05) suggesting construct validity. Only the anterior larynx trials with BF did not demonstrate an improvement in time to intubation between first and last attempts (p < .3125). For the PRS retrognathia model, there was no statistically significant difference in time to intubation between using the BF and the RF (p < .44); in the anterior larynx model, the RF yielded a faster time to intubation than the BF on the final trial attempts (p < .0313). By Cormack–Lehane classification measures, laryngeal visualization by the BF was better than RF in the PRS manikin (p < .0022) while there was no significant difference in grade scores for the anterior larynx manikin (p < .45). All six trainees reported an improved visualization of the larynx with the BF compared to the RF for both the anterior larynx and PRS manikins; at the end of the trial runs, all participants noted an improvement in comfort level using the BF. ConclusionThe difficult airway simulation model is feasible for surgical training. BF adds superior visualization of the anterior larynx in PRS. Otolaryngology training programs may include BF as a supplemental tool in addition to RF as a part of the airway equipment training since there is significant improvement in time to intubation with consecutive practice trials and superior laryngeal visualization.

Sternoclavicular joint osteophytosis: a difficult diagnosis to swallow

Unexplained dysphagia requires prompt investigation to rule out a possible underlying malignancy. We describe the case of a 60-year-old man who presented to his family practitioner with a 1-year history...

Deformable image registration and interobserver variation in contour propagation for radiation therapy planning.

Deformable image registration (DIR) and interobserver variation inevitably introduce uncertainty into the treatment planning process. The purpose of the current work was to measure deformable image registration (DIR) errors and interobserver variability for regions of interest (ROIs) in the head and neck and pelvic regions. Measured uncertainties were combined to examine planning margin adequacy for contours propagated for adaptive therapy and to assess the trade‐off of DIR and interobserver uncertainty in atlas‐based automatic segmentation. Two experienced dosimetrists retrospectively contoured brainstem, spinal cord, anterior oral cavity, larynx, right and left parotids, optic nerves, and eyes on the planning CT (CT1) and attenuation‐correction CT of diagnostic PET/CT (CT2) for 30 patients who received radiation therapy for head and neck cancer. Two senior radiation oncology residents retrospectively contoured prostate, bladder, and rectum on the postseed‐implant CT (CT1) and planning CT (CT2) for 20 patients who received radiation therapy for prostate cancer. Interobserver variation was measured by calculating mean Hausdorff distances between the two observers' contours. CT2 was deformably registered to CT1 via commercially available multipass B‐spline DIR. CT2 contours were propagated and compared with CT1 contours via mean Hausdorff distances. These values were summed in quadrature with interobserver variation for margin analysis and compared with interobserver variation for statistical significance using two‐tailed t‐tests for independent samples (α=0.05). Combined uncertainty ranged from 1.5‐5.8 mm for head and neck structures and 3.1‐3.7 mm for pelvic structures. Conventional 5 mm margins may not be adequate to cover this additional uncertainty. DIR uncertainty was significantly less than interobserver variation for four head and neck and one pelvic ROI. DIR uncertainty was not significantly different than interobserver variation for four head and neck and one pelvic ROI. DIR uncertainty was significantly greater than interobserver variation for two head and neck and one pelvic ROI. The introduction of DIR errors may offset any reduction in interobserver variation by using atlas‐based automatic segmentation.PACS number(s): 87.57.nj, 87.55.D‐

Dandy Walker syndrome with giant occipital meningocele with craniovertebral anomalies: Challenges faced during anaesthesia.

Sir, The coexistence of rare congenital neurodevelopmental and craniofacial abnormalities make proper positioning for endotracheal intubation difficult and alternative methods of positioning and intubation must be sought for. Although difficult airway cart should be in hand, one must give emphasis on proper positioning of patient. A sound knowledge and proper laryngoscopy by experienced anaesthesiologist results in successful intubation even in cases of anticipated difficult airway and thus, prevents the need of surgical airway. We report a rare case of an 8-month-old child weighing 5 kg with Dandy–Walker syndrome (DWS) associated with a giant occipito-cervical meningocele and craniovertebral anomalies, and posted for shunt surgery. Pre-anaesthetic check-up suggested no history of seizure, vomiting, difficulty in feeding, cyanosis or respiratory distress. There were no cardiac or respiratory signs. Power in all limbs was equal. The child had a large head and a giant occipital cervical meningocele measuring 10 cm × 10 cm, extending from occipital protuberance to mid scapula, causing fixed flexion of the neck [Figure 1]. Magnetic resonance imaging (MRI) of the brain showed enlarged posterior fossa with multiple craniovertebral anomalies with meningocele in occipital and upper cervical region communicating with fourth ventricle, hypoplasia of inferior vermis coupled with hypoplasia of cerebellar hemisphere, suggestive of DWS with occipital meningocele. MRI spine [Figure 2] showed multiple craniovertebral anomalies such as cranial bifida and spina bifida in upper cervical vertebrae coupled with occipito-cervical meningocoele. Figure 1 Extension of occipita cervical swelling along with large head Figure 2 Magnetic resonance imaging spine showing huge occipita cervical meningocele On arrival of the child in the operation theatre, monitoring was established with an electrocardiogram pulse oximeter non-invasive blood pressure (BP) and temperature probe. Baseline parameters included BP of 94/70 mmHg pulse rate of 118/min and oxygen saturation of 100%. Injection glycopyrrolate 0.02 mg intravenous (IV) and injection fentanyl 5 μg was given in the cannula in situ. As there was a large and firm swelling at occipito-cervical region along with flexed neck with no neck movement, supine positioning could not be done in our case. The patient was positioned in the left lateral position with head beyond the edge of the table with an assistant stabilising the head of the baby from below and other supporting the body. After pre-oxygenation with 100% oxygen, injection thiopentone IV was administered in titrated manner, and a total of 20 mg was injected. Check laryngoscopy in lateral position was done with Miller's straight blade one by the senior anaesthesiologist. Laryngoscopy revealed Cormack–Lehane laryngeal view Grade 2. Injection succinylcholine, 10 mg IV was administered and eventually trachea was intubated with no. 3.5 mm uncuffed endotracheal tube. After confirmation of bilateral equal air entry, the endotracheal tube was fixed. Injection atracurium 2.5 mg was given, and anaesthesia was maintained with nitrous oxide-oxygen and sevoflurane (1%). Paracetamol 80 mg suppository was placed for post-operative analgesia. Once the tube was properly fixed, the patient was positioned supine by placing large ring under the head and large cotton roll under shoulder for proper surgical field view. All the pressure points were adequately padded. Intraoperative course was uneventful. After completion of surgery, neuromuscular blockade was reversed with injection neostigmine 0.4 mg and injection glycopyrrolate 0.008 mg. Extubation was performed once the patient became awake. After satisfactory recovery, the patient was shifted to paediatric Intensive Care Unit. DWS although a rare clinical entity with incidence being about 1 in 25000-30000 live births with a slight female predominance.[1,2] It is often associated with other congenital anomalies such as cleft lip, cleft palate, hypertelorism and micrognathia making airway management challenging.[3] Ewart and Oh reported a case of 2 weeks old DWS patient with micrognathia and anterior larynx in whom they found difficulty in awake intubation.[4] Our child was positioned laterally during induction and intubation. An alternative technique such was suggested by Mowafi et al.[5] in which child was placed supine in silicon platform so that height of silicon platform equals the size of the sac. We did not go for this technique as the occipital swelling was extending until mid-scapula, making positioning more difficult. Other major concern in patients of DWS is avoidance of further rise in intracranial pressure (ICP). Endotracheal intubation should be as gentle as possible. Inhalational agent causes a dose-dependent rise in intracranial pressure and so better avoided. However, it has been shown that isoflurane and sevoflurane in <1 MAC concentration do not cause a significant rise in ICP.[6] In conclusion, patients with DWS with other associated anomalies can be successfully managed by a thorough evaluation of airway, emphasis on proper positioning during laryngoscopy, preparation for difficult intubation, avoidance of rise in ICP during anaesthesia and proper post-operative care. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

A Comparison of the GlideScope Video Laryngoscope and Standard Direct Laryngoscopy in Children With Immobilized Cervical Spine

Airway management in children with cervical spine may make direct laryngoscopy difficult. Video laryngoscopy is an alternative to direct laryngoscopy. The GlideScope video laryngoscope, successfully used in expected and unexpected difficult pediatric airway situations, has not been studied so far in children with cervical spine immobilization. A total of 23 children underwent laryngoscopy with manual cervical spine immobilization using the GlideScope and a direct laryngoscope (Miller 1 or Macintosh 2 blade). Percentage of glottis opening score, Cormack-Lehane score, and time to best view were recorded. Percentage of glottis opening score using the GlideScope was 50% (1%-87%) and 90% (60%-100%) using direct laryngoscopy (P < 0.001). Cormack-Lehane score using the GlideScope was 1 (1-2.7) and 1 (1-1) in direct laryngoscopy (P < 0.001). Time to best view with the GlideScope was 21 seconds (12.2-28 seconds) and 7 seconds (6-8.7 seconds) in direct laryngoscopy (P < 0.05). Data are presented as median and interquartile range and analyzed using paired t test. In simulated difficult pediatric airway, using the GlideScope resulted in a significantly declined view to the glottic entrance. This result is in contrast to studies in children with difficult airway anatomy due to an anterior larynx, where the GlideScope resulted in improved views.

Stylet-Assisted Tracheal Intubation Through an ILMA in a Patient with an Anterior Larynx

To the Editor Although the intubating laryngeal mask airway (ILMA) has been described for use in morbidly obese patients,1 despite its correct placement, tracheal intubation may be unsuccessful. An obese male patient (body mass index [BMI] = 34) in the intensive care unit with a right middle cerebral artery territory stroke required urgent tracheal intubation owing to poor Glasgow coma scale (E1V1M2). After sedation and paralysis, ventilation via a mask was adequate but intubation using a #4 Macintosh blade, external laryngeal manipulation, and a bougie was not possible. An ILMA (#4 LMA-Fastrach™, The Laryngeal Mask Company Limited, Le Rocher, Victoria, Mahé, Seychelles) was placed and ventilation resumed. Tracheal intubation using the flexometallic tube provided with the ILMA failed as the tube tip was repeatedly displaced into the esophagus. Repositioning of the ILMA and Chandy's maneuver part 22 were attempted but also unsuccessful. Intubation with a 7.0-mm internal diameter cuffed Portex polyvinyl chloride (PVC) endotracheal tube (ETT) (Smiths Medical, UK), together with a flexion maneuver, also did not help because of the anteriorly positioned larynx. Size 5 ILMA and Fiberoptic Bronchoscope were unavailable. Hence, using a stylet, the tip of the portex tube was bent as shown in Figure 1 and reintroduced through ILMA, and the ETT could be easily advanced off the stylet into the trachea.Figure 1: Angle of emergence formed by the tracheal tubes on emerging from the distal aperture of the intubating laryngeal mask airway (ILMA). A, LMA-Fastrach silicone wire-reinforced tube (7.5-mm internal diameter). B, Portex polyvinyl chloride tracheal tube (7.5-mm internal diameter). C, Portex polyvinyl chloride tracheal tube with stylet (PVCT; 7.5-mm internal diameter).In cases of extremely anterior larynx, accentuating the angle of emergence of the tracheal tube from the ILMA may facilitate intubation.3 This may be safely done by ensuring that the tip of the stylet remains within the ETT, about 1 to 2 cm proximal to the tip of ETT. We measured the angle of emergence (using a protractor) of Flexometallic and Portex PVC ETT through ILMA and found them to be 35° and 45°, respectively (Fig. 1A & 1B). Introducing a stylette as suggested increases the angle of emergence to 65° (Fig. 1C), which aids in placement of the tracheal tube tip through ILMA in patients with anterior larynx. Damage to the arytenoids and trachea is a potential complication of blind intubation. Difficulty in advancing the tube due to impingement upon the anterior surface of the larynx is another possibility. Using the Parker flexitip PVC tube is an option in this scenario. The centered, tapered, and flexible distal tip gently flexes when resistance is encountered, thus enabling successful introduction minimizing airway trauma.4 Patient consent statement Written permission from the patient's first degree relative was obtained because the patient passed away at home owing to unrelated causes, months after treatment, prior to this submission. The written consent statement is available from the archival author. Georgene Singh, MD Appavoo Arulvelan, MD Kadarapura N. Gopalakrishna, MD Sethuraman Manikandan, MD Vimala Smita, MD, DM Ramesh C. Rathod, MD Department of Anesthesiology Sree Chitra Tirunal Institute for Medical Sciences and Technology Thiruvananthapuram Kerala, South India [email protected]

Laryngoscopy: time to shed fresh light?

Laryngoscopy: time to shed fresh light?

Local vascularized flaps for augmentation of reinke's space

The purpose of this study is to describe and test a novel surgical strategy for augmentation of Reinke's space using vascularized flaps: a thyroid ala perichondrium flap (TAP) and a composite thyroid ala perichondrium flap (CTAP) from the anterior larynx. We hypothesized that these specially designed vascularized flaps would remain viable once inset into the lamina propria, and that they would not disrupt rheologic, biomechanical, and histologic properties of the native vocal fold. Experimental. In vivo canine model. The length and volume of test flaps harvested in six adult human cadaveric larynges were analyzed to determine suitability for use in augmentation in the lamina propria. Also, 12 beagles randomly underwent unilateral placement of either TAP or CTAP, which were designed in accordance with the human adult cadaveric experiments. Flap perfusion was measured before and after harvest with laser Doppler. After 1 month, the beagles were humanely sacrificed and their larynges subjected to aerodynamic and acoustic evaluation using an excised larynx apparatus. The vocal fold lamina propria of four larynges--two TAP and two CTAP--underwent rheologic evaluation using a simple-shear rheometer. The remaining eight larynges underwent quantitative histologic and immunohistochemical evaluation. The survival and complication (swallowing, airway, local wound) rates of all dogs were noted. Initial studies with adult human cadaveric larynges established that TAP and CTAP possessed length and volume greater than native lamina propria. In the canine experiments, the perfusion change in the flaps was similar between flap groups. The damping ratio (ζ), dynamic viscosity (η'), elastic shear modulus (G'), and viscous shear modulus (G″) of treated and untreated native vocal folds were not statistically different. The glottic function measures of vocal efficiency, laryngeal resistance, jitter, shimmer, and harmonics-to-noise ratio (HNR) of treated and normal larynges were not statistically different. Similarly, the values for collagen, elastin, and glycosaminoglycans (GAGs) in treated and untreated vocal folds were not statistically different. Also, neither neochrondrogenesis nor neoosteogenesis was detected in any treated vocal fold. The values for vascular and cellular proliferation in treated and untreated vocal folds were not statistically different. All test dogs survived and had no complications related to swallowing, airway distress, or the local wound. The test flaps described and tested in this study appear to have conceptually attractive features for augmentation of Reinke's space. When placed in an in vivo setting TAP and CTAP did not reveal unfavorable vascular, rheologic, aerodynamic, acoustic, or histologic characteristics. There was no unanticipated morbidity or mortality to the test animals. Long-term viability of these flaps is unknown. TAP and CTAP may open novel pathways for correction of glottic defects and may offer crossover opportunities with tissue engineering techniques.

Site involvement as a predictor of airway intervention in angioedema

To look for a relationship between which sites are involved in angioedema and the need for airway intervention (intubation, tracheotomy). Retrospective chart review. Charts of 140 patients who were admitted to two hospitals at an academic medical center between July 1, 2006 and June 30, 2008 with the diagnosis of angioedema were reviewed. Charts were reviewed for pertinent data, including demographics, sites of involvement along the upper airway, medical therapy, and airway intervention. Subsites included lips, anterior tongue, floor of mouth, soft palate, base of tongue (BOT), and larynx. The BOT was involved in 19 patients and the larynx was involved in 29 patients. Airway intervention was required in 21 patients (16%). Patients with laryngeal and/or BOT involvement required intervention in 38% of cases (vs. 7% in patients without involvement). Patients with more than three sites involved had a 39% rate of intervention, compared with only 12% in patients with less than three sites involved. Among those patients with laryngeal/BOT involvement, 56% with more than three sites involved required intervention, as compared to 30% of patients with less than three sites involved. Site of involvement was found to correlate with airway intervention. Involvement of anterior tongue, BOT, and larynx significantly increased the likelihood of intubation or tracheostomy, as did involvement of multiple sites. Thorough evaluation, including fiberoptic laryngoscopy, can aid in determining which patients require airway intervention.

Lipoma involving the masticator space

The lipoma is a common tumor of mesenchymal origin, usually seen on the trunk and lower limbs. In the head and neck region, it is usually seen in the posterior neck. It is rarely seen in the anterior neck, infratemporal fossa, oral cavity, pharynx, larynx and parotid gland. It may present in a variety of ways. We report a rare case of a lipoma involving the masticator space.

A prospective, randomised, cross‐over trial comparing the EndoFlex® and standard tracheal tubes in patients with predicted easy intubation

We aimed to determine if using the EndoFlex tracheal tube on the first intubation attempt provided improved placement times and intubation success compared with a standard-type tracheal tube in 50 patients undergoing gynaecological surgery in a prospective, randomised, cross-over trial. We found that using the EndoFlex resulted in shorter intubation times (mean (SD) 14.8 (9.7) vs 30.1 (30.5) s), easier intubation (VAS, median (range) 10 (0-70) vs 20 (0-100)), and an increased rate of successful insertion at the first attempt; all p < 0.001. Flexing the distal tip of the EndoFlex was used in 18 patients. There were reductions in the use of external laryngeal pressure, advancement of laryngoscope blade and increased lifting force when intubating with the EndoFlex. Furthermore, patients with a grade 2 (19/50) or 3 (6/50) laryngoscopic view had shorter intubation times, easier intubation and reduced insertion attempts with the EndoFlex. The EndoFlex is a satisfactory alternative to a standard-type tracheal tube, even with an anterior larynx.