Life-threatening Airway Obstruction Research Articles

Life-threatening central air-way obstruction caused by misdiagnosed migration of silicone tracheal stent

Insertion of silicone stent is a palliative treatment of airway stenosis in patients unfit for surgery. Follow up is mandatory for a prompt diagnosis and treatment of complications related to stent insertion. Herein, we reported a case of dislocated stent that remained undiagnosed 15 years after the insertion and caused a life-threatening obstruction of central air-way. Patient underwent emergent extraction of the stent through rigid bronchoscope. The lack of the elasticity of silicone stent and the presence of tenacious adhesions made particularly challenging this procedure. After extraction of the stent, the granulomas related to dislocated stent were resected with laser to reassure air-way patency. At last follow-up, the patient was in good clinical condition with normal air-way patency.

Dysphagia as a Presentation of Spontaneous Mediastinal Hematoma With Life-Threatening Airway Obstruction

SESSION TITLE: Disorders of the Mediastinum 1 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Spontaneous atraumatic mediastinal hematomas are rare. Considering the infrequency with which it is encountered, the clinical identification and management of them can prove to be challenging. We report a case of spontaneous mediastinal hematoma in a patient presenting with dysphagia. CASE PRESENTATION: An otherwise healthy 67-year-old female presented to the emergency department with a 4 day history of worsening dysphagia to both solids and liquids, chest pain radiating to the upper back, and anterior chest bruising. The patient denied history of trauma, vomiting, cough or other constitutional symptoms. She had no reports of antiplatelet or anticoagulant use and no known personal or family history of bleeding problems. Physical examination was only significant for ecchymosis on the anterior chest. Initial blood work was unremarkable with a hemoglobin level of 13.0 g/dl, normal platelet count and coagulation profile. Over the next 48 hours, her hemoglobin dropped to 9.4 g/dl. Initial plain chest radiograph demonstrated widening of the superior and middle mediastinum. An emergent CT chest revealed a large retrotracheal mass extending from the oropharynx to the level of the subcarinal region, with mass effect and anterior displacement on the trachea consistent with a mediastinal hematoma. A conservative approach was initiated. The patient remained stable under intensive care monitoring. Repeat CT Chest 3-days following admission confirmed a decreasing size of the mediastinal hematoma. The patient's remaining hospital course was uncomplicated and she was discharged 10 days later. Hematologic work up for a bleeding diathesis was unrevealing. DISCUSSION: Less than two dozen cases of spontaneous atraumatic mediastinal hematomas have been reported to date. Mediastinal hematomas are commonly provoked by thoracic trauma, iatrogenic procedures, sustained hypertension, hematologic conditions and transient increase in intra thoracic pressure. Although rare, spontaneous mediastinal hematomas must be recognized as a potential cause for mediastinal widening. Dysphagia as a presenting symptom of spontaneous mediastinal hematoma is infrequently reported in the literature. CONCLUSIONS: Spontaneous mediastinal hematomas pose a life-threatening risk. Timely recognition and awareness of atypical presentations is vital to appropriate treatment and management. Although the primary etiology of the hemorrhage may remain unidentified, awareness of the phenomenon is crucial to the differential diagnosis. Reference #1: Li X, Liu L, Cao D, Sun Y. Spontaneous Hematoma of Posterior Mediastinum with an Uncommon Cause: A Case Report and Review of the Literature. Clinics and Practice. 2016;6(1):838. doi:10.4081/cp.2016.838. Reference #2: Iskander M, Siddique K, Kaul A. Spontaneous Atraumatic Mediastinal Hemorrhage: Challenging Management of a Life-Threatening Condition and Literature Review. Journal of Investigative Medicine High Impact Case Reports. 2013;1(2):2324709613484451. doi:10.1177/2324709613484451 DISCLOSURE: The following authors have nothing to disclose: Phyllis Suen, Abdul Siddiqui, Paul Catella, Shimshon Wiesel, Michel Chalhoub No Product/Research Disclosure Information

HEPARIN INDUCED SUBLINGUAL HEMATOMA: A RARE ORAL COMPLICATION

lingual and sublingual hematoma is a rare complication following heparin therapy which may result in serious life-threatening airway obstruction. A 75-year-old female with ischemic heart disease was heparinized for percutaneous transluminal coronary angioplasty of the left anterior descending artery leading to sublingual hematoma with difficulty in swallowing and breathing. This paper presents a case report and management of sublingual hematoma following heparin therapy.

Perioperative factors related to the severity of vocal cord paralysis after thoracic cardiovascular surgery: A retrospective review.

BACKGROUNDVocal cord paralysis (VCP) is a rare complication of thoracic cardiovascular surgery. In severe cases, life-threatening airway obstruction may occur.OBJECTIVETo evaluate the incidence and severity of VCP among patients who underwent thoracic cardiovascular surgery and to identify possible risk factors.DESIGNSingle-centre retrospective review of adult patients.SETTINGOsaka University Hospital, Suita, Japan, from January 2013 to August 2015.PATIENTSWe included 688 patients in the final analysis. Preoperative, intraoperative and postoperative data were collected from medical records. Patients with preoperative VCP or tracheostomy prior to extubation were excluded. The VCP severity in relation to functional recovery was graded using the following categories: absent; mild, remission at 6 months; moderate, partial or persistent VCP at 6 months; or severe, airway obstruction after extubation requiring reintubation. An otolaryngologist diagnosed all VCP cases.MAIN OUTCOME MEASURESThe incidence and severity of VCP after extubation.RESULTSThe incidence (number) of VCP was 4.7% (32), with those of mild, moderate and severe VCP being 1.7% (12), 1.5% (10) and 1.5% (10), respectively. The ICU stay was significantly longer in patients with severe VCP than in patients without VCP [12.5 days (interquartile range 5.5 to 25.5) vs. 3 days (interquartile range 2 to 5), P = 0.0002]. In our multivariable analysis, type 2 diabetes mellitus [odds ratio (OR) 1.853, P = 0.009], intubation period (OR per 24 h 1.136, P = 0.014), ascending aortic arch surgery with brachiocephalic artery reconstruction (OR 8.708, P < 0.001) and ventricular assist device implantation (OR 3.460, P = 0.005) were independent predictors for VCP.CONCLUSIONThe identification of these risk factors may facilitate screening for VCP before extubation and possibly help anaesthesia personnel to be prepared to treat VCP-related airway obstruction should it occur.

Successful management of a neck hematoma following simulation training

Simulation-based education is gaining widespread acceptance in many medical specialties as an effective method to teach technical and non-technical skills. The ultimate goal of simulation is to improve health care and patient safety. Boet et al. [1] published a review on simulation-based crisis resources management (CRM) teaching, looking for evidence that it can lead to improved workplace practices and patient safety. Amongst hundreds of studies pertaining to CRM, he found only nine that were relevant, and only one that showed reduced mortality. Elaborating and putting forward studies designed to measure the impact of simulation on patient safety and outcomes is by no mean an easy task [2]. Indeed, most studies present various problems, such as biases introduced by the use of historical cohorts rather than control groups, and sample sizes based on convenience rather than power analysis. Furthermore, many significant outcomes such as mortality and major morbidity rates need to be measured over an extended period of time, which leaves room for variables other than the introduction of a simulation-based teaching program to play a confounding role [2]. These are some of the reasons why the majority of publications in simulation-based teaching are focusing mostly if not exclusively on measuring participants’ satisfaction and performance in a simulated environment. At the Universite de Montreal, we developed surgical high-fidelity simulation-based CRM scenarios focusing on teamwork. The specific simulation based training on CRM, which includes this airway management scenario, is given only once a year, in the beginning of their second year of residency. This highly appreciated training [3] place surgical residents in rare and urgent situations, but within a safe simulated environment. One of these scenarios focuses on the management of neck hematoma after thyroidectomy. It teaches a step-by-step approach that emphasizes, amongst other things, the need for bedside evacuation in the setting of significant and life-threatening airway obstruction (figure 1). The purpose of this case report is to describe how a postgraduate year 3 (PGY 3) surgical residents used and credited the training acquired during a simulation-based CRM scenario for positively influencing a patient's outcome.

Clinical anatomy and surgical significance of the lingual foramina and their canals.

The lingual foramina and canals can be categorized as median or lateral based on their relation to the midline of the mandible. Investigation of the mandibular lingual region is often done with gross anatomical dissections of cadavers, 2D panoramic radiographic imaging, CT, and cone beam CT (CBCT). While gross studies are the most reliable at qualifying canal contents and course, CBCT proved to be superior to other radiographic techniques for visualizing lingual foramina and canals. The submental and sublingual arteries, and their branches are found in the lingual vascular canals. There is tremendous variation between individuals in terms of the course of the lingual canals and their anastomosis with other vascular canals. Performing the dental implantation procedures in the anterior and posterior regions of the mandible can result in perforation of the lingual cortex, which could injure the arteries that lie within the lingual canal. If hemorrhage occurs, it could lead to life-threatening upper airway obstruction. Pre-surgical investigation to identify the diameter of the lingual foramina and canal as well as their distance from the alveolar process might be necessary to prevent hemorrhage for all patients. Clin. Anat. 30:194-204, 2017. © 2017 Wiley Periodicals, Inc.

Tracheal Amyloidosis Presenting as Life Threatening Airway Obstruction

Tracheal Amyloidosis Presenting as Life Threatening Airway Obstruction

Continuous education in procedural sedation: life-threatening airway obstruction and contributing perioperative patient factors

Continuous education in procedural sedation: life-threatening airway obstruction and contributing perioperative patient factors

C1-inactivator が著効した血管性浮腫の1例

Angioedema is characterized by rapid and severe swelling of the subcutaneous and submucosal tissues. Angioedema involving the upper airway can lead to life-threatening airway obstruction, and needs prompt diagnosis and treatment. Herein, we report a case of acute angioedema which was suspected as having been caused by estrogen imbalance. A 32-year-old woman who was taking a fertility drug for infertility treatment, presented with sudden swelling of the face and neck region and breathing difficulty. Her symptoms continued to progress despite antibiotic and corticosteroid administration. We suspected hereditary angioedema (HAE), and administered a C1-inactivator, which led to immediate and dramatic resolution of the symptoms. Since the C4 and C1-inhibitor levels were normal, the possibility of HAE type III was considered. However, another possibility was that her complicated hormonal condition, including oral intake of a fertility drug, menstruation, and mental stress may have led to estrogen imbalance causing angioedema. Currently, a variety of hormone therapies is widely used ; therefore, caution is needed against the development of estrogen-dependent angioedema.

Ticagrelor-Induced Angioedema: A Rare and Unexpected Phenomenon

Angioedema can cause potentially life-threatening airway obstruction. This case report describes an exceedingly rare episode of ticagrelor-induced hypersensitivity reaction, manifesting as angioedema with periorbital and likely respiratory involvement. The heart team should be vigilant for this precarious condition which may require emergent airway management. Desensitization protocols and alternative regimens (e.g., clopidogrel, prasugrel, and addition of an adjunctive anticoagulant) should be considered when there is an absolute indication for antiplatelet therapy.

TUBERCULAR PREVERTEBRAL AND EPIDURAL ABSCESS PRESENTING AS STRIDOR AND DYSPHAGIA IN AN INFANT: A RARE PRESENTATION OF TUBERCULOSIS IN INFANCY

Tubercular prevertebral abscess is rare presentation of pott’s spine in infancy. It can lead to life threatening airway obstruction and dysphagia requiring early diagnosis and proper management to prevent consequences. We present a case of 5 month child with tubercular prevertebral and epidural abscess who presented with dysphagia and stridor. Child responded dramatically to anti-tubercular therapy and surgical drainage of abscess. The child is doing well on follow up. Keywords: Anti-tubercular drugs, Pott’s spine, Prevertebral abscess, Tuberculosis

Rapidly progressive complete airway obstruction by acute retropharyngeal hematoma

Background: Although Retropharyngeal Hematoma (RPH) has unknown frequency but considered a rare condition which can cause a life threatening airway obstruction. Various precipitating factors have been mentioned as causes of RPH as blunt head or neck trauma, whiplash injury, coagulopathy, central line insertion, stellate ganglion block, sneezing, severe coughing as well as spontaneous RPH. Methods: We report a case of severe life threatening retropharyngeal hematoma secondary to a closed stable C5-C6 fracture that caused severe upper airway obstruction. Results: As the RPH can develop hours or days, even after an apparently minor precipitating injury, in our patient it took almost 3 hours from time of accident till the development of severe upper airway obstruction (picture to be added in main poster). It was such a large collection hematoma that caused severe upper airway obstruction with cannot intubate cannot intubate situation. Conclusion: RPH can cause a mechanical displacement of the pharynx &amp; larynx making securing airway with ETT almost impossible with conventional laryngoscopy or even video-assisted techniques. On the other hand, the time taken for RPH to develop and to cause mechanical obstruction can be limited enough to allow proper preparations as well as availability of fiberoptic technique. We should keep a high index of suspicion of retropharyngeal hematoma and airway involvement in cases of cervical spine fracture, in order to help other physician to increase their awareness and anticipation of such life threatening &amp; meantime avoidable condition. Keywords: retropharyngeal hematoma, airway obstruction

Rigid bronchoscopic intervention for endobronchial metastasis of renal cell carcinoma.

Renal cell carcinoma is one of the major endobronchial metastases, and it occasionally causes life-threatening airway obstruction. Rigid bronchoscopy is useful as a palliative intervention; however, its utility for metastatic renal cell carcinoma has not been elucidated. The purpose of this study was to evaluate the safety and efficacy of rigid bronchoscopic treatment for endobronchial metastasis of renal cell carcinoma. Among 550 patients who underwent rigid bronchoscopic intervention at a single center from January 2005 to June 2015, 9 with metastatic renal cell carcinoma were retrospectively reviewed. Procedures were performed with rigid and flexible bronchoscopes under general anesthesia. In total, 20 procedures were performed on 9 patients who underwent stent implantation. Bleeding was observed in 12 (60%) procedures while severe hypoxia was observed in 2 (10%). The required amount of supplemental oxygen successfully decreased after all the 10 procedures (100%) in patients who previously needed it. Median survival after the first procedure was of 260 days (range, 63-913 days). Rigid bronchoscopic intervention for endobronchial metastasis of renal cell carcinoma is feasible with safety and effectiveness for palliation of airway obstruction, if one prepares sufficiently for massive intraoperative bleeding.

Management of airway obstruction in two cases of head and neck teratoma

Abstract Head and neck teratomas can present with life-threatening airway obstruction and feeding problems. If diagnosed antenatally, multidisciplinary planning can be done to secure the airway at the time of delivery. Surgical excision is the definitive treatment. We present two such cases in this article.

Life-Threatening Upper Airway Obstruction as a Complication of Corrective Spinal Surgery in a Patient with Parkinson ’s Disease: A Case Report

A 74-year-old female with a 10-year history of Parkinson’s disease visited our hospital complaining of severe kyphoscoliosis deformity. Corrective spinal surgery was performed through a posterior approach. Oral anti-Parkinson medication was continued until the day of surgery, when continuous intravenous dopamine infusion was initiated; dopamine was discontinued and oral medication restarted on the day after surgery. Four weeks after surgery, the patient developed dyspnea. Laryngeal examination revealed rigidity of the neck muscles causing upper airway obstruction. Emergency tracheotomy was performed and the patient’s respiratory condition improved immediately. Because of difficulty of swallowing, gastrostomy was performed 2 weeks after tracheotomy. After tracheotomy and gastrostomy, the patient’s respiratory condition improved. Life-threatening upper airway obstruction can occur after corrective spine surgery in patients with Parkinson’s disease. It is important to ensure the oral administration of anti- Parkinson medication after surgery.

Postoperative respiratory difficulty due to asymptomatic anterior cervical osteophyte after brain tumor surgery: a case report.

Anterior cervical osteophytes are commonly found in elderly patients, but rarely produce symptoms. When symptoms occur, they can range from mild symptoms of dysphagia, dysphonia, and foreign body sensation to severe symptoms of airway obstruction due to compression of the pharynx or larynx. We report the case of a 59-year-old man who underwent brain tumor surgery, and developed post-operative respiratory difficulty due to progressive pharyngo-laryngeal edema, requiring urgent endotracheal intubation, secondary to the presence of a previously asymptomatic anterior cervical osteophyte. It is paramount to recognize that asymptomatic anterior cervical osteophytes are a potential cause of life-threatening post-operative respiratory complications that can rapidly progress to life-threatening airway obstruction after surgeries in the prone position, especially in elderly patients.

광범위한 심경부 감염으로 발현된 함치성 낭종

Dentigerous cyst is one of the most prevalent types of odontogenic cysts and is associated with the crown of an unerupted or developing tooth. Although mostly asymptomatic, some of untreated denigerous cysts may displace adjacent teeth and cause complications such as jaw fracture, maxillary sinusitis or oroantral fistula. We report a 69-year-old female with dentigerous cyst, who had extensive deep neck infection which resulted in a life-threatening airway obstruction. (J Clinical Otolaryngol 2015;26:283-287)

Upper Airway Obstruction in a Newborn with Vallecular Cyst

Vallecular cyst is a rare cause of stridor in neonates, which may present as a life threatening airway obstruction. Here, we report a preterm infant with a congenital vallecular cyst who presented with stridor and respiratory distress that developed immediately after birth. She was successfully treated with endoscopic marsupialization.

Clinical characteristics and surgical treatment outcomes of vallecular cysts in adults

Conclusion: It is suggested that transoral complete excision is the ideal treatment for adult vallecular cyst to avoid life-threatening acute airway obstruction and disease recurrence. Objective: The objective of this study was to review the clinical characteristics and surgical treatment outcomes of vallecular cysts in adults. Methods: A retrospective chart review was performed at Chonnam National University Hwasun Hospital from January 2009 to December 2014. Results: Nine patients (≥ 19-years-of-age) with a vallecular cyst were identified. Most of the patients had minimal or no symptoms at diagnosis. The presence of a vallecular cyst was confirmed in all of the patients by fiberoptic laryngoscopy. All of the cases with a vallecular cyst were treated by the transoral surgical procedure. Recurrence of the vallecular cyst was identified in two (22.2%) patients. One patient had been disease-free after the third operation through the transoral approach. Another patient who underwent marsupialization has been observed without surgery. There were no major complications resulting from surgical intervention.

Invited Commentary

Invited Commentary