Restricted Neck Movements Research Articles

Prevalence of thoracic outlet syndrome among patients visiting physical therapy outpatient department of public sector Tertiary Care Hospitals, Peshawar

The indications and symptoms in the upper extremity brought on by compression of the brachial plexus, subclavian vein, and/or subclavian artery at the thoracic outlet were originally referred to as thoracic outlet syndrome (TOS). The symptoms of neurogenic thoracic outlet syndrome (NTOS) are caused by compression of the brachial plexus roots as they travel through the thoracic outlet. The most typical symptom of thoracic outlet syndrome is neurogenic thoracic outlet syndrome (NTOS). The brachial plexus is compressed and irritated, which causes its symptoms.A cross-sectional study was conducted from March 2023 to June 2023 among patients visiting Physical therapy outpatient department of public sector tertiary care hospitals Peshawar. The DASH questionnaire was distributed to all patients according to inclusion criteria from different hospitals to collect data on the prevalence of thoracic outlet syndrome.The study found that the prevalence of thoracic outlet syndrome was higher in female. The prevalence was higher among female housewives (77.77%) compared to male (63%). Risk factors associated with this pain included improper posture in same position while working, long work durations, repetitive tasks, and restricted neck movements.

Fluorosis Masquerading as Compressive Myelopathy

A 60-year-old woman from Cuddalore presented with restricted neck movements, progressive difficulty in walking, and lower limb weakness, leading to bed confinement. Clinical examination revealed spastic paraparesis, brisk reflexes, and sensory deficits below the hips. Laboratory investigations indicated renal insufficiency and elevated urine fluoride levels. Imaging demonstrated calcifications of sacroiliac, sacrospinous ligaments, interosseous membrane, and posterior longitudinal ligament, with osteosclerosis and osteoporosis. Differential diagnoses included Ankylosing Spondylitis and Diffuse Idiopathic Skeletal Hyperostosis. However, the unique pattern of ligament calcification and elevated fluoride levels supported a diagnosis of fluorosis. This case underscores the importance of considering fluorosis in patients from endemic areas with spastic paraparesis and characteristic radiological findings. Posterior decompression via laminectomy was performed, emphasizing the need for awareness of fluorosis as a potential cause of cervical compressive myelopathy.

Immediate efficacy of acupuncture combined with active exercise as 10 min rapid therapy for pain and movement disorders in patients suffering from acute stiff neck: protocol for a randomised controlled trial

IntroductionStiff neck is a condition mainly characterised by persistent pain and limited neck movement, which can substantially impact patients’ daily lives during acute episodes. Accordingly, rapid pain relief and restoration...

Postoperative rehabilitation and quality of life evaluation for transoral endoscopic thyroidectomy vestibular approach

There are no targeted rehabilitation training modalities and assessment tools for patients after transoral endoscopic thyroidectomy vestibular approach (TOETVA). Herein, we develop a new assessment questionnaire and rehabilitation training modality and evaluate its safety and effectiveness. The THYCA-QoL-TOETVA questionnaire was compiled, and reliability and validity analyses were performed. Patients were divided into the new rehabilitation training group (N) or the conventional rehabilitation training group (C), and 1:1 propensity score matching (PSM) was performed after administering questionnaires to patients in both groups. Cervical range of motion (CROM) data were also measured and collected for statistical analysis. The questionnaire used in this study showed good expert authority, coordination, internal consistency, and questionnaire reliability. A total of 476 patients were included after PSM, and the questionnaire results showed that recovery and quality of life were better in the N group than in the C group (124.55 ± 8.171 vs. 122.94 ± 8.366, p = 0.026). Analysis of cervical spine mobility showed that rehabilitation was better in the N group compared to the C group at postoperative one month (flexion: 1.762°, extension: 4.720°, left lateral bending: 3.912°, right lateral bending: 4.061°, left axial rotation: 5.180°, right axial rotation: 5.199°, p value all of these < 0.001), and at postoperative three months (flexion: 2.866°, extension: 2.904°, left lateral bending: 3.927°, right lateral bending: 3.330°, left axial rotation: 4.395°, right axial rotation: 3.992°, p value all of these < 0.001). The THYCA-QoL-TOETVA provides an appropriate and effective tool for measuring the postoperative quality of life of TOETVA patients. This new rehabilitation training can effectively alleviate the problem of limited neck movement and improve the quality of life of patients after TOETVA surgery.Trial registration: ChiCTR2300069097.

Actinomycosis presenting as a nasopharyngeal mass: A case report

Actinomycetes are predominantly pathogenic bacteria that lack aerial hyphae and do not form spores. They are generally anaerobic or facultative anaerobic Gram-positive bacteria, belonging to the prokaryotic group. Actinomycetes are widely distributed in nature, similar to other bacteria, and are mostly saprophytic, with a few being parasitic. They are named as such due to their colony's radial form. The symptoms and signs of actinomycosis are atypical and rarely manifest in the nasopharynx. Consequently, it can be challenging to distinguish actinomycosis from nasopharyngeal carcinoma, making diagnosis difficult. Histopathology is usually relied upon for diagnosis, although culture may pose challenges. Fortunately, actinomycetes are highly sensitive to penicillin. Therefore, timely treatment with high doses of penicillin is crucial for successful recovery. In this case study, we present the details of a 53-year-old female patient with no history of mucosal damage or tooth decay but with a previous partial thyroidectomy. The patient experienced recurring neck pain accompanied by progressive limitation of neck movement. Nasopharyngoscopy revealed the presence of a smooth-surfaced mass. Subsequent biopsy, clinical imaging, microbiological analysis, and histological findings confirmed the diagnosis of actinomycosis.Following a comprehensive treatment plan involving a combination of penicillin and doxycycline for a duration of two months, the disease was successfully eradicated.

Ayurvedic management in case of Vishwachi (Cervical Radiculopathy): A Case Report

Cervical problems are very similar to Vata Vyadhi disorders. Thus, in the current investigation, in Vata Dosha Janya Vyadhi management by Brimhana Chikitsa is very effective. A disease known as Vishwachi has been described in Ayurvedic Samhitas as one of these illnesses. The symptoms of Cervical Radiculopathy, such as pain in neck region which is radiating to the upper limbs and sometimes restricted neck movements, have been explained in Internal Medicine books (Davidsons, Harrison). Vishwachi is a Vataja Nanatmaja Vyadhi. According to several Acharyas Ruja, Stambhata, Todan, Karmakshaya, and Chestapaharana of Bahus are symptoms that affects the cervical region and upper extremities. According to Acharya Dalhana, the treatment of Vishwachi is similar to Gridhrasi, a disorder that affects the unilateral or bilateral lower extremities and divided into two types: Vataja and Vatakaphaja. Vishwachi has symptoms which are comparable to Cervical Radiculopathy, a degenerative disorder of the cervical spinal part. Nasya Karma has been described as the treatment of Shirogata Vyadhis. Dhatukshaya is a main contributor of disease to the development of Vishwachi. Present study is an effort made to better understanding of disease and its management.

Traumatic Brain Injury and Conversion Disorder in a Veteran’s Atypical Presentation

IntroductionTraumatic brain injury (TBI) induces cognitive and behavioral changes due to environmental impacts on brain tissue.ObjectivesHighlighting the atypical TBI presentation challenging conventional diagnostics and obscured by conversion disorders.MethodsA 36-year-old male veteran, injured by a sniper rifle in 2011, presented with right ear tinnitus and monthly, unresponsive right hemicranial headaches. Seizures occurred every two weeks with no reported loss of consciousness or sensation. The gunshot wound to the neck in 2011 prompted emergency intervention, with entry and exit wounds located in the posterior lateral neck. Post-injury symptoms comprised hearing loss, tinnitus, restricted neck movement, and weakness in the right arm. Seizures persisted, accompanied by numbness and neck movement. Management included physical therapy, hyperbaric oxygen therapy (improving weakness but not tinnitus), and administration of piracetam (2400 mg/day), sertraline (100 mg/day), and ginkgo biloba (2400 mg/day). Psychiatric consultation suggested a diagnosis of “conversion disorder.”ResultsNeuropsychological Evaluation: Raven Standard Progressive Matrices Test showed borderline impairment. Psychiatric Evaluation noted monotonous mimics, occasional depersonalization, reduced emotional involvement, and slowed psychomotor activity. Elevated trait anxiety was observed per the State-Trait Anxiety Inventory. Neurological Examination identified left arm weakness and impaired resting balance. Imaging Findings: F18-FDG PET/CT Scan at 1 year post-GSW showed hypermetabolism in the right frontal lobe, and at 3.5 years post-GSW demonstrated decreased glucose metabolism in the bilateral cerebellar cortex, temporal lobe, and bilateral parietal lobe.ConclusionsA high-kinetic-energy bullet passed through the right lateral base of the neck without causing apparent brain damage. Proposed is the generation of upward pressure waves in neck tissues through the transmission of kinetic energy, compressing and displacing soft tissues toward the skull. Gunshot injuries create cavities, forming high-pressure waves capable of damaging distant brain regions, leading to TBI such as crush injury, edema, and myelin and axonal damage (Courtney &amp; Courtney, 2007). Microscopic brain damage, undetectable by current imaging, may only surface during autopsy (Yilmaz &amp; Pekdemir, 2007). Rat studies after primary blast injuries reveal brain alterations, highlighting that high-pressure pulses can cause neuronal damage, potentially yielding related symptoms (Cernak et al., 2001). The patient’s atypical symptoms, combined with the initial conversion disorder hypothesis, underscore the need for a diagnostic paradigm shift to differentiate traumatic brain injury from other potential misnomers.Disclosure of InterestNone Declared

Grisel Syndrome and Its Anesthesia Management: A Comprehensive Review

Grisel syndrome is an atraumatic rotatory atlantoaxial subluxation associated with head-and-neck inflammatory conditions. It predominantly affects the pediatric population. Anesthetic management in these patients poses several challenges, and astute management is crucial for a good outcome. We present a case of a young male patient who presented for management of painful torticollis and restricted neck movements. He had a history of inadequate treatment of throat infection for a month and was subsequently diagnosed with Grisel’s syndrome. He underwent occipitocervical fusion. This case report reviews the literature and describes perioperative anesthesia care and concerns in a comprehensive manner in the management of Grisel’s syndrome.

Perioperative Challenges in Airway and Ventilatory Management of a Neurosurgical Patient with Klippel–Feil Syndrome

AbstractKlippel–Feil syndrome, a rare congenital anomaly, has a classical triad of low posterior hairline, short neck, and restriction of neck movements. Complex airway anatomy increases the risk of neurological damage while handling the airway during positioning and laryngoscopy. We address the possible anesthetic challenges that one might face in these patients, such as difficult airway, difficult weaning from the ventilator with increased chances of reintubation, prolonged intensive care and mechanical ventilation, and difficult tracheostomy. Every anesthesiologist must be aware of the available options in the management of a difficult airway in emergent circumstances. Despite the numerous encounters, we were able to effectively manage a case of Klippel–Feil syndrome perioperatively.

Atlanto-occipital Assimilation an Incidental Cephalometric Finding: Diagnosis and Clinical Implications – A Case Report

Occipitalization of atlas is an osseous anomaly of the craniovertebral junction, which occurs at the base of the skull in the region of the foramen magnum. It is the fusion of first cervical vertebra with the occipital bone of the skull. A 16-year-old patient reported with chief complaint of irregularly placed teeth. Routine lateral cephalogram assessment revealed the presence of fusion between first cervical vertebrae (C-1) and base of skull. The radiographic investigation revealed the presence of fusion along with the clinical findings of short neck, short face, cleft palate, missing teeth, and pain during neck extension and flexion. Such cases of craniocervical anomaly can cause orthopedic and neurological problems like abnormal posture of head, restricted neck movements, cervical pain, pain in extremities, wasting of muscles, and convulsions. The comprehensive radiographic assessment of all structures visible in cephalogram of orthodontic patient can help in identification of such anomalies and sensitize the patients about symptomatic or asymptomatic condition.

A rare case of disseminated tuberculosis presenting as multiple visceral abscesses: retropharyngeal abscess, epidural abscess, pulmonary Koch’s, hepatic granuloma and splenic abscess

Extrapulmonary TB can present with plethora of clinical signs and symptoms, the spectrum of which remains boundless. Retropharyngeal abscess, epidural abscess, splenic abscess, hepatic granuloma are rare presentations of extrapulmonary TB which requires paramount clinical expertise for diagnosis and timely management thereby preventing dangerous complications. Here is a case report of a 6 year old boy presenting with 2 months history of fever, neck pain and swelling, difficulty in swallowing solid food, restricted neck movements, weight loss and family history of TB contact. Examination revealed bilateral jugulodigastric (level I and II) cervical lymphadenopathy (around 2×2 cm), neck rigidity and a paramedian bulge over posterior pharyngeal wall (measuring 3×3 cm), the inferior extent of which was difficult to visualize on oral cavity examination. Patient was worked up keeping in mind the high possibility of TB, radiography and ultrasonography of neck confirmed the presence of retropharyngeal abscess. CECT neck, chest and abdomen was done to find the extent of lesion and to look any other evidence of tuberculosis which revealed presence of retropharyngeal abscess, epidural abscess, pulmonary Koch’s, hepatic granuloma and splenic abscess with features s/o tuberculosis. He was started on ATT on clinico-radiological basis, his abscess was drained and cheesy material and pus were sent for microbiological and histo-pathological examination, although microbiological evidence was non-contributory, histopathology confirmed tuberculous retropharyngeal abscess. This case reporting was done to elicit the rare presentation of EPTB and the need of high degree of clinical suspicion for early diagnosis and timely treatment to prevent future complications.

Acute suppurative thyroiditis in a 10-year-old child

BACKGROUND: Acute suppurative thyroiditis in children is a rare and potentially life-threatening thyroid disease that requires rapid diagnostics and treatment.&#x0D; CLINICAL CASE DESCRIPTION: A clinical case of a 10-year-old girl with a thyroid abscess is described. She had fever, painful neck swelling, sore throat, tachycardia, restricted neck movement, and dysphagia for 6–7 days. The treatment consisted of antibiotic therapy, incision and drainage of the abscess using local ozone therapy. It was found that causative agents were Staphylococcus aureus and Escherichia coli. The girl had a follow-up examination in 9 months after the discharge — there were no signs of thyroid pathology.&#x0D; CONCLUSION: Although acute suppurative thyroiditis is extremely rare in children, it occurs sometimes. Since this condition may be associated with a piriform sinus fistula, the child must be examined for it because of the risk of recurrence.

Scarless Excision of Second Branchial Cleft Cyst via Retroauricular Hairline Incision.

Second branchial cleft cyst (2nd BCC) is treated by complete excision. Conventional transcervical skin incision on the lesion may leave a prominent scar in the cosmetically sensitive area. The retroauricular hairline incision (RAHI) approach may maintain neurological, mobility, and cosmetic functions of the neck and face after excision. This study evaluated the clinical outcomes and disease control of scarless surgery via RAHI in 57 consecutive patients with 2nd BCC. The patients received the prospective evaluation of postoperative neurological, subjective pain, swallowing, neck motion, and cosmetic functions. Postoperative complications, subjective satisfaction, and recurrence were also assessed in each patient. Excision was performed in all cases without injury to the facial nerve or other neurological complications and conversion to other incisions or approaches with a median operation time of 44min. Complications were minimal, without dysphagia, neurological deficits, or limited neck motion. Postoperative incision scars in the postauricular and hairline region were commonly invisible. Subjective satisfaction with the scar and facial deformity was high after surgery. No patients had a recurrence for a median follow-up of 66months. The RAHI approach for 2nd BCC has excellent cosmetic, functional, and disease control outcomes. This can be safely applied to the treatment of 2nd BCC. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Experience with the management of 2599 cases of congenital muscular torticollis and a multicenter epidemiological investigation in 17 hospitals in China

BackgroundCongenital muscular torticollis (CMT) is a common musculoskeletal disease affecting infants and young children. If CMT is not treated correctly and timely, it can lead to limited head and neck movements, head and neck deviation, and abnormal posture. In order to improve patients' symptoms and alleviate the negative impact of the disease on their lives, we are committed to exploring the treatment of CMT.MethodsThe general clinical and ultrasonographic data of 2599 children with CMT who received standardized treatment at Shenzhen Children’s Hospital from 2004 to 2020 were retrospectively reviewed. According to given treatment, children with CMT were divided into the physiotherapy group, physiotherapy combined with glucocorticoid treatment group, and surgical treatment group. We divided children with CMT into local mass, uniform thickening, and atrophy according to ultrasound features. General clinical information, treatment, and ultrasound examination data in each group were compared. Additionally, electronic medical records of 2344 patients admitted due to CMT in 17 tertiary children’s hospitals of China’s Futang Research Center of Pediatric Development (FRCPD) from 2015 to 2019 were retrospectively analyzed. Data on sex, age, year of admission and discharge, and treatment costs during hospitalization were extracted from the first medical record pages according to the ICD codes. The data were assessed for normality using the Kolmogorov–Smirnov test. Depending on the data distribution, they were analyzed using parametric tests, such as the t-test, or non-parametric tests. Qualitative data are expressed as percentages (%) and analyzed using the chi-square or Fisher’s exact probability test, with α = 0.05 as the test level. P < 0.05 was considered to be indicative of a statistically significant difference.ResultsThree types of CMT were defined based on sternocleidomastoid muscle ultrasound examination characteristics: local mass, uniform thickening, and atrophy. Age at first diagnosis was 69.21 ± 108.41 days in local mass type group, 216.85 ± 324.09 days in uniform thickening group, and 417.88 ± 739.05 days in atrophy- type group; while age at first physiotherapy use was 94.06 ± 206.49 days, 255.00 ± 430.62 days, 540.92 ± 1059.29 respectively. The children included in local mass type group have shown a high success rate of conservative treatment, with a rate of 7.5% of children underwent surgery. Age at first diagnosis was 112.44 ± 224.12 days in the physiotherapy group, 115.87 ± 144.86 days in the physiotherapy combined with glucocorticoid treatment subgroup, whereas the age at first physiotherapy use was 137.38 ± 312.11 and 196.91 ± 344.26 days respectively. In the observation period (2015–2019) the mean age at surgery for CMT in 17 tertiary children’s hospitals of the FRCPD was 50 months. Overall, 663 children with CMT were 1–2 years of age, accounting for the largest proportion (28.3%). Followed by 417 individuals (17.8%) were 7–14 years of age, indicating that there are still more children with CMT receiving surgical treatment later.ConclusionsEarly diagnosis and treatment are essential to improve the conservative treatment success rate and achieve good prognosis in children with CMT. Our team’s concept for treating CMT is as follows: after diagnosing the children, we will adopt the standardized protocol of treatment, with physiotherapy combined with the injection of glucocorticoid drugs and SCM release surgery, when needed. This program has a high conservative treatment success rate and may facilitate the achievement of better prognosis and reduced teratogenicity rate.

A Clinical Study of Ballitarwadi Gutika in the Management of Manyastambha (Cervical Spondylosis)

Manyastambha symptoms and signs are associated to cervical spondylosis. The disease not only negatively impacts a person's health but also greatly impairs quality of life and daily activities. Neck arthritis, also known as cervical spondylosis, can result from disc and ligament problems, as well as bone spurs. This disease primarily affects persons during their productive years of life, with a male-to-female ratio of 3:1 and an incidence of 0.1-1% in the general population. Without regard to sex, religion, or other factors, a total of 45 individuals with the defining signs and symptoms of Manyastambha were chosen for this research trial (Cervical spondylosis). In the current study Ballitarwadi Gutika in the dose of 500mg thrice in a day with Anupana of like warm water for 45 days. Results showed that pain was reduced by 79.33%, stiffness 57.47% and parasthesia 48.44% which were statistically significant. Statistically very significant results were also found in swelling (64.13%), vertigo (52.38%) and neck muscle strength (52.27%). Restricted neck movements like flexion, extension, rotation and lateral flexion were improved by 50.22%, 51.78%, 51.71% and 52.70% respectively. And overall, 57.25% result was observed during the study.

Clinical and Radiological Outcomes after Surgical Stabilization of Craniovertebral Junction – A Single-center Experience

Abstract Background and Objectives: Craniovertebral instability and its surgical management require a thorough knowledge of the anatomy and dynamics of the craniovertebral junction (CVJ). Due to the wide range of mobility and proximity of vital neurovascular structures, these surgeries demand high technical skill and precision. It is very difficult to suggest a single good technique for CVJ stabilization as each procedure has got its own indications and benefits. Novel techniques and gadgets like neuro navigation and robotic arms help surgeons to minimize complications, thereby improving the overall functional outcome. In this study, we are analyzing the retrospective data of CVJ instabilities surgically managed by freehand technique in our institute. Materials and Methods: We did a retrospective analysis of 33 patients operated on for craniocervical junction instability for 7 years from January 1, 2015, to December 31, 2021. We analyzed the clinical and radiological presentations and postoperative outcomes at 3 weeks, 6 months, and after 1 year. The distribution of clinical presentation in terms of neck pain, myelopathy, restricted neck movements, and lower cranial nerve palsy was evaluated and correlated with the demographic parameters. The paired “t”- test was used to correlate the clinical and radiological outcomes after surgery. Results: The paired “t” value of the clinical improvement assessed with the preoperative and postoperative Japanese Orthopedic Association (JOA) myelopathic scores was − 4.376 with P &lt; 0.001, which indicates a significant clinical improvement 6 months after surgery. Among the 33 patients evaluated, only three patients developed a slight reduction in the JOA score after surgery, which was improved within 1 year. All the patients achieved satisfactory trabecular bone formation at the graft site and decorticated joint facets without any clinical or radiological evidence of implant failure. Among the C2 pedicle screws, 3 (7.5%) were having vertebral foraminal impingement, and 2 (5%) were having medial cortical violation and spinal canal impingement. All the patients with radiological evidence of implant malposition were clinically intact and did not show any deterioration of the studied myelopathic score (JOA). Conclusions: As the bony anatomy and the vascular course of the CVJ vary from patient to patient, thorough preoperative planning is mandatory for the surgical management of CVJ instability. In our study, the clinical and radiological improvement after surgical stabilization of craniovertebral instability by freehand technique is comparable with the available data. The overall risk of screw malposition and associated lethal complications may be minimized by adding modern technologies such as neuronavigation, robotic arms, and three-dimensional C-arm in the armamentarium.

Clinical characteristics and therapeutic effectiveness of post craniotomy cervicogenic headache

From January 2019 to December 2021, the clinical data of 151 patients with post craniotomy cervicogenic headache from Beijing Tiantan Hospital affiliated to Capital Medical University were retrospectively collected. The characteristics of cervicogenic headache were summarized, the numerical rating score (NRS) of patients before and after treatment of compound opioids and/or cervical nerve block was compared, and the occurrence of related adverse reactions and complications was counted. The onset of cervicogenic headache in 151 patients was on the (5.5±2.0) d after craniotomy, of which 131 (86.8%) had unilateral pain, pain in 127 (84.1%) could be induced by cervical activity, and 118 (78.1%) had limited neck movement. Of the 124 patients treated with compound capsule of oxycodone and acetaminophen, 85 (68.5%) patients had an NRS of (8.01±0.82) before treatment and 2.0 (1.0, 3.0) after treatment (P<0.001). Thirty-nine patients who did not respond to medical therapy received cervical nerve block, and the NRS scores before and after receiving the nerve block were (7.49±1.12) and 2.0 (1.0, 2.5), respectively, with a statistically significant difference (P<0.001). Twenty-seven patients who received cervical nerve block without medical treatment, and the NRS before and after treatment was (9.0±0.9) and 1.0 (1.0, 3.0), respectively, with a statistically significant difference (P<0.001). Among the 124 patients receiving medication, 14 (11.3%) developed mild dizziness and nausea, which were resolved after stopping the drug, and no other drug-related adverse reactions were found. None of the patients who received nerve blocks saw complications associated with nerve block procedures. Compound capsule of oxycodone and acetaminophen are effective for most of patients with post craniotomy cervicogenic headache. Cervical nerve block is effective and safe for patients with or without drug resistance.

Challenges in Diagnosing Fibrodysplasia Ossificans Progressiva: A Case Report.

A 5-year-old boy presented with multiple bony swellings in the dorsal spine region, restricted left shoulder movement, and a previous misdiagnosis of hereditary multiple exostoses (HMEs) resulting in unnecessary excision of the right scapular lesion. Clinical examination revealed hallux valgus, brachydactyly, and limited neck movement. Radiography and computed tomography confirmed a diagnosis of fibrodysplasia ossificans progressiva (FOP). This case report underscores the importance of accurate diagnosis and differentiation between FOP and HME. Hallux valgus, brachydactyly, and restricted neck movement suggested FOP. It is paramount for orthopaedic surgeons to exclude rare disorders before performing any interventions. Biopsies or resections of bone formation areas should be avoided for patients with FOP.

A quantitative study of airway ultrasound in predicting difficult laryngoscopy: A prospective study

PurposeAs common clinical screening tests cannot effectively predict a difficult airway, and unanticipated difficult laryngoscopy remains a challenge for physicians. We herein used ultrasound to develop some point-of-care predictors for difficult laryngoscopy. MethodsThis prospective observational study included 502 patients who underwent laryngoscopy and a detailed sonographic assessment. Patients under 18 years old, or with maxillofacial deformities or fractures, limited mouth opening, limited neck movement or history of neck surgery were excluded from the study. Laryngoscopic views of all patients were scored and grouping using the modified Cormack-Lehane (CL) scoring system. The measurements acquired comprised tongue width, the longitudinal cross-sectional area of the tongue, tongue volume, the mandible-hyoid bone distance, the hyoid bone-glottis distance, the mandible-hyoid bone-glottis angle, the skin-thyrohyoid membrane distance, the glottis-superior edge of the thyroid cartilage distance (DGTC), the skin-hyoid bone distance, and the epiglottis midway-skin distance. ANOVA and Chi-square were used to compare differences between groups. Logistic regression was used to identify risk factors for difficult laryngoscopy and it was visualized by receiver operating characteristic curves and nomogram. R version 3.6.3 and SPSS version 26.0 were used for statistical analyses. ResultsDifficult laryngoscopy was indicated in 49 patients (CL grade Ⅲ – Ⅳ) and easy laryngoscopy in 453 patients (CL grade Ⅰ – Ⅱ). The ultrasound-measured mandible-hyoid bone-glottis angle and DGTC significantly differed between the 2 groups (p < 0.001). Difficult laryngoscopy was predicted by an area under the curve (AUC) of 0.930 with a threshold mandible-hyoid bone-glottis angle of 125.5° and by an AUC of 0.722 with a threshold DGTC of 1.22 cm. The longitudinal cross-sectional area of the tongue, tongue width, tongue volume, the mandible-hyoid distance, and the hyoid-glottis distance did not significantly differ between the groups. ConclusionDifficult laryngoscopy may be anticipated in patients in whom the mandible-hyoid bone-glottis angle is smaller than 125.5° or DGTC is larger than 1.22 cm.

COVID-19 causing Grisel’s syndrome? A rare case report

Background: Grisel’s syndrome was initially described by Grisel in 1930 to explain the case of a non-traumatic atalanta-axial subluxation (C1 over C2). Exact aetiopathogenesis is unclear with the patient usually presenting as a painful acquired torticollis. Clinical Description: A 9-year-old male child presented with restriction of neck movements, cough for 2 months and tongue deviation for a week. The patient had increased deep tendon reflexes in bilateral upper and lower limbs with bilateral exaggerated plantar reflexes. Power in bilateral lower limbs was 5/5. The patient also had a history of COVID-19 infection 3 weeks back which was managed conservatively. Management: X-ray of the cervical spine revealed subluxation of the atlanto axial joint with an increased atlanto dens interval of 7.5 mm. Magnetic resonance imaging of the Cervical region showed an increased atlanto dens interval of 7.6mm. The patient was immobilised immediately with a hard cervical collar. The patient was started on Inj. Ceftriaxone 850 mg IV twice daily for 21 days, followed by another 21 days of Tab. Cefixime 100 mg twice daily. A repeat X-ray of the cervical spine showed a reduction in atlanto axial dens interval and an improvement in the patient’s condition. Conclusion: Although the diagnosis of Grisel’s syndrome could be challenging at times, it is imperative to manage patients with rare diseases swiftly and precisely to prevent permanent future disabilities. Whether COVID-19 was the trigger for the development of Grisel’s syndrome is up for debate and potential area of new research.