Risk Of Upper Airway Obstruction Research Articles

外傷性咽頭後間隙血腫例

Retropharyngeal hematoma is an uncommonly encountered condition. However, early diagnosis and appropriate treatment are important owing to the risk of upper airway obstruction. We report a case of retropharyngeal hematoma that needed surgical drainage. A 73-year-old man receiving anticoagulant therapy sustained injury when he fell to the ground on his face. Cervical CT and MRI showed a retropharyngeal hematoma extending from the retropharyngeal to the superior mediastinal space. Flexible fiberoptic laryngoscopy revealed no airway obstruction. However, on day 10 after the injury, the hematoma was found to have increased in size; although there was no dyspnea at the time, owing to the imminent risk of airway obstruction, we performed surgical drainage of the hematoma with no tracheostomy. We reviewed 43 articles on retropharyngeal hematoma reported in the literature to elucidate the clinical characteristics, treatment, and outcomes of this condition. More than a half of the cases published in these reports received conservative treatment; however, about 30% of the cases eventually required tracheostomy because of airway obstruction.

The negative health effects of having a combination of snoring and insomnia.

Insomnia and snoring are common sleep disorders. The aim was to investigate the association of having a combination of insomnia symptoms and snoring with comorbidity and daytime sleepiness. The study population comprised 25,901 participants (16-75 years, 54.4% women) from 4 Swedish cities, who answered a postal questionnaire that contained questions on snoring, insomnia symptoms (difficulties initiating and/or maintaining sleep and/or early morning awakening), smoking, educational level, and respiratory and nonrespiratory disorders. Snoring was reported by 4,221 (16.2%), while 9,872 (38.1%) reported ≥ 1 insomnia symptom. A total of 2,150 (8.3%) participants reported both insomnia symptoms and snoring. The association with hypertension (adjusted odds ratio [OR], 1.4; 95% confidence interval [CI], 1.2-1.6), chronic obstructive pulmonary disease (adjusted OR, 1.8; 95% CI, 1.3-2.4), asthma (adjusted OR, 1.9; 95% CI, 1.6-2.3), daytime sleepiness (adjusted OR, 7.9; 95% CI, 7.1-8.8), and the use of hypnotics (adjusted OR, 7.5; 95% CI, 6.1-9.1) was highest for the group with both insomnia symptoms and snoring. Participants with both snoring and insomnia run an increased risk of hypertension, chronic obstructive pulmonary disease, asthma, daytime sleepiness, and use of hypnotics. It is important to consider snoring in patients seeking medical assistance for insomnia and, vice versa, in patients with snoring inquiring about insomnia. Hägg SA, Ilieva E, Ljunggren M, etal. The negative health effects of having a combination of snoring and insomnia. J Clin Sleep Med. 2022;18(4):973-981.

Study on prevention of hypercapnia by nasal high flow in patients undergoing endoscopic retrograde cholangiopancreatography during intravenous anesthesia.

Background:For relatively invasive upper gastrointestinal endoscopy procedures, such as an endoscopic retrograde cholangiopancreatography (ERCP), and also lower gastrointestinal endoscopy procedures, intravenous anesthesia is routinely used to reduce patient anxiety. However, with the use of intravenous anesthesia, even at mild to moderate depth of anesthesia, there is always a risk of upper airway obstruction due to a relaxation of the upper airway muscles.With the advent of nasal high flow (NHF) devices that allow humidified high flow air through the nasal cavity, can be used as a respiratory management method in the context of anesthesia. AIRVO is commonly used for patients with obstructive sleep apnea and other respiratory disorders. This device uses a mild positive pressure load (several cmH2O) that improves carbon dioxide (CO2) washout and reduces rebreathing to improve respiratory function and therefore is widely used to prevent hypoxemia and hypercapnia.This study aims to maintain upper airway patency by applying NHF with air (AIRVO) as a respiratory management method during intravenous anesthesia for patients undergoing an ERCP. In addition, this study investigates whether the use of an NHF device in this context can prevent intraoperative hypercapnia and hypoxemia.Methods/design:This study design employed 2 groups of subjects. Both received intravenous anesthesia while undergoing an ERCP, and 1 group also used a concurrent nasal cannula NHF device. Here we examine if the use of an NHF device during intravenous anesthesia can prevent hypoxemia and hypercapnia, which could translate to improved anesthesia management.Efficacy endpoints were assessed using a transcutaneous CO2 monitor (TCM). This device measured the changes in CO2 concentration during treatment. Transcutaneous CO2 (PtcCO2) concentrations of 60 mm Hg or more (PaCO2 > 55 mm Hg) were considered marked hypercapnia. PtcCO2 concentrations of 50 to 60 mm Hg or more (equivalent to PaCO2 > 45 mm Hg) were considered moderate hypercapnia.Furthermore, the incidence of hypoxemia with a transcutaneous oxygen saturation value of 90% or less, and whether the use of NHF was effective in preventing this adverse clinical event were evaluated.Discussion:The purpose of this study was to obtain evidence for the utility of NHF as a potential therapeutic device for patients undergoing an ERCP under sedation, assessed by determining if the incidence rates of hypercapnia and hypoxemia decreased in the NHF device group, compared to the control group that did not use this device.Trial registration:The study was registered in the jRCTs 072190021.URL https://jrct.niph.go.jp/en-latest-detail/jRCTs072190021.

Study on prevention of hypercapnia by Nasal High Flow in patients with endoscopic submucosal dissection during intravenous anesthesia.

Background:For relatively invasive upper gastrointestinal endoscopy procedures, such as an endoscopic submucosal dissection (ESD), intravenous anesthesia is routinely used to reduce patient anxiety. However, with the use of intravenous sedation, even at mild to moderate depth of anesthesia, there is always a risk of upper airway obstruction due to a relaxation of the upper airway muscles.With the advent of Nasal High Flow (NHF) devices that allow humidified high flow air through the nasal cavity, can be used as a respiratory management method in the context of anesthesia. AIRVO is commonly used for patients with obstructive sleep apnea and other respiratory disorders. This device uses a mild positive pressure load (several cmH2O) that improves carbon dioxide (CO2) washout and reduces rebreathing to improve respiratory function and therefore is widely used to prevent hypoxemia and hypercapnia.This study aims to maintain upper airway patency by applying NHF with air (AIRVO) as a respiratory management method during intravenous anesthesia for patients undergoing an ESD. In addition, this study investigates whether the use of an NHF device in this context can prevent intraoperative hypercapnia and hypoxemia.Methods/design:This study design employed 2 groups of subjects. Both received intravenous anesthesia while undergoing an ESD, and 1 group also used a concurrent nasal cannula NHF device. Here we examine if the use of an NHF device during intravenous anesthesia can prevent hypoxemia and hypercapnia, which could translate to improved anesthesia management.Efficacy endpoints were assessed using a transcutaneous CO2 monitor. This device measured the changes in CO2 concentration during treatment. Transcutaneous CO2 (PtcCO2) concentrations of 60 mmHg or more (PaCO2 > 55 mmHg) were considered marked hypercapnia. PtcCO2 concentrations of 50 to 60 mmHg or more (equivalent to PaCO2 > 45 mmHg) were considered moderate hypercapnia.Furthermore, the incidence of hypoxemia with a transcutaneous oxygen saturation value of 90% or less, and whether the use of NHF was effective in preventing this adverse clinical event were evaluated.Discussion:The purpose of this study was to obtain evidence for the utility of NHF as a potential therapeutic device for patients undergoing an ESD under anesthesia, assessed by determining if the incidence rates of hypercapnia and hypoxemia decreased in the NHF device group, compared to the control group that did not use of this device.Trial registration:The study was registered the jRCTs 072190022.URL https://jrct.niph.go.jp/en-latest-detail/jRCTs072190022

Anaesthetic management in Pierre Robin syndrome with bicuspid aortic valve: A case report

Pierre Robin Sequence (PRS) is an uncommon complex congenital syndrome with a clinical triad of micrognathia, glossoptosis and cleft palate posing a risk of upper airway obstruction and difficulty in feeding with or without multiple secondary abnormalities. We report a case of 3.5yr male child suffering from PRS along with left renal agenesis, bilateral CTEV, bilateral inguinal hernia, pectus carinatum, bicuspid aortic valve where successful ventilation and intubation was done and taking a tongue stitch along with nebulization and prone position helped to maintain airway during recovery. Keywords: Pierre robin syndrome, Bicuspid aortic valve, Cleft palate.

歯磨き中の咽頭外傷から下極型扁桃周囲膿瘍を来した1例(A case presenting with an inferior pole peritonsillar abscess after suffering an oral injury while brushing his teeth)

要旨 下極型扁桃周囲膿瘍は特徴的な症状，局所所見が乏しく診断がむずかしい。このため，診断の遅れにより，喉頭浮腫，深頸部膿瘍・縦隔炎に進展すると致命的となることがある。症例は79歳の男性。数日前に歯磨き中に誤って軟口蓋を傷つけた。その後，咽頭痛，発熱が出現し，さらに呂律障害も出現したことから救急搬送された。来院時の所見では，左咽頭の軽度腫脹を認めたが，その他の異常は認めなかった。感染源精査のために実施した，胸部～骨盤部単純CTで左頸部の脂肪織濃度の上昇を認めた。追加で実施した頸部～胸部造影CTで中咽頭左側壁から喉頭蓋谷に及ぶ低吸収域を認め，下極型左扁桃周囲膿瘍と診断した。喉頭ファイバー検査で上気道閉塞の危険があると判断し，緊急気管切開・膿瘍の切開排膿を行った。下極型扁桃周囲膿瘍の頻度は比較的稀とされてきたが，高齢者では口蓋扁桃が加齢により線維化することから，下極の膿瘍形成が多いと報告されている。本症例でも，歯ブラシ外傷によりできた中咽頭の血腫に感染し，リンパ組織の存在する下極に扁桃周囲膿瘍を形成したと考えられた。高齢者では認知機能低下や脳梗塞等の既存疾患により，典型的な症状や所見を示さないことが多い。発熱で来院した高齢者では感染源として常に鑑別にあげ，積極的に精査をし，適切な処置を迅速に行うべきである。

Axon and Schwann Cell Degeneration in Nerves of Upper Airway Relates to Pharyngeal Dysfunction in Snorers and Patients With Sleep Apnea

The pathophysiologic mechanism of nocturnal obstruction and swallowing dysfunction commonly occurring in patients with sleep apnea is unclear. The goal of this study was to investigate whether nerve injuries in the upper airways of snorers and patients with sleep apnea are associated with pharyngeal dysfunction and severity of sleep apnea. Twenty-two patients undergoing palatal surgery due to snoring and sleep apnea were investigated for a swallowing dysfunction by using videoradiography. Twelve healthy nonsnoring subjects were included as control subjects. Tissue samples from the soft palate at the base of the uvula were obtained in all patients and control subjects. Nerves and muscle were analyzed with immunohistochemical and morphologic methods, and the findings were correlated with swallowing function and degree of sleep apnea. In the soft palate of patients, nerve fascicles exhibited a significantly lower density of axons (5.4 vs17.9× 10-3 axons/μm2; P= .02), a smaller percentage area occupied by Schwann cells (17.5%vs45.2%; P= .001) and a larger number of circular shaped Schwann cells lacking central axons (43.0%vs12.7%; P< 0.001) compared with control subjects. The low density of axons was significantly related to degree of swallowing dysfunction (r= 0.5; P= .03) and apnea-hypopnea index > 5 (P= .03). Regenerating axons were frequently observed in patients compared with control subjects (11.3 ± 4.2%vs4.8 ± 2.4%; P= .02). Axon degeneration in preterminal nerves of the soft palate is associated with pharyngeal dysfunction in snorers and patients with sleep apnea. The most likely cause for the nerve injuries is traumatic snoring vibrations and tissue stretch, leading to swallowing dysfunction and increased risk for upper airway obstruction during sleep.

Indications for Elective Tracheostomy in Reconstructive Surgery in Patients With Oral Cancer.

Oral cancer surgery carries a high risk of upper airway obstruction; yet optimal airway management approach remains controversial. The purpose of the present study was to evaluate the use of tracheostomy in oncological patients undergoing oral cancer surgery with intra oral flap reconstruction. The study cohort included 75 patients with oral cancer, who underwent major intraoral resections and reconstruction with vascularized flaps. Thirty-six percent of the patients received elective tracheostomy (27 patients). Mean hospital stay of the patients with tracheostomy was 28.4 ± 12.5 days compared with 9.7 ± 2.1 days in the nontracheostomy patients. A scoring system rendered from this study suggests that patients with a total scoring at or above 8 should be considered for elective tracheostomy. With appropriate postoperative monitoring, selected patients can be managed without routine elective tracheostomy, yet, patients with comorbidities, mostly elderly patients, which undergo surgical resection and reconstruction in high-risk areas that can result in a bulky flap that pose danger to the postoperative airway, should receive elective tracheostomy.

Problem-based learning is suitable for the curriculum of “Sleep disorders and disease” for students in dentistry

The maintenance of good-quality sleep under adequate circadian rhythm during the night is important. A large body of evidence indicates that sleep disorders can induce several diseases, including metabolic syndrome and cardiovascular diseases. Understanding the fundamental physiological regulation of the sleep cycle and the pathophysiology of sleep medicine are thus important for clinicians as well as the general public. Among several sleep disorder-related diseases, accurate diagnosis and appropriate application of methods to treat obstructive sleep apnea syndrome and bruxism have been established for patients and healthcare workers in dentistry. 1–3 Oral appliance therapy has been reimbursable from governmental insurance in Japan since 2004. However, whether most dentists understand the pathophysiological condition of obstructive sleep apnea and hypopnea based on fundamental knowledge about the normal physiological features of sleep remains unclear. Dentists have made significant efforts to study the diagnosis of and therapy for obstructive sleep apnea and hypopnea syndrome by attending postgraduate training courses throughout their careers as clinicians. Dentists themselves suspect that the dental education curriculum focused on learning the normal physiology of sleep might be lacking before pathophysiological knowledge about sleep disorder-related diseases is obtained. At the Nagasaki University Faculty of Dentistry, we have introduced a new curriculum that focuses on “sleep disorders and disease” for fifth-year students before attending the start of clinical exercises in 2006. During the first year, in 2006, we used a curriculum that comprised six 90-min didactic lectures without using any other effective teaching methods used in other lectures. In 2010, we developed a curriculum using a problem-based learning (PBL) teaching method with a single scenario combined with several lectures. To understand the problems of current curriculum needing to be improved, from 2007 to 2013, we conducted a questionnaire survey asking students about several aspects related to the lecture content of “Sleep disorders and disease.” The questionnaire data show high percentages (>80%) for the validity both of the lecture for “Sleep disorders and disease” and of receiving practical training. Interest in clinical training, such as making an intraoral device, and evaluation of individual sleep cycles tended to show a gradual increase, with 71% of respondents in 2013 stating that “This training is absolutely necessary.” Sixty percent of students recognized the significance of PBL learning, selecting the answer of “Should absolutely undertake this learning.” The results in this study indicate that learning by PBL in combination with six didactic lectures was suitable for undergraduate students studying various aspects of sleep. The type of scenario will be improved for future curricula, because 26% of students replied “Several types of scenarios are needed.” The description of the questionnaire indicates that students desire both to positively adopt practice and training and to access more in-depth knowledge about obstructive sleep apnea. Providing updated guidelines on oral appliances (published by JSSR 30 September 2013) and indicating the possible physiological modulation of interactions between respiration and swallowing caused by modern orthodontic treatment and sleep surgery might be important. In addition, the risk of upper airway obstruction associated with sedative status during dental treatment should be recognized by

Linfangioma cervical fetal: diagnóstico prenatal y resultado perinatal

Se presenta el caso de un linfangioma cervical fetal, tumor de presentación infrecuente y potencial emergencia perinatológica, en relación al compromiso de las vías aéreas fetales. La ecografía y la resonancia nuclear magnética (RMN) son las herramientas para establecer el diagnóstico y pronóstico perinatal de los fetos portadores de linfangioma cervical, así como de otros tumores cervicales. El procedimiento EXIT coordinado con un equipo multidisciplinario debe ser planificado en casos en que el feto presenta un riesgo alto de obstrucción de la vía aérea.

Sugammadex for treatment of postoperative residual curarization in a morbidly obese patient

To the Editor, Small degrees of postoperative residual curarization increase the incidence of critical respiratory events (CREs) in the postanesthesia care unit (PACU). Certain patients, especially morbidly obese subjects, may be more susceptible to CREs, and prompt treatment is required when the situation occurs. This was the case in our patient who provided written consent for the publication of this report. A 44-yr-old woman (height 177 cm, weight 160 kg, body mass index 51 kg m) received a propofol and remifentanil general anesthesia for a laparoscopic sleeve gastrectomy. Her neuromuscular function was monitored by acceleromyography (AMG) (TOF-Watch , Organon Teknik, Ireland) at the adductor pollicis muscle. After anesthesia induction, we used calibration mode 1 on the TOF-Watch, which yielded a train-of-four (TOF) ratio of 1.06. Rocuronium 70 mg was given to facilitate tracheal intubation, followed by intermittent doses of 10 mg to maintain a TOF ratio 0.5 (100 mg iv total). At the end of the uneventful 85-min surgical procedure, remifentanil was discontinued and the propofol infusion was tapered. Neostigmine 4.5 mg and atropine 0.7 mg were administered when the TOF ratio was 0.14. Nine minutes later, the TOF ratio had increased to 0.91, and the propofol infusion was stopped. The tracheal tube was removed six minutes later as the patient was able to respond to verbal commands. The patient, on spontaneous breathing without signs of respiratory distress, was kept in a 30 head-up position and transferred within five minutes to the PACU with supplemental oxygen due to hypoxemia (oxygen saturation [SpO2] 92% on room air). After ten minutes in the PACU (30 min after neostigmine), the patient complained of weakness. Her SpO2 had decreased to 89%, requiring an increase in oxygen flow rate from 4 to 8 L min to maintain SpO2 [ 92%. Low stimulation current (30 mA) was applied to check the patient’s neuromuscular recovery, but no information could be obtained because of patient movement. Postoperative residual curarization was suspected, and sugammadex 50 mg was given. Within five minutes, the patient recovered completely and was able to breathe room air without oxygen (SpO2, [ 92%). The patient was discharged to the surgical ward after a twohour stay in the PACU without further complications. Postoperative CREs can occur despite recovery of a TOF ratio C 0.9 measured by AMG. Mechanomyography (MMG) is the gold standard for monitoring neuromuscular function. Baseline TOF ratio measured using MMG is usually 1.0 or very close to 1.0. Baseline TOF ratio measured by AMG is usually greater than 1.0 and varies widely among patients. Therefore a TOF ratio of 0.9 displayed during recovery does not always indicate adequate neuromuscular recovery unless the value is normalized with respect to baseline. If a CRE occurs after neostigmine, prompt treatment is required and sugammadex should be considered the drug of choice. Neostigmine may also reverse rocuronium-induced residual neuromuscular blockade (NMB), but it is associated with side effects and has a relatively slow onset of action, particularly in morbidly obese patients. Furthermore, there is a ceiling on its efficacy so that doses exceeding 5 mg are unlikely to achieve any additional effect. Finally, neostigmine may impair genioglossus function and decrease upper airway volume when administered after recovery from NMB. Thus, it increases the risk of upper airway obstruction and postoperative CREs, especially in morbidly obese patients. Sugammadex 2 mg kg M. Carron, MD (&) U. Freo, MD C. Ori, MD University of Padova, Padua, Italy e-mail: michele.carron@unipd.it

Temporal progression and spatial distribution of "normal" prevertebral soft tissue swelling following central corpectomy for cervical spondylotic myelopathy

To document the temporal progression and spatial distribution of prevertebral soft tissue swelling (PSTS) after central corpectomy (CC) and to determine the variables affecting its severity. The natural attributes of PSTS following CC for cervical spondylotic myelopathy (CSM) have not been characterized in literature. PSTS was measured at the C2 level and midpoint of the operated segment on lateral radiographs of the cervical spine taken pre-operatively and post-operatively (day 0, day 3/4, day 5 and day 6/7) in 93 patients with CSM undergoing one to three level uninstrumented CC. Patient's age, weight, Nurick's grade, number of corpectomy levels and intubation time were correlated with the PSTS. Proportionately, the swelling was maximal at the C2 level rather than at the level of CC, on all days, irrespective of the level of surgery. At the C2 level, the increase in PSTS was maximum by day 3/4 (P = 0.0001), whereas at the CC level, the PSTS continued to increase till day 5 (P = 0.0001). PSTS was higher in patients undergoing a three-level CC and in those with inclusion of C4 in the CC (P = 0.002). Patients undergoing CC are at risk for upper airway obstruction mainly at the C2 level in the first 3 days after surgery due to the PSTS. Those undergoing three-level CC, or having inclusion of C4 in the CC, have a greater degree of PSTS and have a higher risk of post-operative airway obstruction.

A case of penetrating axillary trauma

Deep penetrating traumas of the axilla extending to the neck are rare and potentially dangerous. An 11-year-old child presented with an impressive penetrating axillary injury extending to the neck after falling on a tree branch. The wound was explored in the operating room (OR). A fragment of the branch was removed without injuring any vascular structure. The only lesion concerned the hypopharynx. Cervical wounds may have an axillary origin. These wounds must be systematically explored in the OR, given the risk of upper airway obstruction and vascular lesion.

Upper airway obstruction associated with flexed cervical position after posterior occipitocervical fusion

Upper airway obstruction resulting from overflexion fixation of the cervical spine is a rare but life-threatening complication after cervical spine surgery. There are few reports of dyspnea after a posterior cervical fusion. We present the case of a 63-year-old woman with rheumatoid arthritis who developed an upper airway obstruction immediately after an O-C4 fusion. She was reintubated with a fiberoptic scope. Revision surgery allowing the angle to return to the neutral position was performed to ameliorate the overflexion of the cervical spine fixation and the consequent upper airway obstruction. After revision surgery, the upper airway obstruction disappeared. Our experience suggests that intraoperative use of fluoroscopy and extubation with a tube exchanger are recommended to avoid this complication, especially in patients at high risk of upper airway obstruction.

Tremulous arytenoid movements predict severity of glottic stenosis in multiple system atrophy

To determine whether tremulous arytenoid movements predict the severity of glottic stenosis in patients with multiple system atrophy (MSA), 28 MSA patients and 14 age-matched controls underwent fiberoptic laryngoscopy with video monitoring during wakefulness and under anesthesia induced by intravenous injection of propofol. Presence or absence of tremulous arytenoid movements was recorded during wakefulness. The ratio of glottic stenosis (%), which represents the extent of airway narrowing under anesthesia, was obtained by measuring the inspiratory glottic angle during wakefulness and under anesthesia. The median ratio of glottic stenosis was significantly higher in patients with MSA (57.5%) than in control subjects (0.5%). Tremulous arytenoid movements were characterized by shaking movements of the arytenoid region including the vocal folds, which are most apparent in the arytenoid cartilage. In this study, tremulous arytenoid movements were observed in 18 (64.2%) of 28 patients with MSA, who displayed a significantly higher median ratio of glottic stenosis (71.2%) than other patients (34.9%). None of the control subjects exhibited tremulous arytenoid movements. A clear correlation existed between the ratio of glottic stenosis and disease duration. Our observations indicate that tremulous arytenoid movements are a marker of the severity of glottic stenosis, which confers an increased risk of upper airway obstruction in patients with MSA.

Syndromic craniosynostosis: complicated airway obstruction calls for progressive strategies in surgical management

Evaluation of: Bannink N, Nout E, Wolvius EB, Hoeve HL, Joosten KF, Mathijssen IM. Obstructive sleep apnea in children with syndromic craniosynostosis: long-term respiratory outcome of midface advancement. Int. J. Oral Maxillofac. Surg. 39(2), 115–121 (2010).Children with syndromic craniosynostosis are at high risk for upper airway obstruction due to midface hypoplasia. Le Fort III osteotomy with midface advancement can expand the naso- and palatopharynx and potentially relieve obstruction. Short-term success has been demonstrated with these surgical techniques; however, little is known regarding the long-term effect of midface advancement on maintaining airway patency. The purpose of this study was to evaluate the long-term effect of midface advancement for treatment of severe obstructive sleep apnea in patients with syndromic craniosynostosis. Results showed that midface advancement had short-term (4 months) success in six of 11 patients with resolution of the need for positive airway pressure, tracheostomy or oxygen (54%); however, long-term success was maintained in only four of these six patients. All failures had concomitant hypopharyngeal obstruction, which cannot be corrected by midface advancement. Endoscopy and 3D CT scan may be useful for predicting which patients will require additional surgical procedures, such as mandibular or genio-hyoid advancement.

Hereditary angio-oedema in Denmark: a nationwide survey

Hereditary angio-oedema (HAE) is a rare disease caused by deficiency of complement C1 inhibitor (C1 inhibitor). The diagnosis is challenging as the disease can have a variety of clinical manifestations. In 2001 a national HAE comprehensive care centre was established and a search for these patients was initiated. To identify and characterize all patients with HAE in Denmark and increase awareness of the disease. Patients were recruited from hospital departments, dermatologists in private practice, Centres for Rare Diseases, the Danish patient organization and the national reference laboratory. Family interviews were conducted and medical records were evaluated. Information was spread through lectures, articles in popular magazines and via television. National guidelines for diagnosis and treatment were published. Eighty-two patients were identified. The mean diagnostic delay was 16.3 years. Five patients had HAE type II. Forty-five patients reported a characteristic serpiginous rash (erythema marginatum). More than 90% of patients had noticed precipitating factors before skin and mucosal swellings. Four patients underwent a total of eight tracheotomies and five families recalled 11 relatives who died of HAE. The minimal prevalence of HAE in Denmark is approximately 1.41 per 100 000 inhabitants. The risk of upper airway obstruction underlines the importance of diagnosing these patients. Precipitating factors, a preceding or concomitant serpiginous erythema and cutaneous swelling and/or abdominal pain attack and/or laryngeal oedema are clues to the diagnosis. As a consequence of this survey, information has been spread to patients, families and physicians.

Development of a tracheostomy scoring system to guide airway management after major head and neck surgery

The use of elective tracheostomy in major head and neck surgery is well established, although practice varies between units. There is no published method that reliably predicts the need for tracheostomy. This paper describes the development of a surgical scoring system designed to achieve that aim. The system was devised using data obtained retrospectively from 148 consecutive major head and neck procedures. These procedures were grouped according to the airway management plan in place at the end of the procedure: elective extubation (group E, 52 procedures, 50 patients); elective overnight ventilation via an endotracheal tube (group ETT, 55 procedures, 52 patients); and elective overnight ventilation via a tracheostomy (group T, 41 procedures, 41 patients). 8 patients from group ETT required a late tracheostomy for either medical or surgical indications. Using statistical methods, a threshold score was defined above which the high risk of upper airway obstruction should prompt consideration of an elective tracheostomy.

Cuff-leak test for the diagnosis of upper airway obstruction in adults: a systematic review and meta-analysis

To evaluate, in adults, the diagnostic accuracy of the cuff-leak test for the diagnosis of upper airway obstruction secondary to laryngeal edema and for reintubation secondary to upper airway obstruction. Systematic review without language restrictions based on electronic databases and manual review of the literature up to December 2008. When appropriate, a random-effects meta-analysis and meta-regression (Moses' method) were performed. Upper airway obstruction was the outcome in nine studies with an overall incidence of 6.9%. There was significant heterogeneity among studies. The pooled sensitivity was 0.56 (95% confidence interval: 0.48-0.63), the specificity was 0.92 (95% CI: 0.90-0.93), the positive likelihood ratio was 5.90 (95% CI: 4.00-8.69), the negative likelihood ratio was 0.48 (95% CI: 0.33-0.72), and the diagnostic odds ratio was 18.78 (95% CI: 7.36-47.92). The area under the curve of the summary receiver-operator characteristic (SROC) was 0.92 (95% CI: 0.89-0.94). Only three studies have evaluated the accuracy of the cuff-leak test for reintubation secondary to upper airway obstruction. Overall incidence was 7%. The pooled sensitivity was 0.63 (95% CI: 0.38-0.84), the specificity was 0.86 (95% CI: 0.81-0.90), the positive likelihood ratio was 4.04 (95% CI: 2.21-7.40), the negative likelihood ratio was 0.46 (95% CI: 0.26-0.82), and the diagnostic odds ratio was 10.37 (95% CI: 3.70-29.13). A positive cuff-leak test (absence of leak) should alert the clinician of a high risk of upper airway obstruction.

Midface advancement in craniofacial anomalies

Midface hypoplasia is a common finding in patients with complex craniosynostosis, like Apert, Crouzon and Pfeiffer syndrome. Midface hypoplasia presents with several clinical findings, most notably at the level of the airway, orbits, occlusion with reduced facial aesthetics and related psychosocial problems. These patients are at high risk for upper airway obstruction and undetected obstructive sleep apnoea syndrome (OSAS), but other factors such as adenotonsillar hypertrophy may be involved as well.