Urgent Tracheostomy Research Articles

Fluoroscopy- and Endoscopy-Guided Transoral Sclerotherapy Using Foamed Polidocanol for Oropharyngolaryngeal Venous Malformations in a Hybrid Operation Room: A Case Series.

Background: Treatment of oropharyngolaryngeal venous malformations (VMs) remains challenging. This study evaluated the effectiveness and safety of fluoroscopy- and endoscopy-guided transoral sclerotherapy for oropharyngolaryngeal VMs in a hybrid operation room (OR). Methods: Patients with oropharyngolaryngeal VMs who underwent transoral sclerotherapy in a hybrid OR were enrolled. Results: Fourteen patients (six females, eight males; median age of 26 years; range, 4-71 years) were analyzed. The symptoms observed were breathing difficulties (n = 3), snoring (n = 2), sleep apnea (n = 1), and swallowing difficulties (n = 1). Lesions were extensive in the face and neck (n = 9) and limited in the oropharyngolarynx (n = 5). A permanent tracheostomy was performed on two patients, while a temporary tracheostomy was performed on five patients. The treated regions were the soft palate (n = 8), pharynx (n = 7), base of the tongue (n = 4), and epiglottis (n = 1). The median number of sclerotherapy sessions was 2.5 (range, 1-9). The median follow-up duration was 81 months (range, 6-141). Treatment outcomes were graded as excellent (n = 2), good (n = 7), or fair (n = 5). The post-treatment complication was bleeding (n = 1), resulting in an urgent tracheostomy. Conclusions: Fluoroscopy- and endoscopy-guided transoral sclerotherapy in a hybrid OR can be effective and safe for oropharyngolaryngeal VMs.

Treatment of combined laryngocele using an endoscopic approach – a case report

Summary Laryngocele is a rare benign disease of the larynx that originates from dilating the laryngeal ventricles. The laryngocele communicates with the laryngeal lumen and so is filled with air. In case of closure, there can be an accumulation of pathological secret presented – mucus (laryngomucocele) and, in case of infection, the pus (laryngopyocele). We distinguish internal or combined laryngocele with the borderline of the thyrohyoid membrane. Clinical features dominate hoarseness, cough, dysphagia, foreign body sensation, and possibly dyspnea or neck mass. It can also be an incidental finding in imaging methods that are being done for other reasons. CT or MRI scans are fundamental in the diagnostic process because the clinical symptoms are not distinctive. The optimal treatment modality is surgery. An endoscopic approach is mainly used for the internal laryngoceles, and the external approach for the combined ones. Nevertheless, in the last few years, several works have been published concerning the use of the endoscope for the resolution, even in combined lesions. Most recently, also the use of transoral robotic surgery has gained popularity. We present the case of a 36-year-old patient who was taken to the local hospital for acute respiratory distress and must undergo an urgent tracheostomy. After the final diagnosis of large combined laryngomucocele was made, he was admitted to the tertiary hospital for definitive surgical treatment. The complete resection was made using the endoscope, and the patient was successfully freed from the tracheostomy tube. Key words laryngomucocele – minimally-invasive surgery – neck mass

Optimization of the complex treatment of patients with locally disseminated malignant thyroid tumors with invasion or compression of the upper respiratory tract

In recent years, the number of widespread malignant tumors of the thyroid gland with invasion or compression of the upper respiratory tract, most often with medium to low histological differentiation, has been increasing rapidly, which worsens the prognosis for the recovery of patients. The most important prognostic factors in the case of widespread malignant tumors of the thyroid gland are histological differentiation and the extent of tumor invasion. The urgency of the issue of comprehensive treatment of patients with locally disseminated malignant thyroid tumors is due to the lack of a single tactic, the choice of the scope of surgical interventions and resections of the upper respiratory tract is not defined.
 Objective — to determine medical and surgical tactics for improving the complex treatment of patients with locally disseminated malignant thyroid tumors with invasion and compression of the upper respiratory tract (URT), depending on the degree of spread and histological structure of the tumor.
 Materials and methods. In total, 2,300 patients with malignant tumors of the thyroid gland have been treated. The experimental group included 165 patients (7.2%) with T4a‑b category locally disseminated malignant thyroid tumors. The clinical and morphological characteristics of the patients in the general and experimental groups were analyzed and compared. The patients of experimental group demonstrated lower morphological differentiation of tumors, significantly higher number of regional and distant metastases, older patients’ age, that worsened the prognosis for recovery, and prevalence of men over women.
 Results. Most often, the tumor was disseminated in the URT, 55 patients had signs of URT stenosis of the I—III degree. Urgent tracheotomy was performed in 9 patients with pronounced stenosis of the III degree, which turned out to be very difficult, and 3 patients died during the operation or in the early postoperative period. In the case of initially inoperable T4b tumors, we performed neoadjuvant antitumor chemotherapy, the resulting tumor regression allowed for radical surgery in most patients. Various resections of the latter with the application of a tracheostomy or primary anastomosis were performed in patients with invasion of the upper respiratory tract. The effectiveness of various methods was analyzed depending on the prevalence of invasion and morphological differentiation of the tumor. In the experimental group of radically operated patients, the mortality rate was 31.0%, the recurrence rate was 39.3%.
 Conclusions. The prognosis for recovery in the group of locally disseminated malignant thyroid tumors is worse due to the lower morphological differentiation of tumors, older age of patients, and a greater number of regional and distant metastases. In case of URT stenosis, it is advisable to prepare the patient for radical surgery with intraoperative placement of a tracheostomy. In the case of an initially inoperable tumor, it is advisable to carry out neoadjuvant polychemotherapy. Surgical treatment of locally disseminated malignant thyroid tumors should be as radical, «aggressive» as possible, and the choice of the method of resection of the upper respiratory tract depends on the prevalence of invasion and the degree of differentiation of the tumor, and must comply with oncological principles.

Diagnostika a léčba krčního emfyzému

Introduction: Emphysema of the neck represents a crucial symptom of swallowing/respiratory pathways injuries or rarely passes to the neck area from diff erent locations. The clinical image can develop dramatically in the fi rst hours after onset and frequently the etiology remains unclear. Dyspnoea, dysphagia, retrosternal or interscapular pain usually follows. In the diff erential dia gnosis, not only traumatic etiology but also other acute conditions must be considered – e. g. acute coronary syndrome etc. The size of emphysema varies, also head and chest area can also be aff ected. Pneumomediastinum or partial pneumothorax are also often presented. The primarily aim of this paper is to discuss a dia gnostic and therapeutic possibilities, not to determine the incidence of emphysema. Methodology: This is a retrospective multicenter study involving patients from three regional ENT departments – Pardubice Hospital, Hradec Králové University Hospital and Liberec Hospital over a period of 15 years (2005–2020). Only clinically signifi cant emphysema, emphysema of unclear origin and emphysema requiring intensive care were in-rolled. Results: In a group of 15 patients, there are the following causes of cervical emphysema – 3 laryngeal injuries, 3 Hamman’s syndromes, 2 tracheal intubations, 2 traumas of swallowing pathways, 2 in COVID-19 disease, 1 tonsillectomy, 1 urgent tracheostomy and 1 sneezing. Etiologically, the Valsalva maneuver is an important (co)factor, dominating especially in adolescents and young adults (53%, 8 patients). Traumatic etiology occurred at the age of 17–53 years (33%, 5 patients). Iatrogenic involvement is more common over the age of 55 years. Pneumomediastinum occurred in 47% and partial pneumothorax in 40% of patients. Four of those initially unclear cases are discussed in detail. Conclusion: Imaging methods and endoscopic examination are indicated in a patient with cervical emphysema of unclear origin. Prophylactic use of broad-spectrum antibio tics, observation and interdisciplinary cooperation are always necessary. Key words emphysema – Hamman’s syndrome – pneumothorax – pneumomediastinum – covid lung injury

A case of generalized tetanus with classical ‘risus sardonicus’

A 50-year-old farmer presented with dysphagia and chest tightness following foot trauma for the last three days. On examination, he had nuchal rigidity, trismus, and hypertonia. A characteristic ‘Risus Sardonicus’ face was noticed (Figure 1). The patient also developed generalized painful spasms and respiratory distress with stridor, following which an urgent tracheostomy was done. Based on clinical presentation, a clinical diagnosis of generalized tetanus was considered. He was given 0.5 ml intramuscular tetanus toxoid and 3000 IU of human tetanus immunoglobulin.

A Transient Inferolateral ST-Segment Elevation on the Electrocardiogram Due to an Iatrogenic Left-Sided Pneumothorax After an Urgent Tracheostomy in a Patient with Metastatic Hypopharynx Cancer.

The presence of ST-segment elevation on the electrocardiogram alerts physicians in patients with chest pain. Emergency coronary angiography is usually performed in these patients. However, there are many conditions that cause ST-segment elevation on the electrocardiogram, such as pericarditis, hyperkalemia, Brugada syndrome, hypothermia, and early repolarization. Pneumothorax is a rare complication of tracheostomy and its symptoms are sudden chest pain and dyspnea. Also, it has been known that pneumothorax may cause ST-segment changes on the electrocardiogram. We presented a transient inferolateral ST-segment elevation on the electrocardiogram due to an iatrogenic left-sided pneumothorax after an urgent tracheostomy in a patient with metastatic hypopharynx cancer and normal coronary angiogram.

Percutaneous dilational tracheostomy in complex anatomical and technical conditions

The work describes a clinical case of urgent percutaneous dilational tracheostomy in complicated conditions. The surgery was performed on a 47-year-old patient with decompensated stenosis of the larynx associated with a massive recurrent malignant tumor of the thyroid gland. It was not possible to perform a standard tracheostomy procedure due to widespread tumor infiltration of the trachea and soft tissues of the neck, extensive scars after previous operations, the inability to extend the neck due to Bekhterev’s disease. In addition, the patient developed severe dyspnoea in the supine position. Given the above, low percutaneous dilational tracheostomy was performed under local anesthesia directly above the jugular notch of the sternum in the patient’s sitting position. Due to the absence of specialized tools at the General Surgery Department of the Central District Hospital, a set for percutaneous nephrostomy was used. This technique can be used in urgent situations when it is impossible to perform standard conicotomy or tracheostomy.

Dyspnea and Dysphagia as First Sign of Hypopharyngoesophageal Lipoma

We present a rare case of a 72-years old male with a big lesion coming out from his mouth suddenly. Examination showed a mucosal lesion seen outside of the mouth, saliva running outside, he was not able to swallow, it was hard to speak and breathe for him. At the time of arrival the patient was stable, later developed a distress and dyspnoe because of the part of tumor inside of his mouth was moving in and out on breathing and was obstructing his airway. This situation required an urgent tracheostomy to secure the patient’s airway. After tracheostomy we continued with endaural approach technique to remove the tumor, the origin of lesion was identified within the postcricoid area. Lesion was removed safely, sent to histology with no complication after. Results came back as a lipoma pedunculated. Literature search did not reveal any cases of limb lipoma presenting with a sudden hanging tumor causing airway compromise and dysphagia, all cases were diagnosed during routine examination. Our case has proven that hypopharyngoesophageal lipoma can present as an acute condition and we have to be able to save and manage patients like this.

Congenital Arhinia—A Case Report

Congenital arhinia is a seldom defect and may be associated with other facial and systemic defects. It is described as complete absence of nose. Case Report: Neonates are obligate nasal breathers but our neonate with complete absence of nose adjusted well to breathing through mouth without any need of urgent ventilator support or tracheostomy. Conclusion: Neonates may adapt breathing through mouth and bypass major respiratory support that is oral intubation or tracheostomy.

A Case Report: Probably Concurrent Nasogastric Tube Syndrome and Cerebrovascular Disease in a Postoperative Patient

Nasogastric tube syndrome (NTS) is characterized by acute upper airway obstruction due to bilateral vocal cord paralysis. Although NTS is a rare cause of vocal cord paralysis, it has the potential of causing serious morbidities even mortality. We here with present a case of concurrent NTS and cerebrovascular disease patient. 73 year-old male was admitted to our university hospital emergency department with acute respiratory distress and stridor days after his cholecystectomy operation and laryngoscopy showed bilateral vocal cord paralysis. The patient was admitted to the intensive care unit (ICU) and urgent tracheotomy was performed. On the day after his discharge from the hospital, his vocal cord movements fully recovered state. Nasogastric tube syndrome can be considered in patient who complains because of acute upper airway obstruction with nasogastric tube inserted. Thinking NTS early may be reducing the complication rate.

DUPATTA STRANGULATION CAUSING TRACHEAL INJURY AND STENOSIS, A COMMON NORTH INDIAN SCENARIO: A CASE REPORT

ABSTRACT: Closed tracheal injuries are rare but are more frequent in northern India. Ladies wear Dupatta (A Scarf ) around the neck which causes strangulation injury when entangled in the rear wheel of motorcycle or rickshaw. Because of rarity of such cases, it is often difficult for physicians at periphery to diagnose it early adding to the morbidity. We report a12-years old girl who presented to us with severe stridor and grade III tracheal Stenosis following dupatta strangulation while she was riding motorcycle. She was previously treated with T-tube placement in the trachea for 6 months, which was removed a week back. The patient underwent urgent tracheostomy followed by CECT which showed 2cm grade III tracheal tenosis below the cricoid cartilage. The patient underwent tracheal resection and anastomosis. The patient recovered well, without any change in voice and restenosis on bronchoscopy in 5 months follow-up

A case of retropharyngeal emphysema as a complication of pneumothorax.

Retropharyngeal emphysema is a rare condition, and it is important to determine whether the patient presents with complications including pneumomediastinum or other severe clinical presentations such as an upper airway obstruction. In such cases, patients should undergo urgent tracheostomy and surgical neck drainage with concurrent administration of broad‐spectrum antibiotics.

A mycosis fungoides prognosztikai faktorai két betegünk kapcsán

Cutaneous T-cell lymphoma is a heterogeneous group of malignancies including both indolent and aggressive forms, with an average 5-year disease-specific survival rate of 11-100%. Prognostic factors in cutaneous T-cell lymphoma according to the different subtypes are not clearly defined, however extracutaneous manifestation seems to predict a poor prognosis. Tonsil involvement was revealed as a cause of oropharyngeal complaints in two of our male patients, treated for histologically confirmed tumour stage of mycosis fungoides. In the first case urgent tracheostomy followed by radiotherapy, while in the other case systemic treatment resulted in complete remission of the tonsil involvement. Both patients were subsequently lost due to the progression of mycosis fungoides. Factors predicting an unfavourable prognosis included extracutaneous manifestation, late stage disease, age over 60 years, elevated lactate-dehydrogenase levels, and large cell transformation. With our cases we would like to shed light to the prognostic markers of mycosis fungoides, and to the rare tonsil involvement, which is potentially life-threatening and requires urgent intervention.

Risk Factors and Outcomes of Postoperative Neck Hematomas: An Analysis of 5,900 Thyroidectomies Performed at a Cancer Center.

Introduction Postoperative neck hematoma (PNH) is an uncommon but potentially-lethal complication of thyroid surgery. Objective To identify the risk factors for postthyroidectomy hematoma requiring reoperation, the timing, the source of the bleeding, the related respiratory distress requiring tracheotomy, and the late outcomes. Methods We retrospectively analyzed the records of 5,900 consecutive patients submitted to surgery for thyroid diseases at a single institution. Results In total, PNH occurred in 62 (1.1%) patients. Most cases of bleeding occurred within the first 6 hours after thyroidectomy, but 12.5% of the hematomas were observed after 24 hours. Obvious bleeding points were detected in 58.1% of the patients during the reoperation, with inferior thyroid artery branches and superior thyroid vessels being the most frequent bleeding sources. Only two patients required urgent tracheostomy. There were no hematoma-related deaths. Permanent hypoparathyroidism and recurrent laryngeal nerve injury are more frequent following reoperation for PNH. The factors significantly associated with PNH were: older age, concurrent lymph node dissection, and chronic lymphocytic thyroiditis. Gender, previous neck irradiation, presentation at diagnosis (symptomatic or incidental), substernal goiter, thyroidectomy for hyperthyroidism, prior thyroid surgery, malignant histology, the extent of the surgery (total versus non-total thyroidectomy), the use of energy-based vessel sealing devices, the use of the hemostatic agent Surgicel, and the placement of a surgical drain were not significantly associated with PNH. Conclusion Hematoma after thyroid surgery is an uncommon complication, but it is related to significant postoperative morbidity. A better understanding of the risk factors and of the time until hematoma formation can help target high-risk patients for preventive measures and closer postoperative observation.

An unusual cause of infant\u2019s stridor \u2013 congenital laryngocele

Congenital laryngocele is an uncommon cause of neonatal stridor. There are only a few cases reported in the literature. The authors present a successfully treated case of an infant, whose life could only be saved by urgent tracheostomy. On the 5th postoperative day endoscopic excision and marsupialization provided patent airway. The patient could be decannulated. During follow-up no recurrence was observed.

Laryngeal Stenosis, a Complication of Multifocal Tuberculosis

Laryngeal stenosis is a permanent, usually acquired, narrowing of the laryngeal duct. Due to the pandemic of Acquired Immunodeficiency Syndrome (AIDS), the etiology of tuberculosis must be investigated. However, the signs of presumption are not specific. Management is controversial and remains difficult in our work context in an under-medicated country south of the Sahara. The purpose of the work is to report a case of laryngeal stenosis secondary to multifocal tuberculosis to discuss the difficulties associated with its management. This was a 35-year-old smoking patient with 25 packs / year. Admitted on 04/12/2017 to the ENT and Head and Neck Surgery Department for assessment of dysphonia associated with unencrypted slimming. The performed laryngoscopy showed disseminated ulceration of the laryngeal margin, and the histology showed granulomatous laryngitis. The intradermal reaction to tuberculin measured 10 mm. A chest X-ray performed on the face showed a chronic interstitial-bronchial syndrom. The diagnosis of laryngeal tuberculosis secondary to a pulmonary focus was retained. The course was marked by the sudden onset of laryngeal dyspnea requiring urgent tracheotomy. Postoperative examination of the larynx revealed synechia of the larynx. Anti-tuberculosis therapy for six months has resulted in favourable outcomes. However, it was noted a complication type laryngeal stenosis despite the attempted re-stabilization with impossibility to decant the patient. Laryngeal stenosis secondary to multifocal tuberculosis remains a rare and dreadful pathology. Therapeutic success depends on early and adequate management.

Dysphagia and Dyspnea Caused by Large Anterior Cervical Osteophyte

Background Data: Unfortunately, large anterior cervical osteophytes are a forgotten cause of dysphagia and dyspnea. They can cause marked change in diet habits or interfere with patients’ daily activities and sleep without significant neck pain or radicular pain. Diffuse idiopathic skeletal hyperostosis, ankylosing spondylitis, degenerative changes, and prior trauma including surgery can cause cervical osteophytes. Conservative medical treatment and diet modification may be a useful option when treating these patients; however, surgery may be mandatory, in particular with sever progressive symptoms not responding to conservative measures with excellent results and accepted incidence of complications. Study Design: This is a retrospective clinical case study. Purpose: To highlight this uncommon cause of dyspnea and dysphagia and define the possible management strategies. Patients and Methods: This study was conducted in Mansoura University Hospital on nine patients presented with dysphagia, dyspnea, or both. The cause of their symptoms was large anterior cervical osteophytes. Six patients were males and 3 were females with their age ranged from 53 to 75 years. All patients were assessed by X-ray, CT, and MRI of the cervical spine and underwent fiber optic nasoendoscopy to assess posterior pharyngeal wall and other causes of upper airway obstruction. All patients had a trial of conservative measures including anti-inflammatory, antireflux medication, corticosteroids, diet modification, and consultations with specialists in rheumatology and speech and swallowing therapy. Results: Of the 9 patients, three patients improved on the above-mentioned conservative measures, and one patient who presented with stridor underwent urgent tracheostomy and refused further surgery. Five patients who failed conservative therapy for at least three months underwent surgical excision of their osteophytes through anterior cervical approach. Improvement of surgical group was satisfactory according to the Dysphagia Scoring System. Conclusion: Although large anterior cervical osteophyte is a rare cause of dysphagia and dyspnea, it should be checked and excluded especially in elderly patients. Adequate conservative therapy is a valid effective option; however, surgery in some of these patients may be simple, safe, and effective. (2019ESJ188)

Submental intubation versus tracheostomy in maxillofacial fractures.

To compare submental intubation with tracheostomy in patients with maxillofacial fractures who were operated under general anesthesia and nasotracheal intubation was contraindicated. This prospective comparative study was conducted on 32 patients undergoing maxillofacial operations. All patients had a panfacial trauma (including naso-ethmoid orbital fracture combined with mandibular fracture). Patients who had unstable cervical vertebra, laryngeal trauma, urgent tracheostomy, and patients with expected prolonged postoperative ventilation were excluded from the study. Patients were randomly assigned to elective tracheostomy and submental intubation groups. The patients were evaluated according to the time required to do elective tracheostomy or submental intubation, the operation comorbidity and complications, and the postoperative scar. The average time required to do submental intubation was 8.35min versus 30.75min required to do elective tracheostomy with significant difference (p < 0.0001). No complication was reported with submental intubation while in elective tracheostomy group, surgical emphysema was registered in two patients. The submental scar was acceptable in all patients while the tracheostomy scar needs scar revision in four cases (p = 0.0325). Submental endotracheal intubation appeared to be a simple, safe, and significantly faster reliable alternative to tracheostomy during surgical reconstruction of selected cases of maxillofacial fractures without indication for prolonged postoperative ventilation support with significantly lower morbidity.

Cost analysis of intraoperative neural monitoring

The recurrent laryngeal nerve (RLN) injury represents one of the most feared complications during thyroidectomy (1). These injuries may cause a temporary or permanent palsy of the RLN and occur, more frequently, monolaterally. If only one side is involved, the palsy results in voice changes, hoarseness, or breathing trouble; in bilateral cases, instead, patients can undergo a potentially fatal airway obstruction needing an urgent tracheostomy (1). This complication, affects the quality of life of the patients, increases the charges for health care, and is the most frequent plea of lawsuits against thyroid surgeons.

Laryngeal condroma

The authors report the case of a 71-year-old patient who is admitted into our hospital with acute respiratory failure, which required urgent tracheotomy. The cli­ni­cal and paraclinical examinations (endoscopic exa­mi­nation, cervical computer-tomography, pulmonary ra­dio­gra­phy, histopathological and immunohistochemical exa­mi­na­tion) establish the diagnosis of laryngeal condroma. The therapeutic method of choice is surgery – in this case, external cricoid tumor ablation through median thy­ro­tomy. The evolution was favorable, the patient being decannulated 30 days postoperatively.