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PubMed2002

Upper airway diseases and airway management: a synopsis.

This article summarizes some of the more important upper airway conditions likely to affect airway management. A number of upper airway conditions may present difficult challenges to the anesthesiologist. For instance, infected airway structures may lead to partial airway obstruction, stridor, or even complete airway obstruction. Partial airway obstruction may be mild, as in snoring or nasal congestion, or may be more severe, perhaps requiring the use of airway adjuncts, such as a nasopharyngeal airway. Complete airway obstruction is usually managed by prompt intubation, but surgical airways are sometimes needed as a last resort.

Anesthesia↗
PubMedDate not supplied

Viral croup: a current perspective.

Viral croup is the most common cause of upper airway obstruction in children 6 months to 6 years of age. Parainfluenza virus accounts for the majority of cases. The disease is characterized by varying degrees of inspiratory stridor, barking cough, and hoarseness because of laryngeal and/or tracheal obstruction. The diagnosis is mainly a clinical one and diagnostic studies usually are not necessary. The management has altered dramatically in the past decade. Good evidence exists to support the routine use of corticosteroid in all children with croup. Intervention at an earlier phase of the illness will reduce the severity of the symptoms and the rates of return to a health care practitioner for additional medical attention, visits to the emergency department, and admission to the hospital. Most children respond to a single, oral dose of dexamethasone. For those who do not tolerate the oral preparation, nebulized budesonide or intramuscular dexamethasone are reasonable alternatives. Nebulized epinephrine should be reserved for patients with moderate to severe croup. Simultaneous administration of corticosteroid and epinephrine reduces the rate of intubation in patients with severe croup and impending respiratory failure.

Administration, Inhalation↗
PubMed2000

PVCM, PVCD, EPL, and irritable larynx syndrome: what are we talking about and how do we treat it?

Paroxysmal vocal cord movement/motion (PVCM), paroxysmal vocal cord dysfunction (PVCD), episodic paroxysmal laryngospasm (EPL), and irritable larynx syndrome (ILS) are terms used to describe laryngeal dysfunction masquerading as asthma, upper airway obstruction, or functional and organic voice disorders. The differential diagnosis of PVCM, PVCD, EPL, and ILS is critical to successful medical and behavioral management of the patient. During the past 10 years, 27 subjects, ages 15-79 years, were identified to have paroxysms of inspiratory stridor, acute respiratory distress, associated aphonia and dysphonia, resulting in misdiagnosis and unnecessary emergency treatments, including endotracheal intubation, cardiopulmonary resuscitation, massive pharmacotherapy, or tracheostomy. A multifactorial management program is proposed utilizing principles of motor learning, neurolinguistic programming model, respiratory and phonatory synchronization, relaxation techniques, concurrent monitoring of behavioral adjustments, and formal psychological counseling.

Adolescent↗
PubMed2002

Laryngeal chondroma.

Cartilaginous tumors of the larynx represent less than 1% of laryngeal tumors. Chondroma and "low-grade" chondrosarcoma are the most common; 70%-75% of these tumors arise on the endolaryngeal surface of the posterior lamina of the cricoid cartilage. The clinical presentation is varied and directly dependent on the size and location of the tumor; stridor, hoarseness, dyspnea, or a neck mass are common presenting signs. CT scanning in the axial plane is the mainstay of radiographic imaging due to its ability to show size, extent of the tumor, and invasion into surrounding structures. Surgical extirpation is the standard therapy with no role for radiation therapy or chemotherapy. Although significant recurrence rates have been reported, there is not a significant difference between initial conservative therapy followed by salvage therapy versus initial radical therapy.

Aged↗
PubMed2002

Bilateral mixed laryngoceles: simultaneous strobovideolaryngoscopy and external video examination.

A music medicine practice affords a unique opportunity to diagnose and treat laryngeal music performers. Strobovideolaryngoscopic (SVL) and external video examination of the voice professional or brass instrument player may focus on the vocal folds, yet abnormalities of the supraglottis, neck, and thorax should be appreciated and documented. Laryngoceles are uncommon laryngeal disorders but may occur in up to 5% of benign laryngeal lesions. While many laryngoceles are asymptomatic, they may cause a cough, hoarseness, stridor, sore throat, pain, snoring, or globus sensation. In particular, musicians who play brass instruments are at high risk for laryngocele development. We highlight two patients with symptomatic laryngoceles to present anatomical, historical, classification, epidemiological, diagnostic, and management considerations.

Cysts↗
PubMed1996

Episodic paroxysmal laryngospasm: voice and pulmonary function assessment and management.

Episodic paroxysmal laryngospasm (EPL) is a sign of laryngeal dysfunction, often without a specific organic etiology, which can masquerade as asthma, vocal fold paralysis, or a functional voice disorder. The intermittent respiratory distress of EPL may precipitate an apparent upper airway obstructive emergency, resulting in unnecessary endotracheal intubation, cardiopulmonary resuscitation, or tracheostomy. During 27 months, seven women and three men, age 30-76 years, were assessed by a high diagnostic index of suspicion, an intensive history including psychosocial factors, physical examination of the airways, provocative asthma testing, and swallowing studies. Videolaryngoscopy, stroboscopy, and pulmonary flow-volume loop testing were definitive. The classic appearance was paradoxic inspiratory adduction of the anterior vocal folds with a posterior diamond-shaped glottic gap. During an attack of stridor or wheezing, attenuation of the inspiratory flow rate as depicted by the flow-volume loop suggested partial extrathoracic upper airway obstruction. Swallowing evaluation by videolaryngoscopy and videosophagography may uncover gastroesophageal reflux disease. Hallmarks of management include patient and family education by observation of laryngoscopic videos, a specific speech therapy program, psychotherapy, and medical treatment of associated disorders. Electromyography may become a valuable future adjunct. Unlike laryngeal dystonia, patients with EPL do not benefit from botulinum toxin type A.

Adult↗
PubMed1996

Traumatic vocal fold avulsion injury in a newborn.

A full-term newborn developed respiratory compromise in the immediate postparturition period requiring urgent intubation. Evaluation of post-extubation stridor later the same day revealed an avulsion injury extending from the left vocal fold into the lateral glottic musculature. Primary repair was accomplished with anatomic realignment of the torn vocal fold and muscle. Endotracheal intubation was utilized for stenting and the patient was extubated following 3 days of paralysis with sedation. Follow-up examination revealed a reparative granuloma, which was lasered. Eight-week follow-up examination revealed normal vocal fold architecture. At 18 months the patient continues to have a normal voice and normal laryngeal development.

Granuloma, Laryngeal↗
PubMed1997

Laser bronchoscopy with transglottic/supraglottic ventilation to relieve dysphonia and subglottic obstruction.

Dysphonia after endotracheal intubation usually indicates a glottic lesion but it can also herald an obstructing subglottic airway mass. Outpatient strobovideolaryngoscopy may be anatomically extended by transglottic videotracheobronchoscopy to achieve a thorough examination of the proximal bronchi, trachea, subglottis, glottis, and supraglottis in selected cases. Combining these techniques with lateral soft tissue x-ray studies of the neck in two patients with dysphonia and stridor, nearly identical postendotracheal intubation subglottic severely obstructing granulation "tumors" were diagnosed. Operative subglottic resection with a rigid ventilating laser bronchoscope combined with transglottic/supraglottic anesthetic ventilation techniques and contact-tip Nd-YAG laser phototherapy relieved the dysphonia and airway obstruction simultaneously. Normal vocal quality and full anatomical airway patency were achieved in both cases. Follow-up postoperative vocal rehabilitation and medical therapy sustained the surgical results.

Aged↗
PubMedDate not supplied

Complications of transesophageal echocardiography in ambulatory adult patients: analysis of 1500 consecutive examinations.

Transesophageal echocardiography is a new approach that can be used to image cardiac structures. It combines two existing technologies: cardiac ultrasound and endoscopy. To obtain a cardiac image, the transesophageal probe has to be positioned properly within the esophagus. The first 1500 consecutive transesophageal echocardiographic examinations in ambulatory adult patients from one center were analyzed to identify conditions associated with failed esophageal intubation and procedural complications. Esophageal intubation was not achieved in 11 patients (0.73%). The reasons for the failure of intubation were operator inexperience, hypersensitive pharynx despite topical anesthesia, and cervical spondylosis. Six of those patients also had a history of dysphagia. Procedural complications were identified in seven patients (0.47%). Tracheal intubation was present in four patients, with immediate development of stridor and incessant cough in two patients. Atrial fibrillation developed in two patients--one had atrial myxoma and one had mitral stenosis. Bronchospasm developed during the transesophageal examination in one patient who was receiving long-term treatment for bronchial asthma. We conclude that transesophageal echocardiography is feasible in most adult patients in the ambulatory setting and that the complication rate is very low. Proper patient selection and preparation are crucial to the successful performance of this procedure.

Adult↗
PubMed2000

[Upper airway obstruction (foreign bodies excluded)].

Upper airway obstruction is a frequent cause of admission to the emergency department and the intensive care unit. Symptoms are mainly represented by dyspnea and stridor. Severity must be rapidly assessed to allow adapted treatment and avoid cardiac arrest and hypoxic encephalopathy. The possible etiologies are numerous, with acquired and congenital ones, but the majority is represented by laryngitis, lymphoid hypertrophy and laryngotracheomalacia. In case of respiratory failure, treatment must first establish airway patency with bag and mask ventilation, and then intubation. If vital prognosis is not threatened, biologic, radiologic or endoscopic examination can be performed to identify the cause of the obstruction and treat it.

Age Factors↗
PubMed2001

[Tracheomalacia and tracheal dyskinesias].

Tracheomalacia is characterized by an expiratory tracheal collapse. The revealing clinical features usually occur after a symptom-free period during the first year of life (during the first three months in 60% of cases): mainly stridor, wheezing, chronic cough, apnoeic attacks, and difficult breathing. Tracheoscopy allows the differentiation of primary tracheomalacia and tracheomalacia secondary to pressure on the trachea from the vascular ring or mediastinal tumour. Tracheomalacia is also frequently associated with oesophageal atresia. Surgical treatment is indicated in severe and secondary forms.

Apnea↗
PubMed1999

[Childhood croup].

Hoarseness, whooping cough and stridor are elements of a syndrome of upper airway obstruction. In childhood, acute laryngotracheobronchitis is by far the commonest cause of this syndrome. Yet, the differential diagnosis includes a number of rare and severe entities. In many cases, the traditional distinction between viral and spasmodic types is not possible. The value of humidifying therapy has not been established. In severe cases, nebulized adrenaline is of benefit but should be reserved for hospital. The effect lasts only two hours and at times a rebound effect is observed. It is now realized that some patients treated with adrenaline can safely be discharged after a two to three hours observation. There is a large body of evidence that all children arriving at the emergency department with croup should receive steroids without delay. This policy results in a much better outcome, with important reduction in hospitalizations, intensive care unit admissions and incubations. Oral dexamethasone is the drug of choice: it is as effective, easier to administer and cheaper than nebulised budesonide. In most studies, dexamethasone has been used at a dose of 0.6 mg/kg but there is some evidence that 0.15 mg/kg may be just as effective.

Child↗
PubMed1997

Removal of the laryngeal mask airway in children: deep anesthesia versus awake.

STUDY OBJECTIVE: To compare the incidence of adverse airway events identified with removal of the laryngeal mask airway (LMA) from an awake child or from a child before his or her airway reflexes had returned. DESIGN: Prospective, randomized study. SETTING: University-affiliated children's hospital. PATIENTS: 333 ASA physical status I and II patients ages 1.5 to 15 years undergoing elective surgery. INTERVENTIONS: At the time of removal of the LMA at the end of surgery, patients were anesthetized or had intact airway reflexes. MEASUREMENTS AND MAIN RESULTS: Any airway problems occurring within 15 minutes of LMA removal were recorded. These problems included airway obstruction (laryngeal spasm and biting of the LMA), peripheral hemoglobin oxygen saturation less than 90%, stridor requiring manipulation of the airway, vomiting, retching, and excessive salivation. Airway problems occurred after LMA removal among 23 children who had their LMA removed prior to return of airway reflexes, and among 13 subjects who had their LMA removed after the return of airway reflexes. CONCLUSION: Removal of the LMA during anesthesia and after return of airway reflexes results in a similar incidence of airway problems in children.

Adolescent↗
PubMed1999

Awake fibreoptic intubation, airway compression and lung collapse in a parturient: anaesthetic and intensive care management.

A 28-year-old primigravida at 35 weeks gestation with acute onset of dyspnoea and stridor due to an intrathoracic neoplasm required semi-urgent caesarean section to allow diagnosis and treatment. Her inability to lie supine precluded regional anaesthesia. She underwent awake fibreoptic oral intubation followed by general anaesthesia. This was complicated by desaturation, high airway pressures, unilateral lung collapse, venous congestion and unexpected blood loss due to an undiagnosed placenta praevia.

Journal Article↗
PubMed1998

Phase II study of oxaliplatin in poor-prognosis non-small cell lung cancer (NSCLC). ATTIT. Association pour le Traitement des Tumeurs Intra Thoraciques.

The aim of this phase II study was to determine the antitumour activity and safety of trans-1-diaminocyclohexane-platinum (oxaliplatin) in previously untreated advanced non-small cell lung cancer (NSCLC) patients. 33 patients with unresectable and measurable NSCLC were entered into this phase II study between January 1992 and January 1994. Patients had either locoregional disease with performance status 2 (19 patients) or a stage IV disease (14 patients). Oxaliplatin (130 mg/m2) was given on an out-patient basis (2-h infusion, every 21 days) without hydration. Response was assessed after every two courses. One hundred courses were administered, with a mean of three courses per patient (range 1-12). All patients were evaluable for response; 1 had a complete response, and 4 a partial response (overall response rate 15%, 95% confidence interval 5.1-31.9%). The median response duration was 5.9 months. All cycles (n = 100) were evaluable for toxicity assessment. Transient reversible, cold-related finger dysesthesias occurred in 29 patients, but were mild, and disappeared in most cases within a few days. We observed brief episodes of pharyngolaryngeal discomfort (8 patients, 11 episodes) accompanied in 4 cases (3 patients), by transient episodes of inspiratory stridor, leading 2 patients to treatment withdrawal. We conclude that oxaliplatin has activity in poor-prognosis NSCLC and that this treatment is feasible in out-patients; the absence of renal and haematological toxicity makes this drug a good candidate for further evaluation in NSCLC.

Aged↗
PubMed2003

Spasmodic dysphonia: clinical features and effects of botulinum toxin therapy in 169 patients-an Australian experience.

Adductor spasmodic dysphonia (SD) is a focal laryngeal dystonia, characterised by strangled, effortful speech with breaks in pitch and phonation. Injection of laryngeal muscles with BTX is widely used in the treatment of SD. A consecutive series of 169 patients with SD, of whom 144 were treated with BTX injections, seen at St. Vincent's Hospital between 1983 and 1999 were studied prospectively. Patients underwent neurological, quantitative voice and otolaryngological assessment. Females (62.1%) outnumbered males (37.9%) and the mean age at diagnosis was 56 years (range 19-88). Adductor SD (89.4%) was more frequent than abductor SD (1.8%) or mixed SD (4.7%). Stridor was present in 14 patients (8.3%) and in 7 was the sole manifestation of the laryngeal dystonia. The median treatment outcome score was excellent in 63.2%, very good in 18.5%, satisfactory in 14.7% and unsatisfactory in 3.5%. Poorer treatment outcome was associated with abductor SD (OR = 4.69, CI [1.23, 17.92] p=0.024] and age >65 (OR = 2.83, CI [0.95, 8.42] p=0.049). Mild post-injection paralytic dysphonia was associated with longer lasting treatment (4.42 vs. 3.62 months p<0.001) and superior treatment outcome rating (1.37 vs. 1.81 p<0.001). We conclude that BTX injections are highly effective and severe adverse events are rare. Older age and abductor SD may confer a relatively poorer treatment outcome. Mild post-injection paralytic dysphonia may be a marker for more effective and lasting treatment in adductor SD.

Adult↗
PubMed1992

G syndrome: a review of the literature and a case report.

In 1969, Opitz et al. reported the first case of G Syndrome (Opitz-Frias Syndrome). They presented their clinical observations on 4 brothers from the 'G Family' who shared a constellation of findings with a generalised tendency to midline defects. Major manifestations of this multiple congenital anomaly syndrome include hypertelorism, prominent forehead, cleft lip and palate, narrow palpebral fissures with epicanthal folds, dysphagia, stridor, laryngotracheal oesophageal clefts, and hypospadias. The most significant manifestation of a midline field developmental defect in these infants is aspiration which poses the greatest threat to life. Urgent evaluation should include a water-soluble contrast oesophagram and aerodigestive endoscopy. In addition to repair of the laryngeal cleft, which occurs in approximately 30% of the cases, a tracheostomy, feeding gastrostomy, and Nissen fundoplication are often needed. We report a male infant born with G. syndrome. BBB Syndrome (Opitz Syndrome) is also discussed which bears a striking resemblance to the G Syndrome; in fact, they may be variants of the same allelic syndrome.

Abnormalities, Multiple↗
PubMed2002

Tracheal stenosis caused by false aneurysm of the right subclavian artery.

The development of tracheal stenosis following insertion of a central venous catheter is a rare complication of this procedure. We present the case of an 81-year-old woman, who suffered acute onset of dyspnea, stridor and dysphagia 4 weeks after coronary artery bypass surgery. Investigations revealed a false aneurysm of the right subclavian artery, compressing the trachea and the oesophagus. The iatrogenic lesion was caused by the insertion of a central venous catheter via the right subclavian route. By the time symptoms developed the catheter had already been removed.

Aged↗