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Background: Limited data exist regarding the diagnostic accuracy of synovial fluid leukocyte count (SFLC) in diagnosing periprosthetic shoulder infection (PSI). The main objective of this study was to determine the diagnostic value of leukocyte count at a common threshold of 3 cells/nL and the optimal cut-off value. Methods: Patients who underwent shoulder arthroplasty revision surgery and aspiration with SFLC between 2012 and 2023 were retrospectively included. The International Consensus Meeting 2018 definition was used to characterize infection status for SFLC threshold and synovial fluid neutrophil percentage (SFNP). Sensitivity and specificity were presented using cross tabulation. The area under the curve was calculated, and the optimal cut-off was determined using maximized Youden Index. Results: 35 cases with an average age of 71 years (43% male) were included in our study. At a threshold of 3 cells/nL, SFLC showed a sensitivity of 70% and specificity of 83%. The corresponding positive and negative predictive values (PPV and NPV) were 89% and 59%, respectively. We found the optimal cut-off for our cohort at 4.7 cells/nL, increasing specificity to 92% while maintaining sensitivity at 70% (PPV = 94%, NPV = 61%). SFNP at a cut-off of 80% demonstrated 50% sensitivity and 91% specificity, with corresponding PPV and NPV of 92% and 48%, respectively. The optimum threshold for SFNP was 54%, which had a sensitivity of 77% and a specificity of 64%, as well as a PPV of 81%, and NPV of 58%. The area under the curve was 0.72 for SFLC and 0.74 for SFNP. Sonication detected pathogens in 63% of cases, while 57% of all cases showed positive tissue cultures and 43% positive aspirate cultures. Especially, the most frequently found microorganism, Cutibacterium acnes, was detected less often in aspirate culture. Conclusions: SFLC shows good specificity but moderate sensitivity for diagnosing PSI when using a threshold of 4.7 cells/nL. Therefore, it can serve as a confirmatory test for diagnosing PSI but not for ruling out infection.

This study delves into the relationship between individual vaccination aspirations and their repercussions within the SEIRS epidemic framework, exploring effects on vaccination behavior, infection dynamics, and societal outcomes through the Vaccination Game concept. The co-evolution of epidemic dynamics and individual decision-making is examined, utilizing the social efficiency deficit (SED) to quantify a social dilemma. A novel aspiration-based model is compared with the conventional cost-based model. Higher aspiration levels correspond to increased vaccination rates, reducing overall infections. Contrary to assumptions favoring natural infection in low transmission scenarios, vaccination proves pivotal even in such contexts. Elevated transmission and immunity waning rates necessitate intensified vaccination for effective infection control, thereby reducing social dilemmas. Low vaccine efficiency coupled with high transmission rates escalates SED, but a specific vaccine efficacy threshold notably diminishes SED. Lower aspiration levels contribute to vaccine hesitancy, elevating SED, and infection rates. Surpassing an aspiration threshold redirects preferences towards vaccination, aligning with socially optimal scenarios and alleviating social dilemmas. The comparative analysis underscores the aspiration-driven approach outperforms in reducing SED, establishing its reliability in mitigating societal disease impact over the cost-based approach, but the optimal choice depends on specific epidemic conditions

Basilar artery (BA) fenestration and its occlusion are relatively rare conditions. Mechanical thrombectomy for fenestrated BA occlusion has a high risk of complications. One limb occlusion or partial occlusion of fenestration mimics arterial stenosis or dissection. We present the case of a 75-year-old woman who presented with slight dysarthria, which subsequently worsened. Magnetic resonance imaging, magnetic resonance angiography, and basi-parallel anatomical scanning (BPAS) revealed BA fenestration and occlusion of the larger limb of the fenestrated BA, for which we performed thrombectomy with aspiration and achieved Thrombolysis in Cerebral Infarction Grade 3 flow restoration without procedure-related complications. If BA occlusion occurs at a site where a thrombus does not normally occur, confirming the anatomy of the BA before thrombectomy is desirable. As we obtained information on BA fenestration and occluded limb diameter using preoperative BPAS, we were able to safely achieve effective recanalization by guiding a relatively large-diameter aspiration catheter to the thrombus coaxially with a micro-guidewire and microcatheter.

A 51-year-old male presented to our tertiary referral hospital with progressive shortness of breath and orthopnea. A computed tomography (CT) of the chest was performed that showed a large cystic middle mediastinal mass. Magnetic resonance imaging (MRI) of the chest demonstrated a large, well-circumscribed, T2-hyperintense cystic middle mediastinal mass resulting in significant compression of the trachea, brachiocephalic artery, superior vena cava, and azygos vein. The patient subsequently developed a right hemispheric stroke due to compression of the brachiocephalic artery and was too clinically unstable to undergo or definitive operative management of the mediastinal cyst. Percutaneous CT-guided aspiration of the cystic middle mediastinal mass was performed, with successful decompression resulting transient improvement in mass-effect on the surrounding mediastinal structures. Six days after successful aspiration of the mass, the patient underwent attempted bronchoscopy for management of tracheobronchial secretions which was complicated by massive pulmonary hemorrhage leading to cardiopulmonary arrest and death. An autospy was conducted, revealing pathological finding consistent with a mature cystic teratoma.

Background: The aim of this study was to build and validate a risk prediction model for aspiration in severe acute pancreatitis patients receiving early enteral nutrition (EN) by identifying risk factors for aspiration in these patients. Methods: The risk factors for aspiration were analyzed to build a prediction model based on the data collected from 339 patients receiving enteral nutrition. Subsequently, we used six machine learning algorithms and the model was validated by the area under the curve. Results: In this study, the collected data were divided into two groups: a training cohort and a validation cohort. The results showed that 28.31 % (77) of patients had aspiration and 71.69 % (195) of patients had non-aspiration in training cohort. Moreover, age, consciousness, mechanical ventilation, aspiration history, nutritional risk and number of comorbidities were included as predictive factors for aspiration in patients receiving EN. The XGBoost model is the best of all machine learning models, with an AUROC of 0.992 and an F1 value of 0.902. The specificity and accuracy of XGBoost are higher than those of traditional logistic regression. Conclusion: In accordance with the predictive factors, XGBoost model, characterized by excellent discrimination and high accuracy, can be used to clinically identify severe acute pancreatitis patients with a high risk of enteral nutrition aspiration. Relevance to clinical practice: This study contributed to the development of a predictive model for early enteral nutrition aspiration in severe acute pancreatitis patients during hospitalization that can be shared with medical staff and patients in the future. No patient or public contribution: This is a retrospective cohort study, and no patient or public contribution was required to design or undertake this research.

Impaired swallowing, or dysphagia, significantly affects patients' well-being and health. Nearly half of the patients with head and neck cancers experience dysphagia or aspiration following radiation therapy or surgery. However, current dysphagia management approaches are primarily symptom-based rather than etiology-specific, owing to a lack of clear understanding of aspiration mechanisms. This study aimed to understand the mechanisms of aspiration in an anatomically accurate pharyngolaryngeal model at different epiglottis angles. A biomechanical swallowing model was developed using transparent casts, and liquid flow dynamics were visualized using fluorescent dye from side and back views. Two liquids and two dispensing conditions were evaluated for their roles in aspiration. The results demonstrated distinct flow dynamics between water and a 1 ​% w/v methylcellulose aqueous solution and, to a lesser extent, between fast and slow dispensing for the same liquid. Three frequent aspiration sites were identified, including the interarytenoid notch, the cuneiform tubercular recess, and the vallecula, corresponding to aspiration mechanisms of notch overflow, recess overflow, and creeping flow, respectively. The angle of the epiglottis influenced flow dynamics in at least three ways: by facilitating gravity-assisted fluid movement, redistributing flow through the gap between the epiglottis tip and pharyngeal wall, and affecting creeping flow via the angle between the epiglottis base and hypopharynx. Slow dispensing of water to the anterior oropharynx resulted in a significantly high aspiration rate with a downward tilted epiglottis due to concurrent tubercle-recess overflow and vallecular creeping flow. The biomechanical model can serve as a testing platform for better understanding aspiration mechanisms and developing etiology-based strategies before and after treatments for head and neck cancers.

The conventional metered dose inhaler (MDI) has long served as a cornerstone in the management of asthma and chronic obstructive pulmonary disease (COPD), affecting millions annually. Despite its advantages, a persistent challenge is seen in the form of patient education and the unchanged design of these inhalers since their inception in 1956. This lack of progress in MDI design has inadvertently contributed to incidences of foreign body inhalation. In this case presentation we report a 50-year-old male with a past medical history of asthma, who faced an incident of foreign body inhalation with use of his inhaler. The patient aspirated a dime when he administered his inhaler, as it had become lodged in the device's mouthpiece, which was uncapped. This case, like many others, demonstrates the need for innovative changes in MDI inhaler design. While numerous articles or cases concentrate on foreign body removal, the primary objective of this case report is to investigate preventative measures and solutions aimed at averting incidents of inhalation.

Objectives: To determine and explore the effectiveness of diet modification on dietary nutrient intake, aspiration, and fluid intake in adults with dysphagia. Participants: Adults with dysphagia. Design: A meta-analysis of randomized controlled trials (RCTs). Methods: We conducted a comprehensive literature search in EMBASE, Cochrane Library, Ovid-Medline, CINAHL, Web of Science, PubMed, and reference lists until November 2023. Quality of the included studies was assessed by the Cochrane Risk of Bias Assessment tool 2.0. Data analysis was performed using Comprehensive Meta-analysis 3.0 for pooled Hedges’ g and odds ratios (ORs) with corresponding confidence interval (CI) adopting a random-effects model. A X2- based test using Cochran’s Q (P < 0.10) and I2 statistics evaluated heterogeneity. Results: In total, 16 RCTs from among 3,854 studies retrieved from the literature search with 1812 adults with dysphagia were included in this meta-analysis. Texture-modified diets revealed a significant small effect on increasing energy intake (g: 0.37, 95% CI = 0.05–0.68) and a medium effect on increasing protein intake (g: 0.56, 95% CI = 0.13–0.99). Thickened fluids revealed a significantly reduced risk of aspiration (OR: 0.59, 95% CI = 0.44–0.79), and thickened fluids combined with water protocol revealed a significant large effect on increasing fluid intake (g: 3.96, 95% C = 0.75–7.16). Conclusions: The findings of this meta-analysis demonstrated that texture-modified diets increase dietary intake of energy and protein for adults with dysphagia. In addition, thickened fluids reduced the risk of aspiration while thickened fluids combined with water protocol increased fluid intake in adults with dysphagia.

Granuloma formation is generally correlated with infection. Pulmonary granulomas caused by foreign bodies aspiration are uncommon. The clinical and radiologic features of such cases often lack specificity, which makes it difficult to distinguish from malignancy. Aspiration is usually not considered in the differential diagnosis of patients presenting with mass-like abnormalities on chest imaging. Occult aspiration history, diverse clinical manifestations, atypical imaging findings, and limited availability of pathogen detection techniques make the precise diagnosis a substantial challenge. Herein, we describe an older patient presenting with chest pain and worrisome lung masses/nodules that proved to be pulmonary granulomas caused by foreign matters aspiration. In addition, the patient developed Mendelson syndrome due to acute macroaspiration. Lung tissue metagenomics next-generation sequencing (mNGS) revealed Streptococcus intermedius, a normal flora of the oropharynx. The aim of this case was to underscore the importance of considering aspiration as a potential differential diagnosis of patients presenting with pulmonary granulomas, especially in patients with recurrent pneumonia or predisposing factors. In addition, mNGS act as a potential, rapid, and effective technique for diagnosing aspiration-related syndrome, showing satisfactory performance in identifying pathogens.

Background: Infants and children with feeding difficulties have swallowing dysfunction and high risk of aspiration, which could be silent without choking, resulting in recurrent pneumonia and long-term respiratory morbidity. Videofluoroscopic swallow study (VFSS) is a useful tool for real-time visualization of the swallowing process and airway aspiration. This study reported a single-institutional 10-year experience of VFSS in pediatric patients with feeding difficulties and the efficacy of swallowing therapy. Methods: From 2011 to 2020, 30 infants and children with feeding difficulties received VFSS examinations in a medical center at a median age of 19 months (range 7 days–8 years). The images of the swallowing process (oral phase, triggering of pharyngeal swallowing, and pharyngeal phase) under videofluoroscopy were analyzed by a radiologist and a speech-language pathologist. Aspiration severity was assessed from VFSS observations and rated by an eight-point Penetration-Aspiration-Scale (PAS), with higher scores indicating increased severity. Swallowing therapy was performed by experienced speech-language therapists, and follow-up of oral feeding tolerance and risk of aspiration pneumonia was done. Results: Of the 30 patients, 24 (80%) had neurological deficits. High PAS scores (6–8) were observed in 25 (83.4%) patients, and 22 had a PAS score of 8, indicating silent aspiration. Of the 25 patients with high PAS scores, 19 (76%) had neurological deficits, and 18 (72%) depended on tube feeding at a median age of 20 months. Swallowing problems occurred most frequently during the pharyngeal phase in the patients with high PAS scores. VFSS-based swallowing therapy improved oral feeding ability and reduced aspiration episodes. Conclusion: Infants and children with swallowing dysfunction and neurological deficits had high risk of severe aspiration. Swallowing problems in the pharyngeal phase were the most common VFSS findings in patients with severe aspiration. VFSS may help guide problem-oriented swallowing therapy to reduce the risk of recurrent aspiration.

Introduction: The aspiration and ingestion of a molar during its extraction is a rare accident, so there is not enough information about the reported cases. The objective of this study is to carry out a systematic review, analyze the articles on intraoperative dental aspiration and intake, and propose an algorithm for the management of this complication. Materials and methods: A systematic review was carried out following the PRISMA criteria in the PubMed database in January 2023 with the following limitations: studies conducted in humans; English language; reports of aspiration and swallowing of teeth during dental extraction, age was not limited. Exclusion criteria: studies of aspiration and ingestion of foreign bodies that do not involve teeth. Results: A total of 5 articles were obtained with 5 reported cases of aspiration. There were no reports associated with the ingestion of a tooth. The most prevalent sex was male, with all cases reported in men, the average age was 24.4 years. The imaging studies of choice were chest radiography and computed tomography. The right bronchus was the most prevalent location site. The first line treatment was bronchoscopy, followed by tracheotomy and thoracotomy. Conclusion: Tooth extraction is a common surgical procedure, so it is essential to be careful in the event of possible complications such as intraoperative aspiration or tooth ingestion. Tooth aspiration can be a life-threatening complication, so prompt management is important. The proposed algorithm allows adequate management for aspiration and swallowing of teeth.

Introduction: Foreign body aspiration (FBA) is defined as asphyxia, suffocation, or inhalation of items of food, such as bone and seed, and non-food, such as toys, into the respiratory tract. Aspiration of foreign bodies is an important and preventable cause of mortality and morbidity in children, especially those less than 3 years of age. The aim of this study was to analyse the clinical and radiological profile, modes of management, and outcomes of foreign body aspiration in children at the University of Gondar Comprehensive Specialized Hospital and identify areas of possible interventions for proper management of such cases. Method: A retrospective review of the medical records of all patients suspected of foreign body aspiration at the University of Gondar Comprehensive Specialized Hospital (UoGCSH) from January 1, 2021, to January 1, 2023, G.C. was conducted. Clinico-radiological features, types and locations of foreign bodies, modes of management, and patient outcomes were studied. Results: A total of 73 patients suspected of having a possible foreign body aspiration were identified. The median age of the patients was 24 months, with an IQR of 14 and 39, with 46 (75.3 %) being under 3 years of age. 45 (61.6 %) were male, while 28 (38.4 %) were female, making the M:F ratio 1.6:1. A foreign body aspiration history could be obtained in 68 (93.1 %) of the patients, while in 4 (5.9 %) of the cases, patients or their families were not aware of any kind of aspiration. Among the children presented, 65 (89 %) had a choking episode, coughing 66 (91 %), vomiting 63 (86.3 %), tachypnea 61 (83.6 %), and stridor 15 (20.5 %). The most common physical finding observed was nasal flaring along with subcostal and intercostal retraction in 59 (80.8 %), followed by decreased air entry in 40 (54.8 %), wheeze in 37 (50.7 %), and absent air entry in the affected side in 4 (5.5 %) of the patients. A chest x-ray was done on all patients. 28 (41.2 %) had normal chest x-rays. With regard to procedure-related complications, 3 (4.1 %) patients had cardiac arrest, 1 (1.36 %) had pneumothorax, and 1 patient died. Conclusion: Any bronchopulmonary infection with an unusual course should be suspected of being the result of the aspiration of a foreign body. Increased public and professional awareness of the importance of early bronchoscopy in all suspected cases of foreign body aspiration is necessary. In order to lower the incidence, those providing care must be taught routine preventive measures.

Summary: Background & Aims: Gastroesophageal reflux (GER) is a common event among mechanically ventilated and tube-fed critically ill patients and it is associated with an increased risk of ventilator-associated pneumonia. Most of the available tools for the detection of GER are experimental and not available bedside. Intraluminal impedance was suggested as a technique for real-time detection and quantification of GER. This study aimed to evaluate the frequency and duration of GER events in mechanically ventilated and tube-fed patients and to determine their correlation with routine procedures performed during patient care. Methods: This was a prospective observational study of 20 critically ill patients hospitalized in a university hospital general intensive care unit. We included adult, mechanically ventilated patients receiving continuous enteral feeding by feeding tube (FT). A FT with multichannel intraluminal impedance sensors capable of detecting movement of gastro-esophageal content above the lower esophageal sphincter was used for GER detection. The frequency, duration, and association with routine procedures (position change, suction, and fluid bolus administration) were evaluated. Results: During the median monitoring time of 2.9 days (IQR 2.8–3) per patient, a median number of 2.7 (IQR 2.1–3.8) GER events were detected every hour. 61% of GERs lasted 10–30 seconds. Position changes, endotracheal suctions, and fluid bolus administrations were associated with a high frequency of GERs. Conclusions: Multichannel impedance sensors embedded on a FT enable real-time bedside detection of GER. This technology provides an opportunity for the development of new strategies aimed to decrease GER prevalence and prevent aspiration. Registration: The study was registered at http://www.clinicaltrials.gov (NCT02705781).

Background: Parkinson's disease (PD) can lead to swallowing dysfunction, resulting in aspiration pneumonia. Among the types of swallowing disorders, a characteristic and serious problem associated with PD is silent aspiration due to pharyngeal and laryngeal hypoesthesia. Methods: This single-arm, open-label study aims to evaluate the effectiveness of percutaneous neck interferential current sensory stimulation in enhancing swallowing function in patients with PD. The efficacy and safety of percutaneous neck interferential current sensory stimulation will be investigated for patients diagnosed with PD, based on the Movement Disorder Society criteria, of Hoehn–Yahr stages 2–4. The patients will receive neck percutaneous interferential current sensory stimulation for 20 min twice a week for 8 weeks using a Gentle Stim® (FoodCare Co., Ltd., Kanagawa, Japan) device. Once the intervention is initiated, evaluations will be performed every 4 weeks for a 16-week period. The primary endpoint to be assessed is the proportion of patients with normal cough with 1% citric acid at the end of the intervention (8 weeks after intervention initiation) compared with that at the beginning. This clinical trial will examine the usefulness of percutaneous neck interferential current sensory stimulation in patients with PD. In addition, this study will use novel instruments, such as multichannel surface electromyography and electronic stethoscope, to evaluate swallowing function. Discussion: This novel evaluation can provide insights into dysphagia in patients with PD and the usefulness of percutaneous neck interferential current stimulation. This exploratory study is limited by its single-arm, open-label design and small size. Trial registration number: jRCTs062220013; pre-results.

Background: Aspiration of the olecranon bursa is a treatment option for acute olecranon bursitis (OB). Typically, the aspirate is sent for microbiologic analysis, cell count, and crystal analysis. This study investigates the utility of fluid aspirate analysis from patients with clinically diagnosed aseptic OB. Methods: In this prospective study (IRB #i20-00986), patients presenting with acute aseptic OB were treated with aspiration as standard of care. Patients consented to participate in this study via phone. Patients with suspected infectious bursitis, open draining wound, and chronic OB were excluded. The aspirate was sent out for routine microbiologic analysis (aerobic and anaerobic cultures and Gram staining) and fluid analyses, including cell count with differential and crystal analysis. Nucleated and differential cell count was reported as absolute numbers per cubic millimeter and percentage, respectively. Compression wrap was applied after OB aspiration, and patients were asked to ice and take anti-inflammatory medications. Clinical follow-up was done after 6 weeks and at 3 months for resolution vs. recurrence of symptoms, and the mean time to resolution was reported. Results: A total of 26 patients (28 cases) with aseptic OB were enrolled in this study. Two patients had bilateral OB. The mean time to aspiration after the onset of symptoms was 26.4 days. One patient had recurrence of swelling after the first aspiration and underwent repeat bursa aspiration. No organisms were isolated or reported on Gram staining on any of the aspirate samples. Two aspirates were reported positive for calcium pyrophosphate dihydrate crystals. No patient had monosodium urate crystals. All patients had resolution of swelling and symptoms without the development of postaspiration infection. Conclusions: This study demonstrates limited clinical utility of routine microbiologic analysis (cell count, microbiologic, and crystal evaluation) of fluid aspirate from clinically diagnosed aseptic OB. Although 7% of fluid aspirates were positive for calcium pyrophosphate dihydrate crystals, it did not change the overall treatment.

Aspiration of iron pill containing ferrous sulfate into the airway can induce fulminant chemical burn and necrosis of the airway mucosa. Acute chemical burn and inflammatory response can result in life-threatening airway compromise. It can also result in long-term sequelae including but not limited to fibrosis and airway stenosis. Considering the common use of iron supplements, and the potential severity of aspiration related airway injury, clinicians should be fully cognizant of the interaction between aspirated iron and airway passages. Herein, we present a case report with pertinent review of the literature.

Pulmonary aspiration of gastric contents is one of the most terrible complications following general anesthesia. It is important for patients to prevent this complication by obeying the preoperative fasting protocol strictly. At present, it has been reported by many studies that bedside ultrasound, as a non-invasive and convenient method, could be used to evaluate gastric contents qualitatively and quantitatively. With the advantages of reliability, accuracy and repeatability, it can greatly reduce the risk of aspiration and ensure patients' life security. But most of the data were acquired from the healthy volunteers. For the gastrointestinal disorder, the pregnant women, obesity, children, the elderly and diabetes patients, the accuracy and reliability of ultrasound to predict the risk of aspiration remains to be identified by more further studies. For these patients with increasing risk of aspiration, I-AIM (Indication, Acquisition, Interpretation, Medical decision-making) framework plays an important role in ensuring the safety of patients. It is crucial to make appropriate clinical decisions by evaluating the gastric contents with ultrasound.

An infant diagnosed with laryngomalacia failed to adequately improve on conservative management and developed recurrent aspiration symptoms. An ENT review revealed a bifid epiglottis and laryngeal cleft. The concurrent presence of both these rare conditions prompted a full body examination; digital anomalies were identified, and a clinical diagnosis of Pallister-Hall Syndrome was made. A barium swallow test confirmed aspiration. A trial of non-surgical interventions with paediatrics and speech therapy support yielded inadequate outcomes and the infant was taken to theatre for full airway evaluation, laryngeal cleft closure and partial supraglottoplasty. Post-operative progress showed resolution of aspiration + adequate weight gain.

Managing large cyst-like periapical lesions poses significant challenges, especially when nonsurgical treatment or retreatment options are ineffective. Despite its efficacy, decompression remains an underutilized minimally invasive alternative in modern dentistry. This case report describes the use of a Penrose drain for decompression following aspiration and irrigation to manage a large periapical lesion associated with a 56-year-old man's maxillary lateral incisor. The lesion had caused thinning and perforation of the facial and palatal cortical plates, as well as the inferior border of the nasal fossa. Cone-beam computed tomography was used to evaluate the lesion preoperatively and to assess the healing progress postoperatively. Complete 3-dimensional healing was observed after a subsequent root-end surgery performed 3.5 years post-decompression. This report suggests that decompression using a Penrose drain in combination with aspiration and irrigation could be a simple but effective modality for managing large cyst-like periapical lesions when nonsurgical endodontics are attempted and deemed ineffective., (Copyright © 2024 American Association of Endodontists. Published by Elsevier Inc. All rights reserved.)

Basilar artery (BA) fenestration and its occlusion are relatively rare conditions. Mechanical thrombectomy for fenestrated BA occlusion has a high risk of complications. One limb occlusion or partial occlusion of fenestration mimics arterial stenosis or dissection. We present the case of a 75-year-old woman who presented with slight dysarthria, which subsequently worsened. Magnetic resonance imaging, magnetic resonance angiography, and basi-parallel anatomical scanning (BPAS) revealed BA fenestration and occlusion of the larger limb of the fenestrated BA, for which we performed thrombectomy with aspiration and achieved Thrombolysis in Cerebral Infarction Grade 3 flow restoration without procedure-related complications. If BA occlusion occurs at a site where a thrombus does not normally occur, confirming the anatomy of the BA before thrombectomy is desirable. As we obtained information on BA fenestration and occluded limb diameter using preoperative BPAS, we were able to safely achieve effective recanalization by guiding a relatively large-diameter aspiration catheter to the thrombus coaxially with a micro-guidewire and microcatheter., (© 2024 The Authors.)

Bronchoesophageal fistula (BEF) is a rare condition caused by a fistulous connection between the bronchus and the esophagus. BEF can be acquired or congenital; congenital BEFs are rarely encountered in adults. Acquired BEF can be due to either a benign or a malignant process. Acquired BEF due to primary lung cancer is a life-threatening and usually a terminal complication. Unlike tracheoesophageal fistula, this condition is much rarer. Patients usually present with symptoms related to recurrent aspiration. Barium esophagogram is the initial diagnostic modality of choice. Treatment is primarily palliative. We are presenting a case of a bronchoesophageal fistula caused by non-small cell lung cancer that was successfully treated with concurrent chemoradiation therapy.

A 66-year-old man presented with a chief complaint of difficulty breathing and productive cough. CT scan of the chest revealed an endobronchial mass with associated “tree-in-bud” opacities. A bronchoscopic biopsy of the mass was performed due to clinical suspicion of malignancy. Microscopic examination revealed inflamed endobronchial mucosa, granulation tissue and abundant fragments of uncharacterized organic material, compatible with aspiration. Detailed history revealed a history of chewing “gutkha”, a form of smokeless tobacco comprising a mixture of betel nut and other condiments. Microscopic sections of a betel nut and the “gutkha mix” processed subsequently in the histology laboratory were found to be similar to the organic material found in the mass. Thus, a diagnosis of impacted betel nut mixture leading to post-obstructive pneumonia was rendered.

Background: The hemoglobin index (HbI) represents the amount of hemoglobin, which reflects the regional tissue blood volume. The HbI is calculated by a regional oxygen saturation monitor. In freshwater drowning, inhaled water is immediately absorbed into the blood causing hemodilution. We hypothesized that this blood dilution could be observed in real time using HbI values in patients with out-of-hospital cardiac arrest (OHCA) due to freshwater drowning. Methods: In this single-center retrospective, observational study, we examined the HbI in patients with OHCA due to freshwater drowning from April 2015 to May 2020. Patients with OHCA due to hanging were selected as a control group. Results: Thirty-two patients in the freshwater drowning group and 21 in the control group were eligible for inclusion. In the freshwater drowning group, the HbI values in the return of spontaneous circulation (ROSC) group were significantly decreased in comparison to the non-ROSC group (−0.28 [IQR −0.55, −0.12] vs. −0.04 [IQR −0.16, 0.025]; p = 0.024). In the control group, the change of HbI during resuscitation in the ROSC and non-ROSC groups was not significantly different (0.11 [IQR −0.3525, 0.4225] vs. −0.02 [IQR −0.14, 0.605]; p = 0.8228). In each patient with ROSC in the freshwater drowning group, the HbI value after ROSC was significantly decreased in comparison to before ROSC (1.2±0.5 vs. 0.9±0.5]; p = 0.0156). In contrast, this difference was not observed in patients with an ROSC in the control group (3.7±1.3 vs. 3.8±1.4]; p = 0.7940). Conclusion: Blood dilution induced by freshwater drowning might be detected in real time using the HbI. To prove the validity of this research’s result, further prospective large study is needed.

Dysphagia is a growing problem among premature and medically complicated infants and children. In 2020, Lawlor et al. published a comprehensive review of the diagnosis and management of children with dysphagia. We wanted to expand on this review by describing what happens to children whose dysphagia does not improve by routine management. Our introduction describes what we know about pediatric dysphagia, and what questions families ask us (and we ask ourselves) when children do not respond to conventional medical treatments. We then describe three cases of dysphagia as diagnostic dilemmas and highlight the importance of a multi-disciplinary approach to manage these children and answering these questions. We incorporate clinical reasoning from our own aerodigestive team (otolaryngology, pediatric pulmonary and pediatric gastro enterology) as well as from experts in pediatric general surgery and neurosurgery to describe our approach to diagnosing and managing these children.

Foreign body (FB) aspiration in children is still a global medical problem. It is responsible for the accidental mortality in children. Non-food FB such as pen components is more frequent in the older children. In this case report, we present a challenging case with a bottom of a pen aspiration and describe a method for bronchoscopic extraction using similar aspirated foreign body.

Objective: Effective thrombectomies in the posterior circulation remain controversial. Previous reports have demonstrated the superiority of contact aspiration in anterior circulation. Aspiration catheters and stent retrievers are often used alone on a global scale, while combined techniques are commonly used in Japan. This study evaluated the effect of first-line contact aspiration with other strategies for the treatment of basilar artery occlusion., Methods: The primary outcome was the frequency of the first-pass effect, and the secondary outcome was the time from puncture to the first-pass effect. A multicenter observational registry including 16 Japanese stroke centers was used. Between December 2013 and February 2021, enrolled patients underwent endovascular thrombectomy for basilar artery occlusion. The efficacy of contact aspiration compared to other methods (including stent retrievers and combined techniques) was evaluated., Results: Eighty-four patients were included, all of whom had achieved effective recanalization. Twenty-six patients were treated with contact aspiration, 13 with combined technique, and 45 with stent retrievers. The two groups: contact aspiration and non-contact aspiration, had different backgrounds. Both had similar frequencies of effective recanalization and first-pass effects. The contact aspiration group experienced better functional outcomes without statistical significance, while this strategy was significantly associated with a shorter puncture-to-recanalization time (38 vs. 55 minutes, P=0.036). In particular, in the 55 patients with the first-pass effect, multivariate Cox proportional hazard analysis showed that contact aspiration was significantly associated with a shorter time from puncture to first-pass effect, independent of age and etiology of large-artery atherosclerosis (hazard ratio 2.02, 95% confidence intervals 1.10-3.69, P=0.023)., Conclusion: This study suggested that contact aspiration for basilar artery occlusion may shorten the puncture-to-first-pass effect, compared to stent retrievers and combined techniques., Competing Interests: Declaration of Competing Interest None., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: Aspiration is a known risk factor for adverse outcomes post-lung transplantation. Airway bile acids are the gold-standard biomarker of aspiration; however, they are released into the duodenum and likely reflect concurrent gastrointestinal dysmotility. Previous studies investigating total airway pepsin have found conflicting results on its relationship with adverse outcomes post-lung transplantation. These studies measured total pepsin and pepsinogen in the airways. Certain pepsinogens are constitutively expressed in the lungs, while others, such as pepsinogen A4 (PGA4), are not. We sought to evaluate the utility of measuring airway PGA4 as a biomarker of aspiration and predictor of adverse outcomes in lung transplant recipients (LTRs) early post-transplant., Methods: Expression of PGA4 was compared to other pepsinogens in lung tissue. Total pepsin and PGA4 were measured in large airway bronchial washings and compared to preexisting markers of aspiration. Two independent cohorts of LTRs were used to assess the relationship between airway PGA4 and chronic lung allograft dysfunction (CLAD). Changes to airway PGA4 after antireflux surgery were assessed in a third cohort of LTRs., Results: PGA4 was expressed in healthy human stomach but not lung. Airway PGA4, but not total pepsin, was associated with aspiration. Airway PGA4 was associated with an increased risk of CLAD in two independent cohorts of LTRs. Antireflux surgery was associated with reduced airway PGA4., Conclusions: Airway PGA4 is a marker of aspiration that predicts CLAD in LTRs. Measuring PGA4 at surveillance bronchoscopies can help triage high-risk LTRs for anti-reflux surgery., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

A 51-year-old male presented to our tertiary referral hospital with progressive shortness of breath and orthopnea. A computed tomography (CT) of the chest was performed that showed a large cystic middle mediastinal mass. Magnetic resonance imaging (MRI) of the chest demonstrated a large, well-circumscribed, T2-hyperintense cystic middle mediastinal mass resulting in significant compression of the trachea, brachiocephalic artery, superior vena cava, and azygos vein. The patient subsequently developed a right hemispheric stroke due to compression of the brachiocephalic artery and was too clinically unstable to undergo or definitive operative management of the mediastinal cyst. Percutaneous CT-guided aspiration of the cystic middle mediastinal mass was performed, with successful decompression resulting transient improvement in mass-effect on the surrounding mediastinal structures. Six days after successful aspiration of the mass, the patient underwent attempted bronchoscopy for management of tracheobronchial secretions which was complicated by massive pulmonary hemorrhage leading to cardiopulmonary arrest and death. An autospy was conducted, revealing pathological finding consistent with a mature cystic teratoma., (© 2024 The Authors. Published by Elsevier Inc. on behalf of University of Washington.)

Introduction/aim: Flexible fiberoptic bronchoscopy is generally the first line procedure for airway foreign body removal. However, removal may be challenging when surface and/or other characteristics make grasping the object difficult. We present a case in which we used a gastrointestinal retrieval net to successfully extract a dental crown, a type of foreign body with difficult-to-grasp surface characteristics. Methods: A 72-year-old male aspirated a dental crown during an attempted molar crown fitting. Semi-emergent flexible fiberoptic bronchoscopy was undertaken using an Olympus bronchoscope with a 2.8mm working channel. Attempts at retrieval using standard forceps, and a four-wire airway retrieval basket were unsuccessful. The retrieval net (RescueNet, Boston Scientific) is a device used in gastrointestinal procedures to retrieve foreign objects, food boluses and tissue fragments. The device's external catheter is 2.5mm in diameter and is passed through the working channel of an endoscope. The handle operates in a similar manner to conventional biopsy forceps and deploys a one-sided fishnet mesh basket with an adjustable string collar that can be manipulated to enclose a target. Results: The dental crown was easily removed with the retrieval net on the second attempt. Upon review of the literature, endobronchial usage of retrieval nets was found to be rare. Conclusion: Clinicians should be aware that gastrointestinal retrieval nets are an option for the retrieval of airway foreign bodies.

Unsuspected, non-asphyxiating, aspirated foreign body often masquerades as unresolved pneumonia, bronchiolitis or bronchial asthma. We report herein an 82-year-old, male patient with pleural effusion. Although the patient received the diagnosis of heart failure and treatment with diuretics, the pleural effusion remained, and a productive cough and a low-grade fever developed. Thoracentesis showed an exudative effusion, and chest computed tomography revealed a pill-like object in the right bronchus intermedius. The foreign body proved to be an iron pill, and the patient finally died from obstructive pneumonia due to severe mucosal damage caused by the pill. The present case emphasizes that foreign body aspiration may mimic not only respiratory but also cardiovascular diseases and should be suspected if the treatment of the initially diagnosed condition fails to ameliorate the patient's condition.

Proper laryngeal anatomy is crucial for airway protection. Congenital malformations of the airway are one cause of respiratory distress in children. An almost 5 month old male presented with increased work of breathing and worsening cough. Laryngoscopy showed the entire lingual surface of the epiglottis was tethered/compressed/grown to the base of tongue and was curled into a slight omega-shape. The arytenoid cartilages also hooded the glottis. The patient had airway collapse and did not have any visible tracheal rings consistent with severe tracheomalacia. A wedge-sling combination for sleeping, continuation of reflux medications, and follow up with the nutrition and feeding team were recommended. Direct laryngoscopy follow-up, sixteen months later, revealed floppy shortened epiglottis with more disconnect between the base of tongue and epiglottis. Moderate tracheomalacia with posterior collapse and right mainstem lateral collapse was also noted, with nearly complete resolution of his symptoms.

Resumen: Introducción: La disfagia es muy frecuente en niños con discapacidad neurológica. Estos pacientes suelen presentar problemas respiratorios y nutricionales. El estudio de la deglución por videofluoroscopia (VFC) suele ser el más recomendado, ya que revela la situación real durante la deglución. Objetivos: Estudiar los resultados obtenidos en la evaluación diagnóstica tras un año desde la implantación de la VFC en nuestro centro, y analizar la mejoría clínica tras la confirmación por VFC y la prescripción de un tratamiento individualizado en los niños con disfagia orofaríngea. Material y métodos: Se recogen las VFC realizadas en el último año. Se analizan las siguientes variables: edad, enfermedad, grado de afectación neurológica, tipo de disfagia (oral, faríngea y/o esofágica), gravedad, aspiraciones y/o penetraciones, tratamiento prescrito y mejora nutricional y/o respiratoria tras el diagnóstico. Se realiza análisis estadístico mediante SPSS v21. Resultados: Se realizaron 61 VFC. Se detectó disfagia en más del 70%, siendo moderadas-graves en el 58%. Se visualizaron aspiraciones y/o penetraciones en el 59%, siendo silentes el 50%. Se prescribió dieta adaptada al 56% y gastrostomía en 13 pacientes (21%). Se encontró asociación estadística entre enfermedad neurológica y la gravedad de la disfagia, existiendo relación según el grado de afectación motora y la presencia de aspiraciones. Tras la evaluación por VFC y la adecuación del tratamiento se encontró una mejoría nutricional en Z-score de peso (+ 0,3 DE) e IMC (+ 0,4 DE) y una mejoría respiratoria en un 71% de los pacientes disfágicos controlados en Neumología. Conclusiones: Tras la implantación de la VFC se ha diagnosticado a un alto porcentaje de pacientes, que se han beneficiado de un diagnóstico y un tratamiento correctos. La VFC es una prueba diagnóstica fundamental que debería ser incluida en los centros pediátricos, como método diagnóstico de los niños con sospecha disfagia. Abstract: Introduction: Dysphagia is very common in children with neurological disabilities. These patients usually suffer from respiratory and nutritional problems. The videofluoroscopic swallowing study (VFSS) is the most recommended test to evaluate dysphagia, as it shows the real situation during swallowing. Objectives: To analyse the results obtained in our centre after one year of the implementation of VFSS, the clinical improvement after confirmation, and the prescription of an individualised treatment for the patients affected. Material and methods: VFSS performed in the previous were collected. The following variables were analysed: age, pathology, degree of neurological damage, oral and pharyngeal and/or oesophageal dysphagia and its severity, aspirations, prescribed treatment, and nutritional and respiratory improvement after diagnosis. A statistical analysis was performed using SPSS v21. Results: A total of 61 VFSS were performed. Dysphagia was detected in more than 70%, being moderate-severe in 58%. Aspirations and/or penetrations were recorded in 59%, of which 50% were silent. Adapted diet was prescribed to 56%, and gastrostomy was performed on 13 (21%) patients. A statistical association was found between neurological disease and severity of dysphagia. The degree of motor impairment is related to the presence of aspirations. After VFSS evaluation and treatment adjustment, nutritional improvement was found in Z-score of weight (+ 0.3 SD) and BMI (+ 0.4 SD). There was respiratory improvement in 71% of patients with dysphagia being controlled in the Chest Diseases Department. Conclusions: After implementation of VFSS, a high percentage of patients were diagnosed and benefited from a correct diagnosis and treatment. VFSS is a fundamental diagnostic test that should be included in paediatric centres as a diagnostic method for children with suspected dysphagia.

The purpose of this study is to determine the role of clinical history, physical examinations, and radiological findings in the evaluation of patients with suspected radiolucent foreign body aspiration. Methods: The medical records of 236 children (under the age of 18 years), on whom a rigid bronchoscopy was performed between 1999 and 2015 because of suspected radiolucent foreign body aspiration, were analyzed retrospectively. Sensitivity, specificity, positive and negative predictive values of clinical history, physical examinations, and radiological findings were evaluated. Results: In 71.1% of all cases, the children were under the age of 3 years. The bronchoscopy showed the presence of a foreign body in 52.9% of cases, with the locations of the foreign bodies being as follows: (1) right main bronchus, 47.2%; (2) left main bronchus, 36.0%; (3) trachea, 11.2%; (4) both bronchi, 5.6%. Organic foreign bodies were found in 78% of the patients, whereas inorganic foreign bodies were detected in 22% of the patients. The sensitivity and specificity of clinical history, physical examinations, and radiological findings were 98.4% and 54.9%, 47.2% and 74.7%, and 35.2% and 92.7%, respectively. Conclusion: Tracheobronchial foreign body aspirations usually occur prior to the age of 3 years, with the most frequently aspirated foreign bodies being food or items of a radiolucent nature. Clinical history, physical examinations, and radiological findings are not able to detect the presence of a radiolucent foreign body aspiration in children. Therefore, a bronchoscopy should be performed on children in whom a choking event has been witnessed, even in cases of normal radiological and clinical findings.

Acute thrombotic occlusions of the large vessels, such as internal carotid artery, arms and legs arteries, and intracranial vessels, frequently require multiple techniques such as selective thrombolysis, manual aspiration, and stent retrievers for mechanical thrombectomy with combination of the mentioned techniques. Because of the massive thrombotic burden associated with these conditions, the response to systemic intravenous thrombolysis is poor. We present a case of a successful massive thrombi aspiration in a single attempt using an 8Fr guide catheter with aspiration syringe, subsequent ipsilateral middle cerebral artery mechanical thrombectomy, and axillary artery clot disruption attempt in a patient with acute ischemic stroke, right arm critical ischemia, and persistent atrial fibrillation.

Background: Brush cytology during endoscopic retrograde cholangiopancreatography (ERCP) is a standard approach in diagnosing biliopancreatic strictures, with yet unsatisfying sensitivity., Aims: We brought additional simultaneous vacuum aspiration to brushing process and re-evaluate the diagnostic performance., Methods: This multi-centered retrospective study was conducted in three tertiary centers. Consecutive patients with biliopancreatic strictures were identified. The patients were divided into two arms: the conventional arm (CA) receiving general brushing approach, and the modified arm (MA) being treated with additional vacuum aspiration when performing bushing. The 1:1 propensity-score matching was implemented to tackle the selective biases., Results: A total of 555 patients were identified and 200 patient pairs (193 males, 207 females, with a mean age of 68.1 ± 13.1 years.) fell into the ultimate evaluation. A final diagnosis of malignant stricture was established in 243 patients. The diagnostic yield of the MA group was substantially better than that of the CA group, whether "suspicious malignancies" were considered malignancies or not. The rates of sensitivity, specificity and accuracy were 46.2%, 100%, 68.0% in the MA group, and 15.3%, 98.7%, and 47.0% in the CA group respectively., Conclusions: Brushing accompanied by simultaneous vacuum aspiration at ERCP improves the diagnostic yield in suspicious biliopancreatic malignancies., Competing Interests: Conflict of interest The authors declare that there is no conflict of interest., (Copyright © 2023 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Background: Tracheal intubation is the gold standard for airway management in emergency medicine, but more difficult to apply for inexperienced individuals than laryngeal mask airway (LMA)., Objective: The aim of our study was to investigate if inexperienced individuals are able to secure the airway with the help of LMA after a short introduction. A second aim was to evaluate Thiel-fixed specimens against unfixed ones., Methods: In a body donor model, LMA application was evaluated between medical students without previous airway experience and anesthesiologists by comparing the sealing of the larynx using a water column applied to the esophagus., Results: LMAs were successfully applied in 46 out of 55 (83.6%) attempts by medical students and in 30 out of 39 (76.9%) attempts by anesthesiologists. Among medical students, 14.1% of all LMA applications were primarily leaky, compared with 18.8% in anesthesiologists. Esophageal sealing was better in Thiel-fixed specimens (leakage 10.9%) compared with unfixed specimens (leakage 22.9%). Our data showed no significant difference between anesthesiologists and medical students in terms of sealing of LMA. Therefore, we conclude that medical students without previous airway experience can quickly learn to apply LMA sufficiently and thus, achieve aspiration protection similar to anesthesiologists., Conclusion: Medical students without previous airway experience can successfully insert LMAs after a short introduction. Thiel-fixed specimens are suitable for studies as well as for training in LMA application., Competing Interests: Declaration of competing interest None., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: This study sought to scrutinize the clinical outcomes associated with first-pass mechanical thrombectomy strategies in the management of intracranial atherosclerosis (ICAS)-related large vessel occlusion (LVO)., Methods: Within this post-hoc analysis of the The Endovascular Treatment With vs Without Tirofiban for Patients with Large Vessel Occlusion Stroke (RESCUE BT) trial, we compared data pertaining to patients with ICAS-LVO situated in the anterior circulation who underwent initial therapeutic interventions utilizing either aspiration thrombectomy or stent-retriever thrombectomy. The analysis encompassed the assessment of intraprocedural recanalization, rescue procedures involving balloon angioplasty or stenting, 48-hour reocclusion rates, occurrences of cerebral hemorrhagic complications, and 90-day Modified Rankin Scale scores., Results: Among the 948 patients encompassed in the RESCUE BT trial, a total of 230 patients with ICAS-LVO in the anterior circulation were enrolled in the study. Of these, 111 underwent aspiration thrombectomy as the first-pass therapy, while 119 patients underwent stent-retriever thrombectomy as the initial intervention. The difference in first pass recanalization rates between aspiration thrombectomy and stent-retriever thrombectomy was not statistically significant (17.1% vs. 14.3%, P = 0.555), and mechanical thrombectomy success rates (90.1% vs. 90.8%, P = 0.864), the use of balloon angioplasty or stenting for rescue therapy (54.6% vs. 45.9%, P = 0.189; 23.4% vs. 25.2%, P = 0.752), and favorable 90-day Modified Rankin Scale outcomes (53.2% vs. 40.3%, P = 0.051) showed no statistically significant differences., Conclusions: Both aspiration thrombectomy and stent-retriever thrombectomy can be considered as primary therapeutic options for patients presenting with ICAS-LVO in the anterior circulation., (Copyright © 2023 Elsevier Inc. All rights reserved.)

There has been no individual ultrasound feature of having high accuracy for diagnosis of thyroid malignancy. In this study, we aimed to establish feature-oriented criteria to characterize benign thyroid nodules that do not require ultrasound (US)-guided fine needle aspiration (FNA). Methods: We reviewed 374 patients with thyroid nodules who had undergone US-guided FNA at our institution (2005–2008). Thyroid nodules were classified into two groups: Category 1 (benign nodules that required follow-up 6–12 months later but not US-guided FNA); and Category 2 (indeterminate nodules or suspected carcinoma that required US-guided FNA). To test the validity, we reviewed 315 consecutive patients who had histologically proven thyroid carcinoma (n = 39) and randomly selected 40 of the 276 patients with benign nodules (2009–2010). Results: Of 374 nodules, 354 (95%) were benign and 20 (5%) malignant. On US, 260 nodules had no calcification, no increase in vascularity, well-defined margin, and no lymphadenopathy (Category 1). Using a combination of these four features, we were able to discriminate benign from indeterminate nodules or suspected malignant nodules with a sensitivity of 73%, and specificity and positive predictive value of 100%. Validity testing revealed that none of the 39 malignant thyroid nodules had all four US features. All Category 1 nodules (2005–2008) remained benign at the 3-years follow up. Conclusion: The combination of four US features of Category 1 nodules is highly predictive of benign disease, and we could avoid unnecessary US-guided FNA in 69.5% of our patients using this combined features.

There is no consensus regarding the effects of deep brain stimulation (DBS) surgery on swallowing outcomes in Parkinson's disease (PD). No prospective studies have compared airway protective outcomes following DBS to the subthalamic nucleus (STN) versus globus pallidus interna (GPi). A recent retrospective study described swallowing outcomes pre- and post-STN vs. GPi DBS in a cohort of 34 patients with PD. The results revealed that the patients who received GPi DBS maintained their swallowing function post-DBS, while those in the STN group significantly worsened in swallowing safety. As DBS surgery becomes a common management option in PD it is important to understand the impact of DBS on airway protective outcomes; especially given that aspiration pneumonia is the leading cause of death in this population. We present a case report in which optimizing DBS settings with the goal of improving laryngeal function resulted in immediate improvements to swallowing safety.

The turban pin inhalation syndrome is known as a subtype of foreign body aspiration, mainly occurring in girls and young women wearing turbans. With the number of turban wearing girls and women increasing all over the world, attention must be brought to the risk associated with the use of hairpins. We present a case of metallic hairpin inhalation. In our case, the turban pin was successfully removed via rigid bronchoscopy.

Although total hip arthroplasty (THA) is accepted as one of the most successful surgical procedures in orthopaedic surgery, periprosthetic joint infection after THA continues to be one of the most devastating complications. However, accurate preoperative identification of periprosthetic joint infection in patients presenting with joint pain or radiographic periprosthetic lucencies is often difficult, even after a comprehensive work-up. The purpose of this article is to review the diagnostic options available to improve the management and results of this potentially catastrophic complication.

Aspiration of foreign bodies during dental procedures is a rare but potentially serious complication. We present a case of a 75-year-old man who aspirated a dental crown requiring flexible bronchoscopic retrieval. We discuss the risk factors for aspiration, the radiographic features of diagnosis, and the techniques for management and retrieval.

Background: Infants and children with feeding difficulties have swallowing dysfunction and high risk of aspiration, which could be silent without choking, resulting in recurrent pneumonia and long-term respiratory morbidity. Videofluoroscopic swallow study (VFSS) is a useful tool for real-time visualization of the swallowing process and airway aspiration. This study reported a single-institutional 10-year experience of VFSS in pediatric patients with feeding difficulties and the efficacy of swallowing therapy., Methods: From 2011 to 2020, 30 infants and children with feeding difficulties received VFSS examinations in a medical center at a median age of 19 months (range 7 days-8 years). The images of the swallowing process (oral phase, triggering of pharyngeal swallowing, and pharyngeal phase) under videofluoroscopy were analyzed by a radiologist and a speech-language pathologist. Aspiration severity was assessed from VFSS observations and rated by an eight-point Penetration-Aspiration-Scale (PAS), with higher scores indicating increased severity. Swallowing therapy was performed by experienced speech-language therapists, and follow-up of oral feeding tolerance and risk of aspiration pneumonia was done., Results: Of the 30 patients, 24 (80%) had neurological deficits. High PAS scores (6-8) were observed in 25 (83.4%) patients, and 22 had a PAS score of 8, indicating silent aspiration. Of the 25 patients with high PAS scores, 19 (76%) had neurological deficits, and 18 (72%) depended on tube feeding at a median age of 20 months. Swallowing problems occurred most frequently during the pharyngeal phase in the patients with high PAS scores. VFSS-based swallowing therapy improved oral feeding ability and reduced aspiration episodes., Conclusion: Infants and children with swallowing dysfunction and neurological deficits had high risk of severe aspiration. Swallowing problems in the pharyngeal phase were the most common VFSS findings in patients with severe aspiration. VFSS may help guide problem-oriented swallowing therapy to reduce the risk of recurrent aspiration., Competing Interests: Conflicts of interest The authors have no conflicts of interest relevant to this article., (Copyright © 2023 Taiwan Pediatric Association. Published by Elsevier B.V. All rights reserved.)