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Introduction The immune reaction developing against Ebstein-Barr virus (EBV) infection may be one of the major determinants of severe adenoid hypertrophy (AH) and chronic otitis media with effusion (COME) needing surgery. In this study, we aimed to investigate the relationship between these antibodies and the need for surgery due to complications such as severe AH and COME. Methods Sixty consecutive patients <15 years old who were admitted to our outpatient clinics between January 2014 and December 2015 with severe AH ± COME and underwent adenoidectomy ± ventilation tube insertion and 129 control patients who had a history of EBV infection at least three months before the inclusion to the study without current symptoms of upper airway obstruction and middle ear disease were included in this study. Two groups of patients and a control group were studied: a) children who underwent adenoidectomy alone with no middle ear disease (group 1), b) children with COME and AH who underwent adenoidectomy and tympanostomy with ventilation tube insertion (group 2), and c) control group without adenoid hypertrophy or otitis media with effusion. Results Patients who needed surgery (Group 1 and 2) had significantly higher levels of anti-EBV VCA IgG antibodies than control patients (19.8 ± 16.4 vs. 1.7 ± 0.8 S/CO, p < 0.001). Anti-EBV VCA IgM levels did not differ between groups. Group 2 patients had also higher levels of Anti-EBV VCA IgG antibodies than group 1 patients (35.8 ± 16.7 vs. 11.8 ± 8.5 S/CO, p < 0.001). ROC curve analysis resulted in a cut-off point of 2.92 S/CO level for anti-EBV VCA IgG antibodies for need for surgery in EBV infected patients with 97% sensitivity and 98% specificity. Conclusion Markedly increased serum anti-EBV VCA IgG antibodies in children who developed upper respiratory tract complications such as severe AH and COME may show the significant role of enhanced immune system reaction in the pathogenesis of these complications due to EBV infection. [ABSTRACT FROM AUTHOR]

Background: Treatment of congenital pulmonary airway malformations (CPAMs) is generally surgical resection; however, there is controversy regarding the optimal timing of surgical intervention, especially in asymptomatic patients.Study Design: Using the American College of Surgeons National Surgical Quality Improvement Program-Pediatric Participant Use Files from 2012 to 2015, children who underwent lung resection for CPAMs were identified. Outcomes in children who underwent lung resection during the neonatal period were compared with those who underwent resection beyond the neonatal period, but during the first year of life (non-neonates).Results: A total of 541 patients (20.7% neonates and 79.3% non-neonates) were identified. Neonates had higher rates of preoperative comorbidities and worse postoperative outcomes when compared with non-neonates (morbidity 19.6% vs 5.4%, p < 0.0001). On multivariable regression analysis, the presence of preoperative symptoms (defined as oxygen dependence or ventilatory support) was independently associated with increased morbidity (odds ratio 3.91 [range 1.6 to 9.57], p = 0.003). In a subgroup analysis of asymptomatic neonates compared with asymptomatic non-neonates, there was no difference in overall morbidity (7.4% vs 4.4%, p = 0.33).Conclusions: These data suggest that lung resection for CPAMs in the neonatal period in asymptomatic children are not associated with increased 30-day morbidity. The presence of preoperative symptoms was independently associated with increased morbidity in a multivariable regression model. More data are needed to better understand the long-term outcomes and better define the optimal timing of surgery in this patient population. [ABSTRACT FROM AUTHOR]

Background: The aim of this study is to investigate the prevalence of central sleep apneas syndrome (CSAS) in children with obstructive sleep apnea syndrome (OSAS) and the effect of adenotonsillectomy (A)TE on CSAS.Methods: Retrospective analysis of polysomnographic data in children diagnosed with OSAS and without comorbidity. A central apnea index (CAI) ≥1/h is considered abnormal and central sleep apnea syndrome (CSAS) is diagnosed at a CAI >5/h. Data are presented as median (25-75 percentile).Results: Data were available for 90 children, 35 girls and 55 boys, age 3.7 years (1.8-5.4), BMI-z score 0.20 (-0.85-0.90), oAHI 10.9/h (5.8-19.1). Sixty-four percent had an abnormal CAI and the prevalence of CSAS was 7.8%. There was a significant correlation between CAI and MinSat (r = -0.48, p = 0.01) and between CAI and age (r = -0.45, p = 0.01). Pre-postop PSG data were available for 41 children with a CAI ≥ 1/h. Central apnea index decreased from 2.2/h (1.7-3.8) to 1.3/h (0.8-2.6) (p < 0.001) following (A)TE along with an improvement in oAHI from 10.9/h (5.9-22.2) to 1.2/h (0.6-2.7) (p < 0.001). No patient had postoperative CSAS and a reduction in the CAI <1/h was observed in 11 patients (26,9%).Conclusion: A central apnea index ≥1/h is common in children with OSAS but CSAS (CAI >5) is rare. We observed a significant decrease in the CAI and a resolution of CSAS after (adeno)tonsillectomy. [ABSTRACT FROM AUTHOR]

Introduction: Non-iatrogenic trauma to the airway is rare and presents a significant challenge to the anaesthetist. Although guidelines for the management of the unanticipated difficult airway have been published, these do not make provision for the 'anticipated' difficult airway. This systematic review aims to inform best practice and suggest management options for different injury patterns.Methods: A literature search was conducted using Embase, Medline, and Google Scholar for papers after the year 2000 reporting on the acute airway management of adult patients who suffered airway trauma. Our protocol and search strategy are registered with and published by PROSPERO (http://www.crd.york.ac.uk/PROSPERO, ID: CRD42016032763).Results: A systematic literature search yielded 578 articles, of which a total of 148 full-text papers were reviewed. We present our results categorized by mechanism of injury: blunt, penetrating, blast, and burns.Conclusions: The hallmark of airway management with trauma to the airway is the maintenance of spontaneous ventilation, intubation under direct vision to avoid the creation of a false passage, and the avoidance of both intermittent positive pressure ventilation and cricoid pressure (the latter for laryngotracheal trauma only) during a rapid sequence induction. Management depends on available resources and time to perform airway assessment, investigations, and intervention (patients will be classified into one of three categories: no time, some time, or adequate time). Human factors, particularly the development of a shared mental model amongst the trauma team, are vital to mitigate risk and improve patient safety. [ABSTRACT FROM AUTHOR]

Objectives With the emergence of propranolol as the primary treatment for hemangiomas the indications for surgical intervention have been greatly reduced. There remains a role for surgical management in those patients who fail medical therapy, particularly for hemangiomas involving the airway. Detailed is our experience with subglottic hemangiomas, including three patients who failed propranolol treatment and were successfully treated with surgical excision and single stage laryngotracheoplasty (LTP) with thyroid ala graft. Methods Retrospective case series (level of evidence: 4). Results Six patients were treated with propranolol for subglottic hemangiomas over a 6 year period (2008–2014). Three patients responded to propranolol therapy and required no adjunctive surgical procedures. Three patients failed propranolol treatment, and required open resection of their subglottic hemangiomas and thyroid ala graft placement. Indications for resection were complete lack of response to propranolol in one patient, and initial response to propranolol with subsequent regrowth in the other two patients. All three patients were treated with submucosal extirpation of their hemangioma and single stage LTP; hemangioma was confirmed in all cases by positive GLUT-1 staining. All three surgical patients were successfully extubated post-operatively and none had hemangioma regrowth. Conclusions Fifty percent of patients in our series did not have long-term response to propranolol for subglottic hemangioma, highlighting the importance of close follow-up. When identified early, subglottic hemangiomas refractory to propranolol treatment can be successfully addressed with single stage LTP and tracheotomy can be avoided. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: Laryngotracheal reconstruction is a common procedure to repair subglottic stenosis. Despite a success rate upwards of 85%, this procedure has significant morbidity associated with it, specifically with the site of the graft harvest and recurrence of stenosis. We propose that a recently described cellular bioscaffold xenograft may be useful in reducing these complications. Methods and materials: 10 Sprague Dawley rats were divided into 2 groups of 5. One group underwent incision through the cricoid and the first two tracheal rings followed by primary closure (G1); the second group underwent incision through the cricoid and the first two tracheal rings followed by placement of the xenograft (G2); additionally, a specimen was harvested from an animal which did not undergo any surgical procedure to compare to the two surgical groups. Specimen harvest occurred on post-operative days 1, 7, 14, 21, and 28. Results: 6 of 10 animals provided usable data. All animals receiving the xenograft survived until the time of specimen harvest. Only 1 animal undergoing primary closure survived beyond post-operative day one. On histology review, the xenograft animals showed a progressive decrease in fibrosis relative to the animals that underwent primary closure. On POD 28, restoration of the respiratory epithelium and intact basement membrane was noted in the xenograft group. Conclusion: We believe that this pilot study shows the potential of utilizing bio-implantable biomaterials, specifically a cellular bioscaffold which encourages the ingrowth of native tissue instead of fibrosis. Histologic analysis shows that use of the xenograft can initiate the proliferation of native tissues decreasing the amount of fibrosis present post-operatively, although significant further analysis is needed before definitively concluding that this approach is superior to utilization of a graft. [Copyright &y& Elsevier]

The study advances the idea of using computational fluid dynamics in the process of planning surgical treatment modalities for patients with obstructive airway disorders. It is hypothesized that the a priori knowledge of the functional outcome of surgical intervention on the flow and airway resistance can guide the surgeon in choosing an effective surgical strategy. Computed tomography images spanning the respiratory tract of an adult patient with a combined glottic and subglottic stenosis are used to reconstruct three-dimensional geometrical models of the airway. Computational fluid dynamics is used to obtain airway flow patterns during inspiration and expiration in these models. Numerical predictions about flow velocity, pressure distribution on the airway lumen, wall shear stress, and airway resistance are obtained so that the relevance of each individual stenotic level is quantified. Four different virtual surgeries in different combinations are assessed in order to remedy the constricted airway. The virtual surgery based airway models are evaluated by comparisons with the pre-treatment flow modeling results. The predicted numerical data revealed that the removal of the constriction at the level of the vocal folds will have the most significant effect on the airway resistance. The flow simulations offer a quantitative method of evaluating the airway resistance in patients with combined glottic and subglottic stenoses. Predictions of airway resistances and other numerical calculations from different virtual surgeries give additional inputs for the surgeon, in deciding the most appropriate surgery on a case-by-case basis. [ABSTRACT FROM AUTHOR]

Abstract: Laryngotracheal stents may damage the highly complex laryngeal structures, impair voice and swallowing functions and cause tissue ingrowths, thereby necessitating airway patency interventions. In benign airway disease, the number of adolescents with laryngotracheal stents is therefore limited. We present two cases of laryngeal metallic stent placement following benign airway disease. Two adolescents presented with severe dyspnea and self-expandable metallic stent placement after benign laryngotracheal stenoses. Granulation tissue ingrowths required additional surgical interventions every 6–8 weeks to recanalize the stent lumen. We performed multi-stage surgery including removal of the embedded stent, segmental resection of the stenotic area, end-to-end-anastomosis and laryngotracheal reconstruction respectively, to achieve patent airway without tracheal cannulation. Montgomery T-tubes were temporarily inserted to bridge the complex reconstructions. In both adolescents, we achieved successful removal of the embedded stent and patent airway. Bilateral vocal fold paralysis required additional surgery to improve the final airway patency and vocal rehabilitation. Stent removal, segmental resection and laryngotracheal reconstruction provide the achievement of patent airway and allow decannulation. Temporary Montgomery T-tubes bridge complex laryngotracheal reconstructions. In benign laryngeal airway disease, stent placement should be avoided, especially in adolescents. Transfer to a specialist center should be considered prior to metallic stent implantation. In general, self-expanding tracheobronchial stents can be placed in selected patients where surgical interventions are limited. [Copyright &y& Elsevier]

Abstract: The article starts by describing the gross anatomy of the trachea and bronchial tree, the pleura and the lungs. The blood supply, lymphatic drainage and innervation are included, with brief reference to the microstructure of the respiratory system. The gross anatomy, blood supply and innervation of the diaphragm conclude the article. [Copyright &y& Elsevier]

Abstract: Objective: The aim of this paper is to study the respiratory muscle strength by evaluating the maximal inspiratory pressure (MIP), maximal expiratory pressure (MEP) and lung volume before and 3 and 6 months after adenotonsillectomy. This is an interventional, before and after trial. It was set at the Department of Otolaryngology, University of São Paulo, School of Medicine. We included 29 children (6–13 years old), both genders, consecutively recruited from the waiting list for adenotonsillectomy. Children were submitted to maximal inspiratory pressures (MIP), maximal expiratory pressure (MEP) evaluation using an analog manovacuometer, lung volume, using incentive expirotometer and thoracic and abdominal perimeter using a centimeter tape. Children were evaluated in 3 different moments: 1 week before and 3 and 6 months after surgery. Results: MIP improved significantly 3 months (p <0.001) after adenotonsillectomy and MEP did not change (p =1). There were increases in lung volume (p =000), chest (p =0.017) and abdominal perimeter (p =0.05). Six months after surgery, all parameters improved. MIP (p =0), MEP (p =0), lung volume (p =0.02), chest (p =0.034) and abdominal perimeter (p =0.23). Conclusion: This study suggests that there was an improvement in respiratory muscular strength, once there was a significant improvement in maximal inspiratory pressure, lung volume and other parameters after adenotonsillectomy. [Copyright &y& Elsevier]

Abstract: Objective: The objective of this paper is to present our surgical experience with a cohort of four infants with laryngotracheoesophageal cleft (LTEC) in order to highlight our early failures and complications and to propose a comprehensive, three-layered approach in treating stages III and IV LTEC. Method: An IRB approved, retrospective chart review was carried out of a cohort of four cases occurring within a 2-year period of time. Results: All patients had other significant anomalies, and the mortality rate was high: 75%. After our initial failures and difficulties with recurrent fistulas, tracheomalacia and tracheotomy dependence, we were able to achieve a successful outcome of a functional separation of the airway and the digestive tract without a tracheotomy in our last two patients. Unfortunately, both these patients died from factors not directly associated with the LTEC so long-term follow up was not possible. We now have one survivor, our second case, who is tracheotomy dependent. Conclusion: Laryngotracheoesophageal clefts are rare congenital anomalies with high morbidity and mortality despite various forms of surgical repair. Fistulas, tracheostomy dependence, tracheomalacia, and chronic lung disease secondary to aspiration are frequent problems following LTEC repairs. We advocate an anterior approach to the cleft repair, a three-layered closure of the cleft to include an interpositional muscular flap, and a physiologic repair of the posterior larynx with a standard cartilage graft technique used in laryngotracheal reconstruction. [Copyright &y& Elsevier]

Abstract: Vagus nerve stimulation (VNS) for medically refractory seizures has been an approved therapy by the Food and Drug Administration since 1997, with additional approval as an adjunct therapy for major depression granted in 2005. Potential applications for VNS therapy in obesity, neuropsychiatric disorders, and chronic pain syndromes are under investigation. Bradyarrhythmias, including asystole, may occur during VNS device placement or as a delayed complication. A peritracheal hematoma may develop following VNS device placement, necessitating emergent management. Other respiratory complications may include vocal cord movement abnormalities with potential for aspiration. Vagus nerve stimulation results in sleep-related breathing pattern changes, with an associated increase in the number of obstructive apneas and hypopneas in both children and adults, which may impact perioperative care. [Copyright &y& Elsevier]

Summary: Evidence is accumulating regarding the local opioid regulation of physiologic respiratory functions. However, anatomical evidence for a local opioid network of the respiratory system is scarce. In this study, tissue samples from 12 lung cancer patients undergoing lobectomy or pneumonectomy were examined immunohistochemically for the expression of the opioid network components met-enkephalin, the respective precursor proenkephalin, the key processing enzymes prohormone convertases 1 and 2, carboxypeptidase E, and the δ opioid receptor in different areas of human lung. Colocalization of proenkephalin with met-enkephalin, prohormone convertase 1, prohormone convertase 2, and carboxypeptidase E was demonstrated by double-immunofluorescence confocal microscopy in alveolar macrophages, submucosal glands, cancerous cells, and pulmonary neuroendocrine cells of bronchial epithelium. Corresponding δ opioid receptor was identified on cells of all these functionally relevant anatomical structures and on substance P–immunoreactive sensory nerve fibers arborizing within bronchial epithelium. Our findings provide evidence of a local opioid network, that is, the exact anatomical localization of proenkephalin, its functionally active peptide met-enkephalin, and the key processing enzymes as well as corresponding δ opioid receptor, linked to functionally important structures of the respiratory system. These findings encourage future studies to examine the functional role of local opioid peptides within the respiratory system. [Copyright &y& Elsevier]

Abstract: Objective: Creation of a patent subglottic airway after partial cricotracheal resection (PCTR) may not always result in successful decannulation due to associated parameters such as co-morbidity and/or glottic involvement. We classified patients after incorporating these additional parameters into the original Myer–Cotton classification to assess whether this could better predict the outcome measures after PCTR. Methods: One hundred children with Myer–Cotton grade III or IV subglottic stenosis who underwent PCTR between 1978 and 2008 were identified from a prospectively collected database. The patients were classified into four groups based on the association of co-morbidity and/or glottic involvement. Delay in decannulation, revision open surgery and rates of decannulation were the outcome measures compared between the groups. Results: There were 68 children with Myer–Cotton grade III and 32 children with grade IV stenosis. Based on the new classification, there were 36 children with isolated SGS, 31 with associated co-morbidity, 19 with associated glottic involvement and 14 children with both co-morbidity and glottic involvement. A trend towards less optimal results was noticed with the association of co-morbidity and/or glottic involvement. Statistical significance was reached for maximum decannulation failure in the group with both co-morbidity and glottic involvement. Delayed decannulation significantly correlated in the group with associated glottic involvement. Conclusion: This new classification is relatively simple and aimed at providing more accurate and uniform prognostic information to both patients and surgeons when dealing with the whole spectrum of severe SGS. [Copyright &y& Elsevier]

Abstract: Background: The term occult pneumothorax (OP) describes a pneumothorax that is not suspected on the basis of either clinical examination or initial chest radiography, but is subsequently detected on computed tomography (CT) scan. The optimal management of OP in the blunt trauma setting remains controversial. Some physicians favour placement of a thoracostomy tube for patients with OP, particularly those undergoing positive pressure ventilation (PPV), while others favour close observation without chest drainage. This study was conducted both to determine the incidence of OP and to describe its current treatment status in the blunt trauma population at a Canadian tertiary trauma centre. Of interest were the rates of tube thoracostomy vs. observation without chest drainage and their respective outcomes. Methods: A retrospective review was conducted of the Nova Scotia Trauma Registry. The data on all consecutive blunt trauma patients between October 1994 and March 2003 was reviewed. Outcome measures evaluated include length of stay, discharge status—dead vs. alive, intervention and time to intervention (tube thoracostomy and its relation to institution of PPV). Direct comparison was made between the OP with tube thoracostomy group and OP without tube thoracostomy group (observation or control group). They were compared in terms of their baseline characteristics and outcome measures. Results: In 1881 consecutive blunt trauma patients over a 102-month period there were 307 pneumothoraces of which 68 were occult. Thirty five patients with OP underwent tube thoracostomy, 33 did not. Twenty nine (82.8%) with tube thoracostomy received positive pressure ventilation (PPV), as did 16 (48.4%) in the observation group. Mean injury severity score (ISS) for tube thoracostomy and observation groups were similar (25.80 and 22.39, p =0.101) whereas length of stay (LOS) was different (17.4 and 10.0 days, p =0.026). Mortality was similar (11.4% and 9.1%). There were no tension pneumothoraces. Conclusion: The natural history of OP in blunt trauma patients at our institution appears to be one of uneventful resolution irrespective of ISS, need for PPV, or placement of tube thoracostomy. This study suggests an interesting hypothesis that observation of the blunt trauma patient with OP, without tube thoracostomy, may be safe and contribute to a shorter hospital stay. These are observations that would benefit from further study in a large, prospective randomised controlled trial. [Copyright &y& Elsevier]

Summary: There is an increasing use of large airway stents for non-malignant disease processes. As advances in stent development and manufacture are made, there are more patients being treated with airway stents. Stenting can be short term or long term and can be used for the management of large airway obstruction where surgery carries both morbidity and mortality. Pre-operative assessment is particularly important and may determine which of the wide range of techniques that have been used is most appropriate for the individual case. The anaesthetic management of patients with stents already in situ is becoming more important as the number of patients with stents increases. There are some specific pitfalls and problems associated with anaesthesia and these are reviewed. [Copyright &y& Elsevier]

Abstract: Objective: The purpose of this study was to examine the feasibility of conducting aerodynamic and acoustic assessment in children following airway reconstruction. Underlying etiologies, co-morbidities and age related factors can present challenges for meaningful instrumental data collection in this population. Methods: A chart review of 100 children who were seen for a complete voice evaluation at the Center for Pediatric Voice Disorders at the Cincinnati Children''s Hospital Medical Center was conducted. Children who completed full or partial aerodynamic and acoustic protocols were identified. Data regarding the ability to participate in the assessment was tabulated, and vowel samples taken from the acoustic data were subjected to signal type classifications (e.g., Type I, II, III). Results: Fifty-three children met the inclusion/exclusion criteria of the chart review. Of those children, 58% (n =31/53) were able to complete the full acoustic and aerodynamic protocols without any modification. In regards to the aerodynamic protocol alone, 64% (n =34/53) could complete protocol. In regards to the acoustic protocol alone, 75% (n =40/53) could complete the entire acoustic protocol without any modification. There were 32% (n =17) who provided a Type I acoustic signal which was appropriate for measurement of F 0. There was a significant correlation between age and ability to complete the protocol for both the aerodynamic (p =.007) and acoustic (p =.004) protocols. Conclusions: This study demonstrated that a majority of children were capable of completing aerodynamic and acoustic protocols. A significant proportion of children in this study had severe dysphonia, precluding the ability to extract fundamental frequency. Although aerodynamic and acoustic measures are feasible for many patients in this population, the severity of dysphonias observed in these patients causes the use of these measures to be limited in some cases for documenting behavioral and surgical outcomes measures. [Copyright &y& Elsevier]

Abstract: Persistent respiratory symptoms often occur after double aortic arch (DAA) repair but rarely require a second operation. We report 4 children with severe respiratory problems (failure to extubate, 2; severe respiratory distress, 2) caused by severe tracheomalacia and tracheal compression after DAA repair, treated by anterior aortopexy. Aortopexy proved effective and safe in improving symptoms and provides a simple treatment option for children with severe malacia or tracheal compression after DAA repair. [Copyright &y& Elsevier]

Abstract: The cone-beam CT (CBCT), which is acquired using an on-board imager (OBI) attached to a linear accelerator, is used effectively in the verification of setup accuracy for lung radiation surgery. In this study, the respiratory organ motional effect on the CBCT was evaluated with a properly devised phantom system, and the level of possible error in conditions of a real clinical process was assessed. In a comparison study between the CBCT in static status and CBCT images acquired in 20 different motional cases, we confirmed that the image quality and information of CBCT were degraded, with an increase of motional ranges in the region of inhomogeneous structures. The 4D-CT MIP (50∼55%) for the planning of lung radiation surgery and the 4D-CT MIP (full phase) were compared with CBCT in the various motional cases for the evaluation of the influence of the motional effect on CBCT in the process of the setup error correction. The average ratio of relative difference between plan CT: 4D-CT MIP (50%∼55%) and CBCT was 5.79% and between plan CT: 4D-CT MIP (50%∼55%) and 4D-CT MIP (full phase) was 42.95% in the phantom study. In the analysis of clinical cases of lung radiation surgery, the gross tumor volumes were compared in each CT image. The average ratio of relative difference between plan CT: 4D-CT MIP (50∼55%) and CBCT was 10.72% and between plan CT: 4D-CT MIP (50∼55%) and 4D-CT MIP (full phase) was 28.19%. These results showed that, although a respiratory organ motional effect on CBCT introduced variation in image quality, the error as a result of this variation could be estimated relatively low in the setup error correction for a gated-lung radiation surgery when the planning was performed in 4D-CT MIP (50∼55%), which already included a related signal of motional effect. [Copyright &y& Elsevier]

Upper airway constriction is an important contributing factor to obstructive sleep apnea (OSA), which may be treated in a palliative manner with mandibular advancement devices (MADs) to increase patency of the airway. It may be the treatment of choice for affected individuals who cannot use a continuous positive airway pressure device or who are not candidates for surgical correction of OSA. The specific distance applied during mandibular advancement, however, is often arbitrarily determined. This project uses cone beam computed tomography imaging in patients with OSA to determine a quantifiable relationship between airway patency and mandibular advancement. This correlation may be the basis to create an ideal technique to diagnose and treat patients having OSA. Twenty-six subjects successfully treated for OSA with a MAD received 2 cone beam computed tomography scans; 1 with and 1 without the MAD. Volumetric, cross-sectional, and cephalometric measurements were gathered from these scans. With the use of linear regression statistical analysis, specific predictor parameters have been identified for volumetric and cross-sectional airway information. An average oropharyngeal volume increase of approximately 2800 mm3 was achieved with MAD therapy. [Copyright &y& Elsevier]

The amelioration of obstructive sleep apnea syndrome (OSAS) by maxillomandibular advancement (MMA) surgery can be predicted by analyzing anatomical airway changes with 3-dimensional (3D) geometrical reconstruction and computational fluid dynamics. Computer Enabling Technology Lab (ETLab) and Computational Simulation Lab (CSLab) can be used to analyze anatomic airway change for previously operated patients with a clinical cure of OSAS. MMA surgery reduces airway resistance and pressure effort (gradient) of OSAS by increasing the dimension of the airway. ETLab has been used to reconstruct the upper airway as a 3D computer model (bone and soft tissue surrounding the pharyngeal airway) from existing helical computed tomography scan format of OSAS patients. ETLab can compare and construct the geometry with numerical meshes of the airway between pre- and postoperative MMA by the use of bioengineering software. This technology uses high-fidelity computation fluid dynamic simulations, developed at the CSLab, for prediction and analysis of the flow field in the airway for pre- and postoperative MMA. It is possible to use the simulation to predict the likely success of future treatment and develop a prognostic factor. The soft- and hard-tissue mesh is used to determine the pre- and postoperative differences in the facial and pharyngeal tongue base for soft-tissue change associated with hard-tissue movement. This correlation predicts the amount of surgical movement necessary to create an adequate airflow. These results help define the surgical techniques in OSAS for more precise identification of upper airway anatomical features. This process correlates the area and pressure change at the velopharynx, oropharynx, and retroglossal space of the upper airway by the ETLab. Results can compare with polysomnogram and cure rates. 3D computer analysis can be used to test flow dynamics in the human airway for surgical treatment of OSAS. [Copyright &y& Elsevier]

Some of the most severe forms of obstructive sleep apnea are attributed to anatomic abnormalities in the facial skeleton. With the use of conventional orthognathic surgical techniques, it is possible to expand the posterior airway. In fact, there is strong evidence in the literature to support maxillomandibular advancement as one of the most efficacious surgical procedures for the treatment of obstructive sleep apnea (OSA). There are complications associated with this procedure but these are minor when compared with the risk of inadequately treated OSA. [Copyright &y& Elsevier]

Obstructive sleep apnea (OSA) syndrome is a serious health problem that affects a large number of individuals. Research in the field has improved our understanding of the disease, and a holistic management of the OSA patient is becoming widely adopted. When continuous positive airway pressure (CPAP) and dental appliance have failed, surgical procedures to improve the posterior airway are performed. When chosen correctly, these procedures have tremendous benefit to the airway and can potentially cure this devastating syndrome. [Copyright &y& Elsevier]

Abstract: At present, the deployment of self-expandable braided stents has become a common and widely used minimally invasive treatment for stenotic lesions in the cardiovascular, gastrointestinal and respiratory system. To improve these revascularization procedures (e.g. increase the positioning accuracy) the optimal strategy lies in the further development of the stent design. In the context of optimizing braided stent designs, computational models can provide an excellent research tool complementary to analytical models. In this study, a finite element based modelling strategy is proposed to investigate and optimize the mechanics of braided stents. First a geometrical and finite element model of a braided Urolume endoprosthesis was built with the open source pyFormex design tool. The results of the reference simulation of the Urolume stent are in close agreement with both analytical and experimental data. Subsequently, a simplex-based design optimization algorithm automatically adjusts the reference Urolume geometry to facilitate precise positioning by reducing the foreshortening with 20% while maintaining the radial stiffness. Therefore, the proposed modelling strategy appears to be a promising optimization methodology in braided stent design. [Copyright &y& Elsevier]

Abstract: Gas exchange is the main function of the lungs. Oxygen and carbon dioxide diffuse along the gradient of their partial pressures across the alveolar capillary membrane. Lungs have a vast area for gas exchange. Alveolar ventilation and pulmonary circulation are closely interlinked to provide efficient gas exchange in the lungs. This means that gas exchange can be impaired after surgery and in various disease states, leading to hypoxia. Hypoxaemia often results from ventilation–perfusion () mismatching and an increase in fractional inspired oxygen (F i o 2) does not fully correct it. A reduced transfer factor for carbon monoxide (TLCO) indicates disease of the pulmonary parenchyma or pulmonary circulation. Various tests are available to assess the pulmonary function including gas exchange. These tests can be used for the purposes of diagnosis, follow-up and fitness for undergoing anaesthesia and surgery. [Copyright &y& Elsevier]

Objective To evaluate the criteria for the insertion and correct placement of the laryngeal mask airway (LMA) in dogs. Study design Prospective descriptive clinical study. Animals Thirty healthy dogs (ASA I or II) of different breeds, age 0.33–7.0 years (2.8 ± 2.1; mean ± SD), weight 2.2–59.0 kg (23.9 ± 14.4), anaesthetized for elective surgery. Materials and methods The dogs were sedated with intravenous (IV) medetomidine (10 μg kg−1) and butorphanol (0.2 mg kg−1). If considered necessary, IV propofol (1 mg kg−1 over 30 seconds) was administered until the LMA was inserted and positioned correctly. The position of the LMA was evaluated using predefined criteria for its insertion and inflation of the cuff, together with the ability to ventilate the dogs through the LMA. Results The criteria for insertion, inflation and ventilation which indicated a clinically optimal position of the LMA and its seal around the larynx were met in 19 dogs (63.3%). The dogs could be manually ventilated with inspiratory peak pressures of 10 cm H2O without capnographic or audible evidence of leakage. In 11 dogs (36.7%), the LMA was positioned suboptimally with leakage during manual ventilation with inspiratory peak pressures not exceeding 10 cmH2O. There was no evidence of breed-related differences in LMA placement and position. Conclusions and clinical relevance The technique for the insertion of the LMA using predefined criteria to evaluate a correct positioning and a seal led to a successful placement in dogs of both brachycephalic and nonbrachycephalic breeds. The LMA, in most of the dogs, was easily placed, well tolerated and offered a useful less invasive means of securing the upper airway. [ABSTRACT FROM AUTHOR]

Abstract: Lung volume reduction surgery (LVRS) improves the fit of severely hyperinflated emphysematous lungs to the surrounding chest cavity and thereby improves respiratory mechanics and expiratory airflow. LVRS is a potent and life extending therapy for some patients with severe emphysema and has a low associated operative mortality. The national emphysema treatment trial (NETT) identified characteristics of patients for whom LVRS improves survival, function and health-related quality of life and characteristics of patients who should not have surgery. Patients with upper-lobe predominant distribution of emphysema on high-resolution computed tomogram are most likely to benefit from LVRS vs. optimal medical therapy and rehabilitation. At long-term follow-up, the survival and functional benefits derived from LVRS are durable. In efforts to make lung volume reduction safer and more broadly accessible physician-scientists have developed bronchoscopic lung volume reduction (BLVR) procedures. Early clinical trials of BLVR performed with endobronchial valves (EVB) and sclerosant biogels demonstrate their safety. The ability of BLVR EBV techniques to produce desired atelectasis and lung volume loss is likely limited in those patients with collateral ventilation, incomplete fissures and those unable to achieve complete lobar exclusion. Results from a phase III BLVR EBV trial are in analysis. [Copyright &y& Elsevier]

Abstract: Background: Surgical resection remains the most effective therapy for metastatic colorectal cancer confined to the liver, although the extrahepatic recurrence rate is high. Aim of the study: To develop a mammal model in order to investigate by which mechanisms liver surgery affects distant tumour recurrence. Methods: In this animal study the effect of partial hepatectomy (phX) on the development of tumour noduli in the lungs was evaluated. CC531 rat colon carcinoma cells were inoculated i.v. 24h before, during or 24h after surgery. Rat serum was obtained at different time-points after phX and added to in vitro CC531 cell cultures. Finally, phX was compared with an ileum resection (ilX). Results: phX leads to increased tumour noduli in the lungs, compared to Sham operation (p =0.002), but only when performed directly before the injection of tumour cells and not when performed 24h before or after the inoculation. Comparable results were obtained for ilX. No growth stimulation of tumour cells after incubation with rat serum, obtained at different time-points after phX, could be detected in vitro. Conclusion: Not only phX, but also surgery, in general promotes distant tumour recurrence exerting the effect during the early phase of tumour cell adhesion and not during tumour outgrowth. [Copyright &y& Elsevier]

Abstract: Background and purpose: To evaluate the feasibility of sparing the parotid glands and surgically transferred submandibular gland (SMG) by intensity modulated radiotherapy (IMRT) in post-operative cases of head and neck cancer (HNC). Materials and methods: Ten patients (larynx-2, base of tongue-4, tonsil-3, and unknown primary-1; pathologic stages III–IV) who underwent SMG transfers on the side of N0 neck along with definitive surgery were selected for this study. IMRT planning was done retrospectively using helical tomotherapy approach. Planning objective was to deliver 60Gy to PTV1 and 54Gy to PTV2 while maintaining the mean dose to the total parotid volume (TPV) and SMG less than 26Gy. Results: The mean dose (±SD) to the TPV and SMG were 25±0.6Gy and 23±1.9Gy, respectively. The D 95 for PTV1 and PTV2 were 59.9±0.1Gy and 54.9±0.3Gy, respectively, satisfying our planning goal for PTV coverage. The D 99 for PTV1 and PTV2 were 58.2±0.7Gy and 49.5±2.2Gy, respectively, showing that sparing the salivary glands did not result in underdosing of the PTVs. Conclusions: By combining the gland transfer and IMRT, the mean dose to TPV and transferred SMG could be reduced to less than 26Gy in post-operative patients of HNC. [Copyright &y& Elsevier]

Background: Whether and how mitral regurgitation impacts perioperative outcome of noncardiac surgery remains unclear. Methods: From November 1999 to August 2004, all patients undergoing noncardiac operations and ever examined by echocardiography within prior 12 months were screened. Those with moderate-severe or severe mitral regurgitation were enrolled provided they were not already trachea-intubated and the surgery was not performed under local anesthesia. The perioperative outcomes of these patients were analyzed, and related prognostic predictors were investigated by multivariate logistic regression analysis. Results: A total of 84 patients (43 men, mean age of 66 years, low surgical risk in 28 and intermediate in 56) complying with the inclusion criteria were included. Their surgery was complicated by frequent (31%) yet minor intraoperative adverse events of controllable hypotension and bradycardia. In contrast, the postoperative outcomes were seriously complicated with high morbidity (27.4%, mostly pulmonary edema and prolonged tracheal intubation) and mortality (11.9%). Atrial fibrillation was identified by multivariate logistic regression analysis as the predictor of inhospital death (OD 11.579, P = .003), whereas surgical risk level (OD 5.118, P = .021), left ventricular ejection fraction (OD 0.958, P = .026), and atrial fibrillation (OD 3.058, P = .045), as independent predictors of postoperative morbidity. Conclusions: Under current anesthetic management, patients with advanced mitral regurgitation could go through fairly safe intraoperative course of noncardiac surgery despite minor complications. Their postoperative outcome was, however, complicated by extraordinarily high morbidity and mortality, especially in those with preexisting atrial fibrillation, higher surgical risk level, and lower left ventricular ejection fraction. [Copyright &y& Elsevier]

Abstract: We report a giant hemangioma that extended from the mesopharynx to the larynx in an adult. The patient was a 39-year-old woman who had demonstrated an asymptomatic pharyngeal hemangioma since she was 1 year-old. She developed vertigo and consulted a hospital at the age of 39. During screening by head MRI for the diagnosis of the vertigo, hemangioma of the laryngopharynx was detected. She was referred to Osaka National Hospital for further examination. Her subjective symptoms were dyspnoea in the lower left lateral-position. On observation by nasopharyngolaryngovideoscope, a giant hemangioma was diagnosed in the left mesopharynx expanding into the larynx. On MRI study, hemangioma widely extended to the right posterior wall at the mesopharynx level. Since we were concerned about risk of choking if the hemangioma of the larynx were left untreated, we recommended surgery. Under the general anesthesia, hemangioma of the larynx was light-coagulated by KTP laser through tracheotomy. The postoperative-course has been good and at 9 months postoperatively, there was no progression of hemangioma. [Copyright &y& Elsevier]

Dorsal stabilization techniques based on the fixateur interne principle are regarded as the primary treatment method for unstable spinal injuries. For certain types of fracture associated with extensive destruction or defects of the vertebral body and the intervertebral discs, reconstruction of the load-bearing anterior spine is required to avoid loss of correction. Further development of endoscopic technique and standardization of the operating procedure have now made it possible to perform the operation on the ventral section of the spine using minimally invasive thoracoscopy. The operation involves removal of the ruptured intervertebral discs and vertebral fragments including, when necessary, decompression of the spinal canal. The load-bearing capacity of the anterior spine is restored using a vertebral body replacement and ventral instrumentation. The extended thoracoscopic approach described here also opens the retroperitoneal segment between Th12 and L3 to the endoscopic procedure via partial detachment of the diaphragm. Thus, it includes the thoracolumbar section of the lumbar spine, which is the area most frequently affected by fractures. [Copyright &y& Elsevier]

To report the functional and oncologic results of larynx preservation surgery with free flap reconstruction for posterior pharyngeal wall carcinoma. Retrospective medical chart review. Tertiary care referral center. We present a series of seven patients, who were treated for an advanced stage posterior pharyngeal wall carcinoma between 1995 and 1998. All patients underwent posterior pharyngectomy with larynx preservation via a suprahyoidal approach for carcinoma of the posterior pharyngeal wall, with radial forearm free flap reconstruction. Complications occurred in three patients with grade 3 comorbidity, one of whom suffered flap loss. After a mean follow-up of 48 months, three patients are alive without disease. One patient is alive with a second primary tongue carcinoma. Two patients died of disease, whereas one patient died of another cause. All patients could be decannulated and maintain their voice. Six out of seven patients were able to take oral nutrition, although four patients needed additional PEG-tube feeding. Posterior pharyngectomy with larynx preservation and radial forearm free flap reconstruction is feasible in selected patients, with acceptable functional results and survival. However, the patient must be aware of the risk of chronic aspiration and the possibility of long-term PEG feedings. [Copyright &y& Elsevier]

The article offers information on the advanced upper airway obstruction in ear, nose and throat (ENT) surgery. It states that defining the extent level of the obstruction is mandatory before surgery which includes fibre-optic nasendoscopy and computed tomography (CT) scan. Procedure in operating includes rehearsing a fall-back position in the operating theatre with a senior ENT surgeon scrubbed, and tracheostomy should be set opened and a rigid bronchoscope at hand.

Airway stenting for complex airway disease is a common procedure performed by interventional pulmonologists and thoracic surgeons. Malignant central airway obstruction with carinal involvement and tracheobronchomalacia are 2 of the more common indications for the placement of a specially designed stent known as a Y stent. We describe the first report in the literature, to our knowledge, of a novel use of the GlideScope (Verathon Inc, Bothell, WA) to facilitate safe and rapid placement of the Dynamic (Y) Stent (Boston Scientific, Natick, MA) and greatly improve on the teaching aspects of the placement of this stent. [ABSTRACT FROM AUTHOR]

Abstract: Objective: Posterior glottic stenosis is a well recognised though rare condition. A wide range of treatment options have been proposed including endoscopic laser techniques and open techniques with grafting. The objective of this study was to present our experience of single stage laryngotracheal reconstruction with endoscopic technique of placement of posterior graft in isolated posterior glottic stenosis. Methods: This study was conducted at the Department of Paediatric Otolaryngology at Great Ormond Street Hospital, London. The senior authors (ALT, DMA) were involved in the management of two children with isolated posterior glottic stenosis operated on as single stage reconstruction. Results: The two children in this small series had isolated posterior glottic stenosis. The aetiology in both the cases was previous prolonged intubation. Both patients underwent a successful placement of the posterior graft endoscopically, though it was a challenging task because of space constraints. None of these children required an intra-operative or post-operative tracheostomy. There were no complications in these patients. At follow up endoscopic examinations, both these patients have had their airway widened successfully. Conclusion: Single stage laryngotracheal reconstruction with endoscopic placement of posterior graft in cases with isolated posterior glottic stenosis is a good alternative to open surgical techniques, although is technically a challenging procedure. [Copyright &y& Elsevier]

Abstract: Objective: Laryngotracheal separation (LTS) is an effective and reliable definitive treatment for intractable aspiration. A major advantage of this treatment for intractable aspiration is its’ potential reversibility. Should the underlying disorder improve, a reversal of the procedure may be attempted. This has been successfully achieved in the adult population. To our knowledge, no previous cases have been reported of successful reversal of LTS in children. Methods: A retrospective review from 2003 to 2010 identified four cases of intractable aspiration treated with LTS in our department. Two of these patients displayed objective evidence of sufficient recovery of their underlying aspiration to consider reversal. Patient selection for reversal was dependent upon successful oral intake for 9 months along with videofluoroscopic evidence of normal or minimally impaired swallow. Results: Two children who were successfully treated for intractable aspiration with LTS demonstrated objective evidence of recovery sufficient to attempt reversal. Both children underwent successful surgical reversal of LTS using a cricotracheal resection with end-to-end anastamosis, similar to that used in treatment of subglottic stenosis. Both children can now tolerate oral diet and their speech and language development is in line with their overall developmental level. Conclusions: Laryngotracheal separation is an effective and reliable definitive treatment for intractable aspiration facilitating protection of the airway and allowing safe swallowing with unimpeded respiration, but with the major drawback of loss of phonation. To our knowledge, we document the first two cases of successful LTS reversal in children. [ABSTRACT FROM AUTHOR]

A rare case of esophageal schwannoma compressing the trachea in pregnancy is presented. A 29-year-old pregnant woman was hospitalized due to severe dyspnea. Imaging studies revealed a homogeneous tumor (8 cm in diameter) in the posterior mediastinum with compression of the lower trachea. After an uneventful cesarean section, the patient underwent a mini-axillary thoracotomy with video-assisted thoracic surgery. The tumor arose from within the muscular layers of the esophagus and was enucleated by gentle blunt dissection. Pathologic and immunohistochemical examinations revealed a benign esophageal schwannoma. [Copyright &y& Elsevier]

Pleural dissection in pleurectomy under videothoracoscopy in patients with pneumothorax is easily and safely performed using argon gas. [ABSTRACT FROM AUTHOR]

Nouveau-né aux échographies ante natales déclarées normales. Dès H 24 de vie, détresse respiratoire progressivement croissante ; avis chirurgical demandé à J 5. Important emphysème global du poumon droit faisant évoquer un obstacle de la bronche souche. Fibroscopie : lésion kystique endo-luminale de la carène obstruant l’ostium de la bronche droite. Une lésion kystique identique existe au niveau de la carène, exo-luminale «en miroir» de la précédente sur le scanner. Aggravation rapide de la détresse respiratoire et intervention en urgence à J 5 par thoracotomie droite : exérèse de la lésion externe avec affaissement de la lésion endo luminale en contrôle endoscopique per opératoire et bon «air-way» du poumon droit. Cependant résultat temporaire car lésion endo-luminale retrouvée égale à elle-même à l’endoscopie à J+5. Intervention per endoscopique à J+6 : réalisation après ponction, d’une «électrofenestration». Suites simples. Anatomopathologie confirmant le kyste bronchogénique. Contrôle endoscopique satisfaisant à + 2 ans chez un enfant asymptomatique. À ce jour, une seule observation identique de kyste bronchogénique trans mural de la carène a été retrouvée dans la littérature avec un traitement uniquement endoscopique. [ABSTRACT FROM AUTHOR]

Objective: To explore diaphragmatic lesions that are potentially associated with catamenial pneumothorax by using an advanced flexible laparoscope with wide optic angle. Design: Case report. Setting: University hospital. Patient(s): A 30-year-old woman who was scheduled for thoracoscopic surgery because of recurrent right-sided catamenial pneumothorax. Intervention(s): The peritoneal surface of the diaphragm was explored with an advanced flexible laparoscope that was equipped with a charge-coupled device on the tip, concurrently with thoracoscopic surgery. Main Outcome Measure(s): Lesions associated with endometriosis on the peritoneal surface of the posterior diaphragm abutting the posterior abdominal wall and liver. Result(s): When the flexible laparoscope was inserted via an umbilical trocar and the peritoneal surface of the right-sided diaphragm was explored, guided by illumination from the thoracoscope, scattered specific lattice lesions and fenestrations were identified in the central tendon of the posterior diaphragm, a region that cannot be visualized with the conventional rigid laparoscope. Conclusion(s): By using the flexible laparoscope, endometriotic lesions potentially related to catamenial pneumothorax were identified on the posterior diaphragm. [Copyright &y& Elsevier]

Abstract: Preoperative cardio-respiratory tests aim to identify patients with increased perioperative risk, enabling clinicians to assign optimal preoperative treatment, anaesthetic management and intraoperative monitoring techniques, and assess the need for postoperative ‘high dependency’ or intensive care. Such evaluation is based on a history and examination supplemented by appropriate clinical tests. One must distinguish patients who require little or no preoperative testing from those for whom specialized testing is necessary. This contribution provides an overview of the more common cardio-respiratory function tests available, and how these tests can provide important information about the cardiac and/or respiratory status of a patient scheduled for surgery. [Copyright &y& Elsevier]