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Achalasia is a rare cause of neck swelling. We report the case of a 75-year-old woman, who presented with an intermittent, unilateral neck swelling, associated with dysphagia, weight loss and regurgitation. The patient underwent a gastroscopy and barium swallow. This confirmed a dilated oesophagus with poor motility and hold up of liquid and food residue above the gastro-oesophageal junction, thus revealing the swelling was secondary to severe achalasia. The patient was managed with botulinum toxin injections and pneumatic dilatations but the results were short lived. She is now having manometry and is being considered for a Heller myotomy or peroral oesophageal myotomy. Delayed diagnosis and treatment of achalasia can result in the development of a neck swelling, which could later cause airway compromise and subsequent mortality. Achalasia should therefore be considered in patients with an initial diagnosis of gastro-oesophageal reflux disease who do not respond to proton pump inhibitors.

Angioedema is a well-recognized and potentially lethal complication of angiotensin-converting enzyme inhibitor (ACEi) therapy. In ACEi-induced angioedema, bradykinin accumulates due to a decrease in its metabolism by ACE, the enzyme that is primarily responsible for this function. The action of bradykinin at bradykinin type 2 receptors leads to increased vascular permeability and the accumulation of fluid in the subcutaneous and submucosal space. Patients with ACEi-induced angioedema are at risk for airway compromise because of the tendency for the face, lips, tongue, and airway structures to be affected. The emergency physician should focus on airway evaluation and management when treating patients with ACEi-induced angioedema.

A previously fit and well 3-month-old baby was admitted to his local hospital with worsening stridor following a 2-week history of croup-like symptoms. Chest radiograph shows a large area of mediastinal and bilateral upper-zone opacification ([figure 1][1]). Due to concerns of progressive airway

Lipoblastomas are benign tumours of immature fat cells presenting in infancy. A lipoblastoma within the airway lumen causing airway compromise is an extremely rare occurrence. We present a 6 hours of life girl who had airway compromise due to a lobulated mass at the base of the tongue. The mass was excised after emergency endotracheal intubation.

Introduction: Adult epiglottitis is a disease process distinct from pediatric epiglottitis in microbiology, presentation, and clinical course. While traditionally considered more indolent and benign than in children, adult epiglottitis remains a cause of acute airway compromise with a mortality rate from 1-20%. Our objective was to characterize the disease course and evaluate the rate and type of airway management in this population at a tertiary, academic referral center. Methods: We conducted a retrospective chart review of all adult patients (age ≥ 18) who were definitively diagnosed with infectious “epiglottitis,” “supraglottitis,” or “epiglottic abscess” by direct or indirect laryngoscopy during a nine-year period. Double data abstraction and a standardized data collection form were used to assess patient demographic characteristics, presenting features, and clinical course. The primary outcome was airway intervention by intubation, cricothyroidotomy, or tracheostomy, and the secondary outcome was mortality related to the disease. Results: Seventy patients met inclusion criteria. The mean age was 50.2 years (standard deviation ± 16.7), 60% of the patients were male, and 14.3% were diabetic. Fifty percent had symptoms that were present for ≥ 48 hours; 38.6% had voice changes, 13.1% had stridor, 12.9% had fever, 45.7% had odynophagia, and 47.1% had dysphagia noted in the ED. Twelve patients (17.1%) received an acute airway intervention including three who underwent emergent cricothyroidotomy, and one who had a tracheostomy. Two patients died and one suffered anoxic brain injury related to complications following difficult airway management. Conclusion: In this case series the majority of patients (82.9%) did not require airway intervention, but a third of those requiring intervention (5.7% of total) had a surgical airway performed with two deaths and one anoxic brain injury. Clinicians must remain vigilant to identify signs of impending airway compromise in acute adult epiglottitis and be familiar with difficult and failed airway algorithms to prevent morbidity and mortality in these patients.

Most patients with undifferentiated thyroid cancer have unresectable disease with a very high rate of airway compromise. Tracheostomy typically entails technical issues in these cases. In fact, it can be very difficult to expose or simply locate the trachea beneath the mass, and the extensive soft tissue involvement can force the surgeon to cut the tumor to place the tracheostomy tube. The combined use of rigid bronchoscopy and percutaneous tracheostomy techniques, applied in an open surgical procedure, can greatly simplify the procedure. Furthermore, by this method, the airways are quickly secured and the risk of intraoperative bleeding is reduced.

ObjectiveThis study aimed to compare treatment outcomes in patients with laryngeal and tracheal stenosis treated during and prior to the coronavirus disease 2019 pandemic period.MethodPatients treated for laryngotracheal lesions with impending airway compromise during the active pandemic period were matched with those treated for similar lesions in the preceding years in a monocentric tertiary hospital setting.ResultsDuring the pandemic period of 55 days, 31 patients underwent 47 procedures. Seven patients (2 children, 5 adults) had open airway surgery, and one had an operation-specific complication. Twenty-four patients (10 children, 14 adults) underwent 40 endoscopic interventions without any complications. Operation specific results during and prior to the pandemic were comparable.ConclusionThe management strategy in patients with laryngotracheal lesions and impending airway compromise should not be altered during periods of risk from coronavirus disease 2019. Avoiding a tracheostomy by performing primary corrective surgery or proceeding with a definitive decannulation would be beneficial in these patients to reduce the risk of contagion.

Background This study aimed to identify the risk factors and evaluate the prognosis of unplanned reintubation caused by acute airway compromise (AAC) after general anesthesia. Methods This case-control study included surgical patients who underwent unplanned reintubation in the operating room and postanesthesia care unit after general anesthesia between January 1, 2014, and December 31, 2018. Cases due to AAC were matched 1:4 with randomly selected controls. Results A total of 123,068 patients were included, and reintubation due to AAC was performed in 36 patients (approximate incidence 0.03%). Univariable analysis revealed that male sex, age > 65, ASA physical status 3, sepsis, heart disease history, cerebral infarction history, Cormack Lehane grade, surgery type, fresh frozen plasma infusion, increased intubation duration, white blood cell count, and creatinine clearance rate were related to AAC-caused unplanned reintubation. Multivariable analysis revealed that age > 65 (OR = 7.50, 95% CI 2.47–22.81, P P = 0.032), head-neck surgery (OR = 4.94, 95% CI 1.33–18.36, P = 0.017) or thoracic surgery (OR = 12.56, 95% CI 2.93–53.90, P P = 0.024) were associated with AAC-caused unplanned reintubation. AAC-caused unplanned reintubation patients had longer postoperative hospital (OR = 5.26, 95% CI 1.57–8.95, P P Conclusions Age > 65, ASA physical status 3, head-neck or thoracic surgery and high fluid load were found to be associated with AAC-caused unplanned reintubation.

Contains fulltext : 238665.pdf (Publisher’s version ) (Open Access) PURPOSE: To evaluate imaging, treatment, and outcomes in neonates with a lymphatic malformation (LM) adjacent to the airway and to evaluate risk factors that can predict outcome. METHODS: A retrospective case series was conducted of ten patients treated between January 2011 and July 2019. The main outcome measures included airway compromise and clinical response to sclerotherapy +/- surgery. Categorical data were compared using the Fisher's exact test. RESULTS: Ex-utero intrapartum therapy was performed in four cases, among whom one died due to sepsis. All patients underwent schlerotherapy, with surgical debulking in two. Four patients showed a good clinical response, and five started experimental systemic treatment. Patients with bilateral disease and patients with an LM with >180 degrees tracheal surrounding were significantly at risk for airway compromise (bilateral: n = 6/6 versus n = 0/4, p = 0.005; >180 degrees : n = 5/5 versus n = 1/5, p = 0.048). The need for LM treatment in the neonatal period was indicative of a poor clinical response ('non-responders' 5/6, 'responders' 0/4; p = 0.048). CONCLUSIONS: This study indicates that bilateral disease and >180 degrees tracheal surrounding are risk factors for airway compromise in neonates with an LM adjacent to the airway. In addition, the need for early treatment seems to be indicative of a poor clinical response.

The contribution of positional asphyxia in opioid-related deaths is currently unknown. Diagnostic criteria for positional asphyxia include finding the decedent in a position that does not allow for adequate respiration and an inability to extricate themselves from the position due to various conditions. Our primary objective was to assess whether positional asphyxia and the resulting airway compromise were a contributing factor to death due to the toxic effects of opioids. We evaluated 225 deaths where the death scene investigation contained adequate information to evaluate for positional asphyxia and performed a Pearson chi-square test to determine if the proportion of deaths found in an airway compromising position was higher when opioid(s) caused the death. The proportion of decedents found in a potential airway compromising position was greater when the death was related to opioid use (p < 0.0001). Further, narrowing the dataset to decedents who were definitely in an airway compromising position [Yes (24.49%) vs. No (11.02%)] showed a statistically significant association between positional asphyxia and deaths related to opioid use (p = 0.0021). Carefully documenting the position in which the decedent was initially found may be a significant factor in accurate reporting and in harm reduction efforts to decrease the opioid mortality rate.

Two cases of clinically undiagnosed laryngeal squamous cell carcinomas in men aged 57 and 66 years, respectively, are reported that resulted in sudden death from upper airway occlusion. The cause of the terminal event differed between the 2 cases with acute airway narrowing being precipitated by tenacious mucopurulent secretions in case 1 and hemorrhage from surface ulceration with glottic occlusion by blood clot in case 2. At autopsy, the immediate cause of acute airway compromise in cases of space-occupying laryngeal lesions may, therefore, be due to the synergistic effects of different factors.

Kikuchi-Fujimoto disease is a rare, benign cause of necrotising lymphadenitis often presenting with fever. We describe a case of a 17-year-old boy with non-verbal autism presenting to our intensive care unit with prolonged fever of unknown cause. This case highlights the role of the intensive care unit in cases of diagnostic dilemma. The critical care community should be aware of Kikuchi-Fujimoto disease as although it is usually benign, it can rarely lead to acute airway compromise.

The impact of the COVID-19 pandemic on otolaryngology practice is nowhere more evident than in acute airway management. Considerations of preventing SARS-CoV-2 transmission, conserving personal protective equipment, and prioritizing care delivery based on acuity have dictated clinical decision making in the acute phase of the pandemic. With transition to a more chronic state of pandemic, heightened vigilance is necessary to recognize how deferral of care in patients with tenuous airways and COVID-19 infection may lead to acute airway compromise. Furthermore, it is critical to respect the continuing importance of flexible laryngoscopy in diagnosis. Safely managing airways during the pandemic requires thoughtful multidisciplinary planning. Teams should consider trade-offs among aerosol-generating procedures involving direct laryngoscopy, supraglottic airway use, fiberoptic intubation, and tracheostomy. We share clinical cases that illustrate enduring principles of acute airway management. As algorithms evolve, time-honored approaches for diagnosis and management of acute airway pathology remain essential in ensuring patient safety.

Although 1st and 2nd generation supraglottic airway devices (SADs) have many desirable features, they are nevertheless inserted in a similar 'blind' way as their 1st generation predecessors. Clinicians mostly still rely entirely on subjective indirect assessments to estimate correct placement which supposedly ensures a tight seal. Malpositioning and potential airway compromise occurs in more than half of placements. Vision-guided insertion can improve placement. In this article we propose the development of a 3rd generation supraglottic airway device, equipped with cameras and fiberoptic illumination, to visualise insertion of the device, enable immediate manoeuvres to optimise SAD position, verify whether correct 1st and 2nd seals are achieved and check whether size selected is appropriate. We do not provide technical details of such a '3rd generation' device, but rather present a theoretical analysis of its desirable properties, which are essential to overcome the remaining limitations of current 1st and 2nd generation devices. We also recommend that this further milestone improvement, i.e. ability to place the SAD accurately under direct vision, be eligible for the moniker '3rd generation'. Blind insertion of SADs should become the exception and we anticipate, as in other domains such as central venous cannulation and nerve block insertions, vision-guided placement becoming the gold standard.

OBJECTIVE. The purpose of this article is to discuss imaging techniques and provide a pictorial review of pediatric tongue lesions. CONCLUSION. Pediatric tongue lesions represent an often-overlooked collection of abnormalities with a variety of clinical and radiologic features. The location of these lesions places the patient at risk for airway compromise. Systematic imaging evaluation of pediatric tongue lesions can help the radiologist arrive at a correct and timely diagnosis, thus improving and expediting patient care.

PURPOSE The purpose of this study was to characterize airway problems, speech outcomes, and facial growth in patients with Stickler syndrome undergoing cleft palate repair. METHODS A retrospective, longitudinal study was performed at the Children's Hospital of Philadelphia on 25 patients with Stickler syndrome and 53 nonsyndromic patients with clefts of the secondary palate repaired between 1977 and 2000. Airway problems were characterized by the incidence of Pierre Robin Sequence (PRS) and the necessity for surgical airway management. Speech was analyzed using the Pittsburgh weighted values for speech symptoms associated with velopharyngeal incompetence (VPI). Longitudinal anthropometric measurements represented up to 12 years of longitudinal cephalofacial growth. RESULTS Seventy-two percent of patients with Stickler syndrome were diagnosed with PRS, 55.6% of whom required surgical airway management. Conversely, 20.8% of nonsyndromic patients were diagnosed with PRS (P < 0.0001), 18% of whom required surgical intervention (P < 0.05). Speech outcomes were poorer in patients with Stickler syndrome with 40% demonstrating borderline VPI and 13.3% demonstrating VPI, compared with 21.8% and 9.1%, respectively, in the nonsyndromic group. Both groups exhibited significantly shallower upper and mid facial depths and wider upper facial breadths when compared with normal standards of facial growth. Although there was a tendency toward decreased facial depths in patients with Stickler syndrome relative to nonsyndromic patients, the differences were nonsignificant. CONCLUSIONS Patients with Stickler syndrome show significant potential for early airway compromise and a poorer prognosis for speech outcome after cleft palate repair. Their cephalofacial growth does not differ significantly from that of nonsyndromic cleft palate patients.

IntroductionAirway compromise is the second leading cause of potentially survivable death on the battlefield. The purpose of this study was to better understand wartime prehospital airway patients.Materials and MethodsThe Role 2 Database (R2D) was retrospectively reviewed for adult patients injured in Afghanistan between February 2008 and September 2014. Of primary interest were prehospital airway interventions and mortality. Prehospital combat mortality index (CMI-PH), hemodynamic interventions, injury mechanism, and demographic data were also included in various statistical analyses.ResultsA total of 12,780 trauma patients were recorded in the R2D of whom 890 (7.0%) received prehospital airway intervention. Airway intervention was more common in patients who ultimately died (25.3% vs. 5.6%); however, no statistical association was found in a multivariable logistic regression model (OR 1.28, 95% CI 0.98–1.68). Compared with U.S. military personnel, other military patients were more likely to receive airway intervention after adjusting for CMI-PH (OR 1.33, 95% CI 1.07–1.64).ConclusionsIn the R2D, airway intervention was associated with increased odds of mortality, although this was not statistically significant. Other patients had higher odds of undergoing an airway intervention than U.S. military. Awareness of these findings will facilitate training and equipment for future management of prehospital/prolonged field care airway interventions.

The Ex Utero Intrapartum Treatment (EXIT) is a surgical procedure performed in cases of expected postpartum fetal airway obstruction, allowing the establishment of patent airway while maintaining placental circulation. Anesthesia for EXIT procedure has several specific features such as adequate uterine relaxation, maintenance of maternal blood pressure fetal anesthesia and fetal airway establishment. The anesthesiologist should be aware of these particularities in order to contribute to a favorable outcome. This is a case report of an EXIT procedure performed on a fetus with a cervical lymphangioma with prenatal evidence of partial obstruction of the trachea and risk of post-delivery airway compromise. Resumo: O procedimento Intraparto Extra-Uterino (EXIT) é procedimento cirúrgico realizado em casos de previsão de obstrução de via aérea fetal no pós-parto, que permite estabelecer via aérea patente enquanto a circulação placentária é mantida. A anestesia para o procedimento EXIT apresenta várias características específicas, tais como relaxamento uterino adequado, manutenção da pressão arterial materna, anestesia fetal e estabelecimento da via aérea fetal. O anestesiologista deve estar ciente dessas especificidades para contribuir para desfecho favorável. Trata-se de relato de caso de procedimento EXIT realizado em feto com linfangioma cervical e evidência pré-natal de obstrução parcial de traqueia e risco de comprometimento de via aérea pós-parto.

Airway compromise is life threatening complication in the maxillofacial fracture. However, the incident of the airway compromise following mandibular fracture was little known. Maxillofacial fractures during the past 3 years from 2017 to 2020 were investigated retrospectively. There were 154 patients with maxillofacial fractures were noted in the past 3 years. Mandibular fractures accounted for 93% of the maxillofacial fracture. The most common cause of injury was falls (75%), followed by sports (12%). Of these, 3 cases (1.9%) needed an airway management at the time of initial treatment, and all were mandibular fractures. The average age was 55.7 ± 10 years and all were male. The cause of the injury was high-energy trauma including traffic accident and work-related injury. Endotracheal intubation was performed at the time of initial treatment. All cases were communicated mandibular fracture included symphysis and para-symphysis region, and the bone fragments including the genial tubercle were largely displaced inward.

OBJECTIVE Airway obstruction in newborns with Pierre Robin sequence (PRS) may be managed with tongue-lip adhesion (TLA), mandibular distraction osteogenesis (MDO), or tracheostomy to prevent airway compromise when conservative airway interventions fail or are contraindicated based on the type of obstruction present. Unfortunately, some of these procedures have the potential to affect a child's speech and feeding development. METHOD The authors retrospectively reviewed the records of all children with PRS treated at our institution in the last 25 years. Our primary outcomes of interests were: (1) consonant production errors; (2) achievement of full oral feeds; (3) need for prolonged gastrostomy tube feeds; and (4) avoidance of tracheostomy. RESULTS Seven (7/73, 10%) children required intubation at birth for respiratory failure. Forty-two children were treated with TLA (42/73, 58%), 2 with MDO (2/73, 3%), and 1 (1/73, 1%) with tracheostomy. Twenty-one (21/73, 29%) were treated with conservative airway interventions. Of the 7 children requiring intubation, 1 required tracheostomy, and 6 required TLA. Five children who received TLA initially proceeded to tracheostomy. Of the 3 children who underwent MDO, 2 required tracheostomy. Of the 2 patients who underwent MDO, 2 failed, requiring tracheostomy. One child required tracheostomy as the first airway intervention. Among all children with PRS, /s,z/ speech errors were the most common. Children treated with conservative airway interventions had significantly fewer /sh/ errors at age 3 (X = 6.604, P

BackgroundRetropharyngeal haematomas are most commonly associated with trauma and anti-coagulant use. This paper describes the first reported case of a spontaneous retropharyngeal haematoma suspected to be due to indomethacin use.Case reportIt is proposed that the combination of indomethacin affecting platelet aggregation, alongside the patient coughing, may have led to this retropharyngeal haematoma.ConclusionThe complexities of management are discussed and the current literature reviewed. In the absence of airway compromise or a rapidly enlarging haematoma, patients can be managed conservatively with observation and close discussion with the haematology department. Follow-up imaging is not necessary if the patient's symptoms settle; however, any increase in parathyroid hormone levels must be investigated to exclude a parathyroid adenoma.

Objective Previous studies have explored the restricted nasopharyngeal airway in Apert syndrome patients. This study aims to investigate the segmented airway volume changes with age and directly analyze their correlations with subcranial dimensions and angulations. Methods Ninety-seven preoperative computed tomography scans (Apert, n = 44; control, n = 53) were included in this study, and divided into 5 age-related subgroups. Computed tomography scans were measured using Mimics and 3-matics software. Results Before 6 months of age, the nasal cavity in Apert syndrome is reduced by 47% (P = 0.002), which gradually approximates normal thereafter; however, there remained a 30% reduction, compared with controls. It is highly correlated with the anteroposterior length of subcranial space, and the position of maxilla and palate. The pharyngeal airway volume in Apert syndrome patients, younger than 6 months, was larger than normal by 129% (P = 0.013). However, between 2 and 6 years of age, the pharyngeal airway becomes smaller than normal, with a 57% (P = 0.010) reduction in childhood and 52% (P = 0.005) in adolescence. It is closely correlated with the intercondylar and intergonial widths. Conclusions Airway compromise in Apert syndrome patients is attributable more to the nasal cavity in infants, but in the older child, it is the pharyngeal region. The restricted nasal airway in Apert syndrome is correlated with the subcranial space length and width, but independent of cranial base flexion. The pharyngeal airway volume in Apert syndrome is not as highly correlated with craniofacial morphology. Rather, it is impacted by the growth of mandible, which often requires surgical intervention later in childhood.

Hoarseness lasting greater than 2 weeks should be thoroughly evaluated. Here, a case is presented of a 38-year-old female with a 10-year history of dysphonia. Endoscopic examination confirmed the presence of a supraglottic mass, for which operative biopsy and imaging were performed. Pathology confirmed the diagnosis of supraglottic schwannoma. This was excised endoscopically with close management postoperatively to monitor for rapid recurrence and airway compromise. At one month postoperatively, the patient is still mildly dysphonic but vocally improved and the operative site continues to heal well.

Background Diltiazem in its extended-release formulation is widely prescribed and is generally well-tolerated. Currently, there are no published case reports of localized inflammation related to extended-release diltiazem causing either significant pill esophagitis or airway inflammation when swallowed incompletely. Case Report We present a case of an 85-year-old female who reported difficulty swallowing roughly 18 h after incomplete ingestion of an extended-release diltiazem tablet. She had mild stridor and visible right-sided neck swelling on examination. Imaging revealed a large inflammatory mass, which was believed to be a subacute to chronic neoplastic process when reviewed both by radiology and otolaryngology. Two days after presentation, however, the patient's symptoms and the inflammatory mass had resolved entirely. Why Should an Emergency Physician Be Aware of This? Extended-release diltiazem can cause an inflammatory mass when ingested incompletely, leading to possible acute airway compromise. Any invasive airway intervention should be approached with caution, given the degree of acute inflammation. Even in patients who do not require intervention, close observation until clinical improvement is warranted in symptomatic patients with a history of recent incomplete ingestion of extended-release diltiazem.

Radioiodine ablation is a commonly utilized treatment for differentiated thyroid carcinoma. Uptake of radioiodine can be enhanced by pretreatment with thyroid hormone withdrawal or administration of recombinant human thyroid-stimulating hormone (rhTSH). rhTSH is generally well-tolerated with minimal adverse effects. However, in patients with extensive tumor burden in confined anatomic spaces, rapid enlargement of normal or neoplastic thyroid tissue secondary to rhTSH administration can result in significant compressive effects. In this report, we describe a case of rapid airway deterioration requiring intubation in a patient with involvement of the thyroid cartilage by papillary thyroid carcinoma. Laryngoscope, 122:0000-0000, 2019 Laryngoscope, 130:2725-2727, 2020.

Obstructive sleep apnoea (OSA) is characterised by repetitive compromise of the upper airway, causing impaired ventilation, sleep fragmentation, and daytime functional impairment. It is a heterogeneous condition encompassing different phenotypes. The prevalence of OSA among patients presenting for elective surgery is growing, largely attributable to an increase in age and obesity rates, and most patients remain undiagnosed and untreated at the time of surgery. This condition is an established risk factor for increased perioperative cardiopulmonary morbidity, heightened in the presence of concurrent medical comorbidities. Therefore, it is important to perform preoperative OSA screening and risk stratification - using the STOP-Bang screening questionnaire, nocturnal oximetry, and ambulatory and in-laboratory polysomnography, for example. Postoperative risk assessment is an evolving process that encompasses evaluation of upper airway compromise, ventilatory control instability, and pain-sedation mismatch. Optimal postoperative OSA management comprises continuation of regular positive airway pressure, a multimodal opioid-sparing analgesia strategy to limit respiratory depression, avoidance of supine position, and cautious intravenous fluid administration. Supplemental oxygen does not replace a patient's regular positive airway pressure therapy and should be administered cautiously to avoid risk of hypoventilation and worsening of hypercapnia. Continuous pulse oximetry monitoring with specified targets of peripheral oxygen saturation measured by pulse oximetry is encouraged.

In December 2018, the Centers for Disease Control declared fentanyl the deadliest drug in America. Opioid overdose is the single greatest cause of death in the United States adult population (ages 18–50), and fentanyl and its analogs [fentanyl/fentanyl analogs (F/FAs)] are currently involved in >50% of these deaths. Anesthesiologists in the United States were introduced to fentanyl in the early 1970s when it revolutionized surgical anesthesia by combining profound analgesia with hemodynamic stability. However, they quickly had to master its unique side effect. F/FAs can produce profound rigidity in the diaphragm, chest wall and upper airway within an extremely narrow dosing range. This clinical effect was called wooden chest syndrome (WCS) by anesthesiologists and is not commonly known outside of anesthesiology or to clinicians or researchers in addiction research/medicine. WCS is almost routinely fatal without expert airway management. This review provides relevant clinical human pharmacology and animal data demonstrating that the significant increase in the number of F/FA-induced deaths may involve α-adrenergic and cholinergic receptor–mediated mechanical failure of the respiratory and cardiovascular systems with rapid development of rigidity and airway closure. Although morphine and its prodrug, heroin, can cause mild rigidity in abdominal muscles at high doses, neither presents with the distinct and rapid respiratory failure seen with F/FA-induced WCS, separating F/FA overdose from the slower onset of respiratory depression caused by morphine-derived alkaloids. This distinction has significant consequences for the design and implementation of new pharmacologic strategies to effectively prevent F/FA-induced death. SIGNIFICANCE STATEMENT: Deaths from fentanyl and F/FAs are increasing in spite of availability and awareness of the opioid reversal drug naloxone. This article reviews literature suggesting that naloxone may be ineffective against centrally mediated noradrenergic and cholinergic effects of F/FAs, which clinically manifest as severe muscle rigidity and airway compromise (e.g., wooden chest syndrome) that is rapid and distinct from respiratory depression seen with morphine-derived alkaloids. A physiologic model is proposed and implications for new drug development and treatment are discussed.

Chronic laryngitis is an inflammatory process of at least 3 weeks duration and affects phonation, breathing, and swallowing. This article describes the infectious, inflammatory, and autoimmune causes of chronic laryngitis. Symptoms of chronic laryngitis are nonspecific and may range from mild to airway compromise requiring emergent tracheostomy.

As the act of deglutition involves much of the central and peripheral nervous systems, neurologic disease can affect swallowing behaviors ranging from mild to profound in severity. The key in working with neurogenic dysphagia is to have a solid foundation in normal swallowing processes, including neural control. Within this framework, then, understanding how the neurologic condition affects neural control will guide hypothesis-based assessment and evidence-based treatment. The purpose of this article is to provide an overview of evaluation and treatment of neurogenic dysphagia in adult populations as well to propose assessment of co-occurring speech, language, and airway compromise. Furthermore, it is vital to be familiar with ethical decision making and end-of-life issues. Continuing education in the form of research articles, conferences, and professional discussion boards is useful in maintaining a high level of service delivery. Whenever possible, an inter- or transdisciplinary approach is recommended.

Background Arterial pseudoaneurysms of the neck are rarely reported in the pediatric population and no dedicated large series are available. Trauma and infection are the most common causes for these aneurysms, with congenital and collagen vascular disorders being the less common causes. These lesions can be life threatening, especially when they present with bleeding or airway compromise. Methods We searched our radiology information system for all cases of pediatric neck aneurysm presented between June 2015 and May 2018. These cases were analyzed for clinicoepidemiologic variables, clinical presentation, imaging findings, management, and follow-up. Results Six children were included in the study (male/female ratio, 5:1), with a mean age of 7.8 years (range, 2.5–15 years). Four presented acutely with either bleeding or rapidly enlarging neck swelling, whereas 2 presented with slowly increasing pulsatile swelling. One had a traumatic cause, 2 had infections, and 1 had infective cervical lymphadenitis complicated by iatrogenic injury whereas no definite causative mechanisms could be accounted for in 2 patients. Two of the children were managed by trapping of the aneurysm and 2 only by proximal parent vessel occlusion. The other 2 children were treated with stent graft deployment across the aneurysm neck to reconstruct the parent vessel. All the patients were doing well during the follow-up period (mean, 14.8 months). Conclusions Endovascular means of treatment for pediatric neck aneurysms is relatively simple and safe. Although parent vessel sacrifice is the gold-standard management, vessel-preserving strategies can be tried in select cases with favorable anatomy.

Pierre Robin sequence consists of clinical triad of micrognathia, glossoptosis, and airway compromise with variable inclusion of cleft palate. Evaluation of airway obstruction includes physical examination, polysomnography for obstruction events, and a combination of nasoendoscopy and bronchoscopy to search for synchronous obstructive lesions. A multidisciplinary approach is required given the high rate of syndromic disease. Management of airway obstruction and feeding starts with nonsurgical maneuvers, such as prone and lateral positioning, nasopharyngeal stenting, and continuous positive airway pressure. Surgical management includes mandibular distraction and tongue-lip adhesion. Subglottic obstruction and central sleep apnea may best be treated with tracheostomy.

The purpose of this Society of Gastroenterology Nurses and Associates Fellowship project was to determine whether capnography is more accurate than oximetry in identifying symptoms of respiratory depression in patients undergoing moderate sedation. Capnography provides an early warning of respiratory depression and airway compromise, especially when the medications used for sedation include opiates and benzodiazepines. It is a standard of care according to the American Society of Anesthesiologists that should be adopted in order to provide the safest possible environment for the delivery of moderate sedation. During this project, the nursing staff were educated on the importance and usage of capnography. Evidence was gathered that helped show that by using capnography, nurses were able to identify signs of respiratory depression earlier and more frequently than with the use of oximetry and cardiac monitoring alone.

Neonatal suppurative submandibular sialadenitis and abscess formation is an exceedingly rare entity. This report describes a complex case of a male neonate with a methicillin-resistant Staphylococcus aureus (MRSA) submandibular abscess, requiring emergency intubation due to acute airway compromise. The patient was admitted to the paediatric intensive care unit, received appropriate antibiotic treatment and underwent urgent surgical drainage of the abscess. He made a full recovery and remains well 18 months later. No comorbidities or common risk factors for the disease were identified. Although extremely uncommon, neonatal submandibular abscesses can lead to significant morbidity. Neonates tend to present insidiously, and sudden clinical deterioration with airway compromise is possible. MRSA has been increasingly implicated in these infections, even in the absence of relevant risk factors. As such, continued clinical vigilance is essential for prompt diagnosis and prevention of life-threatening complications. Multidisciplinary input is paramount for appropriate management of these complex infections.

Background Among the several complications associated with anterior cervical discectomy and fusion (ACDF), airway compromise is considered one of the serious life-threatening conditions and usually requires emergent treatment, including airway establishment and hematoma evacuation surgery. Postoperative retropharyngeal hematoma commonly occurred during the on immediate phase with airway compromise, but have a rarity on late onset of this complication. Enlightened by this existing fact, we report the first case of delayed onset postoperative retropharyngeal hematoma after anterior cervical surgery with a sequela of tracheal stricture. Case presentation A 55-year-old male underwent ACDF for disc herniation at C5–6 that had not responded to conservative treatment over 3 months. The symptoms significantly improved after surgery, and he was discharged on postoperative day 3. On the 7 days after ACDF, the patient complained of sudden-onset left-deviated neck swelling. The follow-up plain radiographs and neck-enhanced computed tomography (CT) scans showed anterior and right lateral displacement of the airway including the trachea by a large retropharyngeal hematoma. We performed an emergent forceful endotracheal intubation that was maintained for 2 days until the patient underwent hematoma evacuation surgery. On the second day after hematoma evacuation surgery, the patient complained of hoarseness with a foul breath odor. Laryngoscopy showed tracheal ischemic mucosal damage that had been induced by forceful endotracheal intubation. Antibiotics and systemic corticosteroids were administered, and the symptoms improved. One month after hematoma evacuation surgery, he complained of dyspnea on exertion, and laryngoscopy showed tracheal stricture. The patient underwent bronchoscopic dilatation and is doing well without recurrence of symptoms. Conclusions Early surgery to remove the delayed onset retropharyngeal hematoma, rather than forceful endotracheal intubation followed by delayed surgery, might yield better results and avoid unexpected complications of tracheal stricture.

Background Angioedema is a complication that has been reported in up to 1.0% of individuals taking angiotensin-converting enzyme inhibitors (ACE-Is). Importantly, the onset of angioedema can occur anywhere from hours to several years after initiation of therapy with ACE-Is. Although most cases of ACE-I–induced angioedema (ACE-I-AE) are self-limiting, a major clinical concern is development of airway compromise, which can potentially require emergent airway management. The underlying pathophysiology of ACE-I-AE is incompletely understood, but is considered to be due in large part to excess bradykinin. Numerous medications have been proposed for the treatment of ACE-I-AE. This article is an update to the 2011 Clinical Practice Committee (CPC) statement from the American Academy of Emergency Medicine. Methods A literature search in PubMed was performed with search terms angioedema and ACE inhibitors from August 1, 2012 to May 13, 2019. Following CPC guidelines, articles written in English were identified and then underwent a structured review for evaluation. Results The search parameters resulted in 323 articles. The abstracts of these articles were assessed independently by the reviewers, who determined there were 63 articles that were specific to ACE-I-AE, of which 46 were deemed appropriate for grading in the final focused review. Conclusions The primary focus for the treatment of ACE-I-AE is airway management. In the absence of high-quality evidence, no specific medication therapy is recommended for its treatment. If, however, the treating physician feels the patient's presentation is more typical of an acute allergic reaction or anaphylaxis, it may be appropriate to treat for those conditions. Any patient with suspected ACE-I-AE should immediately discontinue that medication.

Study design Retrospective review. Objective Anterior cervical discectomy and fusion (ACDF) is a commonly performed procedure that may be complicated by airway compromise postoperatively. This life-threatening complication may necessitate reintubation and reoperation. We evaluated the cost utility of conventional postoperative x-ray. Summary of background data Studies have demonstrated minimal benefit in obtaining an x-ray on postoperative day 1, but there is some utility of postanesthesia care unit (PACU) x-rays for predicting the likelihood of reoperation. Methods We retrospectively reviewed the records of consecutive patients who underwent ACDF between September 2013 and February 2017. Patients were dichotomized into those who received PACU x-rays and those who did not (control group). Primary outcomes were reoperation, reintubation, mortality, and healthcare costs. Results Eight-hundred and fifteen patients were included in our analysis: 558 had PACU x-rays; 257 did not. In those who received PACU x-rays, mean age was 53.7 ± 11.3 years, mean levels operated on were 2.0 ± 0.79, and mean body mass index (BMI) was 30.3 ± 6.9. In those who did not, mean age was 51.8 ± 10.9 years, mean levels operated on were 1.48 ± 0.65, and mean BMI was 29.9 ± 6.3. Complications in the PACU x-ray group were reintubation-0.4%, reoperation-0.7%, and death-0.3% (due to prevertebral swelling causing airway compromise). Complications in the control group were reintubation-0.4%, reoperation-0.8%, and death-0. There were no differences between groups with respect to reoperation (p = 0.92), reintubation (p = 0.94), or mortality (p = 0.49). The mean per-patient cost was significantly higher (p = 0.009) in those who received PACU x-rays, $1031.76 ± 948.67, versus those in the control group, $700.26 ± 634.48. Mean length of stay was significantly longer in those who had PACU x-rays (p = 0.01). Conclusions Although there were no differences in reoperation, reintubation, or mortality, there was a significantly higher cost for care and hospitalization in those who received PACU x-rays. Further studies are warranted to validate the results of the presented study.Level of Evidence: 3.

Background Orthopedic surgery for cervical torticollis poses potential threat to airway management both in tracheal intubation and extubation. Klippel-Feil syndrome (KFS) is a complex syndrome of osseous and visceral anomalies. The anatomical characteristics of KFS might have significant implications for airway management. Case presentation This is a rare case of an 8-year-old boy presenting with osseous torticollis, congenital occipito-atlantal deformity, congenital basilar invagination and KFS undergone elective torticollis correction surgery. Though with difficulty, tracheal intubation was successfully performed. Extubation failed twice on postoperative day 2 and 10, and required tracheostomy. Based on radiological findings, we speculated that prolonged airway edema accounted for the main reason of the failed extubation, the hypertrophic tonsil and occipito-cervical fusion resulted in reduced oropharyngeal space and limited cervical range of motion. Moreover, the Chiari malformation and KFS complicated the airway condition and lead to prolonged airway obstruction. The tracheostomy casing was removed 1 month later. Conclusions Cautions should be taken in extubation of pediatric patients undergone major osseous torticollis surgery. Reintubation should be prepared in case of failed extubation. Severe post-operative airway edema, complicated with hypertrophic tonsil, the structural abnormalities in the oropharyngeal cavity, and occipito-cervical deformities constituted the decreased oropharyngeal space and resulted in failed extubation. For severe airway compromise and prolonged intubation, tracheostomy should be considered.

Background Dental abscess as an end stage of dental disease is common in the community, and patients with dental abscesses are likely to seek care from their primary health provider. Once the infection has spread beyond the confines of the jaws, there is an increasing risk of airway obstruction and septicaemia. If treated with antibiotics alone, the infection will not resolve and will become progressively worse. Objective This article reviews the pathophysiology, demographics and management of severe odontogenic infections. It includes evidence-based studies of a large number of cases treated at a single tertiary hospital. Discussion Prompt assessment and referral to a tertiary hospital is required for cases at risk of airway compromise. The morbidity and mortality of cases is presented in this article, with discussion of risk factors and the financial burden on the health system.

Angioedema resulting in oral and facial swelling with possible airway compromise can be either hereditary or acquired. Hereditary angioedema is an autosomal dominant disease and results from an inh...

Isolated hyoid fractures are rare injuries, usually associated with road traffic accidents, trauma or strangulation.[1][1] The majority present immediately to the emergency department with neck pain, dysphagia and dysphonia. Severe injuries can lead to airway compromise and complications include

The severity of obstructive respiratory difficulty varies among affected Crouzon syndrome patients. The aim of this study was to investigate the correlation between the restricted airway volume in Crouzon syndrome and the associated type of cranial vault suture synostosis. Computed tomography scans of 68 unoperated Crouzon syndrome patients and 89 control subjects were subgrouped into four types: type I, bilateral coronal synostosis; type II, sagittal synostosis; type III, pansynostosis; type IV, perpendicular combinations of synostoses. Measurements were made using Mimics software. Of type I Crouzon patients, 42% had a restricted nasal airway (P = 0.002), while the pharyngeal airway volume was not significantly reduced. Type II Crouzon patients grew normal segmental airway volumes. Crouzon patients of type III developed simultaneously reduced nasal and pharyngeal airway volumes in infancy, by 38% (P = 0.034) and 51% (P = 0.014), respectively. However, the nasal airway achieved a normal volume by 2 years of age without any intervention, while the pharyngeal airway remained significantly reduced up to 6 years of age, by 42% (P = 0.013), compared to controls. Type IV Crouzon patients developed a reduced nasal airway volume (32%, P = 0.048) and a non-significant restricted pharyngeal airway (18%, P = 0.325). Airway compromise in Crouzon syndrome is variable when associated with different craniosynostosis fusion patterns. Type II (sagittal synostosis) Crouzon patients grew a normal nasopharyngeal airway volume. Those with types I (bicoronal synostosis) and IV (perpendicular synostoses) had significantly restricted nasal airways and a tendency towards a reduced pharyngeal volume. Type III (pansynostosis) Crouzon infants had the worst restriction of both airways, although there was some improvement with age.

Extramedullary plasmacytomas represent a rare group of B-cell malignancies that arise outside the bone marrow and their disease process is still poorly understood. Here, we will describe a case of a 76-year-old patient who presented with a large chest wall and subglottic mass causing airway compromise and stridor. Biopsies showed atypical plasma cells with prominent nucleoli which were in keeping with an extramedullary plasmacytoma. Disease progressed despite surgical debulking, targeted radiotherapy, and multiple chemotherapy regimens. Although response to treatment is classically good, patients occasionally present with aggressive disease.

OBJECTIVE Detection of fetal airway compromise through imaging raises the possible need for ex utero intrapartum treatment (EXIT) procedures. Despite EXIT procedures involving massive resource utilization and posing increased risk to the mother, decisions for EXIT are usually based on anecdotal experience. Our objectives were to analyze prenatal consultations with potential fetal airway obstruction for imaging and obstetric findings used to determine management strategy. METHODS Retrospective chart review was performed for prenatal abnormal fetal airway consults between 2004-2019 at a quaternary pediatric facility. Data collected included demographics, imaging characteristics, delivery information, and airway management. Our primary outcome was EXIT performance and the secondary outcome was postnatal airway management. Fisher's exact test was used to compare management decisions, outcomes, and imaging findings. RESULTS Thirty-seven patients met inclusion criteria. The most common diagnoses observed were lymphatic malformation, teratoma, and micrognathia. Of the imaging findings collected, only midline neck mass location was associated with EXIT procedure performance. Factors associated with invasive airway support at birth were mass-induced in-utero neck extension and neck vessel compression, polyhydramnios, and micrognathia. CONCLUSIONS Multidisciplinary input and interpretation of prenatal imaging can guide management of fetal airway-related pathology. EXIT is an overall safe procedure and can decrease risk due to airway obstruction at birth. We identified in-utero neck extension, neck vessel compression, micrognathia, and polyhydramnios as better indicators of a need for invasive airways measures at birth and suggest use of these criteria in combination with clinical judgement when recommending EXIT. LEVEL OF EVIDENCE 4 Laryngoscope, 131:E1357-E1362, 2021.

Crouzon syndrome is a rare form of syndromic craniosynostosis (SC) characterized by premature fusion of the cranial and facial sutures, elevated intracranial pressure, varying degrees of ocular exposure due to exorbitism, and airway compromise caused by midface retrusion. Craniolacunae and upper and lower extremity anomalies are not frequently found in Crouzon syndrome. We present a girl with Crouzon syndrome caused by c.1040 C > G, p.Ser347Cys, a pathogenic mutation in the FGFR2 gene with atypical characteristics, including craniolacunae resembling severe Swiss cheese type of bone formation, and upper and lower extremity anomalies which are more commonly associated with Pfeiffer syndrome patients. Distinguishing between severe Crouzon syndrome patients and patients who have mild and/or moderate Pfeiffer syndrome can be challenging even for an experienced craniofacial surgeon. An accurate genotype diagnosis is essential to distinguishing between these syndromes, as it provides predictors for neurosurgical complications and facilitates appropriate family counseling related to long-term outcomes.

Loss of endotracheal cuff pressure can lead to airway compromise and loss of volume delivery in mechanical ventilation requiring immediate intervention. A 40 years old male posted for bilateral interpositional arthroplasty was intubated nasally with 7.5 mm flexometallic endotracheal tube. In the intraoperative period airway leak was detected due to loss of cuff pressure even after repeated attempt of cuff inflation. After changing endotracheal tube, leak was detected from the inflation tubing distal to the cuff, which was apparent only when cuff pressure was increased above 30 cm of H2O.

In patients with Pierre Robin sequence (PRS), understanding the mechanism of airway obstruction and the potential for concurrent airway lesions is important for determining appropriate intervention. When concomitant airway anomalies are present with PRS, mandibular distraction osteogenesis alone is often contraindicated and unsuccessful at alleviating the obstruction, mandating the need for tracheostomy. Herein, the authors present the second-reported case of PRS with concomitant complete tracheal rings and highlight the importance collaborative surgical efforts to avoid tracheostomy. Our patient was born with signs and symptoms of PRS and concomitant complete tracheal rings. At birth, he developed respiratory compromise that was resistant to invasive and noninvasive intervention and was transferred to our care. The severity of his airway compromise necessitated operative intervention. Due to the patient's complex medical condition, avoiding the long-term sequelae of a tracheostomy and performing mandibular distraction was favorable. However, due to his multi-level airway disease, a 2-staged approach was planned: sliding tracheoplasty to release the tracheal rings, followed by mandibular distraction to correct the micrognathia. The patient tolerated both procedures and was successfully distracted and eventually weaned into room air. When managing patients with PRS in the setting of severe respiratory distress, securing the airway and carefully evaluating for concomitant airway anomalies is crucial. Even in the setting of multi-level airway disease where mandibular distraction is typically contraindicated, by directly addressing each anatomic level of airway obstruction, the airway can be safely secured and the resultant consequences of tracheostomy can be avoided. Careful planning with a multidisciplinary team is essential.

The risk of expansile hematoma and airway compromise following neck surgery have been used to validate overnight observation. We investigated the outcomes of pediatric patients undergoing a Sistrunk procedure via either same day surgery or overnight observation.A retrospective review of patients undergoing Sistrunk procedures between January 1, 2008 to January 1, 2019 was performed. 76 cases were identified for review. Bivariate and multivariable analyses were performed to determine predictive factors for overnight admission as well as associations between overnight observation and adverse outcomes (hematoma, seroma, airway compromise, infection). Factors evaluated for analysis included ASA class, surgeon type, history of pre-operative infection, recurrent case, operation90 min, pharyngeal violation, intraoperative cyst rupture, cyst size, and drain placement.No patients had life-threatening adverse events. There was no difference in complication rates between same day discharge (17%) and overnight observation (23%, p = 0.47). Otolaryngologists were more likely to admit patients overnight (88% vs. 14%, p = 0.042) as well as place a drain (97% vs. 24%, p 0.001) when compared to pediatric surgeons. Drain placement was associated with overnight observation (73% vs. 3%, p 0.001). Multivariable logistic regression demonstrated drain placement (OR 21.9, 95%CI (2.5-189.7), p = 0.005) and otolaryngologist as operative surgeon (OR 11.7, 95%CI (2.8-48.2), p 0.001) as strong predictive variables for overnight observation. There was no association between other investigated variables and adverse events or overnight stay.Same day Sistrunk operations are safe in select healthy patients. Overnight observation appears to be driven by drain placement and surgeon practice patterns.

Introduction: Laryngeal lesions are usually evaluated by microlaryngoscopy/direct laryngoscopy under anaesthesia for disease mapping and tissue diagnosis. However patients with anticipated airway compromise due to laryngeal mass may require either a protective tracheotomy or emergency tracheotomy to secure the airway. To minimise risk of unplanned tracheotomy and expedite the diagnosis we performed ultrasound-guided transcutaneous fine needle aspiration cytology. Objective: To evaluate the feasibility and performance of ultrasound-guided transcutaneous fine needle aspiration cytology of suspicious/recurrent laryngo-hypopharyngeal masses. Methods: Fine needle aspiration cytology was performed under ultrasound guidance. Twenty- four patients were recruited, of which 17 had a pure laryngeal lesion; 6 patients had laryngo-pharyngeal, and one patient had a base tongue lesion with supra-glottis extension. Results: Out of 24 patients, 21 had positive cytology for squamous cell carcinoma, 2 patients had non-diagnostic cytology (atypical cells) and the other had inadequate tissue for definitive diagnosis. Patients with negative and inconclusive cytology underwent direct laryngoscopy biopsy, which was positive for squamous malignancy. All patients tolerated the procedure well and no adverse events were noted. Conclusion: Although direct laryngoscopy remains the standard of care in evaluation of laryngo-hypopharyngeal lesions, this pilot study has shown that ultrasound-guided transcutaneous fine needle aspiration cytology was feasible as an out-patient procedure, employing safe and sensitive technique enabling rapid diagnosis and avoiding the need for direct laryngoscopy under GA for tissue diagnosis. Resumo: Introdução: As lesões laríngeas são geralmente avaliadas por microlaringoscopia/laringoscopia direta sob anestesia para mapeamento da doença e diagnóstico tecidual. No entanto, em pacientes com comprometimento prévio das vias aéreas devido à lesão laríngea, pode ser necessária uma traqueostomia protetora ou traqueostomia de emergência para assegurar as vias aéreas. Para minimizar o risco de uma traqueostomia não planejada e facilitar o diagnóstico, realizamos punção aspirativa por agulha fina guiada por ultrassonografia transcutânea. Objetivo: Avaliar a viabilidade e o desempenho da punção aspirativa por agulha fina guiada por ultrassonografia transcutânea em lesões laríngeo-hipofaríngeas suspeitas/recorrentes. Método: A punção aspirativa por agulha fina foi realizada sob orientação ultrassonográfica. Foram recrutados 24 pacientes, 17 com lesão laríngea apenas, 6 com lesão laríngeo-faríngea e um com lesão na base da língua com extensão supraglótica. Resultados: Dos 24 pacientes, 21 apresentaram citologia positiva para carcinoma espinocelular, 2 citologia não diagnóstica (células atípicas) e o outro tecido inadequado para o diagnóstico definitivo. Os pacientes com citologia negativa e inconclusiva foram submetidos à biópsia através de laringoscopia direta, que foi positiva para lesão maligna espinocelular. Todos os pacientes toleraram bem o procedimento e nenhum evento adverso foi observado. Conclusão: Embora a laringoscopia direta continue a ser o padrão de cuidado na avaliação das lesões laríngeo-hipofaríngeas, este estudo piloto demonstrou que a punção aspirativa por agulha fina guiada por ultrassonografia transcutânea é uma técnica viável, ambulatorial, segura e sensível, permite rápido diagnóstico e evita a necessidade de laringoscopia direta sob anestesia geral para diagnóstico tecidual. Keywords: Laryngeal cancer, Ultrasound guided transcutaneous fine needle aspiration cytology, Laryngeal pharyngeal lesions, Cytology, Palavras-chave: Câncer de laringe, PAFF-USGTC, Lesões laríngeo-hipofaríngeas, Citologia