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Careful airway risk assessment and procedural planning are vital to ensure patients' safety during airway management. Patients with known procedural difficulty during previous airway management or new anatomical changes pose challenges and risks. To improve communication and the value of documented information regarding difficult airway management for future clinical encounters, we utilized existing electronic health record functions to develop a "difficult airway Navigator." We describe this tool's creation and implementation, which allows clinicians to readily review past airway information and efficiently create difficult airway notes, bedside signs, flags, and orders.

Background: Research regarding difficult mask ventilation (DMV) combined with difficult laryngoscopy (DL) is extremely limited even though each technique serves as a rescue for one another. Methods: Four tertiary care centers participating in the Multicenter Perioperative Outcomes Group used a consistent structured patient history and airway examination and airway outcome definition. DMV was defined as grade 3 or 4 mask ventilation, and DL was defined as grade 3 or 4 laryngoscopic view or four or more intubation attempts. The primary outcome was DMV combined with DL. Patients with the primary outcome were compared to those without the primary outcome to identify predictors of DMV combined with DL using a non-parsimonious logistic regression. Results: Of 492,239 cases performed at four institutions among adult patients, 176,679 included a documented face mask ventilation and laryngoscopy attempt. Six hundred ninety-eight patients experienced the primary outcome, an overall incidence of 0.40%. One patient required an emergent cricothyrotomy, 177 were intubated using direct laryngoscopy, 284 using direct laryngoscopy with bougie introducer, 163 using videolaryngoscopy, and 73 using other techniques. Independent predictors of the primary outcome included age 46 yr or more, body mass index 30 or more, male sex, Mallampati III or IV, neck mass or radiation, limited thyromental distance, sleep apnea, presence of teeth, beard, thick neck, limited cervical spine mobility, and limited jaw protrusion (c-statistic 0.84 [95% CI, 0.82–0.87]). Conclusion: DMV combined with DL is an infrequent but not rare phenomenon. Most patients can be managed with the use of direct or videolaryngoscopy. An easy to use unweighted risk scale has robust discriminating capacity.

We describe a pilot study investigating the airway techniques used in the anesthetic management of subglottic stenosis. We searched the electronic clinical information database of the University of Michigan Health System for cases of subglottic stenosis in patients undergoing surgery. Demographics, airway techniques, incidence of hypoxemia, and technique failure were extracted from 159 records. A lower incidence of hypoxemia was found between the 4 most commonly used techniques and the less common techniques. We detected no difference in outcome between individual techniques. This study suggests a larger prospective multicenter study is required to further investigate these outcomes in patients with subglottic stenosis.

Background Research regarding difficult mask ventilation (DMV) combined with difficult laryngoscopy (DL) is extremely limited even though each technique serves as a rescue for one another. Methods Four tertiary care centers participating in the Multicenter Perioperative Outcomes Group used a consistent structured patient history and airway examination and airway outcome definition. DMV was defined as grade 3 or 4 mask ventilation, and DL was defined as grade 3 or 4 laryngoscopic view or four or more intubation attempts. The primary outcome was DMV combined with DL. Patients with the primary outcome were compared to those without the primary outcome to identify predictors of DMV combined with DL using a non-parsimonious logistic regression. Results Of 492,239 cases performed at four institutions among adult patients, 176,679 included a documented face mask ventilation and laryngoscopy attempt. Six hundred ninety-eight patients experienced the primary outcome, an overall incidence of 0.40%. One patient required an emergent cricothyrotomy, 177 were intubated using direct laryngoscopy, 284 using direct laryngoscopy with bougie introducer, 163 using videolaryngoscopy, and 73 using other techniques. Independent predictors of the primary outcome included age 46 yr or more, body mass index 30 or more, male sex, Mallampati III or IV, neck mass or radiation, limited thyromental distance, sleep apnea, presence of teeth, beard, thick neck, limited cervical spine mobility, and limited jaw protrusion (c-statistic 0.84 [95% CI, 0.82-0.87]). Conclusion DMV combined with DL is an infrequent but not rare phenomenon. Most patients can be managed with the use of direct or videolaryngoscopy. An easy to use unweighted risk scale has robust discriminating capacity.

This chapter provides a brief overview of otolaryngologic emergencies. Complete or partial airway obstruction is common in ENT practice and anesthesiologists are familiar with a variety of measures, such as tracheal intubation, to deal with this event. Intubation is often needed in cases of angioedema; this will usually be performed under topical anesthesia with the patient awake or lightly sedated. Airway-related bleeding may occur spontaneously, as with a bleeding tumor, as a consequence of anticoagulation (e.g. for atrial fibrillation), or following surgery (e.g. after UVPP surgery). Posterior epistaxis may be particularly severe, may be accompanied by hematemesis or melena, and may require general anesthesia and intubation as part of the treatment. Airway-related infections such as epiglottitis, retropharyngeal abscess and Ludwig's angina constitute an emergency airway. One approach commonly taken in such cases is awake intubation, especially in conjunction with a fiberscope.

When the first asylums opened, around 1800, mania was a generic term for insanity. Philippe Pinel’s Treatise on Insanity that appeared in 1800was accordingly namedTrait e sur la Manie. For 2000 years before Pinel, the chief determinant of diagnosis in medicine lay in the visible presentation of the patient. These visible presentations could lead to reliable diagnoses of tumours, diabetes, catatonia, epilepsy and insanity. The visible presentations of insanity involved flushing, overactivity and maniacal behaviour. Mania was diagnosed in patients who were overactive and who might now be seen as having schizophrenia, depression, delirium, senility, imbecility and other conditions. Pinel took a stand on the importance of science in medicine, and was the first to call for an Evidence Based Medicine. Faced with patients hospitalized for years, he was the first to incorporate the course of apatients’disorders into his diagnostic considerations. He recorded outcomes where patientswere treated or left untreated, andnoting responses followed by relapses, argued that some disorders were periodic or recurrent and that the vast majority of available treatments made the underlying condition worse. When a final and more complete version of his treatise was published in 1809, it distinguished in its title, Trait e M edico-Philosophique sur l’Ali enation Mentale ou la Manie, between insanity in general and a new, more specific diagnosis of mania [1]. Once this distinction was made, and mania was separated out from idiocy dementia and melancholia, the rates of admission formania settled at approximately 50% of all admissions in asylums in Europe and America until around 1900. While asylumnomenclature remained relatively constant for a century, there was an evolution in the thinking about insanity. The idea that theremight be a distinctmood faculty that could be disordered in its own right was put forward in the 1830s by one of Pinel’s pupils, Jean-Dominique Etienne Esquirol, who described profound sadness – lypemanie – as a distinct disorder. The notion of a disease entity took shape in the 1850s when two of Esquirol’s pupils, Jean-Pierre Falret and Jules Baillarger, both described disorders that laid the basis for what became circular insanity. Falret outlined folie circulaire; Baillarger termed his disorder folie a double forme [2]. The idea that mania or insanity might give rise to protean manifestations had posed little difficulty, but as clinicians moved towards the concept of a disease entity, they had difficulties with the idea that two clinical states that looked so different might be presentations of the same underlying disease state. In their efforts to overcome these conceptual problems, both Falret andBaillarger posited a disorderwith alternating cycles of mania and melancholia of fixed length and with fixed intervals between episodes. But crucially if neither the superficial features of mania nor the superficial features of melancholia accounted for the disorder, then some common ground between them must be responsible for the disorder. Some substrate must be diseased. The new disorder was not one that commanded clinical attention. Both men conceded that what they were describing was a rare condition. The condition described was moreover at this point not clearly a mood disorder. Others described alternating or circular insanity. None of these states were bipolar affective disorder, as that termwould be understood today. The first to approach modern bipolar disorder was Karl Kahlbaum who in 1883 described cyclothymia. Where circular insanity was a psychotic disorder, with regular and stable features that led todegeneration, cyclothymiawas for Kahlbaum a specific mood disorder from which patients could recover. Kahlbaum also introduced disease course as a classificatory principle, but this was resisted. Most academics at the time expected a localization of clinical features in different brain areas to provide the key to unlocking the mysteries of mental illness rather than disease course. However disease coursewas used byCharcot to distinguish between hysteria and Tourette’s syndrome, and later to distinguish between Alzheimer’s and Creutfeld-Jacob disease.

Objectives: We describe the manifestations, diagnosis, and treatment of rare head and neck infections caused by Mycobacterium chelonae, including a case of maxillary osteitis and skull base osteomyelitis. Methods: A comprehensive literature search (MEDLINE from 1951; BIOSIS from 1969; EMBASE from 1980) was performed for the presentation, diagnostic evaluation, and outcomes of patients with M chelonae infections. Results: We report 4 cases of M chelonae infection, including a nasal abscess following septorhinoplasty with a cartilaginous graft, a case of chronic unilateral nasal obstruction, and the first reported cases of skull base osteomyelitis and maxillary osteitis secondary to M chelonae. All 4 cases involved immunocompetent individuals. Conclusions: Mycobacterium chelonae should be considered in cases of abscesses that persist despite broad-spectrum intravenous antibiotics, and in cases of maxillary sinusitis with bony involvement that do not respond to traditional treatment methods.