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Rhinosporidiosis is a type of nasal polypoidal growth arising from the mucosa of nasal cavity and often extending to nasopharynx. Occasionally, this growth may invade the lower airways and cause airway obstruction. The clinical presentation of such cases is often contradictory and airway management during induction of anesthesia requires caution to prevent potential life-threatening situations. A case of large pedunculated rhinosporidiosis involving the epiglottis and laryngeal inlet, with significant airway management challenge has been presented here. Clinical significance: Primary care physicians should be diligent in evaluating patients with rhinosporidiosis and look for signs of airway obstruction to rule out lower airway involvement.

Supraglottic airway devices (SADs) have revolutionised perioperative airway management. These devices have contributed significantly to airway management, especially in the context of anticipated or unanticipated difficult airway, thereby decreasing airway-related morbidity. The use of these devices is now accepted even for positive pressure ventilation due to better seal and modifications (such as a double cuff or cuff material) preventing gastric insufflation with lesser chances of regurgitation. The quality of seal depends on how accurately the cuff matches the dimensions of the laryngeal inlet. Various methods and techniques are used for confirming the optimal placement of SADs with variable success rate. Evaluation based on conventional clinical tests is most commonly used for assessing the correct placement of SADs. However, clinical tests have been associated with limited outcome as they may not definitely be able to detect improper placement of SAD. Malpositioning may increase the incidence of complications such as altered airway dynamics, gastric insufflation, regurgitation and aspiration of gastric contents. The accuracy of these tests to identify malposition has been questioned by recent studies where fibreoptic evaluation of position of SAD identified many unacceptable placements which had been considered acceptable on the basis of clinical tests. Another limitation of these tests is that they fail to provide anatomic evidence of optimal SAD placement. Thus, other methods are required to confirm SAD position to avoid adverse events related to the airway. This review elaborates on the use of ultrasound to assess the optimal placement of supraglottic airway devices.

The purpose of the study was to investigate the influence of the chin-tuck maneuver on the movements of swallowing-related structures in healthy subjects and formulate standard instructions for the maneuver. A total of 40 healthy volunteers (20 men and 20 women) swallowed 10 mL of diluted barium solution in a “normal and comfortable” position (NEUT), a comfortable chin-down position (DOWN), and a strict chin-tuck position (TUCK). Resting state anatomy and kinematic changes were analyzed and compared between postures. Although angles of anterior cervical flexion were comparable between DOWN (46.65 ± 9.69 degrees) and TUCK (43.27 ± 12.20), the chin-to-spine distance was significantly shorter in TUCK than in other positions. Only TUCK showed a significantly shorter anteroposterior diameter of the laryngeal inlet (TUCK vs. NEUT, 14.0 ± 4.3 vs. 16.3 ± 5.0 mm) and the oropharynx (18.8 ± 3.1 vs. 20.5 ± 2.8 mm) at rest. The maximal horizontal displacement of the hyoid bone was significantly less in TUCK (9.6 ± 3.0 mm) than in NEUT (12.6 ± 2.6 mm; p

BACKGROUND AND AIMS: Laryngeal mask airway (LMA), an alternative airway device, provides and maintains a seal around the laryngeal inlet for spontaneous ventilation as well as modest level of positive pressure ventilation. But LMA requires a sufficient depth of anaesthesia& depression of airway reflexes to avoid adverse reactions like gagging, coughing, head & limb movements etc. We intended to test the efficacy of Thiopentone and Midazolam combination as an effective alternative to Propofol for insertion of LMA. MATERIALS AND METHODS: One hundred twenty patients (18-34 years) posted for different minor procedure ( 20 sec) and Severe (Sustained >20sec or needed Propofol to allow LMA insertion). RESULTS: Propofol is superior to combination of thiopentone-midazolam, in terms of achieving conditions like jaw relaxation, coughing & suppression of gagging during LMA insertion but regarding other variables like laryngospasm, hiccup & patient movement, which are equally important prerequisites for successful LMA insertion, there was not much statistically significant difference found between propofol and combination of thiopentone-midazolam. CONCLUSION: Combination of thiopentone - midazolam effectively blunts airway reflexes and adequately facilitates laryngeal mask airway insertion which can be comparable to propofol.

Alternative rigid blade intubation devices have become available in recent years including Glidescope, Airtraq and Bonfils laryngoscopes. The Macintosh curved blade works by displacing the tongue to one side and also into the submandibular space. This allows the device to get into the valleculum and hence lift the hyoid and epiglottis forward to reveal the laryngeal inlet. Under less favourable intubating conditions, the tongue tends to be compressed disproportionately, the valleculum is not accessed and the blade tip cannot be drawn forward. The retro-molar Bonfils avoids this problem by starting from a lower position in the mouth and approaching the larynx below and alongside the tongue. Bonfils also serves as a rigid stylet inside the tracheal tube which also implies minimal tongue displacement. By comparison, the Airtraq does not need to compress the tongue to the same degree as Macintosh and usually sits on the posterior pharyngeal wall, maintaining the view with minimal effort. It houses the tracheal tube a channel from which it is delivered into the field of view. While the optical systems have tended to improve viewing conditions at the laryngeal inlet this has not necessarily resulted in easier intubation conditions, shorter intubation times or improved success rates. Part of the problem has been that they tend to limit the field of view compared with the all round view down to the larynx afforded by Macintosh under ideal conditions.

Background: Laryngeal mask airway has already gained widespread acceptance as an alternative airway device and conduit for endotracheal intubation. Insertion of this Supraglottic Airway Device (SAD) to provide and maintain a seal around the laryngeal inlet for spontaneous ventilation as well as modest level of positive pressure ventilation requires a sufficient depth of anaesthesia and depression of airway reflexes to avoid adverse reactions like gagging, coughing, head and limb movements etc. This study was conducted with the intent to compare Vital Capacity Breath (VCB) inhalation with 8% sevoflurane versus intravenous (IV) propofol for quality and ease of insertion of Laryngeal Mask Airway (LMA) and associated complications Methods: In this prospective, randomized study, 80 adult patients of ASA physical status I and II aged between 20 to 50 years, body weight 0.05).

Softer endotracheal (ET) tubes are more difficult to navigate in the oropharynx than the stiffer polyvinyl chloride (PVC) tubes during nasotracheal intubation (NTI). Cuff inflation has been used to guide PVC tubes into the laryngeal inlet during blind NTI, but it has not been tested when performing NTI under direct laryngoscopic guidance. We assessed the role of cuff inflation in improving oropharyngeal navigation of 3 ET tubes of varying stiffness during direct laryngoscope-guided NTI. Simultaneously, we also assessed and compared the nasotracheal navigability and incidence of nasal injury with these ET tubes during cuff inflation-supplemented, laryngoscope-guided NTI.One hundred sixty-two adults were randomized to undergo NTI with either a conventional PVC (n = 54), wire reinforced (WR; n = 54) or a silicone-tipped WR (SWR; n = 54) ET tube. Ease of insertion of these tubes was assessed during passage from nose into oropharynx, from oropharynx into laryngeal inlet aided by cuff inflation if needed, and from laryngeal inlet into trachea. Nasal morbidity was assessed by a blinded observer.All ET tubes could be inserted into the trachea. Seventy-one of 162 ET tubes could be inserted from the oropharynx into the laryngeal inlet without cuff inflation. Eighty-six of the remaining 91 tubes that did not enter the laryngeal inlet without cuff inflation could be inserted when using the cuff inflation technique. Thus, a total of 157 ET tubes could be inserted into the laryngeal inlet with cuff inflation (95% confidence interval of difference of proportions between total number of tubes passed [157] and those without cuff inflation [71]: 53% [45%-61%]). The remaining 5 tubes had to be inserted with the help of Magill forceps. The incidence of epistaxis was lowest with the SWR tube (difference of proportions [95% confidence interval] SWR versus PVC 27% [8%-45%]; SWR versus WR 20% [1%-38%]; WR versus PVC 7% [-12% to 26%]).The cuff inflation technique consistently improved the oropharyngeal insertion of the 3 ET tubes of varying stiffness during direct laryngoscope-guided NTI. Supplemented with the cuff inflation technique, the SWR ET tube seems to be better than the PVC and WR ET tubes in terms of complete nasotracheal navigability and less perioperative nasal injury.

Lipomas are the most common benign tumors of mesenchymal origin. Although they are rarely seen in the head and neck region, their most common location in the head-neck are the posterior neck. Lipomas of larynx and hypopharynx are very rare. The aim of this paper is to report a case of a giant hypopharyngeal lipoma causing severe respiratory distress. A 76-year-old man with respiratory distress, stridor and voice changes present for 5 months was referred to our department. Videolaryngoscopic examination revealed a pedicled left piriform sinus mass with smooth and yel - lowish surface which was obstructing the laryngeal inlet during respiration. It was removed via endolaryngeal laser excision without any complications. The histopathologic investigation was re - ported as lipoma. Lipoma should be kept in mind in case of a hypopharyngeal large mass with a smooth and yellowish surface. Computerized tomography is useful in the differential diagnosis, and endolaryngeal laser excision is a good surgical treatment option for removal.

ObjectiveThe need for upper gastrointestinal (GI) endoscopy in the evaluation of hoarseness.Study designProspective study, conducted during the period from June 2012 to February 2013.SettingTertiary referral center.ResultsA total of 125 patients were selected for the study and they were evaluated with appropriate history and clinical examination. Out of 125 patients, 41 (32.8%) patients showed laryngeal findings leading to hoarseness, 13 (10.4%) patients showed features of suspected malignancy in other adjacent regions which was confirmed later, two (1.6%) patients showed phonetic gap and 69 (55.2%) patients showed normal laryngeal inlet on indirect laryngoscopy examination. Of the 69 normal patients which were treated conservatively and since they did not show any response they were subjected to upper GI endoscopy. Out of 69 patients, 41 (60%) patients showed features of gastritis, 28 (40%) patients showed features of duodenitis.ConclusionIt is estimated that more than 50% of patients presenting to the ENT OPD for hoarseness are because of GI problems. We strongly advise upper GI endoscopy for the symptomatic otorhinolaryngological patients with a normal laryngeal finding on indirect laryngoscopy for treating the condition accurately or near accurately. Adding to this upper GI endoscopy has the additional advantages of documentation and medicolegal aspect in the present day scenario.How to cite this articleSantosh UP, Kumar MCA, Karanam L. Upper Gastrointestinal Endoscopy in ENT Practice: How Worth is It? Int J Phonosurg Laryngol 2013;3(2):35-38.

Tomasz Gaszyński Department of Anaesthesiology and Intensive Therapy, Medical University of Łódź, Łódź, Poland Abstract: Videolaryngoscopes improve the view of the entry to the larynx in morbidly obese patients. Super obesity is one of the risk factors for difficult mask ventilation as well as difficult intubation. Super obese patients should be intubated awake either with a fiber-optic scope or with a videolaryngoscope. The glottic view during video-intubation in super obese patients using different devices was compared. The McGrath MAC (MGM) was used in all patients and then compared to the King Vision (KV) in three patients, the APA videolaryngoscope in two patients and the Airtraq Avant with a video camera in four patients. The pictures were of the same patient for two used devices. All obtained images were analyzed using the Percentage of Glottic Opening (POGO) scale. The POGO score for the MGM was better than for the KV and the APA but comparable to the Airtraq device. The images were processed electronically, and the best view of the laryngeal inlet that was obtained by the evaluated devices in the same patient was superimposed onto the other one and then compared. Keywords: super obese, videolaryngoscopes, intubation, glottic visualization&nbsp

Background The King LT airway (King Systems, Noblesville, IN) is a popular extraglottic device that is widely used in the prehospital setting. We report a case of tracheal malplacement of the King airway with a severe kink in the distal tube. Case Report A 51-year-old unhelmeted motorcyclist collided with a freeway median and was obtunded when paramedics arrived. After bag mask ventilation, a King airway was placed uneventfully and the patient was transported to the emergency department. Because of the concern for an unstable cervical spine injury, a lateral cervical spine radiograph was obtained on arrival. No cervical injury was seen, but the King airway was noted to be malplaced; the King airway passed through the laryngeal inlet and became lodged on the anterior trachea, creating an acute kink between the two balloons. After reviewing the radiograph, ventilations were reassessed and remained adequate. Both balloons were deflated, and the King airway was removed; the patient was orotracheally intubated without complication. Why Should An Emergency Physician Be Aware of This? The King airway is a valuable prehospital airway that can be placed quickly and blindly with high success rates by inexperienced providers; the King airway, however, is not without complication. Ventilation was not impaired in this patient, but tracheal malplacement may be an important cause of prehospital device failure. If a first placement attempt of a King airway device fails, it is reasonable to reattempt King airway placement with a new, unkinked device before abandoning King airway placement.

Anaesthetists all over the world are doing millions of intubations every year. In about 6% of cases, they will encounter a “difficult airway”. 1 Between 2-8% of cases may be associated with a poor view of the laryngeal inlet, 2 while failure to achieve intubation is rather uncommon at 1-3 per 1000. 2 The American Society of Anesthetists (ASA) defines a difficult airway as a clinical scenario in which a conventionally trained anesthesiologist experiences difficulty with facemask ventilation of the upper airway, difficulty with tracheal intubation or both. 3 These difficulties may range from the case where simple airway maneuvers will improve the situation to the dangerous and feared scenario of "can’t intubate, can’t ventilate".

We present a case of obstructive sleep apnea (OSA) that required multilevel surgical correction of the airway and literature review and discuss the role supraglottic laryngeal collapse can have in OSA. A 34-year-old man presented to a tertiary otolaryngology clinic for treatment of OSA. He previously had nasal and palate surgeries and a Repose tongue suspension. His residual apnea hypopnea index (AHI) was 67. He had a dysphonia associated with a true vocal cord paralysis following resection of a benign neck mass in childhood. He also complained of inspiratory stridor with exercise and intolerance to continuous positive airway pressure. Physical examination revealed craniofacial hypoplasia, full base of tongue, and residual nasal airway obstruction. On laryngoscopy, the paretic aryepiglottic fold arytenoid complex prolapsed into the laryngeal inlet with each breath. This was more pronounced with greater respiratory effort. Surgical correction required a series of operations including awake tracheostomy, supraglottoplasty, midline glossectomy, genial tubercle advancement, maxillomandibular advancement, and reconstructive rhinoplasty. His final AHI was 1.9. Our patient's supraglottic laryngeal collapse constituted an area of obstruction not typically evaluated in OSA surgery. In conjunction with treating nasal, palatal, and hypopharyngeal subsites, our patient's supraglottoplasty represented a key component of his success. This case illustrates the need to evaluate the entire upper airway in a complicated case of OSA. Laryngoscope, 2012

Temporomandibular joint (TMJ) ankylosis exerts an influence on the anatomical position of the hyoid and suprahyoid musculature and the laryngeal inlet, which may have implications during general anesthesia and corrective surgery for such patients. This study was conducted to determine the position of the hyoid and laryngeal inlet in patients with temporomandibular joint ankylosis on computed tomography scans. This was a retrospective study conducted to assess the anatomical position of the hyoid and suprahyoid musculature and the laryngeal inlet in cases of TMJ ankylosis confirmed by radiology. The degree of deformity seemed to vary with each patient. In this study, the age of onset was varied, therefore the normal and abnormal sides of the same patient were compared rather than an inter-patient evaluation. An important finding in this study was the correlation of age and the degree of deformity. The degree of deformity appeared to depend on the age of occurrence of TMJ ankylosis as confirmed by the coefficient of correlation (r = − 0.88). Based on the results it can be concluded that younger patients with early ankylosis during the growth phase will have a more severe resultant deformity. Knowledge of the rotated hyoid apparatus and the laryngeal inlet in TMJ ankylosis would be of great importance to anesthetists and surgeons involved in the care of these patients.

The Pentax AWS is a novel video laryngoscope designed to facilitate tracheal intubation by providing indirect visualization of the laryngeal inlet. We sought to compare the intubation success rate and time to intubation for the Pentax AWS and the classic Macintosh laryngoscope. Specifically, we tested the hypothesis that intubation with the Pentax AWS would be easier and faster than with a standard Macintosh #4 blade in obese patients.One hundred five obese patients (body mass index between 30 and 50 kg/m2) requiring orotracheal intubation for elective surgery were allocated randomly to tracheal intubation with either the Macintosh (using a #4 blade) or the Pentax AWS laryngoscope. Two experienced anesthesiologists served as laryngoscopists. Intubation success rate, time to intubation, ease of intubation, and occurrence of complications were recorded.Intubations using the Macintosh laryngoscope and #4 blade were significantly faster than with the Pentax AWS device: half of the patients' tracheas were intubated successfully within 26 seconds with the Macintosh #4 blade, whereas the same fraction required 38 seconds with the AWS. The first-attempt success rate with the Pentax AWS was 86%; the rate increased to 90% with a second attempt. In contrast, all patients' tracheas were intubated successfully with the Macintosh #4 blade, with a first-attempt success rate of 92%, which increased to 100% by the second attempt.The time required for tracheal intubation using the Pentax AWS was longer than for the Macintosh laryngoscope and #4 blade. The AWS should not routinely be substituted for a conventional Macintosh #4 blade in morbidly obese patients.

BACKGROUND: Poor feeding is a common cause of prolonged hospitalization of preterm infants. Pharyngeal and upper esophageal sphincter (UES) function of preterm infants has been technically difficult to assess and is therefore poorly characterized. The aim of this study was to assess the development of pharyngeal motility, UES function, and their coordination during nutritive swallowing in preterm infants. METHODS: Development of swallowing was assessed in 18 preterm infants. High resolution manometry was performed at first oral feeding attempt (31-32 week) and then weekly for 4 weeks. Pharyngeal and UES pressure changes were characterized in 980 swallows. KEY RESULTS: During swallowing, we observed an age-related increase in peak pharyngeal pressure at the laryngeal inlet (1 cm above UES) but an age-related decrease in the time required for the UES to fully relax to nadir. Analysis of the timing of proximal pharyngeal contractile peak and UES nadir showed that the UES was not fully relaxed when bolus propulsive forces were at their peak in the youngest infants. CONCLUSIONS & INFERENCES: Results show developmental changes in infant swallow physiology that can be clearly linked to the effectiveness of nutritive swallowing. Most preterm infants demonstrated poor pharyngeal pressures at the laryngeal inlet coupled with poor coordination of pharyngeal propulsion with UES relaxation. These pressure patterns were less efficient than those demonstrated by older infants who were more adept at feeding. These observations may explain why infants under 34 weeks are physiologically unable to feed effectively and experience frequent choking and fatigue during feeding.

Primary thyroid lymphoma and laryngeal lymphoma are rare malignancies of the head and neck region. Airway obstruction caused by primary thyroid lymphoma is mainly by means of direct compression of trachea by huge thyroid mass. We present the first case report of diffuse large B cell lymphoma of thyroid gland with extension to pyriform fossa, in the absence of preexisting chronic thyroiditis. In this case, emergency airway obstruction was caused by direct extension of disease into pyriform fossa, occluding laryngeal inlet. We reviewed English literature between 1981 and 2018 for cases of primary thyroid lymphoma. There are no reported cases of primary thyroid lymphoma with direct extension into pyriform fossa. This presentation posed a great challenge in securing a patent airway by means of oral intubation and tracheostomy.

Introduction: We conducted a randomised, controlled, prospective, multicentric comparison of channelled blade versus non-channelled blade of the King Vision™ videolaryngoscope for orotracheal intubation. Patients and Methods: A total of 66 patients included in the study were divided into two groups as follows: Group CH for intubation with channelled blade and Group NC for intubation with non-channelled blade. We compared the intubation time, ease of intubation and best laryngeal view obtained. Ease of intubation was categorised into ease of device insertion and ease of passage of endotracheal tube. Various impingements which occurred at the laryngeal inlet were observed and manoeuvres used to accomplish intubation were noted. Results: The grade of laryngeal exposure and time of laryngeal exposure were similar in both types of blade. We found a shorter intubation time of 15.24 ± 10.6 s in Group CH, whereas it was 28.57 ± 14.09 s in Group NC (P

This study is a retrospective analysis of 14 cases with food bolus upper airway obstruction as the defined cause of death where both postmortem computed tomography and autopsy were performed. Three groups were defined by the images i.e., Type 1: foreign body situated between the oral cavity and oropharynx, while the epiglottis sits in normal position, Type 2: foreign body situated in the oropharynx just above the epiglottis pushing it posteriorly and obstructing the airway, and Type 3: foreign body obstructing the laryngeal inlet while pushing the epiglottis anteriorly. At the time of autopsy, foreign bodies were detected by pathologists, occasionally in a different position, presumably being dislodged in the act of organ removal especially for the "Type 1" pattern. CT imaging provides accurate interrogation of upper airway bolus obstruction prior to autopsy.

A 29-year-old patient presented with dysphonia, dysphagia and a progressive history of stridor over 6 weeks. His past medical history included childhood nasolabial rhabdomyosarcoma treated by surgery, chemotherapy and radiotherapy. This had resulted in marked abnormalities of the facial skeleton, limited neck extension and restricted mouth opening of 1 cm, in part due to dental implants. After careful discussion and planning within a multidisciplinary team, the airway was optimised by temporary removal of the dental implants. This enabled a suspension laryngoscope to be passed, permitting carbon dioxide laser treatment to an obstruction at the laryngeal inlet and eliminating the need for a tracheostomy.

Background and objective: Difficult airways present a clinical challenge for anaesthetists. The Truphatek Truview EVO2© (Truphatek International Ltd, Netanya, Israel) is a new laryngoscope blade used for endotracheal intubation that could be used where there is difficulty in visualizing the laryngeal inlet. Methods: Twenty anaesthetists (12 trainees and eight consultants) compared the Truphatek Truview EVO2© with a conventional Macintosh size 3 blade. The Trucorp Airsim Bronchi© (Trucorp Ltd, Belfast, Northern Ireland, UK) manikin was intubated under normal conditions and under simulated difficult conditions such as tongue inflation and neck rigidity. In each scenario, the Cormack-Lehane grade, time needed for successful intubation, perceived difficulty of tracheal intubation and personal preference of blade were compared. The results were analysed with t-test (time of intubation), Wilcoxon signed-rank sum (Cormack-Lehane grade, ease of manoeuvre, preferred blade) and analysis of variance with Bonferroni correction (augmentation of difficulties in different scenarios). Results: The Truview EVO2 blade allowed the best laryngeal view as judged by the Cormack-Lehane grade (P < 0.05) in two separate situations: under simulated tongue inflation and under simulated neck rigidity. However, this blade did not reduce the intubation time or the ease of tracheal tube placement with respect to conventional Macintosh blade. Conclusion: Compared with the classical Macintosh blade, the Truview EVO2 blade allowed a better view of the larynx, but did not facilitate endotracheal intubation in any of the difficult scenarios created with the adjustable manikin and in most scenarios in fact prolonged the intubation time.

A new case of multiple sulphatase deficiency with onset at birth is described. The patient had many dysmorphic features and hydrocephalus, similar to one other case with early onset described in the literature. The new patient differed from the other case in having chondrocalci-ficans congenita, heart abnormalities and an abnormal fold of tissue present between the laryngeal inlet and the oesophagus. Excessive mucopolysacchariduria was present and there was profound deficiency of all sulphatases examined in plasma, leucocytes and cultured skin fibroblasts.

Background: Most patients with amyotrophic lateral sclerosis (ALS) are treated with mechanical insufflation–exsufflation (MI-E) in order to improve cough. This method often fails in ALS with bulbar involvement, allegedly due to upper-airway malfunction. We have studied this phenomenon in detail with laryngoscopy to unravel information that could lead to better treatment. Methods: We conducted a cross-sectional study of 20 patients with ALS and 20 healthy age-matched and sex-matched volunteers. We used video-recorded flexible transnasal fibre-optic laryngoscopy during MI-E undertaken according to a standardised protocol, applying pressures of ±20 to ±50 cm H2O. Laryngeal movements were assessed from video files. ALS type and characteristics of upper and lower motor neuron symptoms were determined. Results: At the supraglottic level, all patients with ALS and bulbar symptoms (n=14) adducted their laryngeal structures during insufflation. At the glottic level, initial abduction followed by subsequent adduction was observed in all patients with ALS during insufflation and exsufflation. Hypopharyngeal constriction during exsufflation was observed in all subjects, most prominently in patients with ALS and bulbar symptoms. Healthy subjects and patients with ALS and no bulbar symptoms (n=6) coordinated their cough well during MI-E. Conclusions: Laryngoscopy during ongoing MI-E in patients with ALS and bulbar symptoms revealed laryngeal adduction especially during insufflation but also during exsufflation, thereby severely compromising the size of the laryngeal inlet in some patients. Individually customised settings can prevent this and thereby improve and extend the use of non-invasive MI-E. publishedVersion

Summary Background Resistance to the passage of the endotracheal tube (ETT) is frequently encountered in children as it is advanced over the fiberoptic scope for placement into the trachea because it gets hung up at the laryngeal inlet. Literature in adults indicates that a 90° counterclockwise rotation (CCR) of the ETT before advancing results in smooth passage. We found no literature in children. Objectives Our aim was to study if a 90° counterclockwise rotation (CCR) of the ETT before advancement leads to smooth passage of the ETT into the larynx in children. Methods Following IRB approval, we performed this study in two parts: Part 1: An unblinded, observational, pilot study on 20 children scheduled for oral rehabilitation where we concurrently used a fiberoptic scope nasally and GlideScope orally. We visualized the ETT path and observed that 90° CCR allowed smooth passage without hang up. Part 2: A blinded and randomized study on 40 children to confirm if 90° CCR from the outset would improve passage of the ETT during nasal intubation with a fiberoptic scope in children. All children were divided into two groups: group S, ETT bevel facing left; group R, ETT bevel facing down. Results In Part 1, we observed that the ETT got hung up in 57% of children with standard bevel direction (facing left) and in 0% of children when prerotated. In Part 2, efficacy of prerotation was confirmed; the ETT got hung up in 50% of children in group S but in only 10.5% of children in group R. Conclusion A change in ETT tip orientation from bevel facing left to facing down by 90° CCR, leads to a significantly higher first-attempt success rate by nasal approach in children. We believe the ETT should be rotated before insertion into the nostril to ensure that full 90° CCR of the tip has been accomplished.

BACKGROUND Some patients develop dysphagia after OC arthrodesis with RA. A previous report has indicated that establishing appropriate occipito-C2 is important for avoiding these side effects. However, a more recent report has demonstrated that the O-C2 angle did not have a significant effect on the incidence of postoperative dysphagia. OBJECTIVE To investigate the swallowing function of patients with rheumatoid arthritis (RA) before and after they underwent occipitocervical (OC) fusion. METHODS The study was performed in collaboration with the Departments of Orthopaedic, Otorhinolaryngology, and Rehabilitation. Seven consecutive patients (3 men and 4 women; mean age, 66.4 years) with RA-induced upper cervical deformity were enrolled from 2013 to 2014. The patients underwent deglutition analysis, which was performed by otorhinolaryngologists, before and after surgery, and comprised videofluoroscopy and fiberoptic endoscopy. We examined the relationship between imaging studies and swallowing function. RESULTS Preoperatively, subjective dysphagia was reported by 2 patients. Videofluoroscopy identified dysmotility of the epiglottis and incomplete closure of the laryngeal inlet in 2 patients, with contrast medium entering the larynx, and endoscopy identified food residue in the larynx of 1 patient during swallowing evaluation. Postoperatively, 2 patients with preoperative impaired deglutition showed dysphagia. Imaging examinations of the 2 patients revealed a 10°-reduction in the O-C2 angle of 1 patient, but the angle was unchanged in the other patient. CONCLUSIONS To the best of our knowledge, this is the first report to evaluate swallowing function before and after O-C3 arthrodesis. The preoperative O-C2 angle was unchanged after surgery. Impairment of deglutition may be closely associated with air leakage from the oropharynx due to impaired mobility of the soft palate. Because the precise mechanism of dysphagia has not been fully elucidated, further study using dynamic videofluoroscopy and videoendoscopy is needed to examine the swallowing mechanism.

Severe type III laryngomalacia LM is represented by a retroflexed epiglottis that touches the posterior pharyngeal wall and obstructs the laryngeal inlet. Endoscopic epiglottopexy is advised in such cases wherein pexy sutures are passed between the epiglottis and base of tongue. Using conventional needle carriers, it is difficult to pass such sutures that go deep enough into the tongue base. Such a pexy is prone to a break down. We describe a novel technique of placing these glossoepiglottic sutures using the Lichtenberger’s needle carrier. We used this technique in three patients with excellent results and report no complications. We propose to use this technique in cases of epiglottic prolapse seen in severe LM and certain hypotonic conditions.

Rocuronium is commonly used in preference to suxamethonium for rapid sequence induction in the Intensive Care Unit (ICU). We describe a patient who suffered significant neck trauma following a suicide attempt. On initial presentation to accident and emergency, he was an easy intubation with a Grade 1 view obtained at laryngoscopy. After surgery to repair his neck laceration, he was extubated and discharged from ICU. He later developed a severe aspiration pneumonia and required reintubation. After induction and paralysis with suxamethonium, the best view at laryngoscopy was a Grade 3 despite the use of different laryngoscopes. As the muscle paralysis wore off the patient began breathing. This produced bubbles in the back of the patient's pharynx which directed the clinician to the laryngeal inlet to allow successful intubation. In this case, the short duration of action of suxamethonium significantly aided intubation due to the return of spontaneous breathing by the patient.

BACKGROUND: Since the beginning of the Christian era, numerous reports have dealt with the construction and functional organization of the larynx, thus stressing its role as the keystone of vocalization in vertebrates. The purpose of this review is to provide a comprehensive summary of basic anatomical facts and to point out certain new aspects of the innervation of laryngeal muscles. METHODS: The data presented herein were collected from a preliminary gross anatomical study performed in six human individuals at our institute, and from published literature. RESULTS: The basic framework of the human larynx is composed of the hyaline thyroid, cricoid and arytenoid cartilages, the fibroelastic epiglottis and the hyoid bone. Two pairs of synovial articulations, i.e. the cricothyroid and cricoarytenoid joints, provide the mobility needed to adjust the tension of the vocal ligaments. The intrinsic laryngeal muscles may be divided into three functional groups: (i) muscles varying the rima glottidis (the transverse arytenoid as well as the lateral and posterior cricoarytenoid muscles); (ii) muscles regulating tension in the vocal ligaments (i.e. the cricothyroid, posterior cricoarytenoid as well as the compound thyroarytenoid and vocalis muscles) and (iii) muscles modifying the laryngeal inlet (the so-called ‘sphincter aditus’, which is formed by the oblique arytenoid and aryepiglottic muscles and counteracted by the thyroepiglottic muscle). They are innervated by the superior and inferior laryngeal nerves branching off the vagus nerve. The external branch of the superior laryngeal nerve exclusively supplies the cricothyroid muscle. There is strong evidence that the lateral cricoarytenoid and the thyroarytenoid muscles are solely supplied by the inferior laryngeal nerve. All other intrinsic laryngeal muscles seem to receive motor fibres either from both laryngeal nerves or from the internal branch of the superior laryngeal nerve alone. CONCLUSIONS: Thus, the traditional concept of motor innervation of the larynx seems to be out of date. In fact, the internal branch of the superior laryngeal nerve should no longer be seen as purely sensory but rather – as also the inferior laryngeal nerve – as a mixed nerve containing sensory as well as motor fibres.

The primary aim of the study was to explore cardiorespiratory reflexes originating from laryngeal C fiber endings in the neonatal period. Seventeen lambs were instrumented for recording glottal adductor and diaphragm EMG, heart rate, systemic arterial pressure and respiratory movements. C fiber blockade was induced in eight lambs by 30 mg/kg capsaicin, the remaining nine lambs serving as controls. Cardiorespiratory reflexes were induced in non-sedated lambs by flowing air, menthol or 13% CO2, or by injecting water or 50 microg capsaicin in the laryngeal inlet through an endoscope. Responses to all stimuli but capsaicin were similar between the two groups. While cardiorespiratory responses were induced by capsaicin in control lambs, the responses were significantly inhibited in lambs with C fiber blockade. We conclude that laryngeal C fiber endings are functional and responsible for laryngeal chemoreflexes in newborn lambs.

To the Editor, Flexible bronchoscope (FOB)-assisted endotracheal intubation has a well-established role in airway management. Intubation with a FOB involves two steps: first inserting the bronchoscope into the trachea and then advancing an endotracheal tube (ETT) over the FOB. Nevertheless, when advancing the ETT over the FOB, the bevelled tip of the ETT can impinge on the vocal cords, arytenoids, or other hypopharyngeal structures and impede advancement through the laryngeal inlet. To overcome this hindrance, a common maneuver involves withdrawing, rotating (anticlockwise), and repeatedly advancing the ETT, as well as altering the patient’s head or neck position, external laryngeal manipulation, jaw-thrust maneuvers, and lingual traction. All of these measures may provide better alignment of the ETT and FOB with the laryngeal opening. Moreover, some specialized products (e.g., Aintree intubation catheter, tapered ETTs, Parker Flex-Tip ETT) have also been used to minimize the gap between the FOB and the leading edge of the ETT, thus facilitating railroading of the ETT over the FOB. A limitation of the above devices is the necessity for them to be in place prior to the start of the intubation sequence. Furthermore, the efficacy of these various products has been debated, and their availability is somewhat variable. We have used an alternate technique in two cases to facilitate passage of a 7.0-mm ETT over a 3-mm FOB using a 19G epidural catheter. After the conventional techniques had failed and while keeping the bronchoscope in place, the ETT was withdrawn until its tip was visible. One end of an epidural catheter was then used to encircle the FOB; next, the two ends were passed through the Murphy eye of the ETT from the inside out (Figure A) and then through the lumen of the ETT (Figure B). With the catheter kept taut, the ETT (which was then tightly opposed to the FOB; see video) was then easily passed over the FOB through the laryngeal inlet. The bronchoscope was then withdrawn followed by removal of the catheter. The epidural catheter offers advantages as it is soft and smooth and thus minimizes the chances that it might damage tissues. The rigidity of the catheter also enables it to pass easily through the ETT lumen. If the catheter breaks, it can easily be removed as both ends are visible at the ETT connector. Although the feasibility of this technique in all patients is unclear, it may offer an advantage as it can be accomplished without the need to remove the FOB. This will save time and limit the repeated attempts at passing the FOB. For those considering this approach in their airway armamentarium, practicing the technique beforehand in a simulator may offer an advantage. Further investigation will be required to confirm the broader safety and applicability of this technique. Electronic supplementary material The online version of this article (doi:10.1007/s12630-015-0370-7) contains supplementary material, which is available to authorized users.

Study Objective To assess the efficacy of both Bonfils and GlideScope in obese patient with difficult airways for bariatric surgery using awake intubation. Design Comparative study. Setting Operating room. Patients The study was carried out on 60 patients, for laparoscopic bariatric surgery, after approval of the Medical Ethics Committee and having an informed written consent from each patient. Patients were randomly categorized into 2 equal groups 30 patients in each group. Interventions Awake intubation with either Retromolar Bonfils or GlideScope. Measurements Time to visualize the laryngeal inlet, time of intubation, time of scope manipulation, success rate at each attempt, the lowest oxygen saturation, hemodynamic parameters, and any complication. Main Results Regarding intubation criteria, GlideScope achieves shorter times compared with Retromolar for visualization of the vocal cords and intubation, in addition to less intubation attempts, but both without a statistically significant difference. Retromolar shows better patient satisfaction than does GlideScope, with statistically significant difference. Conclusions Both Bonfils fiberscope and the GlideScope can be successfully used for awake intubation in morbidly obese patients with expected difficult airways. Bonfils intubating fiberscope was more tolerated by patients with statistical difference; on the other hand, GlideScope provided shorter intubation time and less intubation attempts but not statistically significant.

Obstructive sleep apnea is rarely caused by laryngomalacia in adult patients. To our knowledge, laryngomalacia secondary to osteogenesis imperfecta inducing obstructive sleep apnea has not been reported. We present an adult osteogenesis imperfecta patient with obstructive sleep apnea. Oral examination demonstrated an extremely long epiglottis in the oral cavity. Fiberoptic nasopharyngoscopy revealed that the epiglottis and redundant mucosa of the arytenoids were drawn into the laryngeal inlet during inspiration. Supraglottoplasty with intraoral and laryngoscopic approach was carried out and resulted in marked decreases in snoring, sleep apnea, and daytime sleepiness. In this report, we describe a unique laryngeal manifestation inducing obstructive sleep apnea in an adult with brittle bone disease. The anomaly of laryngeal structure can be corrected by surgical intervention with good response in the sleep-disordered breathing.

The Shikani Seeing Stylet™ is a recently introduced reusable intubating stylet, produced in adult and paediatric versions. It combines features of a fibreoptic bronchoscope and a lightwand.Inside a malleable stainless steel sheath, the Shikani Seeing Stylet™ has a fibreoptic cable leading to a distal light source and high-resolution lens. In use, the stylet is placed in the lumen of the selected endotracheal tube and the light source enables the stylet to be used as a lightwand, while the fibreoptic capability enables visualization of the laryngeal inlet. It is portable, relatively inexpensive and easy to maintain.This report describes the use of the stylet on eight occasions in seven children, all of whom were assessed preoperatively as being potentially difficult to intubate. Three had been difficult to intubate previously. All were anaesthetized using inhalational anaesthesia. Once an adequate depth of anaesthesia had been achieved, conventional direct laryngoscopy was performed and identified as Grade 3 in six of the patients and Grade 1 in one.Tracheal intubation was then attempted using the Shikani Seeing Stylet™. On six of the eight occasions the attempt was made by different anaesthetists, none of whom had any prior clinical experience with the stylet. There were seven successful intubations and one failure in a patient who could not be intubated by any method.The Shikani Seeing Stylet™ seems a useful device for use in children with difficult airway problems, suspected cervical spine instability or limited mouth-opening.

We studied postoperative swallowing in 4 patients undergoing CHEP and 1 undergoing CHP. Swallowing was obtained by intense swallowing rehabilitation since only 1/4 of the larynx remained after near-total laryngectomy. Our swallowing rehabilitation program is detailed in this paper. The improvement of swallowing is classified into 3 stages. In stage I, volus directly intrudes into the trachea. In stage II, volus stagnates between laryngeal inlet and tracheal stoma. In stage III, volus directly flows through the esophageal inlet. Stage III indicates that rehabilitation is almost completed. Stage I is shortest at 2 to 14 days and Stage II longest at 7 to 80 days. The MTF (Method, Time, Food) score described by Fujimoto et al was used to analyze swallowing. Three cases following CHEP showed high scores shortly after the introduction of rehabilitation and reached the maximum score at discharge (15 points = normal swallowing). At present, these 3 patients are satisfied with swallowing and enjoy a good quality of life. In 2 other cases (1 CHEP and 1 CHP), both had a wide laryngeal inlet and still have some difficulty with liquids. Further modification of the surgical technique is needed especially for CHP.

Background: Aim of present study was to compare the efficacy and safety of supraglottic devices (LMA supreme, LMA proseal and I-Gel) by clinical and fiberoptic evaluation in elective laparoscopic surgeries under general anaesthesia with controlled ventilation.Methods: The design was a prospective, randomized study enrolling total 105 patients of either sex, (age 18-65 years), ASA grade I/II and mallampati score I and II, were randomly allocated to LS (LMAS), LP (PLMA), and IG (I-Gel) groups according to the supraglottic device applied. The three devices were compared as regards insertion parameters, adequacy of ventilation (oxygen saturation, endtidal carbon dioxide and air leak), fibreoptic vision and intra or postoperative complications.Results: The overall ease of insertion of LMAS was found to be better than the other two devices. Adequacy of ventilation was comparable in all the study groups. Safety of these devices was found to be comparable but if OLP was considered as a marker of safety of the device, LMA proseal was a better option than the other two devices. There was no significant difference in the fiberoptic view of the laryngeal inlet between the three study groups but the number of patients with grade 4 view of laryngeal inlet fiberoptic was more in I gel than LMA proseal and LMA supreme.Conclusions: It was concluded that the LMAS, PLMA and I-Gel are effective ventilatory devices during controlled ventilation, without major complications. But in clinical practice it is advisable to monitor peak airway pressure, OLP and laparoscopic view of gastric distension whenever these devices are used in laparoscopic surgeries.

To the Editor, Rhinosporidiosis is a chronic granulomatous disease caused by an aquatic protistan parasite, rhinosporidium seeberi. The disease presents as multiple polypoidal granular lesions involving the mucosa of nasal cavity, nasopharynx, and oropharynx. These lesions are friable, bleed profusely, and have a high tendency to recur. Due to systemic involvement of the disease, including bone and skin, patients require multiple surgeries. There is considerable risk of autoinoculation of the spores during airway management, hence all cases require atraumatic tracheal intubation. We report herein airway management in a case of a large pedunculated nasopharyngeal mass extending into the laryngopharynx and completely covering the laryngeal inlet. The patient gave written informed consent for publication of this case report. A 32-yr-old immunocompromised Hepatitis B Surface Antigen (HBsAg) seropositive male patient from northern India presented with nasal stuffiness and a one-year history of granulomatous growth on his left ear. The surgical removal of an aural lesion histologically confirmed rhinosporidiosis. One year earlier, the patient underwent left below-knee amputation under subarachnoid block for rhinosporidiosis-related osteomyelitis. During all examinations and interventions, universal safety precautions were followed. On examination, the patient was conscious, cooperative, hemodynamically stable, and not in respiratory distress. His cell blood count, electrocardiogram, and chest radiograph were normal, and serology for HBsAg was positive with the ELISA test. On inspection of his airway, a large polypoidal mass was observed anteriorly in the left nostril, and an irregular polypoidal nasopharyngeal mass, observed originating from the uvula, became prominent on protrusion of the tongue (Fig. 1) and moved with swallowing. The airway was judged as a Mallampati 4 airway with an Arne’s score of 13. The patient’s vocal cords could not be visualized on indirect laryngoscopy. An oral 70 rigid endoscope (Karl Storz Hopkins, Germany) revealed a 5 x 5 cm pedunculated polypoidal nasopharyngeal mass originating from the uvula, extending into the laryngopharynx, and completely covering the laryngeal inlet (Fig. 2). Visualization of the vocal cords showed normal movement with no lesions. The anesthetic plan for securing the airway included awake orotracheal intubation using a GlideScope GVL video laryngoscope (Saturn Biomedical Systems, Verathon, Burnaby, BC, Canada) and fibreoptic intubation (Fl-10P2, Pentax medical, Montvale, NJ, USA) if required. We also planned for the possibility of an emergency tracheostomy. These procedures were explained to the patient and informed consent was obtained. Overnight fasting with aspiration prophylaxis was planned, and glycopyrrolate 0.2 mg iv was administered 45 min before surgery. On arrival to the operating room, routine monitoring was commenced using an Aestiva S/5 anesthesia delivery system (Datex-Ohmeda Inc., Instrumentarium Corp., Aestiva /5 Compact, Finland), and no transtracheal blocks were given to prevent any foci for autoinoculation. Topical anesthesia of the airway was provided with inhaled 4% nebulized lidocaine for 20 min. Lidocaine jelly (2%) was applied gently on the ventral surface of the patient’s tongue from the tip to the base of the tongue as far as back as the vallecula. The patient was placed in a 15 head-down position to facilitate moving the uvular mass into the V. Ahuja, MD (&) S. Gombar, MD D. Thapa, DNB K. Bagri, MD Government Medical College and Hospital, Chandigarh, India e-mail: vanitaanupam@yahoo.co.in

Sedation may alter laryngeal anatomy, function, and respiratory mechanics; therefore, it is essential that the practitioner has a thorough understanding of the pediatric airway. Physical examination reveals the general condition of a patient and the degree of the airway compromise. During sedation, adequate oxygenation and ventilation must be maintained despite a relative decrease in rate and depth of respiration. Conditions that interfere with the integrity of the laryngeal inlet or upper larynx may impair effective ventilation as a result of partial or complete airway obstruction. Sleep-disordered breathing (SDB) is a spectrum of disorders ranging from primary snoring to obstructive sleep apnea syndrome (OSAS). When sedation without a secured airway is planned it is imperative that the level of consciousness, adequacy of ventilation, and oxygenation be continuously monitored and the risk of apnea be evaluated. When a child is sedated, the best prevention is to insure that the position provides the best anatomic orientation for airway patency.

c l n nasogastric tube is then gently guided into the gel ring to sit about 2 cm from the tip of the endoscope (Fig. 2). The fter operations on the head and neck, placement of a nasoastric tube is indicated in many patients to aid postoperative eeding and recovery. However, distorted regional anatomy an make this difficult, and several studies have reported hat placement was successful in only 50% of anaesthesised atients who had operations on areas other than the head nd neck.1–3 A number of recommendations have been made o aid placement such as positioning of the head, lateral eck pressure, use of endoscopy, and forceps-assisted and uidewire techniques.1,4–6 We report a novel technique that we have found to be 00% successful in over 20 patients. We have used it at our ospital since 2010 without complication, and it has been idely accepted by colleagues in anaesthetics for placement f tubes in difficult cases. The “transient bond” or “piggyback” is an inexpensive echnique based on a short-acting bond between the nasogasric tube and flexible nasoendoscope to make one functioning nit that can be used by a single operator. The bond is created sing an easily obtainable empty polysaccharide capsule, idely available in health shops and pharmacies (and used o self-fill with vitamins or other products), and the cost is round £4.50/200 the United Kingdom. Endoscopic assisance allows continuous visualisation of the procedure and he surrounding anatomy, and particularly the laryngeal inlet. The capsules, which are the same consistency as those sed in pharmacutical preparations, are either gelatin or

Objective: To report the occurrence of a neonate with a lateral saccular cyst that was successfully managed by flexible, carbon dioxide laser-assisted endoscopic marsupialization and ablation. Case Summary: A full-term, 14-day-old girl presented to the clinic for progressively worsening stridor since birth. On fiber optic laryngoscopy, she was found to have a large, right saccular cyst obstructing the laryngeal inlet. The patient was admitted and underwent microlaryngeal endoscopic CO2 laser marsupialization and ablation of the saccular cyst. She was observed overnight and was discharged without complication the next day. At that time, stridor was no longer present and she remained symptom free at both her 2-week and 3-month follow-up. Discussion: The congenital saccular cyst is a rare, abnormal dilation of the laryngeal saccule that is known to be a cause of airway obstruction. A variety of contrasting treatment strategies for laryngeal saccular cysts in children have been reported in the literature. Determining the definitive treatment modality thus remains a challenge that is compounded further by the rarity of the lesion. Conclusion: We introduce a new surgical technique that employs a 30-degree angled telescope with a flexible laser fiber system that provides excellent visualization of saccular cysts, in particular, lateral lesions that are less visible using line-of-sight technology.

Airway problems are easiest to manage when they are anticipated. Difficult intubation might, however, occur in patients with no obvious signs or symptoms suggesting airway difficulty. We describe a case where laryngeal inlet was obscured by a large vallecular cyst that was discovered during rapid-sequence induction of general anesthesia, causing difficulty in tracheal intubation. Once the patient was allowed to recover from general anesthesia, the trachea could be safely intubated using a fiberoptic bronchoscope.

Laryngopharyngeal reflux (LPR) disease and extraesophageal manifestations of gastroesophageal reflux have been recognized to have dramatic effects in the upper airways. Patient-reported symptoms alone underestimate the presence of LPR, making accurate clinical diagnosis difficult. Many previous studies examine populations with only standard dual-probe pH testing that does not include a test probe in the pharynx. Therefore, documentation of acid exposure at the laryngeal inlet is lacking. In adult patients with subglottic stenosis (SGS), whether due to granulomatous disease or presumed idiopathic causes, LPR is often a contributing or causative factor. a retrospective chart review from 1991 to 1999 identified 19 patients with SGS. Ten of the 19 patients had concomitant disease states, including sarcoidosis (3), Wegener's granulomatosis (3), laryngeal trauma (3), and a history of intubation (1). Fourteen patients underwent 24-hour ambulatory pH probe testing with 3- or 4-port probes. The proximal port in either catheter was positioned by manometric guidance directly behind the laryngeal inlet. Measurements of pH of less than 4 were recorded at the level of the larynx in 12 of the 14 patients tested (86%). This finding was noted in half of the patients despite empirical therapy with proton pump inhibitors at the time of the testing. Seven of 10 patients with underlying disease were studied, and all demonstrated acid reflux in the hypopharynx. In 9 patients, the stenosis was presumed to be idiopathic. Five of the 7 patients (71%) with idiopathic SGS tested had positive pH probe studies (pH below 4 in the pharyngeal probe). Our results demonstrate a strong association of LPR and SGS. In the idiopathic group, reflux is the probable cause of their stenosis. In the group of patients with underlying disease states, reflux was involved in all tested patients and likely acts as a synergistic factor that stimulates their granulomatous disease to react and subsequently result in the development of stenosis. Evaluation for LPR with pharyngeal pH testing should be performed in all patients with SGS.

A new practical classification of laryngeal view at laryngoscopy is presented and evaluated. The best laryngeal view obtained with or without anterior laryngeal pressure is recorded. The laryngeal view is easy (E) when the laryngeal inlet is visible. The view is restricted (R) when the posterior glottic structures (posterior commissure or arytenoids) are visible or the epiglottis is visible and can be lifted; this includes some grade 2 and some grade 3 views as classified by Cormack and Lehane. A difficult (D) view is present when the epiglottis cannot be lifted or when no laryngeal structures are visible. Five hundred patients were studied. Laryngoscopy, with the patient anaesthetised and paralysed, was performed with a Macintosh laryngoscope. If the vocal cords were not visible, a gum elastic bougie was used to aid intubation. Other aids were used only if this did not allow intubation. Each laryngeal view was graded according to the new classification and that of Cormack and Lehane. Intubation was timed and the equipment needed to facilitate intubation was recorded. The new classification stratified increasing difficulty with intubation (time for intubation longer and increasingly complex methods needed) better than the Cormack and Lehane classification. The new classification is as sensitive and more specific than the Cormack and Lehane classification in predicting difficult intubation. It is also more sensitive and more specific in predicting easy intubation.

Ankylosis may be defined as the fusion of joint surfaces. Temporomandibular joint (TMJ) ankylosis is a condition that may cause chewing, digestion, speech, esthetic and psychological disorders. It is a devastating disorder resulting in inability to open the mouth. As a result of this, General anaesthesia, is very difficult to administer because laryngeal inlet is not directly visualized. Even the blind nasal intubation is difficult because of small mandible and tongue fall following relaxation. There are various techniques to overcome these challenges. At times these techniques fail and tracheostomy has to be done. All the risks associated with difficult intubation, and general anaesthesia can be avoided if the surgery is done under conscious sedation. Conscious sedation, a simple but safe and effective method of anaesthesia is described here, which allows successful temporomandibular joint interpositional gap arthroplasty.

To the Editor, We read with interest the articles by Tsui et al. regarding ultrasound imaging of the airway using a sublingual scanning approach. A small footprint high frequency curved transducer placed intra-orally failed to capture images of the epiglottis and the laryngeal inlet due to posterior acoustic shadowing of the hyoid bone. Transcutaneous ultrasound scanning of the airway may overcome some of these challenges. In our pilot study, we were able to image airway structures in the transverse and parasagittal (1 cm away from midline) views using a linear 38 mm, 13–6 MHz transducer with the Sonosite M-Turbo ultrasound machine (Bothell, WA, USA). The epiglottis can be visualized (Fig. 1) through the transverse and parasagittal windows both above and below the hyoid bone. Because the hyoid bone casts an acoustic shadow posteriorly, part of the epiglottis is obscured. The epiglottis is best seen through the hyo-thyroid window between the hyoid bone and the thyroid cartilage. It appears as a hypoechoic structure with a curvilinear shape on parasagittal view and an inverted ‘C’ on transverse view. It is related anteriorly by the hyperechoic triangular preepiglottic space and lined posteriorly by a hyperechoic air–mucosa interface. Compared with the sublingual technique, the transcutaneous scan has several advantages. A high frequency transducer for transcutaneous scan captures images of higher resolution. A good transducer to skin contact can be maintained even at the level of the thyroid prominence with the linear transducer in the parasagittal position. Visualization of the epiglottis is possible without ultrasound beam interference due to hyoid acoustic shadow and attenuation by hypopharyngeal air (as seen with the sublingual scan). Furthermore, airway scanning at the level of the laryngeal inlet is possible and not impaired by restricted caudad transducer angulation due to the presence of upper incisors or the smaller capacity of the sublingual space (as seen with the sublingual scan). Both scanning approaches visualize tongue substance and musculature. Future studies will determine if the sublingual and transcutaneous approaches are complementary to each other. Ultrasound may prove to be an exciting evaluation tool for airway structures and ease of intubation.

A case in which the epiglottis was tucked into the laryngeal inlet by advancement of an endotracheal tube (ETT) during fiberoptic intubation, is presented. In this case, pulling the fibroscope, which was advanced under the displaced epiglottis, was effective for restoration.

Laryngeal cysts are relatively rare benign lesions of the larynx. Congenital cysts can cause neonatal respiratory distress and death, but airway obstruction due to acquired cysts in adults is rare. We present a case report of 51-year-old male with dysphagia who was found to have a mobile pedunculated epiglottic cyst that intermittently caused partial obstruction of the laryngeal inlet. Patient was taken to operating room and following transoral fiberoptic intubation, endoscopic excision of this cyst was accomplished. Patient's postoperative course was uneventful.

The laryngeal mask airway (LMA) was developed in 1981 by Dr. Archie Brain in the United Kingdom, and has been available for clinical use in the United States since 1992. It represents a novel concept in airway management that allows air exchange through a specially designed mask that fits in the hypopharynx and faces the laryngeal inlet, creating an end-to-end seal. During the last decade there has been ample literature, much of it anecdotal, on the many applications of the LMA over a wide patient age range. It has also been the subject of detailed literature reviews and a book.7,12,39,47 The LMA has achieved popularity at a rapid rate, and in certain regions it has become the principal means of airway management during anesthesia. The shape of the LMA mask was developed based on cadaveric studies of the adult pharynx.8 Structurally, pediatric-sized LMAs are simply scaled-down versions of the adult variety, even though newborns and infants display significant differences in airway anatomy from older children and adults. Although its application in the pediatric population has lagged behind adult use, the LMA now has established roles in routine pediatric anesthesia, management of the difficult pediatric airway, and diagnostic airway procedures. There are a number of publications addressing the use of the LMA in pediatric patients.32,36,46 The LMA is generally used in the spontaneously breathing patient, although it can be employed with controlled, positive pressure ventilation.25 The LMA has been used in premies as small as 1 kg in weight.11,31

Background None of the presently used airway devices are ideal regarding ease of insertion, alignment with the laryngeal inlet, and provision of a high-pressure seal from the environment. The purpose of this study was to determine, in awake volunteers, the performance of a new ventilatory device, the glottic aperture seal airway, regarding ease of insertion, alignment with the laryngeal inlet, and forced exhalation seal pressure (PFES). Methods The glottic aperture seal airway consists of a curved tubular component that ends in the middle of an elliptical foam cushion glottic component. The posterior surface of the foam has a curved flexible plastic backing, which imparts a 60 degree angle between the proximal half and the distal half of the foam cushion. When the glottic aperture seal airway is properly in situ in a supine patient, the proximal half of the foam cushion is opposite the laryngeal inlet. The posterior surface of the plastic backing has a balloon attached to it. Inflation of the balloon presses the ventilation hole and foam cushion up against the laryngeal inlet, thereby creating a seal from the environment. Using the laryngeal mask airway as a control device, the glottic aperture seal airway was tested for time and ease of insertion, fiberoptic alignment with the laryngeal inlet, and PFES in 18 lightly sedated and locally anesthetized volunteers. Results The glottic aperture seal and laryngeal mask airways were inserted with equal ease and speed. The fiberoptic alignment with the larynx was excellent for both the glottic aperture seal and laryngeal mask airways. In all volunteers, the mean +/- SD PFES values at 0-, 10-, 20-, 30-, and 40-ml balloon inflation volumes of the glottic aperture seal airway were 23.4 +/- 11.8, 29.6 +/- 12.4, 42.7 +/- 12.5, 56.9 +/- 5.6, and 60 +/- 0 cm H2O, respectively; the PFES at > or = 20 ml balloon inflation volume of the glottic aperture seal airway was significantly greater than with the laryngeal mask airway (19.4 +/- 6.7 cm H2O, P < 0.01). A PFES of > or =60 cm H2O was achieved with the glottic aperture seal airway in all volunteers (n = 2 at 10 ml, n = 3 at 20 ml, n = 9 at 30 ml, and n = 4 at 40 ml). The glottic aperture seal airway did not cause any trauma. Conclusion In awake volunteers, the glottic aperture seal and laryngeal mask airways were equally easy to insert and position. The glottic aperture seal airway was capable of achieving a higher PFES than the laryngeal mask airway.

The aryepiglottic folds extend between the arytenoid cartilage and the lateral margin of the epiglottis on each side and constitute the lateral borders of the laryngeal inlet. They are involved in physiologic closure mechanisms of the larynx and in pathologic conditions such as inspiratory stridor. Information on the normal topography of the aryepiglottic folds is poor and controversial. Therefore, this region was reinvestigated in serial whole-organ sections of 25 plastinated normal adult human larynges. Dorsally, the right and the left aryepiglottic folds are separated by the interarytenoid notch and comprise the corniculate and cuneiform cartilages, as well as numerous groups of mucous glands. Ventrally, the aryepiglottic folds are adjacent to the peri-epiglottic adipose tissue. Both regions are clearly separated by several layers of transversely oriented collagenous fiber layers. The muscular constituent of the aryepiglottic folds is only poorly developed, and no muscle fibers insert at the epiglottis. A coherent quadrangular membrane representing a ligamentous "skeleton" of the aryepiglottic folds is absent. A conspicuous collagenous fiber layer is found only to strengthen the free dorsal margin of the fold. Both muscular and ligamentous components may render the aryepiglottic folds sufficiently tense as to resist inspiratory inward suction in normal cases. However, pliability must be preserved to guarantee adequate folding in approximation of the aryepiglottic folds during deglutition. Thereby, the posterior part of the laryngeal inlet is closed, whereas the anterior part is probably closed by independent inward bulging of the peri-epiglottic adipose tissue.

The aim of the report is to re-emphasize how dangerous fish bone impaction in the esophagus could be and that a combination of pointing sign with radiographic features improves the specificity of the diagnosis. A 45-year-old male civil servant presented with 4 days history of fish bone impaction in the throat while taking meal containing fish with accidental ingestion of fish bone. This was associated with odynophagia, dysphagia, drooling of saliva, failed attempted dislodgement with swallowed boluses and positive pointing sign. Neck X-ray showed prevertebral widening and radio-opaque tracheoesophageal penetrating foreign body. He had endoscopy under general anesthesia with retrieval of the fish bone-Laryngo-esophagoscopy showed a laceration in the esophageal mucosal, which penetrated into the laryngeal inlet. This case report re.emphasizes the danger of attempting to dislodge such sharp foreign bodies with boluses of food.