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Purpose: The innominate artery sometimes compresses the trachea, leading to tracheomalacia and highly fatal tracheoinnominate fistula in patients with severe chest deformity. This study is focused on the indication of innominate artery transection for the definitive treatment of these complications., Patients and Methods: We retrospectively analyzed the medical records of eight patients who underwent transection of innominate artery., Results: All patients had developed severe chest deformity and their symptoms were life-threatening anoxic spell or endotracheal hemorrhage. Bronchoscopy showed tracheomalacia with or without pulsatile granulations on the anterior wall of the trachea underlying the innominate artery. In six cases who had previously undergone tracheostomy or laryngotracheal separation, the tracheal tube tip made granulations or tracheoinnominate fistulas. In addition to transection of innominate artery, the tracheoinnominate fistula was closed in two cases and the artery was transposed in one. All patients survived without neurologic complications and airway symptoms postoperatively., Conclusions: For patients with severe chest deformity, innominate artery transection is indicated when they have tracheal compression by the artery and need to be intubated through the compressed part of trachea to secure the airway. This would be the best timing to schedule the prophylactic operation.

Purpose: Congenital tracheal stenosis is a rare condition and can be difficult to manage. One source of difficulty is postoperative tracheomalacia requiring long-term tracheal stenting. To prevent symptomatic postoperative tracheomalacia, we have been adding aortopexy to tracheal reconstruction since 2008. The aim of this study was to evaluate efficacy of aortopexy for preventing postoperative tracheomalacia after reconstruction of congenital tracheal stenosis., Methods: Retrospective chart review was conducted. From October 2003 to March 2011, 24 had tracheal reconstruction without aortopexy (group A) and 8 with aortopexy (group B). Statistical analysis was performed using Fisher's Exact test., Results: One had anastomotic leakage in group A, and 1, in group B (P = .44). Eleven patients required tracheostomy because of postoperative tracheomalacia confirmed by postoperative bronchoscopy in group A vs none in group B (P = .029)., Conclusions: We found that aortopexy with tracheal reconstruction reduced the need for postoperative tracheostomy in this patient group. Although there is a potential risk of anastomotic leakage because of the suspension suture on the anterior tracheal wall to aorta, we did not detect an increased incidence after aortopexy. Thus, aortic suspension may be a useful adjunct to prevent symptoms of tracheomalacia in these patients., (Copyright © 2012 Elsevier Inc. All rights reserved.)

A 60-year-old man treated for chronic bronchial asthma for more than 5 decades, presented in a debilitated condition. Chest radiography showed mediastinal widening, electrocardiography revealed left anterior hemiblock, magnetic resonance imaging and angiocardiography confirmed double aortic arch. He underwent excision of the anterior arch and release of the trachea and esophagus. Double aortic arch should be considered in the differential diagnosis of chronic asthma when a patient fails to respond to medical treatment.

Background: Huge goiters are common in iodine-deficient endemic regions. They are of concern to the surgeons because of the anticipated risk of difficult dissection and increased chances of surgical complications. Similarly, they are of concern to the anesthesiologists because of anticipated intubation-related difficulties and post-thyroidectomy tracheomalacia. In the present study we aimed to present our experience of managing goiters based on their gross weight, highlighting their clinicopathological profile, perioperative airway-related difficulties, and management of surgical morbidity., Methods: Retrospective analysis of patients who underwent total thyroidectomy in the primary setting at our institute from 1995 to 2009 was carried out based on the gross gland weight. The patients were thus grouped into group A: ≤200 g; group B: 201 to ≤400 g; group C: 401 to ≤600 g; group D: >600 g., Results: Group A (660 cases); group B (108 cases); group C (36 cases); and group D (9 cases) were included. As the goiter size increased, the mean duration of goiter, compressive symptoms, retrosternal extension (RSE), airway deformity, intubation difficulty, and tracheomalacia increased. The rate of tracheostomy, sternotomy, hemorrhage, visceral injury, and hospital stay was high with huge goiters. These features were more marked in malignant goiters compared to benign goiters. However, the postoperative complications were comparable in both of those groups., Conclusions: Long-standing huge goiters are common in iodine-deficient endemic areas. The majority of patients have symptomatic or clinicoradiological evidence of airway involvement. The incidence of RSE, airway deformity, intubation difficulty, and tracheomalacia is high with huge goiters. The surgery is technically demanding with greater associated chances of injury to native structures. Malignancy influences the presentation and outcome in smaller goiters. In centers with experienced endocrine surgeons and dedicated anesthetists, huge goiters can be successfully managed with minimal short-term and long-term morbidity.

Exertional dyspnoea is a common symptom among middle-aged population. Diagnostic evaluation of such patients is often challenging and confusing. We report a patient presenting with exertional dyspnoea and an obstructive ventilatory defect on spirometry that was refractory to bronchodilator therapy. Careful review of the chest radiograph and spirometry pointed towards variable intra-thoracic airways obstruction as a cause of dyspnoea. Contrast enhanced computed tomography (CECT) of the thorax and bronchoscopy established the diagnosis of a right-sided aortic arch resulting in tracheobronchial compression and tracheomalacia.

Objective: The aim of this study was to evaluate the clinical outcome of conservative management of anastomotic leakage (AL) after surgical repair for esophageal atresia., Methods: Data from 85 neonates with esophageal atresia who underwent surgical correction were retrospectively analyzed. Conservative treatment had been adopted for AL. The incidence and severity of postoperative AL as well as its effects were analyzed., Results: Among the 85 neonates, postoperative AL occurred in 21 (25%) cases, with major leaks in 15 cases and minor leaks in 6. The stricture index of the 21 neonates with AL (0.615 ± 0.032) was significantly different (P = .008) from that of the 64 neonates without leakage (0.509 ± 0.018). The overall incidence of gastroesophageal reflux (GER) was 36%. Esophageal dysmotility and clinically significant tracheomalacia were observed in 69 and 7 infants, respectively, of the 80 surviving patients. The incidence of GER, dysmotility, and tracheomalacia in patients with or without AL was similar. The severity of GER in patients with different numbers of sessions of dilation was significantly different (P = .0015)., Conclusions: Postoperative esophageal AL is effectively treatable by conservative methods in most neonates. The occurrence of AL may aggravate the severity of esophageal stricture but does not affect the incidence of GER, esophageal dysmotility, and tracheomalacia., (Copyright © 2011 Elsevier Inc. All rights reserved.)

We present the case of a female neonate with expiratory stridor that was caused by a bronchogenic cyst that led to tracheobronchomalacia. Rigid endoscopy revealed that a severe anterior compression of the tracheobronchial tree had caused tracheomalacia and right bronchomalacia. Computed tomography of the chest with intravenous contrast demonstrated the presence of a mediastinal mass anterior to the trachea and bronchus. Following a complete excision via a median sternotomy, histopathologic examination identified the mass as a bronchogenic cyst with respiratory epithelial lining and cartilage elements. The patient experienced a complete resolution of her respiratory symptoms postoperatively.

Purpose: We describe an unusual combination of dynamic supraglottic, glottic, subglottic, and intrathoracic airway obstructions following a total thyroidectomy. These problems were anticipated, documented videographically, and managed preemptively., Clinical Features: Following a total thyroidectomy, we replaced the endotracheal tube with a laryngeal mask airway, namely, the LMA-Classic™, in a patient with symptomatic tracheal compression and probable obstructive sleep apnea. Spontaneous ventilation was observed bronchoscopically through the LMA-Classic. Supraglottic swelling, extraglottic collapse on inspiration, and intrathoracic collapse on expiration were documented prior to recovery. These observations were of sufficient concern to warrant reinsertion of the endotracheal tube and subsequent tracheal extubation over a tube exchanger. Thereafter, we provided face-mask continuous positive airway pressure using a Boussignac mask with an endotracheal ventilation catheter in situ., Conclusions: Acute airway collapse following thyroid surgery is a rare and potentially serious complication. Diagnosis by conventional methods may be insensitive. Difficulties may not be apparent until the patient becomes distressed after tracheal extubation, and this circumstance will worsen airway compromise. In such a state, re-establishing the airway can become life-threatening. We describe the preemptive identification, physiologic manifestations, and management of the supraglottic and subglottic obstruction exemplified by this case.

Tracheomalacia after thyroidectomy is a life-threatening situation. However, it is difficult to predict postoperative tracheal obstruction with certainty. A case of a 74-year-old woman with a long-standing adenomatous goiter (98 g) is reported. She had undergone partial right lobe thyroidectomy 54 years earlier. After total thyroidectomy, she was reintubated and required a tracheostomy because of tracheomalacia. The right residual thyroid tumor weighed only 5 g, but it extended to the retrotracheal space. Because the right lobe had stretched the membranous wall of the trachea over a long period of time, the tracheal lumen was thought to have collapsed because of loss of the foundation of the tracheal cartilage (the residual right lobe) along with the supportive surrounding tissue (the left lobe) after surgery. The present case suggests that the occurrence of tracheomalacia could be attributed to reoperation and retrotracheal extension. Thus far, six preoperative predictive factors for the development of severe postoperative respiratory obstruction have been reported: goiter for more than 5 years, preoperative recurrent laryngeal nerve palsy, significant tracheal narrowing and/or deviation, retrosternal extension, difficult endotracheal intubation, and thyroid cancer. Two more factors, reoperation and retrotracheal extension of tumor, may also be risks for airway obstruction after thyroidectomy.

Background: Post-thyroidectomy tracheomalacia is a rare but complicated problem. It has often been treated with tracheostomy or prolonged endotracheal intubation. However, noninvasive positive pressure ventilation (NPPV) has been successfully employed with increasing frequency in patients with respiratory failure from other causes. In the present study we describe the use of NPPV in the management of respiratory distress in patients with post-thyroidectomy tracheomalacia., Methods: All 606 patients who underwent thyroidectomy in Chung Gung Memorial Hospital - Kaohsiung Medical Center, Taiwan, from January 2009 to August 2010 were reviewed. If tracheomalacia was diagnosed intraoperatively, the patients were left intubated and taken to the intensive care unit (ICU) (n = 5). If tracheomalacia was diagnosed in the recovery room (stridor and airway compromise not from other causes), the patient was reintubated promptly and taken to the ICU (n = 4). When subsequently re-extubated in the ICU (24-72 h later), NPPV was used to treat recurrent stridor and airway compromise., Results: A total of nine patients (1.5 %) were diagnosed with post-thyroidectomy tracheomalacia, five intraoperatively and four postoperatively. The patients were intubated with an endotracheal tube and then taken to the ICU. After early re-extubation in the ICU, three of the patients with intraoperatively diagnosed tracheomalacia were found not to have respiratory problems, whereas the other six patients developed stridor and airway compromise, which resolved immediately with the initiation of NPPV. Hemoglobin oxygen saturation on pulse oximetry was also elevated. No further respiratory support was required and no complications occurred in these patients., Conclusions: Noninvasive positive pressure ventilation is effective and appears safe in the management of stridor and airway compromise following early extubation in patients with post-thyroidectomy tracheomalacia.

Background: In an emergency, the non-availability of a conventional paediatric tracheostomy tube is a therapeutic challenge for the attending surgeon., Objective: To describe a simple alternative to a paediatric tracheostomy tube for use in an emergency situation., Method: Case report of a 14-year-old boy who developed tracheomalacia following partial cricotracheal resection for subglottic stenosis. As a suitably sized tracheostomy tube (with a long narrow segment) was not available, an endotracheal tube was modified and used successfully. Details of the modification, and a relevant literature review, are also discussed., Conclusion: In the paediatric age group, when an appropriately sized tracheostomy tube is not available, a modified endotracheal tube is a simple temporary alternative; this may be especially useful in an emergency.

Background: Tracheomalacia is a feared complication of goitre surgery, but considered rare in the Western World. This study aimed to estimate the risk of tracheomalacia in a contemporary series of patients with goitres causing significant tracheal compression., Methods: A retrospective review was conducted of thyroidectomies performed in a UK tertiary referral centre over a 30 month period. Anaesthetic, operative, radiological, and pathological data were obtained from medical notes and hospital software systems., Results: Of 334 patients who underwent thyroid surgery, preoperative CT scan was performed in 101 (30%). Tracheal compression was reported in 62 patients (19%) with minimum tracheal diameter ranging from 2 to 15 mm (mean 7.6 mm) due to multinodular goitre (n=50), malignancy (n=10), or thyroiditis (n=2). Critical compression <5 mm was observed in 18 patients (6%) and 35 patients had compression to 6-10 mm. Awake fibreoptic intubation was performed in eight patients (six of those with tracheas <5 mm) and asleep fibreoptic intubation was performed in one. Standard intubation was performed otherwise. All patients were recovered on a general surgical ward. None required tracheostomy or tracheal stenting. The incidence of tracheomalacia was 0 (95% confidence interval 0.0-4.8%). Mean length of stay was 2.4 days in those with tracheas <5 mm and 2.0 days in those >5 mm., Conclusions: We found no evidence of tracheomalacia in high-risk patients with significant tracheal compression. This supports prior work on retrosternal goitres suggesting that the risk of tracheomalacia is minimal in modern thyroid surgery. For risk management, however, we would still advocate that such patients be managed in units with multispeciality support.

We reviewed six cases demonstrating acquired tracheomalacia due to innominate artery compression of the trachea and investigated the benefit and effectiveness of a technique for correcting tracheomalacia. All the patients developed scoliosis and the innominate artery run over the trachea. Four cases had permanent neurologic impairment, whereas two patients developed acquired neurologic impairment. The surgical strategy for acquired tracheomalacia due to innominate artery compression of the trachea involved superior mediastinal exposure, external reinforcement with autologous cartilage graft, anterior sling of the innominate artery with a muscle sling, and tracheopexy. Our surgical procedure has been effective in maintaining the patency of the tracheal lumen in all cases but one. This patient suffered from straight back syndrome and developed recurrence of tracheomalacia owing to mucosal infolding secondary to the deformed spine in a supine position. The authors believe our surgical procedure is effective to relieve the symptoms of tracheomalacia, but it is important to select surgical interventions in accordance with the specific patient's condition., (Copyright © 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.)

Background: Pulmonary artery sling (PA sling) is a rare vascular anomaly in which the left pulmonary artery arises from the right pulmonary artery. It can cause compression of trachea. Due to its rarity, risk factors influencing postsurgical outcome are still unclear. The purpose of our study is to investigate past cases of PA sling to clarify risk factors., Methods: We investigated 7 patients who had undergone one-stage operation of PA sling from 2001 to 2007. Hospital stay, ICU stay and length of artificial ventilation are set as primary outcome. Patients' weight, range of tracheal stenosis, operation time, cardiopulmonary bypass time, presence of tracheal stenosis, bronchial anomaly, preoperative intubation, intracardiac anomaly and postoperative re-intubation were compared., Results: In-hospital mortality was none. Two cases in patients with tracheomalacia were re-intubated. Concomitant tracheoplasty was performed in six patients. Two patients with intracardiac anomaly underwent cardiac operation. No factor except tracheomalacia affected primary outcome., Conclusions: We need more cases to clarify factors affecting outcome of patients with PA sling. However, existence of tracheomalacia is found to be a risk factor of longer artificial ventilation.

Objective: To determine the effectiveness of increasing levels of Positive Expiratory Pressure (PEP) during coughing to enhance expiratory flow and improve efficiency of the cough., Material and Method: Forty children aged 8 to 18 years, with repaired tracheo-oespohageal fistula (TOF) and twenty-one age matched controls performed spirometry followed by cough spirometry with PEP of 0, 5, 10, 15 and 20 cmH2O using an adjustable PEP valve. Cough expiratory flow between 75 and 25% of vital capacity (CEF25-75) for each curve was calculated to represent the effectiveness of cough at mid-lung volume, the region of the flow volume curve most vulnerable in tracheomalacia., Results: In the TOF group, CEF25-75 increased by a mean (95% CI) of 18.8% (4.4, 33.2), 1.7% (-2.6, 26.0) and 0.5% (-13.7, 14.7) at PEP of 5, 10 and 15 cmH2O respectively, but decreased by 2.4% (-13.4, 8.5) at PEP of 20 cmH2O. In the control group the CEF25-75 decreased. The values were -3.1% (-16.7, 10.4), -6.3%(-18.1, 5.6), -22.2% (-33, -11.5) and -19% (-29.3, -8.7) at PEP of 5, 10, 15 and 20cmH2O respectively., Conclusion: The use of a simple adjustable PEP valve increases CEF25-75 during cough spirometry and may provide a useful adjunct to chest physiotherapy in children with tracheomalacia.

We successfully performed transection of the innominate artery in a patient with a neuromuscular disorder through minimally invasive access after confirming the anatomical relationships of the vessel using 3-dimensional multidetector-row computed tomographic angiography. A 16-year-old girl with spinal muscular atrophy type 1 had been on long-term mechanical ventilation with a tracheostomy. She had scoliosis and tracheomalacia. Bronchoscopy showed a flattened and narrow lower trachea and an anterior pulsatile compression by the innominate artery. She underwent transection of the innominate artery to prevent tracheoinnominate artery fistula formation. Based on preoperative 3-dimensional multidetector-row computed tomographic angiography images, the innominate artery was transected through a small transverse curvilinear skin incision just below the suprasternal notch and an oblique partial manubriotomy from the suprasternal notch to the first left intercostal space., (Copyright 2010 Elsevier Inc. All rights reserved.)

There is usually a small pouch within the trachea after ligation and division of a tracheoesophageal fistula. Most are asymptomatic, but some present with cough or by causing problems with endotracheal or tracheostomy tubes. Repeated open transthoracic surgery to ligate the fistula closer to the tracheal wall is problematic because the pouch is within the wall itself. We have found that bronchoscopic treatment with the potassium (K) Titanyl Phosphate laser to divide the party wall provides a quick and effective way to deal with the pouch, and we present a series of four cases to illustrate this technique., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)

Objective: To describe short- (first year of age) and long-term (after 1 year of age) outcome in patients with esophageal atresia and identify early predictive factors of morbidity in the first month of life., Study Design: Charts of children with esophageal atresia born January 1990 to May 2005 were reviewed. A complicated evolution was defined as the occurrence of at least 1 complication: severe gastroesophageal reflux, esophageal stricture requiring dilatations, recurrent fistula needing surgery, need for gavage feeding for >or=3 months, severe tracheomalacia, chronic respiratory disease, and death., Results: A total of 134 patients were included. Forty-nine percent of patients had a complicated evolution before 1 year of age, and 54% had a complicated evolution after 1 year. With bivariate analysis, predictive variables of a complicated evolution were demonstrated, including twin birth, preoperative tracheal intubation, birth weight <2500 g, long gap atresia, anastomotic leak, postoperative tracheal intubation >or=5 days, and inability to be fed orally by the end of the first month. After 1 year of age, the complicated evolution was only associated with long gap atresia and inability to be fed orally in the first month. A hospital stay >or=30 days was associated with a risk of a complicated evolution at 1 year and after 1 year of age (odds ratio, 9.3 [95% CI, 4.1-20.8] and 3.5 [95% CI, 1.6-7.6], respectively)., Conclusion: Early factors are predictive of morbidity in children with esophageal atresia.

Tracheobronchomalacia is a central airway disease characterised by weakness of the wall and dynamic decrease in the tracheal lumen and the large bronchi, particularly while exhaling. It is more common in middle age and the elderly with previous exposure to cigarettes. It causes chronic symptoms such as cough, dyspnea, increase in recurrent infections, and poor secretion management, but it can also progress to chronic respiratory failure and death. It is usually confused with other common diseases like chronic obstructive pulmonary disease (COPD) or asthma. Its causes can be congenital or acquired and its diagnosis involves the dynamic assessment of the airway with tomography and fibrobronchoscopy. It is classified as mild, moderate or severe depending on the degree of collapse of the airway when exhaling. Management consists of a primary phase, in which concomitant diseases must be controlled, such as COPD, asthma or gastro-oesophageal reflux. In diffuse moderate to severe symptomatic tracheobronchomalacia tracheobronchoplasty must be considered with strengthening of the posterior wall. Silicone and "Y" stents can be used to identify patients who could potentially benefit from surgical treatment as well as being used for the definitive symptomatic treatment with high surgical risk. More prospective studies need to be done in order to standardise certain common criteria for the management of this usually under-diagnosed disease., (Copyright (c) 2009 SEPAR. Published by Elsevier Espana. All rights reserved.)

Background: Tracheoesophageal fistula (TEF) is the most common congenital tracheal abnormality, frequently associated with esophageal atresia. Respiratory symptoms are associated with all types of TEF, even after surgical repair of the fistula. Gastroesophageal reflux (GER) with aspiration of gastric contents, structural instability of the airways (tracheomalacia), abnormal respiratory epithelium, abnormal esophageal motility, recurrent TEF, and esophageal stenosis contribute to postsurgical complications., Methods: We review 7 patients between 4 and 14 years of age with a history of TEF repair and persistent or worsening respiratory symptoms despite conventional airway clearance techniques and treatment of GER., Results: Bronchoscopic evaluation in all 7 patients revealed tracheomalacia and a diverticulum on the posterior wall of the trachea at the fistula repair site., Conclusion: We hypothesize that the diverticula impaired airway clearance and contributed to persistent respiratory symptoms. Possible mechanisms for the diverticulum contributing to poor airway clearance include facilitating the pooling of secretions and acting as a "barrier" to the lower airway clearance mechanism. The diagnosis of a diverticulum should be considered early in patients with persistent respiratory symptoms after management of GER and tracheomalacia. Early obliteration of tracheal diverticula might improve respiratory status in some patients.

Slide tracheoplasty can be applied successfully to all types of long segment congenital tracheal stenosis. In case of short segment tracheal stenosis, direct resection and anastomosis is often preferred. We report a case illustrating a new side benefit of the slide tracheoplasty in a patient presenting a relatively short hypoplastic tracheal segment coexisting with tracheomalacia after EA with TEF repair.

To date, major works on tracheomalacia have assumed a structural etiology and have proposed therapies as such. We describe a possible neurologic etiology for tracheomalacia in a child with clinically significant tracheomalacia that resolved in synchrony with each treatment of his recurring hydrocephalus. Endoscopy confirms remarkable expansion of tracheal diameter 7 days after decreasing intracranial pressure. The possibility of a neurologic etiology for tracheomalacia casts this condition in a new light with potential therapeutic implications.

Objective: To assess the prevalence and characteristics of airway involvement in relapsing polychondritis (RP)., Methods: Retrospective chart review and data analysis of RP patients seen in the Rheumatology Clinic and the Complex Airway Center at Beth Israel Deaconess Medical Center from January 2004 through February 2008., Results: RP was diagnosed in 145 patients. Thirty-one patients had airway involvement, a prevalence of 21%. Twenty-two patients were women (70%), and they were between 11 and 61 years of age (median age, 42 years) at the time of first symptoms. Airway symptoms were the first manifestation of disease in 17 patients (54%). Dyspnea was the most common symptom in 20 patients (64%), followed by cough, stridor, and hoarseness. Airway problems included the following: subglottic stenosis (n = 8; 26%); focal and diffuse malacia (n = 15; 48%); and focal stenosis in different areas of the bronchial tree in the rest of the patients. Twelve patients (40%) required and underwent intervention including balloon dilatation, stent placement, tracheotomy, or a combination of the above with good success. The majority of patients experienced improvement in airway symptoms after intervention. One patient died during the follow-up period from the progression of airway disease. The rest of the patients continue to undergo periodic evaluation and intervention., Conclusion: In this largest cohort described in the English language literature, we found symptomatic airway involvement in RP to be common and at times severe. The nature of airway problems is diverse, with tracheomalacia being the most common. Airway intervention is frequently required and in experienced hands results in symptom improvement.

The accidental discovery of a retrotracheal left pulmonary artery in a 4-month-old infant encouraged us to review the various embryologic theories concerning this very rare anomaly and perform an anatomic update in order to better define surgical treatment. Nathan underwent surgery for a bilateral inguinal hernia at the age of 4 months. The postoperative period was marked by malaise associated with dyspnoea, stridor, tachycardia and sweating. A X-ray of the thorax, oesophageal transit and angio scan presented an intertracheo-oesophageal left pulmonary artery and a reimplantation of the left pulmonary artery was successfully performed. A retrotracheal left pulmonary artery is a very rare malformation. From development of pulmonary vascularisation, three embryologic theories have been advanced to explain this anomaly. From an anatomic point of view, Landing et al. proposed in 1982 a classification system of retrotracheal left pulmonary artery. Today, current radiological techniques not only provide a precise diagnosis but also make it possible to define appropriate care for the different types of this malformation.

An asthmatic girl was first hospitalized at age 2(9/12) years because of dyspnoea, lung consolidations and/or atelectasis, and rattling. Between ages 2(9/12) and 6(2/12) years, she required three hospitalizations in ICU out of nine hospitalizations for the same symptoms. Differential diagnosis of this difficult to treat asthma disclosed severe tracheomalacia and persistent asthma. Treatments given according to the clinical, radiological and functional findings failed to decrease frequency and severity of acute respiratory episodes. Eventually, positive pressure ventilation delivered at airway opening (via a mouthpiece) associated to active respiratory physiotherapy succeeded in removing atelectasis and quickly cured the five following acute episodes without any further hospitalization. This case report is about diagnosis procedure, intricate asthma and tracheomalacia, and open mind to unusual therapeutics that may disclose potential help.

Vocal cord paralysis and goiter are 2 common problems encountered in otolaryngology practice. Their coexistence, however, should arouse suspicion of the presence of malignant thyroid disease. Primary tracheal cancer is uncommon, and its incidence is very low compared with laryngeal cancer. Primary tracheal tumors can cause recurrent nerve palsy. We report here a rare case of vocal cord paralysis caused by a clinically occult tracheal squamous cell carcinoma in an 80-year-old patient with coincidental huge multinodular goiter.

Objective: To determine the predictive value of endoscopic examination and radiological imaging in the evaluation of substomal tracheomalacia in advanced laryngotracheal stenosis., Methods: Forty nine patients with advanced laryngotracheal stenosis were preoperatively evaluated with radiological (magnetic resonance imaging [MRI]) and endoscopy to determine the grade of laryngotracheal stenosis and presence of substomal tracheomalacia. The intraoperative findings were compared with the preoperative findings, and the percentage of operative plan changes was calculated., Results: In a preoperative evaluation, 37 patients were found to have no substomal tracheomalacia; but during the surgical procedure, we detected substomal tracheomalacia in 12 (32.4%) of these patients and changed our preoperative plan during the procedure (p < 0.05)., Conclusion: Laryngotracheal reconstruction plans are dependent on preoperative evaluations which can change significantly during the surgical procedure. Therefore, experienced physicians who can alter the preoperative plan immediately during the procedure and successfully perform an alternative procedure are necessary.