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Objectives The Airway Alert banner at our institution alerts physicians to patients with the potential for a difficult intubation. Difficult airway guidelines can reduce intubation complications in the operating room, but little research has been done in the emergency department (ED). We hypothesize that patients meeting criteria for the banner will have a more difficult intubation and increased complications. Methods Patients greater than 18 years old who presented to the ED for any complaint and required intubation were reviewed from January 2015 to January 2020 and divided into those meeting criteria for a difficult airway (“criteria cohort”) and those who did not (“non‐criteria cohort”). Past medical history and details of the intubation were collected. Results The mean number of attempts for intubation was 1.60 in the criteria cohort and 1.36 in the non‐criteria cohort (P > .05). The mean grade of view was 1.73 and 1.39, respectively (P

Background and objectives Caval leiomyosarcomas (cLMS) are rare soft tissue sarcomas historically associated with high recurrence rates and poor prognosis. While radical resection remains the mainstay of therapy for cLMS, new systemic therapies have presented opportunities for multimodality treatment. We examined the clinical outcomes of patients with cLMS treated with modern, multimodality approaches, and compared their outcomes to those of patients with noncaval retroperitoneal LMS (ncLMS). Methods A retrospective, single-institution review identified all patients diagnosed with primary retroperitoneal LMS from 2012 to 2018. Radiographic and pathologic review distinguished patients with cLMS and ncLMS. Standard clinicopathologic variables and response to chemotherapy (when applicable) were analyzed. Primary endpoints were overall (OS) and progression-free survival (PFS). Results Eleven patients with cLMS were identified. Median tumor size was 7.5 cm (IQR, 5.0-14.3 cm); all patients had Stage II/III disease. Seven patients received neoadjuvant chemotherapy. Nine cLMS patients underwent R0/R1 resection; two did not complete resection. Six patients received adjuvant systemic therapy. Twenty patients with ncLMS were treated during the same period. No statistical intergroup differences were noted in tumor size, pathologic grade, stage, or resection margin status. Patients with ncLMS were less likely to receive neoadjuvant (10% vs. 64%) and adjuvant chemotherapy (30% vs. 55%). Two-year OS (81% vs. 78%; p = NS) and PFS (55% vs. 46%; p = NS) were comparable between cLMS and ncLMS patients. Conclusions Multimodality treatment with systemic therapy and aggressive surgical resection may achieve equivalent survival outcomes for patients with cLMS versus similar ncLMS. We recommend that all patients with cLMS be evaluated for multidisciplinary treatment. Genomic and proteomic expression profiling may identify novel or targetable mutations.

Objectives: Expiratory disproportion index (EDI) is the ratio of forced expiratory volume in 1 second (FEV1) divided by peak expiratory flow rate (PEFR) multiplied by 100. Prominent EDI (>50) values can differentiate subglottic stenosis (SGS) from paradoxical vocal fold movement disorder (PVFMD), but this has not been verified when considering body habitus. We hypothesize that the predictive value of elevated EDI in differentiating SGS from PVFMD will be lower in obese patients than non-obese patients. Methods: Patients ≥ 18 years old with recorded PFT values, BMI, and airway imaging were reviewed retrospectively from 01/2011 to 10/2018. EDI was recorded for 4 cohorts: non-obese/SGS, non-obese/ PVFMD, obese/SGS, and obese/ PVFMD, to determine the mean EDI and the sensitivity/specificity of an elevated EDI. Results: Mean EDI values were 69.32 and 48.38 in the non-obese SGS and PVFMD groups, respectively ( P 50, EDI had a sensitivity of 90.0% and specificity of 51.6% in differentiating between SGS and PVFMD cases in non-obese patients and 51.6% and 63.6% in obese patients. Conclusion: Prior literature has established that EDI can distinguish SGS from PVFMD in the general population. Our results show that the mean EDI values were significantly different in both cohorts, but an elevated EDI was not as sensitive at identifying SGS cases in obese patients. This suggests that the EDI should be used with caution in obese patients and should not be relied upon to rule out SGS. Level of Evidence: 3

OBJECTIVES/HYPOTHESIS To identify the incidence and nature of positive findings on imaging studies ordered for evaluation of unilateral vocal fold paralysis (UVFP) of unknown etiology, to analyze these findings based on laterality, and to examine the use of the expanded-field computed tomography (CT) neck protocol in this evaluation. STUDY DESIGN Retrospective review. METHODS A total of 145 patients from 2000 to 2018 with UVFP of unknown etiology were studied. Data on imaging studies ordered, laterality of paralysis, and significant positive results were studied. An expanded-field CT neck protocol that included the entire course of the vagus and recurrent laryngeal nerves was instituted during the study period. RESULTS A total of 20.7% of patients had an etiology for paralysis identified on imaging. Malignancies comprised the majority of findings overall (19/30), whether in the chest (12/18) or the neck (7/12). Etiology was more often found in the chest for left-sided paralysis (15/21) and in the neck for right-sided paralysis (6/9). In 26 patients who underwent both expanded-field CT neck and CT chest, no findings related to the UVFP were seen on CT chest that were not captured by expanded-field CT neck. CONCLUSIONS This is one of the largest retrospective studies examining the incidence of positive findings on imaging studies for evaluation of UVFP of unknown etiology. Imaging in one of five patients with UVFP of unknown etiology will reveal a causative lesion, most often malignant. Left-sided paralysis tends to localize to the chest, and right-sided paralysis to the neck. Expanded-field CT neck may allow practitioners to forego dedicated CT chest in evaluation of UVFP. LEVEL OF EVIDENCE 4 Laryngoscope, 131:1840-1844, 2021.

The expiratory disproportion index (EDI) is the ratio of forced expiratory volume in 1 second divided by peak expiratory flow rate multiplied by 100. An elevated EDI (50) can help differentiate upper airway stenosis from other dyspnea etiologies, but this has not been verified when considering body habitus. We hypothesize that the predictive value of elevated EDI in diagnosing airway stenosis will be lower in obese patients as compared to nonobese patients.Retrospective cohort study.Patients18 years old with recorded pulmonary function test values, body mass index (BMI), and airway imaging were reviewed retrospectively from January 2011 to October 2018. EDI was recorded for four cohorts: nonobese and nonstenotic, obese and nonstenotic, nonobese and stenotic, and obese and stenotic, to determine the mean EDI and the sensitivity and specificity of an elevated EDI.Mean EDI values were 66.53 ± 17.66 and 49.55 ± 2.04 in the nonobese stenotic and nonstenotic groups, respectively (P .01). They were 58.00 ± 10.79 and 45.02 ± 1.42 in the obese stenotic and nonstenotic groups, respectively (P .01). At a threshold of50, EDI had a sensitivity of 83.3% and specificity of 56.2% in differentiating between stenotic and nonstenotic cases in the nonobese cohort and 50.0% and 71.9% in the obese cohort.As previously established, mean EDI values were significantly different in stenotic and nonstenotic patients in both BMI cohorts. However, at the established threshold of50, EDI was not as sensitive at identifying stenotic cases in obese patients as in nonobese patients. This suggests that the EDI remains useful in obese patients when elevated but should not be relied upon to rule out stenosis.4 Laryngoscope, 131:606-609, 2021.

Stroke significantly affects white matter in the brain by impairing axon function, which results in clinical deficits. Axonal mitochondria are highly dynamic and are transported via microtubules in the anterograde or retrograde direction, depending upon axonal energy demands. Recently, we reported that mitochondrial division inhibitor 1 (Mdivi-1) promotes axon function recovery by preventing mitochondrial fission only when applied during ischemia. Application of Mdivi-1 after injury failed to protect axon function. Interestingly, L-NIO, which is a NOS3 inhibitor, confers post-ischemic protection to axon function by attenuating mitochondrial fission and preserving mitochondrial motility via conserving levels of the microtubular adaptor protein Miro-2. We propose that preventing mitochondrial fission protects axon function during injury, but that restoration of mitochondrial motility is more important to promote axon function recovery after injury. Thus, Miro-2 may be a therapeutic molecular target for recovery following a stroke.