Well-Differentiated Laryngeal/Hypopharyngeal Liposarcoma in the MDM2 Era Report of Three Cases and Literature Review

Laryngeal/hypopharyngeal liposarcomas are very rare, fewer than 40 cases have been reported. These tumors are polypoid, with a male predisposition, and usually cause hoarseness and difficulty breathing. Their clinical course is characterized by multiple local recurrences. No distant metastasis has been reported, and dedifferentiation is extremely rare. In sum, the prognosis of these tumors is excellent; the 5-year survival rate is essentially 100 %. Pathologic diagnosis of these well-differentiated liposarcomas can be challenging. Many of them were initially diagnosed as benign lipoma, fibrovascular polyp, or "inflammatory polyp". The correct diagnosis is usually made after multiple recurrences. On the other hand, the literature bears out that these incorrect diagnoses do not impact disease-specific survival. Here, we report three patients with laryngeal/hypopharyngeal well-differentiated liposarcomas; this is the first documentation of MDM2 amplification in liposarcomas at this site.

Airway disorders of the fetus and neonate: An overview

Differences between neonatal, pediatric and adult airway anatomy, structure and function are important to understand. Size, surface area, proportion, resistance and compliance are all very different between age groups and infants are certainly not small adults. Knowledge of these airway differences is essential in rapid correction of an emergency situation. Unanticipated airway emergencies are the most serious of all and may be classified into profiles such as the unanticipated emergency in the non-intubated patient, the unanticipated emergency in the intubated patient, and patients with tracheostomy. A neonatal airway emergency can be effectively managed by a strategy for anticipation, identification, preparation, mobilization, and execution. Furthermore, neonatal airways may be classified by severity in being considered either difficult or critical. These neonatal specific clinical challenges have recently substantiated the need for a distinct neonatal airway algorithm. This strategy is strengthened by regular education of the team and frequent simulation of airway emergencies. Following a predetermined pathway for activating an airway emergency alert and having all necessary equipment readily available are essential components of a well-defined strategy. Finally, knowing the pediatric otolaryngologist's perspective of what defines these airway disorders and current management is key to working collaboratively.

Oroesophageal Fish Bone Foreign Body

Fish bone foreign body (FFB) is the most frequent food-associated foreign body (FB) in adults, especially in Asia, versus meat in Western countries. The esophageal sphincter is the most common lodging site. Esophageal FB disease tends to occur more frequently in men than in women. The first diagnostic method is laryngoscopic examination. Because simple radiography of the neck has low sensitivity, if perforation or severe complications requiring surgery are expected, computed tomography should be used. The risk factors associated with poor prognosis are long time lapse after FB involvement, bone type, and longer FB (>3 cm). Bleeding and perforation are more common in FFB disease than in other FB diseases. Esophageal FB disease requires urgent treatment within 24 hours. However, FFB disease needs emergent treatment, preferably within 2 hours, and definitely within 6 hours. Esophageal FFB disease usually occurs at the physiological stricture of the esophagus. The aortic arch eminence is the second physiological stricture. If the FB penetrates the esophageal wall, a life-threatening aortoesophageal fistula can develop. Therefore, it is better to consult a thoracic surgeon prior to endoscopic removal.

Alterations in oropharyngeal sensory evoked potentials (PSEP) with Parkinson's disease

Movement of a food bolus from the oral cavity into the oropharynx activates pharyngeal sensory mechanoreceptors. Using electroencephalography, somatosensory cortical-evoked potentials resulting from oropharyngeal mechanical stimulation (PSEP) have been studied in young healthy individuals. However, limited information is known about changes in processing of oropharyngeal afferent signals with Parkinson's disease (PD). To determine if sensory changes occurred with a mechanical stimulus (air-puff) to the oropharynx, two stimuli (S1-first; S2-s) were delivered 500ms apart. Seven healthy older adults (HOA; 3 male and 4 female; 72.2±6.9 years of age), and thirteen persons diagnosed with idiopathic Parkinson's disease (PD; 11 male and 2 female; 67.2±8.9 years of age) participated. Results demonstrated PSEP P1, N1, and P2 component peaks were identified in all participants, and the N2 peak was present in 17/20 participants. Additionally, the PD participants had a decreased N2 latency and gated the P1, P2, and N2 responses (S2/S1 under 0.6). Compared to the HOAs, the PD participants had greater evidence of gating the P1 and N2 component peaks. These results suggest that persons with PD experience changes in sensory processing of mechanical stimulation of the pharynx to a greater degree than age-matched controls. In conclusion, the altered processing of sensory feedback from the pharynx may contribute to disordered swallow in patients with PD.

The Reliability of Oral and Pharyngeal Dimensions Captured with Acoustic Pharyngometry

Acoustic Pharyngometry (APh) is a method for quantifying oropharyngeal tract configuration using sound wave reflection and is commonly used in diagnostics and research of sleep apnea. The standard preset output of APh (minimal cross-sectional area) has been established as reliable. However, by conducting post-processing measures on specific breathing tasks, APh data can also reveal oral length, oral volume, pharyngeal length, and pharyngeal volume. Given that these measures may have utility in dysphagia research, the reliability of these measures is unknown and is the focus of the current study. Ten young healthy female volunteers completed two sessions of APh data collection to obtain measures of oral length, oral volume, pharyngeal length, and pharyngeal volume 1 week apart. Two-way mixed intraclass correlation coefficients were calculated to establish intra-rater reliability, inter-rater reliability, and test-retest reliability. Results revealed excellent levels of agreement within and across raters for all oropharyngeal tract parameters. Levels of test-retest agreement for oral length and oral volume indicated these parameters are appropriate for monitoring change within an individual. All parameters were deemed to have acceptable test-retest values as outcome measures in group-level analysis.

Pathophysiology of Radiation-Induced Dysphagia in Head and Neck Cancer

Oncologic treatments, such as curative radiotherapy and chemoradiation, for head and neck cancer can cause long-term swallowing impairments (dysphagia) that negatively impact quality of life. Radiation-induced dysphagia comprised a broad spectrum of structural, mechanical, and neurologic deficits. An understanding of the biomolecular effects of radiation on the time course of wound healing and underlying morphological tissue responses that precede radiation damage will improve options available for dysphagia treatment. The goal of this review is to discuss the pathophysiology of radiation-induced injury and elucidate areas that need further exploration.

Dynamic comparison of pharyngeal stability during sleep in patients with obstructive sleep apnea syndrome treated with maxillomandibular advancement

PURPOSE

To compare the dynamic differences occurring in the pharynx during sleep after maxillomandibular advancement (MMA) surgery for the treatment of patients with obstructive sleep apnea syndrome.

METHODS

This was a prospective, cross-sectional study conducted on 20 patients (15 men and 5 women) with a polysomnography diagnosis of obstructive sleep apnea (OSA) submitted to surgical treatment with MMA. All patients were submitted to magnetic resonance (MR) during propofol-induced sleep before and 6 months after surgery. Thirty linear measurements (30 sections) were obtained over time in the retrolingual (RL) region to compare their variability before and after MMA.

RESULTS

The mean linear anteroposterior increase of the pharynx during induced sleep after MMA was 66 % in the RL region (P < 0.01). The coefficient of variation of the linear measurements was 117.5 % before surgery, being reduced to 51 % after surgery.

CONCLUSIONS

MMA promoted an important increase of the pharynx during induced sleep and a more significant change in the variability of its lumen. With a lower variation in the diameter of the organ during the respiratory movements, there is greater airway stability and a consequent maintenance of the pharyngeal lumen that reduces or even prevents pharyngeal collapse.

Drug-induced sleep endoscopy in the obstructive sleep apnea: comparison between NOHL and VOTE classifications

Obstructive sleep apnea (OSA) is characterized by recurrent episodes of partial or complete collapse of the pharynx that result in a decrease in oxyhemoglobin saturation. Nasofibrolaryngoscopy under induced sleep is a promising alternative for identifying sites of upper airway obstruction in patients with OSA. This study aimed to compare the obstruction sites screened by drug-induced sleep endoscopy (DISE) using the Nose oropharynx hypopharynx and larynx (NOHL) and Velum oropharynx tongue base epiglottis (VOTE) classifications. We also determined the relationship between OSA severity and the number of obstruction sites and compared the minimum SaO₂ levels between DISE and polysomnography (PSG). This was a prospective study in 45 patients with moderate and severe OSA using DISE with target-controlled infusion of propofol bispectral index (BIS) monitoring. The retropalatal region was the most frequent obstruction site, followed by the retrolingual region. Forty-two percent of patients had obstruction in the epiglottis. Concentrically shaped obstructions were more prevalent in both ratings. The relationship between OSA severity and number of obstruction sites was significant for the VOTE classification. Similar minimum SaO₂ values were observed in DISE and PSG. The VOTE classification was more comprehensive in the analysis of the epiglottis and pharynx by DISE and the relationship between OSA severity and number of affected sites was also established by VOTE. The use of BIS associated with DISE is a reliable tool for the assessment of OSA patients.

Design, development and validation of a new laryngo-pharyngeal endoscopic esthesiometer and range-finder based on the assessment of air-pulse variability determinants

Background

Laryngo-pharyngeal mechano-sensitivity (LPMS) is involved in dysphagia, sleep apnea, stroke, irritable larynx syndrome and cough hypersensitivity syndrome among other disorders. These conditions are associated with a wide range of airway reflex abnormalities. However, the current device for exploring LPMS is limited because it assesses only the laryngeal adductor reflex during fiber-optic endoscopic evaluations of swallowing and requires a high degree of expertise to obtain reliable results, introducing intrinsic expert variability and subjectivity.

Methods

We designed, developed and validated a new air-pulse laryngo-pharyngeal endoscopic esthesiometer with a built-in laser range-finder (LPEER) based on the evaluation and control of air-pulse variability determinants and on intrinsic observer variability and subjectivity determinants of the distance, angle and site of stimulus impact. The LPEER was designed to be capable of delivering precise and accurate stimuli with a wide range of intensities that can explore most laryngo-pharyngeal reflexes.

Results

We initially explored the potential factors affecting the reliability of LPMS tests and included these factors in a multiple linear regression model. The following factors significantly affected the precision and accuracy of the test (P < 0.001): the tube conducting the air-pulses, the supply pressure of the system, the duration of the air-pulses, and the distance and angle between the end of the tube conducting the air-pulses and the site of impact. To control all of these factors, an LPEER consisting of an air-pulse generator and an endoscopic laser range-finder was designed and manufactured. We assessed the precision and accuracy of the LPEER’s stimulus and range-finder according to the coefficient of variation (CV) and by looking at the differences between the measured properties and the desired values, and we performed a pilot validation on ten human subjects. The air-pulses and range-finder exhibited good precision and accuracy (CV < 0.06), with differences between the desired and measured properties at <3 % and a range-finder measurement error of <1 mm. The tests in patients demonstrated obtainable and reproducible thresholds for the laryngeal adductor, cough and gag reflexes.

Conclusions

The new LPEER was capable of delivering precise and accurate stimuli for exploring laryngo-pharyngeal reflexes.

Origins of and implementation concepts for upper airway stimulation therapy for obstructive sleep apnea

Upper airway stimulation, specifically hypoglossal (CN XII) nerve stimulation, is a new, alternative therapy for patients with obstructive sleep apnea hypopnea syndrome who cannot tolerate positive airway pressure, the first-line therapy for symptomatic patients. Stimulation therapy addresses the cause of inadequate upper airway muscle activation for nasopharyngeal and oropharyngeal airway collapse during sleep. The purpose of this report is to outline the development of this first-in-class therapy and its clinical implementation. Another practical theme is assessment of the features for considering a surgically implanted device and the insight as to how both clinical and endoscopic criteria increase the likelihood of safe and durable outcomes for an implant and how to more generally plan for management of CPAP-intolerant patients. A third theme is the team building required among sleep medicine and surgical specialties in the provision of individualized neurostimulation therapy.

Zenker's diverticulum: Rotterdam experience

Different surgical techniques exist for the treatment of Zenker’s diverticulum (ZD), of which minimally invasive techniques have become the standard. We reviewed our experience with management and treatment of ZD and sought to determine what type of treatment is most effective and efficient. We selected patients who underwent treatment for ZD between January 2004 and January 2014 at our tertiary referral center. All procedures were performed by ENT surgeons. The medical records were reviewed for pre- and intraoperative characteristics and follow-up. Of our 94 patients (58 male, 36 female), 75 underwent endoscopic cricopharyngeal myotomy (42 stapler, 33 laser) and 6 received treatment via transcervical approach. 13 interventions were aborted. Mean operating time was 49.0 min for stapler, 68.3 for laser and 124.0 for the transcervical approach. Its respective median post-operative admission durations were 2.0, 3.0 and 3.0 days. After the first treatment, of the 75 endoscopic procedures, 45 patients (23 stapler, 22 laser) had complete symptom resolution. In the transcervical group 4 (67 %) patients were symptom free and one patient died of complications. In the endoscopically treated patients, ten complications occurred, of which 8 G1 and 2 G2 (Clavien Dindo classification). In the transcervical group 2 complications occurred, 1 G3b and 1 G5. Both endoscopic techniques provide efficient management of Zenker’s diverticulum with the stapler-assisted modality providing a shorter surgery duration and hospital admission. Although there is no significant difference in terms of complications or recurrence rates for both endoscopic techniques, it seems that stapler patients are at higher risk of having a re-intervention and of having more severe complications.

High-Resolution Manometry Evaluation of the Pharynx and Upper Esophageal Sphincter Motility in Patients with Achalasia

The motility of the pharynx and upper esophageal sphincter (UES) is still poorly understood. It is also unclear if the motility of this area may be compromised in patients with achalasia. This study aims to evaluate the motility of the pharynx, UES, and proximal esophagus in patients with esophageal achalasia. Sixty patients with achalasia underwent high-resolution manometry (HRM) (52 % females, mean age 54 years). Esophageal dilatation was classified according to the radiologic diameter in Type I (<4 cm): 6 %; Type II (4-7 cm): 36 %; Type III (7-10 cm): 34 %; and Type IV (>10 cm): 24 %. HRM classified 43 % of the patients as Chicago Type I and 57 % as Type II. Manometric parameters were compared to normal values obtained from a previous study in volunteers. The motility of the velopharynx showed short, premature, and hypertonic contraction. The epiglottis also showed hypertonic contraction. The UES had increased residual pressure. Chicago classification Type II patients had higher UES residual pressure (p = 0.03). The degree of esophageal dilatation did not correlate with manometric parameters. Achalasia may affect the motility of the pharyngo-upper esophageal area. The changes observed may represent functional alterations to prevent aspiration, especially in patients with Chicago classification Type II achalasia.

Primary Synovial Sarcoma of the Pharynx: A Series of Five Cases and Literature Review

Synovial sarcoma comprises approximately 10 % of all soft tissue sarcomas. Although synovial sarcoma has been reported in practically every organ, the extremities are the commonest site of occurrence followed by the head and neck. Primary synovial sarcoma of the pharynx is rare and only case reports have been published. We report a series of five cases of primary synovial sarcoma involving the pharynx.

fMRI and MRS measures of neuroplasticity in the pharyngeal motor cortex

INTRODUCTION

Paired associative stimulation (PAS), is a novel non-invasive technique where two neural substrates are employed in a temporally coordinated manner in order to modulate cortico-motor excitability within the motor cortex (M1). In swallowing, combined pharyngeal electrical and transcranial-magnetic-stimulation induced beneficial neurophysiological and behavioural effects in healthy subjects and dysphagic stroke patients. Here, we aimed to investigate the whole-brain changes in neural activation during swallowing using functional magnetic resonance imaging (fMRI) following PAS application and in parallel assess associated GABA changes with magnetic resonance spectroscopy (MRS).

METHODS

Healthy adults (n=11, 38±9years old) were randomised to receive real and sham PAS to the 'stronger' motor cortex pharyngeal representation, on 2 separate visits. Following PAS, event-related fMRI was performed to assess changes in brain activation in response to water and saliva swallowing and during rest. Data were analysed (SPM8) at P<.001. MRS data were acquired using MEGA-PRESS before and after the fMRI acquisitions on both visits and GABA concentrations were measured (AMARES, jMRUI).

RESULTS

Following real PAS, BOLD signal changes (group analyses) increased at the site of stimulation during water and saliva swallowing, compared to sham PAS. It is also evident that PAS induced significant increases in BOLD signal to contralateral (to stimulation) hemispheric areas that are of importance to the swallowing neural network. Following real PAS, GABA:creatine ratio showed a trend to increase contralateral to PAS.

CONCLUSION

Targeted PAS applied to the human pharyngeal motor cortex induces local and remote changes in both primary and non-primary areas for water and saliva tasks. There is a possibility that changes of the inhibitory neurotransmitter, GABA, may play a role in the changes in BOLD signal. These findings provide evidence for the mechanisms underlying the beneficial effects of PAS on the brain swallowing network.

Base of Tongue Tuberculosis: A Case Report

INTRODUCTION

Tuberculosis is an infectious disease that has displayed increasing incidence in the last decades. It is estimated that up to 20% of tuberculosis cases affect extra-pulmonary organs. In the ENT area, soft palate and tongue are the least probable locations.

CASE REPORT

A 62-year-old female with a history of rheumatoid arthritis and treatment with corticosteroids and Adalimumab, developed a foreign body sensation in the pharynx accompanied by a sore throat and halitosis. The laryngoscopy with a 70 degree rigid telescope showed an ulcerated hypertrophic lesion in the right vallecula of about 2-3 cm in the base of the tongue. Acid-alcohol resistant bacilli were found positive for M. tuberculosis, through the Ziehl Neelsen method and Löwenstein culture the patient was treated with tuberculostatic medication.

CONCLUSION

TB is a possible diagnosis when in the presence of an ulcerated lesion at the base of the tongue, accompanied by sore throat, dysphagia, or foreign body sensation.

Toothbrush: A Report of an Unusual Foreign Body

INTRODUCTION

Ingestion of a foreign body is a common problem among all age groups. Most of the foreign bodies in the pharynx are usually lodged at the level of cricopharynx. The diagnosis is based on history, clinical, and radiological examination. Most foreign-body ingestions are accidental, but there may be contributory factors such as mental disorder, alcoholism, and prison incarceration. Toothbrush ingestion is uncommon and requires prompt medical attention.

CASE REPORT

In this article, a rare case of a toothbrush foreign body is presented. The ingestion was caused by a seizure and the toothbrush was removed through surgical management.

CONCLUSION

An ingested toothbrush will not pass spontaneously. The best management is early endoscopy performed by a skilled surgeon. If this is unsuccessful, surgical management can be performed.

Signalment, clinical presentation, concurrent diseases, and diagnostic findings in 28 dogs with dynamic pharyngeal collapse (2008-2013)

Background

Most information about pharyngeal collapse in dogs is anecdotal and extrapolated from human medicine. A single case report describing dynamic pharyngeal collapse in a cat has been published, but there is no literature describing this disease process in dogs.

Objective

To describe the signalment, clinical presentation, concurrent disease processes, and imaging findings of a population of client‐owned dogs with pharyngeal collapse.

Animals

Twenty‐eight client‐owned dogs with pharyngeal collapse.

Methods

Radiology reports of dogs for which fluoroscopy of the respiratory system was performed were reviewed retrospectively. Patients with a fluoroscopic diagnosis of pharyngeal collapse were included in the study population. Data regarding clinical signs, diagnostic, and pathologic findings were evaluated.

Results

Twenty‐eight dogs met the inclusion criteria. The median age of affected patients was 6.6 years, whereas median body condition score was 7/9. The most common clinical signs were coughing (n = 20) and stertor (n = 5). In 27 of 28 cases, a concurrent or previously diagnosed cardiopulmonary disorder was detected. The most common concurrent disease processes were mainstem bronchi collapse (n = 18), tracheal collapse (n = 17), and brachycephalic airway syndrome (n = 8). Fluoroscopy identified complete pharyngeal collapse in 20 of 28 dogs.

Conclusions

Pharyngeal collapse is a complex disease process that likely is secondary to long‐term negative pressure gradients and anatomic and functional abnormalities. Based on the findings of this study, pharyngeal fluoroscopy may be useful diagnostic test in patients with suspected tracheal and mainstem bronchial collapse to identify concurrent pharyngeal collapse.

Application and Interpretation of High-resolution Manometry for Pharyngeal Dysphagia

The pharyngeal phase of swallowing is a complex event consisted with subsequent muscular contractions and pressure generation to move a bolus from the mouth to the esophagus. Recently, high-resolution impedance manometry (HRIM) was developed and used for the evaluation of pharyngeal dysphagia. Although HRIM provides precise pharyngeal pressure information, it has yet to be used as part of routine clinical practice for the assessment of dysphagia. The main reasons are thought to be that the test method and result interpretation are not easily applicable and standardized. The anatomical landmarks for HRIM parameters are velopharynx, tongue base, epiglottis, low pharynx, and upper esophageal sphincter. With HRIM, the pressure and timing data could be obtained at a precise anatomical structure. In the present review, we will review how to apply HRIM for the evaluation of pharyngeal dysphagia, including the interpretation of its parameters.

The transnasal VideoPanendoscopy (ViP): diagnostics of the upper aerodigestive tract using an anatomically correct model from the model to the patient

Endoscopy of the upper aerodigestive tract (UADT) develops rapidly. New endoscopes in combination with special imaging techniques allow complete examinations of the UADT in an ambulatory setting. Therefore, it is necessary to educate and train young physicians in a standardized protocol. A special anatomical training model has been designed to allow a stepwise endoscopy training course. It can be used by specialists who would like to take advantage of transnasal VideoPanendoscopy for examination of suitable candidate patients. This method offers advantages for ENT doctors, gastroenterologists as well as endoscopic surgeons.

Gastroesophageal reflux disease and non-esophageal cancer

The association of gastroesophageal reflux disease (GERD) and esophageal cancer is well known. The carcinogenic properties of the gastroduodenal contents may also lead to cancer in target organs for GERD especially considering that they do not have intrinsic protective mechanisms as found in the esophagus. This review focuses on the putative relation between GERD and non-esophageal cancer. Most of the papers reviewed are far from ideal to prove the relationship of extra-esophageal cancer and GERD since a small number of patients is presented, most do not control cases based on tobacco usage and obesity, and the diagnosis of GERD is variable, not always from an objective measurement such as pH monitoring but relying on symptoms in most reports. Nevertheless, head and neck and lung cancer have a growing incidence parallel to GERD and a shift towards non-smoking, female gender and adenocarcinoma (compared to squamous cell carcinoma) is arising, similar to the example of esophageal cancer with the exception of the female gender.

Effect of bolus volume and consistency on swallowing events duration in healthy subjects

Background/Aims

Swallowing is a complex function with the control of the swallowing center being located in the brain stem. Our aim in this investigation was to evaluate, in healthy volunteers, the oral and pharyngeal transit of 2 bolus volumes and 2 consistencies, and the influence of these boluses on the proportion of pharyngeal clearance duration/hyoid movement duration.

Methods

Videofluoroscopic evaluation of swallows was performed in 30 healthy volunteers, aged 29–77 years (mean 58 years). The subjects swallowed in duplicate of 5 mL and 10 mL of thick liquid barium and honey thick barium. We measured the duration of oral transit, pharyngeal transit, pharyngeal clearance, upper esophageal sphincter opening, hyoid movement, oropharyngeal transit, and the relation pharyngeal clearance duration/hyoid movement duration.

Results

A 10 mL bolus volume caused a longer UES opening duration than a 5 mL bolus volume, for both consistencies. The pharyngeal transit was longer for honey thick bolus consistency than for thick liquid, with both the volumes of 5 mL and 10 mL. For pharyngeal clearance, the difference was significant only with the 10 mL bolus volume. There was no difference associated with bolus volume or consistency in the relation between pharyngeal clearance duration and hyoid movement duration.

Conclusions

Increase in the swallowed bolus volume causes a longer UES opening duration and an increase in bolus consistency from thick liquid to honey thick causes a longer pharyngeal transit duration. The proportion between pharyngeal clearance and hyoid movement does not change with bolus volume or bolus consistency.

Simultaneous Optogenetic Stimulation of Individual Pharyngeal Neurons and Monitoring of Feeding Behavior in Intact C. elegans

Optogenetic approaches have proven powerful for examining the role of neural circuits in generating behaviors, especially in systems where electrophysiological manipulation is not possible. Here we describe a method for optogenetically manipulating single pharyngeal neurons in intact C. elegans while monitoring pharyngeal behavior. This approach provides bidirectional and dynamic control of pharyngeal neural activity simultaneously with a behavioral readout and has allowed us to test hypotheses about the roles of individual pharyngeal neurons in regulating feeding behavior.

Cephalometric appraisal of tongue and related soft tissues in normal and open bite subjects at rest

AIM

To compare the tongue position of normal and open bite subjects at rest and to study if there is any difference in the hyoid bone and posterior pharyngeal wall positions in normal and open bite subjects.

MATERIALS AND METHODS

Sample size consisted of 48 individuals with 24 subjects having normal occlusion and 24 subjects having open bite malocclusion within the age range of 16 to 25 y. Standardized Lateral cephalograms were taken for all the subjects. The subjects were asked to protrude their tongue as much as possible. The dorsum of the tongue was then coated with a palatable suspension of Barium Sulphate (MICROBAR). The subjects were asked to swallow on command, after 10 sec of the swallow, lateral cephalograms were taken.

STATISTICAL ANALYSIS

t-test

RESULTS

The antero-posterior relationship of maxilla and mandible to the cranial base is normal in both the groups. The open bite subjects had a larger over jet and as compared to the normal subjects, and had steeper mandibular planes.It was also seen that as the total tongue occupancy area increased so did the partial tongue occupancy area.

CONCLUSION

A significant positive correlation was found between the horizontal position of the tongue tip and the lower incisor position in the normal group, also for the ratio of total tongue area to total oral area & the ratio of upper tongue area to the anterior oral area in the normal and openbite groups. There was no difference in the position of the tongue, hyoid bone and posterior wall in the normal and openbite groups. The mandibular plane angle and palatal plane - mandibular plane angles were found to be larger in the openbite subjects as compared to normal subjects. Supra-eruption of the maxillary molars was seen in the openbite group leading to a downward and backward rotation of the mandible. The maxillary and mandibular incisors were more proclinated in the normal as well as openbite groups.

[Correlation between oro and hypopharynx shape and position with endotracheal intubation difficulty]

BACKGROUND AND OBJECTIVE

Prediction of intubation difficulty can save patients from major preoperative morbidity or mortality. The purpose of this paper is to assess the correlation between oro-hypo pharynx position, neck size, and length with endotracheal intubation difficulty. The study also explored the diagnostic value of Friedman Staging System in prediction cases with difficult intubation.

METHOD

The consecutive 500 ASA (I, II) adult patients undergoing elective surgery were evaluated for oro and hypopharynx shape and position by modified Mallampati, Cormack and Lehane score as well as Friedman obstructive sleep apnea classification systems. Neck circumference and length were also measured. All cases were intubated by a single anesthesiologist who was uninformed of the above evaluation and graded intubation difficulty in visual analog score. Correlation between these findings and difficulty of intubation was assessed. Sensitivity, Specificity, Positive and Negative Predictive Values were also reported.

RESULTS

Cormack-Lehane grade had the strongest correlation with difficulty of intubation followed by Friedman palate position. Friedman palate position was the most sensitive and had higher positive and negative predictive values than modified Mallampati classification. Cormack-Lehane grade was found to be the most specific with the highest negative predictive value among the four studied classifications.

CONCLUSION

Friedman palate position is a more useful, valuable and sensitive test compared to the modified Mallampati screening test for pre-anesthetic prediction of difficult intubation where its involvement in Multivariate model may raise the accuracy and diagnostic value of preoperative assessment of difficult airway.

A gene expression map of the larval Xenopus laevis head reveals developmental changes underlying the evolution of new skeletal elements

The morphology of the vertebrate head skeleton is highly plastic, with the number, size, shape, and position of its components varying dramatically between groups. While this evolutionary flexibility has been key to vertebrate success, its developmental and genetic bases are poorly understood. The larval head skeleton of the frog Xenopus laevis possesses a unique combination of ancestral tetrapod features and anuran-specific novelties. We built a detailed gene expression map of the head mesenchyme in X. laevis during early larval development, focusing on transcription factor families with known functions in vertebrate head skeleton development. This map was then compared to homologous gene expression in zebrafish, mouse, and shark embryos to identify conserved and evolutionarily flexible aspects of vertebrate head skeleton development. While we observed broad conservation of gene expression between X. laevis and other gnathostomes, we also identified several divergent features that correlate to lineage-specific novelties. We noted a conspicuous change in dlx1/2 and emx2 expression in the second pharyngeal arch, presaging the differentiation of the reduced dorsal hyoid arch skeletal element typical of modern anamniote tetrapods. In the first pharyngeal arch we observed a shift in the expression of the joint inhibitor barx1, and new expression of the joint marker gdf5, shortly before skeletal differentiation. This suggests that the anuran-specific infrarostral cartilage evolved by partitioning of Meckel's cartilage with a new paired joint. Taken together, these comparisons support a model in which early patterning mechanisms divide the vertebrate head mesenchyme into a highly conserved set of skeletal precursor populations. While subtle changes in this early patterning system can affect skeletal element size, they do not appear to underlie the evolution of new joints or cartilages. In contrast, later expression of the genes that regulate skeletal element differentiation can be clearly linked to the evolution of novel skeletal elements. We posit that changes in the expression of downstream regulators of skeletal differentiation, like barx1 and gdf5, is one mechanism by which head skeletal element number and articulation are altered during evolution.