Flexible nasopharyngoscopy for fish bone removal from the pharynx

Randomised controlled trial in cadavers investigating methods for intubation via a supraglottic airway device: Comparison of flexible airway scope guided versus a retrograde technique

OBJECTIVE

A supraglottic airway device (SAD) may be utilised for rescue re-oxygenation following a failed attempt at endotracheal intubation with direct or video laryngoscopy. However, the choice of subsequent method to secure a definitive airway is not clearly established. The aim of the present study was to compare two techniques for securing a definitive airway via the in-situ SAD.

METHODS

A randomised controlled trial was undertaken. The population studied was emergency physicians (EPs) attending a cadaveric airway course. The intervention was intubation through a SAD using a retrograde intubation technique (RIT). The comparison was intubation through a SAD guided by a flexible airway scope (FAS). The primary outcome was time to intubation. The trial was registered with ANZCTR.org.au (ACTRN12621000995875).

RESULTS

Four EPs completed intubations using both methods on four cadavers for a total of 32 experiments. The mean time to intubation was 18.2 s (standard deviation 8.8) in the FAS group compared with 52.9 s (standard deviation 11.7) in the RIT group; a difference of 34.7 s (95% confidence interval 27.1-42.3, P < 0.001). All intubations were completed within 2 min and there were no equipment failures or evidence of airway trauma.

CONCLUSION

Successful tracheal intubation of cadavers by EPs is achievable, without iatrogenic airway trauma, via a SAD using either a FAS or RIT, but was 35 s quicker with the FAS.

Comparison of fibre-optic-guided endotracheal intubation through a supraglottic airway device versus hyperangulated video laryngoscopy by emergency physicians: A randomised controlled study in cadavers

Background:

After failed endotracheal intubation, using direct laryngoscopy, rescued using a supraglottic airway device, the choice of subsequent method to secure a definitive airway is not clearly determined.

Objective:

The aim of this study was to compare the time to intubation using a fibre-optic airway scope, to guide an endotracheal tube through the supraglottic airway device, with a more conventional approach using a hyperangulated video laryngoscope.

Methods:

A single-centre randomised controlled trial was undertaken. The population studied were emergency physicians working in an adult major trauma centre. The intervention was intubation through a supraglottic airway device guided by a fibre-optic airway scope. The comparison was intubation using a hyperangulated video laryngoscope. The primary outcome was time to intubation. The trial was registered with ANZCTR.org.au (ACTRN12621000018819).

Results:

Four emergency physicians completed intubations using both of the two airway devices on four cadavers for a total of 32 experiments. The mean time to intubation was 14.0 s (95% confidence interval = 11.1–16.8) in the hyperangulated video laryngoscope group compared with 29.2 s (95% confidence interval = 20.7–37.7) in the fibre-optic airway scope group; a difference of 15.2 s (95% confidence interval = 8.7–21.7, p < 0.001). All intubations were completed within 2 min, and there were no equipment failures or evidence of airway trauma.

Conclusion:

Successful intubation of the trachea without airway trauma by emergency physicians in cadavers is achievable by either fibre-optic airway scope via a supraglottic airway device or hyperangulated video laryngoscope. Hyperangulated video laryngoscope was statistically but arguably not clinically significantly faster than fibre-optic airway scope via supraglottic airway device.

Endoscopic removal of a fish bone foreign body in the hypopharynx with the modified Killian's method

Observing the entire circumference of the hypopharynx is usually difficult because most of the area is anatomically closed in the resting state. The modified Killian's method, consisting of a combination of the modified Killian position, head torsion, and the Valsalva maneuver, is a recently proposed procedure to improve the endoscopic view of the hypopharynx. A fish bone, which was invisible under regular endoscopy but was identified by CT, was successfully observed and removed under the modified Killian's method in a 71-year-old female. This method can be applied to diagnose and treat benign hypopharyngeal disease such as fish bone foreign body in addition to the detection of cancer.

The Utility of the Maxillary Heuwieser for Oropharyngeal Foreign Body Removal Under Nebulized Local Anesthesia: A Case Series

We describe a novel and safe use of existing instrumentation in the removal of select foreign bodies in the upper aerodigestive tract to minimize health-care costs. A retrospective review of 4 cases involving visualized upper aerodigestive tract foreign bodies were identified via flexible laryngoscopy and extracted under local anesthesia from 2016 to 2018. All 4 patients were not in any airway distress and underwent successful removal of the foreign body, which included 2 fishbones, a sewing pin, and a wire bristle with a maxillary Heuwieser or giraffe instrument under flexible laryngoscopy visualizing using local anesthesia without complications. No foreign bodies were dislodged. The use of a maxillary Heuwieser and flexible laryngoscopy visualization is safe, allows for removal of otherwise difficult to reach foreign bodies at the bedside, improving patient comfort, obviates the need for general anesthesia to the patient, and minimizes health-care costs.

Management of Foreign Bodies in Throat: An Emergency Department's Perspective

Objectives

To review the share of emergency physicians and surgeons in the removal of foreign bodies in throat, and to revisit the concept of home observation and elective endoscopic examination for this group of patients.

Design

Retrospective study for a five month period.

Setting

Public general hospital with emergency and surgical departments.

Population

All patients attending the emergency department from 1st January 1999 to 31st May 1999 with a diagnosis or chief complaint of foreign body in throat or foreign body ingestion.

Main outcome measures

Success rate of foreign body retrieval, method of removal, specialty and patient outcome.

Results

79.8% of the foreign bodies were fish bones. Eighty-nine percent foreign bodies was removed by direct laryngoscopy in the emergency department, 6.7% by emergency physicians in the endoscopy unit as outpatients and 4.3% by surgeons after admission.

Conclusion

In the absence of frank clinical or radiological sign, a short period of home observation before proceeding to elective oesophagogastro-duodenoscopy (OGD) assessment may be helpful as well as cost-effective. This policy screens out some unnecessary instrumentation, without increasing the rate of complications. As emergency physicians remove the majority of foreign bodies, their expanded involvement on an ambulatory basis is both reasonable and feasible.

Removal of Fish Bones in the Oropharynx and Hypopharynx Under Video Laryngeal Telescopic Guidance

OBJECTIVE: The study goal was to present the technique and results of removal of fish bones in the oropharynx and hypopharynx under video laryngeal telescopic guidance.

STUDY DESIGN AND SET: From January 2001 to December 2002, a total of 27 patients with fish bones lodged in the oropharynx and hypopharynx were studied at the ENT Department of Taipei Medical University Hospital.

RESULTS: All fish bones were removed smoothly without necessitating further procedures at the time of the initial clinical examination and had an uneventful clinical course.

CONCLUSION: Removal of fish bones lodged at the tongue base, vallecula, and hypopharynx under video laryngeal telescopic guidance has the advantages of good illumination, clear visualization, and precise extraction. The technique has also proven to be efficient, safe, well tolerated, and with low morbidity.

SIGNIFICANCE: Removal of the fish bones from difficult areas in oropharynx and hypopharynx with this technique can reduce the use of direct laryngoscope under general anesthesia.

Office removal of a subglottic bread clip

Objective. The presence of an upper airway foreign body is an emergent, potentially life-threatening situation that requires careful but rapid evaluation and management. Organic or nonorganic material may typically be found in the pyriform sinuses or tongue base or may be aspirated directly into the tracheobronchial tree. We present here an unusual case report of a patient who accidentally ingested a plastic bread clip that was lodged in his subglottis for 15 months and report successful removal in the office under local anesthesia. Methods. Mucosal anesthesia was achieved with inhaled 4% lidocaine spray. Flexible laryngoscopic removal of the foreign body was then successfully accomplished. Results. The patient's symptoms resolved completely following removal, with no sequelae. Conclusions. Office removal of airway foreign bodies is feasible and can be safely done with adequate topical anesthesia, but great caution and emergency planning must be exercised.

Impacted chicken bone in the laryngopharynx: a case report

Objective. To describe a rare case of an impacted large foreign body (chicken bone) in the laryngopharynx. Case Report. A 28-years-old man presented with pain in the neck of 5 days duration. The patient gave a history of severe choking sensation while eating chicken. Laryngoscopic examination revealed a linear whitish large chicken bone impacted in the left pyriform fossa. The bone was removed under local anesthesia with the guidance of telescopic laryngeal examination. Conclusion. This paper describes impaction of a large chicken bone in the hypopharynx in an adult male patient and its removal with guided telescopic laryngeal examination.

Vocal cord fixation caused by an impacted fish bone in hypopharynx: report of a rare case

We report a rare case of vocal cord fixation caused by a fish bone in the hypopharynx. The patient was a 72-year-old woman. She presented with hoarseness that had appeared suddenly while eating baked fish. The diagnosis was suggested by a clinical history and confirmed by a computed tomography scan. The fish bone was removed via microlaryngoscopic operation under general anesthesia. The restoration of her vocal cord mobility required a few months. Vocal cord fixation is an extremely rare complication of a pharyngeal foreign body. In all of the few cases reported previously, the fixation was caused by mechanical obstruction of vocal cord movement or by recurrent nerve palsy secondary to inflammation. Our case is not typical of mechanical or inflammatory fixation. It is possible that the recurrent nerve was damaged directly by the fish bone.

Flexible nasolaryngoscopy. A low-risk, high-yield procedure

Flexible nasolaryngoscopy can be a valuable tool in the primary care physician's office. It is nearly painless for the patient and can yield valuable information about common patient complaints. The equipment is relatively inexpensive, and its use can be easily learned. The procedure is also well tolerated by patients. With proper patient selection, it can clarify otherwise confusing causes of nasopharyngeal or laryngeal disease.

A prospective randomized trial comparing the use of the flexible gastroscope versus the bronchoscope in the management of foreign body ingestion

BACKGROUND

Foreign body ingestion is a common clinical problem in Hong Kong. Some recent reports have proposed the use of flexible nasoendoscopy for foreign body retrieval. The present study is a prospective randomized trial on the use of the flexible gastroscope and bronchoscope in the management of foreign body ingestion.

METHODS

Two hundred sixteen patients older than 11 years were prospectively randomized to flexible endoscopic examination using either the gastroscope (108 patients) or the bronchoscope (108 patients). The duration of the procedure was noted. Patients were asked to assess their overall tolerance to the procedure on a scale of 1 (well tolerated) to 10 (unacceptable).

RESULTS

A foreign body was retrieved in 68 patients (31.5%). There was no difference between the two groups in the foreign body retrieval rate, type of foreign body retrieved, duration of procedure, and tolerance level. In the group managed with the bronchoscope, however, three patients required the additional use of the gastroscope for foreign body retrieval at (for one patient) or below (for two patients) the cricopharyngeus. The patient's tolerance level was related only to the duration of procedure (rho = 0.386; p < 0.001).

CONCLUSION

The use of the flexible gastroscope is recommended because of its efficacy, safety, and tolerability.

Ingested foreign bodies--a contemporary management approach

A prospective study of all foreign body complaints presenting through our Accident and Emergency Department was conducted in a population where the condition is endemic. All patients were managed by otolaryngologists. Six hundred and eight patients were attended to yielding 179 foreign bodies. Making use of modern equipment and a practical approach, the requirement for examination under general anesthesia was 6.3 per cent. In this series there was a complication rate of 0.5 per cent.

The modified Valsalva manoeuvre to improve visualization of the hypopharynx during flexible nasopharyngoscopy

A simple, safe and effective procedure for improving the diagnostic accuracy of nasopharyngoscopy is described. It is most useful for the exposure of the hypopharynx, especially in the elderly patient.

Nasendoscopy guided removal of fish bones from the base of tongue and the vallecula

Impaction of a fish bone at the base of tongue or the vallecula is a very common problem. Removal of the bone from these sites without a general anaesthesia can be challenging to surgeons and patients alike. Various manoeuvres to facilitate this procedure have been described, some are very successful but may require specialized instruments, while others may cause excessive discomfort to the patients and even inadvertent dislodgement of the bone. We describe a method using a flexible fibreoptic nasendoscope to provide a visual guide in order to facilitate peroral removal of the bone with a pair of forceps. This method is well tolerated by patients and avoids the need for a general anaesthesia in many cases.