Severity of Airflow Obstruction Based on FEV1/FVC vs FEV1% of Predicted in the General US Population

RATIONALE

According to GOLD, the ratio of FEV1/FVC is used to confirm airflow obstruction in COPD diagnosis, whereas FEV1% of predicted (FEV1%pred) is used for severity grading. STaging of Airflow obstruction by the FEV1/FVC Ratio (STAR) and its prediction of adverse outcomes has not been evaluated in general populations.

OBJECTIVE

To compare the STAR (FEV1/FVC) versus GOLD (FEV1%pred) classification for the severity of airflow limitation in terms of exertional breathlessness and mortality in the general US population.

METHODS

Severity stages according to STAR and GOLD were applied to the multi-ethnic National Health and Nutrition Examination Survey (NHANES) 2007-2012 survey including ages 18-80 years, using post-bronchodilatory FEV1/FVC<0.70 to define airflow obstruction in both staging systems. Prevalence of severity stages STAR 1-4 and GOLD 1-4 was calculated and associations with breathlessness and mortality were analyzed by multinomial logistic regression and Cox regression, respectively.

RESULTS

STAR versus GOLD severity staging of airflow obstruction showed similar associations with breathlessness and all-cause mortality, regardless of ethnicity/race. In those with airflow obstruction, the correlation between the two classification systems was 0.461 (p<0.001). STAR reclassified 59% of GOLD stage 2 as having mild airflow obstruction (STAR 1). STAR 1 was more clearly differentiated from the non-obstructive compared to GOLD stage 1 in terms of both breathlessness and mortality.

CONCLUSIONS

FEV1/FVC and FEV1%pred as measures of severity of airflow limitation show similar prediction of breathlessness and mortality in the adult US population across ethnicity groups. However, stage 1 differed more clearly from non-obstructive based on FEV1/FVC than FEV1%pred. This article is open access and distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by/4.0/).

Susceptible Young Adults and Development of COPD Later in Life

RATIONALE

Chronic obstructive pulmonary disease (COPD) has its origin in early life, and the Global Initiative for Chronic Obstructive Lung Disease (GOLD) proposes a pre-disease state "pre-COPD".

OBJECTIVE

We tested the hypothesis that susceptible young adults identified with chronic bronchitis and subtle lung function impairment will develop COPD later in life.

METHODS

We followed random non-obstructive individuals aged 20-50years from two population-based cohorts from different smoking eras, the Copenhagen General Population Study from 2003(N=5497) and Copenhagen City Heart Study from 1976-78(N=2609), for 10 and 25years for development of COPD(forced expiratory volume in one second[FEV1]/forced vital capacity[FVC]<0.70) and COPD GOLD 2-4 (additionally FEV1<80% predicted).

MEASUREMENTS AND MAIN RESULTS

After 10 years follow-up, 28% developed COPD and 13% COPD GOLD 2-4 in individuals susceptible to COPD compared to 8% and 1% in those without any susceptibility to COPD. Correspondingly, after 25years, 22% versus 13% developed COPD and 20% versus 8% developed COPD GOLD 2-4. More than half of incident COPD cases developed from a susceptible state. Compared to those without susceptibility to COPD, multivariable adjusted odds ratios in those susceptible to COPD were 3.42(95% confidence interval:2.78-4.21) for COPD and 10.1(6.77-15.2) for COPD GOLD 2-4 after 10years, and 1.54(1.23-1.93) and 2.12(1.64-2.73) after 25years. The ability of a COPD risk score consisting of the susceptibility state to COPD with smoking and asthma as risk factors to predict COPD later in life was high.

CONCLUSIONS

Our study suggests the existence of a pre-disease state of COPD, which can be used for early identification of susceptible individuals at risk for COPD later in life.

The role of cone-beam computed tomography in the radiographic evaluation of obstructive sleep apnea: A review article

The apnea-hypopnea index is widely regarded as a measure of the severity of obstructive sleep apnea (OSA), a condition characterized by recurrent episodes of apnea or hypopnea during sleep that induce airway collapse. OSA is a catastrophic problem due to the wide range of health issues it can cause, including cardiovascular disease and memory loss. This review was conducted to clarify the roles of various imaging modalities, particularly cone-beam computed tomography (CBCT), in the diagnosis of and preoperative planning for OSA. Unfortunately, 2-dimensional imaging techniques yield insufficient data for a comprehensive diagnosis, given the complex anatomy of the airway. Three-dimensional (3D) imaging is favored as it more accurately represents the patient's airway structure. Although computed tomography and magnetic resonance imaging can depict the actual 3D airway architecture, their use is limited by factors such as high radiation dose and noise associated with the scans. This review indicates that CBCT is a low-radiation imaging technique that can be used to incidentally identify patients with OSA, thereby facilitating early referral and ultimately enhancing the accuracy of surgical outcome predictions.

Partial arytenoidectomy with transoral vocal fold lateralisation in treating airway obstruction secondary to bilateral vocal fold immobility

OBJECTIVE

To report the outcome of 18 patients with a tracheostomy secondary to bilateral vocal fold immobility, who were managed using reconstructive transoral laser microsurgical techniques.

METHODS

A retrospective review was conducted of the surgical outcome of 18 patients with bilateral vocal fold immobility and a tracheostomy resulting from different aetiologies. Follow-up duration ranged from one to five years.

RESULTS

A total of 18 patients had a tracheostomy at presentation because of bilateral true vocal fold immobility and stridor. All cases were treated using reconstructive transoral laser microsurgery with arytenoidectomy and vocal fold lateralisation. All patients were successfully decannulated by eight weeks after surgery.

CONCLUSION

Reconstructive transoral laser microsurgery using partial arytenoidectomy with vocal fold lateralisation is minimally invasive, feasible, safe and effective for airway reconstruction in patients who present with stridor due to bilateral true vocal fold immobility.

Use of extracorporeal membrane oxygenation for bronchoscopic removal of a tracheal foreign body in a child

BACKGROUND

Bronchoscopic removal of a foreign body is a common emergency procedure in paediatric otolaryngology. It is potentially life-threatening, as complete airway obstruction caused by the foreign body can lead to hypoxic cardiac arrest during the manipulation of the object.

CASE REPORT

This paper presents a child who had aspirated a foreign body that could not be extracted conventionally via rigid bronchoscopy in the first instance. Subsequently, it was extracted at repeat bronchoscopy under controlled respiratory conditions maintained by an extracorporeal gas exchange circuit - extracorporeal membrane oxygenation, using a polypropylene hollow fibre oxygenator commonly employed in cardiac surgery (rather than a more expensive polymethyl pentene oxygenator commonly used in extracorporeal membrane oxygenation).

CONCLUSION

Extracorporeal membrane oxygenation use can be considered in exceptional cases of upper airway emergencies, even in resource-poor settings, and can avoid more hazardous thoracotomy and bronchotomy procedures.

Associative factors for tracheostomy in patients presenting with stridor or upper airway obstruction

OBJECTIVE

This study aimed to identify associative factors for tracheostomy in patients presenting with airway obstruction.

METHODS

Data from a tertiary hospital were reviewed to identify patients who presented with airway obstruction between 2009 and 2020. Patient demographics, causative pathology and treatments were analysed.

RESULTS

The study identified 297 admitted patients. Of these, 66 underwent a tracheostomy and formed the 'tracheostomy' group and 231 formed the 'other intervention' group. The tracheostomy group had a higher mean age (p = 0.003), and higher percentages of males (p = 0.031) and smokers or ex-smokers (p = 0.020), compared to the other intervention group. The tracheostomy group also had a higher number of patients with a malignancy (p < 0.001) compared to the other intervention group.

CONCLUSION

Being older, male, a previous or current smoker, or developing airway obstruction due to a malignancy were found to be the main associative factors for requiring a tracheostomy.

The Role of Dexmedetomidine in Airway Management for Tracheostomy in Pediatric Patient with Obstructed Airway Due to Diphtheria: A Case Report

Introduction

Diphtheria is an infectious disease caused by exotoxin-producing Corynebacterium diphteriae and was a leading cause of death in childhood during the prevaccine era. This toxin is usually localized in the upper respiratory tract and may cause fatal airway obstruction. Many have used orotracheal intubation to secure the airway in diphtheria cases. However, the efficacy of tracheostomy under sedation while maintaining spontaneous ventilation and analgesia using trans-tracheal and superficial cervical block remains to be elucidated.

Case Presentation

A 6-year-old presented to the emergency room with respiratory distress and was diagnosed with diphtheria. A thick membrane in the oropharyngeal area and chest X-ray showed infiltrations indicative of pneumonia. The patient successfully underwent emergency tracheostomy under sedation using a combination of sevoflurane and dexmedetomidine to achieve prompt sedation and trans-tracheal injection and bilateral superficial cervical block as analgesia for the intra-tracheal and the incision. The patient's condition deteriorated the next day, and the bronchoscopy showed that the carina and main bronchus were covered by a pseudomembrane, obstructing the airway below the tracheostomy. The patient eventually died two days after admission.

Conclusions

Dexmedetomidine has minimal impact on ventilatory function and anti-sialagogue properties, while sevoflurane has minimal effect on respiratory depression. This case presentation showed that a combination of sevoflurane and dexmedetomidine with spontaneous assisted ventilation could be helpful in tracheostomy procedures in pediatric patients with airway obstruction due to diphtheria, along with the use of trans-tracheal and superficial cervical block as the analgesia. This report also indicates that being vigilant in rapidly-progressing and fatal pediatric diphtheria cases is vital.

Oral Health Status and Salivary Properties among Children before and after Tonsillectomy

Objectives: Enlarged adenoids can lead to obstruction of the nasopharyngeal airway and subsequent oral respiration. Oral breathing can cause dry mouth, dehydration in gingival tissue, and resistance to plaque accumulation. This study aimed to evaluate the impact of tonsillectomy on oral health status, salivary pH and flow rate, and common complications caused by tonsillar hypertrophy in children. Materials and Methods: An analytical before-and-after study was conducted on 60 children aged 5-12 years who required tonsillectomy. We gathered data through a questionnaire and collected unstimulated saliva using the spitting method for five minutes. Salivary pH was measured by a pH meter and its volume was determined with a calibrated test tube. The plaque index, bleeding index and modified gingival index were determined using a disclosing tablet, Williams' probe and observational examination, respectively. All measurements were repeated one month after tonsillectomy. Paired t-test was used for data analysis. Results: We found a significant increase in mean pH and salivary flow rate after tonsillectomy and observed a decrease in oral health indices among the children one month after surgery. Over half of the children who reported complications such as dry mouth, itchy nose and throat, snoring, night sweats, and sleep disturbances experienced complete recovery after tonsillectomy. Conclusion: Based on the results obtained in the present study, children with enlarged adenoids showed significant improvements in salivary pH, salivary flow rate, and oral health indices, one month after tonsillectomy.

Are the severity of obstruction and the apnea-hypopnea index related to orofacial anatomy in children with obstructive sleep apnea? a kinetic MRI study

OBJECTIVES

The proportionality between anatomical characteristics and disease severity in children and adolescents with obstructive sleep apnea (OSA) has not been well characterized. The present study investigated the relationship between the dentoskeletal and oropharyngeal features of young patients with OSA and either the apnea-hypopnea index (AHI) or the amount of upper airway obstruction.

METHODS

MRI of 25 patients (8- to 18-year-old) with OSA (mean AHI = 4.3 events/h) was retrospectively analyzed. Sleep kinetic MRI (kMRI) was used to assess airway obstruction, and static MRI (sMRI) was used to assess dentoskeletal, soft tissue, and airway parameters. Factors related to AHI and obstruction severity were identified with multiple linear regression (significance level α = 0.05).

RESULTS

As evidenced by kMRI, circumferential obstruction was present in 44% of patients, while laterolateral and anteroposterior was present in 28%; as evidenced by kMRI, obstructions were retropalatal in 64% of cases and retroglossal in 36% (no nasopharyngeal obstructions); kMRI showed a higher prevalence of retroglossal obstructions compared to sMRI(p = 0.037); the main obstruction airway area was not related to AHI; the maxillary skeletal width was related to AHI (β = -0.512, p = 0.007) and obstruction severity (β = 0.625, p = 0.002); and the retropalatal width was related to AHI (β = -0.384, p = 0.024) and obstruction severity (β = 0.519, p = 0.006).

CONCLUSIONS

In children and adolescents, the severity of OSA and obstruction were inversely proportional to the maxillary basal width and retropalatal airway width. Further studies are needed to assess the benefits of targeted clinical treatments widening the transverse dimension of these structures.

Usefulness of new acoustic respiratory sound monitoring with artificial intelligence for upper airway assessment in obese patients during monitored anesthesia care

Monitored anesthesia care (MAC) often causes airway complications, particularly posing an elevated risk of aspiration and airway obstruction in obese patients. This study aimed to quantify the levels of aspiration and airway obstruction using an artificial intelligence (AI)-based acoustic analysis algorithm, assessing its utility in identifying airway complications in obese patients. To verify the correlation between the stridor quantitative value (STQV) calculated by acoustic analysis and body weight, and to further evaluate fluid retention and airway obstruction, STQV calculated exhaled breath sounds collected at the neck region, was compared before and after injection of 3 ml of water in the oral cavity and at the start and end of the MAC procedures. STQV measured immediately following the initiation of MAC exhibited a weak correlation with body mass index. Furhtermore, STQV values before and after water injection increased predominantly after injection, further increased at the end of MAC. AI-based analysis of cervical respiratory sounds can enhance the safety of airway management during MAC by quantifying airway obstruction and fluid retention in obese patients. J. Med. Invest. 70 : 430-435, August, 2023.

Anesthetic management for emergency tracheostomy in patients with head and neck cancer: a case series

Tracheostomy is a surgical procedure that is commonly used to treat upper airway obstruction. In particular, patients with head and neck cancer may require elective or emergency tracheostomy because of airway obstruction due to massive bleeding of the intraoral tumor mass and rapid growth of the tumor mass in the neck area. Here, we report four cases of tracheostomy in patients with head and neck cancer with narrowed airway space and difficulty in breathing. Based on these cases and a literature review, we recommend that oral and maxillofacial surgeons and dental anesthesiologists should cooperate closely and determine the appropriate timing to perform definitive airway management for such patients during palliative treatment, along with continuous evaluation of tumor location, risk of recurrence, and airway involvement.

Role of Flexible Fiberoptic Bronchoscopy in the Diagnosis and Treatment of Pediatric Airway Foreign Bodies: A 5-Year Experience at a Tertiary Care Hospital in Iran

Background

Foreign body aspiration can be a life-threatening incidence amongst children. The aim of this study was to evaluate the usefulness and outcomes of foreign body removal with emphasis on accuracy of flexible fiberoptic bronchoscopy and the predictors of post-procedure complications in children.

Materials and Methods

Records of patients who had undergone flexible fiberoptic bronchoscopy for foreign body extraction in Namazi Hospital affiliated to Shiraz University of Medical Sciences from 2012 to 2017 were retrospectively reviewed.

Results

109 patients in whom foreign body were detected by flexible fiberoptic bronchoscopy were enrolled. The patients' age range was between 10 days to 16 years, with the male predominance and the peak incidence amongst toddlers aged 1 to 2 years. The majority of foreign body were situated in the left main bronchus (22.9%). Coughing (37.5%) and chocking (20.8%) were the most commonly recorded symptoms. Hyperinflation (63.5%) and lung collapse (19.2%) were the most radiological findings. The duration of the procedure for 50.5% of the patients was 5-8 minutes. No complications were recorded during the flexible fiberoptic bronchoscopy procedure. Ninety-five percent of the patients had more than one visit before their admission for bronchoscopy with incorrect diagnosis of asthma/reactive airway disease and pneumonia, 74 and 20%, respectively.

Conclusion

Although rigid bronchoscopy is still considered as the gold standard and preferred method in managing the airways foreign bodies, flexible fiberoptic bronchoscopy also can be used as an effective diagnostic and therapeutic tool with high success.

Pulmonary artery sling in a symptomatic newborn

Pulmonary arterial sling (PAS) is a relatively rare congenital anomaly in which left pulmonary artery branch originates abnormally from the right pulmonary artery, eventually resulting with respiratory symptoms, due to airway obstruction. In this report, we present a PAS in a neonate who showed progressive respiratory distress in the second week following delivery. At 25 days of age, the patient underwent total surgical correction of the anomaly, during which left pulmonary artery reimplantation to main pulmonary artery without the use of cardiopulmonary bypass was employed. Following an uneventful recovery, the patient was discharged eighteen days after surgery.

Infantile recurrent respiratory papillomatosis: review of adjuvant therapies

BACKGROUND

Recurrent respiratory papillomatosis is a potentially life-threatening condition characterised by the growth of exophytic lesions within the larynx and trachea. The principal aim of management is maintenance of an adequate airway by surgical debulking. Several adjuvant therapies have been used to varying effect to reduce the burden of this disease and increase the interval between debulking procedures. The most severe cases present in children aged under three years, who are therefore most likely to need adjuvant therapies. The current evidence base on adjuvant treatments relating to children who present aged under three years has been reviewed.

METHODS

A literature review of articles in Cochrane, PubMed and Embase databases was carried out. Given the rarity of the condition in this age group, all the literature relates to case reports and case series.

RESULTS AND CONCLUSION

The following adjuvant therapies have been used in children who presented under three years of age: quadrivalent human papilloma virus vaccine, intralesional cidofovir, pegylated interferon, alpha-interferon, cimetidine and cetuximab.

Uvulopalatopharyngoplasty for nasal blockage 21 years after total rhinectomy

BACKGROUND

Total rhinectomy is an invasive procedure that significantly impairs the intranasal turbulence, humidification and heating of inspired air. The use of uvulopalatopharyngoplasty for the treatment of sleep-disordered breathing disorders such as primary snoring and obstructive sleep apnoea has diminished over the past years because of the emergence of less invasive procedures and alternative therapeutic options. This clinical record presents the treatment of a long-term side effect of total rhinectomy using uvulopalatopharyngoplasty.

CASE REPORT

In 1997, a 62-year-old male underwent total rhinectomy for a nasal schwannoma, followed by rehabilitation with a nasal prosthesis. Twenty-one years later, he presented with severe complaints of nasal blockage and breathing difficulties during both daytime and night-time. Clinical examination revealed no major anomalies besides significant velopharyngeal narrowing. Thus, in 2019, uvulopalatopharyngoplasty was performed to re-establish velopharyngeal patency. Hereafter, the symptoms of nasal blockage disappeared, resulting in an improved quality of life.

CONCLUSION

Uvulopalatopharyngoplasty may prove useful to treat selected patients with daytime breathing difficulties due to velopharyngeal narrowing.

Implementation of contextualized, emergency management cognitive aids in a periodontics clinic

BACKGROUND

Emergencies in outpatient clinics are rare. However, potentially catastrophic events can be challenging to manage due to a variety of factors, including limited equipment and staff. The purpose of this quality improvement project was to improve the staff knowledge and familiarity with critical performance elements for emergencies encountered in the setting of a periodontics clinic.

METHODS

Emergency cognitive aids tailored to the clinic's resources were created for anaphylaxis, airway obstruction, and sublingual hemorrhage. The project pre-post-test repeated measures design evaluated the effectiveness of cognitive aids using a combination of hands-on simulation, written knowledge assessments, and self-efficacy surveys. Training sessions and simulations were provided to the clinic's existing care teams made up of a periodontist and two dental assistants with an anesthetist who was present for simulations involving sedation. Due to the small sample size (N = 14) and non-normal distribution, all metrics were evaluated using non-parametric statistics.

RESULTS

Significant improvements were found in knowledge assessment (-2.310, P = 0.021) and self-efficacy (-2.486, P = 0.013) scores when retention after a training session before and after the introduction of cognitive aid was compared. The mean simulation scores and times improved steadily or reached maximum scores during the project progression.

CONCLUSION

Training sessions before and after cognitive aid introduction were effective in improving knowledge, self-efficacy, and simulation performance. Future projects should focus on validating the process for creating contextualized cognitive aids and evaluating the effectiveness of these cognitive aids in larger samples.

Utility of sleep nasendoscopy versus microlaryngotracheobronchoscopy in the diagnosis of paediatric upper airway obstruction

OBJECTIVE

To describe the utility of sleep nasendoscopy in determining the level of upper airway obstruction compared to microlaryngotracheobronchoscopy.

METHODS

A retrospective observational study was conducted at a tertiary level paediatric hospital. Patients clinically diagnosed with upper airway obstruction warranting surgical intervention (i.e. with obstructive sleep apnoea or laryngomalacia) were included. These patients underwent sleep nasendoscopy in the anaesthetic room; microlaryngotracheobronchoscopy was subsequently performed and findings were compared.

RESULTS

Twenty-seven patients were included in the study. Sleep nasendoscopy was able to induce stridor or stertor, and to detect obstruction at the level of palate and pharynx, including tongue base collapse, that was not observed with microlaryngotracheobronchoscopy. Only 47 per cent of patients who had prolapse or indrawing of arytenoids on sleep nasendoscopy had similar findings on microlaryngotracheobronchoscopy. However, microlaryngotracheobronchoscopy was better in diagnosing shortened aryepiglottic folds.

CONCLUSION

This study demonstrates the utility of sleep nasendoscopy in determining the level and severity of obstruction by mimicking physiological sleep dynamics of the upper airway.

Analysis of Infusion Patterns of Propofol and Remifentanil During Rigid Bronchoscopy Under Total Intravenous Anesthesia

OBJECTIVES

We analyzed the dosage pattern of anesthetic drugs administered to maintain anesthesia during rigid bronchoscopy.

METHODS

We enrolled a total of 81 patients who underwent rigid bronchoscopy under total intravenous anesthesia between April 2015 and March 2019. Anesthesia was maintained using propofol (target brain concentration 2.0 - 6.0 µg/mL) and remifentanil (target brain concentration 2.0 - 6.0 ng/mL). We analyzed the dosage patterns of the anesthetic agents during the procedure, as well as the changes in the dose of the anesthetic agents and the number of procedures repeated in the same patient.

RESULTS

The dose of propofol administered per minute to maintain anesthesia was inversely correlated with the total operation time (r² = 0.355, β = -0.067, P < 0.000) but was not significantly correlated with the number of times the procedure was repeated. The dose of remifentanil did not significantly differ during repeated procedures in the same patient.

CONCLUSIONS

The dose of propofol infusion tended to decrease over time during the rigid bronchoscopy procedure. This pattern was specific to propofol but not to remifentanil using TIVA. Understanding the pharmacokinetic properties of anesthetic drugs will help in their appropriate administration.

Characteristics of Obstructive Sleep Apnea Patients With a Low Body Mass Index: Emphasis on the Obstruction Site Determined by Drug-Induced Sleep Endoscopy

OBJECTIVES

This study aimed to elucidate the patterns of upper airway collapse in obstructive sleep apnea (OSA) patients with a low body mass index (BMI).

METHODS

We designed and conducted a retrospective cohort study. Consecutive patients diagnosed with OSA who underwent drug-induced sleep endoscopy (DISE) were included. Patients were classified into four groups according to their BMI. Age, sex, and polysomnography data were investigated. The patterns of upper airway collapse were characterized by the structures involved (soft palate, tongue base, lateral pharyngeal wall, and epiglottis). We compared the patterns of upper airway collapse in the supine and lateral decubitus position among the four BMI groups using the chi-square test and multivariate binary logistic regression analysis.

RESULTS

A total of 627 patients (male, 517; mean age, 47.6±12.8 years) were included, consisting of 45, 79, 151, and 352 patients who were underweight or lower normal-weight (defined as the low BMI group), upper normal-weight, overweight, and obese, respectively. Severity indicators of OSA, such as the overall apnea-hypopnea index and duration of SaO2 below 90%, were significantly lower in patients with a low BMI than in obese patients, while their average oxygen saturation was significantly higher. The most common obstruction site in the supine position was the tongue base in patients with a low BMI (100%), whereas this obstruction site was significantly less common in obese patients (54.8%). Tongue base obstruction was mostly relieved in the lateral position, with no discernible obstruction in 86.7% of the low BMI patients.

CONCLUSION

Airway obstruction in OSA patients with a low BMI is mostly due to tongue base obstruction, which improves in the lateral position. These characteristics should be kept in mind when considering treatment options for this subgroup of OSA patients.

[The cutoff value of FEV(1)/FVC as the criteria of airway obstruction in children]

Objective: To explore the cutoff value of FEV(1)/FVC for evaluating obstructive ventilation dysfunction in children. Methods: Three hundred and eighty-three healthy children (190 boys and 193 girls) aged 6-14 years in primary and middle school in Beijing, who were enrolled from May 2010 to June 2011, had their spirometry done with the Jaeger lung function instrument, and the lower limit of normal (LLN) of FEV(1)/FVC was calculated. Two hundred and thirteen asthmatic children (151 boys and 62 girls) aged 6-14 years from the outpatient Department of Allergy, Capital Institute of Pediatrics were enrolled consecutively from June to July 2018, whose clinical history and pulmonary function parameters were collected. The expected value of spirometric parameters of asthmatic children was calculated according to Zapletal prediction equations. And the LLN of FEV(1)/FVC in healthy children was used as the gold standard to calculate the sensitivity, specificity, Youden index and Kappa value of FEV(1)/FVC<80% and FEV(1)/FVC< 92% predicted. Results: In healthy children, the FEV(1)/FVC and the LLN were 91%±5% and 82% respectively, while 90%±6% and 81% in boys, and 92%±5% and 84% in girls. There were 27 (12.7%) asthmatic children whose FEV(1)/FVC<80% but FEV(1)/FVC≥92% predicted (χ(2)=123.7, P<0.01). The sensitivity, specificity, Youden index and Kappa value of FEV(1)/FVC<80% were 80.3%, 100%, 0.803 and 0.787 respectively when FEV(1)/FVC<80% was used as the criteria to assess lung function, while they were 57.3%, 100%, 0.573 and 0.547, respectively, when FEV(1)/FVC<92% predicted was used as criteria. Conclusions: The 80% of FEV(1)/FVC has a better consistency with the LLN of FEV(1)/FVC than 92% of FEV(1)/FVC% predicted. It is more accarate to use FEV(1)/FVC<80% as the diagnostic criteria for airway obstruction.

Pattern Of Presentation Of Nasal Foreign Bodies, An Experience With 155 Patients

BACKGROUND

Children commonly present to outpatient department with foreign bodies in the nose. Sometimes the history is straightforward but not infrequently presentation is with a foul-smelling unilateral discharge and obstruction. Most of the foreign bodies are inert and do not cause any local tissue reaction but some of these can cause serious complications. The frequency of the different types of foreign bodies is not known in our setup. Our study aims to determine the types and frequencies of different foreign bodies in our catchment area so as to make the attending surgeon aware of the different possibilities he may have to encounter. Also, we aimed to make the general public aware of the hazards which the foreign bodies can create.

METHODS

This descriptive cross-sectional study was carried out at Department of ENT of Ayub Teaching Hospital Abbottabad, from 1st June to 30th November 2017. During the period of study, patients presenting in outpatient department with nasal foreign bodies were included in the study. We recorded patients' age and gender. Types of foreign bodies recovered from the nose were documented and their frequency was calculated.

RESULTS

A total of 155 patients were included in the study. 60% of the foreign objects were inserted in the nasal passage by male children. Children below the age of 4 years comprised more than 55% of the cases. Mean age 4.5±2.36 years. Right nostril was predominantly involved (58%). Various seeds were commonly retrieved (40%). Plastic beads were the second most common foreign bodies (21.2%). Other foreign bodies found were buttons (9%), dry batteries (1.2%), stones (9%), toy pieces (4.5%), and food particles (10%).

CONCLUSIONS

The commonest nasal foreign objects in children were organic seeds followed by plastic beads.

Giant Parapharyngeal Space Pleomorphic Adenoma Causing Acute Airway Obstruction

Primary parapharyngeal space (PPS) tumors are rare, representing only 0.5% of all head and neck neoplasms. About 80% of tumors of this space are benign, and 20% are malignant. They often pose therapeutic and diagnostic problems due to variable non-specific symptoms and the complex anatomy of this space. Pleomorphic adenoma is the most common benign tumor of this space. It presents as an asymptomatic mass causing mild bulging in the soft palate or tonsillar region, or fullness near the angle of the mandible in the neck. We report the case of a 60-year-old male admitted to the emergency department with breathing difficulty and acute stridor. He was unable to maintain oxygen saturation, and an emergency tracheostomy was performed. Radiological and cytological evaluation were performed, and the patient was diagnosed as having primary PPS pleomorphic adenoma. The tumor was excised via the transcervical approach. The rarity of tumor in this space and unusual life-threatening presentation prompted the authors to report this case. To our knowledge, this is the third case reported worldwide of a pleomorphic adenoma causing upper airway obstruction and acute respiratory failure.

End-to-end anastomosis in the management of laryngotracheal defects

OBJECTIVE

To present clinical experience and surgical outcomes of end-to-end anastomosis in the management of laryngotracheal stenosis and tracheal defects following invasive thyroid malignancy resection.

METHODS

A retrospective analysis was performed of 14 patients with laryngotracheal stenosis and tracheal invasive thyroid malignancy. All patients underwent tracheal or cricotracheal resection and primary end-to-end anastomosis.

RESULTS

Length of stenosis was 1.7-4 cm. Stenosis was classified as Myer and Cotton grade II in 4 patients, grade III in 6 and grade IV in 2. Surgical procedures included tracheotracheal end-to-end anastomosis (n = 4), cricotracheal anastomosis (n = 2) and thyrotracheal anastomosis (n = 6). Patients with invasive thyroid malignancy underwent segmental resection of the involved segment with tumour-free margins, and tracheal or cricotracheal end-to-end anastomosis. Successful decannulation was achieved in 13 patients (93 per cent). Post-operative complications were: wound infection (n = 1), subcutaneous emphysema (n = 1), temporary unilateral vocal fold palsy (n = 1), granulation tissue development (n = 1), and restenosis (n = 2).

CONCLUSION

End-to-end anastomosis can be used safely and successfully in the management of advanced laryngotracheal stenosis and wide laryngotracheal defects. Greater success can be achieved using previously described surgical rules and laryngotracheal release manoeuvres.

The introduction of emergency cricothyroidotomy simulation training in Zimbabwe contributed to the saving of two lives

BACKGROUND

In developing countries with limited access to ENT services, performing emergency cricothyroidotomy in patients with upper airway obstruction may be a life-saving last resort. An established Danish-Zimbabwean collaboration of otorhinolaryngologists enrolled Zimbabwean doctors into a video-guided simulation training programme on emergency cricothyroidotomy. This paper presents the positive effect of this training, illustrated by two case reports.

CASE REPORTS

A 56-year-old female presented with upper airway obstruction due to a rapidly progressing infectious swelling of the head and neck progressing to cardiac arrest. Cardiopulmonary resuscitation was initiated and a secure surgical airway was established via an emergency cricothyroidotomy, saving the patient. A 70-year-old male presented with upper airway obstruction secondary to intubation for an elective procedure. When extubated, the patient exhibited severe stridor followed by respiratory arrest. Re-intubation attempts were unsuccessful and emergency cricothyroidotomy was performed to secure the airway, preserving the life of the patient.

CONCLUSION

Emergency cricothyroidotomy training should be considered for all surgeons, anaesthetists and, eventually, emergency and recovery room personnel in developing countries. A video-guided simulation training programme on emergency cricothyroidotomy in Zimbabwe proved its value in this regard.

Laryngeal manifestations of pachyonychia congenita: a clinical case and discussion on management for the otolaryngologist

BACKGROUND

Pachyonychia congenita is a rare keratinising disorder, which typically presents during the first three years of life and usually affects the nails and palmoplantar surfaces. It can involve the larynx and potentially result in life-threatening airway obstruction.

METHODS

A case report is presented and the findings of a literature review are reported. The review involved a PubMed search using the keywords 'pachyonychia congenita' together with 'larynx', 'laryngeal involvement', 'laryngeal obstruction', 'airway obstruction', 'hoarseness' and/or 'stridor'.

RESULTS

A five-year-old boy, with confirmed pachyonychia congenita, presented with complications of laryngeal involvement over a four-year period. He required three intubations and a tracheostomy for acute airway obstruction. Treatment with potassium titanyl phosphate laser laryngoscopy stabilised the progression of laryngeal disease.

CONCLUSION

Patients with pachyonychia congenita and laryngeal involvement can have a varied presentation, ranging from hoarseness to acute airway obstruction. Management can be a challenge, requiring early evaluation, regular surveillance and aggressive treatment. This paper reports our experience in managing and treating the laryngeal complications of a child with pachyonychia congenita.

An interventional airway delivery service for congenital high airway obstruction

BACKGROUND

Congenital airway obstruction is rare but potentially fatal. We developed a complex airways interventional delivery team to manage such cases. Antenatal imaging detects airway compromise at an early stage and facilitates the planning of delivery procedures ('ex utero intrapartum treatment' and 'operation on placental support') which maintain feto-placental circulation whilst an airway is secured.

METHOD

A retrospective review was performed of cases in which ENT input was required at birth for airway obstruction.

RESULTS

Four neonates were delivered before implementation of the service: two were intubated and another two underwent tracheostomy but died in the peri-natal period. Seven neonates were delivered after implementation of the service: six were intubated and one underwent immediate tracheostomy. Five subsequently underwent tracheostomy (three have since been decannulated). One child with multiple congenital anomalies died due to respiratory failure. Airway obstruction was caused by lymphatic malformation, teratoma, costo-craniomandibular syndrome and choristoma.

CONCLUSION

In the absence of other anomalies, interventional airway delivery led to reduced mortality and improved outcomes.

Oropharyngeal 24-Hour pH Monitoring in Children With Airway-Related Problems

Objectives

Diagnosis and clinical presentation of pediatric laryngopharyngeal reflux (LPR) is still controversial. The aims of this work were to study the possibility of performing 24-hour oropharyngeal pH monitoring for children in the outpatient clinic setup and to explore the results of this test in correlation to airway-related problems.

Methods

In this descriptive qualitative study, 26 children suffering from airway-related problems were included. Oropharyngeal 24-hour pH monitoring was performed for all subjects in the outpatient clinic setting. The distribution of airway diagnoses among the study group was studied versus the results of the pH monitoring.

Results

There were 16 males and 10 females participated in the study with a mean age of 6.88 (SD, ±5.77) years. Thirty-five percent of the patients were under the age of 3 years (range, 11 months to 3 years). Eight-five percent of the patients tolerated the pH probe insertion and completed 24-hour of pH recording. Laryngomalacia and subglottic stenosis (SGS) were more frequently reported in the positive LPR patients (77%).

Conclusion

Oropharyngeal 24-hour pH monitoring can be conducted for children in the outpatient setup even in young age children below 3 years old. Among the positive LPR group, SGS and laryngomalacia were the most commonly reported airway findings.

A murine model of subglottic granulation

OBJECTIVE

This study aimed to develop a functional model of subglottic stenosis by inducing direct airway irritation in transplanted mouse laryngotracheal complexes.

METHODS

Laryngotracheal complexes from C57BL/6 mice were harvested and divided into three groups: uninjured, mechanically injured and chemically injured. Donor laryngotracheal complexes from each group were placed in dorsal subcutaneous pockets of recipient mice. Each week, the transplanted laryngotracheal complexes were harvested, and tissues were fixed, sectioned, and stained with haematoxylin and eosin. Representative slides were reviewed by a blinded pathologist, to determine the formation of granulation tissue, and graded as to the degree of granulation formation.

RESULTS

Direct airway irritation induced granulation tissue formation under the disrupted epithelium of airway mucosa; this was seen as early as two weeks after chemical injury.

CONCLUSION

Results indicate that granulation tissue formation in a murine model may be an efficient tool for investigating the development and treatment of subglottic stenosis.

Alterations of mucosa of the larynx and hypopharynx in patients with mucopolysaccharidoses

OBJECTIVE

This study aimed to: assess the mucosal alterations of the larynx and hypopharynx typical for mucopolysaccharidoses, in a standardised manner; compare the severity in different subtypes of mucopolysaccharidoses; and monitor the effect of an enzyme replacement therapy.

METHODS

A classification for mucosal alterations of the larynx and hypopharynx was developed and utilised in 55 patients with mucopolysaccharidoses. Fifteen patients who started treatment with enzyme replacement therapy were followed longitudinally.

RESULTS

The most severe alterations were seen in the posterior region of the larynx and the arytenoids, and in the region of the false vocal folds. The alterations were most severe in patients with mucopolysaccharidosis II. No clear trend was observed in the patients who received enzyme replacement therapy.

CONCLUSION

Quantification of mucosal alterations of the hypopharynx and larynx in mucopolysaccharidoses patients can provide information about the disease's natural process and about the efficacy of enzyme replacement therapy.

Usefulness of Rigid Bronchoscopic Intervention Using Argon Plasma Coagulation for Central Airway Tumors

Objectives

Argon plasma coagulation (APC) is a noncontact form of electrocautery that utilizes ionized argon as the electrical current. A rigid bronchoscopic use of APC for the management of central airway obstruction could be safe and rapidly effective. This study evaluated the usefulness of rigid bronchoscopy with APC for the management of central airway obstructions due to benign or malignant tumors.

Methods

Twenty patients with obstructing central airway tumors were retrospectively reviewed from February 2008 to February 2013 at Chonnam National University Hospital. All patients received rigid bronchoscopic tumor removal under general anesthesia. APC was applied before and after tumor removal.

Results

The median age of patients was 59 years (interquartile range [IQR], 51 to 67 years) and 70% were female. The causes of airway obstruction included malignancy (n=8) and benign tumor (n=12). Airway tumors comprised intraluminal lesions (n=11, 55%) and mixed intraluminal/extraluminal lesions (n=9, 45%). The median tumor size was 15 mm (IQR, 10 to 18 mm). The median degree of airway obstruction was significantly reduced after intervention (90% [IQR, 88% to 96%] vs. 10% [IQR, 0% to 20%], P<0.001). The median American Thoracic Society dyspnea grade (3 [IQR, 1 to 4] vs. 1 [IQR, 0 to 1], P<0.001) and forced expiratory volume in one second (1.03 L [IQR, 0.52 to 1.36 L] vs. 1.98 L [IQR, 1.57 to 2.64 L], P=0.004) were significantly improved after intervention. There were no procedure-related acute complications and deaths.

Conclusion

Rigid bronchoscopy with APC is an effective and safe procedure to alleviate central airway obstruction caused by tumors.

Successful High Flow Nasal Oxygen Therapy for Excessive Dynamic Airway Collapse: A Case Report

Excessive dynamic airway collapse (EDAC) is a disease entity of excessive reduction of the central airway diameter during exhalation, without cartilage collapse. An 80-year-old female presented with generalized edema and dyspnea at our hospital. The patient was in a state of acute decompensated heart failure due to pneumonia with respiratory failure. We accordingly managed the patient with renal replacement therapy, mechanical ventilation and antibiotics. Bronchoscopy confirmed the diagnosis of EDAC. We scheduled extubation after the improvement of pneumonia and heart condition. However, extubation failure occurred due to hypercapnic respiratory failure with poor expectoration. Her EDAC was improved in response to high flow nasal oxygen therapy (HFNOT). Subsequently, the patient was stabilized and transferred to the general ward. HFNOT, which generates physiologic positive end expiratory pressure (PEEP) effects, could be an alternative and effective management of EDAC. Further research and clinical trials are needed to demonstrate the therapeutic effect of HFNOT on EDAC.

Whistles and wheezes: don't miss diseases

Upper airway obstruction (UAO) in infants and children has a broad spectrum of presentations including benign self-resolving conditions, from mild croup, to critical life-threatening conditions which, though uncommon now, require prompt recognition and effective multidisciplinary collaborative management to achieve a good outcome. The aim of this article is to highlight the diagnostic and management difficulties in acute UAO in paediatric patients and encourage a problem-solving approach.

Use of tracheal stenting in the palliation of anaplastic thyroid carcinoma: tertiary centre experience

BACKGROUND

Anaplastic thyroid carcinoma is rare but carries a poor prognosis. Anaplastic thyroid carcinoma leads to tracheal compression, airway compromise and eventually death. Airway compromise, a particularly distressing symptom, can be palliated with tracheal stenting.

METHOD

A retrospective case note analysis was conducted of patients diagnosed with anaplastic thyroid carcinoma between July 2003 and July 2013.

RESULTS

Twelve patients with anaplastic thyroid carcinoma were identified. Four patients underwent palliative tracheal stenting. Three patients had no dyspnoea at the time of stenting. Two stented patients subsequently developed dyspnoea secondary to stent migration; this was managed successfully with stent exchange. The other stented patient remained asymptomatic with regards to dyspnoea. All non-stented patients died with or from airway compromise.

CONCLUSION

Tracheal stenting is a relatively safe and effective method for palliation of distressing airway symptoms in patients with anaplastic thyroid carcinoma. Early prophylactic tracheal stenting in anaplastic thyroid carcinoma may be an effective option to prevent development of airway compromise as the disease progresses.

Serious Complications after Self-expandable Metallic Stent Insertion in a Patient with Malignant Lymphoma

An 18-year-old woman was evaluated for a chronic productive cough and dyspnea. She was subsequently diagnosed with mediastinal non-Hodgkin lymphoma (NHL). A covered self-expandable metallic stent (SEMS) was implanted to relieve narrowing in for both main bronchi. The NHL went into complete remission after six chemotherapy cycles, but atelectasis developed in the left lower lobe 18 months after SEMS insertion. The left main bronchus was completely occluded by granulation tissue. However, the right main bronchus and intermedius bronchus were patent. Granulation tissue was observed adjacent to the SEMS. The granulation tissue and the SEMS were excised, and a silicone stent was successfully implanted using a rigid bronchoscope. SEMS is advantageous owing to its easy implantation, but there are considerable potential complications such as severe reactive granulation, stent rupture, and ventilation failure in serious cases. Therefore, SEMS should be avoided whenever possible in patients with benign airway disease. This case highlights that SEMS implantation should be avoided even in malignant airway obstruction cases if the underlying malignancy is curable.

Loom bands and young children - a tragedy waiting to happen?

BACKGROUND

There has been a surge in the popularity of loom bands amongst children in recent months. These small rubber bands, which can be woven together to make colourful bracelets and necklaces, have become the world's most popular toy. Foreign bodies in paediatric nasal and aural cavities are a common presentation to ENT units across the country. Whilst most are removed without incident, foreign bodies in nasal passages represent a potential risk for inhalation, leading to airway obstruction.

METHOD

This paper reports a case series of four paediatric patients who presented with a loom band associated foreign body in the nose over a 7-day period at a district general hospital in Scotland.

CONCLUSION

Although the four cases presented were resolved without the need for general anaesthetic, the ever-soaring prevalence and popularity of loom bands necessitates a degree of caution and vigilance from parents, retailers and manufacturers alike. We believe there is an urgent need for greater public awareness of their potential hazards.

Silicone stent placement for primary tracheal amyloidosis accompanied by cartilage destruction

Primary tracheal amyloidosis (PTA) can lead to airway obstructions, and patients with severe PTA should undergo bronchoscopic interventions in order to maintain airway patency. Focal airway involvements with amyloidosis can only be treated with mechanical dilatation. However, the PTA with diffused airway involvements and concomitant cartilage destructions requires stent placement. Limited information regarding the usefulness of silicone stents in patients with PTA has been released. Therefore, we report a case of diffused PTA with tracheomalacia causing severe cartilage destruction, which is being successfully managed with bronchoscopic interventions and silicone stent placements.

ADAM19 and HTR4 variants and pulmonary function: Cohorts for Heart and Aging Research in Genomic Epidemiology (CHARGE) Consortium Targeted Sequencing Study

BACKGROUND

The pulmonary function measures of forced expiratory volume in 1 second (FEV1) and its ratio to forced vital capacity (FVC) are used in the diagnosis and monitoring of lung diseases and predict cardiovascular mortality in the general population. Genome-wide association studies (GWASs) have identified numerous loci associated with FEV1 and FEV1/FVC, but the causal variants remain uncertain. We hypothesized that novel or rare variants poorly tagged by GWASs may explain the significant associations between FEV1/FVC and 2 genes: ADAM19 and HTR4.

METHODS AND RESULTS

We sequenced ADAM19 and its promoter region along with the ≈21-kb portion of HTR4 harboring GWAS single-nucleotide polymorphisms for pulmonary function and analyzed associations with FEV1/FVC among 3983 participants of European ancestry from Cohorts for Heart and Aging Research in Genomic Epidemiology (CHARGE) Consortium. Meta-analysis of common variants in each region identified statistically significant associations (316 tests; P<1.58×10(-4)) with FEV1/FVC for 14 ADAM19 single-nucleotide polymorphisms and 24 HTR4 single-nucleotide polymorphisms. After conditioning on the sentinel GWASs hit in each gene (ADAM19 rs1422795, minor allele frequency=0.33 and HTR4 rs11168048, minor allele frequency=0.40], 1 single-nucleotide polymorphism remained statistically significant (ADAM19 rs13155908, minor allele frequency=0.12; P=1.56×10(-4)). Analysis of rare variants (minor allele frequency <1%) using sequence kernel association test did not identify associations with either region.

CONCLUSIONS

Sequencing identified 1 common variant associated with FEV1/FVC independent of the sentinel ADAM19 GWAS hit and supports the original HTR4 GWAS findings. Rare variants do not seem to underlie GWAS associations with pulmonary function for common variants in ADAM19 and HTR4.

Chronic obstructive pulmonary disease: respiratory review of 2013

Chronic obstructive pulmonary disease (COPD) is a common airway disease that has considerable impact on disease burdens and mortality rates. A large number of articles on COPD are published within the last few years. Many aspects on COPD ranging from risk factors to management have continued to be fertile fields of investigation. This review summarizes 6 clinical articles with regards to the risk factors, phenotype, assessment, exacerbation, management and prognosis of patients with COPD which were being published last year in major medical journals.

Cervical decompression and unexpected soft tissue oedema: case report

Abstract

Acute upper airway obstruction (UAO) is a life threatening complication that is well recognized after carotid endarterectomy, thyroidectomy and pharyngeal area intervention. It is not widely acknowledged that airway obstruction can occur after cervical spinal fusion surgery which was first described in 1955. There are a number of common postoperative problems which may become apparent in the short to medium term. These include: sore throat, dysphagia, hoarseness, dysphonia, recurrent laryngeal nerve palsy and soft tissue swelling.

Clinical experience of rigid bronchoscopy in single center

Background

The aim of this study was to analyze clinical situations requiring rigid bronchoscopy and evaluate usefulness of rigid bronchoscopic intervention in benign or malignant airway disorders.

Methods

We retrospectively reviewed 29 patients who underwent rigid bronchoscopy from November 2007 to February 2011 at St. Paul's Hospital, The Catholic University of Korea School of Medicine.

Results

Of the 29 patients, the most frequent underlying etiology was benign stenosis of trachea (n=20). Of those 20 patients, 16 had post-intubation tracheal stenosis (PITS), 2 had tracheal stenosis due to inhalation burn (IBTS) and other 2 had obstructive fibrinous tracheal pseudomembrane (OFTP). Other etiologies were airway malignancy (n=6), endobronchial stenosis due to tuberculosis (n=2), and foreign body (n=1). For treatment, silicone stent insertion was done in 16 cases of PITS and IBTS and mechanical removal was performed in 2 cases of OFTP. In 6 cases of malignant airway obstruction mechanical debulking was performed and silicone stents were inserted additionally in 2 cases. Balloon dilatation and electrocautery were used in 2 cases of endobronchial stenosis due to tuberculosis. In all cases of stent, airway obstructive symptom improved immediately. Granulation tissue formation was the most common complication.

Conclusion

Tracheal stenosis was most common indication and silicone stenting was most common procedure of rigid bronchoscopy in our center. Rigid bronchoscopic procedures, at least tracheal silicone stenting, should be included in pulmonary medicine fellowship programs because it is a very effective and indispensable method to relieve critical airway obstruction which needs training to learn.

Association of bone mineral density with airway obstruction and emphysema

BACKGROUND

Airway obstruction and the extent of emphysema are reported to be responsible for reduced bone mineral density (BMD). Corresponding to different phenotypes of a pulmonary disease, different severity in extra pulmonary features may exist. We compared BMDs of subjects with or without airway obstruction and/or emphysema and investigated the relationships among BMD, the severity of airway obstruction, and the extent of emphysema.

METHODS

Using a university hospital database, we reviewed patients over 40 years old who performed spirometry, computed tomography of chest, and measurement of BMD of the lumbar (L) spine. According to the presence or absence of airway obstruction and/or emphysema, four groups were classified.

RESULTS

Among a total of 59 subjects, 33 (56%) had osteoporosis. The prevalence of osteoporosis in subjects with no airway obstruction and no emphysema, those with only emphysema, those with only airway obstruction, and those with both airway obstruction and emphysema were 42%, 57%, 64%, and 73%, respectively (p=0.047 by linear-by-linear association). The mean T-scores of BMD of L1 (p=0.032) and L1-4 spines were different among the four groups (p=0.034). Although the T-score of L1 BMD negatively correlated with the extent of emphysema (r=-0.275, p=0.035) and positively with each of body mass index (BMI) (r=0.520, p<0.001), forced expiratory volume in one second (FEV(1)) (r=0.330, p=0.011), FEV(1)/forced vital capacity (r=0.409, p=0.001), and forced expiratory flow at 25~75% of FVC (FEF(25-75%)) (r=0.438, p=0.0001), respectively, multiple linear regression analysis indicated that BMI (p<0.001) and FEF(25-75%) were predictive of BMD (p=0.012).

CONCLUSION

Low BMI and airway obstruction were strongly associated with reduced bone density rather than the extent of emphysema.

Congenital nasopharyngeal teratoma in a neonate

BACKGROUND

Congenital germ cell tumors are uncommon. The most common site of teratoma is in the sacrococcygeal region. Teratoma arising from the head and neck comprises less than 10% of reported cases and of these, nasopharyngeal lesions are rare. Teratomas are generally benign, and have a well recognized clinical and histopathological entity. We present a case of nasopharyngeal teratoma (NPT) associated with a wide cleft palate.

CASE PRESENTATION

A 20 day old female neonate with a teratoma of the nasopharyngeal area, and wide cleft palate was referred to our center. The protruded mass which measured 6×4×3cm, was of soft consistency, blocked the airway, and prevented oral feeding. Preoperative evaluation and imaging was performed and mass was excised 2 days after admission. Pathology revealed a well-differentiated mature solid teratoma (hairy polyp). The patient had no complication in the post-operative period. Cleft palate was surgically repaired when 2 years old. She is now a six year old girl with normal development.

CONCLUSION

Congenital nasopharyngeal teratomas are usually benign. Surgery is the treatment of choice, and should be undertaken on an urgent basis, especially in a patient who presents with signs and symptoms of airway obstruction.

Obstructive fibrinous tracheal pseudomembrane after tracheal intubation: a case report

Obstructive fibrinous tracheal pseudomembrane is a rare, but potentially fatal complication associated with endotracheal intubation. It has been known that the formation of tracheal pseudomembrane is related with intracuff pressure during endotracheal intubation or infectious cause. But in the patient described in this case, pseudomembrane formation in the trachea was associated with subglottic epithelial trauma or caustic injuries to the trachea caused by aspirated gastric contents during intubation rather than tracheal ischemia due to high cuff pressure. We report a patient with obstructive fibrinous tracheal pseudomembrane after endotracheal intubation who presented with dyspnea and stridor and was treated successfully with mechanical removal using rigid bronchoscopy.