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Veder LL, Joosten KFM, Timmerman MK, Pullens B. Factors associated with laryngeal injury after intubation in children: a systematic review. Eur Arch Otorhinolaryngol 2024; 281:2833-2847. [PMID: 38329528 PMCID: PMC11065910 DOI: 10.1007/s00405-024-08458-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 01/04/2024] [Indexed: 02/09/2024]
Abstract
PURPOSE The purpose of this study is to evaluate all potential factors associated with laryngeal injury after endotracheal intubation in the pediatric population. METHODS A systematic literature search was conducted in Medline, Embase, Cochrane, web of science and Google scholar up to 20th of March 2023. We included all unique articles focusing on factors possibly associated with intubation-injury in pediatric patients. Two independent reviewers determined which articles were relevant by coming to a consensus, quality of evidence was rated using GRADE criteria. All articles were critically appraised according to the PRISMA guidelines. The articles were categorized in four outcome measures: post-extubation stridor, post-extubation upper airway obstruction (UAO) necessitating treatment, laryngeal injury found at laryngoscopy and a diagnosed laryngotracheal stenosis (LTS). RESULTS A total of 24 articles with a total of 15.520 patients were included. The incidence of post-extubation stridor varied between 1.0 and 30.3%, of post-extubation UAO necessitating treatment between 1.2 and 39.6%, of laryngeal injury found at laryngoscopy between 34.9 to 97.0% and of a diagnosed LTS between 0 and 11.1%. Although the literature is limited and quality of evidence very low, the level of sedation and gastro-esophageal reflux are the only confirmed associated factors with post-extubation laryngeal injury. The relation with age, weight, gender, duration of intubation, multiple intubations, traumatic intubation, tube size, absence of air leak and infection remain unresolved. The remaining factors are not associated with intubation injury. CONCLUSION We clarify the role of the potential factors associated with laryngeal injury after endotracheal intubation in the pediatric population.
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Affiliation(s)
- L L Veder
- Department of Otorhinolaryngology, Erasmus Medical Center, Sophia Children's Hospital, Room SP 1421a, Dr Molewaterplein 60, 3015 GJ, Rotterdam, The Netherlands.
| | - K F M Joosten
- Department of Pediatrics, Intensive Care Unit, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - M K Timmerman
- Department of Otorhinolaryngology, Erasmus Medical Center, Sophia Children's Hospital, Room SP 1421a, Dr Molewaterplein 60, 3015 GJ, Rotterdam, The Netherlands
| | - B Pullens
- Department of Otorhinolaryngology, Erasmus Medical Center, Sophia Children's Hospital, Room SP 1421a, Dr Molewaterplein 60, 3015 GJ, Rotterdam, The Netherlands
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Meguerditchian-Hoffmeyer L, Philouze P, Carsuzaa F, Subtil F, Fath L, Fieux M. Risk factors for laryngeal lesions in adult acute respiratory distress syndrome: A STROBE-compliant French case-control study. Eur Ann Otorhinolaryngol Head Neck Dis 2024:S1879-7296(24)00028-0. [PMID: 38423861 DOI: 10.1016/j.anorl.2024.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
INTRODUCTION The global SARS-CoV-2 pandemic led to an increased incidence of post-intubation laryngeal injuries in patients with acute respiratory distress syndrome (ARDS). The primary objective of this study was to identify risk factors for symptomatic laryngeal lesions in patients with Covid-19-related ARDS. The secondary objective was to analyze the progression of these laryngeal lesions. METHODS A 21 month nested case-control study was conducted in 3 university hospital centers of the Hospices Civils de Lyon (France). Cases encompassed all patients intubated for Covid-19-related ARDS who presented symptomatic laryngeal pathology. The control group consisted of all patients enrolled during the same period for Covid-19-related ARDS without evidence of laryngeal lesions (no specific ENT intervention). Uni- and multi-variate analyses were performed to identify risk factors for the occurrence of laryngeal lesions. RESULTS Forty-nine patients were included in the case group and 50 in the control group. The only significant risk factor for symptomatic laryngeal injury was the number of reintubations, with an odds ratio of 5.08 (95% CI, 1.40-22.12; P=0.013). No other predictive factors were identified among the variables analyzed: obesity, number of prone sessions, self-extubation, duration of intubation and number of days of curarization. CONCLUSION The number of reintubations was the sole independent risk factor associated with the development of symptomatic laryngeal lesions in patients managed for Covid-19-related ARDS.
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Affiliation(s)
- L Meguerditchian-Hoffmeyer
- Service d'ORL et de chirurgie cervico-faciale, hôpital de la Croix Rousse, hospices civils de Lyon, 69310 Pierre Bénite, France
| | - P Philouze
- Service d'ORL et de chirurgie cervico-faciale, hôpital de la Croix Rousse, hospices civils de Lyon, 69310 Pierre Bénite, France; Université de Lyon, Université Lyon 1, 69003 Lyon, France
| | - F Carsuzaa
- Service ORL, chirurgie cervico-maxillo-faciale et audiophonologie, centre hospitalier universitaire de Poitiers, 86000 Poitiers, France
| | - F Subtil
- Hospices civils de lyon, service de biostatistique et bioinformatique, Lyon, France; CNRS, laboratoire de biométrie et biologie évolutive UMR 5558, Villeurbanne, France
| | - L Fath
- Service d'ORL, de chirurgie cervicofaciale, avenue Molière, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 67098 Strasbourg cedex, France
| | - M Fieux
- Université de Lyon, Université Lyon 1, 69003 Lyon, France; Service d'ORL, d'otoneurochirurgie et de chirurgie cervico-faciale, centre hospitalier Lyon Sud, hospices civils de Lyon, 69310 Pierre Bénite, France.
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Atsmoni SC, Kinshuck A. Advances in laryngeal and airway surgery: what has changed? Br J Hosp Med (Lond) 2024; 85:1-7. [PMID: 38416518 DOI: 10.12968/hmed.2023.0257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Abstract
Laryngeal and airway surgery continues to see innovation and advances, similar to other specialties of modern medicine. Research in this field has led to a greater understanding of conditions resulting in new terminology, diagnoses and change in management. This article looks at advances in laryngeal and upper airway surgery and discusses their ongoing impact on clinical practice.
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Affiliation(s)
- Smadar Cohen Atsmoni
- Department of Otolaryngology and Head and Neck Surgery, Liverpool Head and Neck Centre, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Andrew Kinshuck
- Department of Otolaryngology and Head and Neck Surgery, Liverpool Head and Neck Centre, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
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Malkoc A, Wong S, Gnanadev R, Phan A, Farrokhi H, Nguyen DT, Wong DT. Tracheal ulcer development from high volume, low-pressure cuffed endotracheal tubes. Am J Otolaryngol 2024; 45:104098. [PMID: 37979216 DOI: 10.1016/j.amjoto.2023.104098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 10/29/2023] [Indexed: 11/20/2023]
Abstract
INTRODUCTION Iatrogenic injury to the larynx, particularly the vocal cords from prolonged intubation, has been well-studied; however, tracheal injuries are rarely reported. This study investigates the effectiveness of cuffed, high-volume, low-pressure endotracheal tubes in preventing the development of tracheal ulcers in intubated subjects. METHODS A retrospective, IRB-approved review was performed on 1355 subjects who underwent percutaneous tracheostomy from 2002 to 2018. The presence and severity of tracheal ulcers were collected using documentation and photos during percutaneous tracheostomy placement. Primary outcome measures included: the length of time on a ventilator until tracheostomy (LOVT), length of hospitalization (LOH), and mortality in relationship to the severity of the tracheal injury. Data was reported as n (%) and median (IQR). The differences in means between groups were analyzed by ANOVA and Chi-square test with an alpha of 0.05. RESULTS 206 subjects met the inclusion criteria; 65 subjects had an absence of tracheal injury, and 141 subjects developed tracheal ulcers. Subjects with tracheal ulcers were grouped by the following severity scale: no ulcer; mild ulcer (minimal mucosal erosion with exudate); moderate ulcer (mucosal erosion); and severe (tracheal ring exposure). There were no statistically significant differences in age (p = 0.99), gender (p = 0.83), BMI (p = 0.44), LOH (p = 0.88), LOVT (p = 0.93), and mortality (p = 0.306) between subjects with differing severity of ulcers. The average annual incidence of clinically significant ulcers (moderate and severe) was 2.2 %. CONCLUSIONS The lack of statistical correlation between the duration of intubation and tracheal ulcer severity, along with a low annual incidence of tracheal ulcers, supports the improved safety of high-volume, low-pressure cylindrical, cuffed endotracheal tubes. This study is among the first to specifically focus on injuries at the level of the cuff and tip of endotracheal tubes with implications in preventive measures and potential product design changes.
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Affiliation(s)
- Aldin Malkoc
- Arrowhead Regional Medical Center, 400 N Pepper Ave, Colton, CA 92324, USA
| | - Stephanie Wong
- Arrowhead Regional Medical Center, 400 N Pepper Ave, Colton, CA 92324, USA; California University of Science and Medicine, 1501 Violet Street, Colton, CA 92324, USA
| | - Raja Gnanadev
- Arrowhead Regional Medical Center, 400 N Pepper Ave, Colton, CA 92324, USA
| | - Alexander Phan
- Arrowhead Regional Medical Center, 400 N Pepper Ave, Colton, CA 92324, USA
| | - Haley Farrokhi
- University of California, Los Angeles, Los Angeles, CA 90095, USA
| | - Danny T Nguyen
- Arrowhead Regional Medical Center, 400 N Pepper Ave, Colton, CA 92324, USA
| | - David T Wong
- Arrowhead Regional Medical Center, 400 N Pepper Ave, Colton, CA 92324, USA.
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Kelly E, Hirschwald J, Clemens J, Regan J. Persistent Features of Laryngeal Injury Following Endotracheal Intubation: A Systematic Review. Dysphagia 2023; 38:1333-1341. [PMID: 36774422 PMCID: PMC9922098 DOI: 10.1007/s00455-023-10559-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 01/27/2023] [Indexed: 02/13/2023]
Abstract
This systematic review examined (i) prevalence, severity, and impact of persistent post-extubation laryngeal injury beyond hospital discharge and (ii) differences in persistent laryngeal injury between COVID-19 and non-COVID-19 populations. The review was completed following PRISMA-2020 guidelines. Four databases (PubMed, CINHAL complete, EMBASE, Web of Science) were searched (inception to March 2021). Screening, full text review and data extraction were completed by two reviewers. Primary outcomes were swallow, voice and cough and airway measures obtained after hospital discharge. Quality assessment was measured using Downs & Black Tool and Johanna Briggs Institute Checklist for Cohort Studies. Meta-analysis was not completed due to study heterogeneity. Six cohort studies were included. Total number of participants across the included studies was 436. ICU admission diagnoses included respiratory disease 46% (COVID-19 and non-COVID-19), sepsis 14%, non-sepsis-related organ dysfunction 9%, general medical 11%, general surgical 10%, trauma 2%, ENT 0.6% and other not specified by authors 7%. Outcomes were obtained between 2 and 60 months post hospital discharge. Assessment methods included endoscopic evaluation, clinician ratings and patient-reported outcomes. Persistent features of laryngeal injury identified were airway abnormalities (18.9-27%), dysphonia (13.2-60%) and dysphagia (23-33%). Persistent laryngeal injury was associated with ICU length of stay, respiratory diagnosis and tracheostomy. Study quality ranged from poor-good. This is the first systematic review to examine post-extubation laryngeal injury beyond hospital discharge. Significant gaps in the literature were identified. Given the impact on clinical and patient outcomes, large scale, well-designed research is needed to guide post-ICU service delivery.
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Affiliation(s)
- Eileen Kelly
- Department of Clinical Speech & Language Studies, Trinity College Dublin, Dublin, Ireland.
- Highly Specialist Speech & Language Therapist, Adult Critical Care Unit, Royal London Hospital, London, UK.
| | - Julia Hirschwald
- Department of Clinical Speech & Language Studies, Trinity College Dublin, Dublin, Ireland
| | | | - Julie Regan
- Department of Clinical Speech & Language Studies, Trinity College Dublin, Dublin, Ireland
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Shenoy MS, Mathew V, Mathews I, George N, Joseph G. Isolated Cricoid Fracture and Thyroid Hematoma in Blunt Injury of the Neck. Indian J Otolaryngol Head Neck Surg 2022; 74:5028-5032. [PMID: 36742656 PMCID: PMC9895519 DOI: 10.1007/s12070-021-02659-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 05/19/2021] [Indexed: 02/07/2023] Open
Abstract
Introduction Blunt trauma to the neck may result in life threatening injuries due to airway compromise. Thyroid Injury in a previously normal gland is rare, so is Isolated Cricoid Fracture. The expanding thyroid hematoma and an unstable larynx compound the effects of compression and lead to sudden deterioration of the patient. Case Report We report the case of young male, who sustained a blunt injury in front of the neck. He developed a swelling in the front of his neck and suddenly deteriorated, needing intubation and airway management. Computed Tomographic imaging of the neck showed thyroid hematoma and fracture of the cricoid ring requiring an emergency hemi thyroidectomy and fixation of the cricoid fracture. Discussion This case brings forth the occurrence of two rare entities, Thyroid hematoma and Isolated Cricoid fracture in the same patient needing expert airway management and exploration.
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Affiliation(s)
| | - Vivek Mathew
- VPS Lakeshore Hospital, Nettoor, Kochi, 40 Kerala India
| | | | - Nita George
- VPS Lakeshore Hospital, Nettoor, Kochi, 40 Kerala India
| | - George Joseph
- VPS Lakeshore Hospital, Nettoor, Kochi, 40 Kerala India
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Shah G, Joshi C, Prajapati BJ, Gupta NJ. Comparative evaluation of early versus late tracheostomy for reduction of the length of ICU stay, incidence of nosocomial pneumonias, risk of laryngeal injury and mortality of mechanically ventilated patients at a Tertiary Care Hospital in Western India. Indian J Otolaryngol Head Neck Surg 2022; 74:5194-5198. [PMID: 36742921 PMCID: PMC9895706 DOI: 10.1007/s12070-022-03115-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 06/27/2022] [Indexed: 02/07/2023] Open
Abstract
Introduction Tracheostomy is a very common procedure performed in ICU as it offers significant advantages over prolonged endotracheal intubation. It facilitates weaning by decreasing the work of breathing in patients with limited reserve by decreasing the dead space area, decreases the requirement for sedation, and may allow for earlier patient mobilization, feeding, and physical and occupational therapy as compared to prolonged intubation along with lesser oral and oropharyngeal ulcerations, improves pulmonary toileting, and lowers incidence of pulmonary infections. Tracheostomy, however, is not devoid of risks. Complications may include hemorrhage, stoma infections and granulations, pneumothorax, subcutaneous emphysema, tracheal stenosis, tracheomalacia, and rarely death. Hence, performance of tracheostomy should be considerate to outweigh benefit-risk ratio. Aims and objectives To evaluate the early versus late tracheostomy for reduction of the length of ICU stay, incidence of nosocomial pneumonias, risk of laryngeal injury and mortality of mechanically ventilated patients. Materials and methods We conducted a retrospective study from May, 2019 to April, 2021 of patients being tracheostomized in medical ICU at Civil Hospital, Ahmedabad, who were previously intubated endotracheally and were on mechanical ventilation. The decision to tracheostomize would be taken by physicians in their routine rounds in ICU. Results Incidence of endolaryngeal complications like laryngotracheal stenosis, stomal granulations, fistula as well as nosocomial infections have lower incidence in early tracheostomy as compared to with late. Mortality remains same in both the groups as well as hospital and ICU stay.
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Affiliation(s)
- Gati Shah
- Department of OtoRhinoLaryngology, Civil hospital, Ahmedabad, Gujarat, India
| | - Chinmayee Joshi
- Department of OtoRhinoLaryngology, Civil hospital, Ahmedabad, Gujarat, India
| | - Bela J. Prajapati
- Department of OtoRhinoLaryngology, Civil hospital, Ahmedabad, Gujarat, India
| | - Nandini J Gupta
- Department of OtoRhinoLaryngology, Civil hospital, Ahmedabad, Gujarat, India
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Leopard MD, Moorhouse MT. A case of Covid-19 associated laryngeal synechia as a cause for failed tracheostomy decannulation. Trends Anaesth Crit Care 2020; 34:47-49. [PMID: 38620723 PMCID: PMC7834573 DOI: 10.1016/j.tacc.2020.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 07/21/2020] [Accepted: 07/23/2020] [Indexed: 11/18/2022]
Abstract
Post intubation laryngeal injuries are seen relatively commonly in the Intensive Care Unit (ICU) setting. The most common intubation associated laryngeal injuries are characterised by vocal cord oedema, mucosal ulceration, laryngeal granulomas and vocal cord paralysis. Laryngeal stenosis is seen much less commonly and generally presents with posterior adhesions from prolonged intubation or anterior webbing from instrumentation. The finding of adhesions between the vocal cords at the middle third of the glottis without anterior or posterior adhesions and in the absence of previous laryngeal surgery is rare. The authors present a case of a patient with Covid-19 (SARS-CoV-2) who was discovered to have this finding following admission to the Intensive Care Unit for ventilation, tracheostomy for weaning and subsequent failure to decannulate. The patient underwent a microlaryngoscopy and frank adhesions between the middle third of the vocal cords were noted. The authors feel that the mucosal inflammatory component associated with Covid-19 was a significant contributing factor in this clinical finding. Following successful divisions of the adhesions, the patient made a full recovery.
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Kumar Sinha A, Ahmad S, Rashi R, Kumar A, Kumar B. Self-knotting of distal end of nasogastric tube-Not an uncommon possibility. Pediatr Investig 2020; 4:145-147. [PMID: 32851360 PMCID: PMC7331391 DOI: 10.1002/ped4.12180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 01/20/2020] [Indexed: 01/09/2023] Open
Abstract
IMPORTANCE A nasogastric tube is used commonly to decompress the stomach and provide enteral feeding in surgical and medical practice. Sometimes this safe and innocent-looking tube may lead to unexpected complications. We focus here on the possibility of spontaneous 'lariat loop' knotting of the nasogastric tube when some resistance is felt on tube retrieval and describe a method of safe tube removal. CASE PRESENTATION We present a case of self-knotting of a nasogastric tube that was placed to decompress the stomach during the postoperative period after surgical repair of anorectal malformation in a 4-month-old boy. CONCLUSION Self-knotting of the distal end of nasogastric tube is an unusual complication with catastrophic sequelae if not addressed properly. If any resistance is felt during nasogastric tube retrieval, self-knotting of the tube must be suspected.
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Affiliation(s)
- Amit Kumar Sinha
- Department of Pediatric surgeryAll India Institute of Medical SciencesPantaBiharIndia
| | - Sohail Ahmad
- Department of Pediatric surgeryAll India Institute of Medical SciencesPantaBiharIndia
| | - Rashi Rashi
- Department of Pediatric surgeryAll India Institute of Medical SciencesPantaBiharIndia
| | - Amit Kumar
- Department of Pediatric surgeryAll India Institute of Medical SciencesPantaBiharIndia
| | - Bindey Kumar
- Department of Pediatric surgeryAll India Institute of Medical SciencesPantaBiharIndia
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Mehel DM, Özdemir D, Çelebi M, Aydemir S, Akgül G, Özgür A. Classification of laryngeal injury in patients with prolonged intubation and to determine the factors that cause the injury. Am J Otolaryngol 2020; 41:102432. [PMID: 32093977 DOI: 10.1016/j.amjoto.2020.102432] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 02/13/2020] [Accepted: 02/16/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This study aims to evaluate injuries occurring in the larynx of patients intubated in intensive care units for a long time. STUDY DESIGN Prospective clinical study. SETTING Tertiary hospital. SUBJECT AND METHODS Between April 15, 2019, and November 15, 2019, 40 patients who were hospitalized in intensive care units had a tracheotomy procedure due to prolonged intubation, and laryngeal structures were evaluated by direct laryngoscopy. The laryngeal structures were evaluated in four groups as glottic-supraglottic region, arytenoid vocal process, interaritenoid region and subglottic region. Edema, granulation and ulceration findings in these four regions were recorded. The injuries to the laryngeal structures were classified as stages 0-3. As a result of the data obtained, the relationship between the degree of laryngeal lesions and the factors that may cause these lesions was investigated. RESULTS According to our classification, nine patients had stage 1, 16 patients had stage 2 and 15 patients had stage 3 laryngeal injury. There was no significant relationship between the stage of laryngeal injury and age, sex and diameter of the intubation tube. There was a statistically significant relationship between laryngeal injury and the day the tracheotomy was performed (p = 0.007). CONCLUSION In patients that had prolonged endotracheal intubation, injury to the laryngeal structures is inevitable. To minimize this occurrence, tracheotomy should be performed for intubations that extend for more than seven days. When performing the tracheotomy, the laryngeal structures should be evaluated, necessary precautions should be taken for the traumatic lesions that are difficult to heal, and treatment should be started.
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Abstract
Respiratory symptoms and infections are common among athletes. Viral upper respiratory infection symptoms may precede dyspneic symptoms seen in asthmatics or worsen symptoms of exercise-induced bronchoconstriction Knowing how to instruct an athlete on use of inhalers and having an asthma action plan are critical in management of these athletes. Other life-threatening conditions that may be seen are pneumothorax and laryngeal/pharyngeal perforation. Prompt recognition and treatment are crucial if an athlete is suspected to have pulmonary compromise. Laryngeal/pharyngeal perforations are a rare cause of issues within the training room but require a high degree of suspicion to be diagnosed and managed properly.
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Affiliation(s)
- Armando Gonzalez
- Department of Orthopaedics, The University of Pittsburgh, 3200 South Water Street, Pittsburgh, PA 15203, USA.
| | - Aaron V Mares
- Department of Orthopaedics, The University of Pittsburgh, 3200 South Water Street, Pittsburgh, PA 15203, USA
| | - David R Espinoza
- Department of Orthopaedics, The University of Pittsburgh, 3200 South Water Street, Pittsburgh, PA 15203, USA
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Jain S, Singh P, Gupta M, Kamble B, Phatak SS. Comminuted Laryngeal Fracture Following Blunt Trauma: A Need for Strict Legislation on Roads! Ann Maxillofac Surg 2017; 7:124-128. [PMID: 28713750 PMCID: PMC5502499 DOI: 10.4103/ams.ams_60_15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Laryngeal fracture is a rare condition with potential life-long implications related to airway patency, voice quality, and swallowing. Rarity of the condition leads to lack of consensus on the most suitable way to manage this injury. The mode of injury can be prevented by strict legislation on the roads. We report a case of a 28-year-old Indian male who sustained a comminuted displaced fracture of the thyroid cartilage with disruption of anterior commissure due to blunt trauma caused by the metallic side rod of a ladder projecting from the rear of a vehicle in front of the bike on which he was riding. He presented with breathing difficulty, change in voice, surgical emphysema, and pneumomediastinum, but without any skin changes over the neck. His airway could be restored due to early tracheostomy and open reduction with internal fixation with sutures along with laryngeal stenting. He has no significant swallowing or breathing problem and reasonably good voice 6 months after surgery. This case highlights the need for strict legislation on roads in India and the importance of high level of suspicion for laryngeal fracture in acute trauma patient. Early identification and timely internal fixation not only restore the airway but also improve long-term voice and airway outcomes.
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Affiliation(s)
- Shraddha Jain
- Department of Otorhinolaryngology and Head and Neck Surgery, Jawaharlal Nehru Medical College, DMIMSU, Wardha, Maharashtra, India
| | - Pragya Singh
- Department of Otorhinolaryngology and Head and Neck Surgery, Jawaharlal Nehru Medical College, DMIMSU, Wardha, Maharashtra, India
| | - Minal Gupta
- Department of Otorhinolaryngology and Head and Neck Surgery, Jawaharlal Nehru Medical College, DMIMSU, Wardha, Maharashtra, India
| | - Bhavna Kamble
- Department of Otorhinolaryngology and Head and Neck Surgery, Jawaharlal Nehru Medical College, DMIMSU, Wardha, Maharashtra, India
| | - Suresh S Phatak
- Department of Radiodiagnosis, Jawaharlal Nehru Medical College, DMIMSU, Wardha, Maharashtra, India
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Mencke T, Jacobs RM, Machmueller S, Sauer M, Heidecke C, Kallert A, Pau HW, Noeldge-Schomburg G, Ovari A. Intubating conditions and side effects of propofol, remifentanil and sevoflurane compared with propofol, remifentanil and rocuronium: a randomised, prospective, clinical trial. BMC Anesthesiol 2014; 14:39. [PMID: 24860256 PMCID: PMC4032635 DOI: 10.1186/1471-2253-14-39] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Accepted: 04/30/2014] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Tracheal intubation without muscle relaxants is usually performed with remifentanil and propofol or sevoflurane. Remifentanil 1.0 to 4.0 μg·kg(-1) and propofol 2.0-3.0 mg·kg(-1) or sevoflurane up to 8.0 Vol% provide acceptable, i.e. excellent or good intubating conditions. We hypothesized that sevoflurane 1.0 MAC would provide acceptable intubating conditions when combined with propofol and remifentanil. METHODS Eighty-three patients to be intubated were randomised to two groups. The SEVO group received propofol 1.5 mg kg(-1), remifentanil 0.30 μg kg min(-1) and sevoflurane 1.0 MAC; the MR group received the same doses of propofol and remifentanil plus rocuronium 0.45 mg kg(-1). We evaluated intubation and extubation conditions, mean arterial pressure (MAP), heart rate (HR) and bispectral index (BIS). The vocal cords were examined for injury by videolaryngoscopy before and 24 hours after surgery. RESULTS ACCEPTABLE INTUBATING CONDITIONS WERE SEEN MORE FREQUENTLY WITH ROCURONIUM THAN WITH SEVOFLURANE: 97% versus 82%; p = 0.03; the subscore for vocal cords was comparable: 100% versus 98%. MAP before intubation decreased significantly compared with the MAP at baseline to the same extent in both groups; ephedrine IV was given in 15 (SEVO) versus 16 (MR) patients; p = 0.93. BIS at tracheal intubation was 27 (13-65) in the SEVO group, 29 (14-62) in the MR group; p = 0.07. Vocal cord injuries (oedema, haematoma) were similar: 4 patients in each group. CONCLUSIONS Overall intubating conditions were better when rocuronium was used; the subscore for vocal cords was comparable. The incidence of side effects was the same in the two groups. TRIAL REGISTRATION ClinicalTrials.Gov: NCT 01591031.
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Affiliation(s)
- Thomas Mencke
- Department of Anaesthesia and Intensive Care Medicine, University of Rostock, Schillingallee 35, Rostock 18057, Germany
| | - Refa Maria Jacobs
- Department of Anaesthesia and Intensive Care Medicine, University of Rostock, Schillingallee 35, Rostock 18057, Germany
| | - Susann Machmueller
- Department of Anaesthesia and Intensive Care Medicine, University of Rostock, Schillingallee 35, Rostock 18057, Germany
| | - Martin Sauer
- Department of Anaesthesia and Intensive Care Medicine, University of Rostock, Schillingallee 35, Rostock 18057, Germany
| | - Christine Heidecke
- Department of Otorhinolaryngology, University of Rostock, Rostock, Germany
| | - Anja Kallert
- Department of Otorhinolaryngology, University of Rostock, Rostock, Germany
| | - Hans Wilhelm Pau
- Department of Otorhinolaryngology, University of Rostock, Rostock, Germany
| | - Gabriele Noeldge-Schomburg
- Department of Anaesthesia and Intensive Care Medicine, University of Rostock, Schillingallee 35, Rostock 18057, Germany
| | - Attila Ovari
- Department of Otorhinolaryngology, University of Rostock, Rostock, Germany
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Abstract
Self-inflicted laryngeal injuries are rare. This is a case of attempted suicide with a knife. The patient was brought into A&E and initial attempts at repair of the laryngo-skeletal structures were performed Later it became evident that the patient had an insensate hypofunctioning larynx. We present a technique aimed at rehabilitating the poorly functioning, incompetent larynx without the necessity for a permanent tracheostomy or laryngectomy. A single surgical procedure combining a cricopharyngeal myotomy, an anterior hyoid suspension and vocal fold angmentations was performed in an attempt to avoid a laryngectomy in non-malignant pathology. The long-term results of this surgery would need to be subjected to further evaluation.
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Affiliation(s)
- A S Banerjee
- 43 Daylesford Drive South Gosforth, NE3 1TW Newcastle upon Tyne
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