A Case of Tension Pneumomediastinum Treated With Mediastinal Drainage Using a Semi-flexible Fiberscope via a Subxiphoid Approach.

Tension pneumomediastinum with hemodynamic failure is a rare but life-threatening condition. Rapid decompression of the mediastinum by drainage is essential to save the patient's life. This report presents a case of tension pneumomediastinum that developed during conservative management of a pneumomediastinum associated with idiopathic pulmonary fibrosis. Endoscopically guided mediastinal drainage was successfully performed in the emergency situation of tension pneumomediastinum. Using the semi-flexible fiberscope inserted through a subxiphoid approach, the drainage catheter was easily and safely placed at the appropriate site in the mediastinum. Good mediastinal decompression was achieved, and the patient was out of this critical condition.

The difference in rotation angle of the distal endotracheal tube through nasal approach.

BACKGROUND: Nasal intubation using a fiberoptic scope is a useful technique. In clinical practice, we have experienced difficulty in advancing the endotracheal tube (ETT) over the fiberoptic scope because of resistance to the passage of the ETT against rotation in the nasal cavity, when it gets hung up on structures of the laryngeal inlet. Several maneuvers have been proposed to overcome this difficulty. The gap between the tip of the ETT and the fiberoptic scope can be reduced using a thicker fiberoptic scope and a thinner ETT. Moreover, simultaneous rotation of the fiberoptic scope and ETT could lead to successful intubation by reducing impingement on the ETT. However, the discrepancy between these rotation angles is unclear. This observational prospective study aimed to investigate the discrepancy in the rotation angle between the ETT and fiberoptic scope during nasal intubation. METHODS: The patients (aged 20-80 years) who underwent nasal intubation for oral and maxillofacial surgery participated in three sizes of preformed nasal ETT and were intubated using a fiberoptic scope. They were divided into three groups; the ETT internal diameter (ID) 6.5 mm (6.5 group), ID 7.0 mm (7.0 group), and ID 7.5 mm (7.5 group). The ETT was then inserted through the nasal cavity into the pharynx. After the fiberoptic scope was advanced through the ETT above the glottis, simultaneous rotation by both the proximal end of the fiberoptic scope and ETT was performed in 90° and 180° in both right (clockwise) and left (counterclockwise) directions, and the rotation angle at the distal end of the ETT was monitored using a video laryngoscope (Pentax-AWS). RESULTS: A total of 39 patients were included in the study. When both the proximal end of the fiberscope and ETT were simultaneously rotated by 90°, in the 6.5 group (n = 13), the distal end of the ETT rotated by 47.8 ± 1.5°. In the 7.0 °group (n = 13), the distal end of the ETT rotated by 45.5 ± 1.0°. In the 7.5 group (n = 13), the distal end of the ETT rotated by 39.9 ± 1.0°. When the proximal end of the fiberscope and ETT were rotated by 180°, in the 6.5 group, the distal end of the ETT rotated by 166.2 ± 2.5°. In the 7.0 group, the distal end of the ETT rotated by 145.7 ± 2.2°. In the 7.5 group, the distal end of the ETT rotated by 115.1 ± 2.0°. All rotation angles in the distal end of the ETT were significantly lower than those in both the proximal end of the fiberscope and ETT (p < 0.05). Rotating right by 180° was significantly different among the three groups (p < 0.05), although rotating right by 90° was not significantly different. Similar results were obtained for the left rotation. CONCLUSION: Simultaneous rotation by the proximal end of the ETT and fiberscope above the glottis for the nasal approach induced significant differences in the distal end of the ETT. The larger tube lagged by the resistance of the nasal passages during rotation. Therefore, the ETT does not rotate as much as the rotation angle. TRIAL REGISTRATION: This prospective observational study was conducted after receiving approval from the Ethics Review Board of Kyushu University Hospital (Approval No. 30-447).

Clinical efficacy of Hogan posterior pharyngeal flap in repairing velopharyngeal insufficiency secondary to cleft palate in older patients.

OBJECTIVES: The clinical effects and surgical procedures of Hogan posterior pharyngeal flap in the treatment of the older patients with velopharyngeal insufficiency (VPI) after cleft palate repair were investigated. METHODS: A total of 33 patients (aged 10-35 years; average of 20.4 years) with VPI secondary to cleft palate were included. They underwent Hogan posterior pharyngeal flap to improve velopharyngeal closure function. The clinical efficacy of the ope-ration was evaluated with Chinese speech clarity measurement and nasopharyngeal fiberscope (NPF), and the velopharyngeal closure was graded. The average follow-up time was 13.3 months. RESULTS: The wounds of all patients were healed by first intention, and speech assessment showed that the consonant articulation increased and the rate of hypernasality and nasal emission decreased significantly (P<0.05). NPF examination showed that the postoperative velopharyngeal closure function significantly improved, 30 cases (91%) were gradeⅠ, and 3 cases (9%) were grade Ⅱ. CONCLUSIONS: Hogan posterior pharyngeal flap for VPI secondary to cleft palate can significantly improve velopharyngeal closure.

Tone Enhancement Electro-Fiberscope Combined with Strobe Light Source and Re-analysis Past Images-Tone Enhancement Dynamic Stroboscope.

Tone enhancement electro fiberscope combined with strobe light source is benefit for dynamic observation of vocal fold vibration, mucosal waves and voice, it also may be effective for early detection of cases of glottal cancer rather than ordinate stroboscopic examination or simple NBI observation. Laryngoscope, 132:2206-2208, 2022.

Natural nasal-esophageal fiberscopy in the COVID-19 pandemic-preventing sneezing without anesthesia: a case report.

BACKGROUND: We are laryngologists. We observe natural phonatory and swallowing functions in clinical examinations with a trans-nasal laryngeal fiberscope (TNLF). Before each observation, we use epinephrine to enlarge and smooth the common nasal meatus (bottom of nostril) and then insert a wet swab inside the nose, as in taking a swab culture in the nasopharynx. During the current COVID-19 pandemic situation, this careful technique prevents any complications, including nasal bleeding, painfulness, and induced sneezing. Here, we introduce our routine to observe esophageal movement in swallowing in a natural (sitting) position without anesthesia. CASE PRESENTATION: The case was a 70-year-old female who complained that something was stuck in her esophagus; there was a strange sensation below the larynx and pharynx. After enlarging and smoothing the common nasal meatus, we inserted the TNLF (slim type ⌀2.9 mm fiberscope, VNL8-J10, PENTAX Medical, Tokyo, Japan.) in the normal way. We then observed the phonatory and swallowing movements of the vocal folds. As usual, to not interfere with natural movements, we used no anesthesia. We found no pathological condition in the pyriform sinus. We asked the patient to swallow the fiberscope. During the swallow, we pushed the TNLF and inserted the tip a bit deeper, which made the fiberscope easily enter the esophagus, like in the insertion of a nasogastric tube. We then asked the patient to swallow a sip of water or saliva to clear and enlarge the lumen of the esophagus. This made it possible to observe the esophagus easily without any air supply. With tone enhancement scan, the esophagus was found to be completely normal except for glycogenic acanthosis. CONCLUSIONS: The advantage of this examination is that it is easily able to perform without anesthesia and with the patient in sitting position. It is quick and minimally invasive, enabling observation the physiologically natural swallowing. It is also possible to observe without anesthesia down to the level of the esophagogastric junction using with a thin type flexible bronchoscope. In the future, gastric fiberscopes might be thinner, even with narrow band imaging (NBI) function. Before that time, physicians should remember to just insert along the bottom of the nose.

Diagnostic accuracy of flexible fiberoptic laryngoscopy: experience from a tertiary health institution in Nigeria.

BACKGROUND: Flexible fibreoptic laryngoscopy (FFL) is a technique of laryngeal visualization. The instrument (flexible laryngoscope) is relatively scarce in resource challenged countries. Where available, it is a useful compliment to the armamentarium of clinical tools at the disposal of the otolaryngologist. We evaluated the diagnostic value of flexible fibreoptic laryngoscope in a tertiary health institution in Nigeria. And we hypothesized that its diagnostic precision is comparable to direct laryngoscopy. METHODS: This is a retrospective study of records of 360 patients referred for FFL at the ENT clinic. Sensitivity and specificity of FFL for laryngeal lesions were determined using direct laryngoscopy (DL) as the gold standard. RESULTS: Of the 360 FFL reports studied, 336 additionally underwent DL. FFL findings in 311 (92.6%) cases were comparable with that of DL. FFL had a good detection rate for vocal cord palsy (sensitivity 100%, specificity 80.7%). Pick-up rate for vocal nodules, polyps, papillomatosis and palsy were statistically equal for FFL and DL (p value = 0.96). Diagnostic accuracy of FFL was good for supraglottic (sensitivity 100%, specificity 88.0%) and glottic (sensitivity 100%, specificity 92.3%) tumours; relatively lower for subglottic (sensitivity 83.3%; specificity 100%) and transglottic (sensitivity 80.0%, specificity 100%) tumours; and least for tumours involving more than on subsites (sensitivity 50%, specificity 100%). CONCLUSION: The sensitivity and specificity of FFL were not the same for all endo-laryngeal lesions; yet, the overall diagnostic accuracy of FFL is comparable with DL. Clinicians should be mindful of this variability to optimize its application.

Detection of hypopharyngeal cancer (Tis, T1 and T2) by ENT physicians vs gastrointestinal endoscopists.

OBJECTIVES: Hypopharyngeal cancer is typically detected at a late stage by ear, nose, and throat (ENT) physicians, when the prognosis is poor. We evaluated how hypopharyngeal cancer (Tis, T1 and T2) were detected by ENT physicians and gastrointestinal endoscopists (GEs) according to the detection reasons. MATERIALS AND METHODS: A total of 109 consecutive patients with hypopharyngeal cancer (Tis, T1 and T2) who received treatment in our institution from January 2014 to February 2018 was enrolled. The detection detail of hypopharyngeal cancer lesions by ENT physicians and GEs, tumor size and location, and the characteristics of the lesions missed by ENT physicians and GEs were reviewed retrospectively. RESULTS: Twenty seven and 82 of 109 (24.8% and 75.2%) patients were detected by ENT physicians and GEs, respectively. The most frequent original reasons for ENT physicians and GEs were both pharyngeal discomfort screening and examination of swollen neck lymph nodes (12 of 27, 44.4% for each) and pre-treatment or follow-up screening for esophageal cancer (25 of 82, 30.5%), respectively. Among the 13 cases of upper gastrointestinal tract screening of the head-and-neck cancer other than pharyngeal cancer detected by GEs, 11 (84.6%) were missed by ENT physicians. In contrast, among the 25 cases of pre-treatment screening of the esophageal cancer detected by GEs, 12 (48%) were missed by other GEs just before the consultation from other institutions. CONCLUSIONS: The percentage of detection of hypopharyngeal cancer (especially, Tis and T1) by ENT physicians is low. A careful examination of the pharynx should be conducted by GEs.

A Synopsis of Contemporary Anesthesia Airway Management.

New airway equipment has recently become available that has reduced morbidity and mortality. However, airway disasters still occur. This article discusses the prudent escalation of the use of advanced airway equipment to prevent these disasters. We illustrate when and how to use a gum elastic bougie and a video-laryngoscope (VL). We also strongly recommend the combined use of the VL together with a flexible intubation scope (FIS) for both asleep and awake intubation when dealing with a genuinely difficult airway. Blind intubations should no longer be performed today. When an airway has been recognized as difficult it is the safest to aim for an awake or at least a spontaneously breathing intubation if circumstances do not allow for an awake intubation. Emergency cricothyroidotomy needs to be prepared for so that it can be executed rapidly in case the attempted awake intubation leads to complete airway obstruction.

Airway challenges in bilateral temporomandibular joint ankylosis with adenoid hypertrophy: a case report.

Temporomandibular joint ankylosis is one of the most challenging airway disorders associated with varying anatomical abnormalities like adenotonsillar hypertrophy, craniofacial malformations, macroglossia, etc. This case highlights the intubation difficulties confronted during the airway management of a 10-year-old girl presenting lately with bilateral temporomandibular joint ankylosis, hypoplastic mandible, and adenoid hypertrophy. This patient was intubated successfully by using a suction catheter assembly to negotiate the endotracheal tube across the adenoid, and an unmatched-size flexible intubation fiberscope through a "separate insertion" technique and external laryngeal manipulation. This case emphasises the significance of a comprehensive preoperative evaluation in preparing the anaesthetic plan of an anticipated difficult airway in a paediatric population, having diverse anatomical hurdles presenting concurrently.

A Novel Laser Fiberscope for Simultaneous Imaging and Phototherapy of Peripheral Lung Cancer.

BACKGROUND: Phototherapy is an alternative treatment for patients with localized non-small cell lung cancer who are unable to undergo surgical resection. However, phototherapy is currently limited to treatment of centrally located lung cancer, with the much larger proportion of peripheral lesions remaining inaccessible. There are also concerns over the accuracy of targeted laser treatment because of the need to exchange visualization and irradiation fibers during therapy, preventing the operator from confirming the final location of the irradiation fiber. METHODS: A newly developed parallel-type ultrasmall composite optical fiberscope (Laser-eYe Ultrathin fiberscope [LYU]), which enables simultaneous white-light imaging and phototherapy, was evaluated in preclinical lung cancer models. Three models were used: human lung cancer xenografts (A549) in mice, orthotopic VX2 lung tumors in rabbits, and ex vivo pig lungs into which A549 tumor tissue was transplanted. A multifunctional porphyrin-phospholipid nanoparticle (porphysome) was used as a photosensitizer to evaluate fluorescence-guided photothermal therapy. RESULTS: The LYU's 0.97 mm diameter and hydrophilic coating allowed easy passage through the working channel of all types of bronchoscopes and controlled guidance of the LYU tip in any desired direction. The LYU could visualize the peripheral bronchus and porphysome-laden peripheral tumors. The LYU could also perform photothermal therapy with simultaneous imaging. CONCLUSIONS: The LYU enables simultaneous imaging and phototherapy that allows accurate irradiation of peripheral lung cancers. This new laser device may enable ultraminimally invasive transbronchial treatment of peripheral lung cancer.

Difficult airway intubation simulation using Bonfils fiberscope and rigid fiberscope for surgical training.

INTRODUCTION: Pediatric otolaryngologists are frequently called to assist in difficult airway management in newborns with Pierre Robin Sequence (PRS) who have microretrognathia, glossoptosis, and an anterior larynx. The Bonfils fiberscope (BF) is a curved rigid scope designed to provide superior visualization in the anterior larynx. OBJECTIVE: (1) to assess whether BF provides an improvement in intubation success rate, time to intubation, or airway visualization as compared to rigid fiberscope (RF) in a difficult airway simulation setting and (2) to determine whether a training program for BF can improve time to intubation through practice trials. METHODS: Six right-handed trainees completed five trials on each of the three following airway models using the BF and RF: normal anatomy, anterior larynx and PRS. The normal larynx model was intubated only with RF. Main outcome measures were the time needed for tracheal intubation and Cormack-Lehane classification (1-4). RESULTS: The majority of the intubation trials showed a statistically significant difference between first and last completion times (p < .05) suggesting construct validity. Only the anterior larynx trials with BF did not demonstrate an improvement in time to intubation between first and last attempts (p < .3125). For the PRS retrognathia model, there was no statistically significant difference in time to intubation between using the BF and the RF (p < .44); in the anterior larynx model, the RF yielded a faster time to intubation than the BF on the final trial attempts (p < .0313). By Cormack-Lehane classification measures, laryngeal visualization by the BF was better than RF in the PRS manikin (p < .0022) while there was no significant difference in grade scores for the anterior larynx manikin (p < .45). All six trainees reported an improved visualization of the larynx with the BF compared to the RF for both the anterior larynx and PRS manikins; at the end of the trial runs, all participants noted an improvement in comfort level using the BF. CONCLUSION: The difficult airway simulation model is feasible for surgical training. BF adds superior visualization of the anterior larynx in PRS. Otolaryngology training programs may include BF as a supplemental tool in addition to RF as a part of the airway equipment training since there is significant improvement in time to intubation with consecutive practice trials and superior laryngeal visualization.

Oxygen insufflation via working channel in a fiberscope is a useful method: A case report and review of literature.

BACKGROUND: Fiberoptic bronchoscopic intubation is the gold standard for endotracheal intubation in difficult or compromised airway situations. However, oxygen insufflation through the working channel of a fiberscope is a controversial method because of the possibility of gastric distention and rupture during an awake fiberoptic bronchoscopic intubation, despite the advantages of preventing fogging of the fiberoptic bronchoscopic lens, blowing oral secretions away, and oxygenation of patients. CASE SUMMARY: Here, we describe a case of cervical instability where we rapidly performed fiberoptic bronchoscopic intubation using oxygen insufflation through working channel of the broncoscopy to administer general anesthesia after two previous failures due to low visibility. A 50-year-old man with a non-specific medical history underwent emergency cervical spine surgery for posterior fusion of the C2 and C3 vertebrae. After two unsuccessful attempts at intubation using the fiberoptic broncoscopy, we performed it successfully using the oxygen insufflation via the working channel, instead of using suction to remove the secretion from the lens. CONCLUSION: Oxygen insufflation via the working channel of the broncoscopy is a useful method for assisting with difficult intubation cases.

Photodynamic therapy for biliary tract organ via a novel ultra-small composite optical fiberscope.

Photodynamic therapy (PDT) is a method used treat tumors via utilizing photodynamic reactions between photosensitive substances with tumor affinity and lasers. For overall bile duct cancers, PDT has been demonstrated to resolve stenosis and improve prognosis; however, when limited to intrahepatic bile duct cancers, modifications to the laser irradiation are necessary as surrounding hepatocytes incorporate a large amount of photosensitive substances. Furthermore, the intrahepatic bile duct is thin, and a guide sheath and thin fiber are necessary to transport laser irradiation probes to the target region. In the present study, a parallel-type ultra-small composite optical fiberscope (COF) with an outer diameter of 1 mm or smaller was developed to target a thin intrahepatic bile duct. PDT was performed using an animal model and talaporfin sodium (Laserphyrin), which is rapidly excreted by hepatocytes and is suitable for use with a long-wavelength laser due to its high tissue penetrating ability. The results demonstrated that Laserphyrin does not cause necrotic changes in the normal biliary tract mucosa. In addition, COF images of sufficient quality were acquired. The present results suggest that COF may be used for the treatment of deep bile duct lesions.

[A comparative cost analysis of single-use versus reusable fiberoptic bronchoscopes: Is single-use fiberscope worth it?] / Analyse comparative de coût entre les fibroscopes bronchiques à usage unique et réutilisables : le fibroscope à usage unique, est-ce que ça vaut le coût ?

OBJECTIVE: To present a minimization-cost analysis to compare reusable and single-use fiberscopes in a French health institution. MATERIALS AND METHODS: The amortization cost assessment has been achieved over a period of five years, and took into account the acquisition and maintenance costs, as well as the costs related to disinfection of reusable fiberscopes. The cost of single-use fiberscopes was calculated according to its acquisition and elimination costs. Finally, we compared the costs of single-use vs. reusable use during nights, weekends and days off to estimate the additional cost of the referencing of single-use fiberscopes for theses specific periods. RESULTS: The total cost of reusable fiberscopes was 62,511 € including VAT over 5 years whereas the cost of single-use fiberscope was 79,200 € including VAT over 5 years. The total cost of single-use fiberscopes if utilized during nights, weekends and days off was estimated to 19,800 € including VAT over 5 years, with an estimated activity at 15 intubations per year. Conversely, the cost of the utilization of reusable fiberscopes during nights, weekends and days off was estimate to 13,075 € including VAT over 5 years. CONCLUSION: This study shows that the utilization costs of single use and reusable fiberscopes are very close. But because of the benefits of single-use fiberscopes and according to current recommendations, we consider to acquire single-use fiberscope especially for emergencies such as difficult tracheal intubation and for restrictive periods (nights, weekends and day off).

Neuroendoscopy via an Extremely Narrow Foramen of Monro: A Case Report.

Herein, safe and reliable neuroendoscopic biopsy via an extremely narrow foramen of Monro (ENFM) for a non-hydrocephalic patient with hypothalamic and pineal region tumors was successfully applied. A 17-year-old boy presented with hypothalamic manifestations attributed to hypothalamic and pineal region tumors. Small ventricles were seen. Intraoperatively, to advance different diameter steerable fiberscopes via ENFM, the third ventricle was flushed to induce a moment increase in the intraventricular pressure with subsequent dilatation of FM. Postoperative course was uneventful. Histopathological studies revealed a yolk sac tumor. Adjuvant therapy was applied. Follow-up neuroimaging disclosed marvellous improvement of the condition. His symptoms gradually improved.

Comparison of success of tracheal intubation using Macintosh laryngoscope-assisted Bonfils fiberscope and Truview video laryngoscope in simulated difficult airway.

BACKGROUND AND AIMS: Restriction of head and neck movements prevents the alignment of the oral, pharyngeal, and laryngeal axes and increases the incidence of difficult tracheal intubation in patients with cervical spine fractures. Video laryngoscopes have gained an important role in the management of difficult intubation, especially in situations with limited head and neck movements. This study compares the success of intubation using Macintosh laryngoscope assisted Bonfils® fiberscope (ML-BF) with TruviewPCD video laryngoscope (TV) in patients with simulated restricted head and neck movements. MATERIAL AND METHODS: One hundred and fifty-two patients satisfying the inclusion criteria were randomly allocated to two groups of 76 each. Patients were made to lie supine on the table without a pillow and a soft collar was used to restrict head and neck movements. After a standardized premedication-induction sequence, tracheal intubation was done either with ML-BF or TV. Success of intubation, time taken for successful intubation, hemodynamic changes, airway trauma, and postoperative oropharyngeal morbidity were noted. RESULTS: Intubation was successful in all the 76 patients in direct laryngoscopy-Bonfils fiberscope group and 75 out of 76 patients in TV group within the specified time (90 s). The median time taken for successful intubation with TV and ML-BF were 44 (range 26-80) s and 49 (range 28-83) s, respectively. Hemodynamic changes, airway trauma, and postoperative oropharyngeal morbidity were similar in both groups. CONCLUSION: Both TV and ML-BF are equally effective for successful tracheal intubation in patients with simulated restricted head and neck movements. In cases of difficult laryngeal visualization with routine Macintosh laryngoscope, Bonfils can be used as an adjunct to achieve successful intubation in the same laryngoscopy attempt.

Airway management for glossopexy in infants with micrognathia and obstructive breathing.

STUDY OBJECTIVES: To identify airway management and tracheal intubation techniques for glossopexy in infants with preexisting airway obstruction under general anesthesia. DESIGN: Retrospective, observational study. SETTINGS: Operating room of a university hospital between January 2003 and March 2015. All operations were performed by oral and maxillofacial surgeons. PATIENTS: Thirteen patients who received general anesthesia for glossopexy and reversal after 7 months. MEASUREMENTS: The medical records of these infants were retrospectively examined to evaluate the following: age, sex, height and weight at surgery, preoperative airway status, tracheal intubation route (oral or nasal), method for inducing general anesthesia, method for establishing the airway during mask ventilation, apparatus used for tracheal intubation, Cormack-Lehane classification when using a Macintosh laryngoscope and video laryngoscope, and the need for airway placement after extubation. RESULTS: Prone positioning and/or an airway of some kind before surgery were required in 38.5% of infants needing glossopexy. Difficult mask ventilation was common, occurring in 50% of the patients, and the incidence of airway placement during mask ventilation was significantly higher in infants with preoperative complete or incomplete obstruction (100%) than in infants with snoring (25%). Of these high-risk infants, 25% could not be intubated with a direct laryngoscope or Glidescope Cobalt and required fiberoptic intubation. CONCLUSION: There are severe cases of infants with difficult mask ventilation and difficult tracheal intubation in which a fiberscope is required because video laryngoscopy fails to improve the view of the larynx.