Fluoroscopic Comparison of Cervical Spine Motion Using LMA CTrach, C-MAC Videolaryngoscope and Macintosh Laryngoscope.

OBJECTIVE: Endotracheal intubation should be performed with care when cervical spine (C-spine) injury is suspected. The aim of this study was to evaluate the movement of the C-spine using fluoroscopy during intubation with Laryngeal Mask Airway (LMA) CTrach, C-MAC videolaryngoscope and Macintosh laryngoscope. METHODS: This was a single-centre, prospective, observational, controlled trial. In total, 22 surgical patients aged 18-65 years planned to undergo operation under general anaesthesia, were enrolled. X-ray images of the C-spine were obtained using fluoroscopy with the patients' head in a neutral position. All patients underwent laryngoscopy using a Macintosh blade, LMA CTrach and C-MAC videolaryngoscope, and fluoroscopic images of the C-spine were obtained. All the patients were intubated at the last laryngoscopy simulation (using the C-MAC). The atlanto-occipital distance (AOD) and angles between C0C1, C0C2, C0C3, C0C4, C1C2 and C2C3 lines were measured and compared between each device. RESULTS: The mean AOD was measured as 20.4 mm in a neutral position, which decreased to 13.1, 17.2 and 12.3 mm after the insertion of the Macintosh laryngoscope, LMA CTrach and C-MAC videolaryngoscope, respectively. The differences were significant (p<0.001). Moreover, significant difference was noted in C0C2, C0C3 and C1C2 angles with the insertion of the three devices (p<0.001). The LMA CTrach resulted in significantly lesser C-spine movements in C0C2, C0C3 and C0C4 angles compared to the Macintosh laryngoscope and C-MAC videolaryngoscope (p<0.001). CONCLUSION: The LMA CTrach resulted in lesser C-spine movements compared to Macintosh laryngoscope and C-MAC videolaryngoscope. In case of the C-spine injury, LMA CTrach may be preferred and may cause fewer traumas during endotracheal intubation.

Extending Myringotomy Patency with Topical Everolimus in Rats.

BACKGROUND: Everolimus is an immunosuppressant agent that has antiproliferative properties and negative effects on wound healing. The effect of everolimus use to delay the closure time of myringotomy is not known. OBJECTIVES: The aim of the study was to evaluate the impact of topical everolimus on myringotomy patency and to investigate its histopathologic effects on the tympanic membrane. MATERIAL AND METHODS: Twenty Sprague-Dawley rats were bilaterally myringotomized with a myringotomy knife. Gelfoam soaked in 0.05% everolimus in a microemulsion formulation was applied to the right myringotomy site of the rats for 10 min (the everolimus group). The myringotomy sites of the left ears were treated with sterile saline topically (the control group). The tympanic membranes were routinely examined otomicroscopically every other day for 31 days. The membranes were then harvested and evaluated histologically after 31 days. RESULTS: All tympanic membranes were closed by the 15(th) day in the control group, while in the everolimus group the myringotomy remained open in five rats (25%) on day 31. The mean durations of myringotomy patency in the everolimus group and control group were 20.90 ± 7.85 and 10.10 ± 3.14 days, respectively. The difference was found to be statistically significant (p < 0.01). In the histopathological examination of the tympanic membranes, there was less fibrosis and less inflammation in the everolimus group than in the control group (p < 0.01). CONCLUSIONS: Topical everolimus application is effective in extending myringotomy patency in rat tympanic membranes. Inflammatory reactions and fibrosis in the lamina propria were observed to be significantly less when topical everolimus was used.

Efficacy of continuous positive airway pressure on middle ear atelectasis: A double-blind placebo-controlled clinical trial.

OBJECTIVES/HYPOTHESIS: To investigate the effects of continuous positive airway pressure (CPAP) treatment on patients with middle ear atelectasis. STUDY DESIGN: Prospective, double-blind, randomized, placebo-controlled study. METHODS: Fifty-four patients with middle ear atelectasis were randomized to receive CPAP treatment with a pressure level of either 14 cm H2 O (CPAP group) or 0 cm H2 O (placebo group) once per week for a period of 3 hours for 4 sessions. Outcome measures included otomicroscopic examination as well as tympanometric and audiometric evaluation. Patients were followed for 6 months. RESULTS: The CPAP group included 35 atelectatic ears, and the placebo group included 32 atelectatic ears. More ears recovered to normal tympanic membrane or regressed to grade 1 atelectasis in the CPAP group than in the placebo group during all follow-up visits (P < .05). There was a statistically significant increase in the middle ear pressure values of the patients in the CPAP group compared to the placebo group at week 5, month 3, and month 6 (P < .05). There was no significant difference in middle ear pressure values between follow-up visits in the CPAP group (P > .05). Significant improvement of pure-tone air-conduction threshold averages were found in the CPAP group compared to the placebo group at month 6 (P < .05). CONCLUSIONS: CPAP is a safe, well-tolerated way of applying positive pressure to the middle ear for patients with middle ear atelectasis. It contributes to significant improvement in middle ear pressure of these patients, also resulting in an improved degree of atelectasis. LEVEL OF EVIDENCE: 1b. Laryngoscope, 126:1649-1655, 2016.

Vocal fold paresis accompanying vocal fold polyps.

The aim of this study was to evaluate patients with vocal fold polyps using laryngeal electromyography (LEMG) for the presence of vocal fold paresis and to compare transnasal fiberoptic and rigid stroboscopic findings between polyp patients with normal LEMG and with vocal fold paresis. Thirty-five patients with a vocal fold polyp underwent transnasal fiberoptic laryngoscopy, rigid laryngostroboscopy, and LEMG. The findings were compared between the LEMG-confirmed vocal fold paresis patients and the normal LEMG patients. LEMG resulted in a diagnosis of unilateral or bilateral vocal fold paresis in 17 of 35 patients (48.6 %). More men than women with vocal fold polyps had vocal fold paresis (p < 0.05). The vocal fold paresis group had higher presence of axial rotation and hypomobility of vocal folds, higher asymmetry of vertical height of vocal folds, and less presence of longitudinal stretch of vocal folds (p < 0.05). Medial-lateral compression of the false vocal folds and anterior-posterior approximation of the larynx did not show any difference between the groups. No significant difference was found in vibratory wave characteristics between the groups through rigid laryngostroboscopy. Vocal fold paresis was present in almost half of the patients with vocal fold polyps. Paresis can only be accurately diagnosed with LEMG. Transnasal fiberoptic laryngoscopic examination is helpful to recognize vocal fold paresis in vocal fold polyp patients, while stroboscopic examination is not useful to identify it in vocal fold polyp patients.

[Evaluation of benign vocal cord lesions with laryngeal electromyography]. / Benign vokal kord lezyonlarinin larengeal elektromiyografi ile degerlendirilmesi.

OBJECTIVES: This study aims to identify patients with benign vocal cord lesions using laryngeal electromyography (EMG) and to investigate the presence of accompanying vocal cord paresis. PATIENTS AND METHODS: Twenty-eight patients (18 males and 10 females; mean age 38.6±10.2 years; range 22 to 59 years) who were diagnosed with benign vocal cord lesion using a rigid laryngostroboscopy underwent laryngeal EMG and the presence of neurogenic involvement was investigated. RESULTS: Laryngostroboscopic examination revealed polyp in 85.7% (n=24), Reinke's edema in 10.7% (n=3), submucosal cyst in 10.7% (n=3), and contact granuloma in 3.6% (n=1). Of the patients, 14.2% (n=4) were suspected to have vocal cord paresis. Laryngeal EMG revealed neurogenic involvement in at least one of the larynx muscles in 57.2% (n=16) of the patients. Eight patients (28.6%) had unilateral neurogenic involvement, while three (10.7%) demonstrated isolated recurrent laryngeal nerve paresis two (7.2%) demonstrated isolated superior laryngeal nerve paresis, and three (10.7%) demonstrated combined recurrent and superior laryngeal nerve paresis. Six (21.4%) of eight patients with bilateral neurogenic involvement had paresis in three laryngeal nerves, whereas in two (7.2%) patients four laryngeal nerves were affected. CONCLUSION: Our study shows that vocal cord paresis frequently accompanies benign vocal cord lesions. Laryngeal EMG is useful to identify clinically suspected or unsuspected paresis with physical examination precisely.

Management of Difficult Airway in a Failed Intubation with Videolaryngoscopy in an Infant Patient.

The videolaryngoscope is a useful alternative airway device for anaesthesia management of difficult airways. However videolaryngoscope intubation may fail due to lack of experience, incorrect application, inappropriate stylet, prior traumatic attempts, restricted cervical movement and limited oropharyngeal airspace. Using a stylet and correctly shaped endotracheal tube is important to facilitate tracheal intubation with the videolaryngoscope, especially in paediatric patients. However, anatomical difficulty in the placement of the laryngoscope blade, association with facial deformities such as micrognathia, having a short neck, cleft palate and being younger than 1 year increase the likelihood of a difficult airway. In this report, we present our approach to difficult airway management in a failed intubation with a videolaryngoscope in an infant undergoing cleft palate surgery.

The Role of Preoperative Evaluation for Congenital Methemoglobinemia.

Preoperative care includes a clinical examination before invasive or non-invasive interventions for anaesthesia/analgesia and is the responsibility of the anaesthesiologists. Methemoglobinemia should be considered, as well as cardiac, pulmonary, and peripheral circulatory disorders in patients with central cyanosis and low oxygen saturation despite treatment with sufficient oxygen during anaesthesia. Methemoglobinemia is a serious clinical condition, associated with increased blood methemoglobin levels characterized by clinical signs, such as cyanosis and hypoxia due to lack of oxygen-carrying capacity. Here, we present our anaesthesia management in a patient with unnoticed congenital methemoglobinemia during preoperative evaluation, in whom clinical signs of methemoglobinemia developed after local anaesthesia administration before the surgery.

Everolimus-coated tympanostomy tube on rat tympanic membrane.

OBJECTIVES: Everolimus is an immunosuppressant and an antiproliferative macrolide agent which is used for coronary stent coating for local inhibition of in-stent restenosis. The aim of this study was to evaluate the effect of everolimus-coated tympanostomy tubes in rat tympanic membrane. STUDY DESIGN: Prospective controlled animal study. MATERIALS AND METHODS: Twenty-one Sprague-Dawley rats were included in the study. They were bilaterally myringotomized. An everolimus-coated fluoroplastic tympanostomy tube was inserted into one ear of each of the rats (everolimus-coated TT Group; n=21) and a standard fluoroplastic tympanostomy tube was applied to the contralateral ear of the same rats (Standard TT Group; n=21). Tympanic membranes and tubes were routinely examined otomicroscopically every other day for two months. Then the membranes were harvested and evaluated histologically. RESULTS: In everolimus-coated tubes, the tube obstruction was found to be significantly lower than in standard tubes (p<0.05). The tube extrusion rate was less for everolimus-coated tubes than for standard tubes, but no statistically significant difference was observed between the two tubes. There was no statistically significant difference in the incidence of otorrhea between two tubes. Histopathological examination under light microscope revealed that everolimus-coated tubes resulted in less fibrosis and less inflammation in tympanic membranes than standard tubes (p<0.01). CONCLUSION: The study shows the potential role of everolimus-coating of tympanostomy tubes in reducing tube obstruction. In addition, inflammatory reaction and fibrosis were observed to be significantly less with these tubes.

Ultrasound-guided radial arterial cannulation: long axis/in-plane versus short axis/out-of-plane approaches?

Arterial cannulation with ultrasound (US) guidance increases the success rate and reduces complications. US-guided vascular access has two main approaches: long axis in-plane (LA-IP) and short axis out-of-plane (SA-OOP) approaches. The purpose of this study was to compare performance time and possible complications between two techniques. After obtaining ethics committee approval and informed patient consent, a prospective and randomized trial was conducted at ASA I-III, patients between the ages of 20-70 years. 108 patients were scheduled for radial arterial cannulaton in patients undergoing elective surgery under general anesthesia. Patients were divided into two groups as LA-IP and SA-OOP approaches with sealed envelope randomized method. After induction of anesthesia, the distance between skin-to-artery and the diameter of radial artery in US-imaging was recorded. The successful cannulation time, the number of attempts, potential complications such as thrombosis, edema, vasospasm, hematoma and posterior wall puncture were recorded. Demographic and hemodynamic parameters were similar in two groups. The diameter and the depth of artery were also similar in both of groups. Cannulation time was shorter in LA-IP Group compared to SA-OOP (24 ± 17 s vs. 47 ± 34 s respectively, p < 0.05). The arterial cannulation by LA-IP approach increased the rate of cannula-insertion success at the first attempt (76 %) compared to SA-OOP approach (51 %). Posterior wall damage during arterial cannulation were found in 30 patients with SA-OOP Group (56 %) and 11 patients with LA-IP Group (20 %), (p < 0.05). In our study, the use of LA-IP approach during US-guided radial artery cannulation has higher success rate at first insertion. We also found LA-IP approach results in shorter cannulation time and decreased the incidence of complications.

Myopericytoma of the tongue: a case report.

Myopericytoma is a rare benign tumour composed of pericytic cells that show myoid differentiation and have a tendency for concentric perivascular growth. It belongs to a spectrum ofperivascular myoid cell neoplasms. To date, only a small number of cases of myopericytoma involving the oral cavity have been reported. We describe a case of myopericytoma presenting as a slowly growing tongue nodule in a 61-year-old woman. A diagnosis of myopericytoma was established with the histopathological findings combined with immunohistochemical staining. Myopericytoma should be included in the differential diagnosis of well-circumscribed, slow-growing lesions of the oral cavity.

Anaesthetic Management of a Patient with Pseudo-TORCH Syndrome.

BACKGROUND: Pseudo-TORCH syndrome is a rare, chronic disorder that is characterised by dimorphic features such as microcephaly, intracranial calcification, seizures, mental retardation, hepatosplenomegaly and coagulation disorders. CASE REPORT: We present the anaesthetic management of a forty day-old boy with Pseudo-TORCH syndrome during magnetic resonance imaging. Microcephaly, growth failure, high palate and bilateral rales in the lungs were detected in pre-anaesthetic physical examination. The peripheral oxygen saturation was 88-89% in room-air and was 95% in a hood with 5 L/min oxygen. We planned general anaesthesia to ensure immobility during magnetic resonance imaging. After standard monitoring, general anaesthesia was induced with 8% sevoflurane in 100% O2. After an adequate depth of anaesthesia was reached, we inserted a supraglottic airway device to avoid intubation without the use of a muscle relaxant. CONCLUSION: In patients with Pseudo-TORCH syndrome, the perioperative anaesthetic risk was increased. We believe that using a supraglottic airway device to secure the airway is less invasive than intubation, and can be performed without the need of muscle relaxants.