Curious Case of Pediatric One-Lung Ventilation with Two Endotracheal Tubes: A Case Report.

ABSTRACT: One-lung ventilation is indicated during thoracic surgery for visualization and exposure of surgical site. It is achieved with bronchial blockers, double-lumen endobronchial tube, single-lumen endotracheal tubes and Univent tube for infants and children. Fibreoptic bronchoscope is required for placing and confirming the correct position of these tubes. We report a perioperative management of safe conduct of one lung ventilation for a 6-year child undergoing left lower lobe lobectomy through C-MAC video laryngoscope guided two single lumen tubes in limited resource settings where paediatric-sized fibreoptic bronchoscope is unavailable.

Congenital glottic stenosis as a clinical manifestation of FREM1-associated disorders in a neonate with respiratory distress and aphonia.

A female infant born at 38 weeks and 2 days via induced vaginal delivery was admitted to the neonatal intensive care unit for respiratory distress soon after birth. Noted to have aphonia on examination, the patient underwent direct laryngoscopy and was diagnosed with an anterior glottic web and subglottic stenosis. The patient underwent a genetic workup including whole exome sequencing which resulted in a diagnosis of a FREM1-associated disorder. Congenital glottic webs and subglottic stenoses have not been previously described as clinical manifestations of FREM1-associated disorders.

Flexible endoscopic phonosurgery for treatment of functional sequelae after laryngeal oncologic surgery: a narrative review.

Flexible endoscopic phonosurgery (FEPS) is one of the most recent and constantly evolving operative techniques in the field of minimally invasive laryngeal surgery. Thanks in part to the possibility of using new technologies, such as digital endoscopes, laser fibres, and different laryngeal injection materials, its fields of application have rapidly expanded. This narrative review describes the current possible indications of FEPS ranging from injection laryngoplasties in cases of vocal cord paralysis or mass defect, to the correction of dysphagia after open partial horizontal laryngectomies. Use of microscissors, microforceps, and laser fibres also allows this technique to be applied for removal of superficial vocal cord lesions, avoiding general anaesthesia in an increasing number of patients.

[Analysis of vocal fold movement characteristics in patients with laryngeal neurogenic injury].

Objective:To analyze the characteristics of vocal fold movement and glottic closure in patients with laryngeal neurogenic injury. Methods:A total of 185 patients with vocal fold paralysis diagnosed by laryngeal electromyography as neurogenic damage to cricothyroid muscle, thyreoarytenoid muscle and posterior cricoarytenoid muscle were enrolled, they were divided into unilateral vocal fold paralysis group and bilateral vocal fold paralysis group, respectively, and superior laryngeal paralysis group, recurrent laryngeal nerve paralysis group and vagal nerve paralysis group according to nerve injury. The characteristics of vocal fold movement and glottic closure were analyzed under strobe laryngoscope. The qualitative evaluation of vocal fold movement was fixed vocal fold, reduced vocal fold movement and normal vocal fold movement, and the qualitative evaluation of glottic closure was glottic closure and glottic imperfection. The results were analyzed statistically. Results:The proportion of normal, reduced and fixed vocal fold motion in bilateral vocal fold paralysis group was significantly different from that in unilateral vocal fold paralysis group（P<0.05）, the composition of normal and reduced vocal fold motion in bilateral vocal fold paralysis group（47.70%） was significantly greater than that in unilateral vocal fold paralysis group（12.27%）. There was no significant difference between the proportion of glottic closure and glottic imperfecta in bilateral vocal fold paralysis group and unilateral vocal fold paralysis group（P<0.05）. The proportion of decreased vocal fold motion in superior laryngeal nerve paralysis group（50.00%） was higher than that in recurrent laryngeal nerve paralysis group（9.32%） and vagal nerve paralysis group（9.00%）. The proportion of decreased and fixed vocal fold motion in superior laryngeal nerve paralysis group, recurrent laryngeal nerve paralysis group and vagal nerve paralysis group was statistically significant（P<0.05）.There was no significant difference in glottic closure among the three groups（P<0.05）. Conclusion:Vocal fold movement characteristics of patients with laryngeal neurogenic injury were mainly vocal fold fixation, or normal or weakened vocal fold movement. There may be missed diagnosis of unilateral vocal fold paralysis in clinical practice. In half of the patients with superior laryngeal nerve palsy, vocal fold movement is characterized by vocal fold fixation.

A novel combined approach to placement of a double lumen endobronchial tube using a video laryngoscope and fiberoptic bronchoscope: a retrospective chart review.

BACKGROUND: The objective of this study was to evaluate a modern combined video laryngoscopy and flexible fiberoptic bronchoscope approach to placement of a double lumen endobronchial tube and further characterize potential strengths and weaknesses of this approach. METHODS: Retrospective chart review was conducted at our single institution, academic medical center, tertiary-care hospital. Patients aged 18 years of age or older were evaluated who underwent thoracic surgery and one-lung ventilation with placement of a double lumen endobronchial tube using a novel combined video laryngoscopy and flexible fiberoptic bronchoscope approach. No interventions were performed. RESULTS: Demographics and induction and intubation documentation were reviewed for 21 patients who underwent thoracic surgery and one-lung ventilation with placement of a double lumen endobronchial tube using a novel combined video laryngoscopy and flexible fiberoptic bronchoscope approach. First pass success using the combined approach was 86% (18/21). The five patients with an anticipated difficult airway had successful double lumen endobronchial tube placement on the first attempt. There were no instances of desaturation during double lumen endobronchial tube placement. No airway complications related to double lumen endobronchial tube placement were recorded. CONCLUSION: Use of a combined approach employing video laryngoscopy and a flexible fiberoptic bronchoscope may represent a reliable alternative approach to placement of double lumen endobronchial tubes.

Vallecular cyst causing sleep-disordered breathing in an older child.

Consensus-based recommendations are needed to better guide paediatric otolaryngologists in providing standardised care to children with sleep-disordered breathing (SDB). Here we present a unique case of vallecular cyst found during SDB workup in a patient in their middle childhood (6-12 years old). While the patient underwent successful cyst resection, he was noted to have a suspected recurrence 6 months later. Immediately prior to revision excision, repeat awake flexible fibre-optic laryngoscopy revealed complete resolution of the suspected recurrence. This case underscores the significance of performing a complete upper airway examination, including endoscopic examination, to identify structural and anatomical lesions in older children with SDB.

Endotracheal Intubation via Tracheotomy and Subsequent Thoracotomy in Rats for Non-Survival Applications.

Endotracheal intubation and subsequent ventilation are often basic requirements for translational research in rat models for various interventions that require controlled or high ventilation pressures or access to the thoracic cavity and organs. Conventional endoorotracheal intubation using the anatomically existing route through the mouth is well suited for survival experiments. However, this procedure poses some challenges, including generally higher levels of the required experience and technical skill, more advanced equipment, and greater time effort with relevant intubation failure rates and complications such as tracheal perforation, temporary systemic hypooxygenation, and relevant aerial leakage. This manuscript, therefore, presents a detailed step-by-step protocol for endotracheal intubation through tracheotomy in non-survival rat models when guaranteed intubation success, constant oxygenation levels, high ventilation pressures, or open thoracotomy are required. The protocol emphasizes the importance of meticulous surgical technique to ensure consistent and reliable outcomes, especially for researchers who are inexperienced or lack routine in the technique of endoorotracheal intubation via direct laryngoscopy. This procedure is, therefore, expected to minimize animal suffering and unnecessary animal losses.

Prediction of a Difficult Airway Using the ARNE Score and Flexible Laryngoscopy in Patients with Laryngeal Pathology.

Background and Objectives: The ARNE score was developed for the prediction of a difficult airway for both general and ear, nose and throat (ENT) surgery with a universal cut-off value. We tested the accuracy of this score in the case of laryngeal surgery and provided an insight into its effects in combination with flexible laryngoscopy. Materials and Methods: This prospective pilot clinical study included 100 patients who were being scheduled for microscopic laryngeal surgery. We calculated the ARNE score for every patient, and flexible laryngoscopy was provided preoperative. Difficult intubation was assessed according to the intubation difficulty score (IDS). Results: A total of 33% patients had difficult intubation according to the IDS. The ARNE score showed limited accuracy for the prediction of difficult intubation in laryngology with p < 0.0001 and an AUC of 0.784. Flexible laryngoscopy also showed limitations when used as an independent parameter with p < 0.0001 and an AUC of 0.766. We defined a new cut-off value of 15.50 for laryngology, according to the AUC. After the patients were divided into two groups, according to the new cut-off value and provided cut-off value, the AUC improved to 0.707 from 0.619, respectively. Flexible laryngoscopy improved the prediction model of the ARNE score to an AUC of 0.882 and of the new cut-off value to an AUC of 0.833. Conclusions: It is recommended to use flexible laryngoscopy together with the ARNE score in difficult airway prediction in patients with laryngeal pathology. Also, the universally recommended cut-off value of 11 cannot be effectively used in laryngology, and a new cut-off value of 15.50 is recommended.

Evaluation of a novel, low-cost, 3D printed video laryngoscope with borescope in anesthetized Beagle dogs.

OBJECTIVE: To develop and evaluate a low-cost three-dimensional (3D)-printed video laryngoscope (VLVET) for use with a commercial borescope. STUDY DESIGN: Instrument development and pilot study. ANIMALS: A total of six adult male Beagle dogs. METHODS: The VLVET consisted of a laryngoscope handle and a Miller-type blade, and a detachable camera holder that attached to various locations along the blade. The laryngoscope and camera holder were 3D-printed using black polylactic acid filament. Dogs were premedicated with intravenous (IV) medetomidine (15 µg kg-1) and anesthesia induced with IV alfaxalone (1.5 mg kg-1). The VLVET, combined with a borescope, was used for laryngeal visualization and intubation. Performance was evaluated by comparing direct and video-assisted views in sternal recumbency. The borescope camera was sequentially positioned at 2, 4, 6, 8 and 10 cm from the blade tip (distanceLARYNX-CAM), which was placed on the epiglottis during intubation or laryngoscopy. At the 10 cm distanceLARYNX-CAM, laryngeal visualization was sequentially scored at inter-incisor gaps of 10, 8, 6, 4 and 2 cm. Laryngeal visualization scores (0-3 range, with 0 = obstructed and 3 = unobstructed views) were statistically analyzed using the Friedman's test. RESULTS: Under direct visualization, the 2 cm distanceLARYNX-CAM had a significantly lower score compared with all other distanceLARYNX-CAM (all p = 0.014) because the view was obstructed by the camera holder and borescope camera. With both direct and camera-assisted views, visualization scores were higher at inter-incisor gaps ≥ 4 cm compared with 2 cm (all p < 0.05). CONCLUSIONS AND CLINICAL RELEVANCE: During laryngoscopy and intubation, the VLVET and borescope facilitated both direct and video laryngoscopy at distanceLARYNX-CAM in Beagle dogs when inter-incisor gaps were ≥ 4 cm.

Left head rotation (LeHeR), an innovative approach for intubation in patients with missing and loose teeth.

Missing and loose central incisors pose a great difficulty to anaesthesiologists during laryngoscopy and intubation. Left head rotation is a novel technique which facilitates intubation by improving the laryngoscopic view. We report the use of this technique in two patients with missing or loose central incisors to prevent dental trauma.

Determinants of difficult laryngoscopy based on upper airway indicators: a prospective observational study.

BACKGROUND: The main cause of anesthesia-related deaths is the failure to manage difficult airways. Difficult laryngoscopic exposure is a major cause of unsuccessful management of difficult airways. Inadequate preoperative airway assessment hinders the clinical management of difficult airways cases, emphasizing the critical need for accurate identification of difficult airways. Currently, no definitive and reliable indicators are available to predict a difficult airway. Our study aims to predict laryngoscope exposure risk factors by combining ultrasonically measured upper airway anatomic parameters with physical examination indicators. METHODS: Patients aged 18 to 75 years, classified as American Standards Association (ASA) I-III, and scheduled for elective general anesthesia with endotracheal intubation were included. All patients received the upper airway and ultrasonographic measurements. After anesthesia induction, laryngoscope exposure was analyzed using the Cormack-Lehane grading system, with Grades III and IV as indicative of difficult laryngoscopy. Univariate and multivariate logistic regression analyses were performed to identify reliable indicators for predicting difficult laryngoscopy. Receiver Operating Characteristic (ROC) curve analysis was utilized to assess the predictive performance of each indicator. RESULTS: A total of 1120 patients finished the study, with 710 cases found in Grade I laryngoscopic exposure group, 360 cases in Grade II group, and 50 cases in Grade III group. There was no case observed in Grade IV group, thereby resulting in an incidence of difficult laryngoscopy of 4.46%. Univariate logistic regression analysis revealed that several parameters including age, Body Mass Index (BMI), neck circumference, neck mobility, snoring intensity, as well as ultrasound measurements of the pre-epiglottic space and thyromental distance were identified as significant risk factors for difficult laryngoscopy (P < 0.05). Among these, BMI, and neck circumference exhibited notable predictive value, with Area Under The Curve (AUC) values of 0.746 (95%CI 0.649-0.842) and 0.732 (95%CI 0.638-0.827), respectively. Neck mobility was also identified as an independent risk factor for predicting difficult laryngoscopy (P = 0.009) in multivariate logistic regression analysis, with an AUC of 0.672 (0.562-0.782) in the ROC curve. CONCLUSIONS: Our findings revealed a direct correlation between difficult laryngoscopy and age, BMI, neck circumference, neck mobility, snoring intensity, as well as ultrasound measurements of the pre-epiglottic space and thyromental distance. Furthermore, neck mobility was identified as an independent predictive factor. TRIAL REGISTRATION: The trial was registered prior to patient enrollment at clinicaltrials.gov (register no. ChiCTR2100053826, Date of registration: November 30, 2021).

Comparison of the diagnostic and prognostic abilities of flexible laryngoscopy and dynamic digital radiography for vocal cord paralysis: A prospective observational study.

BACKGROUND: Although flexible laryngoscopy (FL) is the reference modality for diagnosing vocal cord paralysis (VCP), FL involves patient discomfort and insertion intolerance. Dynamic digital radiography (DDR) with high spatial and temporal resolution is easier to use and less invasive when evaluating VCP. METHODS: Seventy-eight patients underwent FL and DDR before and after neck surgery. Qualitative and quantitative vocal cord movement (VCM) evaluations were conducted. Patients with postoperative VCP were followed-up regularly. RESULTS: DDR exhibited diagnostic performance with 67% sensitivity and 100% specificity. The cutoff for VCM was 2.4 mm, with DDR exhibiting 100% sensitivity and 78% specificity. All cords with transient VCP had positive VCM at both 3 weeks and 2 months. Additionally, 50% and 75% of cords with permanent VCP had negative VCM at 3 weeks and 2 months, respectively. CONCLUSIONS: DDR is promising for the diagnosis of postoperative VCP and early prediction of permanent postoperative VCP.

A prospective, pragmatic non-inferiority study of emergency intubation success with the single-use i-view versus standard reusable video laryngoscope.

INTRODUCTION: Video laryngoscope (VL) technology improves first-pass success. The novel i-view VL device is inexpensive and disposable. We sought to determine the first-pass intubation success with the i-view VL device versus the standard reusable VL systems in routine use at each site. METHODS: We performed a prospective, pragmatic study at two major emergency departments (EDs) when VL was used. We rotated i-view versus reusable VL as the preferred device of the month based on an a priori schedule. An investigator-initiated interim analysis was performed. Our primary outcome was a first-pass success with a non-inferiority margin of 10% based on the per-protocol analysis. RESULTS: There were 93 intubations using the reusable VL devices and 81 intubations using the i-view. Our study was stopped early due to futility in reaching our predetermined non-inferiority margin. Operator and patient characteristics were similar between the two groups. The first-pass success rate for the i-view group was 69.1% compared to 84.3% for the reusable VL group. A non-inferiority analysis indicated that the difference (-15.1%) and corresponding 90% confidence limits (-25.3% to -5.0%) did not fall within the predetermined 10% non-inferiority margin. CONCLUSIONS: The i-view device failed to meet our predetermined non-inferiority margin when compared to the reusable VL systems with the study stopping early due to futility. Significant crossover occurred at the discretion of the intubating operator during the i-view month.