Ultrasonido como complemento en el manejo de la vía aérea / Ultrasound as a complement in the management of the airway

OBJECTIVE: To analyze the usefulness of ultrasound (US) as a complement to airway management. An overview of how to obtain a real-time airway ultrasound at the bedside is reviewed and the support for its use is checked against the evidence. MATERIALS AND METHODS: The search was carried out in Pubmed and Medline, yielding 722 articles of interest with different levels of evidence. The literature search was limited to studies conducted in humans, published in English and Spanish between August 2011 and August 2021.35 articles were included in this review. DISCUSSION: The usefulness of ultrasound in the evaluation and management of the airway is analyzed: predictors of difficult airway; cervical airway access; confirmation of tracheal intubation; calculation of endotracheal tube (ETT) size and depth. CONCLUSIONS: Airway ultrasound could be a useful tool for anesthesiologists, emergency physicians and intensivists, which could help improve patient care and safety. However, more research is needed to validate its use.

OBJETIVO: Analizar la utilidad del ultrasonido (US) como complemento al manejo de la vía aérea. Se revisa una descripción general de cómo obtener una ecografía de la vía aérea en tiempo real a la cabecera del paciente y se coteja el respaldo de su utilización con la evidencia. MATERIALES Y MÉTODOS: La búsqueda se realizó en Pubmed y Medline, arrojando 722 artículos de interés con distinto nivel de evidencia. La búsqueda bibliográfica se limitó a estudios realizados en humanos, publicados en inglés y español entre agosto de 2011 y agosto de 2021. Se incluyeron 35 artículos en esta revisión. DISCUSIÓN: Se analiza la utilidad del ultrasonido en la evaluación y manejo de la vía aérea: predictores de vía aérea difícil (VAD); acceso cervical de la vía aérea; confirmación de intubación traqueal; cálculo de tamaño de tubo endotraqueal (TET) y profundidad de éste. CONCLUSIONES: El ultrasonido en la vía aérea podría ser una herramienta útil para anestesiólogos, emergenciólogos e intensivistas, que podrían ayudar a mejorar la atención y la seguridad del paciente. Sin embargo, se necesitan más investigaciones para validar su uso.

Caracterización de estructuras anatómicas de la laringe por ultrasonografía / Characterization of anatomical structures of the larynx by ultrasonography

La laringe es un órgano impar situado en la línea mediana del cuello, compuesto por cartílagos, músculos y ligamentos. La TC y la RM se realizan como técnicas de imagen de primera elección en el estudio de la laringe, no obstante, no están exentas de limitaciones. La ecografía es un método accesible, de alta resolución y presenta una relativa buena visualización de las diferentes estructuras de la laringe. El objetivo del trabajo fue determinar las características de estructuras anatómicas de la laringe identificables ecográficamente. En este trabajo de carácter observacional descriptivo de corte transversal prospectivo se estudiaron 20 pacientes, sin patología laríngea con edades entre 20 y 35 años, ambos sexos. Se realizó ecografía laríngea utilizando transductor ecográfico Phillips® con sonda lineal de 4 a 12 MHz, preset de partes blandas.En todos los casos se pudo identificar y medir los cartílagos tiroides, cricoides y epiglotis; y en gran porcentaje de estos las cuerdas vocales, bandas ventriculares y comisura anterior. El cartílago aritenoides solo fue visible en un 85% de los casos.La ecografía se presenta como un método auxiliar útil en el estudio de la anatomía de la laringe, proponiendo el seguimiento y realización de estudios ulteriores que puedan complementar este estudio y su validez.

The larynx is an odd organ located in the midline of the neck, composed of cartilage, muscles and ligaments. CT and MRI are performed as first-choice imaging techniques in the larynx study; however, they are not without limitations. Ultrasound is an accessible, high-resolution method with a relatively good visualization of the different structures of the larynx. The objective of the work was to determine the characteristics of ultrasoundly identifiable larynx anatomical structures.In this prospective cross-sectional descriptive observational work, 20 patients were studied, without laryngeal pathology aged between 20 and 35 years, both sexes. Laryngeal ultrasound was performed using Phillips® ultrasound transducer with linear probe from 4 to 12 MHz, soft parts presetThyroid cartilage, cricoids and epiglotis could be identified and measured in all cases, and in a large percentage of these the vocal cords, ventricular bands and anterior corner. Aritenoid cartilage was only visible in 85% of cases.Ultrasound is presented as a useful auxiliary method in the study of the anatomy of the larynx, proposing the follow-up and conduct of further studies that may complement this study and its validity

Computed tomographic and radiologic anatomy of the lower respiratory tract in the red-foot tortoise (Chelonoidis carbonaria) / Anatomia radiológica e por tomografia computadorizada do trato respiratório inferior no jabuti-piranga (Chelonoidis carbonaria)

The diagnosis of several diseases in chelonians is a challenge in the veterinary clinic, because a detailed physical examination with auscultation and palpation is difficult due the presence of carapace and plastron. Imaging analysis such as radiography and computed tomography (CT) have been shown to be beneficial for diagnosis, prognosis and treatment in numerous animal species. Thus, this study aimed to identify and describe the structures of the lower respiratory tract in red-foot tortoises, by computed tomography, radiography and gross anatomy in twelve red-foot tortoises (Chelonoidis carbonaria), adults and of both sexes. The lower respiratory tract in these animals comprised the larynx, trachea, bronchi and the lungs. The presence of epiglottic cartilage was not observed in the animals studied. CT allowed the observation of the intrapulmonary part of the bronchi, which was accompanied by large intrapulmonary blood vessels. The lungs presented a reticulated parenchyma, without lobulations. Each lung had a small chamber located near the cranial and caudal poles. These structures were identified in CT and 3D CT reconstructions and these could suggest that these chambers could be non-respiratory structures, and could be comparable to the air sacs of birds. This study establishes normal CT anatomy of the lower respiratory tract of the red-foot tortoise; and may be used as a reference in the assessment of respiratory disorders in this tortoise.(AU)

O diagnóstico de diversas afecções em quelônios é um desafio para a clínica veterinária, já que um exame físico detalhado com auscultação e palpação é difícil devido à presença da carapaça e do plastrão. A radiografia e a tomografia computadorizada (TC) tem se mostrado benéficas para o diagnóstico, prognóstico e tratamento em muitas espécies animais. Assim, este estudo teve por objetivo identificar e descrever as estruturas do trato respiratório inferior no jabuti-piranga por meio da tomografia computadorizada, radiografia e anatomia em 12 jabutis-piranga (Chelonoidis carbonara), adultos e de ambos os sexos. Nos animais estudados, o trato respiratório inferior consistiu da laringe, traqueia, brônquios e os pulmões. A cartilagem epiglote não foi observada. A TC permitiu a observação da parte intrapulmonar dos brônquios, a qual estava acompanhada dos vasos sanguíneos intrapulmonares. Os pulmões possuíam um parênquima reticulado, sem lobações. Cada pulmão tinha uma pequena câmara localizada junto aos pólos cranial e caudal. Estas estruturas foram identificadas na TC e na reconstrução 3D a partir da TC e poderiam ser estruturas não-respiratórias, podendo ser comparadas aos sacos aéreos das aves. Este estudo identificou a anatomia normal por meio da TC do trato respiratório inferior do jabuti-piranga, o que pode ser usado como referência para diagnóstico de desordens respiratórias nesta espécie.(AU)

Avaliação do volume das vias aéreas superiores conforme o padrão facial / Upperairway volume assessment accordingto facial pattern

Objetivo: analisar o volume da via aérea superior (VAS) em pacientes adultos saudáveis, a partir de exames de tomografia computadorizada de feixe cônico, comparando os padrões faciais esqueléticos I, II e III, considerando a idade e o sexo. Método: um estudo retrospectivo de análise do banco de dados de uma clínica radiológica, com uma amostra de 129 exames de face total em formato DICOM, datados de 2015 a 2018. Após a divisão da amostra em três grupos, conforme o padrão esquelético, as medidas volumétricas foram obtidas através do aplicativo ITK-SNAP versão 3.6.0, um processador gratuito de segmentação anatômica 3D. Resultados: a amostra foi separada em padrão I com 60 exames, padrão II com 48 exames e padrão III com 21 exames. O sexo feminino foi o mais frequente, com 69,8% (n = 90), e a média de idade foi definida em 35 anos. O volume médio geral foi de 22.774,2 mm³ e a média entre os padrões esqueléticos não apresentou diferença significante (p = 0,251), segundo o teste não paramétrico de Kruskal-Wallis (p < 0,05). Na análise do dimorfismo sexual, os homens apresentaram maior volume, com diferença estatística (p = 0,033) através do teste de Mann-Whitney. Conclusão: o volume médio da VAS entre indivíduos saudáveis com padrões faciais I, II e III não apresentou diferença significativa, apenas uma discreta variação, sendo o padrão III maior em 14,8% do que o padrão I. O sexo masculino se destacou com maior volume, e a variação da idade não teve correlação com o volume do espaço aéreo faríngeo.(AU)

Aims: Analyze upper airway volume in healthy adult patients from CBCT examinations, comparing skeletal facial patterns I, II and III, considering age and gender. Methods: A retrospective study of a radiological clinic database analysis, with a sample of 129 full-face DICOM exams, dated between 2015 and 2018. After dividing the sample into three groups, according to skeletal pattern, volumetric measurements were obtained through the application ITK-SNAP version 3.6.0, a free 3D anatomical segmentation process. Results: The sample was separated into pattern I with 60 exams, pattern II with 48 and pattern III with 21 exams. Females were the most frequent with 69.8% (n = 90) and the mean age was defined as 35 years. The overall mean volume was 22,774.2 mm³ and the mean between skeletal patterns showed no significant difference (p = 0,251), according to the nonparametric Kruskal-Wallis test (p < 0,05). In the analysis of sexual dimorphism, men presented higher volume, with statistical difference (p = 0,033) through the Mann-Whitney test. Conclusion: The mean upper airway volume among healthy individuals with facial patterns I, II and III showed no significant difference, only a slight variation, pattern III being 14.8% higher than pattern I. The male gender stood out with greater volume and the age variation had no correlation with the pharyngeal space volume.(AU)

Trauma laríngeo externo y fractura de cartílago tiroides: revisión de la literatura / External laryngeal trauma and thyroid cartilage fracture: a literature review

RESUMEN El trauma laríngeo constituye un grupo de lesiones infrecuentes, pero de gran importancia clínica dada su alta morbimortalidad. Requiere un alto nivel de sospecha, puesto que muchas de estas lesiones pueden pasar desapercibidas en la evaluación inicial. Se debe sospechar en todo paciente que se presenta con traumatismo cervical y síntomas que van desde la disfonía y el dolor cervical anterior, a la disnea e incluso el compromiso respiratorio severo por obstrucción de la vía aérea. El abordaje de estos pacientes debe iniciar con la evaluación de la vía aérea y asegurar su estabilidad, para luego enfocarse en el diagnóstico y manejo específico de las lesiones. Presentamos a continuación una revisión bibliográfica en cuanto a los mecanismos de trauma, presentación clínica, diagnóstico, clasificación y manejo.

ABSTRACT The laryngeal trauma constitutes a group of infrequent lesions, but with great clinical importance, given its high morbidity and mortality. It requires a high level of suspicion, since many of these injuries may go unnoticed at the initial evaluation. It should be suspected in every patient presenting with cervical trauma and symptoms ranging from dysphonia and anterior cervical pain, to dyspnea or even severe respiratory distress, due to obstruction of the airway. The approach of these patients should begin with the evaluation of the airway and ensure its stability, to then focus on the diagnosis and specific management of the lesions. We present an updated literature review regarding the mechanisms of trauma, clinical presentation, diagnosis, classification and management.

Radiologic Laryngeal Parameters in Acute Supraglottitis in Korean Adults

Soft-tissue lateral neck radiography is important for diagnosing acute supraglottitis. This study aimed to determine the objective criteria for a diagnosis of acute supraglottitis from soft-tissue lateral neck radiographs in Korean adults. The parameters in 30 adult patients with acute supraglottitis were compared with those of age- and sex-matched normal 30 Korean adults. The mean of epiglottis width (EW) and aryepiglottic fold width (AEW) in the control group were 4.37 +/- 0.93 mm, 2.45 +/- 0.71 mm, respectively and in the patient group they were 15.87 +/- 3.60 mm, 6.4 +/- 2.55 mm, respectively. The sensitivity and specificity of an EW greater than 7mm were 100%, and 100% respectively. The sensitivity and specificity of an AEW greater than 4.5 mm were 83%, and 100% respectively.

Endolaryngeal foreign bodies.

Unusual foreign bodies of the larynx viz. a toy gear, a metallic spring, a safety pin, a piece of stone, lodged in the endolaryngeal region are reported. Radiographic documentation with the rare feature of absence of symptoms inspite of lodgement for long duration is recorded.

A utilização da fonação inspiratória na caracterização das lesões benignas da laringe / The Use of Inspiratory Phonation t Characterize Laringeal Benign Lesions

Fonação inspiratória é a produção da voz na inspiração. Além de ser uma técnica fonoaudológica eficaz, tal manobra já foi empregada no auxílio diagnóstico de tumores do vestíbulo laríngeo. Objetivo: O objetivo do presente trabalho é utilizar a fonação inspiratória no diagnóstico clínico das lesões benignas das pregas vocais e verificar sua contribuição na identificação e caracterização das mesmas. Material e método: Foram submetidos ao exame 31 indivíduos com lesão de massa e disfonia. Após a emissão habitual das vogais durante o exame laríngeo, os pacientes foram solicitados a realizar a fonação inspiratória. Os dados das imagens gravadas nas duas formas de fonação, inspiratória e expiratória, foram comparados e analisados de acordo com diversos parâmetros. Resultados: Como resultados, pudemos observar que a fonação inspiratória contribuiu para o diagnóstico em 90,32% dos casos, auxiliando a definir melhor a lesão laríngea, particularmente na identificação de cistos nas pregas vocais, permitindo a localização nas camadas da lâmina própria. De modo geral, quanto mais superficial for a lesão, maior será a expansão da camada superficial da lâmina própria e melhor a visualização do ligamento vocal. Por outro lado, quanto mais profunda a lesão, menor ou ausente será a expansão observada na camada superficial da lâmina própria e menor a visualização do ligamento vocal. Conclusão: Desta forma, a utilização da fonação inspiratória contribuiu para o diagnóstico e caracterização das lesões da cobertura das pregas vocais, possibilitando precisar a localização da lesão e demonstrando que a integridade da mucosa é fundamental para a visualização do ligamento vocal.

Inspiratory phonation is the voice produced during inspiration. Besides being a powerful therapeutic technique, this strategy was already used to help in the identification of laryngeal vestibule tumors. Aim: The goal of the present study is to verify the contribution of inspiratory phonation for clinical diagnosis of laryngeal benign mass lesions. Material and method: Thirty-one participated at this study, - with mass lesions and vocal complaints. Patients were asked to do both normal expiratory sustained phonation followed by an inspiratory one. Both images were taped and selected parameters were thus analyzed. Results: The main results indicated that inspiratory phonation have contributed to diagnosis in 90,32% of the cases. Inspiratory phonation has helped to define the mass lesion, particularly when vocal cysts were considered, leading to define the location of the lesion on the lamina propria. The more superficial the lesion, the larger mucosal expansion obtained, the better the vocal ligament visualization. The deeper the lesion, the smaller mucosal expansion and sometimes no vocal ligament visualization at all. Conclusion: Therefore, inspiratory phonation for diagnostic purposes contributes to characterize vocal fold cover mass lesions, enhancing the ability to localize the lesion and to establish the integrity of the mucosa through the vocal ligament visualization.

Foreign body airway in neonates.

Two cases of foreign body in neonates less than one month of age are reported. Although foreign bodies in neonates are unknown but the possibility should not be overlooked even in neonates especially with sudden onset of respiratory distress, cough or hoarseness in absence of fever.

Laryngeal involvement in pulmonary tuberculosis

Fifty-one patients with established pulmonary tuberculosis underwent clinical evaluation and endoscopic examination, of the larynx to determine the manifestations of laryngeal involvement. There were 46 males and 5 females [mean age 38 years]. Fever, cough and haemoptysis were the prime pulmonary complaints while hoarseness, weak voice and episodic dyspnoea were the main laryngeal symptoms. Sites of laryngeal lesions included true vocal cords, arytenoids and false vocal cords. Oedema, pallor, ulcers, vocal cord immobility and thickening were the main laryngeal lesions observed. Twenty-four [47%] cases showed morphological changes in the larynx. The presentation pattern was consistent with the classical description and predilection for laryngeal involvement was not demonstrated