An Unknown Foreign laryngeal Object: an exotic complication of skull base osteoradionecrosis.

BACKGROUND: Osteoradionecrosis (ORN) of the skull base is a rare complication after head and neck radiation with a broad variety of subsequent complications. METHODS: A 68-year-old woman with a complex oncological history (right-sided sphenoid meningioma; left-sided neck metastasis of a Cancer of Unknown Primary-CUP) was admitted with a right-sided epi-/ oropharyngeal mass and severe pain exacerbations for further evaluation. CT scan revealed an advanced ORN of the skull base with subsequent abruption of the ventral part of the clivus. This dislocated part of the clivus wedged in the oropharynx for 48 h and then moved towards the larynx, resulting in dyspnea and almost complete airway obstruction. RESULTS: Due to the dangerous airway situation, an urgent exploration and removal of the dislocated clivus was necessary. After a potential cervical spine instability was ruled out, the patient's airway was initially secured with an awake tracheotomy and the clivus was removed transorally. The tracheostomy tube was removed during the ongoing inpatient stay, and the patient was discharged with significant pain relief. CONCLUSIONS: The present case illustrates an orphan complication of skull base ORN resulting in a major airway emergency situation.

Multi-institutional quality improvement case series: Pediatric airway emergencies leading to the creation of a pediatric otolaryngology airway cart.

To describe a specialty pediatric airway emergency cart developed as a multi-institutional quality improvement initiative for difficult pediatric intubations. This study was a retrospective case series at two academic tertiary care centers. Baseline data was compiled from consecutive difficult airway cases from 2018 to 2020 and presented to the performance improvement coordinating group to determine whether a specialty emergency airway cart would be of use. Implementation of a pediatric emergency airway cart was accomplished after presentation of these cases. To our knowledge, this is the first description of the use of a specialty pediatric airway cart to help in difficult airways requiring otolaryngologic assistance.

Management of neonatal difficult airway emergencies in the delivery room.

Neonatal airway emergencies in the delivery room are associated with significant morbidity and mortality. Etiologies vary, but often predispose the neonate to life threatening airway obstruction. With the recent expansion of fetal medicine programs, pediatric anesthesiologists are increasingly being asked to care for these patients. In this review, we discuss common etiologies of difficult airway at delivery, management tools and techniques, and surgical approaches.

Laryngeal handshake technique in locating the cricothyroid membrane: a non-randomised comparative study.

BACKGROUND: Evaluation of the anterior neck anatomy is used to identify the cricothyroid membrane (CTM) before front of neck airway access. This has been traditionally performed using palpation which results in misidentification of the CTM in a high proportion of subjects. The 'laryngeal handshake' is currently advocated by the Difficult Airway Society as the method to identify the CTM. We sought to investigate the accuracy of this technique in females. METHODS: Five clinicians were asked to identify the CTM using the 'laryngeal handshake' technique in a total of 45 anaesthetised females (Group L) and by conventional palpation in 45 controls (Group P). We measured and analysed the distance to actual CTM using ultrasound, the time to identification, and perceived difficulty using a visual analogue scale. RESULTS: Successful identification of the CTM occurred in 28/45 (62%) patients in Group L vs 15/45 (33%) in Group P [P=0.006; mean difference, 29%; 95% confidence interval (CI), 21-39%]. Distance to the CTM (P=0.012) and visual analogue scale (P=0.012) were significantly reduced in Group L. Mean time to CTM identification was greater in Group L at 31 (5.6) s, compared with Group P, which took 18 (5.5) s (P<0.001). The midline was accurately identified more frequently in Group L than in Group P (39/45 vs 28/45, P=0.008). CONCLUSIONS: The 'laryngeal handshake' method of palpation is more accurate but takes longer than conventional palpation technique in locating the CTM and the midline. This is of particular relevance if a vertical incision is required to perform front of neck access when anatomy is indistinct.

A Case of Photoimmunotherapy for Nasopharyngeal Carcinoma Requiring Emergency Tracheostomy.

Introduction: Photoimmunotherapy (PIT) is a treatment wherein intravenous cetuximab sarotalocan sodium is administered followed by laser light irradiation. This treatment exhibits a specific antitumor effect if in tumors expressing the epidermal growth factor receptor, regardless of the carcinoma [Mitsunaga et al.: Nat Med. 2011;17(12):1685-91, Sato et al.: ACS Cent Sci. 2018;4(11):1559-69, Nakajima et al.: Cancer Sci. 2018;109(9):2889-96]. The current indications are unresectable, locally advanced, or locally recurrent head and neck cancer. If standard treatments, such as radiotherapy and chemotherapy, are available, they are given priority. However, a significant concern in PIT is the occurrence of airway emergencies related to pharyngeal edema. Prophylactic tracheostomy is often performed in cases of PIT involving the root of the tongue, hypopharynx, or larynx. Case Presentation: In this study, we administered transoral PIT to a patient diagnosed with radiation-induced nasopharyngeal carcinoma (squamous cell carcinoma (SCC) cT1N0M0 stage I). Although previous case reports and our own experiences did not report airway emergencies following PIT for nasopharyngeal carcinoma, a unique case occurred in our study [Omura et al.: Auris Nasus Larynx. 2023;50(4):641-5, Kushihashi et al.: Int J Otolaryngol Head Neck Surg. 2022;11(5, Sep):258-65]. The patient experienced poor oxygenation and a decreased level of consciousness early in the morning following the laser irradiation. Nasal endoscopy revealed airway narrowing due to upper airway edema, and intubation was challenging. Consequently, we performed emergency bedside tracheostomy and the patient's condition improved. Conclusion: Therefore, it is crucial to note that airway emergencies can be life-threatening and should be diligently monitored as a potential complication of PIT.

Three Cases of Chemical Burns Caused Due to Dimethyl Sulfate Poisoning.

Dimethyl sulfate (DMS) is a drug widely used as a pharmaceutical and synthetic raw material. On the other hand, it is highly toxic and requires management and treatment as a hazardous substance. A mass outbreak of chemical burns resulting from DMS poisoning occurred at a drug factory. All three patients were brought to our hospital, a tertiary emergency medical facility, several hours after exposure. Their vital signs were stable, with only eye pain and a sore throat. However, after admission, two patients required emergency tracheostomy or endotracheal intubation due to laryngeal edema. Improvement was achieved through the administration of steroids, but a severely injured patient required an extended treatment period. DMS poisoning is rare; however, it can be fatal depending on the exposure concentration. Furthermore, even if the initial symptoms are mild, laryngeal edema may develop later, requiring careful monitoring and appropriate airway interventions.

A Foreign Body Aspiration Leading to Pneumothorax: A Case of Airway Emergency.

Foreign body (FB) aspiration is a matter that should not be taken lightly. The presence of a foreign object might lead to hazardous complications, particularly in the pediatric population. These complications depend on the type and location of the aspirated object as the tracheobronchial tree has a very small diameter, and foreign bodies become stuck in the upper airways of children, causing stridor and sudden difficulty in breathing. Impaction of a foreign body in the right bronchial tree is more frequent due to the relatively straighter alignment of the right mainstem of the trachea, as opposed to the left side. Herein, we present a 10-year-old Malay boy who accidentally aspirated a pencil cap. An urgent computed tomography (CT) of the thorax revealed a suspicious intraluminal FB in the bronchus leading to pneumothorax and pneumomediastinum. He underwent a right bronchoscopy and a successful FB removal.

Post-traumatic Delayed Bilateral Vocal Cord Paralysis Caused by Cervical Osteophytes: A Case Report.

Vocal fold paralysis occurs when the function of the vagus nerve or its distal branch, the recurrent laryngeal nerve, is diminished or absent. Bilateral vocal fold paralysis can present with varying degrees of severity and is sometimes fatal. Cervical osteophytes are a rare cause of bilateral vocal fold paralysis, with only a few cases reported. A 68-year-old man was brought to the emergency department because of a disturbance in consciousness following a fall. A CT scan of the head showed multiple cranium and brain injuries, and the patient was treated conservatively by neurosurgery. The day after the injury, dysphagia and dysarthria appeared. On the third day of admission, both vocal cords were fixed bilaterally in the paramedian position, and the patient was nearly choking on sputum. A CT scan showed that the intracranial lesions gradually improved, but the vocal cord paralysis remained. A cervical CT scan was performed to investigate the cause of the vocal cord paralysis, which revealed that cervical vertebral osteophytes were compressing the tracheoesophageal groove and the glottis. The patient was transferred to the hospital for rehabilitation, although bilateral vocal cord paralysis remained. Although rare, clinicians need to be aware that cervical osteophytes can cause vocal fold paralysis, which may be manifested when combined with further trauma. It is also important to note that traumatic vocal cord paralysis can be delayed.

Anesthetic Management of a Broken Tracheostomy Tube Stem as a Foreign Body in the Trachea: A Case Report.

Tracheostomy is commonly performed in patients to secure the airway. There are known early and late complications related to tracheostomy. Few case reports have described the rupture of the stem of the tracheostomy tube and its migration into the tracheobronchial tree. Here we describe a pediatric case with a broken stem of the tracheostomy tube in the trachea, acting as a foreign body and causing mild respiratory distress. The patient was successfully managed with neck exploration under general anesthesia using a supraglottic airway device in low-resource settings. In addition, we have described the potential problems that may be faced while managing the airway of such patients and how to deal with these complications.

Two Cases of Emergency Tracheostomy After Head and Neck Photoimmunotherapy.

Background/Aim: Head and neck photoimmuno-therapy (HN-PIT) has been an insured treatment in Japan for approximately three years. The number of treatments has gradually increased to over 350 cases. However, there are still various questions in actual clinical practice, including laryngeal edema. Therefore, it is vital to carefully explain in advance to patients the possibility of laryngeal edema occurring and obtaining consent for tracheostomy as a prophylactic or emergency measure. At our institution, 44 HN-PIT cycles were performed in 23 patients between January 2021 and October 2023. Of these, we experienced two cases in which preventive tracheostomy was not performed because the risk of laryngeal edema was considered low; however, laryngeal edema developed after treatment, and an emergency tracheostomy had to be performed. Case Report: Case 1 was a patient in his 70s with a local recurrence of mandibular gingival carcinoma. HN-PIT using cylindrical diffusers was performed on the target lesion, extending from the lateral wall of the oropharynx to the soft palate. Case 2 was also a patient in his 70s with carcinoma of the mid-pharynx. HN-PIT was performed using a frontal diffuser to target lesions extending from the soft palate to the buccal mucosa. Notably, both patients developed laryngeal edema after HN-PIT, and an emergency tracheostomy had to be performed. Conclusion: HN-PIT treatment is still being established through a trial-and-error method and is still incomplete.

Can't intubate, can't oxygenate? What is the preferred surgical strategy? A retrospective analysis.

INTRODUCTION: Cricothyrotomy (CTM) is currently recommended as the preferred method due to its ease, speed, and safety in life-threatening airway emergencies where standard tracheal intubation and mask ventilation fail. MATERIAL AND METHODS: This retrospective study analyzed 33 cases of "can't intubate, can't oxygenate or ventilate" (CICOV): 12 of percutaneous dilatational tracheostomy (PDT) and 21 of CTM. The CTM group was younger (median age 44) and mainly consisted of trauma patients. The PDT group was more diverse and procedures were performed by anesthesia and critical care consultants. RESULTS: Initial success rates were 100% for PDT (12/12) and 86% for CTM (18/21), with one conversion from CTM to PDT. No perioperative complications occurred in the PDT group, while the CTM group experienced two cases of false tracts requiring re-do and three cases of bleeding. Immediate mortality within 24 hours was reported in 5/19 CTM patients and none in the PDT group. Successful liberation from mechanical ventilation at hospital discharge was achieved in 6/12 PDT patients and 11/21 CTM patients. Among the 21 CTM cases, all 16 survivors underwent subsequent tracheostomy. Tracheal decannulation occurred in 4/12 PDT patients and 10/21 CTM patients. Favorable immediate neurological outcomes (GCS ≥ 11T) were observed in 8/12 PDT patients and 8/21 CTM patients, while 3 PDT patients remained anesthetized until death and 7 CTM patients died within the first 72 hours without recovery attempts. CONCLUSIONS: In experienced hands, PDT could be a legitimate clinical option for the surgical airway in cases of CICOV. CTM may be more suitable for practitioners who encounter CICOV infrequently.

Life-threatening Airway Complication After Radioactive Iodine Treatment: A Case Report and Review of the Literature.

BACKGROUND/AIM: Radioactive iodine (RAI) treatment is a cornerstone of treatment of differentiated thyroid carcinoma. Although serious RAI-related complications are uncommon, there have been reports of airway emergencies. Here, a life-threatening airway complication after RAI treatment is reported and previously reported cases are reviewed. CASE REPORT: A 79-year old man with Hürthle cell carcinoma and a remnant thyroid lobe after surgery developed an edema compromising the airway two days after receiving radioactive iodine treatment. An emergency awake intubation and tracheostomy were performed. He could be successfully de-cannulated 17 days later with no long-term complications. CONCLUSION: Although rare, life-threatening airway complications after radioactive iodine treatment, especially with high dose treatment in patients with remaining thyroid tissue, can occur and these patients should be supervised where these complications can be managed.

Uncovering a Novel Site of Ewing's Sarcoma: the Hypopharynx.

Ewing's sarcoma is usually seen in bones but 20-30% are found in extra skeletal soft tissues like in head and neck region. We present the case of Ewing sarcoma of hypopharynx in a 1 year old child who presented to us with acute respiratory distress. Child was intubated using videolaryngoscope and mass was removed using microdebrider. Final histopathological examination revealed Ewing sarcoma. EWSR1 gene rearrangement studies were advised, which the patient refused. Post-operative patient was started on adjuvant chemotherapy. PET CT after 2 months showed no FDG avid lesions within or elsewhere in the region of the body surveyed. There is no case of Ewing's sarcoma in hypopharynx reported to date. The clinical presentation, management and outcome has been discussed with a review of the literature.

Quality Improvement of Pediatric Airway Emergency Carts: Standardization, Streamlining, and Simulation.

Objective Pediatric airway emergencies are amongst the most tenuous scenarios faced by on-call providers, requiring quick access to the appropriate equipment and a timely response. In the present study, we report on the testing and improvement of pediatric airway carts at our institution. The primary objective was to optimize our pediatric airway emergency carts to improve response times. Secondarily, we aimed to implement a training scenario to improve providers' familiarity and confidence in attaining and assembling equipment. Methods Surveys of airway cart configuration at our hospital and others were used to identify differences. Volunteer otolaryngology physicians were tasked with responding to a mock scenario using an existing cart or one modified based on the survey. Outcomes included (1) time to arrival of the provider with the appropriate equipment, (2) time from arrival to complete assembly of equipment, and (3) time for re-assembly of the equipment. Results The survey revealed differences in cart equipment and location. The inclusion of a flexible bronchoscope and a video tower, as well as the placement of the carts directly within the ICU, resulted in improved time to arrival by an average of 181 seconds, and improved equipment assembly time by an average of 85 seconds. Discussion Standardization of pediatric airway equipment on the cart and location near critically ill patients improved response efficiency. Simulation led to improved confidence and reduced reaction time among providers at all levels of experience. Conclusion The present study provides an example for the optimization of airway carts, which can be adapted by healthcare systems to their local milieu.

The Adult Epiglottitis Enigma: A Case Report.

Adult epiglottitis, once primarily associated with pediatric populations, has emerged as a distinctive clinical entity with potentially life-threatening implications. This condition is characterized by inflammation and swelling of the epiglottis, presenting initially as a seemingly benign sore throat and dysphagia but progressing rapidly to more severe symptoms such as drooling, severe odynophagia, hoarse voice, and acute upper airway obstruction. Timely diagnosis and intervention are paramount, as delayed presentation can result in fatal outcomes even in adults. The cornerstone of treatment involves securing the airway, providing supplemental oxygen, and administering intravenous antibiotics. In this report, we present a case of adult epiglottitis in a 20-year-old individual, discussing the clinical presentation, diagnostic considerations, and the essential components of its management. Recognition of adult epiglottitis as a distinct clinical entity is crucial for healthcare practitioners to ensure prompt intervention and optimize patient outcomes.

Preventing unrecognised oesophageal intubation.

Major harm from unrecognised oesophageal intubation continues, despite the 2018 Royal College of Anaesthetists' 'no trace, wrong place' campaign. It is likely that publicly reported cases represent a fraction of real occurrences. This article summarises a 2022 consensus guideline on the prevention of unrecognised oesophageal intubation from the Project for Universal Management of Airway and international airway societies. The guideline is written for all airway operators and assistants, in any clinical setting, and readers are advised to deepen their understanding by studying the original guideline. The recommendations include how to avoid and recognise oesophageal intubation as well as a set of logical actions to take when it is a plausible possibility, even if it is not suspected. The guideline emphasises the importance of videolaryngoscopy, capnography and oxygen saturation monitoring for all tracheal intubations, wherever performed. It introduces the concept of sustained exhaled carbon dioxide, which is central to identifying oesophageal intubation, and acting to prevent progression to unrecognised oesophageal intubation. In the absence of sustained exhaled carbon dioxide, the default action is to remove the tube. This will mean some tracheal placed tubes are removed but based on a risk-benefit analysis, this is desirable. The tube should only be left in place if there is clear danger in removing it and in this event, its position should be confirmed, using repeat videolaryngoscopy plus one other of bronchoscopy, skilled ultrasound or use of an oesophageal detector device. The importance of human factors is underlined; for instance, the value of a shared and vocalised report of videolaryngoscopy view and trained assistants working with the operator to confirm whether the criteria for sustained exhaled carbon dioxide are met, to minimise error and improve team working.

General Overview of the Facial Trauma Evaluation.

The initial evaluation of maxillofacial trauma in athletes should first focus on the management of life-threatening injuries that require emergent care. Airway, breathing, and circulation are the 3 areas to be addressed first and foremost, as set forth by Advanced Trauma Life Support (ATLS) guidelines. Following the stabilization of the patient, a thorough physical examination and systematic review of any relevant imaging studies are imperative to ensure that injuries are not missed. Ultimately, management by the facial plastic surgeon should balance the goals of facial trauma restoration with the overall needs of the patient.

Airway Emergencies Due to Anterior Mediastinal T-Lymphoblastic Lymphoma Managed With Planned Extracorporeal Membrane Oxygenation and Endotracheal Stent: A Case Report and Literature Review.

Anterior mediastinal tumors can occasionally cause acute respiratory failure by compressing the trachea and bronchi. In such cases, sedative muscle relaxants during tracheal intubation can cause fatal complete tracheal obstruction. We encountered a 15-year-old male patient with T-lymphoblastic lymphoma (T-LBL) of the anterior mediastinum. For his airway emergency due to the stenosis extended from the lower part of the trachea to the tracheal bifurcation, venovenous (VV) extracorporeal membrane oxygenation (ECMO) was introduced from the femoral vein under local anesthesia. After a short period of tracheal intubation management, an endotracheal stent (ES) was immediately placed in the lower trachea. We performed a needle biopsy, and he was diagnosed with T-LBL. Following the diagnosis, chemotherapy was introduced. The ES was able to secure sufficient tracheal diameter, and ECMO and ventilation were promptly discontinued. In the case of tracheal stenosis from the lower part of the trachea due to anterior mediastinal tumor, depending on the degree of stenosis, VV ECMO can be considered. Moreover, ES can lead to early weaning from VV ECMO and a ventilator.

Lava Lamp-Induced Methemoglobinemia in Dementia: A Case Report.

An elderly patient with progressive dementia presented with nonspecific symptoms of fatigue, skin discoloration, shortness of breath, and altered mental status. She quickly developed respiratory failure requiring emergent endotracheal intubation. Initial laboratory results revealed methemoglobinemia levels greater than 30% with blood appearing black in hue. The etiology of her acute symptoms and the inciting substance of the disease was an ongoing discussion with the patient's family, which ultimately revealed accidental ingestion of lava lamp fluid as the cause. Although rare, methemoglobinemia is a medical emergency requiring prompt diagnosis and treatment. When a thorough history fails to reveal a possible source, alternative origins should be investigated, such as household products.

Multiple Wasp Stings on a Child's Supraglottis.

Hymenoptera stings are notorious for producing severe anaphylaxis; localized effects (edema, erythema) are far more common, especially in children. However, even an innocent focused lesion may be life-threatening when the sting is directed to the airway. We present the case of a child enduring consecutive wasp stings on the supraglottis.