Dimensions of the cricoid cartilage and the trachea.

OBJECTIVE: Important dimensions of the cricoid cartilage and trachea have been studied. Knowledge of size, variations in size, and configuration of these structures is important when tracheal intubation, stenting, endoscopy, and transplantation are to be performed. METHODS: In 34 male and 27 female adult human specimens, 1,861 measurements of the cricoid cartilage and trachea were performed. RESULTS: The smallest dimension was found in the frontal plane. The mean inner diameter of the cricoid in this plane with mucous membrane in situ was in women 11.6 mm (range, 8.9-17.0 mm) and in men 15.0 mm (range, 11.0-21.5 mm). The configuration varied more than expected. For example, the angle between the longitudinal axes of the cricoarytenoid joint facets ranged from 42 degrees to 74 degrees in women and from 37 degrees to 75 degrees in men. The mean distance between these joint facets was 10.3 mm (range, 7.4-13.0 mm) in women and 12.6 mm (range, 8.0-18.2 mm) in men. The cross-section of the trachea varied much in configuration, the smallest frontal diameter being as little as 9.9 mm in women and 12 mm in men. CONCLUSIONS: In some women the inner diameter of the cricoid ring does not permit passage of a standard-size (7 mm, internal diameter [ID]) tracheal tube or a standard-size rigid endoscope through the larynx without mucosal damage. The small distance between the cricoarytenoid joints in many women and some men is the basis for of the clinical observation that women, especially, receive pressure necroses at the medial sides of the arytenoid cartilages attributable to tracheal intubation with standard tubes. The large difference in almost all sizes and shapes of the cricoid cartilage and trachea makes it impossible to standardize the rigid stents used in these organs. When transplantation to the larynx is planned, this variation of the anatomy must be considered.

Laryngologic management of infants with the Chiari II syndrome.

As a part of a prospective multi-disciplinary study, all children born with a Chiari II malformation within the Uppsala region during a 3-year period were evaluated for any difficulties in breathing or swallowing. The evaluation was repeated at regular intervals during their first 18 months. Direct laryngoscopies were performed using flexible fiberscopes. Four out of 22 children were found to have disturbed breathing. Among those, two suffered from central apnoeic spells as well as bilateral vocal fold motion impairment, one from apnoeic spells only and one from bilateral vocal fold motion impairment only. All four also had dysphagia with aspiration. Three of the children developed respiratory symptoms within the first 3 months and the symptoms of the fourth begun within the first 6 months. One infant with severe symptoms expired at the age of 3 months. The vocal fold paralysis, apnoeic spells and swallowing difficulties of another infant resolved following active neurosurgical management. The conclusion that laryngologic issues are prominent in the severe Chiari II syndrome was further supported by a review of four more cases managed in recent years. Laryngologic assessment in the neonatal period can help to raise the issue of early neurosurgical intervention as well as identify some of the infants who will need extensive habilitation. Screening of laryngeal function by means of flexible fiberoptic laryngoscopy is recommended.

Long-term follow-up of patients with obstructive sleep apnea treated with uvulopalatopharyngoplasty.

OBJECTIVE: To study the long-term outcome after treatment with uvulopalatopharyngoplasty (UPPP). DESIGN: Long-term follow-up (4-8 years) with polysomnography. SETTING: Referral center for patients with sleep-disordered breathing. PATIENTS: Thirty-four consecutive patients of whom 25 (22 men and 3 women; mean age, 49 years) participated in the follow-up. All patients had obstructive sleep apnea syndrome. INTERVENTION: Uvulopalatopharyngoplasty. MAIN OUTCOME MEASURES: Symptoms and apnea-hypopnea index (AHI) before and after UPPP. Response to treatment defined as a 50% or more reduction in AHI and a postoperative AHI of 10 or less. RESULTS: Reduced prevalence of snoring and daytime sleepiness and reduction in AHI (mean [+/-SD], 40 +/- 26 to 21 +/- 21) at follow-up (P < .001). Sixteen patients (64%) were responders after 6 months and 12 (48%) at the long-term follow-up. Responders had a lower preoperative AHI (25 +/- 7) than did nonresponders (48 +/- 29) (P < .05). None of the 7 patients with preoperative AHI of more than 40 were responders (P < .01). No difference was seen in preoperative body mass index, lung function, ventilatory response to carbon dioxide, computed tomography scan of upper airways, or change in body mass index between responders and nonresponders. CONCLUSIONS: Four to 8 years after UPPP, about half of our patients were clinically and objectively improved. Uvulopalatopharyngoplasty should be reserved for patients with mild or moderate obstructive sleep apnea. After UPPP, long-term follow-up is recommended because some initially successfully treated patients will relapse in the long term.

Prognostic factors for tumour response and skin damage to combined radiotherapy and hyperthermia in superficial recurrent breast carcinomas.

Prognostic factors for complete tumour response and acute skin damage to combined hyperthermia and radiotherapy were analysed in material of patients with breast cancer, recurrent in previously irradiated areas. Radiotherapy was given daily to a total absorbed dose of 30.0 Gy in 2 weeks or 34.5 Gy in 3 weeks. The first radiotherapy schedule was combined with heat twice weekly, a total of four heat treatments (schedule A). The second radiotherapy schedule was combined with heat either once or twice a week resulting in a total of three (schedule B) or six (schedule C) heat treatments. Heat was induced with microwaves (2450, 915 or 434 MHz) via external applicators and always given after the radiotherapy fraction. The complete response (CR) rate in evaluable patients was 71% (49/69). There was no significant difference in CR rate between the three different hyperthermia schedules. The CR rates were 74% (14/19), 65% (15/23) and 74% (20/27) for schedules A, B and C respectively. The only factor predicting CR, evaluated both uni- and multivariately, was the CRE-value for the present radiotherapy dose (p = 0.02). If only tumours treated with 915 MHz were taken into account, however, then the highest minimum temperature at a given heat session predicted complete response (p = 0.03). This was true also in a multivariate analysis of this subgroup of tumours. A Kaplan-Meier analysis (log rank test) showed no significant difference in duration of CR between the different treatment schedules. Cox's proportional hazards method revealed three significant factors: tumour size (negatively correlated, p = 0.007), the time interval between the diagnosis of the primary tumour and the present treatment (p = 0.02) and the average temperature (0.03). Maximum acute skin reactions in the treatment field were scored according to an ordinal scale of 0-8, modified after WHO 1979. Twenty-six treatment areas (32%) expressed more severe skin damage (score > or = 5) in terms of desquamation with blisters (14%) and necrosis or ulceration (19%). Factors correlated with skin damage were the size of the lesion area (p = 0.011), the highest average maximum temperature during a given heat session (p = 0.03) and the fractionation schedule of hyperthermia (p = 0.05). The extent of previous radiotherapy absorbed dose, previous surgery in the treated area or previous chemotherapy had no significant influence on the acute skin reactions.

Pathophysiology of laryngotracheal stenosis. Some important anatomical dimensions.

Three principal effects, increased resistance to air flow, blockage of mucociliary transport mechanism and impaired voice quality are discussed.

Granular cell tumour in a child's trachea--a diagnostic and therapeutic challenge.

Granular cell tumours (GCT) are uncommon benign neoplasms of neurogenic origin, only rarely occurring in the trachea. This report describes a 12-year-old boy suffering from progressing dyspnea. A GCT, located both intra- and extraluminally in the lower cervical trachea, was diagnosed by CT scan and endoscopy. The airway was secured primarily by a low tracheotomy after institution of a femorofemoral bypass in the face of inadequate oxygenation and secondarily by tracheal resection and end-to-end anastomosis.

Ventilation with rigid bronchoscopes. Evaluation of resistance by pressure drop by a proposed international standard.

UNLABELLED: The ISO 8600-2-1 draft standard concerns measuring methods for ventilation properties in rigid bronchoscopes. Two lung models were designed in accordance with this draft, one for conventional ventilation, and the other for jet-ventilation (venturi ventilation). Lung model I: An air supply was connected to a 4 liter container. The test object (bronchoscope) was exposed to air flowing out of the container through the bronchoscope, and the pressure in the container was recorded. The flow velocities were 20-60 l.min-1. Lung model II: A pressure gauge was connected to a 2 liter container. The test object was introduced into the container through an gastight opening. A pressure gas injector was connected to either the instrument port or the ventilation port of the bronchoscope. The injected pressures were 100-500 kPa. RESULTS: Study I. The pressure drop increased exponentially with increasing air flow. It also increased rapidly with decreasing diameter of the bronchoscope. Study II. The pressure in small bronchoscopes increased very fast with increasing injection pressure. Dangerous pressures (above 50 cmH2O) were reached already at 2 kg.cm-2 with the smallest bronchoscopes. We suggest that the results should be given as "pressure drop" and not as "resistance".

Excessive daytime sleepiness and fatigue in nonapnoeic snorers: improvement after UPPP.

Even in the absence of sleep apnoea, heavy snoring may be a cause of excessive daytime sleepiness (EDS) and fatigue. The aim of this investigation was to study whether uvulopalatopharyngoplasty (UPPP) is effective in relieving snoring and excessive daytime sleepiness in nonapnoeic snoring patients. UPPP was assessed in 155 nonapnoeic, snoring patients (136 men and 19 women, mean age 45 yrs). Postoperative evaluation was made after 3 months in 105 patients, and after 12 months in 50 patients. Fifty four patients were evaluated after both 3 and 12 months. In 49 patients, a further evaluation was made after 2 yrs. The results were compared with those of 76 conservatively-treated, nonapnoeic, snoring patients, who were reinvestigated 12 months after their initial examination. The proportion of patients with frequent loud snoring had decreased postoperatively from 96 to 18%. A highly significant improvement was reported in EDS and daytime fatigue. The proportion of patients who reported problems staying awake when driving had decreased from 29 to 7%, and the number who felt rested when awakening in the morning had increased from 23 to 78 after the operation. The patients in the UPPP group had somewhat more severe symptoms before treatment than those treated conservatively. One year after treatment the situation had been reversed, with significantly more snoring and excessive daytime sleepiness in the conservatively-treated group. In conclusion, these results indicate that UPPP is effective in relieving snoring and EDS in nonapnoeic snorers.

Epithelioid leiomyoma of the larynx.

We describe the pathological features of a case of laryngeal epithelioid leiomyoma (leiomyoblastoma) which, to our knowledge, is the second case to be reported in the world literature. A review of the literature confirmed that leiomyoma as such is a very rare neoplasm in the larynx, and only 33 cases have been previously reported. The neoplasm was located in the left vocal cord and consisted of mainly epithelioid, round or spindle-shaped cells, often with clear cytoplasm, which were arranged predominantly in solid nests and sheets. The tumour cells showed positive immunoreactivity for smooth muscle actin and desmin. The tumour showed low mitotic activity and immunostaining with MIB 1 (Ki-67) accordingly revealed the occasional cell only to be positive, confirming a low proliferative activity in agreement with a benign neoplasm. Epithelioid leiomyomas located in other sites have been shown to act occasionally in a malignant fashion, and the necessity for careful long-term follow-up of the patient is therefore emphasized.

Vocal fold lateralization using carbon dioxide laser and fibrin glue.

Lateralization of one or both vocal folds is a generally accepted surgical principle for the relief of the airway obstruction caused by bilateral vocal fold paralysis. A modified, entirely endoscopic method of lateralization has been developed, employing a carbon dioxide laser to reduce the bulk of the fold, and fibrin glue to maintain the lateral position. The results of 18 operations on 15 patients, including six who had unsatisfactory results after previous surgery, were analyzed and compared retrospectively with the results from 22 patients operated on before the introduction of the method. The patient's ability to perform everyday activities improved in 12 cases, which paralleled the results of the previous, more cumbersome methods. The incidence of re-operation was comparable, given the shorter follow-up after the more recent method.

Mucociliary transport with and without the use of a heat and moisture exchanger. An animal study.

The importance to mucociliary transport (MCT) and the condition of the mucus of using a heat and moisture exchanger (HME) was investigated. A high tracheotomy was performed on 10 young pigs. The animals were ventilated using a non-breathing system. In five animals an HME was used; the other five were connected directly to the ventilator circuit. After 6 h the trachea was inspected via a flexible bronchoscope. Mucociliary transport velocity was measured using Tc-99-marked macrospheres and a gamma camera. In the control group the tracheal mucus membrane was desiccated at half the distance from the tube tip to the bifurcation. In the HME group the entire trachea was well moistened, but two cases showed large amounts of abnormally thin and foamy secretion. Mucus quality differed significantly between the two groups. Maximum MCT velocities were 8.3 +/- 4.6 and 4.9 +/- 3.0 mm/min for the HME- and the control groups, respectively. The marker had moved 49 +/- 32 and 35 +/- 21 mm during 24 min. Neither of these differences was statistically significant. In the control group there was no transport over desiccated areas. We conclude: 1) the quality of tracheal secretion differed significantly between the two groups, and 2) a heat and moisture exchanger may retain too much water in the airway.

Symptoms in heavy snorers with and without obstructive sleep apnea.

Five hundred and eighty persons who were heavy snorers filled in a questionnaire regarding symptoms on a 5-grade scale. Of these, 178 had a complete polysomnography investigation while 402 patients underwent oxymetric screening during the night only. On the basis of these investigations. 217 were classified as suffering from the obstructive sleep apnea syndrome (OSAS) and 363 as snorers without OSAS. The symptom scores differed between the two groups, but the range was wide and some persons with OSAS claimed only minor daytime sleepiness, somnolence, etc., while a high proportion of persons without OSAS frequently suffered from such symptoms. Thus, it was not possible to discriminate between patients with and without OSAS on the basis of their symptoms only. Furthermore, there are many persons who are "only" heavy snorers but who have symptoms that affect their career and social life and who so far have only received scant interest from the medical profession. Excessive daytime sleepiness and somnolence thus do not seem to be secondary to hypoxemia at night but rather to poor quality of sleep, which may be the case in association with heavy snoring even without appreciable deterioration of oxygen saturation.

Heat and moisture exchangers and the body temperature: a peroperative study.

The importance of conditioning the inhaled gas for maintaining the body temperature during artificial respiration was investigated. The mean body temperature (MBT) was deduced from readings from five measuring sites, four of which were situated at the skin and the fifth in the rectum. Temperature recordings were made every 15th min. Twenty patients were admitted to the study. In 10 patients a heat and moisture exchanger was used (the HME group), and the other 10 were ventilated without an HME (the control group). The patients were normoventilated, and a non-rebreathing system was used. All operations were made in the ENT-region of the body. Great care was taken to avoid variation of external factors that may affect the MBT. We found that the MBT decreased 0.2 degrees C/h less in the HME group than in the control group. If corrections were made for differences in amounts of fluids given and age factors, a difference in heat loss of 41.6 kJ/h between the two groups could be derived from this figure. This difference was statistically significant. Our finding correlated fairly well with a predicted reduction of heat loss of 26.0 kJ/h for the type of HME used. A certain margin of error seemed to be inevitable in measuring body temperatures, and the reason for this is discussed. Our results support the fact that the investigation is adequately designed, and that the heat conserved with an HME is rather low.

Performance evaluation of six heat and moisture exchangers according to the Draft International Standard (ISO/DIS 9360).

Six commonly available heat and moisture exchangers (HMEs) were tested according to a draft ISO standard for evaluating these devices (ISO = The International Organization for Standardization). The devices tested were: Pall Ultipor Filter, Mallinckrodt Inline, Siemens Servo 152, Engström Edith, Triplus Icor, and Portex Humid Vent 1. The trial period was 24 h and three different ventilator settings were used. For each device the following were determined: humidity-conserving ability, heat-conserving ability, resistance to air flow, internal volume, and gas leakage. The water loss (mg/l) at a common ventilator setting (10 l/min, 20.min-1) was as follows: Pall 10.8, Inline 7.5, Servo 9.0, Edith 6.6, Icor 6.2, and for Humid Vent 13.9, as compared to a control value (= no HME) of 24.8. The temperature differences (degrees C) between exhaled and inhaled gas at the patient port of the HME were: Pall 2.39, Inline 1.31, Servo 1.21, Edith 1.40, Icor 1.12, and for Humid Vent 2.80 as compared to a control value of 5.34. Ventilator settings with higher tidal volumes generally resulted in decreased efficiency. Resistance to air flow was less than 3 hPa.l-1.s-1 for all devices tested. The internal volumes ranged from 11 to 87 ml. The gas leakage was zero for all devices. Based on our findings the HMEs could be divided into three groups: 1) Icor, Servo, Inline, Edith: very good performance, 2) Pall: good performance for tidal volumes up to about 0.7, 1, and 3) Humid Vent 1: acceptable performance for tidal volumes up to 0.5 l.

Early clinical stages (CS1, CS1Mk+ and CS2A) of non-seminomatous testis cancer. Value of pre- and post-orchiectomy serum tumor marker information in prediction of retroperitoneal lymph node metastases. Swedish-Norwegian Testicular Cancer Project (SWENOTECA).

During a 5-year period (1981-86) 588 consecutive patients with nonseminatous germ cell tumors of the testis were included into a prospective Swedish-Norwegian multicenter study (SWENOTECA) and clinically staged according to the Royal Marsden system. A total of 370 patients (63%) had early clinical stages (CS) of disease; 295 (50%) had CS1, 32 (5%) had CS1Mk+ (CS1 with pathological serum tumor marker patterns after orchiectomy) and 43 (7%) had CS2A disease. Pathological staging with retroperitoneal lymph node dissection (RPLND) of the retroperitoneum was performed in 345 (93%) of the early CS patients and 128 (37%) had pathological stage 2 (PS2) disease; 27% of the CS1, 100% of the CS1Mk+ and 66% of the CS2A patients. The overall clinical staging accuracy was 75%. All the 40 patients with pathological serum AFP and/or HCG patterns before RPLND had PS2 disease, compared to 81/282 (29%) of patients with normal marker patterns. The PS2 patients with pathological marker patterns had significantly more and larger retroperitoneal metastases than those with normal AFP and HCG values. Elevated pre-orchiectomy AFP level indicated significantly reduced risk of PS2 disease in CS1 patients, but this effect became non-significant if the CS1Mk+ and CS2A cases were included into univariate or multivariate analyses. We suggest that the 'good risk' effect of pre-orchiectomy AFP elevation for CS1 cases may be caused by a selection mechanism during the clinical staging process.

Laboratory evaluation of heat and moisture exchangers. Assessment of the Draft International Standard (ISO/DIS 9360) in practice.

A lung model and test method in accordance with the ISO draft standard for evaluation of heat and moisture exchangers (HME's) was designed. The trial period was 24 h. The moisture-conserving ability of the HME was determined gravimetrically and the temperature performance was calculated from graphs obtained by temperature probes near the two ports of the HME. To determine the reproducibility of the test results, the model was used without an HME and with two HMEs from different manufacturers. The performance values obtained from all three series indicated that the reproducibility of the method was good. The difference between mean inspiration and mean expiration temperatures at the patient port (dTp) provides a useful, simple and reproducible measure of the HMEs' temperature performance. Based on these data, we suggest certain changes in the test procedures outlined in the proposed ISO draft standard.