Postlaryngectomy supraglottic stenosis revealed by three-dimensional computed tomography reconstruction: A case report.

RATIONALE: Supraglottic stenosis is a rare cause of airway obstruction. It can be induced by radiation, trauma, autoimmune diseases, or caustic exposure, and is often misdiagnosed as asthma. Detailed airway information is necessary to re-establish the normal functioning of the airway. PATIENT CONCERNS: A 78-year-old woman with severe dyspnea and hypercarbia was scheduled for surgery to resolve airway obstruction, previously known as supraglottic stenosis. DIAGNOSES: To determine the exact internal shape of the stenotic lesion, we reconstructed three dimensional computed tomography (CT) images depicted a tubular supraglottic stenosis. INTERVENTIONS: The patient underwent tracheotomy under monitored anesthesia care and local anesthesia, followed by general anesthesia. For long-term management of the patient, the otorhinolaryngologist excised the supraglottic stricture via micro-laryngeal surgery using a CO2 laser and applied mitomycin to prevent further obstruction. OUTCOMES: The patient recovered uneventfully after anesthesia, and symptom due to supraglottic stenosis was improved. LESSONS: During airway management of patients with postlaryngectomy supraglottic stenosis, three-dimensional reconstructed computed tomography images facilitate airway configuration in addition to endoscopy and other radiological findings.

Respiratory Failure during BIS-Guided Sedation in a Patient with Relapsing Polychondritis: A Case Report.

Relapsing polychondritis (RP) is a rare autoimmune disorder that causes inflammation and deterioration of cartilaginous structures such as the ears, nose, joints and laryngotracheobronchial tree. A 42-year-old man receiving treatment for RP underwent open reduction and internal fixation of a femur fracture under spinal anesthesia and with sedation by propofol and remifentanil. The level of sedation was monitored via a bispectral index (BIS), and maintained at between 60 and 80. At the end of the operation, he lost consciousness and displayed weak respiratory effort. During mask ventilation, the patient was judged to have respiratory failure due to high end-tidal CO2 (EtCO2) concentration and respiratory acidosis in an arterial-blood-gas analysis (ABGA). Ventilation through a properly inserted laryngeal-mask-airway or endotracheal intubation were impossible; instead, a surgical tracheotomy was performed. After recovering from respiratory failure with ventilatory support in the intensive care unit (ICU), he experienced the same symptoms three more times, requiring ventilatory support. He was discharged with bilevel positive-airway-pressure (BiPAP), after successful adaptation.

Difficult extubation of a damaged neural integrity monitor electromyogram tracheal tube: A case report.

INTRODUCTION: The purpose of a neural integrity monitor electromyogram (EMG) tracheal tube is to reduce the risk of damage to the recurrent laryngeal nerves. Complications associated with the use of EMG tube are ventilatory failure, tracheal injury, and difficult extubation. PATIENT CONCERNS: We encountered a case of difficult extubation of an EMG tube after thyroidectomy and partial tracheal resection in a 73-year-old woman. DIAGNOSES: The cuff was torn intraoperatively; but, it was kept inflated to maintain the integrity of the ventilatory circuit. During extubation, the vocal cord blocked the torn hole on the shoulder of the cuff, which subsequently was filled with air, complicating the extubation. INTERVENTIONS: We extubated the EMG tube slowly with the help of videolaryngoscopy with a moderate amount of force and re-intubated with a 6.0-mm ID endotracheal tube. OUTCOMES: We examined the airway during and after re-intubation using videolaryngoscopy. The findings were normal and no bleeding or laceration was observed. The subsequent recovery and extubation occurred smoothly. CONCLUSIONS: Awareness of the characteristics and types of damage that can occur in an EMG tube is essential. Because it can be difficult to ascertain the type of damage before extubation, communication between the surgeon and anesthesiologist, along with the preparation for emergency airway management are necessary for cases of difficult extubation.

FTY720 preserved islet ß-cell mass by inhibiting apoptosis and increasing survival of ß-cells in db/db mice.

BACKGROUND: FTY720, an analogue of sphingosine-1-phosphate, has shown potential in the treatment of several autoimmune diseases, such as multiple sclerosis, type 1 diabetes and systemic lupus erythematosus. It prevents development or cure of autoimmune diabetes in animal models. Recently, we reported that FTY720 also prevents development of diabetes in db/db mice by ß-cell regeneration in vivo. This study investigated the effect of FTY720 on apoptosis in ß-cells in db/db mice treated with FTY720 16 weeks. METHODS: Six week old female db/db mice were divided into control and FTY720 groups. FTY720 (10 mg/kg) was orally administrated daily. Body weights and fasting glucose levels were measured once a week after overnight fasting. After 16 weeks of treatment, oral glucose and insulin tolerance tests were performed, serum insulin levels and insulin contents in pancreas were determined, and then all mice were subjected to physiological and histological analyses. RESULTS: FTY720-treated mice showed normal fasting glucose levels, improved glucose tolerance with normal insulin sensitivity and restored ß-cell function to produce and secret insulin. Pancreas histology revealed that FTY720 prevented islet damage and preserved ß-cell mass by inhibiting apoptosis and increasing ß-cell survival in pancreatic islets. CONCLUSIONS: We concluded that early intervention with FTY720 in db/db mice can prevent development of diabetes through preserving ß-cell mass by inhibiting apoptosis and increasing survival of islet ß-cells.

Adipocyte apoptosis after burn injury is associated with altered fat metabolism.

Burn injury often is associated with the abnormal lipid metabolism, including hyperlipidemia, desensitization to lipolytic responses to catecholamines, and reduction in the size of the white adipose tissue. Understanding the biological mechanisms for the decrease in fat mass despite desensitization to catecholamines is important both for the study of lipid metabolism and for the study of its relationship to concomitant insulin resistance. Using epididymal adipose tissue from adult male Sprague-Dawley rats after burn injury (n = 102) or sham-burn injury (n = 102), we tested the hypothesis that a whole-body burn injury causes apoptosis in that tissue. At 1, 3, and 7 days after 40% to 50% body burn injury to the rat, epidydimal adipose tissue was harvested and studied for apoptotic changes and lipolytic properties. For apoptosis, paraformaldehyde-fixed tissue sections were analyzed by in situ TdT-mediated dUTP-X nick-end labeling (TUNEL) staining, and tissue homogenates were also analyzed for DNA fragmentation by enzyme-linked immunoassay and ligation-mediated polymerase chain reaction ladder assay. Isolated adipocytes were stimulated with isoprotenerol, and glycerol production was measured as a reflector of effectiveness of lipolysis. Epididymal adipose tissue showed increased apoptosis manifested by the positive TUNEL staining and increased DNA fragmentation by enzyme-linked immunoassay at day 3 and 7 after burn injury. The DNA fragmentation was confirmed further by the ligation-mediated polymerase chain reaction ladder assay. This elevated DNA fragmentation persisted in the burned animals from day 3 until day 7 after burn injury, the end of observation period. Increase in apoptosis was correlated with decrease in DNA content and tissue weight in the epidydimis. At the functional level, a significant decrease in isoproterenol-induced lipolytic activity (glycerol production) was observed to almost 50% of control level at day 3 and 7 but was not decreased at day 1. Apoptosis of adipocytes may play a role in the altered lipid metabolism, including hyperlipidemia observed in burned subjects.