Congenital Intraoral Dermoid and Epidermoid Cyst with Orocutaneous Fistula Presenting with Life-threatening Airway Obstruction in an Infant.

Dermoid cysts and epidermoid cysts in the floor of the mouth are rare in the pediatric age group. In this case report, we have discussed the presentation, management, and literature review of a 6-month-old female child presenting with both dermoid and epidermoid cysts in the floor of the mouth with an orocutaneous fistula.

Nasal Pyriform Aperture Stenosis in a Newborn: When to Operate.

Congenital nasal pyriform aperture stenosis (CNPAS) is a very rare cause of neonatal respiratory distress and is often missed because of its rarity. It arises from the overgrowth of the nasal process of the maxilla. Maxillofacial CT scan findings of pyriform aperture width <11 mm in a full-term baby, median central incisor, triangular-shaped palate, and median palatal ridge confirm the diagnosis. We describe here a case of CNPAS admitted with respiratory distress that increased further on feeding. An infant feeding tube of size 6 was not negotiable through the nostrils. Resistance was appreciated at the inlet of the nostril. Maxillofacial CT showed pyriform aperture stenosis of 3.4 mm, suggesting CNPAS. The child could not be weaned off a high-flow nasal cannula despite conservative management with decongestants, steroids spray, dilatation, and stenting for 20 days. Subsequently, surgical widening of the nasal aperture by a sublabial approach was done. The child was discharged on the 10th postoperative day on full oral feeds. It is important to suspect CNPAS in neonates with respiratory distress where other common causes have been ruled out, as it can be treated by surgery in cases refractory to conservative management.

Pediatric thermal epiglottitis: insights from a tertiary center experience.

Thermal epiglottitis, a non-infectious cause of epiglottitis, is a rare entity that shares some clinical features with infectious epiglottitis. This study presents 16 years of experience in diagnosing and managing thermal epiglottitis. A retrospective descriptive study in a tertiary center in southern Israel included confirmed cases of thermal epiglottitis in children (0-18 years) between 2004 and 2020 by endoscopy. Of approximately 600,000 pediatric ER admissions between 2004 and 2020, seven children were diagnosed by endoscopy with thermal epiglottitis (mean age 24 months, 71% males). Clinical presentation included stridor, respiratory distress, and drooling. Four children had fever and elevated inflammatory markers at presentation and were treated with systemic antibiotics. All were treated with systemic steroids. The median length of stay in the PICU was five days, and four patients required intubations. All fully recovered without experiencing any sequelae.  Conclusion: Thermal epiglottitis stands as a potential contributor to acute upper airway obstruction. Although it's rarity, it should be discussed in any child with acute upper airway obstruction. It is essential to inquire directly about the accidental intake of hot beverages, particularly in cases lacking fever or elevated inflammatory markers. What is Known: • Thermal epiglottitis is a rare, non-infectious condition sharing clinical features with infectious epiglottitis. • Common presentations include stridor, respiratory distress, and drooling. What is New: • Thermal epiglottitis is a potential contributor to acute upper airway obstruction, urging consideration even in the absence of fever or elevated markers. • Direct inquiry about hot beverage intake for diagnosis is essential for diagnosis.

Correlation of Bronchoscopy and CT in Characterizing Malignant Central Airway Obstruction.

BACKGROUND: Malignant Central Airway Obstruction (MCAO) presents a significant challenge in lung cancer management, with notable morbidity and mortality implications. While bronchoscopy is the established diagnostic standard for confirming MCAO and assessing obstruction subtype (intrinsic, extrinsic, mixed) and severity, Computed Tomography (CT) serves as an initial screening tool. However, the extent of agreement between CT and bronchoscopy findings for MCAO remains unclear. METHODS: To assess the correlation between bronchoscopy and CT, we conducted a retrospective review of 108 patients at Roswell Park Comprehensive Cancer Center, analyzing CT and bronchoscopy results to document MCAO presence, severity, and subtype. RESULTS: CT correctly identified MCAO in 99% of cases (107/108). Agreement regarding obstruction subtype (80.8%, Cohen's κ = 0.683, p < 0.001), and severity (65%, Quadratic κ = 0.657, p < 0.001) was moderate. CT tended to equally overestimate (7/19) and underestimate (7/19) the degree of obstruction. CT was also poor in identifying mucosal involvement in mixed MCAO. CONCLUSIONS: CT demonstrates reasonable agreement with bronchoscopy in detecting obstruction. Nevertheless, when CT indicates a positive finding for MCAO, it is advisable to conduct bronchoscopy. This is because CT lacks reliability in determining the severity of obstruction and identifying the mucosal component of mixed disease.

Incidence and characterization of aerophagia in dogs using videofluoroscopic swallow studies.

BACKGROUND: Aerophagia (ingestion of air), is a functional aerodigestive disorder in people. Criteria for diagnosis of aerophagia in dogs are >1/3 of bolus volume containing air or ingested air resulting in gastric distention (>1/3 of end gastric volume). Aerophagia is highlighted during eating and drinking. Videofluoroscopic swallow studies (VFSS) document aerophagia in dogs, but the incidence, clinical signs (CS), and associated disorders are unknown. OBJECTIVES: Identify the incidence of aerophagia, compare CS between dogs with and without aerophagia, and identify associated and predisposing disorders using VFSS. ANIMALS: A total of 120 client-owned dogs. METHODS: Sequential VFSS and associated medical records from dogs presenting to veterinary teaching hospitals at Auburn University and the University of Missouri were retrospectively reviewed. Statistical comparisons were made using Mann-Whitney and chi-squared tests, odds ratios (OR), and multiple logistic regression (P < .05). RESULTS: The incidence (95% confidence interval [CI]) of aerophagia was 40% (31.7-48.9). Dogs with mixed CS (gastrointestinal [GI] and respiratory; P < .001, 58.3%) were more likely to have aerophagia than dogs with exclusively respiratory CS (25%). Aerophagia was significantly more common in brachycephalic dogs (P = .01; 45.8% vs 13.8%), dogs with nonbrachycephalic upper airway obstruction (P < .001; 33.3% vs 4.1%), pathologic penetration and aspiration (P-A) scores (P = .04; 41.6% vs 23.6%), and gagging (P < .001; 25% vs 11.7%). Mixed CS (P = .01), brachycephaly (P < .001), and upper airway obstruction (P < .001) were independent predictors of aerophagia. CONCLUSIONS AND CLINICAL IMPORTANCE: Aerophagia was common, particularly in dogs with mixed CS. Brachycephalic dogs and dogs with upper airway obstruction are predisposed. Aspiration risk was high, emphasizing overlapping upper aerodigestive pathways.

Plunging or Cervical Ranula as a Rare Cause of Respiratory Distress.

The Plunging or cervical ranula is a mucus pseudocyst extension of the sublingual gland that is located below the mylohyoid muscle. In infants, owing to small sublingual and cervical space, clinically large cervical ranulas can lead to a significant impact on swallowing, crying, and even breathing (Carlini et al. in Pediatr Rep 8(4):6576, 2016; Övet et al. in Turk Arch Otorhinolaryngol 53(3):133-135, 2015). In these clinical pictures, we present a case of cervical ranula that grew in a short period leading to respiratory distress. This ranula was aspirated in a PICU setting to relieve respiratory obstruction before definitive surgery in the operation theatre. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-023-04419-4.

A New Distal Pharyngeal Airway Device Associated with a Reduced Need for Chin-Lift and Jaw-Thrust Maneuvers in Sedated Patients.

Oropharyngeal airways (OPA) or nasopharyngeal airways (NPA) sometimes require chin-lift or jaw-thrust (CLJT) maneuvers to relieve airway obstruction which creates the burden of continuous hands-on care by the anesthesia provider. A new distal pharyngeal airway device (DPA) was used on 63 successive ambulatory surgery patients to assess the frequency of patients requiring manual CLJT maneuvers to prevent airway obstruction. Results were then compared with a contemporaneous group of patients who had used OPA or NPA devices for similar procedures. Patients using the DPA had a 38.5% lower rate of CLJT maneuvers compared with the combined OPA/NPA groups (22.2% of 63 vs. 60.7% of 163, P ≤ .001). Moreover, the results for the DPA group were close to those of the natural airway group (22.2% of 62 vs. 24.8% of 233, P = .66) Results were similar for a sub-set of the above groups who required deep sedation or deep extubation. CLJT maneuvers were common in this ambulatory surgery setting. The new DPA device was associated with a reduced need for such manual maneuvers when compared with similar patients who received OPA or NPA devices and is comparable with the rate for natural airways.

Endoscopic-Guided Suture Lateralization for Bilateral Vocal Fold Paralysis: Surgical Tips for Better Outcome.

OBJECTIVE: This study aims to describe a precise description of suture lateralization (SL) technique and evaluate its effectiveness and safety in management of bilateral vocal fold paralysis (BVFP). METHOD: A preclinical cadaveric study followed by application on a case series of BVFP patients. After the preliminary study executed to precisely localize the optimal sites for needle insertion, a prospective interventional study was conducted on 19 subjects presenting with respiratory distress due to BVFP. Data collection included their clinical presentation and a detailed assessment including auditory perceptual assessment, laryngoscopy (rigid or flexible), and video fluoroscopic swallowing study. RESULTS: Widening of the inter-glottic distance at the site of the sutures was statistically significant (P < 0.001). Decannulation was achieved in three out of four tracheotomized patients. The suturing led to a significant difference in loudness, jitter, and harmonic-to-noise ratio (P = 0.042, 0.004, and ≤0.001, respectively). CONCLUSION: This study suggests that SL is a feasible and effective technique with low incidence of adverse events and the potential of reversibility. Optimal localization of the suture insertion points translated into less intraoperative manipulation of the cords and shorter operative time.

Severity of Airflow Obstruction Based on FEV1/FVC vs FEV1% of Predicted in the General US Population.

RATIONALE: According to GOLD, the ratio of FEV1/FVC is used to confirm airflow obstruction in COPD diagnosis, whereas FEV1% of predicted (FEV1%pred) is used for severity grading. STaging of Airflow obstruction by the FEV1/FVC Ratio (STAR) and its prediction of adverse outcomes has not been evaluated in general populations. OBJECTIVE: To compare the STAR (FEV1/FVC) versus GOLD (FEV1%pred) classification for the severity of airflow limitation in terms of exertional breathlessness and mortality in the general US population. METHODS: Severity stages according to STAR and GOLD were applied to the multi-ethnic National Health and Nutrition Examination Survey (NHANES) 2007-2012 survey including ages 18-80 years, using post-bronchodilatory FEV1/FVC<0.70 to define airflow obstruction in both staging systems. Prevalence of severity stages STAR 1-4 and GOLD 1-4 was calculated and associations with breathlessness and mortality were analyzed by multinomial logistic regression and Cox regression, respectively. RESULTS: STAR versus GOLD severity staging of airflow obstruction showed similar associations with breathlessness and all-cause mortality, regardless of ethnicity/race. In those with airflow obstruction, the correlation between the two classification systems was 0.461 (p<0.001). STAR reclassified 59% of GOLD stage 2 as having mild airflow obstruction (STAR 1). STAR 1 was more clearly differentiated from the non-obstructive compared to GOLD stage 1 in terms of both breathlessness and mortality. CONCLUSIONS: FEV1/FVC and FEV1%pred as measures of severity of airflow limitation show similar prediction of breathlessness and mortality in the adult US population across ethnicity groups. However, stage 1 differed more clearly from non-obstructive based on FEV1/FVC than FEV1%pred. This article is open access and distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by/4.0/).

The effects of bystander interventions for foreign body airway obstruction on survival and neurological outcomes: Findings of the MOCHI registry.

INTRODUCTION: Foreign body airway obstruction (FBAO) is a life-threatening condition. We aimed to quantify the impact of bystander FBAO interventions on survival and neurological outcomes. METHODS: We conducted a Japan-wide prospective, multi-center, observational study including all FBAO patients who presented to the Emergency Department from April 2020 to March 2023. Information on bystander FBAO interventions was collected through interviews with emergency medical services personnel. Primary outcomes included 1-month survival and favorable neurologic outcome defined as Cerebral Performance Category 1 or 2. We performed a multivariable logistic regression and a Cox proportional hazards modeling to adjust for confounders. RESULTS: We analyzed a total of 407 patients in the registry who had the median age of 82 years old (IQR 73-88). The FBAO incidents were often witnessed (86.5%, n = 352/407) and the witnesses intervened in just over half of the cases (54.5%, n = 192/352). The incidents frequently occurred at home (54.3%, n = 221/407) and nursing home (21.6%, n = 88/407). Common first interventions included suction (24.8%, n = 101/407) and back blow (20.9%, n = 85/407). The overall success rate of bystander interventions was 48.4% (n = 93/192). About half (48.2%, n = 196/407) survived to 1-month and 23.8% patients (n = 97/407) had a favorable neurological outcome. Adjusting for pre-specified confounders, bystander interventions were independently associated with survival (hazard ratio, 0.55; 95% CI, 0.39-0.77) and a favorable neurological outcome (adjusted OR, 2.18; 95% CI, 1.23-3.95). CONCLUSION: Bystander interventions were independently associated with survival and favorable neurological outcome, however, they were performed only in the half of patients.

Anesthetic Challenges in a Patient With an Expanding Recurrent Mycotic Pseudoaneurysm of the Right Brachiocephalic Artery: A Case Report and Literature Review.

Airway obstruction requires urgent intervention. When dealing with the right brachiocephalic artery mycotic pseudoaneurysms, the risk of rupture and massive hemorrhage adds greater urgency to the management. Furthermore, tracheal compression presents difficulties during airway management. This report highlights the airway and anesthetic challenges encountered during the procedure and emphasizes the importance of tailored intervention for optimal patient care. We describe the clinical case of a 38-year-old male patient who presented with a large recurrent right brachiocephalic artery pseudoaneurysm associated with tracheal compression. The patient required urgent surgical intervention due to the pseudoaneurysm's enlargement and progressive respiratory distress. Awake fiber-optic intubation was not feasible. A cardiopulmonary bypass was kept on standby in the event of failed intubation and ventilation, or circulatory collapse. Endotracheal intubation was performed successfully using a video-laryngoscopy. After successful surgical repair of the pseudoaneurysm, the patient was transferred to ICU where he was extubated 48 hours post-surgery, following treatment with methylprednisolone for edematous aryepiglottic folds identified during video-laryngoscopy. Overall, this case emphasizes the importance of early diagnosis, prompt surgical intervention, and effective teamwork in managing rare and potentially life-threatening conditions like mycotic pseudoaneurysms. It also highlights the critical role of anesthesiologists in providing optimal perioperative care, ensuring hemodynamic stability, managing airway challenges, and facilitating successful surgical outcomes. In our work, we also provide a summary of the reported similar cases.

A narrative review of oncologic emergencies in patients with head and neck cancers: initial management and the role of radiation therapy.

BACKGROUND AND OBJECTIVE: Head and neck cancers (HNCs) encompass a complex group of malignancies with high morbidity, often leading to critical emergencies such as pain crises, airway obstruction and hemorrhage. This review aims to outline an evidence-based approach to the multidisciplinary management of HNC oncologic emergencies with a focus on the role of emergent radiotherapy (RT). METHODS: A literature search was performed using Medline, Embase and the Cochrane Central Register of Controlled Trials databases with a focus on three common oncological emergencies using the following keywords: "head and neck cancer", "radiation OR radiotherapy", "pain", "bleeding OR haemorrhage", and "airway obstruction". All English language articles published up to April 2022 were screened to identify studies pertaining to the management of oncologic emergencies in HNC. KEY CONTENT AND FINDINGS: The management of oncologic emergencies in HNC present a unique set of challenges that require early recognition and aggressive treatment. In this narrative review, we summarize the evidence supporting the role of RT in the management of HNC patients presenting with pain crisis, malignant airway obstruction and acute haemorrhage. We demonstrate that while RT can be used as a primary or adjunct therapy, optimal management depends on the involvement of a multi-disciplinary team that includes head and neck surgeons, interventional radiology and palliative care. CONCLUSIONS: RT plays a critical role in the multidisciplinary management of HNC oncological emergencies. Further prospective and comparative studies are needed to assess optimal management strategies.

A case of Sjögren's syndrome in which diffuse cystic lung lesions led to an accurate diagnosis.

Key Clinical Message: Even in the absence of other symptoms or other pulmonary manifestations suggesting Sjögren's syndrome (SS), it is necessary to include SS in the differential diagnosis of diffuse cystic lung disease (CLD). Abstract: A case of SS that presented initially with diffuse CLD is reported. This case is considered rare because diffuse pulmonary cysts were observed in the early stage with few symptoms, only cysts were observed without other lung lesions on imaging, cyst formation was histologically considered to be alveolar loss, and airway lesions not observed on imaging were suspected based on lung function testing. The details of this case provide extremely important information to consider for the diagnosis and management of CLD and SS.

Therapeutic bronchoscopy for malignant central airway obstructions caused by non-bronchogenic cancers: Results from the EpiGETIF registry.

BACKGROUND AND OBJECTIVE: Little is known about malignant central airway obstruction (MCAO) complicating the metastatic spread of non-bronchogenic solid cancers (NBC) and their bronchoscopic management. This study aimed to describe the epidemiology of this population and determine prognostic factors before therapeutic bronchoscopy (TB). METHODS: In this multicenter study using the EpiGETIF registry, we analysed patients treated with TB for MCAO caused by NBC between January 2019 and December 2022. RESULTS: From a database of 2389 patients, 436 patients (18%) with MCAO and NBC were identified. After excluding patients with direct local invasion, 214 patients (8.9%) were analysed. The main primaries involved were kidney (17.8%), colon (16.4%), sarcoma (15.4%), thyroid (8.9%) and head and neck (7.9%) cancers. Most patients (63.8%) had already received one or more lines of systemic treatment. Obstructions were purely intrinsic in 58.2%, extrinsic in 11.1% and mixed in 30.8%. Mechanical debulking was used in 73.4% of cases, combined with thermal techniques in 25.6% of cases. Airway stenting was required in 38.4% of patients. Median survival after TB was 11.2 months, influenced by histology (p = 0.002), performance status (p = 0.019), initial hypoxia (HR 1.45 [1.01-2.18]), prior oncologic treatment received (HR 1.82 [1.28-2.56], p < 0.001) and assessment of success at the end of the procedure (HR 0.66 [0.44-0.99], p < 0.001). Complications rate was 8.8%, mostly mild, with no procedure-related mortality. CONCLUSION: TB for MCAO caused by a NBC metastasis provides rapid improvement of symptoms and prolonged survival. Patients should be promptly referred by medical oncologists for bronchoscopic management based on the prognostic factors identified.

Endotracheal enucleation and para-toluenesulfonamide injection for adenoid cystic carcinoma in the upper trachea: A novel therapeutic approach.

We present a case of an adenoid cystic carcinoma (ACC) located in the upper trachea, which resulted in significant airway blockage, that was unsuitable for surgical removal due to concerns about functional impairment. Instead, endotracheal enucleation via rigid bronchoscopy was performed initially, followed by the injection of a novel tumor ablation agent known as para-toluenesulfonamide (PTS). We detail the dosing regimen, effectiveness evaluation, and post-treatment follow-up. The study highlights the potential of PTS injection as a viable alternative treatment option for patients with ACC who cannot undergo surgical resection and feasibility of lipiodol to monitor treatment effect. This research adds to the existing knowledge on ACC treatment and provides new therapeutic possibilities for patients with tracheal ACC.

Economic impact analysis of a minimally invasive temperature-controlled radiofrequency device versus nasal surgery for the treatment of nasal airway obstruction in the United States.

Objective: To determine the economic impact of a minimally invasive temperature-controlled radiofrequency (TCRF) device for treating nasal airway obstruction (NAO).Methods: A budget impact model was developed for two scenarios: a reference scenario of functional rhinoplasty surgery with concomitant septoplasty and inferior turbinate reduction (ITR) performed in the hospital outpatient department where TCRF is not an available a treatment option and a new scenario consisting of in-office TCRF treatment of the nasal valve and ITR. A payor perspective was adopted with a hypothetical population plan size of one million members. Costs were estimated over a time horizon of 4 years. The eligible population included patients with severe/extreme NAO and nasal valve collapse (NVC) as the primary cause or significant contributor. Data inputs were sourced from targeted literature reviews. Uncertainty within the model structure and input parameters was assessed using one-way sensitivity analysis.Results: The introduction of a TCRF device resulted in population-level cost savings of $20,015,123 and per-responder average cost savings of $3,531 through a 4-year time horizon due to lower procedure costs and complication rates of the device relative to the surgical comparator. Results were robust when varying parameter values in sensitivity analyses, with cost savings being most sensitive to the prevalence of NAO and estimated response rates to functional rhinoplasty and TCRF.Conclusions: In patients with severe/extreme NAO, with NVC as the primary or major contributor, introducing TCRF with ITR as a treatment option demonstrates the potential for significant cost savings over functional rhinoplasty with septoplasty and ITR.

Nasal valve dysfunction is a common cause of nasal airway obstruction (NAO) that has significant impact on heath and quality of life for affected individuals. Previously, patients were offered temporary measures or a type of surgery called functional rhinoplasty which is a highly complex surgery that can be costly, requires recovery time and, in rare cases, not be successful. Recently, a new minimally invasive treatment alternative for NAO called temperature-controlled radiofrequency (TCRF) that may be performed in a surgery center or a doctor's office has become available. This paper provides results of budget impact analysis performed to assess whether adding the TCRF procedure in place of surgery as a choice for patients with NAO will result in a cost savings to an insurance payer with 1 million covered individuals in the United States over a period of 4 years. Results show that TCRF may result in an average of 9,416 fewer rhinoplasty surgeries, provide an average 4-year cost-savings of $3,531 for every patient that responds to TCRF treatment and a savings of $20,015,123 over 4 years for the insurance provider. These potential cost savings over 4 years would likely be due to reduced procedure costs and complication rates compared to surgery.

An Uncommon Epiglottic Cyst Presentation in an Adolescent: A Case Report and Literature Review.

Epiglottic cysts are benign lesions of the larynx that are relatively rare beyond infancy age. A 17-year-old adolescent male patient presented to the outpatient specialized oropharyngeal clinic with inspiratory stridor, chronic sore throat, and progressive dyspnea symptoms over the past eight months. Examination by a headlight and a tongue depressor showed a large cystic lesion arising from the hypopharynx. A neck computed tomography (CT) scan revealed a 4 cm oval cyst attached to the lingual epiglottic surface. The relatively large epiglottic cyst was drained directly in the clinic and was later removed by microlaryngosurgery with traditional microinstrumentation in a follow-up visit. Subsequent recovery was uneventful. Regardless of the rarity of epiglottic cysts in adolescents, doctors should keep in mind this etiology as early diagnosis and management could spare the patient from life-threatening complications or tracheostomy and unneeded medical costs.

Nasal airway obstruction in patients with cleft lip nasal deformity: A systematic review.

BACKGROUND: Cleft lip nasal deformity (CLND)-associated nasal airway obstruction (CL-NAO) may be inadequately characterized, with its functional implications subsequently underappreciated and neglected. The purpose of this systematic review is to (1) summarize the available assessment results in CL-NAO, (2) evaluate the reliability of current assessment tools, and (3) identify ongoing gaps and inconsistencies for future study. METHODS: A systematic search of the MEDLINE, EMBASE, and Scopus databases was performed for articles studying CL-NAO. Articles focusing on noncleft populations or surgical techniques were excluded. Extracted data included information about study design, patient demographics, medical history, and assessment scores. RESULTS: Twenty-six articles met criteria for inclusion. Assessments included patient-reported outcome measures (PROMs), anatomic characterizations of CLND, and nasal airflow and resistance studies. Objective assessments were generally more reliable than subjective assessments in CLND. Unilateral CLND was better represented in the literature than bilateral CLND. For unilateral CLND, the cleft side was more obstructed than the noncleft side, with stereotyped patterns of anterior nasal deformity but varied middle and posterior deformity patterns. Overall, there was considerable heterogeneity in study design regarding stratification of CLND cohorts by age, cleft phenotype and laterality, and surgical history. CONCLUSIONS: A wide range of subjective and objective assessment tools were used to characterize CL-NAO, including PROMs, anatomic measurements, and airflow and resistance metrics. Overall, objective assessments of CL-NAO were more reliable than subjective surveys, which may have resulted from variable expectations regarding nasal patency in the CLND population combined with large heterogeneity in study design.