The Effect of Sedating Agents on Drug-Induced Sleep Endoscopy Findings.

OBJECTIVE: Drug-induced sleep endoscopy (DISE) has gained interest for upper airway evaluation in patients with snoring and obstructive sleep apnea (OSA), and different drugs have been used to induce sedation. Nevertheless, all drugs have presented specific advantages and disadvantages with differential effects on respiratory physiology. This study evaluated and compared the effects of midazolam, propofol and dexmedetomidine on DISE findings, O2 nadir, and bispectral index (BIS) in the same sample of patients. STUDY DESIGN: Case series prospective study. METHODS: Consecutive patients who elected to undergo surgery for OSA treatment and were intolerant to conservative therapies underwent DISE with propofol, dexmedetomidine, and midazolam between July 2015 and July 2016. RESULTS: Fifty-two patients were analyzed, and 43 (82.7%) were men. Agreement among drugs for both degree and patterns of obstruction was excellent at all sites (velum, oropharynx, and epiglottis) except for the tongue base. Dexmedetomidine had the least complete collapse sites and highest O2 nadir and was the only drug for which apnea severity and obstruction levels (upper, lower, or combined) were correlated. The variability among drug treatments for the BIS index was considerable, and propofol had the lowest variability and average value. CONCLUSION: Drug selection had a relevant influence in DISE findings. Compared with dexmedetomidine, midazolam and propofol presented higher incidence of tongue base collapse, lower O2 levels, and lower BIS index values. Propofol resulted in an O2 nadir that most resembled that observed during polysomnography. The BIS index variability differed among drugs, and its use was considered relevant for sedation orientation. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:506-513, 2019.

Narrowing of airway caused by ingestion of methyl ethyl ketone peroxide.

Although ingestion of methyl ethyl ketone peroxide (MEKP) is rare, it carries a high risk of morbidity and mortality. This paper reports the first such case from Turkey in which a 70-year-old man unintentionally ingested MEKP in his kitchen. The patient was brought into the emergency department (ED) within 1 hour of ingestion, with the symptoms of sore throat, shortness of breath, nausea and vomiting. Visual examination of the oropharynx revealed minor burns and uvular edema. A laryngoscope examination performed in the ED showed superficial mucosal injury with edema of the oropharynx, uvula, posterior pharynx, epiglottis, arytenoids and vocal cords. Lateral cervical radiography revealed a narrowing of airway due to a thickened epiglottis. After the diagnostic evaluation was completed, the patient was admitted to the gastroenterology intensive care unit for monitoring of adverse reactions. During follow-up, the patient made an uneventful recovery. Ingestion of MEKP generally results from accidental ingestion from a container. Therefore, these containers should be kept in safe places. In addition, the priority following the ingestion of MEKP should be given to maintain open and adequate airway in the ED.

Extent and localization of changes in upper airway caliber with varying concentrations of sevoflurane in children.

BACKGROUND: Previous studies in humans suggest that inhibition of upper airway muscle activity is independent of the dose of inhalational anesthesia. Whether a dose-independent relation applies to changes in airway caliber is unknown. The authors sought to evaluate the configurational changes that lead to upper airway narrowing during inhalational anesthesia with sevoflurane and to determine whether these changes are dose dependent within a clinically relevant dose range. METHODS: Fifteen children undergoing elective magnetic resonance imaging of the brain were studied. Magnetic resonance images of the upper airway were acquired at sevoflurane concentrations of 0.5, 1.0, and 1.5 minimum alveolar concentration (MAC), administered in random sequence. At least 15 min was allowed for equilibration of inspired and alveolar partial pressures of sevoflurane. Images were acquired in early expiration at the level of the soft palate, base of the tongue, and tip of the epiglottis. Airway cross-sectional area (CSA), anteroposterior, and transverse dimension were determined using image-analysis software. RESULTS: At each anatomical level, pharyngeal CSA decreased progressively with increasing depth of sevoflurane anesthesia (P < 0.001). Increasing the sevoflurane concentration from 0.5 to 1.0 MAC reduced airway CSA by 13-18%, and a further increase to 1.5 MAC resulted in an overall 28-34% reduction in CSA. The reduction in CSA was predominantly due to a decrease in anteroposterior dimension. CONCLUSIONS: Increasing the depth of sevoflurane anesthesia resulted in a relatively uniform reduction in pharyngeal caliber at each anatomical level studied. The effect of sevoflurane on upper airway caliber is dose dependent.

Effect of increasing depth of propofol anesthesia on upper airway configuration in children.

BACKGROUND: The upper airway tends to be obstructed during anesthesia in spontaneously breathing patients. The purpose of the current study was to determine the effect of increasing depth of propofol anesthesia on airway size and configuration in children. METHODS: Magnetic resonance images of the upper airway were obtained in 15 children, aged 2-6 yr. Cross-sectional area, anteroposterior dimension, and transverse dimension were measured at the level of the soft palate, dorsum of the tongue, and tip of the epiglottis. Images were obtained during infusion of propofol at a rate of 50-80 microg.kg-1.min-1 and after increasing the depth of anesthesia by administering a bolus dose of propofol and increasing the infusion rate to 240 microg.kg-1.min-1. RESULTS: Overall, the cross-sectional area of the entire pharyngeal airway decreased with increasing depth of anesthesia. The reduction in cross-sectional area was greatest at the level of the epiglottis (24.5 mm2, 95% confidence interval = 16.9-32.2 mm2; P < 0.0001), intermediate at the level of the tongue (19.3 mm2, 95% confidence interval = 9.2-29.3 mm2; P < 0.0001), and least at the level of the soft palate (12.6 mm2, 95% confidence interval = 2.7-22.6 mm2; P < 0.005) in expiration and resulted predominantly from a reduction in anteroposterior dimension. The airway cross-sectional area decreased further in inspiration at the level of the epiglottis. The narrowest portion of the airway resided at the level of the soft palate or epiglottis in the majority of children. CONCLUSION: Increasing depth of propofol anesthesia in children is associated with upper airway narrowing that occurs throughout the entire upper airway and is most pronounced in the hypopharynx at the level of the epiglottis.

Epiglottis involvement in a visceral leishmaniasis.

The visceral form of leishmaniasis caused by Leishmania infantum is frequently observed in Mediterranean countries, however otorhinolaryngeal involvement has only rarely been reported in the literature. We report here the case of a 23-year-old Cameroon man, resident in France since 1991, and presenting with recurrent epistaxis and an epiglottis tumoral lesion. The visceral form of leishmaniasis with hepatosplenomegaly and pancytopenia was diagnosed. Culture of the epiglottal lesion revealed L. infantum. Serological test for human immunodeficiency virus was negative and the patient was not on immunosuppressive drugs. Dramatic improvement was observed with antimony.

Xylazine-induced attenuation of dorsal displacement of the soft palate associated with epiglottic dysfunction in a horse.

An 18-month-old Quarter Horse filly was evaluated because of dorsal displacement of the soft palate associated with epiglottic dysfunction that caused exercise intolerance and an abnormal respiratory noise. The abnormality of the epiglottis was corrected by use of a sedative dose of xylazine hydrochloride. There was no familial predisposition to hyperkalemic periodic paralysis, which may cause similar laryngopharyngeal signs, and the horse did not respond to administration of acetazolamide. There was no known history of trauma that could have caused neuritis, which has also been suggested as a cause of laryngeal dysfunction. It was unusual that a complete response was obtained with xylazine hydrochloride, an alpha2-adrenergic agonist, although this drug has various effects on the respiratory tract in horses. It was also unusual that the response outlasted the sedative effect of the drug.

Epiglottitis following preparation for allogeneic bone marrow transplantation.

We describe a 7-year-old boy who developed acute, airway-threatening, non-infectious epiglottitis following high-dose cytosine arabinoside and total body irradiation preparative regimen for allogeneic BMT. Unlike gastrointestinal symptoms and oropharyngeal mucositis, acute epiglottitis is a previously unreported early complication following allogeneic BMT preparation. The pathogenesis of epiglottitis in our patient was presumably multifactorial, resulting from the combination of chemotherapy and irradiation. We recommend that this diagnosis be considered in the differential diagnosis of patients with significant upper airway symptoms following BMT preparation.

Epiglottic dysfunction after isocyanate inhalation exposure.

Epiglottic dysfunction due to environmental exposure is a well-known entity. The most common causes of epiglottic dysfunction include trauma (thermal, chemical, and blunt), infection, allergy, neoplasm, and neurologic disorders. We report an unusual case of epiglottic dysfunction due to isocyanate inhalation exposure and review the literature concerning this subject. Following inhalation exposure to diphenylmethane diisocyanate, our patient developed persistent repeated airway obstruction during inspiration. Fiberoptic rhinolaryngoscopy showed that the epiglottis obstructed the glottic airway during each inspiratory cycle. The epiglottic dysfunction was also well demonstrated by barium contrast cineradiography. Total epiglottectomy resulted in resolution of the patient's upper airway obstructive symptoms. Histologically, marked inflammatory changes of the epiglottis were noted, including a focal infiltrative pattern, focal fibrosis, edema, and reactive changes.

Responses of neurons in the lamb nucleus tractus solitarius to stimulation of the caudal oral cavity and epiglottis with different stimulus modalities.

Receptors located in the posterior oral cavity and on the epiglottis play an important role in the initiation of upper airway reflexes such as swallowing, gagging, coughing and apnea. Peripheral nerves which innervate these receptor areas terminate in the nucleus tractus solitarius (NTS). We have recorded the responses of 61 neurons in the lamb NTS to stimulation of the caudal tongue, palate and epiglottis with mechanical, chemical and thermal stimuli and mapped receptive field location. Although there was some overlap in the areas of the NTS from which neurons with oral cavity and epiglottal receptive fields could be recorded, a significant difference was observed in the mean recording sites of the two groups of neurons. Neurons with oral cavity receptive fields were located more rostral, lateral and ventral in the NTS than neurons with receptive fields on the epiglottis. Little convergence of sensory input onto single cells in the NTS was observed between the oral cavity and the epiglottis. Only one NTS neuron had a receptive field in both of these receptor areas. In contrast, a large number of neurons with oral cavity receptive fields received input from two receptor areas. These neurons had a receptive field on the tongue which was located directly beneath the receptive field on the palate. Mechanical stimuli were the most effective for neurons with either oral cavity or epiglottal receptive fields and thermal stimuli were the least effective. Neurons which responded to mechanical stimuli responded better to a moving stimulus than to a punctate one, and large increases in the strength of a punctate stimulus were required to elicit significant increases in response frequency. Most NTS neurons responded to more than one of the stimulus modalities. However, a significant difference in the mean number of stimulus modalities which elicited responses was observed between neurons with oral cavity and epiglottal receptive fields. The number of multimodal neurons with epiglottal receptive fields was higher than those with oral cavity receptive fields. The multimodal nature of neurons which responded to epiglottal or oral cavity stimulation combined with their location in reflexogenic areas of the NTS suggests that these neurons could be important in the integration of afferent input from the oral cavity and upper airway. If these NTS neurons are involved in the control of oral and upper airway reflexes it would be important for them to respond to as many of the stimulus cues as possible and the majority of these neurons do just that.

Response properties of fibers in the hamster superior laryngeal nerve.

The purpose of the present investigation was to record electrophysiological responses from single fibers in the hamster superior laryngeal nerve (SLN) that were responsive to chemical stimulation of the larynx. Twenty chemical solutions, commonly used in studies of mammalian gustatory physiology, were applied to taste buds on and around the epiglottis. These stimuli were dissolved in physiological saline. Responses were the number of impulses elicited over a 15-s period following stimulus onset, above or below the background activity elicited by a previous rinse with saline. Unlike fibers in the hamster chorda tympani or glossopharyngeal nerves, SLN units were not easily classifiable into response types. Excitatory stimuli were primarily acids and bitter-tasting stimuli, with the order of their effectiveness being urea much greater than tartaric acid greater than HCl greater than KCl greater than citric acid greater than caffeine greater than quinine hydrochloride greater than acetic acid. The sweet-tasting stimuli and most salts other than KCl were primarily inhibitory, with the order of inhibitory effectiveness being CaCl2 greater than sucrose greater than fructose greater than LiCl greater than NaNO3 greater than Li2SO4 greater than NaCl. A hierarchical cluster analysis of fibers yielded no distinct clusters, yet differing sensitivities across the fibers were suggested. SLN fibers are highly responsive to sour and bitter stimuli, although they are not sensitive to fine differences in taste quality, as are fibers in other gustatory nerves.

Acute klebsiella epiglottitis: considerations for initial antibiotic coverage.

Acute epiglottis due to Klebsiella pneumoniae in an adult patient is described. The patient failed to respond to ampicillin and required cephalosporin therapy as well as surgical drainage. In view of increased resistance of Hemophilus influenzae to ampicillin and because of other possible etiologic agents such as Staphylococcus aureus and non-Hemophilus gram-negative rods, consideration should be given for the initial use of one of the recently introduced cephalosporins such as moxalactam or cefamandole in the treatment of adult epiglottitis.

[Fundamental and clinical investigation of clindamycin-2-phosphate in otorhinolaryngological field (author's transl)].

Some laboratory examinations were made with clindamycin-2-phosphate (CLDM-2-phos.). The drug was applied clinically to several otorhinolaryngological infections and the good results were obtained as follows. 1) Observing by biophotometer, the growth of Staphbylococcus aureus FDA 209P was inhibited well by the serum (diluted 10-fold) 30 minutes, 1, 2, 4 hours after 300 mg of CLDM-2-PHOS. were injected intramuscularly. 2) Serum concentration was determined by thin-layer method with Sarcina lutea ATCC 9341 as the test organism. The peak of serum level was obtained at 1 hour after a single intramuscular injection of 5 mg/kg or 10 mg/kg dosis of CLDM-2-phosphate. The peak of blood concentration was 5.4 mug/ml, 5.6 mug/ml respectively. 3) CLDM-2-phosphate concentration in tissues was estimated one hour after intramuscular injection of CLDM-2-Phosphate. The concentrations in blood and palatine tonsilla were 5.0 mug/ml and 2.9 mug/ml respectively after the intramuscular injection of 10 mg/kg. The concentrations in blood and mucous membrane of maxillar sinusitis were 4.1 mug/ml and 2.5 mug/ml respectively after the intramuscular injection of 10 mg/kg. 4) CLDM-2-phosphate was administered by intramuscular injection into 30 cases with various infections in otorhinolaryngological field. The clinical results were excellent in 22 cases (73.3%), effective in 3 cases (10.0%) and ineffective in 5 cases (16.7%). The effectiveness was 83.3%. 5) No side effects were observed in 30 cases.