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INTRODUCTION: Neonates with cardiorespiratory compromise at delivery are at substantial risk of hypoxic neurologic injury and death. Though mitigation strategies such as ex-utero intrapartum treatment (EXIT) exist, the competing interests of neonatal beneficence, maternal non-maleficence, and just distribution of resources require consideration. Due to the rarity of these entities, there are few systematic data to guide evidence-based standards. This multi-institutional, interdisciplinary approach aims to elucidate the current scope of diagnoses that might be considered for such treatments and examine if treatment allocation and/or outcomes could be improved. METHODS: After IRB approval, a survey investigating diagnoses appropriate for EXIT consultation and procedure, variables within each diagnosis, occurrence of maternal and neonatal adverse outcomes, and instances of suboptimal resource allocation in the last decade was sent to all North American Fetal Treatment Network center representatives. One response was recorded per center. RESULTS: We received a 91% response rate and all but one center offer EXIT. Most centers (34/40, 85%) performed 1-5 EXIT consultations per year and 17/40 (42.5%) centers performed 1-5 EXIT procedures in the last 10 years. The diagnoses with the highest degree of agreement between centers surveyed to justify consultation for EXIT are head and neck mass (100%), congenital high airway obstruction (90%), and craniofacial skeletal conditions (82.5%). Maternal adverse outcomes were noted in 7.5% of centers while neonatal adverse outcomes in 27.5%. A large percentage of centers report cases of suboptimal selection for risk mitigation procedures and several centers experienced adverse neonatal and maternal outcomes. CONCLUSION: This study captures the scope of EXIT indications and is the first to demonstrate the mismatch in resource allocation for this population. Further, it reports on attributable adverse outcomes. Given suboptimal allocation and adverse outcomes, further examination of indications, outcomes, and resource use is justified to drive evidence-based protocols.
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Obstrução das Vias Respiratórias , Doenças Fetais , Terapias Fetais , Gravidez , Feminino , Recém-Nascido , Humanos , Doenças Fetais/diagnóstico , Útero , Cesárea , América do NorteRESUMO
OBJECTIVE: To characterize incidence of mandibular anomalies (MAs) and compare gestational age, airway interventions, and complications among individuals with MA phenotypes (isolated retrognathia, isolated micrognathia, syndromic micrognathia, micrognathia plus cleft palate/cleft lip and palate, agnathia/micrognathia plus cervical auricle/otocephaly, and agnathia/micrognathia plus microstomia) and unaffected individuals. METHODS: The Healthcare Cost and Utilization Project Kids' Inpatient Database was used to collect data over a 20-year period beginning in 2000. Interventions were classified as perinatal when performed on day of life (DOL) 0 or 1 and subsequent when performed during the birth hospitalization after DOL 1. Hypoxic complications included cardiac arrest, birth asphyxia, hypoxic-ischemic encephalopathy, anoxic brain damage, intraventricular hemorrhage or cerebral infarction. Descriptive statistics are reported, and the Rao-Scott chi-square test compared groups. RESULTS: MAs affected 119 per 100,000 birth visits. Preterm delivery was more frequent for all MA phenotypes. Individuals with MA phenotypes are more likely to require medical attention (airway intervention on DOL 0 or 1 OR no airway intervention received but patient sustained hypoxic complication/mortality): 16.2%-70.7% vs. 3.8%, p < 0.01. Despite receipt of airway interventions at a higher rate, collectively individuals with MAs who received an airway intervention on DOL 0 or 1 have a mildly elevated risk of hypoxic complication or mortality (32.4% vs. 26.4%, p < 0.01). CONCLUSIONS: Preterm birth is more common, however, does not account for the elevated rate of airway intervention. Individuals with MAs require higher rates of medical attention, and current airway management paradigms are insufficient to prevent complications and mortality. LEVEL OF EVIDENCE: III Laryngoscope, 2024.
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The current literature fully supports HPV (human papillomavirus)-associated OPSCC (oropharyngeal squamous cell carcinoma) as a unique clinical entity. It affects an unambiguous patient population with defined risk factors, has a genetic expression pattern more similar to cervical squamous cell carcinoma than non-HPV-associated HNSCC (head and neck squamous cell carcinoma), and may warrant divergent clinical management compared with HNSCC associated with traditional risk factors. However, a detailed understanding of the molecular mechanisms driving these differences and the ability to exploit this knowledge to improve clinical management of OPSCC has not yet come to fruition. The present review summarizes the aetiology of HPV-positive (HPV+) OPSCC and provides a detailed overview of HPV virology and molecular pathogenesis relevant to infection of oropharyngeal tissues. Methods of detection and differential gene expression analyses are also summarized. Future research into mechanisms that mediate tropism of HPV to oropharyngeal tissues, improved detection strategies and the pathophysiological significance of altered gene and microRNA expression profiles is warranted.
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Carcinoma de Células Escamosas/virologia , Neoplasias Orofaríngeas/virologia , Infecções por Papillomavirus/complicações , Animais , Carcinoma de Células Escamosas/genética , Regulação Neoplásica da Expressão Gênica , Regulação Viral da Expressão Gênica , Humanos , Neoplasias Orofaríngeas/genética , Infecções por Papillomavirus/genéticaRESUMO
INTRODUCTION: Fetal goiter is a rare congenital disorder that can present with life-threatening neonatal airway obstruction. Lifesaving and function-preserving airway management strategies are available, but routine delivery affords a limited window for intervention. Accordingly, fetal goiter is reported among the most common indications for ex-utero intrapartum treatment (EXIT). While EXIT prolongs the window for airway intervention to benefit the neonate, it elevates the risk to the pregnant person and requires extensive resources; therefore, data to guide ideal treatment selection are essential. This study aims to compare perinatal airway interventions between individuals with a birth hospitalization discharge diagnosis (BHDD) of goiter and the general population. MATERIALS AND METHODS: Individuals with and without BHDD of goiter were identified in the Healthcare Cost and Utilization Project (HCUP) Kids' Inpatient Database from 2000 to 2019. The frequency of airway interventions on day of life (DOL) 0 or 1 were compared using the Rao-Scott chi-square test. Additionally, gestational age, type of intervention, complications, mortality, birth weight, and length of stay were examined for the goiter cohort. RESULTS: Two-hundred eighty-seven weighted cases of goiter were identified in the study period. The population was 61 % male, 55 % White, and median birthweight was 3.3 kg. The median length of stay was 4.3 days, and average total charges were $42,332. Airway intervention on DOL 0 or 1 was performed in 16.9 % of individuals with goiter compared to 1.6 % in neonates without goiter (p < 0.001). Interventions in the goiter cohort included endotracheal intubation in 16 % of cases, laryngoscopy/bronchoscopy in 1-5% of cases, and tracheostomy in <1 % of cases. Fewer than 1 % of individuals undergoing intubation additionally had mass decompression/resection on DOL 0 or 1. No neonates received extracorporeal membrane oxygenation cannulation or cardiopulmonary resuscitation. Hypoxic encephalopathy occurred in <1 % of cases, among which endotracheal intubation was the only airway intervention performed. There were no mortalities among neonates with goiter. CONCLUSION: Individuals with BHDD of goiter receive significantly higher rates of perinatal airway intervention. In most cases, endoscopic interventions alone were sufficient to avoid hypoxic neurological complications. These findings contribute to data to aid in clinical counseling and empower patients to make informed decisions according to their values and treatment goals.
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Obstrução das Vias Respiratórias , Doenças Fetais , Bócio , Gravidez , Recém-Nascido , Feminino , Humanos , Masculino , Pacientes Internados , Doenças Fetais/cirurgia , Manuseio das Vias Aéreas , Obstrução das Vias Respiratórias/terapia , Obstrução das Vias Respiratórias/cirurgia , Custos de Cuidados de Saúde , Bócio/terapia , Bócio/complicaçõesRESUMO
Cervical and craniocervical instability are associated with catastrophic procedural outcomes. We discuss three individuals who required otolaryngologic surgical intervention: two with symptomatic spinal instability and one in whom spinal stability was unable to be assessed. Two cases were managed with procedural positioning precautions and evoked potential monitoring, and the other with procedural positioning precautions alone. Methods of monitoring and triggers for repositioning are discussed. This series is intended to discuss the approach and potential added value of evoked potential monitoring for risk mitigation in pediatric patients with concern for cervical spine instability.
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Potenciais Somatossensoriais Evocados , Monitorização Neurofisiológica Intraoperatória , Humanos , Criança , Potenciais Somatossensoriais Evocados/fisiologia , Potencial Evocado Motor/fisiologia , Pescoço/cirurgia , Procedimentos Neurocirúrgicos , Vértebras Cervicais/cirurgiaRESUMO
OBJECTIVE: To present an uncommon but serious, recently identified complication of checkpoint inhibitor therapy in a patient treated with pembrolizumab infusion for disseminated recurrent respiratory papillomatosis (RRP). METHODS: Case report. RESULTS: A 43-year-old woman with underlying asthma developed acute hypoxic respiratory failure within 24 hours of her third infusion of pembrolizumab for treatment of intractable, disseminated recurrent respiratory papillomatosis. Pulmonary function testing revealed a severe intra-thoracic obstructive ventilatory defect. Discontinuation of pembrolizumab, ventilatory support, and treatment with systemic and inhaled corticosteroids resulted in resolution of respiratory failure; however, her underlying asthma remains poorly controlled. CONCLUSION: To our knowledge, this case is the first report of pembrolizumab-induced obstructive respiratory failure in a patient being treated for RRP.
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Anticorpos Monoclonais Humanizados/efeitos adversos , Inibidores de Checkpoint Imunológico/efeitos adversos , Infecções por Papillomavirus/tratamento farmacológico , Insuficiência Respiratória/induzido quimicamente , Infecções Respiratórias/tratamento farmacológico , Doença Aguda , Adulto , Feminino , Humanos , Insuficiência Respiratória/diagnóstico , Insuficiência Respiratória/terapiaRESUMO
INTRODUCTION: Multiple congenital abnormalities of the epiglottis have been reported and iatrogenic injuries to the larynx and subglottis are well known. We present a new pattern of defect not previously reported in the literature. METHODS: Epiglottic abnormalities at two institutions are reviewed. Cases of defects involving the lateral aspect of the epiglottis and aryepiglottic fold are identified. A literature review of known epiglottic defects is performed. RESULTS: Two children possessing lateral notch injuries at the aryepiglottic attachment to the epiglottis are described. Both children have a history of multiple laryngeal instrumentation attempts and prolonged intubation. Both have swallowing difficulties and are gastrostomy dependent. Congenital epiglottic defects include aplasia and midline bifidity, however, no lateral congenital epiglottic defects have been reported. CONCLUSION: Epiglottic defects, while rare, should be part of the differential for children with aspiration and feeding difficulties. A new pattern of defect is described and iatrogenic etiology proposed.
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Epiglote/anormalidades , Epiglote/lesões , Intubação Intratraqueal/efeitos adversos , Laringoscopia , Epiglote/fisiopatologia , Epiglote/cirurgia , Feminino , Humanos , Lactente Extremamente Prematuro , Recém-Nascido , Músculos Laríngeos/cirurgia , Aspiração Respiratória/fisiopatologiaRESUMO
OBJECTIVES/HYPOTHESIS: The anatomy of children with severe Pierre Robin sequence can present a challenge for direct laryngoscopy and intubation. Advanced techniques including flexible fiberoptic laryngoscopic intubation have been described but require highly specialized skill and equipment. Rigid video laryngoscopy is more accessible but has not been described in this population. STUDY DESIGN: Retrospective cohort study. METHODS: A retrospective review was completed at a tertiary care center of all children between January 2016 and March 2020 with Pierre Robin sequence who underwent a mandibular distraction osteogenesis procedure. Intubation events were collected, and a descriptive analysis was performed. A univariate logistic regression model was applied to direct laryngoscopy and flexible fiberoptic laryngoscopy with rigid video laryngoscopy as a reference. RESULTS: Twenty-five patients were identified with a total of 56 endotracheal events. All patients were successfully intubated. Direct laryngoscopy was successful at first intubation attempt in 47.3% (9/19) of events. Six direct laryngoscopy events required switching to another device. Rigid video laryngoscopy was successful at first intubation attempt in 80.5% (29/36) of events. Two cases required switching to another device. Flexible fiberoptic laryngoscopy was found successful at first intubation attempt in 88.9% (8/9) of events. Direct laryngoscopy was 4 times more likely to fail first intubation attempt when compared to rigid video laryngoscopy (P < .05). There was no significant difference between rigid video laryngoscopy and flexible fiberoptic laryngoscopy for intubation. CONCLUSIONS: For children with Pierre Robin sequence rigid video laryngoscopy should be considered as a first attempt intubation device both in the operating room and for emergent situations. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:1647-1651, 2021.
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Obstrução das Vias Respiratórias/cirurgia , Intubação Intratraqueal/métodos , Laringoscopia/métodos , Síndrome de Pierre Robin/complicações , Adolescente , Obstrução das Vias Respiratórias/etiologia , Criança , Pré-Escolar , Falha de Equipamento , Feminino , Humanos , Lactente , Recém-Nascido , Intubação Intratraqueal/instrumentação , Laringoscópios , Laringoscopia/instrumentação , Masculino , Mandíbula/anormalidades , Mandíbula/cirurgia , Osteogênese por Distração , Síndrome de Pierre Robin/diagnóstico , Estudos Retrospectivos , Índice de Gravidade de Doença , Resultado do TratamentoRESUMO
In April 2010, the Missouri State Medical Association (MSMA) sponsored the Second Annual Medical Student Lobby Day to increase student understanding of the relationship between state politics and medicine, further MSMA policy positions, remove barriers to political action, and improve future Lobby Day events. A detailed description is provided, which could be used as a reproducible model for creating similar events in other states. Participant surveys were administered and outcome data was collected and analyzed.
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Manobras Políticas , Sociedades Médicas , Governo Estadual , Estudantes de Medicina , Humanos , MissouriRESUMO
OBJECTIVE: To make recommendations on the identification, routine evaluation, and management of fetuses at risk for airway compromise at delivery. METHODS: Recommendations are based on expert opinion by members of the International Pediatric Otolaryngology Group (IPOG). A two-iterative Delphi method questionnaire was distributed to all members of the IPOG and responses recorded. The respondents were given the opportunity to comment on the content and format of the survey, which was modified for the second round. "Consensus" was defined by >80% respondent affirmative responses, "agreement" by 51-80% affirmative responses, and "no agreement" by 50% or less affirmative responses. RESULTS: Recommendations are provided regarding etiologies of perinatal airway obstruction, imaging evaluation, adjunct evaluation, multidisciplinary team and decision factors, micrognathia management, congenital high airway obstruction syndrome management, head and neck mass management, attended delivery procedure, and delivery on placental support procedure. CONCLUSIONS: Thorough evaluation and thoughtful decision making are required to optimally balance fetal and maternal risks/benefits.
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Obstrução das Vias Respiratórias , Otolaringologia , Manuseio das Vias Aéreas , Obstrução das Vias Respiratórias/diagnóstico , Obstrução das Vias Respiratórias/etiologia , Obstrução das Vias Respiratórias/terapia , Criança , Consenso , Feminino , Humanos , Placenta , GravidezRESUMO
HYPOTHESIS: Anatomic study of the external auditory canal's (EAC) anterior bulge, scutum, and ossicular chain will generate knowledge applicable to safe ear surgery and instrument design. BACKGROUND: The EAC contains two structures that obscure view of the middle ear: the anterior bulge and the scutum. The dimensions of these structures and their relationships to the ossicular chain have not been previously described. METHODS: Cadaveric temporal bones underwent computed tomography scanning, and three-dimensional reconstructions were created. Dimensions and angles of the EAC, its anterior bulge and scutum were measured. Distances to ossicular landmarks and the facial nerve were examined. RESULTS: The anterior EAC had a swan-neck shape. The thinnest portion was located medially and correlated with the canal thickness at the anterior bulge. However the thickness of the anterior bulge was not correlated with its angulation. The scutum averaged 3.8âmm long with a base thickness of 2.3âmm and a mean tip angle of 33 degrees. The short process of the incus was significantly closer to the scutum than other ossicular landmarks. CONCLUSION: Prominent anterior canal bulges are formed by posterior temporomandibular joints, not thicker bone. The scutum has asymmetric distances to various portions of the ossicles with the incus short process sometimes as close as 0.2âmm, placing it at risk of injury.
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Meato Acústico Externo/anatomia & histologia , Orelha Média/anatomia & histologia , Osso Temporal/anatomia & histologia , Humanos , Procedimentos Cirúrgicos OtológicosRESUMO
INTRODUCTION: Although it is recommended to perform cochlear implantation in both ears at the same time for management of profound hearing loss in children, many centers prefer to perform sequential implantation. There are many reasons as to why a simultaneous bilateral implantation is not commonly accepted and performed. The major risk is the possibility of bilateral vestibular organ impairment. However, it is beyond doubt that children who received the first implant should be given a chance for binaural hearing and associated benefits. In the literature, there are no homogenous criteria for bilateral implantation, and it is hard to find uniform and convincing algorithms for second cochlear implantation. The aim of this study is an attempt to identify a safe way of qualifying for second cochlear implantation in children. MATERIAL AND METHODS: Forty children with one cochlear implant were qualified for the second implantation. During qualification, the following were taken into account: time of the first implantation, audiometry results, use of the hearing aid in the ear without an implant and benefit of the device, speech and hearing development, and vestibular organ function. R esults: Fifteen out of forty children (38%) were qualified for the second implantation. In 35% of children, the decision was delayed with possible second implantation in the future. Eleven children (27%) were disqualified from the second surgery. DISCUSSION: During evaluation according to the protocol presented in our study, 38% of children with a single cochlear implant were qualified for the second implantation with a chance for an optimal development and effective use of the second cochlear implant. We are convinced that sequential implantation with a short interval between surgeries and with an examination of the vestibular organ, hearing and speech development as well as an assessment of potential benefits from the second implant (bimodal stimulation) before the second implantation is the safest and most beneficial solution for children with severe hearing loss.
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Implante Coclear/estatística & dados numéricos , Implantes Cocleares/estatística & dados numéricos , Surdez/terapia , Percepção da Fala/fisiologia , Criança , Pré-Escolar , Feminino , Testes Auditivos , Humanos , MasculinoRESUMO
INTRODUCTION: Acute mastoiditis remains the most common complication of acute otitis media. It may rarely appear also in cochlear implant patients. However, the treatment recommendations for this disease are not precisely defined or employed, and in the current literature the differences regarding both the diagnosis and management are relatively substantial. OBJECTIVE: The aim of this study was to determine a standard and safe procedure to be applied in case of pediatric acute mastoiditis. METHODS: A retrospective chart review of 73 patients with 83 episodes of acute mastoiditis hospitalized at our tertiary-care center between 2001 and 2016 was conducted. Bacteriology, methods of treatment, hospital course, complications, and otologic history were analyzed. Based on our experience and literature data, a protocol was established in order to standardize management of pediatric acute mastoiditis. RESULTS: All the patients treated for acute mastoiditis were submitted to an intravenous antibiotic regimen. In the analyzed group pharmacological treatment only was applied in 11% of children, in 12% myringotomy/tympanostomy was added, and in the vast majority of patients (77%) mastoidectomy was performed. In our study recurrent mastoiditis was noted in 8% of the patients. We also experienced acute mastoiditis in a cochlear implant child, and in this case, a minimal surgical procedure, in order to protect the device, was recommended. CONCLUSIONS: The main points of the management protocol are: initiate a broad-spectrum intravenous antibiotic treatment; mastoidectomy should be performed if the infection fails to be controlled after 48h of administering intravenous antibiotic therapy. We believe that early mastoidectomy prevents serious complications, and our initial observation is that by performing broad mastoidectomy with posterior attic and facial recess exposure, recurrence of acute mastoiditis can be prevented.
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Antibacterianos/uso terapêutico , Mastoidite/tratamento farmacológico , Doença Aguda , Criança , Pré-Escolar , Humanos , Lactente , Mastoidite/etiologia , Otite Média/complicações , Estudos RetrospectivosRESUMO
OBJECTIVES: Recurrent acute mastoiditis is repeatedly reported in the literature, but data to understand the pathogenesis, update treatment recommendations and inform future trials are sparse due to the infrequency of the disease. METHODS: A retrospective chart review from 2001 to 2016 was conducted including 73 children treated for acute mastoiditis. A follow-up survey was attempted for each patient. Bacteriology, method of treatment, hospital course, complications, and otologic history were analyzed. A chi-squared test, Fisher's exact test and Mann-Whitney U test compared recurrent acute mastoiditis to single acute mastoiditis cases. Additionally, a comprehensive PubMed search and review of world literature addressing recurrent pediatric acute mastoiditis was performed for comparative purposes. RESULTS: Among 73 children with acute mastoiditis, six (8%) experienced recurrent acute mastoiditis. Streptococcus pneumoniae was the only bacteria isolated in this group. History of recurrent acute otitis media (>4 per year) prior to the first episode of acute mastoiditis was identified in 24% with single episode of acute mastoiditis and 83% with recurrent mastoiditis (pâ¯<â¯0.05). Fewer intracranial/intratemporal complications were identified among recurrent mastoiditis patients (pâ¯<â¯0.05). In a group of patients treated with more extensive surgical communication during mastoidectomy for primary acute mastoiditis (wide mastoidectomy with broad attic exposure and posterior tympanotomy) no recurrence was observed. CONCLUSION: We identify multiple risk factors associated with recurrence and provide early data supporting anatomic predisposition to the development of recurrent acute mastoiditis. More aggressive opening between the mastoid cavity and middle ear may prevent recurrent acute mastoiditis episodes.
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Mastoidite/etiologia , Mastoidite/terapia , Doença Aguda , Adolescente , Criança , Pré-Escolar , Feminino , Seguimentos , Humanos , Lactente , Masculino , Mastoidite/patologia , Estudos Retrospectivos , Fatores de RiscoRESUMO
Objective To define the presence and relationship of the petrosquamous stalactite (PsS)-a condensation of the trabecular Korner's septum into a bony plate of the petrosquamous suture-to surrounding structures and understand its surgical implications. Study Design Series of cadaver dissections. Setting University of Missouri Alumni Temporal Bone and Microvascular Laboratory. Subjects and Methods Anatomic dissections were conducted on 15 consecutive formalin-preserved and frozen adult human temporal bones. A calibrated Dino-Lite Premier Digital Microscope was used to photograph dissections of each bone. Measurements were conducted with DinoCapture 2.0 software, with measurement agreement between 2 authors. Results The PsS was present in all specimens. A conserved vascular structure courses within the structure, and the superior malleolar ligament inserts on it. The mean ± SEM distances from the PsS to the tegmen tympani and incus buttress were 2 ± 0.24 mm and 4.23 ± 0.14 mm, respectively. The shortest distance from the PsS to the posterior body of the incus was 1.25 ± 0.13 mm, while the greatest distance from the posterior prominence of the PsS to the posterior body of the incus was 4.58 ± 0.25 mm. Conclusion The PsS is a consistently identifiable structure that may facilitate identification of the tegmen tympani and guide the otologic surgeon from the mastoid antrum to the incus. It is important to recognize the contribution of the PsS to the division of the epitympanic space when cholesteatoma involves the region, to avoid leaving a nidus for future disease.
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Processo Mastoide/anatomia & histologia , Osso Temporal/anatomia & histologia , Cadáver , HumanosRESUMO
Nasoenteric tubes provide short-term nutrition support to patients unable to take an adequate oral diet. Bridling systems may be used to secure tubes to guard against displacement. We present the first case of an avulsed magnet from a bridling system to raise awareness of this potential complication. The primary methods of securing a nasogastric tube are reviewed, and comparative assessment of the 3 main systems is presented. Diagnosis and management of nasal foreign bodies relevant to this case are reviewed and prevention/safety considerations discussed.