Foreign body in the vallecula presenting as acute epiglottitis with unilateral supraglottitis

Life threatening inflammatory swelling of the epiglottic and supraglottic regions secondary to a foreign body in the vallecula is an unusual occurrence. Upper airway obstruction is potentially a life threatening sequela. We present a unique case of acute epiglottitis with unilateral supraglottitis secondary to foreign body in the vallecula, which gradually improved after emergency endotracheal intubation for respiratory arrest, followed by intensive conservative management with intravenous antibiotics, cortisone and intravenous fluids. This case emphasizes that a foreign body in the vallecula presenting with severe dysphagia should be taken seriously as it may lead to life threatening complications.

Multifocal adult rhabdomyoma: a case report and literature review

Adult extracardiac rhabdomyoma is an uncommon primary tumor of striated muscle origin that almost exclusively presents in the head and neck region. The occurrence of multifocality is a rare manifestation of this unusual lesion. In this study, we report a rare case of multifocal adult extracardiac rhabdomyoma in a patient presenting with an asymptomatic neck mass and provide a brief review of the literature on this entity.

[Two cases of flaccid epiglottis]

We had two adult cases of flaccid epiglottis. Flaccid epiglottis in adults is quite rare, and it is sometimes misdiagnosed and mistreated. Particularly, it is likely to be treated as an asthma attack, and is often confused with a paradoxical vocal cord movement. Patients are frequently seen with dyspnea owing to upper airway obstruction, with misdiagnosis, and tend to be overtreated with emergency intubation or tracheostomy after failed attempts at ventilation. We had two such difficult cases. The first case is seen with sudden dyspnea after extubation in the I.C.U, and the second had a trouble for ventilation with a difficulty in discriminating asthma and other disease. However, it is quite safe to ventilate sufficiently with appropriate diagnosis.

[Metastatic cystic squamous cell carcinoma in the neck mistaken as primary branchial cleft carcinoma: a report of 4 cases]

OBJECTIVE

To raise the vigilance not to believe easily the diagnosis of a primary branchial cleft carcinoma.

METHODS

Four cases of cystic metastatic squamous cell carcinoma in the neck misdiagnosed as branchiogenic carcinoma from 1993 to 2002 in our hospital were analyzed retrospectively.

RESULTS

The primary sites of these 4 cases were later discovered, 2 in the aryepiglottic fold, 1 in faucial tonsil and 1 in the skin of the head, respectively. The discovery of the primary sites ranged from the day of initial surgery to 41 months.

CONCLUSION

None of the cases reviewed in this study was a branchiogenic carcinoma. Therefore, the diagnosis of a primary branchial cleft carcinoma requires the fulfillment of strict criteria both clinically and pathologically.

Vagal response varies with Valsalva maneuver technique: a repeated-measures clinical trial in healthy subjects

STUDY OBJECTIVE

Variable success rates of the Valsalva maneuver in treatment of paroxysmal supraventricular tachycardia may be due to variations in performance technique. This study aimed to compare the magnitude of the vagal reflexes initiated by 5 variations of the Valsalva maneuver technique (supine, supine with epigastric pressure, supine with leg raise, semirecumbent position, and sitting position).

METHODS

This was a single-blinded, repeated-measures, clinical trial of 65 subjects in sinus rhythm. Subjects performed each Valsalva maneuver technique 5 times in random order. The means of the longest ECG R-R intervals during the relaxation phase (postmaneuver R-R interval) and the postmaneuver pulse rates for each technique were compared. The mean differences between the pre- and postmaneuver R-R intervals for each technique were also compared.

RESULTS

The supine with epigastric pressure and supine techniques resulted in longer mean postmaneuver R-R intervals (1.082 seconds [95% confidence interval (CI) 1.045 to 1.119 seconds] and 1.075 seconds [95% CI 1.035 to 1.114 seconds], respectively) than the leg raise, semirecumbent, and sitting position techniques (1.053 seconds [95% CI 1.019 to 1.086 seconds], 1.044 seconds [95% CI 1.006 to 1.081 seconds], and 1.024 seconds [95% CI 0.990 to 1.059 seconds], respectively), which equates to slower mean postmaneuver pulse rates for the supine with epigastric pressure and supine techniques (55.5 and 55.8 beats/min, respectively) than the leg raise, semirecumbent, and sitting position techniques (57.0, 57.5, and 58.6 beats/min, respectively). The supine with epigastric pressure and supine techniques also resulted in the largest premaneuver versus postmaneuver differences.

CONCLUSION

For healthy subjects in sinus rhythm, the supine with epigastric pressure and supine techniques generated stronger vagal responses, as measured by R-R intervals and pulse rates, than the other techniques examined. However, the vagal responses of these 2 techniques were similar, and the addition of epigastric pressure may confer little advantage.

Fiberoptic assessment of laryngeal mask airway placement: Blind insertion versus direct visual epiglottoscopy

PURPOSE

The study aims to compare the frequency of ideal anatomic placement of the laryngeal mask airway (LMA) using the traditional blind insertion approach with one where placement was facilitated by the use of a laryngoscope (epiglottoscopy).

PATIENTS AND METHODS

A prospective comparison of 132 patients divided into 2 groups (38 with the blind technique and 94 with the direct technique) were evaluated with 2 airway assessment methods, Wilson and Mallampati. We also considered whether there was a relationship between these criteria and the successful placement into an ideal position. Other variables were considered, including breathing airflow dynamics, body size, and skill level of the anesthesia care provider. Five placement visual ordinals were used to grade the LMA position.

RESULTS

All of the patients studied except one had good to excellent breathing patterns after LMA placement. Statistically more patients who had ideal to nearly ideal placement position of the LMA were placed under direct epiglottoscopy than when placed by the classic blind technique. The position of the LMA was assessed by fiberoptic examination through an attachment between the LMA and the anesthetic circuit. Eighty-six of 94 patients (91.5%) in the direct visual placement group had ideal position compared with 16 of 38 (42%) in the blind placement group. Both groups had more successful placement than any other studies by comparison. Even several obese patients were successfully treated by either technique, and even the inexperienced anesthesia care provider could place the LMA with considerable accuracy.

CONCLUSION

One hundred thirty-one of 132 patients had no airway difficulties after LMA placement with either blind (classic) or direct visual epiglottoscopy (laryngoscopy). A fiberoptic scope proved to be a valuable tool to assess the results. When ideal placement is either highly desirable or necessary, the direct visual technique is considered to be a better choice for placement than the blind, classic method.

[Asymptomatic bilateral pharyngocele]

The diverticula of the lateral wall of the pharynx are called pharyngoceles. We present a case of a 71-year old male in whom we discovered, by chance, a bilateral pharyngocele. Given their scarcity, we review the characteristics of the process, highlighting the relevance of the oesophagopharingeal barium swallow. Finally, we describe two possible anatomical locations of the herniated sac.

[Tracheal intubation using a guide wire for a 5-month-old baby with epiglottic cyst]

We report anesthetic management for a 5-month-old baby with an epiglottic cyst causing stenosis of the upper airway and growth failure. A flexible guide wire was first inserted into the trachea through the forceps port of the fiberoptic bronchoscope (O.D. 3.5 mm) nasally. After removal of the bronchoscope, the trachea was then successfully intubated with a trachea tube (I.D. 3.5 mm) passed over it. Her symptom improved after removal of the cyst. A flexible guide wire combined with fiberoptic bronchoscope is useful in tracheal intubation for a baby with a difficult airway.

Small bowel perforation after incomplete removal of percutaneous endoscopic gastrostomy catheter

Percutaneous endoscopic gastrostomy (PEG) is a well-established technique for providing long-term nutritional support. The advantages and most frequent complications have been widely documented, but less is known about the danger of removing or replacing a PEG by cutting the device at skin level without endoscopic assistance to ensure the removal of the inner part. Laparotomy is often required in elderly and high-risk patients to relieve an intestinal obstruction or perforation. We describe a fatal case of small bowel perforation, resulting from the inability to remove an inner bumper.

Intrafraction motions of the larynx during radiotherapy

PURPOSE

To quantify the intrafraction motions of the larynx during radiotherapy of laryngeal cancer. Depending on the magnitude, duration, and incidence, these motions may have clinical consequences for the choice of margins around the clinical target volume.

METHODS AND MATERIALS

The intrafraction motions were analyzed for 10 patients, treated in 33 or 35 fractions. The intrafraction motions of the larynx were visualized using an a-Si flat panel imager. Images were obtained every 200 ms, resulting in a movie of images for each beam. In addition to visual analysis of all movies, the tip of the epiglottis was delineated and used as a landmark, the coordinates of which were followed in time.

RESULTS

Movies were obtained during 79% of the total number of radiotherapy fractions. The total duration of swallowing was on average 0.45% (range 0.0-1.5) of the total irradiation time. Deviations of motions other than swallowing ranged between 0.3 and 11.5 mm. Some of these motions were more sudden, and others were probably related to breathing, because the frequency of these motions was 8-20/min.

CONCLUSION

The incidence and total duration of swallowing is low. Therefore, it is not necessary to apply an internal margin to take into account these displacements. Other motions, however, occur more often. In 95% of the irradiation time, the tip of the epiglottis moves within a range of 7.1 mm. A margin should be applied to the clinical target volume to take into account these motions.

Epiglottic carcinoma as a cause of laryngeal penetration and aspiration

OBJECTIVE. The purpose of our investigation was to review a series of patients with epiglottic carcinoma to elucidate the clinical and videofluoroscopic findings in these individuals. CONCLUSION. Patients with epiglottic carcinoma often present with symptoms of aspiration or pharyngeal dysphagia of relatively brief duration in the absence of a preexisting neurologic disease. In this clinical setting, barium studies are useful not only for detecting the epiglottic carcinoma but also for delineating the presence and mechanism of laryngeal penetration or tracheobronchial aspiration.

Fungal infection of the epiglottis simulating a clinical malignancy

Primary fungal infection of the larynx is rare. We present a case of primary laryngeal invasive fungal infection in a patient with Felty syndrome. The lesion in the epiglottis resembled a malignant process and the whole epiglottis was excised endoscopically. No neoplasia was found and the cultures of the epiglottis grew Candida glabrata. We propose that the diagnosis of laryngeal candidiasis be considered in adult patients with certain predisposing factors, eg, immunodeficiency syndromes, but the possibility of underlying malignancy must be ruled out.

["Tube scratching" in the trachea on nasotracheal intubation: comparison of Macintosh and McCoy laryngoscopes]

BACKGROUND

"Tube scratching" in the trachea, the intratracheal resistance of a tube, on nasotracheal intubation was evaluated using the Macintosh and the McCoy laryngoscope blade.

METHODS

Fifty young patients requiring nasotracheal intubation were studied. Following induction of anesthesia, X-ray was taken before and during the use of two types of laryngoscopes. For analysis of the configuration of the upper airway, we drew three straight lines [axis of pharynx (P), larynx (L) and trachea (T)] on each film. "Tube scratching" was evaluated and graded to four by a supporting anesthesiologists.

RESULTS

"Tube scratching" in the trachea was observed in 14/25 patients with McCoy laryngoscope and 4/25 patients with Macintosh laryngoscope (P < 0.05). Intubation with McCoy laryngoscope decreased more the angles formed by P and L, and L and P those that with Macintosh laryngoscope (P < 0.01). These data indicate that the lines of P, L and T tend not to align with McCoy laryngoscope, preventing the tracheal tube to be passed smoothly.

CONCLUSION

An excessive lifting of the epiglottis, often observed in using McCoy laryngoscope, causes "Tube scratching" in the trachea on nasotracheal intubation.

Colovesical fistula an unusual complication of cytotoxic therapy in a case of non-Hodgkin's lymphoma

A 65-year old man, a known case of non-Hodgkin's lymphoma of base of the tongue and epiglottis presented with complaints of pneumaturia and faecaluria. He had received the first cycle of cytotoxic therapy (CHOP-regimen). At the end of the cycle he developed febrile neutropenia (circulating granulocyte count <1500/mm3). Cystogram showed air in the bladder area and a fistulous communication to a cavity behind the bladder. CT-scan showed air in the bladder, a fistulous communication between the sigmoid colon and bladder along with an intervening small abscess cavity. On exploration a fistulous communication between the sigmoid and bladder along with an intervening small abscess cavity was found. Resection of involved portion of sigmoid and end to end anastomosis along with a diverting colostomy was done. The bladder was closed in two layers with an omental interposition between it and the sigmoid along with a suprapubic cystostomy. The histopathology demonstrated only inflammatory response without any evidence of malignancy or diverticular disease.

[Supracricoid laryngectomy with cricohyoidoepiglotopexy (CHEP). Preliminary report of the National Institute of Cancer]

OBJECTIVE

To present the preliminary results in our institute with supracricoid laryngectomy with cricohyoidoepiglotopexy (CHEP), as well as to evaluate possible short-term complications.

METHODS

This study included eight patients with diagnosis of squamous cell carcinoma of the larynx glottic region (three patients were in stage I, two in II and three in III). Histologic grade was well differentiated in three patients, moderately differentiated in four and poorly differentiated in one.

RESULTS

Supracricoid laryngectomy with cricohyoidoepiglotopexy were performed in all cases, and bilateral elective functional neck dissection was done in 6 patients. Both cricoarytenoid units were preserved in 6 patients and only one in the other two cases. Mean time of hospitalization was 11 days. Mean time of decanulation was 12 days for the whole group; however, in those patients that preserved both cricoarytenoid units, the mean time of decanulation was 6 days, and in those that preserved one cricoarytenoid unit it was 31 days. Physiologic phonation was achieved in all patients at the moment of decanulation. Mean time for remotion of nasogastric sonde was 25 days, and it was 17 days for those who preserved both cricoarytenoid units and for patients with one cricoarytenoid unit it was 46 days.

CONCLUSIONS

Supracricoid laryngectomy with cricohyoidoepiglotopexy allows to preserve the basic functions of the larynx (respiration, degluttion and phonation), as well as the reintegration of affected patients to social life. All patients must be evaluated carefully in order avoid changing the stage or the surgical plan due to substadification of the tumor.

Schwannoma of the epiglottis: first report of a case

Schwannomas of the larynx are rare. Most of the few such reports in the literature have described schwannomas that occurred in the aryepiglottic fold or the true vocal folds. In this article, we report what we believe is the first case of a schwannoma arising from the epiglottis.

Angioneurotic edemas of the upper aerodigestive tract after ACE-inhibitor treatment

There are rare cases in which inhibitors of the angiotensin-converting enzyme can cause an angioneurotic edema of the upper aerodigestive tract. The pathomechanism of this side effect depends on an interaction of the drug with hormones regulating vascular permeability, such as the kallikrein kinin system and the prostaglandin system. Angioedema is characterized by subcutaneous or submucosal swellings, which usually affect the lips, soft palate, tongue and larynx. Pathomechanisms, differential diagnosis and treatment of ACE-inhibitor-induced edema of the upper aerodigestive tract are described in three case reports.