A comparative evaluation of the sniffing, the simple head extension and the head hyperextension positions for laryngoscopic view and intubation difficulty in adults undergoing direct laryngoscopy

OBJECTIVE

This work aimed to compare between the laryngoscopy positions; sniffing, simple head extension and head hyperextension positions to assess whether the laryngeal view, intubation time and intubation difficulty could improve with one of these positions than the others.

DESIGN

Prospective randomized three arms clinical trial.

SETTING

Operation room, the phoniatrics unit [removed for blind peer review].

PARTICIPANTS

The study included 75 cases with 25 cases in each group. Group "A" with head in the sniffing position, Group "B" with the head in simple extension position, Group "C" with head in hyperextension position.

RESULTS

The three groups were compared regarding intubation time and laryngoscopic view time. Intubation time showed statistically significant difference between the three groups. Mean of sniffing group (No. = 25) was 13.19 s (± 3.35). Mean of simple extension group (No. = 25) was 11.29 s (± 3.14). Mean of Hyperextension group (No. = 25) was 14.39 s (± 4.14). Laryngoscopic view time showed statistically highly significant difference between the three groups. Mean of sniffing group (No. = 25) was 17.19 s (± 7.27). Mean of simple group (No. = 25) was 12.18 s (± 4.46). Mean of hyperextension group (No. = 25) was 17.08 s (± 6.51).

CONCLUSION

Comparing the sniffing, the simple extension and the hyperextension positions, the simple extension position showed the best time regarding intubation time and laryngoscopic view time.

Airway management with Hi-flow nasal cannula oxygen in children with severe laryngeal obstruction

BACKGROUND

The aim of this study was to report our initial experience in airway management in young children with severe laryngeal obstruction. Hi-flow nasal cannula oxygen (HFNO) with spontaneous respiration was used as a new airway management strategy in young children undergoing suspension laryngoscopic surgery.

METHODS

Children aged between 1 day and 24 months scheduled for suspension laryngoscopy were retrospectively studied. The data collected included the patients' age, gender, American Society of Anaesthesiologists physical status classification, comorbidities, preoperative physiological status, methods of induction and maintenance of anesthesia, course of the disease and surgical options, lowest oxygen saturation recorded, transcutaneous CO2, duration of operation, and patients' need for rescue methods.

RESULTS

A total of 38 patients successfully underwent suspension laryngoscopy under HFNO with spontaneous respiration. 19 patients were less than 1 year old (7 neonates), while the other half were less than or equal to 2 years old. The median [IQR (range)] lowest oxygen saturation recorded during the operation was 98 [93-99 (91-99)] %. The median [IQR (range)] duration of HFNO with spontaneous respiration was 65 [45-100 (30-200)] minutes. The median [IQR (range)] PCO2/PtcCO2 at the end of the spontaneous ventilation period was 54 [48-63 (39-70)] mmHg, which was the same as the preoperative PCO2 despite a long operation time.

CONCLUSIONS

HFNO with spontaneous respiration emerged as a new airway management strategy in young children with severe laryngeal obstruction that was beneficial in maintaining oxygenation and was superior to transnasal humidified rapid insufflation ventilatory exchange (THRIVE) in terms of the rising rate of PCO2 in these patients, thereby prolonging the safety time of the operation.

Assessment of intracranial pressure with ultrasonographic measurement of optic nerve sheath diameter on patients undergoing suspension direct laryngoscopy

PURPOSE

The study aims to examine the effect on intracranial pressure by calculating the optic nerve sheath diameter (ONSD) using ultrasound in patients who underwent suspension direct laryngoscopy.

METHODS

Thirty-three patients who underwent suspension direct laryngoscopy were included in this prospective observational study. ONSD measurement was performed using a high-frequency linear probe. The ONSD basal (T0) value was determined using ultrasound in the supine position before the induction. Ultrasonography was used to record ONSD in the Boyce Jackson position (T1) just before inserting the laryngeal blade, in the Boyce Jackson position just before removing the laryngeal blade (T2), and in the supine position (T3) just before extubation.

RESULTS

A statistically significant rise (p < 0.001) was seen between the patients' baseline ONSD values and the values at T1, T2, and T3. The optic nerve sheat diameter level recorded prior to withdrawing the laryngeal blade (T2) was considerably greater than the ONSD level calculated instantly before insertion of the laryngeal blade (T1) (p < 0.001). The ONSD value prior to extubation (T3) following the removal of the laryngeal blade was considerably smaller than the ONSD value prior removing the laryngeal blade (T2) (p < 0.001).

CONCLUSIONS

This study found that when the laryngeal blade is mounted during the suspension direct laryngoscopy surgery, there is a significant increase in ultrasonographically measured ONSD and increased the ONSD even further during the time the mouth gag was remained in situ. This is the first research to indicate that measuring ONSD with ultrasonography during suspension direct laryngoscopy raises intracranial pressure.

Complications following laser wedge excision for idiopathic subglottic stenosis

OBJECTIVES

Endoscopic laser wedge excision (LWE) is an effective treatment option for idiopathic subglottic stenosis (iSGS); however, data regarding complications following LWE are limited. The aim of the following analysis was to provide a review of frequency and type of complications that occur with LWE in patients with iSGS.

STUDY DESIGN

Retrospective review.

METHODS

Patients with iSGS undergoing LWE between January 2002 and September 2021 were performed. Demographic data were recorded. Complications were stratified into major and minor categories. The frequency of these complications and the respective treatment for them was analyzed.

RESULTS

212 patients within the study period underwent a total of 573 LWE procedures. All but two patients were female, with a median age of 54 years at time of LWE. Of these patients, 43 (20 %) patients experienced a complication. Of these, only 7 (15 %) of the reported complications were considered major while the rest were minor in nature. Major complications included 3 cases of post-operative hemoptysis, 1 case of tracheitis, and 3 cases of reduced vocal fold hypomobility with concurrent glottic stenosis. Minor complications consisted of 2 cases of tooth fracture and 34 cases of tongue paresthesia post-operatively that was self-limited. There were no mortalities.

CONCLUSION

Major complications occur in <5 % of LWE procedures based off the analysis. All major complications were managed without significant long-term morbidity. Minor complications with the LWE are self-limited in nature. Our data supports the LWE as a safe treatment option for iSGS.

LEVEL OF EVIDENCE: 4

A new transoral modality for the treatment of lingual thyroglossal duct cyst with suspension laryngoscopy by plasma coblation

INTRODUCTION

Lingual thyroglossal duct cysts (LTGDC) are a rare kind of thyroglossal duct cyst. However, Sistrunk surgery is not very suitable for this type of cyst. This study aimed to explore the efficacy of transoral excision of LTGDC by plasma coblation.

METHODS

The present study reviewed 11 patients, comprising seven males and four females, who had been diagnosed with LTGDC preoperatively by computed tomography (CT) and fibre-optic electronic laryngoscopy. Of those patients, two had recurrence after surgery of epiglottic cysts. All these patients underwent transoral excision by plasma coblation. Then, we collected preoperative data of the patients, observed the effect of surgery, and analysed factors relevant to LTGDC, including the estimated bleeding amount, postoperative hospitalisation, complications and recurrence rates.

RESULTS

The connection between LTGDC and hyoid was tapered on sagittal images of CT, which was vital evidence for the diagnosis of LTGDC. Surgery was performed successfully for all 11 patients, and all recovered without complication. There was no evidence of recurrence after surgery, during follow up for 3-43 months.

CONCLUSIONS

Transoral surgery for LTGDC can be performed successfully by plasma coblation, which is an effective and safe surgical treatment. Fibre-optic electronic laryngoscopy and CT are essential to the diagnosis of LTGDC in order to avoid missing detection and misdiagnosis.

The treatment of congenital pyriform sinus fistula: a single-center experience

PURPOSE

Congenital pyriform sinus fistula (CPSF) often presents diagnosis and treatment challenges. This study aimed to explore the treatment principles and to evaluate the effectiveness of the hypothermia plasma cauterization with suspension laryngoscopy for CPSF.

METHODS

The medical records of 56 patients with CPSF from January 2000 to December 2019 were retrospectively reviewed.

RESULTS

Of the 56 cases, the lesions were predominantly located on the left side (95%), and the accuracy of the first diagnosis was 30%. Ultrasound showed an abnormal rate of 86%, while CT or MRI displayed an abnormal anatomic lesion of 92%. The 3D visual reconstruction enabled the analysis of morphological characteristics of CPSF. The positive predictive value of barium esophagography was 89%, whereas the positive rate of the internal opening in CPSF under local anesthesia laryngoscopy was 33%. Nine cases of sinus type underwent open resection, and the recurrence rate was 33%. Interestingly, ten patients with sinus type underwent hypothermia plasma cauterization with suspension laryngoscopy, leading to a success rate of 100% without apparent complications.

CONCLUSIONS

Hypothermia plasma cauterization with suspension laryngoscopy alongside 3D imaging is both minimally invasive and repeatable with neglectable complications, which has the potential to serve as the first-line treatment for CPSF in the future.

Tongue symptoms, suspension force and duration during operative laryngoscopy

PURPOSE

Suspension laryngoscopy is a commonly performed procedure in otolaryngology. During the procedure, the laryngoscope applies direct force to the tongue. Postoperative tongue symptoms include pain, swelling, numbness, taste disturbance, and rarely motor deficits. Duration and magnitude of force applied have previously been associated with post-operative throat and tongue pain, respectively. We sought to correlate postoperative tongue symptoms with magnitude of force applied and/or duration of suspension and investigate any risk factors for tongue morbidity.

MATERIALS AND METHODS

A sample of patients undergoing suspension laryngoscopy between 2015 and 2018 were prospectively recruited. Those with preexisting tongue symptoms, disease or surgery were excluded. Patients completed preoperative and postoperative questionnaires evaluating tongue swelling, numbness, motion and taste disturbance. Symptoms were subjectively scored on a visual scale from 0 to 10. Patient demographics, past medical and social history were also recorded. Intraoperative pressures were measured using a spring force scale, positioned between the suspension arm and Mayo stand. Initial and end suspension forces and duration of suspension were recorded.

RESULTS

120 patients met inclusion criteria, of which 63 completed both preoperative and postoperative questionnaires. 6 patients (9.5%) experienced postoperative tongue symptoms. Suspension force and duration of suspension were not significantly predictive of postoperative tongue symptoms. While all symptomatic patients were current or former cigarette smokers, smoking status was not found to be a statistically significant factor.

CONCLUSIONS

Neither suspension forces nor duration of suspension were predictive of postoperative tongue morbidity. Further research is needed to evaluate the role of smoking status on postoperative tongue symptoms.

Severe bradycardia during suspension laryngoscopy performed after tracheal intubation using a direct laryngoscope with a curved blade -A case report-

There are a few reports about bradycardia or asystole caused by direct laryngoscopy. However, we encountered severe bradycardia in response to suspension laryngoscopy for laryngeal polypectomy after safely completing tracheal intubation using a direct laryngoscope with a curved blade. The tip of the curved blade of the direct laryngoscope is positioned at the vallecula (between the base of the tongue and the pharyngeal surface of the epiglottis) during tracheal intubation, while the blade tip of the suspension laryngoscope lifts the laryngeal surface of the epiglottis or supraglottic area during surgery. Therefore, suspension laryngoscopy can be said more vagotonic than curved-blade direct laryngoscopy. Because of the possibility of bradycardia induced by suspension laryngoscopy, clinicians must be careful about severe bradycardia even after safely completing intubation using direct laryngoscopy.