Undiagnosed tracheomalacia accompanied with accidental expiratory central airway collapse after tracheal intubation

Background

A patient with undiagnosed tracheomalacia undergoing surgery experienced accidental expiratory central airway collapse after tracheal intubation. Here, we aimed to diagnose tracheomalacia from the preoperative data.

Case Presentation

A 73‐year‐old man, scheduled for abdominal surgery, had a clinical history of chronic obstructive pulmonary disease. Preoperative chest computed tomography revealed a lateral narrowing of the tracheal shape. After tracheal intubation, we could not manually ventilate the inflated lung. Emergent bronchoscopy findings, including severe expiratory tracheal collapse, indicated a diagnosis of tracheomalacia. We could fully ventilate the patient by moving the endotracheal tube near the tracheal carina and finally changing it to a double‐lumen tube. Airway collapse did not occur under spontaneous breathing.

Conclusion

Accidental expiratory central airway collapse could occur in patients with undiagnosed tracheomalacia during surgery. A diagnosis of tracheomalacia should be presumed from a deformed trachea on preoperative imaging and history of chronic obstructive pulmonary disease.

Ultrasonic evaluation of hydronephrosis during pregnancy and puerperium

Hydronephrosis frequently occurs during pregnancy. The etiology and significance of this phenomenon are not clearly understood. Further, little information regarding changes in the kidneys during pregnancy and early postpartum is available. This study uses real-time ultrasound in order to investigate whether or not there is a relationship between the degree of calyceal dilatation, kidney size, and creatinine clearance value. Two hundred and eighty-six patients, including 175 pregnant and 111 puerperal individuals, were examined. The overall incidence of hydronephrosis was 67% in the pregnant and 39% in the puerperal women. Moderately and severely affected kidneys were significantly larger than the mildly affected and nonaffected kidneys (p < 0.05, p < 0.001). The creatinine clearance value was lower in patients with severe hydronephrosis than in those with mild and moderate hydronephrosis and in the nonaffected patients, albeit with no statistical significance.

Relationship between fetal growth and echogenicity of the fetal liver

This study investigates the relationships between the incidence and degree of echogenicity of fetal livers and some prognostic variables of pregnancy. This was done by measuring and evaluating the echogenicity of the fetal liver on sonograms and then comparing the degree of echogenicity to tabulations of the incidence of each of the prognostic variables. The echogenicity of each of the fetal livers was established by comparing them to the texture of the fetal bowels. They were then graded and divided into three categories: hypodense (diaphanous), isodense (medium density) and hyperdense (very dense). The results were then compared to the incidences of the complications of pregnancies as they occurred in the same patients. This study reveals that fetuses with hypodense livers have a higher than normal incidence of intrauterine growth retardation (p less than 0.01) and significantly lower than normal birth weight (p less than 0.01), especially when compared to those with isodense livers. Further, fetal distress plus Apgar scores of less than or equal to 7 were more common in fetuses with hyodense livers than in those with hyperdense livers (p less than 0.03). This study demonstrates (1) that measurements and analysis of echogenicity of fetal livers on sonograms are a safe, noninvasive method of evaluating fetal development and (2) that the sonograms can be useful indicators of fetal development and that they can aid physicians in managing the pregnancy.

Measurements of the fetal liver size, hormonal level and pregnancy outcome

To further deepen the understanding of growth and development of a fetal liver, we measured sizes of 108 fetal livers using ultrasound and compared them with levels of urinary estriol excretion and human placental lactogen in the sera of their mothers. The present data suggested that growth and development of a fetal liver correlated with the levels of these hormones. Measurements of the fetal liver sizes also possibly indicate the perinatal outcome.

Detection of intrauterine growth retardation based on measurements of size of the liver

A total of 646 ultrasonic measurements of fetal liver size were made from 18 weeks of gestation through to term. After 29 weeks, size of the liver in the growth-retarded fetuses was significantly small as compared to findings in the control fetuses. The sensitivity and specificity for the detection of growth retardation were 0.86 and 0.89 at 33 weeks, 0.89 and 0.94 at 38 weeks and 0.89 at 40 weeks of gestation. Growth rate of the liver in the growth-retarded fetus was diminished as compared with findings in the control fetus. Also, a method of estimating fetal weight by ultrasonic measurement of the fetal liver size is described.

Antenatal measurement of scapula length using ultrasound

In 76 fetuses from 14 weeks of gestation through to term, measurements of the scapula were made using ultrasound. Statistical analysis of the results revealed a highly significant correlation between scapula measurements and gestational age, biparietal diameter, fetal femur length and fetal abdominal circumference (r = 0.93, 0.91, 0.95, and 0.91, respectively). In particular, values related to length of the scapula were highly correlated with femur length. These findings show that this measurement is useful as an adjunct to assessing development as well as growth of the femur and dating parameters of the fetus in utero.

Ultrasonic evaluation of liver development in the fetus in utero

A total of 573 measurements of the human fetal liver size were made from 18 to 41 weeks gestation. The right hepatic lobe increased linearly throughout gestation, whereas the left lobe increased linearly until approximately 32 weeks gestation, after which a slight slowing was observed. There was a significant correlation between both hepatic lobe sizes and gestational age (r = 0.94, r = 0.88; p less than 0.01, p less than 0.001).

Ultrasonographic measurement of prenatal fetal liver

A total of 290 measurements of the size of the fetal liver in utero were made from 19 through 42 weeks of gestation. The right hepatic lobe circumference and area, considered to be the liver size, increased linearly with the advance of gestation. A statistical analysis of these results showed a highly significant correlation between liver size and gestational age (0.87, 0.77: p less than 0.001). The liver size also closely correlated with such growth parameters as biparietal diameter, femur length, and abdominal circumference (0.86, 0.76; 0.85, 0.76; 0.85, 0.73; p less than 0.001). When the liver size of normally grown fetuses was compared with that of growth-retarded fetuses, the liver of the growth-retarded fetuses was found to be significantly smaller (p less than 0.01). We conclude from this study that the measurement of fetal liver size aids in assessing the intrauterine growth of the fetus.

Ultrasonographic evidence of ileus

Twenty-seven patients with ileus were assessed using ultrasound and the related variables suggestive of ileus are presented. If special attention is directed to these variables when a patient complains of nausea, vomiting, colicky abdominal pain and so forth, this entity can be diagnosed early and accurately. Since the distended, air-filled loops of bowel are not so readily recognized, the combined use of X-ray and ultrasound will aid in a follow-up study during treatment as well as in the diagnosis.

Ultrasonic evaluation of fallopian tube carcinoma

Primary malignant neoplasms of the fallopian tube are the least common of all the gynecologic malignancies, and constitute only about 0.1-1% of all such malignancies. The actual 5-year survival is 64% in those with stage I, 60% in cases of stage II, and 18% and 25% for stages III and IV, respectively. Therefore, early detection of these neoplasm stages is most important to attain a cure. The preoperative diagnosis of this neoplasm has rarely been reported because these lesions are not common. We present herein the clinical and sonographic features in 4 Japanese women with fallopian tube carcinoma. While the sonographic features alone are not distinct enough to establish a definite preoperative diagnosis, the findings as seen in our patients suggest inclusion of tubal carcinoma in the differential diagnosis.

Ultrasonographic evaluation of adrenal involution during antenatal and neonatal periods

Using real-time ultrasonography, 25 adrenal glands from prenatal to neonatal periods were prospectively examined to assess the process of shrinkage. A similar sonographic structure was seen in both prenatal and neonatal adrenal glands. The area of adrenal gland (AGA) and the rate of decrease were calculated during antenatal and early neonatal periods. The values of AGA were 350 +/- 19 mm2 within a week of delivery, 304 +/- 17 mm2 (87 +/- 2%) just after delivery, 273 +/- 25 mm2 (77 +/- 5%) on the 1st day, 246 +/- 24 mm2 (70 +/- 5%) on the 2nd day, 215 +/- 23 mm2 (61 +/- 5%) on the 3rd day, 196 +/- 22 mm2 (56 +/- 5%) on the 4th day, 173 +/- 18 mm2 (50 +/- 4%) on the 5th day, 154 +/- 14 (44 +/- 4%) on the 6th day, 140 +/- 12 mm2 (40 +/- 2%) on the 7th day, respectively. In conclusion, the postnatal involution of the adrenals was documented by ultrasound.

Antenatal diagnosis of congenital heart disease and fetal arrhythmia by ultrasound: prospective study

Fetal echocardiographic and Doppler ultrasonographic prospective studies were performed in utero on 299 babies delivered at Hirata Municipal Hospital, Shimane, Japan, from May 1984 to June 1986. Two or three ultrasonographic examinations were performed on each fetus from 20 weeks of gestation to term. Three congenital heart anomalies and 12 fetal arrhythmias were diagnosed antenatally, but 3 heart anomalies (2 small ventricular septal defects and 1 moderate pulmonary stenosis) were not detected in utero. Routine echocardiographic screening appears to be a useful diagnostic tool to detect congenital heart anomalies and fetal arrhythmia antenatally.

Renal arterial blood flow velocity waveforms in pregnant women

Seventy-two continuous-wave Doppler ultrasonographic examinations were performed on nine nonpregnant and 56 normal pregnant women. The range of gestation was 6 to 40 weeks, and the objective was to record the renal arterial blood flow velocity waveform. Acceleration time and systolic per diastolic ratio of renal arterial blood flow velocity waveforms were assessed. Of 72 examinations, 68 recordings were made of the left renal artery (94.4%) and 28 of the right renal artery (38.9%), respectively. There was no correlation between acceleration time and systolic per diastolic ratio and gestational age, respectively, and no correlation between acceleration time and systolic per diastolic ratio, and caliceal diameter of the renal pelvis, respectively. Acceleration times of the left and right renal arteries were 47 +/- 11 and 40 +/- 8 msec in nonpregnant women and 62 +/- 23 and 62 +/- 23 msec in pregnant women, respectively. The left and right systolic per diastolic ratios were 3.1 +/- 0.7 and 2.9 +/- 0.5 in nonpregnant women and 2.8 +/- 0.6 and 2.6 +/- 0.5 in pregnant women, respectively. Therefore these data provide a foundation for the study of hydronephrosis, which may occur in pregnant women.

Fetal liver measurements by ultrasonography

A total of 378 measurements of fetal liver size were made from 18 weeks gestation through term. Statistical analysis of the results showed a highly significant correlation between fetal liver measurements and gestational age, biparietal diameter, and fetal femur length (R = 0.93, R = 0.89, R = 0.89, respectively). Ultrasonic measurement of the fetal liver is a reliable indicator of fetal growth in the third trimester, as growth rates of the biparietal diameter and head circumference are blunt. Furthermore, consecutive measurements of fetal liver size enhance the detection of symmetrical, fetal growth, by acquisition of various ultrasonic parameters such as biparietal diameter, fetal femur length, fetal abdominal circumference and so forth.

Ultrasonic evaluation of trophoblastic disease and the response to chemotherapy

Ultrasound is an established method of confirming the presence of a hydatidiform mole in utero. However, in agreement with other investigations, we have often noted that the appearance of this entity is less specific than originally reported. To elucidate this, the ultrasonic patterns of 26 patients with trophoblastic disease and 27 with other entities were reviewed. Since there is a paucity of literature with regard to the response of choriocarcinoma to chemotherapy, determined by ultrasound, we simultaneously studied the relationship between findings of the ultrasonograms and the levels of hCG-beta-subunit in sera. We noted variable ultrasonic features in trophoblastic disease, and the sonograms of the choriocarcinoma have occasionally been confused with those of hydatidiform mole. If special attention is directed to the thickness of the placenta-like echoes as well as the sonolucent areas within it, the diagnosis of partial hydatidiform mole may be feasible. We also noted a rough correlation between ultrasonic appearances and the hCG-beta-subunit value, determined during chemotherapy for choriocarcinoma.

Ultrasonographic identification of the human fetal gallbladder in utero

Ultrasonographic studies of the human fetal gallbladder were performed in utero on 149 fetuses ranging from 20 to 39 weeks of gestation. The gallbladder could be identified in 37.5% (20-23 weeks) to 64.7% (24-27 weeks) after 20 weeks of gestation. The normal sonographic characteristics of the fetal gallbladder were described and the area of fetal gallbladder, the length and the width were measured, respectively. The ultrasonographic identification of the fetal gallbladder is a first step in antenatal detection of congenital anomalies affecting the gallbladder.

Ultrasonographic measurement of the human fetal liver in utero

A total of 232 measurements of the size of the human fetal liver were made from 19 weeks gestation through to term. The size of the liver increased linearly with the advance in pregnancy. Statistical analyses showed a highly significant correlation between liver circumference and area and gestational week or fetal abdominal circumference (r = 0.89, r = 0.90, r = 0.90, r = 0.85).

Ultrasonographic in utero identification and measurement of the normal fetal spleen

Sixty-nine ultrasonographic examinations were performed to identify and measure the fetal spleen in utero on 49 women with regular menstrual cycles, at 18-41 weeks of gestation. The length (FS-L), width (FS-W), area (FS-A), and sectional area (length X width; FS-LW) of the fetal spleen correlated well with the gestational age. A very high correlation of FS-LW with FS-A was noted (r = 0.98; p less than 0.001). Ultrasonographic identification and measurement of the fetal spleen in utero is thus a useful indicator of fetal spleen growth and should facilitate detection of in utero splenomegaly, asplenia and other abnormalities.

Ultrasonography for the diagnosis of adenomyosis

An accurate preoperative diagnosis of uterine adenomyosis is often difficult. We reviewed our experience with ultrasound evaluation of this pathological entity. Patients with histologically proven adenomyosis were studied to determine the usefulness of ultrasound for the preoperative diagnosis of this entity. In patients with adenomyosis, variable ultrasound patterns are seen, namely, enlargement of the uterus, irregular vesicular spaces within the myometrium, and an acoustically enhanced posterior wall of the uterus. However, leiomyoma had a similar echopattern. Based on five cases of histologically extensive adenomyoasis, an accurate diagnosis of adenomyosis proved feasible when ultrasonography showed all three ultrasonic patterns mentioned above, associated with a retroverted uterus or possible adhesions between the uterus and structures in close proximity, nodule or outgrowth in the region of the uterosacral ligaments or in combination, as frequently found in conjunction with external endometriosis. The ultrasonographical demonstration of endometrial cyst of the ovary may contribute to an accurate diagnosis of adenomyosis.

[Antenatal diagnosis of congenital heart diseases and fetal arrhythmias]

Fetal echocardiographic, electrocardiographic, and pulsed Doppler ultrasonic examinations were performed to detect congenital heart anomalies and fetal arrhythmias antenatally, from April 1980 to March 1985. In nineteen subjects, these techniques revealed premature atrial contractions (PAC) in five fetuses, PAC and blocked PAC in two, PAC and premature ventricular contraction (PVC) in one, PAC, blocked PAC and PVC in one, sinus bradycardia in one, congenital complete atrio-ventricular block in one, atrial septal defect with PAC and PVC in one, fetal unilateral hydronephrosis with PAC and PVC in one, complicated heart anomalies with dilated colon in one, single atrium and ventricle with esophageal and anal atresiae in one, complicated heart anomalies with encephalocele and single umbilical artery in one, and asymmetrical septal hypertrophy in one, antenatally. In nine out of fifteen cases with fetal arrhythmias, the arrhythmia resolved within the first month of life. Sustained arrhythmias occurred in three cases. In three cases with fetal arrhythmias, in utero therapies with Coenzyme Q10(CoQ10) were performed, and anti-arrhythmic effects of CoQ10 recognized. Deaths occurred in three cases with complicated heart anomalies.

Human corticosteroid-binding capacities in normal, high-risk or pregnancies with an abnormal outcome

To determine whether or not the serum corticosteroid binding capacity (CBC) level is related to the outcome of pregnancy or fetal well-being, a total of 124 determinations of CBC were performed in 96 pregnant individuals, using hydrophobic resin adsorption methods. The serum CBC values were elevated with progression of gestation. On the other hand, high-risk pregnancies or those with an abnormal outcome were among the low CBC group, below the mean value (p less than 0.001), whereas normal pregnancies were more often in the high CBC group, over the mean value, in comparison with the low CBC group below the mean value (p less than 0.001), after 28 weeks of gestation. In addition, the ratios of birth weight/placental weight and maternal weight/placental weight were slightly but not statistically high in the low CBC group, in comparison with the high CBC group. Thus, various events related to placental growth might be important factors regulating the serum CBC level. While there are many determinants of corticosteroid binding globulin production and excretion, assessment of CBC levels seems to be a reliable indicator of the outcome of pregnancy, including high-risk pregnancy, in the 3rd trimester.

[Differential diagnosis between leiomyomata uteri and adenomyosis using CA 125 as a new tumor marker of ovarian carcinoma]

To differentiate pre-operatively between leiomyomata uteri and adenomyosis, we measured serum levels of an antigen (CA 125) common to most nonmucinous epithelial ovarian carcinoma in patients with benign uterine tumor (11 of leiomyomata uteri, 7 of adenomyosis and 1 of adenomyosis with leiomyomata uteri). CA 125 in serum samples pre and postoperatively were measured using an RIA Kit. The normal range of CA 125 levels was below 35U/ml. The mean CA 125 level (+/- S.D.) was 18.3 +/- 6.1U/ml in patients with leiomyomata uteri and 93.3 +/- 49.4U/ml in those with adenomyosis. Student's t-test showed a significant correlation (0.001 less than p less than 0.01). The mean CA 125 level in patients with adenomyosis was statistically higher than that in disease-free women. Among 7 patients with surgically demonstrable adenomyosis, the CA 125 values were over 35U/ml (87.5%). In all 11 patients with surgically demonstrable leiomyomata uteri, the CA 125 level was below 35U/ml. The CA 125 level in patients with adenomyosis gradually decreased postoperatively and in all was below 35U/ml up to one month postoperatively. Using this approach, leiomyomata uteri and adenomyosis can be differentiated, pre-operatively.