A custom device for managing recurrent tracheoesophageal voice prosthesis dislodgement and aspiration due to treatment refractory, severely enlarged puncture: A video case report

We report the case of a laryngectomized patient with an enlarged tracheoesophageal puncture (TEP) that is refractory to standard treatments and culminating in life-threatening recurrent dislodgement and aspiration of custom fabricated dual extra-large flange voice prostheses (VP). The fabrication and use of a novel intraluminal prosthetic device to prevent dislodgement, lessen aspiration, and preserve TE voice is described. A custom device insetting a commercial VP into the posterior wall of a LaryTube (coined "inset-VP") was devised with the primary goal of eliminating chronic VP dislodgement and lessening aspiration while maintaining TE voice. Tools required to fabricate the device included a commercial laryngectomy tube, standard-flanged commercial indwelling voice prosthesis, felt-tip marker, 6 mm biopsy punch, and silk suture. After 7 months of using an inset-VP LaryTube device, the patient has experienced zero episodes of VP aspiration. Thin liquid aspiration control is equivalent or better than prior management with custom 24-30 mm dual collar prostheses. TEP voice is fluent and functional with device in place. Novel strategies are needed to manage the rare but devastating effects of a severely enlarged TEP. Solutions to manage symptoms need to be patient-specific, aligning with their anatomy, physiology, psychosocial needs, and goals. The inset-VP device described in this report may offer improved prosthetic retention in select patients with enlarged TE puncture and frequent VP dislodgements.

Foreign body aspiration in children: our pediatric tertiary care experience

PURPOSE

Inhalation of a foreign body is a real emergency in pediatric age and requires prompt diagnosis and treatment to reduce mortality. The objective of this study is to analyze clinical and radiological details, types, and localization of foreign bodies in patients conducted or to our hospital with suspected inhalation.

METHODS

We conducted a retrospective analysis of all cases of foreign body inhalation admitted to our Pediatric Emergency Room between January 2009 and June 2022.

RESULTS

171 patients were included in the study. In 83 patients, the FB was detected. The mean age of presentation was 2.3 years (SD: ± 2). Cough (73%) and unilateral reduced breath sound (51%) were the most common clinical symptom and clinical sign. The most frequent localization was the right main bronchus (43%). The foreign bodies retrieved were vegetable (83%), of which peanut was the most common. Chest radiographs were normal in 25%. The mean duration of hospitalization was 5 days (± 2.9). Complications such as pneumothorax were seen in two cases.

CONCLUSIONS

Foreign body inhalation represents a true pediatric emergency and still a challenge in clinical practice. The best way to manage it is an early diagnosis and removal by fully trained staff.

Foreign body aspiration score (FOBAS)-a prospectively validated algorithm for the management and prediction of foreign body aspiration in children

Foreign body aspiration (FBA) is a common cause of pediatric morbidity, but a standardized protocol to guide decision-making about bronchoscopy is lacking. We aimed to validate a new Foreign body aspiration score (FOBAS) for the pediatric emergency department (ED). Patients aged 0-18 years referred to the ED for suspected FBA were prospectively enrolled. FOBAS was calculated according to clinical features of a choking episode, sudden cough, exposure to nuts, absence of fever and rhinitis, stridor, and unilateral auscultatory and radiological findings. FBA risk was evaluated based on the total score (low, 1-3; moderate, 4-6; high, 7-10). Low-risk children were discharged from the ED and followed clinically. Moderate-risk children were hospitalized and evaluated by a pediatric pulmonologist, and high-risk children were referred directly for therapeutic bronchoscopy. Among the 100 enrolled children (59% males; median age 20 [interquartile range 11-39] months), a foreign body was diagnosed in 1/49 (2%), 14/41 (34.1%), and 9/10 (90%) with low, moderate, and high FOBAS, respectively (P < .001). Logistic regression indicated a higher risk for FBA with higher scores. The odds ratio for each additional point was 2.75 (95% confidence interval 1.78-4.24), and FOBAS showed a high predictive value for FBA (area under the curve 0.89). FOBAS implementation significantly reduced the rate of negative bronchoscopies, from 67.4% annually during 2016-2019 to 50% in 2020 (P = .042).

CONCLUSION

FOBAS reliably predicts FBA in cases of suspected FBA and improves management and in-hospital decision-making.

WHAT IS KNOWN

• Foreign body aspiration is a major cause of pediatric morbidity and mortality. • Currently, there is no unified protocol for children referred to the emergency department for suspected FBA, therefore, a well-defined algorithm is needed to improve the decision-making process.

WHAT IS NEW

• The pediatric Foreign body aspiration score (FOBAS) is a new, prospectively validated clinical score that shows high sensitivity and specificity for the presence of FBA in children. • FOBAS reduces unnecessary admissions and invasive procedures and leads to better clinical outcomes.

FOREIGN BODY ASPIRATION AND INGESTION IN CHILDREN

Aspiration and ingestion of a foreign body is most frequently seen in children younger than 3 years. Foreign body aspiration is always a life-threatening, urgent state demanding quick recognition and treatment to avoid potentially lethal complications. Most foreign bodies that are ingested pass spontaneously through the gastrointestinal tract without complications, however, some could lead to problems if they become lodged. A literature review was performed via MEDLINE database using key terms. Primary care providers should be trained to give proper initial care. Aspirated/ingested foreign bodies in children removed by rigid or flexible bronchoscopy/gastroscopy always are challenging procedures that require well-planned anesthesia management and excellent intercommunication between anesthesiologists and surgeons. Extracorporeal membrane oxygenation can be used as a rescue mode of support in children with life-threatening foreign body aspiration for stabilization before, during and after removal of the aspirated foreign body. It is of utmost importance that all foreign body extractions, if possible, be done in centers supplied with all the necessary equipment and trained personnel. However, prevention of foreign body aspiration and ingestion is still the best therapy.

Tracheobronchial foreign body aspiration in children: A retrospective single-center cross-sectional study

Foreign body (FB) aspiration is a common and serious problem in childhood as it requires early recognition and treatment to avoid potentially lethal consequences. This study aimed to characterize the clinical and epidemiological features of airway FBs in a pediatric Chinese population.A retrospective review of medical records of children aged 0 to 14 years who attended with a diagnosis of FB aspiration the Shanghai Children's Hospital between January 2013 and December 2017 was carried out. Descriptive analysis was used to assess patient's demographics, clinical, radiographic, bronchoscopic findings, time to presentation, and characteristics of the FBs.Among the 200 patients included in the study, 92% were under 3 years of age, with a peak incidence of FB aspiration occurring between 1 and 2 years old. The male to female ratio was about 2.6:1. Twenty-three percent of the patients were admitted within 24 hours of the event, 40% within 1 week, 30% within 1 month, and 7% more than 1 month after aspiration. The most common presenting symptoms of laryngotracheal FBs were cough, dyspnea, and wheezing; those of bronchial FBs were cough, decreased air entry, and wheezing. Chest X-ray was normal in four-fifths of the children with laryngotracheal FBs, whereas most common abnormal X-ray findings in children with bronchial FBs were mediastinal shift, obstructive emphysema, and pneumonia. There was a trend that in children younger than 2 years FBs were more frequently found in the left bronchus, whereas in older children FBs were more frequently found in the right bronchus. Ninety-three percent of the removed FBs were organic materials such as food items and the most frequently aspirated FBs were peanuts. Flexible bronchoscopy was performed in 82.5% of the patients, while rigid bronchoscopy or direct laryngoscopy in 17.5% of the patients. Four patients were subjected to thoracic surgery and 1 died during rigid bronchoscopy due to acute respiratory failure.FBs is a frequent pathology among Chinese children. Tracheobronchial FBs should be strongly suspected in young children who have sudden onset of cough and wheezing episode, even when physical and radiographic evidence is absent.

[Management of suspected foreign body aspiration in children. 10-year experience in a single center]

INTRODUCTION

Foreign body aspiration (FBA) is a potentially life-threatening event, and is the leading cause of death in children after road traffic injuries. If suspected, a prompt exploration of the airway should be performed. We present our experience in FBA treatment in the last 10 years.

MATERIAL AND METHODS

A retrospective study of patients admitted in our center with suspected FBA between 2005 and 2015 was performed. Clinical history, physical findings, radiologic imaging, treatment and evolution were assessed.

RESULTS

A total of 115 children (70 M/45 F) with a median age of 2 years old (8 months-13 years), presented with a clinical history of FBA. All of them suffered a choking event and the most frequent symptoms were persistent cough (88.3%) and respiratory distress (46.8%). Pathologic physical examination was registered in 75% and an abnormal chest X-ray was seen in 72%. Rigid bronchoscopy (RB) was performed in 100% based on compatible history, regardless of physical and radiologic exams. A foreign body was found during RB in 78 patients (68.1%) and the most frequent were seeds and nuts (63.4%), located mainly in the right bronchus (46.8%). If the criteria for RB had been based on a compatible history along with clinical findings and abnormal chest X-ray, 21 foreign bodies (26.9%) would have been missed, with the subsequent risk of sudden death. All the foreign bodies were removed with success, without any immediate complication during the procedure.

CONCLUSION

FBA is a frequent accident among children. The history, clinical findings and imaging cannot always concur. In case of a positive history of FBA an examination of the tracheobronchial tree must be done.

Fiberoptic bronchoscopic treatment of blood aspiration and use of sugammadex in a patient with epistaxis: A case report

RATIONALE

In patients with oropharyngeal and nasopharyngeal bleeding, blood aspiration can make airway management difficult and lead to severe pulmonary complications.

PATIENT CONCERNS

A 44-year-old male patient with recurrent epistaxis underwent surgery for hemostasis. The patient aspirated blood through the endotracheal tube when he hiccupped during the surgery.

DIAGNOSIS

The patient was diagnosed with blood aspiration after intraoperative fiberoptic bronchoscopy revealed a blood clot and viscous mucus in the airways, but no sign of active bleeding.

INTERVENTIONS

Tracheobronchial suctioning and irrigation with normal saline was performed through the bronchoscope to remove the aspirated blood clot. Prior to emergence from anesthesia, sugammadex was administered to induce complete neuromuscular recovery and enable the patient to cough up any blood remaining in the airways.

OUTCOMES

The patient was successfully extubated and fully recovered with no complications.

LESSONS

Blood aspiration due to oropharyngeal or nasopharyngeal bleeding can be diagnosed and treated by tracheobronchial suctioning via fiberoptic bronchoscopy. In addition, sugammadex can enable patients to recover spontaneous breathing, facilitate extubation, and enable patients to cough up any blood remaining in the airways.

Treatment of Ramsay-Hunt's syndrome with multiple cranial nerve involvement and severe dysphagia: A case report

RATIONALE

Ramsay-Hunt's syndrome (RHS) is a disorder characterized by facial paralysis, herpetic eruptions on the auricle, and otic pain due to the reactivation of latent varicella zoster virus in the geniculate ganglion. A few cases of multiple cranial nerve invasion including the vestibulocochlear nerve, glossopharyngeal nerve and vagus nerve have been reported. However, there has been no report about RHS with delayed onset multiple cranial nerve involvement causing severe aspiration, and a clinical course that improved after more than one year of dysphagia rehabilitation and percutaneous endoscopic gastrostomy (PEG). Here, we report on a 67-year old male with delayed onset swallowing difficulty after 16 days of RHS development.

PATIENT CONCERN

Severe aspiration during swallowing.

DIAGNOSIS

Severe dysphagia caused by RHS with multiple cranial nerve involvement.

INTERVENTION

Application of percutaneous endoscopic gastrostomy (PEG) and rehabilitation therapy of dysphagia.

OUTCOMES

After 13 months from symptom onset, his PAS improved from 7 to 2 in follow-up video-fluoroscopic swallowing study (VFSS). Then, he was re-admitted, and the PEG tube was removed and oral feeding was started.

LESSONS

This case gives us the lesson that optimal doses of acyclovir and corticosteroids are important to prevent progression of multiple cranial involvement in RHS, and swallowing difficulty in RHS patients with multiple cranial nerve involvement can be improved through long-term rehabilitation even if there is no improvement for more than one year.

Risk Factors and In-Hospital Outcomes following Tracheostomy in Infants

OBJECTIVE

To describe the epidemiology, risk factors, and in-hospital outcomes of tracheostomy in infants in the neonatal intensive care unit.

STUDY DESIGN

We analyzed electronic medical records from 348 neonatal intensive care units for the period 1997 to 2012, and evaluated the associations among infant demographics, diagnoses, and pretracheostomy cardiopulmonary support with in-hospital mortality. We also determined the trends in use of infant tracheostomy over time.

RESULTS

We identified 885 of 887 910 infants (0.1%) who underwent tracheostomy at a median postnatal age of 72 days (IQR, 27-119 days) and a median postmenstrual age of 42 weeks (IQR, 39-46 weeks). The most common diagnoses associated with tracheostomy were bronchopulmonary dysplasia (396 of 885; 45%), other upper airway anomalies (202 of 885; 23%), and laryngeal anomalies (115 of 885; 13%). In-hospital mortality after tracheostomy was 14% (125 of 885). On adjusted analysis, near-term gestational age (GA), small for GA status, pulmonary diagnoses, number of days of forced fraction of inspired oxygen >0.4, and inotropic support before tracheostomy were associated with increased in-hospital mortality. The proportion of infants requiring tracheostomy increased from 0.01% in 1997 to 0.1% in 2005 (P < .001), but has remained stable since.

CONCLUSION

Tracheostomy is not commonly performed in hospitalized infants, but the associated mortality is high. Risk factors for increased in-hospital mortality after tracheostomy include near-term GA, small for GA status, and pulmonary diagnoses.

American Cancer Society Head and Neck Cancer Survivorship Care Guideline

Answer questions and earn CME/CNE The American Cancer Society Head and Neck Cancer Survivorship Care Guideline was developed to assist primary care clinicians and other health practitioners with the care of head and neck cancer survivors, including monitoring for recurrence, screening for second primary cancers, assessment and management of long-term and late effects, health promotion, and care coordination. A systematic review of the literature was conducted using PubMed through April 2015, and a multidisciplinary expert workgroup with expertise in primary care, dentistry, surgical oncology, medical oncology, radiation oncology, clinical psychology, speech-language pathology, physical medicine and rehabilitation, the patient perspective, and nursing was assembled. While the guideline is based on a systematic review of the current literature, most evidence is not sufficient to warrant a strong recommendation. Therefore, recommendations should be viewed as consensus-based management strategies for assisting patients with physical and psychosocial effects of head and neck cancer and its treatment. CA Cancer J Clin 2016;66:203-239. © 2016 American Cancer Society.

[Aspiration of water during underwater birth]

BACKGROUND

Underwater birth is becoming increasingly popular because of the advantages for the mother. Women who deliver in this way feel less pain and therefore pain relief is less frequently needed during the delivery. But what seems to be forgotten is the fact that aspiration of water by the neonate could take place during an underwater birth, resulting in respiratory distress.

CASE DESCRIPTION

A one-day-old neonate was admitted because of tachypnoea following underwater delivery at home. The respiratory rate of the neonate was one hundred breaths per minute without evident signs of dyspnoea. Chest radiography showed bilateral patches on the lungs consistent with aspiration of bathwater. After seven days of intravenous antibiotic treatment, the neonate recovered and could be discharged home.

CONCLUSION

An underwater birth may cause respiratory problems in the neonate. If a pregnant woman wants to deliver under water, she should also be advised of the potential detrimental consequences for the neonate.

Accidental Ingestion of a Foreign Body of Orthodontic Origin - A Review of Risks, Complications and Clinical Recommendations

Ingestion/aspiration episodes of foreign bodies are potential complications in almost all branches of dentistry. Occasionally, orthodontic appliances or small orthodontic components are accidentally swallowed and have caused problems with either the airway or the gastrointestinal tract, especially where the patient is supine or semi-recumbent. Despite their rare occurrence, the morbidity from a single incident and the level of specialized medical care that may be needed on emergency basis to manage such incidents is too high to ignore. Moreover, there is also the related risk of malpractice litigation given the fact that these incidents are preventable and increasing awareness among people. This article attempts to review potential risks and complications of ingestion/aspiration episodes based on relevant literature and describe the type of appliances and their parts most likely to cause problems. Certain recommendations based on best available evidence to minimize the incidence of such events are proposed, and strategies to aid the clinician in the event of such an emergency are also formulated.

Pediatric sand aspiration managed using bronchoscopy and extracorporeal membrane oxygenation

Sand aspiration is a rare but potentially fatal occurrence to consider in near-drownings, accidental burials or cave-ins. Optimal management is not well defined.

Retrieving difficult aspirated pen caps by balloon catheter with short working-length flexible endoscopy and noninvasive ventilation support in intensive care unit

OBJECTIVES

Aspirated pen cap (APC) is a clinical challenging issue in children because of the difficulty in both making diagnosis and performing extraction. In case of failed retrieval by rigid endoscopy (RE), more invasive surgical approaches are recommended. The objective of this study is to introduce a new retrieval technique of APC by using laser and balloon catheter (BC) guided with flexible endoscopy (FE) and supported by a novel non-invasive ventilation (NIV) in the intensive care unit (ICU) setting.

METHODS

We retrospectively review the charts and FE video records of our pediatric cases with the diagnosis of APC in the past decade, 2004-2014.

RESULTS

Four consecutive cases with bronchial APC which had failed extraction with RE were transferred to our hospital. All of them were under procedural sedation, topical anesthesia, NIV support and ICU monitoring. After FE confirmed the diagnosis and location, a BC parallel to the endoscope was manipulated to pass through the cap hole of the APC. Two APCs required laser pretreatment before retrieval: one debulked the entrenched granulation whereas another enlarged the size of cap hole. Guide wires also were required in three cases to assist the BC to pass through the cap hole. All four APCs were successfully retrieved on their first attempts with no significant complications.

CONCLUSIONS

FE assisted by laser, guide wire and BC, with this NIV support and ICU monitoring is a feasible, safe and effective modality for retrieving those difficult bronchial APCs in pediatric cases.

Incident management guidelines for an ingested orthodontic object

Dental materials or components of orthodontics devices can fall into a patient's oropharynx, and be swallowed or inhaled. In this paper a short review of accidental foreign body ingestion/aspiration prevention, evaluation, and relevant incident management guidelines are presented. In addition, a case of an accidentally swallowed piece of archwire during a chair side procedure is reported.

[Occult bronchial foreign bodies - analysis of own material]

INTRODUCTION

The aspiration of a foreign body is usually combined with acute clinical symptoms requiring immediate medical intervention. Nevertheless, in approximately one third of patients the symptoms of aspiration are less prominent; such a clinical condition is called occult bronchial foreign body (OBFB). The aim of our study was to assess the frequency of OBFB in the pulmonary unit of a district hospital and to evaluate the diagnostic difficulties and treatment modalities in such patients.

MATERIAL AND METHODS

The examined group consisted of patients hospitalized in the Department of Lung Diseases in Radom District Hospital. A retrospective analysis of medical records was preformed.

RESULTS

In the period 1978-2008 - 12 patients (10 males, 2 females) were hospitalized due to OBFB. The foreign bodies occluded the bronchi over 2 months (3 to 7) in 4 patients. The moment of aspiration was not remembered by 8 patients. Cases of OBFB were rare. In the presented material the frequency was 4 per 10,000 hospitalizations and 8 per 10,000 bronchoscopies. In our region of 600,000 population the index of hospitalization due to OBFB in adults (〉 14 years of age) was 0.07 per 100,000 inhabitants/year. Foreign bodies mainly included bone fragments (5 cases), vegetal remnants - clove of garlic, ear of corn (3 patients), and other food remnants (2 patients). Occasionally other aspirates were found, such as a wooden peg or a piece of plastic. The aspiration took place mostly during meals. The patients developed one or more of the following symptoms: purulent pneumonia (3 cases), pleural empyema (1 case), atelectasis (5 cases), and recurrent bronchitis and pneumonia (2 cases). The foreign body (fragments of plants) was mimicking a bronchial tumour in 4 patients. Fibre optic or rigid bronchoscopy was applied successfully in 11 patients. Only one patient needed surgical intervention.

CONCLUSION

OBFB is a rare condition, but has to be taken into consideration as a cause of chest radiological pathology and in patients with chronic and/or recurrent inflammatory disease of the respiratory system.

Similarities and differences in aspirated tracheobronchial foreign bodies in patients under the age of 3 years

OBJECTIVE

To investigate the clinical pathological features of aspirated tracheobronchial foreign body (FB) cases in children under the age of 3 years and to improve the level of diagnosis and treatment.

METHODS

A retrospective study was conducted examining 316 children under the age of 3 years who had been treated for tracheobronchial FB in Shenzhen children's hospital between January 2004 and December 2008. We analyzed the patients for gender, age, FB localization, treatment history, the history of foreign body aspiration (FBA), the type of foreign body and the cause of death. In addition, each patient was analyzed for FB-related complication, the results of bronchoscopic removal and the presence of foreign bodies in the airways.

RESULTS

Fifty-two infants under the age of one year (median age=10m, group A), 199 children between the ages of 1 and 2 years (median age=17 m, group B) and 65 children between the ages of 2 and 3 years (median age=30m, group C) were included in this study. There were 38 (73.1%) patients with a confirmed history of FBA in group A, a higher percentage than that observed in group B (55.8%) or group C (53.8%) (P<0.05). Earthnuts were the most common cause of FB (171 cases, 54.1%). Melon seeds (including sunflower seeds, watermelon seeds and pumpkin seeds) were the second most common cause of FB (62 cases, 19.6%). Animal sources (including 16 pig bones, 8 fish bones, 7 chicken bones and 4 other animal-based foods) comprised 11.1% (35 cases) of FB cases and were the third most common cause of FB. The percentage of animal-based FBs observed in group A was higher than in groups B and C (P<0.01). Five inorganic FBs (a pushpin, a rubber band, a screw, a small stone and a plastic toy) were also observed and were the least common type of FB. There were no significant differences in the distribution of FBs between the left (41.8%) and right (40.5%) bronchia. There is no difference in the distribution of FBs among the three groups either. The data show that the youngest cohort of patients (0-1 years) is the most likely to be sent to the hospital to receive treatment within 24h of aspiration (50%) (P<0.01). Five patients (1.58%) died as the result of FBA.

CONCLUSIONS

FBAs of animal-derived FBs (especially animal bones) are very common in infants in southern China. Children between the ages of 1 and 2 years are most likely to suffer from FBA. FBA in children under the age of 3 years carries significant hazards, including morbidity and mortality. Asphyxia and/or cardiopulmonary arrest is prone to occur shortly after FBA in infants, but these events can occur days later in older children after FBA because of delays in the diagnosis and/or treatment of this condition.

The complimentary role of diagnostic and therapeutic endoscopy in foreign body aspiration in children

OBJECTIVE

To review the importance and benefits of flexible bronchoscopy and rigid bronchoscopy in airway foreign body inhalation in children. Prompt diagnosis will lead to safer outcomes when both types of endoscopy are employed within the operating room setting.

METHODS

Retrospective review of all cases of foreign body inhalation seen and treated in our Department between July 1986 and December 2010.

RESULTS

Three-hundred and ten children were admitted to our Department from Pediatric Emergency Room for a suspected foreign body inhalation. All patients with suspected FB inhalation underwent bronchoscopy. Of 310 evaluations of tracheobronchial tree performed at our Department, 104 were negative, while an airway FB were observed and removed in 206 cases.

CONCLUSIONS

Rigid bronchoscopy under general anesthesia is an extremely accurate surgical technique to identify, localize and remove airway foreign body. In our experience, flexible bronchoscopy under total intravenous sedation and topical anesthesia is very useful in doubtful cases to absolutely exclude the presence of foreign body in upper airway tracheobronchial tree.

Relevance of GERD in lung transplant patients

Lung transplantation has become a valuable treatment for end-stage pulmonary disorders in an attempt to improve quality of life and extend survival. Development of chronic rejection, also known as bronchiolitis obliterans syndrome (BOS), is responsible for the vast majority of deaths after lung transplantation. Up to 50% of lung transplant patients develop BOS within the first 5 years after transplantation. A high prevalence of gastroesophageal reflux and aspiration of gastric components has been described after lung transplantation. Reflux and aspiration have been implicated in the development of BOS and antireflux surgery has been proposed; however, the causal relationship with BOS and the impact of reflux in lung transplantation survival needs to be further elucidated.

Emergency use of extracorporeal membrane oxygenation for a foreign body obstructing the airway

We report on the successful emergency use of extracorporeal membrane oxygenation to provide oxygenation and ventilation to a patient with lifethreatening airway obstruction, and then facilitating the removal of a tracheal food bolus by rigid bronchoscopy.

A 41-year-old male with cough, wheeze, and dyspnea poorly responsive to asthma therapy

Reactive airway disease is often triggered by an upper respiratory viral infection and readily responds to anti-inflammatory and bronchodilator therapy. The differential diagnosis for unresponsive disease includes poorly controlled asthma, noncompliance with medical regimen, vocal cord dysfunction, rhinosinusitis, gastroesophageal reflux disease or recurrent aspiration, foreign body aspiration, allergic bronchopulmonary aspergillosis, Churg-Strauss vasculitis, cardiac disorders such as congestive heart failure or mitral stenosis, or other pulmonary disorders such as chronic obstructive pulmonary disease, alpha-1 antitrypsin deficiency, interstitial lung disease, bronchiectasis, sarcoidosis, hypersensitivity pneumonitis, pulmonary embolism, cystic fibrosis, airway neoplasms, or laryngotracheomalacia. As is often the case, a meticulous history can expeditiously direct the clinician to the diagnosis, especially in a patient without a smoking, asthmatic, or atopic history.

Lung contusion: inflammatory mechanisms and interaction with other injuries

This article reviews current animal models and laboratory studies investigating the pathophysiology of lung contusion (LC), a common and severe condition in patients with blunt thoracic trauma. Emphasis is on studies elucidating cells, mediators, receptors, and processes important in the innate pulmonary inflammatory response that contribute to LC injury. Surfactant dysfunction in the pathogenesis of LC is also discussed, as is the potential role of epithelial cell or neutrophil apoptosis. Studies examining combination injuries where LC is exacerbated by secondary insults such as gastric aspiration in trauma patients are also noted. The need for continuing mechanism-based research to further clarify the pathophysiology of LC injury, and to define and test potential therapeutic interventions targeting specific aspects of inflammation or surfactant dysfunction to improve clinical outcomes in patients with LC, is also emphasized.

Recurrent postoperative aspiration following jugular foramen tumor resection

We report a 38 year old male patient who underwent a craniotomy for jugular foramen tumor resection. In the postoperative care unit, the patient developed aspiration accompanied with oxyhemoglobin desaturation. Subsequently, he had several episodes of recurrent aspiration which were attributed to cranial nerves (IX, X) palsy as a complication of the surgery at the jugular foramen. It is suggested that aspiration prophylactic measures should be taken and early assessment of lower cranial nerves function should be done prior to tracheal extubation to decrease post-operative aspiration in patients undergoing base of skull surgery.

Severe stridor following the repair of H-type tracheoesophageal fistula in an 11 month infant

Congenital tracheoesophageal fistula without esophageal atresia is commonly known as "H" type and this presents with a different clinical spectrum owing to the presence of a large and patent esophagus. There may be a time lag extending up-to 50 years between first presentation and confirmation of the diagnosis owing to the rarity of the condition, its nonspecific symptomatology, and limitations in its demonstration by contrast radiology and endoscopy. Respiratory sequelae are common following repair and may persist during the rest of life. We present here, the case of an 11 month old child who presented for a definitive repair of H-type tracheoesophageal fistula, diagnosed at the age of 9 months. Following an uneventful intraoperative course the child developed severe stridor in the postanesthesia care unit (PACU) 30 min after arrival necessitating endotracheal intubation. The further course of the child in the hospital, probable reasons for this unusual complication and its management are discussed.

Removal of a foreign body (artificial tooth) from the bronchial tree: a new method

A 70-year-old man who had aspirated an artificial tooth during treatment at a dental clinic visited our hospital. His symptoms and physical condition were not remarkable. CT of chest revealed a foreign body in the right middle bronchus; bronchoscopy revealed it was wedged there. First, the authors tried to remove it using a suction device attached to a bronchoscope, as well as by using a forcep; however, the attempt failed. Therefore, a second effort was made using a cap constructed of a nasogastric tube, based on the concept of attaching an endoscopic cap to a bronchoscope. The latter was successful.

Dysphagia in post-carotid endarterectomy: a prospective study

Dysphagia can be a debilitating complication in carotid endarterectomy. This study describes our experience in the management of this complication. We prospectively assembled an inception cohort of 19 consecutive, hospital-referred patients with dysphagia post-carotid endarterectomy. We performed swallowing evaluation in all the recruited patients both at the bedside and by fiberoptic endoscopic evaluation of swallowing (FEES) 5 days and 3 months after the operation, using standardized methods and diagnostic criteria. The degree of dysphagia was scored using the Penetration-Aspiration Scale (PAS). All patients were undergoing early rehabilitation treatment and were followed up prospectively for 3 months, during which time recovery of swallowing function and any occurrence of pneumonia were recorded. At baseline, 15 patients presented dysphagia for liquid and solid food and four for solid food only, eight were on parenteral nutrition, and six presented bronchial aspiration (by FEES). The mean PAS score at the first evaluation was 5.2. Ten patients completely recovered swallowing function and returned to their preoperative diet within 1 month, and six did so within 3 months; the other three patients did not complete the follow-up. No patient presented pneumonia. At the 3-month follow-up, one patient presented bronchial aspiration and the mean PAS score was 1.2. This preliminary experience suggests that careful evaluation of swallowing and early rehabilitation may be advisable in these patients.

Deglutition and respiration: development, coordination, and practical implications

Temporal coordination of deglutition and respiration is essential for survival because both functions share the pharynx as a common pathway. Disruptions in this interface in young infants may result in dysphagia that may lead to aspiration and injury to the developing lung. Likewise, respiratory problems may contribute to the development of swallowing problems. This article focuses on the coordination between swallowing and breathing in infants and children, aspiration during periods of postnatal lung development and airway protective mechanisms. Identification of infants and children at increased risk for oropharyngeal dysphagia and respiratory disease is critical for optimal intervention. Assessment and management considerations are described.

Advances in the diagnosis and management of chronic pulmonary aspiration in children

Chronic pulmonary aspiration (CPA) in children is an important cause of recurrent pneumonia, progressive lung injury, respiratory disability and death. It is sporadic, intermittent and variable, and often occurs in children with complicated underlying medical conditions and syndromes that produce symptoms indistinguishable from CPA. For most types of aspiration there is no gold-standard diagnostic test. The diagnosis of CPA is currently made clinically with some supporting diagnostic evaluations, but often not until significant lung injury has been sustained. Despite multiple diagnostic techniques, the diagnosis or exclusion of CPA in children is challenging. This is of particular concern given the outcome of unrecognised progressive lung injury and the invasiveness of definitive therapies. Although new techniques have been introduced since the 1990s and significant advances in the understanding of dysphagia and gastro-oesophageal reflux have been made, characterisation of the aspirating child remains elusive.

Aspiration of an impacted lower third molar during its surgical removal under local anaesthesia

In this case of an aspirated impacted lower third molar during its removal under local anaesthesia, the problem was recognized immediately during the surgical procedure. The patient, a 23-year-old male, was subjected to urgent radiological examination. The aspirated tooth was detected in the right bronchus and eventually removed by rigid bronchoscopy. Oral surgeons should suspect any tooth that has been avulsed or extracted and not found as having been aspirated. Early diagnosis and management of such incidents is essential.

Aspiration during swallowing in typically developing children of the First Nations and Inuit in Canada

Children of the First Nations and Inuit in Canada have a high propensity for lower respiratory tract infections. Overcrowding, poor housing, passive smoke exposure, and lack of breast feeding (Martens P, Bond R, Jebamani L, Burchill C, et al. http://www.umanitoba.ca/centres/mchp/reports/pdfs/rfn_pdfs/rfn_report.pdf.; MacMillan H, Walsh C, Jamieson E, Crawford A, Boyle M. http://www.hcsc.gc.ca/fnihbdgspni/fnihb/aboriginalhealth/reports_summaries/regional_survey_ch1.pdf.; Wardman AE, Khan NA. Int J Circumpolar Health 2004;63:81-92) have been cited as important contributing factors in the occurrence of lower respiratory tract infections. However, aspiration during swallowing has thus far not been considered as a co-factor in the occurrence of lower respiratory tract infections in these children. We present a retrospective case series of seven typically developing children of the Canadian First Nations and Inuit, in whom aspiration during swallowing was detected in the course of investigating associations with recurrent lower respiratory tract infections. None of the children had any of the known risk factors for aspiration during swallowing such as developmental variation, prematurity, neuromotor problems, or anatomic abnormalities of the upper aerodigestive tract. We speculate that aspiration during swallowing in typically developing children may be an important, previously unrecognized co-factor in the occurrence of lower respiratory tract infections, particularly in the communities of the Canadian First Nations and Inuit. Further prospective studies will be needed to determine whether aspiration during swallowing represents an independent risk factor for the occurrence of lower respiratory tract infections in these children.