Neonatal Direct Rigid Laryngoscopy and Bronchoscopy: A Near Miss

Airway management is a skill necessary for healthcare providers who manage patients. Intubation is a skill that both anesthesiologists and intensivists use daily. We present a case of a neonate that developed significant worsening stridor after a successful intubation for a hernia repair. After 4 intubation attempts, with easy visualization of the vocal cords and unsuccessful placement of the endotracheal tube, the patient was emergently brought to the operating room for evaluation.

Video versus direct laryngoscopy on successful firstpass endotracheal intubation in ICU patients

BACKGROUND: Airway management in intensive care unit(ICU) patients is challenging. The aim of this study was to compare the rate of successful first-pass intubation in the ICU by using the direct laryngoscopy(DL) and that by using the video laryngoscopy(VL).METHODS: A randomized, non-blinded trial comparing first-pass success rate of intubation between VL and DL was performed. Patients were recruited in the period from August 2014 to August 2016. All physicians working at ICU received hands-on training in the use of the video and direct laryngoscope. The primary outcome measure was the first-pass intubation success. RESULTS: A total of 163 ICU patients underwent intubation during the study period(81 patients in VL group and 82 in DL group). The rate of successful first-pass intubation was not significantly different between the VL and the DL group(67.9% vs. 69.5%, P=0.824). Moreover, the overall intubation success and total number of attempts to achieve intubation success did not differ between the two groups. In patients with successful first-pass intubation, the median duration of the intubation procedure did not differ between the two groups. The Cormack-Lehane grades and the percentage of glottic opening score were similar, and no significant differences were found between the two groups. There were no statistical differences between the VL and the DL group in intubation complications(all P>0.05). CONCLUSION: Among ICU patients requiring intubation, there was no significant difference in the rate of successful first-pass intubation between VL and DL.

The role of direct laryngoscopy in the diagnosis of laryngeal cleft

Objective: To identify the presenting features of a laryngeal cleft in children. To compare rigid and flexible endoscopic methods available for identifying laryngeal cleft and determine their utility. Methods: The charts of all patients diagnosed with laryngeal cleft in a tertiary care institution between 2009 and 2010 were evaluated retrospectively for age, gender, comorbidity, presenting features, and results of bedside swallow evaluation. Findings on flexible and direct laryngoscopy, both performed under general anesthesia, were compared. Results: Eleven patients had a diagnosis of laryngeal cleft, confirmed by direct laryngoscopy. Nine of eleven had signs of aspiration on modified barium swallow study (MBSS). Of the eight subjects who underwent flexible laryngoscopy by a pulmonologist, a deep interarytenoid groove was only reported in four cases. In all eleven cases, the arytenoids could be physically separated during direct laryngoscopy, allowing for definitive diagnosis of the cleft and identification of its type and severity. Conclusion: Video swallow studies and flexible laryngoscopy may raise suspicion or even diagnose a laryngeal cleft, however, a laryngeal cleft must be confirmed by direct laryngscopy in which the interarytenoid space is palpated. Furthermore, a patient in whom symptoms persist but no laryngeal cleft is identified on flexible examination should have a direct laryngoscopy to rule out a cleft.

Pre-formed endotracheal tube and stepwise insertion for more successful intubation with video laryngoscopy

BACKGROUND In anesthesia practice,orotracheal intubation remains the primary concern of the anesthesiologist.The introduction of video laryngoscopy(VL)has increased the success rate of orotracheal intubation;however,conflicting results have been reported regarding the usefulness of the current technique with VL in clinical practice.AIM To describe a modification to improve intubation with VL,followed by evaluation of the practice in vivo.METHODS First,a mannequin trial was conducted with operators having different experience and background.Then,a retrospective analysis was performed for an>1-year period with patients who underwent general anesthesia with orotracheal intubation.The endotracheal tube used had been pre-formed with two curves.Stepwise intubation had been performed with direct eye vision,followed by screen assistance and rotation of the tube as needed to direct it toward the glottis.In the mannequin trial,the outcome measures were quantification of torque(force with angular acceleration during levering),need for external maneuvers,and time to intubate.In the clinical experience,orotracheal intubation used VL(pre-formed tube)or direct laryngoscopy(DL)at the anesthetist’s discretion and throat discomfort was reported by the patient.RESULTS In the mannequin trials using VL,there was less torque with the pre-formed tube than with a regular tube(8%and 65%,respectively).The first-pass rate was higher with the pre-formed tube(95%)than with a regular tube(81%).However,the time to intubate was longer with the pre-formed tube than with a regular tube(22 s and 12 s,respectively).In clinical practice,562 patients underwent surgery under general anesthesia with orotracheal intubation using either VL(n=244)or DL(n=318)at the discretion of the attending anesthetist.VL was specifically planned in 62 of the patients,due to anticipated difficulty.Second attempts by readjustment of the curve of the tube were significantly fewer with VL than with DL(10%vs 18%).Throat discomfort was reported by fewer patients who underwent VL than those who underwent DL(6%vs 24%).CONCLUSION Pre-formed endotracheal tube with stepwise insertion produces less torque,fewer external maneuvers and higher first-pass success rate during VL intubation.Further,prospective studies are warranted.

A quantitative study of airway ultrasound in predicting difficult laryngoscopy:A prospective study

Purpose:As common clinical screening tests cannot effectively predict a difficult airway,and unanticipated difficult laryngoscopy remains a challenge for physicians.We herein used ultrasound to develop some point-of-care predictors for difficult laryngoscopy.Methods:This prospective observational study included 502 patients who underwent laryngoscopy and a detailed sonographic assessment.Patients under 18 years old,or with maxillofacial deformities or fractures,limited mouth opening,limited neck movement or history of neck surgery were excluded from the study.Laryngoscopic views of all patients were scored and grouping using the modified Cormack-Lehane(CL)scoring system.The measurements acquired comprised tongue width,the longitudinal cross-sectional area of the tongue,tongue volume,the mandible-hyoid bone distance,the hyoid boneglottis distance,the mandible-hyoid bone-glottis angle,the skin-thyrohyoid membrane distance,the glottis-superior edge of the thyroid cartilage distance(DGTC),the skin-hyoid bone distance,and the epiglottis midway-skin distance.ANOVA and Chi-square were used to compare differences between groups.Logistic regression was used to identify risk factors for difficult laryngoscopy and it was visualized by receiver operating characteristic curves and nomogram.R version 3.6.3 and SPSS version 26.0 were used for statistical analyses.Results:Difficult laryngoscopy was indicated in 49 patients(CL grade III-IV)and easy laryngoscopy in 453 patients(CL grade I-II).The ultrasound-measured mandible-hyoid bone-glottis angle and DGTC significantly differed between the 2 groups(p<0.001).Difficult laryngoscopy was predicted by an area under the curve(AUC)of 0.930 with a threshold mandible-hyoid bone-glottis angle of 125.5and by an AUC of 0.722 with a threshold DGTC of 1.22 cm.The longitudinal cross-sectional area of the tongue,tongue width,tongue volume,the mandible-hyoid distance,and the hyoid-glottis distance did not significantly differ between the groups.Conclusion:Difficult laryngoscopy may be anticipated in patients in whom the mandible-hyoid boneglottis angle is smaller than 125.5or DGTC is larger than 1.22 cm.

Median effective dose of remifentanil for awake laryngoscopy and intubation

Background Awake intubation requires an anesthetic management that provides sufficient patient safety and comfort, adequate intubating conditions, and stable hemodynamics. In this prospective clinical study, our aim was to determine the median effective dose （ED50） of remifentanil in combination with midazolam and airway topical anesthesia for awake laryngoscopy and intubation. Methods Thirty-six female adult patients, scheduled for elective plastic surgery under general anesthesia requiring orotracheal intubation were included in this study. Ten minutes after intravenous administration of midazolam 0.1 mg/kg, patients were assigned to receive remifentanil in bolus, followed by a continuous infusion. The bolus dose and infusion rate of remifentanil were adjusted by a modified Dixon＇s up-and-down method. Patient＇s reaction score at laryngoscopy and an Observer＇s Assessment of Alertness/Sedation Scale （OAA/S） were used to determine whether the remifentanil dosage regimen was accepted. During laryngoscopy, 2% lidocaine was sprayed into the airway to provide the topical anesthesia. ED50 of remifentanil was calculated by the modified Dixon up-and-down method, and the probit analysis was then used to confirm the results obtained from the modified Dixon＇s up-and-down method. In the patients who were scored as ＂accept＂, patient＇s OAA/S and reactJon scores at dJfferent observed points, JntubatJng conditJon score and patient＇s tolerance to the endotracheal tube after intubation were evaluated and recorded. Blood pressure and heart rate at different measuring points were also noted. Results ED50 of remifentanil for awake laryngoscopy and intubation obtained by the modified Dixon＇s up-and-down method was （0.62±0.02） μg/kg. Using probit analysis, ED50 and ED95 of remifentanil were 0.63 μg/kg （95% CI, 0.54-0.70） and 0.83 μg/kg （95% CI, 0.73-2.59）, respectively. Nineteen patients who were scored as ＂accept＂ had an OAA/S of 〉15 and tolerated well laryngoscopy without significant discomfort or gagging. The mean intubating condition score was 1.8±0.8. The endotracheal tube was well tolerated. During awake laryngoscopy and intubation, blood pressure and heart rate were also kept stable. The postoperative follow up showed that no patient recalled discomfort and pain for airway manipulation. Conclusions When combined with midazolam 0.1 mg/kg and airway topical anesthesia, ED50 of remifentanil for successful awake laryngoscopy and Jntubation is 0.62 μg/kg in bolus followed by continuous infusJon of 0.062 μg·kg·min^-1. This sedation and analgesia regimen can provide patient safety and comfort, ensure adequate intubating conditions, maintain hemodynamic stability, and prevent negative recall of the airway procedure.

Laryngeal and hypopharyngeal carcinoma: comparison of helical CT multiplanar reformation, three-dimensional reconstruction and virtual laryngoscopy

OBJECTIVE: To evaluate the clinical application of helical CT multiplanar reformation (MPR) three-dimensional reconstruction (3D) and virtual laryngoscopy (CTVL) in laryngeal and hypopharyngeal carcinoma. METHODS: Axial helical CT scans were performed in 22 patients with laryngeal or hypopharyngeal carcinoma, along with MPR, 3D and CTVL. These results were compared with the findings of fiber optic laryngoscopy and surgery. RESULTS: Combining axial and MPR images, both the accuracy in preoperative tumor staging and the diagnosis of metastatic lymph nodes were 95%. MPR demonstrated more information about the extent of tumor than axial images in 23% cases; 3D image displayed clearly the extension of tumor, the vessels and airway from multiple views. The location, size and extent of tumors found in cranio-caudal CTVL corresponded well with that of laryngoscopy, and CTVL demonstrated the relationship between the tumor and vocal cords and anterior commissure by caudo-cranial approach, which was inaccessible to fiber optic laryngoscopy in 3 cases. CONCLUSIONS: Axial images of helical CT clearly demonstrate the location, size and extent of laryngeal and hypopharyngeal carcinoma, while MPR and 3D images are useful in displaying the three-dimensional images and anatomical relation of the tumor. CTVL can clearly display the mucosal surface structures of the larynx and hypopharynx and is a good complementary method of laryngoscopy.

Ultrasound for diagnosing new difficult laryngoscopy indicator: a prospective, self-controlled, assessor blinded, observational study

Background: Unpredictable difficult laryngoscopy (DL) remains a challenge for anesthesiologists, especially when difficult ventilation occurs during standard laryngoscopy. Accurate airway assessment should always be performed, but the common airway assessment methods only perform superficial screening. Thus, the deep laryngopharyngeal anatomy may not be evaluated. Ultrasound-based airway assessment has been recently proposed as a useful, simple, and non-invasive bedside tool as an adjunct to clinical methods, which may facilitate identification of DL. The present study aimed to determine the correlation between ultrasound-measured indicators and DL. Methods: Patients undergoing elective surgery under general anesthesia with tracheal intubation were enrolled. Ultrasonic airway assessments were performed before anesthesia induction. Ultrasound diagnostic indicators included the thickness and width of the base of the tongue, the angle between the epiglottis and glottis, the length of the thyrohyoid membrane, and the thickness of the lateral pharyngeal wall. A score of ≥3 in the Modified Cormack-Lehane Scoring System was used as a standard of DL and was also applied to divide patients into DL and non-DL groups. The area under the receiver operating characteristic (ROC) curve was used to evaluate the diagnostic ability of various diagnostic indicators. Results: A total of 499 patients were enrolled into non-DL and DL groups comprising 452 (452/499, 90.6%) and 47 (47/499, 9.4%) patients, respectively. One ultrasonic diagnoses indicator correlated with DL, namely, the angle between the epiglottis and glottis. When the angle between the epiglottis and glottis was 50°, the area under the ROC curve was maximum (0.902), and the best sensitivity (81%) and specificity (89%) were achieved. Conclusions: Airway ultrasounds should be considered to identify DL. The ultrasonic angle measured between the epiglottis and glottis is highly associated with DL, which may occur when the angle is less than 50°. Clinical trial registration:

Diagnostic utility of flexible fiberoptic nasopharyngolaryngoscopy recorded onto a smartphone: A pilot study

Objectives: To evaluate the diagnostic accuracy of flexible fiberoptic examinations of the larynx recorded onto smartphones. Methods: Prospective, blinded study of inpatients requiring laryngoscopy. A live exam was per-formed, then a smartphone was attached to the endoscope using a novel coupling device and the same examination was recorded. The live and recorded exams were evaluated by two lar-yngologists, each blinded to the findings of the other. Results: Eighteen subjects were evaluated. Evaluation of airway patency was identical (Kappa = 1.0 [1, 1]). Evaluation of vocal cord motion was identical for 14 subjects: 9 normal, 3 paretic, 2 paralytic (Kappa = 0.69 [0.38, 1]). Conclusion: There is high correlation between laryngeal diagnoses using live flexible fiberoptic laryngoscopy and recordings using a coupling device to transfer the recordings on to smart-phones. Critical findings such as airway patency and vocal fold motion showed the highest cor-relation.

Optimizing Surgical Conditions with the Use of a Modified Spontaneous Respiration, Intravenous Anesthesia and High-Flow Nasal Oxygen for Pediatric Laser Laryngeal Surgery

The use of SponTaneous Respiration using IntraVEnous anesthesia and High-flow nasal oxygen (STRIVE-Hi) in laryngeal surgery has become more widely reported. This method eliminates the endotracheal tube as a fuel for a potential fire. However, little has been published on its use in the pediatric population. Our case report describes its use in a 2-year-old undergoing micro-direct laryngoscopy with CO2 assisted supraglottoplasty and rigid bronchoscopy for airway obstruction from congenital laryngomalacia. The STRIVE-Hi technique was modified for the pediatric patient by using a lower flow through the nasal cannula (4 L). No major changes in SpO2 were detected during the 30-minute procedure. With back up airway safety equipment in place, STRIVE is proving to be a safe technique with major advantages when used in this unique scenario.

显微支撑喉镜下治疗会厌囊肿的疗效分析

会厌囊肿是耳鼻咽喉科的常见病，患者大多因咽部异物感就诊或体检时发现。如囊肿继发感染可表现为喉部疼痛，可出现咳嗽或声音改变，严重者可致喉阻塞。目前临床手术治疗方式主要包括：常规器械切除、高频电刀、微波、

纤维喉镜下咽鼓管、中耳注药治疗分泌性中耳炎

分泌性中耳炎是以鼓室积液、鼓膜完整和听力下降为特征的中耳非化脓性炎性疾病,临床上常采用综合方法治疗,疗效报道不一。我科对2009年6月～2011年6月以来61例分泌性中耳炎患者行纤维喉镜下咽鼓管、中耳注药治疗分泌性中耳炎,取得良好疗效。

自吸式会厌脓肿切排器的临床分析

1资料与方法 1.1临床资料。选取2011年9月~2014年9月温州医科大学附属第三医院耳鼻咽喉科诊治的急性会厌炎伴脓肿形成患者,男32例,女27例,男女之比为1.18∶1。年龄20~65岁,患者按门急诊随机入院进入病区两个诊疗组,经医院伦理委员会批准,一组(直接喉镜组)28例患者采取直接喉镜下会厌脓肿切开引流,

支撑喉镜下电动切削器治疗声带息肉

声带息肉是耳鼻咽喉科常见病和多发病，手术为主要治疗方式。常规以镰状刀先切开，再用钳咬除并修整创面，亦可采用激光等治疗方法。但对多发性广基甚至全声带息肉样变者，如何准确掌握切除范围及术中出血对手术的干扰是棘手难题，术后。恢复时间长且效果欠佳。我院自2006年1月起采用支撑喉镜下电动切削器辅助手术切除多发性广基声带息肉65例，取得良好效果，报道如下。

电视纤维喉镜诊治疑难性咽部异物

咽部异物大多数可直接钳取或在间接喉镜下钳取，但临床常遇到一些特殊病例，采用上述方法取出困难。我科2003年7月-2005年12月，在电视纤维喉镜下诊治疑难性咽部异物71例，取得较好效果，现报道如下。

支撑喉镜下喉显微手术舌神经损伤分析

随着支撑喉镜下喉显微手术的开展,其处理不当引起的一些手术并发症也日益受到重视,其中舌神经损伤逐步被人们所关注。本文回顾分析我们2003年11月至2010年3月336例支撑喉镜下喉显微手术患者,报道如下。

高龄声嘶患者电子喉镜检查

声嘶通常是喉部疾病的早期或首发症状。电子喉镜检查可为喉部疾病的早期诊断，及时治疗提供便利。我们2002年11月～2006年4月对342例60岁以上高龄声嘶患者进行电子喉镜检查，对结果进行分析。

纤维喉镜下治疗声带良性病变

我科自2005年1月～2009年1月采用电视监控纤维喉镜下喉内微创手术治疗声带息肉和声带小结265例,取得较好效果,现报道如下。

鼻内镜联合支撑喉镜在喉显微手术中的应用

2006年10月－2007年10月，我科应用鼻内镜联合支撑喉镜行喉显微手术42例，均取得满意效果，现报道如下。

支撑喉镜显微镜下电凝吸引钩切除婴儿会厌囊肿

我院自2006年6月～2011年5月共收治16例婴儿会厌囊肿,并施行支撑喉镜显微镜下电凝吸引钩婴儿会厌囊肿切除术,术后均经过6个月以上的随访观察,效果满意,无一例复发。现报道如下。