Symptomatic ossification of the anterior longitudinal ligament with stenosis of the cervical spine: a report of seven cases

Seven men with a mean age of 63.9 years (59 to 67) developed dysphagia because of oesophageal compression with ossification of the anterior longitudinal ligament (OALL) and radiculomyelopathy due to associated stenosis of the cervical spine. The diagnosis of OALL was made by plain lateral radiography and classified into three types; segmental, continuous and mixed. Five patients had associated OALL in the thoracic and lumbar spine without ossification of the ligamentum flavum. All underwent removal of the OALL and six had simultaneous decompression by removal of ossification of the posterior longitudinal ligament or a bony spur. All had improvement of their dysphagia. Because symptomatic OALL may be associated with spinal stenosis, precise neurological examination is critical. A simultaneous microsurgical operation for patients with OALL and spinal stenosis gives good results without serious complications.     

Difficult fiber-optic intubation in a patient with giant neck masses: The role of McCoy laryngoscope in elevating compressed laryngeal aperture

Airway management in patients with giant neck masses is usually a challenge to anesthesiologists. A giant neck mass could compress the airway and thus impede endotracheal intubation. We encountered a situation where the giant neck masses of a patient pushed the epiglottis posteriorly toward the posterior pharyngeal wall and compressed the laryngeal aperture narrowing after anesthetic induction, causing direct laryngoscopic intubation and sequential fiber-optic intubation failed. The neck masses twisted the aryepiglottic fold tortuously and clogged the laryngeal aperture tightly, making a flexible fiber-optic bronchoscope unable to pass through the laryngeal aperture. Later, we utilized a McCoy laryngoscope alternately to lift the compressed larynx up and away from the posterior pharyngeal wall, creating a passage and completing endotracheal intubation successfully with the aid of a gum elastic bougie. Our case suggested that the tilting tip blade of the McCoy laryngoscope could lever the tongue base up against the tumor mass compression to improve laryngeal views and facilitate endotracheal intubation when a difficult fiber-optic intubation was encountered on a compressed laryngeal aperture.     

Clinical and radiological study of ossification of the anterior longitudinal ligament in the cervical spine

Twenty-seven patients with ossification of the anterior longitudinal ligament (OALL) in diffuse idiopathic skeletal hyperostosis (DISH) in the cervical region were diagnosed among 2000 individuals during 10 months and analyzed clinically and radiologically by two neurosurgeons. Sex distribution was 20 men and 7 women with ages ranging from 57 to 82 years (average: 72.3 y.o.). Main signs and symptoms were dysesthesia of the upper extremities, stiff neck, dizziness and dysphagia (33%). Three patients had diabetes mellitus, 14 had hypertension, and 15 had hyperuremia. Ossification of the posterior longitudinal ligament (OPLL) co-existed in 18 patients (66%). Number of vertebral bodies with cervical OALL ranged from 4 to 6 (average: 4.8) and thickness of ossification of the anterior longitudinal ligament was from 2 to 6 (average: 3.1) mm. Originally we divided OALL in the cervical region into 3 types, nodular-type; 16 cases, continuous-type; 7 cases, and mixed-type; 4 cases. Small OPLL can be diagnosed by either cervical CT or myelo-CT. DISH is thought to be a benign clinical entity, but patients with OALL in DISH, accompanied by OPLL and those accompanied by dysphasia are frequently encountered and sometimes may be treated surgically.     

声门上通气装置引导气管插管的临床应用进展

声门上通气装置（SAD）在院前急救、常规麻醉及困难气道的开放、维持氧合等方面发挥着重要作用,同时也为引导气管插管提供了一个可行方式。在日常麻醉及手术室外治疗或抢救中,保持气道通畅和充分氧合是气道管理的关键。困难插管发生率约4.5%～7.5%,困难气道管理仍是麻醉管理中的重中之重。在困难插管发生时,先可放置SAD,后经SAD盲探或在可视设备辅助下行气管插管,迅速建立气道、提高首次插管成功率、减少插管过程中气道损伤。本文着重介绍不同种类可引导气管插管的SAD的临床应用进展。     

An epidemiological study on the ossification of the anterior longitudinal ligament of the spine

An epidemiological study was carried out in connection with the multiphasic screening examination of 1,057 people (442 men and 615 women) in the village of Yachiho. The purpose of this study was to define the etiology of OALL (ossification of the anterior longitudinal ligament) and disc narrowing. The prevalence of disc narrowing increased with age, but OALL was not correlated with aging. OALL was found more frequently in men, but disc narrowing showed no difference between each sexes. The body height and weight-height index were higher in the OALL cases. The body height shrinkage by aging was greater in the patients with disc narrowing cases. The index of thoracic kyphosis was higher in the OALL cases than in the patients with disc narrowing ones. OALL was associated with ossification of the other ligaments of the spine, but disc narrowing was not. This study suggests that despite some similarities, OALL is etiologically different from disc narrowing.     

Airwaymanagement: video-assisted airway management

Endotracheal intubation remains the "goldstandard" in airway management. If with use of conventional techniques intubation of the patient fails, or if an anticipated difficult airway is present, video-assisted techniques may help to increase intubation success. Video-assisted techniques give the possibility to indirectly visualise the laryngeal structures with fibreoptical or camerachip-technique, and to display the videopicture on an external or integrated monitor. For the anticipated difficult airway, awake flexible fibreoptical intubation still is the first choice. However, if Oxygenation and Ventilation can be established with bag-mask ventilation or supraglottic airways, the use of an endoscopic optical stylet or a videolaryngoscope may be alternatives. If the algorithm for the unanticipated difficult airway can be safely administered, the latter techniques may also be used as emergency intubation devices.     

Aortic pulsation prevents the development of ossification of anterior longitudinal ligament toward the aorta in patients with diffuse idiopathic skeletal hyperostosis (DISH) in Japanese: Results of chest CT-based cross-sectional study

Background

The development and etiology of diffuse idiopathic skeletal hyperostosis (DISH) were far from complete understanding. Even the precise mechanism of the development of its typical right-sided ossification of the anterior longitudinal ligament (OALL) frequently compared to ‘flowing candle wax’, a hallmark of DISH, remains unknown.

Use of the Ambu® aScope™ in 10 patients with predicted difficult intubation

Fibreoptic intubation is the gold standard for patients with predicted difficult intubation. The Ambu^® aScope? is a single‐use device for fibreoptic tracheal intubation. We assessed its performance in 10 patients with predicted difficult tracheal intubation. The procedure was easy and successful in nine patients. However, the limited time of use did not permit intubation in one patient who required three attempts with different size tracheal tubes. The limited image resolution that can be expected of a single‐use fibreoptic system and the absence of a suction channel are other potential limitations. On the other hand, being single‐use this device has the advantage of avoiding the risk of infectious disease transmission and is always ready to use.     

A new curved laryngoscope blade for routine and difficult tracheal intubation

We have designed a new curved laryngoscope blade based on a new concept of reversing the peardrop phenomenon to facilitate a view of the larynx sufficient for intubation in a greater variety of patients than the current Macintosh blade affords. The new design has a bifid tip and S-shaped spatula to exert more effective pressure in the vallecula area, elevate the epiglottis and change directions of the forces on the tongue to prevent posteroinferior displacement of the compressed tongue in the submandibular space during laryngoscopy. A radiograph laryngoscopy technique was used to guide the new blade curvature design and compare the performance of the new blade with the Macintosh blade in patients with or without a difficult airway. Our results confirm that the new blade provides a laryngeal view sufficient to accomplish intubation by compressing the root of the tongue in an anterocephalad direction in the submandibular space and elevating the epiglottis effectively in patients with or without unanticipated difficult airway. The new curved blade can also effectively move the U-shaped epiglottis out of the laryngeal view to facilitate intubation in pediatric patients aged 2 mo-13 yr.     

Difficult endotracheal intubation in patients with sleep apnea syndrome

Although sleep apnea syndrome (SAS) is common, studies assessing the anesthetic management of these patients are rare and consist mainly of case studies. We performed a retrospective case-control study to determine the incidence of difficult intubation in SAS patients and to determine the relationship between the severity of SAS and the occurrence of difficult intubation. Among 113 patients included (36 and 77 in the SAS and control groups, respectively), difficult intubation occurred more often in SAS patients than in controls (21.9% versus 2.6%, respectively; P < 0.05). No relationship was found between the severity of SAS and the occurrence of difficult intubation. Disappointingly, no single factor was associated with the occurrence of difficult intubation in SAS patients. We conclude that SAS is a risk factor for difficult intubation. IMPLICATIONS: Because patients with sleep apnea syndrome have an increased risk of difficult endotracheal intubation and may present with cardiovascular disease, preoperative preventive measures should be undertaken to avoid untoward events.     

Poor Man’s LMA: achieving adequate ventilation with a poor mask seal

PURPOSE: This report describes a technique of ventilation prior to laryngoscopy and intubation that proved to be simple, inexpensive and effective for a patient whose airway evaluation suggested difficult mask ventilation. The technique is called Poor Man's LMA. CLINICAL FEATURES: A 60-yr-old male, measuring 170 cm, weighing 117 kg, edentulous and with a full beard, was to undergo uvulopalatopharyngoplasty. After induction of general anesthesia with a hypnotic, analgesic and non-depolarizing muscle relaxant, it was soon determined that mask bag ventilation was difficult due to an inadequate seal between the mask and the patient's full beard. To improve ventilation, an endotracheal tube was placed into the oropharynx, the lips and nose compressed by a colleague in order to prevent gas egress, and effective manual ventilation established by connecting the circle system to the endotracheal tube. Subsequent direct laryngoscopy and intubation were accomplished without incident. CONCLUSION: The patient's clinical features made conventional mask bag ventilation difficult and inadequate. The Poor Man's LMA technique improved oxygenation and ventilation in preparation for intubation. Further investigations on the usefulness of this technique are warranted.     

Obstetrical and Pediatric Anesthesia Anesthetic management of children with Moebius sequence

BACKGROUND: Moebius sequence is a rare congenital absence of the sixth and seventh cranial nerves, although there may be additional congenital cranial neuropathies. Developmental delay, cardiac and musculoskeletal abnormalities may also co-exist. Oro-facial manifestations include bilateral facial nerve palsy resulting in a mask like facies, drooling, incomplete eye closure, and strabismus secondary to the extra-ocular muscle imbalance. This condition has multiple implications for anesthetic care. METHODS: We reviewed 111 anesthesia records of 46 patients with Moebius sequence for anesthesia technique and related complications. RESULTS: Facial nerve palsy was universally present and bilateral in 44 (93.6%) patients. Thirty-two (68%) had concomitant sixth nerve palsy. Oro-facial and limb abnormalities were present in 16 (35%) and 18 (39%) of patients respectively. Endotracheal intubation, when attempted, was easy in 76 of 106 cases. Tracheal intubation was consistently difficult in seven patients and intubation failure occurred in a single patient only. Statistically significant factors associated with difficult tracheal intubation included structural abnormalities of the mandible and palate and abnormalities of four cranial nerves (IX, X, XI, XII). CONCLUSION: We confirm that tracheal intubation may be difficult in patients with Moebius sequence. We identify disease features that might predict a difficult tracheal intubation and thus allow the anesthesiologist an opportunity to plan accordingly.     

Ossification of the spinal ligament. A radiographic reevaluation in Bologna, Italy

A radiographic reevaluation of cervical spine films of 1,258 adult patients and of thoraco-lumbar spine films of 488 of these was performed at the Rizzoli Orthopaedic Institute (Bologne, Italy), in order to detect ossification of the posterior longitudinal ligament (OPLL), the anterior longitudinal ligament (OALL), the yellow ligament (OYL) and the nuchal ligament at the cervical level, and OPLL, OALL and OYL at the thoraco-lumbar level. The incidence of OALL, OYL and ossification of the nuchal ligament corresponded with those previously reported in the literature. Cervical OPLL was found in 1.83%, with a definite prevalence in the 45-64 age group where the figure was 2.83%. This incidence is much higher than that hitherto reported in Caucasians, and is nearly the same as that in Japan. Possible explanations for this discrepancy are proposed.     

Successful fiberoptic intubation for a patient with lingual tonsillar hyperplasia

Hypertrophied lingual tonsils are rare, but may cause difficulty or inability in tracheal intubation during induction of general anesthesia. A 39-yr-old woman was scheduled for resection of symptomatic hypertrophied lingual tonsils. In this patient, we examined two methods of oro-tracheal intubation either with rigid laryngoscopy or flexible fiberoscopy using trans-nasal fiberopic monitoring. Direct laryngoscopy failed to expose the trachea because of large hypertrophied tissue, and fiberoscopic intubation was also difficult since a large mass hindered acquiring a suitable view. However, transnasal fiberoscopic monitoring could guide the orotracheal fiber into the trachea for intubation. When an anesthesiologist can predict the abnormality of lingual tonsils, this combination might be recommended for difficult airway and intubation.     

Le glottiscope AWS-Pentax™, alternative à la fibroscopie dans deux cas d’intubation difficile prévue du brûlé grave

Intubating patients with facial burn is difficult to most anesthesiologists. Awake flexible fiberoptic intubation is the gold standard for management of anticipated difficult tracheal intubation. However, serious facial burn and dysmorphic syndrome can make fiberoptic intubation more difficult or impossible. We report the use of awake oral intubation using the Pentax-Airway Scope (AWS) in two major burn patients with facial injury, in whom awake fiberoptic intubation was impossible. As shown in morbidly obese patient and in patients with unstable necks, AWS could be useful to facilitate tracheal intubation in awake, facial burn patients presenting with a potentially difficult airway. Awake AWS intubation seems as a potential alternative to awake fiberoptic intubation.     

Fiberoptic techniques

Fiberoptic intubation of the spontaneously breathing patient is the gold standard and technique of choice for the elective management of a difficult airway. In the hands of the properly trained and experienced user, it is also an excellent 'plan B' alternative when direct laryngoscopy unexpectedly fails. Fiberscope-assisted intubation through an endoscopy face mask, laryngeal mask airway or intubating laryngeal mask airway secures ventilation and oxygenation, and permits endotracheal intubation in airway emergency situations. Portable fiberscopes can be used in remote settings, increasing patient safety. This review discusses current fiberoptic intubation techniques and their applications in the management of both the anticipated and unanticipated difficult airway.     

Video/endoscope assisted intubation: recent advancement in airway management

The Macintosh laryngoscope has been a gold standard for endotracheal intubation over 60 years. However, even with optimum technique used, the glottis can not be seen in 1-3% of the cases with Macintosh blade resulting in difficult intubation. ASA guideline recommend not to insist using same laryngoscope, but to use alternative approach to solve difficult airway. However, many of these alternative approach use blind/semi-blind technique which also may compromise the airway. Recently, supported by advancement of optical technology, many intubation devices combined with endoscope, fiber optics or video system have become commercially available. These devices can visualize the vocal cord to facilitate intubation These new video/endoscopy assisted airway devices are introduced in this review.     

Fibreoptic intubation

Although not widely utilized, fibreoptic techniques represent a dramatic advance in the management of the difficult intubation. Particularly suited to the awake patient in the elective setting, fibreoptic intubation can abo be useful in selected emergency situations, and can be done under general anaesthesia. In the awake patient fibreoptic intubation maintains a wide margin of safety while producing minimal patient discomfort, but requires adequate local anaesthesia of the airway. Intimate familiarity with the bronchoscope and the anatomy of the upper airway is essential as is careful attention to various aspects of technique. Intubation mannequins can be readily utilized to develop dexterity in bronchoscopic manipulation and intubation workshops are also effective in improving skills. This CME article provides the clinician with a detailed approach to the technique of fibreoptic intubation based on the author’s personal experience supplemented by a limited literature review. Fibreoptic intubation is not a difficult skill to master and should be in the armamentarium of all practising anaesthetists.     

Co-existence of ossification of the nuchal ligament is associated with severity of ossification in the whole spine in patients with cervical ossification of the posterior longitudinal ligament -A multi-center CT study-

Background

Previous studies have shown that patients with cervical ossification of the posterior longitudinal ligament (OPLL) often have co-existing ossification of the nuchal ligament (ONL). However, no studies have focused on ONL and its relevance to the severity of OPLL or ossification of other spinal ligaments, such as anterior longitudinal ligament (OALL), ligamentum flavum (OLF), and supraspinous/interspinous ligament (OSIL).

Lightwand guided intubation in paediatric patients with a known difficult airway: a report of four cases

The anaesthetic management of children with craniofacial abnormalities often presents unique challenges because soft tissue and bony abnormities can affect the airway and influence airway management. We report four paediatric patients with predicted difficult airways due to craniofacial abnormalities. They all had a laryngeal view of Cormack–Lehane grade IV and were impossible to intubate using direct laryngoscopy. Fibreoptic intubation was also repeatedly attempted but was not successful. All the tracheal intubations were completed using a lightwand on the first attempt in less than 30 s. We consider that lightwand guided intubation technique may be a useful alternative approach to fibreoptic intubation technique in managing the difficult paediatric airway.