Airway protection and the laryngeal mask airway in sinus and nasal surgery

OBJECTIVES/HYPOTHESIS: The objective was to compare the laryngeal mask airway and endotracheal tube for airway protection from blood during sinonasal surgery. STUDY DESIGN: Nonrandomized, controlled, prospective clinical trial. METHODS: Patients scheduled to undergo sinonasal surgery (septoplasty and/or endoscopic sinus surgery) were prospectively enrolled and grouped according to type of airway during general anesthesia with choice of airway device based on the anesthesiologist's preference. Clinical data were tabulated by case including airway device, patient age, weight, estimated blood loss, airway pop-off pressure, and emergence quality. At the conclusion of surgery, the airway was examined through the laryngeal mask airway or endotracheal tube with a flexible fiberoptic bronchoscope to determine the amount of blood present on the vocal cords or in the trachea. The airway device was also evaluated postoperatively for the presence of blood. RESULTS: Seventy-six adult patients were initially enrolled; two were excluded because fiberoptic evaluation of the airway could not be completed. Of the remaining 74 patients, an endotracheal tube and laryngeal mask airway were used in 31 and 43 patients, respectively. The two groups did not differ with respect to age, weight, estimated blood loss during surgery, pop-off pressure, or emergence quality (all P >.05). Patients managed with an laryngeal mask airway were significantly less likely to have blood staining the airway (glottis or trachea) than patients with an endotracheal tube (19.5% vs. 84.8%, chi test [P <.001]). However, the endotracheal tube provided better protection than the laryngeal mask airway against distal tracheal blood contamination (3.2% vs. 14.6%, respectively [P =.110]). CONCLUSION: The laryngeal mask airway provides better protection of the upper airway from blood contamination during sinonasal surgery than a standard endotracheal tube, but there is a higher incidence of distal tracheal contamination. The laryngeal mask airway is a reasonable alternative to endotracheal intubation for airway management in sinonasal surgery.     

热塑性头颈肩膜开窗技术在喉癌患者放疗中的应用

目的:观察热塑性头颈肩膜开窗技术对喉癌急性放射性皮炎的保护作用。方法:将73例恶性肿瘤患者随机分为开窗组(38例)和对照组(35例)。开窗组将头颈肩膜中放射野相应区域剪去,射野中心使用激光延长线摆位放疗;对照组保留完整头颈肩膜,常规使用激光十字投射点摆位放疗。观察并比较两组放射性皮炎的发生率及照射野皮肤的疼痛程度。结果:开窗组放射性皮炎的发生率较对照组明显降低(P<0.05),且开窗组照射野皮肤的疼痛程度也较对照组明显减轻(P<0.05)。结论:热塑性头颈肩膜开窗技术能有效减轻喉癌放疗患者急性放射性皮炎的发生。     

Effect of high laryngeal mask airway intracuff pressure on the laryngopharyngeal mucosa of dogs

OBJECTIVES: To evaluate the effect of increased of laryngeal mask airway (LMA) intracuff pressures on the laryngopharyngeal mucosa. STUDY DESIGN: Animal model. METHODS: Sixteen mixed-breed dogs were randomly allocated to two groups, G1 (intracuff volume, 30 mL; n = 8) and G2 (intracuff volume, 54 mL; n = 8), to produce, respectively, high or very high intracuff pressures. Anesthesia was induced and maintained with pentobarbital. Intracuff pressures were measured immediately after insertion and inflation of a No. 4 laryngeal mask airway (LMA) and 30, 60, 90, and 120 minutes thereafter. The dogs were euthanized, and biopsy specimens from eight predetermined areas of the laryngopharynx in contact with LMA cuff were collected for light microscopic (LM) and scanning electron microscopic (SEM) examination. RESULTS: Initial LMA cuff inflation in G1 and G2 resulted in intracuff pressures of 119 mm Hg +/- 4 mm Hg and 235 mm Hg +/- 13 mm Hg, respectively. Over a 2-hour period, the intracuff pressure decreased significantly in G1 (P < .001) and G2 (P < .01), and there was a significant difference between the groups over time (P < .001). The LM study of laryngopharyngeal mucosa in both groups showed mild congestion in the subepithelial layer. There were no differences between the groups (P > .10) or among the areas sampled (P > .10). In some areas of G2, the SEM study showed epithelial desquamation that was more intense than that in G1. CONCLUSIONS: The increase in LMA intracuff pressure caused only mild alterations in the laryngopharyngeal mucosa of the dog.     

Laryngeal mask anesthesia with intraoperative laryngoscopy for identification of the recurrent laryngeal nerve during thyroidectomy

OBJECTIVES/HYPOTHESIS: A critical step in thyroidectomy involves definitive identification of the recurrent laryngeal nerve (RLN). Using the laryngeal mask airway, identification of the RLN can be facilitated by stimulation of the nerve while monitoring vocal cord movement with a fiberoptic laryngoscope. We present this technique as an effective and safe means to identify the RLN during thyroid surgery, with significant advantages over existing techniques in appropriately selected patients. STUDY DESIGN: Retrospective case series. METHODS: We performed thyroidectomy on 8 patients (13 RLN identifications) in which laryngeal mask airway anesthesia with fiberoptic laryngoscopy was used to identify the RLN. Results are reviewed with regard to postoperative vocal cord function, as well as intraoperative and postoperative courses with laryngeal mask airway anesthesia. RESULTS: In all 13 cases in which the RLN was sought, it was definitively identified by witnessing brisk vocal cord movement on a video screen with stimulation of the RLN. No patient had postoperative vocal cord paresis or paralysis. Overall recovery from laryngeal mask airway anesthesia was uneventful and had advantages when compared with general anesthesia with endotracheal intubation. CONCLUSIONS: Laryngeal mask airway anesthesia with intraoperative fiberoptic laryngoscopy to identify the RLN is effective and safe in carefully selected patients. Advantages include decreased postoperative throat discomfort, absence of coughing during emergence from anesthesia, and elimination of the possibility of vocal cord mobility impairment secondary to RLN ischemia from the endotracheal tube balloon. In addition, this technique is applicable in operations besides thyroid surgery, in which definitive identification of the RLN is indicated.     

电击伤所致喉瘘的修复

目的：探讨电击伤所致喉瘘的修复方法。方法：应用胸锁乳突肌皮瓣带蒂移植的方法修复喉瘘,放置喉模防止喉狭窄,恢复喉功能。结果：患者颈部皮损及喉功能恢复良好。结论：利用近处组织瓣修复电击伤,有利于创伤组织的恢复。     

Late recurrence or radiation induced cancer of the larynx

Twenty five patients with squamous carcinoma of the glottis (T_1a, and T_1b) had undergone successful irradiation. Many years later they developed a so-called late recurrence. The following evidence shows that these ‘late recurrences’ are radiation induced: –the interval of 5–18 years (mean 9.9 years) between the first and the second cancer correlates with the interval seen usually in radiation induced malignancy –recurrences generally appear during the first 2 years after irradiation –all the second cancers were found in the previously irradiated area –in patients treated by surgery only, late recurrences are extremely rare –histological examination clearly shows that the second carcinoma originates from the squamous epithelium and not from dormant nests in the deeper layers of the vocal cord. These factors should be taken into consideration when deciding between surgical or radiation therapy in younger patients with high life expectation.     

Neonatal nodular fasciitis of the larynx

We want to describe a case of neonatal laryngeal nodular fasciitis. A 5-day-old female presented with stridor. Fiberoptic transnasal laryngoscopy identified a smooth ball-valving mass obstructing the glottis. Direct microlaryngoscopy demonstrated a lesion originating from the right laryngeal ventricle. Endoscopic therapeutic and diagnostic subtotal biopsies relieved the airway obstruction. Pathologic analysis established nodular fasciitis as the diagnosis. Follow-up endoscopy showed complete resolution of this reactive lesion, and normal laryngeal function. Nodular fasciitis, rarely described in children's head and neck region, has never been reported in the larynx of a neonate. This patient's successful outcome suggests that conservative resection may be both diagnostic and curative.     

Anatomic relation between the external branch of the superior laryngeal nerve and the thyroid gland

AimThis prospective study investigated the anatomic relations between the external branch of the superior laryngeal nerve (EBSLN), the superior thyroid artery (STA) and the thyroid gland in human cadavers.Material and MethodsTwenty-two human cadavers aged over 18 years old, less than 24 hours after death.ResultsThe mean distance between the EBSLN and the superior pole of the thyroid gland was 7.68 ±3.07 mm. A tangent to the inferior edge of the thyroid cartilage between the EBSLN and the STA measured 4.24 ±2.67 mm. A line from the intersection of the EBSLN - related to the STA - to the superior pole of the thyroid gland measured 9.53 ±4.65 mm. A line from the EBSLN to the midline of the most caudal point of the thyroid cartilage measured 19.70 ±2.82 mm. A line from the RENLS to the midline on the most cranial point of the cricoid cartilage was 18.35 ±3.66 mm.ConclusionThere is a variable proximity relation between the EBSLN and the superior pole of the thyroid gland; this distance ranges from 3.25 to 15.75 mm. There was no evidence of significant variation between the measures in the ethnic groups comprising the sample.     

Supraglottic laryngeal cancer: analysis of treatment results

OBJECTIVE: This study reports the results of treatment for supraglottic laryngeal cancer with nine different treatment modalities with long-term follow-up. STUDY DESIGN: Retrospective study of 653 patients with supraglottic laryngeal squamous cell cancer treated from April 1955 to January 1999. METHODS: The study population included previously untreated patients with cancer of the supraglottic larynx treated with curative intent by one of nine treatment modalities and who were eligible for 5-year follow-up. The treatment modalities included subtotal supraglottic laryngectomy (SSL), SSL with neck dissection (SSL/ND), total laryngectomy (TL), TL/ND, radiation therapy (RT), SSL/RT, SSL/ND/RT, TL/RT, and TL/ND/RT. Multiple diagnostic, treatment, and follow-up parameters were studied using standard statistical analysis to determine significance. RESULTS: None of the nine treatment modalities produced a survival advantage, either overall or within the stages. Overall disease specific survival (DSS) by treatment modality included SSL 88.9%, SSL/ND 75.8%, TL 83.3%, TL/ND 66.7%, RT 47.2%, SSL/RT 68.9%, SSL/ND/RT 68.1%, TL/RT 59.3%, and TL/ND/RT 46.7%. Improved DSS and cumulative disease specific survival rates were associated with patients under the age of 65 years (P = .0001), early stage disease, N0 disease (P = .0001), clear resection margins (P = .0094), and no recurrence (P = .0001). Posttreatment function showed that 90% of patients were functional in everyday life, 90.7% were eating satisfactorily, 91.4% were breathing naturally, and 83% of SSL patients, 85.7% of RT patients, and 52.8% of TL patients had "good" voices. Laryngeal preservation was accomplished in 86.1% of SSL patients and 72.7% of RT patients (P = .0190). CONCLUSIONS: No treatment modality produced a survival advantage. Because SSL produced the best rate of laryngeal preservation, we recommend its use in treating the primary in eligible patients. The importance of clear resection margins is stressed. Patients with N+ disease should have the neck treated. Patients with N0 disease may be observed safely with no loss of survival advantage. Because of the pattern of recurrence and the high rates of distant metastasis and second primary cancers, follow-up for a period of not less than 8 years is recommended.