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Objective: Drug-induced sleep endoscopy (DISE) is an established diagnostic procedure to assess the upper airway in patients with obstructive sleep apnea. During DISE airway opening is regularly simulated by various maneuvers. One of them is mandibular advancement by the modified jaw-thrust maneuver (MJTM)., Material and Methods: All DISE examinations evaluated by VOTE classification in the last 15 months were included. The effect of MJTM on anatomical levels was analyzed retrospectively. Frequency and type of collapse at the anatomic levels were recorded. Apnea-hypopnea index (AHI), body mass index (BMI), Epworth Sleepiness Scale (ESS) were determined., Results: 61 patients were included (f=13, m=48, 54.3±12.9 y, ESS 11±5.5, AHI 30.2±19/h, BMI 29.7±4.5 kg/m2). A correlation of r=0.30 was found between AHI and BMI (p=0.02). At velum level, concentric collapse was detected in 16.4%, anterior-posterior (a.p.) collapse in 70.5%, and lateral collapse in 11.5%. A resolution of the collapse using the MJTM was observed in 75.5% of patients. However, in the presence of concentric collapse, opening was evident in 33.3% of cases in contrast to 86.5% in patients with a.p. collapse. Base of tongue collapse was resolved in 98.0% of the cases., Conclusion: A correlation between the success of the MJTM on airway opening at the velum level and the pattern of palatal collapse was found. In therapies aimed at mandibular advancement, e.g. hypoglossal nerve stimulation, an effect on velopalatal airway opening has relevance, so optimization of preoperative diagnosis is of particular importance., Competing Interests: • Toni Hänsel has no conflict of interest to declare. • Heidi Olze received financial support from ImThera Inc. and Apnex Medical Inc. within the framework of research projects related to hypoglossal nerve stimulation therapy. • Philipp Arens received financial support from ImThera Inc. and Apnex Medical Inc. within the framework of research projects related to hypoglossal nerve stimulation therapy. He received a speaker’s fee for an invited talk about hypoglossal nerve stimulation therapy on behalf of Inspire Medical Inc and a surgical procotring honorarium from Inspire Medical Inc., (Thieme. All rights reserved.)

Negative pressure pulmonary edema and alveolar hemorrhage are potentially life-threatening complications after relief of upper airway obstruction. The laryngeal-pharyngeal obstruction results in high negative intrapleural pressures. The increased intrapleural pressures affect the integrity of the alveolo-capillary membrane due to various factors. This review describes clinical symptoms, etiologic factors, pathophysiology and treatment strategies associated with each of these factors. The aim of this review is to equip clinicians with the knowledge base necessary to identify patients at increased risk for negative pressure pulmonary edema and alveolar hemorrhage., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Objective: The aim of the study was to investigate the awareness for the breed-related brachycephalic obstructive airway syndrome (BOAS) and the occurrence of other breed-typical diseases within the framework of an online survey for pug owners., Material and Methods: A digital questionnaire for owners was created, distributed via social media and subsequently evaluated., Results: The questionnaire was completed by 1220 pug owners. According to the owners, 32 % (344/1073) of the animals that did not undergo airway dilatation surgery show slight and 3 % (34/1073) show distinct breathing sounds when at rest. 86 % (326/378) of the owners perceive these breathing sounds as "normal, breed-specific" and 14 % (51/378) consider them as sign of "disease". 20 % (210/1073) of the animals are considered "somewhat" and 5 % (57/1073) "frequently tired and quickly short of breath" after a small amount of time. 24 % (245/1220) of all animals suffer from ocular diseases, 10 % (122/1220) from skin diseases and 11 % (134/1220) from spinal diseases, among others., Conclusion: The survey shows that with 67 % (814/1220) more than half of the pug owners perceive clinical signs of BOAS and/or other breed-specific diseases in their animals, however, a large proportion consider these as being non-problematic., Clinical Relevance: The present study reveals that the animals' clinical limitations associated with brachycephaly are oftentimes not perceived as being pathologic and are hence underestimated by the owners., Competing Interests: Die Autoren bestätigen, dass kein Interessenskonflikt besteht., (Thieme. All rights reserved.)

Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht.

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

In addition to cardiac and pulmonary diseases there is a broad variety of different underlying causes of dyspnea. The spectrum includes the different forms of anemia, all causes of upper airway obstructions, neuromuscular diseases and psychopathological disorders. This article gives a brief review of the entire spectrum by providing information about differential diagnostics as well as the main therapeutic principles. A field of growing interest is dyspnea in the context of palliative care.

Objective: Studies on the surgical treatment of OSAS in adults have shown an improved outcome after targeted therapy by drug-induced sleep endoscopy (DISE). So far, only a few studies have focused on this method in children. The aim of this study is to evaluate the impact of DISE for children with obstructive sleep-disordered breathing and to determine the influence of DISE on treatment recommendations., Subjects and Methods: The medical records of children (n=25) who underwent polysomnography and DISE between 05/2012 and 12/2013 were retrospectively reviewed. The subjects were divided into an UARS (upper airway resistance syndrome)/mild OSAS group (AHI<5; n=10) and a moderate/severe OSAS group (AHI≥5; n=15)., Results: The oropharynx was the most common site of obstruction. Prevalence of complete obstruction at the oropharynx was significantly higher in moderate or severe OSAS (p=0.02). The obstruction pattern of the velopharynx was significantly associated with the size of the adenoids (p=0.02), but tonsil and adenoid size were not related to the severity of OSAS. 71% of children with grade IV tonsils showed complete obstruction of the oropharynx. After DISE, the initial management plan changed in 5 patients (20%)., Conclusion: DISE is a promising technique to identify sites of obstruction in children with OSAS and to guide treatment decisions. Further studies are needed to predict persistent OSAS based on this tool., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Traumatic rupture of the thyroid gland is rare. A common approach does not exist. Surgical and nonsurgical management have been advocated., Method: This work summarizes the publications in PubMed including an own case. This study will analyse the accident mechanism, the underlying thyroid pathologies, possible pathogenetic mechanisms of airway obstruction and the therapeutic options. A present classification is revised in order to develop it into a treatment proposal., Results: A total of 34 case reports were analysed. The first half had to be performed a surgery on, the other half was observed without surgical treatment. None of the patients died of his injury. 59% of the patients, that had to be performed a surgery on had thyroid pathology before rupture. 50% of all patients had a road accident as a cause for the rupture., Conclusion: The revised classification and treatment proposal developed here presents a clinically-viable approach.

Pathologies in the larynx and trachea in the pediatric age can be characterized in 4 main groups: airway stenosis, acute infections, benign neoplasia and foreign body aspiration. In this review main diagnostic strategies and therapeutic options are presented. Laryngomalazia is the most frequent condition of supraglottic stenosis. The term supraglottoplasty summarizes all different techniques used for it's repair using an endoscopic approach. Glottic stenosis is rare in children. Usually a compromise between voice preservation and airway restoration has to be sought. Type of reconstruction and timing are varying considerably in individual cases, endoscopic approaches should be preferred. Subglottic stenosis remains the largest group in paediatric airway pathology, with cicatrial stenosis being predominant. Today, cricotracheal resection is the most successful treatment option, followed by the classical laryngotracheal reconstruction with autologous cartilage. In early infancy subglottic stenosis is particularly demanding. Endoscopic treatment is possible in selected patients, but open reconstruction is superior in more severe cases. Tracheostomy is not a safe airway in early infancy, it's indication should be strict. Foreign body aspiration needs to be managed according to a clear algorhythm. Recurrent respiratory papillomatosis should be treated with emphasis on function preservation. The role of adjuvant medication remains unclear. Infectious diseases can be managed conservatively by a pediatrician in the majority of cases., (© Georg Thieme Verlag KG Stuttgart · New York.)

Unlabelled: HISTORY AND PRESENTATION AT ADMISSION: An 82-year-old male patient presented with a 3 week history of exercise-induced dyspnea, productive cough and left sided chest pain., Investigations: Computertomography of the chest revealed an occluding endobronchial tumor in the left main bronchus with enlarged mediastinal lymph nodes, mediastinal shift and post-stenotic peribronchitis., Treatment and Course: The tumor was removed completely with an optical forceps in rigid bronchoscopy. Histologically an endobronchial sialadenoma papilliferum was diagnosed., Conclusions: Benign tumors of the lower airways are rare. They cannot be distinguished reliably from malignant tumors by their endoscopic and radiologic appearance. Sialadenoma papilliferum is an extremely rare benign salivary gland tumor which is characterized by coexisting glandular and (pseudo) papillar formations. It occurs mainly in the oral cavity. The relapse rate is 10-15%. In single cases a malignant transformation may appear., (© Georg Thieme Verlag KG Stuttgart · New York.)

Anaphylaxis, the maximal manifestation of an immediate allergic reaction, is a life-threatening systemic reaction. The immediate therapy is chosen according to the clinical manifestations and new German guidelines are in preparation. Required measures include immediate removal of allergen, adequate positioning, assessment of severity and organ involvement and activation of emergency medical services. In anaphylaxis with primarily cardiovascular involvement, epinephrine is the treatment of choice and given together with volume substitution, oxygen, H(1)-antihistamines and corticosteroids. Obstruction of the airways is treated with intramuscular and inhaled epinephrine, or alternatively β(2)-sympathicomimetics, and oxygen. Abdominal or cutaneous involvement, such as generalized urticaria, usually can be treated with intravenous H(1)-antihistamines, glucocorticoids and surveillance. In patients with anaphylaxis, the elicitor of the reaction has to be diagnosed by allergy testing. Patients with sustained risk for anaphylaxis should receive a self-medication kit and should be educated about behavioral patterns needed for prophylaxis and therapy of anaphylactic reactions. Patient educational intervention increases knowledge about anaphylaxis, and practical competence and thus, is a basis of a successful management of anaphylaxis.

Objective: The objective of this retrospective study based on the metric evaluation of lateral cephalograms was to investigate the extent to which treatment with two different fixed appliances for the correction of Angle Class II influenced the morphology of the extrathoracic airway space (the posterior airway space, PAS)., Patients and Methods: A total of 43 patients with Angle Class II malocclusion were classified into two groups according to the appliance used for treatment: the functional mandibular advancer (FMA; n = 18) or the Herbst appliance (n = 25). Lateral cephalograms were taken of each patient at the start of functional jaw orthopedic treatment (time point T1) and at its completion (time point T2). Specific distances and angles were measured and analyzed in a cephalometric analysis., Results: We observed major differences among the 43 patients in the depth of the posterior airway space during treatment with fixed appliances for Angle Class II correction. Regression analysis revealed that changes in sagittal and vertical positions had different effects on the depth of specific PAS sections: increases in anterior facial height are associated proportionately with increases in PAS width, particularly in the upper region. On the other hand, increases in posterior facial height and in the mandible's forward displacement correlated inversely to the decreases in depth, particularly in the central and lower PAS regions. The two treatment appliances (FMA, Herbst appliance) had the same effects on extrathoracic airway depth., Conclusions: Analyses of lateral cephalograms indicate that Angle Class II treatment with fixed appliances does not prevent sleep apnea in patients at risk. Nevertheless, this study does not permit absolutely reliable conclusions about the dimensions of the pharyngeal airway space. As the lateral cephalogram provides good images of structures in the midsagittal plane but is incapable of imaging the transverse dimension, there is an automatic lack of information concerning the precise width and volume of the extrathoracic airway space.

Bilateral vocal fold paralysis with paramedian position of the vocal chords can result from iatrogenic or traumatic nerve injuries, neurologic disorders and extralaryngeal malignancies and usually causes significant shortness of breath while the voice is only slightly affected. Only about 10% of the affected patients tolerate the narrowed airway caused by bilateral vocal fold paralysis in adduction, so most patients are candidates for a surgical intervention. Today, a range of intraluminal surgical procedures for enlargement of the glottis in bilateral vocal fold paralysis have been described which intend to avoid or supersede tracheostomy and which have replaced time-consuming external approaches to the glottis. This report provides an overview of the most important intraluminal surgical procedures for bilateral vocal fold paralysis in adduction and comments in detail on indications, surgical techniques, advantages and potential complications of the presented procedures for temporary or definitive enlargement of the glottis.

Primary tumors of the trachea account for less than 0.1% of all tumors. They are malignant in more than 90% of cases with squamous cell carcinoma and adenoidcystic carcinoma accounting for 2/3 of all tracheal tumors. Since they are often misdiagnosed as asthma or chronic lung disease, diagnosis can be delayed for years. Once the diagnosis has been established, surgical resection being the only curative treatment should be considered first. Modern techniques for tracheal surgery such as laryngotracheal, tracheal or carinal resection and different tracheal mobilisation maneuvers such as laryngeal and hilar release allow for resection of more than 50% of the trachea and anastomosis without excessive tension. Results in patients with complete tumor resection are good with 5-year and 10-year survival between 39% and 79% and between 18% and 51%, respectively. However, careful patient evaluation, preservation of tracheal blood supply and accepting the limits of resectability are mandatory to avoid major complications that accompany tracheal resections in more than 20% of cases depending on the type of resection.

The Pierre Robin sequence (PRS) characterized by mandibular micro- or retrognathia and glossoptosis with or without cleft palate, presents clinically with intermittent upper airway obstruction (UAO). It is associated with other malformations in about half the cases. The incidence is about 1:8,500. Isolated PRS without other malformations does not, by itself, appear to affect neurodevelopment. Active intervention may therefore be required to reduce the risk for neurocognitive impairment resulting from UAO. Current treatment options for UAO range from prone positioning, use of a nasopharyngeal tube, glossopexy via tongue lip adhesion, mandibular distraction to tracheostomy. An effective, non-invasive treatment protocol which includes implementation of an intraoral orthodontic appliance with velar extension (the pre-epiglottic baton plate; PEBP) is presented in this article., (© Georg Thieme Verlag KG Stuttgart · New York.)

Whole-body plethysmography is considered the "gold standard" for intrathoracic gas volume measurements and the measurement of specific airway resistance. These parameters are essential to assess a restrictive impairment, overinflation of the lungs and airflow obstruction.

Horses are obligate nasal breathers and depend on patency of their nasal passages. Several dynamic obstructive diseases in the pharyngeal and laryngeal area can be differentiated by high speed treadmill endoscopy and may be responsible for impaired exercise tolerance in the equine athlete. The anatomical specialty of guttural pouches predisposes the horse to species-specific diseases., (Copyright Georg Thieme Verlag KG Stuttgart . New York.)

Introduction: The antibiotic und antitumoral effect of Mitomycin C (MMC), a derivative of Streptomyces caespitosus, has been known since 1956. Besides its use as an adjunction in the treatment of breast, lung and prostate cancer, or as a second-line cytostatic drug for head and neck squamous cell carcinoma (HNSCC), since 1963, MMC has also been successfully used in the suppression of post-operative scar formation, particularly in the field of ophthalmology. This is due to its modulation of fibroblast activity, which enables decreased scarring and fibrosis. In this résumé, we wish to recapitulate our long years of experience in the topical application of Mitomycin C in the treatment of scar formation and stenosis in head and neck organs., Patients and Methods: A retrospective analysis on the basis of clinical disease courses and findings (image documentation, questionnaires, pulmonary function tests) covering an examination period of 10 years, was performed on 40 patients with stenosising lesions and a mean age of 54 years. The fields of application included laryngeal, tracheal, oesophageal stenosis and stenosis of the external ear canal and the choane., Results: After combined application of MMC and surgical intervention in cases of recurrent stenosising processes in head and neck organs, especially the larynx and the trachea, a sustained improvement was achieved in the pre-operative stenosis level as well as in the pre-operative, severely limited, forced inspiratory volume in 1 second (F1V1)., Conclusion: The topical application of MMC appears to be an effective adjunction as a concept of treatment for stenosising, scar-forming lesions. This topical application, however, is not a substitute for correct diagnosis and appropriate surgical treatment. It must be regarded as a purely adjunctive manoeuvre. During the 10 years in which it was used, the clinical findings confirmed an enhancement in the containment of complex cases without the occurrence of any complications., (Georg Thieme Verlag KG Stuttgart, New York.)

Chronic obstructive pulmonary disease (COPD) and bronchial asthma are the most common causes of obstructive pulmonary diseases and acute dyspnoea. In the preclinical emergency situation a distinction between bronchial asthma and exacerbated COPD is difficult because symptoms are similar. Although the preclinical measures differ only marginally, a differential diagnosis from other causes of respiratory obstruction and acute dyspnoea, such as cardiac decompensation, anaphylaxis, aspiration of foreign bodies, tension pneumothorax and inhalation trauma is necessary because alternative treatment options are required. In the treatment of COPD and bronchial asthma inhalative bronchodilatory beta(2)-mimetics are the first choice especially for serious obstructive emergencies because there is an unfavorable relationship between effect and side-effects for the intravenous route. Dosable aerosols, nebulization and if necessary, continuous nebulization, are appropriate application forms even for serious obstructive crises with the need of a respirator. In these cases a minimal inspiratory flow in patients is not required. Theophylline only plays a minor role to beta(2)-mimetics and anticholinergics as a bronchodilator in asthma and COPD guidelines, even in serious obstructive diseases. For severe asthma attacks the administration of magnesium is a possible additional option. Systemic intravenous administration of steroids has an anti-inflammatory effect and for this reason is the second column of treatment for both diseases. Invasive ventilation remains a last resort to ensure respiratory function and indications for this are given in patients with clinical signs of impending exhaustion of breathing.

Wheezing is a clinical feature in patients with chronic obstructive airway diseases. Long-term monitoring of wheezing could provide a new dimension of diagnostic information as compared to lung function if wheezing really does represent airway obstruction. Patients with wheezing who were part of our Marburg Respiratory Sound Database (MARS) were studied. 20 patients with asthma and 17 patients with chronic obstructive pulmonary disease (COPD) were analysed with respect to pathological changes of lung function parameters. The patients were matched with persons without wheezing in regard to age, diagnosis and sex. Additionally, 58 healthy persons with normal lung function tests were analysed for the occurrence of spontaneous wheezing during normal breathing. In patients with wheezing, at least one parameter of lung function was pathological. For asthmatic patients significant differences for MEF (50) (p = 0.011), R (tot) (p = 0.002) and Tiffeneau (p = 0.001) were found. In patients with COPD significant differences for FEV (1) (p = 0.002) and MEF (50) (p = 0.030) were found. In none of the healthy persons with normal lung function did we find wheezing. Wheezing as a clinical sign of bronchial obstruction is useable for long-term monitoring. The method provides additional information that can help to monitor nocturnal asthma.

Bronchial asthma is the most common chronic disease in childhood with a cumulative prevalence of 7-15% in Switzerland. The diagnosis is based on clinical findings due to a lack of objective criteria especially in infants and toddlers. The common base of all asthmatics is an inflammation of the intrathoracic respiratory mucosa. In school-age children allergic mechanisms are documented in up to 80%. Asthma therapy consists of symptom relief by bronchodilators and of antiinflammatory topical steroids. Rhinitis in early childhood is mainly caused by viral infections whereas in school-age children allergic inflammation becomes the main cause. During inflammatory processes of the nose the mucosa of the sinus is affected too causing rhinosinusitis. In infants therapy is normally restricted to symptom relief. The treatment of choice in allergic rhinitis are topical steroids. Antibiotics are rarely indicated. Infants with obstructed nose are prone to severe complications because of exclusive nasal breathing in this age period. The upper and lower airways are functionally linked by different mechanisms (united air ways). Patients with rhinitis often suffer from variable bronchial airflow obstruction and (sub)clinical asthma causing the so-called rhinobronchial syndrome.

We report the case of a 71-year-old man, who was transferred to our clinic with rapidly increasing dyspnea. On examination by flexible bronchoscopy the trachea was found to be almost completely obstructed by metastatic masses of a malignant melanoma. After endoscopic removal of the obstruction, we inserted a covered nitinol stent which led to instantaneous relief of symptoms. Chemotherapy and local radiotherapy were instituted. During the next 9 months there were no signs of recurrence of the tumour in regular pneumological control exams.

Background: Hereditary angioedema (HAE) is extremely rare and clinically characterized by recurrent and self-limiting skin, intestinal and life threatening laryngeal edema. Because of the danger of asphyxiation, it is vital that acute attacks of laryngeal edema be interrupted immediately. The aim of this study is to provide information on the incidence, diagnosis and treatment of laryngeal edema with upper airway obstruction in general and due to HAE., Methods: 102 patients with swelling of the larynx and difficulty in breathing (stridor) and 21 patients with a manifest HAE were surveyed at the Department of Otorhinolaryngology, Head and Neck Surgery of the Ludwig-Maximilians-University of Munich from 2001 to 2004., Results: 63% of the laryngeal swellings with airway obstruction were due to radiotherapy in cancer and the intake of ACE-Inhibitors. Just 22% were due to allergic reactions. Only one patient (< 1%) suffered from HAE. All patients were treated with intravenous steroids and anti-histamines successfully, except the HAE patient. After emergency coniotomy the patient was treated with purified C1 inhibitor concentrate (C1-INH)., Conclusions: According to our experience almost all patients with laryngeal swelling and upper airway obstruction react well to the standard therapy with steroids and anti-histamines. In contrast these drugs have no effect on HAE. Replacement therapy with C1-INH has proved to be effective. The challenge is to realize whether an airway obstruction is due to HAE or not. In this case, careful observation, the right medication and an appropriate airway management are lifesaving. The possibility of sudden airway obstruction and asphyxiation must be discussed with these patients and their relatives.

Parathyroid cysts are a very rare disease entity. Hormone activity is uncommon and they usually present without any clinical symptoms. The differential diagnosis of cystic neck masses should nevertheless include parathyroid cysts as surgical therapy can be very effective. We report the case of a 57-year-old patient presenting to our department with a hormone inactive parathyroid cyst. Final diagnosis was achieved eventually after histological examination of the resected specimen, which is the reason for evaluating the current data for preoperative management of this disease entity in this case report.

Airway inflammation plays a major role in the pathology of both asthma and COPD and is the target of corticosteroid treatment. In daily routine practise, however, airway inflammation is still not often considered by pneumologists to support the diagnostic process or to aid in disease management, despite studies showing that patients could benefit. Eosinophilic airway inflammation is of special interest, as it is not restricted to allergen-induced airway diseases, and because it generally responds well to anti-inflammatory treatment with corticosteroids. Therefore, the early detection of this kind of underlying inflammatory process can have a positive impact on finding a diagnosis as well as for disease management. The non-invasive detection of eosinophilic airway inflammation using induced sputum is too time consuming and therefore too expensive in outpatient settings. As sputum eosinophils correlate with the concentration of exhaled nitric oxide (FeNO), its measurement could serve as a more economic alternative, especially as new small handheld analysers are available now, that allow the rapid FeNO analysis, even in children. This review will cover some basics and technical aspects of FeNO measurements, which should be known to correctly interprete results in clinical practise. In the second part, the clinical value and the limits of FeNO measurements, as well as the potential interpretation of results are discussed based on recently published literature.

Anamnestic factors of importance are, in particular, acute attacks of shortness of breath, dry cough and symptoms of concomitant rhinoconjunctivitis. Wheezing and other rhonchi are the typical findings on auscultation. Of decisive importance for the diagnosis is spirometry showing reduced values for the one-second/forced vital capacity and the Tiffeneau index. After administration of a beta sympathomimetic, an obstruction can be at least partially reversed. An absent primary obstruction should be inducible by unspecific provocation. On the basis of symptoms and lung function, bronchial asthma is divided into four stages. For establishing the allergic genesis of the illness, additional anamnestic data, in particular concerning the nature of possible allergens, are needed before sensitization is proven by the prick test and the detection of specific IgE antibodies. An equivocal situation can be clarified with the aid of specific nasal--more rarely also bronchial--provocation.

Background: Neurilemmoma are benign tumors of the nerve-sheath, also known as schwannoma. Beside intracranial manifestation, neurilemmoma are found at other peripheral nerves of the head and neck., Case Report: We present three cases of patients with seldom manifestation of neurilemmoma of the supraglottis, the retropharyngeal space and a neurilemmoma of the hypoglossal nerve. The histological examination showed two types of Antoni-A-neurilemmoma, whereas one tumor was found with mixed type A and B-neurilemmoma., Conclusion: Although extracranial neurilemmoma of retropharygeal space, neck or supraglottic larynx are rare tumors, neurilemmoma should be involved in differential diagnosis of tumors in these areas. The therapy of choice consists of complete surgical removal and histological examination.