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A 56-year-old man with Marfan's syndrome was scheduled for a valve-sparing aortic root replacement operation because of annuloaortic ectasia and aortic regurgitation. He had severe dyspnea. When the operation started, SpO2 decreased at the time of the median sternotomy, and increased by manual inflation. After sternal closure, PIP increased from 20 cmH2O to 28 cmH2O, SpO2 decreased from 98% to 66%, and the expiratory pattern indicated airway obstruction. Because hypoxemia persisted, we reopened the sternum, resulting in increased SpO2 and decreased PIP, but hypercapnea remained. Fiberoptic bronchoscopy revealed a narrowing of the tracheal and bronchial lumen. We suspected tracheobronchomalacia, and the tracheal tube was advanced to just above the carina. We succeeded in extubating 7 days after the operation. Since he had severe persisting dyspnea, we suggested reopening the partial sternum to decompress the intrathoracic pressure, and closing the skin. The sternum was reopened, and he had no dyspnea after the second operation. The mechanism of tracheobronchomalacia is considered to be related to the connective tissue defect of Marfan's syndrome. Suddenly SpO2 is decreased and PIP and Et(CO2) are increased after closure of the sternum. Bronchoscopy was useful in making the diagnosis.

A 65-year-old woman was scheduled for total knee replacement. She had been suffering from rheumatoid arthritis for 22 years. She also had a history of occasional acute dyspnea, which had been diagnosed as asthmatic bronchitis. Preoperative examinations of the airway revealed limited neck flexion, a small jaw, and normal mouth opening. After epidural catheterization, anesthesia was induced with propofol, and a #3 laryngeal mask airway (LMA) was inserted. However, her lungs could not be ventilated through the LMA. Despite repeated attempts, proper placement of the LMA could not be achieved. Hence, a 7.0 mm ID armored endotracheal tube was inserted through an intubating LMA. Anesthesia was maintained with nitrous oxide and sevoflurane in oxygen. The surgery proceeded uneventfully. Five minutes after extubation, inspiratory dyspnea occurred. The patient's trachea was re-intubated nasally with a bronchofiberscope. Since the bronchofiberscopy revealed remarkable laryngeal edema, percutaneous tracheostomy was performed. On the 3 rd postoperative day, cricoarytenoid arthritis that had caused occasional airway obstruction was diagnosed, although her laryngeal edema disappeared. She went home with a permanent tracheostomy. Although cricoarytenoid arthritis is a common occurrence in patients with rheumatoid arthritis, the diagnosis can be difficult. A scrupulous preoperative evaluation and awareness of cricoarytenoid arthritis are necessary for optimal anesthetic management.

The immunohistochemical localization of bone Gla protein (BGP) and osteonectin (ON) was investigated in normal human bone and cartilage tissues, and in osteosarcomas and chondrosarcomas with their respective antibodies. In normal bone and heterotopic ossification tissues, BGP and ON were detected in preosteoblasts, osteoblasts and young osteocytes, the reaction of which was strongest in osteoblasts. They were also demonstrated in most osteosarcomas, and their reaction was stronger in osteosarcomas with higher differentiation. These observations suggested that BGP and ON were related to the formation of normal and tumoral osteoid. In contrast, the localization of ON in normal cartilage and chondrosarcoma tissues was markedly different from that of BGP in these tissues. In normal growth cartilage, ON reacted with chondrocytes in hypertrophic and calcifying zone and matrix in calcifying zone, whereas BGP did not react. ON was also demonstrated in the cytoplasm and calcifying portion of most chondrosarcomas. These findings indicated that ON plays an important role in calcification of normal and tumoral cartilage tissues. BGP was detected in poorly differentiated and dedifferentiated chondrosarcomas. Thus, these antibodies are expected to be useful for studying calcification of human bone and cartilage and for the diagnosis of human osteosarcomas and chondrosarcomas.