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Background: Central airway stenosis (CAS) is a severe airway complication after lung transplantation associated with bronchial ischemia and necrosis. We sought to determine whether hyperbaric oxygen therapy (HBOT), an established treatment for tissue ischemia, attenuates post-transplant bronchial injury., Methods: We performed a randomized, controlled trial comparing usual care with HBOT (2 atm absolute for 2 hours × 20 sessions) in subjects with extensive airway necrosis 4 weeks after transplantation. Endobronchial biopsies were collected at 4, 7, and 10 weeks after transplantation for a quantitative polymerase chain reaction. Coprimary outcomes were incidence of airway stenting and acute cellular rejection (ACR) at 1 year., Results: The trial was stopped after enrolling 20 subjects (n = 10 per group) after a pre-planned interim analysis showed no difference between usual care and HBOT groups in stenting (both 40%), ACR (70% and 40%, respectively), or CAS (40% and 60%, respectively). Time to first stent placement (median [interquartile range]) was significantly shorter in the HBOT group (150 [73-150] vs 186 [167-206] days, p < 0.05). HIF gene expression was significantly increased in donor tissues at 4, 7, and 10 weeks after transplantation but was not altered by HBOT. Subjects who developed CAS or required stenting had significantly higher HMOX1 and VEGFA expression at 4 weeks (both p < 0.05). Subjects who developed ACR had significant FLT1, TIE2, and KDR expression at 4 weeks (all p < 0.05)., Conclusions: Incidence of CAS is high after severe, established airway necrosis after transplantation. HBOT does not reduce CAS severity or stenting. Elevated HMOX1 and VEGFA expressions appear to associate with airway complications., (Published by Elsevier Inc.)

Background: Obliterative bronchiolitis (OB) is the major complication limiting the long-term survival of allografts after lung transplantation. In this study, we investigated the effect of tacrolimus (FK506) combined with GM6001，a matrix metalloproteinase (MMP) inhibitor， on the formation of OB using a mouse heterotopic tracheal transplantation model., Methods: Syngeneic tracheal grafts were transplanted heterotopically from BALB/c mice to BALB/c mice. Allografts from C57BL/6 mice were transplanted to BALB/c mice. Isograft group, allograft group, allograft+FK506 group, allograft +GM6001 group and allograft+FK506 + GM6001 group was given respectively intraperitoneal injection of saline, saline, FK506, GM6001 and FK506 + GM6001 once a day. At 28 day after transplantation, OB incidence was determined by hematoxylin-eosin staining and the expressions of MMPs and cytokines were assessed using enzyme linked immunosorbent assay, immunohistochemical assays and western blot assay., Results: The tracheal occlusion rates of isograft group, allograft group, allograft+FK506 group, allograft+GM6001 group and allograft+FK506 + GM6001 group were 0, 74.1 ± 9.79%, 34.4 ± 6.04%, 40.3 ± 8.77% and 26.5 ± 5.73% respectively. There were significant differences between the latter two groups (P < .001). The serum MMP-8 and MMP-9 levels of allograft group were significantly higher than those of isograft group (P < .05) and had no significant decrease when treated by FK506. The serum MMP-8 and MMP-9 levels of allograft+FK506 + GM6001 group were significantly lower than those of allograft+FK506 group (P < .05). MMP-8 and MMP-9 protein expression in the grafts of allograft+FK506 + GM6001 group were lower than those of allograft+FK506 group verified by immunohistochemical staining and western blotting., Conclusion: FK506 combined with GM6001 could alleviate tracheal obliteration in mouse heterotopic tracheal transplantation model, due to its inhibitory effect on MMPs., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: A right-sided double-lumen tube (R-DLT) tends to obstruct the right upper lobe intraoperatively due to anatomical distortion during surgery. If the R-DLT is poorly matched with the patient's airway anatomy, it will not be possible to correctly replace the tube with a fiberoptic bronchoscope (FOB). In our study, we aimed to explore an efficient method for difficult repositioning caused by right upper lobe occlusion during surgery: repositioning the R-DLT from the right main bronchus into the left main bronchus. The current study was designed to assess the efficacy and safety of this method., Methods: Sixty adult patients scheduled to undergo left-sided thoracic surgery were randomly assigned to two groups. With the patient in the right lateral position during surgery, the R-DLT was pulled back to the trachea while being rotated 90° clockwise; it was then either rotated 90° clockwise for placement into the left main bronchus (Group L) or rotated 90° anticlockwise and returned to the right main bronchus (Group R) using FOB guidance. The primary outcomes included clinical performance, which was measured by intubation time, and the quality of lung collapse. A secondary outcome was safety, which was determined according to bronchial injury and vocal cord injury., Results: The median intubation time (IQR [range]) required for placement of a R-DLT into the left main bronchus was shorter than the time required for placement into the right main bronchus (15.0 s [IQR, 12.0 to 20.0 s]) vs 23.5 s [IQR, 14.5 to 65.8 s], P = 0.005). The groups showed comparable overall results for the quality of lung collapse during the total period of one-lung ventilation (P = 1.000). The numbers of patients with bronchial injuries or vocal cord injuries were also comparable between groups (Group R, 11/30 vs. Group L 8/30, P = 0.580 for bronchus injuries; Group R, 15/30 vs. Group L 13/30, P = 0.796 for vocal cord injuries)., Conclusions: Repositioning a R-DLT from the right main bronchus into the left main bronchus had good clinical performance without causing additional injury. This may be an efficient method for the difficult repositioning of a R-DLT due to right upper lobe occlusion during surgery., Trial Registration: Chinese Clinical Trial Registry, ChiCTR-IPR-15006933 , registered on 15 August 2015.

Purpose of Review: Postoperative respiratory complications (PRCs) increase hospitalization time, 30-day mortality and costs by up to $35 000. These outcomes measures have gained prominence as bundled payments have become more common., Recent Findings: Results of recent quantitative effectiveness studies and clinical trials provide a framework that helps develop center-specific treatment guidelines, tailored to minimize the risk of PRCs. The implementation of those protocols should be guided by a local, respected, and visible facilitator who leads proper implementation while inviting center-specific input from surgeons, anesthesiologists, and other perioperative stakeholders., Summary: Preoperatively, patients should be risk-stratified for PRCs to individualize intraoperative choices and postoperative pathways. Laparoscopic compared with open surgery improves respiratory outcomes. High-risk patients should be treated by experienced providers based on locally developed bundle-interventions to optimize intraoperative treatment and ICU bed utilization. Intraoperatively, lung-protective ventilation (procedure-specific positive end-expiratory pressure utilization, and low driving pressure) and moderately restrictive fluid therapy should be used. To achieve surgical relaxation, high-dose neuromuscular blocking agents (and reversal agents) as well as high-dose opioids should be avoided; inhaled anesthetics improve surgical conditions while protecting the lungs. Patients should be extubated in reverse Trendelenburg position. Postoperatively, continuous positive airway pressure helps prevent airway collapse and protocolized, early mobilization improves cognitive and respiratory function.

Purpose: Congenital tracheal stenosis (CTS) and a single right lung treated with slide tracheoplasty (ST) has relatively high rates of mortality and morbidity. We report a single institution's experience with adjunctive procedures at the time of ST to reduce postoperative tracheal obstruction in patients with a single right lung and CTS., Methods: With IRB approval, 8 patients with a single right lung and CTS who underwent ST in our institution between 2008 and 2016 were reviewed., Results: Seven of 8 patients (88%) survived, with a median follow-up period of 35 (3-89) months. The only mortality was because of complications unrelated to the airway. Six of 8 patients underwent ST anterior to the aortic arch (tracheal translocation, TT). This was combined with tracheopexy concomitantly in 3 patients and subsequently in one patient. Two patients had insufficient tracheal length for TT. Both underwent aortopexy. Of three patients undergoing TT with tracheopexy concomitantly, two have been successfully extubated, and a third has required tracheostomy for subglottic stenosis. All patients undergoing TT without tracheopexy have experienced severe tracheobronchomalacia., Conclusion: We conclude that adjunctive TT with tracheopexy might be associated with lower rates of tracheobronchial obstruction in patients with a single right lung undergoing ST for CTS., Level of Evidence: Level IV., (Copyright © 2017. Published by Elsevier Inc.)

Introduction and Objective: The most common postoperative complications of velopharyngeal insufficiency surgery are postoperative bleeding and airway obstruction or obstructive sleep apnoea. Consequently, the aim of this study was to evaluate the effect of low level laser therapy (LLLT) during the first postoperative days in children undergoing superiorly based pharyngeal flap (SBF) surgery., Materials and Methods: A randomized double blind clinical study on 30 children divided on two groups 15 patients each, who underwent SBF. LLLT was used in a group and the other was a control group. The study was conducted in academic tertiary care medical centres between 2013 and 2015. The degree of edema, oxygen saturation, occurrence of obstructive sleep apnoea (OSA) and steroid administration were recorded., Results: The mean of the average oxygen saturation was significantly less in the control group in the 1st and 2nd day as compared to the laser group. The need for oxygen and the incidence of OSA in the first 3 days were significantly higher in the control group as compared to the laser group. The degree of edema showed no significant difference in the first day but was significantly higher in the control group in the 2nd and 3rd days. Hence, the need of steroids was significantly higher in the control group in the first 3 days., Conclusions: Preliminary results showed that low level laser therapy is effective in reducing the incidence of early postoperative airway obstruction after SBF operations., (Copyright © 2016 Elsevier España, S.L.U. and Sociedad Española de Otorrinolaringología y Cirugía de Cabeza y Cuello. All rights reserved.)

Background: Prior studies report a high incidence of airway complications in patients with Robin sequence following palatoplasty. The authors' institution uses polysomnography to assess risk of airway compromise before palatoplasty in Robin sequence. This study compares airway complications in Robin sequence to cleft palate only using this screening airway protocol and identifies risk factors for airway complications after palatoplasty., Methods: A 12-year retrospective review of patients with Robin sequence undergoing palatoplasty was performed. Robin sequence patients were divided into nonoperative management and mandibular distraction osteogenesis subgroups. Preoperative variables including comorbidities were recorded. The primary outcome was postoperative airway complication, defined as reintubation, emergency room visit, or hospital admission within 3 months of palatoplasty., Results: One hundred thirteen patients met inclusion criteria: polysomnography, 34.5 percent; Robin sequence, 65.5 percent; and Robin sequence treated with mandibular distraction osteogenesis, 30.1 percent. Screening polysomnography was used to indicate patients for palatoplasty or other airway interventions. The total airway complication rate was 7.1 percent; this was similar in Robin sequence (5.8 percent) and cleft palate only (7.7 percent). In isolated Robin sequence, the reintubation rate was 0 percent. Lower airway anomalies were associated with airway complications (p = 0.03). Significant variables for reintubation were cardiac (p = 0.046), gastrointestinal (p = 0.04), and lower airway anomalies (p = 0.025) and syndromic diagnosis (p = 0.05)., Conclusion: Screening polysomnography can control airway complications following palatoplasty in Robin sequence patients to a rate that is comparable to that of patients with cleft palate only.

Purpose: Interventional bronchoscopy is the main treatment modality in managing benign airway obstructions following lung transplantation. We analyzed the effect of intraluminal brachytherapy on preventing recurrence of hyperplastic tissue., Patients and Methods: From September 2002 to September 2004, a total of 24 intraluminal brachytherapy applications were carried out on 12 lung transplant patients in 15 different locations. A single dose of 3 Gy was calculated at a 5-mm distance from the catheter surface; the target volume included a stenosis plus safety interval of 0.5-1.0 cm., Results: All patients had a mean 10.6 local interventions (Argon plasma coagulation, balloon dilatations, stenting) over 4.4 months before the first application of endobronchial brachytherapy, with a mean amount of 2.4 applications per month. The mean forced expiratory volume in 1 s (FEV1) was 2,219 ml in the 3 months before application of brachytherapy. After endobronchial brachytherapy, all patients experienced improvement in clinical status and respiratory function. The mean level of FEV1 in the 3 months after application was 2,435 ml (p = 0.02), and the number of invasive interventions dropped to a mean rate of 5.2 interventions in the 5.1 months after the first intervention, with an amount of 1 application per month. No treatment-related complications were seen. Four patients were treated twice, 1 patient three times, and 1 patient four times at the same localization., Conclusions: Recurrent symptomatic benign airway obstruction from hyperplastic tissue in the bronchus after lung transplantation can be successfully treated with intraluminal high-dose-rate brachytherapy with a dose of 3 Gy at a 5-mm distance from the catheter surface and a longitudinal safety margin of 1 cm.

Upper airway obstruction (UAO) is a well known complication of cleft palate repair. The aim of this study was to evaluate the efficacy of local tongue base steroid injection in preventing or reducing the lingual oedema that can cause UAO following palatoplasty. Thirty children with unilateral complete cleft palate were included. They were randomly divided into two equal groups. Children in group I received intravenous dexamethasone whilst children in group II received both intravenous dexamethasone and local betamethasone injected at the tongue base. Both groups underwent the same technique of palatoplasty, postoperative breathing was assessed and UAO was rated as mild, moderate or severe. Postoperative UAO developed in six cases (40%) in group I and in two cases (13%) in group II. In group I, it was mild in three cases, moderate in one case, and severe in two cases. In group II, it was mild in one case and moderate in another case. Despite the differences in the number and severity of the condition in both groups, comparison was statistically insignificant. Local steroid injection of the tongue base during cleft palate surgery reduced the incidence and severity of post-palatoplasty UAO., (Copyright © 2012 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Bronchial anastomotic complications develop in 31% of lung transplant recipients, leading to additional operative procedures and increased morbidity. Advances in surgical technique have thus far resulted in only modestly improved outcomes. We hypothesized that creating the bronchial anastomosis at the secondary carina using a combination of running and figure-of-eight sutures would minimize donor bronchial ischemia and airway complications., Methods: This retrospective review of a single surgeon's operative experience from 2000 to 2007 compares a new bronchial anastomotic technique with the conventional technique. The primary outcome was the occurrence of bronchial anastomotic complications requiring invasive intervention. The secondary outcome was distal airway complications. Patients were monitored for 1 year after transplant. Recipient and donor demographic data as well as relevant variables from their preoperative, perioperative, and postoperative courses were collected for analysis. These data were compared using t tests for normally distributed continuous variables, Mann-Whitney tests for nonnormally distributed continuous variables, and χ2 tests or Fisher exact test for categoric variables. Logistic regression was used to control for covariates while comparing the primary outcome between the new and conventional bronchial anastomotic techniques., Results: The analysis included 230 patients, representing 407 anastomoses. The occurrence of anastomotic complications requiring intervention and distal airway complications decreased from 18.1% to 2.3% of anastomoses and 12.2% to 4.4% of patients, respectively. After controlling for available risk factors, the new technique significantly reduced both anastomotic (p<0.001) and distal (p=0.03) airway complications., Conclusions: This new anastomotic technique dramatically reduces anastomotic and distal airway complications after lung transplantation., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

The lateral decubitus and beach-chair positions each offer unique benefits to the shoulder surgeon with respect to visualization, efficiency, and ease during arthroscopic shoulder procedures. The purpose of this article was to comprehensively review the reports and studies documenting independent and dependent complications related to patient positioning and anesthesia during arthroscopic shoulder surgery. The lateral decubitus position has been associated with the potential for peripheral neurapraxia, brachial plexopathy, direct nerve injury, and airway compromise. The beach-chair position has been associated with cervical neurapraxia, pneumothorax, and the potential for end-organ hypoperfusion injuries (when deliberate hypotension is used). Potentially concerning are hypotensive bradycardic events, which may be relatively common in association with the use of epinephrine-containing interscalene anesthetics in beach chair-positioned patients. Irrigant complications (fluid spread, ventricular tachycardia) are avoidable risks not unique to either specific position. Although minor transient anesthetic- and position-related complications (neurapraxia, hypotension) may occur in as many 10% to 30% of patients, major complications such as end-organ damage or permanent impairments are exceedingly rare. Regardless of position, complications are almost uniformly avoidable if surgeon and anesthetist exercise care and prudent attention to position and anesthetic choices. The purpose of this article is to review the potential for position- and anesthesia-related complications and acquaint the shoulder surgeon with the proposed pathophysiologic mechanisms that can lead to them., (Copyright © 2011 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Objective: Postoperative airway obstruction is a complication of cleft palate repair. A technique to control the airway is to place a suture through the tongue at the conclusion of the palate repair, but it is not uniformly adopted by surgeons. Although it has been frequently performed, the use and effectiveness of the tongue suture have not been studied. Our purpose was to determine the usefulness of tongue suture placement., Design: We surveyed health care providers as to their frequency of use and the value of the tongue suture in postoperative airway management of the cleft palate patient. The survey was sent via e-mail to 2080 members of the American Cleft Palate-Craniofacial Association, with a total of 396 responders., Results: Surgeons were nearly equally split on placing a tongue suture, with 41.1% responders reporting that they use a tongue suture all of the time and 41.1% of responders reporting that they never used a tongue suture. Some criterion used for placement was the complexity of the case, syndromic patients, and overseas cleft missions., Conclusions: Many cleft palate repairs are done annually without using tongue sutures, but it does not seem to affect the outcomes among surgeons, thus confounding the question of effectiveness. At this time, tongue suture placement after cleft palate repair is variable and subjective. Further studies need to be performed to assess outcomes after placing a tongue suture.

The objective of the study was to analyze the incidence, treatment, and prevention of early and late respiratory complications in a series of patients who had supracricoid partial laryngectomies with either cricohyoidoepiglottopexy or cricohyoidopexy. From medical charts, we retrospectively reviewed 101 patients who underwent supracricoid partial laryngectomies, from 1980 to 2006, for laryngeal squamous cell carcinoma, and recorded the various postoperative complications and the time of decannulation. The mortality rate was 3.96%. Early complications included broncho-pulmonary infections and laryngeal stenoses which occurred in 9.9%. Univariate analysis showed a statistically significant relationship between the pulmonary complications and neck dissections (p < 0.04). Later, they were due to laryngeal obstruction (neolaryngeal mucosal flap, residual false vocal cord fold or arytenoid edema). The median decannulation time was 8 days, and there was a significant relationship between the decannulation delay and the pulmonary complications. Only two patients had a later definitive tracheotomy. Respiratory complications after supracricoid partial laryngectomy are frequent, but can be easily managed in most cases. A preoperative pulmonary assessment is necessary to select patients. During surgery, a precise impaction of the hyoid bone with the cricoid cartilage and a repositioning of an arytenoid can avoid some postoperative stenoses.

Background: There is controversy about the etiology of early postoperative hypoxemia. Age, weight, intubation, surgical procedure, use of muscle relaxants, and/or administration of opioids may affect the incidence of early postoperative hypoxemia. In this prospective, randomized, and single-blinded study, we evaluated whether the administration of caudal analgesia vs i.v. fentanyl affected the number of children who develop postextubation adverse upper airway respiratory events, (upper airway obstruction, laryngospasm) and/or early postoperative hypoxemia., Methods/materials: Institutional approval and written parental informed consents were obtained. Thirty-eight healthy outpatient boys, aged 1-6 years, scheduled for elective orchidopexy were randomized to receive pain relief either with a presurgical caudal block or by i.v. fentanyl. The primary outcome of the study was the number of children who developed postextubation adverse upper airway respiratory events and/or early postoperative hypoxemia., Results: The number of boys who developed postextubation adverse upper airway respiratory events and/or early postoperative hypoxemia in the caudal group was less compared with those in the fentanyl group (P = 0.04)., Conclusions: Compared to fentanyl, placement of a presurgical caudal block in boys scheduled for orchidopexy was associated with a lower incidence of postextubation adverse upper airway respiratory events and/or early postoperative hypoxemia.

Obstructive sleep apnea (OSA) is associated with postoperative airway obstruction, hypoxemia, cardiac arrhythmias, cardiorespiratory arrest, hypoxic encephalopathy, and death. Three cases highlighting important issues in patients with OSA are presented that occurred prior to and after implementation of an OSA protocol.

Study Design: Prospective, randomized, double-blind study., Objective: To evaluate intravenous corticosteroids in preventing delayed extubation after multilevel corpectomy and strut graft reconstructive procedures and to identify risk factors for delayed extubation in these patients., Summary of Background Data: We performed a prospective, randomized double-blind study in patients undergoing multilevel cervical corpectomy procedures. Our hypothesis was that high-dose perioperative steroids would decrease edema and thus decrease the incidence of delayed extubation., Methods: We studied patients undergoing 2- or 3-level anterior cervical corpectomy procedures with anterior strut graft reconstruction. Sixty-six patients were randomized to receive 3 doses of either intravenous dexamethasone (n = 35) or saline (n = 31). The first dose was given before the incision, with subsequent doses given 8 and 16 hours later. Patients remained intubated until postoperative day 1, at which time a cuff leak test was performed by the anesthesiology attending. If a leak was present, the patient was extubated. If not, the test was repeated each postoperative day until a leak was present, indicating a patent airway., Results: Five of 35 (14%) in the steroid group and 6 of 31 (19%) in the saline group required delayed extubation (P = 0.22). There were no statistical differences in preoperative parameters of age, gender, diagnosis, smoking history, BMI, number of operative levels, or preoperative American Society of Anesthesiologists rating between the 2 groups. Similarly there were no differences between the groups for duration of anesthesia, intraoperative colloids or crystalloids, intraoperative blood loss, or intraoperative urine output. The data for both groups were pooled to evaluate risk factors for delayed extubation. The only statistically significant risk factor for delayed extubation in this study was female gender (P = 0.0001)., Conclusion: Based on our data, we cannot recommend intravenous dexamethasone for prevention of delayed extubation after multilevel anterior cervical corpectomy and strut grafting procedures.

Study Design: A retrospective clinical study., Objective: To confirm the impact of the O-C2 angle on dyspnea and dysphagia after posterior occipitocervical (O-C) fusion., Summary of Background Data: Dyspnea and dysphagia are complications of posterior O-C fusion with malalignment, and may be prolonged or occasionally serious. However, it is difficult to select a safe alignment during surgery, and no indicators of the appropriate alignment have been available to preclude these complications., Methods: The authors retrospectively reviewed 29 consecutive patients who had undergone O-C or occipitocervicothoracic fusion between 2003 and 2008. Data were analyzed for O-C2 angles on plain radiographs and the axial computed tomographic cross-sectional areas of the oropharynx just cranial to the epiglottis before and after surgery. The patients were grouped according to whether they developed postoperative dyspnea and/or dysphagia (group A) or not (group B)., Results: After surgery, 4 patients complained of dysphagia, and 1 patient had dyspnea and dysphagia, although they had all undergone short O-C fusions. The difference in the O-C2 angle (dOC2A = postoperative O-C2 angle--preoperative O-C2 angle) and the percentage change in the cross-sectional area of the oropharynx (S) before and after surgery (% dS) were linearly correlated. Both dOC2A and % dS were significantly lower in group A than in group B. All patients with dOC2A of less than -10 degrees showed % dS of less than -40%, and developed dyspnea and/or dysphagia after surgery. Conversely, no patients with positive dOC2A developed these complications., Conclusion: The O-C2 angle has considerable impact on dyspnea and/or dysphagia after O-C fusion. The O-C2 angle is easily measured during surgery and can be a practical index with which to avoid postoperative dyspnea and dysphagia.

Purpose of the Study: This study was undertaken to highlight the method, usefulness and postoperative morbidity of using a laryngeal mask airway (LMA) to ventilate patients with difficult airways undergoing laryngeal procedures., Procedures: Retrospective chart review where we identified patients deemed to have a difficult airway who underwent laryngeal and upper tracheal procedures, and were electively ventilated using an LMA. The pertinent clinical history, indications for the procedure and postoperative course were discussed., Results: Airway procedures were performed on 6 patients. Airway visualization was excellent, and there were no intraoperative or postoperative complications in any patient., Conclusions: Insertion of an LMA and maintenance of airway and ventilation were performed with ease in all patients. The airway lesions were easy to visualize, there was minimal vocal cord trauma, and it served as a wide conduit for therapeutic bronchoscopes and laryngoscopes. Therefore, we recommend preoperative identification of difficult airways and consideration of elective LMA use with a flexible endoscope during laryngeal and upper tracheal procedures., (Copyright 2010 S. Karger AG, Basel.)

Objective: To assess the capacity of high and low doses of the antimitotic drug mitomycin to prevent laryngeal stenosis in an animal model., Methods: A prospective, randomized, double-blind, controlled study was carried out. End-to-end anastomosis was performed in 18 rabbits after tracheal annulus resection to produce inflammation. There were 3 treatment groups: topical saline (isotonic sodium chloride solution) and low-dose (0.2 mg/mL) and high-dose (0.5 mg/mL) topical mitomycin., Results: A total of 107 procedures were performed: 54 surgical procedures, 35 fibrobronchoscopies, and 18 biopsies. The effect of mitomycin was dose related. In the high-dose mitomycin group, most rabbits progressed to stenosis with a percentage decrease in airway diameter that was significantly greater than in the other 2 groups (P <.001). The mean (SD) percentage of maximum stenosis in the high-dose group was 51% (22%). In the low-dose and saline groups, it was 18% (13%) and 16% (9%), respectively. No significant differences in tracheal stenosis between the low-dose mitomycin and saline groups were observed. Blinded histopathological analysis also showed no significant differences between the saline group and the low-dose mitomycin group. Compared with the other 2 groups, the high-dose mitomycin group had a significant increase in fibroproliferative tissue (P <.001)., Conclusion: These results suggest that topical mitomycin is not effective for avoiding tracheal stenosis and may provoke the opposite effect if the dose is not carefully selected.

Patients scheduled for elective surgery requiring general anaesthesia and hospital admission were assessed for risk of obstructive sleep apnoea (OSA) using history, body mass index and upper airway examination to determine any relation between OSA risk and the rate of respiratory events after surgery. Anaesthesia and postoperative analgesia were at the discretion of the treating anaesthetist, who was made aware of any suspicion of OSA. Respiratory monitoring for apnoeas (central or obstructive), hypopnoeas and oxygen desaturations was continuous for a 12-hour period on the first postoperative night. We used automated analysis and visual scanning of respiratory recordings, but sleep stages were not assessed. Patients classified as OSA risk had more respiratory obstructive events per hour than controls (38+/-22 vs. 14+/-10) and an increased proportion of the 12-hour monitored period with oxygen saturation <90% (7+/-12% vs. 2+/-5% of the 12-hour period). Perioperative morphine dose was predictive of central apnoeas for both OSA risk and control patients (P=0.002). This study suggests that preoperative suspicion of OSA should lead to increased postoperative monitoring and efforts to minimise sedation and opioid dose. It also supports the routine use of supplemental oxygen with patient-controlled opioid analgesia.

This study aimed to investigate the pharmacokinetics after tacrolimus aerosol inhalation and to assess its efficacy to suppress acute and chronic airway allograft rejection. Orthotopic tracheal transplantations were performed and tacrolimus (4 mg/kg) was administered orally (PO) or via aerosol (AER). Tracheal tissue level AUCs(0-12) were similar in both treatment groups, but blood AUCs(0-12) were approximately 5.5-fold lower with AER (p < 0.001). Interestingly, only PO animals showed elevated BUN, cholesterol and triglycerides on POD 60 (p < 0.05). Histology of grafts harvested after 6 and 60 days revealed that both treatment groups were similarly effective in suppressing graft mononuclear infiltration (p < 0.001). Cellular immune activation (assessed by IFN-gamma- and IL-4-ELISPOTS), however, was far more effectively suppressed by tacrolimus PO (p < 0.001). In both treatment groups, the vigorous alloreactive IgM-antibody surge was effectively inhibited (p < 0.001). Due to the insufficient systemic cellular immunosuppression, discontinuation of tacrolimus AER resulted in a far stronger (3.5-fold) graft infiltration on POD 8 compared to PO (p < 0.001). Tacrolimus aerosol reduces systemic side effects and effectively protects the airway graft from early cellular rejection and chronic obliterative airway disease.

Objectives: The Isshiki arytenoid adduction procedure directly closes the open posterior glottis. Postoperative airway obstruction that necessitates emergent tracheotomy is an important complication in arytenoid adduction patients when the standard posterior thyroplasty window is used to approach the posterolateral larynx. Immediate postoperative fiberoptic laryngoscopy shows ipsilateral edema and/or hematoma of the arytenoid and supraglottic mucosa, with occasional obstructing inspiratory collapse. In this study, I sought to modify the posterior window approach during arytenoid adduction surgery, and thereby decrease the incidence of immediate postoperative airway obstruction., Methods: I performed a retrospective chart review of 246 arytenoid adduction patients, looking for immediate postoperative airway compromise., Results: There were no episodes of postoperative airway obstruction that necessitated tracheotomy in the first 30 patients in whom I approached the posterolateral larynx using the classic Isshiki techniques. Nine of the succeeding 132 adduction patients required emergent tracheotomy when the standard posterior window technique was used instead of a classic Isshiki approach (6.8%). In the most recent 84 patients, I used one tacking suture to stabilize the elevated pyriform sinus mucosa to the upper margin of the posterior window cartilage at closure. Four of the 84 patients had audible postoperative airway turbulence that abated with medical treatment, and 1 patient required an emergent tracheotomy (1.2%; p = .0495)., Conclusions: Suture stabilization of the pyriform sinus mucosa is effective and is recommended for prevention of posterior glottic airway obstruction after arytenoid adduction when the posterior window technique is used.

Dentures are routinely removed from the oral cavity before general anesthetic procedures. They are only reinserted much later when the patient returns to the room. This clinical report describes an edentulous patient who developed acute tongue swelling from venous congestion as a result of tongue recovery from general anesthesia. Her complete dentures were used to separate the residual ridges during the recovery period and relieved the congestion. Denture insertion increased the height and volume of the oral cavity, which reduced pressure on the tongue, preventing a cycle of tongue compression, congestion, and swelling. This unusual complication suggests that it may be prudent for the edentulous patient to be accompanied by their dentures in the perioperative period., (Copyright 2001 by The American College of Prosthodontists.)

Patients who have undergone silicone vocal cord medialization and require additional surgery are at risk for airway complications. There is a narrowed glottic aperture that may be prone to develop postoperative laryngeal edema and prosthesis extrusion. This study was designed to assess the management of this difficult airway and to determine the frequency of postintubation complications. We identified 82 patients who had undergone vocal cord medialization with silicone implants between 1991 and 1995. Seventeen of these patients underwent additional surgical procedures requiring general anesthesia. A retrospective review of these patients' charts was performed to determine the management of the airway and the incidence of postintubation complications. There were no postintubation complications in the 17 patients who were studied. The duration of surgery ranged from 40 minutes to 4 hours 15 minutes. Two patients were ventilated via bronchoscope, and 15 patients were intubated orally. The endotracheal tubes ranged from size 6 to size 9 (median size 8). None of the patients required perioperative steroids. All patients were successfully extubated in the recovery room. No patients required intubation or tracheotomy, and there were no implant extrusions. In this study, the incidence of postintubation airway complications in patients who had undergone previous thyroplasty was minimal. Nevertheless, the potential for airway compromise exists. We recommend preoperative discussion with the anesthesiologist, atraumatic intubation with a small endotracheal tube, and diligent observation for airway compromise.

This outcome study was a continuation of a previously published review. It examined whether there had been a decrease in the number of acute perioperative complications surrounding superior pharyngeal flap operations since a patient's death in 1990. A total of 386 patients were divided into two groups: the early group (July of 1985 to December of 1990) n = 164, and the later group (January of 1991 to June of 1996) n = 222, which were statistically comparable. The patient complication rate decreased from 19.5 to 6.3 percent (chi square, p = 0.0001). Airway obstruction decreased from 11 to 3.2 percent (chi square, p = 0.0012). Bleeding complications decreased from 7.3 to 1.4 percent (chi square, p = 0.0027). The majority of airway complications (72 percent) and bleeding complications (80 percent) occurred in the first 24 hours. Predictive factors for complications included the surgeon involved, patients with associated medical conditions, having an associated procedure performed concurrently, and leaving the donor site open (multiple logistic regression). Hospital stay also decreased from 5.8 +/- 2.5 to 3.8 +/- 1.6 days (Student's t test p = 0.0001). The decrease in complication rate was due to the increased awareness of all staff involved and also due to changes in surgical management, including a decrease in the number of surgeons (from seven to four surgeons), a decrease in the number of associated procedures (10.4 to 4.5 percent, chi square, p = 0.026), a decrease in the number of open donor sites (34.8 to 4.5 percent, chi square, p = 0), and an increase in the use of nasopharyngeal airways (17.1 to 45 percent, chi square, p = 0). The superior pharyngeal flap operation has become a safer procedure in this hospital.

Massive swelling of the tongue occurred following the repair of cleft palate in a one-year-old girl and a one-year-old boy. The duration of operation was 285 min and 225 min respectively. Massive swelling of the tongue became prominent within 30 min after the operation in both infants. The trachea was intubated immediately. Swelling of the tongue recovered slowly, and the trachea was extubated 6 and 7 days after the operation, respectively. The compression of the tongue by the retractor for a long time during the operation probably caused the reperfusion edema of the tongue. Early recognition of the swelling and prompt maintenance of the airway are essential to prevent the serious outcomes resulting from the swelling of the tongue.

A case of severe macroglossia, following intraoral surgery, causing respiratory distress is described. Because conventional therapy appeared inadequate, leeches were used and proved an efficient method of reducing this life-threatening swelling of the tongue.

9 cases with tracheotomy before uvulopalatopharyngoplasty (UPPP) were analysed. all of them suffered from severe obstructive sleep apnea syndrome (OSAS). The indications of tracheotomy included, (1) the nocturnal lowest oxygen saturation was lower than 50%; (2) apnea hyponea index (AHI) higher than 50; (3) significant cardiopulmonary problems; (4) severe hypoxia symptoms; (5) obesity, brachyneck and glossohypertrophia.

The visiting surgical team doing cleft lip and cleft palate repair in an underdeveloped country may find long hours and adverse conditions. Some of the trips are undertaken for resident education. It is the responsibility of the expedition leader to implement safety precautions for protection of both the patients and the volunteers in the operative party as suggested in this article. Equipment maintenance and modified sterilization techniques are also described.

Herein we report on a 27-year-old cystic fibrosis (CF) patient who developed bronchospasm, secretory plugging of the trachea, and pneumothorax following general endotracheal anesthesia for intranasal polypectomy and bilateral Caldwell-Luc procedures at an adult facility. Intranasal polypectomy and paranasal sinus procedures are the most common surgical procedures performed on cystic fibrosis patients, making the otolaryngologist a frequent member of the cystic fibrosis team [8]. As survival improves, the pediatric otolaryngologist will find himself following CF patients into their 20's and 30's. Adult care facilities may not be as familiar with these patients as the surgeon would like. The otolaryngologist's familiarity with the unique perioperative requirements of the CF patient can prove invaluable in such a setting. Preoperative assessment should identify any acute pulmonary changes, assess nutritional status, assure good control of blood glucose levels, and rule out clotting abnormalities. Good perioperative hydration and meticulous attention to pulmonary toilet are of foremost importance in the surgical care of the cystic fibrosis patient. Chest physiotherapy and suctioning of the tracheobronchial tree should precede arousal from anesthesia and extubation. By insisting on appropriate anesthetic and perioperative care, the knowledgeable otolaryngologist may circumvent potential postoperative complications in the cystic fibrosis patient.

Successful rhinoplasty achieves both aesthetic and functional goals. This article outlines the pitfalls that cause postoperative obstruction that can occur during the process of cosmetic rhinoplasty. It is my sincere hope that iatrogenic nasal obstruction can be reduced by awareness of these problems and careful attention and planning. The aspects of rhinoplasty that maintain a balance between aesthetics and functional integrity are specifically described. These techniques can be incorporated into the rhinoplastic repertoire of any surgeon and will improve the results dramatically.

Rhinoplasty is one of the most challenging surgical procedures. Surgeons should strive to obtain maximum aesthetic and functional results with minimal operative intervention. Excessive surgery often results in unwarranted impairment of nasal function. The obstructive or sensory complications of rhinoplasty can occur in the early or late postoperative periods. The most common functional sequelae of rhinoplasty, and their causes, prevention and therapy, are discussed.

Prevention of intra- and postoperative complications is one of the main tasks of the anesthesiologist. It is achieved by avoidance of specific anesthesiological dangers and mistakes and by adjustment of anesthetic techniques to the course of operation. Recognition and consideration of preexisting diseases as possible causes of complications and appropriate preoperative measures are the responsibility of the surgical-anesthesiological team. Depending on the given situation and the risk state of the patient during and after operation, special anesthetic procedures may be necessary.

Thirty-five patients requiring tracheostomy or endotracheal intubation, following thyroidectomy are reviewed. Conditions included 30 patients with multinodular goitre, three patients with Graves's disease and two patients with carcinoma of the thyroid. Early in the series, emergency tracheostomy was performed in three patients with airway obstruction following thyroidectomy. Ten patients were deemed at extremely high risk of developing airway obstruction and underwent prophylactic tracheostomy. Endotracheal intubation has been used in preference to tracheostomy in the latter part of the series. Emergency endoctracheal intubation was performed on one patient and prophylactic intubation was carried out in 20 patients. The morbidity and length of hospital stay in this latter group was considerably less than those requiring tracheostomy. It is concluded that patients with potential airway obstruction following thyroidectomy should have prophylactic endotracheal intubation, in preference to tracheostomy.

The causes of respiratory obstruction before, during, and after thyroid surgery are outlined and their clinical features described. The dangers of postoperative respiratory obstruction are emphasised and the measures necessary to prevent it if possible, to anticipate it, and treat it are discussed in detail.