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Introduction: Situational awareness is essential during emergent procedures such as endotracheal intubation. Previous studies suggest that time distortion can occur during intubation. However, only in-hospital intubations performed by physicians have been studied. We aimed to determine whether time distortion affected paramedics performing intubation by examining the perceived vs actual total laryngoscopy time, defined as time elapsed from the laryngoscope blade entering the mouth until the endotracheal tube balloon passes the vocal cords.Methods: For this retrospective study we collected prehospital intubation data from a suburban, fire department-based emergency medical services (EMS) system from January 5, 2021–May 21, 2022. The perceived total laryngoscopy time was queried as a part of the electronic health record. Video laryngoscopy recordings were reviewed by a panel of experts to determine the actual time. Patients >18 years old who underwent intubation by paramedics with video laryngoscopy were included for analysis. The primary outcome was the difference between actual and perceived total laryngoscopy time. Secondary analysis examined the relationship between high time distortion, defined as the highest quartile of the primary outcome, and patient age, paramedic years of experience, perceived presence of difficult anatomy, excess secretions, use of rapid sequence intubation, and multiple intubation attempts. We conducted descriptive analysis followed by logistic regression analysis, chi-square tests, and Fisher exact tests when appropriate.Results: A total of 122 intubations were collected for analysis, and 10 were excluded due to lack of video recording. Final analysis included 112 intubations. Mean actual laryngoscopy time was 50.0 seconds (s)(95% confidence interval [CI] 43.7–56.3). Mean perceived laryngoscopy time was 27.8 s (95% CI 24.7–31.0). The median difference between actual and perceived time was 18 s (interquartile range 6–30). We calculated high time distortion as having a difference greater than 30 s between actual and perceived laryngoscopy time. None of the secondary variables had statistically significant associations with high time distortion. Overall, we show that the paramedic’s perception of total laryngoscopy time is significantly underestimated even when accounting for paramedic experience and perceived airway difficulty.Conclusion: This study suggests that time distortion may lead to an unrecognized prolonged procedure time. Limitations include use of a convenience sample, small sample size, and potential uncollected confounding variables.

Background and Aims: Laryngoscopy and endotracheal intubation are critical aspects of general anesthesia, often provoking significant stress responses that impact circulatory parameters. This study aims to compare the hemodynamic stress responses and intubation conditions between the Macintosh and McCoy blades in patients with ASA grades I and II undergoing various surgical procedures under general anesthesia. Methods: A total of 100 patients were randomly assigned into two groups: Group A (Macintosh blade) and Group B (McCoy blade), each consisting of 50 patients. Hemodynamic parameters, including heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP), were recorded at Pre-Induction, At the Start of Laryngoscopy, Immediately After Intubation, 1 Minute After Intubation, 3 Minutes After Intubation, 5 Minutes After Intubation, 10 Minutes After Intubation. Intubation ease was evaluated by recording the duration of laryngoscopy, Cormack and Lehane Grades, Modified Mallampati scores, and the necessity for optimal external laryngeal manipulation (OELM) or stylet use. Results: The Macintosh group exhibited significantly higher HR, SBP, DBP, and MAP immediately after intubation compared to the McCoy group (p < 0.001). The McCoy blade was associated with better attenuation of the hemodynamic response and facilitated improved laryngeal view under Cormack and Lehane grading, particularly beneficial in patients with higher Mallampati grades. Conclusion: The McCoy blade offers superior hemodynamic stability and enhanced visualization during intubation compared to the Macintosh blade, making it potentially more advantageous for patients with challenging airways, although further research in Mallampati grades III and IV is warranted. [ABSTRACT FROM AUTHOR]

INTRODUCTION During the administration of general anesthesia, the procedures of direct laryngoscopy and endotracheal intubation result in a significant rise in heart rate, arterial pressure, and dysrhythmias in around 90% of patients. These modifications can provide a significant risk to patients with brain or coronary diseases. The aim of present study is to assess the attenuation of hemodynamic changes during laryngoscopy and endotracheal intubation with oral gabapentin versus oral clonidine. MATERIAL AND METHODS The present double blind randomized controlled trial was conducted among patient undergoing elective surgeries under general anesthesia at Govt. Mohan Kumaramangalam Medical College, during the study period of one year. 90 patients were distributed to three groups using sealed envelope technique. Group A of patients received single dose oral 150 µg clonidine, Group B of patients received single dose oral 200 µg clonidine and Group C patients received single dose oral 800 mg gabapentin . Hemodynamic parameters were noted at different time interval and results were analyzed. RESULTS The mean age of subjects was between the age group of 40-50 years and male were higher in number as compared to female. The heart rate was higher in the clonidine 200 group as compared to other two but results were non-significant with (P>0.05). No Significant difference in mean SBP, DBP and MAP was observed at all time intervals. (p>0.05). CONCLUSION Oral clonidine and gabapentin reduce direct laryngoscopy haemodynamics. Gabapentin has fewer adverse effects than clonidine. Compared to -200mcg, 150mcg has no adverse effects. [ABSTRACT FROM AUTHOR]

Background: The process of laryngoscopy and tracheal intubation is potent stressful stimuli that cause sympathetic activation, which is transient. Some of the modalities for attenuation of laryngoscopic and intubation response have been found to be less effective in smokers than in non-smokers. In view of this, the present study was performed to compare the effectiveness of dexmedetomidine in male smoker and non-smoker patients. Aims and Objectives: The aim of this study was to compare the effectiveness of dexmedetomidine in suppressing sympathoadrenal pressor response due to laryngoscopy and endotracheal intubation between smokers and non-smokers. Materials and Methods: This was a hospital-based non-randomized controlled study. Sixty patients were divided into two groups: 30 patients with no history of smoking (Group NS) and 30 patients with a smoking history (Group S). Both groups were received dexmedetomidine 0.75 mcg/kg over 10 min intravenous infusion. Hemodynamic parameters and Ramsay sedation score were measured at perioperative period. Results: Group S patients showed a significant rise in heart rate (HR), systolic blood pressure (SBP), diastolic BP (DBP), mean arterial pressure (MAP), and rate pressure product (RRP) during the immediate post-intubation period, but Group NS showed a decrease in HR, SBP, DBP, MAP and RRP throughout the post-intubation period. Conclusion: Single dose of 0.75 mcg/kg IV dexmedetomidine given over a period of 10 min before the induction of anesthesia is completely effective in attenuating the hemodynamic responses associated with laryngoscopy and intubation in non-smokers, but it is not efficient in smokers. [ABSTRACT FROM AUTHOR]

Background: Securing and maintaining a patent airway for the conduct of general anesthesia are a major concern for an anesthesiologist. Unanticipated difficult intubation in anesthetized patients is the main cause of morbidity or mortality. Several predictors are proposed to anticipate difficult tracheal intubation, but no predictor is found to be 100% accurate. Acromio-axillo-suprasternal notch index (AASI) is a recent addition to the list of predictors. Aims and Objectives: The current study compared the usefulness of AASI and thyromental height test (TMHT) as predictors of difficult visualization of larynx (DVL). Materials and Methods: Following approval by the Institutional Ethics Committee and CTRI registration, written informed consent was taken. The study was conducted on 300 patients aged 18-65 years belonging to American Society of Anesthesiologists' physical status I and II, with modified Mallampati (MMP) Scores of 1 and 2, over a period of 6 months. Preoperatively all patient's airway was evaluated using AASI and TMHT. The DVL during direct laryngoscopy was noted as assessed by Cormack and Lehane grading. We compared the sensitivity and specificity for DVL with regard to AASI and TMHT. Results: The incidence of unanticipated DVL was 14%. The sensitivity, specificity, positive predictive value, and negative predictive value of AASI were 86.4%, 38.1%, 89.6%, and 31.4%, respectively, and for TMHT, they were 94.6%, 4.8%, 85.9%, and 12.5%, respectively. Pearson correlation coefficient was r = -0.068 (P=0.243) when AASI was compared with TMHT. Conclusion: AASI was found to be less sensitive when compared to TMHT and there was statistically no significant correlation between the two parameters to predict the DVL. [ABSTRACT FROM AUTHOR]

Summary: Background: It is not certain whether the blade geometry of videolaryngoscopes, either a hyperangulated or Macintosh shape, affects glottic view, success rate and/or tracheal intubation time in patients with expected difficult airways. We hypothesised that using a hyperangulated videolaryngoscope blade would visualise a higher percentage of glottic opening compared with a Macintosh videolaryngoscope blade in patients with expected difficult airways. Methods: We conducted an open‐label, patient‐blinded, randomised controlled trial in adult patients scheduled to undergo elective ear, nose and throat or oral and maxillofacial surgery, who were anticipated to have a difficult airway. All airway operators were consultant anaesthetists. Patients were allocated randomly to tracheal intubation with either hyperangulated (C‐MAC D‐BLADE™) or Macintosh videolaryngoscope blades (C‐MAC™). The primary outcome was the percentage of glottic opening. First attempt success was designated a key secondary outcome. Results: We assessed 2540 adults scheduled for elective head and neck surgery for eligibility and included 182 patients with expected difficult airways undergoing orotracheal intubation. The percentage of glottic opening visualised, expressed as median (IQR [range]), was 89 (69–99 [0–100])% with hyperangulated videolaryngoscope blades and 54 (9–90 [0–100])% with Macintosh videolaryngoscope blades (p < 0.001). First‐line hyperangulated videolaryngoscopy failed in one patient and Macintosh videolaryngoscopy in 12 patients (13%, p = 0.002). First attempt success rate was 97% with hyperangulated videolaryngoscope blades and 67% with Macintosh videolaryngoscope blades (p < 0.001). Conclusions: Glottic view and first attempt success rate were superior with hyperangulated videolaryngoscope blades compared with Macintosh videolaryngoscope blades when used by experienced anaesthetists in patients with difficult airways. [ABSTRACT FROM AUTHOR]

Background: The European Society of Anesthesiology and Intensive Care recommends the use of neuromuscular blocking agents (NMBA) in adults, to facilitate tracheal intubation and reduce its associated complications. Children who undergo tracheal intubation may suffer some of the same complications, however, no consensus exists regarding the use of NMBA for tracheal intubation in the pediatric population. We will explore the existing evidence assessing the effects of avoidance versus the use of NMBA for the facilitation of tracheal intubation in children and infants. Methods: This protocol follows the preferred reporting items for systematic reviews and meta‐analyses protocols recommendations. We will include all randomized controlled clinical trials assessing the effects of avoidance versus the use of NMBA for facilitation of tracheal intubation (oral or nasal) using direct laryngoscopy or video laryngoscopy in pediatric participants (<18 years). Our primary outcome is incidence of difficult tracheal intubation. Secondary outcomes include incidence of serious adverse events, failed intubation, events of upper airway discomfort or injury, and difficult laryngoscopy. We will conduct a thorough database search to identify relevant trials, including CENTRAL, MEDLINE, EMBASE, BIOSIS, Web of Science, CINAHL, and trial registries. Two review authors will independently handle the screening of literature and data extraction. Each trial will be evaluated for major sources of bias with the "classic risk of bias tool" used in the Cochrane Collaboration tool from 2011. We will use Review manager (RevMan) or R with the meta package to perform the meta‐analysis. We will perform a trial sequential analysis on the meta‐analysis of our primary outcome, providing an estimate of statistical reliability. Two review authors will independently assess the quality of the body of evidence using the grading of recommendations assessment, development, and evaluation (GRADE) approach. We will use GRADEpro software to conduct the GRADE assessments and to create "Summary of the findings" tables. [ABSTRACT FROM AUTHOR]

Laryngopharyngeal reflux disease (LPRD) is a common condition affecting patients reporting to an otolaryngologist. However, the diagnosis of this condition is usually hinged on the combination of largely non-specific symptoms, and clinical findings on laryngoscopy. This study aimed at evaluating the utility of digital image analysis to quantitatively evaluate the severity of signs as recorded with laryngoscopy in patients of LPRD. The study group included individuals who were aged between 18 and 65 years and reported to the ENT OPD. These were then divided into two groups depending on symptoms and laryngoscopic findings. The LPRD group had symptomatic patients with an Reflux finding score (RFS) score >7. Those with an RFS of <6 were designated as the 'Normal group'. The Laryngoscopic images were recorded and analyzed using Image J software as per the set protocol. The Red Green Blue (RGB) values of the laryngoscopic images of each group were obtained and subjected to statistical analysis. 200 participants were enrolled in the study with 100 participants in the LPRD group (mean age = 46.2, 40 males, 60 females) and 100 in the control group (mean age = 43.6, 55 males, 45 females). The measured RGB values were more in the LPRD group as compared to the control group and the results were statistically significant (P < 0.001). By providing an objective value to the degree of inflammation, RGB value measurement provides a quick, economical, adaptable tool for auxiliary and corroborative information for the diagnosis of LPRD. [ABSTRACT FROM AUTHOR]

Endotracheal intubation is a common lifesaving procedure that often is performed outside the operating room in a variety of clinical scenarios. Providers who perform intubation outside the operating room have variable degrees of training, skill development, and experience. A large number of studies were published in 2023 on the topic of intubations outside the operating room across a wide variety of settings and patient populations. Here, we review relevant papers on this topic published in 2023. [ABSTRACT FROM AUTHOR]

Introduction: Narrow‐band imaging (NBI) can improve detection of lesions in the aerodigestive tract. However, its role in benign lesions of the larynx is unclear. This study aims to determine whether NBI improves the detection of scars, sulci, and nodules compared to panchromatic lighting using objective image analysis. Methods: In total, 120 vocal folds (VFs) were analyzed with and without NBI (21 normal, 15 scars, 16 sulci, and 45 nodules). Each VF image had anterior, middle, and posterior thirds analyzed for brightness using an area morphometry software (Optimas 5.1a). The middle‐third with the lesion was analyzed against surrounding VF segments for average and standard deviation (SD) in absolute grayscale. Results: The use of panchromatic light resulted in greater illumination and grayscale values than NBI. All lesions tended to be in the mid‐membranous fold. Under panchromatic light, change in brightness when comparing anterior versus middle (A–M) was +6.1% for normal, versus 6.5%, 8.1%, and 7.1% for sulci, nodules, and scars, respectively. Under NBI, they were 9.0% (normal), 12.3% (sulci), 13.7% (nodules), and 13.1% (scars). A greater SD of luminescence was observed at pathology sites (p < 0.05) when using NBI. The change in absolute grayscale at all lesion sites was greater when using NBI than when using panchromatic light (p < 0.05). Conclusion: NBI significantly enhanced the area of pathology in patients with nodules, sulci, and scars. Greater SD values in grayscale at pathologic sites were observed compared at normal sites. Thus, NBI may improve the detection of phonotraumatic lesions compared to panchromatic light. Level of Evidence: N/A Laryngoscope, 134:4066–4070, 2024 [ABSTRACT FROM AUTHOR]

Objectives: Injury to the recurrent laryngeal nerve (RLNI) is a known possible morbidity after thyroid surgery. The clinical presentation varied in severity, from changes in voice quality and swallowing in unilateral cases to airway compromise in bilateral cases. In minor cases, vocal fold paralysis (VFP) may occur unnoticed. Although many intraoperative measures have been implemented to minimize nerve injury, the risk remains, either transient or permanent. This study evaluated the incidence and potential risk factors of recurrent laryngeal nerve injury after thyroidectomy. Methods: Retrospective data analysis was conducted on 1368 patients who underwent thyroidectomy at the National Guard Hospital, King Abdul-Aziz Medical City, Jeddah, Saudi Arabia, between January 2008 and December 2021. Evaluations were conducted on the pathological features, surgical procedure type, and state of the recurrent laryngeal nerve during surgery as contributing to recurrent laryngeal nerve injury. All patients underwent preoperative and postoperative indirect laryngoscopy examinations with or without videostroboscopy. Physiological testing of the RLN using neurostimulation and laryngeal palpation (NSLP) or intraoperative neuromonitoring (IONM) was performed in all cases. VFP was considered present when vocal fold mobility was absent or significantly reduced. Results: A total of 1368 patients (2177 nerves at risk) who underwent thyroidectomy and fulfilled the inclusive criteria (809 bilateral, 559 unilateral) were evaluated. A total of 62% of patients were more than 45 years old, and the mean age was 48.36 ± 13.03 with a male-to-female ratio of 1:3.6. Eight-hundred one (58.6%) patients underwent total or subtotal thyroidectomies (1602 nerves at risk). Two-hundred seventy-six patients underwent hemithyroidectomy (276 nerves at risk), and 291 patients underwent completion or redo surgeries (299 nerves at risk). Of these 1368 patients, post-surgery laryngoscopy showed reduced or absent vocal fold mobility in 47 (3.4%) patients. Forty-three out of 47 patients had unilateral vocal fold paralysis, and 4 had bilateral VFP. When we analyzed the three risk factors statistically significant for postoperative RLN palsy, age (OR, 1.01; 95% CI, 0.98–1.05; p = 0.365) became non-significant. The other risk factors (extent of surgery and histopathological diagnosis) remained statistically significant (p = 0.004 and 0.031). After adjustment, the extent of surgery, including total thyroidectomy and revision surgery, was strongly associated with a higher risk of odds of postoperative RLN palsy. Physiological RLN stimulation was performed in all cases with NSLP or INOM, and no significant association was observed in the incidence of VFP (p = 0.365). In most cases, symptoms were spontaneously resolved with recovery of vocal fold movement within a few months. Conclusion: In this study, 3.4% of the recurrent laryngeal nerve showed postoperative dysfunction either transient or permanent VFP. Intraoperative identification of the nerve remains the gold standard of care during thyroidectomy. Neuromonitoring aids in detecting the nerve, particularly in severe cases, but does not reduce the nerve injury compared to NSLP. [ABSTRACT FROM AUTHOR]

Summary Background Methods Results Conclusion The VIDIAC score, a prospectively developed universal classification for videolaryngoscopy, has shown excellent diagnostic performance in adults. However, there is no reliable classification system for videolaryngoscopic tracheal intubation in children. We aimed to develop and validate a multivariable logistic regression model and easy‐to‐use score to classify difficult videolaryngoscopic tracheal intubation in children and to compare it with the Cormack and Lehane classification. A secondary aim was to externally validate the VIDIAC score in children.We conducted a prospective observational study within a structured universal videolaryngoscopy implementation programme. We used C‐MAC™ videolaryngoscopes in all children undergoing tracheal intubation for elective surgical procedures. We validated the VIDIAC score externally and assessed its performance. We then identified eligible co‐variables for inclusion in the PeDiAC score, developed a multivariable logistic regression model and compared its performance against the Cormack and Lehane classification.We studied 809 children undergoing 904 episodes of tracheal intubation. The VIDIAC score outperformed the Cormack and Lehane classification when classifying the difficulty of videolaryngoscopic tracheal intubation, with an area under the receiver operating characteristic curve of 0.80 (95%CI 0.73–0.87) vs. 0.69 (95%CI 0.62–0.76), respectively, p = 0.018. Eight eligible tracheal intubation‐related factors, that were selected by 100‐times repeated 10‐fold cross‐validated least absolute shrinkage selector operator regression, were used to develop the PeDiAC model. The PeDiAC model and score showed excellent diagnostic performance and model calibration. The PeDiAC score achieved significantly better diagnostic performance than the Cormack and Lehane classification, with an area under the receiver operating characteristic curve of 0.97 (95%CI 0.96–0.99) vs. 0.69 (95%CI 0.62–0.76), respectively, p < 0.001.We developed and validated a specifically tailored classification for paediatric videolaryngoscopic tracheal intubation with excellent diagnostic performance and calibration that outperformed the Cormack and Lehane classification. [ABSTRACT FROM AUTHOR]

Laryngoscopy and endotracheal intubation is commonly associated with hemodynamic changes due to reflex sympathetic stimulation. The hemodynamic changes are usually transitory, variable and unpredictable and are probably of no consequence in healthy individuals, but may be hazardous to those with history of pre-eclampsia, hypertension, cardiovascular or cerebrovascular diseases. A prospective randomized clinical study was undertaken in patients belonging to ASA-I physical status scheduled for elective surgeries under general anaesthesia with endotracheal intubation. Patients in Group D (n=36) received 0.5mcg/kg dexmedetomidine in 50mL NS over 10minutes before induction. Patients in Group E (n=36) received 0.5mg/kg esmolol diluted to 10mL over 60seconds after induction. The mean HR in dexmedetomidine group (maximum increase of 88.09±10.31 at intubation) was significantly lower than esmolol group (maximum increase of 93.72±8.27 at intubation), which was statistically significant but not clinically. SBP, DBP and MAP changes between the two groups were statistically insignificant at all points. We concluded that dexmedetomidine 0.5mcg/kg and esmolol 0.5mg/kg are comparable in attenuating the hemodynamic stress response to laryngoscopy and tracheal intubation without any adverse effects. [ABSTRACT FROM AUTHOR]

Aim: QT interval is generally related to the increased risk of polymorphic ventricular tachycardias and ventricular arrythmias. Intubation and laryngoscopy might change in cardiac repolarization and an increase in QT interval length. Video laryngoscopes provide better laryngeal view, higher intubation success, and better correct positioning on double-lumen tube (DLT) intubation. We aimed to compare McGRATH MAC 5 video laryngoscope to direct Macintosh laryngoscope and their effects on Tp-e interval, QTc and Tp-e/QTc ration in those patients requiring intubation having DLT. Materials and Methods: The randomly controlled prospective work is carried out on 94 patients, scheduled for thoracic surgery, aged between 18-65. After anaesthetic induction and before tracheal intubation, all patients airway were evaluated Cormack and Lehane in using a Macintosh laryngoscope and patients having Cormack and Lehane grade-1 or -2a views included in study. The patients who are intubated with video laryngoscope (Mc-GRATH MAC) are allocated into Group V and intubated with direct Macintosh Laryngoscope was allocated into Group L. The primary aim was compared between the two devices on Tp-e interval, QTc and Tp-e/QTc ratio with ECG recordings. The secondary goal was assessment of hemodynamic status and intubation conditions. Results: In Group V, QTc interval, Tp-e intreval and Tp-e/QTc ratio was lower in a significant way than Group L. There has not been a significant difference in terms of hemodynamic assessment among those two groups at all measurement periods. Cormack-Lehane scores, intubation times, DLT types and sizes were similar between two groups. Conclusion: McGRATH MAC video laryngoscope decreased Tp-e interval, QTc and Tp-e/QTc ratio compared to direct Maintosh laryngoscope. Hemodynamic response and intubation parameters are seen as similar to each other in both of the present groups. [ABSTRACT FROM AUTHOR]

Background: Securing the airway in the emergency department (ED) is a high-stakes procedure; however, the primary success and complication rate are largely unknown in Germany. The aim of this study was a retrospective analysis of prospectively collected resuscitation room data for endotracheal intubation (ETI) regarding indications, performance and complications. Method: Between 1 January 2020 and 30 June 2023 all ETIs conducted in the ED (Kliniken Maria Hilf, Moenchengladbach, Germany) were analyzed following approval by the ethics committee (EK 23-369). Primary intubations performed by the anesthesiology department were excluded. The core medical team of the ED underwent a six-week training program including a two-week anesthesia rotation prior to performing ETI in the ED. There were standard operating procedures (SOP) for both rapid sequence induction (RSI) and airway exchange with a placed laryngeal tube (LT) utilizing video laryngoscopy (C-Mac, Storz), rocuronium for relaxation and primary intubation with an elastic bougie. The primary success rate, overall success rate and intubation-related complications were analyzed. Additionally, the factor of consultant ED staff and residents was evaluated with respect to the primary success rate. Results: During the study period 499 patients were intubated by the core ED team and 28 patients underwent airway exchange from LT to ETI. Primary success could be achieved in 489/499 (98.0%) ETI and in 25/28 (89.3%) LT exchange patients. Surgically achieved securing of the airway was carried out in 5/527 (0.9%) patients in a cannot intubate situation and 11/527 (2.2%) patients suffered cardiac arrest minutes after the ETI. The overall first pass success rate of endotracheal tube placement was 514/527 (97.4%). The comparison of the primary success of consultants (168/175; 96.0%) vs. residents 320/325 (98.5%) yielded no significant differences (p = 0.08). Conclusion: In clinical acute and emergency medicine, a standardized approach utilizing video laryngoscopy and a bougie following a structured training concept, can achieve an above-average high primary success rate with simultaneous low severe complications in the high-risk collective of critically ill emergency patients in an intrahospital setting. [ABSTRACT FROM AUTHOR]

Summary: Aspiration of gastric contents is a recognised complication during all phases of anaesthesia. The risk of this event becomes more likely with repeated attempts at tracheal intubation. There is a lack of clinical data on the effectiveness of videolaryngoscopy relative to direct laryngoscopy rapid sequence intubation in the operating theatre. We hypothesised that the use of a videolaryngoscope during rapid sequence intubation would be associated with a higher first pass tracheal intubation success rate than conventional direct laryngoscopy. In this multicentre randomised controlled trial, 1000 adult patients requiring tracheal intubation for elective, urgent or emergency surgery were allocated randomly to airway management using a McGrath™ MAC videolaryngoscope (Medtronic, Minneapolis, MN, USA) or direct laryngoscopy. Both techniques used a Macintosh blade. First‐pass tracheal intubation success was higher in patients allocated to the McGrath group (470/500, 94%) compared with those allocated to the direct laryngoscopy group (358/500, 71.6%), odds ratio (95%CI) 1.31 (1.23–1.39); p < 0.001. This advantage was observed in both trainees and consultants. Cormack and Lehane grade ≥ 3 view occurred less frequently in patients allocated to the McGrath group compared with those allocated to the direct laryngoscopy group (5/500, 1% vs. 94/500, 19%, respectively; p < 0.001). Tracheal intubation with a McGrath videolaryngoscope was associated with a lower rate of adverse events compared with direct laryngoscopy (13/500, 2.6% vs. 61/500, 12.2%, respectively; p < 0.001). These findings suggest that the McGrath videolaryngoscope is superior to a conventional direct laryngoscope for rapid sequence intubation in the operating theatre. [ABSTRACT FROM AUTHOR]

Objectives: Ixekizumab, an interleukin (IL)-17A inhibitor, exerts its therapeutic effects in psoriasis by inhibiting the interleukin (IL)-17 signaling pathway. Common adverse reactions to ixekizumab include injection site reactions and upper respiratory tract infections (URIs), while occurrences of inflammatory bowel disease (IBD) and multiple mucosal ulcers are infrequent. We present a case of a 51-year-old man who developed multiple mucosal ulcers after ixekizumab treatment. Methods: A 51-year-old man presented to our hospital with a 1-month history of pharyngalgia. The flexible laryngoscope displayed mild hyperemia in the pharyngeal mucosa and tonsils, redness and swelling of the epiglottis, as well as multiple ulcers in the oral cavity, uvula, and epiglottis. These ulcers did not improve with conventional treatment. Results: Upon evaluation, the ulcers were an immune-related adverse event induced by ixekizumab. Consequently, a decision was made to discontinue the drug and initiate a therapeutic regimen including corticosteroids and thalidomide. Eventually, the patient's symptoms abated. Conclusions: Biologics are now becoming increasingly popular in psoriasis. It is vital for clinicians to be aware of this potential adverse event and to identify and intervene early to alleviate patients' suffering. [ABSTRACT FROM AUTHOR]

Objective: Develop an artificial intelligence assisted computer vision model to screen for laryngeal cancer during flexible laryngoscopy. Methods: Using laryngeal images and flexible laryngoscopy video recordings, we developed computer vision models to classify video frames for usability and cancer screening. A separate model segments any identified lesions on the frames. We used these computer vision models to construct a video stream annotation system. This system classifies findings from flexible laryngoscopy as "potentially malignant" or "probably benign" and segments any detected lesions. Additionally, the model provides a confidence level for each classification. Results: The overall accuracy of the flexible laryngoscopy cancer screening model was 92%. For cancer screening, it achieved a sensitivity of 97.7% and a specificity of 76.9%. The segmentation model attained an average precision at a 0.50 intersection-over-union of 0.595. The confidence level for positive screening results can assist clinicians in counseling patients regarding the findings. Conclusion: Our model is highly sensitive and adequately specific for laryngeal cancer screening. Segmentation helps endoscopists identify and describe potential lesions. Further optimization is required to enable the model's deployment in clinical settings for real-time annotation during flexible laryngoscopy. [ABSTRACT FROM AUTHOR]

Background: Pediatric airway management requires careful clinical evaluation and experienced execution due to anatomical, physiological, and developmental considerations. Video laryngoscopy in pediatric airways is a developing area of research, with recent data suggesting that video laryngoscopes are better than standard Macintosh blades. Specifically, there is a paucity of literature on the advantages of the C‐MAC D‐blade compared to the McCoy direct laryngoscope. Methods: After Ethics Committee approval, 70 American Society of Anesthesiologists physical status 1 and 2 children aged 4–12 years scheduled for elective surgery under general anesthesia were recruited. Patients were randomly allocated to intubation using a C‐MAC video laryngoscope size 2 D‐blade (Group 1) and a McCoy laryngoscope size 2 blade (Group 2). The Intubation Difficulty Scale (IDS) for ease of intubation was the primary outcome, while Cormack–Lehane grades, duration of laryngoscopy and intubation, hemodynamic responses, and incidence of any airway complications were secondary outcomes. Results: Both groups were comparable in terms of patient characteristics. The median (IQR) Intubation Difficulty Scale (IDS) score was better but was statistically nonsignificant with C‐MAC (0 [0–0] vs. 0 [0–2], p =.055). The glottic views were superior (CL grade I in 32/35 vs. 23/35, p =.002), and the time to best glottic view (6 s [5–7] vs. 8.0 s [6–10], p =.006) was lesser in the C‐MAC D‐blade group while the total duration of intubation was comparable (20 s [16–22] vs. 18 s [15–22], p =.374). All the patients could be successfully intubated on the first attempt. None of the patients had any complications. Conclusion: The C‐MAC video laryngoscope size 2 D‐blade provided faster and better glottic visualization but similar intubation difficulty compared to McCoy size 2 laryngoscope in children. The shorter time to achieve glottic view demonstrated with the C‐MAC failed to translate into a shorter total duration of intubation when compared to the McCoy laryngoscope attributable to a pronounced curvature of the D‐blade. [ABSTRACT FROM AUTHOR]

Purpose: Informative image selection in laryngoscopy has the potential for improving automatic data extraction alone, for selective data storage and a faster review process, or in combination with other artificial intelligence (AI) detection or diagnosis models. This paper aims to demonstrate the feasibility of AI in providing automatic informative laryngoscopy frame selection also capable of working in real-time providing visual feedback to guide the otolaryngologist during the examination. Methods: Several deep learning models were trained and tested on an internal dataset (n = 5147 images) and then tested on an external test set (n = 646 images) composed of both white light and narrow band images. Four videos were used to assess the real-time performance of the best-performing model. Results: ResNet-50, pre-trained with the pretext strategy, reached a precision = 95% vs. 97%, recall = 97% vs, 89%, and the F1-score = 96% vs. 93% on the internal and external test set respectively (p = 0.062). The four testing videos are provided in the supplemental materials. Conclusion: The deep learning model demonstrated excellent performance in identifying diagnostically relevant frames within laryngoscopic videos. With its solid accuracy and real-time capabilities, the system is promising for its development in a clinical setting, either autonomously for objective quality control or in conjunction with other algorithms within a comprehensive AI toolset aimed at enhancing tumor detection and diagnosis. [ABSTRACT FROM AUTHOR]

Perianaesthetic dental trauma is a common anaesthesia-related complication. Theprevious studies have shown a lack of knowledge regarding mouthguard usage and controversial results related to perianaesthetic dental trauma prevention. This study aimed to conduct a finite element analysis of the compressive and tensile stresses on the tooth-periodontal ligament-bone complex using custom-made mouthguards of different thicknesses and glass fibre splints to prevent perianaesthetic dental trauma. Custom-fitted ethylene-vinyl acetate mouthguards of two different thicknesses (2 and 3 mm) and glass fibre splint were modelled. A linear static finite element analysis was performed by applying a rigid Macintosh laryngoscope to the palatal surface of the maxillary central incisors at 150 N. The model without a mouthguard and glass fibre splint showed the highest stress values at the palatinal root surfaces during the impact. Increasing the mouthguard thickness significantly decreased the stress-strain values regardless of the presence of the glass fibre splint. Maximum stresses in the group using the 3 mm mouthguard were the lowest compared with the other groups. [ABSTRACT FROM AUTHOR]

Purpose: This case study measured how well the Lee Silverman Voice Treatment (LSVT) improved vocal features, intelligibility, and communicative effectiveness for a multilingual participant with hypokinetic-hyperkinetic dysarthria secondary to suspected progressive supranuclear palsy. LSVT treatment was chosen for the participant due to the strengths and deficits he presented with prior to treatment, and for the anticipated challenges in treatment that may arise from the presence of multilingualism and impaired cognitive functioning. Methods: A multilingual patient in their 60's (English, Spanish, and French) with hypokinetic-hyperkinetic dysarthria secondary to suspected progressive supranuclear palsy completed the standard treatment sessions for LSVT. Assessment measures were taken at baseline, immediately post-treatment, and three-months post-treatment. Results: Improvementswere measured in vocal quality, vocal loudness, intelligibility, and communicative effectiveness immediately post-treatment. Three months posttreatment, improvements in vocal quality and intelligibility were maintained. Conclusion: This case study illustrates that LSVT may be a beneficial treatment for complex clients who are multilingual and present with complex comorbidities and cognitive deficits. LSVT resulted in some meaningful changes in vocal quality, intelligibility, and communicative effectiveness for this individual. Clinicians who work with complex patients may wish to consider the theoretical underpinnings of LSVT, client profile, areas of client need, and ability and desire to complete an intensive treatment program to determine if trialing LSVT is appropriate. The use of LSVT with complex clients may yield positive outcomes. [ABSTRACT FROM AUTHOR]

Background and Objective: Obesity is associated with difficult or failed intubation attempts, making general anesthesia challenging for anesthesiologists to perform. The purpose of this study was to evaluate and compare the efficacy of a McCoy laryngoscope and a C-MAC D-blade video laryngoscope for intubation in obese patients with a body mass index (BMI) ≥ 35 kg/m2. Methods: In total, 104 patients were randomly assigned to be intubated with a McCoy (McCoy group) or C-MAC D-blade video laryngoscope (C-MAC group). The primary outcome was intubation time. The secondary outcomes were vocal cord exposure time, vocal cord passage time, proportion of successful intubation, mask ventilation scale, intubation difficulty scale (IDS), percentage of glottis opening (POGO) score, and hemodynamic variables. Results: Although the intubation time did not significantly differ, the C-MAC group showed shorter vocal cord exposure times and a higher rate of successful vocal cord exposure within 5 s. The IDS value was significantly lower in the C-MAC group than in the McCoy group. The proportion of patients who required an increase in lifting force during laryngoscopy was higher in the McCoy group than in the C-MAC group, which may explain the difference in MAP between the groups. Conclusions: Both the McCoy laryngoscope and the C-MAC D-blade video laryngoscope were useful during the intubation of obese patients. The C-MAC D-blade video laryngoscope might be more useful for obese patients in terms of hemodynamic stability. [ABSTRACT FROM AUTHOR]

Tracheal tube introducers are commonly used tools in airway management, but a systematic review of 21 studies found that airway trauma associated with their use is relatively low risk, with no reports of severe harm. However, the review did highlight limitations in the studies, including heterogeneity and bias. The use of tracheal tube introducers has increased with the popularity of videolaryngoscopy, but caution is needed in their routine and unrestricted use. The standard stylet was found to have a higher incidence of airway trauma compared to other introducers. The article discusses the potential risks and complications associated with the use of a standard stylet during tracheal intubation, emphasizing that incorrect use can make intubation more difficult and traumatic, leading to injury. The article also compares the rate of injury between videolaryngoscopy and direct laryngoscopy, suggesting that the design of hyperangulated blades in videolaryngoscopes may contribute to a higher risk of injury. The authors recommend proper training, awareness of potential complications, and consideration of alternative introducers to minimize airway injury. [Extracted from the article]

Background: In this study, we observed the frequency of side effects encountered when the neural integrity monitor electromyogram endotracheal tube (NIM-EMG-ETT) was used in thyroidectomy and parathyroidectomy surgeries. Methods: After obtaining hospital ethics committee approval, 239 cases affiliated with the American Society of Anesthesiologists (ASA II-IV) who used NIM EMG tubes in thyroid and parathyroid surgery were included in the prospective observational study. Tube and patient-related complications encountered with two different NIM EMG-ETT (silicone and polyvinyl chloride-PVC) were recorded. Results: The average age of the patients is 49.50 ± 13.44 years, the average BMI is 28.25 ± 4.91 kg/m2, the median surgery time is 115 (32–475) minutes, 75.7% are women, 97.5% are ASA II. Additional diseases other than thyroid and parathyroid problems were present in 77.3%. Thyroidectomy was performed in 73.2% of the patients. In our study, only 0.8% of patients with transient recurrent laryngeal nerve RLN paralysis were observed in thyroid and parathyroid surgeries performed using NIM-EMG tubes, 3 patient already had nerve involvement in the preoperative period. The most common complication was loss of stimulation response related to tubes and patient-related ventilation failure. There was no difference between the complications of silicone and PVC tubes except for irregular EMG response. Conclusions: There was no significant difference in side effects other than irregular EMG response in the two different tubes we used in our study. It was observed that prolonging the surgical time increased the risk of irregular EMG response. It should not be forgotten that no matter which NIM-EMG tube is used, additional risks are encountered during the intubation and extubation process. In order to avoid negative consequences, it is necessary to follow the usage rules recommended by the manufacturer when using NIM-EMG tubes. [ABSTRACT FROM AUTHOR]

Simple Summary: Radiotherapy is an important treatment option for esophageal cancer, in addition to surgery and chemotherapy. Ionizing radiation can cause alterations in the patient's anatomy, particularly in the larynx area, which may make advanced airway management more challenging for anesthetists. The existing literature contains data on other entities of cancer and radiotherapy and their impact on advanced airway management. However, there is a lack of data on esophageal cancer. We retrospectively analyzed patients with esophageal cancer who underwent radiotherapy followed by surgery between 2012 and 2023 in our university hospital. It has been shown in the literature that post-radiotherapy effects can increase the risk of difficult endotracheal intubation and airway complications in anesthesiology. However, our study did not indicate any evidence of impaired advanced airway management in patients with esophageal cancer after radiotherapy. (1) Background: Currently, no data are available in the literature investigating the influence of radiotherapy (RT) on endotracheal intubation success in patients with esophageal cancer. This study aims to evaluate the impact of RT on endotracheal intubation quality metrics in patients with esophageal cancer. (2) Methods: Patients with esophageal cancer who underwent RT followed by surgery between 2012 and 2023 at the University Hospital Heidelberg, Germany, were retrospectively analyzed. (3) Results: Fifty-five patients, predominantly males 65.5% with a mean age of 64 years, were enrolled. Overall, 81.8% of the patients had an ASA class of III, followed by 27.2% ASA II. The mean prescribed cumulative total dose to the primary tumor and lymph node metastasis was 48.2 Gy with a mean single dose of 1.8 Gy. The mean laryngeal total dose was 40.0 Gy. Direct laryngoscopy was performed in 80.0% of cases, followed by 12.1% videolaryngoscopy, and 7.2% required fiberoptic intubation. Overall, 96.4% of patients were successfully intubated on the first attempt. (4) Conclusions: It has been demonstrated that post-RT effects can increase the risk of airway management difficulties and complications. The results of our study did not indicate any evidence of impaired advanced airway management in patients with esophageal cancer who had undergone RT. [ABSTRACT FROM AUTHOR]

The aim of this case series report is to provide a new topical view of styletubation (video intubating stylet technique) in obese patients undergoing bariatric surgeries. In contrast to various conventional direct laryngoscopes (DLs), videolaryngoscopes (VLs) have been applied in such obese populations with potentially difficult airway complications. The safety and effectiveness of VLs have been repeatedly studied, and the superiority of VLs has then been observed in and advocated for routine use. In this article, among our vast use experiences with styletubation (more than 54,998 patients since 2016) for first-line routine tracheal intubation, we present the unique experience to apply the styletubation technique in obese patients undergoing bariatric surgery. Consistent with the experiences applied in other patient populations, we found the styletubation technique itself to be swift (the time to intubate from 5 s to 24 s), smooth (first-attempt success rate: 100%), safe (no airway complications), and easy (high subjective satisfaction). The learning curve is steep, but competency can be enhanced if technical pitfalls can be avoided. We, therefore, propose that the styletubation technique can be feasibly and routinely applied as a first-line airway modality in obese patients undergoing bariatric surgery. [ABSTRACT FROM AUTHOR]

Summary Background Methods Results Conclusions Although videolaryngoscopy has been proposed as a default technique for tracheal intubation in children, published evidence on universal videolaryngoscopy implementation programmes is scarce. We aimed to determine if universal, first‐choice videolaryngoscopy reduces the incidence of restricted glottic views and to determine the diagnostic performance of the Cormack and Lehane classification to discriminate between easy and difficult videolaryngoscopic tracheal intubations in children.We conducted a prospective observational study within a structured universal videolaryngoscopy implementation programme. We used C‐MAC™ (Karl Storz, Tuttlingen, Germany) videolaryngoscopes in all anaesthetised children undergoing elective tracheal intubation for surgical procedures. The direct and videolaryngoscopic glottic views were classified using a six‐stage grading system.There were 904 tracheal intubations in 809 children over a 16‐month period. First attempt and overall success occurred in 607 (67%) and 903 (> 99%) tracheal intubations, respectively. Difficult videolaryngoscopic tracheal intubation occurred in 47 (5%) and airway‐related adverse events in 42 (5%) tracheal intubations. Direct glottic view during laryngoscopy was restricted in 117 (13%) and the videolaryngoscopic view in 32 (4%) tracheal intubations (p < 0.001). Videolaryngoscopy improved the glottic view in 57/69 (83%) tracheal intubations where the vocal cords were only just visible, and in 44/48 (92%) where the vocal cords were not visible by direct view. The Cormack and Lehane classification discriminated poorly between easy and difficult videolaryngoscopic tracheal intubations with a mean area under the receiver operating characteristic curve of 0.68 (95%CI 0.59–0.78) for the videolaryngoscopic view compared with 0.80 (95%CI 0.73–0.87) for the direct glottic view during laryngoscopy (p = 0.005).Universal, first‐choice videolaryngoscopy reduced substantially the incidence of restricted glottic views. The Cormack and Lehane classification was not a useful tool for grading videolaryngoscopic tracheal intubation in children. [ABSTRACT FROM AUTHOR]

The article explores the complexities of neonatal anesthesiology, emphasizing the unique challenges of providing anesthesia to neonates up to 28 days old. Topics include the anatomical challenges of intubation in neonates, such as their large heads, narrow nasal passages, and elevated larynx; the physiological differences, like the immature cricoid cartilage and its implications for cuffed versus uncuffed endotracheal tubes; and the importance of understanding neonatal cardiac physiology.

Background: Dexmedetomidine, renowned for its sedative, anxiolytic, and opioid-sparing properties, exerts its effects primarily within the locus ceruleus of the brainstem. By diminishing sympathetic outflow, it effectively attenuates stress responses. Despite its growing popularity, optimal dosing remains uncertain, particularly within the Indian population. This study aimed to compare the hemodynamic response attenuation achieved by two dexmedetomidine doses: 0.5 mcg/kg and 1 mcg/kg during laryngoscopy and intubation. Materials and Methods: One hundred elective surgery cases were consecutively enrolled in this prospective study after obtaining informed consent. The patients were randomly allocated into two groups, each comprising 50 cases. Group A received intravenous dexmedetomidine at 0.5 mcg/kg, while Group B received 1 mcg/kg, both diluted with 20 ml of normal saline over a 10-minute infusion using a pump. Hemodynamic responses from both the groups were then recorded. Results: Baseline diastolic blood pressure was comparable between groups, and at 10 minutes post-drug administration, as well as during intubation and 1 minute post-intubation (p>0.05). However, post-intubation diastolic blood pressure was significantly lower in Group B compared to Group A at 3 minutes post-intubation and remained lower through subsequent readings until 10 minutes post-intubation. Similarly, mean arterial pressure was significantly lower in Group B compared to Group A for all readings up to 10 minutes postintubation. Conclusion: In the context of attenuating the hemodynamic response to laryngoscopy and intubation, this study establishes the superiority of intravenous dexmedetomidine at 1 mcg/kg over 0.5 mcg/kg dosing. The higher dose may be particularly beneficial for patients with a history of myocardial ischemia, hypertension, or cerebrovascular accidents, for whom excessive stress response during laryngoscopy and intubation is undesirable. Caution is advised when administering the 1 mcg/kg dose due to potential bradycardia during drug infusion. [ABSTRACT FROM AUTHOR]

A meta-analysis published in the journal Anaesthesia compared the use of remifentanil with neuromuscular blocking (NMB) drugs for tracheal intubation in adults. The study found that a remifentanil bolus provided comparable rates of successful tracheal intubation compared to NMB drugs. However, this conflicts with the findings of a recent trial that found remifentanil to be statistically inferior to NMB drugs. While the use of NMB drugs is widely recommended, the study suggests that tracheal intubation with high doses of remifentanil may be a safe alternative in certain situations. Further research is needed to investigate the efficacy of tracheal intubation without NMB drugs and to improve patient safety during the procedure. [Extracted from the article]

Congenital tracheo-esophageal fistula/esophageal atresia (TEF/EA) with concomitant pulmonary agenesis is exceedingly rare and has a high mortality rate. While there are several reported cases of successful repair, all but one patient had right-sided pulmonary agenesis. In the case of left-sided pulmonary agenesis, the patient had incomplete agenesis and underwent repair through a left thoracotomy. We present the first successful repair of TEF/EA with complete left-sided pulmonary agenesis. This patient also underwent elective pre-operative veno-venous extracorporeal membrane oxygenation (ECMO) and subsequent repair of the TEF/EA. We discuss the management, anesthesia risks, and role of periprocedural ECMO in pediatric patients who are high anesthetic risk. [ABSTRACT FROM AUTHOR]

Introduction: Unanticipated difficult airway is still a cause of morbidity and mortality. Various parameters are used to predict difficult airways. Recent studies have found that measuring the Sternomental Displacement (SMDD) can help establish a difficult airway. Aim: To find whether the Ratio of Height to Sternomental Displacement (RHSMDD) could be used as a predictor for Difficult Laryngoscopy (DL) and intubation. Secondary objectives included comparing RHSMDD with routine assessment parameters like Modified Mallampati Score (MMT), SMD, Thyromental Distance (TMD), and Inter Incisor Distance (IID). Materials and Methods: A prospective observational study was conducted at Malabar Medical College, Calicut, Kerala, India among 120 adult patients undergoing elective surgeries under general anaesthesia. Airway parameters like MMT, IID, TMD, SMD, Sternomental Displacement (SMDD), RHSMDD, Ratio of Height to Sternomental Distance (RHSMD), and Ratio of Height to Thyromental Distance (RHTMD) were measured preoperatively and associated with Cormack Lehane’s laryngoscopic grading and Intubation Difficulty Scale (IDS) value. A comparison of airway parameters with laryngoscopy and intubation was done by the Mann-Whitney U test. Receiver Operating Characteristics (ROC) curves were constructed, and optimal cut-off values for significant quantitative indices were calculated. Sensitivity, specificity, Positive Predictive Value (PPV), and Negative Predictive Value (NPV) were also calculated and compared. Results: The incidence of DL was 27.5%, and Difficult Intubation (DI) was 10.8%. Age (p-value=0.013), weight (p-value=<0.001), and height (p-value=0.019) showed a significant association with DL. It was found that only RHTMD was statistically significantly higher in the DI group (p=0.044). All other parameters did not show statistical significance in either group. The calculated cutoff value for RHTMD was ≥18.45 cm. The highest specificity (96.3%) and NPV (90.43%) were observed for Body Mass Index (BMI) alone as a predictor of DI. The highest sensitivity (93.75%) was observed for TMD alone in predicting DL. The combination of MMT+RHSMD yielded the highest sensitivity and NPV for DI. Conclusion: RHTMD showed significance in DI and remains a better predictor. RHSMDD cannot be used as a predictor for a difficult airway. The combination of parameters demonstrated high sensitivity and NPV, suggesting they can be combined with modern ultrasound airway measurement for more accuracy. [ABSTRACT FROM AUTHOR]

Purpose: Recent approaches for recurrent respiratory papillomatosis including local injection of bevacizumab and HPV vaccination show promise in reducing the need for frequent surgeries. In this study we propose a new combined approach of surgery, intralesional injection of 25 mg bevacizumab and HPV vaccine that can lead to resolution of RRP. Material and methods: Our study involved 5 patients treated with a combination of transoral microsurgery, intralesional injection of 25 mg bevacizumab, and HPV vaccination with Gardasil 9 between April 2020 and May 2023. Standard video laryngoscopy was performed to assess the presence of papilloma and Derkay score was used to assess the severity of disease. Results: All 5 patients completed the study successfully and a complete response was achieved by all. The follow-up ranged from 8 to 45 months. The mean total Derkay score before treatment was 41 (range 25 to 52) and after the combined approach was 0 both anatomically and clinically in all patients. Conclusions: This study demonstrates the effectiveness of a combined treatment approach for RRP involving surgical intervention, intralesional injection of bevacizumab, and HPV vaccination. [ABSTRACT FROM AUTHOR]

Purpose: This study retrospectively examined patient-reported symptoms, quality of life, and swallowing kinematics in individuals with presumed muscle tension dysphagia (MTDg). Method: Twenty-six individuals met the inclusion criteria. Data were gathered from patient-reported outcome measures (PROs), symptomology, clinician reports of palpation, and hyolaryngeal and hyoid movements measured on a 20-ml thin liquid bolus during videofluoroscopic swallowing studies. Results: All PROs were outside of typical limits, except for the Voice Handicap Index-10. Mean hyoid excursion was 1.52 cm (SD = 0.46, range: 0.76-2.43), and hyolaryngeal excursion was 0.77 cm (SD = 0.44, range: -0.42-1.68). A minority of participants (4%-19%) demonstrated atypical hyoid and/or hyolaryngeal excursion compared to the available normative reference value sets. Conclusions: Individuals demonstrated abnormalities in the clinical evaluation of the areas of palpation and reported perilaryngeal discomfort and symptoms of laryngeal hyperresponsiveness, with a negative impact on their quality of life across various PROs. Atypical hyoid and/or hyolaryngeal excursion during swallowing was rare when compared to available normative reference values. The clinical evaluation of MTDg may be enhanced by including components related to muscle tension and laryngeal hyperresponsiveness in order to differentiate MTDg from idiopathic functional dysphagia and lead the patient to the otolaryngology/speech-language pathology clinic for intervention and management. [ABSTRACT FROM AUTHOR]

Background: Laryngoscopy and intubation are almost always associated with an increased sympathetic activity. To attenuate the pressor response, various drugs have been tried. This study aimed at finding out the different doses of clonidine in attenuating the hemodynamic response to laryngoscopy and intubation in patients posted for any elective surgery under general anaesthesia. Material and methods: This was a prospective, comparative, observational study, which involved two groups of patients. Each group had 30 patients, Group A (n=30) received injection Clonidine 1µg/kg diluted to 10 ml of normal saline and group B (n=30) received injection Clonidine 2µg/kg diluted to 10 ml normal saline intravenously. Patients were observed for 10 minutes. Baseline data of heart rate, mean arterial blood pressure, rate pressure product, respiratory rate, and sedation score were noted. All the parameters were recorded at different intervals up to 10 minutes after intubation. Results were compiled and statistically analysed. Result: In group B, following laryngoscopy and intubation, there is more decrease in HR, MAP, RPP at 2 minutes and 3 minutes after intubation from baseline values compared to group A, which was statistically significant (p<0.01). So, there is more attenuation of hemodynamic response in group B as compare to group A. Conclusion: Clonidine 2 µg/kg was found to be marginally superior to Clonidine 1 µg/kg for attenuation of sympathetic response without any adverse effects. [ABSTRACT FROM AUTHOR]

Background: The introduction of deep sedation & tracheal intubation is demanding and causes severe hemodynamic alterations. Laryngoscopy & tracheal manoeuvres were unpleasant stimuli that cause a short-term rise in autonomic response, resulting in dysrhythmias, elevated arterial pressure, and pulse rate. Objective: To compare the difference in HR, SBP, DBP, and MAP at different intervals (before induction and after induction) in two groups during laryngoscopy and intubation under general anaesthesia. Methods: A randomized control trial was conducted and a total of 98 patients undergoing elective surgeries under General Anaesthesia were taken and were randomly divided in 2 groups: Group A (I.V Lignocaine) and Group B (Nebulized lignocaine) to 49 patients each. GROUP A: 49 patients were given IV Lignocaine (2%) 1.5mg/kg 3 minutes prior to laryngoscopy. GROUP B: 49 patients were given Nebulized Lignocaine (2%) 5ml 5 minutes prior to laryngoscopy. Results: Comparing the nebulized lignocaine group to the IV lignocaine group, we observed a statistically significant decrease of hemodynamic responses after intubation in our research. In our study statistically significant results were seen with heart rate, systolic blood pressure and mean arterial pressure with p value less than 0.05 and insignificant results with diastolic blood pressure and all other demographic variables. Conclusion: Hemodynamic variables were more stable in nebulized lignocaine group and it was seen that nebulized lignocaine attenuates the pressor responses much better than intravenous lignocaine with less hemodynamic instability. [ABSTRACT FROM AUTHOR]

Aim: Evidence shows that 20%–30% of patients who aspirate do so silently. Research to date has not demonstrated clear evidence to indicate which patients are at higher risk of silent aspiration. Our aim was to use univariate logistic regression analysis of retrospective case review to determine potential patterns of silent aspiration. Materials and methods: We conducted a retrospective analysis of 455 fiberoptic endoscopic evaluation of swallowing (FEES) reports. The patients were divided into four groups: G1 – neurological diseases (n = 93), G2 – head and neck surgery (n = 200), G3 – gastroenterological diseases (n = 94) and G4 – other patients (n = 68). Data included the occurrence or absence of saliva penetration or aspiration, of silent fluid/solid food penetration or aspiration, type of penetration or aspiration, occurrence of cranial nerve paresis, radiotherapy and tracheostomy. Univariate logistic regression was used to evaluate independent risk factors of silent aspiration in the study population. Three models with different independent variables were considered. Results: There is a statistically significant difference in the frequency of occurrence of silent penetration and aspiration within the groups (p < 0.001), with intraglutative being most frequent. Fluid and food penetration and aspiration correlated with saliva penetration and aspiration in all groups (p < 0.001). Cranial nerve paresis (IX and X), radiotherapy and tracheostomy correlate with saliva penetration and aspiration (p = 0.020 for cranial nerve paresis; p = 0.004 for radiotherapy; p < 0.001 for tracheostomy). One hundred and fifteen patients (45.81%) in the subgroup of patients with intraglutative aspiration had cranial nerve paresis (IX, X or IX–X). Conclusions: Patients who should be prioritised or considered to be at a higher need of instrumental swallowing evaluation are those with IX and X cranial nerve paresis, tracheostomy and those who have had radiotherapy, with saliva swallowing problems, especially after paraganglioma, thyroid and parathyroid glands and middle and posterior fossa tumour surgery. WHAT THIS PAPER ADDS: What is already known on the subject: Clinical signs of penetration or aspiration include coughing, throat clearing and voice changes, while silent penetration or aspiration patients aspirate without demonstrating any clinical symptoms. The most common consequences of silent aspiration include aspiration pneumonia, recurrent lower respiratory tract infections and respiratory failure. Additionally, malnutrition and dehydration can be indicators of silent aspiration. Patients may unknowingly reduce their oral intake and lose weight. Retrospective studies have shown that 20%–30% of patients aspirate silently (e.g. patients after stroke, acquired brain injury, head and neck cancer treatment, prolonged intubation). Clinical examination of swallowing can miss up to 50% of cases of silent aspiration. What this paper adds to existing knowledge: Currently, silent aspiration is often discussed in neurological literature, but its applications to head and neck surgery are limited. In this study, we identify head and neck surgery patients who should be prioritised or considered to be in higher need of instrumental swallowing evaluation due to a higher risk of silent aspiration. What are the potential or actual clinical implications of this work?: Post‐treatment structural changes can result in lower cranial nerve paresis (IX, X, XII) and face injury, in which vagus and glossopharyngeal nerves are injured. After tracheostomy and radiotherapy, patients with problems swallowing saliva need careful clinical examination, particularly cranial nerve examination. [ABSTRACT FROM AUTHOR]

Background & Aims: Endotracheal intubation is essential for safe general anesthesia practice but it is associated with stress response due to sympathetic stimulation resulting in hypertension and tachycardia. So, to attenuate this stress response during laryngoscopy and endotracheal intubation, the efficacy of intravenous dexmedetomidine and esmolol were compared in this study. Materials And Methods: The study was carried on total 210 ASA grade I or II patients of aged 18-60 years who were scheduled for elective laparoscopy surgery under general anesthesia. All the patients were randomly divided into the three groups of 70 each. In control group (group C)-intravenous (IV) 0.9% saline plain, dexmedetomidine group (group D)- 1 μg/kg dexmedetomidine and esmolol group (group E)- 1.5 mg/kg esmolol diluted with 0.9% saline in volume of 20 ml IV were infused over 10 minutes and after that induction of anaesthesia was done. Hemodynamic parameters were recorded atbaseline, before intubation, during intubation, and then every 1 minute upto 10 minutes. Results: In group D, increase in heart rate and blood pressure after intubation at any time intervals was not statistically significant, whereas in group E, there was a statistically significant increase in blood pressure after intubation at 1, 2, and 3 minutes only and in heart rate up to 5 minutes. Conclusion- Dexmedetomidine is better alternative to esmolol for attenuating the stress response to laryngoscopy and intubation during general anaesthesia. [ABSTRACT FROM AUTHOR]

We present a case report of a patient with a history of aggressive thyroid cancer managed by surgery, chemotherapy, and radiation to the neck. A year later, he presented with hemoptysis. Endobronchial ultrasound showed a pulsatile vessel; however, a CT scan and conventional angiogram were negative. Three days later, a repeat angiogram revealed a pseudoaneurysm arising from the right common carotid artery. Carotid sacrifice was performed after passing balloon test occlusion. Three years later the patient presented with coil herniation into the trachea. The carotid stump was closed with a vascular plug to prevent rebleeding from coil removal. Four months later the patient experienced an intractable cough and underwent laryngoscopy-assisted removal of the residual coil mass. This case report discusses the rare scenario of a carotid blowout into the trachea and the subsequent course of events. [ABSTRACT FROM AUTHOR]

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Background: Securing and maintaining a patent airway for the conduct of general anesthesia are a major concern for an anesthesiologist. Unanticipated difficult intubation in anesthetized patients is the main cause of morbidity or mortality. Several predictors are proposed to anticipate difficult tracheal intubation, but no predictor is found to be 100% accurate. Acromio-axillo-suprasternal notch index (AASI) is a recent addition to the list of predictors. Aims and Objectives: The current study compared the usefulness of AASI and thyromental height test (TMHT) as predictors of difficult visualization of larynx (DVL). Materials and Methods: Following approval by the Institutional Ethics Committee and CTRI registration, written informed consent was taken. The study was conducted on 300 patients aged 18–65 years belonging to American Society of Anesthesiologists’ physical status I and II, with modified Mallampati (MMP) Scores of 1 and 2, over a period of 6 months. Preoperatively all patient’s airway was evaluated using AASI and TMHT. The DVL during direct laryngoscopy was noted as assessed by Cormack and Lehane grading. We compared the sensitivity and specificity for DVL with regard to AASI and TMHT. Results: The incidence of unanticipated DVL was 14%. The sensitivity, specificity, positive predictive value, and negative predictive value of AASI were 86.4%, 38.1%, 89.6%, and 31.4%, respectively, and for TMHT, they were 94.6%, 4.8%, 85.9%, and 12.5%, respectively. Pearson correlation coefficient was r = −0.068 (P=0.243) when AASI was compared with TMHT. Conclusion: AASI was found to be less sensitive when compared to TMHT and there was statistically no significant correlation between the two parameters to predict the DVL.

Background: The process of laryngoscopy and tracheal intubation is potent stressful stimuli that cause sympathetic activation, which is transient. Some of the modalities for attenuation of laryngoscopic and intubation response have been found to be less effective in smokers than in non-smokers. In view of this, the present study was performed to compare the effectiveness of dexmedetomidine in male smoker and non-smoker patients. Aims and Objectives: The aim of this study was to compare the effectiveness of dexmedetomidine in suppressing sympathoadrenal pressor response due to laryngoscopy and endotracheal intubation between smokers and non-smokers. Materials and Methods: This was a hospital-based non-randomized controlled study. Sixty patients were divided into two groups: 30 patients with no history of smoking (Group NS) and 30 patients with a smoking history (Group S). Both groups were received dexmedetomidine 0.75 mcg/kg over 10 min intravenous infusion. Hemodynamic parameters and Ramsay sedation score were measured at perioperative period. Results: Group S patients showed a significant rise in heart rate (HR), systolic blood pressure (SBP), diastolic BP (DBP), mean arterial pressure (MAP), and rate pressure product (RRP) during the immediate post-intubation period, but Group NS showed a decrease in HR, SBP, DBP, MAP and RRP throughout the post-intubation period. Conclusion: Single dose of 0.75 mcg/kg IV dexmedetomidine given over a period of 10 min before the induction of anesthesia is completely effective in attenuating the hemodynamic responses associated with laryngoscopy and intubation in non-smokers, but it is not efficient in smokers.

The Academic Life in Emergency Medicine (ALiEM) Approved Instructional Resources (AIR) Series was created in 2014 to address the Free Open Access Medical Education (FOAM) movements decentralized nature and lack of inherent peer review. The AIR series provides a topic-based, curated list of online educational content vetted by academic emergency medicine (EM) faculty that meets individualized interactive instruction criteria for EM trainees. Relevant FOAM resources were identified from the top 50 FOAM websites using the Social Media Index and then scored by EM faculty using a validated instrument to identify the highest quality posts related to a topic. This article reviews FOAM resources pertaining to EM procedures that were labeled as an Approved Instructional Resource or Honorable Mention using the AIR series methodology.