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Robotic thyroidectomy is one of the most advanced surgical procedures used to manage benign and malignant thyroid nodules. However, complication risks such as tracheal injury still exists. Tracheal injury in robotic thyroidectomy is difficult to detect and is one of the life-threatening complications. This study reviews the current literature on the tracheal injury following robotic thyroidectomy and also discusses our findings on 2060 cases of robotic thyroidectomy via Da Vinci Surgical System performed in our department and finally presents 3 cases treated in our center. PubMed and Web of Science database were searched using Medical Subject Headings (Mesh) related to "tracheal injury" and "robotic thyroidectomy". The search was conducted without publication date limits. We reviewed the literature and summarized common causes, diagnosis and therapeutic options of tracheal injury in robotic thyroidectomy, which has been described in comparison studies or retrospective studies. Tracheal injury is often diagnosed when patients suffer from dyspnea and usually leads to severe postoperative consequences. Tracheal injury can be suspected in all patients having subcutaneous emphysema, pneumomediastinum, pneumothorax or dyspnea after robotic thyroidectomy. Tracheoscopy is necessary to determine the location and size of tracheal injury. In patients whose condition is stable and the injury is contained, conservative treatment is feasible. Certainly, primary closure or tracheotomy is necessary for patients with serious respiratory difficulty or pneumothorax., Competing Interests: Declaration of competing interest The authors declare that there are no conflicts of interest., (Copyright © 2023 Asian Surgical Association and Taiwan Robotic Surgery Association. Published by Elsevier B.V. All rights reserved.)

Objectives: To determine the incidence of tracheocutaneous fistula (TCF) and identify characteristics associated with persistence., Study Design: Prospective cohort., Methods: All successfully decannulated children (<18 years) between 2014 and 2020 at a tertiary children's hospital were included. Revision tracheostomies, concomitant major neck surgery, or single-stage laryngotracheal reconstructions were excluded. A persistent TCF was defined as a patent fistula at 6 weeks after decannulation., Results: A total of 77 children met inclusion criteria with a persistent TCF incidence of 65% (50/77). Children with a persistent TCF were younger at placement (1.4 years (SD: 3.3) vs. 8.5 years (SD: 6.5), p < 0.001) and tracheostomy-dependent longer (2.8 years (SD: 1.3) vs. 0.9 years (SD: 0.7), p < 0.001). On univariate analysis, placement under 12 months of age (86% vs. 26% p < 0.001), duration of tracheostomy more than 2 years (76% vs. 11% p < 0.001), short gestation (64% vs. 26%, p = 0.002), congenital malformations (64% vs. 33%, p = 0.02), newborn complications (58% vs. 26%, p = 0.009), maternal complications (40% vs. 11%, p = 0.009) and chronic respiratory failure (72% vs. 41%, p = 0.01) were associated with persistent TCF. Logistic regression analysis associated duration of tracheostomy (OR: 0.14, 95% CI: 0.05-0.35, p < 0.001) and congenital malformations (OR: 0.25, 95% CI: 0.06-0.99, p = 0.049) with failure to spontaneously close., Conclusions: Two-thirds of children will develop a persistent TCF after tracheostomy decannulation. Persistent TCF is correlated with a longer duration of tracheostomy and congenital malformations. Anticipation of this event in higher-risk children is necessary when caring for pediatric tracheostomy patients., Level of Evidence: 3 Laryngoscope, 133:417-422, 2023., (© 2022 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: Tracheobronchopathia osteochondroplastica (TO) is a rare condition of unknown etiology. TO is characterized by submucosal nodules, with or without calcifications, protruding in the anterolateral walls of the trachea and proximal bronchi. The objective of this study was to describe TO features and associated comorbidities in a series of patients., Methods: Patients suffering from TO were retrospectively included by investigators from the Groupe d'Endoscopie Thoracique et Interventionnelle Francophone (GETIF). Demographic, clinical, comorbidities, bronchoscopic, functional, and radiological characteristics, and outcomes were recorded and analyzed., Results: Thirty-six patients were included (69% male with a mean of 65 ± 12 years). Chronic symptoms were described by 81% of patients including cough (74%) and dyspnea on exertion (74%). TO was associated with COPD in 19% of the cases and gastroesophageal reflux disease in 6%. A mild to severe airflow obstruction was present in 55% of the cases. CT scan showed tracheal submucosal nodules in 93% of patients and tracheal stenosis in 17%. Bronchoscopy identified TO lesions in the trachea in 65% of the cases, and 66% of them were scattered. A bronchoscopic reevaluation was performed in 7 cases, 9 ± 14 months [1-56] after initial diagnosis, and showed the stability of lesions in all cases. Three patients underwent interventional bronchoscopic treatment., Conclusion: The diagnosis of TO relies on typical bronchoscopic findings and can be evoked on a CT scan. Histologic diagnosis can be useful in atypical cases for differential diagnosis. Given its low consequences in terms of symptoms, lung functions, and evolution, no treatment is usually required., (© 2022. The Author(s).)

Objectives: Tracheocutaneous fistula (TCF) is a common occurrence after pediatric tracheostomy decannulation. However, the persistence of TCF after staged reconstruction of the pediatric airway is not well-described. The primary objective was to determine the rate of persistent TCF after successful decannulation in children with staged open airway reconstruction., Methods: A case series with chart review of children who underwent decannulation after double-stage laryngotracheal reconstruction between 2017 and 2019., Results: A total of 26 children were included. The most common open airway procedure was anterior and posterior costal cartilage grafting (84.6%, 22/26). Median age at decannulation was 3.4 years (IQR: 2.8-4.3) and occurred 7.0 months (IQR: 4.3-10.4) after airway reconstruction. TCF persisted in 84.6% (22/26) of children while 15.4% (4/26) of stomas closed spontaneously. All closures were identified by the one-month follow-up visit. There was no difference in age at tracheostomy ( P  = .86), age at decannulation ( P  = .97), duration of tracheostomy ( P  = .43), or gestational age ( P  = .23) between stomas that persisted or closed. Median diameter of stent used at reconstruction was larger in TCFs that persisted (7.0 mm vs 6.5 mm, P  = .03). Tracheostomy tube diameter ( P  = .02) and stent size ( P  < .01) correlated with persistence of TCF on multivariable logistic regression analysis. There were 16 surgical closure procedures, which occurred at a median of 14.4 months (IQR: 11.4-15.4) after decannulation. Techniques included 56.3% (9/16) by primary closure, 18.8% (3/16) by secondary intention and 25% (4/16) by cartilage tracheoplasty. The overall success of closure was 93.8% (15/16) at latest follow-up., Conclusions: Persistent TCF occurs in 85% of children who are successfully decannulated after staged open airway reconstruction. Spontaneous closure could be identified by 1 month after decannulation and was more likely when smaller stents and tracheostomy tubes were utilized. Surgeons should counsel families on the frequency of TCF and the potential for additional procedures needed for closure.

Objectives: Airway reconstruction for subglottic and tracheal stenosis is often successful in achieving tracheostomy decannulation and improving airway symptoms. However, one common reason for late failure is development of a tracheal A-frame deformity, which can necessitate additional surgery. Although knowledge of this deformity exists, the incidence and risk factors have not been reported. This study seeks to determine the incidence of A-frame following airway reconstruction and define factors that correlate with development of this deformity., Study Design: Retrospective case series., Methods: Patients under 21 years of age undergoing open airway reconstruction at our institution between January 2005-December 2006 were retrospectively reviewed. Demographic data, comorbidities, airway history/reconstruction type, and follow-up airway findings were examined using multivariable logistic regression. Kaplan-Meier curves were used to examine time to A-frame repair., Results: Two hundred patients underwent airway reconstruction and 69 (34.5%) developed an A-frame deformity. History of tracheostomy was the most significant contributor to A-frame development (P < .0001). Double- versus single-stage procedures were not associated with increased odds of A-frame development (P = .94), however, patients undergoing resection procedures as opposed to laryngotracheal reconstruction (LTR) with cartilage grafts had a significantly lower chance of developing this deformity (P = .004). Of the patients with an A-frame, 27 (39%) required further surgical intervention., Conclusion: Approximately one-third of patients undergoing airway reconstruction developed a tracheal A-frame deformity, with a significantly higher rate among patients with a history of tracheostomy and those undergoing LTR. Patients should be followed long term to assess for the development of an A-frame., Level of Evidence: IV Laryngoscope, 131:E1363-E1368, 2021., (© 2020 American Laryngological, Rhinological and Otological Society Inc, "The Triological Society" and American Laryngological Association (ALA).)

Myiasis is a parasitic infestation of live vertebrates with the dipteran larvae that grow within the host while feeding on its living or dead tissue. Human myiasis is prevalent among individuals in close association of domestic animals and those inhabiting the unhygienic conditions. Open neglected suppurative wounds are the favourable sites that attract and stimulate the gravid female flies for oviposition. However, the poor personal hygiene, ignorance and the mental illness further add to it. Tracheopulmonary myiasis involves the infestation of foul smelling nasal and oral orifices or neglected wounds like tracheostomal incisions with the parasitic dipteran larvae which may extend up to the trachea, bronchi and lungs leading to serious health complications. Despite the incidence of human tracheopulmonary infestation is rare, the severe medical impediments and heterogeneous worldwide distribution signify the medical importance of this condition. The present manuscript reviews and summarizes the worldwide reported cases of human tracheopulmonary myiasis and the predisposing risk factors for onset of the same, as future reference for parasitologists and medical professionals.

Importance: Full-thickness tracheal lesions and tracheoesophageal fistulas are severe complications of invasive mechanical ventilation. The incidence of tracheal complications in ventilated patients with coronavirus disease 2019 (COVID-19) is unknown., Objective: To evaluate whether patients with COVID-19 have a higher incidence of full-thickness tracheal lesions and tracheoesophageal fistulas than matched controls and to investigate potential mechanisms., Design, Setting, and Participants: This is a retrospective cohort study in patients admitted to the intensive care unit in a tertiary referral hospital. Among 98 consecutive patients with COVID-19 with severe respiratory failure, 30 underwent prolonged (≥14 days) invasive mechanical ventilation and were included in the COVID-19 group. The control group included 45 patients without COVID-19. Patients with COVID-19 were selected from March 1 to May 31, 2020, while the control group was selected from March 1 to May 31, 2019., Exposures: Patients with COVID-19 had severe acute respiratory syndrome coronavirus 2 infection diagnosed by nasopharyngeal/oropharyngeal swabs and were treated according to local therapeutic procedures., Main Outcomes and Measures: The primary study outcome was the incidence of full-thickness tracheal lesions or tracheoesophageal fistulas in patients with prolonged invasive mechanical ventilation., Results: The mean (SD) age was 68.8 (9.0) years in the COVID-19 group and 68.5 (14.1) years in the control group (effect size, 0.3; 95% CI, -5.0 to 5.6). Eight (27%) and 15 (33%) women were enrolled in the COVID-19 group and the control group, respectively. Fourteen patients (47%) in the COVID-19 group had full-thickness tracheal lesions (n = 10, 33%) or tracheoesophageal fistulas (n = 4, 13%), while 1 patient (2.2%) in the control group had a full-thickness tracheal lesion (odds ratio, 38.4; 95% CI, 4.7 to 316.9). Clinical and radiological presentations of tracheal lesions were pneumomediastinum (n = 10, 71%), pneumothorax (n = 6, 43%), and/or subcutaneous emphysema (n = 13, 93%)., Conclusions and Relevance: In this cohort study, almost half of patients with COVID-19 developed full-thickness tracheal lesions and/or tracheoesophageal fistulas after prolonged invasive mechanical ventilation. Attempts to prevent these lesions should be made and quickly recognized when they occur to avoid potentially life-threatening complications in ventilated patients with COVID-19.

Objectives: Although tracheobronchial diverticulum (DV) rarely cause problems, attention should be paid during esophagectomy, which requires careful dissection around the trachea and bronchi. Here, we retrospectively review cases of tracheobronchial DVs among esophageal cancer patients and report two cases of bronchial DV injury during thoracoscopic esophagectomy that were successfully repaired., Methods: The thin-section CT images of esophageal cancer patients who underwent thoracoscopic esophagectomy from January 2013 to December 2015 were retrospectively reviewed. The localization, number, and size (largest axial diameter) of all detected DVs were recorded., Results: A total of 180 patients were enrolled in this study. The incidence of tracheal DV was 5.0%, and that of bronchial DV was 40.0%. The median diameter of the tracheal diverticula was 2.45 [interquartile range (IQR) 2.00-8.17] mm and that of the bronchial diverticula was 1.90 (IQR 1.51-2.46) mm. All tracheal diverticula presented at the right tracheal wall 4.5-6.0 cm below the vocal cords; bronchial diverticula presented at the subcarinal lesions. We experienced two cases with bronchial diverticulum injuries during thoracoscopic esophagectomy, which were repaired by primary closure and confirmed that there was no air leak. No postoperative complications associated with bronchial injury occurred in either patient., Conclusion: Since tracheobronchial DVs are not as rare as previously thought, careful evaluation of thin-slice CT scans is necessary before thoracoscopic esophagectomy. If a tracheobronchial DV is injured during surgery, it is important to carefully repair it and confirm that there is no air leak to avoid complications.

Objectives: Tracheostomy is a basic surgical procedure that most surgeons, regardless of specialty, learn early in their training. With improvements in intensive care medicine, the number of neurosurgical patients requiring tracheostomy has declined. As neurosurgeons advance in their training, familiarity with airway management declines and falls under the domain of other specialties. Because neurosurgeons still manage critically ill patients, they often defer the airway management to other specialists. In many institutions, neurosurgeons no longer perform tracheostomies. The purpose of this study was to evaluate complications and outcomes following tracheostomies performed by neurosurgeons., Patients and Methods: We reviewed a database of all neurosurgical procedures performed at a single institution from 9/2007 to 2/2017. We reviewed the operative and medical records of patients whose tracheostomies were performed by a neurosurgeon., Results: Neurosurgeons performed 72 tracheostomies over the study period. All the procedures were done in an operating room using traditional open technique. Four patients had previous tracheostomy. Five patients were on dual antiplatelet therapy. The procedure was successful in all patients. There were no immediate complications in any patient. One patient required revision for development of tracheo-cutaneous fistula., Conclusion: Tracheostomies can be performed safely by neurosurgeons in this era of sub-specialization. There is a renewed interest in maintaining critical care proficiency in neurosurgery. Airway management is an important part of this skill-set. Neurosurgeons manage patients with brain injuries, cranial nerve deficits, and cervical spine injuries, Consequently, learning how to establish a surgical airway remains necessary in neurosurgical training., (Copyright © 2020. Published by Elsevier B.V.)

Tracheal bronchus (TRB) has been generally considered an anatomical variant of the tracheobronchial tree without a precise pathological effect. Its prevalence is estimated to be between 0.2% to 3% of all children undergoing bronchoscopy and scientific information has been limited to case reports or small case series. Our working hypothesis was that TRB could trigger by itself recurrent or persistent respiratory symptoms. The objective of this retrospective and multicentre study of children with a diagnosis of TRB, coming from the main paediatric pulmonology units of Spain, was to determine the anatomical and clinical characteristics, including comorbidities, of TRB in childhood and their impact in the patients' clinical outcomes. One hundred thirty-three patients from 13 institutions were included in the study. Mean diagnostic age was 3.4 years and flexible bronchoscopy was the initial diagnostic method in 85% of cases. All TRB were located on the right wall of the trachea: 76% in the lower third and 24% in the carina. The most common clinical manifestations were obstructive bronchitis (53.3%) and recurrent pneumonia (46.6%), usually affecting the right upper lobe. Regarding associated anomalies, 33% had tracheomalacia, 32% congenital cardiovascular malformations, 28% gastroesophageal reflux, 22.5% congenital tracheal stenosis, and 8.3% Down syndrome. This series appears to be the most extensive published to date addressing this topic and, according to our data, TRB does not appear to be a mere incidental finding but is more likely linked to a wide range of congenital anomalies and contributes by itself to the recurrent respiratory symptomatology that these children exhibit., (© 2019 Wiley Periodicals, Inc.)

Objective: The aim of this study was to investigate the presence of human papillomavirus (HPV) in biopsy specimens from juvenile and adult patients with histopathological diagnosis of recurrent respiratory papillomatosis (RRP) treated in two public hospitals in Rio de Janeiro, Brazil., Methods: We performed the detection and genotyping of HPV by PCR technique for the types 6, 11, 16, and 18 in biopsy specimens from 41 RRP patients., Results: The juvenile onset RRP (JoRRP) corresponded to 61% and the adult onset RRP (AoRRP) corresponded to 39% of the study group. Prevalence of males was observed in both the adult (81.3%) and the juvenile (56%) groups. Lesions in the larynx were more frequent in the glottis (46%). Genotyping analysis only revealed patients with HPV-6 (34.1%), HPV-11(17.1%), and co-infection HPV-6 and -11 (48.8%). RRP severity was significantly associated with the JoRRP (p<0.001), with extralaryngeal disease and more surgeries. However, no significant association between RRP severity and HPV types was found. One co-infected patient in the JoRRP died due to the evolution of the disease with lung involvement., Conclusion: These results show the strong association of HPV-6 and/or HPV-11 types with RRP and could complement the diagnosis, prognosis, and therapies for these patients. In addition, the HPV vaccination should be encouraged to prevent the disease., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: Our objective was to describe the prevalence and characteristics of tracheal lesions observed in flexile bronchoscopies of tracheostomized patients, and to determine those factors associated with severe injuries., Methods: This is an analytical, observational, and transversal study. The flexible bronchoscopies of tracheostomized patients from our database were reviewed to assess their lesions. The tracheal lesions were classified according to their severity; lesions obstructing above 50% of the lumen were interpreted as severe and those obstructing <50% as mild. The lesions were also classified according to location as glottic, subglottic, at the level of the tracheal ostomy, tracheal, and bronchial. The types of lesions found were granuloma, stenosis, and excessive central airway collapse. Possible predictors of severe lesions were assessed., Results: A total of 414 patients were included in the study, the mean age being 65 years (±16.2 y). Of all the bronchoscopies assessed, 202 (49%) showed mild lesions, and 91 (22%) were severe. We found granulomas in 230 patients (55%), and 32 (26%) were severe. Of the 27 patients with stenosis (7%), 17 (63%) were severe. Excessive central airway collapse was seen in 120 patients (31.8%), and 65 (54%) were severe. There were statistically significant differences related to age in the group that developed severe lesions (mean age, 73 y; Q1 to Q3, 58 to 81) compared with the group free of lesions (mean age, 69 y; Q1 to Q3, 55.7 to 75; P = 0.001) and also in the duration requiring an artificial airway (mean, 84.5 d; Q1 to Q3, 49 to 135.5) compared with the group free of lesions (mean of 59.5 d; Q1 to Q3, 42 to 98; P = 0.035)., Conclusion: There was a high prevalence of tracheal lesions, mainly subglottic granulomas. Age and the duration for which the patient required an artificial airway were related to the presence of severe lesions.

Background: Patients with pulmonary tuberculosis (PTB) have a high risk of concomitant tracheobronchial tuberculosis (TBTB), which commonly causes severe complications such as tracheobronchial stenosis. The prevalence and predictors of TBTB in China remain unclear due to the lack of prospective and large-scale studies., Objectives: To investigate the incidence of TBTB in PTB patients in southern China, and elucidate the predictors of TBTB and related tracheobronchial stenosis., Methods: We prospectively performed bronchoscopy in PTB patients to diagnose TBTB at four medical centres in southern China from September 2015 to August 2016. Clinical and epidemiological data were recorded and analysed to determine predictors of TBTB and related tracheobronchial stenosis., Results: A total of 345 (23.9%) of the 1,442 PTB patients undergoing bronchoscopy were diagnosed with TBTB. Female sex (OR 2.53), age < 50 years (OR 1.88), living in urban (OR 2.19), diabetes (OR 1.84), coughing (OR 2.61), and symptoms ≥4 weeks (OR 1.66) were predictors of PTB concomitant with TBTB. About 59.7% TBTB patients developed tracheobronchial stenosis, of which 23.3% cases presented severe airway narrowing. Female sex (OR 2.27), age < 50 years (OR 2.11), shortness of breath (OR 1.97), and symptoms ≥4 weeks (OR 1.71) were predictors of TBTB-related tracheobronchial stenosis., Conclusions: About 23.9% of PTB patients undergoing bronchoscopy present with TBTB in Guangdong province, southern China. Young and middle-aged females with symptoms persisting for ≥4 weeks (the main predictors of TBTB and related tracheobronchial stenosis) should receive bronchoscopy immediately when diagnosed with PTB., (© 2018 S. Karger AG, Basel.)

Background: Tracheal collapse is a weakness of the tracheal wall leading to expiratory central airway collapse of more than 50% compared to inspiration. It has previously been discussed whether the collapsibility of the greater airways is a stable or a dynamic condition. Indeed, other well-known lung diseases such as asthma are characterized by dynamic changes with respect to pulmonary function indices. There are several different morphologies of the trachea related to collapsibility such as the crescent type and the saber-sheath type both involving the tracheal cartilage and excess dynamic airway collapse only involving the posterior membranous part of the trachea. Is the morphology of the trachea important for the course of the disease? The effect or adverse effects of inhaled corticosteroids are thought to play a role in the increasing incidence of the excess tracheal collapse. In this pilot study, we hypothesized that the excess collapsibility of the tracheal wall is dynamic., Methods: We prospectively examined 20 patients with excessive tracheal collapse on previous CT scans performed primarily due to bronchiectasis. A repeat CT scan was performed in order to evaluate the collapsibility. Before the repeat scan, patients were trained in maximal inspiration, expiration and breathholding. CT was performed in full inspiration and at end-expiration. Image assessment was performed on a dedicated CT workstation using standard lung window display settings. The percentage expiratory collapse based on cross sectional areas from carina to the thoracic inlet was calculated. Pulmonary function tests were performed and analysed in accordance with the American Thoracic Society and the European Respiratory Society guidelines., Results: Repeat CT scan were performed after 24 month +/- 7.2. Six of the 20 participants (30%) were males. Mean age was 67 +/- 11.3 years. Mean FEV1 was 83% of predicted, FVC 96.6 % of predicted and FEV1/FVC-ratio 71%. In 45% of the patients tracheal expiratory collapse improved (by more than 10%) based on percentage change in cross sectional areas in expiration compared to inspiration. 35% of patients showed disease progression with increased collapse and in 20% the collapsibility remained unchanged., Conclusion: We demonstrate that the collapsibility in a large fraction of the patients had actually improved at the follow up examination. We do not find any dependency of the change in collapsibility on the morphology of the trachea after end expiration, use of corticosteroid, or recurrent infections. In addition, no correlation between the changes in collapse and changes in the pulmonary function tests and the symptoms is observed., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

To assess the prevalence of tracheal diverticula (TD) in patients referred for thoracic Computed Tomography (CT).1679 consecutive patients subjected to thoracic CT examination for different causes, from January to June 2017, were included in this cohort study. CT was performed with a 64 slice CT, using a standard protocol and Multiplanar Reformat Images (MPR). A TD was defined as a thin-walled air sac at the paratracheal wall with a communication with the tracheal lumen. Congenital or acquired nature of TD was determined by the anatomical location, being usually the congenital ones located 4 to 5 cm below the vocal cords or a few centimeters above the carina in the right paratracheal area, whereas acquired ones were located at the level of the thoracic inlet, in the posterolateral tracheal wall. Presence of TD was assessed and their number and size recorded based on 2 axial diameters and size of neck.One or more TD were found in 96 patients (5.7% of sample), with a slight preponderance (65%) in male gender. Globally, 124 TD were detected; they were solitary in 75% of cases, double in 20.8%, and in about 4.2% they were triple. Average size of the TD was 1.3×4.9 mm with a mean width of the neck of 1.9 mm. The peak of prevalence (9%) was in patients belonging to the fourth-decade group (see ). According to their anatomical location, the majority (97.6%) of TD were acquired in nature and devoided of specific symptoms (see below).(Table is included in full-text article.)Acquired TD were detected in about 1 out of 20 of thoracic CTs and were usually incidentally. Our findings show a slightly higher frequency than previously reported. The most frequent presentation was in male and as a single entity. Clinically, TD was not associated with specific symptoms, in particular with chronic cough or Chronic Obstructive Pulmonary Disease (COPD).

A right aortic arch (RAA) with a left arterial duct (LAD) together encircle the trachea and have the potential to cause tracheobronchial compression and published guidelines recommend bronchoscopy in symptomatic patients. The aim of the study was to describe the incidence of tracheal compression in a cohort of prenatally diagnosed RAA and LAD. Retrospective review of clinical course and imaging of prenatal cases of RAA and LAD assessed with flexible bronchoscopy over an 11-year period. 34 cases of prenatally diagnosed RAA with LAD underwent bronchoscopy at median age of 9 months (range 0.4-123) of whom 11 had respiratory symptoms and 23 were asymptomatic. In the neonatal period, three cases demonstrated respiratory symptoms. An aberrant left subclavian artery (ALSA) was identified in 29 cases. Pulsatile tracheal compression was identified in 32/34 (94%) cases and two cases showed normal tracheal appearances. Significant tracheal compression (> 70% occlusion) was present in 25/34 (74%) cases of which 16 were asymptomatic. Significant carinal compression (> 70% occlusion) was identified in 14/34 (42%) cases, an ALSA was observed in 13/14. Surgical relief of a vascular ring has been performed in 27 (79%) cases at a median age of 15 months (range 0.6-128 months). At surgery, a fibrous remnant of an atretic left aortic arch was identified in 11/27 (41%) cases. Significant tracheal compression may be present in infants even without symptoms. If early relief of airway compression is to be achieved to promote normal development of tracheal cartilage, early bronchoscopy should be considered.

Objective: To determine whether the risk of developing a tracheocutaneous fistula (TCF) increases with longer tracheostomy dependence times in children., Study Design: Retrospective review of medical records., Method: A retrospective chart review was conducted for all children who both underwent tracheotomy and were decannulated between 2002 and 2011 at a tertiary children's hospital. Charts were analyzed for duration of tracheostomy and evidence of TCF up to 12 months. Data for these criteria was available on 164 out of 182 patients., Results: A significant difference in the duration of tracheostomy dependence between children with and without resultant TCF was determined by the Wilcoxon signed rank test (P = 0.0003). The relative risk (RR) of a persistent TCF was significantly increased when the duration of tracheostomy dependence was greater than 24 months (RR = 2.5217, P < 0.005) when compared to those decannulated before 12 months. The mean tracheostomy dependence times for children with and without TCF were 33.1 and 23.4 months, respectively. Overall, 94 children (57.3%) developed a TCF., Conclusion: To our knowledge, this study represents the largest collection of data for children who have been decannulated following tracheostomy placement. These data demonstrate that the risk of developing a TCF increases with longer tracheostomy dependence times in children., Level of Evidence: 4. Laryngoscope, 127:2709-2712, 2017., (© 2017 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: Tracheal diverticula (TD) are rare anomalies that may harbor infected secretions, posing potential risk to patients with lung disease. In an end-stage cystic fibrosis (CF) cohort, we describe the characteristics and associated post-lung transplant (LTx) outcomes of TD., Methods: Pre-transplant computed tomography (CT)'s were reviewed in CF patients undergoing LTx. TD were characterized radiographically and on autopsy when available. Pre-transplant clinical variables and post-transplant outcomes were compared by TD status., Results: Of 93 patients, 35 (37.6%) had TD. 58% of TD had fat-stranding, and post-mortem TD examinations revealed histology carrying intense submucosal inflammation, and purulent contents that cultured identical species to sputum. There was no difference in post-LTx survival [HR 1.77 (0.82-3.82), p=0.147], bacterial re-colonization, or rejection in patients with TD compared to those without. Patients with TD were more likely to die from infection, but the result was not statistically significant [HR 2.02 (0.62-6.63), p=0.245]., Conclusions: We found a high prevalence of TD in end-stage CF, where diverticula may represent a large-airway bacterial reservoir. TD were not associated with differences in post-LTx outcomes, but given the infectious concerns further investigation is necessary., (Copyright © 2017 European Cystic Fibrosis Society. Published by Elsevier B.V. All rights reserved.)

Background: The objective of this study was to identify the characteristics and incidence of Tracheobronchial branching abnormalities in patients with microtia and to evaluate the risk of anesthesia., Methods: A total of 204 consecutive microtia patients and 465 nose cosmetic patients without microtia received a preoperative chest computed tomography. A retrospective study was performed with the clinical and imaging data from July 2016 to April 2017., Results: With the chest computed tomography images, a total of 7 cases were documented with Tracheobronchial branching abnormalities, including 6 cases among the microtia patients and 1 case among the cosmetic patients without microtia. The incidence of Tracheobronchial branching abnormalities was higher in microtia patients than the cosmetic patients without microtia (2.94% versus 0.22%, P < 0.01)., Conclusions: The incidence of Tracheobronchial branching abnormalities was high in patients with microtia. Preoperative diagnosis of tracheal bronchus can help anesthesiologists avoid complications. Microtia with Tracheobronchial branching abnormalities may involve a new syndrome previously undiscovered or just another extension with the very wide spectrum of microtia., (Copyright © 2017. Published by Elsevier B.V.)

Tracheal cartilaginous sleeve (TCS) is a rare and previously unrecognized source of morbidity and mortality in patients with certain craniosynostosis syndromes. There is a paucity of reporting on this airway anomaly, and the true incidence of TCS is largely unknown. The purpose of this study was to investigate the incidence of TCS among patients with syndromic craniosynostosis at our institution. Patients with syndromic craniosynostosis who underwent direct bronchoscopy and laryngoscopy were evaluated retrospectively by pediatric otolaryngologists for the presence of TCS and associated anomalies. Among patients with a diagnosis of syndromic craniosynostosis in our craniofacial database, 10 (37%) were found to have previous direct bronchoscopy and laryngoscopy reports. Of these 10 patients, 2 had Crouzon syndrome, 3 had Pfeiffer syndrome, 3 had Apert syndrome, 1 had Muenke syndrome, and 1 had Antley-Bixler syndrome. Eighty percent (8/10) of these patients were found to have some evidence of TCS. The most commonly observed associated findings included the following: tracheostomy dependency (7/10; 70%), hearing loss (6/10; 60%), obstructive sleep apnea (5/10; 50%), cervical spine anomalies (5/10; 50%), developmental delay (5/10; 50%), and enlarged cerebral ventricles (4/10; 40%). Larger multicenter studies are required to further characterize this airway anomaly and its impact on this patient population. Our results confirm the importance of thorough airway evaluation at initial presentation and the need for validated screening protocols.

Objective: To demonstrate the diagnostic challenge of tracheal hamartoma in a patient with chronic obstructive pulmonary disease (COPD)., Clinical Presentation and Intervention: A 65-year-old man with COPD was admitted with sudden onset of asphyxia attacks related to the position of his body. Computerized tomography (CT) of the neck showed a soft tissue mass with calcification, which occluded more than two-thirds of the proximal part of the trachea. The tumor was completely removed, and histopathology confirmed hamartoma., Conclusion: This case report showed the detection of a primary tracheal tumor on CT. This finding enabled the correct diagnosis and led to appropriate treatment in the form of surgery., (© 2016 S. Karger AG, Basel.)

Background: We aim to assess the prevalence and describe characteristics of tracheal diverticula (TD) in patients with cystic fibrosis (CF)., Methods: This retrospective study included 92 patients with known CF treated in our medical center who had available chest CT, performed between 2001 and 2013. Presence, number, size, and location of TD were recorded on the most recent chest CT. The severity of CF-related pulmonary CT findings and pulmonary function tests were recorded and correlated with the presence of the diverticula., Results: Twenty-six (28%) of the 92 patients (17 males, 9 females, age range 5-59years) had one or more TD. The size of TD ranged from 2mm to 32mm. TDs were on the right posterolateral aspect of the upper tracheain nearly all patients. Small TDs appeared as a focal paratracheal lucency and larger ones as a soft tissue mass with central air bubbles. There was no significant difference in the Bhalla score between patients with and without TD. There was no correlation between the Bhalla score and patients' age, size, or number of diverticula. Pulmonary function tests were worse and declined faster in patients with TD compared to those without., Conclusions: TDs are quite common on chest CT of CF patients. Those with diverticula have significantly worse pulmonary function tests than those without., (Copyright © 2015 European Cystic Fibrosis Society. Published by Elsevier B.V. All rights reserved.)

Difficult tracheal intubation (DI) is more common in thyroid than in other surgical branches due to thyromegaly. Proper preoperative airway evaluation is necessary in order to reduce the potential numerous complications. The study examined the incidence of DI in thyroid surgery and the influence of tracheal dislocation and other risk factors on DI. A prospective study was conducted on 2379 patients who underwent thyroidectomy at the Center for Endocrine Surgery, Clinical Center of Serbia, from 2007 to 2012. Patients were divided into groups with (n = 162) and without DI (n = 2217). Besides tracheal dislocation, another 13 risk factors contained in 13 screening tests and three additional factors of gender, age and diagnosis were defined. The incidence of DI in our study was 6.81%. The presence of tracheal dislocation was statistically significant, but not an independent predictor of DI. The diagnosis, large circumference and small neck length, previous DI, recessive mandible, tooth characteristics and oral anomalies were the most significant and independent predictors of DI. Neck circumference and small neck length had highest sensitivity. Previous DI had highest specificity. Thyromegaly, if causing tracheal dislocation and/or stenosis, represents a significant DI predictor, not individually, but in combination with other factors.

Tracheobronchopathia osteochondroplastica is a rare benign airway disorder which is characterised by submucosal nodules projecting into the tracheo-bronchial lumen usually involving the cartilaginous portions of the tracheo-bronchial tree or larynx. The condition is usually asymptomatic but can rarely present with difficulty during endotracheal intubation or rarely with obstructive airway complications. Bronchoscopic appearance is usually sufficient to make the diagnosis, and tissue biopsies are seldom required. No specific treatment is required in asymptomatic patients. However, interventional bronchoscopy procedures or surgery may be helpful in symptomatic cases.

Background: This study investigated the incidence, diagnosis, treatment, and risk factors for nonmalignant airway erosion after subtotal esophagectomy for thoracic esophageal carcinoma., Methods: Clinical data from all patients with thoracic esophageal carcinoma who underwent right transthoracic subtotal esophagectomy from 2000 to 2012 at our institution were retrospectively reviewed, and the clinical course and outcome of those who developed airway erosion were investigated in detail. Risk factors for airway erosion were calculated by multivariate analysis., Results: Of 1,091 patients enrolled, 15 patients (1.4%) developed nonmalignant airway erosion, which occurred at postoperative day (POD) 7 to 92 (median, 24). Anastomotic leakage or gastric-tube necrosis was detected prior to airway erosion in 14 cases (93.3%). Endoscopic and surgical therapy was administrated to 3 patients. Airway erosion was cured in 9 patients (60.0%). Five patients died from airway erosion directly (mortality, 33.3%). Alimentary leakage or necrosis (p<0.001), preoperative radiotherapy (p=0.004), and reconstruction through the posterior mediastinal route (p=0.051) were independent risk factors for airway erosion development., Conclusions: Airway erosion is a fatal complication after subtotal esophagectomy. Preoperative radiotherapy dramatically increases the risk of developing airway erosion and reduces the probability of spontaneous healing. Aggressive treatment of alimentary leakage or necrosis and reconstruction through the anterior route help to decrease the risk of airway erosion, especially in high-risk patients., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Purpose: To determine incidence, risk factors and outcome of tracheal ischemic lesions related to intubation., Methods: Planned post hoc analysis using patients from a previous randomized controlled study. Fiberoptic tracheoscopy was performed during the 24 h following extubation. In patients with >2 ischemic lesions, ulcer or tracheal rupture, fiberoptic tracheoscopy was repeated 2 weeks after the last extubation. Tracheal ischemic lesions were predefined based on a quantitative score., Results: Ninety-six adult patients were included in this study. Eighty (83 %) patients had at least one tracheal ischemic lesion. Thirty-seven (38 %) patients had a tracheal ischemia score > median score (5; IQ 1, 7). The most common tracheal ischemic lesion was ischemia (68 %), followed by hyperemia (54 %), ulcer (10 %), and tracheal rupture (1 %). Univariate analysis identified duration of neuromuscular-blocking agent use, overinflation of tracheal cuff (>30 cmH2O), percentage of P cuff determination >30 cmH2O, duration of assist-control ventilation, and plateau pressure as risk factors for having a tracheal ischemia score >5. Duration of assist-control mechanical ventilation was the only factor independently associated with tracheal ischemia score >5 [OR (95 % CI) 1.10 per hour (1.02-1.20)]. A fiberoptic tracheoscopy was performed 2 weeks after extubation in 22 patients. This examination was normal in all patients, except the one with tracheal rupture who had marked improvement., Conclusion: Tracheal ischemic lesions are common in intubated, critically ill patients. Duration of assist-control mechanical ventilation through a tracheal tube is the only independent risk factor. These lesions healed in the majority of patients 2 weeks after extubation.

Tracheobronchomalacia (TBM) and hyperdynamic airway collapse (HDAC) can be debilitating diseases associated with decreased functional capacity and poor quality of life, although there is no standard definition of this complex condition, and there are numerous terms used to describe it. The diverse etiology associated with TBM and HDAC can obscure and delay an accurate diagnosis for years. A thorough medical history is important in understanding possible causes and in guiding diagnostic testing. Medical history may also suggest what treatments may be most beneficial., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: COPD has been described as a risk factor for excessive expiratory tracheal collapse, but its prevalence and clinical correlates have not been fully determined. The purpose of this study is to prospectively determine the prevalence of excessive expiratory tracheal collapse among patients with COPD and to test the hypothesis that clinical and/or physiologic parameters will correlate with the presence of excessive tracheal collapse., Methods: We studied 100 adults meeting GOLD (Global Initiative for Obstructive Lung Disease) criteria for COPD, who underwent full pulmonary function tests (PFTs), 6-min walk test (6MWT), St. George's Respiratory Questionnaire (SGRQ), and low-dose CT scan at total lung capacity and during dynamic exhalation with spirometric monitoring. We examined correlations between percentage dynamic expiratory tracheal collapse and PFTs, 6MWT distance, and SGRQ scores., Results: Patients included 48 women and 52 men with mean age 65 ± 7 years, FEV₁ 64% ± 22% predicted, and percentage expiratory collapse 59% ± 19%. Twenty of 100 participants met study criteria for excessive expiratory collapse. There was no significant correlation between percentage expiratory tracheal collapse and any pulmonary function measure, total SGRQ score, or 6MWT distance. The SGRQ symptom subscale was weakly correlated with percentage collapse of the mid trachea (R = 0.215, P = .03)., Conclusions: Excessive expiratory tracheal collapse is observed in a subset of patients with COPD, but the magnitude of collapse is independent of disease severity and does not correlate significantly with physiologic parameters. Thus, the incidental identification of excessive expiratory tracheal collapse in a general COPD population may not necessarily be clinically significant.

Introduction: The aim of the work was to assess early complications of Griggs percutaneous tracheotomy in the own material., Material and Methods: The study covered 155 patients aged 17-88, including 36 women and 119 men. The patients were treated at the Department of Anaesthesiology and Intensive Therapy between 2006-2010. They underwent Griggs percutaneous tracheostomy by a laryngologist or a trained anaesthesiologist. Each surgical procedure was conducted with the use of Portex Blue Line Ultra Percutaneous Tracheotomy Kit (Smiths Medical Co., USA), the trachea was intubated while the patient was under general anaesthesia with propofol, fentanyl and relaxation with atracurium., Results: The studied material revealed Griggs percutaneous tracheotomy complications in 26 patients (16.8%), in which 11 patients (7.1%) presented complications within the perioperative period while 15 patients (9.7%) reported early complications. Haemorrhage, usually not very profuse, occurred 7 times (4.6%), mainly in tracheopunction, and was the most often perioperative complication. Moreover, in the perioperative period, 3 patients (1.9%) had trachea identifications difficulties, which required tracheopunction many a time, and 1 patient (0.65%) encountered sudden circulatory arrest with asystolia and effective CPR. In the early postoperative period after Griggs percutaneous tracheotomy, the most common complication was haemorrhage in the operative twenty-four hours, which was noted in 10 patients (6.5%). Among other adverse complications were found: infection of the tissues near the tracheostomal region in 3 patients (1.9%), subcutaneous oedema in 1 patient (0.65%), accidental removing the tube from an unformed tracheostoma in 1 patient (0.65%)., Conclusions: In the studied material, complications after Griggs percutaneous tracheotomy amounted to 16.8%, of which 7.1% occurred in the perioperative period while 9.7% were early complications, mainly light bleeding. This may prove good preparation of the surgical team for the surgical procedures., (Copyright © 2012 Polish Otolaryngology Society. Published by Elsevier Urban & Partner Sp. z.o.o. All rights reserved.)

Objectives: To report survey results of members of the American Society of Pediatric Otolaryngology (ASPO) on the practice patterns of surveillance endoscopy and management of suprastomal granuloma (SSG) in children younger than 2 years with indwelling tracheostomy tubes and to review our internal practice patterns., Patients: All patients younger than 2 years who underwent tracheotomy between 1996 and 2006 at a tertiary children's hospital., Interventions: (1) Retrospective medical chart summary and (2) ASPO-approved and -administered online surveys to the membership of a 14-question survey on indications for infant tracheotomy, indications for bronchoscopy after tracheotomy, and treatment preferences for SSG in this population., Main Outcome Measures: Summary and findings of survey results and of data collected from medical chart review, including demographics, medical comorbidities, age at time of tracheotomy, indications for tracheotomy, frequency of bronchoscopy after tracheotomy, frequency of observed SSG, and interventions for SSG., Results: Seventy-five ASPO members completed the online surveys. Practice patterns varied for frequency of bronchoscopy: only as needed, every 12 months, every 6 months, and every 3 months were reported by 38% (n = 26), 25% (n = 17), 24% (n = 17), and 9% (n = 6) of ASPO members, respectively. Most important indications for bronchoscopy were preparation for laryngotracheal reconstruction and decannulation (100% [n = 65] and 92% [n = 60], respectively), bleeding (76% [n = 59]), and difficult tracheostomy tube changes (70% [n = 57]). Lumen obstruction of 25% to 50% and 50% to 75% by SSG would likely receive intervention (30% [n = 22] and 14% [n = 11], respectively) with skin hook eversion and removal being the most popular technique. We reviewed the medical records of a total of 201 infants who underwent tracheotomy at our institution (110 boys [54.7%]). Indications included ventilator dependence (32.2%), craniofacial anomaly (15.0%), cardiopulmonary insufficiency(15.0%), neuromuscular indication (15.0%), and subglottic stenosis (6.7%). Thirty patients (14.9%) were premature (mean gestational age, 27 weeks). Median age at time of tracheotomy was 4 months for premature infants and 3 months for term infants. Practice patterns regarding endoscopy and SSG management varied widely within our own institution. A total of 205 bronchoscopies were performed on 109 patients during the study period. At the time of first bronchoscopy 43 of 109 patients were noted to have an SSG (39.4%). Elective removal of SSG occurred in 20 of 43 cases (46.5%), and 9 of 20 patients were noted to have recurrent SSG at subsequent endoscopy (45%). In addition, of the 23 children who did not have intervention for their SSG, 15 of 23 had spontaneous resolution and no appreciable SSG at the time of follow-up endoscopy (65.0%)., Conclusions: There are currently various practice patterns for surveillance endoscopy and management of SSG in children younger than 2 years with indwelling tracheostomy tubes. Development of clinical practice guidelines on this topic may improve patient care and reduce unnecessary procedures.

Tracheal papillomatosis (TP) is a benign condition characterized by papillomatous growth of the bronchial epithelium that involves the trachea. This abnormal growth is a result of infection with human papilloma virus (HPV). Two subtypes of HPV were found in most cases of TP, HPV-6 and HPV-11. TP, presents in two forms, the juvenile onset (JO) or adult onset (AO). The clinical presentation is typically nonspecific and it ranges from mild symptoms like cough to life-threatening conditions like upper airway obstruction. Treatment depends on the location of the papillomas and age of the patient and the plan of therapy is usually made on an individual basis. Treatment can range from observation with symptomatic control to specific medical therapy and multiple surgeries in case of recurrence or progressively worsening disease. The recent invention of HPV vaccine is expected to be the first step in eradicating respiratory papillomatosis.

Objective: To perform risk analysis of tracheal injuries caused by endotracheal intubation (ETI) and to estimate the financial impact of these sequelae., Study Design: Cost analysis using a national database., Settings: The Agency for Healthcare Research and Quality (AHRQ) 2006 National Inpatient Sample., Subjects and Methods: We identified clinical manifestations and treatments of complications associated with endotracheal tubes and codified them into International Classification of Disease-ninth revision diagnosis and procedure codes, intentionally excluding alternative etiologies of tracheal injury. Using the AHRQ 2006 National Inpatient Sample, we then compared patients with tracheal injury coded during the medical or surgical stay for length of stay (LOS) and mean hospital cost with diagnosis-related group (DRG)-matched controls; we also examined readmissions treating tracheal injury., Results: Tracheal injury presents as tracheal stenosis, tracheomalacia, tracheoesophageal fistula, laryngotracheal ulceration, and vocal cord paralysis. A total of 3232 discharge records met criteria for tracheal injury from ETI within the index hospital stay. Average LOS for patients with tracheal injury (6.3 days; 95% confidence interval [CI] 6.0-6.3) exceeded LOS in the uncomplicated sample (5.2 days; CI 5.1-5.3) by 1.1 days. The average hospital cost was $1888 higher with tracheal injury ($10,375 [CI $9762-$10,988] vs $8487 [CI $8266-$8669]). LOS for procedures treating prior tracheal injury averaged 4.7 days and cost an average of $11,025 per discharge., Conclusion: Tracheal injury from ETI is associated with a significant increase in healthcare costs that accrue both during the index admission and during subsequent hospitalizations required to treat the injury., (2010 American Academy of Otolaryngology-Head and Neck Surgery Foundation. Published by Mosby, Inc. All rights reserved.)

Objective: To assess the rate of tracheocutaneous fistula requiring surgical repair and the complications and outcomes following it in the ENT department of a tertiary referral university paediatric hospital., Methods: A retrospective review of all children requiring airway support with a tracheostomy between 1995 and 2009 and subsequently requiring closure of tracheocutaneous fistula., Results: One hundred and ninety-three children underwent 196 tracheostomies. Seventy-three children were successfully decannulated until now. Twenty-three children (11.9%) required subsequent surgical closure of their tracheocutaneous fistula. In all these children the age at tracheostomy was less than 1 year old, and the median age at decannulation was 4 years old, (range 2-9 yo). Surgical repair was undertaken 6-12 months after decannulation. There were 4 minor complications in the postoperative period (wound infection, haemorrhage and early recurrence) and no major complications. None of the patients have experienced any degree of significant airway stenosis and there was no need for a repeat tracheotomy in any of the tracheocutaneous fistula closure patients. The cosmetic results were deemed to be good., Conclusions: Our rate of tracheocutaneous fistula compares well with the reported rates in the literature (13-43%). There appears to be a significant relation to age at tracheostomy and duration of tracheostomy., (Copyright (c) 2010 Elsevier Ireland Ltd. All rights reserved.)

The aim of this study was to determine the prevalence of airway malacia and its relationship with ancillary morphologic features in patients with chronic obstructive pulmonary disease (COPD). A retrospective review was performed of a consecutive series of patients with COPD who were imaged with inspiratory and dynamic expiratory multidetector computed tomography (MDCT). Airway malacia was defined as > or =50% expiratory reduction of the airway lumen. Both distribution and morphology of airway malacia were assessed. The extent of emphysema, extent of bronchiectasis and severity of bronchial wall thickness were quantified. The final study cohort was comprised of 71 patients. Airway malacia was seen in 38 of 71 patients (53%), and such proportion was roughly maintained in each stage of COPD severity. Almost all tracheomalacia cases (23/25, 92%) were characterised by an expiratory anterior bowing of the posterior membranous wall. Both emphysema and bronchiectasis extent did not differ between patients with and without airway malacia (p > 0.05). Bronchial wall thickness severity was significantly higher in patients with airway malacia and correlated with the degree of maximal bronchial collapse (p < 0.05). In conclusion, we demonstrated a strong association between airway malacia and COPD, disclosing a significant relationship with bronchial wall thickening.

Background: Following esophagectomy, tracheobronchial lesions (TBLs) can occur as a result of ischemia caused by extensive dissection around the tracheobronchus. In this study we assessed the causes and clinical features of these complications, paying particular attention to lymph node (LN)-related factors., Methods: Between January 2000 and March 2007, 305 consecutive patients underwent subtotal esophagectomy using a transthoracic approach with LN dissection for thoracic esophageal cancer. TBLs, including erosions, ulcers, and fistulae, without traumatic injury during the operation, were detected during bronchoscopic examinations performed twice daily after the operation. The correlation between TBLs and tumor or surgical factors were analyzed., Results: TBLs were observed in 14 patients, accounting for an overall incidence of 5%; these included 6 fistulae, 5 ulcers, and 3 erosions. Cases with TBLs significantly more often involved three-field LN dissections (3FLD) than those without TBLs. Six (43%) patients with TBLs had more than four metastatic lymph nodes, while 9 (64%) had cervical and upper-mediastinal LN metastasis (p=0.034 and 0.041, respectively). More than 60 LNs were dissected from 10 (71%) patients with TBLs (p=0.021), and logistic regression analysis revealed that dissection of more than 60 lymph nodes and 3FLD were independent predictors of TBLs., Conclusions: Esophageal cancer patients requiring extensive LN dissection of more than 60 nodes and/or 3FLD have an increased risk of developing a TBL during their postoperative course.

Objective: To describe the clinical and laboratory findings, diagnostic features, and outcome of tracheal collapse in American Miniature Horses at a referral institution., Design: Retrospective case series., Animals: 13 American Miniature Horses with tracheal collapse., Procedures: Medical records of American Miniature Horses with tracheal collapse at a referral hospital were reviewed. Data extracted included signalment, history, clinical signs, laboratory data, diagnostic procedures, outcome, and histologic findings., Results: Tracheal collapse was documented in 5.6% of American Miniature Horses admitted to this referral hospital. Median age at onset of clinical signs was 11 years with a range of 2 to 15 years. Common complaints and clinical signs included respiratory distress, tachypnea, inspiratory honking noises, and increased abdominal expiratory effort, which were exacerbated by stressful events, pregnancy, exercise, a dusty environment, and eating. Tracheal collapse was confirmed by use of radiography, endoscopy, fluoroscopy, or postmortem examination. Dorsoventral flattening of the extra- or intrathoracic trachea, or both, was more common than lateral collapse. Tracheal chondromalacia was identified histologically in 4 cases, and mortality rate for affected horses was 10 of 13., Conclusions and Clinical Relevance: Tracheal collapse was relatively common in this study of American Miniature Horses, and outcome was poor. The etiopathogenesis of the disease remains unknown.

Background: Tracheobronchomalacia (TBM) disorders in children have never been studied using quantified measurements and validated clinical outcome measures. The objectives of the study were to prospectively examine the relationship between malacia lesions and their respiratory illness profiles., Methods: The site of malacia lesions (eg, tracheomalacia, TBM, and bronchomalacia) were determined, measured, and related to the respective cricoid (ie, airway/cricoid ratio) using the color histogram mode technique. These children and normal control subjects were followed up for 12 months with their respiratory illness profiles determined using the Canadian Acute Respiratory Illness Scale (CARIFS) and cough diary scores., Measurements: Outcome measures were respiratory illness frequency (> 12 months), severity score (day-1 CARIFS score), and significant cough interfering with daily activity (score of >or= 3) and illness resolution (time to return to a quarter of CARIFS day 1 score)., Results: The group of 116 children were composed of patients with malacia (n = 81) and control subjects (n = 35). The median age of the group was 2.1 years (age range, 0.2 to 17.3 years). The adjusted relative risk of illness frequency was 2.1 (95% confidence interval [CI], 1.3 to 3.4), and of significant cough was 7.2 (95% CI, 1.01 to 27.22) for the malacia group while CARIFS day 1 score was 1.66 (95% CI, 1.1 to 2.56) compared to control subjects. Illness resolution rates at day 14 in the malacia group trended 25% slower than those for control subjects. Malacia type and severity of lesions were not associated with increased rates of illness or worse clinical profiles., Conclusion: Children with malacia have an increased likelihood of respiratory illness frequency, severity, significant cough, and tendency for delayed recovery. However, neither the site nor the severity of malacia exhibited any significant dose effect on respiratory illness profiles.

Tracheoinnominate fistula is a rare but lethal condition that requires emergent surgical intervention to prevent ensuing exsanguinating hemorrhage. In clinical situations where the risk of open surgery is prohibitively high, endovascular repair may provide a life-saving alternative to control hemorrhage and serve as a temporizing or definitive solution based on a given clinical scenario. The authors report successful endovascular repair of the bleeding tracheoinnominate fistula with a stent in a liver transplant patient with high comorbidities and review the current literature.

Tracheal collapse is common in middle age toy and miniature breed dogs. Cartilaginous defects have been identified histologically and are considered a form of chondromalacia. In addition to tracheal cartilaginous changes, concurrent lower airway histologic changes indicative of inflammation have been noted in dogs with tracheal collapse and these changes may lead t o concurrent bronchiectasis. The purpose of this study was to investigate the prevalence of bronchiectasis in dogs with a previous radiographic diagnosis of tracheal collapse. The thoracic radiographs of 60 dogs with tracheal collapse were evaluated for evidence of concurrent bronchiectasis. Eighteen of 60 (30%) dogs had evidence of bronchiectasis, and all were cylindrical in morphology. The signalment of affected dogs was similar to that previously reported. The occurrence of bronchiectasis in this group of dogs with tracheal collapse (18 dogs) was six times higher (P < 0.05) than the expected prevalence within a random sample population (three dogs). The results of this study provide evidence of a link between tracheal collapse and bronchiectasis. A finding of bronchiectasis with tracheal collapse should encourage further evaluation for chronic lower airway disease in these patients.

Background: Although balloon dilation is a safe procedure, it can lead to laceration of the airway, causing bleeding, pneumothorax, pneumomediastinum, or mediastinitis. We therefore determined the incidence and clinical significance of tracheobronchial lacerations after balloon dilation for treatment of benign tracheobronchial strictures., Methods: We evaluated 97 patients who had undergone balloon dilation in 124 sessions for the treatment of benign tracheobronchial strictures. The degree of airway laceration was evaluated bronchoscopically. The cumulative airway patency rate after balloon dilation was compared in patients with and without lacerations using Kaplan-Meier survival curves and log-rank testing., Results: There were 64 tracheobronchial lacerations (51.6%) during the 124 sessions of balloon dilation. Of these, 60 were superficial and 4 were deep, but there were no incidents of transmural laceration. In patients with lacerations, mild chest pain (n = 5), blood-tinged sputum (n = 21), and pneumomediastinum (n = 2) occurred, but all resolved completely within 24 h. All superficial lacerations healed spontaneously within 1 month, and all deep lacerations healed 2 to 9 months after conservative treatment. During the follow-up period, the median cumulative airway patency period in patients with and without lacerations was 24 and 4 months (p < 0.05), respectively., Conclusion: Laceration secondary to balloon dilation in the tracheobronchial tree is relatively common but rarely progresses to transmural laceration and may improve patency outcomes.

Background: Our institute caters to a large number of patients with large, longstanding multinodular goiters; tracheal deviation and resulting airway problems like tracheomalacia are relatively common. However, the literature is sparse on the criteria of early diagnosis and optimum management of tracheomalacia, which our study highlights., Methods: This retrospective study analyzed 900 thyroidectomies carried out during 1990-2005 for which data from 28 patients treated for tracheomalacia after thyroidectomy were available for analysis. Criteria for making a diagnosis of tracheomalacia after thyroidectomy included one or more of the following: normal vocal cord mobility, absence of glottic or subglottic edema or hematoma, soft and floppy trachea on palpation, obstruction to spontaneous respiration on gradual withdrawal of the endotracheal tube., Results: Mean duration of thyroid enlargement was 13.75 years. Only 7 patients had a history of stridor. Tracheostomy was performed in 26 patients, and 2 patients were put on prolonged intubation. Tracheostomy was performed in 18 patients on the operating table, and 8 in the recovery room. The mean weight of the gland was 442 g and histopathology revealed that 11 cases were benign goiter. The tracheostomy tube was removed after an average of 8.5 days. There were no cases of tracheal stenosis on long-term follow-up., Conclusions: Patients with longstanding goiter, even when benign, are more prone to develop tracheomalacia. On the basis of our experience we strongly advocate tracheostomy intraoperatively if the trachea is soft and floppy and/or collapse of the trachea is observed following gradual withdrawal of the endotracheal tube.

Tracheobronchomalacia and excessive dynamic airway collapse are two separate forms of dynamic central airway obstruction that may or may not coexist. These entities are increasingly recognized as asthma and COPD imitators. The understanding of these disease processes, however, has been compromised over the years because of uncertainties regarding their definitions, pathogenesis and aetiology. To date, there is no standardized classification, diagnosis or management algorithm. In this article we comprehensively review the aetiology, morphopathology, physiology, diagnosis and treatment of these entities.

Many infants with a repaired esophageal atresia (EA) undergo fundoplication, aortopexy, or glossopexy because the mechanisms most responsible for airway obstruction and/or apparent life-threatening event (AO/ALTE) syndrome are considered to be gastroesophageal reflux (GER), tracheal compression (TC), or obstructive apnea, respectively. In the present study, we investigated whether these mechanisms are independent or interrelated. We developed a database of 120 consecutive patients with EA treated by the senior author between 1967-2002. We studied the clinical manifestations of patients with a cervical esophagostomy and/or blind lower esophageal stump, which ruled out TC and/or proximal esophageal GER as a mechanism for AO/ALTE. Of 25 neonates who underwent section/ligation of lower tracheo-esophageal fistula and/or feeding gastrostomy, 10 critically ill neonates died. Of 15 survivors, 9 infants had a feeding gastrostomy without an esophagostomy. Of these, 6 infants presented one or more episodes of AO, and 8 presented ALTE with or without AO. Subsequently, 5 of the 9 infants underwent an esophagostomy. Eventually, 11 infants had a feeding gastrostomy with an esophagostomy. Of the latter, 5 infants presented one or more episodes of AO, and 6 presented ALTE without AO. In conclusion, oral feeding, proximal esophageal GER, and TC are not essential for AO/ALTE syndrome to occur. They are probably factors which offer evidence of an underlying problem with control of upper airway patency.

Surgical wound infection is one of the most frequent complications in pharyngo-laryngeal external surgery. They are usually polimicro with gram-positive, negative both aerobial and anaerobial microrganisms. The trachea is usually sterile and contamination is due to the intoduction during intubation of germs from the oropharyngeal area. A retrospective study was performed including 40 patients with pharyngo-laryngeal carcinoma. When the tracheostomy was done a culture from the internal trachea wall was obtained for micro study. Only one patient had an sterile culture from the trachea. There were 3 patients with just one microorganism and all the rest had at least two, being mixed aerobial and anaerobial flora the most frequent.

Objective: Congenital airway malacia is one of the few causes of irreversible airways obstruction in children, but the incidence in the general population is unknown. Severe airway malacia or malacia associated with specific syndromes is usually recognized and diagnosed early in infancy, but information about clinical features of children with primary malacia, often diagnosed only later in childhood, is scarce., Methods: We analyzed all flexible bronchoscopies performed between 1997 and 2004 in the Sophia Children's Hospital, summarized clinical features of children with primary airway malacia, estimated the incidence of primary airway malacia, and calculated the predictive value of a clinical diagnosis of airway malacia by pediatric pulmonologists., Results: In a total of 512 bronchoscopies, airway malacia was diagnosed in 160 children (94 males) at a median age of 4.0 years (range, 0 to 17 years). Airway malacia was classified as primary in 136 children and secondary in 24 children. The incidence of primary airway malacia was estimated to be at least 1 in 2,100. When pediatric pulmonologists expected to find airway malacia (based on symptoms, history, and lung function) prior to bronchoscopy, this was correct in 74% of the cases. In 52% of the airway malacia diagnoses, the diagnosis was not suspected prior to bronchoscopy. Presenting clinical features of children with airway malacia were variable and atypical, showing considerable overlap with features of allergic asthma. Peak expiratory flow was more reduced than FEV(1)., Conclusion: Primary airway malacia is not rare in the general population, with an estimated incidence of at least 1 in 2,100 children. Airway malacia is difficult to recognize based on clinical features that show overlap with those of more common pulmonary diseases. We recommend bronchoscopy in patients with impaired exercise tolerance, recurrent lower airways infection, and therapy-resistant, irreversible, and/or atypical asthma to rule out airway malacia.

Vascular ring anomalies are developmental anomalies of the thoracic great vessels resulting in complete or partial encircling of the esophagus and the trachea by a vascular ring formation. Persistent right aortic arch with left ligamentum arteriosum accounts for 95% of vascular ring anomalies in dogs. The dog in this report had a double aortic arch, which is a type 4 vascular ring anomaly. Double aortic arch is a rare congenital heart defect resulting from the improper development of the embryonic arches. The prognosis for dogs that have undergone surgery for correction of double aortic arches is generally regarded as poor. The dog in this report underwent surgery for correction of double aortic arches and recovered without dilation or motility disorders of the esophagus. Results indicate that small animals that undergo early surgical correction of double aortic arches with relief of esophageal constriction can have a good prognosis. To the authors' knowledge, there have been no previous reports of dogs that have survived long enough to be discharged from the hospital after surgical correction of double aortic arches.

Purpose: Aspiration as a result of gastroesophageal reflux (GER) and regurgitation remains a serious potential problem in anesthetized patients. The incidence of GER with either the Esophageal Tracheal Combitube (ETC) or the laryngeal mask airway (LMA) was investigated using tracheal and esophageal pH electrodes., Methods: Following approval by the Institutional Review Board and written informed consent, 57 patients of ASA physical status I to III were randomly assigned to receive either an LMA (Group I, n = 28) or an ETC (Group II, n = 29) during general anesthesia. All patients were paralyzed and received positive pressure ventilation. Two monocrystalline antimony catheters were used for pH monitoring: one unipolar catheter with a single pH sensor for tracheal pH measurements and one bipolar catheter with proximal and distal sensors for pharyngeal and esophageal pH measurements, respectively., Results: One episode of GER occurred in a patient in Group II, yet there were no pH changes reflected in the oropharyngeal or tracheal regions. There were 3/25 (12%) patients in Group I vs 1/25 (4%) patients in Group II that met the pH criterion for aspiration (pH below 4.0 that lasted at least 15 sec), yet no patient developed any clinical signs of aspiration. In all patients, hemodynamic and respiratory variables remained stable throughout the period of measurement (data not included)., Conclusion: In this pilot study, the ETC appears comparable to the LMA regarding the incidence of GER and tracheal acid aspiration.