Correlação entre ausculta cervical e eletromiografia de superfície na fase faríngea da deglutição / Correlation between cervical auscultation and electromyography in the pharyngeal phase of swallowing / Correlación entre auscultación cervical y electromiografía de superficie en la fase faríngea de la deglución

Objetivo: Correlacionar os dados acústicos da ausculta cervical com a atividade elétrica dos músculos envolvidos na fase faríngea da deglutição. Métodos: Trata-se de um estudo observacional, transversal, de abordagem quantitativa, aprovado em janeiro pelo CEP/UFSCPA (número 1.389.050). Todos os participantes do estudo assinaram o termo de consentimento livre e esclarecido. A fase faríngea da deglutição foi avaliada por meio de ausculta cervical e eletromiografia de superfície. Os indivíduos ingeriram 90 ml de água. Os dados da ausculta foram transferidos para o DeglutiSom® software, a duração e amplitude da atividade eletromiográfica foram mensuradas durante a deglutição com aparelho de eletromiografia de superfície Miotec®. O nível de significância adotado foi de 5%. Resultados:Cinquenta e sete mulheres participaram deste estudo. A média de idade foi de 23,4 anos. Ressalta-se que quanto maior a frequência média do pico da ausculta, menor é a média do pico do músculo supra-hióideo e quanto maior a intensidade, maior é o pico, assim como a média dos picos supra-hióideos. Foi possível demonstrar que o pico de atividade do músculo supra-hióideo foi significativamente maior do que o pico de atividade do músculo infra-hióideo para a deglutição de 90 ml de água. Conclusão:Os parâmetros acústicos da deglutição em indivíduos saudáveis estão correlacionados com a atividade elétrica dos músculos envolvidos na fase faríngea da deglutição.

Objective: Correlate the acoustic data of cervical auscultation to the electrical activity of the muscles involved in the pharyngeal phase of swallowing. Methods: This is an observational, cross-sectional study involving a quantitative approach and was approved on January by CEP/UFSCPA (number 1.389.050). All participants of the study signed an informed consent form. The pharyngeal phase of swallowing was assessed by employing auscultation and surface electromyography. Individuals ingested 90 ml of water. The auscultation data were transferred to DeglutiSom® software, the duration and amplitude of electromyographic activity was measured during swallowing using a Miotec® surface electromyography device. The level of significance adopted was 5%. Results: Fifty-seven women participated in this study. The average age was 23.4 years on average. It must be highlighted that the greater the average peak frequency of auscultation, lower was the average peak of the suprahyoid muscle and the greater the intensity, the greater was the peak, as well as the average of the suprahyoid peaks. It was possible to demonstrate that the peak of suprahyoid muscle activity was significantly higher than the peak of infra hyoid muscle activity for swallowing 90 ml of water. Conclusion: The acoustic swallowing parameters in healthy individuals are correlated with the electrical activity of muscles involved in the pharyngeal phase of swallowing.

Objetivo: Correlacionar los datos acústicos de la auscultación cervical con la actividad eléctrica de los músculos involucrados en la fase faríngea de la deglución. Métodos: Se trata de un estudio observacional, transversal, de abordaje cuantitativo y aprobado en enero por CEP/UFSCPA (número 1.389.050). Todos los participantes del estudio firmaron un formulario de consentimiento informado. La fase faríngea de la deglución se evaluó mediante auscultación y electromiografía de superficie. Los individuos ingirieron 90 ml de agua. Los datos de auscultación fueron cargados em el software DeglutiSom®, la duración y la amplitud de la actividad electromiográfica se midió durante la deglución utilizando un dispositivo de electromiografía de superficie Miotec®. El nivel de significancia adoptado fue del 5%. Resultados: Cincuenta y siete mujeres participaron en este estudio. La edad promedio fue 23,4 años. Cabe destacar que a mayor frecuencia de pico promedio de auscultación, menor fue el pico promedio del músculo suprahioideo y a mayor intensidad, mayor fue el pico, así como el promedio de los picos suprahioideos. Fue posible demostrar que el pico de actividad del músculo suprahioideo era significativamente más alto que el pico de actividad del músculo infrahioideo para tragar 90 ml de agua. Conclusión: Los parámetros de deglución acústica en individuos sanos se correlacionan con la actividad eléctrica de los músculos involucrados en la fase faríngea de la deglución.

Miniature Non-invasive Blood Pressure Measurement and Verification System / 中国医疗器械杂志

Mercury sphygmomanometer based on traditional auscultation method is widely used in primary medical institutions in China, but a large amount of blood pressure data can not be directly recorded and applied in scientific research analysis, meanwhile auscultation data is the clinical standard to verify the accuracy of non-invasive electronic sphygmomanometer. Focusing on this, we designed a miniature non-invasive blood pressure measurement and verification system, which can assist doctors to record blood pressure data automatically during the process of auscultation. Through the data playback function,the software of this system can evaluate and verify the blood pressure algorithm of oscillographic method, and then continuously modify the algorithm to improve the measurement accuracy. This study introduces the hardware selection and software design process in detail. The test results show that the system meets the requirements of relevant standards and has a good application prospect.

Características demográficas, clínicas, radiológicas y de función pulmonar en pacientes con bronquiectasias / Radiological and pulmonary function clinical demographic characteristics in patients with bronchiectasias

OBJETIVOS: determinar las principales características demográficas, clínicas, radiológicas y de función pulmonar de los pacientes con bronquiectasias en la Clínica del Pulmón. MATERIAL Y MÉTODOS: estudio observacional, retrospectivo. Se revisaron las historias clínicas de 23 pacientes con diagnóstico de dilataciones bronquiales. RESULTADOS: de los 23 pacientes, con una edad media de 49,4 ± 3,87 años, 13 corresponden al sexo femenino y 10 al sexo masculino, el tiempo de evolución de la enfermedad desde el diagnóstico de la patología inicial es de 17,3 ± 2,92 años. La tuberculosis es la etiología principal en 15 pacientes (65,2%). Las manifestaciones clínicas más frecuentes son la tos y expectoración mucopurulenta por varios años en la mayoría de los pacientes, al que añadimos la disnea y hemoptisis, la auscultación pulmonar revela la presencia de crépitos en 17 pacientes (73,9%). La Tomografía de Tórax de Alta Resolución distingue dos tipos de bronquiectasias: La sacular o quística y la cilíndrica, de localización unilobar, bilobar y multilobar (difuso). La Espirometría Forzada fue indicada en 10 pacientes (43,5%) 7 mujeres y 3 varones, el Síndrome Bronquial Obstructivo fue el hallazgo más frecuente. La asociación de Tetraciclina con Metronidazol indicado en 9 pacientes (39,1%) mejoró el cuadro clínico. La fisiopatología de esta entidad clínica está sujeta a una constante actualización. CONCLUSIONES: en pacientes tosedores crónicos, las bronquiectasias deben tener prioridad diagnóstica, se trata de una patología antigua, pero de actualidad permanente.

The purpose of this document is to determine the main epidemiological and clinical characteristics of patients with bronchiectasis at the Lung Clinic. METHOD: observational, retrospective study. The medical records of 23 patients diagnosed with bronchial dilation were reviewed. RESULTS: the results of the 23 patients studied, with a mean age of 49,4 ± 3,87 years, 13 correspond to the female sex and 10 to the male sex, indicate that the time of evolution of the disease from the diagnosis of the initial pathology is: 17,3 ± 2,92 years. Tuberculosis is the main etiology in 15 patients (65,2%). The most frequent clinical manifestations were cough and mucopurulent expectoration of several years in most of the patients, to which we must add dyspnea and hemoptysis, pulmonary auscultation reveals the presence of crepitus in 17 patients (73,9%). High Resolution Chest Tomography distinguishes two types of bronchiectasis: the saccular or cystic and the cylindrical, the localization is unilobar, bilobar and multilobar (diffuse). Forced spirometry was indicated in 10 patients (43,5%), 7 women and 3 men, Chronic Obstructive Pulmonary Disease is the main diagnosis. The association of Tetracycline with Metronidazole indicated in 9 patients (39,1%) had positive results. The pathophysiology of this clinical entity is subject to constant updating. CONCLUSIONS: in chronic coughing patients, bronchiectasis must have diagnostic priority, it is an old pathology, but it is permanently current

Ausculta cervical en el paciente pediátrico con parálisis cerebral Revision narrativa / Cervical auscultation in pediatric patient with cerebral palsy Narrative review

Dentro de la atención clínica, el profesional de la fonoaudiología cuenta con recursos evaluativos para describir la biomecánica secuencial de la ingesta; uno de los recursos utilizados es la Auscultación Cervical (AC). (Dudik et al., 2016) Teniendo en cuenta la descripción de la importancia de la intervención oportuna y efectiva de los procesos de alimentación en los niños con parálisis cerebral, se considera necesario resolver aspectos relevantes alrededor de la relación de las características clínicas de estos niños en su proceso de deglución y los registros del perfil espectrográfico en su fase faríngea de la deglución a partir de la aplicación de la AC. La organización de la revisión establece la búsqueda de artículos científicos en la utilización de la AC en la evaluación clínica de la deglución en sujetos pediátricos y diagnosticados con Parálisis Cerebral. La información encontrada muestra cómo en ausencia de procesos instrumentales de evaluación deglutoria, la AC aporta como beneficio la accesibilidad del procedimiento, además de características de temporalidad en la secuencia de los sonidos deglutorio, sin ningún tipo de factor adverso para su realización. Es por ello que la auscultación es un recurso importante en la evaluación clínica y se puede establecer como un primer paso en el análisis de los aspectos fisiológicos de la fase faríngea de la deglución, pone a la auscultación en una posición privilegiada, pero que debe ser estandarizada por los estudiosos y teóricos del tema.

In the clinical care, the speech language pathologist has evaluative resources to describe the biomechanics of swallowing; one of the resources used is Cervical Auscultation (CA). (Dudik et al., 2016) Taking into account the description of the importance of the timely and effective intervention of the swallowing processes in children with cerebral palsy, it is considered necessary to solve relevant aspects around the relationship of the clinical characteristics of these children in their swallowing process and the records of the spectrographic profile in their pharyngeal phase of swallowing from the application of CA. In the absence of instrumental swallowing evaluation processes, CA provides the accessibility of the procedure as a benefit, in addition to temporality characteristics in the sequence of swallowing sounds, without any type of adverse factor for its performance. The CA is an important resource in clinical evaluation, it establishes a first step in the physiological analysis of swallowing with the physiological aspects of the pharyngeal phase. This puts auscultation in a privileged position, but it must be standardized by cientifics and theorists on the subject.

Instrumentos para captação e análise acústica dos sinais de ausculta cervical na prática clínica fonoaudiológica: uma revisão integrativa de literatura / Instruments for acoustic capture and analysis of cervical auscultation signals in speech-language pathology clinic practice: an integrative literature review

RESUMO Objetivo Descrever os instrumentos utilizados para captação e análise acústica dos sinais de ausculta cervical e identificar aqueles com maior potencial para aplicação na clínica fonoaudiológica. Estratégia de pesquisa Trata-se de uma revisão integrativa de literatura. As buscas foram realizadas nas bases de dados MEDLINE/PubMed, Scopus e Web of Science, a partir da combinação de termos de relevância e operadores booleanos, durante o mês de novembro de 2020. Critérios de seleção Artigos científicos publicados nos idiomas português, espanhol ou inglês, nos últimos cinco anos (2016-2020) e que apresentassem estudo da ausculta cervical. Resultados Foram encontrados 98 artigos. Após a aplicação dos critérios de seleção, 26 artigos foram selecionados para esta revisão. Para captação dos sinais de ausculta cervical, o microfone foi o instrumento mais utilizado, seguido pela técnica de ausculta cervical de alta resolução, que combina sinais acústicos e vibratórios registrados por um microfone e um acelerômetro, respectivamente. Softwares e/ou algoritmos foram selecionados para análise acústica dos sinais, de acordo com o objetivo de cada estudo. Conclusão O método de ausculta cervical de alta resolução e a análise acústica por meio de algoritmos de aprendizado de máquina apresentaram grande potencial para utilização na prática clínica fonoaudiológica para avaliação e monitoramento da deglutição.

ABSTRACT Purpose Describe the instruments used to capture and analyze the acoustic signals obtained from cervical auscultation, and identify those with the greatest potential for application in the speech pathology clinic. Research strategy This is an integrative literature review. Searches were performed in the MEDLINE/PubMed, Scopus and Web of Science databases in November 2020, using relevant keywords combined with Boolean operators. Selection criteria Scientific articles published in Portuguese, Spanish or English in the last five years (2016-2020) and that presented a study of cervical auscultation. Results Ninety-eight articles were found. After the application of selection criteria, 26 articles were selected for this review. Microphones were the most common instruments used to perform cervical auscultation, followed by high-resolution cervical auscultation techniques, which combine acoustic and vibrational signals recorded by a microphone and an accelerometer, respectively. Acoustic analysis was performed using different software packages and/or algorithms depending on the goals of each study. Conclusion The combination of high-resolution cervical auscultation and machine learning for acoustic analysis has great potential for utilization in the clinical assessment and monitoring of swallowing in speech pathology.

La auscultación pulmonar en el siglo 21 / Lung auscultation in the 21th century

La auscultación pulmonar es parte fundamental del examen físico para el diagnóstico de las enfermedades respiratorias. La estandarización que ha alcanzado la nomenclatura de los ruidos respiratorios, sumado a los avances en el análisis computacional de los mismos, han permitido mejorar la utilidad de esta técnica. Sin embargo, el rendimiento de la auscultación pulmonar ha sido cuestionado por tener una concordancia variable entre profesionales de la salud. Aun cuando la incorporación de nuevas herramientas diagnósticas de imágenes y función pulmonar han revolucionado la precisión diagnóstica en enfermedades respiratorias, no existe tecnología que permita reemplazar la técnica de auscultación pulmonar para guiar el proceso diagnóstico. Por una parte, la auscultación pulmonar permite seleccionar a aquellos pacientes que se beneficiarán de una determinada técnica diagnóstica, se puede repetir cuantas veces sea necesario para tomar decisiones clínicas, y frecuentemente permite prescindir de exámenes adicionales que no siempre son fáciles de realizar o no se encuentran disponibles. En esta revisión se presenta el estado actual de la técnica de auscultación pulmonar y su rendimiento objetivo basado en la nomenclatura actual aceptada para los ruidos respiratorios, además de resumir la evidencia principal de estudios de concordancia de auscultación pediátrica y su análisis objetivo a través de nueva tecnología computacional.

Lung auscultation is an essential part of the physical examination for diagnosing respiratory diseases. The terminology standardization for lung sounds, in addition to advances in their analysis through new technologies, have improved the use of this technique. However, traditional auscultation has been questioned due to the limited concordance among health professionals. Despite the revolu tionary use of new diagnostic tools of imaging and lung function tests allowing diagnostic accuracy in respiratory diseases, no technology can replace lung auscultation to guide the diagnostic process. Lung auscultation allows identifying those patients who may benefit from a specific test. Moreover, this technique can be performed many times to make clinical decisions, and often with no need for- complicated and sometimes unavailable tests. This review describes the current state-of-the-art of lung auscultation and its efficacy based on the current respiratory sound terminology. In addition, it describes the main evidence on respiratory sound concordance studies among health professionals and its objective analysis through new technology.

Auscultação dos sons da deglutição de crianças com bronquiolite / Auscultation of swallowing sounds of children with bronchiolitis

RESUMO Objetivo verificar as características acústicas dos sons de deglutição de lactentes com bronquiolite. Métodos estudo retrospectivo por análise de banco de dados aprovado pelo CEP sob o número 1499.911. Os sinais acústicos foram coletados por meio dos estetoscópios eletrônicos da marca Littmann®, modelo 4100. A amostra foi composta por sons da deglutição de lactentes com diagnóstico de bronquiolite viral aguda, internados em um hospital infantil do Sul do país. Os sons armazenados em arquivo digital foram abertos e rodados no software Deglutisom®, sendo verificados e confirmados por dois avaliadores independentes. Estabeleceu-se o pico de frequência, intensidade e intervalos de deglutição. Resultados a amostra de sons da deglutição de 22 crianças, sendo 31,8% do gênero feminino e 68,2% do masculino, apresentou mediana de idade de 81 dias. Encontrou-se diferença entre as características acústicas da deglutição comparadas ao gênero, com maior número de deglutições no gênero feminino (p=0,033). Não houve associação entre as variáveis pico de frequência (m=744 Hz), intensidade (m=52 dB) e tempo de deglutição (5,3s). Conclusão as características acústicas da deglutição da auscultação cervical de lactentes com bronquiolite, analisadas neste estudo, são de pico de frequência grave, intensidade forte, média de duas deglutições por sucção e tempo de deglutição de 5,3 s, havendo diferença entre os gêneros, em relação ao número de deglutições, maior no feminino.

ABSTRACT Purpose To verify the acoustic characteristics of swallowing noise in an infant with bronchiolitis. Methods A retrospective study was performed by database analysis approved by the ERC under the number 1499.911; the acoustic signals were collected through Littmann® model 4100 electronic stethoscopes. The sample was composed of a bank of infants swallowing sounds, diagnosed with acute viral bronchiolitis, children under 12 months-old, hospitalized in a children's hospital in the south of the Country. The sound file storage was opened, and it was rotated in the Deglutisom® software, being verified and confirmed by two independent judges. The peak of frequency, intensity, and swallowing intervals were established. Results The sample totalized a group of 22 babies, 31.8% of the female gender, and 68. 2% of males with a median age of 81 days. There was a difference between the acoustic characteristics of swallowing compared to the gender, regarding the number of swallows, with the highest number of swallows in the female gender (p=0.033). There was no association between the peak frequency (m=744 Hz), intensity (m=52 dB), and swallowing time (5.3s). Conclusion The acoustic characteristics of cervical auscultation swallowing of Infants with bronchiolitis are bass frequency peak, a strong intensity, a mean of two swallows, and a swallowing time of 5.3 s, with the difference between genders concerning the number of swallows, highest in the female.

Análise da concordância da ausculta epigástrica e mensuração do pH na confirmação do posicionamento de sonda nasoenteral / Analysis of epigastric auscultation agreement and pH measurement in the confirmation of nasoenteral tube placement

Justificativa: A sonda nasoenteral é a principal via de escolha para administração de nutrição enteral, líquidos e medicamentos diretamente no trato gastrointestinal. A inserção da sonda naosoenteral às cegas, à beira leito, é um procedimento comum nas instituições de saúde. A confirmação do seu correto posicionamento pode evitar eventos adversos graves, principalmente, os respiratórios. Embora o exame de raios X seja o método de primeira linha para confirmar o posicionamento das sondas nasoenterais, existem restrições quanto ao seu uso. Dentre os métodos clínicos não radiológicos, a ausculta epigástrica é a mais utilizada. Contudo, evidências científicas disponíveis a contraindicam. A mensuração do pH do aspirado gástrico é o método não radiográfico mais recomendado na literatura internacional por apresentar alta sensibilidade, apesar das suas limitações. A partir do exposto, observou-se, no hospital participante deste estudo, práticas não baseadas nas melhores evidências científicas para confirmar o posicionamento de sondas nasoenterais recém inseridas às cegas, à beira leito. A ausculta epigástrica é o método mais utilizado na instituição, seguida pelo exame de raios X. Objetivo: avaliar a concordância entre os métodos clínicos (ausculta epigástrica e mensuração do pH) na confirmação do posicionamento de sonda nasoenteral. Método: estudo transversal realizado em um hospital privado de médio porte do interior do estado de São Paulo. Participaram 49 pacientes que foram submetidos a 90 procedimentos de inserção e confirmação do posicionamento da sonda. Os métodos clínicos foram realizados na seguinte ordem: ausculta epigástrica e mensuração do pH. Em seguida, todos os pacientes foram submetidos ao exame de raios X. Os dados foram coletados por meio de dispositivo móvel e foram inseridos na plataforma on-line Survey Monkey®. Variáveis demográficas, clínicas e terapêuticas foram obtidas do prontuário médico. Foram avaliados parâmetros de sensibilidade, especificidade, valor preditivo positivo e valor preditivo negativo. A concordância, entre os métodos clínicos e o resultado do exame de raios X, foi analisada por meio da estatística AC1, desenvolvida por Gwet. Resultados: A maioria dos pacientes foi do sexo feminino (67,3%), idosa (95,9%), com média de 82 anos de idade, branca (93,8%), aposentada (95,9%) e procedente do estado de São Paulo. O diagnóstico mais frequente, segundo a Classificação Internacional de Doenças (CID-10), foi a colocação de sonda gástrica ou duodenal, e a indicação principal foi a disfagia, seguida de inapetência. Todas as sondas inseridas eram de fino calibre, medidas para serem posicionadas no intestino. A ausculta epigástrica foi o método que apresentou maior sensibilidade (100,0%), porém menor especificidade (2,0%). A ausculta sugeriu que a sonda estava no estômago, quando de fato estava posicionada no intestino, em 51,1%. Ainda, em 2,2%, a ausculta foi positiva para posição gástrica. Contudo, a extremidade distal estava posicionada na junção esofagogástrica. A mensuração do pH apresentou sensibilidade menor (63,0%) que a ausculta, porém, maior especificidade (58%). Entretanto o valor é considerado regular. Ademais, o valor preditivo positivo da mensuração do pH foi de 55% e o negativo, de 66%. Não houve concordância entre a ausculta epigástrica e o exame de raios X (AC1 = 0,109; p = 0,372) e entre o método de mensuração do pH e o exame de raios X (AC1 = 0,206; p = 0,066). Conclusão: Os métodos clínicos avaliados, neste estudo, apresentaram limitações importantes que podem expor os pacientes a riscos. A ausculta epigástrica deve ser abolida da prática clínica e o exame de raios X permanece o método de primeira linha na confirmação do posicionamento de sondas nasoenterais recém inseridas às cegas, à beira leito. Implicações para a prática: Espera-se que os resultados deste estudo possam ser utilizados pelas lideranças do hospital e incorporados ao protocolo institucional para reduzir os riscos relacionados ao mau posicionamento de sondas nasoenterais.

Justification: The nasoenteral tube is the main passage of choice to nutrition management of enteral nutrition, liquids and medication straight to gastrointestinal tract. The blindly insertion of nasoenteral tube at the bedside is an ordinary procedure in health institutions. The confirmation of its correct positioning may prevent adverse events especially respiratory ones. Although the X-ray examination is the first-line method to confirm the placement of nasoenteral tubes, there are restrictions on their use. Among the non-radiological clinical methods, epigastric auscultation is the most used. However, available scientific evidences contraindicate it. The measurement of the gastric aspirated is the non-radiographic method most recommended in the international literature because of its high sensitivity, despite its limitations. From the above, it was observed in the hospital participating in this study, practices non based in the best scientific evidences to confirm the positioning of nasoenteral tubes recently inserted blindly at the bedside. The epigastric auscultation is the most used method in the institution, followed by the X-ray examination. Objective: to evaluate the agreement between the clinical methods (epigastric auscultation and pH measurement) in the confirmation of the nasoenteral tube placement. Method: cross-sectional study carried out in a medium-sized private hospital in the interior of the state of São Paulo. Forty-nine patients who were submitted to ninety insertion procedures and confirmation of tube placement. The clinical methods were performed in the following order: epigastric auscultation and pH measurement. Next, all the patients were submitted to X-ray examination. The data were collected through a mobile device and were inserted in the on-line platform Survey Monkey ®. Demografic, clinical and therapeutic variables were obtained from medical records. Sensitivity, specificity, positive and negative predictive values parameters were evaluated. The agreement of clinical methods and the result of the X-ray examination was analyzed through the AC1 statistics developed by Gwet. Results: most of the patients were female (67.3%), elderly (95.5%), with an average of 82 years old, white (93.8%), retired (95.9%) and from the State of São Paulo. The most frequent diagnosis, according to International Classification of Diseases (ICD10), was the gastric or duodenal tube placement, and the main indication was dysphagia, followed by inappetence. All the tubes inserted were fine caliber, measured to be placed in the intestine. The epigastric auscultation was the method with highest sensitivity (100.0%), but the lowest specificity (2.0%). The auscultation suggested the tube was in the stomach, when in fact was placed in the intestine, at 51.1%. Still, at 2.2% auscultation was positive for gastric position. However, the distal was placed at the esophagogastric junction. The pH measurement was less sensitive (63.0%) than auscultation, but more specific (58%). However, the value is considered regular. Moreover, the positive predictive value of the pH measurement was 55% and the negative, 66%. There was no agreement between epigastric auscultation and X-ray examination (AC1 = 0,109; p = 0,372) and between the pH measurement method and X-ray examination (AC1 = 0,206; p = 0,066). Conclusion: The clinical methods evaluated in this study presented important limitations that can expose patients to risks. The epigastric auscultation should be abolished from clinical practice and X-ray examination remains the first-line method in confirmation of tube placement of newly-inserted nasoenteral tubes blindly at the bedside. Implication for practice: It is hoped that the results of this study can be used by hospital leadership and incorporated to institutional protocol to reduce the risks related to the wrong position of nasoenteral tubes.

Will ultrasound replace the stethoscope?: a case report on neonatal one-lung ventilation / O ultrassom substituirá o estetoscópio?: relato de caso sobre ventilação monopulmonar neonatal

Abstract Background and objectives: One-lung ventilation and selective intubation in neonates can be challenging due to intrinsic physiological specificities and material available. Ultrasound (US) is being increasingly used in many extents of anaesthesiology including confirmation of endotracheal tube position. Case report: We present a case report of a neonate proposed for pulmonary lobectomy by thoracoscopy in which lung exclusion was confirmed by ultrasound. Conclusion: US is a rapid, more sensitive and specific method than auscultation to evaluate tracheal intubation and lung exclusion.

Resumo Justificativa e objetivos: A ventilação monopulmonar e a intubação seletiva em recém-nascidos podem ser um desafio devido às especificidades fisiológicas intrínsecas e ao material disponível. O aparelho de ultrassom tem sido cada vez mais usado em muitas situações no campo da anestesia, incluindo a confirmação da posição do tubo endotraqueal. Relato de caso: Apresentamos o relato do caso de um recém-nascido proposto para lobectomia pulmonar por toracoscopia em que a exclusão pulmonar foi confirmada por ultrassom. Conclusão: O ultrassom é um método rápido, mais sensível e específico do que a ausculta para avaliar a intubação traqueal e a exclusão pulmonar.

A prospective randomized controlled double-blind study comparing auscultation and lung ultrasonography in the assessment of double lumen tube position in elective thoracic surgeries involving one lung ventilation at a tertiary care cancer institute / 대한마취과학회지

BACKGROUND: As lung ultrasound (LUS) can be used to identify regional lung ventilation and collapse, we hypothesize that LUS can be better than auscultation in assessing lung isolation and determining double lumen tube (DLT) position. METHODS: A randomized controlled study was conducted in tertiary care cancer institute from November 2014 to December 2015, including 100 adult patients undergoing elective thoracic surgeries. Patients with tracheostomy, difficult airway and pleural-based pathologies were excluded. After anesthesia induction and DLT insertion, patients were randomized into group A (auscultation) and group B (LUS). Regional ventilation was assessed by experienced anesthesiologists using the respective method for each group. Final confirmation of DLT position with a bronchoscope was performed by a blinded anesthesiologist. Contingency tables were plotted to determine sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy for each method. RESULTS: Data from 91 patients were analyzed (group A = 47, group B = 44). Compared with auscultation, LUS had significantly higher sensitivity (94.1% vs. 73.3%, P = 0.010), PPV (57.1% vs. 35.5%, P = 0.044), NPV (93.8% vs. 75.0%, P = 0.018), accuracy (70.5% vs. 48.9%, P = 0.036) and required longer median time (161.5 vs. 114 s, P < 0.001) for assessment of DLT position. Differences in specificity (55.6% vs. 37.5%, P = 0.101) and area under curve (0.748; 95% CI: 0.604–0.893 vs. 0.554, 95% CI: 0.379–0.730; P = 0.109) were not significant. CONCLUSIONS: Compared to auscultation, LUS is a superior method for assessing lung isolation and determining DLT position.

Blood Pressure Reference Values for Normal Weight Korean Children and Adolescents: Data from The Korea National Health and Nutrition Examination Survey 1998–2016: The Korean Working Group of Pediatric Hypertension

BACKGROUND AND OBJECTIVES: Hypertension is becoming one of the most common health conditions in children and adolescents due to increasing childhood obesity. We aimed to provide the auscultatory blood pressure (BP) normative reference values for Korean non-overweight children and adolescents. METHODS: BP measurements in children and adolescents aged 10 to 18 years were performed in the Korean National Health and Nutrition Examination Survey (KNHANES) from 1998 to 2016. BP was measured using a mercury sphygmomanometer. Sex-, age- and height-specific systolic BP (SBP) and diastolic BP (DBP) percentiles were calculated in the non-overweight children (n=10,442). We used the General Additive Model for Location Scale and Shape method to calculate BP percentiles. RESULTS: The 50th, 90th, 95th, and 99th percentiles of SBP and DBP tables and graphs of non-overweight children and adolescents aged 10 to 18 years were presented by age and height percentiles. We found that the SBP and DBP at the 95th percentile were well correlated with height. The BP tables presented by height contained BP values from 124 cm to 190 cm for boys and from 120 cm to 178 cm for girls. Boys had higher SBP and DBP. CONCLUSIONS: We provided the sex-, age- and height-specific auscultatory BP values using the KNHANES big data. These may be useful in diagnosis and treatment of hypertension in Korean children and adolescents.

Spontaneous pneumothorax in two dogs undergoing combined laparoscopic ovariectomy and total laparoscopic gastropexy

Two dogs underwent a combined laparoscopic ovariectomy and total laparoscopic gastropexy. The intra-abdominal pressure and pulmonary compliance decreased, but the peak airway pressure increased at 20 min after the start of gastropexy with intracorporeal suturing. Right chest auscultation and percussion revealed reduced breath sounds and hyper-resonance. No abnormalities in the functioning of the instruments or diaphragmatic defects were detected. The tidal volume was reduced and a positive end-expiratory pressure of 5 cmH₂O was applied. The right chest of the two dogs was drained off: 950 mL (case 1) and 250 mL (case 2) of gas. After thoracentesis, the pulmonary compliance improved and surgery was completed successfully. The postoperative chest radiographs highlighted the residual right pneumothorax.

Accuracy of chest auscultation in detecting abnormal respiratory mechanics in the immediate postoperative period after cardiac surgery / Acurácia da ausculta torácica na detecção de mecânica respiratória anormal no pós-operatório imediato de cirurgia cardíaca

ABSTRACT Objective: To investigate the accuracy of chest auscultation in detecting abnormal respiratory mechanics. Methods: We evaluated 200 mechanically ventilated patients in the immediate postoperative period after cardiac surgery. We assessed respiratory system mechanics - static compliance of the respiratory system (Cst,rs) and respiratory system resistance (R,rs) - after which two independent examiners, blinded to the respiratory system mechanics data, performed chest auscultation. Results: Neither decreased/abolished breath sounds nor crackles were associated with decreased Cst,rs (≤ 60 mL/cmH2O), regardless of the examiner. The overall accuracy of chest auscultation was 34.0% and 42.0% for examiners A and B, respectively. The sensitivity and specificity of chest auscultation for detecting decreased/abolished breath sounds or crackles were 25.1% and 68.3%, respectively, for examiner A, versus 36.4% and 63.4%, respectively, for examiner B. Based on the judgments made by examiner A, there was a weak association between increased R,rs (≥ 15 cmH2O/L/s) and rhonchi or wheezing (ϕ = 0.31, p < 0.01). The overall accuracy for detecting rhonchi or wheezing was 89.5% and 85.0% for examiners A and B, respectively. The sensitivity and specificity for detecting rhonchi or wheezing were 30.0% and 96.1%, respectively, for examiner A, versus 10.0% and 93.3%, respectively, for examiner B. Conclusions: Chest auscultation does not appear to be an accurate diagnostic method for detecting abnormal respiratory mechanics in mechanically ventilated patients in the immediate postoperative period after cardiac surgery.

RESUMO Objetivo: Investigar a acurácia da ausculta torácica na detecção de mecânica respiratória anormal. Métodos: Foram avaliados 200 pacientes sob ventilação mecânica no pós-operatório imediato de cirurgia cardíaca. Foi avaliada a mecânica do sistema respiratório - complacência estática do sistema respiratório (Cest,sr) e resistência do sistema respiratório (R,sr) - e, em seguida, dois examinadores independentes, que desconheciam os dados referentes à mecânica do sistema respiratório, realizaram a ausculta torácica. Resultados: Nem murmúrio vesicular diminuído/abolido nem crepitações foram associados à Cest,sr reduzida (≤ 60 ml/cmH2O), independentemente do examinador. A acurácia global da ausculta torácica foi de 34,0% e 42,0% para os examinadores A e B, respectivamente. A sensibilidade e a especificidade da ausculta torácica para a detecção de murmúrio vesicular diminuído/abolido e/ou crepitações foi de 25,1% e 68,3%, respectivamente, para o examinador A, versus 36,4% e 63,4%, respectivamente, para o examinador B. Com base nos julgamentos feitos pelo examinador A, houve uma fraca associação entre R,sr aumentada (≥ 15 cmH2O/l/s) e roncos e/ou sibilos (ϕ = 0,31, p < 0,01). A acurácia global para a detecção de roncos e/ou sibilos foi de 89,5% e 85,0% para os examinadores A e B, respectivamente. A sensibilidade e a especificidade para a detecção de roncos e/ou sibilos foi de 30,0% e 96,1%, respectivamente, para o examinador A, versus 10,0% e 93,3%, respectivamente, para o examinador B. Conclusões: A ausculta torácica não parece ser um método diagnóstico acurado para a detecção de mecânica respiratória anormal em pacientes sob ventilação mecânica no pós-operatório imediato de cirurgia cardíaca.

Blood pressure measurement by oscillometric and auscultatory methods in normotensive pregnant women / Evaluación de la presión arterial por los métodos oscilométrico e auscultatorio en embarazadas normotensas / Avaliação da pressão arterial pelos métodos oscilométrico e auscultatório em gestantes normotensas

ABSTRACT Objective: to compare blood pressure values obtained by auscultatory and oscillometric methods in different gestational periods, considering cuff width. Method: it is a cross-sectional and quasi-experimental study approved by the Research Ethics Committee. The sample consisted of 108 low-risk pregnant women. Blood pressure measurements were performed in gestational periods of 10-14, 19-22 and 27-30 weeks. Results: The oscillometric device presented values similar to the auscultatory method in systolic blood pressure, but overestimated diastolic blood pressure. Underestimation of blood pressure occurred when using the standard width cuff rather than the correct width cuff in both measuring methods. Conclusion: Verification of brachial circumference and use of adequate cuffs in both methods are indispensable to obtain reliable blood pressure values in pregnant women. We recommend performance of additional studies to evaluate diastolic blood pressure overestimation by the Microlife 3BTO-A.

RESUMEN Objetivo: Comparar los valores de presión arterial obtenidos por los métodos auscultatorio e oscilométrico en distintos períodos del embarazo, en función del ancho del manguito. Método: Se trata de un estudio transversal y cuasiexperimental aprobado por el Comité de Ética en Investigación. Se analizó una muestra compuesta por 108 embarazadas de bajo riesgo. Las medidas de presión arterial se obtuvieron en los períodos gestacionales de 10-14, 19-22 y 27-30 semanas. Resultados: El aparato oscilométrico presentó valores similares al método auscultatorio en la presión arterial sistólica, sin embargo sobreestimó la presión arterial diastólica. Hubo subestimación de la presión arterial al utilizar el manguito de anchura estándar en lugar del manguito de anchura adecuada, en los dos métodos de medida. Conclusión: La verificación de la circunferencia braquial y el uso de manguitos adecuados en los dos métodos son indispensables para obtener valores confiables de la presión arterial en embarazadas. Recomendamos que se realicen nuevos estudios para evaluar la sobreestimación de la presión arterial diastólica por el aparato Microlife 3BTO-A.

RESUMO Objetivo: Comparar os valores de pressão arterial, obtidos pelos métodos auscultatório e oscilométrico em diferentes períodos gestacionais, em função da largura do manguito. Método: Trata-se de um estudo transversal e quase-experimental aprovado pelo Comitê de Ética em Pesquisa. A amostra foi composta por 108 gestantes de baixo risco. As medidas de pressão arterial foram realizadas nos períodos gestacionais de 10-14, 19-22 e 27-30 semanas. Resultados: O aparelho oscilométrico apresentou valores similares ao método auscultatório na pressão arterial sistólica, porém superestimou a pressão arterial diastólica. Houve subestimação da pressão arterial ao utilizar o manguito de largura padrão ao invés do manguito de largura correta, nos dois métodos. Conclusão: A verificação da circunferência braquial e o uso de manguitos adequados nos dois métodos são indispensáveis para obter valores confiáveis da pressão arterial em gestantes. Recomendamos que novos estudos sejam realizados para avaliar a superestimação da pressão arterial diastólica pelo aparelho Microlife 3BTO-A.

Diagnostic validity of methods for assessment of swallowing sounds: a systematic review / Validade diagnóstica dos métodos de avaliação dos sons de deglutição: uma revisão sistemática

Abstract Introduction: Oropharyngeal dysphagia is a highly prevalent comorbidity in neurological patients and presents a serious health threat, which may lead to outcomes of aspiration pneumonia, ranging from hospitalization to death. This assessment proposes a non-invasive, acoustic-based method to differentiate between individuals with and without signals of penetration and aspiration. Objective: This systematic review evaluated the diagnostic validity of different methods for assessment of swallowing sounds, when compared to videofluroscopy swallowing study to detect oropharyngeal dysphagia. Methods: Articles in which the primary objective was to evaluate the accuracy of swallowing sounds were searched in five electronic databases with no language or time limitations. Accuracy measurements described in the studies were transformed to construct receiver operating characteristic curves and forest plots with the aid of Review Manager v. 5.2 (The Nordic Cochrane Centre, Copenhagen, Denmark). The methodology of the selected studies was evaluated using the Quality Assessment Tool for Diagnostic Accuracy Studies-2. Results: The final electronic search revealed 554 records, however only 3 studies met the inclusion criteria. The accuracy values (area under the curve) were 0.94 for microphone, 0.80 for doppler, and 0.60 for stethoscope. Conclusion: Based on limited evidence and low methodological quality because few studies were included, with a small sample size, from all index testes found for this systematic review, doppler showed excellent diagnostic accuracy for the discrimination of swallowing sounds, whereas microphone-reported good accuracy discrimination of swallowing sounds of dysphagic patients and stethoscope showed best screening test.

Resumo Introdução: A disfagia orofaríngea é uma comorbidade altamente prevalente em pacientes neurológicos e representa uma séria ameaça à saúde, pode levar a desfechos como pneumonia por aspiração, hospitalização e até morte. A avaliação propõe um método não invasivo, acústico, para diferenciar entre indivíduos com e sem sinais de penetração e aspiração. Objetivo: Esta revisão sistemática analisou a validade diagnóstica de diferentes métodos para avaliação dos sons de deglutição, quando comparados com a videofluoroscopia da deglutição para detectar disfagia orofaríngea. Método: Artigos nos quais o objetivo principal era avaliar a acurácia dos sons de deglutição foram pesquisados em cinco bancos de dados eletrônicos sem limitações de idioma ou tempo de publicação. As medidas de acurácia descritas nos estudos foram transformadas para construir curvas ROC (Receptor Operating Characteristic) e gráfico em floresta (forest plot) com o auxílio do software Review Manager v. 5.2 (The Nordic Cochrane Centre, Copenhagen, Dinamarca). A metodologia dos estudos selecionados foi avaliada com a ferramenta Avaliação da Qualidade de Estudos de Acurácia de Testes Diagnósticos-2. Resultados: A busca eletrônica final resultou na identificação de 554 artigos; no entanto, apenas três estudos preencheram os critérios de inclusão. Os valores de acurácia (área abaixo da curva) foram 0,94 para microfone, 0,80 para doppler e 0,60 para estetoscópio. Conclusão: Baseado nas evidências limitadas e da baixa qualidade metodológica, pois foram poucos os estudos incluídos, e com pequeno tamanho amostral, de todos os testes diagnósticos (index testes) encontrados para essa revisão sistemática o doppler mostrou excelente acurácia diagnóstica na discriminação dos sons de deglutição, o microfone demonstrou uma boa acurácia na discriminação dos sons de pacientes disfágicos e o estetoscópio revelou o melhor teste de triagem.

Comparison of auscultatory and oscillometric BP measurements in children with obesity and their effect on the diagnosis of arterial hypertension / Comparación de la medición de PA auscultatoria y oscilométrica en niños con obesidad y su efecto en el diagnóstico de hipertensión arterial

Abstract: Objective: The level of agreement between two blood pressure (BP) reading methods, auscultatory vs oscillometric, was examined using a mercury sphygmomanometer and an electronic device in children and adolescents with different levels of obesity. The readings were compared to determine their impact on the diagnosis of pre-hypertension/hypertension. Methods: Blood pressure readings were taken in children with obesity (body mass index ≥ 95th percentile) and severe obesity (≥120% 95th percentile). Bland-Altman analysis and Intraclass Correlation Coefficient were used to determine the agreement between measurements. Results: The mercury sphygmomanometer readings were lower than those obtained with the electronic device for both systolic and diastolic BP (P = .01 and P = .001, respectively). The mean systolic and diastolic BP differences between the oscillometric vs first mercury reading were 4.2/10.2 mm Hg, respectively. A large difference was observed between the BP measurement methods. The ICC showed regular to moderate reliability for the systolic BP (.595), but poor for the diastolic BP (.330). Screening using the first of three mercury measurements showed that 10.4% of the children and adolescents had BPs within the pre-hypertension/hypertension range. This was reduced to 5.2% when the mean of three mercury readings was used. Conclusions: Large discrepancies were observed in both the systolic and diastolic BP. These differences are not clinically acceptable as to consider the two instruments interchangeable. The electronic device readings were higher, and they overestimated the diagnosis of hypertension. © 2017 Instituto Nacional de Cardiología Ignacio Chávez. Published by Masson Doyma Mèxico S.A. This is an open access article under the CC BY-NC-ND license (https://creativecommons.org/licenses/by-nc-nd/4.0/).

Resumen: Objetivo: Para conocer el grado de concordancia entre 2 métodos de medición de presión arterial (PA), auscultatorio vs oscilométrico se utilizó un esfigmomanómetro de mercurio y un dispositivo electrónico en niños y adolescentes con diferentes grados de obesidad. Las lecturas fueron comparadas para conocer su impacto en el diagnóstico de prehipertensión/hipertensión. Método: Se midió la PA a niños con obesidad (percentil 95 del índice masa corporal) y obesidad severa (120% del percentil 95). Utilizamos análisis de Bland-Altman y Coeficiente de Correlación Intraclase (CCI) para conocer acuerdo entre mediciones. Resultados: Las lecturas con esfigmomanómetro de mercurio fueron más bajas que con el electrónico para la PA sistólica y diastólica (p = 0.01 y 0.001, respectivamente). El promedio de las diferencias en sistólica y diastólica entre oscilométrico vs. primera medición con mercurio fue de 4.2/10.2 mm Hg respectivamente. Se observó una gran diferencia de las mediciones entre los métodos de medición de PA. El CCI mostró una confiabilidad regular a moderada para la sistólica (0.595) pero pobre para la diastólica (0.330). El tamizaje con una medición mediante mercurio mostró que el 10.4% de los niños y adolescentes tenían PA en el rango de prehipertensión/hipertensión, pero se redujo a un 5.2% con el promedio de 3 mediciones. Conclusiones: Se observaron grandes discrepancias en la PA sistólica y diastólica. Tales diferencias no son clínicamente aceptables como para considerar equivalentes los 2 instrumentos. Las mediciones realizadas en este estudio con dispositivo electrónico fueron más altas y sobre estimaron el diagnóstico de hipertensión. © 2017 Instituto Nacional de Cardiología Ignacio Chávez. Publicado por Masson Doyma México S.A. Este es un artículo Open Access bajo la licencia CC BY-NC-ND (https://creativecommons.org/licenses/by-nc-nd/4.0/).

Subcutaneous emphysema, a different way to diagnose / Enfisema subcutâneo: uma forma diferente de diagnosticar

Summary Introduction: Subcutaneous emphysema (SE) is a clinical condition that occurs when air gets into soft tissues under the skin. This can occur in any part of the body depending on the type of pathology. The most common site is under the skin that covers the chest wall or neck. It is characterized by painless swelling of tissues. The classic clinical sign is a crackling sensation upon touch, resembling that of touching a sponge beneath your fingers. Objective: To describe a new way to diagnose subcutaneous emphysema. Method: Our finding was a matter of serendipity while inspecting a patient with subcutaneous emphysema using a stethoscope. Instead only hearing the patient's chest, the stethoscope was gently pressed against the skin with SE and so we were able to detect a different sound. Results: This new way to diagnose subcutaneous emphysema consists in pressing the diaphragm part of stethoscope against the patient's skin where SE is supposed to be. Thus, we are able to hear a sound of small bubbles bursting. Crackle noise has an acoustic emission energy that varies between 750-1,200 Hz, considered high frequency. Conclusion: Although currently the use of imaging methods is widespread worldwide, we would like to strengthen the value of clinical examination. Auscultation is an essential diagnostic method that has become underestimated with the advances of healthcare and medicine as a whole. We therefore propose a different approach to diagnose SE.

Resumo Introdução: O enfisema subcutâneo é uma condição clínica que ocorre quando o ar entra nos tecidos sob a pele. Isso pode ocorrer em qualquer parte do corpo, dependendo do tipo de patologia. O local mais comum é sob a pele que cobre a parede torácica ou o pescoço. É caracterizado por inchaço indolor de tecidos. O sinal clínico clássico é a sensação de crepitação quando se toca a região afetada, assemelhando-se à sensação de se tocar uma esponja. Objetivo: Descrever uma nova maneira de diagnosticar enfisema subcutâneo. Método: Este achado foi uma serendipidade, caracterizada por inspeção clínica de pacientes com enfisema subcutâneo com uso de estetoscópio. Além da auscultação do tórax do paciente, o estetoscópio foi suavemente pressionado contra a pele com enfisema subcutâneo, sendo possível detectar um ruído diferente. Resultados: Essa nova maneira de diagnosticar enfisema subcutâneo consiste em pressionar o diafragma do estetoscópio contra a pele do paciente supostamente afetada por enfisema subcutâneo, sendo possível ouvir o ruído de pequenas bolhas estourando. O ruído de crepitações tem uma energia de emissão acústica que varia de 750-1.200 Hz, considerada alta frequência. Conclusão: Atualmente, o uso de métodos de imagem é generalizado em todo o mundo, mas gostaríamos de fortalecer o valor do exame clínico. Embora a ausculta seja um método de diagnóstico essencial, foi subestimado à medida que os cuidados de saúde e os medicamentos avançaram. Propomos uma maneira diferente de diagnosticar enfisema subcutâneo.

The effect of dental scaling noise during intravenous sedation on acoustic respiration rate (RRa™)

BACKGROUND: Respiration monitoring is necessary during sedation for dental treatment. Recently, acoustic respiration rate (RRa™), an acoustics-based respiration monitoring method, has been used in addition to auscultation or capnography. The accuracy of this method may be compromised in an environment with excessive noise. This study evaluated whether noise from the ultrasonic scaler affects the performance of RRa in respiratory rate measurement. METHODS: We analyzed data from 49 volunteers who underwent scaling under intravenous sedation. Clinical tests were divided into preparation, sedation, and scaling periods; respiratory rate was measured at 2-s intervals for 3 min in each period. Missing values ratios of the RRa during each period were measuerd; correlation analysis and Bland-Altman analysis were performed on respiratory rates measured by RRa and capnogram. RESULTS: Respective missing values ratio from RRa were 5.62%, 8.03%, and 23.95% in the preparation, sedation, and scaling periods, indicating an increased missing values ratio in the scaling period (P < 0.001). Correlation coefficients of the respiratory rate, measured with two different methods, were 0.692, 0.677, and 0.562 in each respective period. Mean capnography-RRa biases in Bland-Altman analyses were −0.03, −0.27, and −0.61 in each respective period (P < 0.001); limits of agreement were −4.84–4.45, −4.89–4.15, and −6.18–4.95 (P < 0.001). CONCLUSIONS: The probability of missing respiratory rate values was higher during scaling when RRa was used for measurement. Therefore, the use of RRa alone for respiration monitoring during ultrasonic scaling may not be safe.

Hypertrophic obstructive cardiomyopathy in a Yorkshire Terrier / 대한수의학회지

An 11-year-old, castrated male dog presented with a 3-month history of cough and depression. Auscultation revealed systolic murmur and thoracic radiographs showing enlargement of both the atrium and left ventricle. Echocardiography showed thickened mitral valve and moderate-to-severe left atrial enlargement. Additionally, M-mode echocardiography showed symmetric left ventricular wall thickening and systolic anterior motion of the mitral valve, while Doppler imaging revealed high velocity turbulent flow through the left ventricular outflow tract. Based on echocardiography, this case was diagnosed with hypertrophic obstructive cardiomyopathy. After 5 months, the dog was clinically static in radiography and echocardiography.

True Aneurysms of the Extracranial Carotid Artery : An Evaluation of Two “Giant Aneurysms” and the Current Literature

True extracranial carotid artery aneurysms (ECCAs) are uncommon. Atherosclerosis is the most common etiological factor. Neck pain, a pulsatile mass and murmur at auscultation are the most common symptoms. ECCAs may exhibit severe clinical manifestations due to complications. Cases of rupture can be fatal. There is a risk of distal embolization and stroke in thrombosed cases. We discuss two cases of enlarged ECCA treated surgically in the light of the most recent literature.