ABSTRACT
Vascular rings are unusual congenital malformations. Among them, double aortic arch (DAA) is often difficult to diagnose due to its low incidence of symptoms. DAA can be associated with tracheal or esophageal compression and, in severe cases, could require tracheal intubation or chronic use of a nasogastric tube. This scenario favors the development of aortotracheal fistulas (ATF) or aortoe-sophageal fistulas (AEF). OBJECTIVE: To present a clinical case with an unusual association of DAA with ATF and to reinforce the importance of maintaining high diagnostic suspicion in patients with massive aerodigestive bleeding without an obvious source. CLINICAL CASE: A 32-week preterm newborn who required prolonged mechanical ventilation and presented intermittent episodes of massive oropharyngeal bleeding with hemodynamic compromise associated with lower airway obstruction without pulmonary hemorrhage. The patient underwent upper endoscopy and exploratory laparotomy without evidence of bleeding. Flexible nasopharyngolaryngoscopy and direct laryngoscopy also showed no abnormalities. A CT angiography showed complete DAA with indentation of the left dominant arch over the trachea, without severe stenosis or evidence of a fistula. AEF was suspected, so exploratory surgery was considered. However, the patient died before surgery due to a massive pulmonary hemorrhage. The autopsy revealed the presence of ATF. CONCLUSIONS: In patients with massive aerodigestive bleeding without an obvious source, the presence of DAA and possible AEF/ ATF should be considered. Imaging studies have a poor performance for this diagnosis, so surgery should be considered for diagnosis and treatment in these patients.
Subject(s)
Esophageal Fistula , Vascular Ring , Humans , Infant, Newborn , Vascular Ring/complications , Vascular Ring/surgery , Esophageal Fistula/diagnosis , Esophageal Fistula/etiology , Esophageal Fistula/surgery , Gastrointestinal Hemorrhage/etiologyABSTRACT
OBJECTIVE: This study aims to create a synthetic laryngeal microsurgery simulation model and training program; to assess its face, content, and construct validity; and to review the available phonomicrosurgery simulation models in the literature. STUDY DESIGN: Nonrandomly assigned control study. SETTING: Simulation training course for the otolaryngology residency program at Pontificia Universidad Católica de Chile. METHODS: Resident (postgraduate year 1 [PGY1]/PGY2) and expert groups were recruited. A laryngeal microsurgery synthetic model was developed. Nine tasks were designed and assessed through a set of programmed exercises with increasing difficulty, to fulfill 5 surgical competencies. Imperial College Surgical Assessment Device sensors applied to the participants' hands measured time and movements. The activities were video-recorded and blindly assessed by 2 laryngologists using a specific and global rating scale (SRS and GRS). A 5-point Likert survey assessing validity was completed by experts. RESULTS: Eighteen participants were recruited (14 residents and 4 experts). Experts performed significantly better than residents in the SRS (p = .003), and GRS (p = .004). Internal consistency was demonstrated for the SRS (α = .972, p < .001). Experts had a shorter execution time (p = .007), and path length with the right hand (p = .04). The left hand did not show significant differences. The survey assessing validity resulted in a median 36 out of 40 points score for face validity; and 43 out of 45 points score, for global content validity. The literature review revealed 20 available phonomicrosurgery simulation models, only 6 with construct validity. CONCLUSION: The face, content, and construct validity of the laryngeal microsurgery simulation training program were established. It could be replicated and incorporated into residents' curricula.
