Clinical application of nasal nitric oxide measurement.

Nitric oxide is present in high concentration in the upper respiratory tract. The main source of this gaseous molecule is the paranasal sinus epithelium. The physiological role of this mediator is to contribute to local host defense, modulate ciliary motility and serve as an aerocrine mediator in helping to maintain adequate ventilationperfusion matching in the lung. Abnormal values of nasal NO (nNO) have been reported in different pathological conditions of the respiratory tract. Reduced nNO values have been recorded in subjects with acute and chronic sinusitis, cystic fibrosis and nasal polyps. Particularly low concentrations have been described in children with primary ciliary dyskinesia, so nNO measurement has been proposed as a reliable screening test for this chronic lung disease.

A new endoscopic technique for suspension of esophageal prosthesis for refractory caustic esophageal strictures.

There is no clear consensus concerning the best endoscopic treatment of benign refractory esophageal strictures due to caustic ingestion. Different procedures are currently used: frequent multiple dilations, retrievable self-expanding stent, nasogastric intubation and surgery. We describe a new technique to fix a suspended esophageal silicone prosthesis to the neck in benign esophageal strictures; this permits us to avoid the frequent risk of migration of the expandable metallic or plastic stents. Under general anesthesia a rigid esophagoscope was placed in the patient's hypopharynx. Using transillumination from the optical device, the patient's neck was pierced with a needle. A n.0 monofilament surgical wire was pushed into the needle, grasped by a standard foreign body forceps through the esophagoscope and pulled out of the mouth (as in percutaneous endoscopic gastrostomy procedure). After tying the proximal end of the silicone prosthesis with the wire, it was placed through the strictures under endoscopic view. This procedure was successfully utilized in four patients suffering from benign refractory esophageal strictures due to caustic ingestion. The prosthesis and its suspension from the neck were well-tolerated until removal (mean duration 4 months). A postoperative transitory myositis was diagnosed in only one patient. One of the most frequent complications of esophageal prostheses in refractory esophageal strictures due to caustic ingestion is distal migration. Different solutions were proposed. For example the suspension of a wire coming from the nose and then fixed behind the ear. This solution is not considered optimal because of patient complaints and moreover the aesthetic aspect is compromised. The procedure we utilized in four patients utilized the setting of a silicone tube hanging from the neck in a way similar to that of endoscopic pharyngostomy. This solution is a valid alternative both for quality of life and for functional results.

Tailored approach to Zenker's diverticula.

BACKGROUND: Zenker's diverticula (ZD) can be treated by diverticulostomy or open surgery (upper esophageal sphincter myotomy and diverticulectomy or diverticulopexy). The aim of this study was to compare the outcome of the two alternative treatments. METHODS: Fifty eight patients were scored for symptoms and upper esophageal sphincter (UES) pressure; relaxations and intrabolus pressures were recorded by manometry. Treatment depended on operative risk and ZD size. Twenty four patients with high surgical risk and/or a <3-cm or >5-cm pouch underwent diverticulostomy; the other 34 had open surgery. RESULTS: Mortality was nil. Five patients had postoperative complications after open surgery (p<0.05). Hospital stay was shorter after diverticulostomy (p<0.001). Follow-up (41 months; range, 1-101) was obtained in 53 patients. Postoperative manometry showed a UES pressure reduction, improved UES relaxation, and lower intrabolus pressure in both groups (p<0.05). In the diverticulostomy group, three patients complained of severe dysphagia. vs none in the open surgery group (p<0.05). CONCLUSION: Diverticulostomy is safe, quick, and effective for most patients with medium-sized ZD, but open surgery offers better long-term results and should be recommended for younger, healthy patients with small or very large diverticula.

[Endotracheal tube and trachebronchial obstruction due to a large blood clot. Case report]. / Ostruzione del tubo endotracheale e dell'albero tracheobronchiale da parte di un voluminoso coagulo. Caso clinico.

A case of endotracheal tube and tracheobronchial acute obstruction caused by a large blood clot reproducing in part the trachea and the right bronchial tree is reported. The event has been anticipated by recurring hemoptyses whose source remained unknown despite any examination. Having established by simple manoeuvres that the obstruction was located at the endotracheal tube level, the tube was removed together with the blood clot without more invasive techniques like rigid or flexible bronchoscopy, embolectomy catheter of fibrinolytic agents. On the other side, those techniques should be used in case of obstruction located under the endotracheal tube. Albeit obstruction of endotracheal tubes due to blood clots is a frequent complication in critical care setting, this case is reported for the peculiar dimension and morphology of the clot, underlying that a precise diagnosis of the obstruction level allows the use of the most suitable technique for its removal.

Endoscopic diverticulotomy for the treatment of Zenker's diverticulum: results in 102 patients with staple-assisted endoscopy.

Endoscopic diverticulotomy for the treatment of Zenker's diverticulum has been reported infrequently in the literature and has engendered considerable controversy. Between March 1992 and September 1996, we attempted to treat 102 patients with endoscopic treatment for pharyngoesophageal diverticula. In 98 patients, the endoscopic surgery was successfully completed. Conversion to open surgery was required in 4 patients (3.92%). One cartridge of staples in 16 patients (16.32%), 2 cartridges in 78 patients (79.59%), and 3 cartridges in 4 patients (4.08%) were used, according to the size of the diverticulum; the median duration of the procedure was 20 minutes (10 to 60 minutes). No postoperative morbidity or mortality was recorded. Oral feeding was started following radiologic control after a median of 2 days; the median hospital stay was 4 days. The median follow-up is 16 months (1 to 45 months). Four patients operated on before the introduction of the modified stapler showed a persistent diverticular pouch: 3 underwent repeat endoscopic operation, and 1 underwent conventional open surgery. All treated patients are asymptomatic. Manometric study performed in 15 patients showed a significant reduction of basal upper esophageal sphincter pressure compared to preoperative data (48.30+/-21.74 versus 29.38+/-5.68 mm Hg; p<.01). We therefore recommend endoscopic diverticulotomy, considering that the procedure is relatively safe and effective, with minimal patient discomfort, and the results are equal to those of the external approach. This procedure offers the advantages of short hospitalization, rapid convalescence, brief operative time, absence of skin incision. predictable resolution of symptoms, and reduced morbidity.

[The treatment of choanal atresia]. / Trattamento dell'atresia coanale.

Choanal atresia occurs in approximately 1 out of every 8000 live births. In about 60% of these cases it is unilateral and is often associated with other major craniofacial anomalies or visceral malformations such as the so-called CHARGE syndrome (i.e. Choloboma, Heart defects, choanal Atresia, Retarded growth and development, Genital anomaly, and Ear defect with deafness) first described by Pagon in 1981. In newborns the clinical manifestations of choanal atresia consist of respiratory distress strictly related to the entity of nasal obstruction. Total bilateral congenial choanal atresia must, therefore, be considered a surgical emergency since nasal obstruction impedes the suction mechanism and hence normal feeding in the newborn. For this reason, prompt surgery is mandatory. The surgical approach employed in choanal atresia consists of both the trans-nasal and trans-palatal approaches. Between 1985 and 1997 31 patients with choanal atresia were treated in our department (16 males, 15 females; age range 2 days-5.5 years; mean 11.4 months). In 25 cases (80.6%) the malformation was bilateral. Associated anomalies were seen in 8 patients (25.8% of cases). All of these patients were treated using the trans-nasal approach, under general anesthesia, and endoscopic control. In 27 cases a trocar was employed to perforate the bony atresia and a stent was then positioned. Three patients underwent contact-laser resection of the stenosis without requiring any further stent and without any complications. None of these patients developed total recurrences, although after varying amounts of time, in 8 of the 27 patients operated using the trocar (29.6% of cases) a partial reduction of the airway occurred, the substenosis requiring dilatation with progressive Hegar dilators. In the remaining cases contact-laser therapy was associated with dilation. Three of the patients were treated by laser-therapy alone and none developed a recurrence. One patient dropped out of the follow-up for other serious malformations.