Micro-CT Imaging of Tracheal Development in Down Syndrome and Non-Down Syndrome Fetuses.

OBJECTIVES: Down syndrome (DS) is associated with airway abnormalities including a narrowed trachea. It is uncertain whether this narrowed trachea in DS is a consequence of deviant fetal development or an acquired disorder following endotracheal intubation after birth. This study aimed to compare the tracheal morphology in DS and non-DS fetuses using microfocus computed tomography (micro-CT). METHODS: Twenty fetal samples were obtained from the Dutch Fetal Biobank and divided into groups based on gestational age. Micro-CT images were processed to analyze tracheal length, volume, and cross-sectional area (CSA). RESULTS: Mean tracheal length and tracheal volume were similar in DS and non-DS fetuses for all gestational age groups. Mean, minimum, and maximal tracheal CSA were statistically significantly increased in the single DS fetus in the group of 21-24 weeks of gestation, but not in other gestational age groups. In 90% of all studied fetuses, the minimum tracheal CSA was located in the middle third of the trachea. CONCLUSION: Tracheal development in DS fetuses was similar to non-DS fetuses between 13 and 21 weeks of gestation. This suggests that the narrowed tracheal diameter in DS children may occur later in fetal development or results from postnatal intubation trauma. The narrowest part of the trachea is in majority of DS and non-DS fetuses the middle third. LEVEL OF EVIDENCE: Level 3 Laryngoscope, 2024.

Management of the brachial plexus in head and neck cancer.

PURPOSE OF REVIEW: The brachial plexus is an important anatomical structure that is regularly encountered by head and neck surgeons and radiation oncologists. Surgical or radiation-induced brachial plexus injury have great impact on arm function and quality of life. Anatomical variations and management of the brachial plexus in head and neck cancer treatment are discussed. RECENT FINDINGS: The brachial plexus consists of spinal roots from C5-C8 and T1. The most prevalent anatomical variations in brachial plexus anatomy include the prefixed brachial plexus (additional contribution from C4) in 11%, the roots of C5 and C6 piercing the belly of the anterior scalene muscle in 6.8%, and presence of the scalenus minimus muscle in 4.1-46%. Due to its location, the brachial plexus is at risk of inadvertent division or neuropraxia during surgical procedures such as neck dissection or robot-assisted transaxillary thyroid surgery (RATS). In case of inadvertent division, nerve reconstruction surgery is warranted and may lead to improved function. The risk of radiation-induced brachial plexus injury is dose-dependent and occurs in approximately 12-22%. Currently, no successful treatment options exist for radiation-induced injury. SUMMARY: Knowledge of anatomical variations is important for head and neck surgeons to minimize the risk of brachial plexus injury. Limiting radiation therapy dose to the brachial plexus is desirable to decrease the risk of brachial plexus injury.

Neonatal respiratory distress due to a third or fourth branchial pouch sinus: A systematic review.

OBJECTIVES: Third and fourth branchial pouch sinuses can be rare causes of respiratory distress in neonates. An overview of this distinct clinical entity is missing in literature. To aid clinicians in recognizing and adequately treating this unique entity, we conducted a systematic review to discuss patient characteristics, diagnostic considerations and treatment strategy. METHODS: MEDLINE and EMBASE were searched from inception to December 29th, 2020. Original studies concerning patients with respiratory symptoms as a result of a third or fourth branchial pouch sinus, as confirmed with rigid endoscopy, videofluoroscopy or during surgery. RESULTS: Thirty-nine studies describing 56 patients (66% male, aged 0-30 days) were analyzed. Symptoms included cervical mass (76.8%), stridor (55.4%), dyspnea (35.7%) and cyanosis (17.9%) due to a third (39.3%) or fourth (60.7%) branchial pouch sinus. Intubation was performed before treatment in 31.3%. The piriform sinus opening was identified with rigid endoscopy in 81.1%. Surgery was the treatment of choice in the majority of patients (85.7%), with a success rate of 100% and a complication rate of 10.7%. Endoscopic cauterization was successful in 40% and endoscopic cauterization followed by sclerotherapy was successful 100%, with no complications. CONCLUSION: Third or fourth branchial pouch sinuses can lead to respiratory distress in neonates. It is important to recognize this distinct clinical picture for adequate diagnosis and treatment. Rigid endoscopy is indicated to demonstrate an opening in the piriform sinus and provides the opportunity to directly perform treatment with endoscopic cauterization. If this is insufficient to relief respiratory symptoms due to a persistent cyst, sclerotherapy or surgical excision should be considered.

Tracheal anomalies associated with Down syndrome: A systematic review.

INTRODUCTION: Airway anomalies are accountable for a substantial part of morbidity and mortality in children with Down syndrome (DS). Although tracheal anomalies occur more often in DS children, a structured overview on the topic is lacking. We systematically reviewed the characteristics of tracheal anomalies in DS children. METHODS: A MEDLINE and EMBASE search for DS and tracheal anomalies was performed. Tracheal anomalies included tracheal stenosis, complete tracheal ring deformity (CTRD), tracheal bronchus, tracheomalacia, tracheal web, tracheal agenesis or atresia, laryngotracheoesophageal cleft type 3 or 4, trachea sleeve, and absent tracheal rings. RESULTS: Fifty-nine articles were included. The trachea of DS children is significantly smaller than non-DS children. Tracheomalacia and tracheal bronchus are seen significantly more often in DS children. Furthermore, tracheal stenosis, CTRD, and tracheal compression by vascular structures are seen regularly in children with DS. These findings are reflected by the significantly higher frequency of tracheostomy and tracheoplasty performed in DS children. CONCLUSION: In children with DS, tracheal anomalies occur more frequently and tracheal surgery is performed more frequently than in non-DS children. When complaints indicative of tracheal airway obstruction like biphasic stridor, dyspnea, or wheezing are present in children with DS, diagnostic rigid laryngotracheobronchoscopy with special attention to the trachea is indicated. Furthermore, imaging studies (computed tomography, magnetic resonance imaging, and ultrasound) play an important role in the workup of DS children with airway symptoms. Management depends on the type, number, and extent of tracheal anomalies. Surgical treatment seems to be the mainstay in severe cases.

Development pattern of tracheal cartilage in human embryos.

INTRODUCTION: Congenital tracheal anomalies are associated with high morbidity and mortality. The etiology of congenital tracheal anomalies is not well understood, but often attributed to malformed tracheal cartilage. The development of tracheal cartilage has not been described in detail. In this study, we aimed to investigate the development pattern and timing of normal tracheal cartilage to better understand the etiology of tracheal anomalies. MATERIALS AND METHODS: The development of tracheal cartilage was examined by studying the trachea in histological sections of 14 healthy human embryos from the Carnegie collection. Two specimens for Carnegie Stages 17-23 (42-60 days of embryological development) were studied. RESULTS: At Carnegie Stages 17-19 (42-51 days), a continuous mesenchymal condensation was observed ventral to the tracheal lumen. At Stages 20 and 21 (51-54 days), this pre-tracheal mesenchyme showed sites of increased condensation indicative of future tracheal rings. Furthermore, growth centers were identified both proximally and distally in the trachea. Characteristic horseshoe shaped tracheal rings were apparent at Carnegie Stages 22 and 23 (54-60 days). CONCLUSIONS: In human embryos, tracheal rings arise from growth centers in the ventral mesenchyme at approximately 51-54 days of embryological development. The observation of proximal and distal growth centers suggests a centripetal growth gradient, potentially contributing to occurrence of complete tracheal ring deformity (CTRD). Although this study shows new insights on tracheal cartilage development, the exact origin of congenital tracheal defects has yet to be elucidated.

[A woman with purulent rhinorrhoea after bathing in the sea]. / Een vrouw met purulente rinorroe na een zeebad.

A 59-year-old woman was referred because of nasal discharge with stones and sand. Some months earlier, a rip current had thrown her over while bathing in the sea. CT showed bilateral stones in the maxillary sinus. A right maxillary sinus rinse was performed, which revealed six small stones.

Adherence to the guidelines of paediatric cervical spine clearance in a level I trauma centre: A single centre experience.

INTRODUCTION: International guidelines define if and what type of radiography is advised in children to clear the cervical spine (C-spine). However, adherence to these guidelines has never been evaluated in a paediatric population. Therefore, we wanted to assess the adherence to the guidelines for C-spine clearance in a level-one trauma centre. METHODS: We retrospectively included all children, presented at the ED between January 2006 and December 2013, in whom radiographic imaging of the C-spine was obtained following blunt trauma. Primary outcome was the adherence to the international guidelines with regard to (1) if the indication for radiographic imaging was correct and (2) if the type of radiographic imaging was correct. RESULTS: Included were 573 patients; 336 boys (58.7%). Median age was 11 years (IQR 5.25-15). The indication for radiographic imaging was correct in all cases. The type of primary imaging modality was concordant with the guidelines in 99,7%. In 41% of the cases supplementary radiographs were made. The most common supplementary view was the odontoid. In 15% an incomplete set of radiographs was obtained. CONCLUSION: The adherence to the international guidelines when to obtain radiographic imaging was 100%. However, in a large proportion of patients (56%), not the recommended number of radiographs was obtained.

Internal or External Stenting of the Ureterovesical Anastomosis in Renal Transplantation.

BACKGROUND: Stenting of the ureterovesical anastomosis reduces the incidence of urological complications (UCs) after renal transplantation, but there are multiple stenting techniques, and there is no consensus regarding which technique is preferred. The aim of this study was to compare an internal versus an external stenting technique on the incidence of UCs. METHODS: This is a retrospective analysis of 419 deceased donor renal transplantations performed between January 2008 and December 2013. Until 2011, 183 patients received an external stent through the ureterovesical anastomosis placed by suprapubic bladder puncture (SP stent). From 2011, 236 recipients received an internal double-J (JJ) stent. RESULTS: The rate of UC was 3.8% in JJ stents, compared to 9.3% in SP stents (p = 0.021). No difference in surgical ureter revision rate was observed between the groups (2.1 vs. 5.5%; p = 0.068). Urinary tract infection (UTI) rate and graft function were comparable between both groups. CONCLUSIONS: Internal JJ stenting significantly decreased the incidence of UC compared to an external SP stent. There was no difference in surgical ureter revision rate, UTI or graft function.

Wound morbidity after kidney transplant.

CONTEXT: Wound morbidity is an important surgical complication after kidney transplant. OBJECTIVE: To assess risk factors for postoperative wound complications and the impact of such complications on outcomes of kidney transplant. DESIGN AND PATIENTS: Retrospectively, 108 consecutive kidney transplant patients between January 2010 and December 2010 were included in the analysis. Wound morbidity was defined as a surgical site infection or symptomatic lymphocele requiring intervention. Patient, donor, and surgical characteristics were reviewed. RESULTS: Eight lymphoceles and 5 surgical site infections occurred in 12 patients. Risk factors for wound complications were recipient's age (P<.01), body mass index (P=.01), urinary tract infection (P=.01), and prolonged postoperative wound drainage (P=.047). Wound morbidity did not increase the incidence of delayed graft function, acute rejection, graft failure, or mortality. Obesity, recipient's age, urinary tract infection, and prolonged wound drainage are risk factors for wound-related complications. Graft and patient survival rates are comparable between patients with and without wound-related complications.

[Renal transplantation at night]. / Niertransplantaties in de nacht.

BACKGROUND: In renal transplantation, prolonged cold ischaemia time (CIT) increases the risk of delayed graft function, rejection and graft failure. To minimise CIT, renal transplantations are performed directly upon graft availability and often take place during the night. Night-time surgery is supposedly associated with an increased risk of surgical complications compared with daytime operations. The aim of this study was to assess the consequences of night-time renal transplantation on surgical complications and graft function. METHOD: 384 adult recipients of deceased-donor renal transplantations performed between January 2007 and June 2012 were retrospectively examined. Night-time renal transplantations were defined as surgery between 11 PM and 6 AM. The primary outcome was the occurrence of surgical complications. The secondary outcome was graft function. RESULTS: No differences in surgical complications or graft function were observed among daytime and night-time groups. CIT was significantly increased in night-time renal transplantation (p < 0.001). CONCLUSION: Night-time renal transplantation is not associated with an increased risk of surgical complications or graft failure, and can be considered a safe procedure. Given the need to minimise CIT, delaying the procedure until the morning is unjustified.