Intubación fibroóptica oral. Localización del lugar de resistencia al avance del tubo traqueal y maniobras para solucionarlo. Estudio de simulación en maniquí / Locating the site of resistance to the endotracheal tube in fiberoptic oral intubation and maneuvers to overcome it: a mannequin simulation study

OBJETIVOS: Determinar el lugar más frecuente deresistencia al avance del tubo traqueal durante la intubación fibroóptica oral en maniquí, aplicando un algoritmo de maniobras para solucionarlo.MÉTODO: Se establecieron 4 grupos de estudio dondese compararon dos tipos de tubo traqueal, uno estándary otro reforzado flexible, de 7,5 mm de diámetro interno,combinándolos o no con una cánula orofaríngea de intubación tipo Williams. Se utilizaron dos fibroscopios, uno para realizar la intubación y el otro para observar la localización de la resistencia y la efectividad de las maniobras para evitarlo. Se clasificó el grado de resistencia según la escala de Jones, modificada, desde el grado 0 (intubación sin resistencia), al grado 4 (no intubación), y se registró la localización de la resistencia y el tiempo necesario para cada intubación.RESULTADOS: Se realizaron 250 intubaciones orales. Seencontró resistencia en el 75,2% de los casos. Las localizaciones principales de la obstrucción fueron el cartílago aritenoides derecho y la comisura posterior. En el 89,6% de los casos se intubó la tráquea sin maniobra alguna o con una rotación antihoraria de 90º. Hubo diferencias estadísticamente significativas en resistencia y tiempo de intubación cuando se utilizó la combinación de tubo reforzado flexible y Williams.CONCLUSIONES: La rotación antihoraria de 90º deltubo fue una maniobra efectiva para superar la resistencia. La combinación de un tubo reforzado flexible y Williams es la que presentó menos resistencia y menores tiempos de intubación

OBJECTIVE: To determine the most common trachealpoints of resistance during orotracheal insertion of afiberoptic tube in a mannequin by applying a maneuveralgorithm to overcome the resistance.METHOD: Four study groups were established to compare 2types of endotracheal tube: a standard tube and a reinforced flexible tube with an internal diameter of 7.5 mm. The tubes were used on their own or in combination with a Williams airway intubator. Two fiberoptic bronchoscopes were used, one to perform the test intubation and the other to observe thelocation of resistance and the effectiveness of the maneuvers for overcoming it. The degree of resistance was scored using a modified Jones scale, from 0 (intubation without resistance) to 4 (intubation impossible); location of resistance and timerequired for each intubation were also recorded.RESULTS: A total of 250 oral intubations were performed.Resistance was encountered in 75.2% of the cases. The main locations of obstruction were the right arytenoid cartilage and the posterior commissure. In 89.6% of the cases, intubation of the trachea was achieved without maneuvering or with a 90° counterclockwise rotation. Statistically significant differences were found in resistance and intubation time when the reinforced flexible tube was used with the Williams intubator.CONCLUSIONS: Rotating the tube 90° counterclockwise was an effective maneuver for overcoming resistance. The combination of a reinforced flexible tube and a Williams intubator was associated with less resistance and shorter intubation times

[Locating the site of resistance to the endotracheal tube in fiberoptic oral intubation and maneuvers to overcome it: a mannequin simulation study]. / Intubación fibroóptica oral. Localización del lugar de resistencia al avance del tubo traqueal y maniobras para solucionarlo. Estudio de simulación en maniquí.

OBJECTIVE: To determine the most common tracheal points of resistance during orotracheal insertion of a fiberoptic tube in a mannequin by applying a maneuver algorithm to overcome the resistance. METHOD: Four study groups were established to compare 2 types of endotracheal tube: a standard tube and a reinforced flexible tube with an internal diameter of 7.5 mm. The tubes were used on their own or in combination with a Williams airway intubator. Two fiberoptic bronchoscopes were used, one to perform the test intubation and the other to observe the location of resistance and the effectiveness of the maneuvers for overcoming it. The degree of resistance was scored using a modified Jones scale, from 0 (intubation without resistance) to 4 (intubation impossible); location of resistance and time required for each intubation were also recorded. RESULTS: A total of 250 oral intubations were performed. Resistance was encountered in 75.2% of the cases. The main locations of obstruction were the right arytenoid cartilage and the posterior commissure. In 89.6% of the cases, intubation of the trachea was achieved without maneuvering or with a 90 degrees counterclockwise rotation. Statistically significant differences were found in resistance and intubation time when the reinforced flexible tube was used with the Williams intubator. CONCLUSIONS: Rotating the tube 90 degrees counterclockwise was an effective maneuver for overcoming resistance. The combination of a reinforced flexible tube and a Williams intubator was associated with less resistance and shorter intubation times.

Replica de los autores a la carta “Paciente no intubable no ventilable” / No disponible

No disponible

[Heart arrest during fibro-bronchoscopic intubation in a patient with parapharyngeal space neoplasia]. / Parada cardíaca durante intubación con fibrobroncoscopio en paciente con neoplasia del espacio parafaríngeo.

A 37-year-old woman a diagnosis of squamous carcinoma of the tongue and a history of partial/hemiglossectomy with cervical lymphadenectomy and postoperative radiotherapy was scheduled for biopsy under general anesthesia given the suspicion of local recurrence. She underwent routine preparation for intubation with a fiberoptic bronchoscope with topical anesthesia of mucosal tissue without sedation. Syncope and asystole presented suddenly during intubation and external cardiopulmonary resuscitation and difficult ventilation through a face mask were necessary. She was finally intubated using a retrograde technique and recovered heartbeat after 20 minutes. No neurological sequelae were observed over the next few days. The etiologic diagnosis of this rare complication was later based on the appearance of the characteristic clinical profile of glossopharyngeal neuralgia-asystole syndrome in combination with parapharyngeal space lesion syncope syndrome; magnetic resonance findings of extensive neoplastic invasion of the space confirmed the diagnosis. Endotracheal intubation with a fiberoptic bronchoscope plays an important role in the management of the anticipated difficult airway. It is safe in the awake patient and facilitates the identification of structures, particularly when there are anatomical alterations due to neoplastic invasion, surgery, or radiotherapy. In the patient we describe, however, stimulation caused asystole.

Parada cardíaca durante intubación con fibrobroncoscopio en paciente con neoplasia del espacio parafaríngeo / Cardiac arrest during intubation with a fiberoptic bronchoscope in a patient with parapharyngeal neoplasm

Una paciente de 37 años de edad con diagnóstico de carcinoma escamoso de lengua, intervenida un año antes de hemiglosectomía con linfadenectomía cervical y radioterapia posterior fue programada para biopsia bajo anestesia general por sospecha de recidiva local. En quirófano se preparó de forma reglada para intubación con fibrobroncoscopio mediante anestesia tópica de mucosas y sin sedación. En el transcurso de la intubación presentó de forma súbita un cuadro sincopal con asistolia, precisando de maniobras de reanimación cardiopulmonar con masaje cardíaco externo y ventilación con mascarilla facial, que resultó ser dificultosa. Finalmente se intubó a la paciente mediante una técnica retrógrada, recuperando el latido cardíaco transcurridos veinte minutos. No se objetivó ningún tipo de secuela neurológica en los días siguientes. El diagnóstico etiológico de esta rara complicación se estableció con posterioridad basándonos en la aparición de clínica característica del síndrome de neuralgia-asistolia del glosofaríngeo, en combinación con el definido síndrome del síncope de lesión del espacio parafaríngeo, una vez que fueron determinados hallazgos en la resonancia magnética de invasión neoplásica extensa de dicho espacio. La intubación endotraqueal con fibrobroncoscopio desempeña un papel preponderante en el manejo de la vía aérea difícil anticipada. En el paciente despierto aporta seguridad al mismo tiempo que facilita la identificación de estructuras, especialmente en situaciones de distorsión anatómica por invasión neoplásica, cambios postquirúrgicos o postradioterapia. Sin embargo, en esta paciente la estimulación que ocasionó provocó la asistolia (AU)

Maternal lung adenocarcinoma metastatic to the scalp of a fetus. Case report.

Maternal malignancy metastatic to the fetus is a rare event, with most neoplasms being either melanocytic or hematopoietic in origin. This report is the first known case of a maternal lung adenocarcinoma metastatic to a fetus. At 2 months of age, this male infant developed multiple scalp masses that were locally resected but rapidly recurred. The histology of the scalp lesions and that of a biopsy of the mother's tumor were both adenocarcinoma and were remarkably similar in appearance. In situ hybridization of tumor cells from this male infant found many large nuclei with XX signals indicating that the tumor was of maternal origin. This patient is alive, well and free of malignancy 5 years after a wide local resection of the scalp and skin grafting.

Paecilomyces variotii in a pediatric patient with lung transplantation.

Aspergillus has been noted to be the most common species of filamentous fungus isolated from the airways of lung transplantation (Tx) patients. In general, the bronchi are colonized asymptomatically with Aspergillus but this places such a patient population at greater risk of invasive infection. Other filamentous fungal species may also assume importance in this patient population. Here we report the post-transplant isolation of Paecilomyces variotii from the airways of a pediatric patient with cystic fibrosis (CF) who underwent bilateral living-donor lobar lung Tx. This is the first report of isolation of P. variotii in the pediatric lung Tx population. The isolation of filamentous fungi, such as Paecilomyces, with variable in vitro susceptibility to currently available antifungal agents further complicates the approach to post-transplant antifungal therapy in patients with lung Tx.

Presence of well-differentiated rhabdomyoblasts at the end of therapy for pelvic rhabdomyosarcoma: implications for the outcome.

The presence of well-differentiated rhabdomyoblasts at the end of therapy for rhabdomyosarcoma has been noted. This study was undertaken to investigate the therapeutic implications of the presence of well-differentiated rhabdomyoblasts at the end of therapy for pelvic rhabdomyosarcoma. Six patients with pelvic rhabdomyosarcoma (bladder-prostate, 4; vulvovaginal, 2) with disease diagnosed between the years 1974 and 1992 were sequentially investigated by cystoscopic or vaginoscopic examination and biopsy during and after completing therapy. All six patients received treatment according to prevailing therapeutic protocols. Biopsy material from all six patients at the end of therapy documented the presence of well-differentiated rhabdomyoblasts. Repeated biopsies demonstrated the presence of rhabdomyoblasts; however, they appeared to decrease in number with time. Mitotic activity was not observed in the biopsy materials obtained. All six patients are alive without evidence of disease from 37 to 233 months after therapy ended. The presence of well-differentiated rhabdomyoblasts at the end of therapy for pelvic rhabdomyosarcoma is a common finding. The biologic nature of these well-differentiated rhabdomyoblasts is not completely known, but they do not appear to connote the persistent presence of malignant disease and are not an indication for the continuation of therapy.

[Headache caused by endocranial hypotension secondary to sacrococcygeal trauma in a patient with a congenital arachnoid cyst]. / Cefalea por hipotensión endocraneal secundaria a un traumatismo sacrococcígeo en un paciente con un quiste aracnoideo congénito.

Headache caused by intracranial hypotension after sacrococcygeal trauma, is a rare syndrome with very similar symptoms and physiopathology to post dural puncture headache. In both situations, cerebrospinal fluid (CSF) leaks through a dural tear, leading to a decrease in its pressure. A 13 year old patient presented a frontal and occipital positional headache, after undergoing sacrococcygeal trauma. In magnetic resonance images, the presence of a spinal arachnoid diverticulum (cyst) and CSF leak were confirmed. After the establishment of conservative medical treatment, complete clinical remission was observed. The diagnosis of intracranial hypotension headache syndrome is mainly clinical, once other possible headache etiologies have been discarded. Magnetic resonance imaging can be used to detect small CSF leaks, and in this case, magnetic resonance imaging clearly showed the existence of an arachnoid cyst. The presence of some meningeal diverticulums such as arachnoid cyst, constitute a risk to undergo this syndrome, due to the possibility of its rupture by minor traumatisms. The initial treatment should be conservative, as the dural tear seals spontaneously and the liquid is reabsorbed.

Pathology review of screening negative neuroblastomas: a report from the Quebec Neuroblastoma Screening Project.

BACKGROUND: The Quebec Neuroblastoma Screening (QNS) Project completed a 5-year program for measuring urinary vanillylmandelic acid (VMA)/homovanillic acid (HVA) levels at age 3 weeks and/or 6 months in 89% of 476,603 Quebec-born infants from 1989-1994; 45 screening positive preclinical cases (S-positive cases) and 20 congenital/neonatal (C/N) cases were identified. As of April 1997, an additional 59 cases in the same birth cohort were diagnosed clinically; these neuroblastomas developed after screening verified normal VMA/HVA levels (S-negative cases). METHODS: Pathology specimens from 45 of 59 S-negative cases were reviewed centrally and classified according to the Shimada system. Results were compared with clinical data and also with S-positive and C/N cases. RESULTS: Of 45 S-negative cases, 27 tumors had favorable histology (FH) and 18 had unfavorable histology (UH). Approximately 52% of FH tumors were diagnosed before age 1 year, whereas UH tumors were nearly exclusively (94%) diagnosed after age 1 year (P < 0.01). Approximately 89% of FH tumors were Stage I, II, or IV-S, whereas 72% UH tumors were Stage III or IV (P < 0.001). All children with FH tumors were alive at last follow-up (range of follow-up period: 9-79 months; median, 35 months), whereas 8 children with UH tumors died of disease even after limited follow-up (range of follow-up period: 0-60 months; median, 20 months). By contrast, S-positive and C/N cases were predominantly (97%) FH tumors, often (76%) Stage I, II, or IV-S, with excellent clinical outcome (survival rate of 98%). CONCLUSIONS: The majority of the UH neuroblastomas that developed in the birth cohort of the QNS Project were included in the group of S-negative cases and could not be detected by the screening at age 3 weeks and/or 6 months.

Locally infiltrative glomus tumors and glomangiosarcomas. A clinical, ultrastructural, and immunohistochemical study.

Six cases of locally aggressive and/or potentially malignant glomus tumors are described. On the basis of clinical and pathologic criteria, the following classification is proposed. The first category is a locally infiltrative glomus tumor (LIGT) which has the usual glomus histologic features. The second group is a cytologically malignant tumor arising and merging with a typical glomus tumor, designated glomangiosarcoma arising in a benign glomus (GABG). The third category and the most difficult to recognize is the de novo glomangiosarcoma (GADN), which must be distinguished from other round cell sarcomas. Most of these locally aggressive glomus tumors are vimentin positive and are immunoreactive for muscle-specific actin. Electron microscopic examination in one GABG case showed cells with numerous microfilaments and pinocytotic vesicles; a second GADN case contained cells with microfilaments and an incomplete basal lamina. As a group these locally aggressive or potentially malignant glomus tumors are larger and more deeply located than the conventional glomus tumor. Although 50% of these tumors recurred locally, none have metastasized.

C-cell hyperplasia in thyroid tissue adjacent to follicular cell tumors.

An immunohistochemical study was conducted on the number and distribution of C-cells in the nonneoplastic thyroid tissue adjacent to tumors of follicular cell origin. It consisted of 49 cases, of which 25 were papillary carcinomas, 22 were follicular adenomas, and 2 were follicular carcinomas. Twenty normal adult thyroids from the Broward's Medical Examiner's morgue served as controls. In 17 of the 49 cases (34.6%), there was a statistically significant increase in the number of C-cells in the normal-appearing thyroid tissue adjacent to follicular cell tumors, with at least 50 C-cells in one low power field, while only one of 20 normal thyroids had a similar number of cells. (P = .02; chi 2 = 5.05). In two tumor cases there were more than 100 C-cells in several low power fields with formation of small C-cell nodules similar to those described in the type II Multiple Endocrine Neoplasia Syndrome (MEN). It was concluded that the nonneoplastic thyroid tissue adjacent to 34.6% of tumors with follicular cell phenotypes contains significantly more C-cells than those present in normal adult thyroids. The possible pathogenesis and clinical significance of these findings are discussed.

Spinal cord tumors presenting with neural tube defects.

Two primary lumbosacral tumors arising at the site of neural tube defects are presented. One was a teratoma diagnosed in an infant with myelomeningocele. The other was an ependymoma that developed in an adult with meningocele. It is postulated that these cases represent a neoplastic transformation of heterotopic primordial elements that have been incorporated within the defect, supporting the view that overgrowth of neural tissue may be the result rather than the cause of neural tube deformity. Such rare occurrences may be due to interaction between intrauterine teratogenic factors and familial predisposition in affected patients.